An early start to life
…..
The Preterm Baby
Dr Faeza Soobadar
Paediatrician/Neonatologist
SSRNH NICU
1
Definitions (1)
Term
 Post-Term

 Preterm
 Moderately PT
 Severely/Very PT
 Extremely PT

37-41
37
41+6 wks
42 wks
<37 wks
32-36+6 wks
28 31+66 wks
28-31
<28 wks
2
Definitions (2)
Low Birth Weight
(LBW)
 Very Low Birth Weight
(VLBW)
 Extremely Low Birth Weight
(ELBW)

<2 5kg
<2.5kg
<1.5kg
<1kg
3
Aetiology 1 - (Maternal)








Idiopathic
Low socio
socio-economic
economic status
Malnutrition
Age <16 or >35
Smoking & drug abuse
Stress
Malformations of uterus & cervix
Previous preterm delivery or late
miscarriage
4
Aetiology 2 - (Maternal)
Maternal illnesses
UTI & asymptomatic bacteriuria
Bacterial vaginosis
Anaemia
Diabetes
Hypertension or PET

5
Aetiology 3 - (Fetal)
Multiple gestation
 Congenital malformation
 Fetal distress
 Polyhydramnios

6
Aetiology 4 - (Iatrogenic)








Fetal distress
IUGR
Uncontrolled PIH/ Eclampsia
APH
Diabetes
Maternal cardiac disease
Chorioamnionitis
Incorrect estimate of gestational age
7
Prevention & Obstetric
management
Health promotion programmes
 Antenatal care – PIH,
PIH diabetes
 Cervical cerclage
 Detection & treatment of infection
 Tocolytics
 Optimising outcome for baby:
Steroids; IUT.

8
PROBLEMS OF
PREMATURITY &
POST--NATAL
POST
MANAGEMENT
9
Resuscitation

Difficulty in extrauterine adaptation.




Delivery in level 3
NICU.
Appropriate planning &
immediate availability of
qualified personnel &
equipment.
Prompt resuscitation &
stabilization.
PNT
10
Temperature regulation
Inability to shiver
 Large SA
 Decreased
subcutaneous fat
 Reduced
R d d brown
b
fat
f
stores

Servo-controlled
incubator
 Humidity
 Easy access to infant
 Humidification
H df
off
ventilator gases

11
12
Respiratory (1)

RDS
 Apnoea of
prematurity





Pulse oxymetry, Cardio
Cardioresp monitoring & ABG.
Oxygen
Respiratory support –
mechanical ventilation,
NCPAP.
S f
Surfactant
therapy
h
Respiratory stimulant
13
14
15
16
17
18
19
20
21
22
Respiratory (2)

Pneumothorax


Pulmonary
haemorrhage

Thoracocentesis
↑Ventilation
 Blood transfusion
 FFP/Vitamin K
23
Cardiovascular

Hypotension

BP monitoring
 Volume expansion
 Inotropic support

PDA

Cardiac echo
 Diuretics
 Indomethacin
 Ibuprofen
24
25
Renal/Metabolic

Electrolyte
disturbances
 Hypocalcaemia
 Hypo/hyper-glycaemia





Regular U’s&E’s
U s&E s
Urine output
Dextrostix
Careful fluid
management &
administration
Insulin infusion
26
27
GIT/Nutrition

Feed intolerance


High requirements


NEC

Gavage feeding
 TPN
EBM+Fortifier
 Pre-term formulas
Gastric
decompression, NBM,
iv antibiotics, surgical
opinion.
28
29
Neurological

IVH
Vitamin E,
E Ethamsylate
 Good ventilation
management &
control of BP
 Regular cranial USS

30
31
32
Others

Haematological –
anaemia/
thrombocytopenia

Multiple blood
transfusions

Immunological –
infection

Multiple courses of
antibiotics; antifungal.
antifungal

Psychological

Parental support
 NIDCAP
33
34
Criteria for home discharge
Clinically stable
 Stable temperature
 Good weight gain
 Mother’s ability to care for baby
 Social circumstances

