High Risk Child: SGA Overview

High Risk Child

• Small for Gestational Age (SGA): Infants with birth weight below the 10th percentile on an intrauterine growth chart for their gestational age.

  • Etiology: Intrauterine growth restriction (IUGR), failure to grow at the expected rate in utero. Maternal nutrition during pregnancy is a key contributor. Adolescents are at higher risk due to their own nutritional needs taking priority over fetal development. Placental anomaly (inadequate nutrient supply or transport) is another common cause.
  • Assessment: Fundal height during pregnancy may be less than expected. May have poor skin turgor, large head relative to body size, widely separated skull sutures, dull hair, small liver, sunken abdomen, and dry/yellow stained umbilical cord.
  • Laboratory Findings: High hematocrit, increased RBC count (polycythemia), prolonged acrocyanosis (blueness of hands and feet), and decreased glycogen stores leading to hypoglycemia.

• Large for Gestational Age (LGA): Infants with birth weight above the 90th percentile for gestational age.

  • Etiology: Overproduction of nutrients and growth hormones in utero. Obese or diabetic mothers are more likely to have LGA babies. Multiparous women (having more than one pregnancy) may also have larger subsequent babies.
  • Assessment: Immature reflexes, potentially low scores on gestational age examinations. Bruising or birth injuries (e.g., fractured clavicle) are a possibility. Potential for large head, exposing it to more pressure during birth. Caput succedaneum or cephalhematoma may be apparent.
  • Appearance: Immature reflexes, potential for birth injuries.

Caput Succedaneum and Cephalhematoma

• Caput succedaneum: Bruising and edema (swelling) of presenting part that extends beyond the margin of the skull bone. Often resolves within a few days. Usually caused by pressure during vaginal delivery, forceps/vacuum use. Associated with prolonged delivery.
• Cephalhematoma: Collection of blood between the cranial bone and periosteum. Does not cross suture lines. Usually resolves within several weeks. More likely to be present if forceps or vacuum birth is used. Occurs more commonly in infants who are born with a forceps delivery or vacuum extraction.

Extracranial Hemorrhage

• Bleeding outside the brain.

Respiratory Distress Syndrome

• Occurs in preterm infants, infants of diabetic mothers, and those with reduced blood perfusion to the lungs.
• Characterized by a hyaline membrane lining the terminal bronchioles and alveoli, impairing gas exchange.
• Often presents with difficulty initiating respirations and respiratory distress symptoms (tachypnea, retractions, cyanosis).

The Post-Term Infant

• Delivered after 41 weeks of gestation.
• Placental function may be compromised, potentially leading to weight loss for the fetus.
• Potential features include wrinkled, patchy, peeling skin, long thin body, open eyes, alert appearance, long nails. Oligohydramnios (low amniotic fluid) increases the likelihood of post-maturity.

Other Congenital Heart Disorders

• Patent Ductus Arteriosus (PDA): Failure of the ductus arteriosus to close. Signs include wide pulse pressure, continuous machine-like murmur, present in the upper left sternal border or under the left clavicle. Often closes spontaneously.
• Ventricular Septal Defect (VSD): An opening in the septum between the ventricles. A systolic murmur, often described as a pansystolic murmur, is a hallmark of VSD.
• Atrial Septal Defect (ASD): An opening in the septum between the atria. Blood flows from the left atria to the right atria, leading to increased volume and hypertrophy in the right side of the heart.
• Coarctation of the Aorta: Narrowing of the aorta, the main artery carrying blood away from the heart. High blood pressure in the upper extremities and low blood pressure in the lower extremities can occur with this condition.
• Tetralogy of Fallot: A combination of four structural defects: ventricular septal defect, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy. Associated with cyanosis and squatting.
• Truncus Arteriosus: A single great artery arises from both ventricles, rather than separate arteries. Usually presents with cyanosis & heart murmurs in newborns.
• Transposition of the Great Vessels (TGA): The aorta connects to the right ventricle, and the pulmonary artery connects to the left ventricle. This requires immediate intervention for survival of the newborn.

