Classification_by_weight-gestation-intrauterine_growth[1].pptx

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1. Classification of Neonates by Weight, Gestation & Intrauterine Growth Dr. Abu Bakarr Kanu

2. Learning Objectives By the end of this session you should be able to: Classify neonates according to weight, gestation and intrauterine growth Attempt clinical assignment of gestational age to neonates in SCBU Identify factors that may affect categorization of patients

3. Outline Introduction Relevance of classification Classification by Weight Classification by Gestation Classification by Intrauterine Growth Feedback/clarifications

4. Introduction Classification of neonates according to weight and intrauterine growth are as important as gestation in determining the hazards faced by them during and immediately after birth. About 15 million babies are born preterm every year worldwide 1 ; 15-20% of all births worldwide are low birth weight 2 . Medical problems encountered by the different categories of babies are different e.g. problems of a preterm vs a small for date baby. Prognosis with respect to their subsequent mental and physical development is also different.

5. Relevance of classification Label/name the neonate. Informed decision on management of the newborn. Predict outcome of the neonate including clinical course and subsequent development. The Every Newborn Action Plan has prioritized gestational age measurement as a high-priority area to improve the epidemiology of preterm birth and SGA 3 .

6. Let’s remind ourselves…. Neonatal period: 0 – 28days Perinatal period: 28 /40 - 1 st week of life Term: > 37 – 42 weeks Preterm: < 37 completed weeks Post-term: >42 weeks Post date: > 40 weeks

7. Classification by weight 4 Normal birth weight: 2500g to less than 4000g Large baby: birthweight > 4000g Low birth weight: less than 2500g Very low birth weight: less than 1500g Extremely low birth weight: less than 1000g

8. Classification by gestation Early pregnancy ultrasound scan Last menstrual period (LMP) Use of gestational age assessment charts ** several challenges with use of 1 st two methods in the low income settings

9. Gestational age (GA) assessment charts Neonates assessed using neurological and physical criteria Each criteria can give a GA assessment but more accurate when combined Neurologic signs more reliable but affected by birth trauma, birth asphyxia, congenital abnormalities, illness. 5

10. Gestational age (GA) assessment charts Physical features relatively constant but rapidly affected by postnatal environment and post natal age. 5 A good method of assessment is to be quick and easy to use, applicable to all ethnic groups and can be used in sick neonates.

11. Gestational age assessment charts Farr et al (1968) 6 Tuncer et al (1981) 7 Eregie (1991) 8 Capurro et al (1978) 9 Kollee et al (1985) 10 Kimek et al (2000) 11 Allan et al (2009) 12 Narayanan et al (1982) 13 Robinson (1966) 14 Parkin et al (1976) 15 Amiel-Tison et al (1999) 16 Feresu et al (2002) 17 Finnstrom (1972) 18 Dubowitz et al (1970) 19 Ballard et al (1979) 20 Ballard et al (New Ballard score) (1991) 21

12. Gestational age assessment charts contd. Some like Farr 6 , Finnstrom 18 and Parkin 15 were based on external criteria only whilst some like Robinson 14 and Amiel-Tison 16 were based on neurological criteria only. Gestational ages estimated by Ballard scoring system and Dubowitz system contained both parameters and have been strongly correlated with the gestational ages computed from the date of mother’s last menstrual period 22 Dubowitz has far less variation with true gestation but too many parameters (21) whilst Modified Ballard score is more user friendly (12) and most widely used.

13. Ballard Score

14. Comparison between original and New Ballard Scores Original New Scores ranged from 5 to 50 (26 to 44 weeks) Scores ranged from -10 to 50 (20 – 44 weeks) Scores starts with 0 Score starts with -1 Inaccurate in extreme preterm More accurate Optimal age for assessment between 30 and 42 hours Optimal age for assessment between birth and 96 hours Eye examination not included Eye examination included

15. Dubowitz Score

16. Classification of Prematurity (gestational age) Extreme prematurity: Less than 28 weeks Severe prematurity: 28 – 31 weeks Moderate prematurity: 32 – 33 weeks Late preterm: 34 – 36 weeks

17. Classification by intrauterine growth Large for gestational age: weight > 90 th percentile for gestation age Appropriate for gestational age: weight between the 10 th and 90 th percentile for gestation Small for gestational age: weight < 10 th percentile for gestation

18. Teaser You are the resident oncall in SCBU when a neonate was admitted with unknown gestation. Use of the Dubowitz/Ballard score chart gave you the following physical maturity scores posture 1, square window 90 , arm recoil 140 -180 , popliteal angle 160 , scarf sign 1, heel to ear 1

