Premature & Growth retarded infants - Part 2
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Premature & Growth retarded infants - Part 2
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Premature & Growth retarded infants - Part 2
- 1. Implement UniversalImplement Universal Precautions and Respect goodPrecautions and Respect good hygiene procedurehygiene procedure Limit as possible intrusive exams suchLimit as possible intrusive exams such as blood samples, if necessary useas blood samples, if necessary use adequate dressing on the wound .adequate dressing on the wound . Don’t bath small baby just wash asDon’t bath small baby just wash as necessary in a warm roomnecessary in a warm room Allow visits to mother and ‘Small baby’Allow visits to mother and ‘Small baby’
- 2. Thermoregulation of ‘SmallThermoregulation of ‘Small Baby’Baby’ ‘‘Small Baby’s body faces important heat lostSmall Baby’s body faces important heat lost due to their important body surface (x 3 adultdue to their important body surface (x 3 adult body surface)body surface) ‘‘Small Baby ‘has difficulty to maintain a stableSmall Baby ‘has difficulty to maintain a stable temperature due to an immaturetemperature due to an immature thermoregulation systemthermoregulation system andand to few storedto few stored reserves (fat, glycogen).reserves (fat, glycogen). Heat lost by the head represents 50% ofHeat lost by the head represents 50% of heat lost ’Small Baby ‘needs to have a hatheat lost ’Small Baby ‘needs to have a hat permanentlypermanently
- 4. Re-warming hypothermicRe-warming hypothermic babybaby If moderate hypothermia (32°C toIf moderate hypothermia (32°C to 36°C36°C)) - skin-to-skin- skin-to-skin - warm room, warm bed- warm room, warm bed - radiant heater- radiant heater - water heated mattress or incubator- water heated mattress or incubator
- 5. SponsoredSponsored Medical Lecture Notes –Medical Lecture Notes – All SubjectsAll Subjects USMLE Exam (America) –USMLE Exam (America) – PracticePractice
- 6. Re-warming hypothermicRe-warming hypothermic babybaby If severe hypothermia (<32°C)If severe hypothermia (<32°C) – Rewarm rapidly, increasing body temperature byRewarm rapidly, increasing body temperature by 1°C/hour1°C/hour – Use a thermostatically controlled heated mattress setUse a thermostatically controlled heated mattress set at 37-38°C or incubatorat 37-38°C or incubator – Promote feeding to meet increased water and energyPromote feeding to meet increased water and energy needs as soon as the t reaches 35°Cneeds as soon as the t reaches 35°C – Oxygen should be available as consumption isOxygen should be available as consumption is increasedincreased Rewarm until baby’s temperature reaches normal rangeRewarm until baby’s temperature reaches normal range Monitored every 15-30 min until the temperature isMonitored every 15-30 min until the temperature is stabilized during 1 hour.stabilized during 1 hour. Monitor glucose level according to severityMonitor glucose level according to severity
- 7. Important periods for ‘smallImportant periods for ‘small baby’baby’ Transition period/Adaptation periodTransition period/Adaptation period -- birth to 7 days, often weight lostbirth to 7 days, often weight lost ‘‘Essential nutrition ‘ to prevent catabolism and nutritionEssential nutrition ‘ to prevent catabolism and nutrition deficienciesdeficiencies Stabilization periodStabilization period -- 7 days to discharge from Maternity/Prematurity7 days to discharge from Maternity/Prematurity DepartmentDepartment Rapid growth period similar as intrauterine growthRapid growth period similar as intrauterine growth Normalization periodNormalization period -- Discharge from Maternity/ Prematurity department to 1Discharge from Maternity/ Prematurity department to 1 year or moreyear or more Growth and development to be similar to a full term babyGrowth and development to be similar to a full term baby
- 8. ‘‘Small baby’ feedingSmall baby’ feeding Challenges (1)Challenges (1) 1.1. Important calories needed to insure rapidImportant calories needed to insure rapid growth.growth. In a neutral thermic environment ‘Small baby’In a neutral thermic environment ‘Small baby’ needsneeds 120-130 kcal/kg/24h during the stabilization period120-130 kcal/kg/24h during the stabilization period 2.2. Immaturity of sucking reflexImmaturity of sucking reflex - Mature suckling reflex and good feeding capacity- Mature suckling reflex and good feeding capacity at 34 -35 weeks .at 34 -35 weeks . - Capacity to use cup or spoon at 30 -32 weeks- Capacity to use cup or spoon at 30 -32 weeks - Before 30 weeks gavage feeding- Before 30 weeks gavage feeding
