Prematurity

Prematurity is a term for the broad category of neonates born at less than 37
weeks' gestation. Preterm birth is the leading cause of neonatal mortality and the
most common reason for antenatal hospitalization. For premature infants born
with a weight of less than 1000 g, the 3 primary causes of mortality are
respiratory failure, infection, and congenital malformation.

Signs and symptoms

Confirmation of gestational age is based on physical and neurologic
characteristics. The Ballard Scoring System remains the main tool clinicians use
after delivery to confirm gestational age by means of physical examination.  The
major parts of the anatomy used in determining gestational age include the
following:
 Ear cartilage (eg, a preterm infant at 28 weeks’ gestation has a small
amount of ear cartilage and/or a flattened pinna)
 Sole (eg, a preterm infant at 33 weeks’ gestation has only an anterior
crease on the sole of the foot)
 Breast tissue (eg, a preterm infant at 28 weeks’ gestation has no breast
tissue, and the areolae are barely visible)
 Genitalia

Diagnosis
Laboratory studies
Initial laboratory studies in cases of prematurity are performed to identify issues
that, if corrected, improve the patient's outcome. Such tests include the
following:
 Complete blood count (CBC): May reveal anemia or polycythemia that is
not clinically apparent
 White blood cell (WBC) count: A high or low WBC count and numerous
immature neutrophil types may be found; an abnormal WBC count may
suggest subtle infection
 Blood type and antibody testing (Coombs test): These studies are
performed to detect blood-group incompatibilities between the mother and
infant and to identify antibodies against fetal red blood cells (RBCs); such
incompatibilities increase the risk for jaundice and kernicterus
 Serum electrolyte levels: Frequent determination of serum sodium,
potassium, and glucose concentrations, in conjunction with monitoring of
daily weight and urine output in extremely low birth weight (ELBW) infants,
assist the practitioner in determining fluid requirements
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Imaging studies
Imaging studies are specific to the organ system affected. Chest radiography is
performed to assess lung parenchyma in newborns with respiratory distress.
Cranial ultrasonography is performed to detect occult intracranial hemorrhage in
ELBW newborns. Prematurity itself is not an indication for an imaging study.
Lumbar puncture
Lumbar puncture is performed in infants with positive blood cultures and in those
who have clinical signs of infection (presumed sepsis) and for whom a full course
of antibiotic coverage is planned.

Management
Stabilization in the delivery room with prompt respiratory and thermal
management is crucial to the immediate and long-term outcome of premature
infants, particularly extremely premature infants.
Respiratory management
 Recruitment and maintenance of adequate or optimal lung volume; in
infants with respiratory distress, this step may be accomplished with early
continuous positive airway pressure (CPAP) given nasally, by mask (Neopuff),
or by using an endotracheal tube when ventilation and/or surfactant is
administered
 Avoidance of hyperoxia and hypoxia by immediately attaching a pulse
oximeter and, using an oxygen blender, keeping the oxygen saturation
(SaO2) between 86% and 93%
 Prevention of barotrauma or volutrauma by using a ventilator that permits
measurement of the expired tidal volume and by keeping it at 4-7 mL/kg
 Administration of surfactant early (< 2 hr of age) when indicated and
prophylactically in all extremely premature neonates (< 29 wk)

Treatment
When premature labor develops and cannot be stopped, the health care team will
prepare for a high-risk birth. The mother may be moved to a center that is set up
to care for premature infants in a neonatal intensive care unit (NICU).
After birth, the baby is admitted to a high-risk nursery. The infant is placed under
a warmer or in a clear, heated box called an incubator, which controls the air
temperature. Monitoring machines track the baby's breathing, heart rate, and
level of oxygen in the blood.

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 A premature infant's organs are not fully developed. The infant needs special care
in a nursery until the organs have developed enough to keep the baby alive
without medical support. This may take weeks to months.
Infants usually cannot coordinate sucking and swallowing before 34 weeks
gestation. A premature baby may have a small, soft feeding tube placed through
the nose or mouth into the stomach. In very premature or sick infants, nutrition
may be given through a vein until the baby is stable enough to receive all nutrition
through the stomach.
If the infant has breathing problems:

 A tube may be placed into the windpipe (trachea). A machine called a

ventilator will help the baby breathe.
 Some babies whose breathing problems are less severe receive continuous
positive airway pressure (CPAP) with small tubes in the nose instead of the
trachea. Or they may receive only extra oxygen.
 Oxygen may be given by ventilator, CPAP, nasal prongs, or an oxygen hood
over the baby's head.
Infants need special nursery care until they are able to breathe without extra
support, eat by mouth, and maintain body temperature and body weight. Very
small infants may have other problems that complicate treatment and require a
longer hospital stay.

