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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.