CARE OF IUGR AND LOW BIRTH WEIGHT BABIES

INTRODUCTION

High incidence of LBW babies in our country is accounted for by a higher number of babies with
intrauterine growth retardation (small fordates) rather than the preterm babies. In the present circumstances, it
is not possible to offer special care to all LBW babies. As babies with a birth weight of less than 1,800 g are
more vulnerable, they deserve priority in admission to the special care nursery.

LOW BIRTH WEIGHT BABIES (LBW)

Babies with a birth weight of less than 2,500 g, irrespective of the period of their gestation, are
classified as low birth weight babies. These include both preterm and term small for dates babies. Their
clinical problems and prognoses are quite different from each other.LBW contributes to 60% to 80% of all
neonatal deaths. The global prevalence of LBW is 15.5%, which amounts to about 20 million LBW infants
born each year, 96.5% of them in developing countries. About 25 to 35 percent of babies in India are LBW.

Even after recovering from neonatal complications, some LBW babies may remain more prone
to malnutrition, recurrent infections, and neurodevelopmental handicaps. Low birth weight,therefore, is
a key risk factor of adverse outcome in early life.

DEFINITION

Low birthweight has been defined by the World HealthOrganization (WHO) as weight at birth of less
than 2,500 grams (5.5 pounds).

Very low birth weight babies : Baby whose birth weight is below 1500gm.

Extremely low birth weight babies: whose birth weight is below 1000gm.

Low birth weight <2.5kg

Very low birth weight 1-1.5kg

Extremely low birth weight < 1kg

TYPES OF LBW

The newborn baby can be LBW because of two reasons.

Preterm or premature: a preterm baby has not yet completed 37 weeks of gestation. Since
fetal size and weight are directly linked to gestation, it is obvious that if the delivery takes place
prematurely, the baby is likely to have less weight.
Intrauterine growth restriction or IUGR: This condition is similar to malnutrition. Here, gestation
may be full term or preterm, but the baby is undernourished, undersized and therefore, low birth
weight. Such a baby is also called a small-for-date or SFD neonate.

ETIOLOGY

Causes for prematurity

Low maternal weight, teenage / multiple pregnancy

 Previous preterm baby, cervical incompetence
Antepartum hemorrhage, acute systemic disease
Induced premature delivery
Majority unknown

Causes for IUGR

Poor nutritional status of mother
Hypertension, toxemia, anemia
Multiple pregnancy, post maturity
Chronic malaria, chronic ill
Tobacco use

DISTINGUISHING FEATURES OF PRETERM AND SGA BABIES

It is desirable and of practical relevance to make clinical distinction between the two types of LBW
babies.Preterm baby is diagnosed on the basis of period of gestation calculated from the last menstrual cycle
of the mother. If it is less than 37 completed weeks.
Distinct physical features
 Soles, deep skin creases are present only on the anterior one third.
 The external ear or the pinna is soft and devoid of cartilage. Hence, it does not recoil back
promptly on being folded.
 In males, the scrotum does not have rugae and testes are not descended into the scrotum. In
females infants, the labia are widely separated, not covering the labia minora, resulting in
the prominent appearance of the clitoris.
 The back of the pretermbabies has abundant growth of fine hair called lanugo

SGA Babies
 The head is bigger than the chest by about 2 cm. In small- for-date babies, the head circumference
exceeds the chest circumference by more than 3 cm.
 When their birth weight is plotted on the intrauterine growth chart, it falls below the 10th centile.
 Emaciated look.
 Loose folds of skin.
 Lack of subcutaneous tissue.

PROBLEMS OF PRETERM BABY

 Birth asphyxia
 Hypothermia
 Feeding difficulties
 Infections
 Hyperbilirubinemia
 Respiratory distress
 Retinopathy of prematurity
 Apneic spells
 Intraventricular hemorrhage
 Hypoglycemia
 Metabolic acidosis
PROBLEMS OF SGA BABIES

 Birth asphyxia
 Meconium aspiration syndrome
 Hypothermia
 Hypoglycemia
 Infections
 Polycythemia

LBW: Issues in delivery

 Transfer mother to a well-equipped centre before delivery

 Skilled person needed for effective resuscitation
 Birth weight <1800 g
 Gestation <34 wks
 Unable to feed
 Sick neonate

NEED FOR HOSPITALIZATION

An otherwise healthy LBW newborn with a birth weight of 1800 gm or above and gestation of 34
weeks or more can be managed at home by the mother and the family under the supervision of a health worker
or a family physician. The indications for hospitalization of a neonate include the following:
a. Birth weight less than 1800 gm
b. Gestation less than 34 weeks
c. Neonate who is not able to take feeds from the breast or by katori- spoon (irrespective of birth
weight and gestation)
d. A sick neonate (irrespective of the birth weight or gestation)

CARE OF LOW BIRTH WEIGHT BABIES

High risk mother should be identified early during the course of pregnancy and referred for
confinement to an appropriate health care facility, which is equipped with good quality obstetrical, and
neonatal care facilities. Mother is indeed an ideal transport incubator!

PRINCIPLES OF CARE
1 .Care at birth
 Suitable place of delivery 'in,utero' transfer to a place with optimum facilities if a LBW
delivery is anticipated.
 Prevention of hypothermia
 Effecient resuscitation.
2. Appropriate place of care
 Birth weight > 1800 g: Home care, if the baby is otherwise well.
 Birth weight 1500,1800 g; Secondary level newborn unit
 Birth weight < 1500 g: Tertiary level newborn care (or intensive care)
3. Thermal protection
 Delay bathing.
 Maternal contact.
 Kangaroo mother care.
 Warm room.
  External heat source (incubator, radiant warmer)
4. Fluids and feeds
 Intravenous fluids for very small babies and those who are sick.
 Expressed breast milk with gavage or katori spoon.
 Direct breasfeeding.
5. Monitoring and early detection of complications
 Weight and other clinical signs.
 Electronic monitoring
 Biochemical monitoring
6. Appropriate management of specific complications

Arrest of premature labour.

Advances in perinatal care including fabrication of a variety of electronic gadgets cannot
compare with unique security and optimal care provided to the fetus by the uteroplacental unit.
Efforts should always be made to arrest the progress of premature labor.
Antenatal corticosteroids
 Antenatal administration of corticosteroids is one of the most cost,effective perinatal strategies
which must be universally exploited. It is associated with 50 percent reduction in the incidence of RDS
due to surfactant d eficiency.
 It provides additional benefits by reducing the incidence of intraventricular hemorrhage and
necrotizing enterocolitis.
 The over all neonatal mortality is reduced by 40 percent by this simple and cheap intervention.
 Injection betamethasone 12 mg IM every 24 hours for 2 doses or dexamethasone 6 mg IM every 12
hours for 4 doses should be administered to the mother if labor starts or is induced before 34
weeks of gestation.

