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CARE OF PRETERM BABY

INTRODUCTION
Prematurity accounts for the largest number of admissions to an NICU. About 10-12 percent
of Indian babies are born preterm (less than 37 completed weeks) as compared to 5 to 7
percent incidence in the West. These infants are anatomically and functionally immature and
therefore their neonatal mortality is high.

PRETERM INFANT
By definition, the term preterm refers to a baby born before a gestation period of 37 weeks or
less. This replaces the old term prematurity.
In practice and from statistical point of view, it refers to a newborn whose birth weight is less
than 2,500g. Such a baby measures 46 cm or less in length and has head circumference of 32
cm or less. The chest circumference is usually less than 30 cm.

CAUSES OF PREMATURITY
The mechanisms initiating labour before term are not clearly understood. There may be
spontaneous onset of premature labour or it may be induced by the obstetrician to safe guard
the interests of the mother or baby.
Spontaneous - The cause of premature onset of labour is uncertain in most instances. The
known causes include poor socio-economic status, low maternal weight, chronic and acute
systemic maternal diseases, antepartum hemorrhage, cervical incompetence, maternal genital
colonization and infections, cigarette smoking during pregnancy, threatened abortion, acute
emotional stress, physical exertion, sexual activity, trauma, bicornuate uterus, multiple
pregnancy and congenital malformations. Premature births are relatively common among
very young and unmarried mothers. Past history of preterm births is associated with 3 to 4
times increased risk of prematurity in the subsequent pregnancies.
Induced The labour is often induced before term when there is impending danger to mother
or fetal life in-utero eg: maternal diabetes mellitus, placental dysfunction as indicated by
unsatisfactory fetal growth, eclampsia, fetal hypoxia, antepartum hemorrhage and severe
rhesus iso-immunization

CLINICAL FEATURES
Measurements Their size is small with relatively large head. Crown-heel length is less than
47 cm, head circumference is less than 33 cm but exceeds the chest circumference by more
than 3 cm.
Activity and Posture The general activity is poor and their automatic reflex responses,
such as Moro response, sucking and swallowing are sluggish or incomplete. The baby
assumes an extended posture due to poor tone.
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Face and Head Face appears small for the disproportionately large head size, sutures are
widely separated and the fontanels are large. Other characteristic features include small chin,
protruding eyes due to shallow orbits and absent buccal pad of fat. Optic nerve is often
unmyelinated but presence of papillary membrane makes its visualisation difficult. Ear
cartilage is deficient or absent with poor recoil. Hair appear woolly and fuzzy and individual
hair fibers can be seen separately.
Skin and Subcutaneous Tissues Skin is thin, gelatinous, shiny and excessively pink with
abundant lanugo and very little vernix caseosa. Edema may be present. Subcutaneous fat is
deficient and breast nodule is small or absent. Deep sole creases are often not present.
Genitals In males testes are undescended and scrotum is poorly developed. In female
infants, labia majora are widely separated exposing labia minora and hypertrophied clitoris.

PHYSIOLOGICAL HANDICAPS
The functional immaturity of various systems results in different clinical problems and their
knowledge is essential for the satisfactory management of these babies.

Central Nervous System


The immaturity of central nervous system central nervous system is expressed as inactivity
and lethargy, poor cough reflex and incoordinated sucking and swallowing in babies
weighing less than 1800 g or born before 35 weeks of gestation. Resuscitation difficulties at
birth and recurrent apnenic attacks are common. Retinopathy of prematurity due to oxygen
toxicity is limited to babies with a gestation of less than 35 weeks. On the other hand, they
are more resistant to toxic effect of hypoxia as compared to the term babies. They are
extremely vulnerable to develop intraventricular periventricular hemorrhage and
leucomalacia due to relative deficiency of vitamin K dependent coagulation factors and
increased capillary fragility. The blood brain barrier, which is possibly a function of available
serum proteins, is inefficient in preterm babies, thus brain damage may occur at lower serum
bilirubin levels.

Respiratory system
The cuboidal alveolar lining in babies with a gestational age of less than 26 weeks results in
poor alveolar diffusion of gases and therefore the infant may not be viable. They pose
resuscitation difficulties at birth, often followed by hyaline membrane disease, if associated
with deficiency of pulmonary surfactant. The breathing is mostly diaphragmatic, periodic and
associated with intercostals recessions due to soft ribs. Pulmonary aspiration and atelectasis
are common. They are vulnerable to develop chronic pulmonary insufficiency due to
bronchopulmonary dysplasia.

Cardiovascular system
The closure of ductus arteriosus is delayed among preterm infants. About one-third infants
with gestational age of 34 weeks or less manifest clinical evidences of patent ductus
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arteriosus with or without congestive heart failure. Its incidence is much higher among
preterm infants with hyaline membrane disease or protracted hypoxia due to any cause. In
grossly immature infants (less than 32 weeks) EKG shows left ventricular preponderance.
They are at risk to develop thrombo-embolic complications and hypertension due to
indwelling venous and arterial catheters.

Gastro intestinal system


Due to poor or incoordinated sucking and swallowing there are difficulties in self feeding,
although their digestive ability is generally good. Animal fat is not tolerated as well as the
vegetable fat. Regurgitation and aspiration are common because of incoordinated sucking,
small capacity of stomach, incompetence of cardioesophageal junction and poor cough reflex.
Gastro- esophageal reflux and its consequences are common. Abdominal distension and
functional intestinal obstruction are due to hypotonia. Enterocolitis occurs when other factors
predisposing are present. Immaturity of glucoronyl transferase system in the liver leads to
hyperbilirubinemia, which may be aggravated by dehydration, delayed feeding and
hypoglycaemia. Relatively low serum albumin, acidosis and hypoxia in these babies
predispose to the development of kernicterus at lower serum bilirubin levels. The poor
hepatic glycogen stores, delayed feeding, birth asphyxia and respiratory distress syndrome
contribute to the development of hypoglycaemia.

Thermo-regulation
Hypothermia is invariable and life threatening unless environmental temperature is
monitored. Excessive heat loss due to relatively large surface area and poor generation of heat
due to paucity of brown fat in a baby who is equipped with an inefficient thermostat.

Infections
Infections are an important cause of neonatal mortality in low birth weight babies. The low
levels of IgG antibodies and insufficient cellular immunity predispose them to infections.
Excessive handling, humid and warm atmosphere, contaminated incubators and resuscitators
expose them to infecting organisms, thus contributing to high incidence of infections.

Renal immaturity
The blood urea nitrogen is high due to low glomerular flltration rate. The renal tubular
ammonia mechanism is poorly developed thus acidosis occurs early. They are vulnerable to
develop late metabolic acidosis especially when fed with a high protein milk formula. The
maximum tubular diluting ability in the newborn is satisfactory but ability to concentrate
urine is very poor. Preterm baby has to pass 4 to 5 rn1 of urine to excrete one milliosmole of
solute as compared to 0.7 rn1 by an adult for the same purpose. Therefore, the baby cannot
conserve water and gets dehydrated readily. The solute retention and low serum proteins
explain occurrence of edema in some preterm infants.

Toxicity of drugs
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Poor hepatic detoxification and reduced renal clearance make a preterm baby
vulnerable to toxic effects of drugs unless caution is exercised during their administration.

Nutritional handicaps
Low birth weight babies are prone to develop anemia around 6 to 8 weeks of age. This
is due to diminished total stores of iron due to short gestation. They may also manifest
deficiencies of folic acid and vitamin E. Vitamin E deficiency occurs among infants weighing
less than 1,500 g, particularly those fed on iron fortified milk formula. These infants are
prone to develop hemolytic anemia, thrombocytopenia, and edema at 6 to 10 weeks of age.
Vitamin E being an antioxidant, its deficiency state may be associated with oxygen toxicity to
the vulnerable tissues in the form of retrolental fibroplasia and bronchopulmonary dysplasia.
Rapid growth following adequate feeding may result in osteopenia and rickets unless
calcium, phosphorus and vitamin D are administered.

