Prematurity

What is prematurity?

A baby born before 37 weeks of pregnancy is considered premature, that is, born before complete maturity. Slightly fewer
than 12 percent of all babies are premature. Overall, the rate of premature births is rising, mainly due to the large numbers
of multiple births in recent years. Twins and other multiples are about six times more likely to be premature than single birth
babies. The rate of premature single births is slightly increasing each year.

Weeks of Pregnancy > 28 weeks 28 to 31 32 to 35 36 37 to 39 40 41

Percentage of Births 0.7 1.2 5.4 4.25 48 21 11

Based on 1999 data from the National Center for Health

Statistics

Other terms often used for prematurity are preterm and "preemie." Most premature babies also weigh less than 2,500 grams
(5.5 pounds) and may be referred to as low birthweight (LBW).

What causes prematurity?

There are many factors linked to premature birth. Some 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 preeclampsia (also known as 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 alcohol, heroin, 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 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 or more)

What are the characteristics of the premature baby?

The following are the most common characteristics of a premature baby. However, each baby may show different
characteristics, depending on of the condition. Characteristics may include:

 small baby, often weighing less than 2,500 grams (5 pounds 8 ounces)
 thin, shiny, pink or red skin, able to see veins
 little body fat
 little scalp hair, but may have lots of lanugo (soft body hair)
 weak cry and poor body tone
 genitals may be small and underdeveloped

Why is prematurity a concern?

Premature babies are born before their bodies and organ systems have completely matured. They may need help breathing,
eating, fighting infection, and staying warm. Very premature babies, those born before 28 weeks, are especially vulnerable.
Many of their organs may not be ready for life outside the mother's uterus and may be too immature to function.

Some of the problems premature babies may experience because of their immaturity include:

 temperature instability - inability to stay warm due to low body fat.

 respiratory problems:

o respiratory distress syndrome - a condition in which the air sacs cannot stay open due to lack of
surfactant (soap-like substance) in the lungs.

o chronic lung disease/bronchopulmonary dysplasia - long-term respiratory problems caused by injury to the
lung tissue.

o air leaking out of the normal lung spaces into other tissues

o apnea (stopping breathing) - occurs in about half of babies born at or before 30 weeks
o desaturation - instances where the oxygen level in the body transiently decreases

 cardiovascular:

o patent ductus arteriosus (PDA) - persistence of a vessel connecting the pulmonary artery to the aorta that is
present in utero.  It can cause too much or too little blood flowing to the lungs and may be associated with
apnea, bradycardia (low heart rate) and desaturation.
o too low or too high blood pressure  

o bradycardia, low heart rate - which often occurs with apnea

 blood and metabolic:

o anemia - may require blood transfusion

o jaundice - due to immaturity of liver and gastrointestinal function

o too low or too high levels of minerals and other substances in the blood such as calcium and glucose (sugar)

o immature kidney function

 gastrointestinal:

o difficulty feeding - many are unable to coordinate suck and swallow before 35 weeks gestation

o poor digestion and slow intestional motility

o necrotizing enterocolitis (NEC) - a serious disease of the intestine common in premature babies.
Treatment
Treatment consists primarily of supportive care including providing bowel rest by stopping enteral feeds, gastric
decompression with intermittent suction, fluid repletion to correct electrolyte abnormalities and third space losses, support
for blood pressure, parenteral nutrition, and prompt antibiotic therapy. Monitoring is clinical, although serial supine and left
lateral decubitus abdominal roentgenograms should be performed every 6 hours. Where the disease is not halted through
medical treatment alone, or when the bowel perforates, immediate emergency surgery to resect the dead bowel is
generally required, although abdominal drains may be placed in very unstable infants as a temporizing measure. Surgery
may require a colostomy, which may be able to be reversed at a later time. Some children may suffer later as a result
of short bowel syndrome if extensive portions of the bowel had to be removed.

 neurologic:

o intraventricular hemorrhage - bleeding in the brain.

o periventricular leukomalacia - softening of tissues of the brain around the ventricles (the spaces in the brain
containing cerebrospinal fluid).

o poor muscle tone

o seizures - may be due to bleeding within the brain

 eyes:
retinopathy of prematurity - abnormal growth of the blood vessels in a baby's eye.
 infections - premature infants are more susceptible to infection and may require antibiotics

The characteristics of prematurity may resemble other conditions or medical problems. Always consult your baby's physician
for a diagnosis.

