Algorythm for early identification of risk newborn babies
Zisovska M. Elizabeta
Clinic for Gynecology and Obstetrics
The birth should be happy event. But, sometimes, fortunately very rarely, it is
interrupted by giving a birth to a newborn caring some risk for the forthcoming growth and
development problems. What does it mean risk factor for the newborn? By the definition, it
is a fact, realistic suspicion or presumption for some condition which in the further life
should influence the normal growth or development. The suspicion and/or the evidence for
the risk occurrence is supported by the plenty of studies for the neonatal outcome treated in
the neonatal departments, especially within the Neonatal intensive care units (NICUs),
actually they rely on evidence based medicine.
Many factors directly or indirectly are related to the morbidity and mortality rates in
the newborns (1,2). As earlier the risk is identified, as better chance for early intervention,
treatment and reduction of the consequences is. All these needs improve the conditions for
better longterm outcome of the risk children.
Only few percents of the children end up by death in the early neonatal period. The
risk factors which are confirmed to endanger the life and/or health of the newborn children
are grouped in dependence of the period of their influence (3).
1. Familiar risks (genetic risks), and most frequently that is Down Syndrome, less
frequently Edwards Syndrome, Cru du chat syndrome, Patau Syndrome, Turner
Syndrome, muscular dystrophy, haemophilia, and metabolic disorders.
2. The risks that are carried by the pregnant women either before or acquired during
the pregnancy; the most of them don’t have direct toxic action to the foetus, but
their influence is indirect, damaging the placenta which become insufficient to
supply the foetus. To this group belong severe chronic diseases of the pregnant
(cardiac, lung, renal, diabetes type 1) or gestational diabetes and pregnancy induced
hypertension which often end with intrauterine growth restriction. These children,
even when they are near term, are more prone to birth asphyxia, disturbances in
Glico regulation, electrolyte balance, higher incidence of birth defects. They carry
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higher risk for motor, sensorial problems, attention deficit syndrome, but if they
were born prematurely, they can even have hearing and eye problems (3,4). There is
evidence that these children have problems with cardiovascular system in
adulthood, according to the Barker’s theory (5).
3. Risks which occur during delivering period (intrapartal) are mainly birth in juries
because of the disproportion between foetal size and birth canal, unusual
presentation of the newborn, or vaginal delivering interventions. Birth asphyxia is
still real problem of the term newborn and one of the possible reasons of cerebral
palsy (6).
4. Postnatal risk factors are those that secondary complicate the existing risk.
In the last few decades the early identification of the risk factor was recognized as the
most important for the long-term outcome of these newborns. There are many scoring
systems developed in order to facilitate the early identification, and the most desired
characteristics of such system are high sensitivity, specificity, and at the same time with
high positive predictive value and low rate of false positive and false negative results
(7,8,9). All these scoring systems for quantitative defining of the risks use history data,
clinical and diagnostic parameters, labelled as indicators, which are recognized as very
significant in the outcome prediction, compared to the traditional assessments including
Apgar score, anthropometric parameters, maturity and the clinical condition which were
shown as insufficient in the outcome prediction. Some of the known scoring systems are:
MAIN (Morbidity Assessment Index of Newborns) with 70 determinants (10), CRIB
(Clinical Risk Index for Babies) score which contains 6 variables applicable only in
developed NICUs using sophisticated diagnostic methods(11),
SNAP II
(Score for
Neonatal Acute Physiology) which is small modification of the CRIB score, but has very
low sensitivity (12), SNAP-PE II (Score for Neonatal Acute Physiology Perinatal
Extension) derived from SNAP II adding the parameters as birth weight, fetal trophics, and
Apgar score in the fifth minute (13, 14); PREM (Prematurity Risk Evaluation Measure)
system is based on gestational age, birth weight, and base deficit, but has low sensitivity
and specificity (15).
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According to the abovementioned scoring systems, none of them is not universal
applicative in neonatology and doesn’t fulfill all requirements and expectations (16, 17,
18). That is the reason why it was recommended to countries to develop its own, specific
List of risk factors which highly correlate with the health care level, and are applicable to
all levels of care. That list should be based on the national results and information of the
long term follow up of the children discharged out of the NICU.
Exactly this need was the leading idea for development and by consensus approved
National list of neonatal risk factors for republic of Macedonia. The list contains factors
which has high correlation with the early morbidity rate, long term growth and
development and the causes of the early neonatal morbidity and mortality in the country.
The list contains the following risk factors:
 Prematurely born newborns of ≤ 32 gestational weeks (g.w.)