CARE OF PRETERM BABIES

Optimal management at birth

 When 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 storesof the
baby. It may also reduce the incidence and severity of hyaline membrane disease.
 Elective intubation of extremely LBW babies (< 1000g) is practised in some centers to support
breathing and for prophy lactic administration of exogenous surfactant.
 The baby should be promptly dried, kept effectively covered and warm. Vitamin K 0.5 mg
should be given intramuscularly.
 The baby should be transferred by the doctor or nurse (not a nursing orderly!) to the NICU as soon as
breathing is established.

Monitoring

 The following clinical parameters should be monitored by specially trained nurses. The
frequency of monitoring depends upon the gestational maturity and clinical status of the baby.
 Vital signs with the help of multichannel vital sign monitor (noninvasive with alarms).
Activity and behaviour.

Tissue perfusion Adequate tissue perfusion is suggested by pink color, capillary refill over upper
chest of < 3 sec, warm and pink extremities, normal blood pressure, urine output of >1.5 ml/kg/hr,
absence of metabolic acidosis and lack of any disparity between paO2 and SaO2.

Medical Care

Stabilization in the delivery room with prompt respiratory and thermal management is crucial to the
immediate and long-term outcome of premature infants, particularly extremely premature infants. The
American Academy of Pediatrics (AAP) has established guidelines for levels of neonatal care.

Principles of respiratory management are as follows:

 Recruit and maintain adequate lung volume or optimal lung volume. In infants with respiratory
distress, this step may be accomplished with early continuous positive airway pressure (CPAP) given
nasally, by mask (Neopuff), or by using an endotracheal tube when ventilation and/or surfactant is
administered.

 Avoid hyperoxia and hypoxia by immediately attaching a pulse oximeter and keeping the oxygen
saturation (SaO2) between 86% and 93% by using an oxygen blender.

 Prevent barotrauma or volutrauma by using a ventilator that permits measurement of the expired tidal
volume and by keeping it 4-7 mL/kg.

 Administer surfactant early (< 2 h of age) when indicated and prophylactically in all extremely
premature neonates (< 29 wk).

Many centers are using early CPAP and a relatively permissive approach to ventilation. Research is needed to
provide evidence to support an approach that provides the best outcome.

A retrospective analysis studied the first 48 hours in 225 infants of 23-28 weeks gestational age. The study
results noted that 140 of these infants could be stabilized with nasal CPAP in the delivery room; 68 with a
favorable outcome and 72 with a failed outcome within 48 hours; history or initial blood gas results were poor
predictors of subsequent nasal CPAP failure. A threshold fraction of inspired oxygen (FiO 2) of greater than or
equal to 0.35-0.45 compared with greater than or equal to 0.6 for intubation may shorten the time to surfactant
delivery, without a relevant increase in intubation rate.

In select extubated preterm infants, nasal cannulae appears to be comparable to CPAP. In a multicenter,
randomized, noninferiority study, Manley and colleagues found that in extubated preterm infants with a
gestational age of at least 26 weeks but less than 32 weeks, breathing support using high-flow nasal cannulae
(HFNC) was comparable to that using nasal continuous positive airway pressure (CPAP).Results were derived
from 303 extubated preterm infants who were treated with HFNC (151 infants) or CPAP (152 infants).

During the 7 days following extubation, the failure rate was 34.2% in the HFNC group and 25.8% in the
CPAP group.However, the reintubation rate in the infants treated with HFNC (17.8%) was lower than in the
CPAP group (25.2%), because half of the infants in whom HFNC failed were successfully treated with CPAP.
The nasal trauma rate was 39.5% in the HFNC group and 54.3% in the CPAP group.

In January 2014 the AAP released a policy statement on respiratory support for newborn preterm
infants.Management of these preterm infants must be individualized, and the healthcare setting and team must
be considered. The AAP recommendations include the following
  Early use of CPAP with subsequent selective use of surfactants: Compared with routine intubation
with prophylactic or early surfactant therapy, early postnatal CPAP in extremely preterm infants
reduces the rates of bronchopulmonary dysplasia and death

 If mechanical ventilation is necessary: Early administration of surfactant and then rapid extubation is
preferable to prolonged ventilation

The AAP notes that early CPAP alone does not increase the risk for adverse outcomes if surfactant therapy is
either delayed or not administered .Moreover, early administration of CPAP may reduce the duration of
mechanical ventilation and postnatal corticosteroid therapy.

Thermoregulation

Maintenance of the neutral thermal environment is critical for minimizing stress and optimizing growth of the
premature infant. The neutral thermal environment is defined as the environmental temperature in which the
neonate maintains a normal temperature and is consuming minimal oxygen for metabolism.

Neonates lose heat by 4 means, as follows:

1. Evaporation: Evaporation is energy consumed by a fluid as it converts from a liquid to gas. This is
primarily in the delivery room. Completely drying the infant is of primary importance in prevention of
hypothermia. This step can be omitted if other resuscitative measures are taking place.

2. Conduction: This is direct transfer of heat from a warm body to a cool object by contact (eg, placing
an infant on a cold scale).

3. Convection: This is the loss of heat from the warm air next to the skin to moving air currents (eg,
windchill effect). Double-walled isolettes help to reduce convective heat loss.

4. Radiation: This is the loss of heat that radiates from a warm body to a cool surface (eg, window,
outside wall).

 Preterm infants are relatively unable to compensate for cold stress because of a small amount of
subcutaneous tissue (insulation) and decreased brown fat to produce heat.
 Preterm infants do not shiver. The increased surface area to body mass allows for rapid heat loss,
especially from the head.
 Decreased posturing ability further diminishes their ability to compensate.
 In extremely low birth weight (ELBW) infants, immature skin further complicates thermoregulation
due to increased evaporative water loss.
 Consequences of cold stress are increased metabolism with loss of weight or failure to gain weight and
increased use of glucose with depletion of glycogen stores and hypoglycemia.
 Metabolic acidosis results in a decreased surfactant production and loss of functional alveolar number,
which results in hypoxia. The hypoxia causes pulmonary vasoconstriction, and further hypoxia.
 Increased oxygen consumption results in hypoxia, anaerobic metabolism, and lactic acid production.
 In the intensive care nursery, radiant warmers may be used to compensate for heat loss. Incubators are
more efficient than radiant warmers because the heated environment decreases heat loss due to
conduction, convection, and radiation. With radiant warmers, consider using plastic wrap and a
humidified environment for ELBW infants. New devices function as both an incubator and an
overhead warmer to enable access for procedures. In all nurseries, maintain the environmental
temperature at more than 70°F (>21°C).
 Temperature maintenance is especially critical during neonatal resuscitation, when the same principles
apply.
Skin care

Premature infants have immature skin, a decreased or absent stratum corneum, decreased cohesiveness
between skin layers, increased water fixation, and tissue edema. The immature skin integrity leads to easy
injury, transdermal absorption of drugs and other materials in contact with the skin and increased risk for
infection.

The National Association of Neonatal Nurses (NANN) and the Association of Women's Health, Obstetric and
Neonatal Nurses (AWHONN) recommended the following areas of newborn skin care, which are based on
clinical and laboratory research.

