Prematurity Management of Premature Babies. Golden Hour in NICU. Neonatal Intensive Care management of Preterm Babies.

1. Prematurity
By: Dr Inayat Ullah
MBBS, FCPS Paeds
Fellow Neonatology PEMH RWP.

2. Definition
• Prematurity is defined as Birth of a baby at 22
completed weeks to less than 37 weeks of
gestation.
• Extreme PT/Extremely low Gestational Age
(ELGA): 22 weeks to 27 +6/7
• Very Low Gest Age (VLGA) Very Preterm (VPT):
28 Completed to less than 32 weeks.
• Moderate Preterm: 32 to 33+6/7 weeks
• Late Preterm: 34 to 36+6/7 weeks.

3. Birth Weight BW Categorization.
Category Birth Weight (BW)
500-999 Grams Extremely Low Birth Weight(ELBW)
1000-1499 Grams Very Low Birth Weight (VLBW)
1500-Less Than 2500 Grams Low Birth Weight (LBW)

4. Appropriate birth weight at different
gestational ages
• Gestational age Mean birth weight
• 24 weeks 600 g
• 25 weeks 750 g
• 26 weeks 850 g
• 28 weeks 1000 g
• 30 weeks 1400 g
• 32 weeks 1750 g
• 34 weeks 2000 g
• 36 weeks 2500 g
• 38 weeks 3000 g
• 40 weeks 3500 g

5. Etiology
• Maternal causes
• Uterine causes
• Fetal causes
• Others

6. Maternal causes
• Malnutrition and anemia
• Teenage pregnancy or multi-parity
• Twin pregnancy
• Pre eclmapsia
• Chronic illness (diabetes, renal disease, heart
disease, hypertension)
• Infection (malaria, UTI, chorioamnionitis)
• Lower socioeconomic status
• Smoking or drug abuse
• Illegitimate birth

7. Uterine causes
• Bicornuate uterus
• Incompetent cervix (premature dilation)
• Placenta previa, abruptio placentae, placental
dysfunction

8. Fetal Causes
• Fetal distress
• Multiple gestation
• Chromosomal disorders (down’s syndrome)
• Intrauterine infections (syphilis, TORCH)
• Erythroblastosis, non immune hydrops

9. Other
• Polyhydramnios
• Trauma
• Premature rupture of membranes
• Iatrogenic

10. Problems/complications of
prematurity
• Immediate
• Long term

11. Immediate (Acute)Complications
• 1. Hypothermia
• 2. Hypoglycemia
• 3. Hypocalcemia
• 4. Respiratory difficulties
• 5. Intra-ventricular hemorrhage (IVH)
• 6. Liver immaturity
• 7. Increased susceptibility to infections
• 8. Necrotizing enterocolitis (NEC)
• 9. Patent ductus arteriosus
• 10. Feeding problems
• 11. Anemia of prematurity
• 12. Retinopathy of prematurity
• 13. Metabolic bone diseases of prematurity

12. Hypothermia
• It occurs in preterm babies due to:
• High surface area to body weight ratio
• Little subcutaneous fat
• Muscular inactivity
• Inadequate sweating mechanism
• Decreased brown fat
• Immature heat regulation mechanism

13. Hypoglycemia
• It is common due to lack of glycogen stores
and immature hepatic and autonomic
responses

14. Hypocalcemia
• Early hypocalcemia occurs due to immaturity
of hormonal control system

15. Respiratory problems
• Hyaline membrane disease due to surfactant
deficiency leading to RDS
• Apneic spells: the immaturity of respiratory
centre may lead to periodic breathing and
frequent Apneic spells

16. Intraventricular Hemorrhage IVH
• It is common in preterm infants due to:
• Immature vasculature
• Disturbed cerebral auto-regulation of blood
flow
• Clotting factor deficiency

17. Liver immaturity
• It results in prolonged physiological jaundice
due to immaturity of liver enzymes and there
is increased risk of kernicterus at relatively
lower bilirubin level

