Preterm Baby

Subject: Midwifery III (Theory)

Overview

A preterm infant is defined arbitrarily as a baby born before 37 weeks of gestation, calculated from the first day of the last menstrual period. Premature birth accounts for two-thirds of all low birthweight babies. Babies born before 37 completed weeks typically weigh 2500 gm or less; nevertheless, less than 51% of babies born before 37 completed weeks may weigh more than 2500 gm. The weight of a preterm newborn corresponds to the average weight (above the 10th percentile) for its gestational age. Preterm birth can be caused by medical conditions such as heart disease, anemia, malnutrition, hypertension, renal disease, and others during pregnancy. Preterm baby treatment involves optimal management at birth, maintaining body temperature, positioning, Kangaroo mother care, oxygen therapy, feeding and nutrition, nutritional supplement, soft rhythmic situation, nosocomial infection prevention, and phototherapy.

A preterm infant is defined arbitrarily as a baby born before 37 weeks of gestation, calculated from the first day of the last menstrual period. Premature birth accounts for two-thirds of all low birthweight babies. Babies born before 37 completed weeks typically weigh 2500 gm or less; nevertheless, less than 51% of babies born before 37 completed weeks may weigh more than 2500 gm. The weight of a preterm newborn corresponds to the average weight (above the 10th percentile) for its gestational age.

A preterm baby accounts for two-thirds of all low birth weight babies. LBW is 30-40% in developing countries and 20-25% in developed countries.

Causes:

Maternal factors:

  • Heart disease, anemia, starvation, hypertension, renal disease, and other medical conditions can occur during pregnancy.
  • Pregnancy complications such as APH
  • Cervical incompetence
  • Physical effort
  • Maternal infection manifested as hyperpyrexia, trauma, heavy smoking, and drug addiction, among other things.

Fetal factors:

  • IUGR in multiple pregnancies
  • Congenital deformity
  • Incompatibility with Rh

Medical factors

  • Diabetes mellitus is uncontrolled in the mother.
  • Toxemia, severe heart sickness
  • Fetal distress and hypoxia
  • Iso-immunization in the mother or hydrops fetalis

Iatrogenic:

  • Incorrect maturity diagnostic in elective deliveries.

Characteristics:

  • Posture: Because of low muscle tone, hypotonic people have impaired reflexes and adopt an extended posture.
  • Skin: thin, gelatinous, glossy, and very pink. Lanugo subcutaneous and very little vernix. There could be edema. Breast nodules are tiny or nonexistent, and subcutaneous fay is inadequate. Deep sole wrinkles are not always present.
  • Face and head: In proportion to the body, the face is little and the head is enormous. Fontanels are huge and sutures are widely apart. Micrognathia and retrognathia are present, as is a projecting eye due to a shallow orbit and the absence of buccal fat pads. Hair appears woolly and fuzzy, with individual hair threads visible.
  • Appearance: appears to be little but healthy
  • Fontanelle and suture: Fontanelle, broad suture, and soft skull bone
  • Ear: The ear pinna is soft and flat.
  • Planter creases: not as dark and fewer in number
  • Nails: Nail beds that are bright pink in hue and have very soft nails.
  • Activity: decreased limb activity
  • Sucking: incapable of sucking or having a low sucking ability
  • Cry: cry of weak and feeble
  • Breast: There is no palpable breast tissue.
  • Genitalia: Males have undescended testes, a weakly pigmented scrotum, and minimal rugosities.
    Female: the labia majora are widely split, revealing the labia minora and clitoris.
  • Reflex: Sucking, swallowing, and other reflexes are also absent or slow.

Physiological handicap and clinical hazards of a premature baby

Central nervous system:

  • Inadequate neonatal reflexes
  • Feeding issues result from uncoordinated sucking and swallowing.
  • Vitamin K insufficiency puts you at risk of developing intraventricular/periventricular hemorrhage.

Respiratory system:

  • Apneas are often less than 20 seconds long.
  • A weak cough response increases the risk of infection.
  • Surfactant deficiency causes respiratory distress syndrome.

Gastrointestinal system:

  • Due to an inadequate cardio-esophageal sphincter and a little stomach capacity, there is a proclivity to regurgitate.
  • Hyperbilirubinemia, hypoglycemia, and poor drug detoxification are all symptoms of functional immaturity of the liver.
  • Hypotonia can cause abdominal distention and necrotizing enterocolitis.

Temperature regulation:

  • Because of the huge surface area, more heat is lost, resulting in hypothermia.
  • Subcutaneous fat has less brown fat than visceral fat.
  • Inadequate heat response as a result of insufficient food consumption.

