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OBJECTIVE
1. Student must be able to understand the definition
2.
3.
Birthweight
# < 2500 g : Low birthweight (LBW)
# < 1500 g : Very low birthweight (VLBW)
# < 1000 g : Extremely low birthweight (ELBW)
Gestational age
# < 37 weeks : Preterm
# 42 weeks : Post term
Size for gestasional age
# Weight beween 90th & 10th centile for gestation
# Weight < 10th centile for gestation
# Weight > 90th centile for gestation
FIGURE 3-2. Classification of newborns (both sexes) by intrauterine growth and gestational age. (Reproduced, with
permission, from Battaglia FC, Lubchenco LO: A practical
lassification for newborn infants by weight and gestational age. J
Pediatr1967;71:159; and Lubchenco LO et al: Intrauterine growth in length and head circumference as estimated from live births at
gestational ages from 26 to 42 weeks. Pediatrics 1966;37:403. Courtesy of Ross Laboratories, Columbus, Ohio 43216.)
THE LOW
BIRTH WEIGHT INFANT
Definition :
A low birth infant baby is one who weigh less
than 2500 gram at birth
The low birth infant divided into two clinical
types :
1. The preterm infant ( prematurity )
2. The small for gestational age infant
( small for dates, light for dates )
1.
Premature or preterm :
# A baby born before the 37th week of
pregnancy.
# May not br ready to live outside the uterus
and may have difficulty initiating breathing,
sucking, figting infection and stay warm.
2.
4.
CLINICAL CHARACTERISTIC
1.
2.
3.
4.
5.
6.
SPECIFIC PROBLEMS
1. Birth asphyxia
2. Thermal instability
3. Lack of primitive survival reflexes, suck, swallow, and
gag with high incidence of milk aspiration.
4. Jaundice
5. Pulmonary disease : apnoe, hyaline membrane disease,
transient tachypnoea of newborn, pneumothorax,
pneumonia, Wilson-Mikity syndrome and
bronchopulmonary dysplasia.
6. Metabolic disturbances: hypoglycaemia, hypocalcaemia,
hypomagnesaemia, hyponatraemia, hypernaetremia.
SUPORTIVE CARE
Resuscitation
The Obstetrician and Paediatrician should ideally function
as a perinatal team during premature labour
appropriate assessment of perinatal asphyxia and
resuscitation can be performed.
Monitoring
Heart rate and respiratory rate, blood pressure and
temperature must be monitored continuously
Monitoring
Total intake-output of fluids should be recorded every 24
hours in critically ill infants.
Head circumference is measured twice weekly and plotted
on a percentile graph.
Daily weights are measured and recorded.
Thermoregulation
Body temperature must be maintained in the normal range
(36,5-37,0C per axilla) by nursing infant in incubator.
Feeding
Infants < 34 weeks gestation should be fed via an orogastric/naso-gastic tube.
Prematures with small gastric volumes require frequent
feeding (every 2 hours) and should be started on
2ml/kg/feed and increased in increment of 1-2ml/kg/every
feed, as tolerated.
Gastric aspirate must be checked before the next feed.
The preterm infant should ideally be fed his own mothers
expressed breast milk.
Parenteral fluids
Sick babies and infants < 1500 g may need parenteral
feeding
Parenteral fluid requirements can only be determined by
close observation of urine-output, urine osmolality, body
weight and electrolytes.
In general, fluid volumes for healthy preterm infants given
enterally are: 60ml/kg-day 1; 80ml/kg-day 2; 100ml/kg-day
3; 120ml/kg-day 4; 140ml/kg-day 5; 160ml/kg-day 6;
180ml/kg-day 7.
Electrolytes
Preterm infants receiving parenteral fluids should receives
maintenance electrolytes after they have passed urine.
Normally they require: sodium 2,5-3,0 mmol/kg/day; potassium
2,0-2,5 mmol/kg/day; calcium 300mg/kg/day.
Vitamins
A single intramuscuar dose 0,5 1,0 mg IM
Preterm babies being fed with breast milk or vitamin fortified
formulae will all need additional vitamin C (by day 3) and vitamin
D.
Anemia
The venous haematocrit should be maintained at > 40% in
all sick babies.
All preterm infants < 2500 g or 34 weeks gestation should
receive supplemental iron in a dose of 30 mg daily from the
age of three weeks.
INSIDEN
Varies between countries, usually :
3-7% of all infants are SGA
20% of stillborn infants are SGA
25% of SGA Infants are Type I
75% of SGA infants are type II
AETIOLOGY
The causes SGA infants can be classified as
extrinsic and intrinsic in origin
1. Extrinsic
Extrinsic mechanisms operate during the latter
half of pregnancy and may be associated with
placental insufficiency. Fetal growth is affected
because of inadequate supply line of nutriens
and/or oxigen.
a. Maternal Factors
# Maternal hypertension e.g. essential,
pregnancy induced, renal.
# Vascular disease, e.g. DM, cardiac, renal,
sickle cell and collagen disease
# Smoking, narcotic abuse
Abnormal placentation
Placental infarct, fibrosis, haemangioma
Premature placental separation
Single umbilical artery
Uterine crowding e.g. multiple
pregnancy, uterine abnormalities
2. Intrinsic
The intrinsic group implies that there is
something wrong with the fetus at the time of
conception or during the first semester.
a. Constitutional e.g. parental stature, racial,
ethnic
b. Chromosomal anomaly e.g. Trisomy 13, 18,
21, Turners Syndrome
c. Fetal infections e.g. TORCH
d. Maternal drugs e.g. chronic alcoholism,
cytotoxic, heroin addiction
e. Primordial dwarf, e.g. achondroplasia, russel
Silver Dwarf
CLINICAL FINDING
IUGR can be suspected by: poor maternal weight
gain, suboptimal uterine growth, low or falling
oestriol levels, reduced growth of biparietal
diameter on serial USG
Physical apperanceof babies in the intrinsic
groupwill be characteristic of the spesific
aetiology e.g. Toxoplasma, rubella, achondroplasia
SGA VS IUGR
A child who is born SGA is not always IUGR
Infants born after a short period of IUGR are
not always SGA
SGA:
IUGR
Constitutionally small infant
Classification
Symmetrical
Asymmetrical
In a normal infant, the brain weighs about three times more than the liver. In
asymmetrical IUGR, the brain can weigh five or six times more than the liver.
Asymmetric IUGR
Type II
Late onset growth
restriction
Head Sparing
Potentially reversible
Associated with
decreased cell size
Infants demonstrate
more catch-up growth
than symmetric IUGR in
first year of life
DIAGNOSIS
Decreased subcutaneous fat with soft tissue,
desquamated skin, meconium stained
Widened cranial sutures with large fontanelles
Thin umbilical cord
Skin and sole creases more mature than GA
alert-looking and jittery
Congenital malformations
Stigmata of congenital infections
SPECIFIC PROBLEMS
1. Intrauterine : sudden fetal death, fetal
distress during labor
2. At birth: birth asphyxia, MAS often
complicated by pneumotorax
3. Neonatal period
# Congenital malformations:
There is 20 x increased incidence of
congenital malformation in SGA babies
compared with their birthweight peers
# Infections:
There is 7 x increased incidence of
infections. The intrauterine infections may
be the cause of the growth retardation, but
SGA babies are also more likely to acquire a
nursery infections
MANAGEMENT
If IUGR suspected: monitoring of fetal &
uteroplacental function will be necessary
with test such as 24 hr urinary oestriol,
serial biparietal diameters, stress & non
stress challenge test & L/S ratio of amniotic
fluid prior to early delivery
A careful decision: best methode of & time
of delivery will need to be made.