CARE OF PRETERM BABIES

INTRODUCTION
Prematurity accounts for the largest number of admissions to an NICU. About 10-12 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.
DEFINITION
Preterm infants (also called premature infants) are those born before the beginning of
38th 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.
A gestational age assessment of a preterm infants size and development may show that the
infant is small, appropriate or large for the amount of time spent in the uterus. Most preterm
infants are appropriate for their gestational age.
In practice and from statistical point of view, it refers to a newborn whose birth weight is less
than 2,500g. Such a baby measures 46 cm or less in length and has head circumference of 32
cm or less. The chest circumference is usually less than 30 cm.

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 mechanism initiating normal labor is not clearly understood and much less is
known about the triggers that initiate labor before term. There may be spontaneous onset of

premature labor or it may be induced by the obstetrician to safe guard the interests of the
mother or baby.
Spontaneous: the cause of premature onset of labor is uncertain in most instances. The known
causes include:
Poor socio-economic status
Low maternal weight
Chronic and acute systemic maternal illness
Antepartum hemorrhage
Cervical incompetence
Maternal genital colonization and infections
Cigarette smoking during pregnancy
Threatened abortion
Acute emotional stress
Physical exertion
Sexual activity
Trauma
Bicornuate uterus
Multiple pregnancy
Congenital malformations
Premature births are relatively common among very young and unmarried mothers. Past
history of preterm birth is associated with 3 to 4 times increased risk of prematurity in the
subsequent pregnancies.
Induced: the labor is often induced before term when there is impending danger to mother
or fetal life in-utero e.g. maternal diabetes mellitus, placental dysfunction as indicated by
unsatisfactory fetal growth, eclampsia, fetal hypoxia, antepartum hemorrhage and severe
rhesus iso-immunization.

Clinical features:

Measurements: their size is small with relatively large head. Crown-heel length is
less than 47cm, head circumference is less than 33cm but exceeds the chest

circumference by more than 3cm.

Activity and posture: the general activity is poor and 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: face appears small for the disproportionately large head size, sutures
are widely separated and the fontanels are large. Other characteristic features include
small chin, protruding eyes due to shallow orbits and absent buccal pad of fat. Opic

nerve is often unmyelinated but presence of papillary membrane makes theits

visualization difficult. Ear cartilage is deficient or absent with poor recoil. Hair

appears woolly and fuzzy and individual hair fibers can be seen separately.
Skin and subcutaneous tissues: skin is thin, gelatinous, shiny and excessively pink
with abundant lanugo and very little vernixcaseosa. Edema may be present.
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. In female
infants, labia majora are widely separated exposing labia minora and hypertrophied
clitoris.

Physiological handicaps:The functional immaturity of

various systems result is

different clinical problems and their knowledge is essential for the satisfactory management
of these babies.
Central nervous system: the immaturity of central nervous system is expressed as inactivity
and lethargy, poor cough reflex and in co-ordinated sucking and swallowing in babies
weighing less than 1,800 g or born before 35 weeks of gestation.

Resuscitation difficulties at birth and recurrent apneic attacks are common.

Retinopathy of prematurity due to oxygen toxicity is limited to babies with a gestation

of less than 35 weeks.

They are extremely vulnerable for intra-ventricular periventricular hemorrhage and
leucomalacia due to relative deficiency of vit-K dependent coagulation factors and

increased capillary fragility.

The blood brain barrier, which is possibly a function of available serum proteins, is
inefficient in preterm babies, thus brain damage may occur at lower serum bilirubin
levels.

Respiratory system:

The cuboidal alveolar lining in babies with a gestational age of less than 26 weeks

results in poor alveolar diffusion of gases and therefore the infant may not be viable.
They pose resuscitation difficulties at birth, often followed by hyaline membrane

disease, if associated with deficiency of pulmonary surfactant.

The breathing is mostly diaphragmatic, periodic and associated with intercostal

recessions due to soft ribs.

Pulmonary aspiration and atelectasis are common.

They are vulnerable to develop chronic pulmonary insufficiency due to bronchopulmonary dysplasia.

Cardio-vascular system:

The closure of ductusarteriosus is delayed among preterm babies.

One third of infants have features of PDA.
The incidence is more among preterm infants with hyaline membrane disease or

protracted hypoxia.
In grossly immature infants (less than 32 weeks) EKG shows left ventricular
preponderance. They are at risk to develop thrombo-embolic complications and
hypertension due to indwelling catheters.

Gastro- intestinal system:

Due to poor and inco-ordinated sucking and swallowing there are difficulties in self

feeding, although their digestive ability is generally good.

Animal fat is not tolerated as well as the vegetable fat.
Regurgitation and aspiration are common because of inco-ordinated sucking, small
capacity of stomach, incompetence of gastro-oesophageal junction and poor cough

reflex.
Gastro-oesophageal reflux and its consequences are common.
Abdominal distention and functional intestinal obstruction are due to hypotonia.
Enterocolitis occurs when other predisposing factors are present.
Immaturity of the glucuronyltransferase system in the liver leads

hyperbilirubinemia.
Relatively low serum albumin, acidosis and hypoxia in these babies predispose to the

development of kernicterus at lower serum bilirubin levels.

The poor hepatic glycogen stores, delayed feeding, birth asphyxia and respiratory

to

distress syndrome contribute to the development of hypoglycaemia.

Thermo-regulation:

Hypothermia is invariable and life threatening unless environmental temperature is

controlled.
Excessive 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 in low birth weight babies.
The low levels of IgG antibodies and inefficient cellular immunity predispose them to

infections.
Excessive handling, humid and warm atmosphere, contaminated incubators and
resuscitators expose them to infecting organisms, thus contributing to high incidence
of infections.

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.
Preterm has to pass 4 to 5 ml of urine excrete one milliosmole of solute as compared

to 0.7 ml by an adult for the same purpose.

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 unless caution is exercise during their
administration.

Nutritional handicaps:

Low birth weight babies are prone to develop anemia around 6 to 8 weeks of age this

is due to diminished total stores of iron due to short gestation.

They may also manifest deficiencies of folic acid and vitamin E especially among

those fed with on iron fortified milk formula.

These infants are more prone to develop haemolytic anemia, thrombocytopenia and

edema 6 to 10 weeks of age.

Vitamin E deficiency along with oxygen toxicity to the vulnerable tissues in the form

of retro-lental fibroplasia and broncho-pulmonary dysplasia.

