PREMATURITY

presented
By
Dr Abdullahi U
Paediatrics Department
FMCB

OUTLINE
Introduction
Incidence
Aetiology
Clinical manifestation
Gestational Age Assessment
Factors Associated with Prematurity

and Low Birth Weight

Problems of Prematurity
Management
Prevention
Prognosis
Discharge
Home Care

INTRODUCTION

Definition:- prematurity is defined as a Live born Infant

delivered before 37week from the 1st day of the last
menstrual period (WHO). Also refered to as Preterm.
It is a High-risk birth that needs urgent medical
attention.
Prematurity and IUGR are associated with neonatal
morbidity and mortality.
In general preterm infants weigh <2500g, have crownheel length<46cm, an OFC<33cm and CC<30cm.
LBW is due to prematurity, poor intrauterine growth, or
both.
Neonatal intensive care has markedly improved survival
of premature and LBW babies.

INCIDENCE
In the united states in 2000 7.6% of live birth
are preterm. 1% of infants weigh <1500g at
birth.
In Nigeria the incidence ranges from 3.5% in the
east (Azubuike 1980) to 21% in the west
(Dawodu and Effiong 1977).
The rate for prematurity for Blacks is twice that
of whites.
Women whose 1st birth are delivered preterm
are at increased risk of recurrent preterm
delivery.

AETIOLOGY

The causes of prematurity is multifactorial and involves complex interaction between

foetal, placental, uterine and maternal factors thus:Foetal factors
Foetal distress
Multiple gestation
Erythroblastosis
Non immune hydrops
Placental factors
Placental dysfunction
Placenta previa
Abruptio placentae
Uterine factor
Bicornuate uterus
Incompetent cervix (premature dilatation)
Maternal factor
Pre eclampsia
Chronic medical illness (e.g. cyanotic heart disease, renal disease)
Infection (e.g. listeria monocytogenes, group B streptococcus, UTI, bacteria
vaginosis, chorioamnionitis)
Drug abuse
Others
Premature Rupture of membrane
Polyhydramnios
Iatrogenic
Trauma

FACTORS RELATED TO PREMATURE

BIRTH AND LBW
Low socio economic status: higher rates of maternal
under nutrition, anaemia and illness.
Inadequate prenatal care
Drug misuse
Obstetric complication
Maternal history of reproductive insufficiency (abortion,
stillbirth, premature/LBW infant
Others are

Single parent families

Teenage pregnancy
Short interpregnancy interval
Parity >4

CLINICAL MANIFESTATION

A premature infant will have a low birth weight. Common symptoms in a premature
infant include:
Body hair
Episodes of absent breathing
Enlarged clitoris (female infant)
Lung problems such as neonatal respiratory distress syndrome
Poor feeding
Small scrotum, smooth without ridges (male infant)
Soft, flexible ear cartilage
Thin, smooth, shiny skin
Transparent skin (can see veins under skin)
Usually inactive -- however, may be unusually active immediately after birth
Weak cry
Wrinkled features
Hypothermia
Investigation
Blood gas analysis
Serum urea and electrolyte
Serum calcium
Serum bilirubin
RBS
CXR

ASSESSMENT OF GESTATION AGE

Assessment of Gestational age may be by the following
Obstetric History

1.

Date of last menstrual period. Estimation of EDD can be calculated

using McDonalds rule
Obstetric scan- considered more accurate if done before 20 wks
gestation
Quickening- first felt at about 16-18weeks.
Date of first fetal heart sound-first detected by ultrasound at 8-10
weeks.

The degree of prematurity estimated by examination of anterior

vascular capsule of the lens in the first 24-48hrs.
Physical examination of Newborn using

2.
3.

Modified Dubowitz
Ballard scoring system

-1

Skin.

Sticky,
friable,
transpare
nt

Gelatino
us, red,
translusc
ent

Smoot,
pink,
visible
veins

Superficial
peeling
and/or
rash, few
veins

Cracking,
pale areas,
rare veins

Parchment,
deep
cracking,
no vessels

Leathery,
cracked
wrinkled

Lanugo.

