Why is prematurity a concern?

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1 Prematurity What is prematurity? A baby born before 37 weeks of pregnancy is considered premature. Approximately 12% of all babies are born prematurely. Terms that refer to premature babies are preterm and preemie. Premature babies are at risk for a number of problems related to the fact that their organs may not be mature at the time of birth. These potential problems may involve breathing, eating and digesting food, brain development, infections, poor growth and more. They are outlined in more detail below in the section titled Why is prematurity a concern? What causes prematurity? Many factors are linked to premature birth. Some factors directly cause early labor and birth while others can make the mother or baby sick and require early delivery. The following factors may contribute to a premature birth: Maternal factors o Preeclampisa (toxemia or high blood pressure of pregnancy) o Chronic medical illness (such as heart or kidney disease) o Infection (such as group B streptococcus, urinary tract infections, vaginal infections, infections of the fetal/placental tissues) o Drug use (such as cocaine) o Abnormal structure of the uterus o Cervical incompetence (inability of the cervix to stay closed during pregnancy) o Previous preterm birth Factors involving the pregnancy o Abnormal or decreased function of the placenta o Placenta previa (low-lying position of the placenta) o Placental abruption (early detachment of the placenta from the uterus) o Premature rupture of membranes (amniotic sac) o Polyhydramnios (too much amniotic fluid) Factors involving the fetus o When fetal behavior indicates the intrauterine environment is not healthy o Multiple gestation (twins, triplets, etc) o Congenital anomalies (fetus with abnormalities)

2 Why is prematurity a concern? The more premature a fetus is, the greater the risk that he/she will experience complications of prematurity. Some of these complications include: Breathing (respiratory) problems o The lungs may be immature and, therefore, may not be making a substance called surfactant, yet. This disease of surfactant deficiency is called respiratory distress syndrome (RDS). Surfactant makes it easy for the thousands of tiny air sacs to stay open when a baby breathes out. Without surfactant, the air sacs collapse and then must be opened every time a baby breathes in. This causes the baby to work harder to breathe. Infants with significant RDS may receive an artificial surfactant administered directly into the lungs. o The lungs of babies born prematurely may become injured because they had to breathe air too early. This lung injury is called chronic lung disease or bronchopulmonary dysplasia. o In extremely premature babies (23-25 weeks) the lungs may be incompletely developed (in addition to being immature). In rare cases, there is not enough lung development to allow a baby to survive outside the womb. o Breathing problems are treated in a variety of ways. Nasal cannulas can provide extra oxygen and air flow. Continuous positive airway pressure (CPAP) provides oxygen along with continuous pressure to the air sacs in the lung to help keep them inflated. If more support is needed a baby may have a tube placed in the trachea (intubation). The tube is then connected to a ventilator or breathing machine. o Breathing pauses (apnea) result from immaturity of the breathing center in the brain. These breathing pauses cause a drop in the oxygen level in the blood which may result in a decrease in the heart rate. Apnea may need to be treated with medicine, a nasal cannula, CPAP, or, rarely, a ventilator. Blood pressure or circulation difficulties o After delivery of a full term baby there is a necessary transition in the way blood flows through the heart and lungs. In premature babies this transition may not occur or may be delayed. o Premature babies, especially if ill with an infection, may have abnormally low blood pressures. This low blood pressure may require treatment with medicine. Digestion and eating problems o Premature babies have immature intestines that may not digest food normally. For this reason, feedings given through the stomach may start at very small (less than 1 teaspoon) amounts. The amount of feeds is increased very slowly (over weeks). Feedings in the most premature infants are frequently started and stopped in the first weeks of life.

