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NewbornAssessments for newborn babies:

Each newborn baby is carefully checked at birth for signs of problems orcomplications. A complete physical assessment will be performed that includes every

body system. Throughout the hospital stay, physicians, nurses, and other healthcareproviders continually assess a baby for changes in health and for signs of problems orillness. Assessment may include:

Apgar scoring:

The Apgar score is one of the first checks of your new baby's health. TheApgar 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 andrespiratory rates, muscle tone, reflexes, and color.

Each area can have a score of zero, one, or two, with ten points as themaximum. 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 offfor blue hands and feet because of immature circulation. If a baby has adifficult 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 babieshave Apgar scores less than seven at five minutes after birth.

Sign Score = 0 Score = 1 Score = 2Heart 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

extremitiesReflex/Irritabilit

y

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 forterm babies (born between 37 and 41 weeks gestation) is about 7 lbs. (3.2 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 asmuch as 10 ounces in the first few days. Premature and sick babies may not

begin to gain weight right away.

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Most hospitals use the metric system for weighing babies. This chart will helpyou convert grams to pounds.

Measurements:

Other measurements are also taken of each baby. These include the following:

head circumference (the distance around the baby's head) - is normally

about one-half the baby's body length plus 10 cm

abdominal circumference - the distance around the abdomen

length - the measurement from crown of head to the heel

Physical examination:

A complete physical examination is an important part of newborn care. Eachbody system is carefully examined for signs of health and normal function. The

physician also looks for any signs of illness or birth defects. Physicalexamination of a newborn often includes the assessment of the following:

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

general appearance - physical activity, tone, posture, and level of

consciousness

skin - color, texture, nails, presence of rashes

head and neck:

appearance, shape, presence of molding (shaping of the headfrom passage through the birth canal)

fontanels (the open "soft spots" between the bones of the baby'sskull)

clavicles (bones across the upper chest)

face - eyes, ears, nose, cheeks

mouth - palate, tongue, throat

lungs - breath sounds, breathing pattern

heart sounds and femoral (in the groin) pulses

abdomen - presence of masses or hernias

genitals and anus - for open passage of urine and stool

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arms and legs - movement and development

Gestational assessment:

Assessing a baby's physical maturity is an important part of care. Maturityassessment 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 itappears by size, and may need different care than a premature baby.

An examination called The Dubowitz/Ballard Examination for Gestational Ageis often used. A baby's gestational age often can be closely estimated using thisexamination. The Dubowitz/Ballard Examination evaluates a baby'sappearance, skin texture, motor function, and reflexes. The physical maturity

part of the examination is done in the first two hours of birth. Theneuromuscular maturity examination is completed within 24 hours afterdelivery. Information often used to help estimate babies' physical andneuromuscular maturity are shown below.

Physical maturity:

The physical assessment part of the Dubowitz/Ballard Examination looks atphysical characteristics that look different at different stages of a baby'sgestational maturity. Babies who are physically mature usually have higherscores than premature babies.

Points are given for each area of assessment, with a low of -1 or -2 for extremeimmaturity to as much as 4 or 5 for postmaturity. Areas of assessment includethe following:

skin textures (i.e., sticky, smooth, peeling).

lanugo (the soft downy hair on a baby's body) - is absent in immature

babies, then appears with maturity, and then disappears again withpostmaturity.

plantar creases - these creases on the soles of the feet range from absent

to covering the entire foot, depending on the maturity.

breast - the thickness and size of breast tissue and areola (the darkened

ring around each nipple) are assessed.

eyes and ears - eyes fused or open and amount of cartilage and stiffness

of the ear tissue.

genitals, male - presence of testes and appearance of scrotum, from

smooth to wrinkled.

genitals, female - appearance and size of the clitoris and the labia.

Neuromuscular maturity:

Six evaluations of the baby's neuromuscular system are performed. Theseinclude:

posture - how does the baby hold his/her arms and legs.

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square window - how far the baby's hands can be flexed toward the

wrist.

arm recoil - how far the baby's arms "spring back" to a flexed position.

popliteal angle - how far the baby's knees extend.

scarf sign - how far the elbows can be moved across the baby's chest.

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 neurologicallymature 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 possiblecare.

