care of preterm 2.docx

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CARE OF PRETERM BABY

INTRODUCTION

Prematurity accounts for the largest number of admissions to an NICU. About 10-12 percent

of Indian babies are born preterm less than !" completed #ee$s% as compared to & to "

percent incidence in the 'est. (hese infants are anatomically and functionally immature and

therefore their neonatal mortality is high.

PRETERM INFANT

)y definition* the term preterm refers to a baby born before a gestation period of !" #ee$s or

less. (his replaces the old term prematurity.

In practice and from statistical point of +ie#* it refers to a ne#born #hose birth #eight is less

than 2*&00g. ,uch a baby measures cm or less in length and has head circumference of !2cm or less. (he chest circumference is usually less than !0 cm.

CAUSES OF PREMATURITY

(he mechanisms initiating labour before term are not clearly understood. (here may be

spontaneous onset of premature labour or it may be induced by the obstetrician to safe guard

the interests of the mother or baby.

Spontaneous - (he cause of premature onset of labour is uncertain in most instances. (he

$no#n causes include poor socio-economic status* lo# maternal #eight* chronic and acutesystemic maternal diseases* antepartum hemorrhage* cer+ical incompetence* maternal genital

coloni/ation and infections* cigarette smo$ing during pregnancy* threatened abortion* acute

emotional stress* physical eertion* seual acti+ity* trauma* bicornuate uterus* multiple

pregnancy and congenital malformations. Premature births are relati+ely common among

+ery young and unmarried mothers. Past history of preterm births is associated #ith ! to

times increased ris$ of prematurity in the subseuent pregnancies.

Induced (he labour is often induced before term #hen there is impending danger to mother

or fetal life in-utero eg maternal diabetes mellitus* placental dysfunction as indicated by

unsatisfactory fetal gro#th* eclampsia* fetal hypoia* antepartum hemorrhage and se+ererhesus iso-immuni/ation

CLINICAL FEATURES

Measureents (heir si/e is small #ith relati+ely large head. Cro#n-heel length is less than

" cm* head circumference is less than !! cm but eceeds the chest circumference by more

than ! cm.

Act!"!t# and Posture (he general acti+ity is poor and their automatic refle responses*

such as 3oro response* suc$ing and s#allo#ing are sluggish or incomplete. (he baby

assumes an etended posture due to poor tone.

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Face and $ead 4ace appears small for the disproportionately large head si/e* sutures are

#idely separated and the fontanels are large. 5ther characteristic features include small chin*

protruding eyes due to shallo# orbits and absent buccal pad of fat. 5ptic ner+e is often

unmyelinated but presence of papillary membrane ma$es its +isualisation difficult. 6ar

cartilage is deficient or absent #ith poor recoil. 7air appear #oolly and fu//y and indi+idualhair fibers can be seen separately.

S%!n and Su&cutaneous T!ssues ,$in is thin* gelatinous* shiny and ecessi+ely pin$ #ith

abundant lanugo and +ery little +erni caseosa. 6dema may be present. ,ubcutaneous fat is

deficient and breast nodule is small or absent. 8eep sole creases are often not present.

'en!ta(s In males testes are undescended and scrotum is poorly de+eloped. In female

infants* labia ma9ora are #idely separated eposing labia minora and hypertrophied clitoris.

P$YSIOLO'ICAL $ANDICAPS

(he functional immaturity of +arious systems results in different clinical problems and their

$no#ledge is essential for the satisfactory management of these babies.

Centra( Ner"ous S#ste

(he immaturity of central ner+ous system central ner+ous system is epressed as inacti+ity

and lethargy* poor cough refle and incoordinated suc$ing and s#allo#ing in babies

#eighing less than 1:00 g or born before !& #ee$s of gestation. ;esuscitation difficulties at

birth and recurrent apnenic attac$s are common. ;etinopathy of prematurity due to oygen

toicity is limited to babies #ith a gestation of less than !& #ee$s. 5n the other hand* theyare more resistant to toic effect of hypoia as compared to the term babies. (hey are

etremely +ulnerable to de+elop intra+entricular < peri+entricular hemorrhage and

leucomalacia due to relati+e deficiency of +itamin = dependent coagulation factors and

increased capillary fragility. (he blood brain barrier* #hich is possibly a function of a+ailable

serum proteins* is inefficient in preterm babies* thus brain damage may occur at lo#er serum

bilirubin le+els.

Resp!rator# s#ste

(he cuboidal al+eolar lining in babies #ith a gestational age of less than 2 #ee$s results inpoor al+eolar diffusion of gases and therefore the infant may not be +iable. (hey pose

resuscitation difficulties at birth* often follo#ed by hyaline membrane disease* if associated

#ith deficiency of pulmonary surfactant. (he breathing is mostly diaphragmatic* periodic and

associated #ith intercostals recessions due to soft ribs. Pulmonary aspiration and atelectasis

are common. (hey are +ulnerable to de+elop chronic pulmonary insufficiency due to

bronchopulmonary dysplasia.

Card!o"ascu(ar s#ste

(he closure of ductus arteriosus is delayed among preterm infants. About one-third infants#ith gestational age of ! #ee$s or less manifest clinical e+idences of patent ductus

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arteriosus #ith or #ithout congesti+e heart failure. Its incidence is much higher among

preterm infants #ith hyaline membrane disease or protracted hypoia due to any cause. In

grossly immature infants less than !2 #ee$s% 6=> sho#s left +entricular preponderance.

(hey are at ris$ to de+elop thrombo-embolic complications and hypertension due to

ind#elling +enous and arterial catheters.

'astro !ntest!na( s#ste

8ue to poor or incoordinated suc$ing and s#allo#ing there are difficulties in self feeding*

although their digesti+e ability is generally good. Animal fat is not tolerated as #ell as the

+egetable fat. ;egurgitation and aspiration are common because of incoordinated suc$ing*

small capacity of stomach* incompetence of cardioesophageal 9unction and poor cough refle.

>astro- esophageal reflu and its conseuences are common. Abdominal distension and

functional intestinal obstruction are due to hypotonia. 6nterocolitis occurs #hen other factors

predisposing are present. Immaturity of glucoronyl transferase system in the li+er leads tohyperbilirubinemia* #hich may be aggra+ated by dehydration* delayed feeding and

hypoglycaemia. ;elati+ely lo# serum albumin* acidosis and hypoia in these babies

predispose to the de+elopment of $ernicterus at lo#er serum bilirubin le+els. (he poor

hepatic glycogen stores* delayed feeding* birth asphyia and respiratory distress syndrome

contribute to the de+elopment of hypoglycaemia.

T)ero-re*u(at!on

7ypothermia is in+ariable and life threatening unless en+ironmental temperature is

monitored. 6cessi+e heat loss due to relati+ely large surface area and poor generation of heatdue to paucity of bro#n fat in a baby #ho is euipped #ith an inefficient thermostat.

In+ect!ons

Infections are an important cause of neonatal mortality in lo# birth #eight babies. (he lo#

le+els of Ig> antibodies and insufficient cellular immunity predispose them to infections.

6cessi+e handling* humid and #arm atmosphere* contaminated incubators and resuscitators

epose them to infecting organisms* thus contributing to high incidence of infections.

Rena( !atur!t#

(he blood urea nitrogen is high due to lo# glomerular flltration rate. (he renal tubular

ammonia mechanism is poorly de+eloped thus acidosis occurs early. (hey are +ulnerable to

de+elop late metabolic acidosis especially #hen fed #ith a high protein mil$ formula. (he

maimum tubular diluting ability in the ne#born is satisfactory but ability to concentrate

urine is +ery poor. Preterm baby has to pass to & rn1 of urine to ecrete one milliosmole of

solute as compared to 0." rn1 by an adult for the same purpose. (herefore* the baby cannot

conser+e #ater and gets dehydrated readily. (he solute retention and lo# serum proteins

eplain occurrence of edema in some preterm infants.

