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1. Management of Premature Babies Dr.L. Srinekethan,Reg,GSFHW

2. Definition Less than 28 weeks - extreme preterm 28 to 31 + 6 weeks - very preterm 32 to 33 + 6 weeks - moderate preterm 34 to 36 + 6 weeks - late preterm Less than 1000 grams - Extreme low birth weight 1000 to 1499 grams - very low birth weight Higher mortality and more prone to malnutrition, recurrent infections and neurodevelopment handicaps. PERIPrem ( perinatal excellence to reduce injury in premature birth) is a unique bundle of 11 interventions- demonstrate a significant impact on brain injury and mortality rates amongst babies born prematurely

3. PERIPrem bundle Birth in the right place Antenatal steroids Magnesium sulphate Optimal cord management Thermoregulation Maternal early breast milk Volume targeted ventilation Caffeine Prophylactic Hydrocortisone Probiotics Intrapartum antibiotics

4. Birth in the right place All women should deliver in a maternity center with an onside NICU Less than 27 weeks gestation Estimated fetal weight less than 800 grams. Less than 28 weeks in the event of multiple birth.

5. Significantly reduced risk of morbidity and mortality. 2-3 x higher risk of severe brain injury. 1.3 x higher risk of death.

6. What to do Prevention of preterm birth Prediction of PTB essential. Use acute tocolytic agents. Allow to antenatal steroids administration, magnesium sulphate and transfer to NICU. Includes Threatened labour and those requiring interventions.

7. Antenatal corticosteroids All women giving birth 22 + 0 to 33 + 6 weeks gestation should receive a full course of steroids within 1 week prior to birth.

8. Benefits of ANC Accelerate the lung maturation. 30% reduction in death. 50% reduction in necrotizing enterocolitis. 40 % reduction in severe intraventricular haemorrhage. Every 8 to 10 women treated with ANC at less than 26 weeks , there will be 1 more surviving baby.

9. What to do Recommend the administration of 12mg of Dexamethasone or Betamethasone, 24 hours a part. Greatest benefit is observed when 2 doses are given,12-24 hours ,at least 24 hours prior to delivery and less than 7 days from the start of treatment. Some benefit remains if given less than 24 hours, if birth is imminent. ANC should be administered if indicated/ predicted PTB is within 7 days and no steroids have been administered within the last 2 weeks . Advise single dose of ANC for women less than 34 weeks who had received the initial course more than 7 days ago and are at risk of delivering in the next 24 hours. No more than two courses of ANC should be given to preterm birth.

10. Magnesium sulphate All women giving birth between 22 to 29 + 6 weeks of gestation. Consider for 30 to 34 + 6 weeks. In established labour or planing delivery within 24 hours. Loading dose, plus a minimum of 4 hours of infusion, within the 24 hours prior of birth. Neuro-protective role. 30 % reduction in the risk of cp

11. Intrapartum Antibiotics All woman in established preterm labour, less than 34 weeks gestation Should receive intrapartum antibiotics for prevention of GBS Irrespective of rupture of membranes . Excludes those not in labour and delivered by caesarean section. GBS- preterm- 2.3 per 1000, Mortality rate: preterm 20 -30%, term 2 - 3 % Reduce the risk of death from GBS: preterm by 25%. Colonization by 86% Abnormal cranial uss by 20%. At least 4 hr before the birth reduce GBS sepsis from 11.1 to 1.6

12. Recommendations Preterm labour . GBS colonization. Previous baby with an invasive GBS infection. Chorioamnionitis .

13. Optimal cord management All babies born less than 34 weeks of gestation Should have cord clamped at or after 1min. Assisting the transition of neonatal circulation and placental transfusion occur. Improve the neonatal outcomes. Immediate assessment of baby’s condition after birth , to make a decision Reducing mortality: preterm by 30%. Better Cardiovascular stability. Improves blood pressure . Reduce the need of packed cell transfusions.by 10%. Reduce incidence of IVH , PVL and LOS. Providing higher level of iron stores 4 to 6months of age.

14. Normothermia All babies born less than 34 weeks Although aim for all babies before 37weeks First temperature within hour of birth Within the normal temperature range 36.5 to 37.5 C. Admission temperature of newly born , non asphyxiated infants - strong predictor of mortality and morbidity at all gestation. Hyperthermia ( 38 o C)- adverse outcomes

15. WHY ? Large surface area to body mass ratio. Decreased brown fat stores . Greater body water content. Reduced skin thickness. Ineffective positioning ability Poorly developed metabolic mechanisms. Reduced ability to maintain heat by peripheral vasoconstriction. Death. Hypoglycemia. Metabolic acidosis. Respiratory distress and acidosis. Necrotizing enterocolitis. Coagulation defects . Interventricular haemorrhage.

16. What to do? Staff -identification of at risk pregnancies babies. Environment Turn off fan/A.C/close the windows. Turn up the temperature of delivery room/ theatre. Turn on resuscitaire heater . Plastic bag. Activated transwarmer. Baby Place in bag apply the hat. Dry/remove wet towels. Parents Awareness of importance of normothermia. Skin to skin.

17. Environmental protocol

18. Maternal breast milk All babies born less of than 34 weeks Should receive own mother’s milk within 24 hours . First milk expression within 8 hours superior. Preterm baby ideally within 6 hours Reduces mortality rates. Reduces rates of sepsis and NEC. Improves the neurodevelopmental outcomes. Lowers rates of BPD and ROP. Fewer hospitalization.

19. Volume targeted ventilation Less than 34 weeks gestation and needing invasive ventilation To be used in conjunction with synchronized ventilation as the primary mode of respiratory support. Protects from volutrauma. Reduces the chance of death , CLD by 27% IVH (¾) by 47%. Risk of pneumothorax and hypocarbia

20. Caffeine Babies less than 30 weeks or weight less than 1500 g Start within 24 hours. Initial- loading dose Daily- maintenance dose Stop- 33 to 35 weeks corrected age , if clinically stable Indirect neuroprotective. Reduce the risk of death Disability Cerebral palsy Cognitive delay

21. Probiotics All baby born less than 32weeks or 1500 g Until 34 weeks. Reduce the death by 50% and NEC by 2/3

22. Other management Judging adequacy of nutrition. Vitamin and minerals supplements. Screening ( uss brain/ ROP/hearing/AOP/Osteopenia/neurological deficit) Discharge planning Vaccination.

23. Follow up Growth Head circumference. Feeding and nutrition. Early complementary feeding. Supplementation for 2years. Early intervention. Developmental assessment Early stimulation Ensure completion of screening.

24. Reference PERIPrem care bundle. Health Innovation, West of England. NHS guidelines. National guidelines of Newborns, Ministry of Health Srilanka.

25. Thank you