Sunday, 24 July 2011

Managing Premature Babies

Published in Panorama

When babies are born premature …

Depending upon where they are born, whether in the developed or under developed countries, whether in hospitals with sound neonatal healthcare facilities or in centres lacking these facilities, about 8% - 14% of babies are born premature, before 37 weeks of gestation. However, 10% of all births in the U.S., it is believed, occur before 37 weeks gestation. The survival rate of premature babies or preemies as they are called, is directly related to their gestational age; the survival rate of babies born over 28 weeks of gestation is 96% or more and reduces to 50% when they are just 24 weeks into gestation, reveals Dr. Badi Alatasi, Specialist Paediatrician, Welcare Hospital, Dubai.

When are babies considered born premature?
A normal pregnancy lasts nine months, or about 38 to 42 weeks. Newborns are considered to be premature if they are born before they are 37 weeks old.

Why is it that some women go into preterm labour?
The risk factors which may increase the chance of a woman having a premature baby, may be related to the mother herself or the baby. The risk factors include: an incompetent cervix in the mother, history of prematurity for unknown reasons, multiple gestation pregnancies, placental bleeding, having too much or too little amniotic fluid, infections in the mother, especially if they spread to the uterus or placenta, uncontrolled diabetes or hypertension in the mother, smoking, maternal malnutrition and infections and malformations in the baby which could include malfunctions of its kidneys and inability to swallow properly. A woman who has delivered a baby premature, has a 20% - 40% risk of delivering a second baby also prematurely.

Are there any warning signals of preterm labour?
Symptoms of preterm labour may include frequent uterine contractions, pain, increased vaginal discharge and bleeding.

Is it possible to stop premature labor?
Sometimes it is possible to stop it if the cause is identified. If it’s a cervical incompetence that’s causing the condition, we put a knot around the cervix and try to hold the baby inside. If the reason is placental bleeding in the mother or baby, the mother is put on complete bed rest; antibiotics are given if infection is the cause and fluids given for dehydration. However, if the baby’s growth is poor and he is in distress, it may only be in the interests of the baby to deliver premature.

Are premature babies always delivered by Caesarian section?
Not necessarily. The labour might start by itself and babies may be delivered normally. However, sometimes, when the mother visits her obstetrician for some other reason as when she feels the baby is not moving properly or she’s having abdominal pain or bleeding, upon examination it may be observed that the baby is in distress. In such a situation, a Caesarian may be done to save the baby’s life.

Once a woman goes into premature labour or it is decided to bring out the baby prematurely, what is the kind of preparation that is done?
Hopefully, the course of action begins before the baby is delivered. The main problem associated with premature births involves the immature lungs of the baby. The obstetrician would give medication to the mother to try to promote the maturity of lungs in the baby before it is delivered. If the mother is suffering from some infection, treatment with antibiotics will be begun before the baby is delivered.

Once the baby is born, what would be the immediate course of action?
Early resuscitation of the preemies is very important. Ensuring the survival, safety and health of preemies requires team work including qualified nurses, neonatologists, or qualified paediatricians and other specialists if required. Once the baby’s condition is stabilized, it is transferred to a Neonatal Intensive Care Unit (NICU). Most preemies will probably be on a cardiorespiratory monitor with a pulse oximeter to measure the oxygen in their blood and they would have a feeding tube hooked on to them.

What are the medical problems preemies may face soon after birth?Most infants, at least those below 30-33 weeks of gestation need to be on a ventilator to help them breath normally. One of the commonest problem that preemies may have on the first few days of life is Respiratory Distress Syndrome (RDS) because of their immature lungs. Therefore they are not able to get sufficient oxygen and are unable to get rid of the carbon dioxide. So they will have to be hooked on to a ventilatory support to provide them the extra oxygen and will probably also receive a medication directly into their lungs.