To,!c!t# o+ dru*s

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Poor hepatic detoification and reduced renal clearance ma$e a preterm baby

+ulnerable to toic effects of drugs unless caution is eercised during their administration.

Nutr!t!ona( )and!caps

?o# birth #eight babies are prone to de+elop anemia around to : #ee$s of age. (his

is due to diminished total stores of iron due to short gestation. (hey may also manifestdeficiencies of folic acid and +itamin 6. @itamin 6 deficiency occurs among infants #eighing

less than 1*&00 g* particularly those fed on iron fortified mil$ formula. (hese infants are

prone to de+elop hemolytic anemia* thrombocytopenia* and edema at to 10 #ee$s of age.

@itamin 6 being an antioidant* its deficiency state may be associated #ith oygen toicity to

the +ulnerable tissues in the form of retrolental fibroplasia and bronchopulmonary dysplasia.

;apid gro#th follo#ing adeuate feeding may result in osteopenia and ric$ets unless

calcium* phosphorus and +itamin 8 are administered.

B!oc)e!ca( d!stur&ances

(hese babies are prone to de+elop hypoglycemia* hypocalcemia* hypoproteinemia* acidosis

and hypoia.

MANA'EMENT

7igh-ris$ mother should be identified early during the course of pregnancy and referred

for confinement to an appropriate health care facility #hich is euipped #ith good uality

obstetrical and neonatal care facilities. 3other is indeed an ideal trasport incubator

ARREST OF PREMATURE LABOR

Ad+ances in perinatal care including fabrication of a +ariety of electronic gadgets cannot

compare #ith uniue security and optimal care pro+ided to the fetus by the uteroplacental

unit. 6fforts should al#ays be made to arrest the progress of premature labor. (he onset of

BtrueB labor is suspected by occurrence of t#o or more uterine contractions lasting at least !0

seconds during a 1&-minute period in association #ith dilatation and effacement of cer+i.

Apart from bed rest and sedation* a +ariety of tocolytic agents are recommended but none is

entirely safe or effecti+e. 6thanol though popular at one stage is rarely used no# due to its

dangers of inebriation* +omiting* headache* flushing* restlessness* disorientation and diuresis.

3agnesium sulphate is more effecti+e and is being increasingly used though there is a

potential ris$ of respiratory depression in the ne#born. (he obser+ational studies ha+e sho#n

that maternal treatment #ith magnesium sulfate is associated #ith reduced ris$ ofN7*

cerebral palsy and mental retardation in their preterm babies.

,ympathomimetic agents specifically mediating +ia beta 2-adrenergic receptors are po#erful

tocolytic agents and currently used. Isosuprine du+adilan% is useful but its effect is

mediated both through beta-1 and beta-2 receptors. Its use is associated #ith unto#ard beta-l

receptor side effects such as apprehension* palpitation* hypotension* fetal tachycardia and

neonatal hypoglycemia. (herapy is initiated by intra+enous infusion of 20 mg isosuprine

diluted in 200 ml of & percent detrose at a rate of 0-&0 dropsminute. (his is follo#ed byintramuscular administration of 10 mg isosuprine e+ery hours for 2 and : hours. 5ral

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therapy is continued for at least 2 #ee$s #ith maintenance doses of 10 mg e+ery hours.

;itodrine has been appro+ed by U, 4ood and 8rug Administration for treatment of

premature labor andBis more effecti+e than ethanol. (he common side effects are maternal and

fetal tachycardia. (he usual dose is 100-00 ugminute intra+enously through an infusion

pump for a period of 12 hours follo#ed by oral ritodrine 10 mg e+ery 2 hours. ,albutamoland terbutaline are selecti+e beta 2-receptor stimulators and are +ery effecti+e tocolytic

agents. (hey are generally safe but an occasional patient may de+elop tachycardia and

pulmonary edema. (erbutaline is administeredD as an intra+enous bolus of 0.2& mg follo#ed

by constant infusion of 10-:0 ugminute for 1-2 hours. After control of uterine contractions*

maintenance therapy is continued by administration of 0.2& mg of terbutaline subcutaneously

or 2.& mg orally% e+ery hours. Indomethacin* an irihibitor of prostaglandin-synthetase has

also offered some hope in arresting premature uterine contractions. It must be used #ith

caution because it may also bloc$ production of prostaglandin 6 thus mar$edly decreasing

uteroplacental perfusion and may cause closure of ductus arteriosus.

INDUCTION OF PREMATURE LABOR

'hen induction of labor is contemplated before term* either in the interest of mother or

the fetus* maturity of fetus should be ascertained by eamination of amniotic fluid for

phosphatidyl glycerol or ?I, ratio. As far as possible* deli+ery should be postponed till fetal

pulmonary maturity is assured. 'hen deli+ery can be safely delayed for ! to : hours*

corticosteroids should be administered to the mother to enhance fetal lung maturity.

ANTENATAL CORTICOSTEROIDS

Antenatal administration of corticosteroids is one of the most cost-effecti+e perinatal

strategies #hich must be uni+ersally eploited. It is associated #ith &0 percent reduction in

the incidence of ;8, due to surfactant deficiency. It pro+ides additional benefits by reducing

the incidence of intra+entricular hemorrhage and necroti/ing enterocolitis. (he o+er all

neonatal mortality is reduced by 0 percent by this simple and cheap inter+ention. In9ection

betamethasone 12 mg 13 e+ery 2 hours for 2 doses or deamethasone mg 13 e+ery 12

hours for doses should be administered to the mother if labor starts or is induced before !

#ee$s of gestation. )etamethasone is more potent and is associated #ith reduced ris$ of side

effects. (hy optimal effect is seen if deli+ery occurs after 2 hours of the initiation of therapy

and its therapeutic effect lasts for " days. (he beneficial effects are better in female babies

compared to the male. (he need and safety of repeat courses of antenatal steroids is

contro+ersial and is under in+estigation by multicentric clinical trials. (ocolytic therapy

should be continued concoplitantly. Corticosteroids can be gi+en e+en in the presence of

maternal hypertension or diabetes mellitus but should preferably be a+oided if preterm

premature rupture of membranes PP;53% is associated #ith definiti+e clinical e+idences of

chorioamnionitis.

CARE OF PRETERM BABIES

OPTIMAL MANA'EMENT AT BIRT$

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'hen a preterm baby is anticipated* the deli+ery should be attended by a senior pediatrician*

fully prepared to resuscitate the baby. (he delayed clamping of cord helps in impro+ing the

iron stores of the baby. It may also reduce the incidence and se+erity of hyaline membrane

disease. 6lecti+e intubation of etremely ?)' babies E 1000g% is practised in some centers

to support breathing and for prophylactic administration of eogenous surfactant. (he babyshould be promptly dried* $ept effecti+ely co+ered and #arm. @itamin = 1.0 mg 0.& mg in

babies E 1&00 g% should be gi+en intramuscularly. (he baby should be transferred by the

doctor or nurse not a nursing orderly% to the NICU as soon as breathing is established.

MONITORIN'

(he follo#ing clinical parameters should be monitored by specially trained nurses. (he

freuency of monitoring depends upon the gestational maturity and clinical status of the baby.

@ital signs #ith the help of multi-channel +ital sign monitor non-in+asi+e #ith

alarms%

Acti+ity and beha+iour

Colour Pin$* pale* grey* blue* yello#

(issue perfusion - Adeuate tissue perfusion is suggested by pin$ colour* capillary

refill o+er upper chest of E 2 sec* #arm and pin$ etremities* normal blood pressure*

urine output of F 1.& ml$ghr* absence of metabolic acidosis and lac$ of any disparity

bet#een pa02 and* ,a02 4luids* electrolytes and A)>Bs

(olerance of feeds by monitoring +omiting* gastric residuals* abdominal girth

(he baby should be #atched for de+elopment of ;8,* apneic attac$s* sepsis* P8A*

N6C* I@7 etc.