High-Risk Newborn

Every family looks forward to the birth of a healthy newborn. It is an exciting timewith so much to look forward to. In some cases, though, unexpected difficulties andchallenges 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 occurduring fetal development, pregnancy conditions of the mother, or problems that mayoccur during labor and birth. Some complications are unexpected and may occurwithout warning. Other times, there are certain risk factors that make problems morelikely.

Fortunately, advances in technology have helped improve the care of sick newborns.Under the care of specialized physicians and other healthcare providers, babies havemuch 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 orbirth 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.

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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 10th and 90th 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 10th 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 90th

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.

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 than2,500 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 lowbirthweight. The overall rate of these very small babies in the United States is

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increasing. This is primarily due to the greater numbers of multiple birth babies whoare more likely to be born early and weigh less. Over half of multiple birth babieshave 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 ofthe 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 weeksgestation). Being born early means a baby has less time in the mother's uterus to growand 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). Thisoccurs when a baby does not grow well during pregnancy because of problems withthe placenta, the mother's health, or birth defects. A baby can have IUGR and be bornat 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 areboth very small and physically immature.

Incidence

Any baby born prematurely is more likely to be very small. However, there are otherfactors 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 birthweightthan Caucasian babies.

Age

Teen mothers (especially those younger than 15 years old) have a much higherrisk of having a baby with low birthweight.

Multiple birth

Multiple birth babies are at increased risk of low birthweight because theyoften are premature. Over half of twins and other multiples have low

birthweight.

Mothers health

Babies of mothers who are exposed to illicit drugs, alcohol, and cigarettes aremore likely to have low birthweight. Mothers of lower socioeconomic status

are also more likely to have poorer pregnancy nutrition, inadequate prenatalcare, 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 heightof the fundus (the top of a mother's uterus) can be measured from the pubic bone. Thismeasurement 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 createa 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 agrowth chart to estimate fetal weight.

Babies are weighed within the first few hours after birth. The weight is compared withthe baby's gestational age and recorded in the medical record. A birthweight less than2,500 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 lowbirthweight.

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 othercomplications. 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 andmore 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 bornwith 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. Becausematernal 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 areessential. Mothers should also avoid alcohol, cigarettes, and illicit drugs, which cancontribute 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 thanthe usual amount for the number of weeks of pregnancy. SGA babies usually havebirthweights below the 10th percentile for babies of the same gestational age. Thismeans that they are smaller than 90 percent of all other babies of the same gestationalage.

SGA babies may appear physically and neurologically mature but are smaller thanother 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 lowerweight 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), mostSGA babies are small because of fetal growth problems that occur during pregnancy.Many babies with SGA have a condition called intrauterine growth restriction (IUGR).

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IUGR occurs when the fetus does not receive the necessary nutrients and oxygenneeded for proper growth and development of organs and tissues. IUGR can begin atany 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:

high blood pressure

chronic kidney disease

advanced diabetes

heart or respiratory disease

malnutrition, anemia

infection

substance use (alcohol, drugs)

cigarette smoking

Factors involving the uterus and placenta:

decreased blood flow in the uterus and placenta

placental abruption (placenta detaches from the uterus)

placenta previa (placenta attaches low in the uterus)

infection in the tissues around the fetus

Factors related to the developing baby (fetus):

multiple gestation (twins, triplets, etc.)

infection

birth defects

chromosomal abnormality

Diagnosis

The baby with SGA is often identified before birth. During pregnancy, a baby's sizecan be estimated in different ways. The height of the fundus (the top of a mother'suterus) can be measured from the pubic bone. This measurement in centimetersusually corresponds with the number of weeks of pregnancy after the 20th week. If themeasurement is low for the number of weeks, the baby may be smaller than expected.

Although many SGA babies have low birthweight, they are not all premature and maynot experience the problems of premature babies. Other SGA babies, especially thosewith IUGR, appear thin, pale, and with loose, dry skin. The umbilical cord is oftenthin, and dull-looking rather than shiny and fat. They sometimes have a wide-eyedlook.

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

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of the fetus' head and abdomen and compared with a growth chart to estimatefetal weight. The fetal abdominal circumference is a helpful indicator of fetalnutrition.

