Prematurity - A primer
Prematurity and related problems are becoming more common and more visible with the advances in medical technology which are improving the survival rates for prematurely born babies. Such babies require a specialized care and that too for a prolonged period. Parents of such babies have many unanswered questions about these ‘preemies’. Here is an attempt to explain this condition and its management.
What is prematurity?
A premature or a pre-term (PT) baby is one born before completion of 37 weeks inside womb whereas a full term baby is born 38 to 42 weeks after the conception. An extremely premature baby is one which is born before 32 weeks of gestation.
Almost all PT babies also have low birth weight (500- 2500 gm).
What causes prematurity?
The exact cause and mechanism of this phenomenon is unknown. Though there are many known risk factors. Factors in mother like age less than 18 or more than 35 years, poor nutrition, physical stress, addictions like smoking, alcohol or drugs, any serious acute or chronic disease or some anatomic abnormalities of uterus / placenta are commonly associated with prematurity. Multiple pregnancy, fetal distress or intrauterine growth retardation can sometimes induce premature delivery.
Why are such babies kept in incubators or warmers?
Warmth is a prime need for any newborn baby, much more so for a pre-term baby. PT baby lacks the insulating pad of body fat and its body temperature regulation mechanisms are not fully functional. Hypothermia or a reduced core temperature is dangerous as it slows down the body’s metabolism. Furthermore the glucose stores in body are burnt up to maintain body-heat and this causes fall in blood glucose levels (hypoglycemia). To prevent all this, PT babies are kept in incubators – transparent plastic boxes where temperature can be accurately adjusted- to keep them warm.
Radiant warmers are electrically warmed beds which are open to air. These are used for PT babies when there is need to frequently access them for medical reasons.
Do they need special feeding?
In the first few weeks, PT babies do need special feeding schedules.
1. In extreme PT babies, milk feeds are postponed for first few days and IV fluids are given. This is done to avoid the risk of NEC (Necrotising entero-colitis) - a serious gastro-intestinal infection.
2. As PT babies (before 32 weeks gestation) don’t have a coordinated sucking and swallowing reflexes, so in them even milk – either breast-milk or formula- has to be initially given through gavage feeding. This means the feeds are given through a tube which is passed through the nose into the stomach.
3. PT babies require more calories, proteins, minerals and vitamins so either they should be fed with specific PT-specific milk formula or in case of breast-fed PT babies, these factors should be provided as extra-supplements.
What is RDS?
PT babies born before 34 weeks, have deficiency of ‘Surfactant protein’ in their lungs. This protein keeps the lung-alveoli (air-sacs) open during respiration and its deficiency leads to collapse of these air-sacs. This leads to RDS (Respiratory distress syndrome) in such babies and causes breathing difficulty.
Oxygen, nasal CPAP (Continuous positive airway pressure), mechanical ventilation and administration of artificial surfactant are the measures to treat RDS.
Administration of corticosteroid injection to mother prior to anticipated PT delivery is one way of reducing risk of RDS.
What are apnea alarms?
Apnea is stoppage of breathing for more than 15 –20 seconds with associated fall in heart-rate (below 100/min.) and/or cyanosis (bluish discolouration of skin and mucous membranes). Because of immaturity of respiratory center in brain and abnormality in some physiologic responses, apnea is a common occurrence in PT babies.
To alert the medical team, special alarms are connected to PT babies, which sound a warning with apnea. Physical stimulation often aborts such spells. Sometimes medicines (like theophylline or caffeine) or measures like nasal CPAP are needed to control them.
Why do they need blood-tests so frequently?
This is so because:
1. The internal biochemical balance in blood is a very delicate one in PT babies. Metabolic disturbances like changes in blood levels of glucose, calcium, magnesium, bilirubin and electrolytes are observed very commonly and they need immediate attention.
2. In ventilated PT babies, arterial blood gas levels (oxygen and carbon dioxide) need to be checked to adjust the ventilator settings.
3. When an infection is suspected, blood cultures are needed to know the infective organism.
When are they discharged home?
When a PT baby is otherwise healthy, growing well, feeding from bottle or breast without any difficulty and is able to maintain body temperature in open crib, it is ready for discharge. Most centers prefer a discharge when the baby is weighing at least 1.8 kg or 4 lbs. Parental readiness to accept the caretaker role is also an important deciding factor.
What are the anticipated family problems with such babies?
