Care of the Preterm Newborn
Preterm is defined as ‘babies born or occurring after a pregnancy significantly shorter than normal, especially after no more than 37 weeks of pregnancy.’ According to the WHO, every year about 15 million babies are born prematurely around the world, which is 1 in 10 babies born globally. Almost 1 million children die each year due to complications of preterm birth. Essential care for every newborn comprises support for immediate and exclusive breastfeeding, thermal care, and hygienic cord and skin care. For babies who do not breathe at birth, rapid neonatal resuscitation is crucial. Neonatal intensive care units in high income settings are de-intensifying care, for example, increasing the use of continuous positive airway pressure (CPAP) and this makes comprehensive preterm care more transferable.
Preterm birth is the number one cause of newborn death worldwide, and the second leading cause of all child deaths under five, following pneumonia. Many preterm babies who survive suffer from various disabilities like cerebral palsy, sensory deficits, learning disabilities and respiratory illness. The morbidity associated with preterm birth often extends to later life, resulting in physical, psychological and economic stress to the individual and family. In the lower-income countries, on average 12% of babies are born too early compared with 9% in higher income countries. Care at birth from a skilled provider is crucial for both women and babies, and all providers should be competent to care for both mother and baby, ensuring that mother and baby are not separated unnecessarily and promote good mother-infant bonding, early and exclusive breastfeeding, necessary hygiene measures, and resuscitation if required. These practices are essential for full-term babies, but for premature babies these are even more necessary and missing (or delaying) any of these can lead to rapid deterioration and/or death. For all babies at birth, minutes count.
Risk factors of preterm and low birth weight babies:
- Feeding difficulties since the coordinated “suck and swallow” process only starts at 34 weeks gestation. Preterm babies need help to feed and are more likely to aspirate.
- Premature babies are at higher risk of dying from sepsis once they get an infection.
- Babies born below 32 weeks of gestation, are at higher risk of developing respiratory distress syndrome (RDS), although this risk can be reduced by antenatal corticosteroids given to the mother at risk of preterm labour.
- Jaundice is more common in premature babies since the immature liver cannot easily metabolise bilirubin and the preterm baby’s brain is at a higher risk since their blood-brain barrier is less developed to protect the brain.
- Brain injury in preterm babies is most commonly intraventricular haemorrhage, occurring in the first few days after birth, in about 1 in 5 babies under 2 kg and is often linked to severity of RDS and hypotension.
- Necrotizing enterocolitis is a rare condition affecting the intestinal wall of very premature babies. Formula feeding increases the risk tenfold compared to babies who are fed exclusive breastmilk.
- Retinopathy of prematurity due to abnormal proliferation of blood vessels around the retina of the eye, which is more severe if the baby is given very high levels of oxygen for long durations.
- Anaemia of prematurity, which often becomes apparent at a few weeks of age due to the delay in producing red blood cells as the bone morrow is immature.
This article systematically highlights the most common difficulties faced by preterm babies and the measures and support required to overcome them.
(i) Feeding difficulties
Early initiation of breastfeeding within one hour after birth has been shown to reduce neonatal mortality. Premature babies benefit from breast milk nutritionally, immunologically and developmentally. The short-term and long-term benefits compared with formula feeding are well established with lower incidence of infection and necrotizing enterocolitis and improved neuro-developmental outcome. Most premature babies require extra support for feeding with a cup, spoon or another device such as gastric tubes (either oral or nasal). Milk-banking services are common in many countries but must be monitored for quality and infection prevention. Extremely preterm babies under about 1000 gram (g) and babies who are very unwell may require intravenous fluids or even total parenteral nutrition, but this requires meticulous attention to volume and flow rates.
The WHO does recommend supplementation with vitamin D, calcium and phosphorus and iron for very low birthweight babies and vitamin K at birth for low birthweight babies. In many units, infants with birth weight of 1000 g or less are given 5000 IU (international units) of vitamin A intramuscularly three times a week for the first 4 weeks. This therapy has been shown to result in a small reduction in the incidence of chronic lung disease.[2,3]
In general, premature birth is associated with increased incidence of early onset sepsis. Group B streptococcus remains an important pathogen, but gram-negative organisms now account for most of early onset sepsis in infants weighing less than 1500 g. We almost always screen for infection immediately after birth and treat with prophylactic antibiotics pending culture result. ELBW (extremely low birth weight) babies are particularly susceptible to nosocomial infections, and in some reports as many as one third of infants weighing less than 1000 g have had at least one episode of late onset sepsis, with wide variation in its incidence between centres.
Risk factors of late onset sepsis include longer duration of mechanical ventilation, umbilical and central venous lines and parenteral nutrition support. Some steps are needed to prevent infection. Foremost amongst these is meticulous attention to hand washing. Parenteral nutrition solutions that have been prepared under laminar flow, and never alter them after preparation should be used. The early introduction of feedings, preferably with human milk, minimize the need for central lines and provides the benefit of milk-borne immune factors.
The skin of premature babies is more vulnerable and is not protected by vernix as in a term baby. Topical application of emollient ointment such as oil reduces water loss, dermatitis, and risk of sepsis, and has been shown to reduce mortality for preterm babies. Another effective and low-cost intervention is appropriate timing for clamping of the umbilical cord, waiting 2-3 minutes or until the cord stops pulsating, whilst keeping the baby below the level of the placenta.
