The Preterm Infant

what is a preterm infant

one born before full term

preterm infants often require additional care beyond that which is provided to the full term infant

true

preterm birth is often associated with a range of risk factors which increase the risk to baby in utero, and these factors may then warrant elective planned preterm birth or may reqult in spontaneous birth before full term

true

survival and outcomes are also strongly correlated with the gestational age at which birth occurs

true

extremely preterm

less than 27+6 weeks

very preterm

28 to 31+6 weeks

moderately preterm 

32 to 33+6 weeks

late preterm

34 to 36+6 weeks gestation

where gestational age is less than 25+6 weeks refer to QCG perinatal care at the threshold of viability

true

what is the Ballard scale

assessment of the newborn infant and extremely preterm infant

what are the 6 aspects of the Ballard assessment neuromuscular score 

posture, square window, arm recoil, popliteal angle, scarf sign, heel to ear

what are the 6 aspects of the Ballard assessment physical maturity score

skin, lanugo, plantar surface, breast, eye/ear, genitals

survival and subsequent outcomes reduce with increased prematurity but with advancing technology survival rates have progressively improved

true

what is the survival rate of infants from 24 weeks gestation

60%

what’s the survival rate of infants over 500g

65%

although survival rates have improved, the short and long term outcomes of infants are not always evident until later in life but can lead to a range of other comorbidities across the lifespan

true

margin of viability for preterm birth is

22-24 weeks gestation

short term risks for preterm infants

respiratory distress syndrome, feeding difficulties, temperature control problems, jaundice, patent ductus arteriosus, hypoglycaemia, sepsis, infection

long term risks for preterm infants

cerebral palsy, cardiovascular complications, renal complications, hearing or visual complications, learning difficulties, asthma, endocrine complications

why is it important to have an accurate gestational age of the fetus/preterm infant

there are significant developmental milestones which occur at each week of gestation and each week in utero and by knowing which week of gestation the baby is gives an indication of the development of different organs and body structures

the presence of experienced staff plays a significant factor in ensuring the neonatal outcomes are optimised

true

it is important for a multidisciplinary team to recognise when there is a need to transfer to a high level facility or to a special care nursery or a NICU and the optimal timing for this

true

education and participation of the multidisciplinary team helps to ensure the stabilisation of the preterm baby

true

what factors may influence the ability to stabilise the infant for transfer

gestation which the baby was born, vitals of the baby, underlying status of the baby (infection, apnoea, cardiovascular complications, MAS), blood glucose

preterm infants will be transferred to a special care or NICU, and the duration of stay is often dependent on what

how the baby responds to transition to extrauterine life

when is respiratory support indicated for the preterm infant

w/ respiratory distress shortly after transition to extrauterine life

risks of excessive oxygen administration to the preterm infant

oxygen toxicity, preterm brain injury, retinopathy of prematurity, bronchopulmonary dysplasia

oxygen saturation targets for preterm infants

90-95%

what are the mechanisms of heat loss of babies

conduction, convection, evaporation, radiation

how can heat loss be prevented

away from ventilation, keep heads warm and dry, ensure you keep babies bodies warm and dry, can thermoregulate within an isolette

how do babies try to preserve heat

vasoconstriction of the peripheries, burning of energy/sugars (leading to hypoglycemia)

why should the oxygen and environment be humidified for preterm infants

their immature skin w/ less layers loses water easily, making them prone to dehydration and hypothermia, also to protect airways from the cold and to assist and maintain lung development

is therapeutic hypothermia useful for the preterm infant

no

why was therapeutic hypothermia used in the past

to protect the baby from brain injury but it has been now found to not be beneficial to the neonate

why is the preterm neonate at risk of skin problems

due to immature skin barrier, thin, fragile, impaired skin function, more susceptible to chemical damage, infection and skin diseases

what are the aims of the special care or NICU environment in minimising skin integrity

to maintain skin integrity and minimise heat loss in the neonate 

what recommendations are made with respect to bathing preterm infants

bathing preterm infants with lotions or soaps can alter the skin pH, and risk infection, infants maybe bathed every 2-3 days, use warm sterile water when areas of skin breakdown are evident