Other conditions associated with high-risk infants

• Hypoplastic left heart syndrome (HLHS): The left side of the heart is underdeveloped, making it difficult to circulate blood.

Hemolytic Disease of the Newborn (HDN)

• Characterized by excessive destruction of red blood cells, resulting in increased bilirubin, a yellow pigment.
• Bilirubin levels higher than 12 mg/dl in term infants and as low as 10 mg/dl in preterm infants can be dangerous to the brain.
• Hyperbilirubinemia is a potential complication of HDN.
• Phototherapy is used to treat elevated bilirubin levels.

Other High-Risk Conditions

• Cleft Lip and Cleft Palate: Incomplete fusion of the lip or palate.
• Gastroschisis: The abdominal wall fails to close properly, allowing intestines to protrude outside the abdomen through the abdominal wall.
• Omphalocele: Intestines and other abdominal organs herniate through a defect in the abdominal wall, often covering the defect with a membrane.
• Tracheoesophageal Atresia (TEA): The esophagus is closed or obstructed, often connecting to the trachea (windpipe).
• Esophageal Atresia (EA) and Tracheoesophageal Fistula (TEF): The esophagus doesn't connect properly to the stomach, often connected to the trachea, causing secretions to enter the lung and requiring immediate surgery.
• Diaphragmatic Hernia (Diaphragmatic Diastasis): A hole, or weakness, in the diaphragm permits the stomach (and likely the intestines) to enter the thoracic cavity, disrupting lung development.
• Congenital Diaphragmatic Hernia (CDH): The diaphragm doesn't properly separate the chest cavity from the abdominal cavity and permits abdominal contents to enter the thoracic cavity, resulting in respiratory distress or failure in newborns.
• Spina Bifida: A neural tube defect resulting in incomplete closure of the spinal cord. Multiple types exist, ranging from mild (Spina Bifida Occulta) to severe (Myelomeningocele).
• Anencephaly: Absence of a major portion of the fetal brain, which occurs when the neural tube fails to close properly.

Post-Partum Hemorrhage

• Uterine Atony: Uterus fails to contract effectively following delivery, resulting in excessive bleeding.
• Retained Placenta: Portions of the placenta remain in the uterus, preventing effective uterine contraction and contributing to bleeding.
• Lacerations: Tears in the cervix, vagina, or perineum during delivery.
• Subinvolution: Incomplete return of the uterus to its pre-pregnancy size and tone. Can happen if the uterus is not contracting adequately.
• Perineal Hematoma: Collection of excessive blood in the tissues of the perineum. Can result from lacerations or excessive pressure during delivery.

Conditions of Pregnancy, Labor, and Delivery

• Dysfunctional Labor: Inefficient or prolonged uterine contractions.
• CPD (Cephalopelvic Disproportion): The fetus's head or size is too large compared to the mother's pelvis.
• Prolonged Latent Phase: The latent phase of labor (early labor) lasts longer than expected.
• Secondary Arrest of Dilation: Cervical dilation stops progressing.
• Prolonged Descent: The baby is not descending in labor at the expected pace.
• Arrest of Descent: Fetal descent has stopped entirely.
• Retained Placental Fragments: Placental fragments are not delivered after birth.

Other High-Risk Issues

• Intussusception : One part of the intestine slides into another part, obstructing blood flow.
• Volvulus: Twisting of the intestines, causing obstruction and/or decreased blood supply.
• Celiac Disease (Malabsorption Syndrome): A condition causing problems with nutrient absorption due to intolerance of gluten.
• Hirschsprung's Disease: Absence of certain nerves in part of the bowels; causes constipation.
• Diaphragmatic Hernia: An opening in the diaphragm permits abdominal contents to enter the chest cavity.
• Inguinal Hernia: A segment of the intestine protrudes into the inguinal canal.
• Umbilical Hernia: A segment of the intestine protrudes through the umbilical opening.
• Inversion of the Uterus: The uterus turns inside out after delivery.