high risk

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Newborn
Assessments for newborn babies:
Each newborn baby is carefully checked at birth for signs of problems or
complications. A complete physical assessment will be performed that includes every
body system. Throughout the hospital stay, physicians, nurses, and other healthcare
providers continually assess a baby for changes in health and for signs of problems or
illness. Assessment may include:
 Apgar scoring:
The Apgar score is one of the first checks of your new baby's health. The
Apgar score is assigned in the first few minutes after birth to help identify
babies that have difficulty breathing or have a problem that needs further care.
The baby is checked at one minute and five minutes after birth for heart and
respiratory rates, muscle tone, reflexes, and color.
Each area can have a score of zero, one, or two, with ten points as the
maximum. A total score of ten means a baby is in the best possible condition.
Nearly all babies score between eight and ten, with one or two points taken off
for blue hands and feet because of immature circulation. If a baby has a
difficult time during delivery, this can lower the oxygen levels in the blood,
which can lower the Apgar score. Apgar scores of three or less often mean a
baby needs immediate attention and care. However, only 1.4 percent of babies
have Apgar scores less than seven at five minutes after birth.
Sign Score = 0 Score = 1 Score = 2
Heart Rate Absent Below 100 per
minute
Above 100 per minute
Respiratory
Effort
Absent Weak,
irregular, or
gasping
Good, crying
Muscle Tone Flaccid Some flexion of
arms and legs
Well flexed, or active
movements of
extremities
Reflex/Irritability No response Grimace or
weak cry
Good cry
Color Blue all
over, or pale
Body pink,
hands and feet
blue
Pink all over
 Birthweight and measurements:
A baby's birthweight is an important indicator of health. The average weight
for term babies (born between 37 and 41 weeks gestation) is about 7 lbs. (3.2
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kg). In general, small babies and very large babies are at greater risk for
problems. Babies are weighed daily in the nursery to assess growth, fluid, and
nutrition needs. Newborn babies may lose as much as 10 percent of their
birthweight. This means that a baby weighing 7 pounds 3 ounces at birth might
lose as much as 10 ounces in the first few days. Premature and sick babies may
not begin to gain weight right away.
Most hospitals use the metric system for weighing babies. This chart will help
you convert grams to pounds.
 Measurements:
Other measurements are also taken of each baby. These include the following:
o head circumference (the distance around the baby's head) - is normally
about one-half the baby's body length plus 10 cm
o abdominal circumference - the distance around the abdomen
o length - the measurement from crown of head to the heel
 Physical examination:
A complete physical examination is an important part of newborn care. Each
body system is carefully examined for signs of health and normal function. The
physician also looks for any signs of illness or birth defects. Physical
examination of a newborn often includes the assessment of the following:
o vital signs:
 temperature - able to maintain stable body temperature 98.6° F
(37° C) in normal room environment
 pulse - normally 120 to 160 beats per minute
 breathing rate - normally 30 to 60 breaths per minute
o general appearance - physical activity, tone, posture, and level of
consciousness
o skin - color, texture, nails, presence of rashes
o head and neck:
 appearance, shape, presence of molding (shaping of the head
from passage through the birth canal)
 fontanels (the open "soft spots" between the bones of the baby's
skull)
 clavicles (bones across the upper chest)
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o face - eyes, ears, nose, cheeks
o mouth - palate, tongue, throat
o lungs - breath sounds, breathing pattern
o heart sounds and femoral (in the groin) pulses
o abdomen - presence of masses or hernias
o genitals and anus - for open passage of urine and stool
o arms and legs - movement and development
 Gestational assessment:
Assessing a baby's physical maturity is an important part of care. Maturity
assessment is helpful in meeting a baby's needs if the dates of a pregnancy are
uncertain. For example, a very small baby may actually be more mature than it
appears by size, and may need different care than a premature baby.
An examination called The Dubowitz/Ballard Examination for Gestational Age
is often used. A baby's gestational age often can be closely estimated using this
examination. The Dubowitz/Ballard Examination evaluates a baby's
appearance, skin texture, motor function, and reflexes. The physical maturity
part of the examination is done in the first two hours of birth. The
neuromuscular maturity examination is completed within 24 hours after
delivery. Information often used to help estimate babies' physical and
neuromuscular maturity are shown below.
 Physical maturity:
The physical assessment part of the Dubowitz/Ballard Examination looks at
physical characteristics that look different at different stages of a baby's
gestational maturity. Babies who are physically mature usually have higher
scores than premature babies.
Points are given for each area of assessment, with a low of -1 or -2 for extreme
immaturity to as much as 4 or 5 for postmaturity. Areas of assessment include
the following:
o skin textures (i.e., sticky, smooth, peeling).
o lanugo (the soft downy hair on a baby's body) - is absent in immature
babies, then appears with maturity, and then disappears again with
postmaturity.
o plantar creases - these creases on the soles of the feet range from absent
to covering the entire foot, depending on the maturity.
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o breast - the thickness and size of breast tissue and areola (the darkened
ring around each nipple) are assessed.
o eyes and ears - eyes fused or open and amount of cartilage and stiffness
of the ear tissue.
o genitals, male - presence of testes and appearance of scrotum, from
smooth to wrinkled.
o genitals, female - appearance and size of the clitoris and the labia.
 Neuromuscular maturity:
Six evaluations of the baby's neuromuscular system are performed. These
include:
o posture - how does the baby hold his/her arms and legs.
o square window - how far the baby's hands can be flexed toward the
wrist.
o arm recoil - how far the baby's arms "spring back" to a flexed position.
o popliteal angle - how far the baby's knees extend.
o scarf sign - how far the elbows can be moved across the baby's chest.
o heel to ear - how close the baby's feet can be moved to the ears.
A score is assigned to each assessment area. Typically, the more neurologically
mature the baby, the higher the score.
When the physical assessment score and the neuromuscular score are added together,
the gestational age can be estimated. Scores range from very low for immature babies
(less than 26 to 28 weeks) to very high scores for mature and postmature babies.
All of these examinations are important ways to learn about your baby's well-being at
birth. By identifying any problems, your baby's physician can plan the best possible
care.

High-Risk Newborn

Every family looks forward to the birth of a healthy newborn. It is an exciting time
with so much to look forward to. In some cases, though, unexpected difficulties and
challenges occur along the way. Some newborns are considered high risk. This means
that a newborn has a greater chance of complications because of conditions that occur
during fetal development, pregnancy conditions of the mother, or problems that may
occur during labor and birth. Some complications are unexpected and may occur
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without warning. Other times, there are certain risk factors that make problems more
likely.
Fortunately, advances in technology have helped improve the care of sick newborns.
Under the care of specialized physicians and other healthcare providers, babies have
much greater chances for surviving and getting better today than ever before.
Definition:
The high-risk neonate: can be defined as a newborn, regardless of gestational age or
birth weight, who has a greater-than-average chance of morbidity or mortality,
because of conditions or circumstances superimposed on the normal course of events
associated with birth and the adjustment to extra uterine existence.
Classification
Classified according to:
1. Birth weight.
 Low-birth-weight (LBW): an infant whose birth weight is less than 2500 g,
regardless of gestational age.
 Very low-birth-weight (VLBW) infant :an infant whose birth weight is less
than 1500g.
 Extremely-low-birth-weight (ELBW) infant: an infant whose birth-weight is
less than1000g.
 Appropriate-for-gestational-age (AGA)INFANT: an infant whose birth-
weight is falls between the 10
th
and 90
th
percentiles on intrauterine growth
curves.
 Small-for-date (SFD) or small-for-gestational age (SGA) infant: an infant
whose rate of intrauterine growth was slowed and whose birth weight falls
below the 10
th
percentile on intrauterine growth curves
 Intrauterine growth restriction (IUGR) found in infants whose intrauterine
growth is restricted
 Large-for-gestational-age (LGA): an infant whose birth weight falls above
the 90
th
percentile on intrauterine growth curves.
2. Classification according to Gestational age
 Premature (preterm) infant: an infant born before completion of 37 weeks of
gestation, regardless of birth weight.
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 Full-term infant: an infant born between the beginning of the 38 weeks and
the completion of the 42 weeks of gestation, regardless of birth weight.
 Post mature (post-term) infant: an infant born after 42 weeks of gestational
age , regardless of birth weight.
3. Classification according to mortality
 Live birth: birth in which the neonate manifests any heartbeat, breathes, or
displays voluntary movement, regardless of gestational age.
 Fetal death: death of the fetus after 20 weeks of gestation and before delivery,
with absence of any signs of life after birth.
 Neonatal death: death that occurs in the first 27 days of life; early neonatal
death occurs in the first weeks of life; late neonatal death occurs at 7-27 days.
4. Classification according to Path physiologic problems
 Associated with the state of maturity of the infant. Chemical disturbances. eg:
hypoglycemia, hypocalcemia.
 Immature organs and systems. eg hyperbilirubinemia, respiratory distress,
hypothermia.
1. Classification according to Birth weight.
Low birth Weight (LBW) Babies:
Low Birthweight
Definition
Low birthweight is a term used to describe babies who are born weighing less than
2,500 grams (5 pounds, 8 ounces). In contrast, the average newborn weighs about 7
pounds. Over 8 percent of all newborn babies in the United States have low
birthweight. The overall rate of these very small babies in the United States is
increasing. This is primarily due to the greater numbers of multiple birth babies who
are more likely to be born early and weigh less. Over half of multiple birth babies
have low birthweight compared with only about 6 percent of single birth babies.
