high risk new born
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HIGH RISK NEW BORN
The new born baby is the gift of the nature, the result of 40 wks of life
in warm, snug and fluid filled intrauterine environment. The birth of an
infant is one of the most awe-inspiring and emotional events that can occur
in one life time after anticipation and preparation the neonate arrives and
flurry of excitement. Every family looks forward to the birth of a worthy
newborn children they are lather delicate vulnerable liodily suffer from the
diseases and disabilities.
some cases, through unexpected difficulties and challenges occur
along the way. !ome new born are considered high risk. This means that a
new born has a greater change of complications because of conditions that
occur during fetal developments pregnancy conditions of the mother or
problems that may occur during labor and birth. !ome complications are
unexpected and may occur without warning other times, there are certain
risk factors that make problems more likely.
"ortunately, advances in technology have helped improve the care of
skin newborns under the care of speciali#ed physicians and other health care
provides, babies have much greater chances for surviving and getting better
today than ever before.
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DEFINITION:
$%igh risk newborn is a newborn regardless of gestational age or birth
weight, who has a greater than average change of morbidity or mortality
because of conditions or circumstances superimposed on the normal cause of
events associated with birth and the ad&ustment to extra uterine existence.
Encompassed the human growth and development from the time of viability
'( days following birth and includes threat of life and hearth that occur
during the prenatal perinatal and portratal periods).
$high-risk infant, any neonate, regardless of birth weight, si#e, or
gestational age, who has a greater than average chance of morbidity and
mortality, especially within first '( days of life. *isk factors include pre
conceptual, prenatal, natal, or postnatal conditions +or circumstances that
interface with the normal birth process or impede &udgment to extraciterene
growth and development).
$edical ictionary)
/n infant at increased risk of suffering co-morbidity and potentially
fatal complications due to fetal, matcher, or placentas anomalies or an
otherwise compromised pregnancy.
$eonatology)
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HIGH RISK NEW BORN
The new born baby is the gift of the nature, the result of 40 weeks of
life in warm, snug and theid filled intrauterine environment. The birth of an
infant is one of the most awe inspiring and emotional events that can occur
in one1s life time after anticipation and preparation the neonate arrives axid
flues of excitement. Every family looks forward to the birth of a healthy new
born children, they are lather delicate vulnerable moodily suffer from the
disease and disabilities.
n some cases, through, unexpected difficulties and challenges occur
along the way. !ome newborns are considered high risk. This means that a
newborn has a greater chance of complications because of conditions that
occur during fetal development, pregnancy conditions of the mother or
problems that may occur during labor and birth. !ome complications are
unexpected and may occur without warning. 2ther times, there are certain
risk factors that make problems more likely.
"ortunately, advances in technologies have helped improve the care
of sick newborns under the care of speciali#ed physicians and other health
care providers, babies have much greater chances for surviving and getting
better today than ever before.
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The high risk neonate can be defined as a newborns regardless of
gestational age +or birth weight, who has a greater than average chance of
morbidity +or ortality because of threats to life and health that occur
during prenatal and postnatal period.
t can also be defined as a neonate exposed to any condition that
makes his life in danger.
FACTORS PREDISPOSING TO HIGH RISK NEONATE:-
MATERNAL FACTORS:-
- %igh risk pregnancies as in lack of antenatal care
- 3oor socioeconomic conditions.
- 3revious history of obstetric complications as abortions, toxemias,
placental insufficiency, still birth etc.
- edical illness of mother as diabetes mellitus, heart and kidney
disease and severe induction.
- omplications of labor and delivery as prolonged rupture of
membranes, cesarean section and still birth.
NEONATAL FACTORS:-
- eonatalasphyxia
- eonatal infections
- ongenital anomalies
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- 3rematurity
- 3ost maturity
- 5ow /pgar score
- %ypoglycemia
- 2thers.
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lassification of new born6-
lassification of new born at birth by both gestational age and weight
provides a more satisfactory method for predicting mortality risk and
providing guidelines for management of neonates.
Gestational age
3reterm
Term
3ostterm
Ao!"ing To Si#e
5ow 7irth 8eight
nfant
9ery 578 nfant
Externally 578 nfant
oderately 578
/ppropriate "or :age
nfant
!mall "or ate
;:*
5arge "or :./ge infant
Gestational age o$ %i!t&
'eig&t
!mall for gestational
age
/ppropriate for
gestational age
5arge for gestational
age.
3reterm6- The neonate is born before term i.e. is less than
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3ost term6- The neonate is born after 4' weeks of gestation.
!mall for gestational age +!:/6-
8hen plotted on in intrauterine growth chart, they lie below =0 th
percentile.
/ppropriate for gestational age +/:/6-
8hen plotted on intrauterine growth chart, they lie between =0 thand
>0thpercentile.
5arge for gestational age +5:/6- 8hen plotted on intrauterine growth
chart, they lie above >0thpercentile.
5ow birth weight +578 nfant6-
/n infant whose birth weight is less than '?00gm regardless of
gestational age.
9ery low birth weight +95786-
/n infant whose birth isles than =?00 gm
9ery very low birth weight +99578 extern low birth weight +E5786-
/n infant whose birth weight is less than =00 gm
oderately low birth weight6- +578
/n infant whose birth weight is =?00- '?00 kg.
/ppropriate for gestational age +/:/ infant6-
/n infant whose weight falls between the =0->0thpercentile.
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!mall for date +!" or small for gestational age.
+!:/ nfant6-
/n infant whose intrauterine growth was slowed and whose birth
weight falls below the =0thpercentile on intra uterine growth curves.
ntrauterine growth retardation +;:*6-
"ound in infants whose intrauterine growth is lactated +sometimes
used as a more descriptive term fro the !:/ infant.
5arge for gestational /ge +5:/ nfant6-
/n infant whose birth weight falls above the >0th percentile on
intrauterine growth charts.
3*ETE* 7/7E!
n human preterm birth refers to birth of a baby of less than
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causes of neonatal death have been markedly deduced, per maturity is the
leading cause of neonatal mortality at '?A.