Rapid growth following adequate feeding may result in osteopenia and rickets unless
calcium, phosphorus and vitamin D are administered.

Biochemical disturbances:

These babies are prone to develop hypoglycaemia, hypocalcemia ,hypoprotenemia,

acidosis and hypoxia.

Management
High risk mothers should be identify early during the course of pregnancy and referred for
confinement to an appropriate health care facility which is equipped with good quality
obstetrical and neonatal care facilities. Mother is indeed an ideal transport incubator.
Arrest of premature labor:

Advances in perinatal care including fabrication of a variety of electronic gadgets

cannot compare with unique security and optimal care provided to the fetus by the

utero-placental unit.
Efforts should always be made to arrest the progress of premature labour.
The onset of true labor is suspected by occurrence of two or more uterine contractions
lasting atleast 30 seconds during a 15-minute period in association with dilatation and

effacement of cervix.
Apart from bed rest and sedation, a variety of tocolytic agents are recommended but

none is entirely safe or effective.

Magnesium sulphate is more effective and is being increasingly used though there is

potential risk of respiratory depression in the newborn.

The observational studies have shown that maternal treatment with reduced risk of

IVH, cerebral palsy and mental retardation in their preterm babies.

Sympathomimetic agents specifically mediating via beta-2-adrenergic receptors are

powerful tocolytic agents and currently used.

Isoxsuprine (duvadilan) is useful but its effect is mediated through beta-1 and beta-2
receptors.
Therapy is initiated by intra-venous infusion of 20mg isoxsuprine diluted in 200

ml of 5 percent dextrose at a rate of 40-50drops/minute.

This is followed by IM administration of 10mg isoxsuprine every 4 hours for 24
and 48 hours. Oral therapy is continued for atleast 2 weeks with maintenance dose

of 10mg every 6 hours.

Ritodrine has been approved by US food and drug administration for treatment of
premature labour. The usual dose is 100-400g/ minute intravenously through an
infusion pump for a period of 12 hours followed by oral ritodrine 10mg every 2 hours.

Salbutamol and terbutaline are selective beta-2 receptor stimulators and are very
effective tocolytic agents. They are generally safe but occasionally patient may

develop tachycardia and pulmonary oedema.

Terbutaline is administered as an IV bolus of 0.25mg followed by constant infusion of
10-80 g/minute for 1-2 hours. After control of uterine contractions, maintenance

therapy is continued by administration of 0.25mg SC every 4 hours.

Indomethacin has also offered some hope in arresting premature uterine contractions.

Induction of premature labour:

When indication of labour is contemplated before term, either in the interest of mother
or the fetus, maturity of fetus should be ascertained by examination of amniotic fluid for
phosphatidyl glycerol or L/S ratio. As far as possible, delivery should be postponed till
maturity is assured. When delivery can be safely delayed for 36 to 48 hours corticosteroids
should be administered to the mother to enhance fetal lung maturity.
Antenatal corticosteroids:
Antenatal administration of corticosteroids is one of the most cost-effective perinatal
strategies which must be universally exploited. It is associated with reduction in the incidence
of RDS due to surfactant deficiency. It provides additional benefit by reducing the incidence
of IVH and necrotizing enterocolitis.

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

every 12 hours for 4 doses should be administered to the other if labour starts or is

induced before 34 weeks of gestation.

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 PRETERM BABIES

Optimal management at birth:
When a preterm is anticipated, the delivery should be attended by a senior
pediatrician, fully prepared to resuscitate the baby.

The delayed clamping of cord helps in improving the iron stores of the baby. It may
also reduce the incidence and severity of HMD.

Elective intubation of extremely LBW babies (<1000g) is practiced in some centres to

support breathing and for prophylactic administration of exogenous surfactant.

The baby should be promptly dried, kept effectively covered and warm.
Vitamin K 1mg (0.5 mg in babies < 1500g) should be given intra-muscularly.
The baby should be transferred by the doctor or nurse to the NICU as soon as
breathing is established.

Monitoring:
The following clinical parameters should be monitored by specially trained nurses.
The frequency of monitoring depends upon the gestational maturity and clinical status of the
baby.

Vital signs with the help of multi-channel vital sign monitor ( non-invasive with

alarms).
Activity and behaviour.
Color: pink, pale, grey, blue, yellow
Tissue perfusion: adequate perfusion is suggested by pink colour, capillary refill over
upper chest of < 2sec, warm and pink extremities, normal blood pressure, urine output
of > 1.5ml/kg/hr, absence of metabolic acidosis and lack of any disparity between

paO2 and SpO2.

Fluids, electrolytes and ABGs.
Tolerance of feeds by monitoring vomiting, gastric residuals, abdominal girth.
The baby should be watched for development of RDS, apneic attacks, sepsis, PDA,

NEC, IVH, etc.

Weight gain velocity.

Criteria for a healthy preterm baby:

During daily clinical evaluation of a preterm baby, the following clinical
characteristics should be looked for because they suggest that the baby is healthy.

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:

Uterus provides ideal ambient conditions to the baby. All attempts should be made to
create uterus-like baby-friendly ecology in the nursery.

Create a soft, comfortable, nestled and cushioned bed.

Avoid excessive light, excessive sound, rough handling and painful procedures. Use

effective analgesia and sedation for conducting procedures.

Provide warmth.
Ensure asepsis.
Prevent evaporative skin losses by effectively covering the baby, application of oil or

liquid paraffin to the skin and increasing humidity to near 100 percent.
Provide effective and safe oxygenation.
Uterus is able to provide unique parenteral nutrition. Efforts should be made to
provide at least partial parenteral nutrition and give trophic feeds with expressed

breast milk (EBM).

Provide rhythmic gentle tactile and kinesthetic stimulation like skin-to-skin contact,
interaction, music, caring and cuddling.

Position of the baby:

A pre-warmed open care system or incubator should be available at all times to
receive any baby with hypothermia or with a birth weight of less than 2000g.

The baby should be nursed in a thermo-neutral environment with a servo sense

geared to maintain skin temperature of mid-epigastric region at 36.5 degree Celsius

so that there is virtually no or minimal metabolic thermogenesis.

Application of oil or liquid paraffin on the skin reduces convective heat loss and

evaporative water losses.

The extremely LBW baby should be covered with a cellophane or thin transparent or
thin transparent plastic sheet to prevent convective heat loss and evaporative losses of

water from skin.