The gastro-intestinal tract (GIT) in most preemies will not be able to tolerate feeding. Feeding them normal amounts of fluids might result in intestinal perforation which can create severe problems. Yet, feeding them is very important so as to restore the calories and nutrients required by their body. Also, if they are not fed, they will not be able to pass motion and this often predisposes them to jaundice and this can cause its own set of problems through the elevated bilirubin level. Hence most of them will be on intravenous fluids, either through an IV or umbilical central line. However, it is not possible to meet the entire nutritive requirements through IV line and hence most often, the central line is the preferred mode of feeding, though this would predispose them to higher chances of infection, and line clotting.

Also, the kidneys and liver of preemies are not very well mature. So you can easily overload the baby with fluid if you are giving too much in the IV; alternatively, if you are not giving the baby enough fluid, the circulation is not going to be adequate and this adds to them problems already existing. So it’s a very tight balance between not giving enough and giving too much and trying to keep up the metabolic demands of the baby.

The brain in Preemies, when they are born before 28 weeks of gestation, is not very mature; they have a higher chance of having a bleeding inside the brain. These are four categories or grades of bleeding and the higher the grade, greater the chances of associated brain problems in later life. Most bleeding occurs in the first few days of life, and except for larger bleeds, grades 3 or 4, many do not cause any long term problems.

Persistent ductus arteriosus (PDA), a blood vessel near the heart, normally closes after birth. However this can remain open in a premature baby and would need to be closed, either with medication or surgery. Preemies may suffer from anemia or low blood counts, which sometimes require blood transfusions.

What about the heart condition of premature babies?
Usually the babies’ hearts are quite strong and they can tolerate the requirements of the body. However, if a baby has had lack of oxygen before it was born, then the heart can fail just like when someone has a heart attack. The lack of oxygen causes the muscles not to contract because they are not strong enough. If you put too much stress on the heart, it might fail since it will not be able to generate enough pressure to give the nutrient to the rest of the organs. The heart will then have to be supported by medication which are quite effective in restoring its functions but not without side effects.

Is it true that premature babies might suffer from retinopathy?
Yes. When you give the baby extra oxygen, it causes damage to most of the organs and the eye is one of them. Retinopathy of Prematurity (ROP) may occur. So every baby that goes on oxygen, should have an eye examination by a retinal specialist at about 42-44 weeks post conceptional age– that is, from the time of its conception, and again six months later or as recommended by the ophthalmologist. However with better understanding of the ventilation of babies and better ways of monitoring the oxygen, the incidence of ROP is dropping, though it is still happening.

So being on the ventilator and extra oxygen, create their own set of problems for the babies?
Most certainly so. Anything that we do to the baby, has side effects. When we give it extra oxygen, we are producing a toxic material inside the lung and this can cause lung damage. There’s something called a chronic lung disease that happens after the baby goes on oxygen. True, while oxygen is life-saving, it is toxic at the same time, given in excess quantity. 21% of the air that we breathe, is oxygen. At 22%, it could become toxic! But sometimes the lungs of a preemie are so immature that 21% is not going to be enough; hence we will have to give extra. The longer the baby goes on oxygen, the more the chances of damage. However, small damages can be repaired by the body since the lungs keep growing until a child is eight years old.

Is it true that preemies are susceptible to inguinal hernia and hydrocele?
There is a higher chance at a later age, of these things happening. It is quite common in babies and very difficult to diagnose because they might just present with a little intolerance to feeding. When you feed them small amounts and keep advancing, at one point they might not tolerate the larger feed. So attending doctors and nurses should be vigilant and look for small clues because if you miss the problem, the babies could have intestinal perforations and severe problems including infection which can spread to all parts of the baby. When there is even the slightest suspicion of a hernia or hydrocele, the pediatric surgeon should step in to identify and rectify the problem with surgery, if needed.