/bout =0-=' percent of ndian babies are born preterm +less than
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- ultiple pregnancy and congenital malformations
- 9ery young and unmarried mothers
- 3art history preterm births
- "ibroids
nduced6-
- mpending danger to mater or fetal life in utero
- aternal diabetes mellitus
- 3lacental dysfunction
- Eclanpsia
- "etal hypoxia
- /nte partum hemorrgae
- !evere rhesus iso- immuni#ation
linical features6-
- !i#e is small with relatively large head
- rown heel length is less than 4@ cm
- %ead circumference is less than
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- /bsence of buccal pad.
- ifficult visuali#ation
- 3oor recoiling of ear cartilage
- 8ooly and fu##y hair
!kin and subcutaneous tissues6-
- Thin gelatinous, shiny and excessively pink with abundant laurgo and
very little vernix caseosa. Edema, deficient subcutaneous fat, breast
nodule is small or absent, /bsence of sole causes.
:enitals6-
- ;ndesernded testes and poorly developed stratum
- 5abia ma&ors are widely separated exposing labia minor and
hypertrophied clitoris.
entral nervous system6-
- 5ethargic poor cough reflex and in coordinated sucking and
swallowing in babies weighting less than =(00 gm +or born before
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- *espiration diaphragmatic, periodic and anociated with intercostals
reunions due to soft ribs
- 3ulmonary aspiration and arterials is
ardiovascular system6-
The closure of ductus arterious is delayed among preterm infants.
They are at risk to develop theomboernolic complications and hypertension
due to indwelling venous and arterial catheters.
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Gast!ointestinal S(ste)
ue to poor or incoordinated sucking and swallowing there are
difficulties in self-feeding, although their digestive ability is generally good.
/nimal fat is not tolerated as well as the vegetable fat. *egurgitation and
aspiration are common because of incoordinated sucking, small capacity of
stomach, incompetence of cardioesophageal &unction and poor cough reflex.
:astro-esophagal reflux and is conseCuences are common. /bdominal
distension and functional intestinal obstruction are due to hypotonia.
Enterocolitis occurs when other predisposing factors are present. mmaturity
of glucuronyl transferase system in the liver leads to hyperbilirubinemia,
which may be aggravated by dehydration, delayed feeding and
hypoglycemia. *elatively low serum albumin, acidosis and hypoxia in these
babies predispose to the development of kernicterus at lower serum bilirubin
levels. The poor hepatic glycogen stores, delayed feeding, birth asphyxia and
respiratory distress syndrome contribute to the development of
hypoglycemia.
T&e!)o-!eg*lation
%ypothermia is invariable and life threatening unless environmental
temperature is monitored. Excessive heat loss is due to relatively large
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surface area and poor generation of heat due to paucity of brown fat in a
baby who is eCuipped with an inefficient thermostat.
In$etions
nfections are an important cause of neonatal mortalit y in low birth
weight babies. The low levels of 5g: antibodies and inefficient cellular
immunity predispose them to nfections. Excessive handling, humid and
warm atmosphere, contaminated incubators and resuscitators expose them to
infecting organisms, thus contributing to high incidence of infections.
Renal i))at*!it(
The blood urea nitrogen is high due to low glomerular filtration rate.
The renal tubular ammonia mechanism is poorly developed thus acidosis
occurs early. They are vulnerable to develop late metabolic acidosis
especially when fed with a high protein milk formula. The maximum tubular
diluting ability in the newborn is satisfactory but ability to concentrate urine
is very poor. 3reterm baby has to pass 4 to ? ml of urine to excrete one
milliosmole of solute as compared to 0.@ ml by an adult for the same
purpose. Therefore, the baby cannot conserve water and gets dehydrated
readily. The solute retention and low serum proteins explain occurrence of
edema in some preterm infants.
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To+iit( o$ "!*gs
3oor hepatic detoxification and reduced renal clearance make a preterm
baby vulnerable to toxic effects of drugs unless caution is exercised during
their administration.
N*t!itional &an"ia,s
5ow birth weight babies are prone to develop anemia around D to (
weeks of age. This is due to diminished total stores of iron due to short
gestation. They may also manifest deficiencies of folic acid and vitamin E.
9itamin E deficiency occurs among infants weighing less than =,?00 g,
particularly those fed on iron fortified milk formula. These infants are prone
to develop hemolytic anemia, thrombocytopenia, and edema at D to =0
weeks of age. 9itamin E being an anti-oxidant, its deficiency state may be
associated with oxygen toxicity to the vulnerable tissues in the form of
retrolental fibroplasia and bronchopulmonary dysplasia. *apid growth
following adeCuate feeding may result in osteopenia and rickets unless
calcium, phosphorus and vitamin are administered.
Bio&e)ial "ist*!%anes
These babies are prone to develop hypoglycemia, hypocalcemia,
hypoproteinemia, acidosis and hypoxia.
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Manage)ent
%igh-risk mother should be identified early during the course of
pregnancy and referred for confinement to an appropriate health care facility
which is eCuipped with good Cuality obstetrical and neonatal care facilities.
other is indeed an ideal transport incubator
A!!est o$ ,!e)at*!e la%o!
/dvances in perinatal care including fabrication of a variety of
electronic gadgets cannot compare with uniCue security and optimal care
provided to the fetus by the uteroplacental unit. Efforts should always be
made to arrest the progress of premature labor. The onset of FtrueF labor is
suspected by occurrence of two or more uterine contractions lasting at least
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magnesium sulfate is associated with reduced risk of 9%, cerebral palsy
and mental retardation in their preterm babies.
!ympathomimetic agents specifically mediating via beta '-adrenergic
receptors are powerful tocolytic agents and currently used. soxsuprine
+duvadila is useful but its effect is mediated both through beta-= and beta-'
receptors. ts use is associated untoward beta-= receptor side effects such as
apprehension, palpitation, hypotension, fetal tachycardia and neonatal
hypoglycemia. Therapy is initiated by intravenous infusion of '0 mg
isoxsuprine diluted in '00 ml of ? percent dextrose at a rate of 40-?0
dropsGminute. This is followed by intramuscular administration of =0 mg
isoxsuprine every 4 hours for '4 and 4( hours. 2ral therapy is continued
for at least ' weeks with maintenance doses of =0 mg every D hours.