Babies with low birthweight look much smaller than other babies of normal
birthweight. A low birthweight baby's head may appear to be bigger than the rest of
the body and he/she often looks thin, with little body fat.
Causes of low birthweight?
The primary cause of low birthweight is premature birth (being born before 37 weeks
gestation). Being born early means a baby has less time in the mother's uterus to grow
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and gain weight. Much of a baby's weight is gained during the latter part of
pregnancy.
Another cause of low birthweight is intrauterine growth restriction (IUGR). This
occurs when a baby does not grow well during pregnancy because of problems with
the placenta, the mother's health, or birth defects. A baby can have IUGR and be born
at full term (37 to 41 weeks). Babies with IUGR born at term may be physically
mature but may be weak. Premature babies can also have IUGR - these babies are
both very small and physically immature.
Incidence
Any baby born prematurely is more likely to be very small. However, there are other
factors that can also contribute to the risk of very low birthweight. These include:
 Race
African-American babies are two times more likely to have low birthweight
than Caucasian babies.
 Age
Teen mothers (especially those younger than 15 years old) have a much higher
risk of having a baby with low birthweight.
 Multiple birth
Multiple birth babies are at increased risk of low birthweight because they
often are premature. Over half of twins and other multiples have low
birthweight.
 Mother’s health
Babies of mothers who are exposed to illicit drugs, alcohol, and cigarettes are
more likely to have low birthweight. Mothers of lower socioeconomic status
are also more likely to have poorer pregnancy nutrition, inadequate prenatal
care, and pregnancy complications - all factors that can contribute to low
birthweight.
Diagnosis
During pregnancy, a baby's birthweight can be estimated in different ways. The height
of the fundus (the top of a mother's uterus) can be measured from the pubic bone. This
measurement in centimeters usually corresponds with the number of weeks of
pregnancy after the 20th week. If the measurement is low for the number of weeks,
the baby may be smaller than expected. Ultrasound (a test using sound waves to create
a picture of internal structures) is a more accurate method of estimating fetal size.
Measurements can be taken of the fetus' head and abdomen and compared with a
growth chart to estimate fetal weight.
Babies are weighed within the first few hours after birth. The weight is compared with
the baby's gestational age and recorded in the medical record. A birthweight less than
2,500 grams (5 pounds, 8 ounces) is diagnosed as low birthweight. Babies weighing
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less than 1,500 grams (3 pounds, 5 ounces) at birth are considered very low
birthweight.
Treatment for low birthweight:
Specific management for low birthweight will be determined by your baby's physician
based on:
 your baby's gestational age, overall health, and medical history
 your baby's tolerance for specific medications, procedures, or therapies
 your opinion or preference
Care for low birthweight babies often includes:
 care in the NICU
 temperature controlled beds
 special feedings, sometimes with a tube into the stomach if a baby cannot suck
 other treatments for complications
Low birthweight babies typically "catch up" in physical growth if there are no other
complications. Babies may be referred to special follow-up healthcare programs.
Prevention of low birthweight:
Because of the tremendous advances in care of sick and premature babies, more and
more babies are surviving despite being born early and being born very small.
However, prevention of preterm births is one of the best ways to prevent babies born
with low birth weight.
Prenatal care is a key factor in preventing preterm births and low birthweight babies.
At prenatal visits, the health of both mother and fetus can be checked. Because
maternal nutrition and weight gain are linked with fetal weight gain and birthweight,
eating a healthy diet and gaining the proper amount of weight in pregnancy are
essential. Mothers should also avoid alcohol, cigarettes, and illicit drugs, which can
contribute to poor fetal growth, among other complications.
Small for Gestational Age
Definition
Small for gestational age (SGA) is a term used to describe a baby who is smaller than
the usual amount for the number of weeks of pregnancy. SGA babies usually have
birthweights below the 10th percentile for babies of the same gestational age. This
means that they are smaller than 90 percent of all other babies of the same gestational
age.
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SGA babies may appear physically and neurologically mature but are smaller than
other babies of the same gestational age. SGA babies may be proportionately small
(equally small all over) or they may be of normal length and size but have lower
weight and body mass. SGA babies may be premature (born before 37 weeks of
pregnancy), full term (37 to 41 weeks), or post term (after 42 weeks of pregnancy).
Causes small for gestational age (SGA)?
Although some babies are small because of genetics (their parents are small), most
SGA babies are small because of fetal growth problems that occur during pregnancy.
Many babies with SGA have a condition called intrauterine growth restriction
(IUGR). IUGR occurs when the fetus does not receive the necessary nutrients and
oxygen needed for proper growth and development of organs and tissues. IUGR can
begin at any time in pregnancy. Early-onset IUGR is often due to chromosomal
abnormalities, maternal disease, or severe problems with the placenta. Late-onset
growth restriction (after 32 weeks) is usually related to other problems.
Some factors that may contribute to SGA and/or IUGR include the following:
 Maternal factors:
o high blood pressure
o chronic kidney disease
o advanced diabetes
o heart or respiratory disease
o malnutrition, anemia
o infection
o substance use (alcohol, drugs)
o cigarette smoking
 Factors involving the uterus and placenta:
o decreased blood flow in the uterus and placenta
o placental abruption (placenta detaches from the uterus)
o placenta previa (placenta attaches low in the uterus)
o infection in the tissues around the fetus
 Factors related to the developing baby (fetus):
o multiple gestation (twins, triplets, etc.)
o infection
o birth defects
o chromosomal abnormality
Diagnosis
The baby with SGA is often identified before birth. During pregnancy, a baby's size
can be estimated in different ways. The height of the fundus (the top of a mother's
uterus) can be measured from the pubic bone. This measurement in centimeters
usually corresponds with the number of weeks of pregnancy after the 20th week. If the
measurement is low for the number of weeks, the baby may be smaller than expected.
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Although many SGA babies have low birthweight, they are not all premature and may
not experience the problems of premature babies. Other SGA babies, especially those
with IUGR, appear thin, pale, and with loose, dry skin. The umbilical cord is often
thin, and dull-looking rather than shiny and fat. They sometimes have a wide-eyed
look.
Other diagnostic procedures may include the following:
 Ultrasound
Ultrasound (a test using sound waves to create a picture of internal structures)
is a more accurate method of estimating fetal size. Measurements can be taken
of the fetus' head and abdomen and compared with a growth chart to estimate
fetal weight. The fetal abdominal circumference is a helpful indicator of fetal
nutrition.
 Doppler flow
another way to interpret and diagnose IUGR during pregnancy is Doppler flow,
which use sound waves to measure blood flow. The sound of moving blood
produces wave-forms that reflect the speed and amount of the blood as it
moves through a blood vessel. Blood vessels in the fetal brain and the umbilical
cord blood flow can be checked with Doppler flow studies.
 Mother’s weight gain
A mother's weight gain can also indicate a baby's size. Small maternal weight
gains in pregnancy may correspond with a small baby
 Gestational assessment
Babies are weighed within the first few hours after birth. The weight is
compared with the baby's gestational age and recorded in the medical record.
The birthweight must be compared to the gestational age. Some physicians use
a formula for calculating a baby's body mass to diagnose SGA.
Treatment of babies who are small for gestational age (SGA):
Specific treatment for SGA will be determined by your baby's physician based on:
 your baby's gestational age, overall health, and medical history
 extent of the condition
 your baby's tolerance for specific medications, procedures, or therapies
 expectations for the course of the condition
 your opinion or preference
Babies with SGA may be physically more mature than their small size indicates. But
they may be weak and less able to tolerate large feedings or to stay warm. Treatment
of the SGA baby may include:
 temperature controlled beds or incubators
 tube feedings (if the baby does not have a strong suck)
 checking for hypoglycemia (low blood sugar) through blood tests
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 monitoring of oxygen levels
Babies who are SGA and are also premature may have additional needs including
oxygen and mechanical help to breathe.
Prevention of small for gestational age (SGA):
Prenatal care is important in all pregnancies, and especially to identify problems with
fetal growth. Stopping smoking and use of substances such as drugs and alcohol are
essential to a healthy pregnancy. Eating a healthy diet in pregnancy may also help.
Intrauterine Growth Restriction (IUGR)
Definition
Intrauterine growth restriction (IUGR) is a term used to describe a condition in which
the fetus is smaller than expected for the number of weeks of pregnancy. Another term
for IUGR is fetal growth restriction. Newborn babies with IUGR are often described
as small for gestational age (SGA).
A fetus with IUGR often has an estimated fetal weight less than the 10th percentile.
This means that the fetus weighs less than 90 percent of all other fetuses of the same
gestational age. A fetus with IUGR also may be born at term (after 37 weeks of
pregnancy) or prematurely (before 37 weeks).
Newborn babies with IUGR often appear thin, pale, and have loose, dry skin. The
umbilical cord is often thin and dull-looking rather than shiny and fat. Babies with
IUGR sometimes have a wide-eyed look. Some babies do not have this malnourished
appearance but are small all-over.
Causes of intrauterine growth restriction (IUGR)?