'eight gain +elocity

CRITERIA FOR A $EALT$Y PRETERM BABY

8uring daily clinical e+aluation of a preterm baby* the follo#ing clinical characteristicsshould be loo$ed for because they suggest that the baby is healthy. (he +ital signs should be

stable. (he healthy baby is alert and acti+e* loo$s pin$ and healthy smells good too%* trun$ is

#arm to touch and etreinities are reasonably #arm and pin$. (he baby is able to tolerate

enteral feeds and there is no respiratory distress or apneic attac$s and baby is ha+ing a steady

#eight gain of 1.0 -1.& percent of his body #eight 10-1& g$gd% e+ery day.

PROIDE IN-UTERO MILIEU

Uterus pro+ides ideal ambient conditions to the baby. All attempts should be made to create

uterus-li$e baby friendly ecology in the nursery.

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Create a soft* comfortable* GnestledG and cushioned bed.

A+oid ecessi+e light* ecessi+e sound* rough handling and painful procedures. Use

effecti+e analgesia and sedation for conducting procedures.

Pro+ide #armth

6nsure asepsis Pre+ent e+aporati+e s$in losses by effecti+ely co+ering the baby* application of oil or

liuid paraffin to the s$in and increasing humidity to near 100 percent. .

Pro+ide effecti+e and safe oygenation

Uterus is able to pro+ide uniue parenteral nutrition. 6fforts should be made to

pro+ide at least partial parentral nutrition and gi+e trophic feeds #ith epressed breast

mil$ 6)3%.

Pro+ide rhythmic gentle tactile and $inesthetic stimulation li$e s$in-to-s$in contact*

interaction* music* caressing and cuddling.

POSITION OF T$E BABY

3ost babies lo+e to lie in a prone position* they cry less and feel more comfortable. It

relie+es abdominal discomfort by passage of flatus and reduces ris$ of aspiration. Prone

posture impro+es +entilation* increases dynamic lung compliance and enhances arterial

oygenation. Unsuper+ised prone positioning* beyond neonatal period* has been recogni/ed

as a ris$ factor for ,I8,.

T$ERMAL COMFORT

A pre-#armed open care system or incubator should be a+ailable at all times to recei+e any

baby #ith hypothermia or #ith a birth #eight of less than 2000 g. (he baby should be nursed

in a thermoneutral en+ironment #ith a ser+o sensor geared to maintain s$in temperature of

mid-epigastric region at !.& HC so that there is +irtually no or minimal metabolic

thermogenesis. Application of oil or liuid paraffin on the s$in reduces con+ecti+e heat loss

and e+aporati+e #ater losses. (he etremely ?)' baby should be co+ered #ith a cellophaneor thin transparent plastic sheet to pre+ent con+ecti+e heat loss and e+aporati+e losses of

#ater from s$in. As soon as babyBs condition stabili/es he should be co+ered #ith a perspe

shield or effecti+ely clothed #ith a froc$* cap* soc$s and mittens. After one #ee$ or so* stable

babies #ith a birth #eight of E 1200g should preferably be nursed in an intensi+e care

incubator. It is associated #ith reduced chances of handling* better temperature control*

reduced e+aporati+e losses from s$in and better #eight gain +elocity. (he mother should be

encouraged to pro+ide partial $angaroo-mother-care to pre+ent hypothermia* to promote

bonding and breast feeding and to transmit healing electromagnetic +ibrations of lo+e and

compassion to her baby.

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O.Y'EN T$ERAPY

5ygen should be administered only #hen indicated* gi+en in the lo#est ambient

concentration and stopped as soon as its use is considered unnecessary. It is difficult to 9udge

the need for oygen therapy on clinical grounds in preterm babies. (he oygen should be

administered #ith a head bo #hen ,a02 falls belo# :& percent and it should be gradually

#ithdra#n #hen ,a52goes abo+e 0 percent. (he lo#est ambient concentration and flo#

rates should be used to maintain ,a02bet#een :&J-&J and pa02bet#een 60-80 mm 7g.

P$OTOT$ERAPY

Kaundice is common in preterm babies due to hepatic immaturity* hypoia* hypoglycemia*

infections and hypothermia. 8ue to immaturity of blood brain barrier* hypoproteinemia and

perinatal distress factors* bilirubin brain damage may occur at relati+ely lo#er serum

bilirubin le+els. 6arly phototherapy is ad+ised to $eep the serum bilirubin le+el #ithin safelimits inorder to ob+iate the need for echange blood transfusion. .

PREENTION OF NOSOCOMIAL INFECTIONS

A preterm baby* #ho sur+i+es the initial stormy and unstable period of one #ee$* is li$ely to

do #ell if protected against infections and pro+ided #ith adeuate nutrition. (he handling

should be reduced to bare minimum. @igilance should be maintained on all procedures

recommended for reduction of infections in the nursery. 7igh inde of suspicion* early

diagnosis and effecti+e treatment of infections are essential for impro+ed sur+i+al.

FEEDIN' AND NUTRITION

,tar+ation should be a+oided and early enteral feeding should be established as soon as the

baby is stable. )abies #eighing less than 1200 g or gestation of E !0 #ee$s and sic$ babies

se+ere birth asphyia* ;8,* sepsis* sei/uresL apneic attac$s* assisted +entilation etc.% should

be started on intra+enous detrose solution l0J detrose in babiesFB1000 g and &J detrose

in babies E 1000 g%. (rophic feeds #ith 6)3 1-2 ml timesd% through a nasogastric tube

can be started in all babies irrespecti+e of their birth #eight or clinical condition to harness its

uniue benefits. 'hen babyBs condition is stabili/ed enteral feeds are begun #ith 6)3

starting #ith a +olume of !0 ml$gd on the first day and depending upon the tolerance* theenteral feeds are increased by 10-20 ml$gd e+ery day and intra+enous fluids are reduced

accordingly.

NUTRITIONAL SUPPLEMENTS

After t#o #ee$s #hen baby is stable and tolerating enteral feeds* 6)3 can be fortified #ith

human mil$ fortifier 734%. (he fortification of 6)3 #ith formula feeds especially during

night% also pro+ides additional calories and protein to the baby. 3ulti+itamin drops

containing folic acid should be started at t#o #ee$s of age. Iron supplementation 2-! mg$g

elemental iron% should be started after 2-! #ee$s #hen baby is ha+ing steady #eight gain.4ree radical lipid peroidation in cell membranes is cataly/ed by iron and polyunsaturated

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fatty acids PUPA% thus increasing the reuirements of +itamin 6 in +ery lo# birth #eight

babies. (he reuirements of +itamin 6 areL therefore* related to linoleic acid content of the

fonnula.D It is recommended that +itamin 6 to linoleic acid ratio should be greater than 1.0

iulgram of linoleic acid yitamin 6 1.0 i.u. M 1.0 mg% in the feeding fonnula for ?)' babies*

(he alpha tocopherolllinoleic acid ratios ate .2!* 1.! and 0.": mgg iKOpman colostrumtrllsitional and mature mil$ respecti+ely. @itamin Iiisa po#erful antioidant and pre+ents

the hemolytic anemia and edema of prematurity. In infants #eighing less than 1&00 g at

birth* mil$ fonnula should pro+ide at least 1.0 i.u. of +itamin 6 per gram of.linoleicacid and

supplemented #ith daily administration of 1& ?u. of +itamin 6. ,upplements of calcium

220 mgd% and phosphorus 100 mgd%Bare essential to Bpre+ent osteopeniaofprematurity. (he

supplements are continued till the baby has achie+ed post conceptional maturity of !: #ee$s

or #eight of 2000 g.

