WELCOME

PRETERM

BABIESPRESENTED BY:

Dhanalakshmy. MFirst year M.Sc NURSINGGovt college of nursing

Alappuzha

Introduction

Birth weight is the single most important marker

of adverse perinatal and neonatal outcome.

Babies with a birth weight of less than 2,500g,

irrespective of their gestation are classified as

low birth weight babies.

These include both preterm and small-for-dates

babies.

Definition Preterm infants (also called premature infants) are those

born before the beginning of 38th week of gestation.

Moderately preterm infants are those born between 32

and 36 completed weeks of gestation.

Late preterm infants fall in the moderately preterm group.

Very preterm infants are those born before 32 completed

weeks of gestation. (Mehrban Singh, 2010)

Incidence

About 10 to 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.

CAUSES OF PREMATURITY

The mechanisms initiating normal labour are not

clearly understood and much less is known about

the triggers that initiate labour before term.

Spontaneous

Induced

Spontaneous

Poor socio-economic status

Low maternal weight

Chronic and acute systemic maternal illness

Antepartum hemorrhage

Cervical incompetence

Maternal genital colonization and infections

Contd… Cigarette smoking during pregnancy

Threatened abortion

Acute emotional stress

Physical exertion

Sexual activity

Trauma

Bi-cornuate uterus

Multiple pregnancy

Congenital malformations

Induced

The labour is often induced before term when there is

impending danger to mother or foetal life in-utero.

Maternal diabetes mellitus

Placental dysfunction as indicated by unsatisfactory

foetal growth

Eclampsia

Foetal hypoxia

Antepartum haemorrhage 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 33cm but

exceeds the chest

circumference by

more than 3cm.

Activity and posture The general activity is

poor

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.

Face and head Disproportionately

large head size

Sutures are widely

separated and the

fontanels are large

Small chin, protruding

eyes due to shallow

orbits and absent

buccal pad of fat.

Contd. Optic nerve is often un-

myelinated but presence of

papillary membrane makes

its visualization difficult.

Ear cartilage is deficient or

absent with poor recoil.

Hair appear woolly and fuzzy

and individual hair fibres 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.

Contd.. Subcutaneous fat is

deficient and breast

nodule is small or

absent.

Deep sole creases are

often not present.

Genitals

In male testes are

undescended and

scrotum is poorly

developed.

Contd..

In female infants,

labia majora are

widely separated

exposing labia minora

and hypertrophied

clitoris.

PHYSIOLOGICAL

HANDICAPS

Central nervous system Immaturity of central

nervous system is

expressed as inactivity

and lethargy, poor

cough reflex and

in-coordinated sucking

and swallowing

Contd.. Resuscitation difficulties at

birth and recurrent apneic

attacks.

Retinopathy of prematurity .

Vulnerable for intra-ventricular

– periventricular hemorrhage

and leuco-malacia

Inefficient blood brain barrier

Respiratory system Cuboidal alveolar lining-

poor alveolar diffusion of

gases

Hyaline membrane

disease

Breathing is mostly

diaphragmatic, periodic

and associated with

intercostal recessions

Contd… Pulmonary aspiration

and atelectasis

They are vulnerable

to develop chronic

pulmonary

insufficiency

Cardio-vascular system The closure of ductus

arteriosus is delayed.

In grossly immature

infants( less than 32

weeks) EKG shows left

ventricular

preponderance.

Risk to develop thrombo-

embolic complications and

hypertension.

Gastro- intestinal system

Due to poor and

incoordinated sucking and

swallowing.

Animal fat is not tolerated

as well as the vegetable

fat.

Regurgitation and

aspiration are common.

Hypoglycaemia

Contd.. Abdominal distention and

functional intestinal

obstruction

Entero-colitis

Immaturity of the glucuronyl

transferase system in the liver

leads to hyper-bilirubinemia.

Development of kernicterus at

lower serum bilirubin levels.

Thermo-regulation

Hypothermia is invariable.

Excessive heat loss due to

relatively large surface

area due to paucity of

brown fat in the baby who

is equipped with an

inefficient thermostat.

Infections Infections are the important

cause of neonatal mortality.

The low levels of IgG

antibodies and inefficient

cellular immunity

Excessive handling, humid

and warm atmosphere,

contaminated incubators and

resuscitators expose them to

infecting organisms.

Renal immaturity The blood urea nitrogen is

high due to low glomerular filtrate rate.

The renal tubular ammonia mechanism is poorly developed thus acidosis occurs early.