- 11. ‘‘Small baby’ feedingSmall baby’ feeding Challenges (2)Challenges (2) Small stomach capacity:Small stomach capacity: ± 20ml/kg± 20ml/kg 1,000 g: stomach capacity 20 ml1,000 g: stomach capacity 20 ml 1,500g: stomach capacity 30 ml1,500g: stomach capacity 30 ml 2,000g: stomach capacity 40 ml2,000g: stomach capacity 40 ml 2.500g: stomach capacity 50 ml2.500g: stomach capacity 50 ml Immaturity of gut, liver and kidneyImmaturity of gut, liver and kidney Mother ‘s milk is the best but only 67Mother ‘s milk is the best but only 67 cal/100 mlcal/100 ml
- 12. Quantity and frequency ofQuantity and frequency of ‘Small baby’ feeding (1)‘Small baby’ feeding (1) Quantity:Quantity: 11StSt day start with 80ml/kg/per day andday start with 80ml/kg/per day and increase by 10-20ml/kg per day untilincrease by 10-20ml/kg per day until 150ml/kg/per day150ml/kg/per day Frequency:Frequency: Divide the total by 8 times or 12 timesDivide the total by 8 times or 12 times depending of the birth weight and babydepending of the birth weight and baby strengthstrength Feed small or ill baby every 2-3 hours (10 -12Feed small or ill baby every 2-3 hours (10 -12 times/24htimes/24h))
- 13. Quantity and frequency ofQuantity and frequency of feeding for ‘Small baby’(2)feeding for ‘Small baby’(2) Approximate quantity to feed by cup in ml,Approximate quantity to feed by cup in ml, every 2 -3 hours from birthevery 2 -3 hours from birth WeightWeight BirthBirth Day1Day1 Day2Day2 Day3Day3 Day4Day4 Day5Day5 Day6Day6 Day7Day7 1,5 –1,5 – 1,9 kg1,9 kg 15ml15ml 17ml17ml 19ml19ml 21ml21ml 23ml23ml 25ml25ml 27ml27ml 27+27+ mlml 2,0 –2,0 – 2,4 kg2,4 kg 20ml20ml 22ml22ml 25ml25ml 27ml27ml 30ml30ml 32ml32ml 35ml35ml 35+35+ mlml 2,5+2,5+ kgkg 25ml25ml 28ml28ml 30ml30ml 35ml35ml 35ml35ml 40+40+ mlml 45+45+ mlml 50+50+ mlml
- 15. How to feed a ‘Small Baby’How to feed a ‘Small Baby’ (1)(1) Which milk is the best for ‘small baby’Which milk is the best for ‘small baby’ Breastmilk is the bestBreastmilk is the best ‘‘Preterm breastmilk’ contains more fat andPreterm breastmilk’ contains more fat and more protein, and brings 30% more caloriemore protein, and brings 30% more calorie than ‘full term breastmilk’.than ‘full term breastmilk’. Preterm infant formulaPreterm infant formula Bringing many calories and otherBringing many calories and other micronutrients to the ‘small baby’, but notmicronutrients to the ‘small baby’, but not widely available and expensivewidely available and expensive
- 16. How to feed a ‘SmallHow to feed a ‘Small Baby’ (2)Baby’ (2) Feeding methodsFeeding methods − Breastfeeding possible at 34-35 weeksBreastfeeding possible at 34-35 weeks − Cup/spoon feeding possible at 30-32Cup/spoon feeding possible at 30-32 weeks using mother expressed milkweeks using mother expressed milk − Breastfeeding supplemented byBreastfeeding supplemented by cup/spoon feedingcup/spoon feeding − Gavage feeding: baby less than 30 weeksGavage feeding: baby less than 30 weeks or ill babyor ill baby
- 17. Alternative methods ofAlternative methods of feedingfeeding
- 18. ‘‘Small Baby’ alternativeSmall Baby’ alternative feeding methodsfeeding methods ExpressedExpressed mother milkmother milk Cup feedingCup feeding /spoon feeding/spoon feeding (possible after(possible after 30-32 weeks)30-32 weeks) • Does not interfere with suckling atDoes not interfere with suckling at breastbreast • Cup easy to cleanCup easy to clean • Safe, the ‘small baby’ drink activelySafe, the ‘small baby’ drink actively the quantity he/she wantsthe quantity he/she wants Cup feeding could completeCup feeding could complete breastfeeding if the babybreastfeeding if the baby is weak or tiredis weak or tired
- 20. MicronutrientsMicronutrients Fe:Fe: No Iron supplementation until 2No Iron supplementation until 2 weeks .weeks . From 2 - 12 months 3-4 mg/kg/24hFrom 2 - 12 months 3-4 mg/kg/24h Vitamin D:Vitamin D: From 1 week of age – 12From 1 week of age – 12 months 400 -800 UImonths 400 -800 UI Vitamin AVitamin A :: Mother milk has enoughMother milk has enough vitamin Avitamin A
