Care of Preterm Babies Final

7/23/2019 Care of Preterm Babies Final

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CARE OF PRETERM BABIES

INTRODUCTION

Prematurity accounts for the largest number of admissions to an NICU. About 10-12 percent

of Indian babies are born preterm less than !" completed #ee$s% as compared to & to "

percent incidence in the 'est. (hese infants are anatomically and functionally immature and

therefore their neonatal mortality is high.

DEFINITION

Preterm infants also called premature infants% are those born before the beginning of

!)th#ee$ of gestation.

*oderately preterm infants are those born bet#een !2 and !+ completed #ee$s of gestation.

,ate preterm infants fall in the moderately preterm group.

ery preterm infants are those born before !2 completed #ee$s of gestation.

A gestational age assessment of a preterm infants si/e and deelopment may sho# that the

infant is small appropriate or large for the amount of time spent in the uterus. *ost preterminfants are appropriate for their gestational age.

In practice and from statistical point of ie# it refers to a ne#born #hose birth #eight is less

than 2&00g. uch a baby measures 3+ cm or less in length and has head circumference of !2

cm or less. (he chest circumference is usually less than !0 cm.

INCIDENCE

About 10 to 12 percent of Indian babies are born preterm less than !" completed #ee$s% as

compared to & to " percent incidence in the #est. (hese infants are anatomically and

functionally immature and therefore their neonatal mortality is high.

Causes of prematurity:

(he mechanism initiating normal labor is not clearly understood and much less is

$no#n about the triggers that initiate labor before term. (here may be spontaneous onset of


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premature labor or it may be induced by the obstetrician to safe guard the interests of the

mother or baby.

pontaneous4 the cause of premature onset of labor is uncertain in most instances. (he $no#n

causes include4

Poor socio-economic status,o# maternal #eightChronic and acute systemic maternal illnessAntepartum hemorrhageCerical incompetence*aternal genital coloni/ation and infectionsCigarette smo$ing during pregnancy(hreatened abortion

Acute emotional stressPhysical e5ertione5ual actiity(rauma6icornuate uterus*ultiple pregnancyCongenital malformations

Premature births are relatiely common among ery young and unmarried mothers. Past

history of preterm birth is associated #ith ! to 3 times increased ris$ of prematurity in the

subse7uent pregnancies.

Induced4 the labor is often induced before term #hen there is impending danger to mother

or fetal life in-utero e.g. maternal diabetes mellitus placental dysfunction as indicated by

unsatisfactory fetal gro#th eclampsia fetal hypo5ia antepartum hemorrhage and seere

rhesus iso-immuni/ation.

Clinial features:

*easurements4 their si/e is small #ith relatiely large head. Cro#n-heel length is

less than 3"cm head circumference is less than !!cm but e5ceeds the chest

circumference by more than !cm.

Actiity and posture4 the general actiity is poor and their automatic refle5 responses

such as moro response suc$ing and s#allo#ing are sluggish or incomplete. (he

baby assumes an e5tended posture due to poor tone.

8ace and head4 face appears small for the disproportionately large head si/e sutures

are #idely separated and the fontanels are large. 9ther characteristic features include

small chin protruding eyes due to shallo# orbits and absent buccal pad of fat. 9pic


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nere is often unmyelinated but presence of papillary membrane ma$es theits

isuali/ation difficult. :ar cartilage is deficient or absent #ith poor recoil. ;air

appears #oolly and fu//y and indiidual hair fibers can be seen separately.

$in and subcutaneous tissues4 s$in is thin gelatinous shiny and e5cessiely pin$

#ith abundant lanugo and ery little erni5caseosa. :dema may be present.

ubcutaneous fat is deficient and breast nodule is small or absent. ora are #idely separated e5posing labia minora and hypertrophied

clitoris.

P!ysiolo"ial !an#iaps:(he functional immaturity of arious systems result is

different clinical problems and their $no#ledge is essential for the satisfactory management

of these babies.

Central nervous system:the immaturity of central nerous system is e5pressed as inactiity

and lethargy poor cough refle5 and in co-ordinated suc$ing and s#allo#ing in babies

#eighing less than 1)00 g or born before !& #ee$s of gestation.

?esuscitation difficulties at birth and recurrent apneic attac$s are common.

?etinopathy of prematurity due to o5ygen to5icity is limited to babies #ith a gestation

of less than !& #ee$s.

(hey are e5tremely ulnerable for intra-entricular @ perientricular hemorrhage and

leucomalacia due to relatie deficiency of it- dependent coagulation factors and

increased capillary fragility.

(he blood brain barrier #hich is possibly a function of aailable serum proteins is

inefficient in preterm babies thus brain damage may occur at lo#er serum bilirubin

leels.

Respiratory system:

(he cuboidal aleolar lining in babies #ith a gestational age of less than 2+ #ee$s

results in poor aleolar diffusion of gases and therefore the infant may not be iable.

(hey pose resuscitation difficulties at birth often follo#ed by hyaline membrane

disease if associated #ith deficiency of pulmonary surfactant.

(he breathing is mostly diaphragmatic periodic and associated #ith intercostal

recessions due to soft ribs. Pulmonary aspiration and atelectasis are common.


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(hey are ulnerable to deelop chronic pulmonary insufficiency due to broncho-

pulmonary dysplasia.

Cardio-vascular system:

(he closure of ductusarteriosus is delayed among preterm babies.

9ne third of infants hae features of P


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Infections are the important cause of neonatal mortality in lo# birth #eight babies.

(he lo# leels of Ig= antibodies and inefficient cellular immunity predispose them to

infections.

