Preterm babies..............

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  • 1. Birth weight is the single most important marker of adverse perinatal and neonatal outcome. Babies with a birth weight of less than 2,500g, irrespective of their gestation are classified as low birth weight babies. These include both preterm and small-for-dates babies.

2. Preterm infants (also called premature infants) are those born before the beginning of 38th week of gestation. Moderately preterm infants are those born between 32 and 36 completed weeks of gestation. Late preterm infants fall in the moderately preterm group. Very preterm infants are those born before 32 completed weeks of gestation. (Mehrban Singh, 2010) 3. About 10 to 12 percent of Indian babies are born preterm ( less than 37 completed weeks) as compared to 5 to 7 percent incidence in the west. These infants are anatomically and functionally immature and therefore their neonatal mortality is high. 4. The mechanisms initiating normal labour are not clearly understood and much less is known about the triggers that initiate labour before term. Spontaneous Induced 5. Poor socio-economic status Low maternal weight Chronic and acute systemic maternal illness Antepartum hemorrhage Cervical incompetence Maternal genital colonization and infections 6. Cigarette smoking during pregnancy Threatened abortion Acute emotional stress Physical exertion Sexual activity Trauma Bi-cornuate uterus Multiple pregnancy Congenital malformations 7. The labour is often induced before term when there is impending danger to mother or foetal life in-utero. Maternal diabetes mellitus Placental dysfunction as indicated by unsatisfactory foetal growth Eclampsia Foetal hypoxia Antepartum haemorrhage and Severe rhesus iso-immunization. 8. Their size is small with relatively large head. Crown-heel length is less than 47 cm Head circumference is less than 33cm but exceeds the chest circumference by more than 3cm. 9. The general activity is poor Their automatic reflex responses such as moro response, sucking and swallowing are sluggish or incomplete. The baby assumes an extended posture due to poor tone. 10. Disproportionately large head size Sutures are widely separated and the fontanels are large Small chin, protruding eyes due to shallow orbits and absent buccal pad of fat. 11. Optic nerve is often un- myelinated but presence of papillary membrane makes its visualization difficult. Ear cartilage is deficient or absent with poor recoil. Hair appear woolly and fuzzy and individual hair fibres can be seen separately. 12. skin is thin, gelatinous, shiny and excessively pink with abundant lanugo and very little vernix caseosa. Edema may be present. 13. Subcutaneous fat is deficient and breast nodule is small or absent. Deep sole creases are often not present. 14. In male testes are undescended and scrotum is poorly developed. 15. In female infants, labia majora are widely separated exposing labia minora and hypertrophied clitoris. 16. Immaturity of central nervous system is expressed as inactivity and lethargy, poor cough reflex and in-coordinated sucking and swallowing 17. Resuscitation difficulties at birth and recurrent apneic attacks. Retinopathy of prematurity . Vulnerable for intra- ventricular periventricular hemorrhage and leuco- malacia Inefficient blood brain barrier 18. Cuboidal alveolar lining- poor alveolar diffusion of gases Hyaline membrane disease Breathing is mostly diaphragmatic, periodic and associated with intercostal recessions 19. Pulmonary aspiration and atelectasis They are vulnerable to develop chronic pulmonary insufficiency 20. The closure of ductus arteriosus is delayed. In grossly immature infants( less than 32 weeks) EKG shows left ventricular preponderance. Risk to develop thrombo- embolic complications and hypertension. 21. Due to poor and incoordinated sucking and swallowing. Animal fat is not tolerated as well as the vegetable fat. Regurgitation and aspiration are common. Hypoglycaemia 22. Abdominal distention and functional intestinal obstruction Entero-colitis Immaturity of the glucuronyl transferase system in the liver leads to hyper-bilirubinemia. Development of kernicterus at lower serum bilirubin levels. 23. Hypothermia is invariable. Excessive heat loss due to relatively large surface area due to paucity of brown fat in the baby who is equipped with an inefficient thermostat. 24. Infections are the important cause of neonatal mortality. The low levels of IgG antibodies and inefficient cellular immunity Excessive handling, humid and warm atmosphere, contaminated incubators and resuscitators expose them to infecting organisms. 25. The blood urea nitrogen is high due to low glomerular filtrate rate. The renal tubular ammonia mechanism is poorly developed thus acidosis occurs early. They vulnerable to develop late metabolic acidosis especially when fed with a high protein milk formula. Concentration of urine is poor. 26. Preterm has to pass 4 to 5 ml of urine excrete one milliosmole of solute Baby gets dehydrated. The solute retention and low serum proteins explain occurrence of edema in preterm infants. 27. Poor hepatic detoxification and reduced renal clearance make a preterm baby vulnerable to toxic effects of drugs 28. Develop anemia around 6 to 8 weeks of age. Deficiencies of folic acid and vitamin E. Develop haemolytic anemia, thrombocytopenia and edema 6 to 10 weeks of age. Osteopenia and rickets 29. These babies are prone to develop : Hypoglycaemia Hypocalcemia Hypoprotenemia Acidosis and Hypoxia. 30. Bed rest and sedation. Tocolytic agents Sympathomimetic agents-beta-2-adrenergic receptors. Isoxsuprine (duvadilan)-beta-1 and beta-2 receptors. Ritodrine Salbutamol and terbutaline -beta-2 receptor Magnesium sulphate Indomethacin 31. Maturity of fetus should be ascertained by examination of amniotic fluid for phosphatidyl glycerol or L/S ratio. Corticosteroids should be administered to the mother to enhance fetal lung maturity. 32. Inj.betamethasone 12mg IM every 24 hours --2 doses or dexamethasone 6mg IM every 12 hours for 4 doses. The optimal effect is seen if delivery occurs after 24 hours of the initiation of therapy and its therapeutic effect lasts for 7 days. 33. Delayed clamping of cord. Elective intubation of extremely LBW babies (1000g and 5% dextrose in babies 1500 60 - 80 *on first 2 days of life 45. Fluid rate can be increased by 10-20 ml/kg/d to gradually reach 150 ml/kg/d Fluid requirements need to be individualized for each baby Enteral nutrition has to be considered once the baby is stable 46. Infants with BW 1000 g Infants with BW 1500 g, done in conjunction with slowly advancing enteral nutrition Infants with BW 1501-1800 g for whom enteral intake is not expected for > 3 days 47. Glucose : 6 - 8 mg/kg/min Amino acids : 1.5 - 2 g/kg/d Lipid : 0.5 - 1 g/kg/d Sodium : 2 - 4 mEq/kg/d Potassium : 2 - 3 mEq/kg/d Chloride : 2 - 4 mEq/kg/d 48. Trophic feeding/ Gut priming Practice of feeding very small amounts of enteral nourishment to stimulate development of the immature GIT Advantages: Improves GI motility Enhances enzyme maturation Improves mineral absorption Lowers incidence of cholestasis Shortens time to regain birth weight 49. Breast milk or or full strength preterm formula at 10ml/kg/d by intermittent gavage/ continuous nasogastric drip Increase by 10-15 ml/kg/d to reach 150ml/kg/d Increments not >20 ml/kg/d IV fluids can be stopped once 120ml/kg/d is reached On reaching 150ml/kg/d,calorie density can be increased 50. PRETERMS 34 wks: Start breast feeding directly; if trial feed takes>20 mins or intake is less than required, switch to gavage feeding 51. Advantages: Higher concentrations of amino acids Higher concentrations of essential fatty acids Lower renal solute load Specific bio-active factors provide immunity Promotes intestinal maturation 52. Disadvantages: Low concentrations of Vitamin D, Ca, P Inadequate iron 53. Energy : 130 - 175 Kcal/kg/d Protein :3.4 - 4.2 g/kg/d Fat :6 - 8 g/kg/d Na :3 - 7 mEq/kg/d Cl :3 - 7 mEq/kg/d K :2 - 3 mEq/kg/d Ca :100 220 mg/kg/d 54. Multivitamin drops. Iron supplementation. Vitamin E supplementation. Supplements of calcium (220mg/day) and phosphorus (100mg/day). 55. Gentle touch, massage, cuddling, stroking and flexing. Rocking bed or placing a preterm baby on inflated gloves. Soothing auditory stimuli. Visual inputs. 56. Kangaroo care is placing a premature baby in an upright position on a mothers bare chest allowing tummy to tummy contact and placing the premature baby in between the mothers breasts. The babys head is turned so that the ear is above the parents heart. 57. Body temperature Mothers have thermal synchrony with their baby. The study also concluded that when the baby was cold, the mothers body temperature would increase to warm the baby up and vice versa. 58. Breastfeeding: Kangaroo care allows easy access to the breast and skin-to-skin contact increases milk let-down. 59. Increase weight gain Kangaroo care allows the baby to fall into a deep sleep which allows the baby to conserve energy for more important things. Increased weight gain means shorter hospital stay. 60. Increased intimacy and attachment 61. A single dose of dexamethasone 0.2mg/kg IV at 4 hours of age. Inhaled steroids. 62. Nosocomial infections Hypothermia Respiratory distress syndrome Aspiration Patent ductus arteriosus Chronic lung disease NEC & IVH ROP & Late metabolic acidosis Nutritional disorders Drug toxicity 63. Loss is upto a maximum of 10 to 15 percent. Regain their birth weight by the end of second week of life. Excessive weight loss, delay in regaining the birth weight or slow weight gain- suggest baby is not being fed adequately or unwell and