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- 1. CARE OF PRETERM BABIES KARTHIKA PEDUPDATE COURSE
- 2. PRETERM BABIES •A babyborn before 37 completed weeks of gestation irrespective of birth weight.
- 3. Categories of preterm •Late preterm-34 to 36 weeks • Moderately preterm-32 to 34 weeks • Very preterm-before 32 weeks • Extremely preterm-before 28 weeks
- 4. ETIOLOGY • Maternal factors •socio economic factors • Pregnancy related factors • Medical conditions • Anatomic issues • Infections
- 5. CHARACTERISTICS OF PRETERMS •Small and scrawny • Proportionally large head to body • Translucent skin • Visible blood vessels
- 6. CHARACTERISTICS OF PRETERMS •Fine lanugo hair • Soft pliable ear cartilage • Soft bones • Closed eyes
- 7. • Few scrotalrugae and undecended testis • Prominent labia and clitoris • Inactive • Extended extremities • Partially developed reflux activities
- 8. • Absent ,weakor ineffective sucking • Inability to maintain body temperature • Limited ability to excrete solutes in urine • Increased susceptibility to infection • Pliable thorax immature lung tissue
- 9. CHARACTERISTICS OF PRETERMS •Moresusceptible to hypoglycemia and hyper bilirubinemia
- 10. PHYSIOLOGIC HANDICAPS • Poorcontrol of body temperature • Respiratory difficulty • Susceptibility to infection • Difficulties with nutrition • Immaturity in renal function
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- 20. HEEL TO EARMANEUVER
- 21. complications OF PRETERMS •Hypothermia • Breathing difficulty • Apnea • RDS • Intra ventricular hemorrhage • Feeding difficulties • Hypoglycemia
- 22. • Metabolic acidosis •Hyperbilirubinemia • ROP • Fluid and electrolyte imbalances • Necrotizing enterocolitis • Anemia • BPD • Infections • Patent ductus
- 23. LONG TERM PROBLEMS •Intellectual disabilities • Cerebral palsy • Vision and hearing loss
- 24. NEW RECOMMENDATIONS ONTHE CARE OF THE PRETERM INFANT BY WHO 2022 • KMC • EARLY INITIATION OF BREAST FEEDING • USE OF CONTINYOUS POSITIVE AIRWAY PRESSURE • CAFFEINE
- 25. • Fluids andfeeds • Monitoring and early detection of complications • Appropriate management
- 26. CARE AT BIRTH •Support breathing by different modes available. • Prophylactic administration of exogenous surfactant.
- 27. MAINTAINING BREATHING • ET/ventilator •NIV • CPAP • 02 supplementation by hood/free flow
- 28. PREVENTION OF HYPOTHERMIA •Mummification • Kmc • Nesting • Delay bath • Warmer/INCUBATORS
- 29. NUTRITION- FLUID ANDFEEDs • <30 WEEKS– IV FLUIDS, NG • 30—34WEEKS - NG ,KATORI, BREAST FEEDS • >34 WEEKS -KATORI, BREAST FEEDS
- 30. NUTRITION • PROTEIN • 10%of daily calories should be derived from proteins. • Recommended allowance for LBW neonates is 3-4 gms/kg/day Carbohydrates • Should provide 40% energy. • Recommended allowance is 10-15 gms/kg/day. Fats • Should provide 50% of total energy. • Recommended allowance is 5.4- 7.2 gms/kg/day
- 31. Electrolytes and vitamins •Sodium- Recommendations are 2.5 to 3.5 meq/ kg/ day each. • Mature Human milk contains 1.1 meq/100 kcal of sodium and premature milk contains 1.9 meq /100 kcal which is often insufficient for VLBW infants. • Vitamin A- An intake of 1500 IU/kg/day is recommended for preterms. • It may promote epithelial repair and minimize fibrosis in preterm babies with CLD. • Vitamin D- Vit. D at 400 IU/day maintains adequate Vit D status and prevents Rickets • Vitamin K- Vit K is required for hepatic synthesis of coagulation factors II, VII, IX, & X. Administration at birth of 0.5 to 1.0 mg.
