PREMATURITY

Learning objectives
At the end of the session, the student should be able to: identify the needs of a preterm baby Provide intensive care to a preterm Explain the physiology of prematurity and its effect on all systems State the criteria for admission to intensive care unit

Define Prematurity
A baby born before the end of the 37th gestational week, regardless of birth weight. sometimes given the nickname, preemies .

Intoduction
A premature newborn is not fully equipped to deal with our world. Their little bodies still have areas that need to mature and fully develop. Some of these areas include the lungs, digestive system, immune system and skin

Causes of Prematurity
Multiple gestation Premature rupture of membranes Maternal short stature Maternal age and parity- 18yrs, primip Poor obstetric history H/O of preterm labour Cervical incompetence Poor social circumstances Infection

PERIODIC BREATHING
Is a normal event Is usually not associated with any physiological changes in the infant Does not merit any treatment APNOEA is the cessation of breathing for more than 20 seconds.

Primary Apnoea
Infant deprived of O (hypoxia) rapid breathing occurs if asphyxia continues respiration ceases/drop heart rate,pale or blue primary apnoea Oxygen & tactile stimulation induce respiration pinks up, moves, cries

Secondary Apnoea
Asphyxia continues deep gasping respiration drop in HR/BP last gasp, cyanosed drop in HR, BP, PaO further unresponsive to stimulation (tactile) Artificial ventilation with ambu bag & mask (100% O )

MANAGEMENT OF APNOEA
Use of O via flush in crib, headbox, mask, nasal prongs, or nasopharyngeal tube Bubble CPAP Continuous positive airway pressure improves oxygenation, prevents collapse of pharynx during expiration Use of mechanical ventilation Use of drugs e.g.. amniophylline

GENERAL MEASURES
Maintain airway, breathing and circulation (ABC) Avoid vigorous suctioning of the oro-pharynx Avoid oral feeds for at least 24 hours. Avoid swings in environmental temperature. Treatment of the underlying cause: sepsis, anemia, polycythaemia, hypoglycemia,RDS

Effects of immaturity on a preterm Baby Immature organs The shorter the gestation, the less muscular activity seen

A. B. C. D. E. F. G. H.

GENERAL APPEARANCE INTEGUMENTARY RESPIRATORY CARDIOVASCULAR GASTRO INTESTINAL TRACT RENAL SYSTEM IMMUNE SYSTEM MUSCULOSKELETAL

GENERAL APPEARANCE
Vital signs: temperature , Pulse, breathing rate General appearance - physical activity, tone, posture, and level of consciousness skin - color, texture, nails, presence of rashes Head and Neck: appearance, shape, presence of molding (shaping of the head from passage through the birth canal) fontanels (the open "soft spots" between the bones of the baby's skull) clavicles (bones across the upper chest) Face - eyes, ears, nose, cheeks

Mouth - palate, tongue, throat Lungs - breath sounds, breathing pattern Heart sounds and femoral (in the groin) pulses Abdomen - presence of masses or hernia Genitals and anus - for open passage of urine and stool Arms and legs - movement and development

 Integumentary -Sticky, smooth, peeling -fragile -Not fully developed -Easily bruised and prone to peelings -Visible veins - reduced keratin in the epidermis loss of heat & water

Respiration Narrow and easily obstructed Soft thoracic cage Uses diaphragm rather than chest Cough reflex poor Respiratory centre poorly developed Apnoea (forgets to breathe)

Heart and Circulation

Adaptation to extrauterine slow Blood pressure low Ductus Arterious capable of opening again unstable oxygen saturation Poor perfusion

Blood Weak capillary walls Reduced clotting factors Bleed easily Bruises easily Blood volume is 80mls/kg body weight Limited volume of blood taken for testing

Gastrointestinal tract Suck & swallow reflex poorly developed Co-ordinated by 34 wks Liver immature- cannot conjugate bilirubin Need oro-gastric feed Can also cup feed Difficulty in breastfeeding

 Renal function - Unable to excrete large fluid loads oedema - Unable to retain sodium - Elimination of toxic drugs minimal - Strict fluid intake - Fluid calculated daily

 Immune system -Passive immunisation from mom -Poorly developed immune system -Very sensitive to minor infections -Can get sick very quickly -Strict hand washing advocated -Use of 5 moments in handwashing

Musculoskeletal Uncordinated muscle movement Poor/flaccid muscle tone Erratic, weak or flailing movement Flattened posture with hips abducted Reduced muscle power & bulk

Characteristics of a Preterm Baby

Generally hypotonic Weak and feeble cry Head large in proportion to body Soft skull bones with large fontanelles and wide sutures Chest small and narrow Large abdomen but tone poor Abundant vernix caseosa

