Problems of prematurity

1. PROBLEMS OF PREMATURITY
PRESENTED BY
DR NWALA KELECHI RICHARD

2. OUTLINE:
• INTRODUCTION/DEFINITION
• EPIDEMIOLOGY
• CAUSES/RISK FACTORS
• PROBLEMS OF PREMATURITY
• TREATMENT
• CONCLUSION
• REFERENCE

3. INTRODUCTION/DEFINITION
Prematurity is a term for the broad category of
neonates born at less than 37 weeks gestation.
Problems associated with prematurity are the causes of
mortality and morbidity in preterm. Prematurity can be
classifed according to gestational age or birth weight.
Extreme preterm less than 28 weeks gestation, early
preterm 28 to 31 weeks gestation, moderate preterm
32 to 33 weeks gestation and late preterm 34 weeks to
36 weeks and also as Low birth weight of 1.5kg to
2.5kg, very low birth weight of 1kg to 1.5kg and
extreme low birth weight less than 1kg.

5. EPIDEMIOLOGY
Problems of prematurity is the leading cause of
neonatal mortality.
Mortality and morbidity are inversely proportional to
the gestational age and birth weight.
The risk is increased in women with socio-economic
status, Africans, teenagers and women older than 40
years.

6. •2023 statistics done in Special Care Baby Unit FTHL
shows total birth of 243, term pregnancy 142 births,
post term pregnancy 2 births and preterm 99(40.7%)
births.

7. A recent statistics of birth from January to Octobers
shows
•Total admission 199, of which preterm admission
accounted for accounted for 77(38.7%)
•Total mortality 23 of which preterm mortality
accounted for 8.

8. Causes/risk factors
•Maternal causes
•Uterine causes
•Fetal causes
•Others

9. Maternal causes
•Malnutrition and anaemia
•Teenage pregnancy or multi parity
•Twin pregnancy
•pre eclampsia
•Chronic illness(diabetes, renal disease, heart disease,
hypertension)
•Infection
•Lower socioeconomic status
•Smoking or drug abuse

10. Uterine causes
•Bicornuate uterus
•incompetent cervix
•placenta previa
•placenta abruptio
•placental dysfunction

11. Fetal causes
• Fetal distress
• Multiple gestation
• Chromosomal disorder ( down’s syndrome)
• Intrauterine infections (syphilis, TORCH)
• Erythroblastosis, non immune hydros

12. Others
•Polyhydramnios
•Trauma
•Premature rupture of membrane
•Iatrogenic

13. Problems of prematurity
Problems associated with prematurity are numerous.
The smaller the birth weight or gestational age, the
higher the risk of developing immediate or long term
problems.

14. Respiratory problem
•Respiratory distress syndrome; a condition in which
the air sacs cannot stay open due to lack of surfactant
in the lungs
•Apnea of prematurity
•Chronic lung disease; long term respiratory problems
caused by injury to the lung tissue
•Incomplete lung development

15. Cardiovascular
•Patent ductus arteriosus; a heart conditin that causes
blood to divert away from the lungs
•Bradycardia
•Hypotension

16. Blood and metabolic
•Anaemia; may require blood transfusion.
•Jaundice; due to immaturity of liver and
gastrointestinal function function.
•Vitamin K deficiency
•Hypoglycemia
•Hyperglycemia
•Hypothermia

17. Gastrointestinal
•Difficulty feeding; may be unable to coordinate suck
and swallow before 34 weeks gestation.
•Poor digestion
•Necrotizing enterocolitis ; a serious disease of the
intestine common in premature

18. Neurologic
•Intraventricular hemorrhage; bleeding in the brain
•Poor muscle tone
•Seizure; may be due to bleeding in the brain.
•Retinopathy of prematurity

19. Infection
•Premature infants are more susceptible to infection
and may require antibiotics

20. Immediate problems
•Hypothermia
•Hypoglycemia
•Respiratory difficulties
•Intra-ventricular hemorrhage
•Liver immaturity
•Increased susceptibility to infection
•Feeding problems
•Anaemia of prematurity

21. •Necrotizing entercoilitis
•Patent ductus arteriosus
•Retinopathy of prematurity
•Metabolic bone disease of prematurity

22. Long term problem
•Chronic lung disease
•Poor growth
•CNS dysfunction

23. Respiratory difficulties include
1. Respiratory distress syndrome(RDS)
•Surfactant deficiency is the primary cause of RDS.
•Low levels of surfactant cause high surface tension
•High surface tension makes it hard to expand the
alveoli.
•When alveolar pressures are too low to maintain
alveoli expansion there will be failure to attain an
adequate lung inflation and therefore reduce gaseous
excahnge.

