G.

CLASSIFICATION OF NEWBORNS ➔ Cell free RNA transcripts in maternal blood: may

be of value in predicting preterm birth
Extremely and Very Preterm Infants
➔ Delivery date: determined 280 days after 1st
day of LMP
➔ 4%: actually delivery at 280 days
➔ 70%: deliver w/in 10 days of EDD
➔ Premature: born before 37 weeks from 1st day
of LMP
➔ Extremely preterm/extremely low gestational
age newborns (ELGANs): born before 28 weeks
gestation
➔ Very preterm: born between 28 & 31 6/7
➔ Moderate & late preterm infants: born between
32 & 36 6/7 weeks gestation
➔ Extremely low birthweight (ELBW): <1000g
➔ Very low birthweight (VLBW): <1500g
➔ Low birthweight (LBW): <2500g
➔ Birthweight: proxy for gestational age
➔ Intrauterine growth restriction (IUGR) &
Small-for-gestational-age (SGA) infants:
birthweight can sometimes be misleading for
true gestational age

Incidence
➔ Preterm birth: common
➔ 15M preterm births occur annually
➔ Majority: late preterm infants
Etiology
➔ Multifactorial
➔ Complex interaction between fetal, placental,
uterine, & maternal factors
➔ In maternal or fetal conditions that prompt
early delivery such as placental & uterine
pathology, causes of preterm birth can
sometimes be identified
➔ Most preterm birth are spontaneous w/o
identifiable cause
➔ Associated w/ preterm birth:
◆ older maternal age
◆ poorer maternal health
◆ history of previous preterm delivery
◆ short interpregnancy interval
◆ lower socioeconomic status (SES)
➔ Racial disparities
➔ Gestational duration & actual preterm birth
have been noted w/ genetic variants in
maternal genome; many of these genes have
roles in regulation of estrogen receptor, uterine
development, maternal nutrition, or vascular
reactivity
Assessment of gestational age
➔ Assess infants at birth for estimated
gestational age
➔ Examination & assessment: needed to
distinguish SGA & IUGR infants from preterm
infants
➔ Compared w/ premature infant of appropriate
weight, infant w/ IUGR has reduced birth weight
& appear to have a disproportionately larger
head relative to body size; infants in both
groups lack subcutaneous fat
➔ Neurologic maturity (nerve conduction
velocity): in absence of asphyxia correlates w/
gestational age despite reduced fetal weight
➔ Physical signs useful in estimating gestational
age at birth
➔ Ballard scoring system: accurate to w/in 2
weeks of actual gestational age
Check Ballard Scoring System (Nelson’s page 903)

Nursery Care
➔ General measures to clear airway, initiate
breathing, care for umbilical cord & eyes, &
administer vitamin K; same for premature
infants as for those w/ normal weight &
maturity
➔ Additional considerations:
◆ Thermal control & monitoring of heat
rate & respiration
◆ Oxygen therapy
◆ Special attention to details of fluid
requirements & nutrition
➔ Safeguards against infection: can never be
relaxed
➔ Routine procedures that disturb these infants →
hypoxia
➔ Need for regular & active participation by
parents & question of prognosis for alter growth
& development: require special consideration
Thermal Control
➔ Neonatal temperature regulation: decreases risk
of morbidity & mortality in ELBW & VLBW
infants
➔ Neonates, ELBW, VLBW infants: increased risk of
heat loss compared w/ older children due to:
◆ Increased body surface/weight ratio
◆ Decreased epidermal & dermal skin
thickness
◆ Minimal subcutaneous fat
◆ Immature nervous system
➔ Preterm infants: neutral thermal environment
◆ Set of thermal conditions, including air
& radiating surface temperatures,
relative humidity, & airflow, at w/c heat
production (measured experimentally
as oxygen consumption) is minimal &
the infant’s core temperature is w/in
normal range
➔ Neutral thermal environment: function of size &
postnatal age of an infant
