Neonatal Resuscitation & Low Birth Weight Management

Neonatal Resuscitation & LBW Management | Nursing Notes

Introduction

Approximately 10% of newborns require some assistance to begin breathing at birth, and less than 1% need extensive resuscitative measures. Low birth weight (LBW) babies, defined as weighing less than 2,500 grams at birth, require specialized nursing care to address their unique needs and prevent complications.

This educational resource presents evidence-based approaches to neonatal resuscitation and the nursing management of low birth weight babies, incorporating the latest guidelines and best practices.

Part 1: Neonatal Resuscitation

Physiological Transitions at Birth

At birth, the neonate transitions from placental gas exchange to pulmonary respiration. This complex process involves clearing fluid from the lungs, establishing regular breathing, and transitioning from fetal to neonatal circulation.

Neonatal Resuscitation Algorithm (2020 American Heart Association Guidelines)

Neonatal Resuscitation Algorithm

Initial Steps (First 30 Seconds):

Provide warmth (place under radiant warmer)
Position head in “sniffing” position
Clear airway as needed (suction)
Dry the infant thoroughly
Stimulate breathing

Assess: Breathing or crying? Good tone? Term gestation?

If YES to all → Routine care: Provide warmth, clear airway as needed, dry, ongoing evaluation

Evaluate Breathing and Heart Rate

Apply pulse oximeter on right hand/wrist
Consider ECG monitoring

If Apnea/Gasping OR HR < 100/min:

Initiate PPV with room air
Apply ECG monitor

Assess: HR < 60/min?

If YES → Begin chest compressions coordinated with PPV (3:1 ratio, 90 compressions and 30 breaths/min)

If HR remains < 60/min despite adequate ventilation and chest compressions:

Consider intubation if not already done
Administer epinephrine
Consider hypovolemia

Mnemonic: “A-B-C-D” of Neonatal Resuscitation

A – Airway (position and clear)
B – Breathing (stimulate and evaluate)
C – Circulation (evaluate heart rate, compressions if needed)
D – Drugs (epinephrine, volume expanders if needed)

Target Oxygen Saturation After Birth

Time after birth	Target SpO₂
1 minute	60-65%
2 minutes	65-70%
3 minutes	70-75%
4 minutes	75-80%
5 minutes	80-85%
10 minutes	85-95%

Equipment for Neonatal Resuscitation

Essential equipment for neonatal resuscitation

Category	Equipment
Thermal Management	Radiant warmer, pre-warmed towels, plastic wrap for VLBW infants, warm cap
Airway Management	Bulb syringe, suction catheters (5F-10F), meconium aspirator, laryngoscope with straight blades (0, 00, 1), endotracheal tubes (2.5-4.0 mm), stylet
Breathing Support	Neonatal resuscitation bag with pressure manometer, face masks (preterm, term), oxygen source, oxygen blender, pulse oximeter
Circulation Support	Stethoscope, ECG monitor leads, umbilical vessel catheterization supplies, IV supplies
Medications	Epinephrine (1:10,000), volume expanders (normal saline, Ringer’s lactate), dextrose 10% solution, naloxone

Clinical Tip: The Golden Minute

The first 60 seconds after birth (the “Golden Minute”) should focus on the initial steps of resuscitation: warming, positioning, clearing the airway, drying, stimulating, and evaluating the infant.

Chest Compressions Technique

Indications: Heart rate < 60 bpm despite 30 seconds of effective ventilation
Technique: Two-thumb method encircling the chest is preferred
Depth: Compress lower third of sternum to a depth of approximately one-third of the anterior-posterior diameter of the chest
Rate: 90 compressions and 30 breaths per minute (3:1 ratio)
Coordination: Compressions and ventilations are delivered sequentially, not simultaneously

Mind Map: Causes of Poor Response to Resuscitation

Ventilation Issues

Inadequate mask seal
Airway obstruction
Improper head position
Secretions/meconium blocking airway
Insufficient inspiratory pressure

Equipment Problems

Disconnected oxygen source
Malfunctioning ventilation bag
Blocked endotracheal tube
Misplaced endotracheal tube
Inaccurate monitoring equipment

Maternal Factors

Maternal sedation/analgesia
Maternal hypertension
Maternal infection
Placental insufficiency

Infant Factors

Congenital anomalies
Pneumothorax
Diaphragmatic hernia
Hypovolemia
Sepsis
Metabolic disorders

Mnemonic: “DR MAAN” – Neonatal Resuscitation Equipment Checklist

D – Drying towels and temperature control
R – Resuscitation bag and mask
M – Meconium aspirator
A – Airway equipment (suction, ET tubes)
A – Access (umbilical catheter supplies)
N – Necessary medications