1. Bathing: Use only water and no soap for infants who weigh less than 1000 g. Decrease the frequency
of using cleansers. Only use neutral-pH cleansers.

2. Disinfectants (eg, povidone-iodine, chlorhexidine): Completely remove these agents after the
procedure to decrease transdermal absorption. Isopropyl alcohol use is discouraged because it is
relatively ineffective as a disinfectant and is drying to the skin. Alcohol burns, and cracked skin can
result.

3. Adhesives: Minimize their use. Use double-backed silk tape versus tape with strong adhesive
properties (Elastoplast). Use hydrogel electrodes. Avoid solvents or bonding agents.

4. Transepidermal water loss: Place infants born at 30 weeks' gestation in a high-humidity (>70%)
environment.

5. Topical solutions: Review ingredients of any topical solution placed on the skin of a preterm infant.
Transdermal absorption can occur. Discourage use of solvents for adhesive removal.

6. Pectin barriers (eg, DuoDERM extra thin, Restore extra thin): These are recommended. Anchoring
devices (umbilical lines) to pectin barriers results in improved skin integrity.

Fluid and electrolyte management

Preterm infants need intense monitoring of their fluid and electrolytes because of their increased transdermal
water loss, immature renal function, and other environmental issues (eg, radiant warming, phototherapy,
mechanical ventilation.

 Tolerance of feeds; Vomiting, gastric residuals, abdominal girth.

 Look for development of RDS, apneic attacks, sepsis, PDA, NEC, IVH etc.
 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 apheic attacks and
baby is having a steady weigh gain of 1.0,1.5 percent (0,15g/kg/d) of his bodyweight every day.

The degree of prematurity and the infant's specific medication problems dictate initial fluid therapy.
However, the following general principles apply to all preterm infants:

 Initial fluids should be a solution of glucose and water. More mature infants can be started at 60-80
mL/kg/d. The most immature infants may need up to 100-150 mL/kg/d. (See Extremely Low Birth
Weight Infant.)
 Environmental aspects of care, eg, radiant warming, phototherapy, and a nonhumidified environment,
increase insensible water loss and the need for fluids. Mechanical ventilation, use of double-walled
isolettes, and provision of humidity decrease insensible water loss.
  The glucose infusion rate (GIR) is usually started at 4-6 mg/kg/min. In general, to obtain this rate, a
solution of dextrose 10% in water (D10W) should be used initially. The exception is the ELBW infant
who should initially be given dextrose 5% in water (D5W) to provide the same GIR and to prevent
hyperglycemia.
 Electrolytes should not be added until 24 hours of age, when urine output is adequate. Electrolytes and
calcium should be monitored at 12-24 hours of age depending on the degree on prematurity and other
medical issues.
 Basal needs are sodium is 2-3 mEq/kg/d, potassium 1-2 mEq/kg/d, and calcium 600 mg/kg/d (as
calcium gluconate). Urinary losses, which may increase in the most immature of infants and in those
exposed to diuretics, dictate the need for supplemental sodium.
 Infants who develop acute tubular necrosis (ATN) should be treated with fluid restriction that equals
insensible water loss plus urine output. Additional fluid is administered by closely and frequently
monitoring the output and electrolytes during the post-ATN diuretic phase.
 Hyponatremia and weight gain should be treated with decreasing fluid administration. Monitoring of
urinary electrolyte losses is sometimes helpful in replacement therapy.
 The patient's weight should be followed up every 24 hours. Results of laboratory monitoring and
change in weight dictate changes in fluid and electrolyte support.

Provide inutero milieu

 Uterus provides ideal ambient conditions to the baby. All attempts should be made to create uterus
like baby friendly ecology in the nursery.
 Create a soft, comfortable, "nestled" and cushioned bed.
 Avoid excessive light, excessive sound, rough handling and painful procedures. Use effective
analgesia and sedation for procedures.

Provide warmth.

 Prevent evaporative skin loses by effectively covering he baby, application of oil or liquid paraffin
to the skin and increasing humidity to near 100 percent.
 Provide effective and safe oxygenation.
 Uterus is able to provide unique parenteral nutrition. Efforts should be made to provide at least
partial parentral nutrition and give trophic feeds with expressed breast milk (EBM).
 Provide rhythmic gentle tactile and kinesthetic stimulation like skin,to,skin contact, interaction, music,
caressing and cuddling.

Position of the baby

 Most babies love to lie in a prone position, they cry less and feel more comfortable. It relieves
abdominal discomfort by passage of flatus and reduces risk of aspiration.
 Prone posture improves ventilation, increases dynamic lung compliance and enhances arterial
oxygenation.
 Unsuperivised prone positioning, beyond neonatal period, has been recognized as a risk factor for
SIDS.

Thermal comfort

 A 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 2000g. The baby should be nursed in a
thermoneutral environment with a servo sensor geared to maintain skin temperature of mid,epigastric
region at 36.5 C so that there is virtually no or minimal metabolic thermogenesis.
  Application of oil or liquid paraffin on the skin reduces convective heat loss and evaporative water
losses.
 The extremely LBW baby should be covered with a cellophane or thin transparent plastic sheet to
prevent convective heat loss and evaporative losses of water from skin.
 As soon as baby's condition stabilizes he should be covered with a perspex shield or effectively
clothed with a frock, cap, socks and mittens.
 After one week or so, stable babies with a birth weight of < 1200 g should preferably be
nursed in an intensive care incubator. It is associated with reduced chances of handling, better
temperature control, reduced evaporative losses from skin and better weight gain velocity.
 The mother should be encouraged to provide KangarooMotherCare (KMC) to prevent
hypothermia, to promote bonding and breast feeding and to transmit healing electromagnetic
vibrations of love and compassion to her baby.

Maintenance of the neutral thermal environment is critical for minimizing stress and optimizing growth
of the premature infant. The neutral thermal environment is defined as the environmental temperature in
which the neonate maintains a normal temperature and is consuming minimal oxygen for metabolism.
Neonates lose heat by 4 means, as follows:
Evaporation: Evaporation is energy consumed by a fluid as it converts from a liquid to gas. This is
primarily in the delivery room. Completely drying the infant is of primary importance in prevention of
hypothermia. This step can be omitted if other resuscitative measures are taking place.
Conduction: This is direct transfer of heat from a warm body to a cool object by contact (eg, placing an
infant on a cold scale).
Convection: This is the loss of heat from the warm air next to the skin to moving air currents (eg,
windchill effect). Double-walled isolettes help to reduce convective heat loss.
Radiation: This is the loss of heat that radiates from a warm body to a cool surface (eg, window,
outside wall).
 Preterm infants are relatively unable to compensate for cold stress because of a small amount of
subcutaneous tissue (insulation) and decreased brown fat to produce heat.
 Preterm infants do not shiver. The increased surface area to body mass allows for rapid heat loss,
especially from the head.
 Decreased posturing ability further diminishes their ability to compensate.
 In extremely low birth weight (ELBW) infants, immature skin further complicates thermoregulation due
to increased evaporative water loss.
 Consequences of cold stress are increased metabolism with loss of weight or failure to gain weight and
increased use of glucose with depletion of glycogen stores and hypoglycemia.
 Metabolic acidosis results in a decreased surfactant production and loss of functional alveolar number,
which results in hypoxia. The hypoxia causes pulmonary vasoconstriction, and further hypoxia.
 Increased oxygen consumption results in hypoxia, anaerobic metabolism, and lactic acid production.
 In the intensive care nursery, radiant warmers may be used to compensate for heat loss. Incubators are
more efficient than radiant warmers because the heated environment decreases heat loss due to
conduction, convection, and radiation. With radiant warmers, consider using plastic wrap and a
humidified environment for ELBW infants. New devices function as both an incubator and an overhead
warmer to enable access for procedures. In all nurseries, maintain the environmental temperature at
more than 70°F (>21°C).

