Preterm Baby In india, 27 million babies are born every year (2010 data) out of which 35 milion are born prematurely which exposes ther to an enormous risk of dying ‘early often shortly after their birth. Preterm birth is the leading cause of newborn deaths (in the frst four weeks of life) and the second leading cause of death after pneumonia in, children uncler five years ‘A report by the UN on Preterm Birth entitled "Born Teo Soan: The Global Action Report” reveals that India ranks number one not only in preterm births, but azo in deaths from complications arising as @ consequence of these births. Addressing preterm birth is now an urgent priority for achieving Millennium Development Goal 4, which calls for the reduction of child deaths by two-thirds by 2015. ‘What is reassuring is that more than three-quarters of these premature babies can be saved with simple ‘and cost effective interventions without the need for sophisticated gadgets and neon tal intensive care, These interventions include antenatal steroid injections, kangaroo mother care, feeding with breast milk, maintaining hygiene and supportive and specific measures to treat newbom infections. Objectives ‘After completion ofthis module the participant should be able to: > Define end categorize preterm babies > Enumerate risk factors for preterm delivery > Identify problems of prematurity and their managernent Focilly Based Definitions Preterm is defined as a baby born alive before 37 completed weeks of pregnancy. The sub-categories eased on gestational age are: («28 weeks) (28 to <32 weeks) > Extremely preterm > Nery preterm > Moderate to Late preterm (32 to <37 weeks) > LBW (Low birth weight) <2500 grams > VLBW (very Low birth weight) <1500 grams > ELBW( Extremely Low birth weight) «1000 grams Identification of a preterm baby has been dealt with in detail in the chapter 3 Risk factors for preterm delivery Most of the times there is no identifiable risk factor but some of the common ones incriminated are as listed below: > History of a previous premature birth > Mother's age ~ <18 yrs and >35 yrs of age Being underweight or overweight before ‘and/or during pregnancy Multiple Pregnancy Conceiving through in vitro fertilization Multiple miscariages or abortions Physical injury or trauma Uterine, cervical or placental abnormalities Substance abuse Poor nutrition vvyvyvyvyY Infections> Chronic conditions, such as high blood pressure and diabetes > ‘Stressful life events, such as the death of a loved one or domestic violence Resuscitation: tho a preterm neonate poses addtional challenges that make the transtion to cexta-uerne life more dificult. General the degree of prematurity determines the extent support required to achieve this transition smoothly. Preterm neonates need addtional resusctative meacures due to the presence of age body surface area, mature organ systems, fragile vain copies, weak chest muscles coupled wth immature ungs anda fall immune system, Special shilsincuding gentle handling are required prevent neurologic injury and heat os, optimize cxnygenation provide respiratory support and prevert infection during resusctation ofthese vulnerable neonates Problems A baby born too soon faces a variety of problems, due to immaturity of various organs, presenting immediately after birth or later during the neonatal petiod requiring special care. The baby is at ris for both short term and long term complications during the SNCU stay and thereafter Some complications that may arise during the course of stay in SNCU may lead to lifelong disability requiting long term Follow-up ‘Some ofthe problems a Preterm baby may face during the neonatal period are enlisted below. > Rypothecmia: The prablem of hypothermia in preterm babies needs special attention becouse of their large body surface area and decreased brown fat. The maintenance ofthe ambient temperature ofthe labour room at 26-28 C and ensuring warm and gentle resuscitation is essential for prevention of hypothermia. Chapter 1 describes in detail the ‘management of hypothermia in neonates, > Feeding difficulty: Preterm neonates have immature oropharyngeal coordination and oor reflexes for feeding. They should be fed expressed breast mil as they benefit not only nutritionally but also immunologically and developmentally from breastmilk. In order to accomplish this, mother needs extra support for expressing breastmilk and the baby needs tobe fed using an orogastrc tube, cup or paladai A neonate at 30 weeks attains the ability to co-ordinate swallowing with respiration, but stil has no suck-swallow coordination. Hence, neonates less than 30 wks (or 1200 gms), need to be gavage fed to avoid aspiration. At 34 wks (1800 gms), the suck-swallow co-ordination is gained and hence, babies > 1800gms can be breastfed. Those weighing less than 1800 gms but more than 1200gms can to be fed by katori spoon/paladai as they are able to swallow but cannot suckle atthe breast. One should also consider the presence or absence of sickness and individual feeding efforts ofthe baby to decide how a LBW neonate should be provided fluids and nutrition. Some of the sick preterm babies and those who are extremely preterm need IV fluids