:5cessie handling humid and #arm atmosphere contaminated incubators and

resuscitators e5pose them to infecting organisms thus contributing to high incidence

of infections.

Renal immaturity:

(he blood urea nitrogen is high due to lo# glomerular filtrate rate.

(he renal tubular ammonia mechanism is poorly deeloped thus acidosis occurs early.

(hey ulnerable to deelop late metabolic acidosis especially #hen fed #ith a high

protein mil$ formula.

Concentration of urine is poor.

Preterm has to pass 3 to & ml of urine e5crete one milliosmole of solute as compared

to 0." ml by an adult for the same purpose.

6aby gets dehydrated.

(he solute retention and lo# serum proteins e5plain occurrence of edema in preterm

infants.

Toxicity of drugs:

Poor hepatic deto5ification and reduced renal clearance ma$e a preterm baby

ulnerable to to5ic effects of drugs unless caution is e5ercise during their

administration.

Nutritional handicaps:

,o# birth #eight babies are prone to deelop anemia around + to ) #ee$s of age this

is due to diminished total stores of iron due to short gestation.

(hey may also manifest deficiencies of folic acid and itamin : especially among

those fed #ith on iron fortified mil$ formula.

(hese infants are more prone to deelop haemolytic anemia thrombocytopenia and

edema + to 10 #ee$s of age.

itamin : deficiency along #ith o5ygen to5icity to the ulnerable tissues in the form

of retro-lental fibroplasia and broncho-pulmonary dysplasia.

?apid gro#th follo#ing ade7uate feeding may result in osteopenia and ric$ets unless

calcium phosphorus and itamin < are administered.

Biochemical disturbances:


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(hese babies are prone to deelop hypoglycaemia hypocalcemia hypoprotenemia

acidosis and hypo5ia.

Mana"ement

;igh ris$ mothers should be identify early during the course of pregnancy and referred for

confinement to an appropriate health care facility #hich is e7uipped #ith good 7uality

obstetrical and neonatal care facilities. *other is indeed an ideal transport incubator.

rrest of premature labor:

Adances in perinatal care including fabrication of a ariety of electronic gadgets

cannot compare #ith uni7ue security and optimal care proided to the fetus by theutero-placental unit.

:fforts should al#ays be made to arrest the progress of premature labour.

(he onset of true labor is suspected by occurrence of t#o or more uterine contractions

lasting atleast !0 seconds during a 1&-minute period in association #ith dilatation and

effacement of ceri5.

Apart from bed rest and sedation a ariety of tocolytic agents are recommended but

none is entirely safe or effectie.

*agnesium sulphate is more effectie and is being increasingly used though there is

potential ris$ of respiratory depression in the ne#born.

(he obserational studies hae sho#n that maternal treatment #ith reduced ris$ of

I; cerebral palsy and mental retardation in their preterm babies.

ympathomimetic agents specifically mediating ia beta-2-adrenergic receptors are

po#erful tocolytic agents and currently used.

Iso5suprine duadilan% is useful but its effect is mediated through beta-1 and beta-2

receptors.

(herapy is initiated by intra-enous infusion of 20mg iso5suprine diluted in 200

ml of & percent de5trose at a rate of 30-&0dropsBminute.

(his is follo#ed by I* administration of 10mg iso5suprine eery 3 hours for 23

and 3) hours. 9ral therapy is continued for atleast 2 #ee$s #ith maintenance dose

of 10mg eery + hours.

?itodrine has been approed by U food and drug administration for treatment of

premature labour. (he usual dose is 100-300gB minute intraenously through an

infusion pump for a period of 12 hours follo#ed by oral ritodrine 10mg eery 2 hours.


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albutamol and terbutaline are selectie beta-2 receptor stimulators and are ery

effectie tocolytic agents. (hey are generally safe but occasionally patient may

deelop tachycardia and pulmonary oedema.

(erbutaline is administered as an I bolus of 0.2&mg follo#ed by constant infusion of

10-)0 gBminute for 1-2 hours. After control of uterine contractions maintenance

therapy is continued by administration of 0.2&mg C eery 3 hours.

Indomethacin has also offered some hope in arresting premature uterine contractions.

Induction of premature labour:

'hen indication of labour is contemplated before term either in the interest of mother

or the fetus maturity of fetus should be ascertained by e5amination of amniotic fluid for

phosphatidyl glycerol or ,B ratio. As far as possible deliery should be postponed till

maturity is assured. 'hen deliery can be safely delayed for !+ to 3) hours corticosteroids

should be administered to the mother to enhance fetal lung maturity.

ntenatal corticosteroids:

Antenatal administration of corticosteroids is one of the most cost-effectie perinatal

strategies #hich must be uniersally e5ploited. It is associated #ith reduction in the incidence

of ?.betamethasone 12mg I* eery 23 hours for 2 doses or de5amethasone +mg I*

eery 12 hours for 3 doses should be administered to the other if labour starts or is

induced before !3 #ee$s of gestation.

(he optimal effect is seen if deliery occurs after 23 hours of the initiation of therapy

and its therapeutic effect lasts for " days.

CARE OF PRETERM BABIES

Optimal mana"ement at $irt!:

'hen a preterm is anticipated the deliery should be attended by a senior

pediatrician fully prepared to resuscitate the baby.

(he delayed clamping of cord helps in improing the iron stores of the baby. It may

also reduce the incidence and seerity of ;*


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:lectie intubation of e5tremely ,6' babies D1000g% is practiced in some centres to

support breathing and for prophylactic administration of e5ogenous surfactant.