Feeding and Nutrition

Nutritional management influences immediate survival as well as subsequent growth and development of low
birth weight (LBW) infants. Early nutrition could also influence the long-term neuro-developmental
outcomes. Term infants with normal birth weight require minimal assistance for feeding in the immediate
postnatal period. They are able to feed directly from mothers' breast. In contrast, feeding of LBW infants is
relatively difficult because of the following limitations:

1. Though majority of these infants are born at term a significant proportion are born premature with
inadequate feeding skills. They might not be able to breastfeed and hence would require other methods
of feeding such as spoon or gastric tube feeding.

2. They are prone to have significant illnesses in the first few weeks of life, the underlying condition
often precludes enteral feeding.

3. Preterm infants have higher fluid requirements in the first few days of life due to excessive insensible
water loss.

4. Since intrauterine accretion occurs mainly in the later part of the third trimester, preterm infants
(particularly those born before 32 weeks of gestation) have low body stores of various nutrients at
birth which necessitates supplementation in the postnatal period.

5. Because of the gut immaturity, they are more likely to experience feed intolerance necessitating
adequate monitoring and treatment.

Calorie requirement

They require more calorie because of relatively greater loss of heat from the body surface. The calorie intake
of 60 calories /kg/day, on 7th day is to be stepped up gradually to 100 on 14th day and about 120-150 on 21st
day.

Method of feeding

Direct and exclusive breast feeding is the ideal method for feeding a LBW baby. However because of the
various limitations, not all the LBW infants would be able to accept breast feeding atleast in the initial few
days after birth. These infants have to be fed by either spoon/ paladai or intragastric tube; those babies who
cannot accept oral feeds by even these methods would require intravenous fluids.

The appropriate method of feeding in a given LBW infant is decided based upon the following factors.

 Whether the infant is sock or not

 Feeding ability of the infant (which depends upon the gestational maturity)

Nutrition based on the level of sickness

It is essential to categorize LBW infants into two major groups, sick and healthy, before deciding the initial
method of feeding.

Sick infants:

This group constitutes infants with respiratory distress requiring assisted ventilation, shock, seizures,
symptomatic hypoglycemia, electrolyte abnormalities renal/cardiac failure, surgical conditions of
gastrointestinal tract, necrotizing enterocolitis (NEC), hydrops, etc: These infants are usually started on
intravenous fluids. Enteral feeds once the acute phase is over and the infants' color, saturation and perfusion
have improved. Similarly, sepsis (unless associated with shock/ sclerema/NEC) is not a contraindication for
enteral feeding.

Healthy LBW infants: Enteral feeding should be initiated immediately after birth in healthy LBW infants
with the appropriate feeding method determined by their oral feeding skills and gestation.
Feeding Ability

Breastfeeding requires effective sucking, swallowing and a proper coordination between suck/swallow and
breathing. These complex skills mature with increasing gestation. A mature sucking pattern that can
adequately express milk from the breast is not present until 32-34 weeks gestation; the coordination between
suck/swallow and breathing is not fully achieved until 37 weeks of gestation. The maturation of oral feeding
skills and the choice of initial feeding method are different at various gestational ages

Maturation of oral feeding skills and the choice of initial feeding method in LBW infants .

Gestational age Maturation of feeding skills Initial feeding method

< 28 weeks No proper sucking efforts

Intravenous fluids
No propulsive motility in the gut

28-31 weeks Sucking bursts develop Oro-gastric (or naso-gastric )tube

feeding with occasional
No coordination between suck,
spoon/paladai
swallow and breath

32-34 weeks Slightly mature sucking pattern feeding by spoon/paladai/cup

Coordination

between breathing and

swallowing begins

>34 weeks Mature sucking pattern More Breastfeeding

coordination between breathing
and swallowing
Choosing initial method of feeding

Choice of milk

All LBW babies, irrespective of their initial feeding method should receive only breast milk. This can be
ensured by giving expressed breast milk for those infants fed by paladai or gastric tube.

Expressed breast milk

All mothers should be counseled to and supported in expressing their own milk for feeding their preterm
infants. Expression should be initiated within hours of delivery so that infants get benefit of feeding
colostrum. Thereafter it should be done 2-3 hourly so that infant is exclusively breast fed and lactation is
maintained in the mother. This can be stored 6 hours at room temperature and 24 hrs in refrigerator.

Breast feeding in case of sick mothers

1.Formula feeds:

a.Preterm formula-in VLBW INFANTS

b.Term formula-in infants weighing >1500g at birth

2.Animal milk, e.g-undiluted cow’s milk

Progression of oral feeding

How much to feed

Infants who are able to suckle effectively at the breast should be breast fed on demand. Small babies usually
demand to feed every 2-3 hours, sometimes more frequently. A small infant, who does not demand to be fed
for 3 hours or more can be offered the breast and encouraged to feed.

Spoon/ paladai feeding

These are on alternative methods of feeding like gavage or spoon feeding.

The daily fluid requirement is determined based on the estimated insensible water loss, other losses, and urine
output. Extreme preterm infants need more fluids in the initial weeks of life because of the high insensible
water loss. It is usual clinical practice to provide VLBW infants about 80 ml/kg fluids on the first day of life
and increase by 10-15 mI/kg/day to a maximum of 160 ml/kg/day by the end of the first week of life. LB.W
infants ;1500 g are usually given about 60 ml/kg fluids on the first day of life and fluid intake is increased by
about 1520 ml/kg/day to a maximum of 160 ml/kg/day by the end of the first week of life. After deciding the
total daily fluid requirement, the individual feed volume to be given every 2 or 3 hours by OG tube or
paladaican be determined.

Nutritional Supplementation

LBW infants, especially those who are born preterm, require supplementation of various nutrients to meet
their high demands. Since the requirements of VLBW infants differ significantly from those with birth
weights of 1500-2499 g.
Supplementation for Infants with Weights of 1500-2499

These infants are more likely to be born at term or near infants are more at risk of osteopenia than healthy
term gestation (>34 weeks) and are more likely to have infants, most neonatal units tend to supplement
vitamin adequate body stores of most nutrients. Therefore, they do not require multi-nutrient supplementation
(unlike VLBW infants). However, vitamin D and iron might still Supplementation in VLBW Infants have to
be supplemented in them. While iron supplementation is mandatory for all infants, supplementation These
infants who are usually born before 32-34 weeks of vitamin D is contentious because of the paucity of the
gestation have inadequate body stores of most of the data regarding its levels and deficiency status in different
populations.

