Deviations in intrauterine growth patterns not only increase the risk of morbidity and mortality in the early newborn period, but may also have long-term implications for altered growth and development and for altered CNS function and learning disabilities in childhood.
This general plan of care is designed to facilitate optimal nursing management of the infant with deviations in intrauterine growth and is to be used in conjunction with the CPs: The Neonate at Two Hours to Two Days of Age, and The Preterm Infant, as appropriate. Growth deviations are classified as SGA, intrauterine growth retardation/restriction (IUGR), and LGA.
SGA/IUGR: Any newborn whose birth weight falls at or below the 10th percentile on classification charts, considering local factors (e.g., ethnicity, altitude).
LGA/Macrosomic: Any newborn whose birth weight is at or above the 90th percentile on classification charts, considering local population at any week in gestation (with special attention to determining appropriate gestational age), or who at birth weighs more than 4000 g (8 lb 13 oz).
NEONATAL ASSESSMENT DATA BASE
SGA Infant
Activity/Rest
Activity level may be excessive, with vigorous cry/hungry suck attributable to chronic intrauterine hypoxia.
MATERNAL FACTORS
Excessive/strenuous exercise program
Circulation
Maternal Factors
Resides at high altitude
Heart/lung disease; bleeding, severe anemia or sickle cell anemia; chronic hypertension or PIH
Elimination
Abdomen may appear scaphoid or concave.
Maternal Factors
Pyelonephritis, chronic renal disease
Food/Fluid
All body parts may be below expected size for gestational age but in proportion/symmetrical to each other (suggests a chronic or prolonged problem throughout gestation).
Disproportionate weight as compared to length and head circumference (appears long and thin with normal head circumference) suggests episodic vascular insufficiency in third trimester.
Sunken abdomen; absence of subcutaneous tissue.
Decreased muscle mass, especially in the cheeks, buttocks, and thighs.
May demonstrate metabolic instability associated with hypoglycemia/hypocalcemia.
Maternal Factors
Small stature
Malnutrition/poor nutritional intake (chronic or during third trimester); history of eating disorders
Advanced diabetes mellitus (class D or above); PKU
Neurosensory
Skull suture and fontanels appear widened; bulging of fontanels caused by inadequate bone growth may be evident.
Small head with protruding forehead, sunken nasal bridge, short upturned nose, thin upper lip, receding chin (indicative of fetal alcohol syndrome [FAS]).
Muscle tone may appear tight with flexion of upper and lower extremities, minor joint/limb abnormalities, and restricted movement (suggests FAS).
Wide-eyed appearance (associated with chronic hypoxia in utero).
Chromosomal syndromes.
Respiration
Signs of respiratory distress may be present (especially in presence of meconium aspiration syndrome [MAS], polycythemia, or infection).
Mucus may be green-tinged.
Maternal Factors
Heavy smoker
Safety
Dry, cracked, and peeling skin present, with loose skin fold; sparse scalp hair.
Meconium staining may be evident with greenish stains on fingernails and at base of umbilical cord.
Umbilical cord may have single artery and/or be thin, slightly yellow, dull, dry.
Congenital anomalies/malformations or infection may be present.
Maternal Factors
Irradiation and use of medications with teratogenic side effects (e.g., antimetabolites, anticonvulsants, trimethadione)
Collagen disease; maternal infections such as rubella, syphilis, cytomegalovirus, toxoplasmosis; uterine tumors
Sexuality
Females tend to be smaller than males at birth.
Maternal Factors
Adolescent or advanced maternal age (younger than age 16 or older than age 40)
Primiparity, grand multiparity
Placenta previa/separation, insufficiency, infarction, fibrosis, thrombosis, hemangioma, abnormal cord insertion and single umbilical artery with vascular anastomoses (twin-to-twin)
Chromosomal abnormalities, chronic intrauterine infections, congenital anomalies, multifetal pregnancy, inborn errors of metabolism
Social Interaction
Maternal Factors
Low socioeconomic class
Other child(ren) at home with history of FTT
May have previous or current involvement with Department of Social Services
Teaching/Learning
May be premature (and/or member of multifetus pregnancy)
Maternal Factors
Poor/incomplete formal education
Alcoholism, drug abuse
Lack of prenatal care
LGA Infant
Activity
Difficulty maintaining quiet, alert state; slower to arouse
Circulation
Skin color ruddy (associated with polycythemia), jaundice (indicative of hyperbilirubinemia)
May have congenital anomalies such as transposition of the great vessels, Beckwith-Wiedemann syndrome, or erythroblastosis fetalis
Food/Fluid
Macrosomia; excess fat deposits and reddened complexion; increased body size proportional (except in infant of diabetic mother [IDM], whose weight may appear disproportionately large for length)
May demonstrate metabolic instability associated with hypoglycemia/hypocalcemia, may have feeding problems
Weight may be 4000 g (8 lb 13 oz) or more (dependent on gestational age)
Maternal Factors
Inappropriate/overnutrition, excessive pregravid weight and/or weight gain >35 lb
Large stature
Diabetes mellitus (class A, B, or C)
Neurosensory
Large amount of scalp hair
May display hypotonia/hypertonia; decreased reflex functioning
Respiration
Signs of respiratory distress may be present if stress of delivery has induced meconium aspiration/asphyxiation, if delivered by cesarean section, or if infection present.