They vulnerable to develop late metabolic acidosis especially when fed with a high protein milk formula.

Concentration of urine is poor.

Contd… Preterm has to pass

4 to 5 ml of urine excrete

one milliosmole of solute

Baby gets dehydrated.

The solute retention and

low serum proteins

explain occurrence of

edema in preterm

infants.

Toxicity of drugs Poor hepatic

detoxification and

reduced renal

clearance make a

preterm baby

vulnerable to toxic

effects of drugs

Nutritional handicaps Develop anemia around 6

to 8 weeks of age.

Deficiencies of folic acid

and vitamin E.

Develop haemolytic

anemia, thrombocytopenia

and edema 6 to 10 weeks

of age.

Osteopenia and rickets

Biochemical disturbances

These babies are

prone to develop :

Hypoglycaemia

Hypocalcemia

Hypoprotenemia

Acidosis and

Hypoxia.

MANAGEMENT

Arrest of premature labor Bed rest and sedation.

Tocolytic agents

Sympathomimetic agents-beta-2-adrenergic

receptors.

Isoxsuprine (duvadilan)-beta-1 and beta-2 receptors.

Ritodrine

Salbutamol and terbutaline -beta-2 receptor

Magnesium sulphate

Indomethacin

Induction of premature labour

Maturity of fetus should be ascertained by

examination of amniotic fluid for phosphatidyl

glycerol or L/S ratio.

Corticosteroids should be administered to the

mother to enhance fetal lung maturity.

Antenatal corticosteroids

Inj.betamethasone 12mg

IM every 24 hours --2 doses

or dexamethasone 6mg IM

every 12 hours for 4 doses.

The optimal effect is seen if

delivery occurs after 24

hours of the initiation of

therapy and its therapeutic

effect lasts for 7 days.

CARE OF PRETER

M BABIES

Optimal management at birth

Delayed clamping of cord.

Elective intubation of extremely LBW babies

(<1000g).

Should be promptly dried, kept effectively covered

and warm.

Vitamin K 1mg ( 0.5mg in babies < 1500g) should be

given intra-muscularly.

Transferred by the doctor or nurse to the NICU as

soon as breathing is established.

Monitoring Vital signs .

Activity and behaviour.

Colour.

Tissue perfusion.

Fluids, electrolytes and ABG’s.

Tolerance of feeds .

Watched for development of

RDS, apneic attacks, sepsis,

PDA, NEC, IVH, etc.

Weight gain velocity.

Criteria for a healthy preterm baby

The vital signs should be stable.

The healthy baby is alert and active, looks pink

and healthy, trunk is warm to touch and

extremities 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 1-1.5

% of his body weight every day.

Provide in-utero milieu

Create a soft, comfortable,

“nestled” and cushioned bed.

Avoid excessive stimuli.

Effective analgesia and

sedation.

Provide warmth.

Ensure asepsis.

Prevent evaporative skin

losses.

Contd…

Provide effective and safe

oxygenation.

Partial parenteral nutrition

and give trophic feeds with

expressed breast milk

(EBM).

Provide rhythmic gentle

tactile and kinaesthetic

stimulation.

Position of the baby Thermo-neutral

environment.

Application of oil or liquid

paraffin on the skin.

Should be covered with a

cellophane or thin

transparent or thin

transparent plastic sheet.

Provide partial

kangaroo0mother-care.

Oxygen therapy

Oxygen should be administered with

a head box when SpO2 falls below

85% and it should be gradually

withdrawn when SpO2 goes above

90%.

The lowest ambient concentration

and flow rates should be used to

maintain SpO2 between 85-95% and

PaO2 between 60-80 mm Hg.

Phototherapy

Early phototherapy is

adviced to keep the serum

bilirubin level within safe

limits in order to obviate

the need for exchange

blood transfusion.

Prevention of nosocomial infections

The handling should be

bare minimum.

Vigilance should be

maintained on all

procedures.

Early diagnosis and prompt

treatment of infections.

Feeding and nutrition

Intra-venous dextrose solution (

10% dextrose in babies >1000g

and 5% dextrose in babies

<1000g).

Trophic feeds with EBM through

NG tube.

Condition is stabilized - enteral

feeds.

