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PREMATURITY

PREMATURITY
.born too soon

Presentor- Dr. Anusha Kattula


DNB(paediatrics)St.Philomenas
hospital, Bangalore
Moderators- Dr. Rajeev
Dr. Mythili
DEFINITION- Liveborn infants delivered before 37 wks(259 days) from the
first day of the last menstrual period are termed premature by the WHO

CLASSIFICATION( by gestational age)


a) preterm- less than 37 completed wks
b) late preterm- (34+1)wks-(36+6)wks(238-258 days)
Birth weight classification
LBW(low birth weight)-less than 2500 gms
a) VLBW(very low birth weight)-less than 1500 gms
b) ELBW(extremely low birth weight)-less than 1000 gms
Why should we be concerned?
The rate of premature births in India is rising and is presently around
21%
3.6 million premature births in India23.6% of the around 15 million
global pre-term births. Of these, 13% are live pre-term births.

The premature deaths contribute to 16.8% of neonatal mortality rate


in India( acc. to NFHS 3)
Differentiating features
Sole- have fine wrinkles, Breast nodule- small or absent
creases are not well formed
EAR- preterm ear cartilages are Skin-skin is thin, gelatinous,shiny
poorly developed, soft and poor and excessively pink, abundant
recoil lanugo
Hair- wooly and fuzzy
testes undescended and Labia majora widely separated in
scrotum poorly developed females
Reflexes are weak-moros,sucking swallowing and grasp
extended posture due to poor tone
new ballard sore
Best- <12hrs( <26 wks)
upto 96 hrs( >26 wks)
Accurate within 2 wks of GA
Overestimates by 2-4 days in 32-37 wks babies
posture
Square window
Arm recoil
Popliteal angle
Scarf sign
Heel to ear
What causes prematurity?
ETIOLOGY multifactorial and involves complex interaction between
fetal, placental, uterine and maternal factors
Fetal
Fetal distress
IUGR
Multiple gestation
Erythroblastosis
Non immune hydrops
Placental
Placental dysfunction
Placenta previa
Abruptio placentae
Uterine
trauma
Bicornuate uterus
Incompetent cervix ( premature dilatation)/surgery
Maternal
women younger than 16 and older than 35
Maternal activity
Prior poor birth outcome
Inadvertent early delivery
Preeclampsia
Chronic medical illness
Infection
Drug abuse
chorioamnionitis
PROM
Polyhydramnios
Iatrogenic/ trauma
How to manage??
PRENATAL CONSIDERATIONS
Tocolytic therapy in threatened preterm delivery
Significant role between 25-34 wks of gestation
No justification after 34 wks
Beta sympathomimetic drugs
Time for corticosteroid therapy
Antenatal steroid therapy( RCOG )
Reduce RDS(44%), IVH(46%), NEC and
neonatal death(31%)

MOA
In response to glucocorticoid, the fetal lung fibroblast produces a
protein, fibroblast-pneumonocyte factor , which in turn stimulates
the formation of saturated phosphatidylcholine

At what GA?- single course between 24-34 wks of GA


Most effective?-24 hours after and upto 7 days after 2nd dose of
corticosteroid
Reduces neonatal death within 1st 24 hours
Contraindication-systemic infection- tuberculosis and sepsis
in chorioamnionitis- can be given but delivery should
not be delayed
Who should receive?
1) risk of preterm birth upto 34+6wks
2) elective LSCS prior to 38+6 wks
3) multifetal pregnancy at risk of preterm
4) diabetes mellitus not a C.I
5) Pregnancies with IUGR at risk
Best dose and route?
Betamethasone 12 mg given intramuscularly in two doses or
dexamethasone 6 mg given intramuscularly in four doses are the
steroids of choice
Betamethasone- 24 hrs apart
Dexamethasone-12 hrs apart
Betamethasone- less neonatal cystic periventricular leukomalacia
larger reduction in RDS
When repeated?
Weekly repeated doses- reduction in weight and head circumference
A single rescue course - initial course was given at less than 26+0
weeks of gestation
Role of magnesium sulphate
Commonly used tocolytic
Reduced rate of cerebral palsy and gross motor dysfunction
initial infusion of 4 to 6 grams over 15 to 30 minutes, and then a
maintenance dose of 2 to 3 grams per hour.
Contraindicated in mothers with myasthenia gravis
PRENATAL CONSIDERATIONS-
Should be delivered in a facility with high risk obstetrical service and
level 3 NICU
Prenatal administration of glucocorticoids to the mother even if there
is no time for full course
ETHICS- counselling should include discussions regarding survival rate
and both short and long term complications
Determining parental wishes when viability is questionable
Defining limits of parental choice; need for caregiver parent
teamwork
DELIVERY ROOM MANAGEMENT
Resuscitation-
Thermoregulation-a
polythene wrap or bag used to prevent
heat loss (<29 wks)
Respiratory support-the NRP recommends availability of pulse
oximetry, blended O2 and low saturation protocol
88-92%-<30 weeks 92-95%->30 wks