Lanugo scarce or none Nipple areola poorly developed/ barely visible Ear pinna flat with little curve Eyes bulge/orbital ridges prominent Cord white, fleshy and glistening Labia minora prominent Testes in inguinal canal descends at 37 wks

A first glance at the Neonatal Intensive Care Unit (NICU)

The NICU is the newborns/preterm's protected environment. It may also be his or her home for a while. Get acquainted and know as much as you can about it. It is equipped with caring staff, monitoring and alarm systems, respiratory and resuscitation equipment, access to physicians in every pediatric specialty & 24 hour laboratory service

Methods of Respiratory Assistance

Endotracheal tube This is a tube that is placed down the newborns trachea. It delivers warm humidified air and oxygen. Ventilator This is also sometimes referred to as a respirator. This is the breathing machine that the endotracheal tube is connected to. It can monitor the amount of oxygen, air pressure and number of breaths. Continuous Positive Airway Pressure (C-PAP) This method is used for babies who can breathe on their own but just need some help getting air to their lungs. Oxygen hood This is an actual clear plastic box that is placed over the baby's head and is attached to a tube that pumps oxygen to the baby.

Monitoring and alarm systems

Monitors record the heart rate, respiratory rate, blood pressure, and temperature. A pulse oximeter may be taken to measure the amount of oxygen in the blood. Alarm systems go off periodically in the NICU and it does not always indicate an emergency. However, need to check the monitor and baby

Methods of feeding
Intravenous lines Umbilical catheter Oral and nasal feeding Central line

What mom s can do?

Touch baby as much as possible, through gentle touch or even stroking motions. Talk to baby. Your baby is used to your voice(s) and it could be comforting to hear you. Along with talking you can read or sing to your baby. Change baby s diaper. Participate in baby s first bath. Depending on your baby s progress, you may use washcloths or sponges to do this. Take baby s temperature.

Criteria for Admission to NICU

1. Immediately Under 1800gms birth weight Less than 36 weeks of gestation Respiratory symptoms such as grunting, tachypnoea or costal recession Congenital malformations and genetic disorders

2.

As symptoms appear Convulsions Persistent vomiting or abdominal distension Hypoglycaemia which does not respond to oral or nasogastric feeding Jaundiced infant needing Exchange transfusion Any ill baby

PREPARATION FOR ADMISSION TO NICU

Warmer/incubator O - head box, nasal prongs, BCAP or ventilator IV cannulation equipment IV pack, specimen bottles, angiocath size 24, micropore tapes, IV fluid (D10%), glucometer with strips, IV infusion set, infusion pump, monitors Paperwork

Fluid Requirement
Choice of fluid Dextrose 10% Dextrose 5% if birth weight is 1000gms Fluid calculations 60mls/kg/day 1st day ( by 30mls/kg/day) 90mls/kg/day - 2nd day (By the end of week, 210mls/kg/day)

Ways to administer O
Crib oxygen ( if baby just needs a flush of O ) Nasal prongs ( up to 2L/min only) Head box O ( than 4L/min) Blended O via machine (Blender O ) Bubble CPAP Mechanical ventilation

Management of Preterm Babies

Strict hand washing Minimal handling 4hrly temperature 2hrly respiration and heart rate Nested in fetal position Nursed in crib/warmer Monitor CBG Monitor IV fluids Monitor fluid intake and output Attend to monitor alarms

Skin care/ cord care Perineal care Oral care Breast feeds/cup feeds/orogastric feeds Aspirate before 4th feed if on orogastric feed Sponge daily Weight check twice weekly

Nap time: 12.30 1.30 pm daily Dim /off lights, draw curtains, no procedures Minimal noise No visitors allowed, only moms No jewelery, no long nails, no nail polish No banging of incubator, or shaking of baby

BASIC CARE FOR PRETERM

S W I F T Sweet, normal CBG range Wet, passing urine Infection free Fluid, hydration Temperature stability, thermoneutral environment

Treatment for Hypoglycaemia

Check CBG CBG 2.5mmols give bolus of D10% fluid @2mls/kg IV check CBG in 30 minutes if improved, monitor CBG 2hrly for 6 hrs

What is Kangaroo Care?

Kangaroo care is placing a premature baby in an upright position on a mother s bare chest allowing tummy to tummy contact placing the premature baby in between the mother s breasts. The baby s head is turned so that the ear is above the parent s heart.

