PREMATURITYPREMATURITYpresented presented

ByByDr Abdullahi UDr Abdullahi U

Paediatrics DepartmentPaediatrics DepartmentF M C BF M C B

OUTLINEOUTLINEIntroductionIntroductionIncidenceIncidenceAetiology Aetiology Clinical manifestationClinical manifestationGestational Age AssessmentGestational Age AssessmentFactors Associated with Factors Associated with Prematurity and Low Birth WeightPrematurity and Low Birth WeightProblems of PrematurityProblems of PrematurityManagementManagementPreventionPreventionPrognosisPrognosisDischargeDischargeHome CareHome Care

INTRODUCTIONINTRODUCTION Definition:- prematurity is defined as a Live born Definition:- prematurity is defined as a Live born

Infant delivered before 37week from the 1Infant delivered before 37week from the 1stst day of the day of the last menstrual period (WHO). Also refered to as last menstrual period (WHO). Also refered to as Preterm.Preterm.

It is a High-risk birth that needs urgent medical It is a High-risk birth that needs urgent medical attention.attention.

Prematurity and IUGR are associated with neonatal Prematurity and IUGR are associated with neonatal morbidity and mortality.morbidity and mortality.

In general preterm infants weigh <2500g, have In general preterm infants weigh <2500g, have crown-heel length<46cm, an OFC<33cm and crown-heel length<46cm, an OFC<33cm and CC<30cm.CC<30cm.

LBW is due to prematurity, poor intrauterine growth, LBW is due to prematurity, poor intrauterine growth, or both.or both.

Neonatal intensive care has markedly improved Neonatal intensive care has markedly improved survival of premature and LBW babies.survival of premature and LBW babies.

INCIDENCEINCIDENCE In the united states in 2000 7.6% of live In the united states in 2000 7.6% of live

birth are preterm. 1% of infants weigh birth are preterm. 1% of infants weigh <1500g at birth.<1500g at birth.

In Nigeria the incidence ranges from 3.5% In Nigeria the incidence ranges from 3.5% in the east (Azubuike 1980) to 21% in the in the east (Azubuike 1980) to 21% in the west (Dawodu and Effiong 1977).west (Dawodu and Effiong 1977).

The rate for prematurity for Blacks is twice The rate for prematurity for Blacks is twice that of whites.that of whites.

Women whose 1Women whose 1stst birth are delivered birth are delivered preterm are at increased risk of recurrent preterm are at increased risk of recurrent preterm delivery.preterm delivery.

AETIOLOGYAETIOLOGY The causes of prematurity is multifactorial and involves complex interaction between foetal, placental, The causes of prematurity is multifactorial and involves complex interaction between foetal, placental,

uterine and maternal factors thus:-uterine and maternal factors thus:- Foetal factorsFoetal factors

Foetal distressFoetal distress Multiple gestationMultiple gestation ErythroblastosisErythroblastosis Non immune hydropsNon immune hydrops

Placental factorsPlacental factors Placental dysfunctionPlacental dysfunction Placenta previaPlacenta previa Abruptio placentaeAbruptio placentae

Uterine factorUterine factor Bicornuate uterusBicornuate uterus Incompetent cervix (premature dilatation)Incompetent cervix (premature dilatation)

Maternal factorMaternal factor Pre eclampsiaPre eclampsia Chronic medical illness (e.g. cyanotic heart disease, renal disease)Chronic medical illness (e.g. cyanotic heart disease, renal disease) Infection (e.g. listeria monocytogenes, group B streptococcus, UTI, bacteria vaginosis, Infection (e.g. listeria monocytogenes, group B streptococcus, UTI, bacteria vaginosis,

chorioamnionitis)chorioamnionitis) Drug abuseDrug abuse

OthersOthers Premature Rupture of membranePremature Rupture of membrane Polyhydramnios Polyhydramnios IatrogenicIatrogenic TraumaTrauma

FACTORS RELATED TO PREMATURE FACTORS RELATED TO PREMATURE BIRTH AND LBWBIRTH AND LBW

Low socio economic status: higher rates of Low socio economic status: higher rates of maternal under nutrition, anaemia and illness.maternal under nutrition, anaemia and illness.