Breathing spontaneously with distress,cyanosis and HR>100- CPAP of


4-6 cms water to prevent atelectasis
T-piece resuscitator- flow controlled and pressure limited

advantages disadvantages
Consistent pressure Compressed gas supply
Control of PEEP and PIP Pressures should be set up prior
Reliable delivery of 100% O2 Changing inflation pressure
No fatigue during resuscitation- difficult
Risk of prolonged inspiratory
time
Targeted saturations
1 min 60-65%
2 min 65-70%
3 min 70-75%
4 min 75-80%
5 min 80-85%
10 min 85-95%
Transport in prewarmed incubator with blended O2 and CPAP
facility
Temperature and humidity control- with neutral thermal
environment
A. incubators and hybrid incubators-prewarmed double wall
incubators
B. humidification-warm humidification within incubator
1) use a respiratory care humidifcation unit- inline humidification of
ventilator gas circuits
2) minimize nosocomial infection in humidified environment
C. monitoring and maintenance of body temperature
1) maintain axillary skin temperature of 36.0C to 36.5C
2) record skin temperature
3) record the incubator humidity
4) weigh LBW infants once daily for management of fluids and
electrolytes
FLUIDS AND ELECTROLYTES

Intravenous fluid therapy- baseline fluid needs inversely proportional


to GA and birth weight

VLBW- more fluid losses during first week-upto 150ml/kg/day


first day of life- according to guidelines
second and subsequent days of life- depends on changes in body
weight,renal function and serum electrolyte concentration
Additional fluid during phototherapy-increased by 10-20ml/kg/day
restriction of fluid intake- prevention and treatment of PDA,renal
insufficiency and BPD
Birth weight(g) IWL(ml/kg/day)

1000-1,250 56

1251-1500 46

>1500 26
Birth Fluid
weight(kg) rate(ml/kg/day)
<24hrs 24-48 hrs >48 hrs

1-1.5 kg 80-100 100-120 120-160

>1.5 60-80 80-120 120-160


Infusion of fluids-UAC or double lumen UVC replaced by PICC or
peripheral arterial lines if needed
monitoring fluid therapy- based on body weight, urine output , heart
rate and arterial BP
electrolyte values- should be monitored atleast twice daily
1) SODIUM-initially Na levels are sufficient
decrease in post diuretic phase(3-5days)-Na added in fluids(3-8
meq/kg/d)

Hyponatremia in prediuretic phase- fluid overload


Hypernatremia in prediuretic phase-dehydration

1) hypernatremia Na >150mEq/l- a) premature addition of Na in


prediuretic phase b) dehydration c) excessive Na intake
2) hyponatremia Na <130 mEq/l- a) fluid overload b) inadequate Na
intake c) excessive Na loss
POTASSIUM
During first 48 hrs- increased serum K levels of >5mEq/l(4-8meq/l)
reason-a) relative hypoaldosteronism
b) Immature Na+K+ATPase pump
c) immature renal tubular function
d) lack of arginine, a precursor to insulin
2) K > 6mEq/l- close ECG monitoring T-wave changes and rhythm
disturbances along with electrolyte trends, acid base status and urine
output
acidosis treated
albuterol MDI
>7- insulin, NaHCO3 and Ca gluconate
3) 3-6 days after birth- when K reaches 4mEq/l add K to IVF
start wit 1-2 meq/kg/d
CALORIES-ENERGY- 70-80 kcal/kg/day-maintenance of body weight
additional calories-growth(25 kcal/kg/day)
AAP-105-130 kcal/kg/day
start with 5-10% dextrose
A) hypoglycemia <40mg/dl for first 48 hrs, then <50mg/dl
causes- lack of glycogen stores,sepsis,cold
stress,hyperinsulinemia
B) hyperglycemia >150mg/dl- osmotic glycosuria
causes- sepsis, NEC,IVH,stress response
maintain glucose infusion- 1.5 mg/kg/min
Carbohydrate-4-8mg/kg/min
advanced at 1-2 mg/kg/min
max- 11-12 mg/kg/min
CALCIUM- monitored daily
hypocalcemia usually occurs on 2nd day
hypocalcemia <7mg/dl
acute treatment-100-200 mg/kg/dose i.v-10-30 min
maintenance- 200-800mg/kg/d Q6HIV/PO
NUTRITION FOR METABOLICALLY STABLE INFANT

