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Care for the Premature Baby 

Babies born before the 37th week of gestation are considered premature and are

sometimes referred to as “preemies”. Mothers whose babies are born prematurely are

often scared and nervous. Premature newborns have increased risk of complications.

The risks increase the earlier the child is born. Any complications of a premature

newborn will be addressed in the neonatal intensive care unit (NICU). The following is a

brief description of what to expect in the care for a newborn preemie.

Why do premature newborns need special care?

Premature babies are not fully equipped to deal with life in our world. Their little bodiesstill have underdeveloped parts that include the lungs, digestive system, immune

system and skin. Thankfully, medical technology has made it possible for preemies to

survive the first few days, weeks or months of life until they are strong enough to make

it on their own.

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

The NICU is your newborn’s protective environment and home for a limited period.

Therefore, it is wise to become as familiar with it as possible. The NICU is equipped

with a caring staff, monitoring and alarm systems, respiratory and resuscitation

equipment, access to physicians in every pediatric specialty, 24 hour laboratory service

and YOU!

The amount of sophisticated equipment in the NICU can be overwhelming and

sometimes scary. Understanding how the various machines and equipment function can

help you relax and prevent you from losing your focus.

Moni tor ing and alarm systems  

Monitoring machines differ depending on the hospital and NICU. However, monitors are

similar in that they all record heart rate, respiratory rate, blood pressure, and

temperature. A pulse oximeter may be used to measure the amount of oxygen in the

blood. You might notice that your newborn has various sticky pads or cuffs on the chest,

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legs, arms or other parts of the body. These pads and cuffs have wires that connect to a

monitor that resembles a television screen and displays various numbers.

*Alarms are triggered periodically in the NICU. When this happens it does not

necessarily point to an emergency. More often than not it is a routine matter and nothing

to be unduly concerned about.

Methods o f respiratory assis tance (Depends on the 

 premature newborn’s individual needs) 

Endotracheal tube – This is a tube that is placed down the newborn ’s windpipe in

order to deliver warm, humidified air and oxygen.

Ventilator   – This machine is sometimes referred to as a respirator. It is the breathingmachine connected to the endotracheal tube that 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 need help getting air to their lungs.

Oxygen hood  – This a clear plastic box that is placed over the baby’s head and is

attached to a tube that pumps oxygen to the baby.

Methods of feeding (Depends on the premature newborn’sindiv id ual needs)  

Intravenous lines  – These lines carry nutrition directly into the baby’s blood stream.

They are used for premature babies who have immature digestive systems and are

unable to suck, swallow and breathe normally. This method is sometimes used when

treatment for other health complications is being implemented. This approach utilizes an

IV that may be placed in the scalp, arm or leg.

Umbilical catheter  – This painless method involves a tube that is surgically placed into

a vessel of the umbilical cord. However, there are risks associated with this method that

include infection and blood clots. Therefore, the method is normally used only in the

most critical cases and where the baby might need this type of feeding for several

weeks. For these babies, it is the safest and most effective way to receive nutrients.

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Oral and nasal feeding  – This method utilizes a narrow flexible tube that is threaded

through their nose (nasogastric tube) or mouth (orogastric tube). It is a solution for 

babies who are ready to digest breast milk or formula but not yet able to suck, swallow

and breathe in a coordinated manner.

Central line (sometimes referred to as a PICC line) - This is an intravenous line that

is inserted into a vein, often in the arm, that allows the use of a larger vein. This is a

method of delivering nutrients and medicines that might otherwise irritate smaller veins.

Other equipm ent  

Incubator  – Incubators are clear plastic cribs that keep babies warm and help protect

them from germs and noise.

Bili lights –  A bright blue fluorescent light located over the baby’s incubator used to

treat jaundice (yellowing of skin and eyes).

The Staff  

The staff usually consists of respiratory therapists, occupational therapists, dietitians,

lactation consultants, pharmacists, social workers, hospital chaplains and a

neonatologist. A neonatologist is a pediatrician with additional training in the care of sick

and premature babies. It is important to familiarize yourself with the staff. You will find

that they can be very informative and helpful.

