Notes for High Risk Infants

Question: What is a Percentile?

Answer: Percentiles are the most commonly used clinical indicator to assess the size and
growth patterns of individual children in the United States. Percentiles rank the position
of an individual by indicating what percent of the reference population the individual
would equal or exceed. For example, on the weight-for-age growth charts, a 5-year-old
girl whose weight is at the 25th percentile, weighs the same or more than 25 percent of
the reference population of 5-year-old girls, and weighs less than 75 percent of the 5-
year-old girls in the reference population.

Centers for Disease Control Prevention

Low birthweight

Babies born weighing less than 5 pounds, 8 ounces (2,500 grams) are considered low
birthweight. Low-birthweight babies are at increased risk for serious health problems as
newborns, lasting disabilities and even death.

About 1 in every 12 babies in the United States is born with low birthweight (1).
Advances in newborn medical care have greatly reduced the number of deaths associated
with low birthweight. However, a small percentage of survivors develop mental
retardation, learning problems, cerebral palsy and vision and hearing loss.

Why are babies born with low birthweight?

There are two main reasons why a baby may be born with low birthweight:

• Premature birth: Babies born before 37 completed weeks of pregnancy are

called premature. About 67 percent of low-birthweight babies are premature (1).
The earlier a baby is born, the less she is likely to weigh. Very low-birthweight
babies (those who weigh less than 3 pounds, 5 ounces or 1,500 grams) have the
highest risk for health problems. Some premature babies born near term do not
have low birthweight, and they may have only mild or no health problems as
newborns.
• Fetal growth restriction: These babies are called growth-restricted, small-for-
gestational age or small-for-date. These babies may be full term, but they are
underweight. Some of these babies are healthy, even though they are small. They
may be small simply because their parents are smaller than average. Others have
low birthweight because something slowed or halted their growth in the uterus.

Some babies are both premature and growth-restricted. These babies are at high risk for
health problems.
What causes low birthweight?
Preterm labor, labor that happens before 37 completed weeks of pregnancy, frequently
results in the birth of a premature, low-birthweight baby. The causes of preterm labor are
not thoroughly understood. However, we do know that women with these risk factors are
at increased risk for delivering prematurely:

• Had a premature baby in a previous pregnancy

• Are pregnant with twins, triplets or more
• Have certain abnormalities of the uterus or cervix

Other factors that may contribute to premature birth and/or fetal growth restriction
include:

• Birth defects: Babies with certain birth defects are more likely to be growth
restricted because genetic conditions and structural abnormalities may limit
normal development (2, 3). Babies with birth defects also are more likely to be
born prematurely (4).
• Chronic health problems in the mother: Maternal high blood pressure,
diabetes, and heart, lung and kidney problems sometimes can reduce birthweight
(2, 3).
• Smoking: Pregnant women who smoke cigarettes are nearly twice as likely to
have a low-birthweight baby as women who do not smoke (5). Smoking slows
fetal growth and increases the risk of premature delivery (5).
• Alcohol and illicit drugs: Alcohol and illicit drugs can limit fetal growth and can
cause birth defects (2, 3). Some drugs, such as cocaine, also may increase the risk
of premature delivery.
• Infections in the mother: Certain infections, especially those involving the
uterus, may increase the risk of preterm delivery (6).
• Infections in the fetus: Certain viral and parasitic infections, including
cytomegalovirus, rubella, chickenpox and toxoplasmosis, can slow fetal growth
and cause birth defects (2, 3).
• Placental problems: Placental problems can reduce flow of blood and nutrients
to the fetus, limiting growth. In some cases, a baby may need to be delivered early
to prevent serious complications in mother and baby.
• Inadequate maternal weight gain: Women who don’t gain enough weight
during pregnancy increase their risk of having a low-birthweight baby (2, 6).
Women of normal weight should usually gain 25 to 35 pounds during pregnancy.
• Socioeconomic factors: Low income and lack of education are associated with
increased risk of having a low-birthweight baby, although the underlying reasons
for this are not well understood. Black women and women under 17 and over 35
years of age also are at increased risk (2).

What can a woman do to reduce her risk of having a low-birthweight baby?

