The Newborn at Risk Because of Altered Gestational Age or Birth

Weight

Infants need to be evaluated as soon as possible after birth to determine their

weight, height, head circumference, and gestational age to determine their
immediate healthcare needs and to help anticipate possible future problems.

Term infants are those born after the beginning of week 38 and before week
42 of pregnancy (calculated from the first day of the last menstrual period).
Infants born before term (before the beginning of the 38th week of pregnancy)
are classified as preterm infants regardless of their birth weight. Infants born
after the end of week 41 of pregnancy are classified as postterm infants or
postmature.

Infants who fall between the 10th and 90th percentiles of weight for their
gestational age, whether they are preterm, term, or postterm, are considered
appropriate for gestational age (AGA). Infants who fall below the 10th
percentile of weight for their age are considered small for gestational age
(SGA). Those who fall above the 90th percentile in weight are considered
large for gestational age (LGA). Other terms used include:
• Low–birth-weight (LBW) infant: one weighing less than 2,500 g at birth
• Very-low-birth-weight (VLBW) infant: one weighing less than 1500 g at
birth
• Extremely-low-birth-weight (ELBW) infant: one weighing less than 1,000
g at birth

THE PRETERM INFANT

A preterm infant is traditionally defined as a live-born infant born before the

end of week 37 of gestation. Neonatal assessments such as inspection for
sole creases, skull firmness, ear cartilage, and neurologic development plus
the mother’s report of the date of her last menstrual period along with a
sonographic estimation of age all can be helpful to determine gestational age.
Most preterm infants need intensive care from the moment of birth to give
them their best chance of survival without neurologic after effects because
they are more prone than others to hypoglycemia and intracranial
hemorrhage. Lack of lung surfactant, because this does not form until about
the 34th week of pregnancy, makes them extremely vulnerable to respiratory
distress syndrome.

Characteristics Between Small-For-Gestational-Age and Preterm Infants

Characteristic Small-for-Gestational- Preterm Infant
Age
Infant
Gestational age 24–44 wk <37 wk

Birth weight <10th percentile Normal for age

Congenital Strong possibility Possibility

malformations

Pulmonary Meconium aspiration, Respiratory distress

problems most pulmonary hemorrhage, syndrome

apt to occur pneumothorax

Possibility Very strong possibility

Hyperbilirubinemia

Very strong possibility Possibility

Hypoglycemia

Strong possibility Possibility

Intracranial
hemorrhage

Possibility Very strong possibility

Apnea episodes

Most likely because of Small stomach capacity;

Feeding problems
accompanying problem immature sucking reflex

such as hypoglycemia
 Weight gain in Rapid Slow
nursery
Possibly always be Not likely to be
Future restricted <10th restricted in growth
growth percentile because of because “catch-up”
poor growth occurs
organ development

Etiology
At least 50% of neonatal deaths are preterm. Infant mortality could be
reduced dramatically if the causes of preterm birth could be discovered and
corrected and all pregnancies could be brought to term. However, even with
the examples of possible causes listed in the following, the exact cause of
premature labor and early birth is rarely exactly known.

Common Factors Associated With Preterm Birth

• Low socioeconomic level
• Poor nutritional status
• Lack of prenatal care
• Multiple pregnancy
• Previous early birth
• Race (non-Whites have a higher incidence of prematurity than Whites)
• Cigarette smoking
• Age of the mother (highest incidence is in mothers younger than age 20
years)
• Order of birth (early birth is highest in first pregnancies and in those beyond
the
fourth pregnancy)
• Closely spaced pregnancies
• Abnormalities of the mother’s reproductive system, such as intrauterine
septum
• Infections (especially urinary tract infections)
• Pregnancy complications, such as premature rupture of membranes or
premature
separation of the placenta
• Early induction of labor
• Elective cesarean birth

Assessment
When interviewing parents of a preterm infant, be careful not to convey
disapproval of reported pregnancy behaviors such as cigarette smoking that
may have contributed to preterm birth. An accurate but comforting answer to a
direct inquiry about why preterm birth occurs is, “No one really knows what
causes prematurity.”