Nutritional supplements for infant with birth weight of 1500-2499g.

Nutrients Method of Dose When to start Till when?

supplementation

Vitamin Multivitamin 200-400 IU/day 2 weeks of life Until 1 year of age

D drops/syrup

Iron Iron drops/syrup 2mg/kg/day 6-8weeksofage Until 1 year of age

(upto15mg/day)

Supplementation in VLBW Infants

These infants who are usually born before 32-34 weeks gestation have inadequate body stores of most of the
nutrients. Since expressed breast milk has inadequate amounts of protein, energy, calcium, phosphorus, trace
elements (iron, zinc) and vitamins 0, E and K, it is often not able to meet the daily recommended intakes of
these infants. Hence, these infants need multi-nutrient supplementation till they reach term gestation (40
weeks, i.e. until the expected date of delivery). The following nutrients have to be added to the expressed
breast milk in them:

1. Calcium and phosphorus (140-160 mg/kg/d and 7080 mg/kg/d respectively for infants on EBM)

2. Vitamin D (400 IU/day), vitamin B complex and zinc (about 0.5 mg/day)-usually in the form of
multivitamin drops.

3. Folate(about 50 mcg/kg/day)

4. Iron (2 mg/kg/day) .

Multi-nutrient supplementation can be ensured by one of the following methods:

1. Supplementing individual nutrients, e.g. calcium, phosphorus, vitamins, etc. These supplements should be
added at different times in the day to avoid abnormal increase in the osmolality.

2. By fortification of expressed breast milk with human milk fortifiers (HMF): Fortification increases the
nutrient content of the milk without compromising its other beneficial effects. Experimental studies have
shown that the use of fortified human milk results in net nutrient retention that approaches or is greater than
expected intrauterine rates of accretion in preterm infants. Preterm VLBW infants fed fortified human milk do
not require any supplementation other than iron. Fortification or supplementation of minerals and vitamins
should be continued only till term gestation in VLBW infants; after this period, only vitamin D and iron needs
to be supplemented similar to infants with birth weights of >1500 g.

Features of feed intolerance

 Vomiting

 Pre-feed residue >25-50%of previous feed or >1ml/kg

 Any evidence of NEC

 Increase in abdominal girth >2c.m

Breast feeding

 Have the mother attempt to breastfeed either when the baby is waking from sleep or when awake
and alert.
 Have the mother sit comfortably, and help her with correct positioning and attachment, if necessary.
 If the baby cannot be breastfed, have the mother give expressed breast milk.

MINIMAL ENTERAL OR TROPHIC FEEDING

Luminal starvation leads to mucosal thinning, flattening of villi & bacterial translocation (as
early as 2 to 3 days). To maintain the structural and functional integrity of GIT, provision of very
small volumes (<10ml/kg/day) is called Trophic feeding.

Benefits of trophic feeding –

 Earlier progression to full enteral feeds,

 Improved levels of gut hormones,
 Improved weight gain,
 Less feeding intolerance,
 Improved Ca & P retention,

FEEDING METHODS

Nasogastric / Orogastricfeeding :In those who do not have ability to coordinate suck,swallow,breathe
patterns due to prematurity (<34 wks gestation) andconditions such as encephalopathy, hypotonia&
maxillofacial abnormalities.

Disadvantage of NG feeding:

Partial airway obstruction & ↑airway resistance.Can be given bolus or as continuous feeds.

Transpyloricfeedings :In Infants intolerant to NG/OG feeding, those at increased risk for aspiration and with
severe gastric retention & regurgitation, & gastrointestinal abnormalities like microgastria.

 Should be delivered continuously.

 Placed under guided fluoroscopy.
 Increased risk of fat malabsorption (as lingual & gastric lipases are bypassed).

Breast Feeding / Bottle Feeding

Gastrostomy Feeding : In Infants who are unable to take sufficient volumes via breast / bottle feeding to
maintain adequate growth / hydration status and in infants requiring tube feedings for long i.e., >3,6months.

 Has not received general acceptance due to high incidence of local leaks & infections.

MANAGEMENT OF SOME COMMOM PROBLEMS

RESPIRATORY DISTRESS SYNDROME

 Neonates suspected to have RDS need to be in the neonatal intensive care, and given IV
fluids and oxygen.
 Mild distresscan be managed without ventilator. The neonate may be ventilated if respiratory
distress is significant or is associated with hypoxemia, hypercarbia or acidosis.
 Intermittent mandatory ventilation (IMV) is required in severe disease, while the baby with
moderatedisease can be managed with continuous positive air
way pressure (CPAP).
 Oxygen should be used judiciously in preterm neonates as this may cause oxygen toxicity. Prognosis is
good if appropriate treatment is given.
 Surfactant is indicated in all neonates with RDS; the route of administration is intratracheal. It can
either be given as a rescue treatment in neonates diagnosed to have RDS or prophylactically in
all neonates less than 28 weeks of gestation

NEONATAL SEPSIS

 Preterm babies are at higher risk of developing sepsis because of immaturity of immune
system and exposure to frequent interventions during intensive care.
 Stricthouse keeping routines and high index of suspicion should be maintained to prevent and make
early diagnosis of nosocomial infection.

NECROTIZING ENTEROCOLITIS

Ensure feeding with human milk, trophic feeds, avoidance of hyperosmolar feeds and overinfusion.

INTRAVENTRICULAR HEMORRHAGE

Antenatal corticosteroids, avoidance of rough handling, excessive CPAP and bolus administration
of sodium bicarbonate may reduce the incidence of IVH.

HYPOTHERMIA

Nurse in a thermoneutral environment.

ASPIRATION.

Availability of trained nurses is essential for safe administration of enteral feeds and for
prevention of aspiration of feeds.

PATENT DUCTUS ARTERIOSUS

Avoid over infusion.

CHRONIC LUNG DISEASE

During assisted ventilation, airway pressure should be kept at the bare minimum without
compromising gas exchange.
RETINOPATHY OF PREMATURITY

Maintain PaO2 below 90mm Hg, avoid excessive light, ROP screening

LATE METABOLIC ACIDOSIS

Protein intake should be restricted to 3 g/kg/d and avoid administration of formula feeds.

NUTRITIONAL DISORDERS.

Provide supplements with calcium, phosphorus, vitamin D, vitamin E, iron and folic acid.

DRUG TOXICITY

Side effects of drugs can be reduced by giving lower doses at 12 hourly intervals

THINGS TO BE AVIODED WHILE CARING LBW BABIES

 Routine oxygen administration without monitoring.

