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

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  • 1.  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.
  • 2.  Preterm infants (also called premature 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.  Late preterm infants fall in the moderately preterm group.  Very preterm infants are those born before 32 completed weeks of gestation. (Mehrban Singh, 2010)
  • 3.  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.
  • 4.  The mechanisms initiating normal labour are not clearly understood and much less is known about the triggers that initiate labour before term. Spontaneous Induced
  • 5.  Poor socio-economic status  Low maternal weight  Chronic and acute systemic maternal illness  Antepartum hemorrhage  Cervical incompetence  Maternal genital colonization and infections
  • 6.  Cigarette smoking during pregnancy  Threatened abortion  Acute emotional stress  Physical exertion  Sexual activity  Trauma  Bi-cornuate uterus  Multiple pregnancy  Congenital malformations
  • 7.  The labour is often induced before term when there is impending danger to mother or foetal life in-utero. Maternal diabetes mellitus Placental dysfunction as indicated by unsatisfactory foetal growth Eclampsia Foetal hypoxia Antepartum haemorrhage and Severe rhesus iso-immunization.
  • 8.  Their 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.
  • 9.  The 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.
  • 10.  Disproportionately large head size  Sutures are widely separated and the fontanels are large  Small chin, protruding eyes due to shallow orbits and absent buccal pad of fat.
  • 11.  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.
  • 12.  skin is thin, gelatinous, shiny and excessively pink with abundant lanugo and very little vernix caseosa.  Edema may be present.
  • 13.  Subcutaneous fat is deficient and breast nodule is small or absent.  Deep sole creases are often not present.
  • 14.  In male testes are undescended and scrotum is poorly developed.
  • 15.  In female infants, labia majora are widely separated exposing labia minora and hypertrophied clitoris.
  • 16.  Immaturity of central nervous system is expressed as inactivity and lethargy, poor cough reflex and in-coordinated sucking and swallowing
  • 17.  Resuscitation difficulties at birth and recurrent apneic attacks.  Retinopathy of prematurity .  Vulnerable for intra- ventricular – periventricular hemorrhage and leuco- malacia  Inefficient blood brain barrier
  • 18.  Cuboidal alveolar lining- poor alveolar diffusion of gases  Hyaline membrane disease  Breathing is mostly diaphragmatic, periodic and associated with intercostal recessions
  • 19.  Pulmonary aspiration and atelectasis  They are vulnerable to develop chronic pulmonary insufficiency
  • 20.  The closure of ductus arteriosus is delayed.  In grossly immature infants( less than 32 weeks) EKG shows left ventricular preponderance.  Risk to develop thrombo- embolic complications and hypertension.
  • 21.  Due to poor and incoordinated sucking and swallowing.  Animal fat is not tolerated as well as the vegetable fat.  Regurgitation and aspiration are common.  Hypoglycaemia
  • 22.  Abdominal distention and functional intestinal obstruction  Entero-colitis  Immaturity of the glucuronyl transferase system in the liver leads to hyper-bilirubinemia.  Development of kernicterus at lower serum bilirubin levels.
  • 23.  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.
  • 24.  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.
  • 25.  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.
  • 26.  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.
  • 27.  Poor hepatic detoxification and reduced renal clearance make a preterm baby vulnerable to toxic effects of drugs
  • 28.  Develop anemia around 6 to 8 weeks of age.  Deficiencies of folic acid and vitamin E.  Develop haemolytic anemia, thrombocytopenia and edema 6 to 10 weeks of age.  Osteopenia and rickets
  • 29.  These babies are prone to develop : Hypoglycaemia Hypocalcemia Hypoprotenemia Acidosis and Hypoxia.
  • 30.  Bed rest and sedation.  Tocolytic 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
  • 31.  Maturity 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.
  • 32.  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.
  • 33.  Delayed 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.  Transferred by the doctor or nurse to the NICU as soon as breathing is established.
  • 34.  Vital signs .  Activity and behaviour.  Colour.  Tissue perfusion.  Fluids, electrolytes and ABG’s.  Tolerance of feeds .  Watched for development of RDS, apneic attacks, sepsis, PDA, NEC, IVH, etc.  Weight gain velocity.