A) parenteral nutrition- on admission with GIR 6-8


aminoacids start at 3-3.5g/kg/d increase by 0.5g/kg/d ----
max 3.5-4g/kg/d

intravenous lipids(20%)- start by 24 hrs-0.5-1g/kg/d increase


by 0.5g/kg/d upto 3g/kg/d
Monitor TG levels - <200mg/dl
C) trophic feeds/ gut priming ( minimal enteral nutrition)
(10-20ml/kg/d)-EBM/ formula/ pasteurized donor human milk
Start asap- by 2-3 days
Benefits-
Improved gut hormones
Less feeding intolerance
Earlier progression to full enteral feeds, fewer days on PN
Improved weight gain and Ca and P retention
gut development,Villous hypertrophy, digestive enzyme secretion,
enhanced motility
Breast milk is best option

Contraindications
Severe hemodynamic instability
Suspected or confirmed NEC
Evidence of ileus
Clinical-intestinal pathology
Feeding problems
Difficulty in self feeding
In coordination of sucking and swallowing
Abdominal distension
Regurgitation and aspiration
Feeding advancements
Use full strength, 67kcal/100 ml human milk or preterm formula
The initial volume- atleast 24 hrs prior to advancement
80ml/kg/day reached- feeds Q2-3H
More rapid advancement- 100ml/kg/day
Do not exceed increments-15 ml/kg every 12 hours
Volume goal-140-160 ml/kg/day
Birth weight (g) Initial rate (ml/kg/day) Volume increase (ml/kg
every 12 hours)
1001-1250 10-20 10
1251-1500 20-30 10-15
1501-1800 30 15
1801-2500 30-40 15-20
Caloric density:
For human milk fed babies- caloric density advanced by 6-12
kcals/100 ml- HMF
Maintained for 24hrs before advancement schedule
As enteral feeds are increased- IV fluids reduced accordingly
RESPIRATORY ISSUES
Poor development of respiratory muscles- CPAP or ventilator support

a) Perinatal depression-special care


air-oxygen mixtures, oximetry monitoring, prevent
heat loss
apnea secondary to respiratory insufficiency
perinatal infection
b) RDS- due to surfactant deficiency
Perinatal asphyxia in premature infants can acutely impair surfactant
production
Antenatal corticosteroid therapy

APNEA
Due to developmental immaturity of central respiratory drive
REM sleep predominates in preterm infants
Chemoreceptor response
In preterms-hypoxia-transient hyperventilation-hypoventilation-
apnea
Ventilatory response to increased CO2 is decreased
Active reflexes- by stimulation of posterior pharynx, lung inflation,
fluid in larynx or chest wall distortion
Ineffective ventilation- impaired coordination of respiratory muscles
Nasal obstruction
inhibitory neurotransmitters
MONITORING AND EVALUATION
For atleast 1 week- heart rate , desaturations
Bradycardia, cyanosis, airway obstruction
Tactile stimulation, ventilation with bag and mask
Other causes ruled out- infection, impaired oxygenation, metabolic
disorders, drugs, temperature instability,intracranial pathology
Evaluation history,physical examination, ABG, CBC, GRBS, Ca and SE
TREATMENT-
Specific therapy
Supplemental O2
Avoid reflexes
Positioning
Nasal CPAP- <32 to 34 wks, residual lung disease
CAFFEINE- a methylxanthine
-respiratory centre stimulation
-antagonism of of adenosine
-improvement of diaphragmatic contractility
Reduces rate of BPD
All infants <1250 gms
Prior to extubation
Loading dose- 20mg/kg of caffeine citrate oral/i.v- 30 min
Maintenance dose-5-8 mg/kg OD- 24 hrs after 1st dose
Serum levels- 5-20mcg/ml- therapeutic
Discontinued-34-36 wks if no apneic spells for 5-7 days
Risks- weight gain was less during 1st 3 weeks
Severe apneas, bradycardia,PCV<25%- PRBCs transfusion
Mechanical ventilation
NEUROLOGIC
Perinatal depression
ICH- from fragile involuting vessels
Maintain stable perfusion maintain normal BP, volume ,
electrolytes, blood gases
Head USG at 5-7 days
CARDIOVASCULAR
A) hypotension-
hypovolemia
cardiac dysfunction
sepsis induced vasodilation
B) PDA- between 24-48 hrs of birth
pulmonary over circulation and diastolic hypotension
PDA- monitor clinically
ECHO to r/o other structural defects, confirm PDA
over hydration avoided
30% PDAs close spontaneously
hemodynamically significant- indomethacin/ ibuprofen
persistent or recurrent PDA- second dose
recurrence of PDA with L-R shunt- surgical ligation
HEMATOLOGIC-
A) anaemia- exaggeration of normal physiologic anaemia
no treatment required
TRANSFUSION- low RBC volume, low hematocrit <40%
transfusion guidelines