➔ Larger, older infants: require lower
environmental temperatures than smaller,
younger infants
➔ Incubators or radiant warmers: maintain body
temperature
➔ Body heat: conserved through warm
environment & humidity
➔ Optimal environmental temp for minimal heat
loss & oxygen consumption for an unclothed
infant: one that maintains the infant’s core
temp at 36.5-37.0C
➔ The smaller & more immature the infant, the
higher is the environmental temp required
➔ Infant warmth: maintained by heating the air to
a desired temp or by servo-control
➔ Continuous monitoring of infant’s temp:
required to maintain optimal body temp
➔ Kangaroo care w/ direct skin-to-skin contact
between infant & parent, w/ a hat & blanket
covering the infant: encouraged; w/o untoward
effects on thermoregulation
➔ Maintaining humidity of 40-60% aids in
stabilizing body temp by:
◆ Reducing heat loss at lower
environmental temp
◆ Preventing drying & irritation of the
lining of respiratory passages, especially
during administration of oxygen & after
or during endotracheal intubation
◆ Thinning viscid secretions & reducing
insensible water loss
➔ Infant should be weaned then removed from
the incubator or radiant warmer only when the
gradual change to the atmosphere of the
nursery does not result in significant change in
the infant’s temp, color, activity, or vital signs
Oxygen Administration
➔ Administering oxygen to reduce risk of injury
from hypoxia & circulatory insufficiency (risk of
cerebral palsy, death) must be balanced against
risk of hyperoxia to the eyes & oxygen injury to
the lungs
➔ Retinopathy of prematurity (ROP): hyperoxia to
the eyes
➔ Bronchopulmonary dysplasia (BPD): oxygen
injury to the lungs
➔ ELBW infants at birth: guidelines should be
followed to determine need for oxygen during
resuscitation to maintain goal O2 saturation
limits
 ➔ Ideal target O2 saturation limits for ELBW infants
after initial resuscitation period: 90-95%
Nutrition for the High-Risk Infant
➔ Extreme prematurity: nutritional emergency
➔ Absence of early parenteral & enteral
nutritional support, deficits in protein & energy
will quickly arue → infant at risk for poor
growth & neurodevelopmental outcomes
➔ Goals of early nutritional support for extremely
premature infants:
◆ Approximating rate & composition of
growth for a normal fetus at the same
postmenstrual age
◆ Requires understanding of the
intrauterine growth rate to be targeted
& the unique nutrient requirements of
premature infants
➔ Strategies to prevent growth faltering:
◆ Combined approach of early parenteral
& enteral nutrition
◆ Fortification of human milk
◆ Use of standardized feeding guidelines
➔ Careful monitoring of weight gain, length, head
circumference using appropriate intrauterine
growth curves & consultation w/ an
experienced neonatal dietitian: important to
achieve optimal growth outcomes
Early Parenteral Nutrition
➔ Absence of IV amino acids: extremely
premature infants lose 1-2% body protein stores
per day
➔ IV amino acids & dextrose: started immediately
after birth
➔ Starter or stock solution of amino acids &
dextrose: accomplish this goal in infants
weighing <1,500g
➔ Minimum of 2g/kg of amino acids: given in the
1st 24 hrs after birth
➔ IV lipids: also needed to meet total energy
requirements
Benefits of Human Milk
➔ Maternal milk
◆ Preferred source of enteral nutrition for
premature infants
◆ Decreased in-hospital morbidity
◆ Lower rates of necrotizing enterocolitis
(NEC), late-onset sepsis, BPD, & severe
ROP
◆ Superior neurodevelopmental
outcomes at 18 & 30 months corrected
age compared to infants fed premature
formula
➔ Donor human milk: used when maternal milk is
not available; lower in protein & energy content
than preterm maternal milk → suboptimal