A woman can do the following before and during pregnancy to reduce her risk of having
a low-birthweight baby:
 • See her health care provider for a preconception checkup. Her provider can help
make sure the woman is as healthy as possible before she conceives. At this visit,
the provider can screen her for certain health problems (diabetes, high blood
pressure, thyroid disease) and various infections, make sure her vaccinations are
up-to-date, and discuss her health habits and nutrition. The provider can make
sure any medications the woman takes are the safest possible choices during
pregnancy.
• Work with her health care provider to control chronic health conditions, such as
high blood pressure and diabetes. Good control of these conditions, starting
before pregnancy, reduces the risk of low birthweight and other pregnancy
complications.
• Take a multivitamin containing 400 micrograms of folic acid daily, starting before
pregnancy. When taken before and early in pregnancy, folic acid helps prevent
certain serious birth defects of the brain and spine. When taken throughout
pregnancy, folic acid may help reduce the risk of having a premature and low-
birthweight baby (7).
• Stop smoking before she becomes pregnant and remain smoke-free throughout
pregnancy. A woman’s health care provider can refer her to a smoking-cessation
program or suggest other ways to help her quit.
• Get early and regular prenatal care. This allows the health care provider to
identify and treat problems early, which may reduce the risk of having a low-
birthweight baby.
• Call her health care provider immediately if she suspects she may be having
preterm labor. Her provider may want to examine her and do some tests to see if
she really is in labor.
• If she is in labor, the provider may give her a medication (called a tocolytic) to try
to delay or stop delivery. These drugs are most effective when given early in
labor. Tocolytics often postpone delivery for only a day or two, but even such a
short delay can make a difference in the baby’s health.
• If she has already had a premature baby in a prior pregnancy, ask her provider if
she could benefit from treatment with the hormone progesterone. The injected
form of progesterone is called 17 alpha-hydroxyprogesterone caproate (17P).
Studies show that this treatment appears to reduce the risk of having another
premature baby by about one-third (8).

One recent study also found that treatment with vaginal progesterone suppositories
reduced the rate of premature birth in women who had a short cervix (diagnosed with an
ultrasound examination), most of whom had no prior history of premature birth (9).

How is fetal growth restriction treated?

About 10 percent of fetuses are growth-restricted (3, 6). A health care provider may
suspect fetal growth restriction if the mother’s uterus is not growing at a normal rate. This
can be confirmed with a series of ultrasounds that monitor how quickly the fetus is
growing. In some cases, fetal growth can be improved by treating any condition in the
mother (such as high blood pressure) that may be a contributing factor.
The provider closely monitors the well-being of a growth-restricted fetus using
ultrasound and fetal heart rate monitoring. If these tests show that the baby is having
problems, the baby may need to be delivered early.

What medical problems are common in low-birthweight babies?

Low-birthweight babies are more likely than babies of normal weight to have health
problems during the newborn period. Many of these babies require specialized care in a
newborn intensive care unit (NICU). Serious medical problems are most common in
babies born at very low birthweight:

• Respiratory distress syndrome (RDS): This breathing problem is common in

babies born before the 34th week of pregnancy. Babies with RDS lack a protein
called surfactant that keeps small air sacs in the lungs from collapsing. Treatment
with surfactant helps affected babies breathe more easily. Babies with RDS may
need additional oxygen and mechanical breathing assistance to keep their lungs
expanded. The sickest babies may temporarily need the help of mechanical
ventilation to breathe for them while their lungs mature.
• Bleeding in the brain (called intraventricular hemorrhage or IVH): Bleeding in
the brain occurs in some very low-birthweight premature babies, usually in the
first three days of life. Brain bleeds usually are diagnosed with an ultrasound.
Most brain bleeds are mild and resolve themselves with no or few lasting
problems. More severe bleeds can cause pressure on the brain that can lead to
brain damage. In such cases, surgeons may insert a tube into the brain to drain the
fluid and reduce the risk of brain damage. In milder cases, drugs sometimes can
reduce fluid buildup.
• Patent ductus arteriosus (PDA): PDA is a heart problem that is common in
premature babies. Before birth, a large artery called the ductus arteriosus lets the
blood bypass the baby’s nonfunctioning lungs. The ductus normally closes after
birth so that blood can travel to the lungs and pick up oxygen. When the ductus
does not close properly, it can lead to heart failure. PDA can be diagnosed with a
special form of ultrasound (echocardiography) or other imaging tests. Babies with
PDA are treated with a drug that helps close the ductus, although surgery may be
necessary if the drug doesn’t work.
• Necrotizing enterocolitis (NEC): This potentially dangerous intestinal problem
usually develops two to three weeks after birth. It can lead to feeding difficulties,
abdominal swelling and other complications. Babies with NEC are treated with
antibiotics and fed intravenously (through a vein) while the intestine heals. In
some cases, surgery is necessary to remove damaged sections of intestine.
• Retinopathy of prematurity (ROP): ROP is an abnormal growth of blood
vessels in the eye that can lead to vision loss. It occurs mainly in babies born
before 32 weeks of pregnancy. Most cases heal themselves with little or no vision
loss. In severe cases, the ophthalmologist (eye doctor) may treat the abnormal
vessels with a laser or with cryotherapy (freezing) to preserve vision.

