WELCOME

PRETE
RM
BABIES
PRESENTED BY:
Dhanalakshmy. M
First year M.Sc NURSING
Govt college of nursing
Alappuzha

Introduction
Birth

weight is the single most important marker

of adverse perinatal and neonatal outcome.

Babies

with a birth weight of less than 2,500g,

irrespective of their gestation are classified as

low birth weight babies.
These

include both preterm and small-for-dates

babies.

Definition

Preterm infants (also called premature infants) are those

born before the beginning of 38 th week of gestation.

Moderately preterm infants are those born between 32

and 36 completed weeks of gestation.

Late preterm infants fall in the moderately preterm

group.

Very preterm infants are those born before 32 completed

weeks of gestation. (Mehrban Singh, 2010)

Incidence
About

10 to 12 percent of Indian babies are born

preterm ( less than 37 completed weeks) as

compared to 5 to 7 percent incidence in the
west.
These

infants are anatomically and functionally

immature and therefore their neonatal mortality

is high.

CAUSES OF
PREMATURITY
The

mechanisms initiating normal labour are not

clearly understood and much less is known about

the triggers that initiate labour before term.
Spontaneous

Induced

Spontaneous
Poor
Low

socio-economic status
maternal weight

Chronic

and acute systemic maternal illness

Antepartum
Cervical

hemorrhage

incompetence

Maternal

genital colonization and infections

Contd
Cigarette

smoking during pregnancy

Threatened
Acute

abortion

emotional stress

Physical
Sexual

exertion

activity

Trauma
Bi-cornuate
Multiple

uterus

pregnancy

Congenital

malformations

Induced
The

labour is often induced before term when there is

impending danger to mother or foetal life in-utero.

Maternal diabetes mellitus
Placental dysfunction as indicated by unsatisfactory
foetal growth
Eclampsia
Foetal hypoxia
Antepartum haemorrhage and
Severe rhesus iso-immunization.

CLINICAL
FEATURES

Measurements
Their

size is small with

relatively large head.

Crown-heel

length is

less than 47 cm
Head

circumference is

less than 33cm but

exceeds the chest
circumference by
more than 3cm.

Activity and posture

The

general activity is

poor
Their

automatic reflex

responses such as moro

response, sucking and
swallowing are sluggish or
incomplete.
The

baby assumes an

extended posture due to

poor tone.

Face and head

Disproportionately
large head size

Sutures are widely

separated and the
fontanels are large

Small chin, protruding

eyes due to shallow
orbits and absent
buccal pad of fat.

Contd.
Optic

nerve is often un-

myelinated but presence of

papillary membrane makes
its visualization difficult.
Ear

cartilage is deficient or

absent with poor recoil.

Hair

appear woolly and fuzzy

and individual hair fibres can

be seen separately.

Skin and subcutaneous

tissues
skin

is thin,

gelatinous, shiny and

excessively pink with
abundant lanugo and
very little vernix
caseosa.
Edema

may be

present.

Contd..
Subcutaneous

fat is

deficient and breast

nodule is small or
absent.
Deep

sole creases are

often not present.

Genitals
In

male testes are

undescended and
scrotum is poorly
developed.

Contd..
In

female infants,

labia majora are

widely separated
exposing labia
minora and
hypertrophied
clitoris.

PHYSIOLOGIC
AL
HANDICAPS

Central nervous system

Immaturity

of central

nervous system is
expressed as inactivity
and lethargy, poor
cough reflex and
in-coordinated sucking
and swallowing

Contd..

Resuscitation difficulties at
birth and recurrent apneic
attacks.

Retinopathy of prematurity .

Vulnerable for intraventricular periventricular

hemorrhage and leucomalacia

Inefficient blood brain barrier

Respiratory system
Cuboidal

alveolar lining-

poor alveolar diffusion of

gases
Hyaline

membrane

disease

Breathing is mostly
diaphragmatic, periodic
and associated with
intercostal recessions

Contd
Pulmonary

aspiration

and atelectasis
They

are vulnerable

to develop chronic
pulmonary
insufficiency

Cardio-vascular system

The closure of ductus

arteriosus is delayed.