Biochemical disturbances
These babies are prone to develop hypoglycemia, hypocalcemia, hypoproteinemia, acidosis
and hypoxia.

MANAGEMENT
High-risk mother should be identified early during the course of pregnancy and referred
for confinement to an appropriate health care facility which is equipped with good quality
obstetrical and neonatal care facilities. Mother is indeed an ideal trasport incubator!

ARREST OF PREMATURE LABOR


Advances in perinatal care including fabrication of a variety of electronic gadgets cannot
compare with unique security and optimal care provided to the fetus by the uteroplacental
unit. Efforts should always be made to arrest the progress of premature labor. The onset of
'true' labor is suspected by occurrence of two or more uterine contractions lasting at least 30
seconds during a 15-minute period in association with dilatation and effacement of cervix.
Apart from bed rest and sedation, a variety of tocolytic agents are recommended but none is
entirely safe or effective. Ethanol though popular at one stage is rarely used now due to its
dangers of inebriation, vomiting, headache, flushing, restlessness, disorientation and diuresis.
Magnesium sulphate is more effective and is being increasingly used though there is a
potential risk of respiratory depression in the newborn. The observational studies have shown
that maternal treatment with magnesium sulfate is associated with reduced risk ofNH,
cerebral palsy and mental retardation in their preterm babies.
Sympathomimetic agents specifically mediating via beta 2-adrenergic receptors are powerful
tocolytic agents and currently used. Isoxsuprine (duvadilan) is useful but its effect is
mediated both through beta-1 and beta-2 receptors. Its use is associated with untoward beta-l
receptor side effects such as apprehension, palpitation, hypotension, fetal tachycardia and
neonatal hypoglycemia. Therapy is initiated by intravenous infusion of 20 mg isoxsuprine
diluted in 200 ml of 5 percent dextrose at a rate of 40-50 drops/minute. This is followed by
intramuscular administration of 10 mg isoxsuprine every 4 hours for 24 and 48 hours. Oral
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therapy is continued for at least 2 weeks with maintenance doses of 10 mg every 6 hours.
Ritodrine has been approved by US Food and Drug Administration for treatment of
premature labor and'is more effective than ethanol. The common side effects are maternal and
fetal tachycardia. The usual dose is 100-400 ug/minute intravenously through an infusion
pump for a period of 12 hours followed by oral ritodrine 10 mg every 2 hours. Salbutamol
and terbutaline are selective beta 2-receptor stimulators and are very effective tocolytic
agents. They are generally safe but an occasional patient may develop tachycardia and
pulmonary edema. Terbutaline is administered as an intravenous bolus of 0.25 mg followed
by constant infusion of 10-80 ug/minute for 1-2 hours. After control of uterine contractions,
maintenance therapy is continued by administration of 0.25 mg of terbutaline subcutaneously
(or 2.5 mg orally) every 4 hours. Indomethacin, an irihibitor of prostaglandin-synthetase has
also offered some hope in arresting premature uterine contractions. It must be used with
caution because it may also block production of prostaglandin E thus markedly decreasing
uteroplacental perfusion and may cause closure of ductus arteriosus.

INDUCTION OF PREMATURE LABOR


When induction of labor is contemplated before term, either in the interest of mother or
the fetus, maturity of fetus should be ascertained by examination of amniotic fluid for
phosphatidyl glycerol or LIS ratio. As far as possible, delivery should be postponed till fetal
pulmonary maturity is assured. When delivery can be safely delayed for 36 to 48 hours,
corticosteroids should be administered to the mother to enhance fetal lung maturity.

ANTENATAL CORTICOSTEROIDS
Antenatal administration of corticosteroids is one of the most cost-effective perinatal
strategies which must be universally exploited. It is associated with 50 percent reduction in
the incidence of RDS due to surfactant deficiency. It provides additional benefits by reducing
the incidence of intraventricular hemorrhage and necrotizing enterocolitis. The over all
neonatal mortality is reduced by 40 percent by this simple and cheap intervention. Injection
betamethasone 12 mg 1M every 24 hours for 2 doses or dexamethasone 6 mg 1M every 12
hours for 4 doses should be administered to the mother if labor starts or is induced before 34
weeks of gestation. Betamethasone is more potent and is associated with reduced risk of side
effects. Thy optimal effect is seen if delivery occurs after 24 hours of the initiation of therapy
and its therapeutic effect lasts for 7 days. The beneficial effects are better in female babies
compared to the male. The need and safety of repeat courses of antenatal steroids is
controversial and is under investigation by multicentric clinical trials. Tocolytic therapy
should be continued concoplitantly. Corticosteroids can be given even in the presence of
maternal hypertension or diabetes mellitus but should preferably be avoided if preterm
premature rupture of membranes (PPROM) is associated with definitive clinical evidences of
chorioamnionitis.

CARE OF PRETERM BABIES


OPTIMAL MANAGEMENT AT BIRTH
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When a preterm baby is anticipated, the delivery should be attended by a senior pediatrician,
fully prepared to resuscitate the baby. The delayed clamping of cord helps in improving the
iron stores of the baby. It may also reduce the incidence and severity of hyaline membrane
disease. Elective intubation of extremely LBW babies (< 1000g) is practised in some centers
to support breathing and for prophylactic administration of exogenous surfactant. The baby
should be promptly dried, kept effectively covered and warm. Vitamin K 1.0 mg (0.5 mg in
babies < 1500 g) should be given intramuscularly. The baby should be transferred by the
doctor or nurse (not a nursing orderly) to the NICU as soon as breathing is established.

MONITORING
The following clinical parameters should be monitored by specially trained nurses. The
frequency of monitoring depends upon the gestational maturity and clinical status of the baby.

Vital signs with the help of multi-channel vital sign monitor (non-invasive with
alarms)
Activity and behaviour
Colour: Pink, pale, grey, blue, yellow
Tissue perfusion - Adequate tissue perfusion is suggested by pink colour, capillary
refill over upper chest of < 2 sec, warm and pink extremities, normal blood pressure,
urine output of > 1.5 ml/kg/hr, absence of metabolic acidosis and lack of any disparity
between pa02 and, Sa02
Fluids, electrolytes and ABG's
Tolerance of feeds by monitoring vomiting, gastric residuals, abdominal girth
The baby should be watched for development of RDS, apneic attacks, sepsis, PDA,
NEC, IVH etc.
Weight gain velocity

CRITERIA FOR A HEALTHY PRETERM BABY


During daily clinical evaluation of a preterm baby, the following clinical characteristics
should be looked for because they suggest that the baby is healthy. The vital signs should be
stable. The healthy baby is alert and active, looks pink and healthy (smells good too), trunk is
warm to touch and extreinities are reasonably warm and pink. The baby is able to tolerate
enteral feeds and there is no respiratory distress or apneic attacks and baby is having a steady
weight gain of 1.0 -1.5 percent of his body weight (10-15 g/kg/d) every day.

PROVIDE IN-UTERO MILIEU


Uterus provides ideal ambient conditions to the baby. All attempts should be made to create
uterus-like baby friendly ecology in the nursery.

Create a soft, comfortable, "nestled" and cushioned bed.


Avoid excessive light, excessive sound, rough handling and painful procedures. Use
effective analgesia and sedation for conducting procedures.
Provide warmth
Ensure asepsis
Prevent evaporative skin losses by effectively covering the baby, application of oil or
liquid paraffin to the skin and increasing humidity to near 100 percent. .
Provide effective and safe oxygenation
Uterus is able to provide unique parenteral nutrition. Efforts should be made to
provide at least partial parentral nutrition and give trophic feeds with expressed breast
milk (EBM).
Provide rhythmic gentle tactile and kinesthetic stimulation like skin-to-skin contact,
interaction, music, caressing and cuddling.