(he baby should be promptly dried $ept effectiely coered and #arm.

itamin 1mg 0.& mg in babies D 1&00g% should be gien intra-muscularly.

(he baby should be transferred by the doctor or nurse to the NICU as soon as

breathing is established.

Monitorin":

(he follo#ing clinical parameters should be monitored by specially trained nurses.

(he fre7uency of monitoring depends upon the gestational maturity and clinical status of the

baby.

ital signs #ith the help of multi-channel ital sign monitor non-inasie #ith

alarms%.

Actiity and behaiour.

Color4 pin$ pale grey blue yello#

(issue perfusion4 ade7uate perfusion is suggested by pin$ colour capillary refill oer

upper chest of D 2sec #arm and pin$ e5tremities normal blood pressure urine output

of E 1.&mlB$gBhr absence of metabolic acidosis and lac$ of any disparity bet#een

pa92 and p92.

8luids electrolytes and A6=s.

(olerance of feeds by monitoring omiting gastric residuals abdominal girth.

(he baby should be #atched for deelopment of ?


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Pro%i#e in&utero milieu:

Uterus proides ideal ambient conditions to the baby. All attempts should be made to

create uterus-li$e baby-friendly ecology in the nursery.

Create a soft comfortable GnestledH and cushioned bed.

Aoid e5cessie light e5cessie sound rough handling and painful procedures. Use

effectie analgesia and sedation for conducting procedures.

Proide #armth.

:nsure asepsis.

Preent eaporatie s$in losses by effectiely coering the baby application of oil or

li7uid paraffin to the s$in and increasing humidity to near 100 percent.

Proide effectie and safe o5ygenation.

Uterus is able to proide uni7ue parenteral nutrition. :fforts should be made to

proide at least partial parenteral nutrition and gie trophic feeds #ith e5pressed

breast mil$ :6*%.

Proide rhythmic gentle tactile and $inesthetic stimulation li$e s$in-to-s$in contact

interaction music caring and cuddling.

Position of t!e $a$y:

A pre-#armed open care system or incubator should be aailable at all times to

receie any baby #ith hypothermia or #ith a birth #eight of less than 2000g.

(he baby should be nursed in a thermo-neutral enironment #ith a sero sense

geared to maintain s$in temperature of mid-epigastric region at !+.& degree Celsius

so that there is irtually no or minimal metabolic thermogenesis.

Application of oil or li7uid paraffin on the s$in reduces conectie heat loss and

eaporatie #ater losses.

(he e5tremely ,6' baby should be coered #ith a cellophane or thin transparent orthin transparent plastic sheet to preent conectie heat loss and eaporatie losses of

#ater from s$in.

As soon as babys condition stabili/es he should be coered #ith Perspe5 shield or

effectiely clothed #ith a froc$ cap soc$s and mittens.

After one #ee$ or so stable babies #ith a birth #eight of D 1200g should preferably

be nursed in an intensie care incubator.

(he mother should be encouraged to proide partial $angaroo0mother-care to preent

hypothermia to promote bonding and breast feeding and to transmit healing electro-

magnetic ibrations of loe and compassion to her baby.


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O'y"en t!erapy:

95ygen should be administered only #hen indicated gien in the lo#est ambient

concentration and stopped as soon as its use is considered unnecessary.

(he o5ygen should be administered #ith a head bo5 #hen p92falls belo# )&F and

it should be gradually #ithdra#n #hen p92 goes aboe 0F. (he lo#est ambient

concentration and flo# rates should be used to maintain p92bet#een )&-&F and

Pa92bet#een +0-)0 mm ;g.

P!otot!erapy:

Jaundice is common in preterm babies due to hepatic immaturity hypo5iahypoglycaemia infections and hypothermia.


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(rophic feeds #ith :6* 1-2 ml 3 timesBday% throough N= tube can be started in all

babies irrespectie of their birth #eight or clinical conditions.

'hen babys condition is stabili/ed enteral feeds are begun #ith :6* starting #ith a

olume of !0mlB$gBday on the first day and depending upon the tolerance the enteral

feeds are increased by 10-20mlB$gBday eery day and I8 are reduced accordingly.

Nutritional supplements:

After t#o #ee$s #hen baby is stable and tolerating enteral feeds :6* can befortified #ith human mil$ fortifier ;*8%. (he fortification of :6* #ith formula feeds

especially during night% also proides additional calories and protein to the baby.

*ultiitamin drops containing folic acid should be started at 2 #ee$s of age.

Iron supplementation 2-! mgB$g elemental iron% should be started after 2-! #ee$s

#hen a baby is haing steady #eight gain.

8ree radical lipid pero5idation in cell membranes is catalysed by iron and

polysaturated fatty acids PU8A% thus increasing the re7uirements of itamin : in

ery lo# birth babies. (he re7uirement of itamin : are therefore related to linoleic

acid content of the formula. It is recommende that itamin : to linoleic acid ratio

should be E 1iuBgram of linoleic acid in the feeding formula for ,6' babies. (he

alpha tocopherolB linoleic acid ratios are +.2! 1.3! and 0.") mgBg in human

colostrum transitional and mature mil$ respectiely.

itamin : is po#erful anti-o5idant and preents the haemolytic anemia and edema of

prematurity.

In infants #eighing less than 1&00g at birth mil$ formula should proide atleast1iu of

itamin : Bg of linoleic acid and supplemented #ith daily administration of 1& iu of

itamin :.

upplements of calcium 220mgBday% and phosphorus 100mgBday% are essential to

preent osteopenia of prematurity.

(he supplements are continued till the baby has achieed post conceptional maturity

of !) #ee$s or #eight of 2000g.

