14. Preterm, LBW, SGA.ppt

Sem 5 PAEDIATRIC NEWBORN: SGA, Preterm, LBW TIME Lapse Pre Lecture Case Vignette • You review a 48-hpur-old term female infant who was admitted for presumed sepsis and neonatal hypoglycemia. The baby was born by normal spontaneous vaginal delivery and birth weight of 1.8 kg and length of 42 cm...

Sem 5 PAEDIATRIC NEWBORN: SGA, Preterm, LBW TIME Lapse Pre Lecture Case Vignette • You review a 48-hpur-old term female infant who was admitted for presumed sepsis and neonatal hypoglycemia. The baby was born by normal spontaneous vaginal delivery and birth weight of 1.8 kg and length of 42 cm and head circumference of 34 cm. • On examination, the baby is polycythemic but having symmetrical movements over all four limbs. • Mother is a smoker and suffers from anorexia nervosa. She enjoys occasional drink. TORCH screen is negative. Pre Lecture Brainstorming A mother and her baby being brought rushes into ED. She just gave birth in the car on the way to hospital followed by severe contractions, but the bay was only 30 weeks of gestational age. She keeps complaining of “ My baby was not supposed to come this early” Baby weighs 2.2 kg and now in respiratory rates of 65 breaths/min, grunting, nasal flaring, cyanosis on extremities and also has intercostal indrawing. What factors affect fetal weight? Terms in GROWTH and GESTATION • LBW, VLBW, EXWL • AGA, SGA, LGA • Term, Preterm, Near Term, Late Preterm, Post Term • IUGR/FGR • Gestational Age, Chronological age, Corrected age (Adjusted Age) Birthweight (BW) Categories LBW <2500 gms (5 lbs 8oz) Low Birthweight VLBW <1500 gms (3 lbs 5oz) ELBW ILBW Very Low BW <1000 gms (2 lbs 3oz) Extremely Low BW <750 gms (1 lb 10oz) <600 gms (1 lb 5oz) <500 gms (1 lb 2 oz) Incredibly Low BW Correlation with Birth Weight SGA • Smaller than usual for the number of weeks of pregnancy • Birth weight below the 10th percentile • Smaller than many other babies of the same gestational age Contributed by Maternal factors Placental Insufficiency Fetal factors Maternal factors • Pregnancy induced hypertension • Preexisting medical conditions such as chronic kidney/liver diseases, diabetes, heart disease or respiratory disease • Malnutrition or anemia • Infection • Alcohol or substance abuse • Cigarette smoking • Maternal weight <100 pounds Placental Insufficiency • • • • • • Pre eclampis Placental/Cord abnormalities Placental Previa Placenta abruption (Chronic) Abnormal cord insertion Chorioamnionitis Fetal factors • Multiple pregnancy, such as twins or triplets (unbalanced placental blood supply, • Congenital Infections, inter fetal blood transmission • Birth defects • Chromosome problems CPUR is a novel Doppler ratio is strongly associated with placental insufficiency and has superior sensitivity in the prediction of SGA SGA preterm, term, or post term infant who is below the 10th percentile for gestational age in head circumference, body weight, or length. - LGA preterm, term, or post term infant who is above the 90th percentile for gestational age in head circumference, body weight, or length. Causes of SGA Cause of LGA Macrosomia baby of diabetic mother Concerns of LGA at time of delivery • • • • Prolonged Vaginal Delivery time Increased Risk of Ceserean delivery Difficult Birth Birth Injury AGA (Appropriate for Gestational Age) • Birthweight between 10th and 90th centile • An appropriate for gestational age full term infant is heavier than 2500 gram and lighter than about 4000 gram. SGA vs IUGR SGA: IUGR: BW less than population norms < 10th centile OR BW < expected inhibition of normal growth potential pathologic or non-pathologic causes. Mostly in the absence of Pathologic cause implies pathology Symmetric Vs Asymmetric IUGR SGA SYMMETRICAL • Low Birth Weight • Low Birth Length • Low Birth OFC (Head Circumference) ASYMMETRICAL • Low Birth Weight • Low Birth Length • Normal Birth OFC • Low Birth Weight • Normal Birth Length • Normal Birth OFC SYMMETRICAL SGA Dysmorphic Features • • • • • Congenital infections Congenital Toxoplasmosis Congenital Syphillis Congenital Rubella Congenital CMV Congenital HSV ASYMMETRICAL SGA Maternal & Placental Factors in last trimester • Pre eclampis • Placental/Cord abnormalities • Placental Previa • Placenta abruption (Chronic) • Abnormal cord insertion • Chorioamnionitis Genetic disorders • • • • Prada Willi Syndrome Silver-russel Syndrome Turner Syndrome Noonan Syndrome Other genetic disorders Impact of preterm birth and low birth weight ) Study: A prospective observational cohort study Area: neonatal intensive care unit (NICU) Period: 9 months Conclusion: Medical conditions, medications prescribed, and mortality rate were significantly higher among preterm and underweight neonates admitted to NICU. WJP https://doi.org/10.1007/s12519-019-00239-1 Preterm, Term, Post term Criteria for Determining Preterm Outcomes • Birthweight • Gestational Age • Maturity (New Ballard Score) DISCHARGE Criteria • The parents and/or caregivers are capable. That is, they demonstrate an ability to meet the needs of the infant. • The patient's caloric intake is adequate for growth. • The patient has been weaned from supplemental heat. • Medical problems are defined and manageable at home. • No apnea or bradycardia is present. Multidisciplinary Approach Research Needed • NICU studies: – Neuroprotection strategies – Better treatments of lung disease – Relationships between nutrition, growth and development • Evaluation of current and all new NICU treatments for impact on neurodevelopmental outcome • Better prediction of neurodevelopmental outcome • Support for long term follow up studies through childhood into adulthood TAKE HOME MESSAGE • SGA can be the result of maternal lifestyle and obstetric factors, placenta dysfunction, and fetal genetic factors • children born SGA need a molecular diagnosis for GH treatment in terms of response prediction and contraindications • GH treatment increases adult height by ~1.25 SD and normalizes body composition • SGA/LBW increases the risk of later noncommunicable conditions such as neurodevelopmental problems and cardiometabolic diseases REFERENCES • Kliegman RM (ed.). Nelson Textbook of pediatrics.20th ed. Elsevier; 2016. • Gomella TR (ed.) Neonatology: Management, Procedures, On-Call Problems, Diseases, and Drugs. 7th ed. McGraw-Hill education. 2013. • W.Hay JR.W et al (ed.). Lange medical book Current diagnosis and treatment Pediatrics. 22nd ed. McGraw-Hill Education. 2014.