Intrauterine growth restriction results when a problem or abnormality prevents cells
and tissues from growing or causes cells to decrease in size. This may occur when the
fetus does not receive the necessary nutrients and oxygen needed for growth and
development of organs and tissues, or because of infection. Although some babies are
small because of genetics (their parents are small), most IUGR is due to other causes.
Some factors that may contribute to IUGR include the following:
 Maternal factors:
o high blood pressure
o chronic kidney disease
o advanced diabetes
o heart or respiratory disease
o malnutrition, anemia
o infection
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o substance abuse (alcohol, drugs)
o cigarette smoking
 Factors involving the uterus and placenta:
o decreased blood flow in the uterus and placenta
o placental abruption (placenta detaches from the uterus)
o placenta previa (placenta attaches low in the uterus)
o infection in the tissues around the fetus
 Factors related to the developing baby (fetus):
o multiple gestation (twins, triplets, etc.)
o infection
o birth defects
o chromosomal abnormality
Diagnosis
During pregnancy, fetal size can be estimated in different ways. The height of the
fundus (the top of a mother's uterus) can be measured from the pubic bone. This
measurement in centimeters usually corresponds with the number of weeks of
pregnancy after the 20th week. If the measurement is low for the number of weeks,
the baby may be smaller than expected.
Other diagnostic procedures may include the following:
 ultrasound
Ultrasound (a test using sound waves to create a picture of internal structures)
is a more accurate method of estimating fetal size. Measurements can be taken
of the fetus' head and abdomen and compared with a growth chart to estimate
fetal weight. The fetal abdominal circumference is a helpful indicator of fetal
nutrition.
 Doppler flow
Another way to interpret and diagnose IUGR during pregnancy is Doppler
flow, which use sound waves to measure blood flow. The sound of moving
blood produces wave-forms that reflect the speed and amount of the blood as it
moves through a blood vessel. Blood vessels in the fetal brain and the umbilical
cord blood flow can be checked with Doppler flow studies.
 mother's weight gain
A mother's weight gain can also indicate a baby's size. Small maternal weight
gains in pregnancy may correspond with a small baby.
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Management
Management of IUGR depends on the severity of growth restriction, and how early
the problem began in the pregnancy. Generally, the earlier and more severe the growth
restriction, the greater the risks to the fetus. Careful monitoring of a fetus with IUGR
and ongoing testing may be needed.
Some of the ways to watch for potential problems include the following:
 fetal movement counting - keeping track of fetal kicks and movements. A
change in the number or frequency may mean the fetus is under stress.
 nonstress testing - a test that watches the fetal heart rate for increases with
fetal movements, a sign of fetal well-being.
 biophysical profile - a test that combines the nonstress test with an ultrasound
to evaluate fetal well-being.
 ultrasound - a diagnostic imaging technique which uses high-frequency sound
waves and a computer to create images of blood vessels, tissues, and organs.
Ultrasounds are used to view internal organs as they function, and to assess
blood flow through various vessels. Ultrasounds are used to follow fetal
growth.
 Doppler flow studies - a type of ultrasound which use sound waves to measure
blood flow.
Treatment for IUGR:
Although it is not possible to reverse IUGR, some treatments may help slow or
minimize the effects. Specific treatments for IUGR will be determined by your
physician based on:
 your pregnancy, overall health, and medical history
 the extent of the disease
 your tolerance for specific medications, procedures, or therapies
 expectations for the course of the disease
 your opinion or preference
Treatments may include:
 nutrition
Some studies have shown that increasing maternal nutrition may increase
gestational weight gain and fetal growth.
 bedrest
Bedrest in the hospital or at home may help improve circulation to the fetus.
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 delivery
If IUGR endangers the health of the fetus, then an early delivery may be
necessary.
Prevention of intrauterine growth restriction:
Intrauterine growth restriction may occur, even when the mother is in good health.
However, some factors may increase the risks of IUGR, such as cigarette smoking and
poor maternal nutrition. Avoiding harmful lifestyles, eating a healthy diet, and getting
prenatal care may help decrease the risks for IUGR. Early detection may also help
with IUGR treatment and outcome.
Large for Gestational Age (LGA)
Definition
Large for gestational age (LGA) is a term used to describe babies who are born
weighing more than the usual amount for the number of weeks of pregnancy. LGA
babies have birthweights greater than the 90th percentile for their gestational age,
meaning that they weigh more than 90 percent of all babies of the same gestational
age.
The average baby weighs about 7 pounds at birth. About 10 percent of all babies
weigh more than 4,000 grams (8 pounds, 13 ounces). Rarely do babies weigh over 10
pounds.
Although most LGA babies are born at term (37 to 41 weeks of pregnancy), a few
premature babies may be LGA.
Causes of large for gestational age (LGA)
Some babies are large because their parents are large; genetics does play a part.
Birthweight may also be related to the amount of a mother's weight gain in pregnancy.
Excessive weight gain can translate to increased fetal weight.
By far, maternal diabetes is the most common cause of LGA babies. Diabetes during
pregnancy causes the mother's increased blood glucose (sugar) to circulate to the
baby. In response, the baby's body makes insulin. All the extra sugar and the extra
insulin production can lead to excessive growth and deposits of fat, thus, a larger
baby.
Diagnosis
During pregnancy, a baby's birthweight can be estimated in different ways. The height
of the fundus (the top of a mother's uterus) can be measured from the pubic bone. This
measurement, in centimeters, usually corresponds with the number of weeks of
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pregnancy. If the measurement is high for the number of weeks, the baby may be
larger than expected. Other diagnostic procedures may include the following:
 Ultrasound (a test using sound waves to create a picture of internal structures)
is a more accurate method of estimating fetal size. Measurements can be taken
of the fetus' head and limbs and compared with a growth chart to estimate fetal
weight.
 A mother's weight gain can also influence a baby's size. Large maternal weight
gains in pregnancy may correspond with a big baby.
Babies are weighed within the first few hours after birth. The weight is compared with
the baby's gestational age and recorded in the medical record. The birthweight must be
compared to the gestational age. Generally, a baby weighing more than 4,000 grams
(8 pounds, 13 ounces) is considered LGA.
Treatment for large for gestational age (LGA):
Specific treatment for large for gestational age will be determined by your baby's
physician based on:
 your baby's gestational age, overall health, and medical history
 extent of the condition
 your baby's tolerance for specific medications, procedures, or therapies
 expectations for the course of the condition
 your opinion or preference
If ultrasound examinations during pregnancy show a fetus is quite large, some
physicians may recommend early delivery before the baby grows much bigger. A
mother may need induction of labor, or a planned cesarean delivery if the baby is
estimated to be very large.
After delivery, a LGA baby will be carefully examined for any birth injuries. Blood
glucose testing is also performed to check for hypoglycemia. Early feeding with a
glucose/water solution is sometimes needed to counter the low blood sugar.
Prevention of large for gestational age (LGA):
Prenatal care is important in all pregnancies, and especially to monitor fetal growth
when a baby seems to be too small or too large. Examinations during pregnancy that
show a large baby can help identify a mother who may have undetected diabetes, or
other problems. Careful management of diabetes in pregnancy can help lower some of
the risks to the baby.
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High-Risk Newborns - Very Low Birthweight
What is very low birthweight?
Very low birthweight is a term used to describe babies who are born weighing less
than 1,500 grams (3 pounds, 4 ounces). Only a few babies, 1.5 percent, are born this
tiny. However, the overall rate of very low birthweight babies in the US is increasing.
This is primarily due to the greater numbers of multiple birth babies who are more
likely to be born early and weigh less.
Babies with very low birthweight look much smaller than other babies of normal
birthweight. A very low birthweight baby's head appears to be bigger than the rest of
the body and he/she often looks extremely thin, with little body fat. The skin is often
quite transparent, allowing the blood vessels to be easily seen.
Statistics for very low birthweight:
Consider the latest available statistics from the National Center for Health Statistics:
Birthweight Percentage of Total Births
less than 2,500 grams (5.5 lbs) 8.2 percent
2,000 to 2,499 grams (4.4 to 5.5 lbs) 5 percent
1,500 to 1,999 grams (3.3 to 4.4 lbs) 1.6 percent
1,000 to 1,499 grams (2.2 to 3.3 lbs) 0.8 percent
500 to 999 grams (1.1 to 2.2 lbs) 0.6 percent
less than 500 grams (less than 1.1 lbs) 0.2 percent
Causes of very low birthweight?
The primary cause of very low birthweight is premature birth (born before 37 weeks
gestation). Very low birthweight babies are often born before 30 weeks of pregnancy.
Being born early means a baby has less time in the mother's uterus to grow and gain
weight. Much of a baby's weight is gained during the latter part of pregnancy.
Another cause of very low birthweight is intrauterine growth restriction (IUGR). This
is when a baby does not grow well during pregnancy because of problems with the
placenta, the mother's health, or birth defects. Most very low birthweight babies who
have IUGR are also born early, and are both very small and physically immature.
Incidence
Any baby born prematurely is more likely to be very small. However, there are other
factors that can also contribute to the risk of very low birthweight. These include:
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 race
African-American babies are twice as likely to have very low birthweight than
Caucasian babies.
 age
Teen mothers (especially those younger than 15 years old) have a much higher
risk of having a baby with very low birthweight.
 multiple birth
Multiple birth babies are at increased risk of very low birthweight because they
often are premature. About 10 percent of twins and one-third of triplets have
very low birthweight.
 mother's health
Women who are exposed to drugs, alcohol, and cigarettes during pregnancy are
more likely to have low or very low birthweight babies. Mothers of lower
socioeconomic status are also more likely to have poorer pregnancy nutrition,
inadequate prenatal care, and pregnancy complications - all factors that can
contribute to very low birthweight.
