Prematurity

Prematurity Management of Premature Babies. Golden Hour in NICU. Neonatal Intensive Care management of Preterm Babies.

1. Prematurity By: Dr Inayat Ullah MBBS, FCPS Paeds Fellow Neonatology PEMH RWP.

2. Definition Prematurity is defined as Birth of a baby at 22 completed weeks to less than 37 weeks of gestation. Extreme PT/Extremely low Gestational Age (ELGA): 22 weeks to 27 +6/7 Very Low Gest Age (VLGA) Very Preterm (VPT): 28 Completed to less than 32 weeks. Moderate Preterm: 32 to 33+6/7 weeks Late Preterm: 34 to 36+6/7 weeks.

3. Birth Weight BW Categorization. Category Birth Weight (BW) 500-999 Grams Extremely Low Birth Weight(ELBW) 1000-1499 Grams Very Low Birth Weight (VLBW) 1500-Less Than 2500 Grams Low Birth Weight (LBW)

4. Appropriate birth weight at different gestational ages Gestational age Mean birth weight 24 weeks 600 g 25 weeks 750 g 26 weeks 850 g 28 weeks 1000 g 30 weeks 1400 g 32 weeks 1750 g 34 weeks 2000 g 36 weeks 2500 g 38 weeks 3000 g 40 weeks 3500 g

5. Etiology Maternal causes Uterine causes Fetal causes Others

6. Maternal causes Malnutrition and anemia Teenage pregnancy or multi-parity Twin pregnancy Pre eclmapsia Chronic illness (diabetes, renal disease, heart disease, hypertension) Infection (malaria, UTI, chorioamnionitis) Lower socioeconomic status Smoking or drug abuse Illegitimate birth

7. Uterine causes Bicornuate uterus Incompetent cervix (premature dilation) Placenta previa, abruptio placentae, placental dysfunction

8. Fetal Causes Fetal distress Multiple gestation Chromosomal disorders (down’s syndrome) Intrauterine infections (syphilis, TORCH) Erythroblastosis, non immune hydrops

9. Other Polyhydramnios Trauma Premature rupture of membranes Iatrogenic

10. Problems/complications of prematurity Immediate Long term

11. Immediate (Acute)Complications 1. Hypothermia 2. Hypoglycemia 3. Hypocalcemia 4. Respiratory difficulties 5. Intra-ventricular hemorrhage (IVH) 6. Liver immaturity 7. Increased susceptibility to infections 8. Necrotizing enterocolitis (NEC) 9. Patent ductus arteriosus 10. Feeding problems 11. Anemia of prematurity 12. Retinopathy of prematurity 13. Metabolic bone diseases of prematurity

12. Hypothermia It occurs in preterm babies due to: High surface area to body weight ratio Little subcutaneous fat Muscular inactivity Inadequate sweating mechanism Decreased brown fat Immature heat regulation mechanism

13. Hypoglycemia It is common due to lack of glycogen stores and immature hepatic and autonomic responses

14. Hypocalcemia Early hypocalcemia occurs due to immaturity of hormonal control system

15. Respiratory problems Hyaline membrane disease due to surfactant deficiency leading to RDS Apneic spells: the immaturity of respiratory centre may lead to periodic breathing and frequent Apneic spells

16. Intraventricular Hemorrhage IVH It is common in preterm infants due to: Immature vasculature Disturbed cerebral auto-regulation of blood flow Clotting factor deficiency

17. Liver immaturity It results in prolonged physiological jaundice due to immaturity of liver enzymes and there is increased risk of kernicterus at relatively lower bilirubin level

18. Susceptibility to Infections It results from lack of the protective maternal immunoglobulins ( IgG ), which are transferred across the placenta during the last trimester In addition to this, delicate surfaces of skin and mucous membranes also predispose to infections Insertion of IV cannula , endotracheal tubes, nasogastric tubes also increase the risk of infections

19. Necrotizing Entercolitis (NEC) There is increased susceptibility to NEC due to immaturity of gut endothelial surfaces and enzyme deficiencies The risk increases with lack of breast feeding, umbilical catheterization and septicemia

20. Patent ductus arteriosus (PDA) The duct may remain open in premature babies leading to heart failure

21. Feeding Problems These result from uncoordinated sucking and swallowing and also from gastro-esophageal reflux leading to frequent aspirations

22. Anemia Due to Prematurity. Anemia occurs due to decreased iron stores, vitamin E deficiency and exaggerated physiological anemia

23. Retinopathy of Prematurity There is abnormal vascularization due to immaturity and oxygen therapy leading to partial or complete blindness

24. Chronic Problems Chronic lung disease (bronchopulmonary dysplasia) Poor growth CNS dysfunctions

25. Chronic lung disease (bronchopulmonary dysplasia) Prolonged ventilation and oxygen toxicity results in chronic oxygen dependency

26. Poor growth Growth is restricted due to feeding problems, vitamin and iron deficiency

27. CNS Dysfunction Cerebral palsy due to intraventricular hemorrhage Post hemorrhagic hydrocephalus Learning problems Deafness Mental subnormality

28. Assessment of gestational age Gestational age can be assessed appropriately in weeks by simple visual assessment of certain physical signs and more accurately by using Ballard scoring system