Inadequate prenatal careInadequate prenatal care Drug misuseDrug misuse Obstetric complicationObstetric complication Maternal history of reproductive insufficiency Maternal history of reproductive insufficiency

(abortion, stillbirth, premature/LBW infant(abortion, stillbirth, premature/LBW infant Others areOthers are

Single parent familiesSingle parent families Teenage pregnancyTeenage pregnancy Short interpregnancy intervalShort interpregnancy interval Parity >4Parity >4

CLINICAL MANIFESTATIONCLINICAL MANIFESTATION A premature infant will have a low birth weight. Common symptoms in a premature infant A premature infant will have a low birth weight. Common symptoms in a premature infant

include:include: Body hair Body hair Episodes of absent breathing Episodes of absent breathing Enlarged clitoris (female infant) Enlarged clitoris (female infant) Lung problems such as Lung problems such as neonatal respiratory distress syndromeneonatal respiratory distress syndrome Poor feeding Poor feeding Small scrotum, smooth without ridges (male infant) Small scrotum, smooth without ridges (male infant) Soft, flexible ear cartilage Soft, flexible ear cartilage Thin, smooth, shiny skin Thin, smooth, shiny skin Transparent skin (can see veins under skin) Transparent skin (can see veins under skin) Usually inactive -- however, may be unusually active immediately after birth Usually inactive -- however, may be unusually active immediately after birth Weak cry Weak cry Wrinkled featuresWrinkled features HypothermiaHypothermia

Investigation Investigation Blood gas analysisBlood gas analysis Serum urea and electrolyteSerum urea and electrolyte Serum calciumSerum calcium Serum bilirubinSerum bilirubin RBSRBS CXRCXR

ASSESSMENT OF GESTATION AGEASSESSMENT OF GESTATION AGE Assessment of Gestational age may be by the followingAssessment of Gestational age may be by the following1.1. Obstetric HistoryObstetric History

Date of last menstrual period. Estimation of EDD can be Date of last menstrual period. Estimation of EDD can be calculated using McDonald’s rulecalculated using McDonald’s rule

Obstetric scan- considered more accurate if done before 20 Obstetric scan- considered more accurate if done before 20 wks gestationwks gestation

Quickening- first felt at about 16-18weeks.Quickening- first felt at about 16-18weeks. Date of first fetal heart sound-first detected by ultrasound at Date of first fetal heart sound-first detected by ultrasound at

8-10 weeks.8-10 weeks.2.2. The degree of prematurity estimated by examination of The degree of prematurity estimated by examination of

anterior vascular capsule of the lens in the first 24-48hrs.anterior vascular capsule of the lens in the first 24-48hrs.3.3. Physical examination of Newborn usingPhysical examination of Newborn using

Modified DubowitzModified Dubowitz Ballard scoring systemBallard scoring system

-1-1 00 11 22 33 44 55

Skin.Skin. Sticky, Sticky, friable, friable, transpartransparentent

GelatinGelatinous, ous, red, red, translustransluscentcent

Smoot, Smoot, pink, pink, visible visible veinsveins

SuperficiaSuperficial peeling l peeling and/or and/or rash, few rash, few veinsveins

Cracking, Cracking, pale pale areas, areas, rare veinsrare veins

ParchmenParchment, deep t, deep cracking, cracking, no no vesselsvessels

LeatheryLeathery, , cracked cracked wrinkledwrinkled

Lanugo.Lanugo. NoneNone SparseSparse AbundanAbundant t

Thinning Thinning Bald Bald areasareas

Mostly Mostly BaldBald

Plantar Plantar surfacesurface

Heel-toe Heel-toe 40-40-50mm; -50mm; -1 1 <40mm;-<40mm;-22

<50 <50 mm, no mm, no creasecrease

Faint red Faint red marksmarks

Anterior Anterior transverstransverse onlye only

Creases Creases on ant. on ant. 2/32/3

Creases Creases over over entire entire solesole

Breast Breast impercepimperceptibletible

Barely Barely perceptiperceptibleble

Flat Flat areola-areola-no budno bud

Stripped Stripped areola, 1-areola, 1-2mm bud2mm bud

Raised Raised areola, 3-areola, 3-4mm bud4mm bud

Full Full areola, 5-areola, 5-10mm 10mm budbud

Eye/EarEye/Ear Lids Lids fused fused loosely(-loosely(-1)1)Tightly(-Tightly(-2)2)