Knowing that your newborn is receiving the best possible care will provide you comfort

and reassurance.

What is Kangaroo Care?

Kangaroo care is a technique where the premature baby is placed in an upright position

on its mother’s bare chest allowing tummy to tummy contact and positioning the baby

between the mother’s breasts. The baby’s head is turned so that its ear is positi oned

above the mother’s heart. Many studies have shown that Kangaroo Care offers

significant benefits. According to Krisanne Larimer, author of “Kangarooing Our Little

Miracles”, Kangaroo care has been shown to help premature newborns with: 

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  Body temperature – Studies have shown that a mother has thermal synchrony

with her baby and that if her baby was cold, her body temperature would

increase to warm up the baby and visa versa.

  Breastfeeding – Kangaroo care allows easy access to the breast, and skin-to-

skin contact increases milk let-down.

  Increase weight gain – Kangaroo care allows the baby to fall into a deeper sleep

allowing it to direct more energy to other bodily functions. Increased weight gain

also means shorter hospital stay.

  Increased intimacy and bonding

Breastfeeding

We have all heard how breastfeeding strengthens a baby’s immune defenses andincreases emotional connections between a mother and her baby. However, in cases

where a baby is born prematurely, a mother might not be allowed to breastfeed her 

baby. Most premature newborns, between 25-29 weeks gestational age, are fed

intravenously or through a tube. So if you are planning to breastfeed you should tell

your doctor and nurses immediately after the birth. You can then begin expressing and

storing your breast milk for the time when your baby is ready for it. The baby’s digestive

system and control of electrolytes will determine when he/she will be able to ingest

breast milk through a tube and when you can use the milk you have stored. Once the

baby’s respiratory system is stabilized it can begin breastfeeding. Most babies born 35-

37 weeks can go straight to breastfeeding.

How YOU can participate in the Neonatal Intensive Care Unit

(NICU)

There are additional ways to provide care for a baby in the NICU. Both the mother and

father are encouraged by the NICU staff to interact with their baby. As a mother or 

father you might not be aware of all the ways that you can interact with your baby. Here

are some suggestions:

1. Touch your baby as much as possible. You can do this by using a gentle touch and

stroking motions.

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2. Talk to your baby. Your baby can recognize your voice(s) and be comforted by

hearing you. Together with talking, you can read or sing to your baby.

3. Change your baby’s diaper. 

4. Par ticipate in your baby’s first bath. Depending on your baby’s progress, you maychoose washcloths or sponges.

5. Take your baby’s temperature. 

Neonatal respiratory distress syndrome

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Neonatal respiratory distress syndrome (RDS) is most commonly seen in premature infants. The

condition makes it difficult to breathe.

Causes

Neonatal RDS occurs in infants whose lungs have not yet fully developed.

The disease is mainly caused by a lack of a slippery, protective substance called surfactant, which helps

the lungs inflate with air and keeps the air sacs from collapsing. This substance normally appears in fully

developed lungs.

Neonatal RDS can also be the result of genetic problems with lung development.

The earlier a baby is born, the less developed the lungs are and the higher the chance of neonatal RDS.

Most cases are seen in babies born before 28 weeks. It is very uncommon in infants born full-term (at 40

weeks).

In addition to prematurity, the following increase the risk of neonatal RDS:

A brother or sister who had RDS

Diabetes in the mother 

Cesarean delivery

Delivery complications that reduce blood flow to the baby Multiple pregnancy (twins or more)

Rapid labor 

The risk of neonatal RDS may be decreased if the pregnant mother has chronic, pregnancy-related high

blood pressure or prolonged rupture of membranes, because the stress of these situations can cause the

infant's lungs to mature sooner.

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Symptoms

The symptoms usually appear within minutes of birth, although they may not be seen for several hours.

