PRESENTED BY VISSALINI JAYABALAN

090100432

SUPERVISED BY DR. BUGIS MADINA LUBIS SP.A (K)

PREMATURE BABY
A baby born before 37 weeks of gestation have passed. The current World Health Organization definition of prematurity is a baby born before 37 weeks of gestation, counting from the first day of the Last Menstrual Period (the LMP).

Different degrees of prematurity are defined by gestational age (GA) or birth weight. Newborn classification based on gestational age Preterm (premature) born at 37 weeks' gestation or less Term born between the beginning of week 38 and the end of week 41 of gestation Post-term (postmature) born at 42 weeks' gestation or more Newborn classification based on birth weight Low birth weight (LBW) less than 2500 g Very low birth weight (VLBW) less than 1500 g Extremely low birth weight (ELBW) less than 1000 g

 In relation to birth weight, most preterm babies are low

birth weight or very low birth weight

Low birth weight: born with birth weight between 1,500-2,499 gm usually be managed safely at home with some extra care and support.
Very low birth weight: born with birth weight less than 1,500 gm A life-threatening problem in such tiny babies is that suckling, swallowing and breathing are not well coordinated, so they require special attention in order to feed them adequately and safely difficulty in maintaining their body temperature, so they are at increased risk of hypothermia

premature baby

Preterm baby

Very preterm baby

baby born before 37 completed weeks of pregnancy

Babies born between the gestational ages of 32-36 weeks of gestation calculated from the mothers last normal menstrual period (LNMP date). can usually be managed safely at home with some extra care and support

born between the gestational ages of 28-31 weeks as calculated from the LNMP date Like very low birth weight babies have problems in feeding and maintaining their body temperature

premature baby

Preterm baby Very preterm baby

Term baby

Birth weight and gestational age Weight less than 1,500 gm Gestational age less than 32 weeks

Classification

Action Refer URGENTLY to a hospital, making sure to keep the baby warm on the journey Keep the newborn baby warm and refer it soon. If there is no other problem:counsel on optimal breast feeding, prevention of infection and keeping the baby warm As above for low birth weight babies As above for low birth weight and preterm

Very low birth weight

Very preterm

Weight 1,500 to 2,500 gm

Low birth weight

Gestational age 32-36 weeks Weight equal to or above 2,500 gm; gestational age equal to or above 37 weeks

Preterm Normal weight and full term

Associated Factors
Maternal Low socioeconomic status Lack of prenatal care Substance abuse, smoking Maternal age < 16yrs or > 35yrs Maternal illness e.g. renal, heart, lung, HPT, DM, etc Multiple gestation Prior preterm delivery Obstetric factors e.g. uterine malformations, cervical incompetence, polyhydramnios, premature rupture of membranes, infection (e.g. chorioamnionitis), placenta praevia, abruptio, etc Abdominal trauma / surgery Foetal Foetal distress, IUGR, etc

BALLARD SCORE
Use this score sheet to assess the gestational maturity of your baby. At the end of the examination the total score determines the gestational maturity in weeks.
NEUROMUSCULAR MATURITY
SCORE SIGN Posture Square Window -1 0 1 2 3 4 5 SIGN SCORE

Arm Recoil

Popliteal Angle Scarf Sign Heel To Ear TOTAL NEUROMUSCULAR SCORE

PHYSICAL MATURITY
SIGN SCORE -1

SIGN SCORE

Skin

gelatinous, Sticky, friable, red, transparent translucent

superficial cracking, pale parchment, leathery, smooth pink, peeling &/or areas, rare deep cracking, cracked, visible veins rash, few veins veins no vessels wrinkled

Lanugo

none heel-toe 40-50mm: -1 <40mm: -2 imperceptable

sparse

abundant

thinning anterior transverse crease only

bald areas

mostly bald

Plantar Surface

>50 mm no crease barely perceptable lids open pinna flat stays folded scrotum empty, faint rugae prominent clitoris & small labia minora

faint red marks flat areola no bud sl. curved pinna; soft; slow recoil

creases ant. 2/3

creases over entire sole full areola 5-10 mm bud

Breast

stippled areola raised areola 1-2 mm bud 3-4 mm bud

Eye / Ear

lids fused loosely: -1 tightly: -2

well-curved formed & firm thick cartilage pinna; soft but instant recoil ear stiff ready recoil testes pendulous, deep rugae majora cover clitoris & minora

