PREMATURITY
(SIXTH YEARS)
DR CHANDA KAPOMA
• Understand what prematurity is
• Understand the complications of prematurity
• Know the investigations in a premature
Objectives neonate
• Know how to manage a premature neonate
1. Introduction
2. Aetiology and Risk Factors
3. Clinical Manifestations
Outline 4. Complications
5. Investigations
6. Management
Introduction
• A neonate born before 37 weeks gestation
from the first day of the last menstrual period
Who is the • Preterm birth is the leading cause of neonatal
mortality
premature
neonate? • Premature newborns have many physiologic
challenges when adapting to the extrauterine
environment
Classification by
body weight
Classification
by gestation
age
• 15 million babies are born preterm each year
• Preterm birth complications are the leading
cause of death in children under 5
Epidemiology
• Most of these deaths could be prevented with
current cost effective methods
• 85% occur at 32-36 weeks
• 10 % occur at 28 to < 32 weeks
Epidemiology
• 5 % occur at < 28 weeks
Epidemiology:
Death Risk
Factors
Aetiology and Risk
Factors
• It is multifactorial
Aetiology • Complex interaction between: maternal,
uterine, fetal and placental
• Fetal distress
Risk Factors: • Multiple gestation
• Erythroblastosis
Fetal • Non-immune hydrops
• Placental dysfunction
Risk Factors: • Placental abruption
Placental • Placenta previa
• Previous preterm birth
• Preeclampsia
Risk Factors: • Black race
Maternal • Chronic medical illness: cyanotic heart disease,
renal disease, thyroid disease
• Infection (Listeria monocytogenes; UTI; GBS;
Bacterial vaginosis; Chorioamnionitis)
Risk Factors: • Short interpregnancy interval
Maternal • Drug abuse (cocaine)
• Young or advanced maternal age
Risk Factors: • Bicornuate uterus
• Incompetent cervix
Uterine
• Premature rupture of membranes
• Polyhydramnios
Risk Factors: • Trauma
Others • Iatrogenic through assisted reproductive
technology
Clinical
Manifestations
• Body hair (lanugo)
• Skin thin and shiny
Physical signs
• Less body fat
• Lower muscle tone
• Less active
Physical signs • May have problems feeding, poor suck
with uncoordinated suck/swallow
Problems of Prematurity?
• Temperature Control Get cold even faster
• Less Body fat Have fewer reserves
• Fragile lungs Don’t breathe effectively
• Infection risk Need to think about need for antibiotics
Problems of Prematurity
• Feeding difficulties May require tube feeding
• Jaundice May need phototherapy
• NEC Cautious increase of milk feeds
Which premature babies do we worry about?
37 to 42 weeks TERM BABIES
34 to 36 weeks
31 to 33 weeks
30 weeks and below DIFFERENT
• The Ballard Scoring System is based on
physical and neurological characteristics
Ballard Scoring • It is used to confirm the gestational age
System • It is accurate within 2 weeks of the actual
gestational age
Ballard Scoring PHYSICAL SIGNS NEUROLOGICAL
System SIGNS
Ear cartilage Posture
Sole of the feet Square window
Breast tissue Arm recoil
Lanugo Popliteal angle
Genitalia Scarf sign
Heel to ear
Physical signs
Neurological
signs
Complications
• Respiratory Distress Syndrome
• Bronchopulmonary Dysplasia
• Pneumothorax and Pneumomediastinum
Respiratory • Congenital pneumonia
• Apnoea
• Patent ductus arteriosus
• Hypotension
Cardiovascular • Bradycardia with apnea
• Anaemia
• Poor motility
Haematological • NEC
and GI • Hyperbilirubinemia
• Spontaneous gastrointestinal perforation
• Hypocalcemia
• Hypoglycemia
Metabolic • Hyperglycemia
• Metabolic acidosis
• Intraventricular haemorrhage
• Periventricular leukomalacia
• Seizures
CNS • Retinopathy of Prematurity
• Deafness
• Hypotonia
Investigations
Investigations
• Cranial ultrasound
• Abdominal X-Ray
• Blood gases
• Echocardiography
• Full Blood Count
• Blood glucose
Investigations • Blood type and Coombs test
• Serum electrolytes
• Chest X-ray