*itodrine has been approved by ;! "ood and rug /dministration for
treatment of premature labor and is more effective than ethanol. The
common side effects are maternal and fetal tachycardia. The usual dose is
=00-400 ugGminute intravenously through an infusion pump for a period of
12 hours followed by oral ritodrine =0 mg every ' hours. !albutamol and
terbutaline are selective beta '-receptor stimulators and are very effective
tocolytic agents. They are generally safe but an occasional patient may
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develop tachycardia and pulmonary edema Terbutaline is administered as
an intravenous bolt
of 0.'? mg followed by constant infusion of =0-(0 ugGminute for =-' hours.
/fter control of uterine contractions, maintenance therapy is continued
administration of 0.'? mg of terbutaline subcutaneously +or '.? mg orally
every 4 hours. ndomethacin, an inhibitor of prostaglandin B synthetase has
also offered some hope in arresting premature uterine contractions. t must
be used with caution because it may also block production of prostaglandin
E thus markedly decreasing uteroplacental perfusion and may cause closure
of ductus arteriosus.
In"*tion o$ ,!e)at*!e la%o!
8hen induction of labor is contemplated before term, either in the
interest of mother or the fetus, maturity of fetus should be ascertained by
examination of amniotic fluid for phosphatidyl glycerol or 5G! ratio. /s far
as possible, delivery should be postponed till fetal pulmonary maturity is
assured. 8hen delivery can be safely delayed for
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/ntenatal administration of corticosteroids is one of the most cost-
effective perinatal strategies which must be universally exploited. t is
associated with ?0 percent reduction in the incidence of *! due to
surfactant deficiency. t provides additional benefits by reducing the
incidence of intraventricular hemorrhage and necroti#ing enterocolitis. The
over all neonatal mortality is reduced by 40 percent by this simple and cheap
intervention. n&ection betamethasone =' mg every '4 hours for ' doses
or dexamethasone D mg every =' hours for 4 doses should be
administered to the mother if labor starts or is induced before
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O,ti)al )anage)ent at %i!t&
8hen a preterm baby is anticipated, the delivery should be attended by
a senior pediatrician, fully prepared to resuscitate the baby. The delayed
clamping of cord helps in improving the iron stores of the baby. t may also
reduce the incidence and severity of hyaline membrane disease. Elective
intubation of extremely 578 babies +H =000g is practised in some centers
to support breathing and for prophylactic administration of exogenous
surfactant. The baby should be promptly dried, kept effectively covered and
warm. 9itamin I 0.? mg should be given intramuscularly. The baby should
be transferred. by the doctor or nurse +not a nursing orderly to the ;
as soon as breathing is established.
Monito!ing
The following clinical parameters should be monitored by specially
trained nurses. The freCuency of monitoring depends upon the gestational
maturity and clinical status of the baby.
9ital signs with the help of multi-channel vital sign monitor +non-
invasive with alarms.
/ctivity and behaviour.
olor6 3ink, pale, grey, blue, yellow.
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Tissue perfusion /deCuate tissue perfusion is suggested by pink color,
capillary refill over upper chest of H' sec, warm and pink extremities,
normal blood pressure, urine output of J =.? mlGkgGhr, absence of
metabolic acidosis and lack of any disparity between pa2', and !a2',.
"luids, electrolytes and /7:Fs.
Tolerance of feeds6 9omiting, gastric residuals, abdominal girth.
5ook for development of *!, apneic attacks, sepsis, 3/, E,
9% etc.
8eight gain velocity.
uring daily clinical evaluation of a preterm baby, the following
clinical characteristics should be looked for because they suggest that the
baby is healthy. The vital signs should be stable. The healthy baby is alert
and active, looks pink and healthy +smells good too , trunk is warm to
touch and extremities are reasonably warm and pink. The baby is able to
tolerate enteral feeds and there is no respiratory distress or apneic attacks
and baby is having a steady weight gain of =.0 - =.? percent +=0-=? gGkgGd
of his body weight every day.
P!o.i"e in-*te!o )ilie*
;terus provides ideal ambient conditions to the baby. /ll attempts should
be made to create uterus-like baby-friendly ecology in the nursery.
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reate a soft, comfortable, KnestledK and cushioned bed.
/void excessive light, excessive sound, rough handling and painful
procedures. ;se effective analgesia and sedation for procedures.
3rovide warmth.
Ensure asepsis.
3revent evaporative skin losses by effectively covering the baby,
application of oil or liCuid paraffin to the skin and increasing humidity
to near =00 percent.
3rovide effective and safe oxygenation.
;terus is able to provide uniCue parenteral nutrition. Efforts should be
made to provide at least partial parentral nutrition and give trophic
feeds with expressed breast milk +E7.
3rovide rhythmic gentle tactile and kinesthetic stimulation like skin-
to-skin contact, interaction, music, caressing and cuddling.
Position o$ t&e %a%(
ost babies love to lie in a prone position, they cry less and feel more
comfortable. t relieves abdominal discomfort by passage of flatus and
reduces risk of aspiration. 3rone posture improves ventilation, increases
dynamic lung compliance and enhances arterial oxygenation. ;nsuperivised
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prone positioning, beyond neonatal period, has been recogni#ed as a risk
factor for !!.
T&e!)al o)$o!t
/ pre-warmed open care system or incubator should be available at all
times to receive any baby with hypothermia or with a birth weight of less
than '000 g. The baby should be nursed in a thermoneutral environment
with a servo sensor geared to maintain skin temperature of mid-epigastric
region at
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electromagnetic vibrations of love and compassion to her baby. "or further
details regarding prevention of hypothermia refer to hapter 15.
Oxygen t&e!a,(
2xygen should be administered only when indicated, given in the lowest
ambient concentration and stopped as soon as its use is considered
unnecessary. t is difficult to &udge the need for oxygen therapy on clinical
grounds in preterm babies. The oxygen should be administered with a head
box when !a2', falls below (? percent and it should be gradually withdrawn
when !a2', goes above >0 percent. The lowest ambient concentration and
flow rates should be used to maintain !a0'between >0A->? A and pa2'
between D0-(0 mm %g.
P&aotot&e!a,(
Laundice is common in preterm babies due to hepatic immaturity,
hypoxia, hypoglycemia, infections and hypothermia. ue to immaturity of
blood brain barrier, hypoproteinemia and perinatal distess factors, bilirubin
brain damage may occur at relatively lower serum bilirubin levels. Early
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phototherapy is advised to keep the serum bilirubin level within safe limits
inorder to obviate the need for exchange blood transfusion.