Prevention
The best ways to prevent prematurity are to:

 Be in good health before getting pregnant

 Get prenatal care as early as possible in the pregnancy
 Continue to get prenatal care until the baby is born
Getting early and good prenatal care reduces the chance of premature birth.
Premature labor can sometimes be treated or delayed by a medication that
blocks uterine contractions. Many times, however, attempts to delay premature
labor are not successful.
Betamethasone (a steroid medication) given to mothers in premature labor can
make some prematurity complications less severe.

Macrocephaly
Macrocephaly (or "big head") is a very common reason for referral to a pediatric
neurosurgeon. Children with macrocephaly have a head circumference (the
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measurement around the widest part of the head) that is greater than the 98th
percentile. Sometimes a large head could mean that there is a problem in the
brain which might require surgery.

Background
Macrocephaly is defined as head circumference more than two standard
deviations (SD) above the mean value for a given age and gender. [1] It has to be
differentiated from megalencephaly, which is defined as increase in the size of the
brain parenchyma. Head circumference is measured to monitor head growth in
infants and children. It is also known as occipitofrontal circumference (OFC) and it
denotes the size of the cranium. Macrocephaly can be the first manifestation of
various congenital and acquired neurologic conditions or may be just a familial
trait.

The measurement of head circumference (also called occipitofrontal

circumference, OFC), a direct reflection of head growth, is an important step in
the evaluation of childhood growth and development. Deviations from normal
head growth may be the first indication of an underlying congenital, genetic, or
acquired problem (eg, congenital infection, genetic syndrome, hydrocephalus,
intracranial hemorrhage, storage disease, or neoplasm). Many genetic conditions
are associated with an abnormal pattern of head growth; the earlier these
conditions are detected, the earlier appropriate treatment, services, and genetic
counseling can be provided.

What causes macrocephaly?

Macrocephaly is not a condition in itself. It’s a symptom of other conditions.
Benign familial macrocephaly is an inherited condition where a family is
predisposed to having a larger head circumference.
Sometimes there is a problem with the brain, such as hydrocephalus or excess
fluid. These underlying conditions will require treatment.

Benign extra-axial collection is a condition where there is a small amount of fluid

in the brain. The amount of fluid is so minor that it does not require treatment.

Other conditions that can cause macrocephaly include:

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 brain tumors
 intracranial bleeding
 chronic hematomas and other lesions
 Morquio syndrome
 Hurler syndrome

Corresponding symptoms
Some children will have benign macrocephaly. Many of these children will
experience no other symptoms aside from a larger head circumference.
In other cases, children may experience developmental delays. These include
delays in reaching learning milestones. Other symptoms include:

 mental disabilities or delays

 rapid head growth
 slowed growth of the rest of the body
 comorbidity with other conditions, including autism or epilepsy

Macrocephaly risk factors

There are certain factors that increase the likelihood of macrocephaly. Genetics is
one factor thought to play a part. Familial macrocephaly is an inherited condition.
It’s also thought that infants with autism have a higher likelihood of
macrocephaly. One study estimates that macrocephaly will be evident in 15 to 35
percent of children with autism.

Other risk factors include:

 hydrocephalus
 Alexander disease
 Canavan disease
 neurofibromatosis
 a mother being infected with Zika virus while pregnant
There is no evidence that macrocephaly affects children of any particular gender,
nationality, or race more often.

How is macrocephaly diagnosed?

A pediatrician can diagnose macrocephaly with an examination of the infant’s head

measurements from birth to present. They may also perform neurological tests. These
can include a CT scan, ultrasound, or MRI to get a better look at the head and brain.

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 Because macrocephaly can be a symptom, your doctor will evaluate the infant’s head to
determine whether there is an increase in pressure. Signs of increased pressure include
vomiting, irritability, and headaches. The doctor will also look for bulging veins and eye
problems. These symptoms will warrant further neurological evaluation to determine the
underlying problem and its severity.
Be sure to tell your doctor of any family history of larger-than-average head size.

How is macrocephaly treated?

Treatment for macrocephaly will depend on the diagnosis.