Diagnosis
During pregnancy, a baby's birthweight can be estimated in different ways. The height
of the fundus (the top of a mother's uterus) can be measured from the pubic bone. This
measurement in centimeters usually corresponds with the number of weeks of
pregnancy after the 20th week. If the measurement is low for the number of weeks,
the baby may be smaller than expected. Ultrasound (a test using sound waves to create
a picture of internal structures) is a more accurate method of estimating fetal size.
Measurements can be taken of the fetus' head and abdomen and compared with a
growth chart to estimate fetal weight.
Babies are weighed within the first few hours after birth. The weight is compared with
the baby's gestational age and recorded in the medical record. A birthweight less than
2,500 grams (5 pounds, 8 ounces) is diagnosed as low birthweight. Babies weighing
less than 1,500 grams (3 pounds, 5 ounces) at birth are considered very low
birthweight.
Treatment for very low birthweight:
Specific treatment for very low birthweight will be determined by your baby's
physician based on:
 your baby's gestational age, overall health, and medical history
 your baby's tolerance for specific medications, procedures, or therapies
 your opinion or preference
Care for very low birthweight babies often includes:
 care in the NICU
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 temperature controlled beds
 special feedings, sometimes with a tube into the stomach if a baby cannot suck
 other treatments for complications
Very low birthweight babies may have a harder time "catching up" in physical growth
because they often have other complications. Many very low birthweight babies are
referred to special follow-up healthcare programs.
Prevention of very low birthweight:
Because of the tremendous advances in care of sick and premature babies, more and
more babies are surviving despite being born early and being born very small.
However, prevention of preterm births is one of the best ways to prevent very low
birthweight.
Prenatal care is a key factor in preventing preterm births and very low birthweight
babies. At prenatal visits, the health of both mother and fetus can be checked. Because
maternal nutrition and weight gain are linked with fetal weight gain and birthweight,
eating a healthy diet and gaining the proper amount of weight in pregnancy are
essential. Mothers should also avoid alcohol, cigarettes, and illicit drugs, which can
contribute to poor fetal growth, among other complications.
Classification according to Gestational age
Prematurity
Definition
A baby born before 37 weeks of pregnancy is considered premature, that is, born
before complete maturity. Slightly fewer than 12 percent of all babies are premature.
Overall, the rate of premature births is rising, mainly due to the large numbers of
multiple births in recent years. Twins and other multiples are about six times more
likely to be premature than single birth babies. The rate of premature single births is
slightly increasing each year.
According to the March of Dimes, about 13 percent of babies born in the US are born
preterm, or before 37 completed weeks of pregnancy. Of the babies born preterm:
 71 percent are born between 34 and 36 weeks of gestation (the time from
conception to birth)
 about 13 percent are born between 32 and 33 weeks of gestation
 about 6 percent are born at less than 28 weeks of gestation
Other terms often used for prematurity are preterm and "preemie." Many premature
babies also weigh less than 2,500 grams (5.5 pounds) and may be referred to as low
birthweight (LBW).
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Premature infants born between 34 and 37 weeks of pregnancy are often called late
preterm or near-term infants. Late preterm infants are often much larger than very
premature infants but may only be slightly smaller than full-term infants.
Late preterm babies usually appear healthy at birth but may have more difficulties
adapting than full-term babies. Because of their smaller size, they may have trouble
maintaining their body temperature. They often have difficulty with breastfeeding and
bottle feeding, and may need to eat more frequently. They usually require more sleep
and may even sleep through a feeding, which means they miss much-needed calories.
Late preterm infants may also have breathing difficulties, although these are often
identified before the infants go home from the hospital. These infants are also at
higher risk for infections and jaundice, and should be watched for signs of these
conditions. Late preterm infants should be seen by a care provider within the first one
or two days after going home from the hospital.
Causes of prematurity
There are many factors linked to premature birth. Some directly cause early labor and
birth, while others can make the mother or baby sick and require early delivery. The
following factors may contribute to a premature birth:
 Maternal factors:
o preeclampsia (also known as toxemia or high blood pressure of
pregnancy)
o chronic medical illness (such as heart or kidney disease)
o infection (such as group B streptococcus, urinary tract infections,
vaginal infections, infections of the fetal/placental tissues)
o drug use (such as cocaine)
o abnormal structure of the uterus
o cervical incompetence (inability of the cervix to stay closed during
pregnancy)
o previous preterm birth
 Factors involving the pregnancy:
o abnormal or decreased function of the placenta
o placenta previa (low lying position of the placenta)
o placental abruption (early detachment from the uterus)
o premature rupture of membranes (amniotic sac)
o polyhydramnios (too much amniotic fluid)
 Factors involving the fetus:
o when fetal behavior indicates the intrauterine environment is not healthy
o multiple gestation (twins, triplets or more)
Characteristics of prematurity
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The following are the most common characteristics of a premature baby. However,
each baby may show different characteristics of the condition. Characteristics may
include:
 small baby, often weighing less than 2,500 grams (5 pounds 8 ounces)
 thin, shiny, pink or red skin, able to see veins
 little body fat
 little scalp hair, but may have lots of lanugo (soft body hair)
 weak cry and body tone
 genitals may be small and underdeveloped
The characteristics of prematurity may resemble other conditions or medical
problems. Always consult your baby's physician for a diagnosis.
Treatment of prematurity:
Specific treatment for prematurity will be determined by your baby's physician based
on:
 your baby's gestational age, overall health, and medical history
 extent of the disease
 tolerance for specific medications, procedures, or therapies
 expectations for the course of the disease
 your opinion or preference
Treatment may include:
 prenatal corticosteroid therapy
One of the most important parts of care for premature babies is a medication
called a corticosteroid. Research has found that giving the mother a steroid
medication at least 48 hours prior to delivery greatly reduces the incidence and
severity of respiratory disease in the baby. Another major benefit of steroid
treatment is lessening of intraventricular hemorrhage (bleeding in the baby's
brain). Although studies are not clear, prenatal steroids may also help reduce
the incidence of NEC and PDA. Mothers may be given steroids when preterm
birth is likely between 24 and 34 weeks of pregnancy. Before that time, or
after, the medication usually is not effective.
Premature babies usually need care in a special nursery called the Neonatal
Intensive Care Unit (NICU). The NICU combines advanced technology and
trained health professionals to provide specialized care for the tiniest patients.
The NICU team is led by a neonatologist, who is a pediatrician with additional
training in the care of sick and premature babies.
Care of premature babies may also include:
 temperature-controlled beds
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 monitoring of temperature, blood pressure, heart and breathing rates, and
oxygen levels
 giving extra oxygen by a mask or with a breathing machine
 mechanical ventilators (breathing machines) to do the work of breathing for the
baby
 intravenous (IV) fluids - when feedings cannot be given, or for medications
 placement of catheters (small tube) into the umbilical cord to give fluids and
medications and to draw blood
 x-rays (for diagnosing problems and checking tube placement)
 special feedings of breast milk or formula, sometimes with a tube into the
stomach if a baby cannot suck. Breast milk has many advantages for premature
babies as it contains immunities from the mother and many important nutrients.
 medications and other treatments for complications, such as antibiotics
 Kangaroo Care - a method of caring for premature babies using skin-to-skin
contact with the parent to provide contact and aid parent-infant attachment.
Studies have found that babies who "kangaroo" may have shorter stays in the
NICU.
Discharge
Premature babies often need time to "catch up" in both development and growth. In
the hospital, this catch-up time may involve learning to eat and sleep, as well as
steadily gaining weight. Depending on their condition, premature babies often stay in
the hospital until they reach the pregnancy due date.
If a baby was transferred to another hospital for specialized NICU care, he/she may be
transferred back to the "home" hospital once the condition is stable.
Consult your baby's physician for information about the specific criteria for discharge
of premature babies at your hospital. General goals for discharge may include the
following:
 serious illnesses are resolved
 stable temperature - able to stay warm in an open crib
 taking all feedings by breast or bottle
 no recent apnea or low heart rate
 parents are able to provide care including medications and feedings
Before discharge, premature babies also need an eye examination and hearing test to
check for problems related to prematurity. Parents need information about follow-up
visits with the pediatrician for baby care and immunizations. Many hospitals have
special follow-up healthcare programs for premature and low birthweight babies.
Even though they are otherwise ready for discharge, some babies continue to have
special needs such as extra oxygen or tube feedings. With instruction and the right
equipment, these babies are often able to be cared for at home by parents. A hospital
social worker can often help coordinate discharge plans when special care is needed.
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Ask your baby's physician about a "trial run" overnight stay in a parenting room at the
hospital before your baby is discharged. This can help you adjust to caring for your
baby while healthcare providers are nearby for help and reassurance. Parents may also
feel more confident taking their baby home when they have been given instructions in
infant CPR (cardiopulmonary resuscitation) and infant safety.
Prevention of prematurity:
Because of the tremendous advances in the care of sick and premature babies, more
and more babies are surviving despite being born early and being very small. But
prevention of early birth is the best way of promoting good health for babies.
