Nursing management of Preterm, Term, Post-term and IUGR Baby.pptx

Pediatrics, MSC NURSING NURSING MANAGEMENT OF PRE TERM,TERM,POST-TERM AND IUGR BABY
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2. Nursing management of preterm, term, post term and IUGR baby UNIT - x Presented by:- SWARAJ SUMAN MSC.1 ST YEAR STUDENT AIIMS BBSR

3. introduction A newborn regardless of gestational age or birth weight , who has a greater than average chance of morbidity because of conditions or circumstances superimposed on the normal course of events associated with birth and the adjustment to extra uterine existence. About 10-20% of all births require special or neonatal intensive care. Normal infants are at low risk of developing problems in the newborn period and , therefore require primary care only.

4. CLASSIFICATION OF HIGH RISK INFANTS Classification according to size LBW - Birth weight < 2.5kg (2500g) VLBW - Birth weight < 1.5 kg (1500g) ELBW - Birth weight < 1 kg (1000g) SGA AGA LGA IUGR – Found in infants whose intrauterine growth is restricted ( also used as a term for SGA infants.) Source – Wong’s essential’s of Paediatric nursing (first south Asia edition) page no - 203

5. Classification according to gestational age Preterm/premature infant – Born before completion of 37 weeks of gestation. Full-term infant - Born between 37 weeks and completion of 41 weeks of gestation. Post-term/postmature infant - Born after 42 weeks of gestational age.

6. Premature Baby • A baby born before 37 weeks of gestation calculating from the first day of last menstrual period is defined as preterm baby/ premature baby. • These babies are known as preemies . Age of Viability - Most neonatologist define the age of viability as being about 24 weeks of gestation .

7. S tages of prematurity and post maturity, World Health Organization's (2016) Neonatal classifications ( based on Maturity at birth). Definition of maturity at birth Completed weeks of gestation Extremely preterm < 28 Very preterm 28 – <32 Moderate to late preterm 32 – <37 Term 37 – 41 Post-term ≥42 weeks

8. A  late preterm  infant, also known as a  near-term   infant, is also considered a high-risk newborn regardless of birth weight. https://edition.cnn.com/2017/11/08/health/premature-baby-21-weeks-survivor-profile/index.html

9. incidence In 2020 an estimated 5 million children under the age of 5 years died, mostly from preventable and treatable causes. Approximately half of those deaths, 2.4 million , occurred among newborns (in the first 28 days of life). The leading causes of death in children under 5 years are :- C omplication of prematurity B irth asphyxia/trauma P neumonia D iarrhea A ll of which can be prevented or treated with access to affordable interventions in health and sanitation.

10. Contd….

11. Access to basic life-saving interventions such as skilled delivery at birth, postnatal care, breastfeeding and adequate nutrition, vaccinations and treatment for common childhood diseases can save many young lives. Malnourished children, particularly those with (SAM) severe acute malnutrition , have a higher risk of death from common childhood illness such as diarrhea, pneumonia and malaria. Nutrition-related factors contribute to about 45% of deaths in children under 5 years of age. Contd….

12. Why do premature newborns need special care? • A premature newborn is not fully ready to deal with our world. • Their little bodies still have areas that need to mature and fully develop.

13.   Causes Maternal factor Pre eclampsia Heart or kidney disease Infection (such as TORCH, group B streptococcus, urinary tract infections, vaginal infections, infections of the fetal/placental tissues) Abnormal structure of the uterus Cervical incompetence (inability of the cervix to stay closed during pregnancy) Previous preterm birth

14.   Fetal factor Multiple pregnancy IUGR Congenital malformation Rh incompatibility Fetal distress Non immune hydrops Contd….

15. Characteristic • Posture – Hypotonic, Partially flexed (frog like posture) – A ssume extended posture due to poor muscle tone • Skin : – Thin, gelatinous, shiny and excessive pink with abundant lanugo . V ery little vernix edema may be present. B reast nodules are small or absent (<5mm). Subcutaneous fat is deficient. D eep sole creases are often not present in preterm baby.