Genitals (Male)

scrotum flat, smooth

testes in upper testes canal, descending, rare rugae few rugae prominent clitoris & enlarging minora majora & minora equally prominent

testes down, good rugae

Genitals (Female)

clitoris prominent & labia flat

majora large, minora small

TOTAL PHYSICAL MATURITY SCORE

MATURITY RATING

TOTAL SCORE (NEUROMUSCULAR + PHYSICAL)

WEEKS

-10
-5 0 5 10 15 20 25 30 35 40 45 50

20
22 24 26 28 30 32 34 36 38 40 42

Factor Heart rate Breathing

Score 0 No heart rate No breathing

Score 1 Below 100 beats/min Slow and irregular Some flexing of arms and legs

Score 2 Above 100 beats/min Good Actively moving

Muscle tone Limp and loose Reflexes

Vigorously cries when No reflex responses Grimaces or frowns when reflexes are reflexes are stimulated stimulated

Colour

Blue and pale

Body is pink but hands and feet are blue

Entire body is pink

Skin
Lanugo Limbs Head size Chest

may be reddened. The skin may be thin so blood vessels are easily seen. there is a lot of fine hair all over the babys body. the limbs are thin and may be poorly flexed or floppy due to poor muscle tone. appears large in proportion to the body. The fontanelles (open spaces where skull bones join) are smooth and flat. no breast tissue before 34 weeks of pregnancy.

Sucking ability
Genitals

weak or absent.
in boys the testes may not be descended and the scrotum may be small; in girls the clitoris and labia minora may be large. creases are located only in the anterior (front) of the sole, not all over, as in the term baby

Soles of feet

Respiratory distress is a symptom complex arising from disease processes that cause failure to maintain adequate gaseous exchange

Tachypnea (>60bpm)
Grunting, Flaring, Retractions/ recessions (GFR) Cynosis Reduced air entry

 >> premature infants, correlating with structural and

functional lung immaturity >> infants born at fewer than 28 weeks gestation 1/3 of infants born at 28 to 34 weeks gestation < 5 % of those born after 34 weeks gestation.
The condition is more common in boys, and the

incidence is approximately six times higher in infants whose mothers have diabetes, because of delayed pulmonary maturity despite macrosomia1.

CAUSES OF RESPIRATORY DISTRESS

Obstruction of the airway
123Choanal atresia Congenital stridor Tracheal or bronchial stenosis 1234-

Lung parenchymal disease

Meconium aspiration Respiratory distress syndrome Pneumonia Transient tachypnea of the newborn (retained lung fluid) 5- Pneumothorax 6- Atelectasis 7- Congenital lobar emphysema

Non-pulmonary causes
123Heart failure Intracranial lesions Metabolic acidosis 1-

Miscellaneous
Disorders of the diaphragm e.g. (diaphragmatic hernia) 2- Pulmonary haemorrhage 3- Pulmonary hypoplasia

In Silverman-Anderson score, inspection or auscultation of the upper and lower chest and nares are scored on a scale of 0, 1 or 2 using this system are:

A score greater than 7 indicates that the baby is in respiratory failure.

DOWNEs SCORING OF RESPIRATORY DISTRESS

0 1 2

Cyanosis None
Retractions None Grunting None Air entry Clear Respiratory Under 60 rate

In room air
Mild

In 40% FIO2
Severe

Audible with stethoscope

Audible without stethoscope

Decreased or delayed Barely audible 60-80 Over 80 or apnea

Score: > 4 = Clinical respiratory distress; monitor arterial blood gases > 8 = Impending respiratory failure

RISK FACTORS
Neonates younger than 33-38 weeks Weight less than 2500g Maternal diabetes Cesarean delivery without preceding labor Precipitous labor Fetal asphyxia Second of twins Cold stress Previous history of RDS in sibling Males whites

 Surfactant deficiency is the 1O cause of RDS.

Low levels of surfactant cause high surface tension

High surface tension makes it hard to expand the alveoli. Tendency of affected lungs to become atelectatic at end-

expiration when alveolar pressures are too low to maintain alveoli in expansion Leads to failure to attain an adequate lung inflation and therefore reduced gaseous exchange

PATHOPHYSIOLOGY
Pulmonary Surfactant decreases surface tension

Homogenous opaque infiltrates and air bronchograms, indicating contrast in airless lung tissue seen against air-filled bronchi, decreased lung volumes also can be detected

Oxygenation with blow-by oxygen, nasal cannula, or mechanical ventilation (CPAP). Corticosteroid therapy accelerates fetal lung maturation by increasing formation and release of surfactant. Surfactant replacement therapies Nutrition

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