Fluid requirement

Fluid requirements are higher in LBW

infants due to:

Greater insensible water losses

Faster breathing rates

Decreased ability to concentrate urine

Greater use of radiant warmers

Greater use of phototherapy units

Rate of administration*

Birth weight (g)

Fluid rate (ml/kg/day)

500 - 600 140 - 200

601 - 800 120 - 130

801 - 1000 90 - 110

1000 - 1500 80 - 100

>1500 60 - 80

*on first 2 days of life

Rate of administration

Fluid rate can be increased by 10-20

ml/kg/d to gradually reach 150 ml/kg/d

Fluid requirements need to be

individualized for each baby

Enteral nutrition has to be considered

once the baby is stable

Total parenteral nutritionINDICATIONS

Infants with BW ≤ 1000 g

Infants with BW ≤ 1500 g, done in

conjunction with slowly advancing enteral

nutrition

Infants with BW 1501-1800 g for whom

enteral intake is not expected for > 3 days

Total parenteral nutrition

Glucose : 6 - 8 mg/kg/min

Amino acids : 1.5 - 2 g/kg/d

Lipid : 0.5 - 1 g/kg/d

Sodium : 2 - 4 mEq/kg/d

Potassium : 2 - 3 mEq/kg/d

Chloride : 2 - 4 mEq/kg/d

Early enteral nutritionTrophic feeding/ Gut priming

Practice of feeding very small amounts of enteral

nourishment to stimulate development of the immature

GIT

Advantages:

Improves GI motility

Enhances enzyme maturation

Improves mineral absorption

Lowers incidence of cholestasis

Shortens time to regain birth weight

Enteral nutrition Breast milk or ½ or full strength preterm formula

at 10ml/kg/d by intermittent gavage/ continuous

nasogastric drip

Increase by 10-15 ml/kg/d to reach 150ml/kg/d

Increments not >20 ml/kg/d

IV fluids can be stopped once 120ml/kg/d is

reached

On reaching 150ml/kg/d,calorie density can be

increased

Feeding guidelines

PRETERMS

<1200 g/ <32 wks: IV fluids for first 2-3 days,

once stable start gavage feeding

1200-1800 g/ 32-34 wks: Start gavage feeding,

once vigorous start spoon/ breast feeding

>1800 g/ >34 wks: Start breast feeding directly;

if trial feed takes>20 mins or intake is less than

required, switch to gavage feeding

Preterm human milk

Advantages:

Higher concentrations of amino acids

Higher concentrations of essential fatty

acids

Lower renal solute load

Specific bio-active factors provide immunity

Promotes intestinal maturation

Preterm human milk

Disadvantages:

Low concentrations of

Vitamin D, Ca, P

Inadequate iron

Enteral nutrition Energy : 130 - 175 Kcal/kg/d

Protein :3.4 - 4.2 g/kg/d

Fat :6 - 8 g/kg/d

Na :3 - 7 mEq/kg/d

Cl :3 - 7 mEq/kg/d

K :2 - 3 mEq/kg/d

Ca :100 – 220 mg/kg/d

Nutritional supplements

Multivitamin drops.

Iron supplementation.

Vitamin E supplementation.

Supplements of calcium

(220mg/day) and

phosphorus (100mg/day).

Gentle rhythmic stimulation

Gentle touch, massage,

cuddling, stroking and

flexing.

Rocking bed or placing a

preterm baby on inflated

gloves.

Soothing auditory stimuli.

Visual inputs.

Kangaroo CareKangaroo care is placing a

premature baby in an upright position on a

mother’s bare chest allowing tummy to

tummy contact and placing the premature

baby in between the mother’s breasts.

The baby’s head is turned so that the ear

is above the parent’s heart.

Body temperature

Mothers have thermal synchrony with their baby.

The study also concluded that when the baby was

cold, the mother’s body temperature would

increase to warm the baby up and vice versa.

Contd…

Breastfeeding:

Kangaroo care allows easy access to the breast and

skin-to-skin contact increases milk let-down.

Contd…

Contd…

Increase weight gain

Kangaroo care allows the baby to fall into a deep

sleep which allows the baby to conserve energy

for more important things. Increased weight gain

means shorter hospital stay.

Contd.. Increased intimacy and attachment

Utility of corticosteroids

A single dose of

dexamethasone 0.2mg/kg IV at

4 hours of age.

Inhaled steroids.

Prevention, early diagnosis and prompt management of common

problems Nosocomial infections Hypothermia Respiratory distress syndrome Aspiration Patent ductus arteriosus Chronic lung disease NEC & IVH ROP & Late metabolic acidosis Nutritional disorders Drug toxicity

Weight record Loss is upto a maximum of 10

to 15 percent.

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

baby is not being fed

adequately or unwell and

needs immediate attention.

What to avoid in the care of preterm babies??

Routine oxygenation without monitoring.