P!e.ention o$ nosoo)ial in$etions
/ preterm baby, who survives the initial stormy and unstable period of
one week, is likely to do well it protected against infections and provided
with nutrition. The handling should be reduced to bare minimum. 9igilance
should be maintained on all procedures recommended for reduction of
infections in the nursery. %igh index of suspicion, early diagnosis and
effective treatment of infections are essential for improved survival. "or
further details regarding prevention of nosocomial infections refer to
hapter 4.
Fee"ing an" n*t!ition
!tarvation should be avoided and early enteral feeding should be
established as soon as the baby is stable. 7abies weighing less than ='00 g
or gestation of H
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condition is stabili#ed, enteral feeds are begun with E7 starting with a
volume of
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0.@( mgGg in human colostrurn, transitional and mature milk respectively.
9itamin E is a powerful amiloxldam and prevents the hemolvtic anemia and
edema of prematurity. n infants weighing less than =?00g at birth, milk
formula should provide at least =.0 i.u. of vitamin E per gram of linoleic acid
and supplemented with daily administration of =? i.u. of vitamin E.
!upplements of calcium +''0 mgGd and phosphorus +=00 mgGd are essential
to prevent osteopenia of prematurity. The supplements are continued till the
baby has achieved post conceptional maturity of
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the stress of procedure and enhance weight gain velocity of preterm babies.
9isual inputs can be provided with the help of colored ob&ects, diffuse light
and eye-to-eye contact.
/tilit( o$ o!tioste!oi"s
;nnecessary administration of corticosteroids should be avoided due to
its potential side effects. /ntenatal administration of betamethasone or
dexamethasone is universally recommended if labor starts before
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for shortterm +%ypertension, hyperglycemia, : bleeding. infections and
long term +cerebral palsy and neuromotor disability side effects.
P!e.ention0 Ea!l( Diagnosis an" P!o),t Manage)ent o$ Co))on
P!o%le)s
*efer to appropriate hapters regarding details for the management of
specific disorders which are common in preterm babies.
Nosoo)ial in$etions. %ouse keeping rituals, strict house keeping
routines and high index of suspicion should be maintained to prevent and
make early diagnosis of nosocomial infections.
H(,ot&e!)iaurse in a thermoneutral environment.
Res,i!ato!( "ist!ess s(n"!o)e /ntenatal administration of
corticosteroids, prevention and effective treatment of perinatal distress,
prophylactic administration of exogenous surfactant to reduce the incidence
of hyaline membrane disease (HMD).
As,i!ation/vailability of trained nurses is essential for safe administration
of enteral feeds and for prevention of aspiration of feeds.
Patent "*t*s a!te!ios*s/void over infusion.
C&!oni L*ng "isease uring assisted ventilation, airway pressure
should be kept at the bare minimum without compromising gas exchange. n
infants H =000 g, administration of vitamin / ?000 units = < times in a
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week for 4 weeks has been shown to reduce the risk of 5 by =0 percent.
orticosteroids should preferably be avoided or only short courses should be
used due, to potentialrisk of causing neuromotor disability.
Ne!oti#ing ente!oolitis Ensure feeding with human milk, trophic
feeds, avoidance of hyperosmolar feeds and over infusion.
int!a.ent!i*la! &e)o!!&age /ntenatal corticosteroids, avoidance of
rough handling. excessive 3/3 and bolus administration of sodium
bicarbonate may reduce the incidence of 9%.
Retino,at&( o$ ,!e)at*!it(aintain pa2'below >0 mm %g, avoid
excessive light, blood transfusions and ensure feeding with human milk.
Late)eta%oli ai"osis3rotein intake should he restricted to < gGkgGd
and avoid administration of formula feeds.
N*t!itional "iso!"e!s3rovide supplements with calcium, phosphorus,
vitamin , vitamin E, iron and folic acid.
D!*g to+iit( !ide effects of drugs can be reduced by giving lower
doses at =' hourly intervals.
Weig&t !eo!"
/ccurate weighing of babies is a sensitive index of their well being. The
weight is routinely recorded every day but in sick babies twice daily weight
record is recommended. ost preterm babies lose weight during the first
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to 4 days of life and loss is upto a maximum of =0 to =? percent of the birth
weight. The weight remains stationary for the next 4 to ? days and then the
babies start gaining at a rate of =.0 to =.? per cent of body weight +=0-=?
gGkgGd per day. They regain their birth weight by the end of second week of
life. Excessive weight loss, delay in regaining the birth weight or slow
weight gain suggest that either the baby is not being fed adeCuately or he is
unwell and needs immediate attention. !udden weight loss in a baby who
had been gaining weight satisfactorily would suggest the possibility of
dehydration. Excessive weight gain of =00 g or more per day may occur in
babies with cardiac failure though sometimes healthy babies may also gain
weight more rapidly.
W&at to a.oi" in t&e a!e o$ ,!ete!) %a%ies1
n the care of preterm babies, at times greater harm is done by
unnecessary therapeutic interventions which may lead to iatrogenic
disorders. The following interventions should be avoided because they are
unnecessary, useless and often associated with serious side effects.
*outine oxygen administration without monitoring.
ntravenous immunoglobulins for prophylaxis of neonatal sepsis.
3rophylactic antibiotics +except during assisted ventilationN
3rophylactic administration of indomethacin or high doses of vitamin E
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;nnecessary blood transfusions +efinite indications include hematocrit
of H 40A in a sick neonate. H
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Fa)il( S*,,o!t
The prolonged stay of preterm and sick newborn babies in the ; is
associated with emotinal trauma, uncertainty, anxiety and lack of bonding
with the baby on the part of parents. The family dynamics are -greatly
disturbed apart from tremendous physical stress and fiscal implications due
to high cost of neonatal intensive care. These issues and problems should be
handled with eCuanimity, compassion, concern and caring attitude of the
health team. The frightening scene of ; should be demystified and
family should be constantly informed and involved in the care of their baby.
The mother should be encouraged to touch and talk with her baby and
provide routine care under the guidance of nurses. !he should be assisted to
provide partial kangaroomother-care to her baby in the ; which would
enhance. bonding and promote breast feeding. !he should provide visual and
auditory stimuli to her baby and try to establish eye-to-eye contact. The
anxiety and concern of the family should be cushioned by providing
necessary emotional support and guidance.