Lids Lids open open pinna pinna flat, flat, stays stays foldedfolded

Slightly Slightly curved curved pinna, pinna, soft, slow soft, slow recoilrecoil

Well curved Well curved pinna, soft pinna, soft but ready but ready recoilrecoil

Formed Formed and firm, and firm, instant instant recoilrecoil

Thick Thick cartilage, cartilage, ear stiffear stiff

Genitals Genitals MaleMale

Scrotum Scrotum flat, flat, smoothsmooth

Scrotum Scrotum empty, empty, faint faint rugaerugae

Testes in Testes in upper upper canal, canal, rare rare rugaerugae

Testes Testes descendindescending few g few rugaerugae

Testes Testes down, down, good good rugaerugae

Testes Testes penduloupendulous, deep s, deep rugaerugae

GenitalsGenitalsFemaleFemale

Clitoris Clitoris prominenprominent, labia t, labia flatflat

Prominent Prominent clitoris clitoris small small labia labia minoraminora

Prominent Prominent clitoris, clitoris, enlarging enlarging larbia larbia minoraminora

Major and Major and minora minora equally equally prominentprominent

Majora Majora large, large, minora minora smallsmall

Majora Majora cover cover clitoris clitoris and and minoraminora

Neuromuscular maturityNeuromuscular maturity

Maturity RatingMaturity RatingScoreScore weeksweeks-10-10 2020-5-5 222200 242455 26261010 28281515 30302020 32322525 34343030 36363535 38384040 40404545 42425050 4444

The physical and neurologic scores The physical and neurologic scores are added to calculate gestational are added to calculate gestational age.age.

PROBLEMS OF PREMATURITYPROBLEMS OF PREMATURITY RESPIRATORY SYSTEMRESPIRATORY SYSTEM

Respiratory distress syndrome (Hyaline membrane disease)*Respiratory distress syndrome (Hyaline membrane disease)* Bronchopulmonary dysplasiaBronchopulmonary dysplasia Pneumothorax, Pneumomediastinum, Interstitial Pneumothorax, Pneumomediastinum, Interstitial

emphysemaemphysema Congenital PneumoniaCongenital Pneumonia Pulmonary HypoplasiaPulmonary Hypoplasia Pulmonary HaemorrhagePulmonary Haemorrhage Apnoea*Apnoea*

CARDIOVASCULAR SYSTEMCARDIOVASCULAR SYSTEM Patent Ductus Arteriosus*Patent Ductus Arteriosus* HypotensionHypotension HypertensionHypertension Bradycardia (with Apnoea)Bradycardia (with Apnoea)

PROBLEM OF PREMATURITY contPROBLEM OF PREMATURITY cont HAEMATOLOGIC SYSTEMHAEMATOLOGIC SYSTEM

AnaemiaAnaemia Hyperbilirubinaemia*Hyperbilirubinaemia* Subcutaneous, Organ (liver, adrenal) haemorrhage*Subcutaneous, Organ (liver, adrenal) haemorrhage* Disseminated Intravascular CoagulopathyDisseminated Intravascular Coagulopathy Vitamin K DeficiencyVitamin K Deficiency hydropshydrops

GASTROINTESTINAL SYSTEMGASTROINTESTINAL SYSTEM Poor Gastrointestinal function-poor motility*Poor Gastrointestinal function-poor motility* Necrotising EnterocolitisNecrotising Enterocolitis Hyperbilirubinaemia- direct and indirectHyperbilirubinaemia- direct and indirect Congenital anomalies producing polyhydramniosCongenital anomalies producing polyhydramnios Spontaneous GI isolated PerforationSpontaneous GI isolated Perforation

PROBLEMS OF PREMATURITY PROBLEMS OF PREMATURITY contcont

METABOLIC- ENDOCRINE SYSTEMMETABOLIC- ENDOCRINE SYSTEM Hypocalcaemia*Hypocalcaemia* Hypoglycaemia*Hypoglycaemia* Hyperglycaemia*Hyperglycaemia* Late metabolic AcidosisLate metabolic Acidosis Hypothermia*Hypothermia* Euthyroid but low-thyroxin statesEuthyroid but low-thyroxin states

CENTRAL NERVOUS SYSTEMCENTRAL NERVOUS SYSTEM Interventricular Haemorrhage*Interventricular Haemorrhage* Periventricular LeukomalaciaPeriventricular Leukomalacia Hypoxic Ischaemic EncephalopathyHypoxic Ischaemic Encephalopathy SeizuresSeizures Retinopathy of PrematurityRetinopathy of Prematurity DeafnessDeafness Hypotonia*Hypotonia* Congenital MalformationCongenital Malformation Kernicterus (Bilirubin Encephalopathy)Kernicterus (Bilirubin Encephalopathy)