As soon as babys condition stabilizes he should be covered with Perspex shield or

effectively clothed with a frock, cap, socks and mittens.

After one week or so, stable babies with a birth weight of < 1200g should preferably

be nursed in an intensive care incubator.

The mother should be encouraged to provide partial kangaroo0mother-care to prevent
hypothermia, to promote bonding and breast feeding and to transmit healing electromagnetic vibrations of love and compassion to her baby.

Oxygen therapy:
Oxygen should be administered only when indicated, given in the lowest ambient
concentration and stopped as soon as its use is considered unnecessary.

The oxygen should be administered with a head box when SpO 2 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 SpO 2 between 85-95% and
PaO2 between 60-80 mm Hg.

Phototherapy:
Jaundice is common in preterm babies due to hepatic immaturity, hypoxia,
hypoglycaemia, infections and hypothermia. Due to immaturity of blood brain barrier,
hypoproteinemia and perinatal distress factors, bilirubin brain damage may occur at relatively
lower serum bilirubin levels.

Early phototherapy is adviced to keep the serum bilirubin level within safe limits
inorder to obviate the need for exchange blood transfusion.

Prevention of nosocomial infections:

A preterm baby, who survives the initial stormy and unstable period of one week, is
likely to do well if protected against infections and provided with adequate nutrition.

The handling should be reduced to bare minimum.

Vigilance should be maintained on all procedures recommended for reduction of

infections in the nursery.

Early diagnosis and prompt treatment of infections are essential for improved
survival.

Feeding and nutrition:

Starvation should be avoided and early enteral feeding should be established as sooon
as the baby is stable.

Babies weighing less than 1200g or gestation of <30 weeks and sick babies should be
started on intra-venous dextrose solution (10% dextrose in babies >1000g and 5%
dextrose in babies <1000g).

Trophic feeds with EBM ( 1-2 ml 4 times/day) throough NG tube can be started in all

babies irrespective of their birth weight or clinical conditions.

When babys condition is stabilized enteral feeds are begun with EBM starting with a
volume of 30ml/kg/day on the first day and depending upon the tolerance, the enteral
feeds are increased by 10-20ml/kg/day every day and IVF are reduced accordingly.

Nutritional supplements:
After two weeks when baby is stable and tolerating enteral feeds, EBM can be
fortified with human milk fortifier (HMF). The fortification of EBM with formula feeds
(especially during night) also provides additional calories and protein to the baby.

Multivitamin drops containing folic acid should be started at 2 weeks of age.

Iron supplementation (2-3 mg/kg elemental iron) should be started after 2-3 weeks

when a baby is having steady weight gain.

Free radical lipid peroxidation in cell membranes is catalysed by iron and
polysaturated fatty acids (PUFA) thus increasing the requirements of vitamin E in
very low birth babies. The requirement of vitamin E are therefore related to linoleic
acid content of the formula. It is recommende that vitamin E to linoleic acid ratio
should be > 1iu/gram of linoleic acid in the feeding formula for LBW babies. The
alpha tocopherol/ linoleic acid ratios are 6.23, 1.43 and 0.78 mg/g in human

colostrum, transitional and mature milk respectively.

Vitamin E is powerful anti-oxidant and prevents the haemolytic anemia and edema of

prematurity.
In infants weighing less than 1500g at birth, milk formula should provide atleast1iu of
vitamin E /g of linoleic acid and supplemented with daily administration of 15 iu of

vitamin E.
Supplements of calcium (220mg/day) and phosphorus (100mg/day) are essential to

prevent osteopenia of prematurity.

The supplements are continued till the baby has achieved post conceptional maturity
of 38 weeks or weight of 2000g.

FEEDING OF PRETERM INFANTS

Proper nutrition in infancy is essential for normal growth, resistance to infection,

long term health and optimal neurologic and cognitive development. Providing adequate
nutrition to preterm infants is challenging because of several problems, some of them unique
to these small infants. These problems include immaturity of bowel function, inability to suck
and swallow, high risk of necrotizing enterocolitis (NEC), illnesses that may interfere with
adequate enteral feeding (e.g., RDS, patent ductus arteriosus) and medical interventions that
preclude feeding (e.g., umbilical vessel catheters, exchange transfusion, indomethacin
therapy).
PHYSIOLOGY AND PATHOPHYSIOLOGY
The gut has formed and has completed its rotation back into the abdominal cavity by 10
weeks of gestation. By 16 weeks, the fetus can swallow amniotic fluid. GI motor activity is
present before 24 weeks, but organized peristalsis is not established until 29-30 weeks and is
facilitated by antenatal corticosteroid treatment. Coordinated sucking and swallowing
develops at 32-34 weeks. By term, the fetus swallows about 150 cc/kg/day of amniotic fluid,
which has 275 mOsm/L, contains carbohydrates, protein, fat, electrolytes, immunoglobulins
and growth factors, and plays an important role in development of GI function. Preterm birth
interrupts this development. Even if nutrients are provided parenterally, lack of enteric intake
leads to decreased circulating gut peptides, slower enterocyte turnover and nutrient transport,
decreased bile acid secretion, and increased susceptibility to infection due to impaired barrier
function by intestinal epithelium, lack of colonization by normal commensal flora and
colonization by pathogenic organisms. For fat digestion, the newborn depends on lingual
lipase, which is stimulated by sucking and swallowing and by nutrients in the stomach but not
the small bowel. The figure is a chronological representation of GI development during fetal
life.
CONTRA-INDICATIONS TO FEEDING
Do not start feeds if the infant:
is receiving indomethacin, or received it within the previous 48hours
has a hemodynamically significant patent ductus arteriosus
has either an umbilical arterial or venous catheter. Do not start feedings until the
catheters have been removed for 8hurs
is polycythemic
has significant metabolic acidosis.
has severe respiratory instability or there is impending endotracheal intubation

 has hemodynamic instability as evidenced by clinical signs of sepsis, hypotension,

is receiving dopamine (at a dose >3 mcg/kg/min) or other vasopressor drugs
received an exchange transfusion within the past 48hours.
has abdominal distension or other signs of GI dysfunction.
has had an episode of severe asphyxia (perinatal or post-natal) in the previous
72hours
FEEDING PROTOCOL: The following are guidelines for the initiation and advance of
enteral feedings in preterm infants:
1. Method of feeding:
Because these infants usually have not yet developed coordinated sucking and
swallowing, they must be fed by gavage:
Orogastric tubes are usually used. Because infants are obligate nose breathers,
it is best not to occlude the nares with a tube. In addition, repeated insertion of
a nasal gastric tube can cause inflammation of the nose with subsequent

obstruction.
Estimate length of tube that must be inserted to reach the stomach.
Insert the tube and aspirate to see if gastric contents are returned. While
listening over stomach with stethoscope, inject ~5cc of air. If tube is in
stomach, you should hear bubbling as you inject air. If you cannot hear any
bubbling, tube may be in the trachea. Therefore, do not feed infant until you

are certain that tube is in stomach.