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 bloodproduces wave-forms that reflect the speed and amount of the blood as itmoves through a blood vessel. Blood vessels in the fetal brain and the umbilicalcord blood flow can be checked with Doppler flow studies.

Mothers weight gain

A mother's weight gain can also indicate a baby's size. Small maternal weightgains 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 usea 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


expectations for the course of the condition


Babies with SGA may be physically more mature than their small size indicates. Butthey may be weak and less able to tolerate large feedings or to stay warm. Treatmentof 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

monitoring of oxygen levels

Babies who are SGA and are also premature may have additional needs includingoxygen and mechanical help to breathe.

Prevention of small for gestational age (SGA):

Prenatal care is important in all pregnancies, and especially to identify problems withfetal growth. Stopping smoking and use of substances such as drugs and alcohol areessential 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 whichthe fetus is smaller than expected for the number of weeks of pregnancy. Another term

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for IUGR is fetal growth restriction. Newborn babies with IUGR are often describedas 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 ofpregnancy) or prematurely (before 37 weeks).

Newborn babies with IUGR often appear thin, pale, and have loose, dry skin. Theumbilical cord is often thin and dull-looking rather than shiny and fat. Babies withIUGR sometimes have a wide-eyed look. Some babies do not have this malnourishedappearance but are small all-over.

Causes of intrauterine growth restriction (IUGR)?

Intrauterine growth restriction results when a problem or abnormality prevents cellsand 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 anddevelopment of organs and tissues, or because of infection. Although some babies aresmall 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:

high blood pressure

chronic kidney disease

advanced diabetes

heart or respiratory disease malnutrition, anemia

infection

substance abuse (alcohol, drugs)

cigarette smoking

Factors involving the uterus and placenta:

decreased blood flow in the uterus and placenta

placental abruption (placenta detaches from the uterus)

placenta previa (placenta attaches low in the uterus)

infection in the tissues around the fetus

Factors related to the developing baby (fetus):

multiple gestation (twins, triplets, etc.)

infection

birth defects chromosomal abnormality

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Diagnosis

During pregnancy, fetal size can be estimated in different ways. The height of thefundus (the top of a mother's uterus) can be measured from the pubic bone. Thismeasurement 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 takenof the fetus' head and abdomen and compared with a growth chart to estimatefetal weight. The fetal abdominal circumference is a helpful indicator of fetalnutrition.

Doppler flowAnother way to interpret and diagnose IUGR during pregnancy is Dopplerflow, 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 itmoves through a blood vessel. Blood vessels in the fetal brain and the umbilicalcord 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 weightgains in pregnancy may correspond with a small baby.

Management

Management of IUGR depends on the severity of growth restriction, and how earlythe problem began in the pregnancy. Generally, the earlier and more severe the growthrestriction, the greater the risks to the fetus. Careful monitoring of a fetus with IUGRand 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. Achange in the number or frequency may mean the fetus is under stress.

nonstress testing - a test that watches the fetal heart rate for increases withfetal movements, a sign of fetal well-being.

biophysical profile - a test that combines the nonstress test with an ultrasoundto 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 fetalgrowth.

Doppler flow studies - a type of ultrasound which use sound waves to measureblood flow.

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Treatment for IUGR:

Although it is not possible to reverse IUGR, some treatments may help slow orminimize 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


Treatments may include:

nutrition

Some studies have shown that increasing maternal nutrition may increasegestational weight gain and fetal growth.

bedrest

Bedrest in the hospital or at home may help improve circulation to the fetus.

delivery

If IUGR endangers the health of the fetus, then an early delivery may benecessary.

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 gettingprenatal care may help decrease the risks for IUGR. Early detection may also helpwith 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 babiesweigh 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 fewpremature 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.

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By far, maternal diabetes is the most common cause of LGA babies. Diabetes duringpregnancy 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.

DiagnosisDuring pregnancy, a baby's birthweight can be estimated in different ways. The heightof the fundus (the top of a mother's uterus) can be measured from the pubic bone. Thismeasurement, in centimeters, usually corresponds with the number of weeks of

pregnancy. If the measurement is high for the number of weeks, the baby may belarger 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 takenof the fetus' head and limbs and compared with a growth chart to estimate fetalweight.