'ENTLE R$YT$MIC STIMULATION

A+ailability of sophisticated high technology has re+olutioni/ed the care of pretenn and sic$

ne#born babies. )ut the technology should not be allo#ed to become a barrier bet#een the

communication* compassion and concern of the treating team and the family* >entle touch*

massage* cuddling* stro$ing and fleing by the nurse or preferably by the mother pro+ide

useful tactile stimuli to the baby. ;oc$ing bed or placing a pretenn baby on inflated glo+es

rhythmically roc$ed by a +entilator pro+ide useful +estibular-$inesthetic stimuli for

pre+ention of apneic attac$s ofprematurity. ,oothing auditory stimuli can be gi+en to the

pretenn baby in the fonnof taped heart beats* family +oices or music. 3usic has been sho#n

to reduce the stress of procedure andehhance #eight gain +elocity of pretenn babies. @isual

inputs can be pro+ided #ith the help of colored ob9ects* diffuse light and eye-to-eye contact.

UTILITY OF CORTICOSTEROIDS

Unnecessary administration of corticosteroids should be a+oided due t its potential side

effects. Antenatal administration ofB betamethasone or deamethasone is uni+ersally

recommended if labour starts before ! #ee$s of gestation. A single dose of deamethasone

0.2 mg$g I@ at hours of age may be gi+en to +ery ?)' babies E 1&00 g% to reduce the

incidence and se+erity of 738 and I@7* but its use is contro+ersial. Corticosteroids o

indicated to assist the process of difficult #eaning follo#ing prolonged assisted +entilation

and for attenuation of inflammatory changes in infants #ith bronchopulmonary dysplasia.

Inhaled steroids ha+e not been found to be useful to reduce the ris$ of chronic lung disease

C?8%. Corticosteroids ha+e some therapeutic utility in the management of sclerema

neonatorum. (hey ha+e no role in the management of. hypoic-ischemic encephalopathy*

sepsis* meningitis and meconium aspiration syndrome. (here is increasing e+idence to

suggest that prolonged use of corticosteroid therapy should be a+oided in ne#born babies

because of serious concerns for short term 7ypertension* hyperglycemia* >I bleeding*

infections% and long term cerebral palsy and neuromotor disability% side effects.

TRANSIENT $YPOT$YRO.INEMIA OF PREMATURITY

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In preterm babies belo# !0 #ee$s gestation* total (le+els may be lo# but free (* (! and

(,7 le+els are usually normal. (he condition is transient and is attributed to a normal

adapti+e response of an immature hypothalamic-pituitary ais or to sic$ euthyroid syndrome.

Its clinical significance is contro+ersial. (he current Cochrane Neonatal Collaborati+e

;e+ie# does not recommend routine ( supplementation in preterm babies.

PRIORITY PACKAGES AND EVIDENCE-BASED INTERVENTIONS

All ne#born babies are +ulnerable gi+en that birth and the follo#ing fe# days hold the

highest concentrated ris$ of death of any time in the human lifespan. 6+ery baby needs

essential ne#born care* ideally #ith their mothers pro+iding #armth* breastfeeding and a

clean en+ironment. Premature babies are especially +ulnerable to temperature instability*

feeding difficulties* lo# blood sugar* infections and breathing difficulties. (here are also

complications that specifically affect premature babies. ,a+ing li+es and pre+enting disability

from preterm birth can be achie+ed #ith a range of e+idence-based care increasing incompleity and ranging from simple care such as #armth and breastfeeding up to full

intensi+e care. (he pac$aged inter+entions in this chapter are adapted from a recent etensi+e

e+idence re+ie# and a consensus report* 6ssential Inter+entions Commodities and

>uidelines for ;eproducti+e 3aternal* Ne#born and Child 7ealthQ P3NC7* 2011%.

;ecognition of small babies and distinguishing #hich ones are preterm are essential first

steps in prioriti/ing care for the highest ris$ babies. (he highest-ris$ babies are those that are

both preterm and gro#th restricted.

PAC/A'E 01 ESSENTIAL AND E.TRA NE2BORN CARE

Care at birth from a s$illed pro+ider is crucial for both #omen and babies and all pro+iders

should ha+e the competencies to care for both mother and baby* ensuring that mother and

baby are not separated unnecessarily* promoting #armth* early and eclusi+e breastfeeding*

cleanliness and resuscitation if reuired '75* 2010%. (hese practices are essential for full-

term babies* but for premature babies* missing or delaying any of this care can rapidly lead to

deterioration and death. 4or all babies at birth* minutes count.

T)era( care

,imple methods to maintain a babyRs temperature after birth include drying and #rapping*

increased en+ironmental temperature* co+ering the babyRs head* s$in-to-s$in contact #ith the

mother and co+ering both #ith a blan$et. 8elaying the first bath is promoted* but there is a

lac$ of e+idence as to ho# long to delay* especially if the bath can be #arm and in a #arm

room. =angaroo 3other Care =3C% has pro+en mortality effect for babies E2*000 g.

6uipment-dependent #arming techniues include #arming pads or #arm cots* radiant

heaters or incubators and these also reuire additional nursing s$ills and careful monitoring.

,leeping bags lac$ e+idence for comparison #ith s$in to- s$in care or of large-scale

implementation. (here are se+eral trials suggesting benefit for plastic #rappings but* to date*

these ha+e been tested only for etremely premature babies in neonatal intensi+e care units.

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Feed!n* support

At the start of the 20th century* Pierre )udin* a famous 4rench obstetrician* led the #orld in

focusing on the care of #ea$lings*Q as premature babies #ere $no#n then. 7e promoted

simple care--#armth* breastfeeding and cleanliness. 7o#e+er* by the middle of the 20th

century* formula mil$ #as #idely used and the standard tet boo$s said that premature babiesshould not be fed for the first fe# days. After 10* the resurgence of attention and support

for feeding of premature babies #as an important factor in reducing deaths before the ad+ent

of intensi+e care. 6arly initiation of breastfeeding #ithin one hour after birth has been sho#n

to reduce neonatal mortality. Premature babies benefit from breast mil$ nutritionally*

immunologically and de+elopmentally .(he short-term and long-term benefits compared #ith

formula feeding are #ell established #ith lo#er incidence of infection and necroti/ing

enterocolitis and impro+ed neurode+elopmental outcome. 3ost premature babies reuire

etra support for feeding #ith a cup* spoon or another de+ice such as gastric tubes either oral

or nasal%. In addition* the mother reuires support for epressing mil$. 'here this is not

possible* donor mil$ is recommended. In populations #ith high 7I@ pre+alence* feasible

solutions for pasteurisation are critical. 3il$-ban$ing ser+ices are common in many countries

and must be monitored for uality and infection pre+ention. 6tremely preterm babies under

about 1*000 g and babies #ho are +ery un#ell may reuire intra+enous fluids or e+en total

parenteral nutrition* but this reuires meticulous attention to +olume and flo# rates. ;outine

supplementation of human mil$ gi+en to premature babies is not currently recommended by

'75. '75 does recommend supplementation #ith +itamin 8* calcium and phosphorus and

iron for +ery lo# birth #eight babies and +itamin = at birth for lo# birth #eight babies.

In+ect!on pre"ent!on

Clean birth practices reduce maternal and neonatal mortality and morbidity from infection-

related causes* including tetanus. Premature babies ha+e a higher ris$ of bacterial sepsis.

7and cleansing is especially critical in neonatal care units. 7o#e+er basic hygienic practices

such as hand #ashing and maintaining a clean en+ironment are #ell $no#n but poorly done.