On gross inspection, a preterm infant’s head appears disproportionately large

(≥3 cm greater than chest size). The skin is generally unusually ruddy
because there is so little subcutaneous fat beneath it, making veins easily
noticeable; a high degree of acrocyanosis may be present. Newborns
delivered at greater than 28 weeks of gestation are typically covered with
vernix caseosa. In very preterm newborns, however (less than 28 weeks of
gestation), the vernix will be lacking. Lanugo is usually scant the same way in
very low gestation infants but will be extensive, covering the back, forearms,
forehead, and sides of the face in late preterm babies. Both anterior and
posterior fontanelles will be small. There are few or no creases on the soles of
the feet.
An immature newborn at birth. (Photodisc/PunchStock.)
 Examples of physical examination findings and reflex
tests used to judge gestational age. (A) A resting posture. (B) Wrist
flexion. (C) Recoil of extremities (legs). (D) The scarf sign. (E) Heel
to ear. (F) Plantar creases. (G) Breast tissue. (H) Ears. (I) Male
genitalia. (J) Female genitalia.

The eyes of most preterm infants appear small in relation to term infants.
Although difficult to elicit, a pupillary reaction is present. A preterm infant has
varying degrees of myopia (nearsightedness) because of a lack of eye globe
depth.
The ears appear large in relation to the head. The cartilage of the ear is
immature and allows the pinna to fall forward. The level of the ears should be
carefully inspected to rule out chromosomal abnormalities
 Neurologic function in the preterm infant is often difficult to evaluate
because the neurologic system is still immature. Observing the infant make
spontaneous or provoked muscle movements can be as important as formal
reflex testing. During an examination, a preterm infant is much less active
than a mature infant and rarely cries. If the infant does cry, the cry is weak
and high pitched.

Potential Complications
Because of immaturity, preterm infants are prone to several specific
conditions

Anemia of Prematurity
Many preterm infants develop a normochromic, normocytic anemia (normal
cells, just few in number), which can make infants appear pale, lethargic, and
anorectic. Anemia occurs from a combination of immaturity of the
hematopoietic system (the effective production of red cells with an elevated
reticulocyte count may not begin until 32 weeks of pregnancy) combined with
the destruction of red blood cells because of low levels of vitamin E, a
substance that normally protects red blood cells against oxidation. Excessive
blood drawing for electrolytes, complete blood counts, or blood gas analysis
after birth can potentiate the problem. Delaying cord clamping at birth to allow
a little more blood from the placenta to enter the infant may also help reduce
the development of anemia.

Acute Bilirubin Encephalopathy

Acute bilirubin encephalopathy (ABE) is the destruction of brain cells by
invasion of indirect or unconjugated bilirubin. This invasion results from the
high concentration of indirect bilirubin that forms in the bloodstream from an
excessive breakdown of red blood cells at birth. Preterm infants are more
prone to this condition than term infants because, with the acidosis that
occurs from poor respiratory exchange, brain cells appear to be more
susceptible to the effect of indirect bilirubin than usual. Preterm infants also
have less serum albumin available to bind indirect bilirubin and inactivate its
effect.
Persistent Patent Ductus Arteriosus
Because preterm infants may lack surfactant, their lungs are noncompliant, so
it is more difficult for them to move blood from the pulmonary artery into the
lungs. This condition leads to pulmonary artery hypertension, which then
interferes with closure of the ductus arteriosus.

Periventricular/Intraventricular Hemorrhage
Preterm infants are prone to periventricular hemorrhage (bleeding into the
tissue surrounding the ventricles) or intraventricular hemorrhage (bleeding
into the ventricles) because of fragile capillaries and immature cerebral
vascular development. When there is a rapid change in cerebral blood
pressure, such as could occur with hypoxia, intravenous infusion, ventilation,
or pneumothorax (lung collapse), capillary rupture could occur; brain anoxia
then occurs distal to the rupture.

Intraventricular hemorrhage occurs most often in VLBW infants and is

classified as:
• Grade 1, bleeding in the periventricular germinal matrix regions or germinal
matrix, occurring in one ventricle
• Grade 2, bleeding within the lateral ventricle without dilation of the ventricle
• Grade 3, bleeding causing enlargement of the ventricles
• Grade 4, bleeding in the ventricles and intraparenchymal hemorrhage

A long-term effect of hemorrhage may be the development of hydrocephalus if

there was bleeding into the narrow aqueduct of Sylvius. Infants with grade 1
or 2 bleeds have a good long-term prognosis; the prognosis of those with
more intense bleeds is guarded until further complications are ruled out.

Other Potential Complications

Preterm infants are also particularly susceptible to several illnesses in the
early postnatal period, which can also occur in term infants, including
respiratory distress syndrome, apnea, and retinopathy of prematurity, as well
as necrotizing enterocolitis .
 Nursing Diagnoses and Related Interventions

Nursing Diagnosis Risk: Impaired gas exchange related to immature

pulmonary functioning.