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 withthe baby's gestational age and recorded in the medical record. The birthweight must becompared 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'sphysician based on:






If ultrasound examinations during pregnancy show a fetus is quite large, some

physicians may recommend early delivery before the baby grows much bigger. Amother may need induction of labor, or a planned cesarean delivery if the baby isestimated to be very large.

After delivery, a LGA baby will be carefully examined for any birth injuries. Bloodglucose testing is also performed to check for hypoglycemia. Early feeding with aglucose/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 growthwhen 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, orother problems. Careful management of diabetes in pregnancy can help lower some ofthe 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 lessthan 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 morelikely to be born early and weigh less.

Babies with very low birthweight look much smaller than other babies of normalbirthweight. A very low birthweight baby's head appears to be bigger than the rest ofthe body and he/she often looks extremely thin, with little body fat. The skin is oftenquite 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 weeksgestation). 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 gainweight. 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). Thisis 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 whohave 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 otherfactors that can also contribute to the risk of very low birthweight. These include:

race

African-American babies are twice as likely to have very low birthweight thanCaucasian 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 theyoften are premature. About 10 percent of twins and one-third of triplets havevery low birthweight.

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mother's health

Women who are exposed to drugs, alcohol, and cigarettes during pregnancy aremore likely to have low or very low birthweight babies. Mothers of lowersocioeconomic 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 heightof the fundus (the top of a mother's uterus) can be measured from the pubic bone. Thismeasurement 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 createa 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 withthe baby's gestational age and recorded in the medical record. A birthweight less than2,500 grams (5 pounds, 8 ounces) is diagnosed as low birthweight. Babies weighingless 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'sphysician based on:




Care for very 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

Very low birthweight babies may have a harder time "catching up" in physical growthbecause they often have other complications. Many very low birthweight babies arereferred to special follow-up healthcare programs.

Prevention of very low birthweight:

Because of the tremendous advances in care of sick and premature babies, more andmore 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. Becausematernal 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

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essential. Mothers should also avoid alcohol, cigarettes, and illicit drugs, which cancontribute 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, bornbefore 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 ofmultiple births in recent years. Twins and other multiples are about six times morelikely to be premature than single birth babies. The rate of premature single births isslightly increasing each year.

According to the March of Dimes, about 13 percent of babies born in the US are bornpreterm, 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 prematurebabies also weigh less than 2,500 grams (5.5 pounds) and may be referred to as lowbirthweight (LBW).

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 verypremature infants but may only be slightly smaller than full-term infants.

Late preterm babies usually appear healthy at birth but may have more difficultiesadapting than full-term babies. Because of their smaller size, they may have troublemaintaining their body temperature. They often have difficulty with breastfeeding and

bottle feeding, and may need to eat more frequently. They usually require more sleepand may even sleep through a feeding, which means they miss much-needed calories.

Late preterm infants may also have breathing difficulties, although these are oftenidentified before the infants go home from the hospital. These infants are also athigher 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 oneor two days after going home from the hospital.

Causes of prematurity

There are many factors linked to premature birth. Some directly cause early labor andbirth, while others can make the mother or baby sick and require early delivery. Thefollowing factors may contribute to a premature birth:

Maternal factors:

preeclampsia (also known as toxemia or high blood pressure of

pregnancy) chronic medical illness (such as heart or kidney disease)

infection (such as group B streptococcus, urinary tract infections,

vaginal infections, infections of the fetal/placental tissues)

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drug use (such as cocaine)

abnormal structure of the uterus

cervical incompetence (inability of the cervix to stay closed during

pregnancy)

previous preterm birth

Factors involving the pregnancy:

abnormal or decreased function of the placenta

placenta previa (low lying position of the placenta)

placental abruption (early detachment from the uterus)

premature rupture of membranes (amniotic sac)

polyhydramnios (too much amniotic fluid)

Factors involving the fetus:

when fetal behavior indicates the intrauterine environment is not healthy

multiple gestation (twins, triplets or more)

Characteristics of prematurity

The following are the most common characteristics of a premature baby. However,each baby may show different characteristics of the condition. Characteristics mayinclude:

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 medicalproblems. Always consult your baby's physician for a diagnosis.