Intravenous immuno-globulins. Prophylactic antibiotics. Prophylactic administration of

indomethacin or high doses of vitamin E.

Unnecessary blood transfusions.

Formula feeds. Rough handling, excessive

light and loud sound.

Immunizations It is desirable to administer

0-day vaccines(BCG, OPV,

HBV) on the day of discharge

from the hospital.

If mother is HBV carrier and

is e-antigen positive-

hepatitis B vaccine and

hepatitis B specific

immunoglobulins within 72

hours of age.

Contd…

Live vaccines should be

avoided in symptomatic HIV-

positive mothers.

WHO recommends that BCG

and oral polio vaccine can be

given to asymptomatic HIV-

positive infants.

Family support The family dynamics are

greatly disturbed. The problems and issues

should be handled with equanimity, compassion, concern and caring attitude of the health team.

Encouraged to touch and talk with her baby.

Provide kangaroo-mother-care.

Emotional support and guidance.

Transfer from incubator to cot

A baby who is feeding from the

bottle or cup and is reasonably

active with a stable body

temperature, irrespective of his

weight, qualifies for transfer to

the open cot.

Discharge policy The mother should be

mentally prepared and provided with essential training and skills.

The mother- baby dyad should be kept in step-down nursery.

The baby should be stable, maintaining his body temperature and should not have any evidences of cold stress.

Contd.. 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 Common infective illnesses,

reactive airway disease,

hypertension, renal dysfunction,

gastro-oesophageal reflux.

Feeding and nutrition.

Immunizations.

Physical growth, nutritional

status, anemia, osteopenia/

rickets.

Contd.. Neuro-motor development,

cognition and seizures.

Eyes: Retinopathy of

prematurity, vision,

strabismus.

Hearing.

Behavioural problems,

language disorders and

learning disabilities.

Home care of preterm babies

She must be explained about the importance of asepsis.

Keeping the baby warm and ensuring satisfactory feeding routine.

The services of postpartum programme public health nurse and social worker can be utilized.

Environmental control The infant should be effectively covered taking care to

avoid smothering.

Woollen cap, socks and mittens should be worn.

The infant should preferably lie next to the mother.

In winter, the room can be warmed with a radiant

heater or angeethi.

A table lamp having 100 watt bulb can be used to

provide direct radiant heat.

Hot water bottle should never come in contact with the

baby.

Contd.. The cot of the mother and infant should be located

away from the walls . The mother and health worker should be trained to

assess the temperature of the newborn baby by touch.

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,

EBM should be given with a bottle or dropper or spoon or paladay depending upon his maturity.

Formula for premature babies is recommended. If cow’s or buffalo’s 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 risk of neurodevelopmental

handicaps is increased 3-fold for LBW

babies and 10-fold for very LBW

babies(<1500g).

The prognosis is good if no birth

asphyxia, apneic attacks,RDS,

hypoglycaemia and hyperbilirubinemia.

Preterm AFD babies catch up in their

physical growth with term counterparts

by the age of 1 to 2 years.

Contd..

15 to 20 % incidence of

neurological handicaps in the

form of CP, seizures, ROP,

hydrocephalus, deafness and

MR.

There is high incidence of

minor neurologic disabilities.

Neurological prognosis is

adversely affected by degree

of immaturity.

Nursing management

Obtain detailed antenatal,

intra-natal history.

Assess the gestational age and

birth weight of the baby.

Assess the features of clinical

immaturity.

Assess the behaviour of

preterm neonate.

Assessment of common

problems.

Nursing diagnosis and interventions

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

Assess the respiratory pattern and colour of the baby

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

2.Impaired breathing pattern : distress related to immaturity and surfactant deficiency

Assess 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 physiotherapy Administer bronchodilators Administer anti inflammatory medications Administer antibiotics

3. Activity intolerance related to increased work of

breathing secondary to distress

Arrange to provide routine care

Schedule periods of uninterrupted rest

Determine infant’s stress level

Reduce nonessential lighting

Use positioning devices

4. Ineffective airway clearance related to excessive

trachea-bronchial secretions

Assess the child’s 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

5. 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 tolerating the feed

Monitor the vital signs and blood pressure

Assess the skin tone, pallor and signs of dehydration

Administer IV fluids

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 and ABG 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 support to the family 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

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 it’s 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

Summary Definition and incidence

Causes of prematurity

Clinical features

Physiological handicaps

Management

Care of preterm babies

Prognosis

Nursing assessment

Nursing diagnosis and interventions

CONCLUSION….