None

Sparse

Abundant

Thinning

Bald areas

Mostly Bald

Plantar
surface

Heel-toe
40-50mm;
-1
<40mm;-2

<50 mm,
no crease

Faint red
marks

Anterior
transverse
only

Creases on
ant. 2/3

Creases
over entire
sole

Breast

impercepti
ble

Barely
perceptibl
e

Flat
areola-no
bud

Stripped
areola, 12mm bud

Raised
areola, 34mm bud

Full areola,
5-10mm
bud

Eye/Ear

Lids fused
loosely(-1)
Tightly(-2)

Lids open
pinna flat,
stays
folded

Slightly
curved
pinna, soft,
slow recoil

Well curved
pinna, soft
but ready
recoil

Formed
and firm,
instant
recoil

Thick
cartilage,
ear stiff

Genitals
Male

Scrotum
flat,
smooth

Scrotum
empty,
faint
rugae

Testes in
upper
canal, rare
rugae

Testes
descending
few rugae

Testes
down,
good rugae

Testes
pendulous,
deep rugae

Genitals
Female

Clitoris
prominent,
labia flat

Prominent
clitoris
small labia
minora

Prominent
clitoris,
enlarging
larbia
minora

Major and
minora
equally
prominent

Majora
large,
minora
small

Majora
cover
clitoris and
minora

Neuromuscular maturity

Maturity Rating
Score

weeks

-10

20

-5

22

24

26

10

28

15

30

20

32

25

34

30

36

35

38

40

40

45

42

50

44

The physical and neurologic scores are

added to calculate gestational age.

PROBLEMS OF PREMATURITY

RESPIRATORY SYSTEM

Respiratory distress syndrome (Hyaline membrane disease)*

Bronchopulmonary dysplasia
Pneumothorax, Pneumomediastinum, Interstitial emphysema
Congenital Pneumonia
Pulmonary Hypoplasia
Pulmonary Haemorrhage
Apnoea*

CARDIOVASCULAR SYSTEM

Patent Ductus Arteriosus*

Hypotension
Hypertension
Bradycardia (with Apnoea)

PROBLEM OF PREMATURITY cont

HAEMATOLOGIC SYSTEM

Anaemia
Hyperbilirubinaemia*
Subcutaneous, Organ (liver, adrenal) haemorrhage*
Disseminated Intravascular Coagulopathy
Vitamin K Deficiency
hydrops

GASTROINTESTINAL SYSTEM

Poor Gastrointestinal function-poor motility*

Necrotising Enterocolitis
Hyperbilirubinaemia- direct and indirect
Congenital anomalies producing polyhydramnios
Spontaneous GI isolated Perforation

PROBLEMS OF PREMATURITY cont

METABOLIC- ENDOCRINE SYSTEM

Hypocalcaemia*
Hypoglycaemia*
Hyperglycaemia*
Late metabolic Acidosis
Hypothermia*
Euthyroid but low-thyroxin states
CENTRAL NERVOUS SYSTEM
Interventricular Haemorrhage*
Periventricular Leukomalacia
Hypoxic Ischaemic Encephalopathy
Seizures
Retinopathy of Prematurity
Deafness
Hypotonia*
Congenital Malformation
Kernicterus (Bilirubin Encephalopathy)

PROBLEMS OF PREMATURITY cont

RENAL SYSTEM
Hyponatraemia*
Hypernatraemia*
Hyperkalaemia*
Renal Tubular Acidosis
Renal Glycosuria
Oedema
OTHERS
Infections ( congenital, perinatal, nosocomial;
bacterial, viral, fungal, protozoan)

MANAGEMENT
When premature labor develops and cannot be
stopped medically, the health care team should
be prepare for a high-risk birth.
Specific treatment for prematurity will be
determined by physician based on:

The gestational age, overall health, and medical

history
The tolerance for specific medications, procedures, or
therapies
The expectations for the course of the disease
The opinion or preference of parents

MANAGEMENT cont

The measures needed in Resuscitation at birth for

clearing the Airways, Initiating Breathing and adequate
Circulation, caring for the cord and eyes, and
administering vit. K are the same in preterm babies as in
those of term and normal babies.
Special care is required to maintain a patent airway and
avoid potential aspiration of gastric content.
Other considerations are:

The need for Thermal control and monitoring of HR & RR

The need for oxygen therapy
The need for special attention to details of feeding

MANAGEMENT cont

THERMAL CONTROL

The survival rate of preterm and sick infants is higher when they
are cared for at or near their neutral thermal environment.
Optimal environmental temperature for minimal heat loss &
oxygen consumption for an unclothed infant is one that maintain
infants core temperature at 36.5-37C.

This depend on infant size maturity and postnatal age.

Incubators or Radiant warmers can be used to maintain body

temperature.
Additional plexiglas heat shield or head cap and body clothing
may be required for ELBW infant.
An infant should be weaned and gradually removed from the
incubator only when the gradual change in to the atmosphere of
the nursery does not result in significant change in infants
temperature, colour, activity or vital signs.