Treatment of prematurity:Specific treatment for prematurity will be determined by your baby's physician basedon:


extent of the disease

tolerance for specific medications, procedures, or therapies



Treatment may include:

prenatal corticosteroid therapy

One of the most important parts of care for premature babies is a medicationcalled a corticosteroid. Research has found that giving the mother a steroid

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medication at least 48 hours prior to delivery greatly reduces the incidence andseverity of respiratory disease in the baby. Another major benefit of steroidtreatment is lessening of intraventricular hemorrhage (bleeding in the baby's

brain). Although studies are not clear, prenatal steroids may also help reducethe 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 NeonatalIntensive Care Unit (NICU). The NICU combines advanced technology andtrained health professionals to provide specialized care for the tiniest patients.The NICU team is led by a neonatologist, who is a pediatrician with additionaltraining in the care of sick and premature babies.

Care of premature babies may also include:

temperature-controlled beds

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 thestomach 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. Inthe hospital, this catch-up time may involve learning to eat and sleep, as well assteadily gaining weight. Depending on their condition, premature babies often stay inthe hospital until they reach the pregnancy due date.

If a baby was transferred to another hospital for specialized NICU care, he/she may betransferred 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 thefollowing:

serious illnesses are resolved

stable temperature - able to stay warm in an open crib

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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 tocheck for problems related to prematurity. Parents need information about follow-upvisits with the pediatrician for baby care and immunizations. Many hospitals havespecial follow-up healthcare programs for premature and low birthweight babies.

Even though they are otherwise ready for discharge, some babies continue to havespecial needs such as extra oxygen or tube feedings. With instruction and the rightequipment, these babies are often able to be cared for at home by parents. A hospitalsocial worker can often help coordinate discharge plans when special care is needed.

Ask your baby's physician about a "trial run" overnight stay in a parenting room at thehospital 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 alsofeel more confident taking their baby home when they have been given instructions ininfant CPR (cardiopulmonary resuscitation) and infant safety.

Prevention of prematurity:

Because of the tremendous advances in the care of sick and premature babies, moreand 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 isalso 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 thebest 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 anybaby born after 42 weeks gestation or 294 days past the first day of the mother's lastmenstrual period. About 6 percent of all babies are born at 42 weeks or later. Otherterms 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 morelikely when a mother has had one or more previous post-term pregnancies. Sometimesa mother's pregnancy due date is miscalculated because she is not sure of her last

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menstrual period. A miscalculation may mean the baby is born earlier or later thanexpected.

Symptoms of postmaturity

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 thefollowing:

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 basedon:






In a prolonged pregnancy, testing may be done to check fetal well-being and identifyproblems. Tests often include ultrasound, non-stress testing (how the fetal heart rateresponds 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 helpidentify changes in the heart rate due to low oxygenation. Changes in a baby'scondition 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.

blood tests for hypoglycemia (low blood sugar).

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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 bymeasurements 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 alsocalled intrauterine fetal death or demise. Causes of stillbirth may include thefollowing:

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 womanmay 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 consultyour physician for a diagnosis.

Management

Treatment of stillbirth depends on many factors such as the number of weeksgestation, 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

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Neonatal Death

When a baby dies in the first 28 days of life, it is called neonatal death. In the UnitedStates 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 babywith their health care providers.

CausesPremature birth (before 37 completed weeks of pregnancy) is the most common causeof neonatal death. Prematurity and its complications cause almost 30 percent ofneonatal deaths . The earlier a baby is born, the more likely he is to die. About 20 to35 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 27weeks, survive

About 12 percent of babies are born prematurely. The causes of premature delivery arenot thoroughly understood. In some cases, a pregnant woman may have health

problems (such as high blood pressure) or pregnancy complications (such asplacentalproblems) that increase her risk of delivering prematurely. Women who have had aprevious preterm delivery, are pregnant with twins (or other multiples), or have certainabnormalities of the uterus or cervix also are at increased risk. More often, pretermlabor develops unexpectedly in a pregnancy that had been problem-free.

Premature babies, especially those born at less than 32 weeks of pregnancy andweighing 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 keepssmall air sacs in the lungs from collapsing. Treatment with surfactant has greatlyreduced the number of babies who die from RDS. However, about 880 babies a yeardie 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 bleedsoften result in brain damage or even death.