In grossly immature
infants( less than 32
weeks) EKG shows left
ventricular preponderance.

Risk to develop thromboembolic complications and

hypertension.

Gastro- intestinal
system
Due

to poor and

incoordinated sucking and

swallowing.
Animal

fat is not tolerated

as well as the vegetable

fat.
Regurgitation

and

aspiration are common.

Hypoglycaemia

Contd..

Abdominal distention and

functional intestinal
obstruction

Entero-colitis

Immaturity of the glucuronyl

transferase system in the liver
leads to hyper-bilirubinemia.

Development of kernicterus at
lower serum bilirubin levels.

Thermo-regulation
Hypothermia
Excessive

is invariable.

heat loss due to

relatively large surface

area due to paucity of
brown fat in the baby who
is equipped with an
inefficient thermostat.

Infections
Infections

are the important

cause of neonatal mortality.

The

low levels of IgG

antibodies and inefficient

cellular immunity
Excessive

handling, humid

and warm atmosphere,

contaminated incubators and
resuscitators expose them to
infecting organisms.

Renal immaturity
The blood urea nitrogen is
high due to low glomerular
filtrate rate.
The renal tubular ammonia
mechanism is poorly
developed thus acidosis
occurs early.
They vulnerable to develop
late metabolic acidosis
especially when fed with a
high protein milk formula.
Concentration of urine is poor.

Contd
Preterm

has to pass

4 to 5 ml of urine excrete
one milliosmole of solute
Baby gets dehydrated.
The

solute retention and

low serum proteins

explain occurrence of
edema in preterm
infants.

Toxicity of drugs
Poor

hepatic

detoxification and
reduced renal
clearance make a
preterm baby
vulnerable to toxic
effects of drugs

Nutritional handicaps

Develop anemia around 6

to 8 weeks of age.

Deficiencies of folic acid

and vitamin E.

Develop haemolytic
anemia, thrombocytopenia
and edema 6 to 10 weeks
of age.

Osteopenia and rickets

Biochemical
disturbances
These

babies are

prone to develop :
Hypoglycaemia
Hypocalcemia
Hypoprotenemia
Acidosis and
Hypoxia.

MANAGEMENT

Arrest of premature labor

Bed rest and sedation.

Tocolytic agents
Sympathomimetic agents-beta-2-adrenergic
receptors.
Isoxsuprine (duvadilan)-beta-1 and beta-2 receptors.
Ritodrine
Salbutamol and terbutaline -beta-2 receptor

Magnesium sulphate

Indomethacin

Induction of premature
labour
Maturity

of fetus should be ascertained by

examination of amniotic fluid for phosphatidyl

glycerol or L/S ratio.
Corticosteroids

should be administered to the

mother to enhance fetal lung maturity.

Antenatal
corticosteroids

Inj.betamethasone 12mg IM
every 24 hours --2 doses or
dexamethasone 6mg IM
every 12 hours for 4 doses.

The optimal effect is seen if

delivery occurs after 24
hours of the initiation of
therapy and its therapeutic
effect lasts for 7 days.

CARE OF
PRETER
M
BABIES

Optimal
management at birth

Delayed clamping of cord.

Elective intubation of extremely LBW babies

(<1000g).

Should be promptly dried, kept effectively covered

and warm.

Vitamin K 1mg ( 0.5mg in babies < 1500g) should be

given intra-muscularly.

Transferred by the doctor or nurse to the NICU as

soon as breathing is established.

Monitoring
Vital

signs .

Activity

and behaviour.

Colour.
Tissue

perfusion.

Fluids,

electrolytes and ABGs.

Tolerance
Watched

of feeds .

for development of

RDS, apneic attacks, sepsis,

PDA, NEC, IVH, etc.
Weight

gain velocity.

