Karazin Kharkiv National University

Department of Pediatrics

Nursing principles of preterm infants in

delivery hospital and at the second stage
of nursing.

Assistant Tatyana Golovko

 Medical care in maternity hospitalof
newborns with low birth weight

At premature delivery or delivery with intrauterine

growth retardation there must be doctor-
pediatrician-neonatologist in the delivery room!
The medical care technique also must be prepared!
If term of gestation is 34-36 weeks and child's
condition is satisfactory, the medical care for
infant is the same as for the healthy newborn.
If term of gestation is 32-33 weeks, the
management of medical care is determined in
accordance with baby’s condition.
If term of gestation is less than 32 weeks, the
medical care is determined in accordance with
protocol of primary reanimation of newborn.
 Indicators of adaptation of newborns
with low birth weight
Indicators Reference range

heart rate 100-160/min

respiration rate 30-60/min

coloration central cyanosis is absent

movements Active or moderate decreased

(moderate hypotonia)
lying position flexor or semiflexor (moderate
hypotonia)
the breathing character expiratory groan and intercostal
retraction are absent
Children with birth weight > 1500 grams
and gestation term > 32 weeks without
signs of disease at birth do not require any
diagnostic laboratory tests.
Determination of blood glucose levels must
take place once in the first 4-6 hours for
newborn with birth weight 1500 grams and
lower as well as children with clinical signs
of hypoglycemia. Re-defining of blood
glucose level is conducted in accordance
with the clinical condition of the child and
the results of previous research.
Doctor-pediatrician-neonatologist carries
out the primary assessment of a health
newborn with low birth weight just after
delivery. In case of any pathological signs
doctor-pediatrician-neonatologist also
carries out the primary physical
examination of a newborn immediately.
If the adaptation of the newborn with low
birth weight in contact 'skin-to-skin' runs
smoothly, primary physical examination of
a newborn is carried out on the warm
swaddling table under radiant heat two
hours later after birth before the transfer to
the round-the-clock rooming-in mother and
child
Doctor which carried out the primary
physical examination of a newborn records
the results of the examination into the
medical documentation and informs parents
about the baby’s health at the time of
inspection.
 Medical examination is carried system by
system, avoiding baby’s hypothermia.
lying position
is flexor or semiflexor. Head is slightly adduction to chest, arms are
moderately flexuosus at the elbow joint, legs are moderately flexuosus at the
knee and hip joints.

Fig.1 Normal physiological position of preterm newborn and term newborn

Cry: loud or mean tension emotional.
Skin: In healthy newborns the whole skin is pink.
The skin is elastic, can be covered by vernix
caseosa. Baby with gestation age near 37 weeks
may have dry skin which may peel. Babies have lot
of lanugo. It is located on the back, on the extension
superficies of extremities. Baby with gestation age
near 37 weeks have areas without it. The skin on the
soles is with barely visible red lines or with visible
only front transverse fold. In baby with gestation
age near 37 weeks the folds occupy 2/3 of the
surface. Mass of subcutaneous tissue is thin or
absent.
Head and skull: head form can be brachiocephalic or
dolichocephalic. Circumference is 24-32 cm. Cranium is round,
cranial bones are pliable, cranial sutures and
occipital fontanel are open.
Ear auricles are boggy, moderate involute and slowly developed.
Baby with gestation age near 37 weeks has boggy, well involute
and well developed ears.
Mammary gland: areola is two-dimensional, nipple is not above
the skin surface. In baby with gestation age near 37 weeks the
areola is overhang above the skin surface, nipple is 1-2mm.
Chest: Inferior thoracic aperture is unfold, true position of ribs is
symmetrical and approaches to horizontal. Circumference is 21-30
cm. Chest excursion is symmetrical with rate 30-60 /min.
Lungs: at auscultation over lungs the symmetrical puerile
breathing can be determined. In basal parts breathing may be
absent.
Heart: heart rate is 100-160 /min.
Neurological status: moderately hypotonia, spontaneous motor
activity. Small and impermanent tremor of extremities and chin,
small and impermanent horizontal nystagmus, a moderate
hyporeflexia in a child with satisfactory general condition. It is a
transitory status and it does not require any special therapy.
Abdomen: round form, takes part in the act of breathing, soft,
available deep palpation. The liver can come forward on 1.0-2.0 cm
from under the edge of costal arch. Edge spleen can palpate under
costal arch.
Genitals and anus: scrotum in boys may be empty or testis can be
found at the top of the channel. Baby with gestation age near 37
weeks has one or both testis are in scrotum but they can easily hide in
the inguinal ring when pressing on them. Girls’s large labia does not
fully cover small ones. Clitoris overhang. The presence of anus can
be determined.
Inguinal region: pulse of the femoral artery is palpated and checked
symmetrically.
Osseous system: breeding in the hip joints full or excessive.
 It is necessary to determine the gestational age by
Ballard score from the 12th to the 36th hour of life
in newborns with low body weight at birth .
Ballard score is based on taking into account the total
evaluation of the neuromuscular and physical maturity
to establish the gestational age of the baby
from the 20th to the 44th week of gestation.
Accuracy of age both healthy and sick baby can vary
within two weeks of gestation.
Neuromuscular maturity.
Physical maturity.
 Method of estimation.
1.1 It is recommended to mark (cross out) the cell in the tables the
neuromuscular and physical maturity, which corresponds to a
specific sign in a child. It facilitates and speeds up the work with the
score by marking cell, a work moves on without any delay.
1.2 Each of the indicators included in the scale is estimated in points,
the amount of which may vary from 0 to 50.
1.3 After evaluating all the signs of neuromuscular and physical
maturity the neonatologist who carried the assessment calculates the
total number.
1.4 If it is impossible to assess objectively the neuromuscular
maturity (e.g., a child receives sedating drugs, or reside on forced
ventilation), result assessment of physical maturity can multiply by 2
and the gestational age of the baby determines according to the table
of assessment of maturity.
 Position of newborn
Observations is carried out when the child is resting and
lying on his back.
1.Score 0 - upper and lower extremities are unbent.
2.Score 1 – is initial flexion of the lower extremities in the
hip and knee joints, upper extremities are unbent.
3.Score 2 – is stronger flexion of the lower extremities,
upper extremities are unbent.
4.Score 3 - upper extremities are slightly flexion, the lower
extremities are flexion and rear.
5. Score 4 – is full flexion in upper and lower extremities.
 Square window.