Some premature babies may develop an intestinal problem called necrotizing

enterocolitis (NEC). Treatment with antibiotics and surgery can save many affectedbabies. However, some develop severe bowel damage and die.

Premature babies have immature immune systems and sometimes develop seriousinfections such as pneumonia (lung infection), sepsis (blood infection), and meningitis(infection of membranes surrounding the brain and spinal cord). In spite of treatmentwith antibiotics and antiviral drugs, some babies die.

While deaths due to prematurity are still too common, the outlook for these babies isimproving. 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 pregnancyshould be treated at least several days before delivery with drugs calledcorticosteroids, which speed maturation of fetal lungs. Studies show this treatmentreduces RDS, brain bleeds and infant deaths.

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Birth defects cause about 21 percent of neonatal deaths. Babies with birth defects maybe premature or full-term. Sometimes parents learn about their baby's birth defectsbefore birth from prenatal tests, such as ultrasound, amniocentesis and chorionic villussampling (CVS).

Ultrasound uses sound waves to take a picture of the fetus. It can help diagnosestructural birth defects, such as spina bifida (open spine), anencephaly (brain and skulldefect), and heart or kidney defects. In amniocentesis, the doctor inserts a thin needlethrough 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 athin tube that is inserted through the vagina or a needle that is inserted through theabdomen. 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 thefirst 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 inthe surgical treatment and medical management of these defects, most affected babiessurvive and do well. However, some babies with severe heart defects may not surviveuntil surgery, or may not survive the surgery. Many babies who die of heart defects inthe first month of life have a specific heart defect called hypoplastic left heartsyndrome. In this heart defect, the main pumping chamber of the heart is too small tosupply blood to the body. New surgical procedures are saving more babies with thisheart defect, but many still die. In most cases, doctors do not know why a baby is bornwith 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 notknown. In most cases, lung defects occur because other birth defects or pregnancycomplications interfered with lung development. Many babies die due tocomplications that occur in immature lungs as a result of premature birth.

Chromosomal abnormalities are also a common cause of neonatal death. Humansnormally have 46 chromosomes. Chromosomes are tiny thread-like structures in ourcells that carry our genes; genes are the basic units of heredity that dictate all traitsfrom 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 achromosomal 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 (calledtrisomy 18 or trisomy 13) have multiple birth defects and generally die in the first

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weeks or months of life. Babies with less severe chromosomal abnormalities, suchas Down syndrome(trisomy 21), often survive, although affected children have mentalretardation 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 aremissing. Affected babies may be stillborn (fetus died before birth) or die in the firstdays 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 earlymonths 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 gettingpregnant 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 supportfrom family, friends and health care professionals. They should never hesitate to asktheir baby's doctors and nurses about their baby's comfort and care. Parents may wantto ask how they can share in their baby's care so they can feel that they are helpingtheir baby and creating memories of their baby. Some hospitals have support groupswhere parents of very sick newborns can share their feelings. Many also have supportgroups for parents of sick newborns and for parents of babies who have died. Parentswho are having trouble coping with their grief, before or after the baby's death, shouldask their health care provider for a referral to a counselor who is experienced indealing with infant death.

Some NICUs have a March of Dimes NICU Family Support project, which providesinformation, comfort and services to families with a baby in the NICU. Forinformation and resources from NICU Family Support, clickhere.

Parents also can visit Share You r Story an online community for families who haveor 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 aninfant 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 from1 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. Deathoccurs quickly, usually during a sleep time.

Causes

The exact causes of SIDS are still unclear and research is ongoing. There are somefactors which make babies more vulnerable to SIDS. Some risk factors are

preventable, but others are not. Evidence has shown that some babies who die fromSIDS have the following:

brain abnormalitiesSome SIDS babies are born with brain abnormalities that make themvulnerable to sudden death during infancy. Studies of SIDS victims show thatmany SIDS babies have abnormalities in the "arcuate nucleus," a part of the

brain that probably helps control breathing and waking during sleep. Babies

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born with defects in other portions of the brain or body may also be more proneto a sudden death. These abnormalities may result from exposure of the fetus toa toxic substance, or a decrease in oxygen. Cigarette smoking during

pregnancy, for example, can reduce the amount of oxygen the fetus receives.

events after birthEvents such as lack of oxygen, excessive carbon dioxide intake, overheating, oran infection may be related to SIDS. Examples of a lack of oxygen andexcessive carbon dioxide levels may include the following:

respiratory infections that cause breathing problems.