Criteria for a healthy

preterm baby
The

vital signs should be stable.

The

healthy baby is alert and active, looks pink

and healthy, trunk is warm to touch and

extremities are reasonably warm and pink.
The

baby is able to tolerate enteral feeds and

there is no respiratory distress or apneic attacks

and baby is having a steady weight gain of 1-1.5
% of his body weight every day.

Provide in-utero milieu

Create

a soft, comfortable,

nestled and cushioned bed.

Avoid

excessive stimuli.

Effective

analgesia and

sedation.
Provide
Ensure

warmth.
asepsis.

Prevent

losses.

evaporative skin

Contd

Provide effective and safe

oxygenation.

Partial parenteral nutrition

and give trophic feeds
with expressed breast
milk (EBM).

Provide rhythmic gentle

tactile and kinaesthetic
stimulation.

Position of the baby

Thermo-neutral
environment.

Application of oil or liquid

paraffin on the skin.

Should be covered with a

cellophane or thin
transparent or thin
transparent plastic sheet.

Provide partial
kangaroo0mother-care.

Oxygen therapy

Oxygen should be administered

with a head box when SpO2 falls
below 85% and it should be
gradually withdrawn when SpO 2
goes above 90%.

The lowest ambient concentration

and flow rates should be used to
maintain SpO2 between 85-95%
and PaO2 between 60-80 mm Hg.

Phototherapy
Early

phototherapy is

adviced to keep the serum

bilirubin level within safe
limits in order to obviate
the need for exchange
blood transfusion.

Prevention of nosocomial
infections
The

handling should be

bare minimum.
Vigilance

should be

maintained on all
procedures.
Early

diagnosis and prompt

treatment of infections.

Feeding and nutrition

Intra-venous

dextrose solution (

10% dextrose in babies >1000g

and 5% dextrose in babies
<1000g).
Trophic

feeds with EBM through

NG tube.
Condition

feeds.

is stabilized - enteral

Fluid requirement
Fluid requirements are higher in LBW infants
due to:
Greater
Faster

insensible water losses

breathing rates

Decreased

ability to concentrate urine

Greater

use of radiant warmers

Greater

use of phototherapy units

Rate of administration*
Birth weight
500 - 600

Fluid rate
(ml/kg/day)
140 - 200

601 - 800

120 - 130

801 - 1000

90 - 110

1000 - 1500

80 - 100

>1500

60 - 80

(g)

*on first 2 days of life

Rate of administration
Fluid

rate can be increased by 10-20 ml/kg/d

to gradually reach 150 ml/kg/d

Fluid

requirements need to be individualized

for each baby

Enteral

nutrition has to be considered once

the baby is stable

Total parenteral nutrition

INDICATIONS

Infants

with BW 1000 g

Infants

with BW 1500 g, done in

conjunction with slowly advancing enteral

nutrition
Infants

with BW 1501-1800 g for whom

enteral intake is not expected for > 3 days

Total parenteral nutrition

Glucose
Amino

: 6 - 8 mg/kg/min

acids : 1.5 - 2 g/kg/d

Lipid

: 0.5 - 1 g/kg/d

Sodium

: 2 - 4 mEq/kg/d

Potassium

: 2 - 3 mEq/kg/d

Chloride

: 2 - 4 mEq/kg/d

Early enteral nutrition

Trophic feeding/ Gut priming
Practice of feeding very small amounts of enteral
nourishment to stimulate development of the immature GIT
Advantages:
Improves GI motility
Enhances enzyme maturation
Improves mineral absorption
Lowers incidence of cholestasis
Shortens time to regain birth weight