B) Hyperbilirubinemia- prematurity is a risk factor


10-12 on 5th day-15 mg/dl
- keep SBR <10 mg/dl
monitor SBR twice daily
exchange transfusion if > 12mg/dl
Gastrointestinal- increased risk of NEC
formula feeding is an additional risk factor
breast milk- protective
gradual increments in feeds
Renal- immature kidneys-low GFR
cant handle water, solute and acid loads
SKIN CARE- zinc based tape, hydrogel adhesive
minimal handling
-hydrogel skin probe with min. size
-rotation of oximeter probe
-BP cuffs and urine bags- min usage
SPECIAL CONSIDERATIONS-
A) INFECTION
1) cultures- delivery in infected environment-blood and CSF
cultures
surveillance skin cultures
2) antibiotics- septic risk-empiric ampicillin and gentamicin
3) nosocomial infection- immature immune system, poor skin
integrity, extended stay
hand hygiene, bacitracin to nares
D) pain- should be assessed as 5th vital sign
several multidimensional pain assessment scales
1) PIPP-Premature Infant Pain Profile
HR and Spo2
2) CRIES-Crying,Requires O2 for Spo2< 95%,Increased vital
signs,expression,sleepless
3) NIPS- Neonatal Infant Pain Scale
4) Neonatal Pain,Agitation,and Sedation scale( N-PASS)
SOCIAL PROBLEMS- parents invited in infants care- parent infant
bonding
Parent conferences involving physician, social worker and primary
nurse
DEVELOPMENTAL ISSUES
1)minimal stimulation- stressors like noise, light and activity
minimized
2)positioning- flexed position
change in position every 4 hrs
3) KMC- promotes behavioral state organization
parental attachment/confidence
support growth and development
4) environmental issues- decrease ambient noise
cyclic lighting- circadian rythms
5) parental education- family centred care
containment techniques,calming interactions
Prophylactic therapy
VITAMIN A- decreases CLD
start in first week-5000IU i.m3 times/wk for 4 weeks

SURFACTANT- during first 4 hrs- to reduce CLD


CPAP in delivery room> prophylactic surfactant
criteria- absence of AN steroids, increased O2
demand>30%, CXR supportive
FOLLOW UP CARE
Respiratory syncytial virus most important cause of respiratory
infection in premature infants
Good hand hygiene, avoid passive cigarette smoking exposure
Influenza vaccine- when older than 6 months

air travel not recommended for BPD infants


supplemental O2- if PaO2 <80mm Hg
Immunizations-same schedule as term infants with exception of
hepatitis B
Medically stable,thriving infants- hep B as early as 30 days of age
regardless of gestational age or b.wt
Rotavirus-not given until NICU discharge
Growth infants with BPD increased caloric needs
Abnormal or delayed oral motor development and oral aversion
If growth failure persists even after excess calorie intake GERD and GH
deficiency should be ruled out
Gastrostomy tube- severe feeding problems
Anaemia- supplemental iron(2-3mg/kg) for first 12-15 months of life
Multivitamin drops- 2 weeks of age
Rickets- higher risk infants- long term parenteral nutrition,
furosemide and fat malabsorption
All breast fed infants- 400 IU of vit D along with calcium 200mg/kg at
time of discharge
Metabolic screening at 3-4 weeks of age
Sensory issues-
Opthalmologic follow up- infants with severe ROP- increased risk of
significant vision loss or blindness
<1500 gms, <30 weeks
<26 wks- 6 wks
27-28 wks-5 wks
29-30 wks-4 wks
>30 wks-3 wks
Examined every 2 wks until retina is mature
They can also have refractive errors, amblyopia, strabismus,
anisometropia
All VLBW- follow up with ophthalmologist by 8-10 months of age and
then annually or again at 3 yrs of age
Hearing follow up- hearing loss in 2% to 11% of VLBW infants-both
sensorineural and conductive hearing loss
BERA/OAE before discharge
Screening neonatal period and 1 yr
Auditory dys-synchrony(auditory neuropathy) and central auditory
processing problems
Dental problems- enamel hypoplasia and discoloration
palate and alveolar ridge deformation
dentist- first 18 months

