CARE OF

PRETERM BABIES
CHINCHU.M

WHO IS PRETERM?

Preterm 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.
Very preterm infants are those born
before 32 completed weeks of
gestation.

CAUSES OF PREMATURITY
Spontaneous
poor

socio-economic status
low maternal weight
chronic and acute systemic maternal diseases
antepartum hemorrhage
cervical incompetence
maternal genital colonization and infections

 cigarette

smoking during pregnancy

threatened abortion
acute emotional stress
physical exertion
sexual activity
trauma
bicornuate uterus
multiple pregnancy
congenital malformation

INDUCED
maternal

diabetes mellitus
Eclampsia
fetal hypoxia
antepartum hemorrhage
severe rhesus iso-immunization
placental dysfunction as indicated by
unsatisfactory fetal growth

CLINICAL FEATURES
Measurements
length

is less than 47 cm

head circumference is less than 33 cm

but exceeds the chest circumference by
more than 3 cm.

Size

is small with relatively large head

ACTIVITY AND POSTURE

general
reflex

activity is poor

such as Moro response,

sucking and swallowing are sluggish

extended

posture due to poor tone.

FACE AND HEAD

Face appears small for the disproportionately
large head size
sutures are widely separated and the fontanels
are large
small chin
protruding eyes due to shallow orbits
absent buccal pad of fat
Optic nerve is often unmyelinated
Ear cartilage is deficient or absent with
poor recoil.
Hair appear woolly and fuzzy

SKIN AND SUBCUTANEOUS

TISSUES
Skin

is thin, gelatinous, shiny and excessively

pink with abundant

lanugo and very

little
vernix caseosa.

Edema may be present.

Subcutaneous fat is deficient and breast

nodule is small or absent.

Deep sole creases are often not present.

GENITALS
In

males testes are undescended and

scrotum is poorly developed.

In females, labia majora are widely

separated exposing labia minora and
hypertrophied clitoris

PHYSIOLOGICAL HANDICAPS
Central Nervous System

Resuscitation difficulties at birth and recurrent

apneic attacks are common.

Retinopathy
extremely

of prematurity due to oxygen toxicity.

vulnerable for intra-ventricular

periventricular hemorrhage and leucomalacia due to

relative deficiency of vit-K dependent coagulation
factors and increased capillary fragility.

RESPIRATORY SYSTEM
The

cuboidal alveolar lining in babies with a

gestational age of less than 26 weeks results in

poor alveolar diffusion of gases and therefore
the infant may not be viable.
Resuscitation

difficulties at birth, often

followed by hyaline membrane disease

 The

breathing is mostly diaphragmatic, periodic

and associated with intercostal recessions due to

soft ribs.
Pulmonary
They

aspiration and atelectasis are common.

are vulnerable to develop chronic pulmonary

insufficiency due to broncho-pulmonary dysplasia.

CARDIOVASCULAR SYSTEM
The

closure of ductus arteriosus is delayed

among preterm babies.

One

third of infants have features of PDA.

The

incidence is more among preterm

infants with hyaline membrane disease or

protracted hypoxia.

GASTRO INTESTINAL SYSTEM

Due to poor and inco-ordinated sucking and

swallowing there are difficulties in self feeding,
although their digestive ability is generally good.

Animal fat is not tolerated as well as the vegetable

fat.

Regurgitation and aspiration are common because

of inco-ordinated sucking, small capacity of
stomach, incompetence of gastro-oesophageal
junction and poor cough reflex.

Gastro-oesophageal reflux and its consequences are

common.

Abdominal distention and functional intestinal

obstruction are due to hypotonia.

Enterocolitis occurs when other predisposing factors

are present.

Immaturity of the glucuronyl transferase system in the

liver leads to hyperbilirubinemia.

Relatively low serum albumin, acidosis and

hypoxia in these babies predispose to the
development of kernicterus at lower serum
bilirubin levels.

The poor hepatic glycogen stores, delayed feeding,

birth asphyxia and respiratory distress syndrome
contribute to the development of hypoglycaemia.

THERMO-REGULATION

Hypothermia is invariable and life threatening

unless environmental temperature is controlled.

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.

INFEC
TIONS

Infections are the important cause of neonatal

mortality in low birth weight babies.

The low levels of IgG antibodies and inefficient cellular

immunity predispose them to infections.

Excessive handling, humid and warm atmosphere,

contaminated incubators and resuscitators expose
them to infecting organisms, thus contributing to high
incidence of infections.

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.

Preterm has to pass 4 to 5 ml of urine excrete one

milliosmole of solute as compared to 0.7 ml by an adult
for the same purpose.

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 unless
caution is exercise during their
administration.