When such a PT baby comes home after winning the initial battle in NICU (Neonatal intensive care unit), different problems are awaiting there. Parents who are initially elated, later on get exhausted and may feel lonely and abandoned in their efforts to attend to the special needs of such a baby. Sometimes even when such a baby is perfectly normal, parents still go on with an extra-protective attitude whereas sometimes they are antagonistic towards it as they are unable to overcome the initial ‘battle-strain’. Siblings may display hostility as they sense more attention being given to the new entrant.
All these problems should be discussed in detail with the family members all throughout the hospitalization so that they can cope with it better.
How do we manage PT babies at home?
Once the PT baby comes home, following are the basic principles of care:
· Maintain a positive parental attitude. Otherwise, negative feelings like denial, dejection, defeatism, blame, guilt and ambivalent attitude towards baby are common in parents of such babies.
· In order to prevent infections, follow practices like hand-washing with before handling the baby, minimum handling of the baby by family members and no handling by casual visitors and avoiding crowded places for outing. If somebody in the proximity is having an infection (like flu or conjuctivitis), then they should be wearing a face mask or other protective gear.
· To prevent hypothermia, maintain an ambient temperature of around 27-28*C (80*F) and cover the baby in adequate clothing. A practical guideline is:
At 28*C (80*F) – Put on a single vest and a diaper.
24-28*C (75-80*F) – add one more layer of clothing.
21-24*C (70-75* F) – add 2 more layers of clothing.
Less than 21*C (70*F) - add 2 more layers of clothing. Also put on a cap and blanket.
Feeding such babies depends upon their weight and ability to suck from breast or a bottle. Till they attain an adequate weight (2 kg or more), maintain a strict 2 hourly feeding schedule. Expressed breast milk or sometimes a prescribed premature milk formula is used as the feed. The simple way of giving such feeds is through a spoon, a bondla (a snouted spoon) or a syringe. Take care to burp well after any feed.
Usually supplements like multivitamins, iron and calcium are needed and they can be added to the milk feeds.
Regular follow-up with a paediatrician to monitor baby’s growth, development, vaccination and any other related conditions.
What are the danger- signals to watch out for in such babies?
Doctor’s opinion should be immediately sought for, if following things are observed:
· Extremes of temperature (Fever or Hypothermia)
· Refusal to feed, poor sucking or reduced feeding
· Lethargy, irritability or excessive sleepiness.
· Severe, prolonged and frequent breath-holding spells
· Symptoms like breathing difficulty, cyanosis (bluish discoloration of lips/mouth), diarrhea, vomiting, prolonged constipation, abdominal distension, dark black or bloody stools, less urination, ear discharge, eye discharge, umbilical discharge, redness around umbilicus or foul smell from umbilicus
Is there any difference in the vaccination schedule for PT babies?
Usually there is no difference in vaccination schedule in a stable PT baby from any other normal newborn. There is no need to postpone the vaccines by thinking that these babies are too fragile. In fact, that’s why they need the vaccine protection from various illnesses even more.
Previously there was a slight difference in Hepatitis B vaccine schedule of the PT babies. But now it is recommended that a stable PT baby weighing 1 kg or more should receive the first dose of Hepatitis B vaccine at birth or within first few days and then complete three more doses at 2, 4 and 6 months of age (just like any full-term baby). Only in cases of PT babies who are less than 1 kg at birth, the first dose of Hepatitis B vaccine is delayed till they reach the weight of 1 kg or more.
What are the complications of prematurity?
Although overall survival and long term outlook for PT babies has improved a lot, there are many battles still to be won. Cerebral palsy, mental retardation, visual/hearing impairment, retinopathy of prematurity (an eye condition caused by excessive proliferation of blood vessels in retina) and chronic lung disease like bronchopulmonary dysplasia are some major complications. Relatively ‘invisible’ problems like behavioural abnormalities, language and learning disorders, attention deficit hyperactivity disorder, poor growth, increased chances of post-neonatal illnesses and hospitalizations, increased risk of congenital anomalies and increased risk of child-abuse are the grey areas which need to be tackled.
But don’t unnecessarily worry over these issues as each case is different. With good medical care and positive informed parenting, most prematurity-related problems can be well-controlled or cured.
When it comes to prematurity, we have to be pretty mature to handle all its consequences!
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Right Parenting.Com is a site dedicated to offer compassionate scientific guidance on various parenting and child-health issues. It is managed by Dr. Mandar V. Bichu, a Sharjah-based paediatrician with the help of experts in various fields.
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