16.  • Face and head : S mall and head is large as per body. • Sutures are widely separated and fontanels are large. • Protruding eye due to shallow orbit and absent of buccal pads of fat. • Ear cartilage - P oor recoil • Hair appears wooly and fuzzy.

17. • Planter creases - V ery few in number • Nails - Bright pink colored nail beds and very soft nails • Activity - L ess activity of limbs • Sucking - P oor sucking ability • Cry : Weak cry • Breast : No breast tissue palpable

18. Systemic characteristics • Central Nervous system – Poor reflexes Reflexes - M oro, sucking, swallowing and other reflexes are absent or sluggish. Uncoordinated sucking swallowing leads to feeding difficulties. Vulnerable to develop intra ventricular/peri ventricular hemorrhage.

19.   Respiratory system Period of apnea usually < 20 seconds Poor cough reflex leads to increase risk of infection. Deficiency of surfactant leads to respiratory distress syndrome

20. Silverman Anderson score

21. • Gastro intestinal system Functional immaturity of liver cause hyperbilirubinemia, hypoglycaemia and poor detoxification of drug Tendency to regurgitate to an incompetent cardio- oesophageal sphincter and small capacity of the stomach. • Prone to complications like n ecrotizing enterocolitis (NEC).

22. Temperature regulation Loose more heat due to large area so cause hypothermia Subcutaneous fat is less, less brown fat . Inadequate thermal response.

23.  • Cardio- vascular system Delayed closure of ductus arteriosus Inadequate peripheral circulation Intra cranial haemorrhage due to poor auto regulation of cerebral blood flow •

24. Renal immaturity Glomerulus filtration rate ( GFR) and urine concentration are reduced • Metabolic distribution - Hypoglycemia , Hypocalcemia , Hypoproteinemia , Hypoxic

25. • Nutritional deficiency - Prone to develop anemia at 6-8 weeks because of low iron storage. • Susceptibility of infection - 3 to 10 times more vulnerable to infection than term babies. - Low level of IgG antibody.

26. • Genitalia I n male Testes are undescended Scortum poorly pigmented. • I n female L abia majora are widely separated exposing labia minora and clitoris

27. Management I mmediate management following birth A ir passage should be cleared of mucus promptly and gently using a mucus sucker. Adequate oxygenation through mask or nasal catheter if baby is not maintaining oxygen saturation. The baby should be wrapped, including head in a sterile warm towel (Normal temperature 36.5- 37.5°C). Hypothermia and its sequelae: Hypoxia →→Hypoglycemia → Anaerobic metabolism → Metabolic acidosis. Aqueous solution of vitamin K 1 mg is to be injected intramuscularly to prevent hemorrhagic manifestations. Term – 1mg Preterm – 0.5 mg Baby Weight < 1000 g – 0.5mg

28. Contd.…. • Maintain body temperature Keep the baby under neonatal warmer with temperature and humidity maintained • Positioning Change the baby’s position 2 hourly from prone position. I t relives abdominal discomfort by passage of flatus and prevent aspiration. Nesting :- R eferred to as 'developmentally supportive positioning'.

29. NESTING

30.   • Kangaroo mother care – Encourage KMC and exclusive breastfeeding Birth weight

31. • Oxygen therapy – It should be administered only when indicated – O2 should administer, when O2 saturation falls below 85%.

32. Feeding and nutrition Birth weight Preferred method of feeding < 1250 g Baby may need I/V fluids initially , then initiate orogastric feeding gradually. 1250- 1500 g Baby need spoon/ paladai while some need orogastric feeding 1500- 2000 g Most baby would accept breastfeeding while some might need paladai feeding. > 2000 g Breastfeed in normal birth weight baby , but with monitoring.