NUTRITIONAL HANDICAPS

Low

birth weight babies are prone to develop

anemia around 6 to 8 weeks of age this is due to

diminished total stores of iron due to short
gestation.
They

may also manifest deficiencies of folic acid

and vitamin E especially among those fed with on

iron fortified milk formula.

These infants are more prone to develop haemolytic

anemia, thrombocytopenia and edema 6 to 10 weeks of
age.

Vitamin E deficiency along with oxygen toxicity to the

vulnerable tissues in the form of retro-lental
fibroplasia and broncho-pulmonary dysplasia.

Rapid growth following adequate feeding may result in

osteopenia and rickets unless calcium, phosphorus and
vitamin D are administered.

BIOCHEMICAL DISTURBANCES
These

babies are prone to

develop hypoglycemia,
hypocalcemia, hypoproteinemia,
acidosis and hypoxia

MANAGEMENT
ARREST OF PREMATURE LABOR

Efforts should always be made to arrest the

progress of premature labour.

Apart from bed rest and sedation, a variety of

tocolytic agents are recommended but none is
entirely safe or effective.

Magnesium sulphate is more effective and is being

increasingly used though there is potential risk of
respiratory depression in the newborn.

The observational studies have shown that

maternal treatment with reduced risk of IVH,
cerebral palsy and mental retardation in their
preterm babies.

Sympathomimetic agents specifically mediating

via beta-2-adrenergic receptors are powerful
tocolytic agents and currently used.

 Isoxsuprine

(duvadilan) is useful but its effect

is mediated through beta-1 and beta-2

receptors.
Therapy

is initiated by intra-venous infusion of

20mg isoxsuprine diluted in 200 ml of 5

percent dextrose at a rate of 4050drops/minute.
This

is followed by IM administration of 10mg

isoxsuprine every 4 hours for 24 and 48 hours.

 Ritodrine

has been approved by US food and drug

administration for treatment of premature labour.

The usual dose is 100-400g/ minute intravenously
through an infusion pump for a period of 12 hours
followed by oral ritodrine 10mg every 2 hours.
Salbutamol

and terbutaline are selective beta-2

receptor stimulators and are very effective tocolytic

agents. They are generally safe but occasionally
patient may develop tachycardia and pulmonary
oedema.

 Terbutaline

is administered as an IV bolus of

0.25mg followed by constant infusion of 10-80

g/minute for 1-2 hours. After control of uterine
contractions, maintenance therapy is continued
by administration of 0.25mg SC every 4 hours.
Indomethacin

has also offered some hope in

arresting premature uterine contractions.

INDUCTION OF PREMATURE LABOUR:

Corticosteroids should be administered to the

mother to enhance fetal lung maturity.

ANTENATAL CORTICOSTEROIDS:

Inj.betamethasone 12mg IM every 24 hours for 2

doses or dexamethasone 6mg IM every 12 hours
for 4 doses should be administered to the other if
labour starts or is induced before 34 weeks of
gestation.

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 PRETERM BABIES

Optimal management at birth:

The delayed clamping of cord helps in improving

the iron stores of the baby. It may also reduce the
incidence and severity of HMD.

Elective intubation of extremely LBW

babies(<1000g) is practiced in some centres to
support breathing and for prophylactic
administration of exogenous surfactant.

The baby should be promptly dried, kept

effectively covered and warm.

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

be given intra-muscularly.

The baby should be transferred by the doctor or

nurse to the NICU as soon as breathing is
established.

MONITORING:
Vital signs with the help of multi-channel vital
sign monitor ( non-invasive with alarms).
Activity and behaviour.
Color: pink, pale, grey, blue, yellow
Tissue perfusion: adequate perfusion is
suggested by pink colour, capillary refill over
upper chest of < 2sec, warm and pink
extremities, normal blood pressure, urine output
of > 1.5ml/kg/hr, absence of metabolic acidosis
and lack of any disparity between paO2 and SpO2.

Fluids, electrolytes and ABGs.

Tolerance of feeds by monitoring vomiting,
gastric residuals, abdominal girth.
The baby should be 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 light, excessive sound, rough
handling and painful procedures. Use effective
analgesia and sedation for conducting
procedures.
Provide warmth.
Ensure asepsis.
Prevent evaporative skin losses by effectively
covering the baby, application of oil or liquid
paraffin to the skin and increasing humidity to
near 100 percent.

Provide effective and safe oxygenation.

Uterus is able to provide unique parenteral

nutrition. Efforts should be made to provide at
least partial parenteral nutrition and give
trophic feeds with expressed breast milk (EBM).

Provide rhythmic gentle tactile and kinesthetic

stimulation like skin-to-skin contact, interaction,
music, caring and cuddling.