Enteral nutrition
Breast

milk or or full strength preterm formula at

10ml/kg/d by intermittent gavage/ continuous

nasogastric drip
Increase

by 10-15 ml/kg/d to reach 150ml/kg/d

Increments
IV

not >20 ml/kg/d

fluids can be stopped once 120ml/kg/d is reached

On

reaching 150ml/kg/d,calorie density can be

increased

Feeding guidelines
PRETERMS

<1200 g/ <32 wks: IV fluids for first 2-3 days, once

stable start gavage feeding

1200-1800 g/ 32-34 wks: Start gavage feeding, once

vigorous start spoon/ breast feeding

>1800 g/ >34 wks: Start breast feeding directly; if trial

feed takes>20 mins or intake is less than required,
switch to gavage feeding

Preterm human milk

Advantages:
Higher

concentrations of amino acids

Higher

concentrations of essential fatty acids

Lower

renal solute load

Specific

bio-active factors provide immunity

Promotes

intestinal maturation

Preterm human milk

Disadvantages:
Low

concentrations of Vitamin

D, Ca, P
Inadequate

iron

Enteral nutrition
Energy

: 130 - 175 Kcal/kg/d

Protein

:3.4 - 4.2 g/kg/d

Fat

:6 - 8 g/kg/d

Na

:3 - 7 mEq/kg/d

Cl

:3 - 7 mEq/kg/d

:2 - 3 mEq/kg/d

Ca

:100 220 mg/kg/d

Nutritional
supplements
Multivitamin
Iron

drops.

supplementation.

Vitamin

E supplementation.

Supplements

of calcium

(220mg/day) and
phosphorus (100mg/day).

Gentle rhythmic
stimulation
Gentle

touch, massage,

cuddling, stroking and

flexing.
Rocking

bed or placing a

preterm baby on inflated

gloves.
Soothing
Visual

auditory stimuli.

inputs.

Kangaroo Care
Kangaroo

care is placing a

premature baby in an upright position on a

mothers bare chest allowing tummy to
tummy contact and placing the premature
baby in between the mothers breasts.
The

babys head is turned so that the ear

is above the parents heart.

Contd
Body

temperature

Mothers have thermal synchrony with their baby.

The study also concluded that when the baby was

cold, the mothers body temperature would
increase to warm the baby up and vice versa.

Contd
Breastfeeding:

Kangaroo care allows easy access to the breast and

skin-to-skin contact increases milk let-down.

Contd
Increase

weight gain

Kangaroo care allows the baby to fall into a deep

sleep which allows the baby to conserve energy
for more important things. Increased weight gain
means shorter hospital stay.

Contd..
Increased

intimacy and attachment

Utility of
corticosteroids
A

single dose of

dexamethasone 0.2mg/kg IV at
4 hours of age.
Inhaled

steroids.

Prevention, early diagnosis and

prompt management of common
problems
Nosocomial

infections
Hypothermia
Respiratory distress syndrome
Aspiration
Patent ductus arteriosus
Chronic lung disease
NEC & IVH
ROP & Late metabolic acidosis
Nutritional disorders
Drug toxicity

Weight record

Loss is upto a maximum of 10

to 15 percent.

Regain their birth weight by

the end of second week of life.

Excessive weight loss, delay in

regaining the birth weight or
slow weight gain- suggest
baby is not being fed
adequately or unwell and
needs immediate attention.

What to avoid in the care of

preterm babies??
Routine

oxygenation without
monitoring.
Intravenous immuno-globulins.
Prophylactic antibiotics.
Prophylactic administration of
indomethacin or high doses of
vitamin E.
Unnecessary blood transfusions.
Formula feeds.
Rough handling, excessive light
and loud sound.

Immunizations
It

is desirable to administer

0-day vaccines(BCG, OPV,

HBV) on the day of discharge
from the hospital.
If

mother is HBV carrier and

is e-antigen positivehepatitis B vaccine and

hepatitis B specific
immunoglobulins within 72
hours of age.

Contd
Live

vaccines should be

avoided in symptomatic HIVpositive mothers.

WHO

recommends that BCG

and oral polio vaccine can be

given to asymptomatic HIVpositive infants.