NEURODEVELOPMENTAL OUTCOMES- intracranial


hemorrhage(parenchymal) or periventricular white matter injury-
neuromotor and cognitive delay
visuomotor problems,visual field deficits
complete neurodevelopmental examination before discharge
neuromotor problems- CP-7%-12% in VLBW infants
most common-spastic diplegia
referral for early intervention programs- at time of discharge
social development- autism
Emotional and behavourial health
1) sleep problems
2) behavior problems- hyperactivity or ADHD, less socially competent
special educational programs, psychotherapy
services

MANAGEMENT OF LATE PRETERM INFANT


COMPLICATIONS
A)respiratory distress syndrome- 21% (33wks),7.3%(35-36wks),
0.6%(37-42wks)
deprived of normal hormonal changes that promote
clearance of lung fluid
B) length of stay- jaundice and poor feeding
C) jaundice- hepatic immaturity, bilirubin induced hepatic
dysfunction(BIND)
D) poor feeding-suck swallow co-ordination and intestinal motility-
immature
Lactation failure
E) temperature instability
F)hypoglycemia-10-15%- delay in activity of hepatic glucose
phosphate
poor intake- exacerbates gluconeogenesis
SIDS and apnea- immature autonomic nervous system
(33-36k weekers- twice likely to die of SIDS than
term)
H) readmission-twice likely
jaundice and infection
J) RSV- incomplete lung development,impaired immunity
risk equal to early preterms
AAP recommends pavilizumab- upto 35 wks only
When is infant ready for discharge??

A sustained pattern of weight gain(15-25 gm)


Adequate maintenance of normal temperature fully clothed
Competent feeding by breast or pallada without cardiorespiratory
compromise
Physiologically mature and stable cardiorespiratory function
Appropriate immunisations
Appropriate metabolic screening
An apnea free period(5-7days)
New born screening
Hematologic status assessed and appropriate therapy given
Nutritional risks assessed and therapy dietary modification
Hearing evaluation
Fundoscopic examination
Neurodevelopmental and neurobehavioral status assessed and
explained to parents
Review of hospital course completed
Unresolved medical problems identified
Predischarge physical examination
Plans for follow-up monitoring and treatment
Family and parents:
Determine familys caregiving and psychosocial readiness
Pre discharge education-safe sleep practices and SIDS prevention
Parents should be able to- independently and confidently care for
their infant;
provide medications, nutritional supplements and any special medical
care;
recognize signs and symptoms of illness and respond appropriately,
especially in emergency situations; and
understand the importance of infection control measuresand a
smoke-free environment.
Follow up plan
Communicated and understood by parents
Communication with identified primary care physician
Summary of infants birth history and care
follow-up by a qualified health care professional within 72 h
medical and surgical follow-up appointments as required, including
ROP screening
neonatal neurodevelopmental follow-up, if indicated;
follow-up of hearing and newborn screening results
community resources and supports; and
a neonatologists or paediatricians advice and support to the primary
care physician, as needed.
November 17th is World Prematurity Day
November 17th has been established as World Prematurity Day.
On this day, efforts are made to increase awareness of the
health risks associated with preterm birth and how to reduce
them.
MARCH OF DIMES
The March of Dimes Foundation is a United States nonprofit organization that
works to improve the health of mothers and babies
Founded in 1938
In 2003, the March of Dimes launched the Prematurity Campaign to address the
crisis and help families have full-term, healthy babies. theyre funding
lifesaving research and speaking out for legislation that improves care for moms
and babies. Worldwide, 15 million babies are born prematurely each year. In
2008, they expanded the campaignglobally.
THANK YOU