Symptoms may include:

Bluish color of the skin and mucus membranes (cyanosis)

Brief stop in breathing (apnea)

Decreased urine output

Grunting

Nasal flaring

Rapid breathing

Shallow breathing

Shortness of breath and grunting sounds while breathing

Unusual breathing movement -- drawing back of the chest muscles with breathing

Exams and Tests

 A blood gas analysis shows low oxygen and excess acid in the body fluids.

 A chest x-ray shows the lungs have a characteristic "ground glass" appearance, which often develops 6

to 12 hours after birth.

Lab tests are done to rule out infection and sepsis as a cause of the respiratory distress.

Treatment

High-risk and premature infants require prompt attention by a neonatal resuscitation team.

Despite greatly improved RDS treatment in recent years, many controversies still exist. Delivering artificial

surfactant directly to the infant's lungs can be enormously important, but how much should be given and

who should receive it and when is still under investigation.

Infants will be given warm, moist oxygen. This is critically important, but needs to be given carefully to

reduce the side effects associated with too much oxygen.

 A breathing machine can be lifesaving, especially for babies with the following:

High levels of carbon dioxide in the arteries

Low blood oxygen in the arteries

Low blood pH (acidity)

It can also be lifesaving for infants with repeated breathing pauses. There are a number of different types

of breathing machines available. However, the devices can damage fragile lung tissues, and breathing

machines should be avoided or limited when possible.

 A treatment called continuous positive airway pressure (CPAP) that delivers slightly pressurized air 

through the nose can help keep the airways open and may prevent the need for a breathing machine for 

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many babies. Even with CPAP, oxygen and pressure will be reduced as soon as possible to prevent side

effects associated with excessive oxygen or pressure.

 A variety of other treatments may be used, including:

Extracorporeal membrane oxygenation (ECMO) to directly put oxygen in the blood if a breathingmachine can't be used

Inhaled nitric oxide to improve oxygen levels

It is important that all babies with RDS receive excellent supportive care, including the following, which

help reduce the infant's oxygen needs:

Few disturbances

Gentle handling

Maintaining ideal body temperature

Infants with RDS also need careful fluid management and close attention to other situations, such asinfections, if they develop.

Outlook (Prognosis)

The condition often worsens for 2 to 4 days after birth with slow improvement thereafter. Some infants

with severe respiratory distress syndrome will die, although this is rare on the first day of life. If it occurs, it

usually happens between days 2 and 7.

Long-term complications may develop as a result of too much oxygen, high pressures delivered to the

lungs, the severity of the condition itself, or periods when the brain or other organs did not receive enough

oxygen.

Possible Complications

 Air or gas may build up in:

The space surrounding the lungs (pneumothorax)

The space in the chest between two lungs (pneumomediastinum)

The area between the heart and the thin sac that surrounds the heart (pneumopericardium)

Other complications may include:

Bleeding into the brain (intraventricular hemorrhage of the newborn) 

Bleeding into the lung (sometimes associated with surfactant use)

Blood clots due to an umbilical arterial catheter 

  Bronchopulmonary dysplasia 

Delayed mental development and intellectual disability associated with brain damage or bleeding

  Retinopathy of prematurity and blindness

When to Contact a Medical Professional

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This disorder usually develops shortly after birth while the baby is still in the hospital. If you have given

birth at home or outside a medical center, seek emergency attention if your baby develops any difficulty

breathing.

Prevention

Preventing prematurity is the most important way to prevent neonatal RDS. Ideally, this effort begins withthe first prenatal visit, which should be scheduled as soon as a mother discovers that she is pregnant.

Good prenatal care results in larger, healthier babies and fewer premature births.

 Avoiding unnecessary or poorly timed cesarean sections can also reduce the risk of RDS.

If a mother does go into labor early, a lab test will be done to determine the maturity of the infant's lungs.

When possible, labor is usually halted until the test shows that the baby's lungs have matured. This

decreases the chances of developing RDS.