Do not use duodenal or jejunal tubes for gavage feedings as feedings are less
well tolerated and do not stimulate secretion of lingual lipase. In addition,

residuals are no longer useful in assessing tolerance of feedings.

Nipple feedings can be considered as the infant matures. The best judge of
when to start nipple feedings is an experienced Nurse.

2. Content of feeding: Begin with either:

Breast milk (preterm breast milk is 290 mOsm/L) or

Formula for preterm infants (e.g., Premature Enfamil or Similac Special Care,

260 mOsm/L).
Some physicians use half-strength feedings, but there is no evidence that this is
beneficial. In fact, hypo-osmolar solutions may slow gastric emptying, leading to

increased incidence of residuals and feeding intolerance

Remember that fetuses swallow amniotic fluid, which is 275 mOsm/L, and this
swallowing begins at 16 weeks gestation.

3. Guidelines for Feeding: Initiation of feedings, their volume and the rate of advance of
feedings are related to birth weight, gestational age and how the infant has tolerated feeds to
date. General guidelines include:

Initial volume is 2 cc/kg per feeding with a minimal absolute volume of 2 cc

Do not advance feedings faster than 20 cc/kg/d.
Do not advance feedings if there are any signs that the baby is not tolerating

feeds. Aggressive advances of feedings increase the risk of NEC.

A small volume, even if not advanced, is much better than nothing at all. Even very

small volumes stimulate maturation of gut motility and production of enteric peptides.
Bolus feedings are preferable to continuous feedings.
The goals for full feedings are:
-Volume: 150-160 cc/kg/d
-Calories: 110-120 kcal/kg/d
-Some SGA infants will require a higher caloric intake to achieve consistent

weight gain.
FORTIFYING FEEDINGS not only provides mores calories but also improved intake of
calcium, phosphorus and protein. Fortify feedings (breast milk and formula) as follows:
-When infant is tolerating 100 cc/kg/d, feedings may be fortified to 22 cal/oz.
-When infant has been tolerating 150 cc/kg/d for at least 2d, feedings may be fortified to 24
cal/oz.
INTOLERANCE TO FEEDINGS is common among very small preterm infants, and most
such infants will have episodes that require either temporary discontinuation of feedings or a
delay in advancing feedings. Although most episodes resolve spontaneously and without
sequelae, any signs of feeding intolerance should be regarded as potentially serious because
of the increased risk of NEC among these infants. Signs that indicate possible intolerance of
feeding include:

Gastric residuals or emesis

Abdominal distension
Blood in the stool (gross or occult)
Loose stools or diarrhea
Metabolic acidosis
Temperature instability
Onset of apneic episodes
Hyperglycemia

MANAGEMENT OF FEEDING INTOLERANCE should be related to the type and

severity of the presenting signs, as described below:
1. Gastric residuals:

Non-bilious residuals:
If these are smaller than the volume of a feeding and are not increasing in volume,
and if the infant otherwise appears well, feeding can continue but the infant should be
observed carefully for other signs of feeding intolerance. If the infant has any other
worrisome findings, hold the feedings, consider obtaining an abdominal radiograph

and observe the infant.

If the residuals are greater than the volume of a feeding or are progressively

increasing in volume, hold the feedings and observe closely.

Bilious residuals are a serious sign. Hold feedings, evaluate infant closely, and
consider further workup including abdominal radiograph, CBC and platelets.

2. Abdominal distension is a serious sign. Discontinue feedings, obtain abdominal

radiograph, and consider further evaluation and treatment.
3. Blood in stools: Discontinue feedings,consider obtaining clotting studies and
abdominal radiograph.
4. If metabolic acidosis occurs, hold feedings, evaluate closely for NEC, sepsis,
hypotension and a patent ductus arteriosus. Metabolic acidosis in the presence of NEC
is a grave prognostic sign.
5. 5. Loose stools, temperature instability, apnea, hyperglycemia: Hold feedings and
evaluate infant carefully. If feedings have to be stopped for any of these reasons,
notify the Neonatology Fellow and/or the Attending Physician, so that they can follow
the infants condition with you. If there is any doubt about how well an infant is
tolerating feedings, it is best to hold feedings, evaluate the infant and discuss the
case with the other members of the team.

Gentle rhythmic stimulation:

Availability of sophisticated high technology has revolutionized the care of preterm
and sick newborn babies. But the technology should not be allowed to become a barrier
between the communication, compassion and concern of the treating team and family.

Gentle touch, massage, cuddling, stroking and flexing by the nurse or preferably by
the mother provide useful tactile stimuli to the baby.

Rocking bed or placing a preterm baby on inflated gloves rhythmically rocked by a

ventilator provide useful vestibular- kinaesthetic stimuli for prevention of apneic

attacks of prematurity.
Soothing auditory stimuli can be given to the preterm baby in the form of taped heart

beats, family voices or music.

Music has been shown to reduce the stress of procedure and enhance weight gain

velocity of preterm babies.

Visual inputs can be provided with the help of colored objects, diffuse light and eyeto-eye contact.

Utility of corticosteroids:
Unnecessary administration of corticosteroids should be avoided due to its potential
side effects. Antenatal administration of betamethasone or dexamethasone is universally
recommended if labor starts before 34 weeks of gestation.

A single dose of dexamethasone 0.2mg/kg IV at 4 hours of age may be given to very

low birth weight babies to reduce the incidence of HMD and IVH, but its use is

controversial.
Corticosteroids are also indicated to assist the process of difficult weaning following
prolonged assisted ventilation and for attenuation of inflammatory changes in infants

with broncho-pulmonary dysplasia.

Inhaled steroids has not been found to be useful to reduce the risk of chronic lung

disease(CLL).
Corticosteroids

scleremaneonatorum.
There is increasing evidence to suggest that prolonged use of corticosteroid therapy

have

some

therapeutic

utility

in

the

management

of

should be avoided in newborn babies because of serious concerns for short term
( hypertension, hyperglycemia, GI bleeding, infections) and long term (cerebral palsy
and neuromotor disability) side effects.