initially. Chapters 5 and 6 describe the details of feeding and intravenous fluid requirements of preterm neonates Respiratory distress: Due to physical immaturity of the lungs (deficiency of surfactant) preterm babies often present with respiratory distress soon after birth. They may also develop respiratory distress later due to hypothermia, pneumonia, late onset sepsis or ‘metabolic problems like hypoglycemia etc. Precaution needs to be taken while giving ‘oxygen to these small babies to avoid further complications related to hyperoxia, Details of ‘managing a neonate with respiratory distress are addressed in chapter 11 Metabolic: Most common metabolic problem associated with prematurity is hypoglycemia This can be avoided by careful monitoring of blood glucose at specified intervals and providing appropriate fluids and feeds. Calcium and other electrolytes also need‘careful monitoring. For details regarding metabolic problems refer to chapter 6 and 7. Infections: Prematurity is one of the most important risk factor for both early and late onset sepsis. Decreasing invasive interventions, maintaining temperature, rminimal handling, promoting breastfeeding and KMC and maintaining proper hand hygiene are the best preventive strategies to reduce the occurrence of sepsis. For details of management of Neonatal sepsis refer to chapter 14, Jaundice: Preterm babies, due to the functional immaturity ofthe liver and other factors related to prematurity have increased bilirubin production and poor bilirubin conjugating capability leading to high bilirubin levels. They are at risk of developing rneuro-toxicity at lower bilirubin levels than full term babies due to immaturity of the blood brain barrier. To prevent ths, frequent ‘monitoring of bilirubin tevels and timely initiation of phototherapy is required, Refer to chapter 12 for details of management of Neonatal Jaundice. Brain injury: Babies born before 28 weeks are at risk of bleeding in the brain, known as an intro-ventricular Baemorrhage due to fragile capillaries, Most haemorrhages are mild and resolve with ttle short-term impact. But some babies may have larger bleeds which can ‘cause permanent brain injury. To minimise the risk of occurrence of bleeds, fluids and drugs should be administered slowy and sudden changes in blood pressure should be avoided. {A policy of minimal handling should be followed. ‘Apnea of prematurity: Preterm babies may have apnoeic spells without any evident attributable cause due to immaturity of the respiratory centre. Close monitoring end prompt action by way of stimulation, drugs or assisted ventilation may be required. (Refer to chapter 10). Anemia of prematurity: Physiological anemia gets exaggerated in Preterm babies due to various factors. Itis prudent to ‘monitor the hemoglobin levels and treat the anemia according to standard protocols (Refer to chapter 15) > Retinopathy of Prematurity (ROP): The immature retina of preterm babies is very susceptible to oxidant damage. Onygen levels should be meticulously monitored during respiratory therapy using pulse oximetry and at no time should the saturation be more than 194%, This would help reduce oxidant damage and risk of development of ROR, a major cause cof blindness. (Refer to chapter 17 on Follow- up of high risk neonate) > Hearing loss: The risk for sensorineural hearing loss increases as the gestation and birth weight decreases. Hearing loss can be caused by ototoxic drugs like aminoglycosides and furosemide which are commonly used in preterms. Asphyxia, severe jaundice needing ‘exchange transfusion, prolonged ventilator support (> 5 days), sepsis and meningitis are all important risk factors of sensorineural hearing loss. All preterm babies must undergo hearing screening at specified times. (Refer to chapter 17 on Follow-up of high risk neonate) > Others: A few babies develop other long term ‘complications like cerebral palsy, impaired cognitive skills, behavioural and psychological problems, chronic health issues, et. Itis very important to follow these babies to detect ‘and treat disabilities as early 2s possible. {Refer to chapter 17 on Follow-up of high risk neonate) Follow-up: All preterm babies discharged from SNCU must be followed up for growth monitoring, feeding, immunization, systemic ‘examination and early detection of disability by a team of specialists (Chapter 17). Prevention of Premature births its dificult to prevent al premature births as most often risk factors cannot be identified but timely attention to the following aspects will go a long way in preventing premature birth and its complications:Zino > Female education, better nutrition, better > Ensuring availability of functional equipment, access to family planning and increased essential drugs and trained staff in the Health ‘empowerment, as well as improved care facilities. " before, between and during pregnancies. > Safe transport and a Functional and effective > Ante natal steroids (ANS). referral system, > Institutional deliveries attended by trained staff Et Exercise 1.” How will you define a preterm baby Fe are ee es 2st five risk factors for preterm delivery ee a Se 3. _ ist five problems of prematurity