Management
• Most premature babies are breathing at birth
and just need help with transition to air
Assistance vs breathing
Resuscitation • Most premature babies do not need to be
resuscitated
• Keep babies warm
• Consider delayed cord clamping for 1-3
At birth minutes
• Resuscitation takes priority over delayed cord
clamping
Advantages of • Increases circulating blood volume
• Improves cardiovascular stability
delayed cord • Decreases the need for a blood transfusion
clamping • Decreases intraventricular haemorrhage (all grades)
• Decreases the risk of necrotising enterocolitis (NEC
• Wrap in dry warm towels
• Hat on head
Thermal
regulation • Wrap in polythene bag those below 1200 g or
30 weeks gestation
• Maintain environmental temperature 24-26oC
If baby not breathing or breathing
ineffective and needs ventilation-
• Choose appropriate size mask
Gentle lung • Use gentle bag-valve-mask
inflation… ventilation
• Enough 'squeeze' to see chest wall
rise
• Once lungs aerated, ventilate at
about 30 breaths a minute
• Transfer to the neonatal unit
Post
resuscitation • Keep warm, KMC if necessary
care
• They are expected to lose 15%
of their body weight
• Maintain glucose between 2.6
Fluid Requirements and 7 mmol/l
• Give 10% Dextrose 3 ml/kg if
hypoglycaemic
Fluid requirements…
Birth Weight(g) Fluids Day 1 (ml/kg/day) Glucose (mg/kg/min)
<1000 5% Dextrose 90 3.2
1000 – 1199 10% Dextrose 80 5.6
1200 – 1499 10% Dextrose 70 4.2
>1500 10% Dextrose 60 4.2
• Increase fluid by 10-20 ml/kg/day depending
on urine output, weight and serum sodium
Fluid • After 48 hours, change to ¼ strength darrows
requirements… in 10% dextrose
• Normal urine output: 0.5-1 ml/kg/day
• Breast milk feeding must be encouraged for all
infants.
Enteral feeding • Donor breast milk is preferable to formula for
preterm infants unable to access mother’s
own breast milk.
In the absence of mother’s own milk,
consider preterm formula
≥ 1500 g or 32 Start on bolus feeds 2 -3 hourly at 60ml/kg
on day 1
weeks Increase to 75, 100, 125, 150ml/kg/d from
D2-D5 as feeds are tolerated
• Start with bolus tube feeds (expressed breast
< 1500 grams or milk (EBM))
• Orogastric tubes are preferable to nasogastric
< 32 weeks tube
• Start milk on D1 at 12-24 ml/kg/d
• Increase feeds daily by 24 ml/kg/day
• Stop supplemental IV fluids when enteral intake of
150 ml/kg/day
• Increase enteral volume incrementally to 180-200
Enteral feeding ml/kg/day
• The feeding tube must be changed weekly and the
administration set three times a week
LBW infants on feeds at 150ml/kg or more
should be given the following for 6 months:
Preterm • Multivit 0.6 ml PO daily
supplements • Iron/ferrodrops 0.6 ml (2 to 3 mg/kg/day) PO
from 28 days or on discharge (whichever
occurs first)
• Introduce Multivit 0.3ml PO daily 48 hours
after establishing full feeds
• Iron syrup or ferro drops 0.2 ml PO from day
Preterm
28 of life
• Add human milk fortifier to breastmilk 24
supplements hours after establishing full feeds
• Given prophylactically to all preterm neonates
< 33 weeks gestational age or <1500 g birth
weight.
Aminophylline • Load with 6mg/kg given slowly over 20 min
for AOP then start maintenance at 2.5mg/kg twice
daily starting 24hours after loading.
prevention
• Prematurity is birth before 37 completed
TAKE HOME… weeks of gestation
• Prematurity has many complications in the
different systems
• Investigations are tailored to suspected
complications and physical findings
• The management involves resuscitation,
thermal control, enteral feeding and good
oxygen management.
• Medscape. Prematurity. Susan A Furdon
• UpToDate. Premature birth. George T
Mandy
• WHO. Preterm birth
References • Nelson Textbook of Paediatrics
• Zambia Paediatrics Draft Protocol
• Dr Kapembwa Neonatology Training slides
• Global causes of under five mortality 2019
ANY
QUESTIONS
