These are the disorders of weight and gestation.

2. Lecture-8
Prof. Dr. Sunil Natha Mhaske
Dean
Dr. Vithalrao Vikhe Patil Foundation’s Medical College and Hospital,
Ahmednagar (M.S.) India-414111
Mo- 7588024773
Mail-sunilmhaske1970@gmail.com
Preterm, post-term, SGA and LGA babies.

3. Preterm Birth (Premature Birth)
• Preterm birth is the most common cause of death among infants
worldwide
• About 15 million babies are preterm each year i.e. 5% to 18% of
all deliveries.
• Any live baby born before 37 completed weeks of gestational age
or 259 days irrespective of the birth weight.
• These babies are known as preemies or premmies

4. Sub-categories of preterm birth-
 Late preterm- baby born between 34 and 36 completed
weeks of pregnancy.
 Moderately preterm- baby born between 32 and 34 weeks
of pregnancy.
 Very preterm- baby born at less than 32 weeks of pregnancy
 Extremely preterm- baby born at or before 25 weeks of
pregnancy

5. Risk Factors for Prematurity-
Diabetes Underweight
High blood pressure Vaginal infections
Pregnant with more than one baby Tobacco smoking
Obese Psychological stress.

6. Growth and Developmental milestones in premature
babies:
• A premature baby’s development typically follows the same
sequence as it would in the womb.
• All babies are different and their behavior and development are
different too.
• With premature babies, the differences also have a bit to do with
when they were born.
• a premature baby born at 32 weeks is likely to act differently from a
baby born at 26 weeks, who has had many medical challenges by
the time she gets to 32 weeks.
• The baby born at 26 weeks might take extra time to put on weight,
learn to feed and come out into the social world.

7. 26 weeks
• Baby is 35 cm long and weighs about 760 gm.
• Premature babies are often small for their age.
• A baby born at 26 weeks probably fit snugly into her father’s hand.
• At this age premature baby’s main job is to grow, sleep and become
medically stable.
• Baby might open his eyes occasionally, but he can’t focus.
• Light or other visual stimuli might stress his body’s systems.
• Baby’s movements are often jerks, twitches or startles.
• Baby doesn’t yet have good muscle tone and can’t curl up.
• Baby might have apnoea.
• Baby’s ears and hearing structures are already fully formed, but he
might be sensitive to external sounds.
• Baby might notice your voice but he can’t yet respond to you yet.
• Baby won’t be able to feed from your breast yet.
• baby’s skin is fragile and sensitive.

8. 26-28 weeks
• At this age, babies start blinking.
• They also grow eyelashes and eyebrows.
• Baby still has low muscle tone and is likely to have twitches and
tremors.
• Baby’s sleep and wake cycles aren’t clear yet.
• Have active and quiet periods and very brief alert times.
• Baby might open her eyes, but still can’t focus or get eyes moving
together.
• Baby’s responses to sound might change from hour to hour or day
to day.
• Baby might respond to voice but get stressed by other noises.
• Baby’s skin is still fragile and sensitive.

9. 28-30 weeks
• Baby might move and stretch more actively as muscle tone
gets better.
• baby’s quiet deep sleep and light sleep increase at about
30 weeks.
• One can see the short alert and eye-opening periods.
• baby is starting to close her eyelids tightly if it’s bright, but she still can’t
move eyes together very much.
• baby keeps responding to pleasant sounds and is still sensitive to other
sounds.
• He might be quiet and attentive to your voice
• One can start to talk or sing to your baby during his short alert times.
• baby’s rooting reflex – turning to a touch on the cheek – might start
around this time. This means she’s getting ready for breastfeeding
• baby might still be sensitive to touch.
• he likes steady, gentle, hands-on touch or skin-to-skin contact.

