pediatrics

1. Complications
of the
Preterm baby

2. Classifications
of Infants
Term (37 - 41 )
Preterm < 37 weeks
Post-term >42 weeks
By weight (SGA, AGA, LGA, IUGR)

3. Preterm Infants
• Prematurity is defined as Birth of a baby at 22
completed weeks to less than 37 weeks of
gestation.
• The lower the GA the Complications increase
• Majority are Late Preterm – Approx. 75%
• Contributory factors
• Heredity
• Placental insufficiency
• Maternal disease processes
• Genetics

4. CLASSIFICATION
• Classifications based upon GA:
Extremely preterm-GA <28 WKS
Very preterm(VPT) –GA 28-32 WKS
Moderate to Late preterm-GA btn 32 -37 WKS
• Classifications based upon BW
• Category
• Birth Weight (BW)
• 500-999 Grams
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)

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

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

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. CLINICAL PRESENTATION

11. • Weak or absent moro reflex, sucking and grasping may be extended due to poor tone

12. Common Preterm
Infant Complications:
• Respiratory Distress Syndrome (RDS)
• Bronchopulmonary Dysplasia (BPD)
• Hypothermia
• Sepsis
• Nutritional problems and Necrotizing Enterocolitis (NEC)
• Anemia of Prematurity
• Apnea of prematurity
• Hyperbilirubinemia
• Developmental delays
• Retinopathy of prematurity (ROP)
• Hemorrhage into ventricles of the brain (IVH)

13. 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

14. NEONATAL PROBLEMS ASSOCIATED WITH
PREMATURE INFANTS
RESPIRATORY
•Respiratory distress syndrome (hyaline membrane disease,)
•Pneumothorax, and baro trauma when providing oxygen
•Congenital pneumonia
•Apnea, immature respiratory centre
CARDIOVASCULAR
Patent ductus arteriosus
hypotension
Bradycardia (with apnea)
Hematologic
Anemia (early or late onset)
Disseminated intravascular coagulopathy
Vitamin K deficiency

15. GASTROINTESTINAL
Poor gastrointestinal function—poor motility
Necrotizing enterocolitis
Hyperbilirubinemia—direct and indirect
METABOLIC -ENDOCRINE
Hypocalcemia
Hypoglycemia
Hyperglycemia
hypothermia

16. LONG TERM COMPLICATIONS
• Recurrent hospitalisations
• Broncho pulmonary displasia
• Retinopathy of prematurity
• Poor growth due to feeding problems, vit& Iron defociency
• CNS dysfunction, CP, Learning difficulty, deafness, hydrocephalus

17. CARE AFTER BIRTH
• The presence of a pediatrician in delivery room is very important
• Initiate breathing (resuscitation may be needed)
• Care for the umbilical cord
• Eye prophylaxis
• Vit K
• Thermal regulation » »36.5- 37.0°c +head cap+KMC
• Monitoring (HR and saturation)
• Oxygenotherapy
• Feeding, 105-130 kcal/kg/day, hypoglycemia below 40mg/dl in 48h and
then below 50
• Discuss with mother on complications of prematurity

18. 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)
• 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.

19. 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.

21. Care Priorities for A Patient
Threatening Preterm Delivery
Corticosteroids
• (betamethasone, 12mg IM)
• 2 doses
• 24 hours apart
• Accelerates surfactant production in the preterm infant
• Decreases the risk of IVH (intraventricular hemorrhage)
• Decreases the risk of NEC(necrotizing enterocolitis)
• Risks to mom:
• Hyperglycemia
• Increased edema
• Pulmonary edema
Magnesium Sulfate
• IVPB infusion given if a patient threatening to deliver
prior to 34 weeks-if preterm delivery is imminent
• Magnesium sulfate has a neuroprotective effect on the
preterm infant
• Magnesium sulfate therapy decreases the preterm
newborn risk for:
• intraventricular hemorrhage (IVH)
• Cerebral palsy (CP
• Decreased incidence of substantial gross motor dysfunction
• Antidote is calcium gluconate
• Maternal Care:
• Vital signs
• DTRs
• I&O

22. Hypothermia
• High risk infants are susceptible to heat loss and its complications
• Low birth weight infants
• Preterm Infants
• Due to limited capacity to increase metabolic rate
• Immaturity of skin Increased transepidermal water loss
• Treatment:
• warm bed
• prewarmed isolette
• plastic bag to dec. heat and water loss
• skin to skin between stable infant
• Nursing Care: Maintain thermoneutral condition
• Signs/symptoms:
• Pale
• mottled
• skin is cool to touch
• Acrocyanosis
• respiratory distress
• Hypoglycemia
• As hypothermia worsens infant can have apnea,
brady and central cyanosis.