Transient hypothyroxinemia of prematurity:

In preterm babies below 30 weeks of gestation, total T 4 levels may be low but free T4,
T3 and TSH levels are usually normal. The condition is transient and is attributed to normal
adaptive response of an immature hypothalamic-pituitary axis or to sick euthyroid syndrome.

Its clinical significance is controversial. The current Cochrane Neonatal Collaborative

Review does not recommended routine T4 suplementation in preterm babies.

Prevention, early diagnosis and prompt management of common problems:

Nosocomial infections:house keeping rituals, strict house keeping routines and high
index of suspicion should be maintained to prevent and make early diagnosis of

nosocomial infections.
Hypothermia: Nurse in a thermoneutral environment.
Respiratory distress syndrome: Antenatal administration of corticosteroids,
prevention and effective treatment of perinatal distress, prophylactic administration of

exogenous surfactant to reduce the incidence and severity of HMD.

Aspiration: Availability of trained nurses is essential for safe administration of enteral

feeds and for prevention of aspiration of feeds.

Patent ductusarteriosus: Avoid over infusion.
Chronic lung disease: During assisted ventilation, airway pressure should be kept at
the bare minimum without compromising gas exchange. In infants <1000g,
administration of vitamin A 5000 units IM 3 times in a week has been shown to
reduce the risk of CLD by 10%. Corticosteroids should preferably be avoided or only

short courses should be used due to potential risk of causing neuromotor disability.
Necrotisingenterocolitis: Ensure feeding with human milk, trophic feeds, avoidance

of hyperosmolar feeds and over infusion.

Intra-ventricular haemorrhage: Antenatal corticosteroids, avoidance of rough
handling, excessive CPAP and bolus administration of sodium bicarbonate mau

reduce the incidence of IVH.

Retinopathy of prematurity: Maintain PaO2 BELOW 90 mm Hg, avoid excessive

light, blood transfusions and ensure feeding with human milk.

Late metabolic acidosis: Protein intake should be restricted to 3g/kg/d and avoid use

of formula feeds.
Nutritional disorders: Provide supplements with calcium, phosphorus, vitamin D,

vitamin E, iron and folic acid.

Drug toxicity: Side effects of drugs by giving lower doses at 12 hourly intervals.

Weight record:
Accurate weighing of babies is a sensitive index of their well being. The weight is
routinely recorded every day but in sick babies twice daily weight record is recommended.

Most preterm babies lose weight during the first 3 to 4 days of life and loss is upto

a maximum of 10 to 15 percent of the birth weight.

The weight remains stationary for the next 4 to 5 days and then the babies start

gaining at a rate of 1 to 1.5 % of body weight (10-15g/kg/d) per day.

They regain their birth weight by the end of second week of life.
Excessive weght loss, delay in regaining the birth weight or slow weight gain
suggest that either the baby is not being the baby is not being fed adequately or he

is unwell and needs immediate attention.

Sudden weight loss in a baby who had been gaining weight satisfactorily would

suggest the possibility of dehydration.

Excessive weight gain of 100g or more per day may occur in babies with cardiac
failure though sometimes healthy babies may also gain weight more rapidly.

What to avoid in the care of preterm babies??

In the care of preterm babies, at times greater harm is done by unnecessary
therapeutic interventions which may lead to iatrogenic disorders. The following interventions
should be avoided because they are unnecessary, useless and often associated with serious
side effects.

Routine oxygenation without monitoring.

Intravenous immunoglobulins for prevention of neonatal sepsis.
Prophylactic antibiotics ( except during assisted ventilation).
Prophylactic administration of indomethacin or high doses of vitamin E.
Unnecessary blood transfusions (definite indications include haematocrit of<40% in
a sick neonate, <30% in a symptomatic neonate and <25% in an asymptomatic

neonate).
Formula feeds.
Rough handling, excessive light and loud sound.

Immunizations:
Preterm babies are able to mount a satisfactory immune response and they can be
vaccinated at the usual chronological age like term babies. The dose of vaccine is not reduced
in preterm babies. However, there is some evidence to suggest that administration of hepatitis
B vaccine in preterm infants is associated with low sero-conversion rate.

Because during their stay in the NICU, there is no risk of contracting vaccinepreventable diseases, 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 positive, baby should be given hepatitis B

vaccine and hepatitis B specific immunoglobulins within 72 hours of age.

Live vaccines should be avoided in symptomatic HIV-positive mothers.
WHO recommends that BCG and oral polio vaccine can be given to asymptomatic
HIV-positive infants.

Family support:
The prolonged stay of preterm and sick newborn babies in the NICU is associated
with emotional trauma, uncertainly, anxiety and lack of bonding with the baby on the part of
parents.

The family dynamics are greatly disturbed apart from tremendous physical stress and
fiscal implications due to high cost of neonatal intensive care. These problems and
issues should be handled with equanimity, compassion, concern and caring attitude of

the health team.

The frightening scene of NICU should be demystified and family should be constantly

informed and involved in the care of their baby.

The mother should be encouraged to touch and talk with her baby provide routine care

under the guidance of nurses.

She should be assisted to provide kangaroo-mother-care to her baby and try to

establish eye-to-eye contact.

The anxiety and concern of the family should be cushioned by providing necessary
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.

The baby should be observed for another 12 hours after putting the incubator off to

see whether he can maintain his body temperature.

The infant should stay in the incubator for as short a period as possible because
incubators are a potent source of nosocomial infection.

Discharge policy:
The mother should be mentally prepared and provided with essential training and
skills for handling a preterm baby before she is discharged from the hospital.

The mother- baby dyad should be kept in step-down nursery where she is able to
independently look after the essential needs of her baby like maintenance of body
temperature, ensuring sepsis, feeding with a cup and spoon/ paladay or breast

feeding, toilet needs,etc.

The baby should be stable, maintaining his body temperature and should not have

any evidences of cold stress.

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:
After discharge from the hospital, babies should be regularly followed up for
assessment of the following parameters. The specialized perinatal follow-up services demand
a close collaboration and interaction with a large number of specialists like paediatrician,
Developmental physician, dietitian, ophthalmologist, audiologist, child psychologist, physiooccupational therapist and social worker. The following parameter should be closely
monitored and followed:

Common infective illnesses, reactive airway disease, hypertension, renal dysfunction,

gastro-oesophageal reflux.
Feeding and nutrition.
Immunizations.
Physical growth, nutritional status, anemia, osteopenia/ rickets.
Neuromotor development, cognition and seizures.
Eyes: Retinopathy of prematurity, vision, strabismus.
Hearing.
Behavioural problems, language disorders and learning disabilities.