 Intravenous immunoglobulins for prophylaxis of neonatal sepsis.
 Prophylactic antibiotics (except during assisted ventilation?)
 Prophylactic administration of indomethacin or high doses of vitamin E.
 Unnecessary blood transfusions (Definite indications include hematocrit of < 40% in a
sick neonate, < 30% in a symptomatic neonate and < 25%% in an asymptomatic neonate).
 Formula feeds
 Rough handling, excessive light and sound

IMMUNIZATIONS

 Preterm babies are able to mount a satisfactory immune response and they can be vaccinated at
the usual chronological age like term babies.
 The dose of vaccine is not reduced in preterm babies.
 O,day vaccines (BCG, OPV, HBV) on the day of discharge from the hospital.

ENSURE FAMILY SUPPORT

 The frightening scene of NICU 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.
 She should be assisted to provide partial kangaroo,mother,care to her baby in the NICU, which would
enhance bonding and promote breast feeding.
 The anxiety and concern of the family should be cushioned by providing necessary emotional
support and guidance.

DISCHARGE POLICY

 The mother should be mentally prepared and providedwith essential training and skills for handling a
preterm baby before she is discharged from the hospital.
 The baby should be stable, maintaining his body temperature and should not have any evidences
of cold stress.
 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

FOLLOW-UP PROTOCOL

After discharge from the hospital, babies should beregularly followed up for assessment of the following
parameters.

 Common infective illnesses, reactive airway disease, hypertension, renal dysfunction, gastro
esophageal reflux.
 Feeding and nutrition.
 Immunizations.
 Physical growth, nutritional status, anemia, osteopenia/rickets.
 Neuromotor development, congnition and seizures.
 Eyes: Retionopathyof prematurity, vision and strabismus.
 Hearing.
 Behaviour problems, language disorders and learning disabilities

NURSING MANAGEMENT

Assessment:

 Obtain detailed antenatal, intra-natal history.

 Assess the gestational age and birth weight of the baby.
 Assess the features of clinical immaturity.
 Assesss the behaviour of preterm neonate.
 Assessment of common problems:
The infants respiratory status must be observed constantly. The lungs are assessed for adventitious
breath sounds or areas of absent breath sounds. The Silverman-Anderson index ia s useful tool for
evaluating the degree of respiratory distress. Look for the apneic spells.
Thermoregulation: the infant’s temperature is monitored continuously by a skin probe on the infant’s
abdomen, which is attached to the heat control mechanism of the radiant warmer. The temperature
usually maintained at 36 degree to 36.5 degree Celsius. It should be recorded every 30 to 60 minutes
initially and every 3 to 4 hours when stable. Assess axillary temperature every 4 to 8 hours and
compare with the probe temperature. Look for signs of hypothermia.
Feeding and electrolyte balance: monitor intake-output of fluids determine fluid balance. The nurse
also must track of the amount of blood taken. Assess the urine output by weighing the diapers. Weigh
the child daily. Look for signs of dehydration ( decreased urine output <1ml/hr, increased specific
gravity, weight loss and dry skin and mucous membrane, sunken fontanel, increased sodium) or
overhydration ( increased urine output >3ml/hr with a below normal specific gravity, edema, weight
gain, bulging fontanelles, moist breath sounds and decreased blood sodium and protein).
Skin: frequently assess the condition of the infant’s skin and record any changes. The infant’s response
to product used for cleansing and disinfection must be noted.
 Infection: the nurse should be alert for signs of infection at all times like general signs, respiratory,
cardio-vascular, GI and neurologic signs.
Pain: because pain is afifth vital sign, it should be assessed frequently (high pitched cry, intense and
harsh cry, mouth open, grimacing, furrowing or bulging of the brow, tense,rigid muscles and color
changes) and must assess the response to potentially painful stimuli and to pharmacologic and non-
pharmacologic interventions.
 Assess the amount of noise to which the infant is exposed. Determine how often interruptions occur
and how the infant responds to different types of care.
 Assess the infant’s adjustment to feeding, readiness for change and indicating intolerance.
 Assess the activity level of the preterm baby.
 Continually assess the infant’s responses to all feeding methods and watch for distress, weigh the
infant dailynand observe the change’s ability to take feedings. Assess the improvement in suck and
swallow co-ordination.
 Assess the parental anxiety and promote maternal bonding and assess the support system and coping
pattern.
 Assess the knowledge level and support decision making.

Nursing diagnosis and interventions:

1. Impaired gas exchange related to immaturity of lungs and deficiency of surfactant

Interventions:

 Assess the respiratory pattern and colour of the baby

 Observe for any apneic episode.
 Oxygen hood is often used for able to breathe alone but need extra oxygen.
 Oxygen also may be given by nasal cannula to the infant who breathes alone.
 Humidify the oxygen
 CPAP may be necessary to keep the alveoli open and improve expansion of lungs
 Frequent monitoring of ABG
 Frequent position changes every 2 to 3 hours
 Check the suction equipment and suction the airway and applied for only 5 to 10 seconds.
 The mouth is suctioned before the nose.
 Maintain adequate hydration
2. Impaired breathing pattern : distress related to immaturity and surfactant deficiency
 Asess the respiratory rate,heart rate and chest retractions
 Position the child for maximal ventilatory efficiency and airway patency
 Provide humidified oxygen
 Spo2 monitoring
  Provide suctioning
 Provide chest physio therapy
 Administer bronchodilators
 Administer anti inflammatory medications
 Administer antibiotics
3. Activity intorance related to increased work of breathing secondary to distress
 Arrange to provide routine care
 Schedule periods of uninterrupted rest
 Determine infant’s stress level
 Reduce nonessential lighting
 Use positioning devices
4. Ineffective airway clearance related toexcessive trachea-bronchial secretions
 Assess the child’s breathing pattern
 Check the vital signs
 Provide suctioning
 Provide humidified oxygen
 Assess the ABG analysis
 Provide C-PAP using mask /hood/nasal prongs
 Observe for risks of C-PAP
 Assist in CMV with PEEP if needed
5. Hypothermia related to immature thermoregulation system
 Monitor vital signs frequently
 Wrap the baby well and keep warm
 Provide small and frequent breast feeding as tolerated
 Look for hypoglycemia
 Administer IV fluids if not tolefeed intolerance
 Monitor the vital signs and blood pressure
 Assess the skin tone, pallor and signs of dehydration
 Administer IV fluids
 Assess the lab investigations for Hb, RBCs, platelet count, coagulation profile
 If necessary, administer blood
 Administer required amount of inj. Vitamin K
6. Imbalanced nutrition less than body requirement related to feeding difficulty, respiratory distress,or
NPO status
 Assess the sucking and swallowing ability of the newborn
 Assess the tolerance of the child
  Monitor the blood glucose level frequently
 Administer IV fluids if not tolerating oral fluids
 Administer human milk fortifier if the child is preterm
7. Fatigue related to increased demand for nutrients and deterioration of the general condition of the baby
 Assess the general condition of the baby
 Assess the level of activity
 Monitor the blood glucose level
 Breast fed the baby
 Check for from any part of the body
 Provide top up feed
8. Risk for complications hypotension, shock, cerebral hypoxia related to progression of the disease
condition
 Assess the vital signs, respiratory rate, pulse rate, temperature and blood pressure
 Check blood culture and sensitivity and sepsis screening
 Monitor for any signs of dehydration
 Administer IV fluids or blood as necessary
 Assess the serum electrolyte values andABG values
 Closely monitor for the early signs and symptoms of complications
9. Anxiety of parents related to the outcome of the newborn condition
 Assess the mental status, anxiety and knowledge of family members
 Assess the supporting system for the family
 Assess the coping strategies of the family members
 Explain the disease process to the family members
 Explain each and every procedure to the care giver
 Provide psychological supporttothefamily members
10. Interrupted mother-child bonding related to infectious process
 Assess the breast feeding ability including sucking and swallowing ability
 Keep the child with the mother if possible
 Provide frequent breast feed 2 hourly
 If breast feeding is not tolerated give EBM
 Allow the mother to visit the child
 Provide kangaroo mother care in case of pre term if tolerated
11. Interrupted family process related to hospitalization of the newborn
 Assess the mental status, anxiety and knowledge of family members
 Encourage mother-child bonding if possible
 Assess the coping strategies of the family members
  Explain the disease process to the family members
 Explain each and every procedure to the care giver
 Allow the family members to visit the child
12. Knowledge deficit regarding care of the baby and treatment modalities
 Assess the knowledge level of the care giver
 Explain disease condition and it’s progress to the family members
 Educate regarding treatment and its prevention
 Educate about the monitoring of the baby
 Provide adequate explanation regarding nutritional need of the baby
 Clarify their doubts and promote understanding
13. Risk for delayed growth and development related to prematurity
14. Risk for caregiver role strain related to need for long term care