35
LONG TERM PROBLEMS
& FOLLOWFOLLOW-UP
36
Respiratory
CLD
 Recurrent respiratory
infections







Dexamethasone
Nebulized/Inhaled therapy
Chest physio
Long term oxygen &
prolonged hosp stay
Recurrent re-admissions
Immunization
37
38
Nutrition & Growth

Poor growth

Growth charts
 High
High-calorie
calorie formula
& vits

Anaemia


Rickets of prematurity

Hb monitoring
 Iron supplementation
Phosphate supp
39
Neurological

PVL & Cerebral palsy







Convulsions
Hydrocephalus
y
p
ROP
Hearing impairment




Prevention
Neuro-developmental
follow-up
PT & OT
Anticonvulsants
Neurosurgical opinion
Ophthalmology r/v
Hearing assessment
40
41
Psycho--social
Psycho

Learning difficulties
Behavioural problems
 Family/social impact

Developmental
psychologist
 Special educational
programme
 Psychotherapy
 Parent support groups

42
STATISTICS
43
Incidence of prematurity
SSRNH
2003
5.5%
2004
9.2%
2005
5.5%
2006
4.4%
2007
7.5%
2008
9.0%
Other countries
USA (2006)
12.7%
UK (2007)
8.6%
France
7%
Australia (2002)
7%
44
Admissions to NICU
2002
2003
2004
2005
2006
2007
2008
Admissions
226
235
225
200
208
201
163
Mortality %
21
17
27
27
27
24
28
Preterm %
72
71
72
67
57
62
61
Moderately PT
(survival)
58%
(92%)
51%
(91%)
53%
(84%)
44%
(80%)
37%
(89%)
49%
(79%)
42%
(79%)
Severe PT
(survival)
30%
(63%)
42%
(79%)
34%
(65%)
46%
(79%)
49%
(55%)
36%
(71%)
33%
(64%)
Extreme PT
(survival)
12%
(26%)
7%
(55%)
12%
(45%)
10%
(8%)
14%
(44%)
14%
(50%)
24%
(71%)
45
NMR & IMR – SSRNH & MRU
25
21.9
19.4
20
19.4
15.4
14 8
14.8
14.6
14.2
12 4
12.4
15
8.8
9
NMR SSRN
NMR MRU
IMR SSRN
IMR MRU
10.2
10.9
11.8
10
8.5
6.2
5
IMR MRU
IMR SSRN
NMR MRU
0
1998
2003
NMR SSRN
2007
2008
46
NMR & IMR WORLDWIDE
200
184.4
150
100
50
0
NMR 2004
IMR 2007
59.4
2.3 3.2
1 1 23.4 4.6 5 6.4 15.4 22.1
3
3
4 10 18 17
54
2004
NMR 2004
47
Survival of a 1616-oz. baby (450g)
DOB 30.01.1949; GA 26 wks







Case report; Dr H
Fakim; RMO; Civil
Hospital; Mauritius
BMJ 19.08.1950
31 y old mother
At birth the infant was
very feeble & did not
cry…nikethamide….
Wrapped up in cotton
wool
ool …cot
cot lined with
ith
blankets & kept warm
with hot water bottle
Fed on glucose water
..EBM…condensed
milk
3.06kg at 5½m
48
Acknowledgements
My grateful thanks to:
•Dr A G Mohamedbhai, Consultant Paediatrician, for laboriously
over the years
years, compiling the statistics for SSRN Hospital.
Hospital
•Dr Oochita Jhummun, NICU RMO, for computerizing the data.
•All the children for performing in front of the camera.
•All obstetricians
bt ti i
ffor kkeeping
i us on our ttoes all
ll the
th time.
ti
•And of course to all Paediatricians & NICU nursing staff &
RMO’s, past & present, without whose dedication the NICU
would not exist & these children would not be alive today.
49