POSITION OF THE BABY


Most babies love to lie in a prone position, they cry less and feel more comfortable. It
relieves abdominal discomfort by passage of flatus and reduces risk of aspiration. Prone
posture improves ventilation, increases dynamic lung compliance and enhances arterial
oxygenation. Unsupervised prone positioning, beyond neonatal period, has been recognized
as a risk factor for SIDS.

THERMAL COMFORT
A pre-warmed open care system or incubator should be available at all times to receive any
baby with hypothermia or with a birth weight of less than 2000 g. The baby should be nursed
in a thermoneutral environment with a servo sensor geared to maintain skin temperature of
mid-epigastric region at 36.5 C so that there is virtually no or minimal metabolic
thermogenesis. Application of oil or liquid paraffin on the skin reduces convective heat loss
and evaporative water losses. The extremely LBW baby should be covered with a cellophane
or thin transparent plastic sheet to prevent convective heat loss and evaporative losses of
water from skin. As soon as baby's condition stabilizes he should be covered with a perspex
shield or effectively clothed with a frock, cap, socks and mittens. After one week or so, stable
babies with a birth weight of < 1200g should preferably be nursed in an intensive care
incubator. It is associated with reduced chances of handling, better temperature control,
reduced evaporative losses from skin and better weight gain velocity. The mother should be
encouraged to provide partial kangaroo-mother-care to prevent hypothermia, to promote
bonding and breast feeding and to transmit healing electromagnetic vibrations of love and
compassion to her baby.

OXYGEN THERAPY
Oxygen should be administered only when indicated, given in the lowest ambient
concentration and stopped as soon as its use is considered unnecessary. It is difficult to judge
the need for oxygen therapy on clinical grounds in preterm babies. The oxygen should be
administered with a head box when Sa02 falls below 85 percent and it should be gradually
withdrawn when SaO2 goes above 90 percent. The lowest ambient concentration and flow
rates should be used to maintain Sa02 between 85%-95% and pa02 between 60-80 mm Hg.

PHOTOTHERAPY
Jaundice is common in preterm babies due to hepatic immaturity, hypoxia, hypoglycemia,
infections and hypothermia. Due to immaturity of blood brain barrier, hypoproteinemia and
perinatal distress factors, bilirubin brain damage may occur at relatively lower serum
bilirubin levels. Early phototherapy is advised to keep the serum bilirubin level within safe
limits inorder to obviate the need for exchange blood transfusion. .

PREVENTION OF NOSOCOMIAL INFECTIONS


A preterm baby, who survives the initial stormy and unstable period of one week, is likely to
do well if protected against infections and provided with adequate nutrition. The handling
should be reduced to bare minimum. Vigilance should be maintained on all procedures
recommended for reduction of infections in the nursery. High index of suspicion, early
diagnosis and effective treatment of infections are essential for improved survival.

FEEDING AND NUTRITION


Starvation should be avoided and early enteral feeding should be established as soon as the
baby is stable. Babies weighing less than 1200 g or gestation of < 30 weeks and sick babies
(severe birth asphyxia, RDS, sepsis, seizures; apneic attacks, assisted ventilation etc.) should
be started on intravenous dextrose solution (l0% dextrose in babies>'1000 g and 5% dextrose
in babies < 1000 g). Trophic feeds with EBM (1-2 ml 4 times/d) through a nasogastric tube
can be started in all babies irrespective of their birth weight or clinical condition to harness its
unique benefits. When baby's condition is stabilized enteral feeds are begun with EBM
starting with a volume of 30 ml/kg/d on the first day and depending upon the tolerance, the
enteral feeds are increased by 10-20 ml/kg/d every day and intravenous fluids are reduced
accordingly.

NUTRITIONAL SUPPLEMENTS
After two weeks when baby is stable and tolerating enteral feeds, EBM can be fortified with
human milk fortifier (HMF). The fortification of EBM with formula feeds (especially during
night) also provides additional calories and protein to the baby. Multivitamin drops
containing folic acid should be started at two weeks of age. Iron supplementation (2-3 mg/kg
elemental iron) should be started after 2-3 weeks when baby is having steady weight gain.
Free radical lipid peroxidation in cell membranes is catalyzed by iron and polyunsaturated
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fatty acids (PUPA) thus increasing the requirements of vitamin E in very low birth weight
babies. The requirements of vitamin E are; therefore, related to linoleic acid content of the
fonnula. It is recommended that vitamin E to linoleic acid ratio should be greater than 1.0
iulgram of linoleic acid (yitamin E 1.0 i.u. = 1.0 mg) in the feeding fonnula for LBW babies,
The alpha tocopherolllinoleic acid ratios ate 6.23, 1.43 and 0.78 mg/g i~J+pman colostrum
tr~llsitional and mature milk respectively. Vitamin Iiisa powerful antioxidant and prevents
the hemolytic anemia and edema of prematurity. In infants weighing less than 1500 g at
birth, milk fonnula should provide at least 1.0 i.u. of vitamin E per gram of.linoleicacid and
supplemented with daily administration of 15 Lu. of vitamin E. Supplements of calcium
(220 mg/d) and phosphorus (100 mg/d)'are essential to 'prevent osteopeniaofprematurity. The
supplements are continued till the baby has achieved post conceptional maturity of 38 weeks
or weight of 2000 g.

GENTLE RHYTHMIC STIMULATION


Availability of sophisticated high technology has revolutionized the care of pretenn and sick
newborn babies. But the technology should not be allowed to become a barrier between the
communication, compassion and concern of the treating team and the family, Gentle touch,
massage, cuddling, stroking and flexing by the nurse or preferably by the mother provide
useful tactile stimuli to the baby. Rocking bed or placing a pretenn baby on inflated gloves
rhythmically rocked by a ventilator provide useful vestibular-kinesthetic stimuli for
prevention of apneic attacks ofprematurity. Soothing auditory stimuli can be given to the
pretenn baby in the fonnof taped heart beats, family voices or music. Music has been shown
to reduce the stress of procedure andehhance weight gain velocity of pretenn babies. Visual
inputs can be provided with the help of colored objects, diffuse light and eye-to-eye contact.

UTILITY OF CORTICOSTEROIDS
Unnecessary administration of corticosteroids should be avoided due t9 its potential side
effects. Antenatal administration of' betamethasone or dexamethasone is universally
recommended if labour starts before 34 weeks of gestation. A single dose of dexamethasone
0.2 mg/kg IV at 4 hours of age may be given to very LBW babies (< 1500 g) to reduce the
incidence and severity of HMD and IVH, but its use is controversial. Corticosteroids ~o
indicated to assist the process of difficult weaning following prolonged assisted ventilation
and for attenuation of inflammatory changes in infants with bronchopulmonary dysplasia.
Inhaled steroids have not been found to be useful to reduce the risk of chronic lung disease
(CLD). Corticosteroids have some therapeutic utility in the management of sclerema
neonatorum. They have no role in the management of. hypoxic-ischemic encephalopathy,
sepsis, meningitis and meconium aspiration syndrome. There is increasing evidence to
suggest that prolonged use of corticosteroid therapy should be avoided in newborn babies
because of serious concerns for short term (Hypertension, hyperglycemia, GI bleeding,
infections) and long term (cerebral palsy and neuromotor disability) side effects.

TRANSIENT HYPOTHYROXINEMIA OF PREMATURITY

In preterm babies below 30 weeks gestation, total T4 levels may be low but free T4, T3 and
TSH levels are usually normal. The condition is transient and is attributed to a normal
adaptive response of an immature hypothalamic-pituitary axis or to sick euthyroid syndrome.
Its clinical significance is controversial. The current Cochrane Neonatal Collaborative
Review does not recommend routine T4 supplementation in preterm babies.