FEEDIN( OF PRETERM INFANTS


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Proper nutrition in infancy is essential for normal gro#th resistance to infection

long term health and optimal neurologic and cognitie deelopment. Proiding ade7uate

nutrition to preterm infants is challenging because of seeral problems some of them uni7ue

to these small infants. (hese problems include immaturity of bo#el function inability to suc$

and s#allo# high ris$ of necroti/ing enterocolitis N:C% illnesses that may interfere #ith

ade7uate enteral feeding e.g. ?


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has !emo#ynami insta$ility as eidenced by clinical signs of sepsis- !ypotension-

is receiing #opamine at a dose E! mcgB$gBmin% or other asopressor drugs receied an e'!an"e transfusion #ithin the past 3)hours.

has a$#ominal #istension or other signs of =I dysfunction.

has had an episode of se%ere asp!y'ia perinatal or post-natal% in the preious"2hours

FEEDIN( PROTOCO+: (he follo#ing are guidelines for the initiation and adance of

enteral feedings in preterm infants4

., Met!o# of fee#in":

6ecause these infants usually hae not yet deeloped coordinated suc$ing and

s#allo#ing they must be fed by gaage4

9rogastric tubes are usually used. 6ecause infants are obligate nose breathers

it is best not to occlude the nares #ith a tube. In addition repeated insertion of

a nasal gastric tube can cause inflammation of the nose #ith subse7uent

obstruction. :stimate length of tube that must be inserted to reach the stomach.

Insert the tube and aspirate to see if gastric contents are returned. 'hile

listening oer stomach #ith stethoscope in>ect L&cc of air. If tube is in

stomach you should hear bubbling as you in>ect air. If you cannot hear any

bubbling tube may be in the trachea. (herefore do not feed infant until you

are certain that tube is in stomach. e>unal tubes for gaage feedings as feedings are less

#ell tolerated and do not stimulate secretion of lingual lipase. In addition

residuals are no longer useful in assessing tolerance of feedings. Nipple feedings can be considered as the infant matures. (he best >udge of

#hen to start nipple feedings is an e5perienced Nurse.

/, Content of fee#in": 6egin #ith either4

Breast mil0 preterm breast mil$ is 20 m9smB,% or

Formula for preterm infants e.g. Premature :nfamilM or imilac pecial CareM

2+0 m9smB,%. ome physicians use half-strength feedings but there is no eidence that this is

beneficial. In fact hypo-osmolar solutions may slo# gastric emptying leading to

increased incidence of residuals and feeding intolerance ?emember that fetuses s#allo# amniotic fluid #hich is 2"& m9smB, and this

s#allo#ing begins at 1+ #ee$s gestation.


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1, (ui#elines for Fee#in": Initiation of feedings their olume and the rate of adance of

feedings are related to birth #eight gestational age and ho# the infant has tolerated feeds to

date. =eneral guidelines include4

Initial olume is / 20" per fee#in" 3it! a minimal a$solute %olume of /


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MANA(EMENT OF FEEDIN( INTO+ERANCE should be related to the type and

seerity of the presenting signs as described belo#4

1. (astri resi#uals:

Non-bilious residuals4 If these are smaller than the olume of a feeding and are not increasing in olume

and if the infant other#ise appears #ell feeding can continue but the infant should be

obsered carefully for other signs of feeding intolerance. If the infant has any other

#orrisome findings hold the feedings consider obtaining an abdominal radiograph

and obsere the infant.

If the residuals are greater than the olume of a feeding or are progressiely

increasing in olume hold the feedings and obsere closely.

6ilious residuals are a serious sign. ;old feedings ealuate infant closely andconsider further #or$up including abdominal radiograph C6C and platelets.

2. A$#ominal #istension is a serious sign.


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?oc$ing bed or placing a preterm baby on inflated gloes rhythmically roc$ed by a

entilator proide useful estibular- $inaesthetic stimuli for preention of apneic

attac$s of prematurity.

oothing auditory stimuli can be gien to the preterm baby in the form of taped heart

beats family oices or music.

*usic has been sho#n to reduce the stress of procedure and enhance #eight gain

elocity of preterm babies.

isual inputs can be proided #ith the help of colored ob>ects diffuse light and eye-

to-eye contact.

Utility of ortiosteroi#s:

Unnecessary administration of corticosteroids should be aoided due to its potential

side effects. Antenatal administration of betamethasone or de5amethasone is uniersally

recommended if labor starts before !3 #ee$s of gestation.

A single dose of de5amethasone 0.2mgB$g I at 3 hours of age may be gien to ery

lo# birth #eight babies to reduce the incidence of ;*< and I; but its use is

controersial.

Corticosteroids are also indicated to assist the process of difficult #eaning follo#ing

prolonged assisted entilation and for attenuation of inflammatory changes in infants

#ith broncho-pulmonary dysplasia.

Inhaled steroids has not been found to be useful to reduce the ris$ of chronic lung

diseaseC,,%.

Corticosteroids hae some therapeutic utility in the management of

scleremaneonatorum.

(here is increasing eidence to suggest that prolonged use of corticosteroid therapy

should be aoided in ne#born babies because of serious concerns for short term

hypertension hyperglycemia =I bleeding infections% and long term cerebral palsy

and neuromotor disability% side effects.

Transient !ypot!yro'inemia of prematurity:

In preterm babies belo# !0 #ee$s of gestation total (3 leels may be lo# but free (3

(! and (; leels are usually normal. (he condition is transient and is attributed to normal

adaptie response of an immature hypothalamic-pituitary a5is or to sic$ euthyroid syndrome.