If tests indicate no problems and brain scans come back normal, the
infant’s head will continue to be monitored. During the monitoring phase,
parents are advised to watch for:

 a bulging soft spot

 vomiting
 lack of interest in food
 abnormal movements in the eyes
 excessive sleeping
 irritability

Macrocephaly complications
Complications rarely occur with benign macrocephaly. But they can occur in all
types of macrocephaly. People with brain overgrowth may experience brainstem
compression. This requires a surgical procedure to decompress the brain stem.

Hydrocephalus, or an abnormally high accumulation of cerebrospinal fluid in the

brain, is commonly seen in people with macrocephaly.

Other complications include:

 seizures or epilepsy
 perinatal risk factors
 neurologic comorbidity, or the coexistence of two conditions (this can lead
to other complications and health problems)

Pneumonia
Pneumonia is an infection that inflames the air sacs in one or both lungs. The air
sacs may fill with fluid or pus (purulent material), causing cough with phlegm or
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pus, fever, chills, and difficulty breathing. A variety of organisms, including
bacteria, viruses and fungi, can cause pneumonia.

Pneumonia can range in seriousness from mild to life-threatening. It is most

serious for infants and young children, people older than age 65, and people with
health problems or weakened immune systems.

 The most common bacterial type that causes pneumonia is Streptococcus

pneumoniae.

Symptoms
The signs and symptoms of pneumonia vary from mild to severe, depending on
factors such as the type of germ causing the infection, and your age and overall
health. Mild signs and symptoms often are similar to those of a cold or flu, but
they last longer.

Signs and symptoms of pneumonia may include:

 Chest pain when you breathe or cough

 Confusion or changes in mental awareness (in adults age 65 and older)
 Cough, which may produce phlegm
 Fatigue
 Fever, sweating and shaking chills
 Lower than normal body temperature (in adults older than age 65 and
people with weak immune systems)
 Nausea, vomiting or diarrhea
 Shortness of breath
Newborns and infants may not show any sign of the infection. Or they may vomit,
have a fever and cough, appear restless or tired and without energy, or have
difficulty breathing and eating.

Causes
Many germs can cause pneumonia. The most common are bacteria and viruses in
the air we breathe. Your body usually prevents these germs from infecting your
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lungs. But sometimes these germs can overpower your immune system, even if
your health is generally good.

Pneumonia is classified according to the types of germs that cause it and where
you got the infection.

Community-acquired pneumonia

Community-acquired pneumonia is the most common type of pneumonia. It

occurs outside of hospitals or other health care facilities. It may be caused by:

 Bacteria. The most common cause of bacterial pneumonia in the U.S. is

Streptococcus pneumoniae. This type of pneumonia can occur on its own or
after you've had a cold or the flu. It may affect one part (lobe) of the lung, a
condition called lobar pneumonia.
 Bacteria-like organisms. Mycoplasma pneumoniae also can cause
pneumonia. It typically produces milder symptoms than do other types of
pneumonia. Walking pneumonia is an informal name given to this type of
pneumonia, which typically isn't severe enough to require bed rest.
 Fungi. This type of pneumonia is most common in people with chronic
health problems or weakened immune systems, and in people who have
inhaled large doses of the organisms. The fungi that cause it can be found in
soil or bird droppings and vary depending upon geographic location.
 Viruses. Some of the viruses that cause colds and the flu can cause
pneumonia. Viruses are the most common cause of pneumonia in children
younger than 5 years. Viral pneumonia is usually mild. But in some cases it
can become very serious.
Hospital-acquired pneumonia

Some people catch pneumonia during a hospital stay for another illness. Hospital-
acquired pneumonia can be serious because the bacteria causing it may be more
resistant to antibiotics and because the people who get it are already sick. People
who are on breathing machines (ventilators), often used in intensive care units,
are at higher risk of this type of pneumonia.

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Health care-acquired pneumonia

Health care-acquired pneumonia is a bacterial infection that occurs in people who

live in long-term care facilities or who receive care in outpatient clinics, including
kidney dialysis centers. Like hospital-acquired pneumonia, health care-acquired
pneumonia can be caused by bacteria that are more resistant to antibiotics.

Aspiration pneumonia
Aspiration pneumonia occurs when you inhale food, drink, vomit or saliva into
your lungs. Aspiration is more likely if something disturbs your normal gag reflex,
such as a brain injury or swallowing problem, or excessive use of alcohol or drugs.

