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An early start to life …..An early start to life …..The Preterm BabyThe Preterm Baby

Dr Faeza Soobadar

Paediatrician/Neonatologist

SSRNH NICU

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Definitions (1)Definitions (1)

Term 37 41+6 wks Term 37-41+6 wks Post-Term 42 wks Preterm <37 wks Moderately PT 32-36+6 wks Severely/Very PT 28 31+6 wks Severely/Very PT 28-31 6 wks Extremely PT <28 wks

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Definitions (2)Definitions (2)

Low Birth Weight <2 5kg Low Birth Weight <2.5kg(LBW)

Very Low Birth Weight <1.5kg(VLBW)

Extremely Low Birth Weight <1kg Extremely Low Birth Weight <1kg(ELBW)

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Aetiology 1 Aetiology 1 -- (Maternal)(Maternal)

Idiopathic Low socio-economic statusLow socio economic status Malnutrition Age <16 or >35 Smoking & drug abuse Stress Malformations of uterus & cervix Malformations of uterus & cervix Previous preterm delivery or late

miscarriage

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Aetiology 2 Aetiology 2 -- (Maternal)(Maternal)

Maternal illnessesUTI & asymptomatic bacteriuriaUTI & asymptomatic bacteriuriaBacterial vaginosisAnaemiaDiabetesHypertension or PETHypertension or PET

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Aetiology 3 Aetiology 3 -- (Fetal)(Fetal)

Multiple gestation Multiple gestation Congenital malformation Fetal distress Polyhydramnios

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Aetiology 4 Aetiology 4 -- (Iatrogenic)(Iatrogenic)

Fetal distress IUGR IUGR Uncontrolled PIH/ Eclampsia APH Diabetes Maternal cardiac disease Chorioamnionitis Incorrect estimate of gestational age

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Prevention & Obstetric Prevention & Obstetric managementmanagement Health promotion programmes Antenatal care PIH diabetes Antenatal care – PIH, diabetes Cervical cerclage Detection & treatment of infection Tocolytics Optimising outcome for baby: Optimising outcome for baby:Steroids; IUT.

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PROBLEMS OF PROBLEMS OF PREMATURITY & PREMATURITY & POSTPOST--NATAL NATAL MANAGEMENTMANAGEMENTMANAGEMENTMANAGEMENT

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ResuscitationResuscitation

Difficulty in extra- Delivery in level 3 Difficulty in extra-uterine adaptation.

Delivery in level 3 NICU.

Appropriate planning & immediate availability of qualified personnel & equipment.

Prompt resuscitation & Prompt resuscitation & stabilization.

PNT

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Temperature regulationTemperature regulation

Inability to shiver Large SA Decreased

subcutaneous fatR d d b f

Servo-controlled incubator

Humidity Easy access to infant

H d f f Reduced brown fat stores

Humidification of ventilator gases

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1 3

Respiratory (1)Respiratory (1)

Pulse oxymetry, Cardio-

RDS Apnoea of

prematurity

Pulse oxymetry, Cardioresp monitoring & ABG.

Oxygen

Respiratory support –mechanical ventilation, NCPAP.

S f h Surfactant therapy

Respiratory stimulant

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1 5

1 6

1 7

1 8

1 9

2 0

2 1

2 2

2 3

Respiratory (2)Respiratory (2)

Pneumothorax Thoracocentesis

Pulmonary haemorrhage

↑Ventilation Blood transfusion FFP/Vitamin K

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CardiovascularCardiovascular

Hypotension BP monitoring Hypotension

PDA

BP monitoring Volume expansion Inotropic support

Cardiac echo Diuretics Indomethacin Ibuprofen

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2 6

Renal/MetabolicRenal/Metabolic

Regular U’s&E’s Electrolyte

disturbances Hypocalcaemia Hypo/hyper-glycaemia

Regular U s&E s Urine output Dextrostix Careful fluid

management & administrationadministration

Insulin infusion

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2 8

GIT/NutritionGIT/Nutrition

Feed intolerance Gavage feeding TPN

High requirements

TPN

EBM+Fortifier Pre-term formulas

Gastric NEC

Gastric decompression, NBM, iv antibiotics, surgical opinion.

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3 0

NeurologicalNeurological

IVH Vitamin E Ethamsylate IVH Vitamin E, Ethamsylate Good ventilation

management & control of BP

Regular cranial USS

3 1

3 2

3 3

OthersOthers

Haematological – Multiple blood Haematological –anaemia/ thrombocytopenia

Immunological –infection

Multiple blood transfusions

Multiple courses of antibiotics; antifungalinfection

Psychological

antibiotics; antifungal.