Unnecessary separation from the mother or sharing of incubators should be a+oided as these

practices increase spread of infections. 4or the poorest families gi+ing birth at home* the use

of clean birth $its and impro+ed practices ha+e been sho#n to reduce mortality.

;ecent cluster-randomi/ed trials ha+e sho#n some benefit from chlorheidine topicalapplication to the babyRs cord and no identified ad+erse effects. (o date* about half of trials

ha+e sho#n a significant neonatal mortality effect especially for premature babies and

particularly #ith early application* #hich may be challenging for home births.

Another possible benefit of chlorheidine is a beha+iour change agent S in many cultures

around the #orld* something is applied to the cord and a policy of chlorheidine application

may accelerate change by substituting a helpful substance for harmful ones.

(he s$in of premature babies is more +ulnerable* and is not protected by +erni li$e a term

babyRs. (opical application of emollient ointment such as sunflo#er oil reduces #ater loss*dermatitis and ris$ of sepsis and has been sho#n to reduce mortality for preterm babies.

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Another effecti+e and lo# cost inter+ention is appropriate timing for clamping of the

umbilical cord* #aiting 2-! minutes or until the cord stops pulsating* #hilst $eeping the baby

belo# the le+el of the placenta. 4or preterm babies this reduces the ris$ of intracranial

bleeding and need for blood transfusions as #ell as later anemia. Possible tension bet#eendelayed cord clamping and acti+e management of the !rd stage of labor #ith controlled cord

traction has been debated* but the Cochrane re+ie# and also recent-e+idence statements by

obstetric societies support delayed cord clamping for se+eral minutes in all uncomplicated

births.

PAC/A'E 31 NEONATAL RESUSCITATION

)et#een & to 10J of all ne#borns and a greater percentage of premature babies reuire

assistance to begin breathing at birth. )asic resuscitation through use of a bag-and-mas$ or

mouth-to-mas$ tube and mas$% #ill sa+e four out of e+ery fi+e babies #ho need

resuscitationL more comple procedures* such as endotracheal intubation* are reuired only

for a minority of babies #ho do not breathe at birth and #ho are also li$ely to need ongoing

+entilation. ;ecent randomi/ed control trials support the fact that in most cases assisted

+entilation #ith room air is eui+alent to using oygen* and unnecessary oygen has

additional ris$s. 6pert opinion suggests that basic resuscitation for preterm births reduces

preterm mortality by about 10J in addition to immediate assessment and stimulation. An

education program entitled 7elping )abies )reathe has been de+eloped by the American

Academy of Pediatrics and partners for promotion of basic neonatal resuscitation at lo#er

le+els of the health system in lo#-resource settings and is currently being scaled up in o+er

!0 lo#-income countries and promises potential impro+ements for premature babies

PAC/A'E 41 /AN'AROO MOT$ER CARE

=3C #as de+eloped in the 1"0s by a Colombian pediatrician* 6dgar ;ey* #ho sought a

solution to incubator shortages* high infection rates and abandonment among preterm births

in his hospital. (he premature baby is put in early* prolonged and continuous direct s$in-to-

s$in contact #ith her mother or another family member to pro+ide stable #armth and to

encourage freuent and eclusi+e breastfeeding. A systematic re+ie# and meta analysis of

se+eral randomi/ed control trials found that =3C is associated #ith a &1J reduction in

neonatal mortality for stable babies #eighing E2*000g if started in the first #ee$* compared toincubator care. (hese trials all considered facility-based =3C practice #here feeding support

#as a+ailable. An updated Cochrane re+ie# also reported a 0J reduction in ris$ of post-

discharge mortality* about a 0J reduction in neonatal infections and an almost :0J

reduction in hypothermia. 5ther benefits included increased breastfeeding* #eight gain*

mother-baby bonding and de+elopmental outcome. In addition to being more parent and baby

friendly* =3C is more health-system friendly by reducing hospital stay and nursing load and

therefore gi+ing cost sa+ings. =3C #as endorsed by the '75 in 200! #hen it de+eloped a

program implementation guide. ,ome studies and program protocols ha+e a lo#er #eight

limit for =3C* e.g.* not belo# :00g* but in contets #here no intensi+e care is a+ailable*some babies under :00g do sur+i+e #ith =3C and more research is reuired before setting a

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lo#er cut off. 8espite the e+idence of its cost effecti+eness* =3C is underutili/ed although it

is a rare eample of a medical inno+ation mo+ing from the ,outhern hemisphere* #ith recent

rapid upta$e in neonatal intensi+e care units in Europe.

PAC/A'E 51 SPECIAL CARE OF PREMATURE BABIES ANDP$ASED SCALE UP OF NEONATAL INTENSIE CARE

3oderately-premature babies #ithout complications can be cared for #ith their mothers on

normal postnatal #ards or at home* but babies under !2 #ee$s gestation are at greater ris$ of

de+eloping complications and #ill usually reuire hospital admission. 4e#er babies are born

under 2: #ee$s of gestation and most of these #ill reuire intensi+e care.

Care o+ &a&!es 6!t) s!*ns o+ !n+ect!on

Impro+ed care in+ol+es early detection of such danger signs and rapid treatment of infection*

#hile maintaining breastfeeding if possible. Identification is complicated by the fact that ill

premature babies may ha+e a lo# temperature* rather than fe+er. 4irst le+el management of

danger signs in ne#borns has relati+ely recently been added to Integrated 3anagement of

Childhood Illness guidelines. '75 recommends that all babies #ith danger signs be referred

to a hospital. 'here referral is not possible* then treatment at the primary care center can be

lifesa+ing.

Care o+ &a&!es 6!t) 7aund!ce

Premature babies are at increased ris$ of 9aundice as #ell as infection* and these may occur

together compounding ris$s for death and disability. ,ince se+ere 9aundice often pea$s

around day !* the baby may be at home by then. Implementation of a systematic pre

discharge chec$ of #omen and their babies #ould be an opportunity to pre+ent complications

or increase care see$ing* ad+ising mothers on common problems* basic home care and #hen

to refer their baby to a professional.

Ba&!es 6!t) Resp!rator# D!stress S#ndroe

4or premature babies #ith ;8,* methods for administering oygen include nasal prongs* or

nasal catheters. ,afe oygen management is crucial and any baby on continuous oygen

therapy should be monitored #ith a pulse oimeter. (he basis of neonatal care of +ery

premature babies since the 10s #as assisted +entilation. 7o#e+er* reducing se+erity of

;8, due to greater use of antenatal corticosteroids and increasing concerns about lung

damage prompted a shift to less intensi+e respiratory support* notably CPAP commonly using

nasal prongs to deli+er pressuri/ed* humidified* #armed gas air andor oygen% to reduce

lung and al+eoli collapse. (his model of lo#er intensity may be feasible for #ider use in

middle-income countries and for some lo#-income countries that ha+e referral settings #ith

stronger systems support such as high-staffing* 2-hour laboratories.

;ecent trials ha+e demonstrated that CPAP reduces the need for positi+e pressure +entilationof babies less than 2: #ee$s gestation* and the need for transfer babies under !2 #ee$s

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gestation to neonatal intensi+e care units. 5ne +ery small trial in ,outh Africa comparing

CPAP #ith no +entilation among babies #ho #ere refused admission to neonatal intensi+e

care units found CPAP reduced deaths. In 3ala#i* a CPAP de+ice de+eloped for lo#-resource

settings is being trialed in babies #ith respiratory distress #ho #eigh o+er 1*000g. 6arly

results are encouraging* and an important outcome #ill be to assess the nursing time reuiredand costs.

Increasing use of CPAP #ithout regulation is a concern. 3any de+ices are in the

homemadeQ categoryL se+eral lo# cost bubble CPAP de+ices are being de+eloped

specifically for lo#-income countries but need to be tested for durability* reliability and

safety. CPAP-assisted +entilation reuires adeuate medical and nursing s$ill to apply and

deli+er safely and effecti+ely* and also reuires other supporti+e euipment such as an

oygen source* oygen monitoring de+ice and suction machine.