Home care of preterm babies:

Most healthy near term or borderline preterm infants with a birth weight of 1,800g or
more and gestational maturity of 35 weeks or more can be managed at home. The policy of
early discharge from the hospital in an effort to decongest the nurseries, has imposed
additional responsibilities that their care be extended to their home.

It is essential that a LBW infant should not be discharged unless he has regained his
birth weight, is self feeding from the bottle or breast and is showing a steady weight

gain.
Before discharge, the mother should be encouraged breast fed her baby and look after

his toilet needs.

She must be explained about the importance of maintaining asepsis, keeping the baby

warm and ensuring satisfactory feeding routine.

The services of postpartum programme public health nurse and social worker can be

utilized to provide home care after discharge.

It is essential that proper appraisal of available physical facilities, resources and
environmental conditions be made by a predischarge home visit by a health visitor or

a public health nurse before the baby is discharged.

It should be followed by periodic home visits to assess the progress of the child.

Environmental control:
It must be remembered that the desirable environmental temperature to safeguard the
biological needs of the low- birth weight infant.

The infant should be effectively covered taking care to avoid smothering.

Woollen cap, socks and mittens should be worn.
The infant should preferably lie next to the mother which serves as a useful

biologically controlled heat source.

In 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, if ever used, should never come in contact with the baby.
The cot of the mother and infant should be located away from the walls to reduce

radiation heat loss.

The mother and health worker should be trained to assess the temperature of the
newborn baby by touch and advised tpo ensure that extremities are kept warm and

pink.
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.

In case formula feeding is unavoidable, specially designed 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 nprevent contamination of feeds.

Prognosis
The outcome of uncomplicated premature babies is comparable to the babies born
after full maturity. In fact, several renowned and famous people, who were born premature,
grew upto become world leaders and intellectuals. Sir Isaac Newton, the greatest
mathematician genius, weighed merely 3 lbs at birth. Sir Winston Churchill, the legendary
Prime Minister of Britain was born after 7 months of pregnancy when his mother was
participating in a royal dance. The parents of premature children, therefore, should not feel
despondent because there is enough historical evidence that their infant has a bright future
and he may grow up to become an intellectual giant.
Prognosis for survival is directly related to the birth weight of the child and quality of
neonatal care over three-fourth of neonatal deaths occur among LBW babies. Therefore in
countries with high incidence of LBW babies, neonatal mortality is likely to be higher.

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.
Long term follow up studies of infants with a birth weight of 1500g and less have
revealed 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 in the form of language

disorder, learning disabilities, behaviour problems, ADHD requiring specialized

support for education.

The incidence of neurological handicaps is related to the quality of obstetrical and

neonatal services.
Neurological prognosis is adversely affected by degree of immaturity, IUGR, severity
of perinatal hypoxia, IVH, periventricular leukomalacia and severity of respiratory
failure demanding assisted ventilation.

PRIORITY PACKAGES AND EVIDENCE-BASED INTERVENTIONS

All newborn babies are vulnerable given that birth and the following few days hold the
highest concentrated risk of death of any time in the human lifespan. Every baby needs
essential newborn care, ideally with their mothers providing warmth, breastfeeding and a
clean environment. Premature babies are especially vulnerable to temperature instability,
feeding difficulties, low blood sugar, infections and breathing difficulties. There are also
complications that specifically affect premature babies. Saving lives and preventing disability
from preterm birth can be achieved with a range of evidence-based care increasing in
complexity and ranging from simple care such as warmth and breastfeeding up to full
intensive care. The packaged interventions in this chapter are adapted from a recent extensive
evidence review and a consensus report, Essential Interventions Commodities and
Guidelines for Reproductive Maternal, Newborn and Child Health.Recognition of small
babies and distinguishing which ones are preterm are essential first steps in prioritizing care
for the highest risk babies. The highest-risk babies are those that are both preterm and growth
restricted.

PACKAGE 1: ESSENTIAL AND EXTRA NEWBORN CARE

Care at birth from a skilled provider is crucial for both women and babies and all providers
should have the competencies to care for both mother and baby, ensuring that mother and
baby are not separated unnecessarily, promoting warmth, early and exclusive breastfeeding,
cleanliness and resuscitation if required (WHO, 2010). These practices are essential for fullterm babies, but for premature babies, missing or delaying any of this care can rapidly lead to
deterioration and death. For all babies at birth, minutes count.

Thermal care

Simple methods to maintain a babys temperature after birth include drying and wrapping,
increased environmental temperature, covering the babys head, skin-to-skin contact with the
mother and covering both with a blanket. Delaying the first bath is promoted, but there is a
lack of evidence as to how long to delay, especially if the bath can be warm and in a warm
room. Kangaroo Mother Care (KMC) has proven mortality effect for babies <2,000 g.
Equipment-dependent warming techniques include warming pads or warm cots, radiant
heaters or incubators and these also require additional nursing skills and careful monitoring.
Sleeping bags lack evidence for comparison with skin to- skin care or of large-scale
implementation. There are several trials suggesting benefit for plastic wrappings but, to date,
these have been tested only for extremely premature babies in neonatal intensive care units.

Feeding support
At the start of the 20th century, Pierre Budin, a famous French obstetrician, led the world in
focusing on the care of weaklings, as premature babies were known then. He promoted
simple care--warmth, breastfeeding and cleanliness. However, by the middle of the 20th
century, formula milk was widely used and the standard text books said that premature babies
should not be fed for the first few days. After 1960, the resurgence of attention and support
for feeding of premature babies was an important factor in reducing deaths before the advent
of intensive care. Early initiation of breastfeeding within one hour after birth has been shown
to reduce neonatal mortality. Premature babies benefit from breast milk nutritionally,
immunologically and developmentally .The short-term and long-term benefits compared with
formula feeding are well established with lower incidence of infection and necrotizing
enterocolitis and improved neurodevelopmental outcome. Most premature babies require
extra support for feeding with a cup, spoon or another device such as gastric tubes (either oral
or nasal). In addition, the mother requires support for expressing milk. Where this is not
possible, donor milk is recommended. In populations with high HIV prevalence, feasible
solutions for pasteurisation are critical. Milk-banking services are common in many countries
and must be monitored for quality and infection prevention. Extremely preterm babies under
about 1,000 g and babies who are very unwell may require intravenous fluids or even total
parenteral nutrition, but this requires meticulous attention to volume and flow rates. Routine
supplementation of human milk given to premature babies is not currently recommended by
WHO. WHO does recommend supplementation with vitamin D, calcium and phosphorus and
iron for very low birth weight babies and vitamin K at birth for low birth weight babies.