MANAGEMENT cont

OXYGEN THERAPY
Administration to reduce the risk of injury from
hypoxia and circulatory insufficiency must be
balanced against the risk of hyperoxia to the eyes and
oxygen injury to the lungs.
Administration is by face mask, nasal prung, CPPV
apparatus or endotracheal tube to maintain stable &
safe inspire oxygen concentration.
Although cyanosis must be treated immediately
oxygen is a drug and must be carefully regulated to
maximise benefit and minimise potential harm (adjust
base on PaO2).

MANAGEMENT cont

FLUID REQUIREMENT
Fluid need vary according to GA, environmental condition &
disease state.
Assuming minimal water loss in the stool of infants not
receiving oral fluids, their water needs are equal to their
insensible water loss, excretion of renal solutes, growth and any
unusual ongoing loss.
Insensible loss is directly related to GA
<1000g may loss 2-3ml/kg/hr.
2000g-2500g may loss 0.6-0.7ml/kg/hr.
An adequate fluid intake is essential for excretion of urinary
solute load (e.g. U, E, P )
Amount varies with dietary intake and the anabolic or
catabolic state of nutrition.
Formulas with high solute, high protein intake and
catabolism increase the end product that require urinary
excretion and thus increase requirement for water.

MANAGEMENT cont

FLUID REQUIREMENT

Newborn especially those with VLBW are less able to

conc. urine; thus the fluid intake required to excrete
solutes increases.
Water intake in term infants at birth is 60-70ml/kg; its
increase by 10-15ml/kg/24hr.
Water intake in preterm infants at birth is 7080ml/kg.
Daily weight, urine, serum urea, nitrogen with
electrolyte should be monitored carefully to determine
water balance and fluid needs.

MANAGEMENT cont

PARENTERAL NUTRITION
Before oral feeding is established or when it is impossible for
prolong period, total intravenous alimentation may provide
sufficient fluid, calories, amino acids electrolytes and vitamins to
sustain the growth of preterm infant.
The GOAL is to deliver sufficient calories from glucose, protein
and lipids to to promote optimal growth.
Infusate should contain:
2.5-3g/dl of synthetic amino acid.
10-15g/dl of glucose.
Appropriate amount of electrolytes, trace minerals & vitamins
Intravenous fat emulsion such as 20% intrapid (2.2kcal/ml) may
be administered to provide calories without an appreciable
osmotic load there by decreasing the need for infusion of high
glucose conc. And preventing development of essential fatty acid
deficiency. (initiated at 0.5g/kg/24hr and advanced to
3g/kg/24hr if tryglyceride level remains normal).

MANAGEMENT cont

PARENTERAL NUTRITION
Electrolytes, trace minerals and vitamins are added in
amount establishing i.v. maintenance requirement.
The content should be determined daily after carefully
assessing the infant clinical and biochemical status.
After establishing calorie intake of 100kcal/kg/24hrby
parenteral nutrition preterm can be expected to gain
weight by 15g/kg/24hr with positive nitrogen balance
of 150-200mg/kg/24hr in the absence of sepsis,
surgical procedure.
The goal of parenteral nutrition can be achieved by
infusion of:
2.5-3.5g/kg/24hr amino acid.
10% dextrose.
2-3g/kg/24hr intralipid.

MANAGEMENT cont

FEEDING
The method of feeding each preterm/LBW infant should be
individualised.
Avoid fatigue and aspiration of feed by regurgitation or by
feeding process.
No feeding method avert these problem unless the person
feeding is the infant has been well trained in the method.
Direct oral feeding should not be initiated or should be
discontinued in infant with; resp. distress, hypoxia, circulatory
insufficiency, excessive secretion, gagging, CNS depression,
immaturity or signs of serious illness.
Preterm infants at 34wks GA can be directly breast feed.
The limiting factor is sucking effort.

MANAGEMENT cont

INITIATION OF FEEDING
The main principle of feeding premature baby is to proceed
cautiously and gradually.
Once baby is stable small volume feeding is given in addition to
I.V.F/nutrition. (feeding is gradually increase & parenteral
nutrition decreased: this approach may decrease incidence of
NEC).
Attempt oral feeding if infant is making sucking movements and
is in no distress.
N.B. infants <1500g require tube feeding because their inability to
coordinate sucking, breathing and swallowing.
GIT readiness for oral feeding is determined by; active bowel
sound, passage of meconium and absence of abdominal
distension, bilious gastric aspirate and vomiting.

MANAGEMENT cont

INITIATION OF FEEDING cont

Preterm <1000g:

Preterm >1500g:

Half strength or full strength breast milk 10ml/kg/24hr stat

divided 2hrly or continuous.
If well tolerated increase by 10-15ml/kg/24hr.
Full strength breast milk 20-25ml/kg/24hr stat divided 2hrly.