Outcome Evaluation: Newborn initiates breathing at birth after resuscitation;

maintains normal newborn respirations of 30 to 60 breaths/min free of
assisted ventilation; exhibits oxygen saturation levels of at least 95% as
evidenced by pulse oximetry.

Preterm infants have great difficulty initiating respirations at birth because

pulmonary capillaries are still so immature, and lung surfactant, which does
not form in adequate amounts until about the 34th to 35th week of pregnancy,
may not be present. Inadequate lung surfactant leads to alveolar collapse with
each expiration.
Even term infants experience temporary respiratory acidosis until they
take a first breath. Once respirations are established, however, this condition
quickly clears.
Many preterm babies, particularly those under 32 weeks of age,
continue to have an irregular respiratory pattern. There is no bradycardia with
this irregular pattern (sometimes termed periodic respirations). If true apnea,
which needs immediate attention, is occurring, the pause in respirations is
more than 20 seconds and usually results in bradycardia
The soft rib cartilage of a preterm infant is yet another source of
respiratory problems because it causes ribs to collapse on expiration.

Nursing Diagnosis: Risk for deficient fluid volume related to

insensible water loss at birth and small stomach capacity

Outcome Evaluation: Plasma glucose is between 40 and 60 mg per

100 ml; specific gravity of urine is maintained at 1.003 to 1.020; urine output is
maintained at a minimum of 1 ml/kg/hr; electrolyte levels are within normal
limits.
 A preterm newborn experiences a high insensible water loss because
of a large body surface relative to total body weight. Preterm infants also
cannot concentrate urine well because of immature kidney function. Because
of this, a high proportion of body fluid is excreted. All these factors may make
a preterm baby need a higher percentage of fluid daily than a term infant
The amount of urine output for the first few days of life in preterm
babies is high in comparison with that of the term baby because of poor urine
concentration: 40 to 100 ml/kg per 24 hours, compared with 10 to 20 ml/kg
per 24 hours, respectively. The specific gravity is low, rarely more than 1.012
(normal term babies may concentrate urine up to 1.030).
Blood glucose determinations should range between 40 and 60 mg/dl.
Check for blood in stools to evaluate possible bleeding from the intestinal tract
because this can help determine a cause of hypovolemia if this occurs.

Nursing Diagnosis: Risk for imbalanced nutrition, less than body

requirements, related to additional nutrients needed for maintenance of rapid
growth, possible sucking difficulty, and small stomach

Outcome Evaluation: Infant’s weight follows percentile growth curve, skin

turgor is good, specific gravity of urine is maintained between 1.003 and
1.020; the infant has no more than 15% weight loss in the first 3 days of life
and continues to gain weight after this point.

Nutrition problems can arise with a preterm infant because the infant’s body is
attempting to continue to maintain the rapid rate of intrauterine growth
appropriate for the gestational age.
If these nutrients are not supplied, an infant can develop hypocalcemia
(decreased serum calcium) or azotemia (low protein level in the blood).
Delayed feeding and a resultant decrease in intestinal motility may also add to
hyperbilirubinemia, a problem infants already are at high risk of developing
when fetal red blood cells begin to be destroyed.
Digestion and absorption of nutrients in a preterm infant’s stomach and
intestine may be immature, making the digestion of milk difficult. Nutrition
problems are further compounded by a preterm infant’s immature reflexes,
which make swallowing and sucking difficult. An immature cardiac sphincter
(between the stomach and esophagus) allows regurgitation to occur readily.
The lack of a cough reflex may lead an infant to aspirate regurgitated formula.

Feeding Schedule. With the early administration of intravenous fluid to

prevent hypoglycemia and supply fluid, feedings may be safely delayed until
an infant has stabilized his or her respiratory effort from birth. Very preterm
infants may be fed by total parenteral nutrition until they are stable enough for
enteral feedings. Breast, gavage, or bottle feedings are then begun as soon
as the infant is able to tolerate them to prevent the deterioration of the
intestinal villi.

Gavage Feeding. Although a sucking reflex is present earlier, the ability to

coordinate sucking and swallowing is inconsistent until approximately 34
weeks of gestation. A gag reflex is not intact until 32 weeks of gestation. For
this reason, for infants who are ill or experiencing respiratory distress may be
started on gavage feedings; bottle feeding or breastfeeding will then be
gradually introduced as the infant matures and begins to demonstrate feeding
behaviors such as being awake, moving, or fussing as if hungry.