,urfactant is administered to premature babyRs lungs to replace the missing natural surfactant*

#hich is one of the reasons babies de+elop ;8,. (he first trials in the 1:0s demonstrated

mortality reduction in comparison to +entilation alone. (he cost also remains a significant

barrier. In India* surfactant costs up to T00 for a dose. 8ata from India and ,outh Africa

suggest that surfactant therapy is restricted to use in babies #ith potential for better sur+i+al*

usually o+er 2: #ee$sR gestation due to its high price. Costs may be reduced by synthetic

generics and simplified administration* for eample #ith an aerosoli/ed deli+ery system* but

before #ide upta$e is recommended* studies should assess the additional li+es sa+ed by

surfactant once antenatal corticosteroids and CPAP are used.

PREENTION8 EARLY DIA'NOSIS AND PROMPT MANA'EMENT

OF COMMON PROBLEMS

Nosoco!a( !n+ect!ons - 7ouse $eeping rituals* strict house $eeping routines and high inde

of suspicion should be maintained to pre+ent and ma$e early diagnosis of nosocomial

infections.

$#pot)er!a- Nurse in a thermoneutral en+ironment.

Resp!rator# d!stress s#ndroe< Antenatal administration of corticosteroids* pre+ention

and effecti+e treatment of perinatal distress* prophylactic administration of eogenoussurfactant to reduce the incidence and se+erity of hyaline membrane disease 738%.

Asp!rat!on- A+ailability of trained nurses is essential for safe administration of enteral

feeds and for pre+ention of aspiration of feeds.

Patent ductus arter!osus- A+oid o+er infusion.

C)ron!c (un* d!sease - 8uring assisted +entilation* air#ay pressure should be $ept at the

bare minimum #ithout compromisinggas echange. In infants E 1000 g* administration of

+itamin A &000units I3 !times in a #ee$ for #ee$s has been sho#n to reduce the ris$ of

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C?8 by 10 percent. Corticosteroids should preferably be a+oided or only short courses

should be used due to potential ris$ of causing neuromotor disability.

Necrot!9!n* enteroco(!t!s- 6nsure feeding #ith human mil$* trophic feeds a+oidance of

hyperosmolar feeds and o+er infusion.

Intra"entr!cu(ar )eorr)a*e- Antenatal corticosteroids* a+oidance of rough handling*

ecessi+e CPAP and bolus administration of sodium bicarbonate may reduce the incidence of

I@7.

Ret!nopat)# o+ preatur!t#< 3aintain pa52belo# 0 mm 7g* a+oid ecessi+e light* blood

transfusions and ensure feeding #ith human mil$.

Late eta&o(!c ac!dos!s- Protein inta$e should be restricted to !g$gd and a+oid use of

formula feeds.

Nutr!t!ona( d!sorders- Pro+ide supplements #ith calcium* phosphorus* +itamin 8* +itamin

6* iron and folic acid.

Dru* to,!c!t#- ,ide effects of drugs can be reduced by gi+ing lo#er doses at 12 hourly

inter+als

2EI'$T CONTROL

Accurate #eighing of babies is a sensiti+e inde of their #ell being. (he #eight is routinely

recorded e+ery day but in sic$ babies t#ice daily #eight record is recommended. 3ost

preterm babies lose #eight during the first ! to days of life and loss is upto a maimum of

10 to 1& percent of the birth #eight. (he #eight remains stationary for the net to & days

and then the babies start gaining at a rate of 1.0 to 1.& percent of body #eight 10-1&

g$gd% per day. (hey regain their birth #eight by the end of second #ee$ of life. 6cessi+e

#eight loss* delay in regaining the birth #eight or slo# #eight gain suggest that either the

baby is not being fed adeuately or he is un#ell and needs immediate attention. ,udden

#eight loss in a baby #ho had been gaimng #eight satisfactorily #ould suggest the

possibility of dehydration. 6cessi+e #eight gain of 100 g or more per day may occur in

babies #ith cardiac failure though sometimes healthy babies may also gain #eight more

rapidly.

2$AT TO AOID IN T$E CARE OF PRETERM BABIES:

In the care of preterm babies* at times greater harm is done by unnecessary therapeutic

inter+entions #hich may lead to iatrogenic disorders. (he follo#ing inter+entions should be

a+oided because they are unnecessary* useless and often associated #ith serious side effects.

;outine oygen administration #ithout monitoring.

Intra+enous immunoglobulins for pre+ention of neonatal sepsis.

Prophylactic antibiotics ecept during assisted +entilation%

Prophylactic administration of indomethacin or high doses of +itamin 6

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Unnecessary blood transfusions 8efinite indications include hematocrit of E 0J in

a sic$ neonate* E !0J in a symptomatic neonate and E 2&J in an asymptomatic

neonate%.

4ormula feeds

;ough handling* ecessi+e light arid loud sound.

IMMUNI;ATIONS

Preterm babies are able to mount a satisfactory immune response and they can be +accinated

at the usual chronological age li$e term babies. (he dose of +accine is not reduced in preterm

babies. 7o#e+er* there is some e+idence to suggest that administration of hepatitis ) +accine

in preterm infants is associated #ith lo# sero con+ersion rate. )ecause during their stay in the

NICU* there is no ris$ of contracting +accine-pre+entable diseases* it is desirable to

administer 0-day +accines )C>* 5P@L 7)@% on the day of discharge from the hospital. (hispolicy seems more logical and appropriate to ensure satisfactory immune response against

+arious +accines. 7o#e+er* if mother is 7)@ carrier and is e-antigen positi+e* baby should

be gi+en hepatitis ) +accine and hepatitis ) specific immunogiobulins #ithin "2 hours of

age. ?i+e +accines should be a+oided in symptomatic 7I@-positi+e babies. '75

recommends that )C> and oral polio +accine can be gi+en to asymptomatic 7I@- positi+e

infants.

FAMILY SUPPORT

(he prolonged stay of preterm and sic$ ne#born babies in the NICU is associated #ith

emotional trauma* uncertainty* aniety and lac$ of bonding #ith the baby on the part of

parents. (he family dynamics are greatly disturbed apart from tremendous physical stress

and* fiscal implications due to high cost of neonatal intensi+e care. (hese issues and

problems should be handled #ith euanimity* compassion* concern and caring attitude of the

health team. (he frightening scene of NICU should be demystified and family* should be

constantly informed and in+ol+ed in the care of their baby. (he mother should be encouraged

to touch and tal$ #ith her baby and pro+ide routine care under* the guidance of nurses. ,he

should be assisted to pro+ide partial $angaroo-mother care to her baby in the NICU #hich

#ould enhance bonding and promote breast feeding. ,he should pro+ide +isual and auditorystimuli to her baby and try to establish eye-to-eye contact. (he aniety and concern of the

family should be cushioned by pro+iding necessary emotional support and guidance.

TRANSFER FROM INTUBATOR TO-COT

A baby #ho is feeding from the bottle or cup and spoon and is reasonably acti+e #ith a stable

body temperature* irrespecti+e of his #eight* ualifies for transfer to the open cot. (he baby

should be obser+ed for another 12 hours after putting the incubator off to see #hether he can

maintain his body temperature. (he infant should stay in the incubator for as short a period aspossible because incubators are a potent source of nosocomial infection.