29. Rapid visual assessment of gestational age Physical signs Assessment Gestational Age Sole creases Absent 32 wks or less 1-2 anterior sole 36 wks All over sole 40 wks Breast nodule Not palpable 34 weeks 3 mm 36 wks 4-10 mm 40 wks Scalp hair Short fuzzy 37 wks Coarse, individual 40 wks Ear cartilage Poorly developed 32-34 weeks Well developed 36-40 weeks Testicular descent Undescended 25 weeks Inguinal 32 wks Complete descent 40 wks in 90% Scrotal rugae Anterior 36 wks Entire Scrotum 40 wks

30. Ballard score Physical and neuromuscular criteria of maturity are given in Expanded New Ballard score (NBS). It now also includes extremely premature infants and has been refined to improve accuracy in more mature infants In Ballard score, physical and neurologic scores are added and by this added score, gestational age is calculated The score is accurate within 2 weeks of gestation in infants weighing >999 g at birth and is most accurate at 30-42 hours of age

31. Management The Golden Hour Approach

32. What to be done in golden Hour Prompt stabilization of the airway and cardiopulmonary support to establish / maintain vital signs. ( +temperature in newborn) Paying attention to multiple aspects of the patients condition. (vital signs, saturation, and response to resuscitation.) Attention to injury prevention & progression. ( alveolar recruitment vS Spine stabilization, O2 toxicity vS shock) Rapid initiation of vascular access Rapid initiation of therapeutic intervention. (Surfactant vS Volume resuscitation)

33. The golden hour strategy is a philosophical approach that reinforces communication and collaboration using evidence based protocols and procedures that standardize as many elements as possible for delivery and initial management of a very preterm birth. Golden hour strategies in Periviable neonates : Myra Wyckoff. Initial resuscitation and stabilization of the periviable neonate – The Golden hour approach. Semin . Perinatol . Semin Perinatol 2014 Feb;38(1):12-6.

34. Some steps specific to Prematurity 1. Delivery room temperature stabilization. 2. Delayed cord clamping. 3. Delivery room respiratory support. 4. Delivery room oxygen use. 5. Cautious use of cardiac compressions and medication.

35. Delivery room care Every preterm delivery should be attended by a pediatrician Proper resuscitation at birth, early stabilization of vital signs, prevention of hypothermia and hypoglycemia in delivery room is related with good outcomes with minimal complications

36. After birth Care Maintain thermo-neutral environment Maintenance of fluid and electrolyte balance Oxygen administration Feeding Supplementation of iron and vitamins Protection from infection Early detection and management of complications of prematurity Immaturity of drug metabolism

37. Maintain thermo-neutral environment It is environmental temperature at which heat production and O2 consumption is minimal yet the core temperature is maintained within normal range Maintain temperature of nursery in range of 25- 30°C Place the baby in incubator, keep humidity at 70%

38. Maintenance of fluid and electrolyte balance Preterm babies need more fluids as compared to full term infants Baby should be carefully monitored for hypoglycemia, hypo or hypernatremia and hyperkalemia by frequent blood samples and their correction

39. Oxygen Administration O2 administration should be carefully monitored in a very premature infant because concentration of O2 more than 40% increases the risk of lung and visual toxicity (bronchopulmonary dysplasia and retrolental fibroplasia ) Aim is to keep spo2 between 90-95%

40. Feeding The method of feeding should be individualized as it varies with weight and gestational age of infant The process of oral feeding in addition to sucking requires coordination of swallowing, epiglottic closure of larynx, normal esophageal motility, a synchronized process which is usually absent prior to 34 weeks of gestation

41. Feeding cont’d If the infant is more than 35 wk gestation, weighing 2kg and there is no contraindication of feeding like persistent vomiting, RDS, sepsis , seizures etc ; he should be started on oral feeding preferably by breast milk EBM or infant formula with bottle or cup and spoon If baby cannot suck and general condition is better, tube feeding is preferred If very sick or premature, then total or partial parenteral nutrition is the choice

42. Multivitamin and Iron supplements Every preterm infant should receive supplement vitamins in addition to breast milk until full mixed feeding is established or weight is more than 2250 gm All preterm babies should receive vitamin K prophylaxis 1 mg at birth Requirement of vitamin A, D, B6 and C is fulfilled by simply prescribing Mutivitamin drops per oral

43. Iron supplements Iron supplementation should be started at the age of 4-8 weeks at dose of 2mg/kg/day Before this age it is not well absorbed and also increases the risk of gastrointestinal infection and also predisposes to vitamin E deficient hemolysis

44. Infection prevention Proper antiseptic measures should be taken in maintenance of nursery, incubator and other equipment and in addition proper hand washing, cleansing of preterm baby, proper cord care are very important All procedures in nursery should be done with strict aseptic measures

45. Early detection and management of complications of prematurity It can be done by good nursing care, monitoring of heart rate, respiratory rate, temperature, blood pressure, activity, daily weight, FOC, Apnea monitoring and intake and output record Oxygen saturation monitoring is very important in care of preterm babies

46. Immaturity of drug metabolism Due to renal and hepatic immaturity there is diminished renal and hepatic clearance of almost all drugs. Intervals between doses should be extended according to gestational age and weight. In case of liver injury, renal injury (AKI) dosages should be adjusted according to GFR.

47. Discharge criteria for premature babies A premature infant should be taking feed by nipple (either bottle or breast feed) Baby should be gaining weight properly (10-30 g/day) Temperature should be stabilized in an open cot There should be no recent episode of apnea or bradycardia There should be no parenteral drug administration, it may be converted to oral dosing

48. Thank You