  • 35.  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.
  • 36.  Create a soft, comfortable, “nestled” and cushioned bed.  Avoid excessive stimuli.  Effective analgesia and sedation.  Provide warmth.  Ensure asepsis.  Prevent evaporative skin losses.
  • 37.  Provide effective and safe oxygenation.  Partial parenteral nutrition and give trophic feeds with expressed breast milk (EBM).  Provide rhythmic gentle tactile and kinaesthetic stimulation.
  • 38.  Thermo-neutral environment.  Application of oil or liquid paraffin on the skin.  Should be covered with a cellophane or thin transparent or thin transparent plastic sheet.  Provide partial kangaroo0mother-care.
  • 39.  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.
  • 40.  Early phototherapy is adviced to keep the serum bilirubin level within safe limits in order to obviate the need for exchange blood transfusion.
  • 41.  The handling should be bare minimum.  Vigilance should be maintained on all procedures.  Early diagnosis and prompt treatment of infections.
  • 42.  Intra-venous dextrose solution ( 10% dextrose in babies >1000g and 5% dextrose in babies <1000g).  Trophic feeds with EBM through NG tube.  Condition is stabilized - enteral feeds.
  • 43. 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
  • 44. 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
  • 45.  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
  • 46. 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
  • 47.  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
  • 48. 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
  • 49.  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
  • 50. 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
  • 51. 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
  • 52. Disadvantages: Low concentrations of Vitamin D, Ca, P Inadequate iron
  • 53.  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
  • 54.  Multivitamin drops.  Iron supplementation.  Vitamin E supplementation.  Supplements of calcium (220mg/day) and phosphorus (100mg/day).
  • 55.  Gentle touch, massage, cuddling, stroking and flexing.  Rocking bed or placing a preterm baby on inflated gloves.  Soothing auditory stimuli.  Visual inputs.
  • 56. 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.
  • 57.  Body temperature  Mothers have thermal synchrony with their baby.  The study also concluded that when the baby was cold, the mother’s body temperature would increase to warm the baby up and vice versa.
  • 58.  Breastfeeding: Kangaroo care allows easy access to the breast and skin-to-skin contact increases milk let-down.
  • 59.  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.
  • 60.  Increased intimacy and attachment
  • 61.  A single dose of dexamethasone 0.2mg/kg IV at 4 hours of age.  Inhaled steroids.
  • 62.  Nosocomial infections  Hypothermia  Respiratory distress syndrome  Aspiration  Patent ductus arteriosus  Chronic lung disease  NEC & IVH  ROP & Late metabolic acidosis  Nutritional disorders  Drug toxicity
  • 63.  Loss is upto a maximum of 10 to 15 percent.  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 baby is not being fed adequately or unwell and needs immediate attention.
  • 64.  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.
  • 65.  It 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.
  • 66.  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.
  • 67.  The family dynamics are greatly disturbed.  The problems and issues should be handled with equanimity, compassion, concern and caring attitude of the health team.  Encouraged to touch and talk with her baby.  Provide kangaroo-mother- care.  Emotional support and guidance.
  • 68.  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.
  • 69.  The 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.
  • 70.  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.
  • 71.  Common infective illnesses, reactive airway disease, hypertension, renal dysfunction, gastro-oesophageal reflux.  Feeding and nutrition.  Immunizations.  Physical growth, nutritional status, anemia, osteopenia/ rickets.
  • 72.  Neuro-motor development, cognition and seizures.  Eyes: Retinopathy of prematurity, vision, strabismus.  Hearing.  Behavioural problems, language disorders and learning disabilities.
  • 73.  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.
  • 74.  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.
  • 75.  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.
  • 76.  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.
  • 77.  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.
  • 78.  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.
  • 79.  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.
  • 80. 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
  • 81. 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
  • 82. 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
  • 83. 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
  • 84. 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
  • 85. 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
  • 86. 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
  • 87. 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
  • 88. 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
  • 89. 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
  • 90. 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
  • 91. 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
  • 92.  Definition and incidence  Causes of prematurity  Clinical features  Physiological handicaps  Management  Care of preterm babies  Prognosis  Nursing assessment  Nursing diagnosis and interventions

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