Professional Documents
Culture Documents
presented
By
Dr Abdullahi U
Paediatrics Department
FMCB
OUTLINE
Introduction
Incidence
Aetiology
Clinical manifestation
Gestational Age Assessment
Factors Associated with Prematurity
INTRODUCTION
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
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
1.
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
PROBLEMS OF PREMATURITY
RESPIRATORY SYSTEM
CARDIOVASCULAR SYSTEM
HAEMATOLOGIC SYSTEM
Anaemia
Hyperbilirubinaemia*
Subcutaneous, Organ (liver, adrenal) haemorrhage*
Disseminated Intravascular Coagulopathy
Vitamin K Deficiency
hydrops
GASTROINTESTINAL SYSTEM
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:
MANAGEMENT cont
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.
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
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
Preterm <1000g:
Preterm >1500g:
MANAGEMENT cont
PREVENTION OF INFECTION
MANAGEMENT cont
PREVENTION
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
DISCHARGE cont
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