PROBLEMS OF PREMATURITY PROBLEMS OF PREMATURITY contcont

RENAL SYSTEMRENAL SYSTEMHyponatraemia*Hyponatraemia*Hypernatraemia*Hypernatraemia*Hyperkalaemia*Hyperkalaemia*Renal Tubular AcidosisRenal Tubular AcidosisRenal GlycosuriaRenal GlycosuriaOedemaOedema

OTHERSOTHERSInfections ( congenital, perinatal, nosocomial; Infections ( congenital, perinatal, nosocomial;

bacterial, viral, fungal, protozoan)bacterial, viral, fungal, protozoan)

MANAGEMENTMANAGEMENT When premature labor develops and cannot When premature labor develops and cannot

be stopped medically, the health care team be stopped medically, the health care team should be prepare for a high-risk birth.should be prepare for a high-risk birth.

Specific treatment for prematurity will be Specific treatment for prematurity will be determined by physician based on:determined by physician based on: The gestational age, overall health, and medical The gestational age, overall health, and medical

history history The tolerance for specific medications, The tolerance for specific medications,

procedures, or therapies procedures, or therapies The expectations for the course of the disease The expectations for the course of the disease The opinion or preference of parentsThe opinion or preference of parents

MANAGEMENT contMANAGEMENT cont The measures needed in Resuscitation at birth for The measures needed in Resuscitation at birth for

clearing the Airways, Initiating Breathing and clearing the Airways, Initiating Breathing and adequate Circulation, caring for the cord and eyes, adequate Circulation, caring for the cord and eyes, and administering vit. K are the same in preterm and administering vit. K are the same in preterm babies as in those of term and normal babies.babies as in those of term and normal babies.

Special care is required to maintain a patent Special care is required to maintain a patent airway and avoid potential aspiration of gastric airway and avoid potential aspiration of gastric content.content.

Other considerations are:-Other considerations are:- The need for Thermal control and monitoring of HR & RRThe need for Thermal control and monitoring of HR & RR The need for oxygen therapyThe need for oxygen therapy The need for special attention to details of feedingThe need for special attention to details of feeding

MANAGEMENT contMANAGEMENT cont THERMAL CONTROLTHERMAL CONTROL

The survival rate of preterm and sick infants is higher when The survival rate of preterm and sick infants is higher when they are cared for at or near their neutral thermal they are cared for at or near their neutral thermal environment.environment.

Optimal environmental temperature for minimal heat loss Optimal environmental temperature for minimal heat loss & oxygen consumption for an unclothed infant is one that & oxygen consumption for an unclothed infant is one that maintain infants core temperature at 36.5-37maintain infants core temperature at 36.5-37°C.°C.

This depend on infant size maturity and postnatal age.This depend on infant size maturity and postnatal age. Incubators or Radiant warmers can be used to maintain Incubators or Radiant warmers can be used to maintain

body temperature.body temperature. Additional plexiglas heat shield or head cap and body Additional plexiglas heat shield or head cap and body

clothing may be required for ELBW infant.clothing may be required for ELBW infant. An infant should be weaned and gradually removed from An infant should be weaned and gradually removed from

the incubator only when the gradual change in to the the incubator only when the gradual change in to the atmosphere of the nursery does not result in significant atmosphere of the nursery does not result in significant change in infants temperature, colour, activity or vital change in infants temperature, colour, activity or vital signs.signs.

MANAGEMENT contMANAGEMENT cont OXYGEN THERAPYOXYGEN THERAPY

Administration to reduce the risk of injury from Administration to reduce the risk of injury from hypoxia and circulatory insufficiency must be hypoxia and circulatory insufficiency must be balanced against the risk of hyperoxia to the balanced against the risk of hyperoxia to the eyes and oxygen injury to the lungs.eyes and oxygen injury to the lungs.

Administration is by face mask, nasal prung, Administration is by face mask, nasal prung, CPPV apparatus or endotracheal tube to CPPV apparatus or endotracheal tube to maintain stable & safe inspire oxygen maintain stable & safe inspire oxygen concentration.concentration.