Parental support NIDCAP

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3 5

Criteria for home discharge Criteria for home discharge

Clinically stable Clinically stable Stable temperature Good weight gain Mother’s ability to care for baby Social circumstances Social circumstances

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LONG TERM PROBLEMS LONG TERM PROBLEMS & FOLLOW& FOLLOW--UP UP

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RespiratoryRespiratory

CLD Dexamethasone CLD Recurrent respiratory

infections

Dexamethasone

Nebulized/Inhaled therapy

Chest physio

Long term oxygen & prolonged hosp stay

Recurrent re-admissions

Immunization

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Nutrition & Growth Nutrition & Growth

Poor growth Growth charts High-calorie formula

Anaemia

High calorie formula & vits

Hb monitoring Iron supplementation

Rickets of prematurity Phosphate supp

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NeurologicalNeurological

PVL & Cerebral palsy PreventionPVL & Cerebral palsy

Convulsions

Hydrocephalus

Prevention

Neuro-developmental follow-up

PT & OT

Anticonvulsants

Neurosurgical opiniony p

ROP

Hearing impairment

Ophthalmology r/v

Hearing assessment

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4 2

PsychoPsycho--socialsocial

Learning difficulties Developmental Learning difficulties

Behavioural problems Family/social impact

Developmental psychologist

Special educational programme

PsychotherapyParent support groups Family/social impact Parent support groups

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STATISTICSSTATISTICS

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Incidence of prematurityIncidence of prematurity

SSRNHSSRNH

2003 5.5%

2004 9.2%

2005 5.5%

2006 4.4%

Other countries

USA (2006) 12.7%

UK (2007) 8.6%

France 7%

2007 7.5%

2008 9.0%Australia (2002) 7%

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Admissions to NICU2002 2003 2004 2005 2006 2007 2008

Admissions 226 235 225 200 208 201 163

Mortality % 21 17 27 27 27 24 28

Preterm % 72 71 72 67 57 62 61

Moderately PT(survival)

58%(92%)

51%(91%)

53%(84%)

44%(80%)

37%(89%)

49%(79%)

42%(79%)

Severe PT(survival)

30%(63%)

42%(79%)

34%(65%)

46%(79%)

49%(55%)

36%(71%)

33%(64%)

Extreme PT(survival)

12%(26%)

7%(55%)

12%(45%)

10%(8%)

14%(44%)

14%(50%)

24%(71%)

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20

25

19.4

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21.919.4

12 4

15.414.6

NMR & IMR – SSRNH & MRU

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10

15

6.28.5

11.8

14.8

910.98.8

10.2

14.212.4

NMR SSRN

NMR MRU

IMR SSRN

IMR MRU

NMR SSRN

NMR MRU

IMR SSRN

IMR MRU

0

5

19982003

20072008

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150

200184.4

NMR & IMR WORLDWIDE

2004

0

50

100

1 1 2 3 3 4 10 18 17

542.3 3.2 3.4 4.6 5 6.4 15.4 22.1

59.4 NMR 2004

IMR 2007

NMR 2004

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Survival of a 16Survival of a 16--oz. baby (450g)oz. baby (450g)DOB 30.01.1949; GA 26 wksDOB 30.01.1949; GA 26 wks

Case report; Dr H Fakim; RMO; Civil Hospital; MauritiusHospital; Mauritius

BMJ 19.08.1950 31 y old mother At birth the infant was

very feeble & did not cry…nikethamide….

Wrapped up in cotton ool cot lined ithwool …cot lined with

blankets & kept warm with hot water bottle

Fed on glucose water ..EBM…condensed milk

3.06kg at 5½m

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Acknowledgements

My grateful thanks to:

•Dr A G Mohamedbhai, Consultant Paediatrician, for laboriously over the years compiling the statistics for SSRN Hospitalover the years, compiling the statistics for SSRN Hospital.

•Dr Oochita Jhummun, NICU RMO, for computerizing the data.

•All the children for performing in front of the camera.

•All b t t i i f k i t ll th ti•All obstetricians for keeping us on our toes all the time.

•And of course to all Paediatricians & NICU nursing staff & RMO’s, past & present, without whose dedication the NICU would not exist & these children would not be alive today.