What Are Potential Complications of Large for Gestational Birthweight?

Patient Presentation
A newborn male, term, infant was born to a G2P2, Pacific Islander female by an uncomplicated pregnancy and vaginal delivery. Gestational age had been confirmed by a 21 week ultrasound. Because of increased fundal height measurements, the mother had been monitored by ultrasound in the third trimester and a birth weight of around 4300g had been expected. There was no gestational diabetes but the mother’s other child was large for gestational age (LGA).

The pertinent physical exam showed a large male with birth weight of 4430 grams (98%), head circumference of 37 cm (98%) and length of 53 cm (90%) and was symmetric. HEENT was normal. His clavicles were intact. There was no heart murmur. His spine was normal. The rest of his examination was normal.

The diagnosis of a LGA male was made, most likely due to genetic disposition. He was monitored by glucose protocol because of the risk of hypoglycemia but never needed intervention. His was breastfed and was discharged at 2 days with a 5% decrease in birth weight.

Discussion
Infant size at birth is determined mainly by genetics, but also pregnancy and environmental factors. Large for gestational age (LGA) is defined as a mean weight > 2 standard deviations above the weight for gestational age or above the 90th percentile on growth charts (or ~4000 g on WHO growth charts). Macrosomia is a term used for a term infant who is > 4000g.

Risk factors for LGA infants includes:

  • Male infant
  • Maternal
    • Genetic disposition
    • Hispanic ethnicity
    • Diabetic
    • Multiparity or grand parity
    • Obesity
  • History of previous LGA infant

Prenatal ultrasound is very helpful for antenatal management. First trimester fetal ultrasound is excellent for determining gestational age. Fetal abdominal circumference 1-2 weeks before anticipated delivery (before 40 weeks gestation) is also excellent at determining fetal weight. After 40 weeks gestation it is not accurate for determining fetal weight.

Similar to SGA infants having “catch-up” growth, LGA babies do show “catch-down” growth over time most of which is in the first 3 months of life especially for head circumference and length. However, LGA babies then show slower weight changes and long term consistently have higher BMI and subcutaneous fat. One study found, “The growth patterns of LGA preterm-born children are distinctly different from other preterm or full term children. In particular, we found substantially greater weight gains and relatively higher BMIs is among them, which added to their already increased metabolic risks based on their gestational age.”

Learning Point
For infants and children being LGA increases the risks for:

  • Asphyxia
  • Cognitive impairments
  • Congenital malformations and genetic syndromes – a review of overgrowth syndromes can be found here
  • Cardiomyopathy
  • Fetal death rates are higher in babies weighing > 4000 g in diabetic mothers, and > 4250g in non-diabetic mothers
  • Electrolyte disorders – hypocalcemia, hypoglycemia
  • Hematological problems – iron deficiency, polycythemia
  • Infant of a diabetic mother risks, can be reviewed here
  • Labor complications
    • Prolonged labor
    • Shoulder dystocia
    • Brachial plexus injuries
    • Clavicle or humerus fractures
  • Meconium aspiration
  • Obesity and overweight
  • Persistent pulmonary hypertension
  • Renal vein thrombosis
  • Respiratory distress syndrome

For mothers includes:

  • Hemorrhage
  • Increased Cesarean section deliveries
  • Infection
  • Lacerations – perineal, vaginal, cervical

Questions for Further Discussion
1. What are common problems for an infant who is small for gestation age? A review can be found here
2. What monitoring and treatment must be done for infants who are LGA?
3. What defines grand parity vs multiparity?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Birth Weight

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Lawrence EJ. A matter of size: Part 2. Evaluating the large-for-gestational-age neonate. Adv Neonatal Care. 2007 Aug;7(4):187-97.
Taal HR, Vd Heijden AJ, Steegers EA, Hofman A, Jaddoe VW. Small and large size for gestational age at birth, infant growth, and childhood overweight. Obesity (Silver Spring). 2013 Jun;21(6):1261-8.

Bocca-Tjeertes IF, Kerstjens JM, Reijneveld SA, Veldman K, Bos AF, de Winter AF. Growth patterns of large for gestational age children up to age 4 years. Pediatrics. 2014 Mar;133(3):e643-9.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What Are The Potential Complications of a Tracheostomy?

