Prematurity and IUGR Dr. Kalpana Malla MD Pediatrics Manipal Teaching HospitalDownload more documents and slide shows on The Medical Post [ www.themedicalpost.net ]
• Preterm – born before 37 completed weeks of gestation• IUGR - birth weight is <10TH CENTILE FOR GESTATIONAL AGE or > 2 SDs below mean for GA.
Types of IUGR• Symmetric IUGR: weight,length and head circumference are all below the 10 th percentile. (33 % of IUGR Infants)• Asymmetric IUGR: weight is below the 10 th percentile and head circumference and length are preserved. (55 % IUGR)• Combined type IUGR: Infant may have skeletal shortening, some reduction of soft tissue mass. (12 % of IUGR)
Characteristics of IUGRSymmetric (chronic)• Early onset - Due to 1. intrinsic cong infection or chromosomal genetic defects 2. Extrinsic factor (early gestational life) – maternal malnutrition, alcohol, smoking• Normal ponderal index• Brain symmetrical to body• Decreased growth potentialExamples - Genetic causes, chromosomal - TORCH infections - Anomalad Syndromes
Characteristics of IUGRAsymmetric (acute)• Late onset- Environmental factors• Brain sparing• Has better prognosisExamples• Hypoxia• Preeclampsia (PIH, PET)• Chronic hypertension
Ponderal Index• Way of characterizing the relationship of height to mass for an individual. 3• PI = 1000 x Mass (kgs) Height (cms)• Typical values are 20 to 25.• PI is normal in symmetric IUGR.• PI is low in asymmetric IUGR.
Factors Associated with IUGR• Maternal hypoxemia - Hemoglobinopathies - High altitudes• Others - Short stature - Younger or older age (<15 and >45) - Low socioeconomic class - Primiparity - Grand multiparity - Low pregnancy weight - Previous h/o preterm IUGR baby
• Small but plump • Wasted• Red or very pimk • White or pale pink• Length <50cm • Length ≥ 50 cm• HC<35cm • HC≥ 35 cm• Lanugo hair,vernix ++ • Thick,dark hair• Skin –shiny transparent • Skin – dry,loose thick thin,edematous • Ears,breast,genitalia –• Ears,breast,genitalia – mature premature • Good muscle tone• Hypotonic (floppy
IUGR• Heads are disproportionately large for their trunks and extremities• Facial appearance has been likened to that of a “wizened old man”.
Problems of IUGR (SGA) Infants• Hypoxia - Perinatal asphyxia - Persistent pulmonary hypertension - Meconium aspiration• Thermoregulation - Hypothermia due to diminished subcutaneous fat and elevated surface/volume ratio
Problems of IUGR (SGA) Infants• Metabolic - Hypoglycemia - result from inadequate glycogen stores. - diminished gluconeogenesis. - increased BMR - Glucose needs of hypoxia - Hypothermia - Large brain - Hypocalcemia - due to high serum glucagon level, which stimulate calcitonin excretion
Problems of IUGR (SGA) Infants• Hematologic - hyperviscosity and polycythemia due to increase erythropoietin level sec. to hypoxia• Immunologic - IUGR have increased protein catabolism and decreased in protein, prealbumin and immunoglobulins, which decreased humoral and cellular immunity.
Problems of IUGR (SGA) Infants• Skeletal: Decreased ossification of endochondral & membranous cartilage.• Malformations: Increased incidence of Cong.malformations.
Problems with Premature InfantsHEMATOLOGIC• Anemia (early or late onset)• Hyperbilirubinemia–indirect• Subcutaneous, organ (liver, adrenal) hemorrhage• Disseminated intravascular coagulopathy• Vitamin K deficiency
Management of IUGR• Delivery and Resuscitation• Hypoglycemia - close monitoring of blood glucose - early treatment ( IV dextrose, early feeding )• Hematological Disorder - Hct to detect polycythemia• Congenital infection - TORCH titer screening - Viral cx of urine, nasopharynx - Head CT to r/o calcification
Management-PRETERM /LBW DELIVERY ROOM CARE• Warmth and drying• Resuscitation / Respiratory support • Oxygen blow-by • Bag-and-mask ventilation • Endotracheal intubation and ventilation • Exogenous surfactant • Nasal CPAP if required• Transfer to NICU in transport incubator
CRITERIA FOR NICU ADMISSION OF LBW BABIES *• Gestational age <34 weeks• Birth weight < 1800 g• SGA with birth weight <3rd percentile• Any sick neonate, irrespective of BW and gestational age * Recommendations of the National Neonatology Forum
NICU CARE• Temperature control• Respiratory support• Fluids and electrolytes• Nutritional support• Infection control• Cardiovascular support• Others- Skin care, Hyperbilirubinemia• Suplement
1. TEMPERATURE CONTROL• Aim: a) Maintaining temperature b) Prevent cold stress c) Reduce insensible water loss• Methods: – Radiant warmer (290 C-310 C) – Pre warmed incubator ( 320C- 350C) – Warm room – ( 210 C) – Heat shield – Warm clothing-cap, socks – KMC – Bath postponed
3. FLUID REQUIREMENTFluid requirements are higher in LBWinfants due to – Greater insensible water losses – Faster breathing rates – Decreased ability to concentrate urine – Greater use of radiant warmers – Greater use of phototherapy units
RATE OF ADMINISTRATION* Birth weight Fluid rate(g) (ml/kg/day) 500 - 600 140 - 200 601 - 800 120 - 130 801 - 1000 90 - 110 1000 - 1500 80 - 100 >1500 60 - 80 *on first 2 days of life