In some cases, medicines called corticosteroids may be given to help speed up lung maturity in the

developing baby. They are often given to pregnant women between 24 and 34 weeks of pregnancy whoseem likely to delivery in the next week. The therapy can reduce the rate and severity of RDS, as well as

the rate of other complications of prematurity, such as intraventricular hemorrhage,  patent ductus

arteriosus, and necrotizing enterocolitis. It is not clear if additional doses of corticosteroids are safe or 

effective.

Alternative Names

Hyaline membrane disease; Infant respiratory distress syndrome (IRDS); Respiratory distress syndrome

in infants; RDS - infants

Pathophysiology ARDS is associated with diffuse alveolar damage (DAD) and lung capillary endothelial injury. The earlyphase is described as being exudative, whereas the later phase is fibroproliferative in character.

Early ARDS is characterized by an increase in the permeability of the alveolar-capillary barrier, leading toan influx of fluid into the alveoli. The alveolar-capillary barrier is formed by the microvascular endotheliumand the epithelial lining of the alveoli. Hence, a variety of insults resulting in damage either to the vascular endothelium or to the alveolar epithelium could result in ARDS.

The main site of injury may be focused on either the vascular endothelium (eg ,sepsis) or the alveolar epithelium (eg, aspiration of gastric contents). Injury to the endothelium results in increased capillarypermeability and the influx of protein-rich fluid into the alveolar space.

Injury to the alveolar lining cells also promotes pulmonary edema formation. Two types of alveolar epithelial cells exist. Type I cells, which make up 90% of the alveolar epithelium, are injured easily.Damage to type I cells allows both increased entry of fluid into the alveoli and decreased clearance of fluid from the alveolar space.

Type II alveolar epithelial cells are relatively more resistant to injury. However, type II cells have severalimportant functions, including the production of surfactant, ion transport, and proliferation anddifferentiation into type l cells after cellular injury. Damage to type II cells results in decreased productionof surfactant with resultant decreased compliance and alveolar collapse. Interference with the normalrepair processes in the lung may lead to the development of fibrosis.

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Neutrophils are thought to play a key role in the pathogenesis of ARDS, as suggested by studies of bronchoalveolar lavage (BAL) and lung biopsy specimens in early ARDS. Despite the apparentimportance of neutrophils in this syndrome, ARDS may develop in profoundly neutropenic patients, andinfusion of granulocyte colony-stimulating factor (G-CSF) in patients with ventilator-associatedpneumonia(VAP) does not promote its development. This and other evidence suggests that theneutrophils observed in ARDS may be reactive rather than causative.

Cytokines (tumor necrosis factor [TNF], leukotrienes, macrophage inhibitory factor, and numerousothers), along with platelet sequestration and activation, are also important in the development of ARDS. An imbalance of proinflammatory and anti-inflammatory cytokines is thought to occur after an incitingevent, such as sepsis. Evidence from animal studies suggests that the development of ARDS may bepromoted by the positive airway pressure delivered to the lung by mechanical ventilation. This is termedventilator-associated lung injury (VALI).

 ARDS expresses itself as an inhomogeneous process. Relatively normal alveoli, which are morecompliant than affected alveoli, may become overdistended by the delivered tidal volume, resulting inbarotrauma (pneumothorax and interstitial air). Alveoli already damaged by ARDS may experience further injury from the shear forces exerted by the cycle of collapse at end-expiration and reexpansion by positivepressure at the next inspiration (so-called volutrauma).

In addition to the mechanical effects on alveoli, these forces promote the secretion of proinflammatorycytokines with resultant worsening inflammation and pulmonary edema. The use of positive end-expiratory pressure (PEEP) to diminish alveolar collapse and the use of low tidal volumes and limitedlevels of inspiratory filling pressures appear to be beneficial in diminishing the observed VALI.