- 32. CHOICE OF MILK •EBM • Donor human milk • Formula feeds
- 34. FEEDING GUIDELINES • Ng/ogt •Frequency • Positioning
- 35. SUPPLEMENTS • VITAMIN D •Ca and Ph • ZINC • IRON
- 36. PREVENTION FOR COMPLICATIONS • Infectionprevention Protocol • Immunisation • 5 cleans
- 37. 5 CLEANS • CLEANHAND • CLEAN CORD • CLEAN CORD CLAMP • CLEAN SURFACE • CLEAN PROCEDURES
- 38. USE OF DRUGS •Corticosteroids • Synthetic surfactant • Vit k • Antibiotics
- 39. Monitoring • Vital signs •Activity and behavior • Color; Pink, pale, grey, blue, yellow. • Tissue perfusion • Fluids, electrolytes and ABG
- 40. MONITORING • Tolerance offeeds; Vomiting, gastric residuals, abdominal girth. • Look for development of RDS, Apneic attacks, sepsis, PDA, NEC, IVH • Weight gain
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- 43. TAKE HOME MSGTO PARENTS • FEEDING PRACTISES • HAND HYGEINE • KMC • INFECTION CTRL • IMMUNISATION • DANGER SIGNS
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- 45. Developmentally supportive care Definition: Developmentally supportive care is defined as care of an infant to support positive growth and development, while allowing stabilization of physiologic and behavioral functioning (National Association of Neonatal Nurses, 2000)
- 46. The virtues ofthe Womb
- 47. The virtues ofthe Womb • Cushioned and comfortable aquatic abode • Thermal comfort • Zero insensible water losses • Shielded from light • Protected form sound • Effective and safe ECMO-like oxygenation • Optimal excretion of waste products • Isolation and asepsis • Parenteral nutrition ( Singh M, 2003 )
- 48. Dev Supp Care- Principles • NICU design and environment • Nursing care routines & plans • Use of positioning aids • Use of self regulation aids • Feeding methods • Management of pain • Parental participation & support • Neonatologist’ attitude
- 49. NICU Environment Infant states 1.Quiet sleep - regular breathing, no REM, no spontaneous movements. 2. Light sleep - irregular breathing, REM, spontaneous movements. 3. Transition / drowsy - variable activity, dull look 4. Awake - alert - minimal activity, bright look. 5. Awake - hyperactive - very reactive, fussy, increased motor activity. 6. Crying
- 50. NICU Environment Signs ofneonatal stability Autonomic : Stable colour, stable heart & RR, feeding tolerance. Motor : Flexed or relaxed posture, hand to mouth / sucking State : Clear sleep state, interaction (Gupta G, 2001)
- 51. NICU Environment Signs ofneonatal stress Autonomic : Color changes, alterations in HR & RR, alterations in SaO2, Hiccoughs Motor : Hypotonic, increased movements, open mouth State : Hyperalert, fussing, diffuse sleep states (Gupta G, 2001)
- 52. NICU Environment –Sound Adverse effects of loud sound (>60 db) Interferes with sleep • Increase in Heart Rate • Peripheral vasoconstriction • Sudden loud noise may TcPo2, ICP, ? IVH • Hearing loss ( Lefrak L, 2001)
- 53. NICU Environment -Sound • In-utero, 40-60 db • Usual noise levels in NICU, 50-80 db • Levels > 90 db for long times, hearing loss • In PT on aminoglycosides, at lower db levels
- 54. NICU Environment –Sound Sources of Noise • Inside incubater, 55-88 db (Peak 117) • Additional 10-40 db with surrounding equipments • Routine care activities, 58-76 db. • Loud, sharp sound - 100-200 db. • 4994 peak noises - 90% due to human related factors (Chang et al, 2001)
- 55. NICU Environment –Sound Interventions to reduce noise •Decrease noise in NICU •Decrease monitor noise •Respond quickly to alarms •Rounds & reports away from bedside •Speak softly •Decrease telephone & intercom noise ( Ctd--)
- 56. NICU Environment –Sound Interventions to reduce noise ( Ctd--) •Move equipments quietly, repair noisy ones •Decrease staff generated noises •Prepare medications & feedings away from bedside •Gently open doors and drawers •Follow the sound limit recommendations