Susceptibility to infection too must be quite high in preemies, yes?
True. Being born premature itself carries the risk of higher infection since their immune system may not be sound. Secondly, when feeds have to be given through the central line, this adds to the infection risk because when you are putting something into the main veins, any little infection can spread easily and seep into the heart. Also, the baby’s body has a capability to produce clots because of the foreign body being put into it and the body identifies it as a foreign object and begins to form little clots. If bacteria get inside these little clots, it becomes very difficult to eradicate and sometimes we have to take the line out. And this is not an easy procedure – to put in and pull out the central line. The babies can contract infection even from the nursery, the NICU and this can happen any time that a baby has a central line in. Anyone with even a little cold, if they come into the NICU, can pass on the virus to the baby and the infection can be very severe in them. Also, if you keep treating the baby with antibiotics to fight the bacterial infections, you are predisposing the baby to having fungal infection! Further, this also prevents the baby from absorbing the nutrients which in turn implies, its growth will be impaired.

Whenever you put anything extra on the baby, whether it be an intubation tube, IV catheter or even a little sticker to monitor the heart rate, they can all lead to infection. So the less you do, the better it is; yet, these are necessary evils that have to be done for the baby’s survival!

Whatever the problems that arise in preemies, how soon after birth do they show up and how long do they normally last?
Normally all these problems arise within 24 to 48 hours of the baby’s birth. If the baby has infection into the lungs, it might show up a little later. If the mother has an infection which has spread to the baby, this is of two types: one that shows up early and the other which can show up as late as in the first two months of its life. This is the reason why it is very important to treat fever in any child less than two months old, not only preemies, very seriously, because it is a serious infection until proven otherwise. It is important to get a blood test, urine test and also spinal fluid to rule out meningitis in the baby. A chest X Ray is also in order for a baby having fever at less than two months of age, according to international guidelines, except when the fever is brought on in response to vaccination. To check the fever out in preemies is all the more important because their immunity is lower than normal babies.

For how long will preemies require hospital care?
This again depends on the baby’s gestational age and overall medical condition. On an average, babies are hospitalized till they reach about full term, at least 37 – 38 weeks. If a baby is born at 32 weeks, one can expect a further hospital stay of 5 – 7 weeks. This is a general rule but exceptions may be there. If the baby comes out a little early from his problems, if the mother had already been given steroids to promote the baby’s lung maturity before its birth, if the baby’s weight is fine, it is able to tolerate feeding well, if the reason for prematurity was related to the mother and not the baby, there is a higher chance of the baby going out of the hospital, sooner.

Once the baby is out of the hospital and the critical two month period for possible fever is passed, what are the chances that the baby will grow normally like any other baby born full term?
When you are born premature, your body size is small and most of the times, it stays small. This again depends on the level of prematurity. Studies of growth charts of preemies indicate that they do not catch up even at 18 months or up to 3 years. When you are born small, you can never keep up because you cannot have the adequate environment like the uterus. The more you intervene, the more damage you cause and so greater the side effects and greater the chance that they are not going to grow faster. This is with respect to intellectual as well as physical growth of the baby.

Having said that, until 18 months, a lot of babies recover and do fine. But most of them do have problems which can be related to emotional instability since a newborn preemie does not get to be held close to its mother which is very essential for sound emotional bonding and status of the child in later life, as shown by many research studies. Further, the pricks and procedures such a baby is put too is known to be traumatic to the baby and early painful stimulation to the baby is known to cause a lot of emotional problems later in life. In fact, it has been proved that when the baby comes in skin contact with the mother following birth, it has a better oxygenation and less stress. The higher the pain, higher the level of stress hormones in the body, the greater the possibility that these can cause problems to the brain and other organs of the body. If babies are born very premature, the physical and mental growth and development of these babies will be less than that enjoyed by full term babies. However, if they are born after 28 weeks, chances are that they will be fine since the chances of brain damage and their requirement for all kinds of external support is less.

In these instances of birth before 28 weeks, do the genes not influence enough to counter these inhibitory factors?
No. Some premature babies that are born at 24 weeks, are scientist now! They are fine and excellent. But that doesn’t mean if they were not premature, they would not have been any brighter!


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