 ARDS causes a marked increase in intrapulmonary shunting, leading to severe hypoxemia. Although ahigh FIO2 is required to maintain adequate tissue oxygenation and life, additional measures, like lungrecruitment with PEEP, are often required. Theoretically, high FIO2 levels may cause DAD via oxygenfree radical and related oxidative stresses, collectively called oxygen toxicity. Generally, oxygenconcentrations higher than 65% for prolonged periods (days) can result in DAD, hyaline membraneformation, and, eventually, fibrosis.

 ARDS is uniformly associated with pulmonary hypertension. Pulmonary artery vasoconstriction likelycontributes to ventilation-perfusion mismatch and is one of the mechanisms of hypoxemia in ARDS.

Normalization of pulmonary artery pressures occurs as the syndrome resolves. The development of progressive pulmonary hypertension is associated with a poor prognosis.

The acute phase of ARDS usually resolves completely. Less commonly, residual pulmonary fibrosisoccurs, in which the alveolar spaces are filled with mesenchymal cells and new blood vessels. Thisprocess seems to be facilitated by interleukin (IL)-1. Progression to fibrosis may be predicted early in thecourse by the finding of increased levels of procollagen peptide III (PCP-III) in the fluid obtained by BAL.This and the finding of fibrosis on biopsy correlate with an increased mortality rate.

EtiologyMultiple risk factors exist for ARDS. Approximately 20% of patients with ARDS have no identified riskfactor. ARDS risk factors include direct lung injury (most commonly, aspiration of gastric contents),systemic illnesses, and injuries. The most common risk factor for ARDS is sepsis.

Given the number of adult studies, major risk factors associated with the development of ARDS includethe following:

  Bacteremia 

Sepsis

  Trauma, with or without pulmonary contusion

  Fractures, particularly multiple fractures and long bone fractures

Burns

Massive transfusion

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Pneumonia

Aspiration

Drug overdose

  Near drowning 

Postperfusion injury after cardiopulmonary bypass

  Pancreatitis 

Fat embolismGeneral risk factors for ARDS have not been prospectively studied using the 1994 EACC criteria.However, several factors appear to increase the risk of ARDS after an inciting event, including advancedage, female sex (noted only in trauma cases), cigarette smoking,[3] and alcohol use. For any underlyingcause, increasingly severe illness as predicted by a severity scoring system such as the Acute Physiology And Chronic Health Evaluation (APACHE) increases the risk of development of ARDS.

Genetic factors

 A study by Glavan et al examined the association between genetic variations in the FAS gene and ALIsusceptibility. The study identified associations between four single nucleotide polymorphisms andincreased ALI susceptibility.[4] Further studies are needed to examine the role of FAS  in ALI.

ARDS (Acute Respiratory Distress Syndrome) Acute respiratory distress syndrome ( ARDS) is a rapidly developing, life-threatening condition in which

the lung is injured to the point where it can't properly do its job of moving air in and out of the blood.

Doctors first recognized the syndrome in 1967, when they came across 12 people who developed

sudden breathing problems and rapid lung failure. All of them had similar patchy spots on their chest X-

rays.

 At first, the condition was called adult  respiratory distress syndrome, so people would not confuse it with a

similar type of lung distress seen in infants. But because ARDS can also occur in children aged 1 andolder, doctors now refer to it as acute respiratory distress syndrome. Acute means sudden or new.

 ARDS may also be called acute lung injury, noncardiac pulmonary edema, and increased-permeability

pulmonary edema. In the past it was also called stiff lung, wet lung, and shock lung.

 According to the National Heart Lung and Blood Institute, about 190,000 people in the U.S. develop

 ARDS each year.

What Causes ARDS?

 ARDS can occur when a major injury or extreme inflammation somewhere in the body damages the small

blood vessels including those in the lungs. As a result, the lungs are unable to fill with air and can't move

enough oxygen into the bloodstream.

The lung damage can be direct or indirect.