24. •With advancing gestational age, increasing amount of
phospholipids are synthesized and stored.
•The amounts produced or released maybe insufficient to
meet postnatal demands because of immaturity.
•Clinical presentation of RDS include ; tachypnea, nasal
flaring, intercostal or sternal recession, grunting and
cyanosis.

26. • Apnoea of prematurity; this refers to a respiratory pause
for 20 seconds or more, or any respiratory pause associated
with bradycardia and cyanosis in a newborn before 37
completed weeks of gestation.Apnoea can be classified into
Central apnoea; refers to complete cessation of airflow and
respiratory efforts with no chest wall movements
• A pause in alveolar ventilation due to a lack of
diaphragmatc activity
• There is no signal breathe being transmited from the CNS
to the respiratory muscles.
• This is due to immaturity of brainstem control of central

27. •The premature infant also manifest an immature response tp
peripheral vagal stimulation.
Obstructive apnoea; refers the absence of a noticeable airflow
but with the continuation of chest wall movements
•A pause in alveolar ventilation due to destruction of airway
within the upper airway, particularly at the level of the pharynx.
•Once collapsed, mucosal adhesive forces tend to prevent the
reopening of the airway during expiration.
•Neck flexion will worsen this form of apnea.
•Excessive secretion in the nasopharynx and hypopharynx may
also cause obstructive apnoea.

28. Mixed apnoea
•A combination of both types of apnea representing as
much as 50% of all episodes.
•Mixed apnoea consists of obstructed respiratory efforts
usually following central pauses.
•Central apnoea is either preceded or followed by airway
obstruction

29. •Transient tachypnea of the newborn ; Is a self-limiting
condition characterized by tachypnoea, mild retractions,
hypoxia and occasional grunting. Usually the child does not
have signs of severe respiratory distress. It is atypically a
disease of term or near term infants or caesarean section
without prior labour. Infant of diabetic mothers and those with
a poor respiratory drive from maternal sedation or analgesia
are also at risk.
• Bronchopulmonary dysplasia; Is a chronic respiratory disease
that most often occurs in low weight or premature infants who
have received supplemental oxyge or have spent long periods
of time on a breathing machine(mechanical ventilation), such
as infants who have acute respiratory distress syndrome.

30. •Anaemia of prematurity
•It is as a result of postnatal suppression of erythropoiesis,
shortened red blood cell survival in the presence of rapid
body growth, and blood loss.
• Iatrogenic (repeated phlebotomy)
• Iron stores, even in preterm neonates, are usually
inadequate until an infant's birthweight has doubled.

31. • Hypothermia; Preterm are prone to rapid heat loss
because of the large surface area to body mass ratio,
decreased subcutaneous fat, immature skin, high body
water content, poorly developed metabolic mechanism
and altered skin blood flow.
• Retinopathy of prematurity ;It is due to abnormal
proliferation of retinal vessels, more severe with
administration of unblended 100% oxygen for prolonged
periods.

32. •. Hypoglycaemia (blood glucose level less than 40mg/dl
(2.2mmol/L)
it is due to Inadequate glycogen store, Impaired glycogenolysis or
immature liver.
• Jaundice ; It occurs as a result of impaired bilirubin metabolism
due to immaturity of the liver.
•Infection; It is due to immature immune system and other factors
like; use of unsterilized equipment, improper handling of baby
with unwashed hand, prolong use of parental tubes like umbilical
venous catheters, cannula which may act as site for infection.

33. • Intraventricular haemorrhage; It can be due to Immaturity
of the germinal matrix of the lateral ventricles, acidosis,
asphyxia, shock ,blood pressure fluctuations are risk factors
•Necrotizing enterocolitis; Prematurity is associated with
immaturity of the gastrointestinal tract, including decreased
integrity of the intestinal mucosal barrier, depressed mucosal
enzymes, suppressed gastrointestinal hormones, suppressed
intestinal host defense system, decreased coordination of
intestinal motility, and differences in blood flow
autoregulation, which is thought to play a significant role in
the pathogenesis of NEC.

34. •Feeding problem ; preterm especially less than
33 weeks gestation age have Uncoordinated
sucking and swallowing process.