Daily intake of 130-150ml/kg may be necessary for

some infants to gain weight.
Weight gain may not be achieved by10-12days.
During tube feeding aspirate content of the stomach
before each feeding.

Once a premature infant takes 120ml/kg/24hr, breast

milk fortifiers are added to supplement breast milk with
protein, calcium and phosphorus.
At 34-36wks GA infants who are not receiving breast
milk should be switched to a term formular.
Breast milk from the infant mother is the preferred milk
for the including VLBW.
Properly fed premature infant passed stool 1-6times
daily of semisolid consistency.
Premature infant should not vomit or regurgitate.
They should be satisfied and relaxed after feeding, but
may show normally activity of hunger shortly before the
next feeding.

MANAGEMENT cont

PREVENTION OF INFECTION

Preterm infants have increase susceptibility to

infection and thus meticulous attention to infection
control is required.
Prevention strategies include:

Hand washing and universal precaution.

Avoid over crowding and limit Nurse-patient ratio.
Minimise risk of catheter contamination.
Meticulous skin care.
Encourage early appropriate increase in oral feeding.
Education and feedback to staff.
Surveillance of nosocomial infection rates in the nursery.

MANAGEMENT cont

PREVENTION OF INFECTION cont

Although no one with infection should be allowed into

the neonatal unit, the risk of infection must be
balanced against the disadvantage of limiting contact
with the family.
Routine immunisation should be given at standard
dose.
When epidemic occurs in a neonatal unit, cohort
nursing and isolation rooms should be used.

PREVENTION

The most important steps to preventing prematurity is to receive

prenatal care as early as possible in the pregnancy, and to continue
such care until the baby is born .
Premature labour can sometimes be treated or delayed by a
medication that blocks uterine contractions.
Because maternal nutrition and weight gain are linked with fetal
weight gain and birth weight, eating a healthy diet and gaining
weight in pregnancy are essential.
Other ways to help prevent prematurity and to provide the best care
for premature babies may include:
Identifying mothers at risk for preterm labour.
Prenatal education of the symptoms of preterm labour.
Avoiding heavy or repetitive work or standing for long periods of time
which can increase the risk of preterm labour.
Early identification and treatment of preterm labour.

PROGNOSIS
Infants weighing 1500-2500g have 95% chance of
survival (based on available facility), but those weighing
less still ha significant higher mortality.
Intensive care has extended the period during which a
VLBW infant is at increased risk of dying of complication
of prematurity e.g. BPD, NEC, nosocomial infection.
Post discharge mortality rate is greater than that of a
term infant in the 1st 2yrs of life.
Preterm infant have increased risk of FTT, SIDS, child
abuse, inadequate maternal-infant bonding.
Congenital anomalies is present in approximately 3-7%.
VLBW infant may not catch up especially in the presence
of severe chronic sequele, insufficient nutritional intake
or an inadequate caretaking environment.

PROGNOSIS cont
The greater the immaturity and the birth weight,
the greater the likelihood of intellectual and
neurologic deficit.
Small head circumference at birth may be
similarly related to a poor neurobehavioral
prognosis.
Most surviving preterm LBW infants have
hypotonia before 8month corrected age and
improves by 8month to 1yr old. This transient is
not a poor prognostic sign.

DISCHARGE

Before discharging a preterm infant should be taking all

nutrition directly.
There should be steady increase in growth of 2030g/24hr.
Temperature should be stabilised in an open cot.
There should be no recurrent episodes of apnea or
bradycadia.
Parenteral drugs should have been discontinued or
converted to oral.
All infants with birth weight of <1500g and those
between 1500-2000g with an unstable clinical course
requiring oxygen should have an eye examination to
screen for retinopathy of prematurity.
All premature infant should have a hearing test.

DISCHARGE cont

Those with indwelling umbilical arterial catheter should

have their BP measured to check for renal vascular
hypertention.
Check Hb for anaemia.
After resolution of all major medical problems and home
setting is adequate, premature infants may be
discharged when their weight approaches 1800-2100g.
Close follow up plus easy access to health care provider
is essential for early discharge.
Standard vaccination with full doses should be
commenced after discharge, with vaccines that do not
contain live viruses.

HOMECARE
While baby is in hospital, mother should
be instructed in how to care for the baby
after discharge.
Ideally these programme should include at
least one visit to her home by some one
capable of evaluating domestic
arrangement and advising about any
needed improvement.

References

Nelson Textbook of Pediatrics 17th EditionBehrman, Kliegman and Jenson.

Jollys Disease of Children 2nd Edition- M Levene.
Tropical Paediatrics-Azubuike and Nkanginame.
www.healthsystem.virginia.educ... last update
18th march 2008.
www.medicineplus.gov last update 18th march
2008.

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