Conditions that can directly injure the lungs and possibly lead to ARDS include:

Breathing in smoke or poisonous chemicals Breathing in stomach contents while throwing up (aspiration)

Near drowning

  Pneumonia 

Severe acute respiratory syndrome (SARS), a lung infection

Conditions that can indirectly injure the lungs and possibly lead to ARDS include:

Bacterial blood infection (sepsis)

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Drug overdose

Having many blood transfusions

Heart-lung bypass

Infection or irritation of the pancreas (pancreatitis) 

Severe bleeding from a traumatic injury (such as a car accident)

Severe hit to the chest or head

The conditions that have most commonly been linked to ARDS include sepsis, traumatic injury, and lung

infections such as pneumonia. However, it's important to note that not everyone who has these conditions

develops ARDS. Doctors are not sure why some people develop ARDS and others do not.

What Are the Symptoms of ARDS?

Symptoms of ARDS come on suddenly, usually within hours or days of the event that initially caused

injury to the lung.

 ARDS is defined by three main signs and symptoms:

Rapid breathing

Feeling like you can't get enough air in your lungs Low oxygen levels in your blood, which can lead to organ failure and symptoms such as rapid heart rate,

abnormal heart rhythms, confusion, and extreme tiredness

Other symptoms can occur, depending on the event that caused the ARDS. For example, if pneumonia is

causing the ARDS, symptoms may also include chest pain and fever . 

 ARDS is a medical emergency. If you have symptoms of ARDS, call 911. The severe loss of oxygen can

rapidly lead to death without prompt treatment.

How Is ARDS Diagnosed?

There is no test to definitively diagnose ARDS. The doctor will perform a physical exam and listen to your 

heart and lungs using a stethoscope. If you have ARDS, your doctor will hear abnormal breathing sounds,such as wheezing or crackles.

If you have low blood oxygen levels, your  skin and lips may be a bluish color. An arterial blood gas test is

done to check the oxygen level in your blood. Low blood oxygen levels can be a sign of ARDS.

Other tests that are done to help diagnose ARDS include:

Chest X-ray to check for fluid in the air spaces in your lungs

Complete blood count and other blood tests to look for signs of infection

Sputum culture to see if bacteria or fungi are present in a sample of mucus that you coughed up from

your lungs

Lung CT scan to look for fluid in the lungs, signs of pneumonia, or other lung problems

Heart tests are also done to rule out heart failure as the cause. Heart failure can cause fluid buildup in the

lungs.

How Is ARDS Treated?

Most people who develop ARDS are very sick and already in the hospital. A person who has ARDS is

admitted to the hospital's intensive care unit (ICU).

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There is no specific treatment for ARDS. The goal is to support breathing and allow the patient's lungs to

heal. This involves the use of a breathing machine (mechanical ventilator) and supplemental oxygen.

Researchers continue to study new ways to provide patients oxygen. A study by the National Heart Lung

and Blood Institute found that smaller puffs of air from a mechanical ventilator lowered the death rate and

allowed a patient to be off the machine for more days.

It's also very important to treat the underlying cause of the ARDS. For example, if there is a bacterial

infection, antibiotics will be prescribed.

The patient will also be given fluids and nutrients through an IV or feeding tube. The fluid balance will be

carefully monitored to make sure fluid does not build up in the lungs.

The Outlook for Patients With ARDS

The survival rate for people with ARDS has improved in recent years, although doctors aren't sure why.

Some people who get ARDS make a full recovery, but others have lasting lung damage and long-term

breathing problems.

The following factors have been associated with a poor prognosis:

Active cancer  Advanced age

Bacteria blood infection (sepsis)

Being African-American

Long-term alcohol abuse

Long-term liver  disease

HIV infection

Multiple organ failure

Organ transplant

It can take many months or even years to recover from ARDS. Some people are very tired and weak after 

being on a breathing machine, and still have some shortness of breath after going home from the

hospital. Pulmonary rehabilitation is an important part of recovery. Such therapy teaches patients how toexercise their lungs and become active again. Support groups and counseling can also be helpful.

PCT Stands for Plateletcrit