HIGH RISK INFANT

DR. CH LIM JABATAN PEDIATRIK HRPZ

WHO ARE THEY?

Those infants who had high risk situation and condition which may had possibility developing problem after birth anticipate problem in those high risk infants
in utero during delivery after birth

High risk delivery

Preterm delivery intrauterine growth retardation maternal drug use fetal distress

history

Maternal
parents age and social backgrond obstetric history h/o current pregnancy medication h/o family h/o communication ability

fetal
abnormalities FHR and Fetal tracing

General approach to the parents

Communicate effectively
avoid medical terms, abbreviation

expected during delivery possible complication possible outcome

Specific approach- Preterm

The more immature,the higher the risk of

death complication of prematurity health sequele neurodevelopmental disabilities

by gestational age & BW

predict the outcome of the baby

if there is sign of fetal distress in utero, signal of ongoing or impending insult to the fetus

Prematurity

Complication of prematurity
the frequency decrease with the gestational age acute
respiratory distress syndrome metabolic problem infection necrotising enterocolitis PDA intar ventricular haemorrhage

Prematurity
chronic
chronic lung disease hydrocephalus poor nutrition retinopathy of prematurity hearing impairment

Specific approach- IUGR

Outcome depending of the cause

usually normal baby can tolerate supply deprivation compared with those had

complication
vulnerable to perinatal cx. Acute
perinatal asphyxia cold stress hypoglycemia

 chronic
fullterm-minor neuromotor dysfunction,learning disability & behaviour problem preterm IUGR- major disability risk

Specific approach- maternal use

of drugs

What kind of drugs may ass/w IUGR neonatal withdrawal syndrome

expose to opiates or cocaine

cocaine exposure and known risk

CNS infarction subsequent risk for cerebral palsy esp hemiplegia

Cigarette smoking
Sudden infant death syndrome

Specific approach- fetal distress

Any changes in
FHR pattern fetal reactivity meconium staining decrease fetal movement

anticipate if the patient need resucitation upon delivery n may need assisted ventilation.

 Poor Apgar score

mortality severe perinatal depression

hypoxic ischaemic encephalopathy

predict neurodevelopmental outcome may develop multiple disabilities

but majority who had the sign fetal distress do not develop all those complication

HOW TO FOLLOW UP THESE PT

GOALS

Early identification of developmental disability parents counseling

reassured by observing the +ve improvement to recognize sign in school n behavioral problem

to identify and treat medical complication

Risk of developmental disability

PREMATURITY higher incidence of cerebral palsy n MR than general population
5-10% preterm with BW<1500gm

 CLD abnormal neonatal neurodevelomental examn

cranium ultrasound
IVH

cortical atrophy ventricular dilatation intraparenchymal cyst- high incidence of disabilities

IUGR Full term SGA

less incidence of MR or cerebral palsy high incidence of learning disability

preterm SGA
high incidence in MR and cerebral palsy equal risk with pt AGA preterm infants with the gestational age

the risk depend

cause of IUGR timing of insult subsequent perinatal asphyxia

ASPYXIA Perinatal asphyxia ass/w later dev. Of disabilities Most outcome study done for those severely asphyxiated,Usually those required prolonged ventilation n symptomatic in newborn
mortality rate 50% 25 % had handicap
severe MR spastic quadriplegia microcephaly seizure sensory impairment

Other risk factor

TORCH infection
who are symptomatic at birth have high incidence of developmental disability (60 90%) even if asymptomatic
risk of sensory impairment

Other risk factor

INFECTION
Especially meningitis Significant risk of later dev. Disability

HYPOGLYCAEMIA
if symptomatic and not treated may cause brain insult

Other risk factor

IN UTERO EXPOSURE TO DRUG

Maternal use of heroin and methadone
neonatal withdrawal syndrome high rate of Attention deficit n behavior problem

fetal alcohol syndrome

growth def dysmorphism congenital anomalies mental retardation hyperactivity

Other risk factor

IN UTERO EXPOSURE TO DRUG

maternal use of cocaine
lower birth weight microcephaly cerebral infarction abruptio placenta fetal distress

The parameter to be assessed during follow up

growth

Must be monitored each follow up including length, weight and head circumference plotting the growth chart

Breathing disorder

Apnea
need close follow up especially those who are receiving treatment

chronic lung disease

poor growth sleeping and feeding difficulty rising haematocrit those who stable on room air may had intermittent problems if develop upper or lower tract

hearing

Family h/o childhood hearing problem congenital perinatal hearing infection

torch

h/o hyperbilirubinaemia require exchange transfusion bacterial meningitis who had expose to ototoxicity drugs:
frusemide, gentamycin, vancomycin

Vision: retinopathy of prematurity

Assessment should be performed for those premature <1500mg-1800mg @ gestational age <30-35 require oxygen requirement <1300mg or <30 weeks POG, need ophtalmology assessment regardless of oxygen exposure

Language and motor skill

Assessment should be done to compare with the age norm

delay- late acquisition of milestones dissociation delay in one area compared to other area may help in diagnosing the disability eg;normal languag dev with delay in gross and fine motor suggest cerebral palsy

deviance
acquisition of milestone out of normal sequence eg : pt can stand, however unable to sit properly

Neurodevelopmental examination

Posture muscle tone in extremities axial muscle tone deep tendon reflex pathologic reflex (babinski) postural reaction

Thank you