Feeding a preterm infant. Notice the small bottle used. (Fuse/PunchStock.)

Observe preterm infants closely after oral or gavage feeding to be

certain their filled stomach is not causing respiratory distress. Offering a
pacifier during gavage feeding can help strengthen the sucking reflex, better
prepare an infant for bottle feeding or breastfeeding, and provide oral
satisfaction.
Gavage feedings may be given intermittently every few hours or
continuously via tubes passed into the stomach or intestine through the mouth
or nose. This can be helpful for infants on ventilators or those who cannot
tolerate intermittent feedings because of the volume. If feedings are given
intermittently, stomach contents may be aspirated, measured, and replaced
before each feeding. Feedings should not be increased and possibly even cut
back to ensure better digestion and to decrease the possibility of regurgitation
and aspiration.

Breast Milk. There is increasing evidence that although preterm infants grow
well on commercial formulas, the best milk for them, the same as with term
infants, is breast milk. The immunologic properties of breast milk may play a
major role in preventing neonatal necrotizing enterocolitis as well as an
increase in immune defenses.
Mothers can express breast milk manually or with a breast pump for
their infant’s gavage feedings. It is better for infants to receive their own
mother’s breast milk rather than banked milk if possible. This high level of
sodium seems to be necessary for fluid retention in the preterm infant.

Formula. The caloric concentration of formulas used for preterm infants is

usually 22 calories per ounce compared to 20 calories per ounce for a term
baby. Supplementing additional minerals such as iron, calcium, and
phosphorus and electrolytes such as sodium, potassium, and chloride may be
necessary, depending on the newborn’s blood studies.
Nursing Diagnosis: Ineffective thermoregulation related to immaturity

Outcome Evaluation: Infant’s temperature is maintained at 97.6°F (36.5°C)

axillary.

Preterm newborns have a great deal of difficulty maintaining body

temperature because they have a relatively large surface area per kilogram of
body weight.
A preterm infant has little subcutaneous fat for insulation and poor
muscular development and so cannot move as actively as an older infant to
produce body heat. A preterm infant also has a limited amount of brown fat,
the special tissue present in newborns that helps maintain body temperature.
Preterm infants also cannot shiver, a useful mechanism to increase body
temperature, nor can they sweat and thereby reduce body temperature
because of their immature central nervous system and hypothalamic control.
If an infant is going to be transported to a department within the
hospital, such as the X-ray department, or to a regional center for specialized
care, keeping the newborn warm during transport is crucial.

Nursing Diagnosis: Risk for infection related to immature immune defenses

in the preterm infant

Outcome Evaluation: Temperature is maintained at 97.6°F (36.5°C) axillary;

further signs and symptoms of infection such as poor growth or a reduced
temperature are absent.

The skin of a preterm infant is easily traumatized and therefore offers less
resistance to infection than the skin and mucous membrane of a mature
infant. In addition, preterm infants have a lowered resistance to infection
because they have difficulty producing phagocytes to localize infection as well
as a deficiency of immune globulin M (IgM) antibodies because of insufficient
production.
Nursing Diagnosis: Risk for impaired parenting related to interference with
parent– infant attachment resulting from hospitalization of infant at birth

Outcome Evaluation: Parents visit frequently and hold the infant; parents
speak of their child in positive terms.

In a preterm infant, the first and second periods of reactivity normally

observed in newborns at 1 hour and 4 hours of life may be delayed. In some
infants, no period of increased activity or tachycardia may appear until 12 to
18 hours of age. If the purpose of a period of reactivity is to stimulate
respiratory function, this places a preterm infant at an even greater threat of
respiratory failure because respiratory efforts may not be stimulated. A
second consequence of a delayed period of reactivity is the loss of an
opportunity for interaction between parents and the newborn in the early
postpartum period.
Although it is extremely important to conserve a preterm infant’s
strength by reducing sensory stimulation as much as possible and handling
an infant gently, preterm infants appear to need as much attention and
affection as term newborns.

Nursing Care Planning to Empower a Family

Here are some guidelines that should be helpful:

- Learn the name of your child’s primary healthcare provider and primary
nurse or care manager. Make a point of talking to them when you visit so the
information you receive is consistent and so these important people can get to
know you.
- Discuss with your child’s primary nurse the time you will usually visit so she
or he can schedule your baby’s procedures and rest times other than when
you visit so there is time for you to hold your child and interact with him
uninterrupted
- Ask for explanations of any equipment or medications being used with your
child so you understand the plan of care.
- Any day you are unable to visit, call the nursery and ask to talk to your
child’s primary care nurse.
- Ask if you can supply expressed breast milk for your infant as soon as
feedings are started so you can feel you’re having a greater part in your
baby’s care.
- You might supply a tape recording of your voice so your baby can learn to
recognize it, as well as supply a small toy for your baby’s bed.
- Use your baby’s name when you talk about him (not “the baby”) to help you
gain a firm feeling that this is your baby, not the nursery’s.
- If your child is hospitalized a distance from home, ask if transfer to a local
hospital in a less technical environment will be possible as soon as he’s not
so ill.