PRIORITY PACKAGES AND EVIDENCE-BASED INTERVENTIONS


All newborn babies are vulnerable given that birth and the following few days hold the
highest concentrated risk of death of any time in the human lifespan. Every baby needs
essential newborn care, ideally with their mothers providing warmth, breastfeeding and a
clean environment. Premature babies are especially vulnerable to temperature instability,
feeding difficulties, low blood sugar, infections and breathing difficulties. There are also
complications that specifically affect premature babies. Saving lives and preventing disability
from preterm birth can be achieved with a range of evidence-based care increasing in
complexity and ranging from simple care such as warmth and breastfeeding up to full
intensive care. The packaged interventions in this chapter are adapted from a recent extensive
evidence review and a consensus report, Essential Interventions Commodities and
Guidelines for Reproductive Maternal, Newborn and Child Health (PMNCH, 2011).
Recognition of small babies and distinguishing which ones are preterm are essential first
steps in prioritizing care for the highest risk babies. The highest-risk babies are those that are
both preterm and growth restricted.

PACKAGE 1: ESSENTIAL AND EXTRA NEWBORN CARE


Care at birth from a skilled provider is crucial for both women and babies and all providers
should have the competencies to care for both mother and baby, ensuring that mother and
baby are not separated unnecessarily, promoting warmth, early and exclusive breastfeeding,
cleanliness and resuscitation if required (WHO, 2010). These practices are essential for fullterm babies, but for premature babies, missing or delaying any of this care can rapidly lead to
deterioration and death. For all babies at birth, minutes count.

Thermal care
Simple methods to maintain a babys temperature after birth include drying and wrapping,
increased environmental temperature, covering the babys head, skin-to-skin contact with the
mother and covering both with a blanket. Delaying the first bath is promoted, but there is a
lack of evidence as to how long to delay, especially if the bath can be warm and in a warm
room. Kangaroo Mother Care (KMC) has proven mortality effect for babies <2,000 g.
Equipment-dependent warming techniques include warming pads or warm cots, radiant
heaters or incubators and these also require additional nursing skills and careful monitoring.
Sleeping bags lack evidence for comparison with skin to- skin care or of large-scale
implementation. There are several trials suggesting benefit for plastic wrappings but, to date,
these have been tested only for extremely premature babies in neonatal intensive care units.

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Feeding support
At the start of the 20th century, Pierre Budin, a famous French obstetrician, led the world in
focusing on the care of weaklings, as premature babies were known then. He promoted
simple care--warmth, breastfeeding and cleanliness. However, by the middle of the 20th
century, formula milk was widely used and the standard text books said that premature babies
should not be fed for the first few days. After 1960, the resurgence of attention and support
for feeding of premature babies was an important factor in reducing deaths before the advent
of intensive care. Early initiation of breastfeeding within one hour after birth has been shown
to reduce neonatal mortality. Premature babies benefit from breast milk nutritionally,
immunologically and developmentally .The short-term and long-term benefits compared with
formula feeding are well established with lower incidence of infection and necrotizing
enterocolitis and improved neurodevelopmental outcome. Most premature babies require
extra support for feeding with a cup, spoon or another device such as gastric tubes (either oral
or nasal). In addition, the mother requires support for expressing milk. Where this is not
possible, donor milk is recommended. In populations with high HIV prevalence, feasible
solutions for pasteurisation are critical. Milk-banking services are common in many countries
and must be monitored for quality and infection prevention. Extremely preterm babies under
about 1,000 g and babies who are very unwell may require intravenous fluids or even total
parenteral nutrition, but this requires meticulous attention to volume and flow rates. Routine
supplementation of human milk given to premature babies is not currently recommended by
WHO. WHO does recommend supplementation with vitamin D, calcium and phosphorus and
iron for very low birth weight babies and vitamin K at birth for low birth weight babies.

Infection prevention
Clean birth practices reduce maternal and neonatal mortality and morbidity from infectionrelated causes, including tetanus. Premature babies have a higher risk of bacterial sepsis.
Hand cleansing is especially critical in neonatal care units. However basic hygienic practices
such as hand washing and maintaining a clean environment are well known but poorly done.
Unnecessary separation from the mother or sharing of incubators should be avoided as these
practices increase spread of infections. For the poorest families giving birth at home, the use
of clean birth kits and improved practices have been shown to reduce mortality.
Recent cluster-randomized trials have shown some benefit from chlorhexidine topical
application to the babys cord and no identified adverse effects. To date, about half of trials
have shown a significant neonatal mortality effect especially for premature babies and
particularly with early application, which may be challenging for home births.
Another possible benefit of chlorhexidine is a behaviour change agent in many cultures
around the world, something is applied to the cord and a policy of chlorhexidine application
may accelerate change by substituting a helpful substance for harmful ones.
The skin of premature babies is more vulnerable, and is not protected by vernix like a term
babys. Topical application of emollient ointment such as sunflower oil reduces water loss,
dermatitis and risk of sepsis and has been shown to reduce mortality for preterm babies.
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Another effective and low cost intervention is appropriate timing for clamping of the
umbilical cord, waiting 2-3 minutes or until the cord stops pulsating, whilst keeping the baby
below the level of the placenta. For preterm babies this reduces the risk of intracranial
bleeding and need for blood transfusions as well as later anemia. Possible tension between
delayed cord clamping and active management of the 3rd stage of labor with controlled cord
traction has been debated, but the Cochrane review and also recent-evidence statements by
obstetric societies support delayed cord clamping for several minutes in all uncomplicated
births.

PACKAGE 2: NEONATAL RESUSCITATION


Between 5 to 10% of all newborns and a greater percentage of premature babies require
assistance to begin breathing at birth. Basic resuscitation through use of a bag-and-mask or
mouth-to-mask (tube and mask) will save four out of every five babies who need
resuscitation; more complex procedures, such as endotracheal intubation, are required only
for a minority of babies who do not breathe at birth and who are also likely to need ongoing
ventilation. Recent randomized control trials support the fact that in most cases assisted
ventilation with room air is equivalent to using oxygen, and unnecessary oxygen has
additional risks. Expert opinion suggests that basic resuscitation for preterm births reduces
preterm mortality by about 10% in addition to immediate assessment and stimulation. An
education program entitled Helping Babies Breathe has been developed by the American
Academy of Pediatrics and partners for promotion of basic neonatal resuscitation at lower
levels of the health system in low-resource settings and is currently being scaled up in over
30 low-income countries and promises potential improvements for premature babies

PACKAGE 3: KANGAROO MOTHER CARE


KMC was developed in the 1970s by a Colombian pediatrician, Edgar Rey, who sought a
solution to incubator shortages, high infection rates and abandonment among preterm births
in his hospital. The premature baby is put in early, prolonged and continuous direct skin-toskin contact with her mother or another family member to provide stable warmth and to
encourage frequent and exclusive breastfeeding. A systematic review and meta analysis of
several randomized control trials found that KMC is associated with a 51% reduction in
neonatal mortality for stable babies weighing <2,000g if started in the first week, compared to
incubator care. These trials all considered facility-based KMC practice where feeding support
was available. An updated Cochrane review also reported a 40% reduction in risk of postdischarge mortality, about a 60% reduction in neonatal infections and an almost 80%
reduction in hypothermia. Other benefits included increased breastfeeding, weight gain,
mother-baby bonding and developmental outcome. In addition to being more parent and baby
friendly, KMC is more health-system friendly by reducing hospital stay and nursing load and
therefore giving cost savings. KMC was endorsed by the WHO in 2003 when it developed a
program implementation guide. Some studies and program protocols have a lower weight
limit for KMC, e.g., not below 800g, but in contexts where no intensive care is available,
some babies under 800g do survive with KMC and more research is required before setting a
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lower cut off. Despite the evidence of its cost effectiveness, KMC is underutilized although it
is a rare example of a medical innovation moving from the Southern hemisphere, with recent
rapid uptake in neonatal intensive care units in Europe.