Patient Presentation
A 4-year-old male came to clinic with increased respiratory secretions for the past 24 hours. He had a tracheostomy and the secretions were increased in amount and were thicker and yellowish in color instead of white. He had problems sleeping the night before because of coughing, which had continued into the daytime. He did not have problems breathing after suctioning but needed it at least hourly and often more. He also had copious clear rhinorrhea. He was uncommunicative, but his mother didn’t believe he was having any pain. He was afebrile, and was urinating and stooling as usual.

The past medical history was positive for a currently unidentified neurological condition where he had hypotonia, decreased strength and cognitive deficits. He had a tracheostomy and a gastrostomy tube placed around 1 year of life after multiple episodes of hospitalization for respiratory infections and failure to thrive. During that hospitalization, he needed chronic ventilatory support. Since that time he had been hospitalized 2-3 times/year for respiratory infections and pulmonary toilet. He had a decannulation attempt the previous year that failed because of general intolerance. The family history was positive for an adoptive brother who had congenital heart disease.

The pertinent physical exam showed a thin male with a respiratory rate of 42/minute, heart rate of 98 beats/min, with a normal blood pressure and temperature. His saturation was 90%. Weight had increased ~250 grams from an office visit 5 weeks ago. HEENT showed copious clear rhinorrhea, clear throat, and dull tympanic membranes bilaterally without fluid. His trach cannula was in place and the stoma was clear without erythema or granulation tissue. Lungs were quite coarse with fluid that moved with coughing. He had no specific wheezing or decreased breath sounds. His abdomen was soft and non-tender with a gastrostomy tube in place. The stoma site showed normal skin tissue. Neurologically, he was uncommunicative but would follow the examiner with his eyes. He had hypotonia and decreased strength. After he was suctioned, his saturation increased to 94%.

The work-up included a chest radiograph that was normal for the patient and without specific focal consolidation. A tracheostomy culture and gram-stain was sent. Some gram-positive cocci in pairs were seen along with increased polymorphonuclear cells.

The diagnosis of an upper respiratory tract infection with increased secretions was made. The mother was concerned about being able to care for the child because her husband was out of town and her backup nursing staff was not available. “I’m not sure that I can really take care of him, along with his brother by myself. I don’t want him to be hospitalized, but he needs to be watched all the time,” she said. The pediatrician called his pulmonologist who agreed with the mother. “He gets sick pretty quickly and he probably would be okay if there was nursing care, but I don’t feel comfortable with her being alone. She’s very good and if she is worried, then I know I should be worried too,” the pulmonologist said. Over the night, the patient’s clinical course worsened slightly and he need very frequent suctioning and 2 liters of oxygen/minute by trach cuff. He still remained afebrile. Over the next 2 days, he was slowly weaned off the oxygen and the secretions decreased in amount. He was discharged home.

Discussion
In the past, indications for tracheostomy were often because of infection, but today are more often due to need for chronic airway support and/or ventilation. Many more children and infants are having tracheostomies placed. Decannulation rates for these children are low due to concomitant complex chronic disease such as neurological, pulmonary and congenital heart diseases. Co-morbidies are common with 3-4 being average, and frequently also including chronic technology such as gastrostomy tubes or ventriculoperitoneal shunts. Approximately 8% of children do not survive the hospitalization where the tracheostomy is placed. It is believe this is not specifically due to the tracheostomy, but is secondary to underlying medical conditions. About 15-20% of children with tracheostomies have a tracheostomy-related complication and many have frequent hospitalizations. Frequent hospitalizations are often due to respiratory issues (50.8% with pneumonia accounting for 15.4%) and neurological and otolarygological problems accounting for 8.4% each in a 2015 study.

Decannulation is highly individual and many children will need the tracheostomy for their lifetimes. In general before a decannulation attempt, there should be no ventilatory support needed for at least 3-6 months, no aspiration events, no need for supplemental oxygen, no need for elective surgery in the near future necessitating intubation, and co-morbidies that have resolved or are improved. Patients who are being considered for decannulation often will have a trial of capping the trach during the day and night, and/or have the tracheostomy tube downsized. All have some type of formal airway assessment usually by laryngoscopy to evaluate the overall airway and to detect potential problems such as granulation tissue in the airway. A favorable direct airway evaluation is a good predictor of decannulation success.