- 21. Kangaroo Mother CareKangaroo Mother Care MethodMethod
- 22. Discharge Criteria forDischarge Criteria for ‘Small Baby’‘Small Baby’ Weight - 1.500-2000g if following conditions met:Weight - 1.500-2000g if following conditions met: – weight gain since 3 subsequent daysweight gain since 3 subsequent days (at least 15-20(at least 15-20 g/kg per day)g/kg per day) – good thermoregulation (the baby temperature isgood thermoregulation (the baby temperature is stable )stable ) – good sucking reflexgood sucking reflex – mother able to take care of baby at homemother able to take care of baby at home andand having easy access to health carehaving easy access to health care – precise advices and counsels provided toprecise advices and counsels provided to mother/familymother/family – Follow up visit after 7 daysFollow up visit after 7 days
- 23. Advices to the mother to takeAdvices to the mother to take care of the ‘small baby’ aftercare of the ‘small baby’ after dischargedischarge Keep baby warmKeep baby warm Breastfeed at least 8-10 times per day (day andBreastfeed at least 8-10 times per day (day and night)night) Bath the baby in warm room, dry with warmBath the baby in warm room, dry with warm towelstowels Baby back sleeping positionBaby back sleeping position Baby room not more than 22-23 °CBaby room not more than 22-23 °C No smoking in baby roomNo smoking in baby room Follow up visit 7 daysFollow up visit 7 days
- 24. Advices to the mother to takeAdvices to the mother to take care of the ‘small baby’ aftercare of the ‘small baby’ after dischargedischarge Come back immediately if a ‘small baby’Come back immediately if a ‘small baby’ -- refuse breastfeedingrefuse breastfeeding - become sick- become sick
Editor's Notes
- If the mother is taking care by herself of her baby (strict rooming in ) this will prevent many cross contamination, and nosocomial infection The mother need to be teach kindly how to wash her hand properly ,this practice need to be check and support by the staff The cord of small baby need to be openly managed, not covered with any dressing, no use of alcohol or disinfectant, teach mother to use soap and water if the cord is spoiled with urine or stools. Limit as possible biologic blood exams they are painful ,expensive, dangerous increasing the risk of infection and also leading to anemia in small baby Small baby don’t need to be bath , if they are spoiled wash with warm water the special part of their body It is important that relative could visit and support mother and small baby, it is evidence based that this visit will not increase the risk of infection .
- After the adaptation period the temperature of an healthy baby small or with normal weight is similar as older child or adult . Normal temperature few days after birth is similar to older child (‘small baby comfort&apos; temperature is 36.8 °C - 37.2 °C) During the first days of life the axillary temperature is identical to the rectal temperature
- The most appropriate method to maintain temperature or to rewarm Skin-to-skin contact as the chest of the mother just after delivery is 38 C. Water filled mattresses which are extremely useful and better to use that incubator expensive and difficult to clean Radiant warmers could also be used as well as air heated incubators If the baby is suffering from severe hypothermia &lt; 32° C it is not recommended to feed this hypothermic baby, but glucose IV infusion could improve the situation If glycemy level &lt; 2,6 mUmol/l or 45 mg/dl ( or 0.45 g/l )start injecting directly in IV glucose using 10% glucose solution give 2-2,5 ml/кg or using 25 % glucose solution give 1 ml/кg . After this emergency treatment use 10% solution of glucose providing 6-8 mg/kg/min. Measure the glucose level each 30 minutes until the glycemy level is stable&gt; 2,6 mUmol/l or 45 mg/dl ( or 0.45 g/l for at least one hour , then measure the glycemy each 3 hours during the first day. Further control of temperature: measure temperature until the receiving of two same results &gt; than 36,5 °C, and than in 1 hour Teach the mother to touch often the baby feet , if feet are cold this is an excellent sign that the baby is hypothermic .