(iii)Respiratory distress syndrome
The primary cause of respiratory distress syndrome is inadequate pulmonary surfactant. Preterm birth is the most common etiologic factor. The manifestations of the disease are caused by the resultant diffuse alveolar atelectasis, oedema and cell injury. The key to the management of infants with respiratory distress syndrome is surfactant replacement, one of the best studied therapies in neonates. It has been shown in numerous clinical trials to be successful in ameliorating respiratory distress syndrome.
Premature infants experience increased mechanism of heat loss combined with decreased heat production capabilities. Premature infants subjected to acute hypothermia respond with peripheral vasoconstriction, causing anaerobic metabolism and metabolic acidosis.
Premature infants are at higher risk of hypothermia due to:
- A higher ratio of skin surface area to weight
- Highly permeable skin which leads to increased trans epidermal water loss
- Decreased subcutaneous fat with less insulative capacity
- Less developed stores of brown fat
- Decreased glycogen stores
- The inability to take enough calories to provide nutrients for thermogenesis and growth
- Limited oxygen consumption when pulmonary problems exist.
Management to prevent heat loss:[5,6]
- External heat sources, skin to skin care and trans warmer mattresses have demonstrated a reduction in the risk of neonatal hypothermia
- A radiant warmer should be used during resuscitation and stabilization. A heated incubator should be used for transport.
- Humidification of incubators has been shown to reduce evaporative heat loss and decrease insensible water loss.
- Double walled incubators not only limit radiant heat loss but also decrease convective and evaporative losses.
- Current technology includes the development of newer hybrid warming devices such as the “Versalet” and the “Giraffe Omnibed.” They feature both a traditional radiant warmer bed and an incubator in single device.
Kangaroo Mother Care (KMC):
The premature baby is put in early, prolonged and continuous, direct skin-to-skin contact with the mother (or another family member) to provide stable warmth and it also encourages frequent and exclusive breastfeeding. A systematic review and meta-analysis of several randomised control trials found that KMC is associated with a 51% reduction in neonatal mortality for stable babies weighing < 2000 g if started in the first week, compared to incubator care. Other benefits included increased breastfeeding, weight gain, increased mother-baby bonding and developmental outcomes. In addition to promoting these outcomes as it is parent and baby friendly, KMC is also healthcare friendly as it reduces hospital cost, duration, and nursing care, therefore offering considerable cost savings.
(v) Growth impairment
During the first two years of life, growth is plotted using corrected-age for prematurity. Growth charts for the “average” premature infant have been designed for this purpose. Special neonatal growth charts are also available for the sick or small-for-gestational-age infant. After the infant reaches two years of age, a standard growth chart for chronologic age may be used.
Many premature infants have catch-up growth. Catch-up growth is usually first noted in the infant’s head circumference, followed by the infant’s weight and length. This usually occurs during the first two to three years of life and is maximum at 36 to 40 weeks after conception. Little catch-up growth occurs after three years of age. Premature infants with intrauterine growth retardation and no catch-up growth have a higher risk of developmental delay and other medical problems than premature infants with a normal growth rate. Even in adolescence, children who were born prematurely may be smaller than children not born prematurely. Menarche also occurs later in girls who were born prematurely. One study showed that women who were born prematurely are more likely to deliver premature infants themselves. Another study found a trend for this to happen, but it was not statistically significant.
(vi) Developmental delay
The infant’s development during the first two years should be plotted from the infant’s estimated due date rather than the infant’s birth date. The Denver Prescreening Developmental Questionnaire, the Denver Developmental Screening Test and the Gesell Screening Inventory are all accepted tests. Using a standardized developmental test is more important than the choice of test.
Measures to be taken at home:
Ensure the baby gets enough nutrition: Breast milk is the best nutrition any baby can get, and this holds true even in the case of preterm babies. In some cases, if the baby in unable to latch on properly to the breast due to numerous issues, express the milk and try to give it to the baby with the help of other tools.
Regular follow up:
Premature babies are more likely to suffer from various complications like eye disorders, respiratory distress syndrome etc. A premature baby should be regularly screened for any of these complications. In routine check-ups, the doctor checks whether the baby is growing properly or not.
Since a premature baby is not fully developed in the womb, there are higher chances that he/she might develop certain complications. Hence, one must be vigilant for certain danger signs that the parents should pick up and seek immediate medical attention. Remember the acronym ABCDH which stands for A-apnea, B- breathing difficulties, C- cold hands and feet, C- convulsions, D-decreased feeds, D- decreased activity, H-hyperthermia/hypothermia. If the baby shows any of these signs, it best to visit the paediatrician immediately.
Spend time with the baby:
It is a must that the mother spends a lot of time with a premature baby. It not only makes the baby feel warm and secure but also helps strengthen the maternal-infant bond.
It is without doubt that parent/family members support is deemed of utmost importance. Having a premature infant is often an extremely stressful experience for the parents and other caregivers. Providing specialized care in assessment, supportive counselling, and resources to families caring for very low birth weight (VLBW) infants, is essential and also includes particular attention to issues of postpartum affective conditions and anxiety following the potentially traumatic experience of having a critically ill infant.
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- Stoll BJ, Hansen N, Fanaroff AA, Wright LL, Carlo WA, Ehrenkranz RA, Lemons JA, Donovan EF, Stark AR, Tyson JE, Oh W. Late-onset sepsis in very low birth weight neonates: the experience of the NICHD Neonatal Research Network. Pediatrics. 2002 Aug; 110(2):285-91.
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