T!ans$e! $!o) in*%ato! to ot
/ baby who is feeding from the bottle or cup and spoon and is
reasonably active with a stable body temperature, irrespective of his weight,
Cualifies for transfer to the open cot. The baby should be observed for
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another =' hours after putting the incubator off to see whether he can
maintain his body temperature. The infant should stay in the incubator for as
short a period as possible because incubators are a potent source of
nosocomial infection.
Dis&a!ge Poli(
The mother should be mentally prepared and provided with essential
training and skills for handling a preterm baby before she is discharged from
the hospital. The mother-baby dyad should be kept in a step-down nursery
where she is able to independently look after the essential needs of her baby
like maintenance of body temperature, ensuring aspsis, feeding with a cup
and spoonGpaladey or breast feeding, toilet needs etc. The baby should be
stable, maintaining his body temperature and should not have any evidences
of cold stress. /t the time of discharge, the baby should be having daily
steady weight gain velocity of at least l0gGkg. The home conditions should
be satisfactory before the baby is discharged. The public health nurse should
assess the home conditions and visit the family at home every week for a
month or so.
Follo'-*, P!otool
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/fter discharge from the hospital, babies should be regularly followed
up for assessment of the following parameters. The speciali#ed perinatal
follow-up services demand a close collaboration and interaction with a large
number of specialists like pediatrician, developmental physician, dietetian,
ophthalmologist, audiologist, child psychologist, physio-occupational
therapist and social worker. The following parameters should be closely
monitored and followed6
ommon infective illnesses, reactive airway disease, hypertension,
renal dysfunction, gastro esophageal reflux.
"eeding and nutrition.
mmuni#ations.
3hysical growth, nutritional status, anemia, osteopenia Grickets.
euromotor development, congnition and sei#ures.
Eyes6 *etinopathy of prematurity, vision and strabismus.
%earing.
7ehaviour problems, language disorders and learning disabilities.
Ho)e Ca!e o$ P!ete!) Ba%ies
n view of rather marked disparity between the available facilities for
special care of low birth weight babies versus number of such babies
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reCuiring care in developing countries, it is essential that general principles
of home care are highlighted. ost healthy infants with a birth weight of
=,(00 g or more and gestational maturity of
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En.i!on)ental ont!ol
t must be remembered that the desirable environmental temperature to
safeguard the biological, needs of the low birth weight infant, is rather
uncomfortable for an adult. The infant should be effectively covered taking
care to avoid smothering. 8oolen cap, socks and mittens should be worn.
The infant should preferably lie next to the mother which serves as a useful
biologically controlled heat source. n winter, the room can be warmed with
a radiant heater or angeethi. / table lamp having a =00 watt bulb can be
used to provide direct radiant heat. %oc water bottle, if ever used, should
never come in direct contact with the baby. The cot of the mother and, infant
should be located away from the walls to reduce radiation heat loss. The
mother and health workers- should be trained to assess the temperature of a
newborn baby by touch and advised to ensure that the extremities are kept
warm and pink. 5ow birth weight babies do relatively much better in
summer than in winter.
The visitors and handling of the infant should be restricted to the bare
minimum. The hands must be washed before touching or feeding the baby.
The emotional urge for kissing the baby should be curbed. The linen should
be clean and sun-dried.
Fee"ing
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8henever feasible, breast feeding is ideal a6 must be encouraged. 8hen
infant is unable to such from the breast, expressed breast milk should be
given with a bottle or dropper or spoon or palady depending upon his
maturity. n case formula feeding is unavoidable, undiluted cowFs milk or
full strength evaporated milk is recommended. f buffaloFs milk is
unavoidable it should be given after
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infant has a bright future and he may grow up to become an intellectual
giant.
3rognosis for survival is directly related to the birth weight of the
child and Cuality of the neonatal care. 2ver three-fourth of neonatal deaths
occur among low birth weight babies. Therefore, in countries with high
incidence of 578 babies, neonatal mortality is likely to be higher. The risk
of neuro developmental handicaps is increased
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neurological handicaps is related to the Cuality of obstetrical and neonatal
services. eurological prognosis is adversely affected by degree of
immaturity, intrauterine growth retardation, severity of perinatal hypoxia,
intraventricular hemorrhage, periventricular leukomalacia and severity of
respiratory failure demanding assisted ventilation.
SMALL-FOR-DATES BABIES 2LIGHT-FOR-DATES0 SMALL-FOR-
GESTATIONAL AGE0 INTRA/TERINE GROWTH
RETARDATION3
There is lack of consensus regarding the definition of small-for-dates
babies. !ome pediatricians classify a baby as small-for-dates if its weight
falls below =0th percentile for the period of gestation, while others accept
the dividing line of - ' ! or
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and O or P chromosome from the father and shares the genetic material of
both the parents. t is endowed with a tremendous growth potential. "rom a
weight of about 0.00? mg at conception, #ygote grows rapidly to achieve an
average weight of
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life compared to somatic growth. The birth weight of a baby is about ?
percent of an adult but his brain weight is @0 per cent of the adult. 7oys
grow faster than girls though differences are marginal and combined
intrauterine growth curves of infants of both sexes are satisfactory for
clinical purposes.
uring early fetal or embryonic life, virtually all growth is due to
increase in cell number. 5ater in gestation, there is both increase in cell
number and si#e including increase in intercellular material. !ubseCuently
and during postnatal period, growth occurs virtually by increase in cell si#e.
The impact and outcome of a growth-impairing insult depends upon its
timing in relation to specific phase of growth. nterference with the growth
of fetus during the embryonic period is associated with permanent
retardation of growth potentiality of the fetus because of less Cuota of body
cells. 8hen an insult operates during the period of growth characteri#ed by
increase in cell si#e alone, the affected fetus would have normal number of
small-si#ed cells. These infants with malnourished or small si#ed cells can
be rehabilitated effectively by providing optimal nutrition after birth. They
grow fast and catch up with their growth deficit in due course of time.