COMPLICATIONS

 Birth asphyxia
 Hypothermia
 Feeding difficulties
 Infections
 Hyperbilirubinemia
 Respiratory distress
 Apneic spells
 Intraventricular hemorrhage
 Hypoglycemia
 Metabolic acidosis

INTRA UTERINE GROWTH RETARDATION ( IUGR)

Intrauterine growth retardation (IUGR) occurs when the unborn baby is at or below the 10th weight
percentile for his or her age (in weeks). (D.C Dutta,2004)

The fetus is affected by a pathologic restriction in its ability to grow. Other names of IUGR babies are

 Intra Uterine Growth Restriction

 Small for gestational age (SGA)

 Fetal growth restriction

 'Wasted' and 'stunted'

DEFINITION

The most common definition of intrauterine growth restriction (IUGR) is a fetal weight that is
below the 10th percentile for gestational age as determined through an ultrasound. This can also be called
small-for gestational age (SGA) or fetal growth restriction
 TYPES

The babies with intrauterine growth failure do not constitute a homogeneous group and are composed
of at least three types of babies.

1.Malnourished small-for-dates babies (asymmetric IUGR)

The fetus gets malnourished during the latter part of gestation due to placental dysfunction and appears
long, thin and marasmic .Head circumference and brain weight are unaffected or show minima1reduction
while internal organs, such as liver is grossly shrunken, so that brain/liver weight ratio is more than five. Head
circumference is generally more than 3 cm bigger than chest circumference. Double-skin fold thickness is
reduced.· Due to loss of subcutaneous fat, skin is loose. and often hangs in folds at buttocks. The ponderal
index can be calculated as follows:

P.I. = Weight in grams I (Length in cm)3 x 100

The index is usually less than 2 in these infants as compared to ponderal index of more than 2.5 in term AGA
infant. The growth retardation is mainly due to reduction in the size of cells whereas the number of cells are
unaffected.

2.Hypoplastic small-for-dates babies (symmetric IUGR)

Intrauterine infections and certain genetic and chromosomal disorders exert their adverse influence
from early embryonic life and result in reduced growth potential of the fetus. The baby is proportionately
small in all parameters including the head size. The ponderal index is usually more than 2. They have a high
incidence of congenital anomalies including abnormal palmar creases and dermatoglyphics. Their cell
population is also reduced, resulting in permanent mental and physical growth retardation.

3.Mixed small-for-dates babies

They are the outcome of adverse intrauterine environmental influences operating from early or mid
pregnancy. These infants, though small for the period of their gestation, neither look obviously malnourished
nor grossly hypoplastic. They show varying degrees of reduction in cell population and size. The
constitutionally small babies of small mothers also fall into this category.

Features of symmetrical and asymmetrical IUGR fetuses

Symmetrical Asymmetrical

Uniformly small Head larger than abdomen

Normal P.I Low
Etiology is genetic disease or infection Chronic placental insufficiency
Total cell no is less Normal
Cell size is normal Smaller
 Neomatal course is complicated with poor Uncomplicated,good prognosis
Prognosis

Newer classification

 Normal small fetuses- have no structural abnormality, normal umbilical artery & liquor but wt., is
less.They are not at risk and do not need any special care.

 Abnormal small fetuses- have chromosomal anomalies or structural malformations. They are lost
cases and deserve termination as nothing can be done.

 Growth restricted fetuses- are due to impaired placental function.Appropriate& timely treatment or
termination can improve prospects

PROBLEMS OF IUGR BABIES

 Low birth weight

 Difficulty handling the stresses of vaginal delivery

 Decreased oxygen levels

 Hypoglycemia (low blood sugar)

 Low resistance to infection

 Low Apgar scores (a test given immediately after birth to evaluate the newborn's physical condition
and determine need for special medical care)

 Meconium aspiration (inhalation of stools passed while in the uterus), which can lead to breathing
problems

 Trouble maintaining body temperature

 Abnormally high red blood cell count

 In the most severe cases, IUGR can lead to stillbirth. It can also cause long-term growth problems.

RISK FOR DEVELOPING IUGR

Pregnancies that have any of the following conditions may be at a greater risk for developing IUGR:

1. General- Racial / Ethnic origin, Small maternal / paternal height / weight, Fetal sex.

2. Maternal causes.

3. Fetal causes.

4. Placental causes.

5. Idiopathic- In a majority of cases (40%) the cause is unknown– probably due to placental
insufficiency.

Maternal causers

 Maternal weight of less than 100 pounds

 Poor nutrition during pregnancy

 Use of drugs, cigarettes, and/or alcohol: Tobacco use is a risk factor for placental abruption and
accounts as a factor for 15% of preterm births and 20-30% of ELBW infants.

 Pregnancy induced hypertension (PIH)

 Placental abnormalities

 Multiple pregnancy

 Gestational diabetes in the mother

 Low levels of amniotic fluid or oligohydramnios

 Advanced diabetes

 High blood pressure or heart disease

 Infections such as rubella, cytomegalovirus, toxoplasmosis, and syphilis

 Kidney disease or lung disease

 Malnutrition or anemia

 Sickle cell anemia

Fetal causes

• Fetal causesExposure to an infection-German measles (rubella), cytomegalovirus, herpes simplex,

tuberculosis, syphilis, or toxoplasmosis, TB, Malaria, Parvo virus B19.

