IUGR
IUGR
Asymmetric IUGR
Chronic fetal distress
(hypoxia)
Preeclampsia
Chronic hypertension
Diabetes classes D to F
Poor caloric intake
Symmetric IUGR
Genetic
Torch
Chromosomal
Anomalad syndromes
Insulin like growth type
1 deficiency
Perinatal problems
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Fetal death
Asphyxia
Meconium aspiration pneumonia
Fasting hypoglycemia
Alimented hyperglycemia
Polycythemia/ hyperviscosity
Temperature instability
Dysmorphology
Pulmonary hemorrhage
Immunodeficiency
Decreased bone mineral density
DIC
Hypoglycemia
1.
2.
3.
4.
5.
6.
Decreased hepatic glycogen stores
Inactive gluconeogenesis
Diminished use and oxidation of FFA
Hyperinsulinism
Deficient catecholamine release
Failure of response to exogenic glucagon
Thermal control
neutral thermal environment“
This environment is a set of thermal conditions, including air
and radiating surface temperatures, relative humidity, and
airflow, at which heat production (measured experimentally as
oxygen consumption) is minimal and the infant's core
temperature is within the normal range.
It is a function of the size and gestational age and
chronological age of an infant; larger, older infants require
lower environmental temperatures than smaller, younger
infants do.
Methods of heat loss
1- conduction
2- convection
3- evaporation
4- irradiation
The concept of "Warm Chain"
 1. Warm delivery room (> 25°C)
 2. Warm resuscitation
 3. Immediate drying
 4. Skin-to-skin contact between baby and the mother
 5. Breastfeeding
 6. Bathing and weighing postponed
 7. Appropriate clothing and bedding
 8. Mother and baby together
 9. Warm transportation
 10. Training/awareness of healthcare providers
KMC
Incubator care
Warmer care
oxygen
Administering oxygen to reduce the risk of
injury from hypoxia and circulatory
insufficiency must be balanced against the
risk of hyperoxia to the eyes (retinopathy of
prematurity) and oxygen injury to the
lungs.
oxygen
Although cyanosis must be treated immediately,
oxygen is a drug and its use must be carefully regulated
to maximize benefit and minimize potential harm. The
concentration of inspired oxygen must be adjusted in
accordance with the oxygen tension of arterial blood
(Pa02) or noninvasive methods such as continuous pulse
oximetry or transcutaneous oxygen measurements.
Oxyhood
Nasal CPAP
pulseoximetery
In general
oxygen saturation should be maintained in the range of 85% to
95%.
Fluid therapy
Water intake in term infants is usually begun at
70 ml/kg on day 1 and increased to 120 ml/kg
by days 2-3.
Smaller, more premature infants may need to
start with
80 ml/kg on day 1 and advance gradually to 150
ml/kg/day.
IV fluid in neonates
day
1
2
3
4
5
6
term
70cc/kg
80cc/kg
90cc/kg
100cc
/kg
110cc
/kg
120cc
/kg
preterm
80cc/kg
90cc/kg
100cc
/kg
110cc
/kg
120cc
/kg
130cc
/kg
7
8
140cc
/kg
150cc
/kg
Insensible water loss
BW
<1000
1000 - 1250
1251 - 1500
1501 - 1750
1751 - 2000
>2000
IWL(cc/kg/day)
65
55
40
25
20
20
IV fluid
 Daily weights
 urine out put - USG
 BUN

Na
should be monitored carefully to determine water balance
and fluid needs.
Clinical observation and physical examination are poor
indicators of the state of hydration of premature infants.
TPN
 The goal of parenteral alimentation is to deliver
sufficient calories from glucose, protein, and lipids to
promote optimal growth.
 If a peripheral vein is used, it is advisable to keep the
glucose concentration below 12.5 g/ dL. If a central vein
is used, glucose concentrations as high as 25 g/ dL may
be used (rarely).
 Intralipid may be initiated at 0.5 g/kg/24 hr and
advanced to 3 g/kg/24hr, if triglyceride levels remain
normal; 0.5 g/kg/24 hr is sufficient to prevent essential
fatty acid deficiency.
 Aminoacids may be initiated at 0.5-1g/kg on first day of
life, advanced to 1.5g/kg/day.
Control
Intralipid infusion with TG
Triglyceride concentrations are most often used as an
indication of lipid tolerance, and maintaining
triglyceride
concentrations below 150 to 200 mg/ dL seems prudent.
Aminoacid infusion with ALT – AST
Glucose infusion with BS
Weight gain
After a caloric intake of
>100 kcal/kg/24 hr
is established by total parenteral intravenous nutrition,
LBW infants can be expected to gain about
15 g/kg/24 hr.
Feeding
Oral feeding (nipple) should not be initiated or should be
discontinued in infants with:
1.
2.
3.
4.
5.
6.
7.
8.
9.
respiratory distress,
hypoxia,
circulatory insufficiency,
excessive secretions,
gagging,
Severe sepsis
central nervous system depression,
severe immaturity, or
signs of serious illness.
Oral feeding
The process of oral alimentation requires, in
addition to a strong sucking effort, coordination
of swallowing, epiglottal and uvular closure of
the larynx and nasal passages, and normal
esophageal motility, a synchronized process that
is usually absent before 34 wk of gestation.
feeding
most infants
weighing <1,500 g
require tube
feeding because
they are unable to
coordinate
breathing, sucking,
and swallowing.