18. Susceptibility to Infections
• It results from lack of the protective maternal
immunoglobulins (IgG), which are transferred
across the placenta during the last trimester
• In addition to this, delicate surfaces of skin
and mucous membranes also predispose to
infections
• Insertion of IV cannula, endotracheal tubes,
nasogastric tubes also increase the risk of
infections

19. Necrotizing Entercolitis (NEC)
• There is increased susceptibility to NEC due to
immaturity of gut endothelial surfaces and
enzyme deficiencies
• The risk increases with lack of breast feeding,
umbilical catheterization and septicemia

20. Patent ductus arteriosus (PDA)
• The duct may remain open in premature
babies leading to heart failure

21. Feeding Problems
• These result from uncoordinated sucking and
swallowing and also from gastro-esophageal
reflux leading to frequent aspirations

22. Anemia Due to Prematurity.
• Anemia occurs due to decreased iron stores,
vitamin E deficiency and exaggerated
physiological anemia

23. Retinopathy of Prematurity
• There is abnormal vascularization due to
immaturity and oxygen therapy leading to
partial or complete blindness

24. Chronic Problems
• Chronic lung disease (bronchopulmonary
dysplasia)
• Poor growth
• CNS dysfunctions

25. Chronic lung disease (bronchopulmonary
dysplasia)
• Prolonged ventilation and oxygen toxicity
results in chronic oxygen dependency

26. Poor growth
• Growth is restricted due to feeding problems,
vitamin and iron deficiency

27. CNS Dysfunction
• Cerebral palsy due to intraventricular
hemorrhage
• Post hemorrhagic hydrocephalus
• Learning problems
• Deafness
• Mental subnormality

28. Assessment of gestational age
• Gestational age can be assessed appropriately
in weeks by simple visual assessment of
certain physical signs and more accurately by
using Ballard scoring system

29. Rapid visual assessment of gestational age
Physical signs Assessment Gestational Age
Sole creases Absent 32 wks or less
1-2 anterior sole 36 wks
All over sole 40 wks
Breast nodule Not palpable 34 weeks
3 mm 36 wks
4-10 mm 40 wks
Scalp hair Short fuzzy 37 wks
Coarse, individual 40 wks
Ear cartilage Poorly developed 32-34 weeks
Well developed 36-40 weeks
Testicular descent Undescended 25 weeks
Inguinal 32 wks
Complete descent 40 wks in 90%
Scrotal rugae Anterior 36 wks
Entire Scrotum 40 wks

30. Ballard score
• Physical and neuromuscular criteria of maturity
are given in Expanded New Ballard score (NBS). It
now also includes extremely premature infants
and has been refined to improve accuracy in
more mature infants
• In Ballard score, physical and neurologic scores
are added and by this added score, gestational
age is calculated
• The score is accurate within 2 weeks of gestation
in infants weighing >999 g at birth and is most
accurate at 30-42 hours of age

33. Management
The
Golden Hour Approach

34. What to be done in golden Hour
• Prompt stabilization of the airway and
cardiopulmonary support to establish / maintain vital
signs. ( +temperature in newborn)
• Paying attention to multiple aspects of the patients
condition. (vital signs, saturation, and response to
resuscitation.)
• Attention to injury prevention & progression. ( alveolar
recruitment vS Spine stabilization, O2 toxicity vS shock)
• Rapid initiation of vascular access
• Rapid initiation of therapeutic intervention. (Surfactant
vS Volume resuscitation)

35. • The golden hour strategy is a philosophical
approach that reinforces communication and
collaboration using evidence based protocols
and procedures that standardize as many
elements as possible for delivery and initial
management of a very preterm birth.
Golden hour strategies in Periviable neonates : Myra Wyckoff. Initial resuscitation and stabilization of the
periviable neonate – The Golden hour approach. Semin. Perinatol. Semin Perinatol 2014 Feb;38(1):12-6.