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 triggersthe 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 babywith a flawed arcuate nucleus, however, might lack this protective mechanism.

This may explain why babies who sleep on their stomachs are more susceptibleto SIDS, and why a large number of SIDS babies have been reported to haverespiratory infections prior to their deaths. This may also explain why moreSIDS cases occur during the colder months of the year, when respiratory andintestinal infections are more common.

immune system problems

The numbers of cells and proteins made by the immune system of some SIDSbabies have been reported to be higher than normal. Some of these proteins caninteract 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 causethe 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. Onesuch disorder is medium chain acyl-CoA dehydrogenase deficiency, which

prevents the baby from properly processing fatty acids. A build up of these acidmetabolites could eventually lead to a rapid and fatal interruption in breathingand heart functioning. If there is a family history of this disorder or childhooddeath of unknown cause, genetic screening of the parents by a blood test candetermine 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 moreat risk than others. For example, SIDS is more likely when a baby is between 1 and 4months old, it is more common in boys than girls, and most deaths occur during thefall, winter, and early spring months.

Factors that may place a baby at higher risk of dying from SIDS include thefollowing:

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

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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

The diagnosis of SIDS is given when the cause of death remains unexplained after acomplete 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 fromSIDS, including the following:

prenatal careEarly and regular prenatal care can help reduce the risk of SIDS. Propernutrition, no smoking or drug or alcohol use by the mother, and frequentmedical check-ups beginning early in pregnancy might help prevent a babyfrom 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 ishigher 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 theirbacks to sleep has reduced the number of SIDS cases by as much as a half incountries 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 ifplaced on their backs, studies have not found any evidence of increased risk ofchoking or other problems.

place baby on his/her stomach while awake

A certain amount of tummy time while the infant is awake and being observedis recommended for motor development of the shoulders. In addition, awaketime on the stomach may help prevent flat spots from developing on the backof the baby's head. Such physical signs are almost always temporary and willdisappear soon after the baby begins to sit up.

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proper bedding

Make sure that your baby sleeps on a firm mattress or other firm surface. Donot use fluffy blankets or comforters under the baby. Do not let the baby sleepon 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.

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 isdifficult to arouse. The temperature in the baby's room should feel comfortableto an adult and overdressing the baby should be avoided. Keep the temperaturein 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 ofSIDS 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 andbaby can alter sleep patterns of the mother and her baby. While bed sharingmay have certain benefits (such as encouraging breastfeeding), there are noscientific studies demonstrating that bed sharing reduces SIDS. Some studiessuggest that bed sharing, under certain conditions, may actually increase therisk of SIDS. Avoid putting your baby to sleep in a bed with other children oron 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 yourbaby. Smoking in pregnancy is a major risk factor for SIDS. Babies and youngchildren exposed to smoke have more colds and other diseases, as well as anincreased risk of SIDS.

pediatric healthcare

If your baby seems sick, call your physician right away. Parents should taketheir babies for regular well baby check-ups and routine immunizations. Claims

that immunizations increase the risk of SIDS are not supported by research. If ababy 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 insufficientevidence to suggest that breastfeeding might reduce the risk of SIDS, a fewstudies have found SIDS to be less common in babies who have been breastfed.This may be because breast milk can provide protection from some infectionsthat can trigger sudden death in babies.

home monitors for babies at riskAlthough some electronic home monitors can detect and sound an alarm whena baby stops breathing, there is no evidence that such monitors can preventSIDS. In 1986, the National Institutes of Health recommended that homemonitors not be used for babies who do not have an increased risk of suddenunexpected death. The monitors may be recommended, however, for babies

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who have experienced one or more severe episodes during which they stoppedbreathing and required resuscitation or stimulation, premature babies withapnea (stopping breathing), and siblings of two or more SIDS babies. If anincident has occurred, or if a baby is on a monitor, parents need to know how to

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 pacifiershould be offered at nap time and bedtime. The pacifier should not be sugarcoated. Pacifiers should be cleaned and replaced often. Breast-fed infantsshould 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 theblood 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 liverfunction.