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Its clinical significance is controersial. (he current Cochrane Neonatal Collaboratie

?eie# does not recommended routine (3 suplementation in preterm babies.

Pre%ention- early #ia"nosis an# prompt mana"ement of ommon pro$lems:

Nosocomial infections:house $eeping rituals strict house $eeping routines and high

inde5 of suspicion should be maintained to preent and ma$e early diagnosis of

nosocomial infections. !ypothermia:Nurse in a thermoneutral enironment.

Respiratory distress syndrome: Antenatal administration of corticosteroids

preention and effectie treatment of perinatal distress prophylactic administration of

e5ogenous surfactant to reduce the incidence and seerity of ;*


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*ost preterm babies lose #eight during the first ! to 3 days of life and loss is upto

a ma5imum of 10 to 1& percent of the birth #eight.

(he #eight remains stationary for the ne5t 3 to & days and then the babies start

gaining at a rate of 1 to 1.& F of body #eight 10-1&gB$gBd% per day.

(hey regain their birth #eight by the end of second #ee$ of life.

:5cessie #eght loss delay in regaining the birth #eight or slo# #eight gain

suggest that either the baby is not being the baby is not being fed ade7uately or he

is un#ell and needs immediate attention.

udden #eight loss in a baby #ho had been gaining #eight satisfactorily #ould

suggest the possibility of dehydration.

:5cessie #eight gain of 100g or more per day may occur in babies #ith cardiac

failure though sometimes healthy babies may also gain #eight more rapidly.

6!at to a%oi# in t!e are of preterm $a$ies77

In the care of preterm babies at times greater harm is done by unnecessary

therapeutic interentions #hich may lead to iatrogenic disorders. (he follo#ing interentions

should be aoided because they are unnecessary useless and often associated #ith serious

side effects.

?outine o5ygenation #ithout monitoring.

Intraenous immunoglobulins for preention of neonatal sepsis.

Prophylactic antibiotics e5cept during assisted entilation%.

Prophylactic administration of indomethacin or high doses of itamin :.

Unnecessary blood transfusions definite indications include haematocrit ofD30F in

a sic$ neonate D!0F in a symptomatic neonate and D2&F in an asymptomatic

neonate%.

8ormula feeds.

?ough handling e5cessie light and loud sound.

Immuni8ations:

Preterm babies are able to mount a satisfactory immune response and they can be

accinated at the usual chronological age li$e term babies. (he dose of accine is not reduced

in preterm babies. ;o#eer there is some eidence to suggest that administration of hepatitis

6 accine in preterm infants is associated #ith lo# sero-conersion rate.


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6ecause during their stay in the NICU there is no ris$ of contracting accine-

preentable diseases it is desirable to administer 0-day accines 6C= 9P ;6%

on the day of discharge from the hospital.

If mother is ;6 carrier and is e-antigen positie baby should be gien hepatitis 6

accine and hepatitis 6 specific immunoglobulins #ithin "2 hours of age.

,ie accines should be aoided in symptomatic ;I-positie mothers.

';9 recommends that 6C= and oral polio accine can be gien to asymptomatic

;I-positie infants.

Family support:

(he prolonged stay of preterm and sic$ ne#born babies in the NICU is associated

#ith emotional trauma uncertainly an5iety and lac$ of bonding #ith the baby on the part of

parents.

(he family dynamics are greatly disturbed apart from tremendous physical stress and

fiscal implications due to high cost of neonatal intensie care. (hese problems and

issues should be handled #ith e7uanimity compassion concern and caring attitude of

the health team.

(he frightening scene of NICU should be demystified and family should be constantly

informed and inoled in the care of their baby. (he mother should be encouraged to touch and tal$ #ith her baby proide routine care

under the guidance of nurses.

he should be assisted to proide $angaroo-mother-care to her baby and try to

establish eye-to-eye contact.

(he an5iety and concern of the family should be cushioned by proiding necessary

emotional support and guidance.

Transfer from inu$ator to ot:

A baby #ho is feeding from the bottle or cup and is reasonably actie #ith a stable

body temperature irrespectie of his #eight 7ualifies for transfer to the open cot.

(he baby should be obsered for another 12 hours after putting the incubator off to

see #hether he can maintain his body temperature.

(he infant should stay in the incubator for as short a period as possible because

incubators are a potent source of nosocomial infection.


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Dis!ar"e poliy:

(he mother should be mentally prepared and proided #ith essential training and

s$ills for handling a preterm baby before she is discharged from the hospital.

(he mother- baby dyad should be $ept in step-do#n nursery #here she is able to

independently loo$ after the essential needs of her baby li$e maintenance of body

temperature ensuring sepsis feeding #ith a cup and spoonB paladay or breast

feeding toilet needsetc.

(he baby should be stable maintaining his body temperature and should not hae

any eidences of cold stress.

At the time of discharge the baby should be haing daily steady #eight gain elocity

of at least 10gB$g.

(he home conditions should be satisfactory before the baby is discharged.

(he public health nurse should assess the home conditions and isit the family at

home eery #ee$ for a month or so.

Follo3&up protool:

After discharge from the hospital babies should be regularly follo#ed up for

assessment of the follo#ing parameters. (he speciali/ed perinatal follo#-up serices demand

a close collaboration and interaction #ith a large number of specialists li$e paediatrician


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*ost healthy near term or borderline preterm infants #ith a birth #eight of 1)00g or

more and gestational maturity of !& #ee$s or more can be managed at home. (he policy of

early discharge from the hospital in an effort to decongest the nurseries has imposed

additional responsibilities that their care be e5tended to their home.