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DISC$AR'E POLICY

(he mother should be mentally prepared and pro+ided #ith essential training and s$ills for

handling apreterm baby before she is discharged from the hospital. (he mother-baby dyad

should be $ept in a step-do#n nursery #here she is able to independently loo$ after the

essential needs of her baby li$e maintenance of body temperature* ensuring asepsis* feeding

#ith a cup and spoonor breast feeding* toilet needs etc. (he baby should be stable*

maintaining his body temperature and should not ha+e any e+idences of cold stress. At the

time of discharge the baby should be ha+ing daily steady #eight gain +elocity of at least

10g$g. (he home conditions should be satisfactory before the baby is discharged. (he

public health nurse should assess the home conditions and +isit the family at home e+ery

#ee$ for a month or so.

FOLLO2-UP PROTOCOL

After discharge from the hospital* babies should be regularly follo#ed up for assessment of

the follo#ing parameters. (he speciali/ed perinatal follo#-up ser+ices demand a close

collaboration and interaction #ith a large number of specialists li$e pediatrician*

de+elopmental physician* dietician* ophthalmologist* audiologist* child psychologist* physio-

occupational therapist and social #or$er. (he follo#ing parameters should be closely

monitored and follo#ed

Common infecti+e illnesses* reacti+e air#ay disease* hypertension* renal dysfunction*

gastro esophageal reflu

4eeding and nutrition

Immuni/ations

Physical gro#th* nutritional status* anemia* osteopenia ric$ets

Neuromotor de+elopment* cognition and sei/ures

6yes retinopathy of prematurity* +ision* strabismus

7earing

)eha+ioural problems* language disorders and learning disabilities

$OME CARE OF PRETERM BABIESIn +ie# of rather mar$ed disparity bet#een the a+ailable facilities for special care of lo#

birth #eight babies +ersus number of such babies reuiring care in de+eloping countries* it

is essential that general principles of home care are highlighted. 3ost healthy near term or

borderline preterm infants #ith a birth #eight of 1*:00 g or more and gestational maturity of

!& #ee$s or more can be managed at home. (he policy of early discharge from the hospital

in an effort to decongest the nurseries* has imposed additional responsibilities that their care

be etended to their homes. It is* ho#e+er* essential that a lo# birth #eight infant should not

be discharged unless he has regained his birth #eight* is self feeding from the bottle or

breast and is sho#ing a steady #eight gain. )efore discharge* the mother should be

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encouraged to breast feed her baby and loo$ after his toilet need. ,he must be eplained

about the need and importance of maintaining asepsis* $eeping the baby #arm and ensuring

satisfactory feeding routine. It is true* though unfortunate* that many a lo# birth #eight

babies after discharge from the hospital* do come bac$ or succumb to diarrhoea* sepsis and

eposure to cold. (he ser+ices of postpartum program public health nurse and social#or$er can be utili/ed to pro+ide home care after discharge. It is essential that proper

appraisal of a+ailable physical facilities* resources and en+ironmental conditions be made by

a predischarge home +isit by a health +isitor or a public health nurse before the baby is

discharged. It should be follo#ed by periodic home +isits to assess the progress of the child.

ENIRONMENTAL CONTROL

It must be remembered that the desirable en+ironmental temperature to safeguard the

biological needs of the lo# birth #eight infant* is rather uncomfortable for an adult. (he

infant should be effecti+ely co+ered ta$ing care to a+oid smothering. 'oolen cap* soc$s andmittens should be #orn. (he infant should preferably lie net to the mother #hich ser+es as a

useful biologically controlled heat source. In #inter* the room can be #armed #ith a radiant

heater or angeethi. A table lamp ha+ing a 100 #att bulb can be used to pro+ide direct radiant

heat. 7ot #ater bottle* if e+er used* should ne+er come in direct contact #ith the baby. (he

cot of the mother and infant should be located a#ay from the #alls to reduce radiation heat

loss. (he mother and health #or$ers should be trained to assess the temperature of a

ne#born baby by touch and ad+ised to ensure that the etremities are $ept #arm and pin$.

?o# birth #eight babies do relati+ely much better in summer than in #inter.

(he +isitors and handling of the infant should be restricted to the bare minimum. (he handsmust be #ashed before touching or feeding the baby. (he emotional urge for $issing the baby

should be curbed. (he linen should be clean and sun-dried.

FEEDIN'

'hene+er feasible breast feeding is ideal and must be encouraged. 'hen infant is unable to

suc$ from the breast* epressed breast mil$ should be gi+en #ith a bottle or dropper or spoon

depending upon his maturity. In case formula feeding is una+oidable* specially designed

formula for premature babies is recommended. If co#Rs mil$ or buffaloRs mil$ is una+oidableit should be gi+en after !1 dilution. 3other must be gi+en detailed instructions and practical

demonstration for maintenance of bottle hygiene to pre+ent contamination of feeds

PRO'NOSIS

(he outcome of uncomplicated premature babies is comparable to the babies born

after full maturity. In fact* se+eral reno#ned and famous people* #ho #ere born premature*

gre# up to become #orld leaders and intellectuals. ,ir Isaac Ne#ton* the greatest

mathematician genius* #eighed merely ! lbs at birth. ,ir 'inston Churchill* the legendary

Prime 3inister of )ritain #as born after " months of pregnancy #hen his mother #asparticipating in a royal dance. (he #orld reno#ned artists Pablo Picasso and Anna Pa+lo+a*

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came into this #orld a bit too early and left mar$ for succeeding generations. (he parents of

premature children* therefore* should not feel despondent because there is enough historical

e+idence that their infant has a bright future and he may gro# up to become an intellectual

giant.

Prognosis for sur+i+al is directly related to the birth #eight of the child and uality

of the neonatal care. 5+er three-fourth of neonatal deaths occur among lo# birth #eight

babies. (herefore* in countries #ith high incidence of ?)' babies* neonatal mortality is

li$ely to be higher. (he ris$ of neurode+elopmental handicaps is increased !-fold for ?)'

babies and l0-fold for +ery ?)' babies E1&00 g%. (he prognosis for mental de+elopment is

good if the baby had not suffered from birth asphyia* apneic attac$s* respiratory distress

syndrome* hypoglycemia or hyperbilirubinemia. (heir physical gro#th correlates better #ith

their conceptional age rather than the age calculated from the date of birth. Preterm A48

babies catch up in their physical gro#th #ith term counterparts by the age of 1 to 2 years.

?ong term follo# up studies of infants #ith a birth #eight of 1&00 g and less ha+e re+ealed1& to 20 percent incidence of neurological handicaps in the form of cerebral palsy* sei/ures*

hydrocephalus* microcephaly* blindness due to ;5P%* deafness and mental retardation. (here

is high incidence of minor neurologic disabilities in the form of language disorder* learning

disabilities* beha+iour problems* attention deficit* hyperacti+ity disorder reuiring speciali/ed

support for education. (he incidence of neurological handicaps is related to the uality of

obstetrical and neonatal ser+ices. Neurological prognosis is ad+ersely affected by degree of

immaturity* intrauterine gro#th retardation* se+erity of perinatal hypoia* intra+entricular

hemorrhage* peri+entricular leu$omalacia and se+erity of respiratory failure demanding

assisted +entilation.

FEEDIN' OF PRETERM INFANTS

Proper nutrition in infancy is essential for normal gro#th* resistance to infection*

long term health and optimal neurologic and cogniti+e de+elopment. Pro+iding adeuate

nutrition to preterm infants is challenging because of se+eral problems* some of them uniue

to these small infants. (hese problems include immaturity of bo#el function* inability to suc$

and s#allo#* high ris$ of necroti/ing enterocolitis N6C%* illnesses that may interfere #ith

adeuate enteral feeding e.g.* ;8,* patent ductus arteriosus% and medical inter+entions thatpreclude feeding e.g.* umbilical +essel catheters* echange transfusion* indomethacin

therapy%.