Before effective bonding can be established, parents may need time to come
to terms with their feelings of disappointment that the infant is so small or guilt
that they were not able to prevent the preterm birth. Helping them air these
feelings and develop a more positive attitude toward their preterm infant is an
important nursing responsibility.
Because parents may not be psychologically ready for birth when a
preterm infant is born, it may be more difficult for them to believe they have a
child and to begin interacting than if the infant had been born at term.
Encourage the mother to come to the nursery and hold the infant before and
after gavage feedings and to breastfeed or bottle feed as soon as the baby is
ready for this.
If the baby is going to be transferred to a regional center, make sure
the parents have an opportunity to see the infant before the transfer. A
photograph of the infant for them to keep is helpful in making the birth more
real.
On days they cannot visit, parents can still stay in touch by telephone,
video, or nursery e-mail. By these means, by the time the baby is ready for
discharge, the parents should be able to feel they are taking home “their”
baby, one whom they know and have already begun to love.
Parents visiting a high-risk nursery often need a great deal of support
from nursing personnel. In such a high-tech setting, a parent may want very
much to touch his or her infant but is so afraid touching might set off an alarm
that he or she stands with arms folded

Nursing Care Planning Tip for Effective Communication

Visiting a NICU can be intimidating for parents, not only because of the high-
tech equipment that surrounds their baby but also because their baby often
appears much smaller or sicker than they imagined.

Encourage families to visit with immature infants to establish bonding.

(Phanie/Alamy Stock Photo)

Because preterm infants can be hospitalized for long periods, parents can feel
baffled by receiving information from a parade of different healthcare
providers or a different person every time they visit. Consistent caregiver
helps to reduce the number of people who contact the parents and who
communicate the parents’ needs to the rest of the staff.
Try to make a baby’s siblings as welcome in a high-risk nursery as the
baby’s parents in order to build family unity. Check to be certain siblings do
not have an upper respiratory infection or fever. Also, their immunizations
should be up to date and they should not have been recently exposed to a
communicable disease, such as chickenpox, before they visit
Nursing Diagnosis: Deficient diversional activity (lack of stimulation) related
to preterm infant’s rest needs

Outcome Evaluation: Infant demonstrates interaction with caregivers by

attuning to faces or voices. Preterm infants need rest to conserve energy for
growth and respiratory function, to combat hypoglycemia and infection, to
stabilize temperature, and to develop inner balance and attentiveness.
Preterm infants may have more difficulty blocking out stimuli than term infants
do because their nervous systems are so immature. They may demonstrate
they are overstimulated by such behaviors as gagging, crying, splaying
fingers and toes, or going limp when exposed to bright lights, noise, pain, or
overly strenuous handling. Until ready to take in stimuli, the infant may need
to be shielded from noise and light and pain may need to be limited as much
as possible.
Just as a preterm infant needs rest, he or she also needs planned
periods of pleasing sensory stimulation. Like all newborns, preterm infants
respond best to stimulation that appeals to their senses of sight, sound, and
touch.
The acrylic dome of an incubator can distort an infant’s view. Also,
most people view an infant in an incubator with themselves standing up and
the infant lying horizontally. This means that an infant’s face is rarely in the
same line of vision as the adult’s (an en face position). As infants mature,
they should have mobiles (perhaps black and white) or bright objects placed
in view. As an infant’s position is changed from the left side to the right side,
move the object to be in line with the child’s vision
Infants in closed incubators may be able to hear nothing but the sound
of the incubator motor. They may see people looking or nodding at them and
may see their mouths moving, but they cannot benefit from the sound of their
voices because this is obscured by the continuous hum of the motor.
Even an infant who cannot be removed from an incubator should not
suffer from lack of touch. Gently stroking an infant’s back or smoothing the
back of the head should not be tiring. Pulse oximetry can be used to help you
recognize when an infant is comforted by handling (e.g., oxygen saturation
remains steady or increases) and when the infant is growing tired (e.g.,
oxygen saturation falls). Be certain during every nursing shift that close
interaction is provided, particularly if clinical interventions with an infant
include uncomfortable procedures such as suctioning or blood drawing. As
soon as infants can be out of incubators or removed from warmers, they need
special time just to be rocked and held.