10. 30-33 weeks
• At this age, a baby’s organs are all maturing.
• A baby born now might not need much medical help.
• premature baby’s movement is smoother and more controlled.
• she’ll start to bend her arms and legs for herself.
• baby’s deep sleep increases.
• His alert periods come more often
• He shuts his eyes tightly if it’s bright.
• Baby might focus on your face or another interesting object.
• He might show an obvious response to your voice.
• Baby might like eye contact, cuddling or talking during these times
• Baby might start to suck rhythmically.
• Baby might still be very sensitive to touch and handling.

11. 33-36 weeks
• Baby is now approaching the date he was due to be born.
• But he isn’t necessarily like a full-term baby.
• Baby can now move more smoothly and bend her arms and legs.
• She can also move her head from side to side, and her muscle tone is
stronger.
• Baby will be much less likely to experience apnoea.
• Baby’s states are clear – quiet sleep, active sleep, drowsy, quiet and
alert, awake and fussy, or crying.
• His alert states are still quite short, but they’re getting longer and
happening more often.
• He can have longer social times.
• He can now turn away or close his eyes when he’s had enough.
• Baby is more likely to respond to sounds and noises
• baby probably still doesn’t cry much.
• Baby can usually start breastfeeding around this time.
• Baby might still be sensitive to touch and handling.

12. Preterm Infant Growth Charts
• Preterm growth charts aim to mimic growth that occurs during a
term pregnancy.
• The Fenton preterm growth chart is used by many medical
professionals.
• Fenton growth charts:
 Are based on birth size of over 4 million infants with confirmed
gestational ages in developed countries.
 Begin at 22 weeks and end at 50 weeks.
 Should be used in conjunction with term charts after 40 weeks.
 Are gender-specific.
 Include Weight, Length and Head Circumference in weekly
increments.
 Do not include Weight-for-Length or BMI.
 Include percentiles, as follows: 3rd, 10th, 50th, 90th and 97th.

14. • It should be used for preterm infants who are corrected to term age.
Corrected age is used to describe the child’s age from the original
due date.
 When plotting a baby’s growth, it is recommended to use corrected
age through 2 years from the original due date. Some experts
recommend correcting through 3 years.
 If age is not corrected, the infant may appear to be growing sub
optimally.
 Catch-up growth can occur during this 2 year period.
 Catch-up growth here refers to rapid growth of preterm infants that
minimizes the size difference with term counterparts.
 Using corrected age during a period of catch-up growth provides
the infant time to achieve typical growth standards.
 Rate of catch-up growth is affected by birth weight, gestational age
at birth, genetic potential and medical condition.
WHO growth charts

15. Weight, length and head circumference by gestational age for boys
Gestational age Weight Length Head circumference
40 weeks 3.6 kg 51 cm 35 cm
35 weeks 2.5 kg 46 cm 32 cm
32 weeks 1.8 kg 42 cm 29.5 cm
28 weeks 1.1 kg) 36.5 cm 26 cm
24 weeks 650 gms 31 cm 22 cm
Weight, length and head circumference by gestational age for Girls.
Gestational age Weight Length Head circumference
40 weeks 3.4 kg 51 cm 35 cm
35 weeks 2.4 kg 45 cm 31.5 cm
32 weeks 1.7 kg 42 cm 29 cm
28 weeks 1.0 kg 36 cm 25 cm
24 weeks 600 kg 32 cm 21 cm

16. Signs of prematurity -
 Small size with a disproportionately large head.
 Sharper looking, less rounded features than a full-term
baby's features, due to a lack of fat stores.
 Fine hair (lanugo) covering much of the body.
 Low body temperature.
 Labored breathing or respiratory distress.
 Lack of reflexes for sucking and swallowing.

17. Complications of Prematurity-
• Patent ductus arteriosus
• Respiratory distress syndrome
• bronchopulmonary dysplasia
• Neonatal hypoglycemia.
• Feeding difficulties
• Rickets of prematurity
• Hypocalcemia
• inguinal hernia
• Necrotizing enterocolitis.
• Anemia of prematurity
• thrombocytopenia
• Hyperbilirubinemia
• kernicterus.
• Neonatal sepsis
• Pneumonia
• urinary tract infection
• Increased risk of sudden infant
death syndrome (SIDS).