36. Some steps specific to Prematurity
• 1. Delivery room temperature stabilization.
• 2. Delayed cord clamping.
• 3. Delivery room respiratory support.
• 4. Delivery room oxygen use.
• 5. Cautious use of cardiac compressions and
medication.

38. Delivery room care
• Every preterm delivery should be attended by
a pediatrician
• Proper resuscitation at birth, early
stabilization of vital signs, prevention of
hypothermia and hypoglycemia in delivery
room is related with good outcomes with
minimal complications

39. After birth Care
• Maintain thermo-neutral environment
• Maintenance of fluid and electrolyte balance
• Oxygen administration
• Feeding
• Supplementation of iron and vitamins
• Protection from infection
• Early detection and management of
complications of prematurity
• Immaturity of drug metabolism

40. Maintain thermo-neutral environment
• It is environmental temperature at which heat
production and O2 consumption is minimal
yet the core temperature is maintained within
normal range
• Maintain temperature of nursery in range of
25- 30°C
• Place the baby in incubator, keep humidity at
70%

41. Maintenance of fluid and
electrolyte balance
• Preterm babies need more fluids as compared
to full term infants
• Baby should be carefully monitored for
hypoglycemia, hypo or hypernatremia and
hyperkalemia by frequent blood samples and
their correction

42. Oxygen Administration
• O2 administration should be carefully
monitored in a very premature infant because
concentration of O2 more than 40% increases
the risk of lung and visual toxicity
(bronchopulmonary dysplasia and retrolental
fibroplasia)
• Aim is to keep spo2 between 90-95%

43. Feeding
• The method of feeding should be
individualized as it varies with weight and
gestational age of infant
• The process of oral feeding in addition to
sucking requires coordination of swallowing,
epiglottic closure of larynx, normal esophageal
motility, a synchronized process which is
usually absent prior to 34 weeks of gestation

44. Feeding cont’d
• If the infant is more than 35 wk gestation,
weighing 2kg and there is no contraindication of
feeding like persistent vomiting, RDS, sepsis,
seizures etc; he should be started on oral feeding
preferably by breast milk EBM or infant formula
with bottle or cup and spoon
• If baby cannot suck and general condition is
better, tube feeding is preferred
• If very sick or premature, then total or partial
parenteral nutrition is the choice

45. Multivitamin and Iron supplements
• Every preterm infant should receive
supplement vitamins in addition to breast milk
until full mixed feeding is established or
weight is more than 2250 gm
• All preterm babies should receive vitamin K
prophylaxis 1 mg at birth
• Requirement of vitamin A, D, B6 and C is
fulfilled by simply prescribing Mutivitamin
drops per oral

46. Iron supplements
• Iron supplementation should be started at
the age of 4-8 weeks at dose of 2mg/kg/day
• Before this age it is not well absorbed and
also increases the risk of gastrointestinal
infection and also predisposes to vitamin E
deficient hemolysis

47. Infection prevention
• Proper antiseptic measures should be taken
in maintenance of nursery, incubator and
other equipment and in addition proper hand
washing, cleansing of preterm baby, proper
cord care are very important
• All procedures in nursery should be done with
strict aseptic measures

48. Early detection and management of
complications of prematurity
• It can be done by good nursing care,
monitoring of heart rate, respiratory rate,
temperature, blood pressure, activity, daily
weight, FOC, Apnea monitoring and intake and
output record
• Oxygen saturation monitoring is very
important in care of preterm babies

49. Immaturity of drug metabolism
• Due to renal and hepatic immaturity there is
diminished renal and hepatic clearance of
almost all drugs.
• Intervals between doses should be extended
according to gestational age and weight.
• In case of liver injury, renal injury (AKI)
dosages should be adjusted according to GFR.

50. Discharge criteria for premature
babies
• A premature infant should be taking feed by
nipple (either bottle or breast feed)
• Baby should be gaining weight properly (10-30
g/day)
• Temperature should be stabilized in an open cot
• There should be no recent episode of apnea or
bradycardia
• There should be no parenteral drug
administration, it may be converted to oral dosing