Nursing Diagnosis: Risk for disorganized infant behavior related to

prematurity and environmental overstimulation

Outcome Evaluation: Newborn’s vital signs remain within normal limits;

infant demonstrates increasing ability to adapt to stimuli; demonstrates
decreasing levels of irritability, crying, respiratory pauses, tachypnea, and
color changes.

The amount of rest and stimulation required by preterm infants for healthy
development is best individualized. Developmental care (care designed to
meet the specific needs of each infant) can lead to increased weight gain and
decreased crying and apnea spells in preterm infants.

Developmental Care

Developmental care is medical attention specially tailored to a preterm infant's needs.

Behavioral cues to accommodate a preterm or newborn baby's unique needs. Common
measures consist of a parent welcoming procedure. Make parents feel welcome in a
neonatal intensive care environment by both words and actions. Provide room around
incubators or warmers for rocking chairs so parents can hold their baby comfortably.
Encourage parent participation in feeding or supplying non nutritive sucking experiences.
Demonstrate the infant's capabilities and how, although immature, these are correct for the
infant's age or weight. Keep parents informed of their baby's progress and the rationale for
therapies. Ask parents for input into their baby's rhythm of care that will best suit them and
the infant after they return home.
INFANT DEVELOPMENTAL PROCEDURES

 Provide a consistent routine to help the infant develop sleep/wake

cycles.
 Time infant care and feeding based on the sleep/wake cycle of the
infant.
 Cluster aspects of care so the infant enjoys the longest possible sleep
intervals to conserve energy.
 Provide a "nest" with blankets to offer a sense of boundaries or
security.
 Position infants so they can self-soothe-curled on side, or hands near
face, knee tucked near body, or whatever way each baby seems to
prefer.
 Provide quiet or rest times by covering an incubator and limiting sound.
 Provide tactile stimulation by back stroking or massage.
 Provide audio and visual stimulation by the use of mobiles and music
or a parent's voice.
 Halt procedures as soon as the infant evidences stress.

Nursing Diagnosis: Parental health-seeking behaviprs related to preterm

infant's needs for health maintenance

Outcome Evaluation: Parents describe schedule for basic immunizations

and health assessments and state who will provide ongoing health care.

Discharge from a NICU is a major transition for parents as well as their infant.
Before discharge, the parents of a preterm infant need to learn and practice
any specialmethods of care necessary for their infant and interventions to help
maximize their child's development. Some parents tend to overprotect preterm
infants, such as notallowing visitors or not taking an infant outside. Let parents
know their concern is normal but overprotection is not necessary.
Ongoing health maintenance of a preterm infant follows the usual pattern of
well-child care. Basic immunizations are given according to the chronologic
age of aninfant. In many communities, NICUs maintain their own well-child
settings for infants who were hospitalized there.However, preterm infants can
be followed by any healthcare provider for well-child care.When plotting the
height and weight of preterm infants at well-child visits, remember to account
for early birth on the growth chart by double charting-that is, plotting the child's
weight and height accoding to the chronologic age (a pattern that, in the early
months, probably places the child below the 10th percentile). Then, in another
color, plot the height and weight according to an infant's adjusted age, or plot
the weight of a baby born 2 months early 2 months earlier on the graph. A
preterm baby typically gains "catch-up" weight in the first 6 months of life, so
by 1 year of age, a baby plots over the 10th pereentile on a growth chart
without accounting for a setback age.

THE SMALL-FOR-GESTATIONAL-AGE INFANT

An infant is SGA (also called microsomia) if the birth weight is below the 10th
percentile on an intrauterine growth curve for that age. Such infants may be
born:
Preterm: before week 38 of gestation
Term: between weeks 38 and 42
Postterm: past 42 weeks

Etiology
A woman's nutrition during pregnancy plays a major role in fetal growth, so a
lack of adequate nutrition may be a major contributor to IUGR (Ota, Tobe-Gai,
Mori, et Al. 2012). Adolescents are prone to having a high incidence of SGA
infants because if they eat only enough to meet their own nutritional and
growth needs, the needs of a growing fetus can be compromised. In still other
instances, the placental supply of nutrients is adequate but an infant cannot
use them because of a chromosomal abnormality or anintrauterine infection
such as rubella or toxoplasmosis.Even in light of these nutritional influences,
the most common cause of IUGR is a placental issue: either the placenta did
not obtain sufficient nutrients from the uterine arteries or uit was inefficient at
transporting nutrients to the fetus.