18. Long-term complications
• Cerebral palsy.
• Impaired learning.
• Vision problems.
• Hearing problems.
• Dental problems.
• Behavioral and psychological problems.
• Chronic health issues- Infections, asthma and feeding
problems

19. Diagnosis
• Placental alpha microglobulin-1 (PAMG-1)- Fetal
fibronectin-biomarker.
• Obstetric ultrasound.

20. Prevention-
Before pregnancy-
- Pre-conceptional - folic acid
- Reducing smoking.
During pregnancy
- Healthy eating
- vitamin supplements- C and E
- 1.5–2 g of calcium supplements daily
- Screening for asymptomatic bacteriuria.
- Routine ultrasound examination of the length of the cervix
identifies patients at risk.

21. 1. Steroids
2. Antibiotics
3. Tocolysis
4. Nonsteroidal anti-inflammatory drugs
5. Calcium channel blockers
6. Beta mimetics
7. Atosiban.
8. mother a dose of vitamin K.
Management of Mother

22. - Proper nutrition
- Avoiding stress
- Seeking appropriate medical care
- Avoiding infections
- Reduce working long hours while standing on feet
- Self-monitoring vaginal PH
- Cervical assessment by ultrasound
- Antibiotics
- Cervical cerclage
Self-care methods

23. • After the baby is born it should be wrapped in a warm towel and
placed head downwards in the cot or basket.
• Gentle wiping out of the mouth
• oxygen may be administered for a short period to produce a good
saturation of the arterial blood.
• Incubator/open care-
•Monitoring of your baby's vital signs-blood pressure, heart rate,
breathing and temperature. A ventilator may be used to help your
baby breathe.
•Iv fluids
•Blood transfusion to raise blood volume
•Steroids
•Antibiotics
•Surfactants
•Kangaroo mother care-
Management of Baby

24. • First American newborn intensive care unit, designed by Louis
Gluck, was opened in October 1960 at Yale new haven hospital.
•Dr. Stephane Tarnier is generally considered to be the father of
the incubator (having developed it to attempt to keep premature
infants in a Paris maternity ward warm.
Neonatal Intensive Care Unit (NICU)
Dr. Stephane Tarnier

26. -With the smallest infants this will usually mean
beginning with feeds of 30 to 60 minims (1.8-3.5
ml.) every hour by day and two-hourly by night.
-Gradually this is increased to 4 oz. two-hourly
by day and three-hourly by night, until 1 oz. is
taken every three hours round the clock.
-If the mother's milk supply has been established
the infant may be tried at the breast at least once a
day if over A lb. (2 kg.) in weight at birth, or
when this weight is achieved.
Nasogastric Feeding

27. IV Fluids-
• Initiate fluid therapy at 60-80 ml/kg/d with D10W.
• 80-150 ml/kg/d for infants ≤ 26 weeks
• For serum Na+ >145 mEq/L, increase infusate by ~10 mL/kg/d
without Na+ in the infusate.
• Infuse Na+ free fluids (including flushes) until serum Na+ <145
and good urine output is established (post diuretic phase). Then add
3-5 meq/kg/d Na+.
• Add KCl (2-3 meq/kg/d) to IV fluids after urine output is well
established and K+ <5 mEq/L (usually 48-72 hours).
• Increase fluid administration gradually over the first week of life to
120-130 cc/kg/d by day 7, allowing for expected physiologic
weight loss

28. STANDARD MAINTENANCE FLUID
First 24 hours of age 10% Glucose (500 mL)
More than 24 hours of age 10% Glucose (500 mL)
+ 10 mmoL Potassium Chloride
+ 0.225% Sodium Chloride
Wt. gms Less than
750
75-1000 1000-2500 More than
2500
Fluids ml 120 100 80 60