 Prematurely born newborns of 33-36 (g.w.)
 Newborn baby with birth weight of ≤ 1500 grams
 Small for gestational age newborn (SGA baby)
 Birth asphyxia
 Intracranial hemorrhage
 Neonatal sepsis/meningitis
 Birth defects
 Newborns treated in NICU
 Newborns of high risk pregnancies
 Neonatal abstinence syndrome
 Twin newborns
 Newborns left for adoption
 Newborns born at home
In line with the early detection, during the antenatal period it should be performed
following:
Identification of the pregnancy risk
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 Transport of the high risk pregnant woman to the facility of appropriate health care level
by transport “in utero”
 Follow up of the risk and treatment of the disease (preventable risks)
 Determining the optimal period and mode of delivery.
After the delivery, in addition of the early detection, should be performed:
 Postnatal assessment of the neonatal condition, vigorousness (Apgar score)
 Gestational age assessment by morphologic and neuromuscular parameters (eutrophy,
hypotrophy and hypertrophy)
 Measuring anthropometric parameters (birth weight, length, head and chest
circumference)
 Physical examination by systems
 Early detection of the deviation
 Preparation of the high risk newborn for discharge
o Inclusion of the parents in the care, thir education for at home
o Clear recommendations for at home
o Evaluation of the unsolved problems
o Plan for home care
o Identification of the follow up service
 Notification and referring of the risk newborns according to the approved List of risk
factors
o Existing database
o Selection according to the severity of the risk factor
o Referring to the competent facility
o Including the social worker depending of the indication
 Evaluation of the feed back results of the follow up of such risk children
All these actions could be included in an algorithm (picture number 1) which could be of
value for the professional health workers dealing with high risk newborns.
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NO
Risk before or
during pregnancy
Delivery
YES
Treatment of the
condition or
prevention of
adverse affect
Transport to the
facility of higher
level
High risk
newborn
Healthy
newborn
Birth in
appropriate
condition (level)
Baby
friendly
hospital
PARENTS
Intensive
care unit
Intensive
therapy
unit
Plan for
follow
up
Social
services
Picture number 1. Algorythm for follow up of risk newborn children
During the period of care of the high risk newborn babies, the questions of the
parents posed to the health workers go through a type of evolution, depending on the
current condition of the baby. In the beginning, the key questions are:
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 Is the baby going to survive? The answer should be looked in the Unit’s data about the
outcome of such condition.
 Should be some improvement in near future?
 Are there risks for the later growth and development?
It is very difficult to give an exact answer, and that is the reason why should the health
workers be very careful, neither give unreal hope, nor discourage in the cases where the
data about the outcome are not very precise and reliable. The parent bonding with their own
child is crucial in forming emotional tie between them. This concept is always mystic and
confusing one, mixed with the strong feelings of love, instinct and possessing. The
separation between the parents and baby affects this process.
The care of the newborn with risk factor has to be directed to the whole family, and this
concept recognizes the family as a constant in the child’s life. This type of care gives
support to the parents, gives them strength and courage to deal with the situation. And to
keep in mind anytime that the parents are not only visitors, they are central actors within
the team of professionals dealing with the care and treatment of the high risk babies.
Despite the rapid progress of the neonatal intensive care, still there are some questions
and dilemmas that remained unanswered, as the following:
 What is the importance of the quality of life?
 Which survival rate is a measure of efficient intensive neonatal care?
 Who is responsible for decision making in maintenance the life?
 When is the empirical treatment acceptable?
 When are the clinical studies with newborns ethical?
We have to expect that many years will pass until we get answers to some of above
mentioned questions. But, every step forward will be of great value.
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References:
1. Nhu Thi Nguyen Ngoc, Mario Merialdi et al. Causes of stillbirths and early neonatal
deaths: data from 7993 pregnancies in six developing countries. Bull World Health
Organ. 2006 September; 84(9): 699-705
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Medicine. 2005; vol 352:2047-2048
3. Serra B. and Scazzocchio E. Evaluation and classification of high risk, Chapter 8. In:
Recommendations and Guidelines in Perinatal Medicine. Matres Mundi, 2007
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Declercq E. Effect of late-preterm birth and maternal medical conditions on newborn
morbidity risk. Pediatrics. 2008 Feb;121(2):e223-32.
5. Barker DJ. The fetal and infant origins of adult disease. BMJ. 1990 Nov
17;301(6761):1111.
6. Zisovska
Elizabeta:
Rodilna
asfiksija.
Menora,
Skopje,
1999 godina
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Pediatrics 2009 November 124(5): 1001-006
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