%owever, if an intrauterine constraint operates over a longer period of time
when increase in both cell number and si#e is taking place, the organism
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would have relatively less number of small-si#ed cells. 2n nutritional
rehabilitation, these infants do grow but they are unable to catch up their
peers who did not encounter any intrauterine growth constraints.
ntrauterine malnutrition which operates mostly during second half of
pregnancy produces profound affect on somatic and organ,growth. 7ody
weight is significantly reduced because of lack of subcutaneous fat and
muscle mass. !keletal growth is less affected but there may be delay in the
appearances of epiphyseal centers at the distal ends of femur and proximal
end of tibia. 7rain, heart and lungs are least affected by intrauterine
malnutrition. 7rain growth may not be spared if malnutrition is severe and
prolonged. 2ther viscera such as liver, spleen, thymus and adrenals are
severely reduced in si#e during state of under nutrition.
Classi$iation o$ S)all-$o!-Dates Ba%ies
The babies with intrauterine growth failure do not constitute a
homogeneous group and an composed of at least three types of babies.
Malno*!is&e" s)all-$o!-"ates %a%ies 2as())et!i I/GR3
The fetus gets malnourished during the latter part of gestation due to
placental dysfunction and appears long, thin and marasmicc. %ead
circumference and brain weight are unaffected or show minimal reduction
while internal organs, such as liver is grossly shrunken, so that brain Gliver
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weight ratio is more than five. %ead circumference is generally more than ( among well nourished women. t is estimated that population
attributable risk for ;:* may be as high as 40 percent or more in women
of developing countries who gain less than @ kg of weight during pregnancy.
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Ene!g( an" ,!otein inta4e
The effects of low caloric intake or food deprivation during pregnancy
are less profound because of relatively slow growth of human fetus as
compared to certain experimental animals like rats. "or example, at term,
weight of the litter in mice approximates
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populations with lower nutritional status and higher incidence of 578
babies.
Ene!g( e+,en"it*!e an" ,&(sial ati.it( !trenuons physical activity
during third trimester of pregnancy may adversely affect fetal growth
because energy is consumed by the mother for physical labor and denied for
fetal growth. 3hysical activity entails energy expenditure, may reduce
uterine blood flow when physical work is conducted in an upright posture
and may cause psychological stress. The need for continued physical labor
through out pregnancy is more urgent in economically deprived,
nutritionally compromised and illiterate women who work as labor force in
the fields and for civil construction work.
T&e !ole o$ )i!on*t!ients There is enough evidence to suggest that
nutritional anemia during pregnancy is associated with compromised fetal
growth. !upplements of iron +D0 mgGd of elemental iron and folic acid
+?00ugGd during second half of pregnancy is associated with mean
improvement in birth weight by
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copper is suspected to cause hypercholesterolemia and immuno-deficiency.
oncomitant administration of magnesium helps in better absorption of
calcium. There is controversial evidence to suggest that supplements of
calcium, riboflavin and vitamin during pregnancy may reduce the risk of
pregnancy-induced hypertension.
Plaental "(s$*ntion an" "iso!"e!s 3regnancy-induced hypertension,
toxemia of pregnancy and post-maturity are important causes or fetal growth
retardation. Toxemia of pregnancy is more common among primigravida
mothers belonging to low socio-economic status. ultiple pregnancy 4s
associated with fetal growth retardation because two fetuses can be
nourished satisfactorily upto
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Mate!nal in$etions alaria, tuberculosis, urinary tract infection and
recurrent diarrheaGdysentery during pregnancy are recongni#ed correlates of
fetal growth retardation. n endemic areas, prophylaxis against malaria
during pregnancy has been shown to improve birth weight on an average by
=@0 g. The infections during pregnancy should be promptly identified and
adeCuately treated with appropriate antibiotics.
oloni#ation of maternal genital tract by hlamydia trachomatis,
ycoplasma hominis, ;reaplasma urealyticus and bacterial vaginosis have
been found to be associated with birth of relatively smaller babies both by
virtue of prematurity and ;:* though the impact is not of great clinical
relevance.
Mate!nal s*%stane a%*se rug abuse during pregnancy is associated
with several adverse effects on the fetus including developmental defects
and compromised fetal growth. The incidence of 578 babies doubles if the
pregnant woman smokes more than '0 cigarettes per day. Tobacco chewing
which is common among rural and tribal women in several states in ndia, is
also associated with ;:*. There is evidence to suggest that if a pregnant
woman chews 400 mg of tobacco every day, the birth weight of her baby is
reduced by upto ?4' g compared to control women. f a mother consumes
two alcoholic drinks every day during pregnancy, the birth weight of the
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baby is reduced on an average by =?? g. Effect of mari&uhana and 5!
addiction of the pregnant woman on the birth weight of her baby is not
conclusive and is controversial. n many women who are addicted to various
drugs, the socio-economic status of the mother, family background, neglect
of nutrition, conception out of wedlock, occurrence of sexually-transmitted
diseases etc. may have the adverse effects on the birth weight rather than the
addictive drugs per se.
En.i!on)ent ,oll*tants nsectisides and pollutants may adversely
affect the birth weight of the babies. t has been shown that women living in
5ove anal, ew Pork, a waste dump site, had high incidence of 578
babies. n Lapan, women living near the airport gave birth to babies with a
lower birth weight due to increased noise pollution caused by the aircraft.
7ut a utch study did not support the association between noise pollution
and fetal growth retardation.
Fetal Con"itions
!ex The female infants are lighter at birth compared to male babies. 7ut,
the differences are not significant and combined +computing birth weight
data of boys and girls together intrauterine growth charts are used in clinical
practice.
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C&!o)oso)al an" geneti "iso!"e!s Trisomy syndromes, Turner
syndrome and various types of short limbed dwarfism are associated with
hypoplastic babies. !ome babies are classified as primordial dwarfs due to
genetic or constitutional factors.
Int!a*te!ine in$etions *ubella, cytomegalic inclusion disease and
toxoplasmosis are classical examples in this group. These infants are
hypoplastic at birth and suffer from physical growth retardation and
neuromoter seCuelae during childhood.
T&e!a,e*ti Inte!.entions $o! Int!a*te!ine G!o't& Rest!ition
Ea!l(-onset Fetal G!o't& Rest!ition
8hen life-theratening congenital malformations are identified during
first trimester, medical termination of pregnancy is recommended.
dentification of T2*% infections during early pregnancy does not have
any therapeutic implications. %owever, when maternal toxoplasmosis is
diagnosed, treatment of the mother with spiramycin, sulfadia#ine and
pyrimethamine have been shown to reduce the risk of congenital
toxoplasmosis.