30. How to feed
Birth weight
(g)
Infant sucking response
Good suck Slow suck No suck
<1600 NGF. Try BF
as soon as
possible
NGF. Try BF
as soon as
possible
NGF. Try BF
as soon as
possible
1600-2000 Breast feed Breast Feed
+ cup/spoon
NGF. Try BF
as soon as
possible
Ad lib feeding is recommended in older well babies

31. How much to feed
Birth Weight
(g)
Starting
volume
(ml/kg/d)
Volume Increment
each day (ml/kg/d)
Maximum
volume
(ml/kg/d)
Frequency of
feeds
>1600 60 30 150 3 hrly
1200-1599 60 30 180 2 hrly
<1200 10-20 20 ml/kg/d after
day 2-3 days
180 2 hrly

32. • The development of this reflex can be enhanced by allowing
the neonate to suck on the empty breast – non-nutritive
sucking.
• this can shorten the time to transition to breast feeding. The
other advantage of this technique is that it aids maintaining
lactation in the mother.
• Transition to breast feeds can achieved by gradual introduction
of spoon feeds in NG fed babies along with NNS and then
introduction of breast feeds.
• Neonates with gestation > 32 weeks, fair sucking and clinically
stable can all be allowed to transit to breast feeding.
Non-nutritive sucking (NNS).

33. • Calcium- approx. 100 mg/kg/d of elemental calcium each day.
• Phosphorous. -40-50mg/kg/d
• Iron- started at about 4 weeks at a dose of 2 mg/kg/day, Continue
supplements till about 6-9 months age
Vitamin supplements-
Vitamin A 1000-1500 IU
Vitamin D 400 IU
Vitamin E 25 IU
Vitamin C 40-50 mg
Vitamin B1 1000 g
Vitamin B12 3-5 g
Niacin 5-10 mg
Folic acid 50 g
Start when enteral intake 150 ml/kg/day
vitamin K after birth to prevent hypoprothrombinaemia
Supplements

34. Surfactant
• Surfactants are compounds that lower the surface tension (or
interfacial tension) between two liquids, between a gas and a liquid,
or between a liquid and a solid.
• Treatment with exogenous surfactant has saved the lives of thousands
of premature babies in the past few decades
Modes of delivering surfactant into the pulmonary airways
1. Bolus administration
○ One dose: complete dose given within a single time frame
○ Multiple doses: total dose divided into two or more amounts
(aliquots) and given separately in time
2. Continuous infusion (slow administration of the surfactant)
3. Nebulization: suspension of aerosolized surfactant that is
subsequently inhaled-volume of 4 mL/kg

35. <24 weeks’ gestational age: these infants should be intubated
immediately after birth and surfactant given prophylactically (within
the first 15 min to 30 min of life). Between intubation and surfactant
administration, these infants should be ventilated very carefully with
low tidal volume and pressures.
≥24 weeks’ gestational age:
1 For infants intubated immediately after birth, it is recommended that
surfactant be given as early treatment (<2 h of age), except if the infant
is on room air and minimal ventilatory support on neonatal intensive
care unit admission. These infants should be immediately extubated to
nasal ventilation or nasal continuous positive airway pressure.
Criteria for surfactant administration

36. 2 Infants initially treated with noninvasive ventilation,
endotracheal intubation and surfactant administration is
recommended under one the following circumstances:
a) Fraction of inspired oxygen (FiO2) >0.5 to maintain oxygen
saturation (SpO2) >88% or a partial pressure of arterial
oxygen (PaO2) >45 mmHg
b) Partial pressure of arterial carbon dioxide (PaCO2) >55
mmHg to 60 mmHg with a pH <7.25
c) Apnea requiring bag and mask ventilation
d) >6 apneas/6 h
e) Evidence of significant work of breathing (retractions,
grunting and chest wall distortion in infants presenting with
increases in oxygen needs)

37. Kangaroo Mother Care
• The Kangaroo Mother Program is a ray of hope for the millions of children
throughout the world who are born premature and underweight.” UNICEF
• 1979-doctors Hector Martinez and Edgar Rey Sanabria, of the Maternal –
Infant Institute of Bogotá, Columbia, Initiated KMC for the first Time as an
alternative to inadequate and Insufficient incubator care for those preterm
newborn
• Kangaroo Mother Care is a Special way of caring of low birth weight babies.
• It fosters their health and well being by promoting effective thermal control,
breastfeeding, infection prevention and bonding.
• in KMC, the baby is continuously kept in skin to skin contact by the mother
and breastfed exclusively to the utmost extent.
• KMC is initiated in the hospital and continued at home.