33. Weeks of gestation Preferred method of feeding < 28 weeks IV fluids 28- 31 weeks Naso/ orogastric feed 32 – 34 weeks Paladai / KSF > 34 weeks Breastfeeding

34.  • Nutritional supplement – When the baby is stable and tolerate eternal feeding, EBM fortified milk, multivitamin and zinc can be given. – Iron supplementation as iron syrup or drop (2-3mg/kg/day elemental iron) till 6-8 weeks to 1 year of age. _ After 40 weeks , only vitamin D and iron - Vitamin D – Orally as drop /syrup Preterm- 800 IU Term – 400 IU Vitamin E- 50 IU/kg , oral Vitamin K – 1mg(Term) , 0.5 mg (Preterm) IM

35. • Gentle rhythmic stimulation – Gentle tactile stimuli by the mother. – Soothing auditory stimuli as family voice, music. – Eye to eye contact, colored object provide visual inputs. • Prevention of nosocomial infection • Strict hand washing before and after touching the baby. • Maintain aseptic technique during procedures.

36. •Phototherapy S pecial type of light (not sunlight). U sed  to treat newborn jaundice by making it easier for your baby's liver to break down and remove the bilirubin from your baby's blood . To prevent need for exchange transfusion usually premature baby may develops hyperbilirubinemia.

37. Nursing Care The infant is placed under a radiant warmer or in an incubator to maintain a warm environment. The temperature of the incubator is adjusted so that the infant’s body temperature is at an optimal level (36.2° to 37° C [97.1° to 98.6° F]).

38. Hypoglycemia and Hypocalcemia Hypoglycemia  ( hypo,  “less than,” and  glycemia,  “sugar in the blood”) is common among preterm infants. Plasma glucose levels lower than 40 mg/dL indicate hypoglycemia in a term infant, and in a preterm infant, lower than 30 mg/dL. The brain needs a steady supply of glucose, and hypoglycemia must be anticipated and treated promptly. Preterm infants may be too weak to suck and swallow formula and often require gavage or parenteral feedings to supply their 120- to 150-kcal/kg/day needs. Hypocalcemia   It is also seen in preterm and sick newborns. Calcium is transported across the placenta throughout pregnancy, but in greater amounts during the third trimester. Early birth can result in infants with lower serum calcium levels. Hypocalcemia is treated by administering intravenous calcium gluconate. Adding calcium lactate powder to the formula.

39. Possible Complications • Anemia Possible long-time complications • Bronchopulmonary dysplasia (BPD) • Mental or physical disability • Neonatal sepsis • Retinopathy of prematurity, • Risk of Disabilities • Low blood sugar (hypoglycemia) • Neonatal respiratory distress syndrome • pulmonary haemorrhage • Kernicterus • Patent ductus arteriosus • Severe intestinal inflammation(necrotizing enterocolitis)

40. Developmentally supportive care Developmentally supportive care reduces stress and promotes growth in the preterm neonate. Stimulation of the early developing senses tactile, olfactory-gustatory and protecting the later developing senses auditory and visual is the core principle of developmentally supportive care.

41. Definition : Developmentally supportive care is defined as care of an infant to support positive growth and development, while allowing stabilization of physiologic and behavioral functioning (National Association of Neonatal Nurses, 2000)

42. Dev Supp Care - Principles • NICU design and environment • Nursing care routines & plans • Use of positioning aids • Use of self regulation aids • Feeding methods • Management of pain • Parental participation & support • Neonatologist’ attitude

43. NICU Environment – Sound Interventions to reduce noise . •Move equipment's quietly, repair noisy ones •Decrease staff generated noises •Prepare medications & feedings away from bedside •Gently open doors and drawers •Follow the sound limit recommendations NICU Environment -Sound • Monitor decibel readings & keep level < 45 dB (AAP, 1997)

44. Positioning Guidelines Preferred, Prone / side lying • Swaddle / cover to keep in flexed position • Attempt to “nest” the infant • Promote midline alignment • Head support • Avoid : Hyperextension of neck - Frequent head turning to side - Lower extremity frogging

45. NICU Interventions - Stimulation • Should begin in the womb. • Fetuses known to respond to mother’s heart beats and voice. •Any stimulation through special senses during fetal / neonatal life beneficial.