Hand is sandwiched between thumb and

forefinger of a doctor and bent toward the
forearm.
During this manipulation the rotation of the wrist
joint of newborn should not be allowed.
 The reaction of the arms.
Baby lies on back. Upper limbs are bent in the elbow joint
and are held in this position for 5 seconds. Then they are
unbent completely by pulling hand and are abruptly let
go. Here you can start the evaluation.
1.Score 0 - upper extremities are unbent or automatic
movement may take place.
2.Score 2 - if the angle of the elbow joint is 100-180 °.
3.Score 3 - if the angle of the elbow joint is 90-100 °.
4.Score 4 - if the angle of the elbow joint is 90 °.
 Popliteal angle.

The child lies on his back, pelvis is pressed

against the surface of the table. The doctor by his
forefinger of his left hand holds the femur in the
knee-chest position and the thumb supports the
knee baby. In this position the lower limbs are
unbent easily by pressing with the right
forefinger on the back of the ankle joint and
measuring the popliteal angle.
 Symptom collar (oblique motion).
The child lies on his back, the upper limb is held by the hand and
the neonatologist tries to make it as far as possible beyond the neck
to the opposite shoulder. The implementation of this movement
helps move the elbow along the body.
1. Score 0 – the elbow reaches the anterior axillary line.
2. Score 1 – elbow is between the median line of the body and the
opposite anterior axillary line.
3. Score 2 - the elbow reaches the median line of the body.
4. Score 3 – the elbow doesn’t reach the median line of the body.
 Adduction calx to ear.

The child lies on his back. Foot is as closer to the

head as possible without much effort.
Determine the distance between the foot and the
head and the degree of extension of limb in the
knee. Result is estimated in points.
 Feeding of preterm newborns

Gestation age Feeding

Before 30 week Gastrogavage (through
enteral tube)
30 – 33 week gastrogavage or from cup

34 - 35 week breast feeding or from cup

> 36 week breast feeding

Tabl. 1 Selection of the feeding of newborns

 Body weight , g Stomach size, ml
900 18
1000 20
1250 25
1500 30
1750 35
2000 40
2500 50

Tabl. 2 Approximate size of the stomach in depending on the body weight of

the newborn
 Breast feeding
Breast feeding of a newborn with low birth weight
should be initiated as soon as possible in
depending on the child's condition.
It is also necessary to assess the correct application
of the child to the breast while breast-feeding:
-the chin touches the breast;
-the baby's mouth is wide open;
-lower lip of a baby is inverted outwards;
-child grasps the lower part of areola.
At the beginning of breast feeding it is necessary to
evaluate:
- the sucking ability of a child;
- availability of posseting or vomiting during feeding
or after that. Baby can choke with milk or cough
because muscle tone is low. Posseting or vomiting
can occur because gastroesophageal reflux can be
observed and swallowing air while sucking, so the
mother and staff must carefully follow these signs
during and after feeding.