Although cyanosis must be treated immediately Although cyanosis must be treated immediately oxygen is a drug and must be carefully regulated oxygen is a drug and must be carefully regulated to maximise benefit and minimise potential to maximise benefit and minimise potential harm (adjust base on PaO2).harm (adjust base on PaO2).

MANAGEMENT contMANAGEMENT cont FLUID REQUIREMENTFLUID REQUIREMENT

Fluid need vary according to GA, environmental condition & Fluid need vary according to GA, environmental condition & disease state.disease state.

Assuming minimal water loss in the stool of infants not Assuming minimal water loss in the stool of infants not receiving oral fluids, their water needs are equal to their receiving oral fluids, their water needs are equal to their insensible water loss, excretion of renal solutes, growth and insensible water loss, excretion of renal solutes, growth and any unusual ongoing loss.any unusual ongoing loss.

Insensible loss is directly related to GAInsensible loss is directly related to GA<1000g may loss 2-3ml/kg/hr.<1000g may loss 2-3ml/kg/hr.2000g-2500g may loss 0.6-0.7ml/kg/hr.2000g-2500g may loss 0.6-0.7ml/kg/hr.

An adequate fluid intake is essential for excretion of urinary An adequate fluid intake is essential for excretion of urinary solute load (e.g. U, E, P )solute load (e.g. U, E, P )

Amount varies with dietary intake and the anabolic or Amount varies with dietary intake and the anabolic or catabolic state of nutrition.catabolic state of nutrition.

Formulas with high solute, high protein intake and Formulas with high solute, high protein intake and catabolism increase the end product that require urinary catabolism increase the end product that require urinary excretion and thus increase requirement for water.excretion and thus increase requirement for water.

MANAGEMENT contMANAGEMENT cont FLUID REQUIREMENTFLUID REQUIREMENT

Newborn especially those with VLBW are less Newborn especially those with VLBW are less able to conc. urine; thus the fluid intake able to conc. urine; thus the fluid intake required to excrete solutes increases.required to excrete solutes increases.

Water intake in term infants at birth is 60-Water intake in term infants at birth is 60-70ml/kg; its increase by 10-15ml/kg/24hr.70ml/kg; its increase by 10-15ml/kg/24hr.

Water intake in preterm infants at birth is 70-Water intake in preterm infants at birth is 70-80ml/kg.80ml/kg.

Daily weight, urine, serum urea, nitrogen with Daily weight, urine, serum urea, nitrogen with electrolyte should be monitored carefully to electrolyte should be monitored carefully to determine water balance and fluid needs.determine water balance and fluid needs.

MANAGEMENT contMANAGEMENT cont PARENTERAL NUTRITIONPARENTERAL NUTRITION

Before oral feeding is established or when it is impossible for Before oral feeding is established or when it is impossible for prolong period, total intravenous alimentation may provide prolong period, total intravenous alimentation may provide sufficient fluid, calories, amino acids electrolytes and vitamins sufficient fluid, calories, amino acids electrolytes and vitamins to sustain the growth of preterm infant.to sustain the growth of preterm infant.

The GOAL is to deliver sufficient calories from glucose, protein The GOAL is to deliver sufficient calories from glucose, protein and lipids to to promote optimal growth.and lipids to to promote optimal growth.

Infusate should contain:Infusate should contain: 2.5-3g/dl of synthetic amino acid.2.5-3g/dl of synthetic amino acid. 10-15g/dl of glucose.10-15g/dl of glucose. Appropriate amount of electrolytes, trace minerals & Appropriate amount of electrolytes, trace minerals &

vitaminsvitamins Intravenous fat emulsion such as 20% intrapid (2.2kcal/ml) Intravenous fat emulsion such as 20% intrapid (2.2kcal/ml)

may be administered to provide calories without an may be administered to provide calories without an appreciable osmotic load there by decreasing the need for appreciable osmotic load there by decreasing the need for infusion of high glucose conc. And preventing development of infusion of high glucose conc. And preventing development of essential fatty acid deficiency. (initiated at 0.5g/kg/24hr and essential fatty acid deficiency. (initiated at 0.5g/kg/24hr and advanced to 3g/kg/24hr if tryglyceride level remains normal).advanced to 3g/kg/24hr if tryglyceride level remains normal).