19. Teaser The following neuromuscular maturity scores superficial peeling of the skin with some bald areas, plantar surface has faint red marks, breast had stippled areola, had slightly curved pinna with slow recoil, testes were descending with few rugae ). The baby’s weight on admission was 1.9kg How will appropriately classify this baby? Please give one differential diagnosis

20. Learning Objectives By now you should be able to: Classify neonates according to weight, gestation and intrauterine growth Attempt clinical assignment of gestational age to neonates in SCBU Identify factors that may affect categorization of patients

21. References World prematurity day ref WHO Global nutrition targets 2025: Low birthweight policy brief. World Health Organization (WHO); United Nations International Children’s Emergency Fund (UNICEF). Every Newborn: An Action Plan to End Preventable Deaths (ENAP). Geneva, Switzerland: World Health Organization; 2014 World Health organization(WHO); Centre for Disease Control (CDC). Classification of babies according to weight International Journal of Reproduction, Contraception, Obstetrics and Gynecology Singhal S et al. Int J Reprod Contracept Obstet Gynecol. 2017 Jul;6(7):3096-3102 Farr V. Estimation of gestational age by neurological assessment in first week of life. Arch Dis Child. 1968;43(229):353–357 Tunçer M, Yilgör E, Erdem G. A new, simple three-step method for determining gestational age. Turk J Pediatr . 1982;23(2):85–97 Eregie CO. Assessment of gestational age: modification of a simplified method. Dev Med Child Neurol. 1991;33(7):596–600 Capurro H, Konichezky S, Fonseca D, Caldeyro -Barcia R. A simplified method for diagnosis of gestational age in the newborn infant. J Pediatr . 1978;93(1):120–122

22. References contd. 9. Capurro H, Konichezky S, Fonseca D, Caldeyro -Barcia R. A simplified method for diagnosis of gestational age in the newborn infant. J Pediatr . 1978;93(1):120–122 10. Kollée LA, Leusink J, Peer PG. Assessment of gestational age: a simplified scoring system. J Perinat Med. 1985;13(3):135–138 11. Klimek R, Klimek M, Rzepecka-Weglarz B. A new score for postnatal clinical assessment of fetal maturity in newborn infants. Int J Gynaecol Obstet. 2000;71(2):101–105 29. Allan RC, Sayers S, Powers 12. Allan RC, Sayers S, Powers J, Singh G. The development and evaluation of a simple method of gestational age estimation. J Paediatr Child Health. 2009;45(1–2):15–19 13. Narayanan I, Dua K, Gujral VV, Mehta DK, Mathew M, Prabhakar AK. A simple method of assessment of gestational age in newborn infants. Pediatrics. 1982;69(1):27–32 14. Robinson RJ. Assessment of gestational age by neurological examination. Arch Dis Child. 1966;41(218):437–447 15. Parkin JM, Hey EN, Clowes JS. Rapid assessment of gestational age at birth. Arch Dis Child. 1976;51(4):259–263 16. Amiel-Tison C; Maillard , F; Lebrun, F; Breart , G; Papiernik E. Neurological and physical maturation in normal growth singletons from 37 to 41 weeks’ gestation. Early Human Development. 1999;54:145–156

23. 17. Feresu SA, Gillespie BW, Sowers MF, Johnson TR, Welch K, Harlow SD. Improving the assessment of gestational age in a Zimbabwean population. Int J Gynaecol Obstet. 2002;78(1):7–18 18. Finnström O. Studies on maturity in newborn infants. II. External characteristics. Acta Paediatr Scand. 1972;61(1):24–32 19. Dubowitz LM, Dubowitz V, Goldberg C. Clinical assessment of gestational age in the newborn infant. J Pediatr . 1970;77(1):1–10 20. Ballard JL, Novak KK, Driver M. A simplified score for assessment of fetal maturation of newly born infants. J Pediatr . 1979;95(5, pt 1):769–774 21. Ballard JL, Khoury JC, Wedig K, Wang L, Eilers-Walsman BL, Lipp R. New Ballard score, expanded to include extremely premature infants. J Pediatr . 1991;119(3):417–423 22. Lee AC, Panchal P, Folger L, et al. Diagnostic Accuracy of Neonatal Assessment for Gestational Age Determination: A Systematic Review. Pediatrics. 2017;140(4):e20171423 References contd.

24. THANKS FOR YOUR ATTENTION