Can medical problems in premature, low-birthweight newborns be prevented?

When a provider suspects that a woman may deliver before 34 weeks of pregnancy, he
may suggest treating the mother with a medicine called corticosteroids. Corticosteroids
speed maturation of the fetal lungs and significantly reduce the risk of RDS, IVH, NEC
and infant death. These drugs are given by injection (a shot) and are most effective when
administered at least 24 hours before delivery. Treatment with tocolytic drugs to delay
labor can give corticosteroids time to work. The provider also can arrange for delivery in
a hospital with a NICU that can give specialized care to a premature, low-birthweight
infant.

Does low birthweight contribute to adult health problems?

Some studies suggest that individuals who were born with low birthweight may be at
increased risk for certain chronic conditions in adulthood. These conditions include high
blood pressure, type 2 (adult-onset) diabetes and heart disease. When these conditions
occur together, they are called metabolic syndrome. One study found that men who
weighed less than 6 1/2 pounds at birth were 10 times more likely to have metabolic
syndrome than the men who weighed more than 9 1/2 pounds at birth (10, 11).

It is not yet known how low birthweight contributes to these adult conditions. However, it
is possible that growth restriction before birth may cause lasting changes in certain
insulin-sensitive organs like the liver, skeletal muscles and pancreas. Before birth, these
changes may help the malnourished fetus use all available nutrients. However, after birth
these changes may contribute to health problems.

Is the March of Dimes supporting research on low birthweight?

The March of Dimes has long supported research on low birthweight and the related issue
of prematurity. From 2004 to 2008, the March of Dimes awarded approximately $11.5
million to grantees as part of the Prematurity Research Initiative, which aims to learn
more about the causes of prematurity. These grantees are exploring the role of genes,
uterine muscle activity, infections, immune system changes and lung activity in
triggering preterm labor, which may lead to better ways to prevent or treat it.

Other grantees are seeking to improve the treatment for premature, low-birthweight
babies. For example, some are attempting to develop treatment that can help prevent
brain damage and cerebral palsy in premature infants. Others are seeking to develop
improved treatments for PDA, NEC and ROP. One grantee is studying the role of a
family of proteins on development and functioning of the placenta, in order to develop
treatments for placental problems that contribute to fetal growth restriction and premature
birth.

The March of Dimes also promotes the health benefits of smoking prevention and
cessation by providing educational materials for consumers, promoting evidence-based
smoking-cessation methods, and supporting projects that increase smoking-cessation
services available to pregnant women who smoke.

Source:
http://www.modimes.org/Professionals/medicalresources_lowbirthweig
ht.html
Low birth weight: Excerpt from Handbook of Signs & Symptoms
(Third Edition)

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Two groups of neonates are born weighing less than the normal minimum birth weight of
5½ lb (2,500 g) — those who are born prematurely (before 37 weeks’ gestation) and
those who are small for gestational age (SGA). Premature neonates weigh an appropriate
amount for their gestational age and probably would have matured normally if carried to
term. Conversely, SGA neonates weigh less than the normal amount for their age;
however, their organs are mature. Differentiating between the two groups helps direct the
search for a cause.

In the premature neonate, low birth weight usually results from a disorder that prevents
the uterus from retaining the fetus, interferes with the normal course of pregnancy, causes
premature separation of the placenta, or stimulates uterine contractions before term. In
the SGA neonate, intrauterine growth may be retarded by a disorder that interferes with
placental circulation, fetal development, or maternal health. (See Maternal causes of low
birth weight.)

Regardless of the cause, low birth weight is associated with higher neonate morbidity and
mortality; in fact, these neonates are 20 times more likely to die within the first month of
life. Low birth weight can also signal a life-threatening emergency.

SGA neonates who will demonstrate catch-up growth do so by 8 to 12 months. Some

SGA neonates will remain below the 10th percentile. Weight of the premature neonate
should be corrected for gestational age by approximately 24 months.

