PRETERM BABIES

&
IT’S PROBLEMS
Prof. Srijana Dongol Singh
KUSMS
DEFINATION:
PREMATURE:
Infants delivered before 37 week from the 1st day of the last menstrual period(WHO)

• Extremely preterm(extremely low gestational age newborns): Infants born before 28 weeks
of gestation(WOG).
• Very preterm: infants born between 28 WOG to 31+6 WOG
• Moderate preterm: infants born between 32 to 33+6 WOG
• Late preterm: infants born between 34 to 36+6 WOG

On the basis of gestational weight

• Extremely low birth weight: Birth weight<1000gms
• Very low birth weight: Birth weight <1500gms
• Low birth weight: Birth weight<2500gms
CAUSES OF PRETERM BIRTH
1. FETAL
• Fetal distress
• Multiple gestation
• Erythroblastosis
• Nonimmune hydrops
• Congenital malformation
• Congenital infection

2. PLACENTAL
• Placental dysfunction
• Placenta previa
• Abruptio placenta
3.UTERINE
• Bicornuate uterus
• Incompetent cervix (premature dilation)
• streptococcus, urinary tract infection, bacterial vaginosis, chorioamnionitis)
• Drug abuse (cocaine)

4.OTHERS
• Premature rupture of membranes
• Polyhydramnios
• Trauma
• Maternal anxiety, depression
• Acute emotional stress , Excessive physical exertion
Others
• Previous history of premature labor
• Low socioeconomic status
• Low educational standing
• Unmarried mother
• Low maternal weight - BMI, malnutrition, short stature, poor maternal weight gain
during pregnancy/ maternal vitamins & minerals deficiency,
• Acute or chronic systemic diseases in mother
• Closely spaced pregnancy
• Obesity ,diabetes and hypertension
• Genetic factors
• Cigarette smoking, alcohol, drugs by mother during pregnancy
MODIFIED BALLARD SCORE:

Square windowPopliteal angle

skin lanugo Plantar surface

Arm recoil

Scarf sign Heel to ear sign

Male genitals Female genitals
FEATURES OF PREMATURITY:
PROBLEMS OF PREMATURITY:
1. Central nervous system:
• Intraventricular hemorrhage
• Hypotonia
• Periventricular leukomalacia
• Seizures
• Retinopathy of prematurity
2. Respiratory system:
• Respiratory distress syndrome (hyaline membrane disease)
• Apnea
• Bronchopulmonary dysplasia (requirements for supplemental oxygen for longer than
28 days of age to maintain PaO2 above 50 mm Hg.)
3. Cardiovascular system:
• Patent ductus arteriosus
• Bradycardia (with apnea)
• Hypotension
4. Gastrointestinal system:
• Poor gastrointestinal function(poor motility)
• Necrotizing enterocolitis
• Difficulty in feeding, regurgitation, aspiration
• Hyperbilirubinemia
• Spontaneous gastrointestinal isolated perforation
5. Renal system:
• Dyselectrolytemia: Hyponatremia, Hypernatremia, Hyperkalemia
• Renal tubular acidosis
6. Metabolic and endocrine:
• Hypocalcemia
• Hypoglycemia
• Late metabolic acidosis
• Hypothermia
• Osteopenia
7. Hematological:
• Anemia (early or late onset)
8. Others: infection
9. Drugs: Poor hepatic detoxification and reduced renal clearance cause toxicity
LATE SEQUELAE OF PRETERM BIRTH
• Cerebral palsy, mental retardation, visual and hearing impairments, and poor health and growth.
• Behavioral and social-emotional problems
• Learning difficulties
• Increased risk of conditions such as Attention Deficit-Hyperactivity Disorder (ADHD), Sudden
Infant Death Syndrome (SIDS)
• Short bowel syndrome, malabsorption, malnutrition.
• Cirrhosis, hepatic failure
• Child abuse or neglect
• Increased rates of childhood illness and readmission to the hospital.
Respiratory distress syndrome (hyaline
membrane disease) RDS/HMD
• RDS stands for "respiratory distress syndrome." It is the most
common lung disease in premature infants and it occurs because the
baby’s lungs are not fully developed. The more premature the infant,
the more likely it is for the baby to have RDS.
• RDS occurs when there is not enough surfactant in the lungs. An unborn
baby starts to make surfactant at about 26 weeks of pregnancy.
• When there is not enough surfactant, the tiny alveoli collapse with each
breath. As the alveoli collapse, damaged cells collect in the airways. They
further affect breathing.
• As the baby's lung function gets worse, the baby takes in less oxygen. More
carbon dioxide builds up in the blood. This can lead to increased lactic
acidosis.
• This condition can affect other body organs. Without treatment, the baby
becomes exhausted trying to breathe and over time gives up. A ventilator
must do the work of breathing instead.
Clinical feature of RDS
• Signs of RDS appear immediately after birth or within 4 h.
• RDS is characterized by tachypnea (>60 breaths/min), intercostal and subcostal
retractions, nasal flaring, grunting, and cyanosis in room air.
• Tachypnea is due to an attempt to increase minute ventilation to compensate for a
decreased tidal volume and increased dead space.
• Retractions occur as the infant is forced to generate a high intrathoracic pressure
to expand the poorly compliant lungs.
• Grunting results from the partial closure of the glottis during forced expiration in
an effort to maintain FRC.
• After an initial improvement with resuscitation and stabilization, an uncomplicated
course is often characterized by a progressive worsening for 48 to 72 h.
• Other clinical features may include hypotension, acidosis and
hyperkalemia.
• The typical chest radiograph shows low lung volumes and a bilateral,
reticular granular pattern (ground glass appearance) with
superimposed air bronchograms.
• In more severe cases, there is complete “white out” of the lung
fields. Application of positive airway pressure may minimize or even
eliminate these radiographic findings.
Grading of RDS