Risk factors
Pneumonia can affect anyone. But the two age groups at highest risk are:

 Children who are 2 years old or younger

 People who are age 65 or older

Complications

Even with treatment, some people with pneumonia, especially those in high-risk
groups, may experience complications, including:

 Bacteria in the bloodstream (bacteremia). Bacteria that enter the

bloodstream from your lungs can spread the infection to other organs,
potentially causing organ failure.
 Difficulty breathing. If your pneumonia is severe or you have chronic
underlying lung diseases, you may have trouble breathing in enough oxygen.
You may need to be hospitalized and use a breathing machine (ventilator)
while your lung heals.
 Fluid accumulation around the lungs (pleural effusion). Pneumonia may
cause fluid to build up in the thin space between layers of tissue that line the
lungs and chest cavity (pleura). If the fluid becomes infected, you may need
to have it drained through a chest tube or removed with surgery.

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  Lung abscess. An abscess occurs if pus forms in a cavity in the lung. An
abscess is usually treated with antibiotics. Sometimes, surgery or drainage
with a long needle or tube placed into the abscess is needed to remove the
pus.

Intrauterine Device (IUD)

An IUD is a small, T-shaped plastic device that is wrapped in copper or contains
hormones. The IUD is inserted into your uterus by your doctor. A plastic string
tied to the end of the IUD hangs down through the cervix into the vagina. You
can check that the IUD is in place by feeling for this string. The string is also
used by your doctor to remove the IUD.
Types of IUDs

 Hormonal IUD. The hormonal IUD releases levonorgestrel, which is a form

of the hormone progestin. The hormonal IUD appears to be slightly more
effective at preventing pregnancy than the copper IUD. Hormonal IUDs
prevent pregnancy for 3 to 5 years, depending on which IUD is used.
 Copper IUD. The most commonly used IUD is the copper IUD. Copper wire
is wound around the stem of the T-shaped IUD. The copper IUD can stay in
place for up to 10 years and is a highly effective form of contraception.

How it works

Both types of IUD prevent fertilization of the egg by damaging or killing sperm.

The IUD also affects the uterine lining (where a fertilized egg would implant and
grow).

 Hormonal IUD. This IUD prevents fertilization by damaging or killing sperm

and making the mucus in the cervix thick and sticky, so sperm can't get
through to the uterus. It also keeps the lining of the uterus (endometrium)
from growing very thick.1 This makes the lining a poor place for a fertilized
egg to implant and grow. The hormones in this IUD also reduce menstrual
bleeding and cramping.
 Copper IUD. Copper is toxic to sperm. It makes the uterus and fallopian
tubes produce fluid that kills sperm. This fluid contains white blood cells,
copper ions, enzymes, and prostaglandins.

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Insertion

You can have an IUD inserted at any time, as long as you are not pregnant and
you don't have a pelvic infection. An IUD is inserted into your uterus by your
doctor. The insertion procedure takes only a few minutes and can be done in a
doctor's office. Sometimes a local anesthetic is injected into the area around the
cervix, but this is not always needed.
IUD insertion is easiest in women who have had a vaginal childbirth in the past.
Your doctor may have you feel for the IUD string right after insertion, to be sure
you know what it feels like.

What To Expect After Treatment

You may want to have someone drive you home after the insertion procedure.
You may experience some mild cramping and light bleeding (spotting) for 1 or 2
days.
Do not have sex, use tampons, or put anything in your vagina for the first 24
hours after you have an IUD inserted.

Risks

Risks of using an intrauterine device (IUD) include:

 Menstrual problems. The copper IUD may increase menstrual bleeding or

cramps. Women may also experience spotting between periods. The
hormonal IUD may reduce menstrual cramps and bleeding.1
 Perforation. In 1 out of 1,000 women, the IUD will get stuck in or puncture
(perforate) the uterus.1 Although perforation is rare, it almost always occurs
during insertion. The IUD should be removed if the uterus has been
perforated.
 Expulsion. About 2 to 10 out of 100 IUDs are pushed out (expelled) from the
uterus into the vagina during the first year. This usually happens in the first
few months of use. Expulsion is more likely when the IUD is inserted right
after childbirth or in a woman who has not carried a pregnancy.1 When an IUD
has been expelled, you are no longer protected against pregnancy.

Disadvantages of IUDs include the high cost of insertion, no protection against STIs,
and the need to be removed by a doctor.

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