It is essential that a ,6' infant should not be discharged unless he has regained his

birth #eight is self feeding from the bottle or breast and is sho#ing a steady #eight

gain.

6efore discharge the mother should be encouraged breast fed her baby and loo$ after

his toilet needs.

he must be e5plained about the importance of maintaining asepsis $eeping the baby

#arm and ensuring satisfactory feeding routine.

(he serices of postpartum programme public health nurse and social #or$er can be

utili/ed to proide home care after discharge.

It is essential that proper appraisal of aailable physical facilities resources and

enironmental conditions be made by a predischarge home isit by a health isitor or

a public health nurse before the baby is discharged.

It should be follo#ed by periodic home isits to assess the progress of the child.

%nvironmental control:

It must be remembered that the desirable enironmental temperature to safeguard the

biological needs of the lo#- birth #eight infant.

(he infant should be effectiely coered ta$ing care to aoid smothering.

'oollen cap soc$s and mittens should be #orn.

(he infant should preferably lie ne5t to the mother #hich seres as a useful

biologically controlled heat source.

In #inter the room can be #armed #ith a radiant heater or angeethi.

A table lamp haing 100 #att bulb can be used to proide direct radiant heat. ;ot #ater bottle if eer used should neer come in contact #ith the baby.

(he cot of the mother and infant should be located a#ay from the #alls to reduce

radiation heat loss.

(he mother and health #or$er should be trained to assess the temperature of the

ne#born baby by touch and adised tpo ensure that e5tremities are $ept #arm and

pin$.

(he isitors and handling of the infant should be restricted to the bare minimum.

(he hands must be #ashed before touching or feeding the baby.

(he emotional urge for $issing the baby should be curbed.


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(he linen should be clean and sun-dried.

&eeding:

'heneer feasible breast feeding is ideal and must be encouraged.

'hen infant is unable to suc$ from the breast :6* should be gien #ith a bottle or

dropper or spoon or paladay depending upon his maturity.

In case formula feeding is unaoidable specially designed formula for premature

babies is recommended.

If co#s or buffalos mil$ is unaoidable it should be gien after !41 dilution.

*other must be gien detailed instructions and practical demonstration for

maintenance of bottle hygiene to npreent contamination of feeds.

Prognosis

(he outcome of uncomplicated premature babies is comparable to the babies born

after full maturity. In fact seeral reno#ned and famous people #ho #ere born premature

gre# upto become #orld leaders and intellectuals. ir Isaac Ne#ton the greatest

mathematician genius #eighed merely ! lbs at birth. ir 'inston Churchill the legendary

Prime *inister of 6ritain #as born after " months of pregnancy #hen his mother #as

participating in a royal dance. (he parents of premature children therefore should not feel

despondent because there is enough historical eidence that their infant has a bright future

and he may gro# up to become an intellectual giant.

Prognosis for surial is directly related to the birth #eight of the child and 7uality of

neonatal care oer three-fourth of neonatal deaths occur among ,6' babies. (herefore in

countries #ith high incidence of ,6' babies neonatal mortality is li$ely to be higher.

(he ris$ of neurodeelopmental handicaps is increased !-fold for ,6' babies and

10-fold for ery ,6' babiesD1&00g%.

(he prognosis is good if no birth asphy5ia apneic attac$s?


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(here is high incidence of minor neurologic disabilities in the form of language

disorder learning disabilities behaiour problems A


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imple methods to maintain a babys temperature after birth include drying and #rapping

increased enironmental temperature coering the babys head s$in-to-s$in contact #ith the

mother and coering both #ith a blan$et.


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Infetion pre%ention

Clean birth practices reduce maternal and neonatal mortality and morbidity from infection-

related causes including tetanus. Premature babies hae a higher ris$ of bacterial sepsis.;and cleansing is especially critical in neonatal care units. ;o#eer basic hygienic practices

such as hand #ashing and maintaining a clean enironment are #ell $no#n but poorly done.

Unnecessary separation from the mother or sharing of incubators should be aoided as these

practices increase spread of infections. 8or the poorest families giing birth at home the use

of clean birth $its and improed practices hae been sho#n to reduce mortality. ?ecent

cluster-randomi/ed trials hae sho#n some benefit from chlorhe5idine topical application to

the babys cord and no identified aderse effects. (o date about half of trials hae sho#n a

significant neonatal mortality effect especially for premature babies and particularly #ith

early application #hich may be challenging for home births.

Another possible benefit of chlorhe5idine is a behaiour change agent in many cultures

around the #orld something is applied to the cord and a policy of chlorhe5idine application

may accelerate change by substituting a helpful substance for harmful ones.

(he s$in of premature babies is more ulnerable and is not protected by erni5 li$e a term

babys. (opical application of emollient ointment such as sunflo#er oil reduces #ater loss

dermatitis and ris$ of sepsis and has been sho#n to reduce mortality for preterm babies.

Another effectie and lo# cost interention is appropriate timing for clamping of the

umbilical cord #aiting 2-! minutes or until the cord stops pulsating #hilst $eeping the baby

belo# the leel of the placenta. 8or preterm babies this reduces the ris$ of intracranial

bleeding and need for blood transfusions as #ell as later anemia. Possible tension bet#een

delayed cord clamping and actie management of the !rd stage of labor #ith controlled cord

traction has been debated but the Cochrane reie# and also recent-eidence statements by

obstetric societies support delayed cord clamping for seeral minutes in all uncomplicated

births.