46. NICU Interventions Supplemental stimulation • Kangaroo Mother Care ( KMC ) • Non-nutritive sucking ( NNS ) • Massage therapy • Multimodal stimulation • Breast feeding • Pain management

47. NICU Interventions Massage Therapy •Tactile / Kinesthetic stimulation •Massage therapy with moderate pressure may be useful. •Stimulation of tactile and pressure receptors important. •Hypothetical mechanisms of benefit Touch - Increased vagal tone - Increased insulin levels - Increased growth hormone secretion

48. NICU Interventions Massage Therapy Proposed benefits Better weight gain • More time in active, alert state • More quiet sleep • Better motor maturity scores • Better long-term outcome

49. NICU Interventions - Multimodal Stimulation ATVV - Auditory, tactile, visual & vestibular • Soft & soothing music • Gentle touch • Use of pictures (human face), bright toys • Olfactory stimulation, use of “breast milk” (avoid cologne / spray). • Better weight gain and early discharge Mother’ voice & human face

50. NICU Interventions Pain Management Non-pharmacologic Interventions • Positioning & containment • Swaddling • Non-nutritive sucking / pacifiers • Skin to skin contact • Rocking • Music • Breast milk • Oral glucose / sucrose . Pharmacologic interventions • Local anaesthetics (EMLA) • Regional anaesthesia • Systemic analgesia (Gilbert R, 2001)

51. Journal for lbw

52. Knowledge and Practice of Nursing Students on Management of Preterm Babies   Geetarani Nayak Asst. Professor, SUM Nursing College, Siksha ‘O’ Anusandhan University, sector -8, Kalinga nagar , Ghatikia , Bhubaneswar, -751030 *Corresponding Author’s Email: [email protected]   ABSTRACT: Premature babies are vulnerable to various physiological handicapped conditions with high mortality rate due to their anatomical and functional immaturity.  Mortality of preterm low birth weight baby is inversely related to gestation and birth weight and directly to the severity of complication which can be prevented by proper management and care. Design- Pre experimental one group pre test and post test design with evaluative approach was undertaken to assess the effectiveness of information booklet on management of preterm babies among the G.N.M. students of selected School of Nursing, Odisha. Data were collected from 50 G.N.M .third year students   selected by purposive sampling through structured questionnaire and observational checklist. Data were analyzed by descriptive and inferential statistics. Result : The overall mean post test knowledge score 14.78 was higher than the mean pre-test knowledge score 10.78 and the mean post test practice score 10.56 was higher than mean pre-test practice score 7.8. The pre and post-test practice (t=12.6>2.01 at P=0.001) showed that the post test score was significantly increased and the information booklet regarding management of preterm babies was very effective among third year G.N.M. students. The result proved that information booklet on management of preterm babies prepared by the investigator has helped the third year G.N.M. students to improve their knowledge and practice on management of preterm babies.

53. Standardized Slow Enteral Feeding Protocol and the Incidence of Necrotizing Enterocolitis in Extremely Low Birth Weight Infants Author - Kera McNelis   2 ,  Dennis Super   3 ,  Douglas Einstadter   4 ,  PMID:  25316681  ,2022 Background:  Compared with early enteral feeds, the delayed introduction and slow advancement of enteral feedings to reduce the incidence of necrotizing enterocolitis (NEC) are not well studied in extremely low birth weight (ELBW) infants. Objective:  To study the effects of a standardized slow enteral feeding (SSEF) protocol in ELBW infants. Methods:  ELBW infants who followed an SSEF protocol (September 2009 to December 2012) were compared with a similar group of historical controls (January 2003 to July 2009). Short-term outcomes between the 2 groups were compared by propensity score (PS) analysis. Results:  One hundred twenty-five infants in the SSEF group were compared with 294 historical controls. Compared with the controls, feeding initiation day, full enteral feeding day, parenteral nutrition (PN) days, and total central line days were longer in the SSEF group. There was no significant difference in overall NEC (5.6% vs 11.2%, respectively; P = .10) or surgical NEC (1.6% vs 4.8%, respectively; P = .17) between the SSEF group and controls. However, in infants with birth weight <750 g, NEC (2.1% vs 16.2%, respectively; P < .01) or combined NEC/death (12.8% vs 29.5%, respectively; P = .03) was significantly less in the SSEF group compared with controls. In infants who survived to discharge, there was no significant difference in the discharge weight or length of stay in PS-adjusted analysis. Conclusions:  An SSEF protocol significantly reduces the incidence of NEC and combined NEC/death in infants with birth weight <750 g. Despite taking longer to achieve full enteral feeding on this protocol, surviving ELBW infants demonstrated comparable weight gain at discharge without prolonging their hospital stay.