 Body temperature mothers have thermal synchrony with their baby. Study concluded that when the baby was cold, the mother s body temperature would increase to warm the baby up and visa versa. Breastfeeding Kangaroo care allows easy access to the breast and skin-to-skin contact increases milk letdown. Increase weight gain Kangaroo care allows the baby to fall into a deep sleep which allows the baby to conserve energy for more important things. Increased weight gain means shorter hospital stay. Increased intimacy and attachment

DISCHARGE PLAN
Baby is able to maintain body temperature in an open crib for at least 24-48 hours Able to take all feedings by cup or breast without supplemental tube feedings Steady weight gain Mother is confident in taking care of baby

BEFORE DISCHARGE
Discharge weight of 1.8kg Head scan Eye check Receives immunisation before discharge Book for Neo Natal Clinic (NNC) for follow up Attends MCH clinic only when the weight has reached 2.5kg Due immunisations given while coming for weight checks every week

Respiratory Distress Syndrome

Also known as Hyaline Membrane Disease (HMD) Respiratory Distress Syndrome (RDS) is caused by pulmonary surfactant deficiency in the lungs of neonates, most commonly in those born at < 37 wk gestation. Risk increases with degree of prematurity.

Etiology
Pulmonary surfactant is a mixture of phospholipids and lipoproteins secreted by type II pneumocytes. It diminishes the surface tension of the water film that lines alveoli, thereby decreasing the tendency of alveoli to collapse and the work required to inflate them.

Pathophysiology
With surfactant deficiency, the lungs become diffusely atelectatic, triggering inflammation and pulmonary edema. Because blood passing through the atelectatic portions of lung is not oxygenated, the infant becomes hypoxemic. Lung compliance is decreased, thereby increasing the work of breathing. In severe cases, the diaphragm and intercostal muscles fatigue, and CO2 retention and respiratory acidosis develop.

Signs and Symptoms

Rapid, labored, grunting respirations appearing immediately or within a few hours after delivery, Suprasternal and substernal retractions Flaring of the nasal alae. As atelectasis and respiratory failure progress, symptoms worsen, with cyanosis, lethargy, irregular breathing, and apnea. Neonates weighing < 1000 g may have lungs so stiff that they are unable to initiate or sustain respirations in the delivery room. On examination, breath sounds are decreased. Peripheral pulses may be decreased with peripheral extremity edema and decreased urine output.

Diagnosis
Clinical presentation ABG (hypoxemia and hypercapnia) Chest x-ray Blood, CSF, and tracheal aspirate cultures

Treatment
Surfactant Supplementary O2 as needed Mechanical ventilation as needed Antibiotics Support therapy

Necrotizing Enterocoloitis
Necrotizing Enterocolitis (NEC) "Necrotizing" means the death of tissue, "entero" refers to the small intestine, "colo" to the large intestine, and "itis" means inflammation

Physiology
NECROTIZING ENTEROCOLITIS (NEC) is a common life-threatening gastrointestinal (GI) emergency in the low birth weight infant Characterized by necrosis of the intestine which often leads to perforation of the GI tract

Signs and symptoms

poor tolerance to feedings feedings stay in stomach longer than expected decreased bowel sounds abdominal distension (bloating) and tenderness greenish (bile-colored) vomit redness of the abdomen increase in stools, or lack of stools bloody stools

Causes
Unknown too little oxygen or blood flow added stress of food moving through the intestine allows bacteria normally found in the intestine to invade and damage the wall of the intestinal tissues. The damage may affect only a short segment of the intestine or can progress quickly to involve a much larger portion

Diagnosis
Abdomen X-ray Ultrasound Abdominal girth daily Blood tests Stool for culture

Treatment
Stop oral feeds Free naso/orogastric drainage (inserting a tube through the nasal passages down to the stomach to remove air and fluid from the stomach and intestine) intravenous (IV) fluids for fluid replacement and nutrition antibiotics for infection frequent examinations and X-rays of the abdomen

 If surgery involved then colostomy performed, which may be reversed at a later time. Some children may suffer later as a result of short bowel syndrome if extensive portions of the bowel had to be removed.

Prevention
Providing small amounts of oral feeds of human milk starting ASAP While the infant is being primarily fed intravenously Reason To prime the immature gut to mature and become ready to receive greater oral intake

Prevention of preterm delivery

If a fetus must be delivered between 24 wk and 34 wks: give the mother 2 doses of betamethasone 6 mg IV or IM q12hr at least 48hr before delivery induce fetal surfactant production & reduce the risk of RDS or decreases its severity

Conclusion
Question of survival primary concern Intensified with increasing prematurity Once out of danger, ongoing daily communications should continue It helps the parents feel for their babies Facilitates attachment and bonding

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