23. GI:
Hypoglycemia
• Blood glucose level lower than 40 in the
first 72 hours
• Glucose levels stabilize by 2-3 days of life
• Can lead to neurological injury if persists
• Infants at risk for Hypoglycemia
• SGA
• LGA
• preterm
• low birth weight
• Infant of Diabetic Mothers (IDM)
• Infants who experience perinatal
stress
• asphyxia, cold stress or
respiratory distress
• those with active infection
• Signs/Symptoms:
• Jitteriness
• Lethargy
• Poor feeding
• Abnormal cry
• Hypotonia
• Temperature instability
• Respiratory distress
• Apnea
• Seizures
• Management:
• Early and frequent feeds.
• Monitor blood sugar
levels in at risk infants

24. Hyperbilirubinemia
• Physiologic
• Most common
• After 24 hours of age
• More common in LPI (late preterm) and preterm infants
• Rapid breakdown of RBC
• Immature liver
• Dehydration
• Pathologic
• Before 24 hours of age
• Greater than 14 days of life
• Associated with bilirubin encephalopathy or
kernicterus
• Causes:
• ABO incompatibilities
• Maternal infections
• Maternal diabetes
• Maternal ingestion of sulfonamides, diazepam or
salicylates near term

25. Hyperbilirubinemia- Nursing Care Priorities
Increase PO intake
Phototherapy-position
light at least 10 cm from
infant
Protect eyes Skin care – frequent stools
Make sure no ointments
or creams applied to body
when receiving
phototherapy
Reposition frequently Discharge Teaching Feed frequently
Observe for lethargy
Count number of diapers
(bilirubin is excreted
through urine & stool)
• wet – 6-8/day
• soiled diapers 1/day
Follow up appointments

26. Hemolytic disease of the newborn
• This may occur with term, post-term or preterm infants.
• Blood group of mother and baby are different
• Occurs when maternal antibodies cross the placenta, cause hemolysis of
the fetal RBC’s -> resulting in possible hyperbilirubinemia, jaundice anemia
• If a mother is exposed to an incompatible blood type, form antibodies
against the antigen in that blood.
• 4 Major Blood groups/ Blood types
• A, B, AB, O
• Rh Factor
• Genetically determined factor present on RBC’s
• Rh factor present - positive
• Rh factor not present - negative

27. Hemolytic disease- ABO incompatibility
• ABO Incompatibility
• Most common cause of hemolytic disease
• Of the 20% with ABO incompatibility, only 5% with clinical effects
• Risk factors:
• Occurs with Maternal type O blood & fetal type A, B, or AB
• Mothers immune system may react -> forms antibodies against baby’s RBC
• Diagnosed by: Coombs’ test/ Direct antiglobulin test (DAT)
• If DAT +, obtain cord bili and stat bilirubin level.
• Can cause:
• Mild Anemia
• Hyperbilirubinemia
• Treatment: Phototherapy, fluids, IVIG, occasionally exchange transfusion

28. Hemolytic Disease- RH factor
• Rh Incompatibility
• Occurs when maternal antibodies are present or develop in response to exposure to an antigen (different blood
type)
• Maternal sensitization
• Maternal antibodies cross the placenta
• Causes hemolysis of fetal RBC’s
• Isoimmunization – leading to fetal anemia
• Erythroblastosis Fetalis – immature erythrocytes
• Worst with consecutive pregnancies
• RhoGam (immunoprophylaxis) given for Rh - mothers
• Significant decrease in incidence of Rh incompatibility
• Given at 28 weeks and if any incidence of bleeding

29. Meconium Aspiration Syndrome
• Largely affects post-term infants but can be
seen in Term Infants
• What is Meconium Aspiration Syndrome?
• Meconium is aspirated into the airways
• As a result of gasping respirations in
utero
• Or the initial breaths following birth
• Can lead to mechanical obstruction of
the airways and air trapping
• 8% of all newborns exposed to
meconium develop MAS
• Can also cause chemical pneumonitis or
pneumonia resulting in:
• Tachypnea and deactivation of surfactant
• May lead to Persistent Pulmonary
Hypertension
• Rarely occurs before 38 weeks gestation
• Nursing care and Priorities:
• Minimize work of breathing
• Neutral thermal environment
• Nutrition
• Comfort