Part 2: Nursing Management of Low Birth Weight Babies

Classification of Low Birth Weight Infants

Category	Weight Range
Low Birth Weight (LBW)	< 2500 grams
Very Low Birth Weight (VLBW)	< 1500 grams
Extremely Low Birth Weight (ELBW)	< 1000 grams

Common Complications of Low Birth Weight

Respiratory Complications

Respiratory distress syndrome (RDS)
Bronchopulmonary dysplasia (BPD)
Apnea of prematurity
Pneumonia

Cardiovascular Complications

Patent ductus arteriosus (PDA)
Hypotension
Bradycardia
Poor peripheral perfusion

Metabolic Complications

Hypoglycemia
Hypocalcemia
Hyponatremia
Metabolic acidosis

Neurological Complications

Intraventricular hemorrhage (IVH)
Periventricular leukomalacia (PVL)
Seizures
Developmental delays

Gastrointestinal Complications

Necrotizing enterocolitis (NEC)
Feeding intolerance
Gastroesophageal reflux
Delayed oral feeding skills

Other Complications

Hyperbilirubinemia
Retinopathy of prematurity (ROP)
Anemia of prematurity
Immunodeficiency
Thermoregulation issues

Comprehensive Nursing Assessment of LBW Infants

Mnemonic: “ABCDEF ASSESSMENT” for LBW Babies

A – Airway (patency and breathing pattern)
B – Body temperature (thermoregulation status)
C – Circulation (heart rate, blood pressure, perfusion)
D – Dextrose (blood glucose monitoring)
E – Electrolytes and fluid balance
F – Feeding tolerance and nutrition

Assessment Area	Key Observations
Respiratory Status	Respiratory rate and pattern Signs of respiratory distress (grunting, nasal flaring, retractions) Oxygen saturation levels Breath sounds
Cardiovascular Status	Heart rate and rhythm Blood pressure Peripheral pulses Capillary refill time Color of skin and mucous membranes
Thermoregulation	Axillary temperature Ability to maintain core temperature Signs of cold stress (acrocyanosis, mottling)
Neurological Status	Level of consciousness Muscle tone and posture Reflexes (Moro, sucking, grasp) Fontanelles (size, tension)
Gastrointestinal Status	Abdominal distension or tenderness Feeding tolerance Stool pattern and characteristics Presence of vomiting or regurgitation
Skin Integrity	Skin color and perfusion Presence of breakdown or pressure areas Edema Jaundice
Fluid and Electrolyte Balance	Hydration status Urine output (frequency, volume, color) Signs of dehydration or fluid overload Electrolyte levels

Nursing Interventions for LBW Babies

1. Thermoregulation Management

Kangaroo Mother Care (KMC) for low birth weight infants

Maintain Neutral Thermal Environment

Use radiant warmers or incubators for infants < 1800g
Monitor axillary temperature every 2-4 hours
Maintain temperature between 36.5°C and 37.5°C
Use plastic wrap or bags for extremely low birth weight infants
Pre-warm all items that come in contact with the infant

Implement Kangaroo Mother Care (KMC)

Position infant upright between mother’s breasts in skin-to-skin contact
Cover infant’s back with blanket
Ensure infant’s head is turned to side and slightly extended
Provide privacy and support during KMC sessions
Encourage minimum of 1-2 hours per session

Clinical Tip: Benefits of Kangaroo Mother Care

KMC significantly reduces mortality in LBW infants, improves thermoregulation, promotes breastfeeding, reduces hospital-acquired infections, and strengthens maternal-infant bonding.

2. Nutritional Support

Assess Feeding Readiness

Evaluate gestational age and weight
Assess sucking and swallowing reflexes
Monitor respiratory status during feeds
Assess gastrointestinal readiness

Implement Appropriate Feeding Method

Breast milk is the preferred nutrition source
For stable infants >32 weeks with good reflexes: direct breastfeeding
For infants 28-32 weeks: gavage feeding plus non-nutritive sucking
For infants <28 weeks: gavage feeding or TPN
Advance feeds gradually (10-20 mL/kg/day) based on tolerance

Monitor Nutritional Status

Track daily weight, length, and head circumference
Monitor intake and output
Assess for feeding intolerance (abdominal distension, residuals)
Evaluate weight gain pattern (optimal: 15-20g/kg/day)

Weight Range	Recommended Feeding Method	Volume Guidelines
<1000g (ELBW)	TPN initially, then slow progression to gavage feedings	Start with 10-20 mL/kg/day, increase by 10-20 mL/kg/day as tolerated
1000-1500g (VLBW)	Gavage feeding, transition to nipple as tolerated	Start with 20-30 mL/kg/day, increase by 20-30 mL/kg/day as tolerated
1500-2500g (LBW)	Nipple feeding if mature enough, otherwise gavage	Start with 30-60 mL/kg/day, increase to full feeds over 3-5 days