Cardiovascular system:

  • Delayed ductus arteriosus closure
  • Peripheral circulation is insufficient.
  • Intracranial bleeding is caused by insufficient autoregulation of cerebral blood flow.

Renal immaturity:

  • Because GFR and urine concentration is lowered, the patient is more likely to develop acidosis. Dehydration occurs when 4-5 ml of urine is passed to eliminate one milliosmole of solute as opposed to 0.7ml in an adult.

Metabolic disturbance: Hypoglycemia, hypocalcemia, hypoproteinemia, acidosis, and hypoxia are all symptoms of hypoglycemia.

Nutritional deficiency: Anemia is more likely to occur after 6-8 weeks due to a lack of iron storage. To catch up on postnatal growth, nutritional requirements are increased.

Susceptibility of infection:

  • Premature babies are three to four times more prone to infection than term babies.
  • Have a low IgG level.

Management of preterm babies

Optimal management at birth:

  • All resuscitation preparation for a baby should be attended by a senior pediatrician.
  • To avoid hypervolemia and the development of hyperbilirubinemia, the chord must be clamped as soon as possible.
  • Dry quickly and kept warm with moderate handling.
  • To prevent hemorrhage, take 1 mg of vitamin K.

Maintain body temperature:

  • Maintain the temperature and humidity of the newborn incubator. Alternatively, the infant could be cared for in a radiant warmer.
  • The room temperature should be between 25 and 30 degrees Celsius, with the incubator temperature set according to weight.

Weight of baby

Incubator temperature by weight
 

35°C

34°C

33°C

32°C

Less than 1.5 kg

1-10 days

11-21 days

3-5 days

More than 5 weeks

1.5-2kg

  

1-10days

11-28 days

More than 4 weeks

2.1 to 2.5 kg

  

1-2 days

3-21 days

More than 3 weeks

More than 2.5 kg

    

1-2 days

More than 2 weeks
  • Cover the baby's head with clothing as needed; do not expose body parts unless absolutely necessary for observation and assessment.
  • If the baby is getting EBM IV fluid, increase the volume of fluid and/or milk by 10% of the total daily volume per day for those who are under a radiant warmer.
  • Every hour, check the temperature of the warmer and the room and modify the temperature setting accordingly.
  • Eight baby covers with a cellphone to prevent heat loss through convection for extremely low births.

Positioning

  • Most babies prefer to sleep in a prone posture because it allows them to cry less and feel more at ease. It improves stomach discomfort and prevents aspiration by allowing flatus to escape.
  • Every two hours, the baby should change positions.

Kangaroo mother care

  • Encourage KMC and exclusive breastfeeding if the infant is not unwell. KMC keeps a baby warm, allows him to feed more comfortably, and reduces apnea episodes.

Oxygen therapy

  • Oxygen should be provided only when indicated and should be discontinued as soon as it is deemed unneeded.
  • When Sao2 goes below 85 percent, O2 should administer with a head box. It should be kept between 90 and 95 percent, while PaO2 should be kept between 60 and 80 percent.
  • The FiO2 level in the room should be between 20 and 40%.

Feeding and nutrition

  • Babies weighing 1.2 kg or having a gestation of 30 weeks, as well as unwell babies, should begin receiving IV dextrose solution (10% Dextrose > 1.0 kg and 5% Dextrose 1.0 kg).
  • EBM (1-2 mL) All babies, regardless of age or weight, can be started on 2-3 hourly NG tube feedings (2 hourly 1kg and 3 hourly > 1.2 kg).

Volume of EBM according to baby’s weight and baby

Weight of baby kg

Day 1 ml

Day 2 ml

Day 3 ml

Day 4 ml

Day 5 ml

Day 6 ml

 

Day 7 ml

1.5-1.49

12

18

22

26

30

33

35

1.25-1.49

10

15

18

22

26

28

30

<1.25

0

0

3

5

8

11

15
  • Gradually increase the volume of EBM while decreasing the IV drip.
  • If the infant still needs to be fed after 7 days, increase the amount by 20ml/kg/day until the baby is receiving 180ml/kg of breast milk each day.

Nutritional supplement

  • EBM enriched with human milk fortifier, multivitamin, and folic acid can be administered once the baby is stable and tolerates enteral feeding.
  • After 2-3 weeks, take an iron supplement (2-3 mg/kg elemental iron).
  • 1 mg vitamin E to prevent hemolytic anemia
  • Calcium (220 mg/day) and phosphorus (100 mg/day) supplementation to avoid osteopenia in 1.5 kg.