growth unless adequately fortified; reduction in
NEC
Enteral Nutrition
➔ Early enteral feedings: recommended in ELBW &
VLBW infants; beginning between 6 & 48 hrs w/
some period of trophic/minimal enteral feeding
volume
➔ Feedings: advanced slowly (15-30 mL/kg/day)
➔ Target goal:
◆ 110-135 kcal/kg/day
◆ 3.5-4.5 g protein/kg/day
➔ Human milk must be fortified or premature
formula give to accomplish goals
Standardizing Feeding Guidelines
➔ Manage feeding intolerance in ELBW & VLBW
infants
➔ Having feeding guideline leads to:
◆ Improved outcomes (time to regain
birth weight & time to reach full enteral
nutrition)
◆ Decreased rates of late-onset sepsis &
NEC
◆ Improved growth at 36 weeks
postmenstrual age
◆ Reduced length of hospital stay
Transitioning to Discharge Nutrition
➔ The earlier an infant is born before expected,
the greater the likelihood that not all nutritional
deficits will be resolved before hospital
discharge
➔ Use of higher concentrations of calcium &
phosphorus after discharge: strong evidence for
improved bone mineralization regardless of
weight gain during initial hospital stay
➔ Fortified human milk or preterm formula w/
higher protein, minerals, & trace elements:
recommended after discharge
➔ Individualized approach to post discharge
nutrition should be developed to transition
from NICU

Prevention of Infection
➔ Extremely premature infants: increased
susceptibility to infection; meticulous attention
to infection control is required
➔ Prevention strategies:
◆ Strict compliance w/ handwashing &
universal precautions
◆ Minimizing risk of catheter
contamination & duration
◆ Meticulous skin care
◆ Encouraging early appropriate
advancement of enteral feeding
◆ Education and feedback to staff
◆ Surveillance of nosocomial infection
rates in the nursery
➔ No one w/ an active infection should be
permitted in the nursery
➔ Risks of infection must be balanced against the
disadvantages of limiting the infant’s contact w/
the family
➔ Early & frequent participation by parents in the
nursery care of their infant does not increase
risk of infection when preventive precautions
are maintained
➔ Preventing transmission of infection from infant
to infant: difficult because neither term nor
premature newborn infants have clear clinical
evidence of an infection early in its course
➔ Cohort nursing & isolation rooms: should be
used when epidemics occur w/in a nursery
➔ Hand hygiene: upmost importance
➔ Premature infants have immature immune
function: some will develop nosocomial
infection even when all precautions are
followed
➔ Routine immunization: given on a regular
schedule based on chronological age at
standard doses
IMMATURITY OF DRUG METABOLISM
➔ Renal clearance of almost all substances
excreted in urine: diminished in newborn
infants; greater extent in premature infants
➔ Glomerular filtration rate: rises w/ increasing
gestational age
➔ Drug dosing recommendations: vary w/ age
➔ Drugs primarily excreted by kidneys: longer
intervals between doses needed w/ increasing
degree of prematurity
➔ Drugs detoxified in liver or require chemical
conjugation before renal extraction: given w/
caution & in does smaller than usual
➔ Many drugs are safe for adults but may be
harmful to newborns, esp premature infants
➔ Oxygen & a number of drugs: proved toxic to
premature infants in amounts not harmful to
term infants
➔ Administering any drug (in high doses) that has
not undergone pharmacologic testing in
premature infants should be undertaken
carefully after risks have been weighed against
benefits
MORBIDITY AND MORTALITY
➔ Rates of neonatal morbidity & mortality: high in
extremely preterm infants & risks increase w/
decreasing gestational age & lower birth weight
➔ 42% BPD
➔ 16% Grade III or IV intraventricular