MANAGEMENT contMANAGEMENT cont PARENTERAL NUTRITION PARENTERAL NUTRITION

Electrolytes, trace minerals and vitamins are added in Electrolytes, trace minerals and vitamins are added in amount establishing i.v. maintenance requirement.amount establishing i.v. maintenance requirement.

The content should be determined daily after carefully The content should be determined daily after carefully assessing the infant clinical and biochemical status.assessing the infant clinical and biochemical status.

After establishing calorie intake of 100kcal/kg/24hrby After establishing calorie intake of 100kcal/kg/24hrby parenteral nutrition preterm can be expected to gain parenteral nutrition preterm can be expected to gain weight by 15g/kg/24hr with positive nitrogen balance of weight by 15g/kg/24hr with positive nitrogen balance of 150-200mg/kg/24hr in the absence of sepsis, surgical 150-200mg/kg/24hr in the absence of sepsis, surgical procedure.procedure.

The goal of parenteral nutrition can be achieved by infusion The goal of parenteral nutrition can be achieved by infusion of:of:2.5-3.5g/kg/24hr amino acid.2.5-3.5g/kg/24hr amino acid.10% dextrose.10% dextrose.2-3g/kg/24hr intralipid.2-3g/kg/24hr intralipid.

MANAGEMENT contMANAGEMENT cont FEEDINGFEEDING

The method of feeding each preterm/LBW infant should be The method of feeding each preterm/LBW infant should be individualised.individualised.

Avoid fatigue and aspiration of feed by regurgitation or by Avoid fatigue and aspiration of feed by regurgitation or by feeding process.feeding process.

No feeding method avert these problem unless the person No feeding method avert these problem unless the person feeding is the infant has been well trained in the method.feeding is the infant has been well trained in the method.

Direct oral feeding should not be initiated or should be Direct oral feeding should not be initiated or should be discontinued in infant with; resp. distress, hypoxia, discontinued in infant with; resp. distress, hypoxia, circulatory insufficiency, excessive secretion, gagging, circulatory insufficiency, excessive secretion, gagging, CNS depression, immaturity or signs of serious illness.CNS depression, immaturity or signs of serious illness.

Preterm infants at ≥34wks GA can be directly breast feed.Preterm infants at ≥34wks GA can be directly breast feed. The limiting factor is sucking effort.The limiting factor is sucking effort.

MANAGEMENT contMANAGEMENT cont INITIATION OF FEEDINGINITIATION OF FEEDING

The main principle of feeding premature baby is to The main principle of feeding premature baby is to proceed cautiously and gradually. proceed cautiously and gradually.

Once baby is stable small volume feeding is given in Once baby is stable small volume feeding is given in addition to I.V.F/nutrition. (feeding is gradually increase addition to I.V.F/nutrition. (feeding is gradually increase & parenteral nutrition decreased: this approach may & parenteral nutrition decreased: this approach may decrease incidence of NEC).decrease incidence of NEC).

Attempt oral feeding if infant is making sucking Attempt oral feeding if infant is making sucking movements and is in no distress.movements and is in no distress.

N.B. infants <1500g require tube feeding because their N.B. infants <1500g require tube feeding because their inability to coordinate sucking, breathing and swallowing.inability to coordinate sucking, breathing and swallowing.

GIT readiness for oral feeding is determined by; active GIT readiness for oral feeding is determined by; active bowel sound, passage of meconium and absence of bowel sound, passage of meconium and absence of abdominal distension, bilious gastric aspirate and abdominal distension, bilious gastric aspirate and vomiting.vomiting.

MANAGEMENT contMANAGEMENT cont INITIATION OF FEEDING contINITIATION OF FEEDING cont

Preterm <1000g:Preterm <1000g: Half strength or full strength breast milk 10ml/kg/24hr Half strength or full strength breast milk 10ml/kg/24hr

stat divided 2hrly or continuous.stat divided 2hrly or continuous. If well tolerated increase by 10-15ml/kg/24hr.If well tolerated increase by 10-15ml/kg/24hr.

Preterm >1500g:Preterm >1500g: Full strength breast milk 20-25ml/kg/24hr stat divided Full strength breast milk 20-25ml/kg/24hr stat divided

2hrly.2hrly. Daily intake of 130-150ml/kg may be necessary Daily intake of 130-150ml/kg may be necessary

for some infants to gain weight.for some infants to gain weight. Weight gain may not be achieved by10-12days.Weight gain may not be achieved by10-12days. During tube feeding aspirate content of the During tube feeding aspirate content of the

stomach before each feeding.stomach before each feeding.