Methods of feeding
intermittent bolus feedings
continuous feeding
nasojejunal feeding
Gastrostomy feeding
Trophic feeding
is the practice of feeding very small amounts of enteral
nourishment to VLBW preterm infants to stimulate
development of the immature gastrointestinal tract.
The benefits of trophic feeding include enhanced gut
motility, improved growth, decreased need for parenteral
nutrition, fewer episodes of sepsis, and shortened hospital
stays.
Feeding advancement
Feeding is started at
1cc/kg q3h,
the rate of daily advancement should not be more than
20cc/kg/day.
Drop back in feeding
vomiting, abdominal distention, or gastric
residuals from previous feedings should arouse
suspicion of
sepsis,
necrotizing enterocolitis, or
intestinal obstruction.
Adding supplements
When the amount of feeding approaches 120cc/kg/day
corresponding to caloric intake of
80kcal/kg/day
the milk should be fortified by adding supplements.
Supplements
1-folic acid ¼ tab qd for 3months
2-vitamin E ¼ tab qod for 3months
3-zinc sulfate 1-2mg/kg daily for 6months
4-Ferrous sulfate 2-4mg/kg day*
5-calcium as gluconate salt 100mg/kg/day
6-phosphorus as phosphate Sandoze 50mg/kg/day
7-multivitamin 1ml daily(400U vitamin D)
8-Erythropoietin 250-400U/kg SC three days/week for
3weeks if birth weight is 1250-1500 and for 6weeks if
birth weight is below 1250g.
Ferrous sulfate
*ferrous sulfate is started at 2mg/kg from the age 2 weeks
if birth weight is 1500-2500g and at 4mg/kg from the age of
4 weeks if birth weight is less than 1500g.
In those babies under erythropoietin treatment the dose
of ferrous sulfate is 6mg/kg.
Preterm formula
 Premature formulas contain a reduced amount of lactose (40% to 50%)
because intestinal lactase activity may be low in premature infants. The
remainder of the carbohydrate content is in the form of glucose
polymers, which maintain low osmolality of the formula.
 The fat blends of preterm formulas are 20% to 50% MCTs to compensate
for low intestinal lipase and bile salts.
 The protein content
of preterm formulas is higher than that of
term formulas (2.7 to 3 g/100 kcal), which promotes a rate of
weight gain and body composition similar to that of the reference
fetus. Premature formulas are whey predominant, which
reduces the risk of lactobezoar formation and may provide a
more optimal amino acid intake.
 Calcium and phosphorus
content is also higher in preterm formulas, which results in
improved mineral retention and bone mineral content.
Preterm formula
If the baby is taking
preterm formula at
150cc/kg/day
there will be no need
for adding the
supplements.
Growth
 SGA neonates who have symmetric IUGR related
to congenital viral, chromosomal, or
constitutional syndromes remain small
throughout life.
 Those infants whose intrauterine growth was
inhibited late in gestation because of uterine
constraints, placental insufficiency, or
nutritional deficits will have catch-up growth
after birth and approach their
inherited growth potentials when provided with
an optimal environment.
Developmental outcome
Intellectual and neurologic functions in IUGR depends on the presence or
absence of adverse perinatal events , in addition to the specific cause of
IUGR.
Cerebral morbidity will be worsened by hypoxic ischemic
encephalopathy subsequent to birth asphyxia, and by the postnatal
problems of hypoxia and hypoglycemia.
When these perinatal problems are minimal or are avoided, the neonate who is
SGA may still demonstrate cerebral developmental problems, especially in the
presence of relative head growth retardation.
Another major determining influence on neonatal neurodevelopmental
outcome in infants who are SGA is the family socioeconomic status.
vaccination
 Palivizumab (Synagis) should be given
according to the respiratory syncytial
virus (RSV) policy.
 Breast feeding by a mother who is positive
for hepatitis B surface antigen (HBsAg)
poses no additional risk for acquisition of
hepatitis B virus (HBV) infection by the
infant.
Vaccination schedule
age
birth
vaccine
comments
BCG- OPV
hepatitis B
0.05ml dose in
infants for
BCG
2 months
DPT- OPV
hepatitis B
4 months
6 months
DPT- OPV
12 months
18 months
4-6 years
MMR
DPT- OPV
hepatitis B
DPT- OPV
DPT- OPV
MMR
Retinopathy of prematurity
IVH= intraventricular hemorrhage
Bleeding from subepandymal germinal matrix.
Grade1= bleeding is confined to germinal matrix
Grade 2=intraventricular hemorrhage without ventricular
dilation
Grade3=intraventricular hemorrhage with acute
ventricular dilation (clot fills >50% of the ventricle)
Grade4= intraparenchymal lesion
intraventricular hemorrhage
Intraventricular hemorrhage
AOP= apnea of prematurity = idiopathic apnea
Apnea: Cessation of respiration for more than 20 seconds,
or any duration if associated with bradycardia and
cyanosis.
The etiology of AOP is immature respiratory center.
NEC=necrotizing enterocolitis
A common gastrointestinal emergency of premature neonates that
presents with abdominal distention and can culminate in intestinal
perforation if left untreated.
Etiology: ischemia + infection + concentrated formula
Stage 1
Suspected NEC
Abdominal distention – bloody stools –
emesis – gastric residuals
Stage 2
Proven NEC
Pneumatosis intestinalis and/or portal
venous gas ± metabolic acidosis –
thrombocytopenia
Stage 3
Advanced NEC
Pneumoperitoneum – hypotension –
DIC – neutropenia