Preterm babies..............

1. WELCOME

2. PRETERM BABIES PRESENTED BY: Dhanalakshmy . M First year M .Sc NURSING Govt college of nursing Alappuzha

3. 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.

4. Definition Preterm infants (also called premature infants) are those born before the beginning of 38 th 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)

5. 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.

6. 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

7. Spontaneous Poor socio-economic status Low maternal weight Chronic and acute systemic maternal illness Antepartum hemorrhage Cervical incompetence Maternal genital colonization and infections

8. Contd … Cigarette smoking during pregnancy Threatened abortion Acute emotional stress Physical exertion Sexual activity Trauma Bi- cornuate uterus Multiple pregnancy Congenital malformations

9. Induced The labour is often induced before term when there is impending danger to mother or foetal life in-utero. Maternal diabetes mellitus P lacental dysfunction as indicated by unsatisfactory foetal growth Eclampsia Foetal hypoxia A ntepartum haemorrhage and S evere rhesus iso -immunization.

10. CLINICAL FEATURES

11. Measurements T heir 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.

12. Activity and posture T he 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.

13. Face and head D isproportionately large head size S utures are widely separated and the fontanels are large S mall chin, protruding eyes due to shallow orbits and absent buccal pad of fat.

14. 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.

15. Skin and subcutaneous tissues skin is thin, gelatinous, shiny and excessively pink with abundant lanugo and very little vernix caseosa . Edema may be present .

16. Contd.. S ubcutaneous fat is deficient and breast nodule is small or absent. Deep sole creases are often not present .

17. Genitals I n male testes are undescended and scrotum is poorly developed.

18. Contd.. In female infants, labia majora are widely separated exposing labia minora and hypertrophied clitoris.

19. PHYSIOLOGICAL HANDICAPS

20. Central nervous system I mmaturity of central nervous system is expressed as inactivity and lethargy, poor cough reflex and in-coordinated sucking and swallowing

21. Contd.. Resuscitation difficulties at birth and recurrent apneic attacks. Retinopathy of prematurity . V ulnerable for intra-ventricular – periventricular hemorrhage and leuco-malacia Inefficient blood brain barrier

22. Respiratory system C uboidal alveolar lining- poor alveolar diffusion of gases H yaline membrane disease B reathing is mostly diaphragmatic, periodic and associated with intercostal recessions

23. Contd … Pulmonary aspiration and atelectasis They are vulnerable to develop chronic pulmonary insufficiency

24. Cardio-vascular system The closure of ductus arteriosus is delayed. In grossly immature infants( less than 32 weeks) EKG shows left ventricular preponderance. R isk to develop thrombo -embolic complications and hypertension.

25. 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. H ypoglycaemia

26. Contd.. Abdominal distention and functional intestinal obstruction Entero -colitis Immaturity of the glucuronyl transferase system in the liver leads to hyper- bilirubinemia . D evelopment of kernicterus at lower serum bilirubin levels.

27. 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.

28. 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 .

29. 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.

30. 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.

31. Toxicity of drugs Poor hepatic detoxification and reduced renal clearance make a preterm baby vulnerable to toxic effects of drugs

32. Nutritional handicaps D evelop anemia around 6 to 8 weeks of age. D eficiencies of folic acid and vitamin E. D evelop haemolytic anemia , thrombocytopenia and edema 6 to 10 weeks of age . O steopenia and rickets

33. Biochemical disturbances These babies are prone to develop : Hypoglycaemia Hypocalcemia Hypoprotenemia Acidosis and Hypoxia .

34. MANAGEMENT

35. Arrest of premature labor B ed rest and sedation. T ocolytic 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

36. Induction of premature labour M aturity 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.

37. 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.

38. CARE OF PRETERM BABIES

39. Optimal management at birth D elayed 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. T ransferred by the doctor or nurse to the NICU as soon as breathing is established.

40. Monitoring Vital signs . Activity and behaviour. Colour. Tissue perfusion. Fluids, electrolytes and ABG’s. Tolerance of feeds . W atched for development of RDS, apneic attacks, sepsis, PDA, NEC, IVH, etc. Weight gain velocity.

41. 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.

42. Provide in-utero milieu Create a soft, comfortable, “nestled” and cushioned bed. Avoid excessive stimuli. E ffective analgesia and sedation. Provide warmth. Ensure asepsis. Prevent evaporative skin losses.

43. 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.

44. Position of the baby T hermo-neutral environment. Application of oil or liquid paraffin on the skin. S hould be covered with a cellophane or thin transparent or thin transparent plastic sheet. P rovide partial kangaroo0mother-care.

45. Oxygen therapy O xygen should be administered with a head box when SpO 2 falls below 85% and it should be gradually withdrawn when SpO 2 goes above 90%. The lowest ambient concentration and flow rates should be used to maintain SpO 2 between 85-95% and PaO 2 between 60-80 mm Hg.

46. Phototherapy Early phototherapy is adviced to keep the serum bilirubin level within safe limits in order to obviate the need for exchange blood transfusion .

47. Prevention of nosocomial infections The handling should be bare minimum. Vigilance should be maintained on all procedures. Early diagnosis and prompt treatment of infections.

48. Feeding and nutrition I ntra-venous dextrose solution ( 10% dextrose in babies >1000g and 5% dextrose in babies <1000g ). Trophic feeds with EBM through NG tube. C ondition is stabilized - enteral feeds.

49. 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

50. 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

51. 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

52. Total parenteral nutrition Indications 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

53. 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

54. Early enteral nutrition Trophic 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

55. 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

56. 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

57. 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

58. Preterm human milk Disadvantages: Low concentrations of Vitamin D, Ca , P Inadequate iron

59. 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

60. Nutritional supplements Multivitamin drops. Iron supplementation. Vitamin E supplementation . Supplements of calcium (220mg/day) and phosphorus (100mg/day ).

61. 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.

62. Kangaroo Care Kangaroo 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.

63. Body temperature Mothers have thermal synchrony with their baby. The study also concluded that when the baby was cold, t he mother’s body temperature would increase to warm the baby up and vice versa. Contd …

64. Breastfeeding: Kangaroo care allows easy access to the breast and skin-to-skin contact increases milk let-down. Contd …

65. 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.

66. Contd.. Increased intimacy and attachment

67. Utility of corticosteroids A single dose of dexamethasone 0.2mg/kg IV at 4 hours of age. Inhaled steroids.

68. 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

69. Weight record L oss is upto a maximum of 10 to 15 percent . R egain 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.

70. 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.

71. Immunizations I t 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.

72. 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.

73. 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 . E ncouraged to touch and talk with her baby. P rovide kangaroo-mother-care. E motional support and guidance.

74. 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.

75. Discharge policy T he 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.

76. 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.

77. 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.

78. Contd.. Neuro -motor development, cognition and seizures. Eyes: Retinopathy of prematurity, vision, strabismus. Hearing. Behavioural problems, language disorders and learning disabilities.

79. 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.

80. 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.

81. 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.

82. 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.

83. 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.

84. 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.

85. 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.

86. Nursing diagnosis and interventions

87. 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

88. 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

89. 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

90. 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

91. 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

92. 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

93. 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

94. 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

95. 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

96. 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

97. 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

98. 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

99. Summary Definition and incidence Causes of prematurity Clinical features Physiological handicaps Management Care of preterm babies Prognosis Nursing assessment Nursing diagnosis and interventions

100. CONCLUSION….