Learning Point
Potential complications of tracheostomy include:

  • Early complications
    • Air leak
      • Pneumothorax
      • Pneumomediastinum
      • Subcutaneous emyphasema
    • Airway obstruction
      • Decannulation, accidental
      • Mucous plugging
    • Hemorrhage
      • Aberrant vessels
      • Innominate artery
      • Thyroid gland
    • Pulmonary edema
    • Respiratory arrest
    • Surrounding tissue injury
      • Cricoid cartilage
      • Esophagus
      • Recurrent laryngeal nerve
    • Tube placement injuries
      • Main bronchus cannulation
      • Tracheal tear/fistula
  • Delayed complications
    • Airway obstruction
      • Decannulation, accidental
      • Mucous plugging
    • Hemorrhage
      • Stomal
      • Tracheal mucosa
      • Tracheo innominate fistula
    • Swallowing or speech problems
    • Stomal problems
      • Granulation tissue
      • Tracheocutaneous fistula
    • Tracheal lesions
      • Granuloma, suprastomal or distal
      • Suprastomal collapse
      • Subglottic stenosis
    • Tracheoesophageal fistula

Modified from Watters, 2017.

Questions for Further Discussion
1. What is the general formula for sizing an endotracheal tube or tracheostomy tube?
2. What are the treatments for stomal granulation tissue?
3. What special problems may infants or young children have with development because of a tracheostomy?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Tracheal Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Yaneza MM, James HL, Davies P, Harrison S, McAlorum L, Clement WA, Kubba H. Changing indications for paediatric tracheostomy and the role of a multidisciplinary tracheostomy clinic. J Laryngol Otol. 2015 Sep;129(9):882-6.

Zhu H, Das P, Roberson DW, Jang J, Skinner ML, Paine M, Yuan J, Berry J. Hospitalizations in children with preexisting tracheostomy: a national perspective. Laryngoscope. 2015 Feb;125(2):462-8.

Watters K, O’Neill M, Zhu H, Graham RJ, Hall M, Berry J. Two-year mortality, complications, and healthcare use in children with medicaid following tracheostomy. Laryngoscope. 2016 Nov;126(11):2611-2617.

Watters KF. Tracheostomy in Infants and Children. Respir Care. 2017 Jun;62(6):799-825.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Holiday Break

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The next case will be published on January 7th. In the meantime, please take a look at the Archives and Curriculum Maps listed on the right side of the page.

We appreciate your patronage,
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What Causes Hyperpigmentation?

Patient Presentation
A 15-year-old female came to clinic at the end of the summer for her health supervision visit and sports physical. She played volleyball and had been spending significant amounts of time outside playing sports over the summer. She had no concerns except that she had noted darker brown patches on sunexposed areas of her arms, thighs, face and upper chest. She had noticed them more over the course of the summer. They caused no pain or pruritis and she denied any swelling, erythema or scaling. She denied any drug use including not wearing sunscreen, as she stated, “Why should I wear it? I just tan and it gets in my eyes and sticks to the sand or grass when I play sports.” The past medical history and family history were non-contributory.

The pertinent physical exam showed a healthy female who was 90% for height and 25% for weight and was tracking appropriately. Her skin examination showed skin that was overall tanned, with what looked to be normal variations in skin tone, including her face. She had 1 cafe-au-lait lesion on her left shoulder/upper back that was 1.5 cm in size. She had no freckling of her face or axilla. She also had some mild closed comedomal acne on the bridge of her nose.

The diagnosis of a healthy female was made with tanning and one cafe-au-lait lesion, and mild acne. The pediatrician recommended for her to always use sunscreen especially as she lead an active lifestyle and was outdoors often. “Even if you tan, you still need to use sunscreen to prevent the risk of premature aging of your skin and skin cancer. Especially if you are outdoors a lot you need to have your skin checked at least every year and maybe more often as you get older. You can also use some benzoyl peroxide for your acne.” the pediatrician counseled. The teenager looked unimpressed with the diagnosis and counseling. “If you would like, I can refer you to the dermatologist who may have more specific recommendations for sunscreen and monitoring, and your acne,” she also offered. The teenager started to smile when the referral was offered.