3 o The very best nutrition for babies is breast milk. Babies fed breast milk have fewer infections, better digestion, less serious intestinal problems (see NEC below), and enhanced development. We strongly encourage mothers to provide breast milk for their babies. o A disease called necrotizing enterocolitis (NEC) is more common in premature babies and may have severe consequences. o Premature babies have immature brains. The ability to coordinate sucking, swallowing, and breathing at the same time may not be developed. This coordination will occur naturally, usually when babies reach weeks. Before that time babies are fed through a tiny tube that enters their nose or mouth and ends in their stomachs. Brain and eye development and brain bleeding problems o The brains of premature babies have blood vessels that are very prone to breaking and bleeding. This risk is greatest in the most premature babies. When bleeding occurs it can range from insignificant to severe. The more severe brain bleeds are associated with more brain tissue injury and, thus, a greater risk of lifelong developmental problems. o Even premature babies without brain bleeds are at higher risk of developmental difficulties such as cerebral palsy (difficult muscle control, stiffness), mental retardation, blindness, deafness, learning disabilities, and behavioral problems. o The retina of the eyes is developing until the 34 th week of a pregnancy. Babies born early may have an interrupted or abnormal blood vessel growth in the retinas. This problem can, ultimately, lead to detachment of the retina. Ophthalmologists examine premature babies while they are in the hospital to check on the retinal blood vessel growth. Blood and metabolic problems o Frequent blood tests are often needed to adjust breathing machine support and nutrition and to monitor a baby s progress. These blood tests may, over time, make a baby s red blood cell count low. Blood transfusions are sometimes necessary to treat this low red blood cell level (anemia). o Jaundice occurs in premature infants as it does in full term infants. Most jaundice is caused by an immature liver and poor digestion in the first days to week of life. Phototherapy or bilirubin lights are often necessary to treat jaundice. Infection risks o Premature infants are more susceptible to infections. This is because of an immature immune system and the IV lines and catheters necessary to monitor blood pressure, draw blood, and provide IV nutrition. o Antibiotics will be given to a baby if an infection is suspected until blood, urine, or spinal fluid tests confirm the actual presence of an infection.

4 What is the Neonatal Intensive Care Unit? Premature babies usually stay in the Neonatal Intensive Care Unit (NICU) from the time they are born until they go home. The NICU is an intensive care unit that provides highly specialized care to babies born prematurely or who have difficulties or illnesses soon after birth. Although there are some infants who are critically ill in the NICU, some babies are more stable and are learning how to eat. The NICU caregivers include the following: o Neonatologists are pediatricians who have undergone extra years of training in the care of sick newborn infants o Pediatricians who work only in the hospital assist the neonatologists in caring for babies in the NICU. o Neonatal nurse practitioners (NNPs) are nurses who have received additional specialized training in the care of sick newborn infants. They work with the neonatologist in caring for babies in the NICU. o Nurses and respiratory therapists in the NICU have extensive experience in caring for premature babies. o Dietitians, physical therapists, and many other health care professionals may also be involved in the care of a premature baby. While in the NICU babies have heart rate, breathing rate, and oxygen levels monitored continuously. Most premature babies are placed in an isolette or incubator after birth. This house provides babies with warm moist air. Before discharge they will be placed in a regular crib. How can I parent my baby while she is in the NICU? Parents are encouraged to participate in as much care of their baby as they are comfortable providing. This may involve holding, Kangaroo Care, diaper changes, giving baths, helping with feeding (through the small tube or through breast or bottle attempts). Parents are updated frequently about their baby s progress by neonatologists, pediatricians, or neonatal nurse practitioners (NNPs), and nursing staff. Mothers frequently provide pumped breast milk for their premature baby. Breast milk is the best nutrition for a premature baby, especially as it contains infectionfighting substances and is more easily digested by the immature intestines of a premature infant. When can a premature baby go home? A premature baby must keep himself warm and gain weight in a regular crib and must be taking all feeds either by breast or bottle (or a combination of the two) before he can safely go home. Any other remaining problems of prematurity that are present after feeding and temperature control have been mastered must be stable before discharge home.

5 The process of preparing a premature baby for discharge home occurs over the weeks before discharge to allow parents to become as comfortable as possible with the care of their baby.

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