Family support
The

family dynamics are

greatly disturbed.
The problems and issues
should be handled with
equanimity, compassion,
concern and caring attitude of
the health team.
Encouraged to touch and talk
with her baby.
Provide kangaroo-mother-care.
Emotional support and
guidance.

Transfer from incubator to

cot
A

baby who is feeding from the

bottle or cup and is reasonably

active with a stable body
temperature, irrespective of his
weight, qualifies for transfer to
the open cot.

Discharge policy
The

mother should be
mentally prepared and
provided with essential
training and skills.
The mother- baby dyad
should be kept in stepdown nursery.
The baby should be stable,
maintaining his body
temperature and should
not have any evidences of
cold stress.

Contd..
At

the time of discharge,

the baby should be having
daily steady weight gain
velocity of at least 10g/kg.
The home conditions
should be satisfactory
before the baby is
discharged.
The public health nurse
should assess the home
conditions and visit the
family at home every
week for a month or so.

Follow-up protocol
Common

infective illnesses,

reactive airway disease,

hypertension, renal dysfunction,
gastro-oesophageal reflux.
Feeding

and nutrition.

Immunizations.
Physical

growth, nutritional

status, anemia, osteopenia/

rickets.

Contd..
Neuro-motor

development,

cognition and seizures.

Eyes:

Retinopathy of

prematurity, vision,
strabismus.
Hearing.
Behavioural

problems,

language disorders and

learning disabilities.

Home care of preterm

babies
She

must be explained
about the importance of
asepsis.
Keeping the baby warm
and ensuring satisfactory
feeding routine.
The services of
postpartum programme
public health nurse and
social worker can be
utilized.

Environmental control
The

infant should be effectively covered taking care to

avoid smothering.
Woollen
The
In

cap, socks and mittens should be worn.

infant should preferably lie next to the mother.

winter, the room can be warmed with a radiant heater

or angeethi.
A

table lamp having 100 watt bulb can be used to

provide direct radiant heat.

Hot

water bottle should never come in contact with the

baby.

Contd..
The

cot of the mother and infant should be located

away from the walls .

The

mother and health worker should be trained to

assess the temperature of the newborn baby by
touch.

The

visitors and handling of the infant should be

restricted to the bare minimum.

The

hands must be washed before touching or

feeding the baby.

The

emotional urge for kissing the baby should be

curbed.

The

linen should be clean and sun-dried.

Feeding
Whenever

feasible, breast feeding is ideal and

must be encouraged.
When infant is unable to suck from the breast,
EBM should be given with a bottle or dropper or
spoon or paladay depending upon his maturity.
Formula for premature babies is recommended.
If cows or buffalos milk is unavoidable it should
be given after 3:1 dilution.
Mother must be given detailed instructions and
practical demonstration for maintenance of
bottle hygiene to prevent contamination of feeds.

Prognosis

The risk of neurodevelopmental

handicaps is increased 3-fold for LBW
babies and 10-fold for very LBW
babies(<1500g).

The prognosis is good if no birth

asphyxia, apneic attacks,RDS,
hypoglycaemia and hyperbilirubinemia.

Preterm AFD babies catch up in their

physical growth with term counterparts
by the age of 1 to 2 years.

Contd..

15 to 20 % incidence of
neurological handicaps in the
form of CP, seizures, ROP,
hydrocephalus, deafness and
MR.

There is high incidence of

minor neurologic disabilities.

Neurological prognosis is
adversely affected by degree
of immaturity.

Nursing management

Obtain detailed antenatal,

intra-natal history.

Assess the gestational age and

birth weight of the baby.

Assess the features of clinical

immaturity.

Assess the behaviour of

preterm neonate.

Assessment of common
problems.

