The Post Term Infant

Characteristics of a post term infant.

A post term infant is a baby born after 294 days, that is, 40 weeks of gestation. Accurate dating and
calculation of the gestation period is important. The main characteristic features of a post term
infant include:
 Skin is loose, dry and disquamating (peeling off)
 Skull bones are hard and firm
 Small fontanelles and narrow sutures
 Nails are overgrown hence long
This infant is at risk of developing complications because:
 The placenta starts diminishing in its functions and hence the foetus may not get enough
nutrients and oxygen. This will lead to asphyxia in utero and passing of meconium which will
affect the infant’s life.
 Since the bones of the skull are firm, moulding is not effective and this may lead to a difficult
delivery.
In managing the infant, care should be taken to resuscitate the baby first in the same manner as with a
preterm infant.
Due to inborn errors of metabolism the post term infant will not thrive, will be irritable, may have changes
in stool and will suffer from colic or vomiting with weight loss. Any infant not doing well on the usual
formula or breast milk should be evaluated for some type of inborn error of metabolism.
The two common causes of metabolic disorder in newborn post term infants are:
 Hypoglycaemia and Hyperglycaemia
 Hypocalcaemia and Hypercalcaemia

Hypoglycaemia
Hypoglycaemia should be corrected if glucose is < 3 mmol/l (54 mg/dl).

Symptoms of hypoglycaemia in the newborn can be divided into major and minor symptoms.
Major symptoms include apnoea, convulsions and coma.
Minor symptoms include jitteriness, irritability, tremors, apathy, cyanotic spells and temperature
instability.
Many babies may remain asymptomatic. It is unusual for a newborn with hypoglycaemia to have an
autonomic nervous system response with sweating, pallor and tachycardia as occurs in adults. It is,
therefore, not possible to confidently diagnose neonatal hypoglycaemia clinically as the symptoms are so
similar to infection.

There are several causes of hypoglycaemia. These include:

 Decreased glucose substrate (a substance upon which an enzyme acts) availability, for example,
in small for gestational age infants and premature infants
 Increased glucose utilisation, for example, inborn errors of amino acid metabolism, glycogen
storage disease,
and galactosaemia
 Infants of diabetic mothers and large for gestational age infants are also at risk of developing
hypoglycaemia
 Miscellaneous factors like birth asphyxia and endocrine deficiencies in growth hormone and
cortisol
The major aim of management is to prevent hypoglycaemia from developing. However, if it does occur, it
should be detected early, before symptoms are fully apparent.
The following steps should be taken:
1. Monitor blood glucose frequently depending on previous blood glucose levels.
2. Early and frequent feeding leads to good prognosis in asymptomatic hypoglycaemia. In diabetic
infants hypoglycaemia can be prevented.
 3. Treatment should be initiated without any delay and plasma glucose level rechecked directly to
ensure that the problem
is resolved.
4. Give 5 ml/kg of 10% glucose (dextrose) solution IV rapidly. If IV access is not possible, place an
intraosseous needle or give sublingual sugar solution.
5. Recheck the blood glucose after 30 min, and repeat the dextrose (5 ml/kg) if the level is low (<
3.0 mmol/l; < 54 mg/dl).
6. Prevent further hypoglycaemia in an unconscious child by giving 10% dextrose in normal saline
or Ringer’s lactate for maintenance infusion (add 20 ml of 50% glucose to 80 ml of 0.9% normal
saline or Ringer’s lactate).
7. Do not exceed the maintenance fluid requirements for the child’s weight

Prognosis
Infants with asymptomatic hypoglycaemia are usually normal at follow up assessment. Some of the
babies with major symptoms of hypoglycaemia die or have a severe neurological handicap at follow up.
The problems they may have include:
 Mental retardation
 Convulsion
 Spasticity and microcephally

Hyperglycaemia
This is usually defined as blood sugar levels greater than 9 mmol/l at which level glycosuria may occur.
It frequently occurs in an infant who is receiving 10% dextrose infusion or parenteral nutrition.
Hyperglycaemia usually responds to decreasing the glucose concentration or the infusion rate.
Hyperglycaemia must be considered to be a sign of septicaemia.
In management, soluble insulin 0.1 units per kg body weight should be given intravenously and repeated
as necessary to keep blood sugar below 9 mmol/l.
Next you will look at other deficiencies closely related to hypoglycaemia and hyperglycaemia.

Hypocalcaemia
This is usually defined as a serum calcium concentration of less than 1.8 mmol/l (7.5mg/dl). The newborn
rarely develops symptoms unless the plasma calcium is lower than 1.7 mmol/l. The condition usually
occurs within 72 hours of life in the following situations:
 Premature neonates
 Associated with RDS
 Birth asphyxia
 Infants of diabetic mothers
 Neonatal sepsis
The reasons why it occurs are not fully understood but persistent hypocalcaemia is due to
hypoparathyroidism.
This is a rare condition and may be inherited in either x-linked or autosomal recessive manner. Late
hypocalcaemia is often referred to as neonatal tetany and occurs after the first week of life. In the past it
was commonly a result of feeding the infant on unmodified cow’s milk. Late hypocalcaemia, which is rare,
is due to maternal hyperparathyroidism.

SIGNS & SYMPTOMS: Hypocalcaemia can cause: tetany, jitteriness and convulsions, as well as
seizures, which may be identical to those due to hypoglycaemia or other cerebral causes. Occasionally
bradycardia and apnoea may also result from hypocalcaemia.

Management
 Symptomatic hypocalcemia (tetany / convulsions) - administer IV bolus of 10% calcium gluconate
0.5 ml/kg (0.11 mmol/kg) to a maximum of 20 ml/kg over 5 - 10 min then continuous IV infusion
over 24 h of 1.0 mmol/kg (maximum 8.8 mmol).
 Mild hypocalcemia - administer 50 mg /kg / day of elemental calcium PO in 4 divided doses
  Observe the infusion site carefully as extravasation may cause severe tissue injury.
 Severe and resistant hypocalcaemia such as that which occurs in congenital parathyroidism may
require Vitamin D supplementation. Some cases of hypocalcaemia will not respond to calcium
gluconate infusion and require magnesium sulphate.

Prognosis
Most infants recover completely with no adverse neurodevelopmental consequences. Severe dental
caries may be seen in the primary dentition of some infants with tetany due to hypocalcaemia. Remember
that calcium is essential to the development of bones including teeth.

Hypercalcaemia
This may occur as a complication of calcium overdose. Usually, serum calcium is greater than
2.75mmol/l, which is often due to excessive use of calcium gluconate in intravenous fluid therapy.
Other causes include:
 Renal failure
 Inappropriate anti-diuretic hormone secretion
 Hyperparathyroidism
 Vitamin D intoxication