PACKAGE 4: SPECIAL CARE OF PREMATURE BABIES AND


PHASED SCALE UP OF NEONATAL INTENSIVE CARE
Moderately-premature babies without complications can be cared for with their mothers on
normal postnatal wards or at home, but babies under 32 weeks gestation are at greater risk of
developing complications and will usually require hospital admission. Fewer babies are born
under 28 weeks of gestation and most of these will require intensive care.

Care of babies with signs of infection


Improved care involves early detection of such danger signs and rapid treatment of infection,
while maintaining breastfeeding if possible. Identification is complicated by the fact that ill
premature babies may have a low temperature, rather than fever. First level management of
danger signs in newborns has relatively recently been added to Integrated Management of
Childhood Illness guidelines. WHO recommends that all babies with danger signs be referred
to a hospital. Where referral is not possible, then treatment at the primary care center can be
lifesaving.

Care of babies with jaundice


Premature babies are at increased risk of jaundice as well as infection, and these may occur
together compounding risks for death and disability. Since severe jaundice often peaks
around day 3, the baby may be at home by then. Implementation of a systematic pre
discharge check of women and their babies would be an opportunity to prevent complications
or increase care seeking, advising mothers on common problems, basic home care and when
to refer their baby to a professional.

Babies with Respiratory Distress Syndrome


For premature babies with RDS, methods for administering oxygen include nasal prongs, or
nasal catheters. Safe oxygen management is crucial and any baby on continuous oxygen
therapy should be monitored with a pulse oximeter. The basis of neonatal care of very
premature babies since the 1990s was assisted ventilation. However, reducing severity of
RDS due to greater use of antenatal corticosteroids and increasing concerns about lung
damage prompted a shift to less intensive respiratory support, notably CPAP commonly using
nasal prongs to deliver pressurized, humidified, warmed gas (air and/or oxygen) to reduce
lung and alveoli collapse. This model of lower intensity may be feasible for wider use in
middle-income countries and for some low-income countries that have referral settings with
stronger systems support such as high-staffing, 24-hour laboratories.
Recent trials have demonstrated that CPAP reduces the need for positive pressure ventilation
of babies less than 28 weeks gestation, and the need for transfer babies under 32 weeks
13

gestation to neonatal intensive care units. One very small trial in South Africa comparing
CPAP with no ventilation among babies who were refused admission to neonatal intensive
care units found CPAP reduced deaths. In Malawi, a CPAP device developed for low-resource
settings is being trialed in babies with respiratory distress who weigh over 1,000g. Early
results are encouraging, and an important outcome will be to assess the nursing time required
and costs.
Increasing use of CPAP without regulation is a concern. Many devices are in the
homemade category; several low cost bubble CPAP devices are being developed
specifically for low-income countries but need to be tested for durability, reliability and
safety. CPAP-assisted ventilation requires adequate medical and nursing skill to apply and
deliver safely and effectively, and also requires other supportive equipment such as an
oxygen source, oxygen monitoring device and suction machine.
Surfactant is administered to premature babys lungs to replace the missing natural surfactant,
which is one of the reasons babies develop RDS. The first trials in the 1980s demonstrated
mortality reduction in comparison to ventilation alone. The cost also remains a significant
barrier. In India, surfactant costs up to $600 for a dose. Data from India and South Africa
suggest that surfactant therapy is restricted to use in babies with potential for better survival,
usually over 28 weeks gestation due to its high price. Costs may be reduced by synthetic
generics and simplified administration, for example with an aerosolized delivery system, but
before wide uptake is recommended, studies should assess the additional lives saved by
surfactant once antenatal corticosteroids and CPAP are used.

PREVENTION, EARLY DIAGNOSIS AND PROMPT MANAGEMENT


OF COMMON PROBLEMS
Nosocomial infections - House keeping rituals, strict house keeping routines and high index
of suspicion should be maintained to prevent and make early diagnosis of nosocomial
infections.
Hypothermia - Nurse in a thermoneutral environment.
Respiratory distress syndrome Antenatal administration of corticosteroids, prevention
and effective treatment of perinatal distress, prophylactic administration of exogenous
surfactant to reduce the incidence and severity of hyaline membrane disease (HMD).
Aspiration - Availability of trained nurses is essential for safe administration of enteral
feeds and for prevention of aspiration of feeds.
Patent ductus arteriosus - Avoid over infusion.
Chronic lung disease - During assisted ventilation, airway pressure should be kept at the
bare minimum without compromising gas exchange. In infants < 1000 g, administration of
vitamin A 5000units IM 3times in a week for 4 weeks has been shown to reduce the risk of

14

CLD by 10 percent. Corticosteroids should preferably be avoided or only short courses


should be used due to potential risk of causing neuromotor disability.
Necrotizing enterocolitis - Ensure feeding with human milk, trophic feeds avoidance of
hyperosmolar feeds and over infusion.
Intraventricular hemorrhage - Antenatal corticosteroids, avoidance of rough handling,
excessive CPAP and bolus administration of sodium bicarbonate may reduce the incidence of
IVH.
Retinopathy of prematurity Maintain paO2 below 90 mm Hg, avoid excessive light, blood
transfusions and ensure feeding with human milk.
Late metabolic acidosis - Protein intake should be restricted to 3g/kg/d and avoid use of
formula feeds.
Nutritional disorders - Provide supplements with calcium, phosphorus, vitamin D, vitamin
E, iron and folic acid.
Drug toxicity - Side effects of drugs can be reduced by giving lower doses at 12 hourly
intervals

WEIGHT CONTROL
Accurate weighing of babies is a sensitive index of their well being. The weight is routinely
recorded every day but in sick babies twice daily weight record is recommended. Most
preterm babies lose weight during the first 3 to 4 days of life and loss is upto a maximum of
10 to 15 percent of the birth weight. The weight remains stationary for the next 4 to 5 days
and then the babies start gaining at a rate of 1.0 to 1.5 percent of body weight (10-15
g/kg/d) per day. They regain their birth weight by the end of second week of life. Excessive
weight loss, delay in regaining the birth weight or slow weight gain suggest that either the
baby is not being fed adequately or he is unwell and needs immediate attention. Sudden
weight loss in a baby who had been gaimng weight satisfactorily would suggest the
possibility of dehydration. Excessive weight gain of 100 g or more per day may occur in
babies with cardiac failure though sometimes healthy babies may also gain weight more
rapidly.

WHAT TO AVOID IN THE CARE OF PRETERM BABIES?


In the care of preterm babies, at times greater harm is done by unnecessary therapeutic
interventions which may lead to iatrogenic disorders. The following interventions should be
avoided because they are unnecessary, useless and often associated with serious side effects.

Routine oxygen administration without monitoring.


Intravenous immunoglobulins for prevention of neonatal sepsis.
Prophylactic antibiotics (except during assisted ventilation)
Prophylactic administration of indomethacin or high doses of vitamin E

15

Unnecessary blood transfusions (Definite indications include hematocrit of < 40% in


a sick neonate, < 30% in a symptomatic neonate and < 25% in an asymptomatic
neonate).
Formula feeds
Rough handling, excessive light arid loud sound.