what precautions should be taken with respect to adhesives in NICU

choose adhesives known to cause the least trauma which effectively secure medical devices, consider protecting the skin with silicone-based skin protective films, avoid removing adhesives at least 24 hours after application, use warm water to remove adhesive, avoid using solvents

risk factors for nappy rashes (perineal dermatitis

frequent stooling, AB use, malabsorption, opiate withdrawal, abnormal rectal sphincter tone

how to prevent nappy rashes

change nappies every 4-6 hours , evaluate the perineal area each nappy change, disposable nappies preferred, do not remove barrier creams between changes just apply more cream over the top, steroids maybe indicated if nappy rash does not improve

how to prevent pressure injuries'

be mindful of equipment causing pressure injuries, position changes w/ cluster cares, soft padding beneath neonate, clean dry skin, maintain skin pH, do not rub skin vigorously, frequent nappy changes 4-6 hours

why are preterm babies nutrient deficient

lower stores of nutrients at birth, increased nutritional needs, immature digestive system for absorption

what impact do nutrient deficiencies have on long term outcomes of preterm infants

impaired growth, poorer cognitive function, increased risk of metabolic diseases, nutrient deficiencies later in life

what is the preferred nutritional source of preterm infants

human milk ( especially from their mother at the appropriate gestation), woman with a preterm baby will produce colostrum for longer as the baby needs colostrum at that stage of life

what is the purpose of milk fortifiers

to supplement the nutrition of premature or very-low-birth-weight infants who are fed breast milk ensuring they receive additional protein, vitamins and minerals needed to grow and develop as they would have recieved in the final stages of pregnancy

why may NG feeding be required in the newborn infant

they may struggle with attachment and feeding at the breast or bottle, and to reduce energy expenditure

NG feeding allows the baby to be nourished without expending excess energy whilst also still being bale to receive breastmilk

true

how to transition to full breastmilk and breastfeeding if under 34 weeks gestation after using an NG tube

shot spells of breastfeeding or cup feeding (this helps aid breast milk supply and make the transition to full breastfeeding easier, can also feed using skin to skin contact

what benefit does non-nutritive sucking have in this transition to full breastmilk

maturing feeding skills, improving physiological stability

is bottle feeding indicated to prepare a baby for breastfeeding

no

What challenges might be experienced in transitioning to the breast for a preterm infant

underdeveloped sucking reflex, weak coordination of sucking, swallowing and breathing, low muscle tone, immature digestive system, tiring easily, lack of maternal confidence w/ handling baby

how can intake of breastmilk be measured during a feed

test weighing

what is test weighing

weighing an infant before and after a feed

How often should women be encouraged to express in the early postnatal period to increase milk supply

every 2-3 hours

what supplements maybe needed for a preterm infant

iron, vitamins A, E, D, C, folate, K, protein, calcium, potassium, sodium, potassium

care of the preterm neonate for any length of time can contribute to higher levels of stress on the preterm infant

true

what stressors are preterm babies exposed to

bright lights, loud sounds, suctioning, nappy changes, separation from parents, infection/sepsis

what impact can NICU and its environment have on infant-parent relationship

separation and parental stress can impact relationship building, an environment not open or welcome to visitors can impact relationship parents can build, calm nurturing welcoming environments are important for parents, informing parents of feeding time, allowing nappy changes etc can help parents bond with their baby

how is skin to skin advantageous

promotes parent-baby bonding, babies less likely to cry and expend energy, remain warm, reduce stress hormones and promote release of endorphins (oxytocin) between mum and baby to promote bonding, promotes sensory development w/ tactile auditory and olfactory exposure to parents, encourages responsive caregiving of parents, supports breastfeeding, builds confidence in parents and reduces stress

complications may arise during special care or ICU stay, and these can be underlying to pathology or may be due to the fact that the baby is premature