Infection prevention
Clean birth practices reduce maternal and neonatal mortality and morbidity from infectionrelated causes, including tetanus. Premature babies have a higher risk of bacterial sepsis.
Hand cleansing is especially critical in neonatal care units. However basic hygienic practices
such as hand washing and maintaining a clean environment are well known but poorly done.
Unnecessary separation from the mother or sharing of incubators should be avoided as these
practices increase spread of infections. For the poorest families giving birth at home, the use
of clean birth kits and improved practices have been shown to reduce mortality. Recent
cluster-randomized trials have shown some benefit from chlorhexidine topical application to
the babys cord and no identified adverse effects. To date, about half of trials have shown a
significant neonatal mortality effect especially for premature babies and particularly with
early application, which may be challenging for home births.
Another possible benefit of chlorhexidine is a behaviour change agent in many cultures
around the world, something is applied to the cord and a policy of chlorhexidine application
may accelerate change by substituting a helpful substance for harmful ones.
The skin of premature babies is more vulnerable, and is not protected by vernix like a term
babys. Topical application of emollient ointment such as sunflower oil reduces water loss,
dermatitis and risk of sepsis and has been shown to reduce mortality for preterm babies.
Another effective and low cost intervention is appropriate timing for clamping of the
umbilical cord, waiting 2-3 minutes or until the cord stops pulsating, whilst keeping the baby
below the level of the placenta. For preterm babies this reduces the risk of intracranial
bleeding and need for blood transfusions as well as later anemia. Possible tension between
delayed cord clamping and active management of the 3rd stage of labor with controlled cord
traction has been debated, but the Cochrane review and also recent-evidence statements by
obstetric societies support delayed cord clamping for several minutes in all uncomplicated
births.

PACKAGE 2: NEONATAL RESUSCITATION

Between 5 to 10% of all newborns and a greater percentage of premature babies require
assistance to begin breathing at birth. Basic resuscitation through use of a bag-and-mask or
mouth-to-mask (tube and mask) will save four out of every five babies who need

resuscitation; more complex procedures, such as endotracheal intubation, are required only
for a minority of babies who do not breathe at birth and who are also likely to need ongoing
ventilation. Recent randomized control trials support the fact that in most cases assisted
ventilation with room air is equivalent to using oxygen, and unnecessary oxygen has
additional risks. Expert opinion suggests that basic resuscitation for preterm births reduces
preterm mortality by about 10% in addition to immediate assessment and stimulation. An
education program entitled Helping Babies Breathe has been developed by the American
Academy of Pediatrics and partners for promotion of basic neonatal resuscitation at lower
levels of the health system in low-resource settings and is currently being scaled up in over
30 low-income countries and promises potential improvements for premature babies

PACKAGE 3: KANGAROO MOTHER CARE

KMC was developed in the 1970s by a Colombian pediatrician, Edgar Rey, who sought a
solution to incubator shortages, high infection rates and abandonment among preterm births
in his hospital. The premature baby is put in early, prolonged and continuous direct skin-toskin contact with her mother or another family member to provide stable warmth and to
encourage frequent and exclusive breastfeeding. A systematic review and meta analysis of
several randomized control trials found that KMC is associated with a 51% reduction in
neonatal mortality for stable babies weighing <2,000g if started in the first week, compared to
incubator care. These trials all considered facility-based KMC practice where feeding support
was available. An updated Cochrane review also reported a 40% reduction in risk of postdischarge mortality, about a 60% reduction in neonatal infections and an almost 80%
reduction in hypothermia. Other benefits included increased breastfeeding, weight gain,
mother-baby bonding and developmental outcome. In addition to being more parent and baby
friendly, KMC is more health-system friendly by reducing hospital stay and nursing load and
therefore giving cost savings. KMC was endorsed by the WHO in 2003 when it developed a
program implementation guide. Some studies and program protocols have a lower weight
limit for KMC, e.g., not below 800g, but in contexts where no intensive care is available,
some babies under 800g do survive with KMC and more research is required before setting a
lower cut off. Despite the evidence of its cost effectiveness, KMC is underutilized although it
is a rare example of a medical innovation moving from the Southern hemisphere, with recent
rapid uptake in neonatal intensive care units in Europe.

PACKAGE 4: SPECIAL CARE OF PREMATURE BABIES AND

PHASED SCALE UP OF NEONATAL INTENSIVE CARE
Moderately-premature babies without complications can be cared for with their mothers on
normal postnatal wards or at home, but babies under 32 weeks gestation are at greater risk of
developing complications and will usually require hospital admission. Fewer babies are born
under 28 weeks of gestation and most of these will require intensive care.

Care of babies with signs of infection

Improved care involves early detection of such danger signs and rapid treatment of infection,
while maintaining breastfeeding if possible. Identification is complicated by the fact that ill
premature babies may have a low temperature, rather than fever. First level management of
danger signs in newborns has relatively recently been added to Integrated Management of
Childhood Illness guidelines. WHO recommends that all babies with danger signs be referred
to a hospital. Where referral is not possible, then treatment at the primary care center can be
lifesaving.

Care of babies with jaundice

Premature babies are at increased risk of jaundice as well as infection, and these may occur
together compounding risks for death and disability. Since severe jaundice often peaks
around day 3, the baby may be at home by then. Implementation of a systematic pre
discharge check of women and their babies would be an opportunity to prevent complications
or increase care seeking, advising mothers on common problems, basic home care and when
to refer their baby to a professional.