3. Infection Prevention

Implement Strict Hand Hygiene

Perform hand hygiene before and after infant contact
Use alcohol-based hand rubs or antimicrobial soap
Ensure all staff and visitors adhere to hand hygiene protocols

Maintain Skin Integrity

Minimize adhesive use on fragile skin
Use appropriate barrier products
Reposition infant regularly
Provide gentle skin care with minimal handling

Monitor for Signs of Infection

Temperature instability
Feeding intolerance
Respiratory changes (apnea, tachypnea)
Lethargy or irritability
Color changes or poor perfusion

Warning: Sepsis Red Flags

LBW infants with sepsis may present with subtle signs. Any unexplained deterioration, temperature instability, or changes in feeding patterns should trigger prompt evaluation for infection.

4. Respiratory Support

Monitor Respiratory Status

Assess respiratory rate, effort, and pattern
Monitor oxygen saturation continuously
Observe for signs of respiratory distress
Auscultate lung fields regularly

Position for Optimal Respiratory Function

Maintain neutral head position
Provide prone positioning when appropriate (with monitoring)
Elevate head of bed 30 degrees
Use supportive positioning aids

Provide Respiratory Support as Needed

Supplemental oxygen
CPAP (Continuous Positive Airway Pressure)
Mechanical ventilation
Surfactant administration
Monitor caffeine therapy for apnea of prematurity

Parent Education and Support

Mind Map: Parent Education for LBW Infant Care

Feeding Techniques

Proper breastfeeding positions
Effective latch techniques
Expressing breast milk
Supplemental feeding methods
Reading hunger cues

Kangaroo Care

Proper positioning
Duration guidelines
Benefits for infant and parents
Transfer techniques
Signs of infant stress during KMC

Home Care Preparation

Home temperature management
Infection prevention strategies
Medication administration
Equipment operation
CPR training
Follow-up appointments

Recognition of Warning Signs

Respiratory distress
Feeding intolerance
Temperature instability
Color changes
Lethargy or excessive irritability
When to seek medical attention

Mnemonic: “SMALL” – Key Principles for LBW Care

S – Skin-to-skin contact (Kangaroo care)
M – Minimal handling (cluster care activities)
A – Airway protection and monitoring
L – Lactation support (breast milk is optimal)
L – Loving, developmental care environment

Nursing Documentation for LBW Infants

Documentation Component	Key Elements to Include
Vital Signs	Temperature, heart rate, respiratory rate, blood pressure, oxygen saturation
Respiratory Assessment	Respiratory effort, breath sounds, oxygen requirements, ventilator settings if applicable
Nutritional Intake	Feeding method, volume, tolerance, residuals, weight changes
Elimination	Urine output, stool frequency and characteristics
Skin Assessment	Integrity, color, presence of breakdown or pressure areas
Neurological Status	Level of activity, tone, reflexes, response to stimuli
Parent Interaction	Visits, participation in care, kangaroo care sessions, educational needs
Medications	Time, dose, route, response, side effects
Procedures	Type, time, response, complications

Clinical Case Studies

Case Study 1: Neonatal Resuscitation

Clinical Scenario: A term infant is born with meconium-stained amniotic fluid. At birth, the infant is limp, cyanotic, and not breathing. Heart rate is 80 bpm.

Key Interventions:

Place infant under radiant warmer
Position head in “sniffing” position
Suction mouth and nose if visible secretions
Dry thoroughly and stimulate
Begin positive pressure ventilation with room air
Reassess after 30 seconds – heart rate improves to 120 bpm, infant begins breathing
Apply pulse oximeter to right hand
Monitor vital signs and oxygenation

Learning Points: This case illustrates the importance of prompt initial steps and effective positive pressure ventilation. Most infants respond to these basic measures without need for chest compressions or medications.

Case Study 2: Management of VLBW Infant

Clinical Scenario: A female infant born at 29 weeks gestation with a birth weight of 1100g (VLBW) is admitted to the NICU.

Nursing Management:

Maintain thermoregulation: Place in pre-warmed incubator, use plastic wrap initially
Respiratory support: CPAP via nasal prongs, monitor oxygen saturation continuously
Nutritional support: Start parenteral nutrition, initiate trophic feedings with mother’s expressed breast milk when stable
Infection prevention: Strict hand hygiene, minimal handling, monitor for signs of infection
Developmental care: Cluster care activities, provide appropriate positioning, minimize environmental stressors
Parent education: Teach kangaroo care, involve parents in care planning

Outcome: With comprehensive nursing care, the infant maintains temperature stability, gradually weans from respiratory support, achieves full enteral feedings by day 14, and is discharged at 36 weeks corrected age weighing 2200g.

Key Points Summary