RATE OF ADMINISTRATION• Fluid rate can be increased by 10-20 ml/kg/d to gradually reach 150 ml/kg/d• Fluid requirements need to be individualized for each baby• Enteral nutrition has to be considered once the baby is stable
FLUID COMPOSITION & MONITORING• Dextrose solutions to give 6 -8 mg/kg/min of glucose• Sodium supplementation from day 2• Frequent monitoring of • Serum glucose levels • Urine output & specific gravity • Weight (twice daily) • Serum electrolytes (ideally q8h – q12h) • Physical assessment
4. TOTAL PARENTERAL NUTRITION• Indications – Infants with BW ≤ 1000 g – Infants with BW ≤ 1500 g, done in conjunction with slowly advancing enteral nutrition – Infants with BW 1501-1800 g for whom enteral intake is not expected for > 3 days
EARLY ENTERAL NUTRITIONTrophic feeding/ Gut priming Practice of feeding very small amounts of enteral nourishment to stimulate development of the immature GITAdv: Improves GI motility Enhances enzyme maturation Improves mineral absorption Lowers incidence of cholestasis Shortens time to regain birth weight
ENTERAL NUTRITION• Breast milk or ½ or full strength preterm formula at 10ml/kg/d by intermittent gavage/ continuous nasogastric drip• Increase by 10-15 ml/kg/d to reach 150ml/kg/d• Increments not >20 ml/kg/d• IV fluids can be stopped once 120ml/kg/d is reached• On reaching 150ml/kg/d,calorie density can be increased
FEEDING GUIDELINESPRETERMS• <1200 g/ <32 wks: IV fluids for first 2-3 days, once stable start gavage feeding• 1200-1800 g/ 32-34 wks: Start gavage feeding, once vigorous start spoon/ breast feeding
FEEDING GUIDELINES• >1800 g/ >34 wks: Start breast feeding directly; if trial feed takes>20 mins or intake is less than required, switch to gavage feedingTERM IUGRs/ SGA• Breast feeding
PRETERM HUMAN MILKAdvantages: – Higher concentrations of amino acids – Higher concentrations of essential fatty acids – Lower renal solute load – Specific bio-active factors provide immunity – Promotes intestinal maturation
PRETERM HUMAN MILKDisadvantages: – Low concentrations of Vitamin D, Ca, P – Inadequate iron
ENTERAL NUTRITION• Energy : 130 - 175 Kcal/kg/d• Protein :3.4 - 4.2 g/kg/d• Fat :6 - 8 g/kg/d• Na :3 - 7 mEq/kg/d• Cl :3 - 7 mEq/kg/d• K :2 - 3 mEq/kg/d• Ca :100 – 220 mg/kg/d
5. INFECTION CONTROL• LBW infants are at a greater risk of sepsis• Practices that can prevent/minimize infections: – Strict adherence to hand-washing – Minimal handling & clustering of procedures – Barrier nursing – Antibiotics
5. INFECTION CONTROL– Practices that can prevent/minimize infection:– Restriction of broad spectrum antibiotics use– Minimizing duration of mechanical ventilation– Early initiation of enteral feeds– Central & peripheral venous catheter care
7. SKIN CARE• Stratum corneum is deficient in preterms• Mature epidermal barrier is established by 2 weeks post natal age• Limited use of adhesives• Frequent repositioning of infant• Use of soft bedding or water mattress• Prophylactic use of emollients is no longer recommended• Jaundice – early management
8. SUPPLEMENTATION• Human Milk Fortifiers• Calcium:50-100 mg/kg/d from end of 1st week to 40 weeks post-conceptional age• Iron:2-2.5 mg/kg/d from 6-8 wks of age till 12 months of age• Vitamins – Vitamin A(1000U/d) & Vitamin D(400U/d) ,Vit C – 50mg/d from 2 weeks of age – Vitamin E -15 IU/d for VLBW infants till 37 weeks
Outcome• Symmetric vs. Asymmetric IUGR - symmetric has poor outcome compare to asymmetric• Preterm IUGR has high incidence of abnormalities• IUGR with chromosomal disease has 100% incidence of handicap• Congenital infection has poor outcome - handicap rate > 50%• IUGR has higher rate of learning disability.
“Long term” Morbidity of IUGR Factors associated with abnormal outcome ? Microcephaly Hypoxic ischemic encephalopathy Symptomatic hypoglycemia Symptomatic hyperviscosity
Fetal Origins of Adult Diseases ? • Coronary artery disease correlates inversely with birth weight • Rate of non-insulin dependent diabetes mellitus is highest in the “thinnest” babies at birth (low ponderal index) • High serum cholesterol are linked to disproportionate size at birth (body smaller than head) • Increased rate of hypertension in infants who were thin, short, &/or proportionately small at birth
Sequelae of Low Birth weight• Mental retardation• Poor school performance• Spasticity• Seizures• Hydrocephalus• Sensorineural injury-Hearing• Short-bowel syndrome• Malabsorption
Sequelae of Low Birth weight• Visual impairment• Retinopathy of prematurity• Strabismus, myopia• Bronchopulmonary dysplasia,• Bronchospasm• Recurrent pneumonia
Sequelae of Low Birthweight• Growth failure - Failure to thrive• Gastroesophageal reflux• PEM• Osteopenia, fractures,• Anemia
Follow-up• Anemia• Retinopathy of prematurity• Hearing screenings• Cholestasis• Stable temperature regulation• Gaining weight on oral feedings• Nutritional support
Follow-up• Breast-feeding• Appropriate immunizations• Ophthalmologic examination if <27 wk or <1,250?g at birth
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