Once a premature infant takes 120ml/kg/24hr, Once a premature infant takes 120ml/kg/24hr, breast milk fortifiers are added to supplement breast milk fortifiers are added to supplement breast milk with protein, calcium and phosphorus.breast milk with protein, calcium and phosphorus.

At 34-36wks GA infants who are not receiving At 34-36wks GA infants who are not receiving breast milk should be switched to a term formular.breast milk should be switched to a term formular.

Breast milk from the infant mother is the Breast milk from the infant mother is the preferred milk for the including VLBW.preferred milk for the including VLBW.

Properly fed premature infant passed stool 1-Properly fed premature infant passed stool 1-6times daily of semisolid consistency.6times daily of semisolid consistency.

Premature infant should not vomit or regurgitate.Premature infant should not vomit or regurgitate. They should be satisfied and relaxed after feeding, They should be satisfied and relaxed after feeding,

but may show normally activity of hunger shortly but may show normally activity of hunger shortly before the next feeding.before the next feeding.

MANAGEMENT contMANAGEMENT cont PREVENTION OF INFECTIONPREVENTION OF INFECTION

Preterm infants have increase susceptibility to Preterm infants have increase susceptibility to infection and thus meticulous attention to infection and thus meticulous attention to infection control is required.infection control is required.

Prevention strategies include:Prevention strategies include: Hand washing and universal precaution.Hand washing and universal precaution. Avoid over crowding and limit Nurse-patient ratio.Avoid over crowding and limit Nurse-patient ratio. Minimise risk of catheter contamination.Minimise risk of catheter contamination. Meticulous skin care.Meticulous skin care. Encourage early appropriate increase in oral feeding.Encourage early appropriate increase in oral feeding. Education and feedback to staff.Education and feedback to staff. Surveillance of nosocomial infection rates in the Surveillance of nosocomial infection rates in the

nursery.nursery.

MANAGEMENT contMANAGEMENT cont PREVENTION OF INFECTION contPREVENTION OF INFECTION cont

Although no one with infection should be Although no one with infection should be allowed into the neonatal unit, the risk of allowed into the neonatal unit, the risk of infection must be balanced against the infection must be balanced against the disadvantage of limiting contact with the disadvantage of limiting contact with the family.family.

Routine immunisation should be given at Routine immunisation should be given at standard dose.standard dose.

When epidemic occurs in a neonatal unit, When epidemic occurs in a neonatal unit, cohort nursing and isolation rooms should be cohort nursing and isolation rooms should be used.used.

PREVENTIONPREVENTION The most important steps to preventing prematurity is to The most important steps to preventing prematurity is to

receive prenatal care as early as possible in the pregnancy, receive prenatal care as early as possible in the pregnancy, and to continue such care until the baby is bornand to continue such care until the baby is born . .

Premature labour can sometimes be treated or delayed by Premature labour can sometimes be treated or delayed by a medication that blocks uterine contractions.a medication that blocks uterine contractions.

Because maternal nutrition and weight gain are linked with Because maternal nutrition and weight gain are linked with fetal weight gain and birth weight, eating a healthy diet and fetal weight gain and birth weight, eating a healthy diet and gaining weight in pregnancy are essential. gaining weight in pregnancy are essential.

Other ways to help prevent prematurity and to provide the Other ways to help prevent prematurity and to provide the best care for premature babies may include:best care for premature babies may include: Identifying mothers at risk for preterm labour.Identifying mothers at risk for preterm labour. Prenatal education of the symptoms of preterm labour.Prenatal education of the symptoms of preterm labour. Avoiding heavy or repetitive work or standing for long periods Avoiding heavy or repetitive work or standing for long periods

of time which can increase the risk of preterm labour.of time which can increase the risk of preterm labour. Early identification and treatment of preterm labour.Early identification and treatment of preterm labour.

PROGNOSISPROGNOSIS Infants weighing 1500-2500g have 95% chance of Infants weighing 1500-2500g have 95% chance of

survival (based on available facility), but those weighing survival (based on available facility), but those weighing less still ha significant higher mortality.less still ha significant higher mortality.

Intensive care has extended the period during which a Intensive care has extended the period during which a VLBW infant is at increased risk of dying of complication VLBW infant is at increased risk of dying of complication of prematurity e.g. BPD, NEC, nosocomial infection.of prematurity e.g. BPD, NEC, nosocomial infection.