Grade II

• Reticulonoduler pattern • Widespread airbronchogram

become visible
Grade III GradeIV

• More air bronchogram with • Complete ground glass or white

obliteration of cardiac and out lung
diaphragmatic shadow
MANAGEMENT OF PRETERM BABIES:
1. Antenatal corticosteroid(BEFORE 34 WEEKS):
• Associated with reduction in incidence of RDS by 50% and mortality by 40%
• Reduce IVH, NEC in the first 48 hours of life

2. Optimal management at birth:

• Attended by senior pediatrician
• Delayed cord clamping
• Promptly dried, kept effectively covered and warm.
• Elective intubation of extremely low birth babies
• Transferred to NICU

3. Monitoring in NICU:
• Vitals, activity, color, tissue perfusion
• Fluid electrolytes and ABGs
• Tolerance of feeds
• Weight gain velocity
• Watch for development of RDS, apneic attacks, sepsis, PDA, NEC, IVH
4. Provide in utero environment :
• Soft, comfortable nestled and cushioned bed
• Avoid excessive light, sound, rough handling and painful procedure.
• Provide warmth
• Ensure asepsis
• Prevent evaporative skin losses
• Effective and safe oxygenation
• Provide partial parental nutrition and give trophic feeds with expressed breast milk.
• Rhythmic gentle tactile and kinesthetic stimulation like skin to skin contact, music, caressing
and cuddling.

5. Position of baby

6. Thermal comfort:
• Pre warmed radiant warmer or incubator for birth weight less than 1200gms
• Nursed in thermoneutral environment
• Application of liquid paraffin
• Extremely low birth weight should be covered with thin transparent plastic sheet
• Warm clothes (caps, socks, mittens, frock)
• Kangaroo mother care
7. Oxygen therapy:
• To prevent hypoxic brain damage.
• Precaution should be taken to safeguard against possible retinal toxicity.
• Institute oxygen when saturation falls below 85% and gradually withdrawn.
Respiratory support
• Bubble CPAP -continuous positive pressure ventilation
CPAP
8.Surfactant therapy
Surfactant in intubated patient or surfactant and kept in ventillator
8.Surfactant therapy
• INSURE technique
• INSURE technique meas surfactant administration through
intubation-surfactant-extubation.
MIST: Minimally Invasive surfactant therapy
9.Oxygen therapy:
• To prevent hypoxic brain damage.
• Precaution should be taken to safeguard against possible retinal toxicity.
• Institute oxygen when saturation falls below 85% and gradually withdrawn.

10.Feeding and nutrition:

• Parenteral fluid is indicated in babies weighing less than 1200 g or <30 WOG and sick babies.
• Trophic feeding with expressed breast milk through NG tube at 1-2ml 4times day can be started
• Once stable enteral feeding started with volume of 30ml/kg/day and increased by 10-20ml/kg
depending upon tolerance.

11.Nutritional supplements:
• When baby stable and tolerating enteral feeds expressed breast milk is fortified with human milk
fortifier
• Multivitamin drop containing iron from 2 weeks of age
• Iron supplementation(2-3 mg/kg) after 2-3 weeks when baby is having steady weight gain.
• Vitamin E 15 units/day
• Calcium supplement: 50-100 mg/kg/day from end of 1st week to 40 weeks post-conceptional age
12.Prevention of nosocomial infection:
• Minimal handling.
• Vigilance maintained in all procedures performed for aseptic measures
• High index of suspicion in early diagnosis & treatment of infection are essential for
improvement and survival.

13.Phototherapy:
• Jaundice is common in preterm babies due to hepatic immaturity, hypoxia, hypoglycemia,
infection, hypothermia.

14. Cardiovascular support

• Blood pressure maintenance with Fluids, pressor agents if required
• PDA:
• Fluid restriction
• Diuretic therapy
• Indomethacin therapy
• Consider surgical ligation after failed medical therapy.
• THANK YOU