hemorrhage (IVH)
➔ 3% Periventricular leukomalacia (PVL)
➔ Mortality increased w/ lower gestational age
➔ 94% mortality in infants born at 22 weeks
➔ 8% mortality at 28 weeks
➔ Group of extremely preterm infants: 28%
mortality rate; 37% surviving w/os significant
neonatal morbidity
➔ For infants who survive to discharge,
Prematurity & Neonatal morbidities →
increased risk for developmental delays &
impairment as they age
➔ Major neonatal morbidities:
◆ Bronchopulmonary dysplasia
◆ Necrotizing enterocolitis
◆ Intraventricular hemorrhage
◆ Periventricular leukomalacia
◆ Retinopathy of prematurity
◆ Infections (congenital, perinatal,
nosocomial: bacterial, viral, fungal,
protozoal)
Check Table 117.4 Potential Adverse Reactions to Drugs
Administered to Premature Infants & Table 117.5
Neonatal Morbidities Associated With Prematurity
(Nelson’s page 905)
Moderate and Late Preterm Infants
➔ Moderate to late preterm birth: 32-36 6/7 wk
postmenstrual age (PMA)
➔ Late preterm: 34-36 6/7 wk PMA
➔ Moderate preterm: 32-33 6/7 wk PMA
MODERATE PRETERM INFANT
➔ Still at risk for postnatal morbidities; lesser
extent than very preterm
➔ Morbidities:
◆ Poor feeding
◆ Weight loss
◆ Respiratory distress syndrome
◆ Risk of NEC
◆ Difficulty w/ thermoregulation
➔ Moderate preterm infants w/ birthweight
>1,500 g & fairly remarkable NICU course: fairly
minimal risk for IVH; do not routinely need a
head ultrasound
➔ 29-33 wk gestational age: 33.3 days mean
hospital stay w/ increased morbidities (BPD,
early & late-onset sepsis, NEC, PVL)
LATE PRETERM INFANT
➔ 8-9% all births; ¾ of all preterm births in US
➔ Near-term infants; significantly increased
morbidity & mortality compared to term infants
➔ Immediately after birth, they have an increased
risk of requiring resuscitation
➔ Increased incidence of hypoglycemia,
respiratory distress, apnea, feeding difficulties,
jaundice
➔ Higher rehospitalization rate compared to term
➔ Antenatal corticosteroids: traditionally
recommended for pregnant women 24-34 wk
gestation at risk of preterm delivery w/in the
next 7 days; reduce incidence of death &
respiratory distress syndrome
➔ ACOG recommendation:
◆ single course of antenatal
corticosteroids for pregnant women
34-36 6/7 wk gestation at risk for
preterm birth w/in 7 days, who have
not received previous course of
antenatal corticosteroids
➔ 34-36 6/7 wk gestation: critical period for
growth & development
➔ Elective deliveries w/o medical indications
occurred as early as 35 wk (in the past)
➔ ACOG recommendation:
◆ elective delivery w/o medical
indications only after 39 wk gestation in
well-dated pregnancies
➔ Higher risk of lower school readiness at
kindergarten & increase risk of academic
difficulties in childhood compared to term peers
Term and Postterm Infants
➔ Early term: 37-38 6/7 wk
➔ Full term: 39-40 6/7 wk
➔ Late term: 41-41 6/7 wk
➔ Risk factors for term infants which put them at
higher risk for complications:
◆ Meconium aspiration syndrome
◆ Hemolytic disease of the newborn
◆ Infant of a diabetic mother
◆ Neonatal abstinence syndrome
◆ Small for gestational age (SGA)
◆ Large for gestational age (LGA)
SMALL FOR GESTATIONAL AGE AND IUGR
➔ Small for Gestational Age (SGA)
◆ Based on physical evaluation of infant at
birth by a pediatrician or neonatologist
◆ <10th percentile weight
◆ Diagnosis does not differentiate
between normal biologic growth
potential & pathologic or
growth-restricted state in utero
➔ Intrauterine Growth Restriction (IUGR)
◆ Prenatal diagnosis
◆ Describe a fetus who fails to reach in
utero growth potential
◆ Diagnosed by obstetrician
➔ Not all infants w/ IUGR are SGA; not all infants
who are SGA have IUGR
➔ Evaluation of postnatal outcomes may be based
on either SGA or IUGR
➔ IUGR is associated w/ medical conditions that
