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Prematurity

October 30, 2008

* Neonatal Intensive Care Unit(NICU), Ameerah Rahmah Hospital

* Neonatal Intensive Care Unit(NICU), Ameerah Rahmah Hospital

What is it?

Prematurity is a term used to describe infants who are born any time before the 37th week of pregnancy.

What causes it?

Why some infants are born prematurely is not often known. However, low income and undereducated women are more likely to deliver prematurely, as are women who are unmarried. Poor prenatal care, poor nutrition, and untreated illness or infection during pregnancy are common causes of preterm labor and early delivery. Cervical or uterine abnormalities can also cause preterm labor. Doctors and parents sometimes need to make a decision to deliver a baby prematurely if the pregnancy is causing serious health problems for the mother, or if the baby has a serious health condition that he or she might not survive if carried full term. In many cases, twins are born prematurely.

What are the symptoms?

Premature infants usually have very thin pink, red, or dark skin, with very little fat, which means they have difficulty maintaining a normal body temperature. Because the skin is so thin, the veins are clearly visible. These infants are very small in size and weight, have little hair, and a relatively large head. The external organs may be perfectly formed; however, boys may have a very small scrotum, with one or both testicles undescended. Girls may not have fully developed labia, the large, fleshy tissue outside the vagina. While internal organs may be perfectly formed, they are usually not mature enough to function as they should. The most critical area of development in a premature newborn is the lungs. Tiny air sacs in the lungs, called alveoli, must be able to fill with air and remain open. The alveoli are responsible for passing oxygen into the blood. In the last stages of pregnancy, from 34 to 37 weeks, the cells in the alveoli normally produce a substance called surfactant.

Surfacant reduces the surface tension of fluids that coat the lungs so the air sacs can expand at birth and the infant can breathe normally. When an infant is born prematurely, the cells in the alveoli do not yet have enough surfacant formed and the alveoli cannot expand. Very premature babies may have lungs that are so stiff they cannot breathe on their own. Or, the baby may be able to start breathing, but the ÒairlessÓ lungs collapse and cause respiratory distress syndrome. Treatment to help the baby breathe can also cause inflammation of the lungs and lead to chronic lung disease. However, most children outgrow any lung problems during the first several months of life. Because the premature infant’s brain is also underdeveloped, he or she may suffer from episodes of apnea, which means forgetting to breathe. If the oxygen or blood supply is interrupted to the premature infant’s brain, there is a greater danger of bleeding (intraventricular hemorrhage) or injury to the brain. Also, because the brain is not yet mature, the infant may not have normal sucking or swallowing reflexes needed for normal feeding. 

Other complications of prematurity occur because the infant’s immune system is not fully developed. This creates a risk of serious infections, such as infections of the bloodstream, called sepsis. Some premature infants also develop an inflammatory disease of the intestines called necrotizing enterocolitis. Necrotizing enterocolitis occurs when feedings don’t pass through the intestine well, which is signaled by blood in the baby’s bowel movements. Premature infants are at risk for a condition called retinopathy of prematurity (ROP). With ROP, the baby’s sensitive eyes react to oxygen and light by growing extra blood vessels. While these blood vessels usually go away around 10 to 12 weeks after birth, they can pull on the retina and cause it to separate from the back of the eye. This can cause vision problems and, in severe cases, blindness. As premature children get older, they are also at greater risk for eye muscle problems and may need glasses. 

Anemia and high or low blood sugar levels are extremely common during the first two months of a premature infant’s life. Anemia is a low red blood cell count. This occurs because an infant cannot make new blood to replace lost blood until two months after birth. Premature infants may also lack full kidney and liver function immediately after birth. Because the liver is responsible for excreting bilirubin, a yellow pigment that results from the normal breakdown of red blood cells, many premature infants have a condition called jaundice. Jaundice is the appearance of a yellowish skin tone caused by the excess bilirubin in the bloodstream. In severe cases, high levels of bilirubin can cause a form of brain damage called kernicterus.

How is it diagnosed?

Any infant born before 37 weeks of pregnancy is diagnosed as premature. Complications of prematurity are diagnosed through careful examination and diagnostic testing. Infant respiratory distress syndrome is diagnosed based upon the symptoms present at birth. Tests include a chest x-ray, which will show whether the infant’s lungs are fully expanded, and a test of the oxygen level in the blood. Blood oxygen level can be checked by taking a blood sample or by clipping a device called an oximeter to the earlobe, toe, or finger. If complications during pregnancy indicate that a premature birth is likely, doctors can test the amniotic fluid for surfacant. To do this, a long thin needle is placed through the abdomen into the uterus and a fluid sample is removed. This procedure is called amniocentesis. Doctors can use this test to track the fetus’ lung development so delivery can be delayed as long as possible until the lungs are mature. Doctors can even measure the amount of surfacant in the lungs from a sample of fluid after your water breaks. If necrotizing enterocolitis is suspected, x-rays are taken of the baby’s intestines. Your pediatrician will also look closely for signs of infection, such as increasing apnea spells, labored breathing, and poor digestion of feedings. Ultrasounds of the baby’s head will show any sign of bleeding. An ultrasound scan creates a picture on a monitor from the reflection of sound waves in the body. Ultrasound can also be used to check the development of the child’s major internal organs. Every baby born more than 8 weeks prematurely receives a complete eye exam around six weeks after birth to check for retinopathy. The baby should receive regular exams from an eye specialist until the extra blood vessels are gone.

What is the treatment?