Discussion
Skin color is primarily due to genetic factors. Melanocytes are usually found in skin in the basal layer of the epidermis which is also where the melanin usually lies. There are a range of normal skin phenotypes that have been described by Fitzpatrick and range from I-VI:

    I – pale white skin, blond hair, blue eyed, does not tan, always burns
    II – fair skin, blue eyed, tans poorly, burns easily
    III – darker white skin, burns initially then tans
    IV – light brown skin, tans easily, burns minimally
    V – brown skin, tans darkly easily, burns rarely
    VI – dark brown skin, always tans darkly, never burns

Melanocytes in increased numbers, producing more melanin or in abnormal locations can cause hyperpigmentation. Here are some examples:

  • Epidermal melanosis – increased melanin but normal number of melanocytes
    • Cafe-au-lait spots
    • Urticaria pigmentosa
  • Dermal melanosis – melanin in the dermis
    • Drug eruption
    • Incontinentia pigmenti
    • Lichen planus
    • Post inflammatory hyperpigmentation
  • Mixed – melanin in epidermis and dermis
    • Post inflammatory hyperpigmentation

Just like hypopigmentation (which can be reviewed here), hyperpigmentation can be worrisome for many families because of cosmesis and the worry that “something is wrong.” The normal natural changes in skin-tone over the year due to different light exposure and wide variations within individuals is not something that many people are aware of. Post-inflammatory hyperpigmentation is one of the most common causes of hyperpigmentation. Treatment can be difficult but mainstays are bleaching agents and laser therapy.

Learning Point
Some causes of hyperpigmentation include:

  • Normal variation
    • Tanning or increased UV light exposure
    • Familial periorbital hyperpigmentation
    • Futcher’s or Voight’s lines – sharp demarcation between normal and hyperpigmented skin
    • Joint extensor surfaces
    • Mongolian spots – dermal melanocytosis
    • Palmar or plantar hyperpigmentation – can also be due to medications or Addison’s disease
  • Abnormal
    • Post-inflammatory hyperpigmentation
    • Addison’s disease
    • Drugs
    • Dyschromatosis symmetric hereditaria
    • Familial progressive hyperpigmentation
    • Fanconi’s anemia
    • Lentiginosis – Peutz-Jeghers, LEOPARD syndrome
    • Lentigo solaris
    • Linear or whorled nevoid hypermalanosis
    • McCune-Albright syndrome
    • Melasma – due to pregnancy, contraceptives but also cosmetics, phototoxic drugs, anti-convulsants and UV-radiation
    • Metabolite accumulation – Gaucher’s disease, hemochromatosis
    • Neurofibromatosis type 1
    • Nevus of Ota or Nevus of Ito – grey-brown to blue color, often presenting around the time of birth. Nevus of Ota is on the face (Trigeminal nerve distribution – ophthalmic and maxillary branches), Nevus of Ito on shoulder and neck.
    • Renal failure
    • Vitamin B12 deficiency
    • Xeroderma pigmentosum

Questions for Further Discussion
1. How much SPF sunscreen factor is recommended? A review can be found here
2. What are the risks of ultraviolet light?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Skin Pigmentation Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Oakley A. Fitzpatrick skin phenotype. DermNet NZ. Available from the Internet at: https://www.dermnetnz.org/topics/skin-phototype/ (rev. 2012, cited 10/16/18).

Nieuweboer-Krobotova L. Hyperpigmentation: types, diagnostics and targeted treatment options. J Eur Acad Dermatol Venereol. 2013 Jan;27 Suppl 1:2-4.

Speeckaert R, Van Gele M, Speeckaert MM, Lambert J, van Geel N. The biology of hyperpigmentation syndromes. Pigment Cell Melanoma Res. 2014 Jul;27(4):512-24.

Nicolaidou E, Katsambas AD. Pigmentation disorders: hyperpigmentation and hypopigmentation. Clin Dermatol. 2014 Jan-Feb;32(1):66-72.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa