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7/23/2019 Care of Preterm Babies Final
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CARE OF PRETERM BABIES
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$s% as compared to & to "
percent incidence in the 'est. (hese infants are anatomically and functionally immature and
therefore their neonatal mortality is high.
DEFINITION
Preterm infants also called premature infants% are those born before the beginning of
!)th#ee$ of gestation.
*oderately preterm infants are those born bet#een !2 and !+ completed #ee$s of gestation.
,ate preterm infants fall in the moderately preterm group.
ery preterm infants are those born before !2 completed #ee$s of gestation.
A gestational age assessment of a preterm infants si/e and deelopment may sho# that the
infant is small appropriate or large for the amount of time spent in the uterus. *ost preterminfants are appropriate for their gestational age.
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 3+ cm or less in length and has head circumference of !2
cm or less. (he chest circumference is usually less than !0 cm.
INCIDENCE
About 10 to 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.
Causes of prematurity:
(he mechanism initiating normal labor is not clearly understood and much less is
$no#n about the triggers that initiate labor before term. (here may be spontaneous onset of
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premature labor or it may be induced by the obstetrician to safe guard the interests of the
mother or baby.
pontaneous4 the cause of premature onset of labor is uncertain in most instances. (he $no#n
causes include4
Poor socio-economic status,o# maternal #eightChronic and acute systemic maternal illnessAntepartum hemorrhageCerical incompetence*aternal genital coloni/ation and infectionsCigarette smo$ing during pregnancy(hreatened abortion
Acute emotional stressPhysical e5ertione5ual actiity(rauma6icornuate uterus*ultiple pregnancyCongenital malformations
Premature births are relatiely common among ery young and unmarried mothers. Past
history of preterm birth is associated #ith ! to 3 times increased ris$ of prematurity in the
subse7uent pregnancies.
Induced4 the labor is often induced before term #hen there is impending danger to mother
or fetal life in-utero e.g. maternal diabetes mellitus placental dysfunction as indicated by
unsatisfactory fetal gro#th eclampsia fetal hypo5ia antepartum hemorrhage and seere
rhesus iso-immuni/ation.
Clinial features:
*easurements4 their si/e is small #ith relatiely large head. Cro#n-heel length is
less than 3"cm head circumference is less than !!cm but e5ceeds the chest
circumference by more than !cm.
Actiity and posture4 the general actiity is poor and their automatic refle5 responses
such as moro response suc$ing and s#allo#ing are sluggish or incomplete. (he
baby assumes an e5tended posture due to poor tone.
8ace and head4 face appears small for the disproportionately large head si/e sutures
are #idely separated and the fontanels are large. 9ther characteristic features include
small chin protruding eyes due to shallo# orbits and absent buccal pad of fat. 9pic
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nere is often unmyelinated but presence of papillary membrane ma$es theits
isuali/ation difficult. :ar cartilage is deficient or absent #ith poor recoil. ;air
appears #oolly and fu//y and indiidual hair fibers can be seen separately.
$in and subcutaneous tissues4 s$in is thin gelatinous shiny and e5cessiely pin$
#ith abundant lanugo and ery little erni5caseosa. :dema may be present.
ubcutaneous fat is deficient and breast nodule is small or absent. ora are #idely separated e5posing labia minora and hypertrophied
clitoris.
P!ysiolo"ial !an#iaps:(he functional immaturity of arious systems result is
different clinical problems and their $no#ledge is essential for the satisfactory management
of these babies.
Central nervous system:the immaturity of central nerous system is e5pressed as inactiity
and lethargy poor cough refle5 and in co-ordinated suc$ing and s#allo#ing in babies
#eighing less than 1)00 g or born before !& #ee$s of gestation.
?esuscitation difficulties at birth and recurrent apneic attac$s are common.
?etinopathy of prematurity due to o5ygen to5icity is limited to babies #ith a gestation
of less than !& #ee$s.
(hey are e5tremely ulnerable for intra-entricular @ perientricular hemorrhage and
leucomalacia due to relatie deficiency of it- dependent coagulation factors and
increased capillary fragility.
(he blood brain barrier #hich is possibly a function of aailable serum proteins is
inefficient in preterm babies thus brain damage may occur at lo#er serum bilirubin
leels.
Respiratory system:
(he cuboidal aleolar lining in babies #ith a gestational age of less than 2+ #ee$s
results in poor aleolar 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 intercostal
recessions due to soft ribs. Pulmonary aspiration and atelectasis are common.
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(hey are ulnerable to deelop chronic pulmonary insufficiency due to broncho-
pulmonary dysplasia.
Cardio-vascular system:
(he closure of ductusarteriosus is delayed among preterm babies.
9ne third of infants hae features of P
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Infections are the important cause of neonatal mortality in lo# birth #eight babies.
(he lo# leels of Ig= antibodies and inefficient cellular immunity predispose them to
infections.
:5cessie handling humid and #arm atmosphere contaminated incubators and
resuscitators e5pose them to infecting organisms thus contributing to high incidence
of infections.
Renal immaturity:
(he blood urea nitrogen is high due to lo# glomerular filtrate rate.
(he renal tubular ammonia mechanism is poorly deeloped thus acidosis occurs early.
(hey ulnerable to deelop late metabolic acidosis especially #hen fed #ith a high
protein mil$ formula.
Concentration of urine is poor.
Preterm has to pass 3 to & ml of urine e5crete one milliosmole of solute as compared
to 0." ml by an adult for the same purpose.
6aby gets dehydrated.
(he solute retention and lo# serum proteins e5plain occurrence of edema in preterm
infants.
Toxicity of drugs:
Poor hepatic deto5ification and reduced renal clearance ma$e a preterm baby
ulnerable to to5ic effects of drugs unless caution is e5ercise during their
administration.
Nutritional handicaps:
,o# birth #eight babies are prone to deelop anemia around + to ) #ee$s of age this
is due to diminished total stores of iron due to short gestation.
(hey may also manifest deficiencies of folic acid and itamin : especially among
those fed #ith on iron fortified mil$ formula.
(hese infants are more prone to deelop haemolytic anemia thrombocytopenia and
edema + to 10 #ee$s of age.
itamin : deficiency along #ith o5ygen to5icity to the ulnerable tissues in the form
of retro-lental fibroplasia and broncho-pulmonary dysplasia.
?apid gro#th follo#ing ade7uate feeding may result in osteopenia and ric$ets unless
calcium phosphorus and itamin < are administered.
Biochemical disturbances:
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(hese babies are prone to deelop hypoglycaemia hypocalcemia hypoprotenemia
acidosis and hypo5ia.
Mana"ement
;igh ris$ mothers should be identify early during the course of pregnancy and referred for
confinement to an appropriate health care facility #hich is e7uipped #ith good 7uality
obstetrical and neonatal care facilities. *other is indeed an ideal transport incubator.
rrest of premature labor:
Adances in perinatal care including fabrication of a ariety of electronic gadgets
cannot compare #ith uni7ue security and optimal care proided to the fetus by theutero-placental unit.
:fforts should al#ays be made to arrest the progress of premature labour.
(he onset of true labor is suspected by occurrence of t#o or more uterine contractions
lasting atleast !0 seconds during a 1&-minute period in association #ith dilatation and
effacement of ceri5.
Apart from bed rest and sedation a ariety of tocolytic agents are recommended but
none is entirely safe or effectie.
*agnesium sulphate is more effectie and is being increasingly used though there is
potential ris$ of respiratory depression in the ne#born.
(he obserational studies hae sho#n that maternal treatment #ith reduced ris$ of
I; 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.
Iso5suprine duadilan% is useful but its effect is mediated through beta-1 and beta-2
receptors.
(herapy is initiated by intra-enous infusion of 20mg iso5suprine diluted in 200
ml of & percent de5trose at a rate of 30-&0dropsBminute.
(his is follo#ed by I* administration of 10mg iso5suprine eery 3 hours for 23
and 3) hours. 9ral therapy is continued for atleast 2 #ee$s #ith maintenance dose
of 10mg eery + hours.
?itodrine has been approed by U food and drug administration for treatment of
premature labour. (he usual dose is 100-300gB minute intraenously through an
infusion pump for a period of 12 hours follo#ed by oral ritodrine 10mg eery 2 hours.
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albutamol and terbutaline are selectie beta-2 receptor stimulators and are ery
effectie tocolytic agents. (hey are generally safe but occasionally patient may
deelop tachycardia and pulmonary oedema.
(erbutaline is administered as an I bolus of 0.2&mg follo#ed by constant infusion of
10-)0 gBminute for 1-2 hours. After control of uterine contractions maintenance
therapy is continued by administration of 0.2&mg C eery 3 hours.
Indomethacin has also offered some hope in arresting premature uterine contractions.
Induction of premature labour:
'hen indication of labour is contemplated before term either in the interest of mother
or the fetus maturity of fetus should be ascertained by e5amination of amniotic fluid for
phosphatidyl glycerol or ,B ratio. As far as possible deliery should be postponed till
maturity is assured. 'hen deliery can be safely delayed for !+ to 3) hours corticosteroids
should be administered to the mother to enhance fetal lung maturity.
ntenatal corticosteroids:
Antenatal administration of corticosteroids is one of the most cost-effectie perinatal
strategies #hich must be uniersally e5ploited. It is associated #ith reduction in the incidence
of ?.betamethasone 12mg I* eery 23 hours for 2 doses or de5amethasone +mg I*
eery 12 hours for 3 doses should be administered to the other if labour starts or is
induced before !3 #ee$s of gestation.
(he optimal effect is seen if deliery occurs after 23 hours of the initiation of therapy
and its therapeutic effect lasts for " days.
CARE OF PRETERM BABIES
Optimal mana"ement at $irt!:
'hen a preterm is anticipated the deliery should be attended by a senior
pediatrician fully prepared to resuscitate the baby.
(he delayed clamping of cord helps in improing the iron stores of the baby. It may
also reduce the incidence and seerity of ;*
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:lectie intubation of e5tremely ,6' babies D1000g% is practiced in some centres to
support breathing and for prophylactic administration of e5ogenous surfactant.
(he baby should be promptly dried $ept effectiely coered and #arm.
itamin 1mg 0.& mg in babies D 1&00g% should be gien intra-muscularly.
(he baby should be transferred by the doctor or nurse to the NICU as soon as
breathing is established.
Monitorin":
(he follo#ing clinical parameters should be monitored by specially trained nurses.
(he fre7uency of monitoring depends upon the gestational maturity and clinical status of the
baby.
ital signs #ith the help of multi-channel ital sign monitor non-inasie #ith
alarms%.
Actiity and behaiour.
Color4 pin$ pale grey blue yello#
(issue perfusion4 ade7uate perfusion is suggested by pin$ colour capillary refill oer
upper chest of D 2sec #arm and pin$ e5tremities normal blood pressure urine output
of E 1.&mlB$gBhr absence of metabolic acidosis and lac$ of any disparity bet#een
pa92 and p92.
8luids electrolytes and A6=s.
(olerance of feeds by monitoring omiting gastric residuals abdominal girth.
(he baby should be #atched for deelopment of ?
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Pro%i#e in&utero milieu:
Uterus proides ideal ambient conditions to the baby. All attempts should be made to
create uterus-li$e baby-friendly ecology in the nursery.
Create a soft comfortable GnestledH and cushioned bed.
Aoid e5cessie light e5cessie sound rough handling and painful procedures. Use
effectie analgesia and sedation for conducting procedures.
Proide #armth.
:nsure asepsis.
Preent eaporatie s$in losses by effectiely coering the baby application of oil or
li7uid paraffin to the s$in and increasing humidity to near 100 percent.
Proide effectie and safe o5ygenation.
Uterus is able to proide uni7ue parenteral nutrition. :fforts should be made to
proide at least partial parenteral nutrition and gie trophic feeds #ith e5pressed
breast mil$ :6*%.
Proide rhythmic gentle tactile and $inesthetic stimulation li$e s$in-to-s$in contact
interaction music caring and cuddling.
Position of t!e $a$y:
A pre-#armed open care system or incubator should be aailable at all times to
receie any baby #ith hypothermia or #ith a birth #eight of less than 2000g.
(he baby should be nursed in a thermo-neutral enironment #ith a sero sense
geared to maintain s$in temperature of mid-epigastric region at !+.& degree Celsius
so that there is irtually no or minimal metabolic thermogenesis.
Application of oil or li7uid paraffin on the s$in reduces conectie heat loss and
eaporatie #ater losses.
(he e5tremely ,6' baby should be coered #ith a cellophane or thin transparent orthin transparent plastic sheet to preent conectie heat loss and eaporatie losses of
#ater from s$in.
As soon as babys condition stabili/es he should be coered #ith Perspe5 shield or
effectiely clothed #ith a froc$ cap soc$s and mittens.
After one #ee$ or so stable babies #ith a birth #eight of D 1200g should preferably
be nursed in an intensie care incubator.
(he mother should be encouraged to proide partial $angaroo0mother-care to preent
hypothermia to promote bonding and breast feeding and to transmit healing electro-
magnetic ibrations of loe and compassion to her baby.
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O'y"en t!erapy:
95ygen should be administered only #hen indicated gien in the lo#est ambient
concentration and stopped as soon as its use is considered unnecessary.
(he o5ygen should be administered #ith a head bo5 #hen p92falls belo# )&F and
it should be gradually #ithdra#n #hen p92 goes aboe 0F. (he lo#est ambient
concentration and flo# rates should be used to maintain p92bet#een )&-&F and
Pa92bet#een +0-)0 mm ;g.
P!otot!erapy:
Jaundice is common in preterm babies due to hepatic immaturity hypo5iahypoglycaemia infections and hypothermia.
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(rophic feeds #ith :6* 1-2 ml 3 timesBday% throough N= tube can be started in all
babies irrespectie of their birth #eight or clinical conditions.
'hen babys condition is stabili/ed enteral feeds are begun #ith :6* starting #ith a
olume of !0mlB$gBday on the first day and depending upon the tolerance the enteral
feeds are increased by 10-20mlB$gBday eery day and I8 are reduced accordingly.
Nutritional supplements:
After t#o #ee$s #hen baby is stable and tolerating enteral feeds :6* can befortified #ith human mil$ fortifier ;*8%. (he fortification of :6* #ith formula feeds
especially during night% also proides additional calories and protein to the baby.
*ultiitamin drops containing folic acid should be started at 2 #ee$s of age.
Iron supplementation 2-! mgB$g elemental iron% should be started after 2-! #ee$s
#hen a baby is haing steady #eight gain.
8ree radical lipid pero5idation in cell membranes is catalysed by iron and
polysaturated fatty acids PU8A% thus increasing the re7uirements of itamin : in
ery lo# birth babies. (he re7uirement of itamin : are therefore related to linoleic
acid content of the formula. It is recommende that itamin : to linoleic acid ratio
should be E 1iuBgram of linoleic acid in the feeding formula for ,6' babies. (he
alpha tocopherolB linoleic acid ratios are +.2! 1.3! and 0.") mgBg in human
colostrum transitional and mature mil$ respectiely.
itamin : is po#erful anti-o5idant and preents the haemolytic anemia and edema of
prematurity.
In infants #eighing less than 1&00g at birth mil$ formula should proide atleast1iu of
itamin : Bg of linoleic acid and supplemented #ith daily administration of 1& iu of
itamin :.
upplements of calcium 220mgBday% and phosphorus 100mgBday% are essential to
preent osteopenia of prematurity.
(he supplements are continued till the baby has achieed post conceptional maturity
of !) #ee$s or #eight of 2000g.
FEEDIN( OF PRETERM INFANTS
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Proper nutrition in infancy is essential for normal gro#th resistance to infection
long term health and optimal neurologic and cognitie deelopment. Proiding ade7uate
nutrition to preterm infants is challenging because of seeral problems some of them uni7ue
to these small infants. (hese problems include immaturity of bo#el function inability to suc$
and s#allo# high ris$ of necroti/ing enterocolitis N:C% illnesses that may interfere #ith
ade7uate enteral feeding e.g. ?
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has !emo#ynami insta$ility as eidenced by clinical signs of sepsis- !ypotension-
is receiing #opamine at a dose E! mcgB$gBmin% or other asopressor drugs receied an e'!an"e transfusion #ithin the past 3)hours.
has a$#ominal #istension or other signs of =I dysfunction.
has had an episode of se%ere asp!y'ia perinatal or post-natal% in the preious"2hours
FEEDIN( PROTOCO+: (he follo#ing are guidelines for the initiation and adance of
enteral feedings in preterm infants4
., Met!o# of fee#in":
6ecause these infants usually hae not yet deeloped coordinated suc$ing and
s#allo#ing they must be fed by gaage4
9rogastric tubes are usually used. 6ecause 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 subse7uent
obstruction. :stimate 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 oer stomach #ith stethoscope in>ect L&cc of air. If tube is in
stomach you should hear bubbling as you in>ect 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. e>unal tubes for gaage 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. Nipple feedings can be considered as the infant matures. (he best >udge of
#hen to start nipple feedings is an e5perienced Nurse.
/, Content of fee#in": 6egin #ith either4
Breast mil0 preterm breast mil$ is 20 m9smB,% or
Formula for preterm infants e.g. Premature :nfamilM or imilac pecial CareM
2+0 m9smB,%. ome physicians use half-strength feedings but there is no eidence 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"& m9smB, and this
s#allo#ing begins at 1+ #ee$s gestation.
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1, (ui#elines for Fee#in": Initiation of feedings their olume and the rate of adance of
feedings are related to birth #eight gestational age and ho# the infant has tolerated feeds to
date. =eneral guidelines include4
Initial olume is / 20" per fee#in" 3it! a minimal a$solute %olume of /
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MANA(EMENT OF FEEDIN( INTO+ERANCE should be related to the type and
seerity of the presenting signs as described belo#4
1. (astri resi#uals:
Non-bilious residuals4 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
obsered carefully for other signs of feeding intolerance. If the infant has any other
#orrisome findings hold the feedings consider obtaining an abdominal radiograph
and obsere the infant.
If the residuals are greater than the olume of a feeding or are progressiely
increasing in olume hold the feedings and obsere closely.
6ilious residuals are a serious sign. ;old feedings ealuate infant closely andconsider further #or$up including abdominal radiograph C6C and platelets.
2. A$#ominal #istension is a serious sign.
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?oc$ing bed or placing a preterm baby on inflated gloes rhythmically roc$ed by a
entilator proide useful estibular- $inaesthetic stimuli for preention of apneic
attac$s of prematurity.
oothing auditory stimuli can be gien to the preterm baby in the form of taped heart
beats family oices or music.
*usic has been sho#n to reduce the stress of procedure and enhance #eight gain
elocity of preterm babies.
isual inputs can be proided #ith the help of colored ob>ects diffuse light and eye-
to-eye contact.
Utility of ortiosteroi#s:
Unnecessary administration of corticosteroids should be aoided due to its potential
side effects. Antenatal administration of betamethasone or de5amethasone is uniersally
recommended if labor starts before !3 #ee$s of gestation.
A single dose of de5amethasone 0.2mgB$g I at 3 hours of age may be gien to ery
lo# birth #eight babies to reduce the incidence of ;*< and I; but its use is
controersial.
Corticosteroids are also indicated to assist the process of difficult #eaning follo#ing
prolonged assisted entilation and for attenuation of inflammatory changes in infants
#ith broncho-pulmonary dysplasia.
Inhaled steroids has not been found to be useful to reduce the ris$ of chronic lung
diseaseC,,%.
Corticosteroids hae some therapeutic utility in the management of
scleremaneonatorum.
(here is increasing eidence to suggest that prolonged use of corticosteroid therapy
should be aoided in ne#born babies because of serious concerns for short term
hypertension hyperglycemia =I bleeding infections% and long term cerebral palsy
and neuromotor disability% side effects.
Transient !ypot!yro'inemia of prematurity:
In preterm babies belo# !0 #ee$s of gestation total (3 leels may be lo# but free (3
(! and (; leels are usually normal. (he condition is transient and is attributed to normal
adaptie response of an immature hypothalamic-pituitary a5is or to sic$ euthyroid syndrome.
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Its clinical significance is controersial. (he current Cochrane Neonatal Collaboratie
?eie# does not recommended routine (3 suplementation in preterm babies.
Pre%ention- early #ia"nosis an# prompt mana"ement of ommon pro$lems:
Nosocomial infections:house $eeping rituals strict house $eeping routines and high
inde5 of suspicion should be maintained to preent and ma$e early diagnosis of
nosocomial infections. !ypothermia:Nurse in a thermoneutral enironment.
Respiratory distress syndrome: Antenatal administration of corticosteroids
preention and effectie treatment of perinatal distress prophylactic administration of
e5ogenous surfactant to reduce the incidence and seerity of ;*
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*ost preterm babies lose #eight during the first ! to 3 days of life and loss is upto
a ma5imum of 10 to 1& percent of the birth #eight.
(he #eight remains stationary for the ne5t 3 to & days and then the babies start
gaining at a rate of 1 to 1.& F of body #eight 10-1&gB$gBd% per day.
(hey regain their birth #eight by the end of second #ee$ of life.
:5cessie #eght loss delay in regaining the birth #eight or slo# #eight gain
suggest that either the baby is not being the baby is not being fed ade7uately or he
is un#ell and needs immediate attention.
udden #eight loss in a baby #ho had been gaining #eight satisfactorily #ould
suggest the possibility of dehydration.
:5cessie #eight gain of 100g or more per day may occur in babies #ith cardiac
failure though sometimes healthy babies may also gain #eight more rapidly.
6!at to a%oi# in t!e are of preterm $a$ies77
In the care of preterm babies at times greater harm is done by unnecessary
therapeutic interentions #hich may lead to iatrogenic disorders. (he follo#ing interentions
should be aoided because they are unnecessary useless and often associated #ith serious
side effects.
?outine o5ygenation #ithout monitoring.
Intraenous immunoglobulins for preention of neonatal sepsis.
Prophylactic antibiotics e5cept during assisted entilation%.
Prophylactic administration of indomethacin or high doses of itamin :.
Unnecessary blood transfusions definite indications include haematocrit ofD30F in
a sic$ neonate D!0F in a symptomatic neonate and D2&F in an asymptomatic
neonate%.
8ormula feeds.
?ough handling e5cessie light and loud sound.
Immuni8ations:
Preterm babies are able to mount a satisfactory immune response and they can be
accinated at the usual chronological age li$e term babies. (he dose of accine is not reduced
in preterm babies. ;o#eer there is some eidence to suggest that administration of hepatitis
6 accine in preterm infants is associated #ith lo# sero-conersion rate.
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6ecause during their stay in the NICU there is no ris$ of contracting accine-
preentable diseases it is desirable to administer 0-day accines 6C= 9P ;6%
on the day of discharge from the hospital.
If mother is ;6 carrier and is e-antigen positie baby should be gien hepatitis 6
accine and hepatitis 6 specific immunoglobulins #ithin "2 hours of age.
,ie accines should be aoided in symptomatic ;I-positie mothers.
';9 recommends that 6C= and oral polio accine can be gien to asymptomatic
;I-positie infants.
Family support:
(he prolonged stay of preterm and sic$ ne#born babies in the NICU is associated
#ith emotional trauma uncertainly an5iety 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 intensie care. (hese problems and
issues should be handled #ith e7uanimity compassion concern and caring attitude of
the health team.
(he frightening scene of NICU should be demystified and family should be constantly
informed and inoled in the care of their baby. (he mother should be encouraged to touch and tal$ #ith her baby proide routine care
under the guidance of nurses.
he should be assisted to proide $angaroo-mother-care to her baby and try to
establish eye-to-eye contact.
(he an5iety and concern of the family should be cushioned by proiding necessary
emotional support and guidance.
Transfer from inu$ator to ot:
A baby #ho is feeding from the bottle or cup and is reasonably actie #ith a stable
body temperature irrespectie of his #eight 7ualifies for transfer to the open cot.
(he baby should be obsered 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 as possible because
incubators are a potent source of nosocomial infection.
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Dis!ar"e poliy:
(he mother should be mentally prepared and proided #ith essential training and
s$ills for handling a preterm baby before she is discharged from the hospital.
(he mother- baby dyad should be $ept in step-do#n nursery #here she is able to
independently loo$ after the essential needs of her baby li$e maintenance of body
temperature ensuring sepsis feeding #ith a cup and spoonB paladay or breast
feeding toilet needsetc.
(he baby should be stable maintaining his body temperature and should not hae
any eidences of cold stress.
At the time of discharge the baby should be haing daily steady #eight gain elocity
of at least 10gB$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 eery #ee$ for a month or so.
Follo3&up protool:
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 serices demand
a close collaboration and interaction #ith a large number of specialists li$e paediatrician
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*ost healthy near term or borderline preterm infants #ith a birth #eight of 1)00g or
more and gestational maturity of !& #ee$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 e5tended to their home.
It is essential that a ,6' 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.
6efore discharge the mother should be encouraged breast fed her baby and loo$ after
his toilet needs.
he must be e5plained about the importance of maintaining asepsis $eeping the baby
#arm and ensuring satisfactory feeding routine.
(he serices of postpartum programme public health nurse and social #or$er can be
utili/ed to proide home care after discharge.
It is essential that proper appraisal of aailable physical facilities resources and
enironmental 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.
%nvironmental control:
It must be remembered that the desirable enironmental temperature to safeguard the
biological needs of the lo#- birth #eight infant.
(he infant should be effectiely coered ta$ing care to aoid smothering.
'oollen cap soc$s and mittens should be #orn.
(he infant should preferably lie ne5t to the mother #hich seres as a useful
biologically controlled heat source.
In #inter the room can be #armed #ith a radiant heater or angeethi.
A table lamp haing 100 #att bulb can be used to proide direct radiant heat. ;ot #ater bottle if eer used should neer come in 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$er should be trained to assess the temperature of the
ne#born baby by touch and adised tpo ensure that e5tremities are $ept #arm and
pin$.
(he isitors and handling of the infant should be restricted to the bare minimum.
(he hands must be #ashed before touching or feeding the baby.
(he emotional urge for $issing the baby should be curbed.
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(he linen should be clean and sun-dried.
&eeding:
'heneer feasible breast feeding is ideal and must be encouraged.
'hen infant is unable to suc$ from the breast :6* should be gien #ith a bottle or
dropper or spoon or paladay depending upon his maturity.
In case formula feeding is unaoidable specially designed formula for premature
babies is recommended.
If co#s or buffalos mil$ is unaoidable it should be gien after !41 dilution.
*other must be gien detailed instructions and practical demonstration for
maintenance of bottle hygiene to npreent contamination of feeds.
Prognosis
(he outcome of uncomplicated premature babies is comparable to the babies born
after full maturity. In fact seeral reno#ned and famous people #ho #ere born premature
gre# upto become #orld leaders and intellectuals. ir Isaac Ne#ton the greatest
mathematician genius #eighed merely ! lbs at birth. ir 'inston Churchill the legendary
Prime *inister of 6ritain #as born after " months of pregnancy #hen his mother #as
participating in a royal dance. (he parents of premature children therefore should not feel
despondent because there is enough historical eidence that their infant has a bright future
and he may gro# up to become an intellectual giant.
Prognosis for surial is directly related to the birth #eight of the child and 7uality of
neonatal care oer three-fourth of neonatal deaths occur among ,6' babies. (herefore in
countries #ith high incidence of ,6' babies neonatal mortality is li$ely to be higher.
(he ris$ of neurodeelopmental handicaps is increased !-fold for ,6' babies and
10-fold for ery ,6' babiesD1&00g%.
(he prognosis is good if no birth asphy5ia apneic attac$s?
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(here is high incidence of minor neurologic disabilities in the form of language
disorder learning disabilities behaiour problems A
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imple methods to maintain a babys temperature after birth include drying and #rapping
increased enironmental temperature coering the babys head s$in-to-s$in contact #ith the
mother and coering both #ith a blan$et.
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Infetion pre%ention
Clean birth practices reduce maternal and neonatal mortality and morbidity from infection-
related causes including tetanus. Premature babies hae a higher ris$ of bacterial sepsis.;and cleansing is especially critical in neonatal care units. ;o#eer basic hygienic practices
such as hand #ashing and maintaining a clean enironment are #ell $no#n but poorly done.
Unnecessary separation from the mother or sharing of incubators should be aoided as these
practices increase spread of infections. 8or the poorest families giing birth at home the use
of clean birth $its and improed practices hae been sho#n to reduce mortality. ?ecent
cluster-randomi/ed trials hae sho#n some benefit from chlorhe5idine topical application to
the babys cord and no identified aderse effects. (o date about half of trials hae sho#n a
significant neonatal mortality effect especially for premature babies and particularly #ith
early application #hich may be challenging for home births.
Another possible benefit of chlorhe5idine is a behaiour change agent in many cultures
around the #orld something is applied to the cord and a policy of chlorhe5idine application
may accelerate change by substituting a helpful substance for harmful ones.
(he s$in of premature babies is more ulnerable and is not protected by erni5 li$e a term
babys. (opical application of emollient ointment such as sunflo#er oil reduces #ater loss
dermatitis and ris$ of sepsis and has been sho#n to reduce mortality for preterm babies.
Another effectie and lo# cost interention is appropriate timing for clamping of the
umbilical cord #aiting 2-! minutes or until the cord stops pulsating #hilst $eeping the baby
belo# the leel of the placenta. 8or preterm babies this reduces the ris$ of intracranial
bleeding and need for blood transfusions as #ell as later anemia. Possible tension bet#een
delayed cord clamping and actie management of the !rd stage of labor #ith controlled cord
traction has been debated but the Cochrane reie# and also recent-eidence statements by
obstetric societies support delayed cord clamping for seeral minutes in all uncomplicated
births.
PAC9A(E /: NEONATA+ RESUSCITATION
6et#een & to 10F of all ne#borns and a greater percentage of premature babies re7uire
assistance to begin breathing at birth. 6asic resuscitation through use of a bag-and-mas$ or
mouth-to-mas$ tube and mas$% #ill sae four out of eery fie babies #ho need
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resuscitationO more comple5 procedures such as endotracheal intubation are re7uired only
for a minority of babies #ho do not breathe at birth and #ho are also li$ely to need ongoing
entilation. ?ecent randomi/ed control trials support the fact that in most cases assisted
entilation #ith room air is e7uialent to using o5ygen and unnecessary o5ygen has
additional ris$s. :5pert opinion suggests that basic resuscitation for preterm births reduces
preterm mortality by about 10F in addition to immediate assessment and stimulation. An
education program entitled ;elping 6abies 6reathe has been deeloped by the American
Academy of Pediatrics and partners for promotion of basic neonatal resuscitation at lo#er
leels of the health system in lo#-resource settings and is currently being scaled up in oer
!0 lo#-income countries and promises potential improements for premature babies
PAC9A(E 1: 9AN(AROO MOT)ER CARE
*C #as deeloped in the 1"0s by a Colombian pediatrician :dgar ?ey #ho sought a
solution to incubator shortages high infection rates and abandonment among preterm births
in his hospital. (he premature baby is put in early prolonged and continuous direct s$in-to-
s$in contact #ith her mother or another family member to proide stable #armth and to
encourage fre7uent and e5clusie breastfeeding. A systematic reie# and meta analysis of
seeral randomi/ed control trials found that *C is associated #ith a &1F reduction in
neonatal mortality for stable babies #eighing D2000g if started in the first #ee$ compared to
incubator care. (hese trials all considered facility-based *C practice #here feeding support
#as aailable. An updated Cochrane reie# also reported a 30F reduction in ris$ of post-
discharge mortality about a +0F reduction in neonatal infections and an almost )0F
reduction in hypothermia. 9ther benefits included increased breastfeeding #eight gain
mother-baby bonding and deelopmental outcome. In addition to being more parent and baby
friendly *C is more health-system friendly by reducing hospital stay and nursing load and
therefore giing cost saings. *C #as endorsed by the ';9 in 200! #hen it deeloped a
program implementation guide. ome studies and program protocols hae a lo#er #eight
limit for *C e.g. not belo# )00g but in conte5ts #here no intensie care is aailable
some babies under )00g do surie #ith *C and more research is re7uired before setting a
lo#er cut off.
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PAC9A(E ;: SPECIA+ CARE OF PREMATURE BABIES AND
P)ASED SCA+E UP OF NEONATA+ INTENSI
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middle-income countries and for some lo#-income countries that hae referral settings #ith
stronger systems support such as high-staffing 23-hour laboratories.
?ecent trials hae demonstrated that CPAP reduces the need for positie pressure entilation
of babies less than 2) #ee$s gestation and the need for transfer babies under !2 #ee$s
gestation to neonatal intensie care units. 9ne ery small trial in outh Africa comparing
CPAP #ith no entilation among babies #ho #ere refused admission to neonatal intensie
care units found CPAP reduced deaths. In *ala#i a CPAP deice deeloped for lo#-resource
settings is being trialed in babies #ith respiratory distress #ho #eigh oer 1000g. :arly
results are encouraging and an important outcome #ill be to assess the nursing time re7uired
and costs.
Increasing use of CPAP #ithout regulation is a concern. *any deices are in the
GhomemadeH categoryO seeral lo# cost bubble CPAP deices are being deeloped
specifically for lo#-income countries but need to be tested for durability reliability and
safety. CPAP-assisted entilation re7uires ade7uate medical and nursing s$ill to apply and
delier safely and effectiely and also re7uires other supportie e7uipment such as an
o5ygen source o5ygen monitoring deice and suction machine.
urfactant is administered to premature babys lungs to replace the missing natural surfactant
#hich is one of the reasons babies deelop ?
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Assessment of common problems4
(he infants respiratory status must be obsered constantly. (he lungs are assessed for
adentitious breath sounds or areas of absent breath sounds. (he ilerman-Anderson
inde5 ia s useful tool for ealuating the degree of respiratory distress. ,oo$ for the
apneic spells.
(hermoregulation4 the infants temperature is monitored continuously by a s$in probe
on the infants abdomen #hich is attached to the heat control mechanism of the
radiant #armer. (he temperature usually maintained at !+ degree to !+.& degree
Celsius. It should be recorded eery !0 to +0 minutes initially and eery ! to 3 hours
#hen stable. Assess a5illary temperature eery 3 to ) hours and compare #ith the
probe temperature. ,oo$ for signs of hypothermia.
8eeding and electrolyte balance4 monitor inta$e-output of fluids determine fluidbalance. (he nurse also must trac$ of the amount of blood ta$en. Assess the urine
output by #eighing the diapers. 'eigh the child daily. ,oo$ for signs of dehydration
decreased urine output D1mlBhr increased specific graity #eight loss and dry s$in
and mucous membrane sun$en fontanel increased sodium% or oerhydration
increased urine output E!mlBhr #ith a belo# normal specific graity edema #eight
gain bulging fontanelles moist breath sounds and decreased blood sodium and
protein%.
$in4 fre7uently assess the condition of the infants s$in and record any changes. (he
infants response to product used for cleansing and disinfection must be noted.
Infection4 the nurse should be alert for signs of infection at all times li$e general
signs respiratory cardio-ascular =I and neurologic signs.
Pain4 because pain is afifth ital sign it should be assessed fre7uently high pitched
cry intense and harsh cry mouth open grimacing furro#ing or bulging of the bro#
tenserigid muscles and color changes% and must assess the response to potentially
painful stimuli and to pharmacologic and non-pharmacologic interentions. Assess the amount of noise to #hich the infant is e5posed. ustment to feeding readiness for change and indicating
intolerance.
Assess the actiity leel of the preterm baby.
Continually assess the infants responses to all feeding methods and #atch for
distress #eigh the infant dailynand obsere the changes ability to ta$e feedings.
Assess the improement in suc$ and s#allo# co-ordination.
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Assess the parental an5iety and promote maternal bonding and assess the support
system and coping pattern.
Assess the $no#ledge leel and support decision ma$ing.
Nursin" #ia"nosis an# inter%entions:
1 Impaired gas e5change related to immaturity of lungs and deficiency of surfactant
Interentions4
Assess the respiratory pattern and colour of the baby
9bsere for any apneic episode.
95ygen hood is often used for able to breathe alone but need e5tra o5ygen.
95ygen also may be gien by nasal cannula to the infant #ho breathesalone.
;umidify the o5ygen
CPAP may be necessary to $eep the aleoli open and improe e5pansion
of lungs
8re7uent monitoring of A6=
8re7uent position changes eery 2 to ! hours
Chec$ the suction e7uipment and suction the air#ay and applied for only &
to 10 seconds.
(he mouth is suctioned before the nose.
*aintain ade7uate hydration
2 Impaired breathing pattern 4 distress related to immaturity and surfactant deficiency
Asess the respiratory rateheart rate and chest retractions
Position the child for ma5imal entilatory efficiency and air#ay patency
Proide humidified o5ygen
po2 monitoring
Proide suctioning
Proide chest physio therapy
Administer bronchodilators
Administer anti inflammatory medications
Administer antibiotics
! Actiity intorance related to increased #or$ of breathing secondary to distress
Arrange to proide routine care
chedule periods of uninterrupted rest
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Proide suctioning
Proide humidified o5ygen
Assess the A6= analysis
Proide C-PAP using mas$ BhoodBnasal prongs
9bsere for ris$s of C-PAP Assist in C* #ith P::P if needed
& ;ypothermia related to immature thermoregulation system
*onitor ital signs fre7uently
'rap the baby #ell and $eep #arm
Proide small and fre7uent breast feeding as tolerated
,oo$ for hypoglycemia
Administer I fluids if not tolefeed intolerance
*onitor the ital signs and blood pressure
Assess the s$in tone pallor and signs of dehydration
Administer I fluids Assess the lab inestigations for ;b ?6Cs platelet count coagulation
profile
If necessary administer blood
Administer re7uired amount of in>. itamin
+ Imbalanced nutrition less than body re7uirement related to feeding difficulty
respiratory distressor NP9 status
Assess the suc$ing and s#allo#ing ability of the ne#born
Assess the tolerance of the child
*onitor the blood glucose leel fre7uently Administer I fluids if not tolerating oral fluids
Administer human mil$ fortifier if the child is preterm
" 8atigue related to increased demand for nutrients and deterioration of the general
condition of the baby
Assess the general condition of the baby
Assess the leel of actiity
*onitor the blood glucose leel
6reast fed the baby
Chec$ for from any part of the body Proide top up feed
) ?is$ for complications hypotension shoc$ cerebral hypo5ia related to progression of
the disease condition
Assess the ital signs respiratory rate pulse rate temperature and blood
pressure
Chec$ blood culture and sensitiity and sepsis screening
*onitor for any signs of dehydration
Administer I fluids or blood as necessary
Assess the serum electrolyte alues andA6= alues
Closely monitor for the early signs and symptoms of complications
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An5iety of parents related to the outcome of the ne#born condition
Assess the mental status an5iety and $no#ledge of family members
Assess the supporting system for the family
Assess the coping strategies of the family members
:5plain the disease process to the family members
:5plain each and eery procedure to the care gier
Proide psychological supporttothefamily members
10 Interrupted mother-child bonding related to infectious process
Assess the breast feeding ability including suc$ing and s#allo#ing ability
eep the child #ith the mother if possible
Proide fre7uent breast feed 2 hourly
If breast feeding is not tolerated gie :6*
Allo# the mother to isit the child
Proide $angaroo mother care in case of pre term if tolerated
11 Interrupted family process related to hospitali/ation of the ne#born Assess the mental status an5iety and $no#ledge of family members
:ncourage mother-child bonding if possible
Assess the coping strategies of the family members
:5plain the disease process to the family members
:5plain each and eery procedure to the care gier
Allo# the family members to isit the child
12 no#ledge deficit regarding care of the baby and treatment modalities
Assess the $no#ledge leel of the care gier
:5plain disease condition and its progress to the family members
:ducate regarding treatment and its preention :ducate about the monitoring of the baby
Proide ade7uate e5planation regarding nutritional need of the baby
Clarify their doubts and promote understanding
1! ?is$ for delayed gro#th and deelopment related to prematurity13 ?is$ for caregier role strain related to need for long term care
CONC+USION
Any infant #ho is born dysmature before term or post term or #ho is under#eight or
oer#eight for gestational age% is at ris$ for complications at birth or in the first fe# days of
life. Parents need thorough education about their babys health because these problems
re7uire hospitali/ation or additional follo#-up at home.
BIB+IO(RAP)*
1 *ehrbaningh.Car of thene#born."thedition.Ne#
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2 ClohertyP>ohn.*anualof neonatal care."thedition.Ne#