IMMUNIZATIONS
Preterm babies are able to mount a satisfactory immune response and they can be vaccinated
at the usual chronological age like term babies. The dose of vaccine is not reduced in preterm
babies. However, there is some evidence to suggest that administration of hepatitis B vaccine
in preterm infants is associated with low sero conversion rate. Because during their stay in the
NICU, there is no risk of contracting vaccine-preventable diseases, it is desirable to
administer 0-day vaccines (BCG, OPV; HBV) on the day of discharge from the hospital. This
policy seems more logical and appropriate to ensure satisfactory immune response against
various vaccines. However, if mother is HBV carrier and is e-antigen positive, baby should
be given hepatitis B vaccine and hepatitis B specific immunogiobulins within 72 hours of
age. Live vaccines should be avoided in symptomatic HIV-positive babies. WHO
recommends that BCG and oral polio vaccine can be given to asymptomatic HIV- positive
infants.

FAMILY SUPPORT
The prolonged stay of preterm and sick newborn babies in the NICU is associated with
emotional trauma, uncertainty, anxiety and lack of bonding with the baby on the part of
parents. The family dynamics are greatly disturbed apart from tremendous physical stress
and, fiscal implications due to high cost of neonatal intensive care. These issues and
problems should be handled with equanimity, compassion, concern and caring attitude of the
health team. The frightening scene of NICU should be demystified and family, should be
constantly informed and involved in the care of their baby. The mother should be encouraged
to touch and talk with her baby and provide routine care under, the guidance of nurses. She
should be assisted to provide partial kangaroo-mother care to her baby in the NICU which
would enhance bonding and promote breast feeding. She should provide visual and auditory
stimuli to her baby and try to establish eye-to-eye contact. The anxiety and concern of the
family should be cushioned by providing necessary emotional support and guidance.

TRANSFER FROM INTUBATOR TO-COT


A baby who is feeding from the bottle or cup and spoon and is reasonably active with a stable
body temperature, irrespective of his weight, qualifies for transfer to the open cot. The baby
should be observed for another 12 hours after putting the incubator off to see whether he can
maintain his body temperature. The infant should stay in the incubator for as short a period as
possible because incubators are a potent source of nosocomial infection.
16

DISCHARGE POLICY
The mother should be mentally prepared and provided with essential training and skills for
handling a preterm baby before she is discharged from the hospital. The mother-baby dyad
should be kept in a step-down nursery where she is able to independently look after the
essential needs of her baby like maintenance of body temperature, ensuring asepsis, feeding
with a cup and spoon or breast feeding, toilet needs etc. The baby should be stable,
maintaining his body temperature and should not have any evidences of cold stress. At the
time of discharge the baby should be having daily steady weight gain velocity of at least
10g/kg. The home conditions should be satisfactory before the baby is discharged. The
public health nurse should assess the home conditions and visit the family at home every
week for a month or so.

FOLLOW-UP PROTOCOL
After discharge from the hospital, babies should be regularly followed up for assessment of
the following parameters. The specialized perinatal follow-up services demand a close
collaboration and interaction with a large number of specialists like pediatrician,
developmental physician, dietician, ophthalmologist, audiologist, child psychologist, physiooccupational therapist and social worker. The following parameters should be closely
monitored and followed:
Common infective illnesses, reactive airway disease, hypertension, renal dysfunction,
gastro esophageal reflux
Feeding and nutrition
Immunizations
Physical growth, nutritional status, anemia, osteopenia/ rickets
Neuromotor development, cognition and seizures
Eyes : retinopathy of prematurity, vision, strabismus
Hearing
Behavioural problems, language disorders and learning disabilities

HOME CARE OF PRETERM BABIES


In view of rather marked disparity between the available facilities for special care of low
birth weight babies versus number of such babies requiring care in developing countries, it
is essential that general principles of home care are highlighted. Most healthy near term or
borderline preterm infants with a birth weight of 1,800 g or more and gestational maturity of
35 weeks or more can be managed at home. The policy of early discharge from the hospital
in an effort to decongest the nurseries, has imposed additional responsibilities that their care
be extended to their homes. It is, however, essential that a low birth weight infant should not
be discharged unless he has regained his birth weight, is self feeding from the bottle or
breast and is showing a steady weight gain. Before discharge, the mother should be

17

encouraged to breast feed her baby and look after his toilet need. She must be explained
about the need and importance of maintaining asepsis, keeping the baby warm and ensuring
satisfactory feeding routine. It is true, though unfortunate, that many a low birth weight
babies after discharge from the hospital, do come back or succumb to diarrhoea, sepsis and
exposure to cold. The services of postpartum program public health nurse and social
worker can be utilized to provide home care after discharge. It is essential that proper
appraisal of available physical facilities, resources and environmental conditions be made by
a predischarge home visit by a health visitor or a public health nurse before the baby is
discharged. It should be followed by periodic home visits to assess the progress of the child.

ENVIRONMENTAL CONTROL
It must be remembered that the desirable environmental temperature to safeguard the
biological needs of the low birth weight infant, is rather uncomfortable for an adult. The
infant should be effectively covered taking care to avoid smothering. Woolen cap, socks and
mittens should be worn. The infant should preferably lie next to the mother which serves as a
useful biologically controlled heat source. In winter, the room can be warmed with a radiant
heater or angeethi. A table lamp having a 100 watt bulb can be used to provide direct radiant
heat. Hot water bottle, if ever used, should never come in direct contact with the baby. The
cot of the mother and infant should be located away from the walls to reduce radiation heat
loss. The mother and health workers should be trained to assess the temperature of a
newborn baby by touch and advised to ensure that the extremities are kept warm and pink.
Low birth weight babies do relatively much better in summer than in winter.
The visitors and handling of the infant should be restricted to the bare minimum. The hands
must be washed before touching or feeding the baby. The emotional urge for kissing the baby
should be curbed. The linen should be clean and sun-dried.

FEEDING
Whenever feasible breast feeding is ideal and must be encouraged. When infant is unable to
suck from the breast, expressed breast milk should be given with a bottle or dropper or spoon
depending upon his maturity. In case formula feeding is unavoidable, specially designed
formula for premature babies is recommended. If cows milk or buffalos milk is unavoidable
it should be given after 3:1 dilution. Mother must be given detailed instructions and practical
demonstration for maintenance of bottle hygiene to prevent contamination of feeds

PROGNOSIS
The outcome of uncomplicated premature babies is comparable to the babies born
after full maturity. In fact, several renowned and famous people, who were born premature,
grew up to become world leaders and intellectuals. Sir Isaac Newton, the greatest
mathematician genius, weighed merely 3 lbs at birth. Sir Winston Churchill, the legendary
Prime Minister of Britain was born after 7 months of pregnancy when his mother was
participating in a royal dance. The world renowned artists Pablo Picasso and Anna Pavlova,
18

came into this world a bit too early and left mark for succeeding generations. The parents of
premature children, therefore, should not feel despondent because there is enough historical
evidence that their infant has a bright future and he may grow up to become an intellectual
giant.
Prognosis for survival is directly related to the birth weight of the child and quality
of the neonatal care. Over three-fourth of neonatal deaths occur among low birth weight
babies. Therefore, in countries with high incidence of LBW babies, neonatal mortality is
likely to be higher. The risk of neurodevelopmental handicaps is increased 3-fold for LBW
babies and l0-fold for very LBW babies (<1500 g). The prognosis for mental development is
good if the baby had not suffered from birth asphyxia, apneic attacks, respiratory distress
syndrome, hypoglycemia or hyperbilirubinemia. Their physical growth correlates better with
their conceptional age rather than the age calculated from the date of birth. Preterm AFD
babies catch up in their physical growth with term counterparts by the age of 1 to 2 years.
Long term follow up studies of infants with a birth weight of 1500 g and less have revealed
15 to 20 percent incidence of neurological handicaps in the form of cerebral palsy, seizures,
hydrocephalus, microcephaly, blindness (due to ROP), deafness and mental retardation. There
is high incidence of minor neurologic disabilities in the form of language disorder, learning
disabilities, behaviour problems, attention deficit, hyperactivity disorder requiring specialized
support for education. The incidence of neurological handicaps is related to the quality of
obstetrical and neonatal services. Neurological prognosis is adversely affected by degree of
immaturity, intrauterine growth retardation, severity of perinatal hypoxia, intraventricular
hemorrhage, periventricular leukomalacia and severity of respiratory failure demanding
assisted ventilation.