Assessment
The SGA infant may be detected in utero when fundal height during
pregnancy
becomes progressively less than expected. However, if a woman is unsure of
the date of her last menstrual period, this discrepancy can be hard to
substantiate; a sonogram can then demonstrate the decreased size. A
biophysical profile including a nonstress test, placental grading, amniotic fluid
amount, and an ultrasound examination documents additional information on
placental function and fetal growth.

Appearance
Generally, an infant who suffers nutritional deprivation early in pregnancy,
when fetal growth consists primarily of an increase in the number of body
cells, is below average in weight, length, and head circumference. An infant
who suffers deprivation late in pregnancy, when growth consists primarily of
an increase in cell size, may have only a reduction in weight. Regardless of
when deprivation occurs, the infant tends to have an overall wasted
appearance :
 The infant may have poor skin turgor and generally appears to have a
large head because the rest of the body is so small.
 Skull sutures may be widely separated. Hair may be dull and lusterless
 The infant may have a small liver, which can cause difficulty regulating
glucose, protein, and bilirubin levels after birth.
 The abdomen may be sunken. The umbilical cord often appears dry
and may be stained yellow.
Laboratory Findings

Blood studies at birth usually show a high hematocrit level (less than
normal amounts of plasma in proportion to red blood cells are present
because of a lack of fluid) and an increase in the total number of red blood
cells (polycythemia). The increase in red blood cells occurs because anoxia
during intrauterine life stimulated excess development of them. An immediate
cffect of polycythemia is to cause increased blood viscosity, a condition that
puts extra work on the infant's heart because it is more difficult to effectively
circulate thick blood. As a consequence, acrocyanosis (blueness of the hands
and feet) may be prolonged and persistently more marked than usual. If the
polycythemia is extreme, vessels may actually become blocked and thrombus
formationcan result. If the hematocrit level is more than 65% to 70%, an
exchange transfusion to dilute the blood may be necessary.

Nursing Diagnosis: Ineffective breathing pattern related to underdeveloped

body systems at birth.

Outcome Evaluation: Newborn maintains respirations at a rate of 30 to 60

breaths/min after resuscitation at birth.

Birth asphyxia is a common problem for SGA infants, both because they have
underdeveloped chest muscles and because they are at risk for developing
meconium aspiration syndrome (MAS) as a result of meconium release, which
occurs when fetal anoxia develops during labor to cause reflex relaxation of
the anal sphincter. When gasping for breath in utero, the fetus draws
meconium discharged from the intestine into the amniotic fluid down into the
trachea and bronchi. Acting as a foreign substance, this blocks airflow into the
alveoli and causes the SGA infant to need resuscitation at birth. Closely
observe both respiratory rate and characterinthe first few hours of life as
underdeveloped chest muscles not only make taking the first breath difficult
but can make SGA infants unable to sustain an adequate newborn respiratory
rate.

Nursing Diagnosis: Risk for ineffective thermoregulation related to lack of

subcutaneous fat.

Outcome Evaluation: Infant's temperature is maintained at 36.5°C

(97.8°F)axillary.

THE LARGE-FOR-GESTATIONAL-AGE INFANT

An infant is LGA (also termed macrosomia) if the birth weight is above

the 90th percentile on an intrauterine growth chart for that gestational age.
Such a baby appears deceptively healthy at birth because of the weight, but a
gestational age examination often reveals immature development. It is
important that LGA infants be identified immediately so they can be given care
appropriate to their gestational age rather thanbeing treated as term
newborns (Sjaarda, Albert, Mumford, et al., 2014).

Etiology
Infants who are LGA have been subjected to an overproduction of
nutrients and ggrowth hormone in utero. This happens most often to infants of
women who are obese or wwh have diabetes mellitus (Sjaarda et al., 2014).

Assessment
 A fetus is suspected of being LGA when a woman's uterus appears to be
unusually
large for the date of pregnancy. Abdominal size can be deceptive, however.
Because a fetus lies in a flexed fetal position, he or she does not occupy
significantly more space at10 b than at 7 lb. If a fetus does seem to be
growing at an abnormally rapid rate, a sonogram can confirm the suspicion. A
nonstress test to assess the placenta's ability tt sustain a large fetus during
labor may be prescribed. Lung maturity may be assessed bB aamniocentesis If
an infant's large size was not detected during pregnancy, it may be ffirs
recognized during labor when the baby appears too large to descend through
the pelvic rim. If this happens, a cesarean birth may be necessary because
shoulder dystocia (tth wide fetal shoulders cannot pass; or needs significant
manipulation to pass through tth outlet of the pelvis) would halt vaginal birth at
that point.