interfere w/:
◆ Circulation & efficiency of placenta
◆ Development or growth of fetus
◆ General health & nutrition of mother
➔ IUGR: decreased insulation production or
insulin-growth factor (IGF) action at the
receptor level
➔ Infants w/ IGF-1 receptor defects, pancreatic
hypoplasia, or transient neonatal diabetes: have
IUGR
➔ Genetic mutations affecting glucose-sensing
mechanisms of the pancreatic islet cells →
decreased insulin release (loss of function of
glucose-sensing glucokinase gene) → IUGR
➔ IUGR: may be normal fetal response to
nutritional or oxygen deprivation; issue is on the
ongoing risk of fetal malnutrition or hypoxia
➔ Reduced growth:
◆ Symmetric: head circumference, length,
weight equally affected
◆ Asymmetric: sparing of head growth
➔ Symmetric IUGR: earlier onset in first
trimester; associated w/ diseases that affect
fetal cell number (conditions w/ chromosomal,
genetic, malformation, teratogenic, infectious,
or severe maternal hypertensive etiologies)
➔ Assess gestational age carefully in infants
suspected to have symmetric IUGR
➔ Incorrect overestimation of gestational age →
diagnosis of symmetric IUGR
➔ Asymmetric IUGR
◆ Late onset in 2nd half of pregnancy
◆ Preservation of Doppler waveform
velocity to carotid vessels
◆ Poor maternal nutrition
◆ Late onset or exacerbation of maternal
vascular disease (preeclampsia, chronic
hypertension)
➔ Both preterm & term infants: SGA is associated
w/ increased risk of neurodevelopmental
impairment
LARGE-FOR-GESTATIONAL-AGE INFANTS
➔ Birth weight >90th percentile for gestational
age: large for gestational age (LGA)
➔ Neonatal mortality rates decrease w/ increasing
birth weight until 4,000 g, after w/c they
increase
 ➔ Preterm infants w/ weights high for gestational
age: significantly higher mortality than infants of
same size born at term
➔ Maternal diabetes & obesity: predisposing
factors
➔ Some infants are constitutionally large because
of large parental size
➔ LGA infants: oversized infants; born at term
◆ Regardless of gestational age, higher
incidence of birth injuries:
● Cervical & brachial plexus
injuries
● Phrenic nerve damage w/
paralysis of diaphragm
● Fractured clavicles
● Cephalohematomas
● Subdural hematomas
● Ecchymoses of head & face
◆ Increased risk for hypoglycemia &
polycythemia
◆ Higher incidence of congenital
anomalies (congenital heart disease)
◆ Meconium aspiration syndrome
◆ Persistent pulmonary hypertension
◆ Hypoglycemia
◆ Hypocalcemia
◆ Polycythemia
➔ Infants born >42 wk gestation age: 3x mortality
of infants born at term
➔ Elective delivery during 39th wk of gestation for
nulliparous & multiparous women: decreased
maternal & neonatal complications
➔ Careful obstetric monitoring: Nonstress testing
(NST), Biophysical Profile (BPP), or Doppler
velocimetry: provides rational basis for choosing
1 of 3 courses: nonintervention, induction of
labor, or cesarean delivery
➔ Induction of labor or cesarean birth: indicated in
older primagravidas >2 wk beyond term, esp if
evidence of fetal distress is present
➔ Medical problems in newborn are treated if
they arise

POSTTERM INFANTS
➔ Postterm infants: born after 42 completed wks
of gestation base from mother’s LMP
➔ 12% result in delivery after 42 wks
➔ Obstetric interventions to induce labor: before
42 wk
➔ Cause of postterm birth or postmaturity is
unknown
➔ Postterm infants: normal length & head
circumference; decreased weight if there is
placental insufficiency
◆ Desquamation
◆ Long nails
◆ Abundant hair
◆ Pale skin
◆ Alert faces
◆ Loose skin (thighs & buttocks): give
appearance of having recently lost
weight
◆ Meconium-stained nails, skin, vernix,
umbilical cord, placental membranes
➔ Common complications of postmaturity:
◆ Perinatal depression