- 57. NICU Environment -Sound • Monitor decibel readings & keep level < 45 db (AAP, 1997)
- 58. NICU Environment –Sound Helpful Effects •Sound of mother’ voice (calming effect) •Music may be beneficial •Lullabies, womb sound, heart beat music. - Better weight gain - Decreased hospital stay, - Better behavioral organization (Chapman JS,1998)
- 59. NICU Environment –Light Present scenario •Fetal life - near darkness (ND) •NICU- Usually very bright light •Continuous light exposure •Usual range - 50-150 foot candles •Procedure & PT lights - 200-400 foot candle
- 60. NICU Environment –Light Light effects: •Effect on central visual system •“Shutting out” behavior • Quiet sleep & physiological instability •Effect on circadian rhythms •Effect on G & D •? risk of ROP ( Slevin M, 2000 )
- 61. NICU Environment –Light Light Reduction Safe level not established • Shade head of crib / incubator • when required , use spot light / procedure light •Eye covers must with PT • use available natural light
- 62. NICU Environment –Light Light Reduction Cycled lighting better than near Darkness - More time in sleep state - weight gain - Motor activity levels - Heart rate (Brandon HD et al, 2002).
- 63. NICU Environment -Light Monitor NICU Light with Luxmeter
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- 65. NICU Environment -Positioning •Effect on respiratory physiology • Body alignment important • Prevent postural deformities • Promote self-soothing activities • Decided by GA, degree of illness, paralytic agents.
- 66. NICU Environment –Positioning Guidelines Preferred,Prone / side lying • Swaddle / cover to keep in flexed position • Attempt to “nest” the infant • Promote midline alignment • Head support • Avoid : - Hyperextension of neck - Frequent head turning to side - Lower extremity frogging - Bigger diaper
- 67. NICU Environment -Handling • Physiologic and behavioral stress • Pace the care according to baby • Time the care around sleep / wake cycles • No routine procedure • Provide 2-3 hrs of uninterrupted sleep • Watch for S/o stress
- 68. NICU Environment - “MinimalHandling” or “Quiet hour” Protocol • Reduce noise • Reduce lights • Allow minimum two hours of rest • Cluster the caregiving procedure • Sensitize the nursing staff
- 69. NICU Interventions -Stimulation • Should begin in the womb. • Fetuses known to respond to mother’s heart beats and voice. • Indian mythology - Abhimanyu learnt to enter Chakaryuh in his mother’s womb. • Any stimulation through special senses during fetal / neonatal life beneficial (Singh M, 2003)
- 70. NICU Interventions Supplemental stimulation •Kangaroo Mother Care ( KMC ) • Non-nutritive sucking ( NNS ) • Massage therapy • Multimodal stimulation • Breast feeding • Pain management • NIDCAP • Wee care
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- 72. NICU Interventions Kangaroo MotherCare • Skin to skin contact • Practiced in many cultures Components : • Kangaroo positioning • Kangaroo feeding • Kangaroo discharge Forms : • Hospitals with no / poor facilities • Insufficient technical & human resources • In tertiary level NICUs (Kirsten G.F., PCNA, 2001)
- 73. NICU Interventions Kangaroo MotherCare Likely Benefits : Successful breast feeding •Better physiologic stability •Increased maternal confidence & bonding •Reduced infection rates •Cost savings (Kirsten G.F., PCNA, 2001)
- 74. NICU Interventions Non-nutritive Sucking •Different from nutritive sucking • On empty breast / pacifier • Provides comfort • Promotes physiological organization • Pain-reducing effect • Promotes suck- swallow co-ordination • Facilitates transition to breast feeding • Better weight gain & shorter hospital stay. (Field TM, 2003)