FEEDING OF PRETERM INFANTS


Proper nutrition in infancy is essential for normal growth, resistance to infection,
long term health and optimal neurologic and cognitive development. Providing adequate
nutrition to preterm infants is challenging because of several problems, some of them unique
to these small infants. These problems include immaturity of bowel function, inability to suck
and swallow, high risk of necrotizing enterocolitis (NEC), illnesses that may interfere with
adequate enteral feeding (e.g., RDS, patent ductus arteriosus) and medical interventions that
preclude feeding (e.g., umbilical vessel catheters, exchange transfusion, indomethacin
therapy).
PHYSIOLOGY AND PATHOPHYSIOLOGY
The gut has formed and has completed its rotation back into the abdominal cavity by 10
weeks of gestation. By 16 weeks, the fetus can swallow amniotic fluid. GI motor activity is
present before 24 weeks, but organized peristalsis is not established until 29-30 weeks and is
facilitated by antenatal corticosteroid treatment. Coordinated sucking and swallowing
develops at 32-34 weeks. By term, the fetus swallows about 150 cc/kg/day of amniotic fluid,
19

which has 275 mOsm/L, contains carbohydrates, protein, fat, electrolytes, immunoglobulins
and growth factors, and plays an important role in development of GI function. Preterm birth
interrupts this development. Even if nutrients are provided parenterally, lack of enteric intake
leads to decreased circulating gut peptides, slower enterocyte turnover and nutrient transport,
decreased bile acid secretion, and increased susceptibility to infection due to impaired barrier
function by intestinal epithelium, lack of colonization by normal commensal flora and
colonization by pathogenic organisms. For fat digestion, the newborn depends on lingual
lipase, which is stimulated by sucking and swallowing and by nutrients in the stomach but not
the small bowel. The figure is a chronological representation of GI development during fetal
life.
CONTRA-INDICATIONS TO FEEDING
Do not start feeds if the infant:
is receiving indomethacin, or received it within the previous 48hours
has a hemodynamically significant patent ductus arteriosus
has either an umbilical arterial or venous catheter. Do not start feedings until the
catheters have been removed for 8hurs
is polycythemic
has significant metabolic acidosis.
has severe respiratory instability or there is impending endotracheal intubation
has hemodynamic instability as evidenced by clinical signs of sepsis, hypotension,
is receiving dopamine (at a dose >3 mcg/kg/min) or other vasopressor drugs
received an exchange transfusion within the past 48hours.
has abdominal distension or other signs of GI dysfunction.
has had an episode of severe asphyxia (perinatal or post-natal) in the previous
72hours
FEEDING PROTOCOL: The following are guidelines for the initiation and advance of
enteral feedings in preterm infants:
1. Method of feeding:
Because these infants usually have not yet developed coordinated sucking and
swallowing, they must be fed by gavage:
Orogastric tubes are usually used. Because infants are obligate nose breathers,
it is best not to occlude the nares with a tube. In addition, repeated insertion of
a nasal gastric tube can cause inflammation of the nose with subsequent
obstruction.
Estimate length of tube that must be inserted to reach the stomach.
Insert the tube and aspirate to see if gastric contents are returned. While
listening over stomach with stethoscope, inject ~5cc of air. If tube is in
stomach, you should hear bubbling as you inject air. If you cannot hear any
bubbling, tube may be in the trachea. Therefore, do not feed infant until you
are certain that tube is in stomach.
Do not use duodenal or jejunal tubes for gavage feedings as feedings are less
well tolerated and do not stimulate secretion of lingual lipase. In addition,
residuals are no longer useful in assessing tolerance of feedings.
20

Nipple feedings can be considered as the infant matures. The best judge of
when to start nipple feedings is an experienced Nurse.
2. Content of feeding: Begin with either:
Breast milk (preterm breast milk is 290 mOsm/L) or
Formula for preterm infants (e.g., Premature Enfamil or Similac Special Care,
260 mOsm/L).
Some physicians use half-strength feedings, but there is no evidence that this is
beneficial. In fact, hypo-osmolar solutions may slow gastric emptying, leading to
increased incidence of residuals and feeding intolerance
Remember that fetuses swallow amniotic fluid, which is 275 mOsm/L, and this
swallowing begins at 16 weeks gestation.
3. Guidelines for Feeding: Initiation of feedings, their volume and the rate of advance of
feedings are related to birth weight, gestational age and how the infant has tolerated feeds to
date. General guidelines include:
Initial volume is 2 cc/kg per feeding with a minimal absolute volume of 2 cc
Do not advance feedings faster than 20 cc/kg/d.
Do not advance feedings if there are any signs that the baby is not tolerating
feeds. Aggressive advances of feedings increase the risk of NEC.
A small volume, even if not advanced, is much better than nothing at all. Even very
small volumes stimulate maturation of gut motility and production of enteric peptides.
Bolus feedings are preferable to continuous feedings.
The goals for full feedings are:
-Volume: 150-160 cc/kg/d
-Calories: 110-120 kcal/kg/d
-Some SGA infants will require a higher caloric intake to achieve consistent
weight gain.

FORTIFYING FEEDINGS not only provides mores calories but also improved intake of
calcium, phosphorus and protein. Fortify feedings (breast milk and formula) as follows:
-When infant is tolerating 100 cc/kg/d, feedings may be fortified to 22 cal/oz.
-When infant has been tolerating 150 cc/kg/d for at least 2d, feedings may be fortified to 24
cal/oz.
INTOLERANCE TO FEEDINGS is common among very small preterm infants, and most
such infants will have episodes that require either temporary discontinuation of feedings or a
delay in advancing feedings. Although most episodes resolve spontaneously and without
sequelae, any signs of feeding intolerance should be regarded as potentially serious because
of the increased risk of NEC among these infants. Signs that indicate possible intolerance of
feeding include:
Gastric residuals or emesis
Abdominal distension
Blood in the stool (gross or occult)
Loose stools or diarrhea
Metabolic acidosis
Temperature instability
21

Onset of apneic episodes


Hyperglycemia

MANAGEMENT OF FEEDING INTOLERANCE should be related to the type and


severity of the presenting signs, as described below:
1. Gastric residuals:
Non-bilious residuals:
If these are smaller than the volume of a feeding and are not increasing in volume,
and if the infant otherwise appears well, feeding can continue but the infant should be
observed carefully for other signs of feeding intolerance. If the infant has any other
worrisome findings, hold the feedings, consider obtaining an abdominal radiograph
and observe the infant.
If the residuals are greater than the volume of a feeding or are progressively
increasing in volume, hold the feedings and observe closely.
Bilious residuals are a serious sign. Hold feedings, evaluate infant closely, and
consider further workup including abdominal radiograph, CBC and platelets.
2. Abdominal distension is a serious sign. Discontinue feedings, obtain abdominal
radiograph, and consider further evaluation and treatment.
3. Blood in stools: Discontinue feedings,consider obtaining clotting studies and
abdominal radiograph.
4. If metabolic acidosis occurs, hold feedings, evaluate closely for NEC, sepsis,
hypotension and a patent ductus arteriosus. Metabolic acidosis in the presence of NEC
is a grave prognostic sign.
5. 5. Loose stools, temperature instability, apnea, hyperglycemia: Hold feedings and
evaluate infant carefully. If feedings have to be stopped for any of these reasons,
notify the Neonatology Fellow and/or the Attending Physician, so that they can follow
the infants condition with you. If there is any doubt about how well an infant is
tolerating feedings, it is best to hold feedings, evaluate the infant and discuss the
case with the other members of the team.