• A birth defect (cardiovascular, renal, anencephally, limb defect, etc).

• A chromosome defect- trisomy-18 (Edwards’ syndrome),21(Down’s syndrome), 16, 13, xo (turner’s

syndrome).

• A primary disorder of bone or cartilage.

• A chronic lack of oxygen during development (hypoxia).

• Developed outside of the uterus.

• Inborn errors of metabolism

• Cardiovascular disease

• Multiple gestation (twins, triplets, or more).

Placenta or Umbilical cord defects.

• Placental causes Uteroplacental insufficiency resulting from -.

– Improper / inadequate trophoblastic invasion and placentation in the first trimester.

– Lateral insertion of placenta.

– Reduced maternal blood flow to the placental bed.

 • Fetoplacetal insufficiency due to-.

– Vascular anomalies of placenta and cord.

– Decreased placental functioning mass-.

Small placenta, abruptio placenta, placenta previa, post term pregnancy.

PATHOPHYSIOLOGY

Reduced availability of nutrients in the mother

Reduced transfer of nutrients by the placenta to the fetus

Reduced utilization by the fetus

Brain cell size and cell numbers are reduced

Reduced liver glycogen content

Intra uterine hypoxia

IUGR

SYMPTOMS

 The main symptom of IUGR is a small for gestational age baby. Specifically, the baby's estimated
weight is below the 10th percentile -- or less than that of 90% of babies of the same gestational age.

 Depending on the cause of IUGR,

 The baby may be small all over or look malnourished.

 They may be thin and pale and have loose, dry skin.

 The umbilical cord is often thin and dull instead of thick and shiny.
DIAGNOSIS

 Diagnosis important things when diagnosing IUGR is to ensure accurate dating of the pregnancy.
Gestational age can be calculated by using the first day of your last menstrual period (LMP) and also
by early ultrasound calculations.

 Once gestational age has been established, the following methods can be used to diagnose IUGR:

 Fundal height that does not coincide with gestational age

 Measurements calculated in an ultrasound are smaller than would be expected for the gestational age

 Lab studies

- Blood sugar - urine shell vial (cmv)

- calcium - viral cultures (hsv)

- CBC diff/plt - Bilirubin

- head ultrasound - chromosomes

- totalIgMvs specific

 Abnormal findings discovered by a Doppler ultrasound.

 Uterine artery Doppler measurement

 Umbilical artery Doppler measurement

 Middle cerebral artery Doppler.

PREVENTION

Strategies include

 Prenatal care modalities,

 Protein/energy supplementation.

 Treatment of anaemia,

 Vitamin/mineral supplementation,

 Fish oil supplementation

 Prevention and treatment of :

 Hypertensive disorders,

 Foetal compromise

 Infection.
Management and Delivery Planning
Hypothermia?
The goal in the management of IUGR, because no
effective treatments are known, is to deliver the most Decreased subcutaneous fat,
mature fetus in the best physiological condition possible increased surface- volume ratio,
while minimizing the risk to the mother.
decreased heat production
Once IUGR has been detected, the management of the Hypoglycemia?
pregnancy should depend on a surveillance plan that
maximizes gestational age while minimizing the risks of Decreased glycogen stores/
neonatal morbidity and mortality. glycogenolysis/ gluconeogenesis/increased
metabolic rate/deficient catecholamine
TREATMENT release

IUGR has many causes, therefore, there is not one Hypocalcemia?

treatment that always works.
Associated with perinatal stress,
 Although there are many causes of IUGR, the asphyxia, prematurity
treatment consists of either delivery or remaining in
utero and improving blood flow to the uterus.

 When blood flow is improved, the delivery of oxygen and other nutrients to the foetus occurs. If the
foetus is lacking in these substances, their increased availability may result in improved growth and
development.

 If IUGR is caused by a problem with the placenta and the baby is otherwise healthy, early diagnosis
and treatment of the problem may reduce the chance of a serious outcome.

 There is no treatment that improves foetal growth, but IUGR babies who are at or near term have the
best outcome if delivered promptly.

MATERNAL BED REST

This is the initial approach for the treatment of IUGR. The benefit of bed rest is that it results in
increased blood flow to the uterus. Studies have shown, however, that in most cases bed rest at home is just as
effective as bed rest in the hospital environment.

ASPIRIN THERAPY

 The use of aspirin to treat foetuses with IUGR is still controversial.

 If aspirin is used, it may be advantageous if given to patients before 20 weeks of gestation. It is

minimal to limited benefit if given at the time of diagnosis (third trimester).

At the present time it is not recommended as a form of prevention for low risk patients.

OTHER FORMS OF TREATMENT

Other forms of treatment that have been studied are

 Nutritional supplementation,

 Zinc supplementation,
  Fish oil,

 Hormones and

 Oxygen therapy.

RISKS OF IUGR

• Increased perinatal morbidity and mortality.

– Intra uterine / Intrapartum death.

– Intrapartuum fetal acidosis characterized by-.

• Late deceleration.

• Severe variable deceleration.

• Beat to beat variability.

• Episodes of bradicardia.

– Intrapartum fetal acidosis may occur in as many as 40 % of IUGR, leading to a high incidence
of LSCS.

– IUGR infants are at greater risk of dying because of neonatal complications- asphyxia,
acidosis, meconium aspiration syndrome, infection, hypoglycemia, hypothermia, sudden infant
death syndrome.

 IUGR infants are likely to be susceptible to infections because of impaired

immunity.

MANAGEMENT

 Early delivery is indicated if there is arrest of fetal growth and pulmonary maturity is
satisfactory.

 Fetal 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 adequate feeding must be enusred to prevent hypoglycemia. Breast feeding
should be initiated immediately after birth.

 Symptomatic polycythemia should be managed with partial exchange with plasma or physiological
saline. The blood glucose and hematocrit should be monitored during first three days of life

 When adequately fed, they do not lose weight and start gaining w eight after 2 to 3 days of age.
Their initial weight gain is rapid which subsequently slows down after three months of age.
CONCLUSION
Any infant who is born dysmature (before term or post term, or who is underweight or overweight for
gestational age) is at risk for complications at birth or in the first few days of life. Parents need thorough
education about their baby’s health because these problems require hospitalization or additional follow-up at
home.

BIBLIOGRAPHY

1. Text book on Care of Newborn – Meharban Singh, VI Edition 2004.

2. O.P Ghai Essential Pediatrics, VI Edition, 2004 CBS Publication .
3. Nelson Text Book of Pediatrics – 17th Edition 2004.
4. Johncloherty.EricEichenwald.Manual of Neonatal Care.7th Edition.Lippincottwilliiams and
Wilkins.2012
5. Dipak.K.Guha.GuhasNeonatology.Principles and Practice.3rd Edition.Jaypee publication.
6. Managing Newborn Problems. A guide for doctors, nurses, and midwives: WHO Publication,
2003