Safety
Birth injury(s) may be present, e.g., bruising, caput succedaneum, cephalhematomas; facial/phrenic nerve paralysis, brachial palsy; fractured clavicles, intracranial bleeding/depressed skull fracture(s); bulging fontanel indicative of neurological problems, depressed fontanel suggestive of dehydration.
Intrapartal/delivery events may reveal fetal distress, meconium-stained amniotic fluid, oligohydramnios, late/variable decelerations, scalp pH levels7.20, resuscitative measures.
Evidence of congenital malformations may involve the heart, CNS, kidney, lungs, GI tract.
Long, hard nails extending beyond ends of toes and fingers.
Absence of vernix caseosa/lanugo; desquamation or epidermis.
Sexuality
Higher incidence in males
Maternal Factors
Birth of previous LGA infant
Cesarean birth because of cephalopelvic disproportion or oxytocin-induced labor related to diabetes/fetal distress/prolonged pregnancy
Multiparity
Social Interactions
Slow to orient to maternal face/voice (generally improves within 48 hr)
Teaching/Learning
May be preterm/postterm by clinical assessment
May be postterm (42 wk or more) because of postconceptional bleeding, leading to a miscalculation of dates/prolonged pregnancy associated with menstrual cycle longer than 28 days.
This general plan of care is designed to facilitate optimal nursing management of the infant with deviations in intrauterine growth and is to be used in conjunction with the CPs: The Neonate at Two Hours to Two Days of Age, and The Preterm Infant, as appropriate. Growth deviations are classified as SGA, intrauterine growth retardation/restriction (IUGR), and LGA.
SGA/IUGR: Any newborn whose birth weight falls at or below the 10th percentile on classification charts, considering local factors (e.g., ethnicity, altitude).
LGA/Macrosomic: Any newborn whose birth weight is at or above the 90th percentile on classification charts, considering local population at any week in gestation (with special attention to determining appropriate gestational age), or who at birth weighs more than 4000 g (8 lb 13 oz).
NEONATAL ASSESSMENT DATA BASE
SGA Infant
Activity/Rest
Activity level may be excessive, with vigorous cry/hungry suck attributable to chronic intrauterine hypoxia.
MATERNAL FACTORS
Excessive/strenuous exercise program
Circulation
Maternal Factors
Resides at high altitude
Heart/lung disease; bleeding, severe anemia or sickle cell anemia; chronic hypertension or PIH
Elimination
Abdomen may appear scaphoid or concave.
Maternal Factors
Pyelonephritis, chronic renal disease
Food/Fluid
All body parts may be below expected size for gestational age but in proportion/symmetrical to each other (suggests a chronic or prolonged problem throughout gestation).
Disproportionate weight as compared to length and head circumference (appears long and thin with normal head circumference) suggests episodic vascular insufficiency in third trimester.
Sunken abdomen; absence of subcutaneous tissue.
Decreased muscle mass, especially in the cheeks, buttocks, and thighs.
May demonstrate metabolic instability associated with hypoglycemia/hypocalcemia.
Maternal Factors
Small stature
Malnutrition/poor nutritional intake (chronic or during third trimester); history of eating disorders
Advanced diabetes mellitus (class D or above); PKU
Neurosensory
Skull suture and fontanels appear widened; bulging of fontanels caused by inadequate bone growth may be evident.
Small head with protruding forehead, sunken nasal bridge, short upturned nose, thin upper lip, receding chin (indicative of fetal alcohol syndrome [FAS]).
Muscle tone may appear tight with flexion of upper and lower extremities, minor joint/limb abnormalities, and restricted movement (suggests FAS).
Wide-eyed appearance (associated with chronic hypoxia in utero).
Chromosomal syndromes.
Respiration
Signs of respiratory distress may be present (especially in presence of meconium aspiration syndrome [MAS], polycythemia, or infection).