54. Term baby A newborn born between 37 weeks and 42 weeks  (259-293 days) of gestation was considered "term." The average baby weighs at term around 2.5 -4 kg .

55. Characteristics of term baby Scalp hair – S/S/S- Smooth, Silky ,Shiny Breast nodule- >5mm Genitals Lanugo Plantar creases

56. Characteristics of term baby

57. management T R A I N

58. Nutritional needs of the term newborn Calories: 120 kg/calories/day Proteins: 2.5 to 3.5 gm/day Fat: 30 gm/day Iron 0.27 mg/day Calcium: 200 mg/day Vitamin D: 400 1.U Vitamin- C: 50 I.U Fluids 120 ml/kg/day

59. Post term • Baby who Born after 42 weeks of gestational age is termed as post-term baby. • Average incidence is about 3-12% (10%) • Many suspected post-term pregnancies/post term birth are actually wrongly dated.

60. INCIDENCE The generally quoted incidence of Post term birth is 10%. Incidence is decreasing because of better estimation of duration of gestation and timely induction of labor. The cause of prolonged pregnancy is unknown. Factors associated with post maturity include anencephaly and trisomy 16 to 18.

61. Etiology • Wrong dates - inaccurate LMP (most common) • Biological variability (hereditary/familial) Family history - Race (White>black) • Maternal factors:- - Primiparity - Previous prolonged pregnancy - Sedentary habit and obesity - Elderly multipara

62. • Fetal factors:- - Congenital anomalies: Anencephaly - Congenital adrenal hyperplasia • Placental factors: - Sulphatase deficiency → low estrogen level

63. Assessment Findings of post-term baby Clinical manifestations include: Dry loose peeling skin , thin new-born with wasted appearance, parchment-like skin. M econium-stained skin, nails, and umbilical cord. Overgrown f ingernails are long and lanugo is absent. Large amount of hair on the head . - More alert and wide-eyed. Meconium aspiration syndrome is manifested by fetal hypoxia, meconium staining of amniotic fluid, R espiratory distress may develop at delivery.

64. Nursing Management 1. Manage meconium aspiration syndrome. Suction the infant’s mouth and nares while the head is on the perineum and before the first breath is taken to prevent aspiration of meconium that is in the airway. Once the infant is dry and on the warmer, intubate (if needed). Perform chest physiotherapy with suctioning to remove excess meconium and secretions. Provide supplemental oxygen and respiratory support as needed.

65. 2.  Obtain serial blood glucose measurements. 3. Provide early feeding to prevent hypoglycemia, if not contraindicated by respiratory status. 4.   Maintain skin integrity. Keep the skin clean and dry. Avoid the use of powders, creams, and lotions. Contd…

66. Complications to the post term baby • Big baby (macrosomia) • Placental insufficiency, which might cause:- - Oligohydramnios (decreased amniotic fluid), which might lead to IUGR - I ncreased risk of cord compression -poor oxygen supply • Meconium aspiration syndrome • Hypoglycemia

67. Story A mother is at 38 weeks of gestation asked - Doctor – what is the expected weight of her baby ???? Doctor- 2.5 -4 kg After 5 days mother undergoes – NVD – Baby weight (1400g)

68. IUGR Fetal growth restriction (FGR) is said to be present in those babies whose birth weight is below the 10 th centile of the average for the gestational age. It can occur in preterm, term or post term babies. Intrauterine growth restriction – it is a clinical definition and SGA (Small for date) is a statistical definition.