Nursing
diagnosis and
interventions

1. Impaired gas exchange related to immaturity of

lungs and deficiency of surfactant
Assess

the respiratory pattern and colour of the

baby
Observe for any apneic episode.
Oxygen hood is often used for able to breathe
alone but need extra oxygen.
Oxygen also may be given by nasal cannula to
the infant who breathes alone.
Humidify the oxygen
CPAP may be necessary to keep the alveoli open
and improve expansion of lungs

2.Impaired breathing pattern : distress related to

immaturity and surfactant deficiency
Assess

the respiratory rate, heart rate and chest

retractions
Position the child for maximal ventilatory
efficiency and airway patency
Provide humidified oxygen
Spo2 monitoring
Provide suctioning
Provide chest physiotherapy
Administer bronchodilators
Administer anti inflammatory medications
Administer antibiotics

3. Activity intolerance related to increased work of

breathing secondary to distress
Arrange

to provide routine care

Schedule

periods of uninterrupted rest

Determine
Reduce
Use

infants stress level

nonessential lighting

positioning devices

4. Ineffective airway clearance related to excessive

trachea-bronchial secretions

Assess the childs breathing pattern

Check the vital signs

Provide suctioning

Provide humidified oxygen

Assess the ABG analysis

Provide C-PAP using mask /hood/nasal prongs

Observe for risks of C-PAP

Assist in CMV with PEEP if needed

5. Hypothermia related to immature thermoregulation

system
Monitor
Wrap

vital signs frequently

the baby well and keep warm

Provide

small and frequent breast feeding as

tolerated
Look

for hypoglycemia

Administer
Monitor
Assess

IV fluids if not tolerating the feed

the vital signs and blood pressure

the skin tone, pallor and signs of dehydration

Administer

IV fluids

6. Imbalanced nutrition less than body requirement

related to feeding difficulty, respiratory distress, or
NPO status
Assess

the sucking and swallowing ability of the

newborn
Assess

the tolerance of the child

Monitor

the blood glucose level frequently

Administer

IV fluids if not tolerating oral fluids

Administer

human milk fortifier if the child is

preterm

7. Fatigue related to increased demand for

nutrients and deterioration of the general condition
of the baby
Assess

the general condition of the baby

Assess

the level of activity

Monitor

the blood glucose level

Breast

fed the baby

Check

for from any part of the body

Provide

top up feed

8. Risk for complications hypotension, shock, cerebral

hypoxia related to progression of the disease condition

Assess the vital signs, respiratory rate, pulse rate,

temperature and blood pressure

Check blood culture and sensitivity and sepsis

screening

Monitor for any signs of dehydration

Administer IV fluids or blood as necessary

Assess the serum electrolyte values and ABG values

Closely monitor for the early signs and symptoms of

complications

9. Anxiety of parents related to the outcome of the

newborn condition
Assess

the mental status, anxiety and knowledge of

family members
Assess

the supporting system for the family

Assess

the coping strategies of the family members

Explain

the disease process to the family members

Explain

each and every procedure to the care giver

Provide

psychological support to the family members

10. Interrupted mother-child bonding related to

infectious process
Assess

the breast feeding ability including

sucking and swallowing ability

Keep

the child with the mother if possible

Provide
If

frequent breast feed 2 hourly

breast feeding is not tolerated give EBM

Allow

the mother to visit the child

Provide

kangaroo mother care in case of pre term

if tolerated

11. Interrupted family process related to

hospitalization of the newborn
Assess

the mental status, anxiety and

knowledge of family members

Encourage
Assess

mother-child bonding if possible

the coping strategies of the family

members
Explain

the disease process to the family

members
Explain

giver

each and every procedure to the care

12. Knowledge deficit regarding care of the baby

and treatment modalities
Assess

the knowledge level of the care giver

Explain

disease condition and its progress to the

family members
Educate

regarding treatment and its prevention

Educate

about the monitoring of the baby

Provide

adequate explanation regarding

nutritional need of the baby

Clarify

their doubts and promote understanding

Summary

Definition and incidence

Causes of prematurity

Clinical features

Physiological handicaps

Management

Care of preterm babies

Prognosis

Nursing assessment

Nursing diagnosis and interventions

CONCLUSION.