Prenatal care is a key factor in preventing preterm births and low birthweight babies.
At prenatal visits, the health of both mother and fetus can be checked. Because
maternal nutrition and weight gain are linked with fetal weight gain and birthweight,
eating a healthy diet and gaining weight in pregnancy are essential. Prenatal care is
also important in identifying problems and lifestyles that can increase the risks for
preterm labor and birth. Some ways to help prevent prematurity and to provide the
best care for premature babies may include the following:
 identifying mothers at risk for preterm labor
 prenatal education of the symptoms of preterm labor
 avoiding heavy or repetitive work or standing for long periods of time which
can increase the risk of preterm labor
 early identification and treatment of preterm labor
Postmaturity
Definition
The normal length of pregnancy is from 37 to 41 weeks. Postmaturity refers to any
baby born after 42 weeks gestation or 294 days past the first day of the mother's last
menstrual period. About 6 percent of all babies are born at 42 weeks or later. Other
terms often used to describe these late births include post-term, postmaturity,
prolonged pregnancy, and post-dates pregnancy.
Causes of postmaturity?
It is not known why some pregnancies last longer than others. Postmaturity is more
likely when a mother has had one or more previous post-term pregnancies. Sometimes
a mother's pregnancy due date is miscalculated because she is not sure of her last
menstrual period. A miscalculation may mean the baby is born earlier or later than
expected.
Symptoms of postmaturity
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The following are the most common symptoms of postmaturity. However, each baby
may show different symptoms of the condition. Symptoms may include:
 dry, peeling skin
 overgrown nails
 abundant scalp hair
 visible creases on palms and soles of feet
 minimal fat deposits
 green/brown/yellow coloring of skin from meconium staining (the first stool
passed during pregnancy into the amniotic fluid)
Symptoms of postmaturity may resemble other conditions or medical problems.
Always consult your baby's physician for a diagnosis.
Diagnosis
Postmaturity is usually diagnosed by a combination of assessments, including the
following:
 your baby's physical appearance
 length of the pregnancy
 your baby's assessed gestational age
Treatment of postmaturity:
Specific treatment for postmaturity will be determined by your baby's physician based
on:
 your baby's gestational age, overall health, and medical history
 extent of the condition
 your baby's tolerance for specific medications, procedures, or therapies
 expectations for the course of the condition
 your opinion or preference
In a prolonged pregnancy, testing may be done to check fetal well-being and identify
problems. Tests often include ultrasound, non-stress testing (how the fetal heart rate
responds to fetal activity), and estimation of the amniotic fluid volume.
The decision to induce labor for post-term pregnancy depends on many factors.
During labor, the fetal heart rate may be monitored with an electronic monitor to help
identify changes in the heart rate due to low oxygenation. Changes in a baby's
condition may require a cesarean delivery.
Special care of the postmature baby may include:
 checking for respiratory problems related to meconium (baby's first bowel
movement) aspiration.
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 blood tests for hypoglycemia (low blood sugar).
Prevention of postmaturity:
Accurate pregnancy due dates can help identify babies at risk for postmaturity.
Ultrasound examinations early in pregnancy help establish more accurate dating by
measurements taken of the fetus. Ultrasound is also important in evaluating the
placenta for signs of aging.
Classification according to mortality
Live birth:
birth in which the neonate manifests any heartbeat, breathes, or displays voluntary
movement, regardless of gestational age.
Fetal death/Stillbirth
What is stillbirth?
Stillbirth is a common term for death of a baby while still in the uterus. It is also
called intrauterine fetal death or demise. Causes of stillbirth may include the
following:
 mother with diabetes or high blood pressure
 infection in the mother or in the fetal tissues
 congenital abnormalities
 Rh disease - a blood incompatibility problem between the mother and fetus.
 cord problems including knots, tightened cord, cord wrapped around fetal body
or neck, cord prolapse (falling down through the open cervix during labor)
 placental problems including poor circulation, twin-to-twin transfusion (when
twin circulations connect in a shared placenta
symptoms
The following are the most common symptoms of stillbirth. However, each woman
may experience symptoms differently. Symptoms may include:
 stopping of fetal movement and kicks
 spotting or bleeding
 no fetal heartbeat heard with stethoscope or Doppler
 no fetal movement or heartbeat seen on ultrasound
The symptoms of stillbirth may resemble other medical conditions. Always consult
your physician for a diagnosis.
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Management
Treatment of stillbirth depends on many factors such as the number of weeks
gestation, the size of the fetus, and how long since the fetal heartbeat stopped.
Treatment may include the following:
 waiting until the mother goes into labor on her own
 dilating the cervix and using instruments to deliver the fetus and tissues
 induction of labor using medications to open the cervix and make the uterus
contract and push out the fetus and tissues
Neonatal Death
When a baby dies in the first 28 days of life, it is called neonatal death. In the United
States in 2002, about 19,000 babies died in their first month (1).
As parents attempt to cope with a loss, they may have many questions about what
happened to their baby. The following may help parents discuss the loss of their baby
with their health care providers.
Causes
Premature birth (before 37 completed weeks of pregnancy) is the most common cause
of neonatal death. Prematurity and its complications cause almost 30 percent of
neonatal deaths . The earlier a baby is born, the more likely he is to die. About 20 to
35 percent of babies born at 23 weeks of pregnancy survive, while about 50 to 70
percent of babies born at 24 to 25 weeks, and more than 90 percent born at 26 to 27
weeks, survive
About 12 percent of babies are born prematurely. The causes of premature delivery
are not thoroughly understood. In some cases, a pregnant woman may have health
problems (such as high blood pressure) or pregnancy complications (such as placental
problems) that increase her risk of delivering prematurely. Women who have had a
previous preterm delivery, are pregnant with twins (or other multiples), or have certain
abnormalities of the uterus or cervix also are at increased risk. More often, preterm
labor develops unexpectedly in a pregnancy that had been problem-free.
Premature babies, especially those born at less than 32 weeks of pregnancy and
weighing less than 3 1/3 pounds, often develop respiratory distress syndrome (RDS).
About 23,000 babies develop RDS each year .
Babies with RDS have immature lungs that lack a protein called surfactant that keeps
small air sacs in the lungs from collapsing. Treatment with surfactant has greatly
reduced the number of babies who die from RDS. However, about 880 babies a year
die in the neonatal period due to RDS.
About 25 percent of babies born preterm, usually before 32 weeks of pregnancy,
develop bleeding in the brain called intraventricular hemorrhage (IVH). While mild
brain bleeds usually resolve themselves with no or few lasting problems, severe bleeds
often result in brain damage or even death.
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Some premature babies may develop an intestinal problem called necrotizing
enterocolitis (NEC). Treatment with antibiotics and surgery can save many affected
babies. However, some develop severe bowel damage and die.
Premature babies have immature immune systems and sometimes develop serious
infections such as pneumonia (lung infection), sepsis (blood infection), and meningitis
(infection of membranes surrounding the brain and spinal cord). In spite of treatment
with antibiotics and antiviral drugs, some babies die.
While deaths due to prematurity are still too common, the outlook for these babies is
improving. Surfactant and other treatments are saving more of these babies after birth.
And treatment before birth can sometimes prevent or lessen the complications of
prematurity. Women who are likely to deliver between 24 and 34 weeks of pregnancy
should be treated at least several days before delivery with drugs called
corticosteroids, which speed maturation of fetal lungs. Studies show this treatment
reduces RDS, brain bleeds and infant deaths.
Birth defects cause about 21 percent of neonatal deaths. Babies with birth defects may
be premature or full-term. Sometimes parents learn about their baby's birth defects
before birth from prenatal tests, such as ultrasound, amniocentesis and chorionic villus
sampling (CVS).
Ultrasound uses sound waves to take a picture of the fetus. It can help diagnose
structural birth defects, such as spina bifida (open spine), anencephaly (brain and skull
defect), and heart or kidney defects. In amniocentesis, the doctor inserts a thin needle
through the abdomen to obtain a small sample of amniotic fluid for testing. In CVS,
the doctor takes a tiny sample of tissue from the developing placenta, either using a
thin tube that is inserted through the vagina or a needle that is inserted through the
abdomen. Amniocentesis and CVS are used to diagnose chromosomal abnormalities,
such as Down syndrome, and many genetic birth defects.
Other causes of neonatal death include problems related to:
 Complications of pregnancy
 Complications involving the placenta, umbilical cord and membranes (bag of
waters)
 Infections
 Asphyxia (lack of oxygen before or during birth)
Risk factors
Heart defects are the most common birth defect-related cause of infant death in the
first year of life. Heart defects cause nearly one-third of infant deaths.
About 1 in every 125 babies is born with a heart defect . Because of improvements in
the surgical treatment and medical management of these defects, most affected babies
survive and do well. However, some babies with severe heart defects may not survive
until surgery, or may not survive the surgery. Many babies who die of heart defects in
the first month of life have a specific heart defect called hypoplastic left heart
Page 27

syndrome. In this heart defect, the main pumping chamber of the heart is too small to
supply blood to the body. New surgical procedures are saving more babies with this
heart defect, but many still die. In most cases, doctors do not know why a baby is born
with a heart defect, although both genetic and environmental factors are believed to
play a role.