- 75. NICU Interventions Massage Therapy •Tactile/ Kinesthetic stimulation •Tactile stimulation only, may be aversive. •Massage therapy with moderate pressure may be useful. •Stimulation of tactile and pressure receptors important. •Hypothetical mechanisms of benefit - Touch - Growth gene interaction - Increased vagal tone - Increased insulin levels - Increased growth hormone secretion (Field TM, 2003)
- 76. NICU Interventions Massage Therapy Proposedbenefits : Better weight gain • More time in active, alert state • More quiet sleep • Better motor maturity scores • ? Better long-term outcome (Mathai S. et al, 2001)
- 77. NICU Interventions Massage Therapy UnresolvedIssues : •Collapse / disorganization due to over- stimulation •Response of full term Vs preterm infants •Response of SGA Vs AGA babies •Maternal Vs nurse’ touch (Feldman R et al, 1998)
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- 79. NICU Interventions Breast Feeding •Humanized and natural • Species specific & baby specific • Minimal enteral feeds (Trophic feeds) • Multiple benefits of MEN • Early contact and bonding Support and encourage breast feeding
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- 81. NICU Interventions- NIDCAP •Neonatalindividualized developmental and assessment program (NIDCAP) •Developed by Als et al •Four standards of care - Structuring the environment - Timing, organizing & giving direct care - Working collaboratively - Supporting & strengthening family relationships. •Individualized plan for each baby •Meta-analysis : Significant decrease in O2 requirement : Improved outcome at 12 mths. (Jacobs SE et al, J Ped, 2002).
- 82. NICU Interventions - MultimodalStimulation • ATVV - Auditory, tactile, visual & vestibular • Soft & soothing music • Gentle touch • Use of pictures (human face), bright toys • Olfactory stimulation, use of “breast milk” (avoid cologne / spray). • Better weight gain and early discharge (Standly JM, 1998)
- 83. NICU Interventions - MultimodalStimulation Mother’ voice & human face
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- 85. NICU Interventions Pain Management NeonatalPain - Misconceptions • Newborns lack anatomical & physiological structures to transmit pain sensation. • Can not express pain sensation • Have no memory of pain • Would not tolerate analgesia / anesthesia
- 86. NICU Interventions Pain Management NeonatalPain - Facts : Nociceptive mechanisms well developed even in preterm. • Pain expression and assessment possible • Various consequences of pain & stress • Various nonpharmacologic & pharmacologic strategies useful for treatment
- 87. NICU Interventions Pain Management Non-pharmacologicInterventions • Positioning & containment • Swaddling • Non-nutritive sucking / pacifiers • Skin to skin contact • Rocking • Music • Breast milk • Oral glucose / sucrose
- 88. NICU Interventions Pain Management Pharmacologicinterventions • Local anaesthetics (EMLA) • Regional anaesthesia • Systemic analgesia (Gilbert R, 2001)
- 89. NICU Interventions - FamilyInvolvement • NICU - a barrier • Provision of privacy (for bonding) • Social interaction & support • Parental education & counselling • Involvement of mother in care • Mother - based NICU, need of hour (Cisler - Cahill et al 2002)
- 90. NICU Interventions -future issues Co-bedding for twins (Dellaporta K, 1998)
- 91. NICU Interventions -future issues Parent focussed care (COPE) (Melnyk BM , 2001)
- 92. NICU Interventions -future issues Spiritual & cultural care (Catlin EA, 2001)
- 93. NICU Interventions -future issues Effect of NICU Env on Health-worker
- 94. NICU Interventions -future issues Quality Assessment & Improvement
- 95. NICU Interventions -future issues Early Disharge from NICU