Post discharge mortality rate is greater than that of a Post discharge mortality rate is greater than that of a term infant in the 1term infant in the 1stst 2yrs of life. 2yrs of life.

Preterm infant have increased risk of FTT, SIDS, child Preterm infant have increased risk of FTT, SIDS, child abuse, inadequate maternal-infant bonding.abuse, inadequate maternal-infant bonding.

Congenital anomalies is present in approximately 3-7%.Congenital anomalies is present in approximately 3-7%. VLBW infant may not catch up especially in the presence VLBW infant may not catch up especially in the presence

of severe chronic sequele, insufficient nutritional intake or of severe chronic sequele, insufficient nutritional intake or an inadequate caretaking environment.an inadequate caretaking environment.

PROGNOSIS contPROGNOSIS cont The greater the immaturity and the birth The greater the immaturity and the birth

weight, the greater the likelihood of weight, the greater the likelihood of intellectual and neurologic deficit.intellectual and neurologic deficit.

Small head circumference at birth may be Small head circumference at birth may be similarly related to a poor neurobehavioral similarly related to a poor neurobehavioral prognosis.prognosis.

Most surviving preterm LBW infants have Most surviving preterm LBW infants have hypotonia before 8month corrected age hypotonia before 8month corrected age and improves by 8month to 1yr old. This and improves by 8month to 1yr old. This transient is not a poor prognostic sign.transient is not a poor prognostic sign.

DISCHARGEDISCHARGE Before discharging a preterm infant should be taking Before discharging a preterm infant should be taking

all nutrition directly.all nutrition directly. There should be steady increase in growth of 20-There should be steady increase in growth of 20-

30g/24hr.30g/24hr. Temperature should be stabilised in an open cot.Temperature should be stabilised in an open cot. There should be no recurrent episodes of apnea or There should be no recurrent episodes of apnea or

bradycadia.bradycadia. Parenteral drugs should have been discontinued or Parenteral drugs should have been discontinued or

converted to oral.converted to oral. All infants with birth weight of <1500g and those All infants with birth weight of <1500g and those

between 1500-2000g with an unstable clinical course between 1500-2000g with an unstable clinical course requiring oxygen should have an eye examination to requiring oxygen should have an eye examination to screen for retinopathy of prematurity.screen for retinopathy of prematurity.

All premature infant should have a hearing test.All premature infant should have a hearing test.

DISCHARGE contDISCHARGE cont Those with indwelling umbilical arterial catheter Those with indwelling umbilical arterial catheter

should have their BP measured to check for renal should have their BP measured to check for renal vascular hypertention.vascular hypertention.

Check Hb for anaemia.Check Hb for anaemia. After resolution of all major medical problems and After resolution of all major medical problems and

home setting is adequate, premature infants may home setting is adequate, premature infants may be discharged when their weight approaches 1800-be discharged when their weight approaches 1800-2100g.2100g.

Close follow up plus easy access to health care Close follow up plus easy access to health care provider is essential for early discharge.provider is essential for early discharge.

Standard vaccination with full doses should be Standard vaccination with full doses should be commenced after discharge, with vaccines that do commenced after discharge, with vaccines that do not contain live viruses.not contain live viruses.

HOMECAREHOMECAREWhile baby is in hospital, mother While baby is in hospital, mother

should be instructed in how to care should be instructed in how to care for the baby after discharge.for the baby after discharge.

Ideally these programme should Ideally these programme should include at least one visit to her home include at least one visit to her home by some one capable of evaluating by some one capable of evaluating domestic arrangement and advising domestic arrangement and advising about any needed improvement.about any needed improvement.

References References Nelson Textbook of Pediatrics 17Nelson Textbook of Pediatrics 17thth Edition- Edition-

Behrman, Kliegman and Jenson.Behrman, Kliegman and Jenson. Jolly’s Disease of Children 2Jolly’s Disease of Children 2ndnd Edition- M Edition- M

Levene.Levene. Tropical Paediatrics-Azubuike and Tropical Paediatrics-Azubuike and

Nkanginame.Nkanginame. www.healthsystem.virginia.educ... – last www.healthsystem.virginia.educ... – last

update 18update 18thth march 2008. march 2008. www.medicineplus.govwww.medicineplus.gov –last update 18 –last update 18thth

march 2008.march 2008.

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