38. Benefits of KMC
• Breast feeding
• Thermal control
• Early discharge
• Less morbidity
• mothers: bonding, increased
confidence and satisfaction
• Fathers: bonding, more relaxed
and comfortable

39. Kangaroo positioning
• The baby should be placed between the
mother’s breasts in an upright position.
• The head should be turned to one side and
in a slightly extended head position keeps
the airway open and allows eye to contact
between the mother and her baby.
• The hips should be flexed and abducted in
a “frog” position ; the arms should also be
flexed.
•Baby’s abdomen should be at the level of
the mother’s epigastria. Mother’s breathing
stimulates the baby, thus reducing the
occurrence of apnea.
•Support the baby’s bottom with a
sling/binder.
Monitoring during
KMC
Ensure that baby’s :
‾ Neck is not too
flexed or too extended,
‾ Breathing is normal
‾ Feet and hands are
warm

40. The chance of survival at-
- 22 weeks preterm baby is about 6%,
- 23 weeks it is 26%
- 24 weeks 55%
- 25 weeks about 72% as of 2016.
Prognosis-

41. Notable cases-
Winston Churchill Isaac Newton

42. Post maturity in the Newborn (prolonged pregnancy,
and post-dates pregnancy.)
 Previous post-term
 First pregnancy
 Male baby
 Older mother
 Obese mother
 Mother or father with personal
history of post maturity
 White mother
Definition- newborn babies born after 42 weeks of gestational age
or 294 days, irrespective of the birth weight.
Very few babies are born at 42 weeks or later.
Risk factors for post maturity-

44. Clinical features-
 Dry, loose, peeling skin
 Overgrown nails
 Large amount of hair on the head
 Visible creases on palms and soles of feet
 Small amount of fat on the body
 Green, brown, or yellow coloring of skin from baby passing
stool in the womb
 More alert and "wide-eyed"

45. Clinical manifestations include:
1.A long, thin newborn with wasted
appearance, parchment-like skin, and
meconium-stained skin, nails, and
umbilical cor. Fingernails are long and
lanugo is absent.
2.Meconium aspiration syndrome is
manifested by fetal hypoxia, meconium
staining of amniotic fluid, respiratory
distress at delivery, and meconium-stained
vocal cords

46. Diagnosis-
 baby's physical appearance
 length of pregnancy
 How old baby appears to be
 Ultrasound
 Nonstress testing.
 Fetal movement recording
 Biophysical profile-it is a noninvasive procedure that uses
the ultrasound to evaluate the fetal health based on NST
and four ultrasound parameters: fetal movement, fetal
breathing, fetal muscle tone, and the amount of amniotic
fluid surrounding the fetus. A score of 2 points is given for
each category that meets the criteria or 0 points if the
criteria is not met (no 1 point).

47. Problems of post maturity-
 Less amniotic fluid.
 Poor oxygen supply.
 Meconium aspiration.
 Hypoglycemia or low blood sugar.
 Placental insufficiency
 Oligohydramnios
 Meconium aspiration syndrome
 Macrosomia
 Shoulder dystocia
 Assisted birth
 Increased labor induction
 Increased caesarean birth

48. • higher morbidity and mortality
• Perinatal asphyxia
• Meconium aspiration syndrome
• Perinatal asphyxia
• Meconium aspiration syndrome
• Persistent pulmonary hypertension
• Neonatal hypoglycemia
Complications