If baby cough and posseting during feeding, mother can

use vertical position.
For more effective breastfeeding of
infants with low birth weight it is necessary to
implement the nursing method of “Mother-
Kangaroo” as soon as possible.
“Mother Kangaroo” - this is not traditional
method of care for preterm neonates or neonates
with low body weight at birth after stabilization
of their condition.
The task of method “Mother Kangaroo”
1. It ensures the formation of close psychoemotional
contact between mother and child.
2. Increases the frequency and duration of
breastfeeding.
3. Reduce the risk of nosocomial infections.
4. Promotes family participation in nursing children
with low birth weight.
5. Provides an alternative approach to preserve and
maintain the body temperature of the child.
 Preparing of babies.
Put on little cap, socks and
pampers on baby.
In addition put on a shirt,
but not button it to ensure
the contact 'skin-to-skin'.
 Kangaroo-position.
1. Place the child in a vertical position between
the breasts of mother.
2. Head , neck, body of baby had to be rectified.
3. Arms of baby must be on mother’s breast.
4. The legs of the child must be placed lower
the breast of mother and half-bent. Such a
position is similar to the position of
“frogling”.
5. Fix baby towards to the mother’s body by a
fabric or "bag“.
6. The fabric should not cover the entire head of the
child, but only part of the ear.
7. Cover the baby by mother’s clothes.
8. It is necessary to support baby during the method of
“Mother - Kangaroo". ‘Skin-to-skin' contact is desirable
to maintain for 24 hours a day with breaks.
 Feeding a baby with a cup
If baby cannot take the breastfeeding on a reason of his or her
own illness or mother’s illness or milk supply failure, it is
necessary to provide feeding baby with a cup.
1.Pour in a cup the appropriate amount of milk;
2.Put your baby on your knees semivertically;
3.Set a cup to lips and tilt it so that milk touches the lips of the
child. At this time the child starts to suck it and begins to
swallow it;
4.Do not pour the milk into the baby's mouth;
5.Do not stop feeding until the child closes his or her eyes and
stops 'swallowing' milk by him or herself.
6.Evaluate the amount of food eaten and plan the amount of milk
for the next feeding.
Birth freque 1 2 day 3 day 4 day 5 day 6 – 13 > 14
weight ncy day days day
of feed
ing
≥ 1500 60 60 80 90 100 110 120 - 180 -
g ml/kg ml/k ml/kg ml/kg ml/kg ml/kg 180 200
g ml/kg ml/kg

Table 3 Daily total amount of milk (or liquid) in depending on day of life
 Birth frequen 0 – 1 day 2 day 3 day 4 day 5 day 6 day ≥7
weight cy 24 day
,g of feed hours
ing in
day
1500- 8-12 15 17 ml 19 ml 21 ml 23 ml 25 ml 27 ml 27 ml
1999 ml and
higher

2000- 8-12 20 22 ml 25 ml 27 ml 30 ml 32 ml 35 ml 35 ml
2499 ml and
higher

2500 8-12 25 28 ml 30 ml 30 ml 35 ml 40 and higher 50 ml

and ml higher and
higher higher

Table 4 The approximate amount of milk for one feeding, depends on body weight
and day of life every 2-3 hours from the moment of birth
 Feeding a baby with enteral feeding tube

If baby cannot take the breastfeeding or feeding

with a cup, it is necessary to provide feeding baby
with enteral feeding tube.

Putting the enteral feeding tube is a sterile procedure,

which requires compliance with relevant requirements.
 Used two types of enteral feeding tube:

nasogastral tube orogastric tube

The necessary equipment and materials for putting the
enteral feeding tube should be prepared :
a. For babies with body weigh < 2000,0 g enteral feeding
tube № 5-F, > 2000,0 g enteral feeding tube № 8-F.
b. sterile syringes 2 ml and 5 ml for aspiration of stomach
contents;
c. measuring tape;
d. adhesive plaster;
e. scissors;
f. water for injection or sterile solution of 0,9% NaCl;
g. cup with expressed breast milk.
Process your hands and put on sterile gloves!!!
Measure the length of the enteral feeding tube:
-nasogastral tube: from the tip of the nose to the ear lobe
and xiphoid process;
-orogastric tube: from the angle of the mouth to the ear
lobe and the xiphoid process.
Wet with water for injection or sterile solution of 0,9%
NaCl the tip of enteral feeding tube.
Moderately bend neck of baby and slowly enter the
feeding tube on the measured distance through the
mouth or anterior nostril.
In case the tube does not pass easily through the nostril,
remove it and try to put into the other one.
If this fails, enter the tube through the mouth. Never
make efforts to pushing the tube to prevent injury.
Fix the tube with adhesive plaster.
Check the location of the tube. By sterile syringes
enter 1 – 2 ml air in the stomach and hear the
movement of air over the tube with stethoscope. If
the noise of air is heard, the tip of the tube is in the
stomach. If the noise of air is absent, immediately
pull out the tube and repeat the procedure. It is not
viable to set a new tube for each feeding, because
it increases the risk of injury, infection and apnoea.
At the adherence of all instructions the tube can
function up to 3 days.
 Method of feeding through a tube.
1. Take sterile syringe and extract the plunger out of it.
2. Connect the tube with syringe and pour into there
calculated amount of expressed breast milk.
3. Help the mother to put the baby correctly. Baby's
mouth should be at the level of the nipple and open.
4. Syringe with milk must be kept at a distance 5-10
centimeters over baby.
5. Continue feeding for at least 10-15 minutes.
6. During feeding milk should slowly drain out of the
syringe.
7. Adjust the speed of the flowing of milk during
feeding, gradually changing the distance between the
syringe and the child (raising and lowering it).
8. Do not enter milk under pressure!
9. When feeding through a tube carefully watch the
baby, color the skin and mucous membranes, respiratory
rate and character.
10. During the feeding through a tube baby may be
latched on breast depending on it is clinical condition.
11. When appear the weakness sucking reflex in baby, it
can feeding with cup or breastfeeding within the
shortest possible time!!!
 Screening examinations of newborns
with low body weight at birth
1. All newborns must pass examinations on phenylketonuria
and hypothyroid infantilism.
2. Contraindications for examinations are absent!
3. Examinations carried out by the informed consent of the
mother.
4. Examination on phenylketonuria must pass all newborns
with low body weight at birth, at least after 24 hours feeding
breast milk or milk mixture, but before to discharge from the
hospital.
5. Examination on hypothyroid infantilism must pass all
newborns with low body weight at birth after second day of
life, but before to discharge from the hospital.
 Prevention measures

Prevention of hemorrhagic disease of the newborn:

1.Once all newborns with low birth weight must take
Vitamin K1 in an amount of 1.0 mg per intramuscular
injected in the first days after birth.
2.If the presence of an oral form of vitamin K1
recommended dose of 2 mg, which is introduced in the
first and seventh days of life baby.
 The preventative administration
of vitamins A and E

Newborns with low birth weight > 1500 grams

do not require routine administration of vitamins
A and E. Timely and full feeding breast milk to
prevent the development of deficiency of
vitamins A and E.
 The preventative administration
of vitamin D.

From the end of the 1st week of life with the

enteral feeding it is necessary to begin
preventative administration of vitamin D in dose
400 - 800 IU (International units), daily. When
feeding mixture additionally prescribe vitamin D
to get a total daily dose of 800 IU.
 The preventative administration
of Fe (iron)

Newborn with birth weight <1800 g and gestational age

< 32 weeks from the beginning of 3 weeks of life, with
the enteral feeding and to end of one chronological year
of life is recommended appointment of 2-4 mg / kg of
elemental iron internally per day daily.
If necessary, along with the introduction of elemental
iron can be assigned to the introduction of folic acid at a
rate of 50 mg / day every day.
 Discharge criteria are as follows:
1) child has weight ≥ 2000 g
2) the parents and/or caregivers are capable. That is, they
demonstrate an ability to meet the needs of the infant;
3) the patient's caloric intake is adequate for growth;
4) the patient does not require additional heat. He or she has
stabile temperature over a period of 3 days;
5) medical problems are defined and are manageable at home;
6) the patient does not have apnea and bradycardia more than 7
days before the discharge.
7) child has stabile respiratory rate 30-60 per minute. Idrawing
intercostal spaces are absent. Cyanosis of skin and mucouses is
absent.
8) the daily volume of feeding child is uptake and put on weight
over a period of 3 days.
9) The umbilical cord is clean and dry, don’t have inflammation's
sings.
10) Mother and family members are know above the dangerous
conditions:
- suckle is bed;
- child has weakness or hyperactivation;
- child has a convulsion;
- child has a respiratory rate more than 60 p/m or less
than 30 p/m;
- child has hypothermia or hyperthermia.
Parents must going to the doctor immediately!!!
THE END