Birth defects of the lungs are another common cause of neonatal death. Sometimes,
one or both lungs does not develop at all or is malformed for reasons that are not
known. In most cases, lung defects occur because other birth defects or pregnancy
complications interfered with lung development. Many babies die due to
complications that occur in immature lungs as a result of premature birth.
Chromosomal abnormalities are also a common cause of neonatal death. Humans
normally have 46 chromosomes. Chromosomes are tiny thread-like structures in our
cells that carry our genes; genes are the basic units of heredity that dictate all traits
from eye color to workings of internal organs. However, sometimes a baby is born
with too many or too few chromosomes. In most cases, an embryo with a
chromosomal abnormality will not survive, and the pregnancy will end in miscarriage.
In other cases, the baby survives until birth but dies in the early weeks of life.
For example, babies with an extra copy of chromosome 18 or chromosome 13 (called
trisomy 18 or trisomy 13) have multiple birth defects and generally die in the first
weeks or months of life. Babies with less severe chromosomal abnormalities, such
as Down syndrome(trisomy 21), often survive, although affected children have mental
retardation and other serious problems.
Birth defects involving the brain and central nervous system are another cause of
neonatal death. One example is anencephaly, in which most of the brain and skull are
missing. Affected babies may be stillborn (fetus died before birth) or die in the first
days of life. This birth defect often can be detected before birth with a blood test,
ultrasound or amniocentesis. Anencephaly may be prevented in subsequent
pregnancies when the woman takes the B vitamin folic acid before and in the early
months of pregnancy. A woman who has had a baby with anencephaly, or a related
birth defect called spina bifida, should consult her health care provider before getting
pregnant again to find out how much folic acid to take. Generally, a higher-than-
normal dose is recommended (usually 4 milligrams) (9).
Support is available for parents who experience a loss?
Parents of critically ill babies in the neonatal intensive care unit (NICU) need support
from family, friends and health care professionals. They should never hesitate to ask
their baby's doctors and nurses about their baby's comfort and care. Parents may want
to ask how they can share in their baby's care so they can feel that they are helping
their baby and creating memories of their baby. Some hospitals have support groups
where parents of very sick newborns can share their feelings. Many also have support
groups for parents of sick newborns and for parents of babies who have died. Parents
who are having trouble coping with their grief, before or after the baby's death, should
ask their health care provider for a referral to a counselor who is experienced in
dealing with infant death.
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Some NICUs have a March of Dimes NICU Family Support project, which provides
information, comfort and services to families with a baby in the NICU. For
information and resources from NICU Family Support, click here.
Parents also can visit Share Your Story an online community for families who have
or have had a baby in the NICU, including families who have experienced a loss.
Sudden Infant Death Syndrome (SIDS)
Definition
Sudden infant death syndrome (SIDS) is the sudden and unexplained death of an
infant under 1 year of age. SIDS is sometimes called crib death because the death
occurs when a baby is sleeping in a crib. It is the major cause of death in babies from
1 month to 1 year of age, occurring most often between two and three months of age.
The death is sudden and unpredictable; in most cases, the baby seems healthy. Death
occurs quickly, usually during a sleep time.
Causes
The exact causes of SIDS are still unclear and research is ongoing. There are some
factors which make babies more vulnerable to SIDS. Some risk factors are
preventable, but others are not. Evidence has shown that some babies who die from
SIDS have the following:
 brain abnormalities
Some SIDS babies are born with brain abnormalities that make them
vulnerable to sudden death during infancy. Studies of SIDS victims show that
many SIDS babies have abnormalities in the "arcuate nucleus," a part of the
brain that probably helps control breathing and waking during sleep. Babies
born with defects in other portions of the brain or body may also be more prone
to a sudden death. These abnormalities may result from exposure of the fetus to
a toxic substance, or a decrease in oxygen. Cigarette smoking during
pregnancy, for example, can reduce the amount of oxygen the fetus receives.
 events after birth
Events such as lack of oxygen, excessive carbon dioxide intake, overheating, or
an infection may be related to SIDS. Examples of a lack of oxygen and
excessive carbon dioxide levels may include the following:
o respiratory infections that cause breathing problems.
o rebreathing exhaled air trapped in underlying bedding when babies sleep
on their stomachs.
Normally, babies sense when they do not get enough air and the brain triggers
the babies to wake from sleep and cry. This changes their heartbeat or
breathing patterns to make up for the lowered oxygen and excess carbon
dioxide. A baby with a flawed arcuate nucleus, however, might lack this
protective mechanism.

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This may explain why babies who sleep on their stomachs are more susceptible
to SIDS, and why a large number of SIDS babies have been reported to have
respiratory infections prior to their deaths. This may also explain why more
SIDS cases occur during the colder months of the year, when respiratory and
intestinal infections are more common.
 immune system problems
The numbers of cells and proteins made by the immune system of some SIDS
babies have been reported to be higher than normal. Some of these proteins can
interact with the brain to change heart rate and breathing during sleep, or can
put the baby into a deep sleep. Such effects might be strong enough to cause
the baby's death, particularly if the baby has an underlying brain defect.
 metabolic disorder
Some babies who die suddenly may be born with a metabolic disorder. One
such disorder is medium chain acyl-CoA dehydrogenase deficiency, which
prevents the baby from properly processing fatty acids. A build up of these acid
metabolites could eventually lead to a rapid and fatal interruption in breathing
and heart functioning. If there is a family history of this disorder or childhood
death of unknown cause, genetic screening of the parents by a blood test can
determine if they are carriers of this disorder. If one or both parents is found to
be a carrier, the baby can be tested soon after birth.
risk factors
About 2,600 babies in the United States die of SIDS each year. Some babies are more
at risk than others. For example, SIDS is more likely when a baby is between 1 and 4
months old, it is more common in boys than girls, and most deaths occur during the
fall, winter, and early spring months.
Factors that may place a baby at higher risk of dying from SIDS include the
following:
 babies who sleep on their stomachs rather than their backs
 babies who sleep on soft surfaces, have loose bedding, and are covered by
many blankets
 babies who share a bed with other children
 mothers who smoke during pregnancy (three times more likely to have a SIDS
baby)
 exposure to passive smoke from smoking by mothers, fathers, and others in the
household (doubles a baby's risk of SIDS)
 mothers who are younger than 20 years old at the time of their first pregnancy
 babies born to mothers who had no or late prenatal care
 premature or low birthweight babies
diagnosis
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The diagnosis of SIDS is given when the cause of death remains unexplained after a
complete investigation, which includes the following:
 an autopsy
 examination of the death scene
 review of the symptoms or illnesses the infant had prior to dying
 any other pertinent medical history
prevention
There currently is no way of predicting which babies will die from SIDS. However,
there are a few measures parents can take to lower the risk of their baby dying from
SIDS, including the following:
 prenatal care
Early and regular prenatal care can help reduce the risk of SIDS. Proper
nutrition, no smoking or drug or alcohol use by the mother, and frequent
medical check-ups beginning early in pregnancy might help prevent a baby
from developing an abnormality that could put him/her at risk for sudden death.
These measures may also reduce the chance of having a premature or low
birthweight baby, which also increases the risk for SIDS. The risk of SIDS is
higher for babies whose mothers smoked during pregnancy.
 put your baby on his/her back for sleep, even at naptime
Parents and other caregivers should put babies to sleep on their backs as
opposed to on their stomachs. Studies have shown that placing babies on their
backs to sleep has reduced the number of SIDS cases by as much as a half in
countries where babies had traditionally slept on their stomachs. The back sleep
position is the best position for babies from 1 month to 1 year for sleep,
including naps.

Although many parents are afraid babies will choke on spit-up or vomit if
placed on their backs, studies have not found any evidence of increased risk of
choking or other problems.
 place baby on his/her stomach while awake
A certain amount of tummy time while the infant is awake and being observed
is recommended for motor development of the shoulders. In addition, awake
time on the stomach may help prevent flat spots from developing on the back
of the baby's head. Such physical signs are almost always temporary and will
disappear soon after the baby begins to sit up.
 proper bedding
Make sure that your baby sleeps on a firm mattress or other firm surface. Do
not use fluffy blankets or comforters under the baby. Do not let the baby sleep
on a waterbed, sofa, sheepskin, a pillow, or other soft materials. When your
baby is very young, do not place soft stuffed toys or pillows in the crib with
him/her. Some babies have smothered with these soft materials in the crib.
Tuck blankets in around the crib mattress so that the baby's face is not covered.
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 temperature control
Babies should be kept warm, but they should not be allowed to get too warm.