Position of the baby:

The baby should be nursed in a thermo-neutral
environment with a servo sense geared to maintain
skin temperature of mid-epigastric region at 36.5
degree Celsius so that there is virtually no or minimal
metabolic thermogenesis.
Application of oil or liquid paraffin on the skin reduces
convective heat loss and evaporative water losses.
The extremely LBW baby should be covered with a
cellophane or thin transparent or thin transparent
plastic sheet to prevent convective heat loss and
evaporative losses of water from skin.

As soon as babys condition stabilizes he should be covered

with Perspex shield or effectively clothed with a frock, cap,
socks and mittens.

After one week or so, stable babies with a birth weight of <
1200g should preferably be nursed in an intensive care
incubator.

The mother should be encouraged to provide partial

kangaroo0mother-care to prevent hypothermia, to promote
bonding and breast feeding and to transmit healing electromagnetic vibrations of love and compassion to her baby.

OXYGEN THERAPY:

The 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 inorder to
obviate the need for exchange blood transfusion.

PREVENTION OF NOSOCOMIAL
INFECTIONS:

The handling should be reduced to bare

minimum.

Vigilance should be maintained on all procedures

recommended for reduction of infections in the
nursery.

Early diagnosis and prompt treatment of

infections are essential for improved survival.

FEEDING AND NUTRITION:

Babies weighing less than 1200g or gestation of <30 weeks and sick
babies should be started on intra-venous dextrose solution ( 10%
dextrose in babies >1000g and 5% dextrose in babies <1000g).

Trophic feeds with EBM ( 1-2 ml 4 times/day) throough NG tube can

be started in all babies irrespective of their birth weight or clinical
conditions.

When babys condition is stabilized enteral feeds are begun with

EBM starting with a volume of 30ml/kg/day on the first day and
depending upon the tolerance, the enteral feeds are increased by 1020ml/kg/day every day and IVF are reduced accordingly.

NUTRITIONAL SUPPLEMENTS

Multivitamin drops containing folic acid should

be started at 2 weeks of age.

Iron supplementation (2-3 mg/kg elemental iron)

should be started after 2-3 weeks when a baby is
having steady weight gain.

Free radical lipid peroxidation in cell membranes is

catalysed by iron and polysaturated fatty acids(PUFA) thus
increasing the requirements of vitamin E in very low birth
babies. The requirement of vitamin E are, therefore, related
to linoleic acid content of the formula. It is recommende
that vitamin E to linoleic acid ratio should be > 1iu/gram of
linoleic acid in the feeding formula for LBW babies. The
alpha tocopherol/ linoleic acid ratios are 6.23, 1.43 and 0.78
mg/g in human colostrum, transitional and mature milk
respectively.

Vitamin E is powerful anti-oxidant and prevents

the haemolytic anemia and edema of
prematurity.

In infants weighing less than 1500g at birth,

milk formula should provide atleast1iu of
vitamin E /g of linoleic acid and supplemented
with daily administration of 15 iu of vitamin E.

Supplements of calcium (220mg/day) and

phosphorus (100mg/day) are essential to prevent
osteopenia of prematurity.

The supplements are continued till the baby has

achieved post conceptional maturity of 38 weeks
or weight of 2000g.

PRIORITY PACKAGES AND EVIDENCE-BASED

INTERVENTIONS

PACKAGE 1: ESSENTIAL AND EXTRA

NEWBORN CARE
Thermal care
Feeding support
Infection prevention

PACKAGE 2: NEONATAL RESUSCITATION

PACKAGE 3: KANGAROO MOTHER CARE

PACKAGE 4: SPECIAL CARE OF PREMATURE BABIES

AND PHASED SCALE UP OF NEONATAL INTENSIVE CARE

Care of babies with signs of infection

Care of babies with jaundice
Babies with Respiratory Distress Syndrome

PREVENTION, EARLY DIAGNOSIS AND

PROMPT MANAGEMENT OF COMMON
PROBLEMS
Nosocomial infection
Hypothermia
Respiratory distress syndrome
Aspiration
Patent ductus arteriosus
Chronic lung disease

Necrotizing enterocolitis
Intraventricular hemorrhage
Retinopathy of prematurity
Late metabolic acidosis
Nutritional disorders
Drug toxicity

WEIGHT CONTROL
Daily weight monitoring .
Preterm babies lose weight during the first 3 to 4 days
of life and loss is upto a maximum of 10 to 15 percent
of the birth weight.
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 that either the
baby is not being fed adequately or he is unwell and
needs immediate attention. Sudden weight loss in a
baby who had been gaimng weight satisfactorily would
suggest the possibility of dehydration. Excessive
weight gain of 100 g or more per day may occur in
babies with cardiac failure though sometimes healthy
babies may also gain weight more rapidly.