Premature infants are treated by a specialized team, including a neonatologist, who is a pediatrician with special training in the care of premature infants; neonatal nurses; and a respiratory therapist. A social worker can help your family find the resources it needs to meet the baby’s developmental needs, as well as help your family with the emotional stress of having a premature infant. As your baby grows, he or she may need the help of an occupational therapist who will put together and monitor your child’s developmental program. Very premature babies are usually hospitalized until they reach their actual due dates. However, many premature infants can go home before that time if they are doing well. By the same token, some babies may need to stay longer. Premature infants are kept in a special warming bed that keeps their body temperatures within normal ranges. Monitors that track respiratory and heart rate alert the staff if there is any change in the infant’s vital functions. The warming beds also have temperature alarms. A device called a pulse oximeter is attached to the baby’s earlobe, finger, or toe to record the oxygen level in the baby’s skin. The main goal of treatment is to help the child to grow. Until the baby is strong enough to eat on his or her own, he may be fed intravenously (through a vein). At first these feedings will be a solution of sugar and water to give the baby energy. If the baby still cannot take milk feedings within a few days, he or she is given hyperalimentation fluids. These fluids contain sugar, protein, minerals, and fats and are also given intravenously. Because most premature babies are too small and weak to suck on the breast or bottle, milk feedings are given through a tube. Gavage feedings are given through a tube that passes through the mouth or nose and into the stomach. The milk drips in by gravity. 

Another type of tube, called a nasojejunal tube, goes from the nose to the stomach and then directly into the intestine. This type of feeding prevents overfilling the stomach. Your baby may be fed your breast milk, which you will express using a breast pump, or a special formula for premature babies. What type of milk is best for your baby depends upon any other medical conditions he or she may have. When the baby is strong enough, he or she can be fed by breast or bottle. Because the intestinal tract is immature, the baby may have problems with bowel movements, vomiting, and gas. These problems will go away as the child matures.

Other treatments depend upon how prematurely the child is born and the complications of prematurity. Underdeveloped lungs can be treated before the baby is even born if your baby’s birth cannot be delayed until he or she is full term. A steroid hormone, called a corticosteroid, will cross the placenta when given to the mother and help the fetus’ lungs to produce surfactant. This drug will also reduce the risk of bleeding in the brain after birth even if the baby develops respiratory distress syndrome. Other drugs can be used to actually hold off premature labor as long as possible. Infants born with mild respiratory distress syndrome may need nothing more than an oxygen hood for a short time to assist with breathing. Oxygen can also be delivered through nasal prongs or a tube placed through the nose, called continuous positive airway pressure (CPAP). Infants with more severe respiratory distress syndrome may need the help of a ventilator to breathe. A ventilator is a mechanical device that forces air in and out of the lungs through a tube passed through the nose or mouth and into the windpipe (trachea). This treatment must be closely monitored because the pressure on the lungs can cause more damage. Too much oxygen can also damage the retina and cause vision problems. Your doctor will continue to monitor your baby’s blood oxygen level so he or she can be given only as much oxygen as necessary and can be weaned of the breathing assistance as soon as possible. Severe cases are also treated with a drug that is close to the natural surfacant found in the lungs. This drug is dripped into the lungs through a very thin tube in the baby’s trachea. This treatment reduces the risk of lung rupture and within a few days the infant is usually breathing more easily. Sometimes babies who are born prematurely but without signs of respiratory distress syndrome are given the surfacant drug as a preventive measure. If your child has a collapsed lung (pneumothorax), air has leaked into the chest cavity and needs to be removed right away. Your doctor will remove the air from the chest using a syringe and needle. A tube is then placed in the chest to stop air from accumulating. A premature baby’s lungs sometimes fill with extra fluid. Fluid in the lungs is treated with diuretics, a medicine that makes the baby urinate more often, which rids the body of excess water. Drugs may also be used to stimulate the part of the brain that controls breathing to prevent episodes of apnea. If the baby has necrotizing enterocolitis, feedings are stopped and the infant is given antibiotics, usually for 7 to 10 days. Surgery may be necessary if the intestines are seriously damaged. If retinopathy is causing problems, the extra blood vessels can be destroyed using laser surgery or by freezing them (cryosurgery). 

Premature babies are given extra iron in their diet so they have the iron needed to make new red blood cells when their bodies can make blood. Babies with extremely low red blood cell counts may need blood transfusions. High bilirubin levels can be treated by placing the infant under special bilirubin lights, which helps the bilirubin to be excreted by the liver more rapidly. Once they are released from the hospital, premature babies should have regular pediatric checkups to make sure they continue to grow and receive childhood immunizations. They should also be monitored for developmental problems so they can be referred to the appropriate special education or therapy programs.

Self-care tips

Premature birth, in many cases, can be prevented by good prenatal care. If your baby is born prematurely, educate yourself as much as possible about the needs of a premature infant. Don’t be afraid to ask questions and become an active participant in your baby’s care, especially while he or she is in the hospital. Once your baby is home, schedule regular checkups with your child’s pediatrician and any other specialists involved in the baby’s care. Just as you would with any newborn, be careful not to expose your baby to other children or adults with colds or the flu.

p/s: Artikel ni bersempena round pediatrics di Rahmah Hospital. Minggu ni khas untuk NICU….agak bes jugak la, hari-hari tengok baby baru lahir. Subhanallah.

~ Abu Thana’, Irbid ~

3 Comments leave one →
  1. Atiqah permalink
    October 31, 2008 5:01 pm

    nak bace macammane ni?

  2. irbidmall permalink
    November 8, 2008 10:54 am

    artikel ni abang syam yg karang ke? haha, mantap englishnye, tahniah.. bangga

  3. February 26, 2011 7:28 pm

    Salam, artikel yg mnarik.tmbhan pula memng sem nih ambil NICU, blajar psal premature baby. thanks utk prkongsian, sb dpt tmbah info & pmahaman.

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