An overheated baby is more likely to go into a deep sleep from which it is
difficult to arouse. The temperature in the baby's room should feel comfortable
to an adult and overdressing the baby should be avoided. Keep the temperature
in your baby's room so that it feels comfortable to you.
 same room
Place baby's crib or bassinet in parents' room for first 6 months. The risk of
SIDS is reduced when a baby sleeps in the same room as the mother.
 avoid bed sharing
Recently, scientific studies have shown that bed sharing between mother and
baby can alter sleep patterns of the mother and her baby. While bed sharing
may have certain benefits (such as encouraging breastfeeding), there are no
scientific studies demonstrating that bed sharing reduces SIDS. Some studies
suggest that bed sharing, under certain conditions, may actually increase the
risk of SIDS. Avoid putting your baby to sleep in a bed with other children or
on a sofa with another person as these have been found to increase the risk of
SIDS. Infants can be brought into the parents' bed for feedings and comforting,
but should be returned to their own crib for sleep.
 smoke-free environment
Do not smoke when you are pregnant and do not let anyone smoke around your
baby. Smoking in pregnancy is a major risk factor for SIDS. Babies and young
children exposed to smoke have more colds and other diseases, as well as an
increased risk of SIDS.
 pediatric healthcare
If your baby seems sick, call your physician right away. Parents should take
their babies for regular well baby check-ups and routine immunizations. Claims
that immunizations increase the risk of SIDS are not supported by research. If a
baby ever has an incident where he/she stops breathing and turns blue or limp,
the baby should be medically evaluated for the cause of such an incident.
 breastfeed your baby
If possible, you should breastfeed your baby. While there is insufficient
evidence to suggest that breastfeeding might reduce the risk of SIDS, a few
studies have found SIDS to be less common in babies who have been breastfed.
This may be because breast milk can provide protection from some infections
that can trigger sudden death in babies.
 home monitors for babies at risk
Although some electronic home monitors can detect and sound an alarm when
a baby stops breathing, there is no evidence that such monitors can prevent
SIDS. In 1986, the National Institutes of Health recommended that home
monitors not be used for babies who do not have an increased risk of sudden
unexpected death. The monitors may be recommended, however, for babies
who have experienced one or more severe episodes during which they stopped
breathing and required resuscitation or stimulation, premature babies with
apnea (stopping breathing), and siblings of two or more SIDS babies. If an
incident has occurred, or if a baby is on a monitor, parents need to know how to
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properly use and maintain the device, as well as how to resuscitate their baby if
the alarm sounds.
 use of pacifiers
According to the latest guidelines from the American Academy of Pediatrics
(2005), the use of a pacifier for the first year of life is recommended. A pacifier
should be offered at nap time and bedtime. The pacifier should not be sugar
coated. Pacifiers should be cleaned and replaced often. Breast-fed infants
should not be started on a pacifier until one month after breast-feeding has
begun.
Classification according to Path physiologic problems
Hypoglycemia
Definition
Hypoglycemia is a condition in which the amount of blood glucose (sugar) in the
blood is lower than normal.
Causes of hypoglycemia
Hypoglycemia may be caused by conditions that:
 lower the amount of glucose in the bloodstream
 prevent or lessen storage of glucose
 use up glycogen stores (sugar stored in the liver)
 inhibit the use of glucose by the body
Many different conditions are associated with hypoglycemia, including the following:
 inadequate maternal nutrition in pregnancy
 excess insulin produced in a baby of a diabetic mother
 severe hemolytic disease of the newborn (incompatibility of blood types of
mother and baby)
 birth defects and congenital metabolic diseases
 birth asphyxia
 cold stress (conditions that are too cold)
 liver disease
Babies who are more likely to develop hypoglycemia include:
 Babies born to diabetic mothers may develop hypoglycemia after delivery
when the source of glucose (the mother's blood) is gone and the baby's insulin
production metabolizes the existing glucose.
 Small for gestational age or growth-restricted babies may have too few
glycogen stores.
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 Premature babies, especially those with low birthweights, who often have
limited glycogen stores (sugar stored in the liver) or an immature liver
function.
Symptoms
Symptoms of hypoglycemia may not be obvious in newborn babies. The following are
the most common symptoms of hypoglycemia. However, each baby may experience
symptoms differently. Symptoms may include:
 jitteriness
 cyanosis (blue coloring)
 apnea (stopping breathing)
 hypothermia (low body temperature)
 poor body tone
 poor feeding
 lethargy
 seizures
The symptoms of hypoglycemia may resemble other conditions or medical problems.
Always consult your baby's physician for a diagnosis.
Diagnosis
A simple blood test for blood glucose levels can diagnose hypoglycemia. Blood may
be drawn from a heel stick, with a needle from the baby's arm, or through an umbilical
catheter (a tube placed in the baby's umbilical cord). Generally, a baby with low blood
glucose levels will need treatment.
Treatment for hypoglycemia:
Specific treatment for hypoglycemia will be determined by your baby's physician
based on:
 your baby's gestational age, overall health, and medical history
 extent of the disease
 your baby's tolerance for specific medications, procedures, or therapies
 expectations for the course of the disease
 your opinion or preference
Treatment includes giving the baby a rapid-acting source of glucose. This may be as
simple as giving a glucose/water mixture or formula as an early feeding. Or, the baby
may need glucose given intravenously. The baby's blood glucose levels are closely
monitored after treatment to see if the hypoglycemia occurs again.
Prevention of hypoglycemia:
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There may not be any way to prevent hypoglycemia, only to watch carefully for the
symptoms and treat as soon as possible. Mothers with diabetes with blood glucose
levels in tight control can help minimize the amount of glucose that goes to the fetus.
Hypocalcemia
Definition
Hypocalcemia is a condition in which there is too little calcium in the blood. A
common form of hypocalcemia in babies is called neonatal hypocalcemia. This
condition may occur at different times with different causes, including the following:
 early hypocalcemia - occurs in the first three days of life.
 late hypocalcemia - develops between the fifth to tenth days of life, usually
after several days of formula feedings. Some formulas have high levels of
phosphate which can lower the blood calcium levels.
Causes of hypocalcemia
The causes of early hypocalcemia are unknown, while late hypocalcemia has a
number of known causes, related primarily to calcium and phosphorus levels in the
body as well as parathyroid hormone function.
Hypocalcemia is more common in premature and low birthweight babies, because
their parathyroid glands are less mature. It can also occur in babies who have a
difficult birth and in babies of diabetic mothers.
Symptoms of hypocalcemia
Symptoms of hypocalcemia may not be obvious in newborn babies. The following are
the most common symptoms of hypocalcemia. However, each baby may experience
symptoms differently. Symptoms may include:
 irritability
 muscle twitches
 jitteriness
 tremors
 poor feeding
 lethargy
 seizures
The symptoms of hypocalcemia may resemble other conditions or medical problems.
Always consult your baby's physician for a diagnosis.
Diagnosis
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In addition to a complete medical history and physical examination, diagnosis of
hypocalcemia is made by testing the blood for the amount of calcium.
Treatment for hypocalcemia:
Hypocalcemia may get better without treatment in some cases, especially if there are
no symptoms. However, specific treatment for hypocalcemia will be determined by
your baby's physician based on:
 your baby's gestational age, overall health, and medical history
 extent of the disease
 your baby's tolerance for specific medications, procedures, or therapies
 expectations for the course of the disease
 your opinion or preference
Treatment may include:
 supplemental calcium gluconate (a form of calcium that is easily absorbed)
given by mouth
 intravenous (IV) calcium gluconate
Hyperbilirubinemia and Jaundice
Definition
Hyperbilirubinemia is a condition in which there is too much bilirubin in the blood.
When red blood cells break down, a substance called bilirubin is formed. Babies are
not easily able to get rid of the bilirubin and it can build up in the blood and other
tissues and fluids of the baby's body. This is called hyperbilirubinemia. Because
bilirubin has a pigment or coloring, it causes a yellowing of the baby's skin and
tissues. This is called jaundice.
Depending on the cause of the hyperbilirubinemia, jaundice may appear at birth or at
any time afterward.
Causes of hyperbilirubinemia?
During pregnancy, the placenta excretes bilirubin. When the baby is born, the baby's
liver must take over this function. There are several causes of hyperbilirubinemia and
jaundice, including the following:
 physiologic jaundice
Physiologic jaundice occurs as a "normal" response to the baby's limited ability
to excrete bilirubin in the first days of life.
 breast milk jaundice
About 2 percent of breastfed babies develop jaundice after the first week. Some
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develop breast milk jaundice in the first week due to low calorie intake or
dehydration.
 jaundice from hemolysis
Jaundice may occur with the breakdown of red blood cells due to hemolytic
disease of the newborn (Rh disease), having too many red blood cells, or
bleeding.
 jaundice related to inadequate liver function
Jaundice may be related to inadequate liver function due to infection or other
factors.
About 60 percent of term newborns and 80 percent of premature babies develop
jaundice. Infants of diabetic mothers and of mothers with Rh disease are more likely
to develop hyperbilirubinemia and jaundice.
Symptoms of hyperbilirubinemia?
The following are the most common symptoms of hyperbilirubinemia. However, each
baby may experience symptoms differently. Symptoms may include:
 yellow coloring of the baby's skin (usually beginning on the face and moving
down the body)
 poor feeding or lethargy
The symptoms of hyperbilirubinemia may resemble other conditions or medical
problems. Always consult your baby's physician for a diagnosis.
Diagnosis
The timing of the appearance of jaundice helps with the diagnosis. Jaundice appearing
in the first 24 hours is quite serious and usually requires immediate treatment. When
jaundice appears on the second or third day, it is usually "physiologic." However, it
can be a more serious type of jaundice. When jaundice appears on the third day to the
first week, it may be due to an infection. Later appearance of jaundice, in the second
week, is often related to breast milk feedings, but may have other causes.