- The most appropriate method to maintain temperature or to rewarm Skin-to-skin contact as the chest of the mother just after delivery is 38 C. Water filled mattresses which are extremely useful and better to use that incubator expensive and difficult to clean Radiant warmers could also be used as well as air heated incubators If the baby is suffering from severe hypothermia &lt; 32° C it is not recommended to feed this hypothermic baby, but glucose IV infusion could improve the situation If glycemy level &lt; 2,6 mUmol/l or 45 mg/dl ( or 0.45 g/l )start injecting directly in IV glucose using 10% glucose solution give 2-2,5 ml/кg or using 25 % glucose solution give 1 ml/кg . After this emergency treatment use 10% solution of glucose providing 6-8 mg/kg/min. Measure the glucose level each 30 minutes until the glycemy level is stable&gt; 2,6 mUmol/l or 45 mg/dl ( or 0.45 g/l for at least one hour , then measure the glycemy each 3 hours during the first day. Further control of temperature: measure temperature until the receiving of two same results &gt; than 36,5 °C, and than in 1 hour Teach the mother to touch often the baby feet , if feet are cold this is an excellent sign that the baby is hypothermic .
- Each period could have a different duration, these duration are just an average During the transition/adaptation period the goal is not to gain weight but to prevent catabolism , and acute malnutrition
- What is a neutral thermic environment : an environment where the body doesn’t need to use any calorie to maintain body temperature not to hot not to cold For ‘small baby’ neutral thermic environment is Warm room 26 ºC to 30 ºC depending on the baby weight and gestational age Incubator 32 ºC to 35 ºC for a stable baby with an appropriate clothing and hat Good feeding capacity include capacity to coordinate suckling swallowing and breathing The stabilization period is covering all the duration of hospitalization in maternity or in special department
- As example a baby of 1,500g is not able to have feeding more than 30 ml . One of the more difficult challenge is to combine the important needs in calories and the limited stomach capacity, the solution is to feed ‘small baby ‘ very often with small quantity , each 2 hours which need dedication and patience .
- Signs that baby is receiving adequate amount of milk: - baby is satisfied with the feed . - weight lost &lt;10% the first week of life. - ‘small baby’ gains at least 160g-180 per weeks(15-20g/day). - baby urinates more than 6 times a day. - baby’s stools are yellow by the 3rd day.
- Check the baby’s 24 hours intake, Size of individual feeds may vary If the baby doesn’t take the calculate amount: feed for a longer time or feed more often Teach the mother to measure the baby intakes over 24 hours not just at each feed Continue until the baby takes the required quantity . Be patient, this is the reason the mother needs to feed the baby she is more patient than the staff Wash the cup with soap and water after each feed .
- Never use cow milk to feed small baby, if you don’t have any other solution be sure the milk is boiled and you add water and sugar (for 100 ml of cow milk add 20 ml of boiled water and 10 g of sugar The relative risk of enterocolitis is smaller than with infant formula
- This slide is hidden for participants only for the facilitator use
- Before 30-32 weeks only gavage feeding could be use to feed very small or ill baby. Cup feeding possible at 30 -32 weeks of gestational age . Advantages of cup compare to spoon , spoon seems more easy, but the suckling of the baby is interrupted each time the spoon is empty and to do it properly ‘3 hands are needs, one to fill the spoon , one to hold the baby, the third one to feed the child ! Spoon feeding could also be replace by dropper feeding
- It is important that ‘small baby ‘ would go home as earlier as possible obviously when their status is stable, good thermoregulation, good suckling reflex and good weight gain during at least 3 consecutive days. Baby and mother will be better at home with support and love of the family than in an hospital , baby will be less expose to nosocomial infection Social condition are important but take into consideration also the need for the family to be together.
- The small baby needs to be kept warm but not to warm! The baby is comfortable if his/her body temperature is normal 36.8 °C – 37.2°C ,the baby has fever if the body temperature is over 37.5 °C. All these advices need to be teach to mother and family before leaving the maternity or the second stage department. It will be good if all these advises will be given to family in on a written document Be sure that the mother/family understand what to do using checking question such as “what the best position for your baby to sleep” or “what will be the temperature in your baby room ?”
- The small baby needs to be kept warm but not to warm! The baby is comfortable if his/her body temperature is normal 36.8 °C – 37.2°C ,the baby has fever if the body temperature is over 37.5 °C. All these advices need to be teach to mother and family before leaving the maternity or the second stage department. It will be good if all these advises will be given to family in on a written document Be sure that the mother/family understand what to do using checking question such as “what the best position for your baby to sleep” or “what will be the temperature in your baby room ?”