Gentle rhythmic situation

  • Gentle contact, massage, caressing, stroking, and flexing, preferably by the mother, give the newborn useful tactile sensations.
  • The use of a rocking bed and inflated gloves provides vestibular kinesthetic for the prevention of apneic attacks.
  • Soothing auditory cues such as family voices and music lessen procedure stress and increase weight gain.
  • Colored items and eye-to-eye contact give visual inputs.

Prevention of nosocomial infection

  • Hand cleaning before and after touching the baby is strictly enforced.
  • Treatment of suspected infections of any origin that is effective.

Phototherapy

  • Early phototherapy is recommended to keep serum bilirubin levels within a safe range and avoid the need for exchange transfusions in patients who develop hyperbilirubinemia prematurely.

Factors to be avoided for preterm babies

  • Provide O2 administration without supervision.
  • Intravenous immunoglobulin or neonatal sepsis prophylaxis
  • Antibiotics for prophylaxis.
  • Administration of indomethacin and vitamin E for prophylaxis.
  • Unnecessary transfusion of blood
  • Feeding with a formula
  • Excessive light and loudness, as well as rough handling.

Complication:

  • Oxygen deprivation
  • Pulmonary syndromes include pulmonary edema, intra-alveolar hemorrhage, and idiopathic respiratory distress syndrome, sometimes known as RDS.
  • Hemorrhage in the brain
  • Shock to the fetus
  • Failure of the heart
  • Nosocomial infections
  • Hypothermia
  • Infections include bronchopneumonia, meningitis, and gastroenteritis.
  • Jaundice
  • Acidaemia and dehydration
  • Anemia
  • Hypoglycemia
  • Feeding issues
Things to remember
  • A preterm infant is defined arbitrarily as a baby born before 37 weeks of gestation, calculated from the first day of the last menstrual period.
  • Premature birth accounts for two-thirds of all low birthweight babies. Babies born before 37 completed weeks typically weigh 2500 gm or less; nevertheless, less than 51% of babies born before 37 completed weeks may weigh more than 2500 gm.
  • The weight of a preterm newborn corresponds to the average weight (above the 10th percentile) for its gestational age.
  • A preterm baby accounts for two-thirds of all low birth weight babies.
  • LBW is 30-40% in developing countries and 20-25% in developed countries.
  • Preterm birth can be caused by medical conditions such as heart disease, anemia, malnutrition, hypertension, renal disease, and others during pregnancy.
  • Preterm birth can also be caused by maternal infections such as hyperpyrexia, trauma, heavy smoking, and drug addiction, among other things.
  • Preterm baby treatment involves optimal management at birth, maintaining body temperature, positioning, Kangaroo mother care, oxygen therapy, feeding and nutrition, nutritional supplement, soft rhythmic situation, nosocomial infection prevention, and phototherapy.
Questions and Answers

A preterm baby is one who was born before 37 weeks of gestation, as measured from the first day of the previous menstrual cycle. Premature births account for 2/3 of low birthweights. Babies born before 37 full weeks typically weigh 2500 g or less, though less than 51% of preterm births result in infants weighing more than 2500 g. Preterm babies typically weigh more than the 10th percentile for their gestational age.

  • Maternal factors:
    • Pregnancy-related illnesses include heart disease, kidney disease, anemia, malnutrition, and hypertension.
    • Pregnancy complications such as APH.
    • Failure of the cervix
    • Physical effort
    • Hyperpyrexia, trauma, maternal infection, heavy smoking, and drug abuse, etc.
  • Fetal factors:
    • Several pregnancies
    • IUGR
    • Congenital anomaly
    • Rhe sensitivity
  • Medical factors
    • Mother's uncontrolled diabetes mellitus.
    • Severe heart disease and toxicity
    • Fetal distress and hypoxia
    • Severe maternal iso-immunization or hydrops fetalis
  • Iatrogenic:
    • Incorrect maturity diagnosis for elective deliveries.

Management of preterm babies:

  • Optimal management at birth:
    • The senior pediatrician should be present with all baby resuscitation preparations for the best possible care at birth.
    • To avoid hypervolemia and the development of hyperbilirubinemia, the chord needs to be clamped right away.
    • prompt drying and gentle handling to maintain warmth.
    • Give 1 mg of vitamin K to stop bleeding.
  • Maintain body temperature:
    • Keep your body temperature steady by maintaining the humidity and temperature in the baby incubator. The infant could also be cared for in a radiant warmer.
    • 25–30°C should be the ambient temperature, and the incubator's temperature should be adjusted for weight.
    • When necessary, cover the baby's head with clothing. Only expose body parts if absolutely necessary for observation and evaluation.
    • If the infant is receiving IV fluid or EBM, you should give them 10% more fluid or milk each day if they are being warmed by a radiant source.
    • Every hour, check the warmer and room temperatures and adjust the temperature setting as necessary.
    • Eight baby covers with a cellphone are used in cases of extremely low birthrates to stop convectional heat loss.
  • Positioning
    • Most babies enjoy lying prone because it makes them feel more comfortable and reduces their crying. By allowing flatus to pass through, it eases stomach discomfort and stops aspiration.
    • Baby should turn over every two hours.
  • Kangaroo mother care
    • Encourage KMC and exclusive breastfeeding if the baby is healthy. A baby will feel warmer thanks to KMC, be able to feed more easily, and experience apnea episodes less frequently.
  • Oxygen therapy
    • Only use oxygen when essential and discontinue it as soon as it becomes superfluous.
    • When Sao2 drops below 85%, O2 should administer a head box. PaO2 should be kept at 60-80% and it should be maintained at 90-95%.
    • Room FiO2 should range from 20 to 40%.
  • Feeding and nutrition
    • Sick infants should begin receiving IV dextrose solution (10% Dextrose > 1.0 kg and 5% dextrose 1.0 kg) if they weigh less than 1.2 kg or are under 30 weeks gestation.
    • All babies, regardless of age or weight, can begin receiving 1-2 ml EBM 2-3 hours per day using an NG tube (2 hours 1 kilogram and 3 hours > 1.2 kg).
    • Increase EBM dosage gradually while reducing IV drip.
    • If the baby still needs to be fed after seven days using a different feeding technique, up the amount of breast milk by 20 ml per kilogram per day until the baby is receiving 180 ml per day.
  • Nutritional supplement
    • EBM fortified with a multivitamin, folic acid, and human milk fortifier can be administered once the infant is stable and able to tolerate enteral feeding.
    • 1-2 weeks later, take an iron supplement (2–3 mg/kg of elemental iron).
    • 1 mg of vitamin E to stop hemolytic anemia.
    • supplementation with 100 mg/day of phosphorus and 220 mg/day of calcium to prevent osteopenia in 1.5 kg.
  • Gentle rhythmic situation
    • The baby receives beneficial tactile stimulation through the mother's gentle touch, massage, snuggling, stroking, and flexing.
    • Vestibular kinesthetic is provided by rocking in bed and wearing inflatable gloves to prevent apneic attacks.
    • Family voices and soothing music can help you relax during a procedure and increase your weight gain.
    • Colored objects provide visual inputs when in eye contact.
  • Prevention of nosocomial infection
    • Minimum handling of the preterm and strict hand washing before and after.
    • Effective treatment for any infection that may be present.
  • Phototherapy
    • To avoid the need for an exchange transfusion, early phototherapy is advised to maintain the serum bilirubin level within the safe range. This is because hyperbilirubinemia typically develops prematurely.
  • Factors to be avoided for preterm babies
    • Administer O2 without being observed.
    • Intravenous immunoglobulin or newborn sepsis prevention.
    • Antibiotics for prevention.
    • Administration of indomethacin and vitamin E for prevention.
    • The needless transfusion of blood
    • Feeding formula
    • Rough treatment, too much light, and sound.
  • Hypotonic posture with impaired reflexes and stretched posture brought on by weak muscles
  • Skin: very thin, gelatinous, glossy, and pink. lanugo subcutaneous and scant vernix. There could be edema. Breast nodules are minimal or nonexistent due to a lack of subcutaneous fat. There are frequently no deep sole wrinkles.
  • Face and head: Compared to the body, the head is larger and the face smaller. Fontanels are huge and sutures are widely spaced. Present micrognathia and retrognathia, protruding eye from shallow orbit, and lack of buccal fat pads Individual hair fibers can be seen, and hair appears woolly and fuzzy.
  • Looks tiny but in good health
  • Wide suture, soft skull bone, and fontanelle make up the fontanelle.
  • Ear: soft, flat ear pinna.
  • Not very deep and infrequent planter creases
  • Nails: Very soft nails with nail beds that are bright pink in color.
  • Activity: less movement of the limbs
  • Lack of or subpar sucking ability
  • Cry: a feeble, weak cry
  • Breast: no discernible breast tissue.
  • Male genitalia include undescended testes, a sparsely pigmented scrotum, and few rugosities. The female's labia majora are widely spaced apart, exposing the clitoris and labia minora.
  • Other reflexes, such as those for swallowing, sucking, and more, are absent or sluggish.

© 2021 Saralmind. All Rights Reserved.