true

what is apnoea

the absence of respiratory effort for greater than 20 seconds in the neonate OR a lack of respiratory effort <20 seconds if accompanied by cyanosis or bradycardia

what is the incidence of neonatal jaundice in the preterm infant

85%

what is jaundice caused by

build up of bilirubin underneath the skin due to an inability of the baby to excrete through urine and faeces

why is jaundice more common in premature infants

due to immature immune system that is not able to successfully excrete excess bilirubin concentration

what is generally the management of jaundice

phototherapy

what treatment is required in more severe jaundice

exchange transfusion

why can hearing and vision problems be evident in the preterm infant

due to a range of comorbidities of prematurity

what can cause hearing impairments

abnormalities of the inner ear, damage to the cochlea or brainstem or a combination of factors

what commonly causes visual issues

oxygen exposure leading to retinopathy of prematurity

what are the 3 types of apnoea

central, obstructive and mixed

what is central apnoea caused by

respiratory control centers in the brainstem being immature and not sending signals to respiratory muscle

what is obstructive apnoea caused by

a physical blockage in the airway often due to poor muscle tone, pharyngeal collapse or neck flexion despite a respiratory drive

what is mixed apnoea

a combination of both central and obstructive apnoea

causes of apnoea of prematurity

immaturity of the respiratory center in the brain

how should babies be monitored

using sats probe and 3 lead ECG monitoring, observe breathing and respiratory effort, provide PEEP and PIP if required, if apnoea w/ bradycardia consider compressions

acute management for apnoea

PEEP and PIP, aspirate airway

what medication can be used for apnoea

caffeine

types of hyperbilirubinemia

conjugated and unconjugated

what level of bilirubin results in a clinical diagnosis of jaundice

if TcB is greater than 250micromol/L or less than 50 micromol/L below threshold for phototherapy

What other method may be used to assess jaundice

assessing skin and eye colour, symptoms of jaundice: drowsiness, difficulty feeding, pale or clay coloured stool, dark urine

In what situations should a baby be assessed for jaundice?

routine checks at the hospital, as well as if the baby presents w/ signs and symptoms of jaundice

what investigations of jaundice occur

TCB and SBR, FBE and coombs depending on clinical presentation

Why is onset of jaundice important in determining the cause

physiological is not due to underlying conditions of the liver and can be normal (occurs after 24 hours), pathophysiological jaundice is not normal (occurs within 24 hours)

what effect does phototherapy have on the bilirubin

breaks down bilirubin under the skin and helps to be cleared from the body

How often should serum bilirubin be measured after commencement of phototherapy for neonates

6 hours after starting and every 12 hours following this, should be redone 12-24 hours after the completion of phototherapy

what precautions should be taken for the baby on phototherapy 

eyes should be covered, continuous obs on baby, temperature check, ensure continues to feed, assess hydration status and output

complications of phototherapy

temperature regulation overheating, dehydration and water loss, diarrhoea

What is in exchange transfusion and when is it indicated?

removes the patients blood and replaces it with donor blood or plasma in severe jaundice

what is retinopathy prematurity (ROP)

an eye disease in premature babies where blood vessels in the retina develop abnormally post birth

what is the 1st and 2nd stage of ROP

babies can go without treatment

what is stage 3 of ROP

some babies need treatment to have vision, others do not

what is stage 4 of ROP

babies have partially detached retinas and need treatment

what is stage 5 of ROP

the retina detaches completely even with treatment, babies in stage 5 may have vision loss or blindness

how is ROP treated

laser treatment, injections (anti-VEGF drugs which work by blocking growth of blood vessels), eye surgery 

caring for the preterm and ill baby can raise a number of ethical dilemmas

true

what is the most common ethical dilemma for a preterm babies

whether to treat or not to treat

what are the four common ethical dilemmas for caring for preterm infants

beneficence, non-maleficence, autonomy, equality or distributive justice

what is beneficence

discontinuing futile treatment, treatment does not offer benefit but only prolongued the dying process and these should not be employed (this is the argument)

what is non-maleficence

do no harm to the baby