Late-onset Fetal G!o't& Rest!ition
8hen fetal growth restriction is identified after '( weeks of gestation,
abnormalities in the uteroplacental unit and placental dysfunction are
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common incriminating factors. There is no consensus in the literature
regarding the most effective management strategy. The following
interventions have been tried mostly in experimental animals with variable
results.
Be" !est
7ed rest is usually recommended to conserve energy and improve
circulation of blood in the uteroplacental unit. o consistent benefits of bed
rest have been demonstrated and results of various studies are variable.
oreover, there is increased risk of deep vein thrombosis and pulmonary
embolism during bed rest.
Mate!ial ,a!ente!al n*t!ition
There are sporadic reports that intravenous hyperalimentation with =0
percent glucose and =' percent amino acids to women with fetal growth
restriction may improve the birth weight. t has not received universal
acceptance due to lack of convincing evidence for its benefits.
N*t!itional s*,,le)ents to t&e $et*s
t has been estimated that ingestion of amniotic fluid provides the fetus
with =0-=< caloriesGday and 0.'-0.
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in rabbits. There are no controlled clinical trials of T/"" in human
pregnancy. irect intragastric and intravenous administration of nutritional
supplements have been shown to improve fetal growth in experimental
sheep model. The relevance of these experimental studies to clinical practice
remains to be determined.
O+(gen t&e!a,(
hronic hypoxia due to placental insufficiency, maternal cyanotic heart
disease and living at high altitudes is associated with compromised fetal
growth. t has been found that umbilical venous oxygen tension is
significantly lower in growth-retarded fetuses. Therapeutic utility of
continuously administered oxygen to the mother +??A oxygen at a rate of
(5G min around-the-clock has been evaluated. There was no significant
improvement in birth weight but perinatal mortality rate was significantly
lower in babies born to mothers who received oxygen supplementation.
Anti%ioti t&e!a,(
t has been incriminated that genital coloni#ation with mycoplasma and
chlamydia may be associated with both prematurity and intrauterine growth
retardation. 3rophylactic therapy with erythromycin during third trimester of
pregnancy is associated with variable results and is not recommended in
clinical practice.
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P&a!)aologi t&e!a,(
t has been shown that low-dose aspirin +=-' mgG kgGday single dose
inactivates platelet cycloxygenase en#yme and results in decreased synthesis
of thronmboxane +Tx /' while it has no effect on prostacyclin +3:, which
is a vasodilator. The results of various therapeutic trials for prevention and
treatment of intrauterine fetal growth restriction are conflicting. 5ow-dose
aspirin has been shown to cause a modest reduction in the incidence of pre-
eclampsia but its use may be associated with increased incidence of abruptio
placenta. !ome obstetrical anesthetists view low-dose aspirin use as a
relative contraindication for regional anesthesia for cesarean section. 7ased
on current data from large randomi#ed controlled trials, one can conclude
that the efficacy of aspirin has yet to be proven in the prevention and
treatment of ;:*. ipyridamole, a phosphodiesterase inhibitor causes
delay in the degradation of cyclic adenosine monophosphate +c/3 which
renders platelets more sensitive to degradation and enhances synthesis of
prostacyclin. %owever, most clinical trials have not demonstrated any
additional therapeutic benefits by adding dipyradimole to low-dose +D0
mgGday aspirin regime.
7-adrenergic agonists are credited to cause myometrial relaxation with
decreased resistance to uterine blood flow. They are also known to have
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direct vasodilatory effect on uterine perfusion. 7ut clinical trials with 7-
agonists have failed to demonstrate consistent benefits to enhance fetal
growth.
/trial natriuretic peptide +/3 is an endogenous peptide synthesi#ed in
the right atrium that has direct diuretic, natriuretic and vasodilator effects.
The role of /3 in the pathogenesis of ;:* resulting from uteroplacental
insufficiency has been studied recently. !tudies have shown that plasma
/3 levels are significantly higher while there is (0A reduction in the
number of /3 receptors in pregnancies complicated by ;:*. t has been
shown that continuous low-dose infusion of /3 to pregnant guinea pigs in
whom uterine artery is ligated, is associated with 'DA increase in blood flow
to the placenta. "urther research is needed to elucidate the role of /3 in the
pathogenesis of ;:* before human trials are conducted.
*ecent advances in the understanding of somatotrophic axis has
unfolded the role of nsulin-line :rowth "actors +especially :"-= in
various experimental animal models of ;:*. t has been shown that there
is a decrease in the level of circulating :"- and increase in :" binding
proteins +:"73 when ;:* is induced in experimental animals. :"
molecules have structural similarity to proinsulin and is bound to at least six
specific :"-binding proteins that regulate its effect. t has been recently
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documented that cord blood :"-= levels are significantly decreased in
;:* babies. The therapeutic utility of exogenous :"- = to improve fetal
growth has been studied in experimental animals with positive results.
7ecause maternal :"-= does not cross the placenta, the mechanism for
beneficial effect of exogenous :"-= on fetal growth is unclear. There is a
need to study stomatotrophic axis in human pregnancies complicated by
;:* before clinical trials can be launched for administration of :"-=
through the mother or to the fetus directly.
Inte!n)ent a%"o)inal "eo),!ession
t has been shown that intermittent abdominal decompression is
associated with improvement in uteroplacental blood flow and fetal
oxygenation. The abdominal decompression is produced by wearing a
plastic suit over a rigid frame in which pressure can be reduced with a
vacuum. / negative pressure +@0 mm %g is applied for
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Ea!l( "eli.e!( a$te! ens*!ing ,*l)ona!( )at*!it(
Early delivery is indicated to ensure intact survival of the baby whenever
there is late-onset fetal growth restriction with uteroplacental dysfunction.
The indications for delivery include severe oligohydramnias or lack of fetal
growth over a period of two weeks especially when fetal well being is at
stake as assessed by biophysical profile, !T and doppler velocimetery
studies. uring labor, upto ?0A of growth-restricted fetuses are likely to
exhibit evidences of fetal distress. elay in delivery may lead to in-utero
death of the fetus, fetal distress, birth asphyxia and adverse neuromotor
conseCuences. 8hen a baby is delivered prematurely, he is likely to suffer
from conseCuences of immaturity +like *!, 9%, E etc. although there
is some evidence that chronic stress in ;:* babies may be associated with
elaboration of endogenous corticosteroids that may enhance pulmonary
maturity. evertheless, antenatal administration of corticosteroids are
recommended whenever delivery is being contemplated before
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Co))on P!o%le)s in S)all-$o!-Dates Ba%ies Their clinical problems and
outcome are very different as compared to preterm babies. 7y and large
most clinical problems and biochemical abnormalities are limited to grossly
small-for-dates babies with a birth weight of less than minus two standard
deviations below the mean for gestational age or less than
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n preterm small-for-dates babies, combined ha#ards of immaturity and
intrauterine growth retardation would be manifest.