Symptoms

Symptoms of hypoglycemia may not be obvious in newborn babies. The following arethe most common symptoms of hypoglycemia. However, each baby may experiencesymptoms 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 umbilicalcatheter (a tube placed in the baby's umbilical cord). Generally, a baby with low bloodglucose levels will need treatment.

Treatment for hypoglycemia:

Specific treatment for hypoglycemia will be determined by your baby's physicianbased on:






Treatment includes giving the baby a rapid-acting source of glucose. This may be assimple as giving a glucose/water mixture or formula as an early feeding. Or, the babymay need glucose given intravenously. The baby's blood glucose levels are closelymonitored after treatment to see if the hypoglycemia occurs again.

Prevention of hypoglycemia:

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 glucoselevels in tight control can help minimize the amount of glucose that goes to the fetus.

Hypocalcemia

Definition

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Hypocalcemia is a condition in which there is too little calcium in the blood. Acommon form of hypocalcemia in babies is called neonatal hypocalcemia. Thiscondition 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, usuallyafter 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 anumber 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, becausetheir 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 arethe most common symptoms of hypocalcemia. However, each baby may experiencesymptoms 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

In addition to a complete medical history and physical examination, diagnosis ofhypocalcemia 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 areno symptoms. However, specific treatment for hypocalcemia will be determined byyour baby's physician based on:






Treatment may include:

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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 arenot easily able to get rid of the bilirubin and it can build up in the blood and othertissues 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 andtissues. This is called jaundice.

Depending on the cause of the hyperbilirubinemia, jaundice may appear at birth or atany time afterward.

Causes of hyperbilirubinemia?

During pregnancy, the placenta excretes bilirubin. When the baby is born, the baby'sliver 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 abilityto excrete bilirubin in the first days of life.

breast milk jaundice

About 2 percent of breastfed babies develop jaundice after the first week. Some

develop breast milk jaundice in the first week due to low calorie intake ordehydration.

jaundice from hemolysis

Jaundice may occur with the breakdown of red blood cells due to hemolyticdisease 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 otherfactors.

About 60 percent of term newborns and 80 percent of premature babies developjaundice. Infants of diabetic mothers and of mothers with Rh disease are more likelyto develop hyperbilirubinemia and jaundice.

Symptoms of hyperbilirubinemia?

The following are the most common symptoms of hyperbilirubinemia. However, eachbaby 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 medicalproblems. Always consult your baby's physician for a diagnosis.

Diagnosis

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The timing of the appearance of jaundice helps with the diagnosis. Jaundice appearingin 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, itcan be a more serious type of jaundice. When jaundice appears on the third day to thefirst 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 liverso 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:Specific treatment for hyperbilirubinemia will be determined by your baby's physician

based on:






Treatment depends on many factors, including the cause of the hyperbilirubinemia andthe level of bilirubin. The goal is to keep the level of bilirubin from increasing todangerous levels. Treatment may include:

phototherapy

Since bilirubin absorbs light, jaundice and increased bilirubin levels usuallydecrease when the baby is exposed to special blue spectrum lights.Phototherapy may take several hours to begin working and it is usedthroughout the day and night. The baby's position is changed to allow all of theskin to be exposed to the light. The baby's eyes must be protected and the

temperature monitored during phototherapy. Blood levels of bilirubin arechecked 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

bloodExchange transfusion helps increase the red blood cell count and lower thelevels of bilirubin. An exchange transfusion is done by alternating giving andwithdrawing blood in small amounts through a vein or artery. Exchangetransfusions 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

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one to two days and giving the baby formula often helps lower the bilirubinlevels. 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 treatmentare important in preventing bilirubin levels from rising to dangerous levels.

Respiratory DistressSyndrome/Hyaline Membrane Disease

DEFINITIONHyaline membrane disease (HMD), also called respiratory distress syndrome (RDS),is one of the most common problems of premature babies. It can cause babies to needextra oxygen and help breathing. The course of illness with hyaline membrane diseasedepends 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 heartcondition), and whether or not the baby needs mechanical

high-risk ncm 102

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