Mucus may be green-tinged.
Maternal Factors
Heavy smoker
Safety
Dry, cracked, and peeling skin present, with loose skin fold; sparse scalp hair.
Meconium staining may be evident with greenish stains on fingernails and at base of umbilical cord.
Umbilical cord may have single artery and/or be thin, slightly yellow, dull, dry.
Congenital anomalies/malformations or infection may be present.
Maternal Factors
Irradiation and use of medications with teratogenic side effects (e.g., antimetabolites, anticonvulsants, trimethadione)
Collagen disease; maternal infections such as rubella, syphilis, cytomegalovirus, toxoplasmosis; uterine tumors
Sexuality
Females tend to be smaller than males at birth.
Maternal Factors
Adolescent or advanced maternal age (younger than age 16 or older than age 40)
Primiparity, grand multiparity
Placenta previa/separation, insufficiency, infarction, fibrosis, thrombosis, hemangioma, abnormal cord insertion and single umbilical artery with vascular anastomoses (twin-to-twin)
Chromosomal abnormalities, chronic intrauterine infections, congenital anomalies, multifetal pregnancy, inborn errors of metabolism
Social Interaction
Maternal Factors
Low socioeconomic class
Other child(ren) at home with history of FTT
May have previous or current involvement with Department of Social Services
Teaching/Learning
May be premature (and/or member of multifetus pregnancy)
Maternal Factors
Poor/incomplete formal education
Alcoholism, drug abuse
Lack of prenatal care
LGA Infant
Activity
Difficulty maintaining quiet, alert state; slower to arouse
Circulation
Skin color ruddy (associated with polycythemia), jaundice (indicative of hyperbilirubinemia)
May have congenital anomalies such as transposition of the great vessels, Beckwith-Wiedemann syndrome, or erythroblastosis fetalis
Food/Fluid
Macrosomia; excess fat deposits and reddened complexion; increased body size proportional (except in infant of diabetic mother [IDM], whose weight may appear disproportionately large for length)
May demonstrate metabolic instability associated with hypoglycemia/hypocalcemia, may have feeding problems
Weight may be 4000 g (8 lb 13 oz) or more (dependent on gestational age)
Maternal Factors
Inappropriate/overnutrition, excessive pregravid weight and/or weight gain >35 lb
Large stature
Diabetes mellitus (class A, B, or C)
Neurosensory
Large amount of scalp hair
May display hypotonia/hypertonia; decreased reflex functioning
Respiration
Signs of respiratory distress may be present if stress of delivery has induced meconium aspiration/asphyxiation, if delivered by cesarean section, or if infection present.
Safety
Birth injury(s) may be present, e.g., bruising, caput succedaneum, cephalhematomas; facial/phrenic nerve paralysis, brachial palsy; fractured clavicles, intracranial bleeding/depressed skull fracture(s); bulging fontanel indicative of neurological problems, depressed fontanel suggestive of dehydration.
Intrapartal/delivery events may reveal fetal distress, meconium-stained amniotic fluid, oligohydramnios, late/variable decelerations, scalp pH levels7.20, resuscitative measures.
Evidence of congenital malformations may involve the heart, CNS, kidney, lungs, GI tract.
Long, hard nails extending beyond ends of toes and fingers.
Absence of vernix caseosa/lanugo; desquamation or epidermis.
Sexuality
Higher incidence in males
Maternal Factors
Birth of previous LGA infant
Cesarean birth because of cephalopelvic disproportion or oxytocin-induced labor related to diabetes/fetal distress/prolonged pregnancy
Multiparity
Social Interactions
Slow to orient to maternal face/voice (generally improves within 48 hr)
Teaching/Learning
May be preterm/postterm by clinical assessment
May be postterm (42 wk or more) because of postconceptional bleeding, leading to a miscalculation of dates/prolonged pregnancy associated with menstrual cycle longer than 28 days.
DIAGNOSTIC STUDIES
Dextrostix Glucose Estimations: Less than 40 mg/dl in LGA infant or 25 mg/dl in SGA infant during first 3 days indicates hypoglycemia.
Serum Glucose: Verifies Dextrostix value <40>
NURSING PRIORITIES
1. Maintain physiological homeostasis.
2. Prevent and/or treat complications.
3. Identify/minimize effects of birth trauma.
4. Provide family with appropriate information/strategies for meeting short- and long-term needs associated with growth deviation.
2. Prevent and/or treat complications.
3. Identify/minimize effects of birth trauma.
4. Provide family with appropriate information/strategies for meeting short- and long-term needs associated with growth deviation.
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