This document discusses prematurity, intrauterine growth restriction (IUGR), and their associated risks and management. It covers: - Definitions and types of prematurity and IUGR - Characteristics and causes of symmetric vs asymmetric IUGR - Problems that can occur in IUGR and premature infants like respiratory distress, hypoglycemia, and intraventricular hemorrhage - Factors associated with IUGR including placental and maternal factors - Guidelines for admission to the neonatal intensive care unit (NICU) - Important aspects of care in the NICU like temperature control, respiratory support, fluid management, and infection control

1. Prematurity and IUGR
Dr. Kalpana Malla
MD Pediatrics
Manipal Teaching Hospital
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3. • Preterm – born before 37 completed
weeks of gestation
• IUGR - birth weight is <10TH CENTILE
FOR GESTATIONAL AGE
or > 2 SDs below mean for GA.

4. 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)

5. Characteristics of IUGR
Symmetric (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 potential
Examples - Genetic causes, chromosomal
- TORCH infections
- Anomalad Syndromes

6. Characteristics of IUGR
Asymmetric (acute)
• Late onset- Environmental factors
• Brain sparing
• Has better prognosis
Examples
• Hypoxia
• Preeclampsia (PIH, PET)
• Chronic hypertension

7. 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.

8. Causes of Preterm Birth
FETAL
• Fetal distress
• Multiple gestation
• Erythroblastosis
• Nonimmune hydrops
PLACENTAL
• Placental dysfunction
• Placenta previa
• Abruptio placentae

9. Causes of Preterm Birth
UTERINE
• Bicornuate uterus
• Incompetent cervix (premature
dilatation)

10. Causes of Preterm Birth
MATERNAL
• Preeclampsia
• Chronic medical illness (e.g., cyanotic
heart disease, renal disease)
• Infection (e.g., Listeria monocytogenes,
group B streptococcus, urinary tract
infection, bacterial vaginosis,
chorioamnionitis)
• Drug abuse (e.g.cocaine)

11. Causes of Preterm Birth
OTHER
• Premature rupture of membranes
• Polyhydramnios
• Trauma

12. Factors Associated with IUGR
FETAL
• Chromosomal disorders
• Chronic fetal infections (e.g.,
cytomegalic inclusion disease, congenital
rubella, syphilis)
• Congenital anomalies–syndrome
complexes
• Irradiation

13. Factors Associated with IUGR
FETAL
• Multiple gestation
• Pancreatic hypoplasia
• Insulin deficiency
• Insulin-like growth factor type I
deficiency

14. Factors Associated with IUGR
PLACENTAL FACTORS
• Placental insufficiency ( most imp in 3rd trimester)
• Villous placentitis (bacterial, viral, parasitic)
• Infarction
• Tumor (chorioangioma, hydatidiform mole)
• Premature placental separation
• Small Placenta
• Twin transfusion syndrome

15. Factors Associated with IUGR
Maternal Factors:
• Decrease Uteroplacental blood flow:
- Pre eclampsia / eclampsia
- chronic renovascular disease
- Chronic hypertension
• Maternal malnutrition, & chronic illness
• Multiple pregnancy
• Drugs
- Cigarettes, alcohol, heroin, cocaine
- Teratogens, antimetabolites and therapeutic
agents warfarin, phenytoin

16. 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

19. • 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

20. IUGR
• Heads are disproportionately large for their
trunks and extremities
• Facial appearance has been likened to that of
a “wizened old man”.

21. 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

22. 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

23. 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.

24. Problems of IUGR (SGA) Infants
• Skeletal: Decreased ossification of
endochondral & membranous cartilage.
• Malformations: Increased incidence of
Cong.malformations.

25. Problems of IUGR (SGA) Infants
Dysmorphology
• Syndrome anomalads
• chromosomal-genetic disorders
• Oligohydramnios-induced deformations
• TORCH infection
• Pulmonary hemorrhage

26. Problems with Premature Infants
RESPIRATORY
• Respiratory distress syndrome (hyaline
membrane disease)
• Bronchopulmonary dysplasia
• Pneumothorax, pneumomediastinum;
interstitial emphysema
• Congenital pneumonia
• Pulmonary hypoplasia
• Pulmonary hemorrhage
• Apnea

27. Problems with Premature Infants
CARDIOVASCULAR
• Patent ductus arteriosus
• Hypotension
• Hypertension
• Bradycardia (with apnea)
• Congenital malformations

28. Problems with Premature Infants
HEMATOLOGIC
• Anemia (early or late onset)
• Hyperbilirubinemia–indirect
• Subcutaneous, organ (liver, adrenal)
hemorrhage
• Disseminated intravascular coagulopathy
• Vitamin K deficiency

29. Problems with Premature Infants
GASTROINTESTINAL
• Poor gastrointestinal function–poor
motility
• Necrotizing enterocolitis
• Congenital anomalies producing
polyhydramnios
• Spontaneous gastrointestinal isolated
perforation