Diagnostic procedures for hyperbilirubinemia may include:
 direct and indirect bilirubin levels
These reflect whether the bilirubin is bound with other substances by the liver
so that it can be excreted (direct), or is circulating in the blood circulation
(indirect).
 red blood cell counts
 blood type and testing for Rh incompatibility (Coomb's test)
Treatment for hyperbilirubinemia:
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Specific treatment for hyperbilirubinemia will be determined by your baby's physician
based on:
 your baby's gestational age, overall health, and medical history
 extent of the disease
 your baby's tolerance for specific medications, procedures, or therapies
 expectations for the course of the disease
 your opinion or preference
Treatment depends on many factors, including the cause of the hyperbilirubinemia and
the level of bilirubin. The goal is to keep the level of bilirubin from increasing to
dangerous levels. Treatment may include:
 phototherapy
Since bilirubin absorbs light, jaundice and increased bilirubin levels usually
decrease when the baby is exposed to special blue spectrum lights.
Phototherapy may take several hours to begin working and it is used
throughout the day and night. The baby's position is changed to allow all of the
skin to be exposed to the light. The baby's eyes must be protected and the
temperature monitored during phototherapy. Blood levels of bilirubin are
checked to monitor if the phototherapy is working.
 fiberoptic blanket
Another form of phototherapy is a fiberoptic blanket placed under the baby.
This may be used alone or in combination with regular phototherapy.
 exchange transfusion to replace the baby's damaged blood with fresh
blood
Exchange transfusion helps increase the red blood cell count and lower the
levels of bilirubin. An exchange transfusion is done by alternating giving and
withdrawing blood in small amounts through a vein or artery. Exchange
transfusions may need to be repeated if the bilirubin levels remain high.
 ceasing breastfeeding for one or two days
Treatment of breast milk jaundice often requires stopping the breastfeeding for
one to two days and giving the baby formula often helps lower the bilirubin
levels. Breastfeeding can then be resumed.
 treating any underlying cause of hyperbilirubinemia, such as infection
Prevention of hyperbilirubinemia:
While hyperbilirubinemia cannot be totally prevented, early recognition and treatment
are important in preventing bilirubin levels from rising to dangerous levels.



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Respiratory DistressSyndrome/Hyaline Membrane Disease

DEFINITION
Hyaline membrane disease (HMD), also called respiratory distress syndrome (RDS),
is one of the most common problems of premature babies. It can cause babies to need
extra oxygen and help breathing. The course of illness with hyaline membrane disease
depends on the size and gestational age of the baby, the severity of the disease, the
presence of infection, whether or not a baby has a patent ductus arteriosus (a heart
condition), and whether or not the baby needs mechanical help to breathe. HMD
typically worsens over the first 48 to 72 hours, then improves with treatment.
CAUSES
HMD occurs when there is not enough of a substance in the lungs called surfactant.
Surfactant is made by the cells in the airways and consists of phospholipids and
protein. It begins to be produced in the fetus at about 24 to 28 weeks of pregnancy.
Surfactant is found in amniotic fluid between 28 and 32 weeks. By about 35 weeks
gestation, most babies have developed adequate amounts of surfactant.
Surfactant is normally released into the lung tissues where it helps lower surface
tension in the airways. This helps keep the lung alveoli (air sacs) open. When there is
not enough surfactant, the tiny alveoli collapse with each breath. As the alveoli
collapse, damaged cells collect in the airways and further affect breathing ability.
These cells are called hyaline membranes. The baby works harder and harder at
breathing, trying to re-inflate the collapsed airways.
As the baby's lung function decreases, less oxygen is taken in and more carbon
dioxide builds up in the blood. This can lead to increased acid in the blood called
acidosis, a condition that can affect other body organs. Without treatment, the baby
becomes exhausted trying to breathe and eventually gives up. A mechanical ventilator
(breathing machine) must do the work of breathing instead.
HMD occurs in over half of babies born before 28 weeks gestation, but only in less
than one-third of those born between 32 and 36 weeks. Some premature babies
develop HMD severe enough to need a mechanical ventilator (breathing machine).
The more premature the baby, the higher the risk and the more severe the HMD.
Although most babies with HMD are premature, other factors can influence the
chances of developing the disease. These include the following:
 Caucasian or male babies
 previous birth of baby with HMD
 cesarean delivery
 perinatal asphyxia
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 cold stress (a condition that suppresses surfactant production)
 perinatal infection
 multiple births (multiple birth babies are often premature)
 infants of diabetic mothers (too much insulin in a baby's system due to
maternal diabetes can delay surfactant production)
 babies with patent ductus arteriosus
Symptoms of RDS
The following are the most common symptoms of HMD. However, each baby may
experience symptoms differently. Symptoms may include:
 respiratory difficulty at birth that gets progressively worse
 cyanosis (blue coloring)
 flaring of the nostrils
 tachypnea (rapid breathing)
 grunting sounds with breathing
 chest retractions (pulling in at the ribs and sternum during breathing)
The symptoms of HMD usually peak by the third day, and may resolve quickly when
the baby begins to diurese (excrete excess water in urine) and begins to need less
oxygen and mechanical help to breathe.
The symptoms of HMD may resemble other conditions or medical problems. Always
consult your baby's physician for a diagnosis.
DIAGNOSIS
HMD is usually diagnosed by a combination of assessments, including the following:
 appearance, color, and breathing efforts (indicate a baby's need for oxygen)
 chest x-rays of lungs - often show a unique "ground glass" appearance called a
reticulogranular pattern. X-rays are electromagnetic energy used to produce
images of bones and internal organs onto film.
 blood gases (tests for oxygen, carbon dioxide and acid in arterial blood) - often
show lowered amounts of oxygen and increased carbon dioxide.
 echocardiography (EKG) - sometimes used to rule out heart problems that
might cause symptoms similar to HMD. An electrocardiogram is a test that
records the electrical activity of the heart, shows abnormal rhythms
(arrhythmias or dysrhythmias), and detects heart muscle damage.
Treatment for RDS:
Specific treatment for HMD will be determined by your baby's physician based on:
 your baby's gestational age, overall health, and medical history
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 extent of the condition
 your baby's tolerance for specific medications, procedures, or therapies
 expectations for the course of the condition
 your opinion or preference
Treatment for HMD may include:
 placing an endotracheal (ET) tube into the baby's windpipe
 mechanical breathing machine (to do the work of breathing for the baby)
 supplemental oxygen (extra amounts of oxygen)
 continuous positive airway pressure (CPAP) - a mechanical breathing machine
that pushes a continuous flow of air or oxygen to the airways to help keep tiny
air passages in the lungs open
 surfactant replacement with artificial surfactant - most effective if started in the
first six hours of birth. Surfactant replacement has been shown to reduce the
severity of HMD. Surfactant is given as prophylactic (preventive) treatment for
some babies at very high risk for HMD. For others it is used as a "rescue"
method. The drug comes as a powder to be mixed with sterile water and then is
given through the ET tube (breathing tube). Surfactant is usually given in
several doses.
 medications (to help sedate and ease pain in babies during treatment)
Complications of RDS:
Babies with HMD sometimes develop complications of the disease or problems as
side effects of treatment. As with any disease, more severe cases often have greater
risks for complications. Some complications associated with HMD include the
following:
 air leaks of the lung tissues such as:
o pneumomediastinum - air leaks into the mediastinum (the space in the
thoracic cavity behind the sternum and between the two pleural sacs
containing the lungs).
o pneumothorax - air leaks into the space between the chest wall and the
outer tissues of the lungs.
o pneumopericardium - air leaks into the sac surrounding the heart.
o pulmonary interstitial emphysema (PIE) - air leaks and becomes trapped
between the alveoli, the tiny air sacs of the lungs.
 chronic lung disease, sometimes called bronchopulmonary dysplasia
Prevention of RDS:
Preventing a preterm birth is the primary means of preventing HMD. When a preterm
birth cannot be prevented, giving the mother medications called corticosteroids before
delivery has been shown to dramatically lower the risk and severity of HMD in the
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baby. These steroids are often given to women between 24 and 34 weeks gestation
who are at risk of early delivery.
Neonatal Hypothermia
The neonate is at high risk of hypothermia, particularly if premature, small for dates,
or sick.
At delivery the wet surface of an infant increases the heat loss to at least 0.25øC per
minute. It is for this reason that a priority of resuscitation is that the child is dried,
wrapped, and managed under a warmer.
Methods available to the neonate to preserve heat include adoption of a flexed posture,
subcutaneous fat insulation, and active thermogenesis by brown adipose. The more
premature or underweight a baby the less these methods are available.
The preterm neonate has a poor thermoregulatory balance for several reasons:
 neural feedback control is not finely tuned
 high surface area to volume ratio
 the skin is not fully developed until 29 weeks of age
 preterm infants especially have low brown fat reserves along the scapula and
paravertebral gutter
Risk factors include:
 prematurity
 small for dates
 sepsis
complication
Hypothermia in the neonate can result in reduced surfactant production, and thus
hypoxaemia with grunting. The concomitant acidosis with increased oxygen and
calorie consumption can result in hypoglycaemia.
Prevention
Prevention of early neonatal hypothermia is by rapid drying, wrapping, and
performing any resuscitation under a warmer.
In premature or sick infants heat losses are prevented as follows:
 evaporative loss may be reduced by applying oil
 conductive losses can be reduced with insulated or heatd matresses
 convective losses should be monitored in convective incubators
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 radiant heat loss is reduced with bubble foam sheets and by keeping the room
temperature - outside the incubator - fairly high
Term infants simply need to be properly clothed and kept in a draught free cot