49. Management-
- Suction the infant’s mouth and nares while the head is on the
perineum and before the first breath is taken to prevent aspiration
of meconium that is in the airway.
- Keep baby dry and on the warmer, intubate with direct tracheal
suctioning.
- Perform chest physiotherapy with suctioning to remove excess
meconium and secretions.
- Provide supplemental oxygen and respiratory support as needed.
- Obtain serial blood glucose measurements.
- Provide early feeding to prevent hypoglycemia.
- Maintain skin integrity.
• Keep the skin clean and dry.
• Avoid the use of powders, creams, and lotions.
• Avoid the use of tape

50. Small for gestational age/small for date/
Intrauterine growth retardation of newborn
• Birth weight of neonate is less than 10th percentile for that
period of gestation.
• It refers to poor growth of a fetus while in the mother's womb
during pregnancy.
- poor maternal nutrition
- lack of adequate oxygen supply to the fetus.
• At least 60% of the 4 million neonatal deaths that occur
worldwide every year are associated with low birth
weight (LBW)

51. 1. Asymmetrical
• Restriction of weight followed by length.
• Head continues to grow at normal or near-normal rates
• A lack of subcutaneous fat leads to a thin and small body.
• Normally at birth the brain of the fetus is 3 times the weight of
its liver. In IUGR, it becomes 5-6 times.
• Embryo/fetus has grown normally for the first
two trimesters but encounters difficulties in the third trimester.
• Dry, peeling skin and an overly-thin umbilical cord.
• Increased risk of hypoxia and hypoglycaemia.
• Caused by Chronic high blood pressure, Severe malnutrition,
Genetic: ehlers–danlos syndrome
Types of IUGR -

52. 2. Symmetrical
• Symmetrical IUGR is commonly known as global growth restriction.
• fetus has developed slowly throughout the duration of the pregnancy
and was thus affected from a very early stage.
• The head circumference of such a newborn is in proportion to the rest
of the body.
• most neurons are developed by the 18th week of gestation, the fetus
with symmetrical IUGR is more likely to have permanent
neurological sequelae.
• Common causes include:
 Early intrauterine infections-
cytomegalovirus, rubella or toxoplasmosis
 Chromosomal abnormalities
 Anemia
 Maternal substance abuse (Fetal alcohol syndrome)

53. Factors contributing to SGA and/or IUGR-
•Maternal factors:
• High blood pressure
• Chronic kidney disease
• Advanced diabetes
• Heart or respiratory disease
• Malnutrition, anemia
• Infection
• Substance use (alcohol, drugs)
• Cigarette smoking
Factors involving the uterus and placenta:
 Decreased blood flow in the uterus and placenta
 Placental abruption (placenta detaches from the uterus)
 Placenta previa (placenta attaches low in the uterus)
 Infection in the tissues around the fetus
Factors related to the developing baby (fetus):
• Multiple gestation (for example, twins or triplets)
• Infection
• Birth defects
• Chromosomal abnormality

54. Problems at birth-:
•Decreased oxygen levels
•Low Apgar scores
•Meconium aspiration
•Hypoglycemia
•Difficulty maintaining normal body temperature
•Polycythemia

55. •Temperature maintenance.
•IV fluids
•Tube feedings
•Checking for hypoglycemia
•Monitoring of oxygen levels
•As early as possible start breast feeding.
•Kangaroo Mother care
Management-

56. Large for Gestational Age/ Macrosomia
• Birth weight of neonate is more than 90th percentile for that
period of gestation.
• Large for gestational age (LGA) is used to describe newborn
babies who weigh more than usual for the number of weeks of
pregnancy.

58. Several factors can contribute to large birth weight.

59. Complications-
• Respiratory distress syndrome
• Birth injuries - broken collar bone or damaged nerves in the
arm (brachial plexus)
• Hypoglycemia
• Polycythemia
• conjugated jaundice.

60. Management
Early breast feeding
Rule Diabetes in baby

61. Thanks a lot