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1. PRETERM, LOW BIRTH WEIGHT BABY, PROBLEMS AND MANAGEMENT BY: DR AMADU JALLOH

2. OUTLINE Overview Causes of Prematurity Problems of Preterms Management of Preterms

3. PRETERM BIRTHS – SIERRA LEONE In Sierra Leone, 23,000 babies are born too soon each year and 2,840 children under five die due to direct preterm complications. Live born infants delivered before 37 completed weeks from the first day of the last menstrual period (WHO) By gestational age less than 28 weeks (extreme prematurity), 28–31 weeks (severe prematurity), 32–33 weeks (moderate prematurity), 34–36 weeks (late preterm)

4. TERMINOLOGIES low birth weight(LBW ) less than 2500 g Very Low Birth Weight (VLBW) less than 1500g, Extremely Low Birth Weight (ELBW) less than 1000 g Normal Weight at term delivery is 2500g – 3999g

5. CAUSES OF PREMATURITY/LBW (IUGR) The causes of Prematurity/LBW is multifactorial It involves a complex interaction between fetal, placental, uterine and maternal factors.

6. CAUSES OF PREMATURITY Fetal Fetal distress Multiple gestation Erythroblastosis fetalis Congenital anomalies Placental Dysfunction Placenta previa Abruptio placenta Maternal Preeclampsia Chronic medical condition Drug abuse INFECTION (Chorioamnionitis, Sepsis, Malaria) Low socioeconomic status Lack of prenatal care

7. CAUSES OF PREMATURITY Uterine Incompetent cervix (premature dilation) Other trauma iatrogenic Premature rupture of membranes Polyhydramnios

8. PROBLEMS OF PRETERM NEONATES Neurologic Ophthalmologic Respiratory Cardiovascular Gastrointestinal and nutritional Renal Liver Haematologic Infection Social

9. PROBLEMS OF PRETERMS CNS Intraventricular Haemorrhage Periventricular Leukomalacia Perinatal Asphyxia Immature coordination of sucking and swallowing reflexes with closure of air passages. Ophthalmic Retinopathy of Prematurity

10. PROBLEMS OF PRETERMS Respiratory Respiratory Distress Syndrome Apnea of Prematurity Bronchopulmonary Dysplasia Cardiovascular Patent ductus arteriosus

11. PROBLEMS OF PRETERMS Gastrointestinal and Nutritional Necrotizing enterocolitis Feeding intolerance Growth failure Liver Impaired conjugation and excretion of bilirubin Deficiency of vitamin K dependent clotting factors

12. PROBLEMS OF PRETERMS Renal Inability to excrete large solute loads. Less ability to concentrate urine due to immature renal tubular function Acid-base disturbances Hematologic Anaemia of Prematurity Hyperbilirubinemia

13. PROBLEMS OF PRETERMS Immunologic, Infection Immune deficiency Perinatal infection Nosocomial infection Metabolic Hypoglycaemia Hypothermia

14. THERMOREGULATION Less amount of brown fat and glycogen stores to produce heat Preterm infants do not shiver. Preterm infants are at increased risk of heat loss compared with older children due to: increased body surface/weight ratio, decreased epidermal and dermal skin thickness, minimal subcutaneous fat

15. THERMOREGULATION

16. THERMOREGULATION Mechanisms of heat loss Conduction : skin surface touches a colder object, such as a cold blanket, table or weighing scale. Convection : When heat is transferred from the skin to the environment through moving air or water

17. THERMOREGULATION Radiation: emission of heat from the body surface an infant may lose heat to a cold wall located nearby Evaporation: Heat loss from evaporation occurs through the skin or respiratory tract when water is converted to a gas There is higher evaporation rates at lower levels of humidity

18. CONSEQUENCES OF HYPOTHERMIA Increased oxygen consumption Tissue hypoxia and metabolic acidosis. Inhibition of the formation of surfactant Systemic and pulmonary vasoconstriction decreased oxygen delivery to the cells and tissues

19. CONSEQUENCES OF HYPOTHERMIA Increased glucose consumption result in exhaustion of glycogen store Increased insensible heat loss dehydration fluid electrolyte imbalance, hypotension, irritability

20. THERMONEUTRAL ENVIRONMENT (TNE) TNE or neutral thermal environment refers to a narrow range of environmental factors at which the basal metabolic rate (BMR) of the baby is at a minimum and the baby maintains its normal body temperature.

21. HOW TO ACHIEVE A THERMONEUTRAL ENVIRONMENT Room temperature at least 25-32˚C, humid and free of draughts At birth the baby should be immediately dried and covered in warm clothes Should be laid on a warm surface like the mother’s chest (skin to skin) or under a radiant warmer or in an incubator with skin probes to regulate the desired temperature

22. HOW TO ACHIEVE A THERMONEUTRAL ENVIRONMENT Warm clothes, socks, blanket, caps, polythene wraps for all babies Bathing should be postponed Breast feeding should start within 1 hour of delivery Frequent monitoring of body temperature

23. PRETERM NEONATES: MANAGEMENT Prepare well before delivery Clear the airway and maintain patent airway, initiate breathing, give surfactant if available Stabilization in the delivery room prompt respiratory and thermal management

24. PRETERM NEONATES: MANAGEMENT Thermal control and high humidity (the smaller the infant the higher the environmental temperature should be). Incubator. Vit K, and antibiotics (Ampicillin and Gentamycin or Cefotaxime ), Apnoea prophylaxis (Aminophylline or Caffeine Citrate) Monitoring of heart rate and respiratory, Oxygen therapy Continuous positive airway pressure (CPAP)

25. PRETERM NEONATES: MANAGEMENT Care for umbilical cord General hygiene Minimal handling Fluid requirements TPN might be needed. Calculate gestational age

26. PRETERM NEONATES: MANAGEMENT Nutrition: Should be individualised, Delayed initiation of feeding, trophic feeding, breast feeding, EBM, tube feeding (continuous/intermittent) KMC if baby is stable Daily weighing (weight gain of 15-30g/day) Vitamins Iron and other minerals after 2 weeks

27. FLUID AND ELECTROLYTE MANAGEMENT Initial fluids should be a solution of glucose and water (dextrose 10% in water (D10W). The exception is the ELBW infant who should initially be given dextrose 5% in water) Electrolytes should not be added until 24 hours of age Basal needs are sodium is 2-3 mEq /kg/d, potassium 1-2 mEq /kg/d, and calcium 600 mg/kg/d (as calcium gluconate).

28. THANK YOU