PAC9A(E /: NEONATA+ RESUSCITATION

6et#een & to 10F of all ne#borns and a greater percentage of premature babies re7uire

assistance to begin breathing at birth. 6asic resuscitation through use of a bag-and-mas$ or

mouth-to-mas$ tube and mas$% #ill sae four out of eery fie babies #ho need


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resuscitationO more comple5 procedures such as endotracheal intubation are re7uired only

for a minority of babies #ho do not breathe at birth and #ho are also li$ely to need ongoing

entilation. ?ecent randomi/ed control trials support the fact that in most cases assisted

entilation #ith room air is e7uialent to using o5ygen and unnecessary o5ygen has

additional ris$s. :5pert opinion suggests that basic resuscitation for preterm births reduces

preterm mortality by about 10F in addition to immediate assessment and stimulation. An

education program entitled ;elping 6abies 6reathe has been deeloped by the American

Academy of Pediatrics and partners for promotion of basic neonatal resuscitation at lo#er

leels of the health system in lo#-resource settings and is currently being scaled up in oer

!0 lo#-income countries and promises potential improements for premature babies

PAC9A(E 1: 9AN(AROO MOT)ER CARE

*C #as deeloped in the 1"0s by a Colombian pediatrician :dgar ?ey #ho sought a

solution to incubator shortages high infection rates and abandonment among preterm births

in his hospital. (he premature baby is put in early prolonged and continuous direct s$in-to-

s$in contact #ith her mother or another family member to proide stable #armth and to

encourage fre7uent and e5clusie breastfeeding. A systematic reie# and meta analysis of

seeral randomi/ed control trials found that *C is associated #ith a &1F reduction in

neonatal mortality for stable babies #eighing D2000g if started in the first #ee$ compared to

incubator care. (hese trials all considered facility-based *C practice #here feeding support

#as aailable. An updated Cochrane reie# also reported a 30F reduction in ris$ of post-

discharge mortality about a +0F reduction in neonatal infections and an almost )0F

reduction in hypothermia. 9ther benefits included increased breastfeeding #eight gain

mother-baby bonding and deelopmental outcome. In addition to being more parent and baby

friendly *C is more health-system friendly by reducing hospital stay and nursing load and

therefore giing cost saings. *C #as endorsed by the ';9 in 200! #hen it deeloped a

program implementation guide. ome studies and program protocols hae a lo#er #eight

limit for *C e.g. not belo# )00g but in conte5ts #here no intensie care is aailable

some babies under )00g do surie #ith *C and more research is re7uired before setting a

lo#er cut off.


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PAC9A(E ;: SPECIA+ CARE OF PREMATURE BABIES AND

P)ASED SCA+E UP OF NEONATA+ INTENSI


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middle-income countries and for some lo#-income countries that hae referral settings #ith

stronger systems support such as high-staffing 23-hour laboratories.

?ecent trials hae demonstrated that CPAP reduces the need for positie pressure entilation

of babies less than 2) #ee$s gestation and the need for transfer babies under !2 #ee$s

gestation to neonatal intensie care units. 9ne ery small trial in outh Africa comparing

CPAP #ith no entilation among babies #ho #ere refused admission to neonatal intensie

care units found CPAP reduced deaths. In *ala#i a CPAP deice deeloped for lo#-resource

settings is being trialed in babies #ith respiratory distress #ho #eigh oer 1000g. :arly

results are encouraging and an important outcome #ill be to assess the nursing time re7uired

and costs.

Increasing use of CPAP #ithout regulation is a concern. *any deices are in the

GhomemadeH categoryO seeral lo# cost bubble CPAP deices are being deeloped

specifically for lo#-income countries but need to be tested for durability reliability and

safety. CPAP-assisted entilation re7uires ade7uate medical and nursing s$ill to apply and

delier safely and effectiely and also re7uires other supportie e7uipment such as an

o5ygen source o5ygen monitoring deice and suction machine.

urfactant is administered to premature babys lungs to replace the missing natural surfactant

#hich is one of the reasons babies deelop ?


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Assessment of common problems4

(he infants respiratory status must be obsered constantly. (he lungs are assessed for

adentitious breath sounds or areas of absent breath sounds. (he ilerman-Anderson

inde5 ia s useful tool for ealuating the degree of respiratory distress. ,oo$ for the

apneic spells.

(hermoregulation4 the infants temperature is monitored continuously by a s$in probe

on the infants abdomen #hich is attached to the heat control mechanism of the

radiant #armer. (he temperature usually maintained at !+ degree to !+.& degree

Celsius. It should be recorded eery !0 to +0 minutes initially and eery ! to 3 hours

#hen stable. Assess a5illary temperature eery 3 to ) hours and compare #ith the

probe temperature. ,oo$ for signs of hypothermia.

8eeding and electrolyte balance4 monitor inta$e-output of fluids determine fluidbalance. (he nurse also must trac$ of the amount of blood ta$en. Assess the urine

output by #eighing the diapers. 'eigh the child daily. ,oo$ for signs of dehydration

decreased urine output D1mlBhr increased specific graity #eight loss and dry s$in

and mucous membrane sun$en fontanel increased sodium% or oerhydration

increased urine output E!mlBhr #ith a belo# normal specific graity edema #eight

gain bulging fontanelles moist breath sounds and decreased blood sodium and

protein%.

$in4 fre7uently assess the condition of the infants s$in and record any changes. (he

infants response to product used for cleansing and disinfection must be noted.

Infection4 the nurse should be alert for signs of infection at all times li$e general

signs respiratory cardio-ascular =I and neurologic signs.