Manage)ent
Early delivery is indicated if there is arrest of fetal growth and
pulmonary maturity is satisfactory. "etal hypoxia may necessitate
emergency cesarean section and the pediatrician should be prepared to
receive an asphyxiated baby. The suctioning of glottic area under direct
vision is essential if baby is meconium stained. The baby should be screened
for any congenital malformations. Early and adeCuate feeding must be
ensured to prevent hypoglycemia. 7reast feeding should be initiated
immediately after birth. 7abies weighing less than
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Di$$e!ene %et'een ,!ete!) an" te!n s)all $o! "ates %a%ies
P!o%le)s P!ete!) Te!) s)all $o!
"ates
ntrauterine hypoxia R RRR
*espiratory difficulties
+a7irth asphyxia
+b/spiration in-utero
+c%yaline membrane disease
+d/pneic attacks
R
R
RRR
RRR
RRR
RRR
0
0
"eeding difficulties
+anability to suck and swallow
+b/spiration of feeds
+c"unctional obstruction and
enterocolitis
RRR
RR
RR
0
0
R
!ymptomatic hypoglycemia R RRR
%ypothermia RRR R
3olycythemia R RRR
%yperbilirubinemia RRR R
!usceptibility to infections RRR RR
ongenital malformations R RRR%emorrhage
+a ntraventricular
+b 3ulmonary
RRR
R
0
RRR
3rognosis
+ammediate
+b"uture physical and mental
development
%igh mortality
:ood if no perinatal
complications occur
except in extremely
preterm babies
7etter prognosis but
increased mortality
when compared with
normally grown
babies.
3oor especially in
hypoplastic and
severe
:* babies. There is
increased risk ofdevelopment of
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adeCuately fed, they do not lose weight and start gaining weight after ' to 0th percentile for
the period of gestation. nfants with a birth weight of more than ' standard
deviations from the mean weight for gestation or more than >@th percentile
are likely to pose clinical problems.
Ca*ses
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=. Geneti o! onstit*tional Tall and heavy mother is likely to produce
a big baby. There is no relationship between si#e of the father and
birth weight of the offspring.
'. Mate!nal "ia%etes )ellit*s an" ,!e"ia%etes. t is the commonest
cause of large-for-dates babies. ;tili#ation of large Cuantities of
transplacentally transmitted glucose appears to be the basic
mechanism producing islet cell hyperplasia and overgrowth of the
fetus, %uman placental lactogen, a growth-hormone like substance is
increased in infants of diabetic mothers +see hapter ? for details.
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?. C!etinis) The mean birth weight is higher in babies with congenital
hypothyroidism.
D. O.e!g!o'n s(n"!o)es 'it& a".ane" s4eletal )at*!ation n a
number of babies with fetal macrosomia due to endocrinal or
developmental disorders, advanced skeletal maturation provides a
useful diagnostic marker.
a /dministration of progestins during pregnancy or virili#ing ovarian
tumor in the mother.
b ongenital adrenal hyperplasia
c Thyrotoxicosis
d Wie"e)ann-Be4'it& s(n"!o)e These babies have characteristic
grooves in the ear lobes, macroglossia, exomphalos, visceromegaly
and somatic overgrowth +"ig [email protected]. They are prone to develop
hypoglycemia due to hyperplasia of islet-cells. %ypospadias, cleft
palate, coloboma of the iris and capillary hemangiomata may be
associated. They are at increased risk to develop 8ilmFs tumor. There
is higher incidence of mental seCuelae during childhood. n some
patients partial duplication of chromosome == has been demonstrated
on karyotyping studies with banding techniCue.
e Ma!s&all-S)it& S(n"!o)e. The craniofacial characteristics include
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broad forehead with hypertelorism, large ears, micrognathia, long
philtrum and mild microstomia. The &oints cannot be extended due to
hypertonia. These babies also manifest disproportionately advanced
maturation of carpal bones but can be distinguished from infants with
cerebral gigantism by the presence of large punctate epiphyses,
broadened ends of long bones and continuation of excessive growth
postnatally as well. The developmental retardation is absent or mild.
f Ce!e%!al gigantis) 2Sotos s(n"!o)e3 They are characteri#ed by
their large si#e at birth, macrognathia, large hands and feet and
disproportionate lag in maturation of carpal bones as compared to
phalangeal maturation. They are clumsy and show mental
subnormality later in life. ranial ultrasonography may show
ventricular dilatation.
Manage)ent
The infant should be accorded special care depending upon his
gestational maturity and etiology of his somatic overgrowth. They must be
fed early with sugar-fortified feeds and blood glucose should be monitored
during first @' hours of life because most overgrown infants are associated
with hypertrophy of islet-cells of pancreas. %ematocrit should be monitored
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to identify polycythemia and managed appropriately. "or clinical problems
and management of infants of diabetic mothers, refer to hapter ?.
32!T-TE* 7/7E!
+32!T/T;*E, 32!T-/TE, 72* 5/TE
nfants born at a gestation of 4' weeks or later are called post-term. n
ma&ority of instances the cause of postmaturity remains uncertain. 3ost-
dating of labor is common among primiparous women. "etus with
anencephaly fails to initiate labor at term because of failure of pelvic
engagement of the head and lack of pituitary-adrenal axis. nfants with
trisomy =D-=( or !eckelFs syndrome +bird-headed dwarfism are generally
several weeks post-term.
Clinial $eat*!es
%uman placenta can generally sustain the growth of fetus upto 4'
weeks, beyond which it becomes too senile or dysfunctional to support the
growth. n developing countries, due to nutritional constraints, plateau in
intrauterine growth is reached around
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aspiration. 9arnix caseosa and Cuantity of liCuor begins to decreases around
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for dysmature infants. /pplication of oil or cold cream prevents dryness of
skin due to desCuamation.