Appearance

At birth, LGA infants may show immature reflexes and low scores on
gestational age examinations in relation to their size. They may have
extensive bruising or a birth injury such as a broken clavicle or Erb-Duchenne
paralysis from trauma to the cervical nerves if they were stressed in order for
the wide shoulders to be born vaginally. Because the head is large, it may
have been exposed to more thán the usual amount of pressure during birth,
causing a prominent caput succedaneum, cephalohematoma, or
molding.often immature, they require cautious.

Important Assessment Criteria for a Large-For-Gestationa-Age

Infant
 Assessment Rationale
Assess skin color for ecchymosis, Bruising occurs with vaginal birth
ppolycythemi jaundice, and erythema because of the large size;
ppolycythemi jaundice, and erythema
causes ruddiness of skin.Ecchymosis
is important to document bbecause
jaundice may occur from breakdown
ccchymotic collections of blood.

Assess motion of upper extremities is

occur because of problem at birth of
Clavicle or cervical nerve injuries may
spontaneous and also occurs in
Assess motion of upper extremities is
response wider than usual shoulders.
occur because of problem at birth of
to a Moro reflex to detect if clavicle
spontaneous and also occurs in
fracture (crepitus or swelling may tthe
response wider than usualshoulders.
be palpated at the fracture site) or
Erb's palsy caused by edema of the
ccervical nerve plexus are present.

Assess asymmetry of the anterior

chest or unilateral lack of movement The cervical nerve may be stretced by
to detect the phrenic nerve. birth of wide shoulders.

Assess asymmetry of the anterior The cervical nerve may be stretched by

chest or unilateral lack of movement birth of wide shoulders.
to detect diaphragmatic paralysis
from edema ofthe phrenic nerve

. The larger than usual head can be more

Assess eyes for evidence of compressed than usual resulting in
unresponsive or dilated pupils; increased intracranial
assess for vomiting, bulging pressure.Compression of the third,
fontanelles, or a high-pitched
fourth, and sixth cranial nerves limits eye
cry suggestive of increased
response; other signs are additional signs
intracranial pressure.
of increasedintracranial pressure.
Cardiovascular Dysfunction

Polycythemia may occur in an LGA fetus as the fetus attempts to fully

oxygenate more than the average amount of body tissue. Following birth,
observe LGA infants closely for signs of hyperbilirubinemia that may result
from absorption of blood from bruising and breakdown of the extra red blood
cells created by polycythemia.

Hypoglycemia

LGA infants also need to be carefully assessed for hypoglycemia in the early
hours of life because large infants require large amounts of nutritional stores
to sustain their weight. If the mother had diabetes that was poorly controlled
(the cause of the large size), the infant would have had an increased blood
glucose level in utero to match the mother's glucose level; this caused the
infant to produce elevated levels of insulin. After birth, these increased insulin
levels will continue for up to 24 hours of life, possibly causing rebound
hypoglycemia.

Nursing Diagnosis: Ineffective breathing pattern related to possible birth

trauma in the LGA newborm.

Outcome Evaluation: Newborn initiates independent breathing at birth;

maintains usual newborn respiratory rate of 30 to 60 breaths/min.
 THE POSTTERM INFANT

A postterm infant is one born after the 41st weck of a pregnancy

(Rahimian, 2013). Infants who stay in utero past week 41 are at special risk
because a placenta appears to function effectively for only 40 weeks. After
that time, it seems to lose its ability to carry nutrients effectively to the fetus,
and the fetus begins to lose weight (postterm syndrome). Infants with this
syndrome demonstrate many of the characteristics of the SGA infant: dry,
cracked, almost leatherlike skin from lack of fluid, and an absence of vemix.
They may be SGA, and the amount of amniotic fluid surrounding them may be
less at birth than usual and it may be meconium stained. Fingernails will have
grown well beyond the end of the fingertips. Because they are older than a
term infant, they may demonstrate an alertness much more like a 2-week-old
baby than a newborm When a pregnancy becomes postterm, a sonogram 1s
usually obtained to measure the biparietal diameter of the fetus. A nonstress
test or complete biophysical profile may be done to establish whether the
placenta is still functioning adequately.