Pain4 because pain is afifth ital sign it should be assessed fre7uently high pitched

cry intense and harsh cry mouth open grimacing furro#ing or bulging of the bro#

tenserigid muscles and color changes% and must assess the response to potentially

painful stimuli and to pharmacologic and non-pharmacologic interentions. Assess the amount of noise to #hich the infant is e5posed. ustment to feeding readiness for change and indicating

intolerance.

Assess the actiity leel of the preterm baby.

Continually assess the infants responses to all feeding methods and #atch for

distress #eigh the infant dailynand obsere the changes ability to ta$e feedings.

Assess the improement in suc$ and s#allo# co-ordination.


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Assess the parental an5iety and promote maternal bonding and assess the support

system and coping pattern.

Assess the $no#ledge leel and support decision ma$ing.

Nursin" #ia"nosis an# inter%entions:

1 Impaired gas e5change related to immaturity of lungs and deficiency of surfactant

Interentions4

Assess the respiratory pattern and colour of the baby

9bsere for any apneic episode.

95ygen hood is often used for able to breathe alone but need e5tra o5ygen.

95ygen also may be gien by nasal cannula to the infant #ho breathesalone.

;umidify the o5ygen

CPAP may be necessary to $eep the aleoli open and improe e5pansion

of lungs

8re7uent monitoring of A6=

8re7uent position changes eery 2 to ! hours

Chec$ the suction e7uipment and suction the air#ay and applied for only &

to 10 seconds.

(he mouth is suctioned before the nose.

*aintain ade7uate hydration

2 Impaired breathing pattern 4 distress related to immaturity and surfactant deficiency

Asess the respiratory rateheart rate and chest retractions

Position the child for ma5imal entilatory efficiency and air#ay patency

Proide humidified o5ygen

po2 monitoring

Proide suctioning

Proide chest physio therapy

Administer bronchodilators

Administer anti inflammatory medications

Administer antibiotics

! Actiity intorance related to increased #or$ of breathing secondary to distress

Arrange to proide routine care

chedule periods of uninterrupted rest


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Proide suctioning

Proide humidified o5ygen

Assess the A6= analysis

Proide C-PAP using mas$ BhoodBnasal prongs

9bsere for ris$s of C-PAP Assist in C* #ith P::P if needed

& ;ypothermia related to immature thermoregulation system

*onitor ital signs fre7uently

'rap the baby #ell and $eep #arm

Proide small and fre7uent breast feeding as tolerated

,oo$ for hypoglycemia

Administer I fluids if not tolefeed intolerance

*onitor the ital signs and blood pressure

Assess the s$in tone pallor and signs of dehydration

Administer I fluids Assess the lab inestigations for ;b ?6Cs platelet count coagulation

profile

If necessary administer blood

Administer re7uired amount of in>. itamin

+ Imbalanced nutrition less than body re7uirement related to feeding difficulty

respiratory distressor NP9 status

Assess the suc$ing and s#allo#ing ability of the ne#born

Assess the tolerance of the child

*onitor the blood glucose leel fre7uently Administer I fluids if not tolerating oral fluids

Administer human mil$ fortifier if the child is preterm

" 8atigue related to increased demand for nutrients and deterioration of the general

condition of the baby

Assess the general condition of the baby

Assess the leel of actiity

*onitor the blood glucose leel

6reast fed the baby

Chec$ for from any part of the body Proide top up feed

) ?is$ for complications hypotension shoc$ cerebral hypo5ia related to progression of

the disease condition

Assess the ital signs respiratory rate pulse rate temperature and blood

pressure

Chec$ blood culture and sensitiity and sepsis screening

*onitor for any signs of dehydration

Administer I fluids or blood as necessary

Assess the serum electrolyte alues andA6= alues

Closely monitor for the early signs and symptoms of complications


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An5iety of parents related to the outcome of the ne#born condition

Assess the mental status an5iety and $no#ledge of family members

Assess the supporting system for the family

Assess the coping strategies of the family members

:5plain the disease process to the family members

:5plain each and eery procedure to the care gier

Proide psychological supporttothefamily members

10 Interrupted mother-child bonding related to infectious process

Assess the breast feeding ability including suc$ing and s#allo#ing ability

eep the child #ith the mother if possible

Proide fre7uent breast feed 2 hourly

If breast feeding is not tolerated gie :6*

Allo# the mother to isit the child

Proide $angaroo mother care in case of pre term if tolerated

11 Interrupted family process related to hospitali/ation of the ne#born Assess the mental status an5iety and $no#ledge of family members

:ncourage mother-child bonding if possible

Assess the coping strategies of the family members

:5plain the disease process to the family members

:5plain each and eery procedure to the care gier

Allo# the family members to isit the child

12 no#ledge deficit regarding care of the baby and treatment modalities

Assess the $no#ledge leel of the care gier

:5plain disease condition and its progress to the family members

:ducate regarding treatment and its preention :ducate about the monitoring of the baby

Proide ade7uate e5planation regarding nutritional need of the baby

Clarify their doubts and promote understanding

1! ?is$ for delayed gro#th and deelopment related to prematurity13 ?is$ for caregier role strain related to need for long term care

CONC+USION

Any infant #ho is born dysmature before term or post term or #ho is under#eight or

oer#eight for gestational age% is at ris$ for complications at birth or in the first fe# days of

life. Parents need thorough education about their babys health because these problems

re7uire hospitali/ation or additional follo#-up at home.

BIB+IO(RAP)*

1 *ehrbaningh.Car of thene#born."thedition.Ne#


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2 ClohertyP>ohn.*anualof neonatal care."thedition.Ne#

Documents

Care of Preterm Babies Final