Because low birth weight may be associated with poorly developed body systems,
particularly the respiratory system, your priority is to monitor the neonate’s respiratory
status. Be alert for signs of distress, such as apnea, grunting respirations, intercostal or
xiphoid retractions, or a respiratory rate exceeding 60 breaths/minute after the first hour
of life. If you detect any of these signs, prepare to provide respiratory support.
Endotracheal intubation or supplemental oxygen with an oxygen hood may be needed.

Monitor the neonate’s axillary temperature. Decreased fat reserves may keep him from
maintaining normal body temperature, and a drop below 97.8 ° F (36.5° C) exacerbates
respiratory distress by increasing oxygen consumption. To maintain normal body
temperature, use an overbed warmer or an Isolette. (If these are unavailable, use a
wrapped rubber bottle filled with warm water, but be careful to avoid hyperthermia.)
Cover the neonate’s head to prevent heat loss.

History and physical examination

As soon as possible, evaluate the neonate’s neuromuscular and physical maturity to

determine gestational age. (See Ballard Scale for calculating gestational age, pages 382
and 383.) Follow with a routine neonatal examination.

Medical causes

This section lists some fetal and placental causes of low birth weight as well as the
associated signs and symptoms pres-ent in the neonate at birth.

Chromosomal aberrations

Abnormalities in the number, size, or configuration of chromosomes can cause low birth
weight and possibly multiple congenital anomalies in a premature or SGA neonate

For example, a neonate with trisomy 21 (Down syndrome) may be SGA and have
prominent epicanthal folds, a flat-bridged nose, a protruding tongue, palmar simian
creases, muscular hypotonia, and an umbilical hernia.

Cytomegalovirus infection

Although low birth weight in cytomegalovirus infection is usually associated with

premature birth, the neonate may be SGA

Assessment at birth may reveal these classic signs: petechiae and ecchymoses, jaundice,
and hepatosplenomegaly, which increases for several days. The neonate may also have a
high fever, lymphadenopathy, tachypnea, and dyspnea, along with prolonged bleeding at
puncture sites.

Placental dysfunction

Low birth weight and a wasted appearance occur in an SGA neonate

He may be symmetrically short or may appear relatively long for his low weight.
Additional findings reflect the underlying cause. For example, if maternal
hyperparathyroidism caused placental dysfunction, the neonate may exhibit muscle
jerking and twitching, carpopedal spasm, ankle clonus, vomiting, tachycardia, and
tachypnea.

Rubella (congenital)

Usually, the low-birth-weight neonate with this congenital rubellais born at term but is
SGA

A characteristic “blueberry muffin” rash accompanies cataracts, purpuric lesions,

hepatosplenomegaly, and a large anterior fontanel

Abnormal heart sounds, if present, vary with the type of associated congenital heart
defect.

Varicella (congenital)

Low birth weight is accompanied by cataracts and skin vesicles.

Special considerations

To make up for low fat and glycogen stores in the low-birth-weight neonate, initiate
feedings as soon as possible and continue to feed him every 2 to 3 hours. Provide gavage
or I.V. feeding for the sick or very premature neonate. Check abdominal girth daily or
more frequently if indicated, and check stools for blood because increasing girth and
bloody stools may indicate necrotizing enterocolitis. A sepsis workup may be necessary
if signs of infection are associated with low birth weight.

Check the neonate’s vital signs every 15 minutes for the first hour and at least once every
hour thereafter until his condition stabilizes. Be alert for changes in temperature or
behavior, feeding problems, respiratory distress, or periods of apnea — possible
indications of infection. Also, monitor blood glucose levels and watch for signs and
symptoms of hypoglycemia, such as irritability, jitteriness, tremors, seizures, irregular
respirations, lethargy, and a high-pitched or weak cry. If the neonate is receiving
supplemental oxygen, carefully monitor arterial blood gas values and the oxygen
concentration of inspired air to prevent retinopathy.

Monitor the neonate’s urine output by weighing diapers before and after voiding. Check
urine color, measure specific gravity, and test for the presence of glucose, blood, or
protein. Also, watch for changes in the neonate’s skin color because increasing jaundice
may indicate hyperbilirubinemia.

Encourage the parents to participate in their neonate’s care to strengthen bonding, and
allow ample time for their questions.
Source: http://www.wrongdiagnosis.com/p/pregnancy/book-diseases-
5c.htm