P$YSIOLO'Y AND PAT$OP$YSIOLO'Y

(he gut has formed and has completed its rotation bac$ into the abdominal ca+ity by 10

#ee$s of gestation. )y 1 #ee$s* the fetus can s#allo# amniotic fluid. >I motor acti+ity is

present before 2 #ee$s* but organi/ed peristalsis is not established until 2-!0 #ee$s and is

facilitated by antenatal corticosteroid treatment. Coordinated suc$ing and s#allo#ing

de+elops at !2-! #ee$s. )y term* the fetus s#allo#s about 1&0 cc$gday of amniotic fluid*

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#hich has 2"& m5sm?* contains carbohydrates* protein* fat* electrolytes* immunoglobulins

and gro#thfactors* and plays an important role in de+elopment of >I function. Preterm birth

interrupts this de+elopment. 6+en if nutrients are pro+ided parenterally* lac$ of enteric inta$e

leads to decreased circulating gut peptides* slo#er enterocyte turno+er and nutrient transport*

decreased bile acid secretion* and increased susceptibility to infection due to impaired barrierfunction by intestinal epithelium* lac$ of coloni/ation by normal commensal flora and

coloni/ation by pathogenic organisms. 4or fat digestion* the ne#born depends on lingual

lipase* #hich is stimulated by suc$ing and s#allo#ing and by nutrients in the stomach but not

the small bo#el. (he figure is a chronological representation of >I de+elopment during fetal

life.

CONTRA-INDICATIONS TO FEEDIN'

8o not start feeds if the infant

is recei+ing !ndoet)ac!n* or recei+ed it #ithin the pre+ious :hours

has a )eod#na!ca((# s!*n!+!cant patent ductus arter!osus

has either an u&!(!ca( arter!a( or "enous cat)eter< 8o not start feedings until the

catheters ha+e been remo+ed for :hurs is po(#c#t)e!c

has significant eta&o(!c ac!dos!sI dysfunction.

has had an episode of se"ere asp)#,!a perinatal or post-natal% in the pre+ious

"2hours

FEEDIN' PROTOCOL1 (he follo#ing are guidelines for the initiation and ad+ance of

enteral feedings in preterm infants

0< Met)od o+ +eed!n*1

)ecause these infants usually ha+e not yet de+eloped coordinated suc$ing and

s#allo#ing* they must be fed by ga+age 5rogastric tubes are usually used. )ecause infants are obligate nose breathers*

it is best not to occlude the nares #ith a tube. In addition* repeated insertion of

a nasal gastric tube can cause inflammation of the nose #ith subseuentobstruction.

6stimate length of tube that must be inserted to reach the stomach.

Insert the tube and aspirate to see if gastric contents are returned. 'hile

listening o+er stomach #ith stethoscope* in9ect &cc of air. If tube is in

stomach* you should hear bubbling as you in9ect air. If you cannot hear any

bubbling* tube may be in the trachea. (herefore* do not feed infant until you

are certain that tube is in stomach. 8o not use duodenal or 9e9unal tubes for ga+age feedings as feedings are less

#ell tolerated and do not stimulate secretion of lingual lipase. In addition*

residuals are no longer useful in assessing tolerance of feedings.

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Nipple feedings can be considered as the infant matures. (he best 9udge of

#hen to start nipple feedings is an eperienced Nurse.

3< Content o+ +eed!n*1 )egin #ith either

Breast !(% preterm breast mil$ is 20 m5sm?% or

Foru(a +or preter !n+ants e.g.* Premature 6nfamilV or ,imilac ,pecial CareV*20 m5sm?%.

,ome physicians use half-strength feedings* but there is no e+idence that this is

beneficial. In fact* hypo-osmolar solutions may slo# gastric emptying* leading to

increased incidence of residuals and feeding intolerance ;emember that fetuses s#allo# amniotic fluid* #hich is 2"& m5sm?* and this

s#allo#ing begins at 1 #ee$s gestation.

4< 'u!de(!nes +or Feed!n*1 Initiation of feedings* their +olume and the rate of ad+ance of

feedings are related to birth #eight* gestational age and ho# the infant has tolerated feeds to

date. >eneral guidelines include

Initial +olume is 3 cc=%* per +eed!n* 6!t) a !n!a( a&so(ute "o(ue o+ 3 cc

8o not ad+ance feedings faster than 3> cc=%*=d.

Do not ad"ance +eed!n*s !+ t)ere are an# s!*ns t)at t)e &a !s not to(erat!n*

+eeds< Aggressi+e ad+ances of feedings increase the ris$ of N6C.

A small +olume* e+en if not ad+anced* is much better than nothing at all. 6+en +ery

small +olumes stimulate maturation of gut motility and production of enteric peptides.

)olus feedings are preferable to continuous feedings.

(he goals for full feedingsQ are

-@olume 1&0-10 cc$gd

-Calories 110-120 $cal$gd -,ome ,>A infants #ill reuire a higher caloric inta$e to achie+e consistent

#eight gain.

FORTIFYIN' FEEDIN'S not only pro+ides mores calories but also impro+ed inta$e of

calcium* phosphorus and protein. 4ortify feedings breast mil$ and formula% as follo#s

-'hen infant is tolerating 100 cc$gd* feedings may be fortified to 22 calo/.

-'hen infant has been tolerating 1&0 cc$gd for at least 2d* feedings may be fortified to 2

calo/.

INTOLERANCE TO FEEDIN'S is common among +ery small preterm infants* and most

such infants #ill ha+e episodes that reuire either temporary discontinuation of feedings or a

delay in ad+ancing feedings. Although most episodes resol+e spontaneously and #ithout

seuelae* any signs of feeding intolerance should be regarded as potentially serious because

of the increased ris$ of N6C among these infants. ,igns that indicate possible intolerance of

feeding include

>astric residuals or emesis

Abdominal distension

)lood in the stool gross or occult%

?oose stoolsQ or diarrhea

3etabolic acidosis (emperature instability

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5nset of apneic episodes

7yperglycemia

MANA'EMENT OF FEEDIN' INTOLERANCE should be related to the type and

se+erity of the presenting signs* as described belo#1. 'astr!c res!dua(s1

Non-bilious residuals

If these are smaller than the +olume of a feeding and are not increasing in +olume*

and if the infant other#ise appears #ell* feeding can continue but the infant should be

obser+ed carefully for other signs of feeding intolerance. If the infant has any other

#orrisome findings* hold the feedings* consider obtaining an abdominal radiograph

and obser+e the infant.

If the residuals are greater than the +olume of a feeding or are progressi+ely

increasing in +olume* hold the feedings and obser+e closely.

)ilious residuals are a serious sign. 7old feedings* e+aluate infant closely* and

consider further #or$up including abdominal radiograph* C)C and platelets.

2. A&do!na( d!stens!on is a serious sign. 8iscontinue feedings* obtain abdominal

radiograph* and consider further e+aluation and treatment.

4< B(ood !n stoo(s 8iscontinue feedings*consider obtaining clotting studies and

abdominal radiograph.

. If eta&o(!c ac!dos!s occurs* hold feedings* e+aluate closely for N6C* sepsis*hypotension and a patent ductus arteriosus. 3etabolic acidosis in the presence of N6C

is a gra+e prognostic sign.&. ?< Loose stoo(s8 teperature !nsta&!(!t#8 apnea8 )#per*(#ce!a1 7old feedings and

e+aluate infant carefully. If feedings ha+e to be stopped for any of these reasons*

notify the Neonatology 4ello# andor the Attending Physician* so that they can follo#

the infantRs condition #ith you. I+ t)ere !s an# dou&t a&out )o6 6e(( an !n+ant !s

to(erat!n* +eed!n*s8 !t !s &est to )o(d+eed!n*s8 e"a(uate t)e !n+ant and d!scuss t)e

case 6!t) t)e ot)er e&ers o+ t)e tea

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