30. Problems with Premature Infants
METABOLIC-ENDOCRINE
• Hypocalcemia
• Hypoglycemia
• Hyperglycemia
• Late metabolic acidosis

31. Problems with Premature Infants
RENAL
• Dyselectrolytemia – hyponatremia,
hypernatremia,hyperkalemia
• Renal tubular acidosis

32. Problems with Premature Infants
CENTRAL NERVOUS SYSTEM
• Intraventricular hemorrhage
• Periventricular leukomalacia
• Hypoxic-ischemic encephalopathy
• Seizures
• Retinopathy of prematurity
• Deafness
• Hypotonia

33. Problems with Premature Infants
• Congenital malformations
• Kernicterus (bilirubin encephalopathy)
• Drug (narcotic) withdrawal
OTHER
• Infections (congenital, perinatal,
nosocomial: bacterial, viral, fungal,
protozoal)

34. 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

35. Management of IUGR
• Genetic anomalies
- screening- chromosomal analysis
• Others
- serum calcium to r/o hypocalcemia
- Mx - meconium aspiration

36. 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

37. 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

38. NICU CARE
• Temperature control
• Respiratory support
• Fluids and electrolytes
• Nutritional support
• Infection control
• Cardiovascular support
• Others- Skin care, Hyperbilirubinemia
• Suplement

39. 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

40. KANGAROO MOTHER CARE
• Benefits
– Thermoregulation
– Exclusive breast feeding
– Physiologic stability
– Decreased incidence of infection
– Infant-mother bonding
– Cost effective

41. 2. RESPIRATORY SUPPORT
• Free flow oxygen
• Ventilatory support
• Surfactant therapy

42. 3. FLUID REQUIREMENT
Fluid requirements are higher in LBW
infants due to
– Greater insensible water losses
– Faster breathing rates
– Decreased ability to concentrate urine
– Greater use of radiant warmers
– Greater use of phototherapy units

43. 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

44. 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

45. 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

46. 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

47. TOTAL PARENTERAL NUTRITION
• Glucose : 6 - 8 mg/kg/min
• Amino acids : 1.5 - 2 g/kg/d
• Lipid : 0.5 - 1 g/kg/d
• Sodium : 2 - 4 mEq/kg/d
• Potassium : 2 - 3 mEq/kg/d
• Chloride : 2 - 4 mEq/kg/d

48. TOTAL PARENTERAL NUTRITION
• Calcium
• Phosphorous
• Magnesium
• Others:
– Zinc
– Copper
– Chromium
– Selenium
– Molybdenum

49. EARLY ENTERAL NUTRITION
Trophic feeding/ Gut priming
Practice of feeding very small amounts of
enteral nourishment to stimulate
development of the immature GIT
Adv:
 Improves GI motility
 Enhances enzyme maturation
 Improves mineral absorption
 Lowers incidence of cholestasis
 Shortens time to regain birth weight

50. 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

51. FEEDING GUIDELINES
PRETERMS
• <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

52. 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 feeding
TERM IUGRs/ SGA
• Breast feeding

53. PRETERM HUMAN MILK
Advantages:
– Higher concentrations of amino acids
– Higher concentrations of essential fatty
acids
– Lower renal solute load
– Specific bio-active factors provide
immunity
– Promotes intestinal maturation

54. PRETERM HUMAN MILK
Disadvantages:
– Low concentrations of Vitamin D, Ca, P
– Inadequate iron

55. 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

56. 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

57. 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

58. 6.CARDIOVASCULAR SUPPORT
• Blood pressure maintenance with
• Fluids
• Pressor agents if required
• PDA:
– Fluid restriction
– Diuretic therapy
– Increased ventilatory support
– Indomethacin therapy
– Surgical ligation

59. 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

60. 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

61. 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.

62. “Long term” Morbidity of IUGR
Factors associated with abnormal
outcome ?
Microcephaly
Hypoxic ischemic encephalopathy
Symptomatic hypoglycemia
Symptomatic hyperviscosity

63. 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

64. Sequelae of Low Birth weight
• Mental retardation
• Poor school performance
• Spasticity
• Seizures
• Hydrocephalus
• Sensorineural injury-Hearing
• Short-bowel syndrome
• Malabsorption

65. Sequelae of Low Birth weight
• Visual impairment
• Retinopathy of prematurity
• Strabismus, myopia
• Bronchopulmonary dysplasia,
• Bronchospasm
• Recurrent pneumonia

66. Sequelae of Low Birthweight
• Growth failure - Failure to thrive
• Gastroesophageal reflux
• PEM
• Osteopenia, fractures,
• Anemia

67. Follow-up
• Anemia
• Retinopathy of prematurity
• Hearing screenings
• Cholestasis
• Stable temperature regulation
• Gaining weight on oral feedings
• Nutritional support

68. Follow-up
• Breast-feeding
• Appropriate immunizations
• Ophthalmologic examination if <27 wk
or <1,250?g at birth

69. Thank you
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