69. TYPES Symmetrical Asymmetrical Early onset (Insult of fetal growth occurs from first trimester of pregnancy) Late onset (Insult of fetal growth from 2nd trimester of pregnancy) The size of head ,body weight, and length are equally reduced. Head larger than abdomen Ponderal index < 2 Ponderal index > 2 Etiology- - Genetic , Chromosomal defect TORCH( Most commonly rubella will affect fetus) Etiology- - Chronic placental insufficiency Mother with eclampsia, preeclampsia Poor maternal diet (Anemia) Newborn will have more complication(brain and heart involved) - Poor prognosis Usually less complication ( brain not affected) – Good prognosis

70. PONDERAL INDEX Ponderal index= Weight(g) 100 Height(cm)3 Normal ponderal index (AGA) = > 2.5

71. questions What is ponderal index of a neonate with weight 2 kg , height 50 cm. Weight (g) - 2kg = 2000g Height 3 = 50 X 50 X 50 =125,000 Ponderal index= Weight(g) X 100 Height(cm)3 Ans- 1.6 (Symmetrical IUGR)

72. Clinical features of iugr baby All SGA babies are IUGR but all IUGR babies are not SGA. Loose skin folds in buttock region Decrease subcutaneous fat Peeling of skin Small abdomen Thin umbilical cord Old man like appearance

73. IUGR v/s prematurity IUGR Prematurity Hypoxia Hypocalcemia Hypoglycemia Complications- MAS –(Meconium aspiration syndrome ) Complications- HMD Apnea of prematurity( Less surfactant)

74. Why IUGR baby leads to jaundice ? IUGR- (Less hemoglobin ) Hypoxia- so more RBC production Polycythemia More RBC will break means more jaundice More hemolysis take place.

75. Diagnosis of IUGR Clinically- Serial measurement of fundal height and abdominal girth. Fetal biometry: 1. BPD(Biparietal Diameter) - When growth rate of BPD is below 5th percentile, 82% of births are below 10th percentile 2. Abdominal circumference AC and fetal weight are most accurate ultrasound parameters for diagnosis of IUGR. AC < 5mm/week reduction is suggestive of IUGR 3. Measurement ratios - HC/AC: Persistence of a head to abdomen ratio <1 late in gestation is predictive of asymmetric IUGR. 4. Femur length : serial measurements of femur length are effective for detecting symmetric IUGR.

76. Contd…. 5. Amniotic fluid index(AFI)- between 8 and 25 is normal. Sonographic evaluation- 6. Doppler Ultrasonography - Doppler flow studies are important adjuncts to fetal biometry in identifying the IUGR fetuses at risk of adverse outcome. 7. Uterine artery flow abnormalities : predict IUGR as early as 12-14 weeks of gestation 8. Umbilical Artery doppler :- In IUGR there is increased umbilical artery resistance

77. management Antenatal Care in IUGR - Once IUGR is diagnosed, various treatments such as :- B ed rest Increased or supplemental food intake to increase the baby’s weight Treatment of any medical condition (If recommended). W omen who are severely malnourished, better food may make some difference in the growth of the baby. The mother of an IUGR baby should stop habits such as smoking, drinking and taking drugs. Good food, rest and regular prenatal care may help to some extent to control some factors contributing to IUGR. Of course, this will also help to ensure the baby is born in a good environment where people are prepared to take care of a high-risk newborn.

78. Management of the Delivery Process During the birth process, it is important to choose the type of delivery so that the baby does not suffer from birth asphyxia, or lack of oxygen during birth.