35. Treatment
• Respiratory distress syndrome
RDS is due to immature lung leading to insufficient
surfacant.
• To prevent preterm birth maternal cervical cerclage, bed
rest, treatment of infections and administration of
tocolytic medications are done.
• When premature delivery is unavoidable, the
administration of corticosteroids( e.g betamethasone) to
the mother and thus to the stimulates fetal lung

36. production of surfactant; this approach requires
multiple doses for at least 48 hours with GA less than
34 weeks before delivery.
• After birth, RDS may be prevented or its severity
reduced by intratracheal administration of exogenous
surfactant immediately after birth in the delivery or
within few hours of birth. Types of surfactant include
natural surfactant which contain apoprotein SP-B &
SP-C ( curosurf, survanta, infasurf) and synthetic
surfactant which do not contain proteins(exocerf,
ALEC, lucinacatant).
•Oxygen administration

37. • Continuous positive airway pressure(CPAP) is a form of non-
invasive respiratory support and it involves the application of
positive pressure to the airways of the spontaneously
breathing patient throughout the respiratory cycle. CPAP
keeps the alveoli open at the end of expiration and maintain
functional residual capacity at end expiration. It increases
ventilation-perfusion relationships and potentially decreases
oxygen requirements. The earlier CPAP is applied the greater
the chance of avoiding mechanical ventilation.
• Mechanical ventilation should be used to support babies with
respiratory failure and extremely low birth weight babies. All
modes of mechanical can induce lung and should be limited to
the shortest possible duration and using the least tidal

38. CPAP

39. •Apnea of prematurity; Treatment involves physical
cutaneous stimulation, bag and mask ventilation,
administration of oxygen to hypoxic baby. High-flow
nasal cannula therapy and nasal continuous positive
airway pressure of 4 to 6 cm H2O also are effective
and relatively safe methods of treating obstructive or
mixed apneas; they may work by stimulating the
infant. Methylxanthines(caffeine or theophylline) are
mainstay of pharmacologic treament of apnoea.

42. Bronchopulmonary dysplasia
•Treatment is geared towards minimizing damage to the
lungs and providing enough support to allow an affected
infant’s lung heal and grow. Treatment include
•Mechanical ventilation; ventilators are only used when
absolutely necessary and affected infants are taken off as
early as possible. Some infantsmay require supplemental
oxygen after being taking off ventilation. Proper nutritional
management is also necessary to ensure the proper growth
and development of the lungs.

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.
• If the infant is more than 33 weeks gestation, weight greater
than 2kg and there is no contraindication of feeding . Oral

44. feeding preferably by breast milk or infant formula with cup
and spoon.
• If baby is less than 33 weeks or cannot suck tube feeding is
preferred.
Infection
• 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.

45. •Anaemia of prematurity ; treament include
• Iron supplementation (2 mg/kg/24 hr) be started.
• Erythropoeitin can also be used.
• Minimize volume of blood per phlebotomy session
• Transfuse blood in severe cases
• And treat the underlying cause

46. Hypothermia
• Mild Hypothermia ( 36 to 36.4°C)
• • Skin-to-skin contact, in a warm room (at least 25°C).
• • Appropiate clothing
• Moderate Hypothermia ( 32 to 35.9°C)
• • Under a radiant heater
• • In a pre-warmed incubator
• • if the newborn is clinically stable, skin-to-skin contact
with the mother can be used in a warm room (at least
25°C)

48. •Severe Hypothermia (< 32°C)
•• Using a pre-warmed incubator (temperature should be
set at 1 to 1.5°C higher than the body temperature) and
should be adjusted as the newborn’s temperature
increases.
•• Aim to rewarm at rate of 0.5°C per hour
•• If no equipment is available, skin-to-skin contact or a
warm room or cot can be used

49. Jaundice
•Treatment modalities include
•Phototherapy; Is the use of high intensity light energy
to reduce bilirubin levels on the skin surface.
•Pharmacological management; example
phenobartitone, oral agar(cholesteramine),
intravenous immunoglobin.
•Exchange blood transfusion; Done to rapidly lower the
serum bilirubin concentration and or

50. Hypoglycemia
• Hypoglycemia can be treated through early introduction of
breast feeds
• Alternate glucose and breastmilk during 1st few days while
baby adapts to DBF
• For infant who cannot tolerate oral feeding and are
symptomatic or in whom oral feeds do not maintain glucose
level, give 200-400mg/kg i.e. 2-4ml of 10% DW bolus and
maintain at 6-8mg/kg/min For preterm neonates and 4-
6mg/kg/min for full-term neonates.

51. CONCLUSION
A good knowledge of the problems of these preterm
and how to care for them will help to prevent or reduce
the occurrence of such problems and ensure proper
development.

52. Reference
• 1. paediatrics and child health in the tropical region Azubuike &
Nkanginieme. 3rd edition.
• Nelson essentials of paediatrics 7th edition
• SCUB statistics 2023 by DR Abubakar
• SCUB statistics January to October by Dr Ojo
• The guide paediatrics