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Figure 6.4. The premature infant has a large head in relation to body size and the eyes are protruding due to disproportion between the size of the eyeballs and the orbital cavity. The skin is red to pink, shiny due to edema, transparent with highly visible arterioles and venules, and is covered by lanugo. Subcutaneous tissue is poorly developed. Scalp hair is sparse and straight. Vernix is not formed and no nipples or areolae are seen. Note that the infant lies flat on the bed, in a frog-leg position with shoulders, elbows, and knees all touching the mattress. The head is to one side or other, not in line with the trunk.

Figure 6.5. The postmature infant appears long and skinny due to decreased subcutaneous fat stores with advancing gestation near term. The skull is hard because the sutures have started to fuse. Note the wizened facies and alert expression typical of the post-term baby. These infants tend to be wakeful and have desquamation of the skin. The hands are like a washerwomen's, dry and wrinkled, with long fingernails. Meconium staining may be seen on the umbilical cord and fingernails more commonly in the post-term infants.

Figure 6.6. When a fetus is undergrown due to intrauterine dysfunction, the sequence begins with loss of fat and muscle mass as noted in this growth-retarded infant. This is followed by loss of mass of less essential organs (liver, thymus, spleen, adrenals), loss of mass of more essential organs (heart), and finally loss of brain mass. If head circumference is compromised, it indicates that malnutrition must have been very severe, and it carries a poor prognosis.

Figure 6.5. The postmature infant appears long and skinny due to decreased subcutaneous fat stores with advancing gestation near term. The skull is hard because the sutures have started to fuse. Note the wizened facies and alert expression typical of the post-term baby. These infants tend to be wakeful and have desquamation of the skin. The hands are like a washerwomen's, dry and wrinkled, with long fingernails. Meconium staining may be seen on the umbilical cord and fingernails more commonly in the post-term infants.

Figure 6.6. When a fetus is undergrown due to intrauterine dysfunction, the sequence begins with loss of fat and muscle mass as noted in this growth-retarded infant. This is followed by loss of mass of less essential organs (liver, thymus, spleen, adrenals), loss of mass of more essential organs (heart), and finally loss of brain mass. If head circumference is compromised, it indicates that malnutrition must have been very severe, and it carries a poor prognosis.

Figure 6.7. Two systems are useful clinically to determine gestational age by examination of the eye. First, examination of die anterior eye for the presence of the tunica vasculosa lentis, apparent generally from 27 to 34 weeks. Note in this composite figure the tunica vasculosa lentis Grade IV at 27 to 28 weeks completely covers the anterior surface of the lens and then gradually decreases to Grade I by 33 to 34 weeks when only peripheral remnants of the vessels are visible on the anterior surface of the lens.

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Figure 6.7. Two systems are useful clinically to determine gestational age by examination of the eye. First, examination of die anterior eye for the presence of the tunica vasculosa lentis, apparent generally from 27 to 34 weeks. Note in this composite figure the tunica vasculosa lentis Grade IV at 27 to 28 weeks completely covers the anterior surface of the lens and then gradually decreases to Grade I by 33 to 34 weeks when only peripheral remnants of the vessels are visible on the anterior surface of the lens.

Figure 6.8. The second system used to determine gestational age involves examination of the fundus to assess macular development from 34 weeks to term. This composite figure shows Stage I - dark red pigmentation appearing, 34 to 35 weeks gestation; Stage II - the annular reflex is partially evident, 36 weeks gestation; Stage III - the complete annular reflex is present, 37 weeks gestation; Stage IV - the foveolar pit can be seen, 38 weeks gestation.

Figure 6.9. Because calcium is preferentially deposited in die last few weeks before birth, the stiffness of the baby's ear cartilage provides another test of maturity. In premature infants, the ear cartilage is deficient and the soft pinna does not spring back. On release it remains crumpled against the side of the head. At term the cartilage is more rigid similar to the adult ear.

Figure 6.9. Because calcium is preferentially deposited in die last few weeks before birth, the stiffness of the baby's ear cartilage provides another test of maturity. In premature infants, the ear cartilage is deficient and the soft pinna does not spring back. On release it remains crumpled against the side of the head. At term the cartilage is more rigid similar to the adult ear.

Figure 6.10. The presence of teeth seen by radiography in the jaw is a relatively accurate method of assessing gestational age. In the figure on the top left, incisors and cuspids have appeared but no molars, indicating a gestational age of less than 33 weeks. In the top right is shown the appearance of incisors and first deciduous molars consistent with 33 to 37 weeks gestation. On the bottom, the second deciduous molar and follicle of first permanent molar are present, indicating a gestation of greater than 37 weeks. This method is not useful in assessing infants with anhydrotic ectodermal dysplasia who have adentia.

Figure 6.11. Hair, particularly on the head, is a reliable marker of maturity. Premature hair is fuzzy and the hair ends tend to clump together. In the term infant the hairs are distinct, coarse and silky. Lanugo is absent prior to 20 to 22 weeks gestation, but by 30 to 32 weeks becomes diffuse over the body. By term, lanugo has mostly disappeared. There are marked racial differences among babies with respect to lanugo characteristics. Hispanic infants, in general, have considerably more body hair persisting to term and black infants often have less than average lanugo.

Figure 6.11. Hair, particularly on the head, is a reliable marker of maturity. Premature hair is fuzzy and the hair ends tend to clump together. In the term infant the hairs are distinct, coarse and silky. Lanugo is absent prior to 20 to 22 weeks gestation, but by 30 to 32 weeks becomes diffuse over the body. By term, lanugo has mostly disappeared. There are marked racial differences among babies with respect to lanugo characteristics. Hispanic infants, in general, have considerably more body hair persisting to term and black infants often have less than average lanugo.

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