Babies with Respiratory Distress Syndrome

For premature babies with RDS, methods for administering oxygen include nasal prongs, or
nasal catheters. Safe oxygen management is crucial and any baby on continuous oxygen
therapy should be monitored with a pulse oximeter. The basis of neonatal care of very
premature babies since the 1990s was assisted ventilation. However, reducing severity of
RDS due to greater use of antenatal corticosteroids and increasing concerns about lung
damage prompted a shift to less intensive respiratory support, notably CPAP commonly using
nasal prongs to deliver pressurized, humidified, warmed gas (air and/or oxygen) to reduce
lung and alveoli collapse. This model of lower intensity may be feasible for wider use in

middle-income countries and for some low-income countries that have referral settings with
stronger systems support such as high-staffing, 24-hour laboratories.
Recent trials have demonstrated that CPAP reduces the need for positive pressure ventilation
of babies less than 28 weeks gestation, and the need for transfer babies under 32 weeks
gestation to neonatal intensive care units. One very small trial in South Africa comparing
CPAP with no ventilation among babies who were refused admission to neonatal intensive
care units found CPAP reduced deaths. In Malawi, a CPAP device developed for low-resource
settings is being trialed in babies with respiratory distress who weigh over 1,000g. Early
results are encouraging, and an important outcome will be to assess the nursing time required
and costs.
Increasing use of CPAP without regulation is a concern. Many devices are in the
homemade category; several low cost bubble CPAP devices are being developed
specifically for low-income countries but need to be tested for durability, reliability and
safety. CPAP-assisted ventilation requires adequate medical and nursing skill to apply and
deliver safely and effectively, and also requires other supportive equipment such as an
oxygen source, oxygen monitoring device and suction machine.
Surfactant is administered to premature babys lungs to replace the missing natural surfactant,
which is one of the reasons babies develop RDS. The first trials in the 1980s demonstrated
mortality reduction in comparison to ventilation alone. The cost also remains a significant
barrier. In India, surfactant costs up to $600 for a dose. Data from India and South Africa
suggest that surfactant therapy is restricted to use in babies with potential for better survival,
usually over 28 weeks gestation due to its high price. Costs may be reduced by synthetic
generics and simplified administration, for example with an aerosolized delivery system, but
before wide uptake is recommended, studies should assess the additional lives saved by
surfactant once antenatal corticosteroids and CPAP are used.

NURSING MANAGEMENT
Assessment:

Obtain detailed antenatal, intra-natal history.

Assess the gestational age and birth weight of the baby.
Assess the features of clinical immaturity.
Assesss the behaviour of preterm neonate.

Assessment of common problems:

The infants respiratory status must be observed constantly. The lungs are assessed for
adventitious breath sounds or areas of absent breath sounds. The Silverman-Anderson
index ia s useful tool for evaluating the degree of respiratory distress. Look for the

apneic spells.
Thermoregulation: the infants temperature is monitored continuously by a skin probe
on the infants abdomen, which is attached to the heat control mechanism of the
radiant warmer. The temperature usually maintained at 36 degree to 36.5 degree
Celsius. It should be recorded every 30 to 60 minutes initially and every 3 to 4 hours
when stable. Assess axillary temperature every 4 to 8 hours and compare with the

probe temperature. Look for signs of hypothermia.

Feeding and electrolyte balance: monitor intake-output of fluids determine fluid
balance. The nurse also must track of the amount of blood taken. Assess the urine
output by weighing the diapers. Weigh the child daily. Look for signs of dehydration (
decreased urine output <1ml/hr, increased specific gravity, weight loss and dry skin
and mucous membrane, sunken fontanel, increased sodium) or overhydration
( increased urine output >3ml/hr with a below normal specific gravity, edema, weight
gain, bulging fontanelles, moist breath sounds and decreased blood sodium and

protein).
Skin: frequently assess the condition of the infants skin and record any changes. The

infants response to product used for cleansing and disinfection must be noted.
Infection: the nurse should be alert for signs of infection at all times like general

signs, respiratory, cardio-vascular, GI and neurologic signs.

Pain: because pain is afifth vital sign, it should be assessed frequently (high pitched
cry, intense and harsh cry, mouth open, grimacing, furrowing or bulging of the brow,
tense,rigid muscles and color changes) and must assess the response to potentially

painful stimuli and to pharmacologic and non-pharmacologic interventions.

Assess the amount of noise to which the infant is exposed. Determine how often

interruptions occur and how the infant responds to different types of care.
Assess the infants adjustment to feeding, readiness for change and indicating

intolerance.
Assess the activity level of the preterm baby.
Continually assess the infants responses to all feeding methods and watch for
distress, weigh the infant dailynand observe the changes ability to take feedings.
Assess the improvement in suck and swallow co-ordination.

Assess the parental anxiety and promote maternal bonding and assess the support

system and coping pattern.

Assess the knowledge level and support decision making.

Nursing diagnosis and interventions:

1

Impaired gas exchange related to immaturity of lungs and deficiency of surfactant

Interventions:

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
Frequent monitoring of ABG
Frequent position changes every 2 to 3 hours
Check the suction equipment and suction the airway and applied for only 5

to 10 seconds.
The mouth is suctioned before the nose.
Maintain adequate hydration
Impaired breathing pattern : distress related to immaturity and surfactant deficiency
Asess 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 physio therapy
Administer bronchodilators
Administer anti inflammatory medications
Administer antibiotics
Activity intorance related to increased work of breathing secondary to distress
Arrange to provide routine care
Schedule periods of uninterrupted rest
Determine infants stress level
Reduce nonessential lighting
Use positioning devices
Ineffective airway clearance related toexcessive 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
Hypothermia related to immature thermoregulation system
Monitor vital signs frequently
Wrap the baby well and keep warm
Provide small and frequent breast feeding as tolerated
Look for hypoglycemia
Administer IV fluids if not tolefeed intolerance
Monitor the vital signs and blood pressure
Assess the skin tone, pallor and signs of dehydration
Administer IV fluids
Assess the lab investigations for Hb, RBCs, platelet count, coagulation

profile
If necessary, administer blood
Administer required amount of inj. Vitamin K
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
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
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 andABG values
Closely monitor for the early signs and symptoms of complications

10

11

12

13
14

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 supporttothefamily members
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 frequent breast feed 2 hourly
If 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
Interrupted family process related to hospitalization of the newborn
Assess the mental status, anxiety and knowledge of family members
Encourage mother-child bonding if possible
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
Allow the family members to visit the child
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
Risk for delayed growth and development related to prematurity
Risk for caregiver role strain related to need for long term care

CONCLUSION
Any infant who is born dysmature (before term or post term, or who is underweight or
overweight for gestational age) is at risk for complications at birth or in the first few days of
life. Parents need thorough education about their babys health because these problems
require hospitalization or additional follow-up at home.

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