NURSING MANAGEMENT
Assessment:

Obtain detailed antenatal, intra-natal history.


Assess the gestational age and birth weight of the baby.
Assess the features of clinical immaturity.
Assesss the behaviour of preterm neonate.
Assessment of common problems:
22

The infants respiratory status must be observed constantly. The lungs are assessed for
adventitious breath sounds or areas of absent breath sounds. The Silverman-Anderson
index is a useful tool for evaluating the degree of respiratory distress. Look for the
apneic spells.
Thermoregulation: the infants temperature is monitored continuously by a skin probe
on the infants abdomen, which is attached to the heat control mechanism of the
radiant warmer. The temperature usually maintained at 36 degree to 36.5 degree
Celsius. It should be recorded every 30 to 60 minutes initially and every 3 to 4 hours
when stable. Assess axillary temperature every 4 to 8 hours and compare with the
probe temperature. Look for signs of hypothermia.
Feeding and electrolyte balance: monitor intake-output of fluids determine fluid
balance. The nurse also must track of the amount of blood taken. Assess the urine
output by weighing the diapers. Weigh the child daily. Look for signs of dehydration (
decreased urine output <1ml/hr, increased specific gravity, weight loss and dry skin
and mucous membrane, sunken fontanel, increased sodium) or over hydration
( increased urine output >3ml/hr with a below normal specific gravity, edema, weight
gain, bulging fontanelles, moist breath sounds and decreased blood sodium and
protein).
Skin: frequently assess the condition of the infants skin and record any changes. The
infants response to product used for cleansing and disinfection must be noted.
Infection: the nurse should be alert for signs of infection at all times like general
signs, respiratory, cardio-vascular, GI and neurologic signs.
Pain: because pain is a fifth vital sign, it should be assessed frequently (high pitched
cry, intense and harsh cry, mouth open, grimacing, furrowing or bulging of the brow,
tense, rigid muscles and colour changes) and must assess the response to potentially
painful stimuli and to pharmacologic and non-pharmacologic interventions.
Assess the amount of noise to which the infant is exposed. Determine how often
interruptions occur and how the infant responds to different types of care.
Assess the infants adjustment to feeding, readiness for change and indicating
intolerance.
Assess the activity level of the preterm baby.
Continually assess the infants responses to all feeding methods and watch for
distress, weigh the infant daily and observe the changes ability to take feedings.
Assess the improvement in suck and swallow co-ordination.
Assess the parental anxiety and promote maternal bonding and assess the support
system and coping pattern.
Assess the knowledge level and support decision making.

Nursing diagnosis and interventions:


1

Impaired gas exchange related to immaturity of lungs and deficiency of surfactant

Interventions:

Assess the respiratory pattern and colour of the baby


23

Observe for any apneic episode.


Oxygen hood is often used for able to breathe alone but need extra oxygen.
Oxygen also may be given by nasal cannula to the infant who breathes
alone.
Humidify the oxygen
CPAP may be necessary to keep the alveoli open and improve expansion
of lungs
Frequent monitoring of ABG
Frequent position changes every 2 to 3 hours
Check the suction equipment and suction the airway and applied for only 5
to 10 seconds.
The mouth is suctioned before the nose.
Maintain adequate hydration
Impaired breathing pattern : distress related to immaturity and surfactant deficiency
Asess the respiratory rate, heart rate and chest retractions
Position the child for maximal ventilatory efficiency and airway patency
Provide humidified oxygen
Spo2 monitoring
Provide suctioning
Provide chest physio therapy
Administer bronchodilators
Administer anti inflammatory medications
Administer antibiotics
Activity intorance related to increased work of breathing secondary to distress
Arrange to provide routine care
Schedule periods of uninterrupted rest
Determine infants stress level
Reduce nonessential lighting
Use positioning devices
Ineffective airway clearance related to excessive trachea-bronchial secretions
Assess the childs breathing pattern
Check the vital signs
Provide suctioning
Provide humidified oxygen
Assess the ABG analysis
Provide C-PAP using mask /hood/nasal prongs
Observe for risks of C-PAP
Assist in CMV with PEEP if needed
Hypothermia related to immature thermoregulation system
Monitor vital signs frequently
Wrap the baby well and keep warm
Provide small and frequent breast feeding as tolerated
Look for hypoglycemia
Administer IV fluids if not tolefeed intolerance
Monitor the vital signs and blood pressure
24

Assess the skin tone, pallor and signs of dehydration


Administer IV fluids
Assess the lab investigations for Hb, RBCs, platelet count, coagulation
profile
If necessary, administer blood
Administer required amount of inj. Vitamin K
6 Imbalanced nutrition less than body requirement related to feeding difficulty,
respiratory distress,or NPO status
Assess the sucking and swallowing ability of the newborn
Assess the tolerance of the child
Monitor the blood glucose level frequently
Administer IV fluids if not tolerating oral fluids
Administer human milk fortifier if the child is preterm
7 Fatigue related to increased demand for nutrients and deterioration of the general
condition of the baby
Assess the general condition of the baby
Assess the level of activity
Monitor the blood glucose level
Breast fed the baby
Check for from any part of the body
Provide top up feed
8 Risk for complications hypotension, shock, cerebral hypoxia related to progression of
the disease condition
Assess the vital signs, respiratory rate, pulse rate, temperature and blood
pressure
Check blood culture and sensitivity and sepsis screening
Monitor for any signs of dehydration
Administer IV fluids or blood as necessary
Assess the serum electrolyte values andABG values
Closely monitor for the early signs and symptoms of complications
9 Anxiety of parents related to the outcome of the newborn condition
Assess the mental status, anxiety and knowledge of family members
Assess the supporting system for the family
Assess the coping strategies of the family members
Explain the disease process to the family members
Explain each and every procedure to the care giver
Provide psychological supporttothefamily members
10 Interrupted mother-child bonding related to infectious process
Assess the breast feeding ability including sucking and swallowing ability
Keep the child with the mother if possible
Provide frequent breast feed 2 hourly
If breast feeding is not tolerated give EBM
Allow the mother to visit the child
Provide kangaroo mother care in case of pre term if tolerated
11 Interrupted family process related to hospitalization of the newborn
25

Assess the mental status, anxiety and knowledge of family members


Encourage mother-child bonding if possible
Assess the coping strategies of the family members
Explain the disease process to the family members
Explain each and every procedure to the care giver
Allow the family members to visit the child
12 Knowledge deficit regarding care of the baby and treatment modalities
Assess the knowledge level of the care giver
Explain disease condition and its progress to the family members
Educate regarding treatment and its prevention
Educate about the monitoring of the baby
Provide adequate explanation regarding nutritional need of the baby
Clarify their doubts and promote understanding
13 Risk for delayed growth and development related to prematurity
14 Risk for caregiver role strain related to need for long term care

CONCLUSION
Globally, progress is being made in reducing maternal deaths and child death after the first
month of life. However the 1.1 million deaths among premature babies are less likely to be
reduced though trickle down from other programs and indeed it was the specific
vulnerability and needs of the premature baby that catalyzed the specialty of neonatology.
There are simple solutions that will reduce deaths among premature babies immediately for
the poorest families at home in the lowest income settings for example early and exclusive
breastfeeding, chlorhexidine cord applications and skin-to-skin care. However, higher-impact
facility-based care, such as KMC is needed and is dependent on nurses and others with skills
in caring for small babies and can be phased over time to add increased complexity. Starting
with intensive care will fail if simple hygiene, careful attention to feeding and other basic
building blocks are not in place. Many countries cannot afford to rapidly scale up neonatal
intensive care but no country can afford to delay doing the simple things well for every baby
and investing extra attention in survival and health of newborns especially those who are
preterm.

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