79. When is delivery right? If all the antenatal tests show that the baby is doing reasonably well and is still growing, the pregnancy is allowed to continue until term. Administer glucocorticoid injections in the period between 24 and 34 weeks so that the baby’s lungs can mature. If the tests become abnormal - fetal growth stops and the baby is very preterm – Then decision is taken after explaining all R isks associated with delivering a preterm baby R isks of having a stillborn or severely asphyxiated (suffocated) baby if the pregnancy is allowed to continue. A test involving the use of oxytocin, a drug which induces contractions of the uterus, combined NST is done - To see if the baby can tolerate this type of stress.

80. The Right Place of Delivery The delivery should take place only in a center equipped to handle such babies and to offer emergency C-sections if required. Management After Birth Complete physical examination of the baby is important to try and identify the type of IUGR – birth weight, the head circumference, the mid-arm circumference, the abdominal circumference and the length . In addition, the baby should be tested for hypoglycemia (low blood sugar). B lood test to detect infections and high red cell count (polycythemia). Administer intravenous fluids to maintain fluid balance in baby. They should be given a higher caloric intake as they grow to help them achieve catch-up growth. (100 kilocalories or more per kg per day). Regular assessments will help determine what areas of mental and physical development require special help.

81. Care during vaginal delivery • Equipped institution where intensive intranatal monitoring (clinical and electronic) is possible and having facilities for NICU. • Caesarean section - when risks of vaginal delivery is difficult. (Fetal acidemia, absent or reversed diastolic flow in umbilical artery or unfavorable cervix) • Ensure adequate fetal oxygenation by giving oxygen to mother by mask. • Epidural analgesia is of choice • Episiotomy may be done to minimize head compression. • Cord is to be clamped immediately at birth. P rovide newborn care as like preterm baby.  

82. Prognosis In most cases, infants with IUGR ultimately have good outcomes, with a reported  mortality rate of only 0.2 to 1 percent . These infants often exhibit fast catch-up growth in the first three months of life and attain normal growth curves by one year of age.

83. Journal review Intrauterine Growth Restriction: Antenatal and Postnatal Aspects Deepak Sharma , Sweta Shastri , and  Pradeep Sharma Published by:- PUBMED, 2016 Abstract Intrauterine growth restriction (IUGR), a condition that occurs due to various reasons, is an important cause of fetal and neonatal morbidity and mortality. It has been defined as a rate of fetal growth that is less than normal in light of the growth potential of that specific infant. Usually, IUGR and small for gestational age (SGA) are used interchangeably in literature, even though there exist minute differences between them. SGA has been defined as having birth weight less than two standard deviations below the mean or less than the 10th percentile of a population-specific birth weight for specific gestational age. These infants have many acute neonatal problems that include perinatal asphyxia, hypothermia, hypoglycemia, and polycythemia. The likely long-term complications that are prone to develop when IUGR infants grow up includes growth retardation, major and subtle neurodevelopmental handicaps, and developmental origin of health and disease. In this review, we have covered various antenatal and postnatal aspects of IUGR.

84. Bibliography Books Jane ball, ruth bindler , principles of pediatric nursing , first Indian edition, 2013, wolters kluwer (India) publication, page no- 155-161 O.p ghai, essential pediatrics, 9 th edition, 2022, CBS publications pvt. Ltd , page no- 133-159 Terri kyle and susan carman , essentials of pediatrics nursing , 2 nd edition, Lippincott Williams publications, page no- 359-361 Marilyn j. Hockenberry, wong’s essential of pediatric nursing , first south Asia edition , 2016, Elsevier publication, page no- 203-218

85. Journals John Kingdom, Philip Baker, Intrauterine growth restriction, springer publisher, 2012 (1) , Page no- 56-60 Websites https://nursekey.com/13-preterm-and-postterm-newborns/ https://www.futurelearn.com/info/courses/neonatal-assessment/0/steps/51130 https://edition.cnn.com/2017/11/08/health/premature-baby-21-weeks-survivor-profile/index.html