Treatment of the premature infant:

Specific treatment of the premature infant will be determined by your baby's physician based on:

 your baby's gestational age, overall health, and medical history

 extent of disease
 indicated medications, procedures, or therapies
 expectations for the course of the disease
 your opinion or preference

Premature babies usually need care in a special nursery called the Neonatal Intensive Care Unit (NICU). The NICU combines
advanced technology and trained health professionals to provide specialized care for the tiniest patients. The NICU team is
led by a neonatologist, who is a pediatrician with additional training in the care of sick and premature babies.

Maternal treatment may include:

 prenatal corticosteroid therapy

Research has found that giving the mother a steroid medication at least 24 hours prior to delivery greatly reduces
the incidence and severity of respiratory disease in the baby. Another major benefit of steroid treatment imay be
lessening of intraventricular hemorrhage (bleeding in the baby's brain). Although studies are not clear, prenatal
steroids may also help reduce the incidence of NEC and PDA. Mothers may be given steroids when preterm birth is
likely between 24 and 34 weeks of pregnancy. Before that time, or after, the medication usually is not effective. 

Care of premature babies may also include:

  temperature-controlled beds - isolettes or specially heated  (radiant warmer) open beds

 monitoring of temperature, blood pressure, heart and breathing rates, and oxygen levels

 giving extra oxygen by a mask, nasal prongs, cannula or hood 

 mechanical ventilators (breathing machines) to help do the work of breathing for the baby

 intravenous (IV) fluids - when feedings cannot be given, or for medications

 placement of catheters (small tube) into the umbilical cord to give fluids and medications and to draw blood ; or
place a small catheter into a vein leading toward the heart (percutaneous central ventrical line - PCVL - or
percutaneous inserted central catheter)

 x-rays (for diagnosing problems and checking tube placement)

 special feedings of breast milk or formula, sometimes with a tube into the stomach if a baby cannot suck. Breast
milk has many advantages for premature babies as it contains immunie substances from the mother and many
important nutrients.

 medications and other treatments for complications, such as antibiotics

 kangaroo care - a method of caring for premature babies using skin-to-skin contact with the parent to aid parent-
infant bonding. Studies have found that babies who "kangaroo" may have shorter stays in the NICU.

When can a premature baby go home from the hospital?

Premature babies often need time to "catch up" in both development and growth. In the hospital, this catch-up time may
involve learning to eat and sleep, as well as steadily gaining weight. Depending on their condition, premature babies often
stay in the hospital until the pregnancy due date.

If a baby was transferred to another hospital for specialized NICU care, he/she may be transferred back to the "home"
hospital  - once the condition is stable - to grow and mature.

Consult your baby's physician for information about the specific criteria for discharge of premature babies at your hospital.
General goals for discharge may include the following:

 serious illnesses are resolved

 stable temperature - able to stay warm in an open crib
 taking all feedings by breast or bottle
 no recent apnea or low heart rate
 parents are able to provide care including medications and feedings

Before discharge, premature babies need an eye examination and hearing test to check for problems. Parents will be
provided information about follow-up visits with the pediatrician for baby care and immunizations. Many hospitals have
special follow-up healthcare programs for premature and low birthweight babies.

Even though they are otherwise ready for discharge, some babies continue to have special needs such as extra oxygen or
tube feedings. With instruction and the right equipment, these babies are often able to be cared for at home by parents. A
hospital social worker can often help coordinate discharge plans when special care is needed.

Long-term neuro-developmental follow-up is important for premature babies.  Some of them (especially of lesser gestational
age) may develop problems such as delayed development, intellectual deficits, cerebral palsy, poor coordination and learning
problems and will need early therapeutic intervention.

Prevention of prematurity

Because of the tremendous advances in the care of sick and premature babies, more and more babies are surviving despite
being born early and being very small. But prevention of early birth is the best way of promoting good health for babies.
Prenatal care is a key factor in preventing preterm births and low birthweight babies. At prenatal visits, the health of both
mother and fetus can be checked. Because maternal nutrition and weight gain are linked with fetal weight gain and
birthweight, eating a healthy diet and gaining weight in pregnancy are essential. Prenatal care is also important in identifying
problems and lifestyles that can increase the risks for preterm labor and birth. Some ways to help prevent prematurity and
to provide the best care for premature babies may include the following:

 prenatal care
 proper nutrition
 identifying mothers at risk for preterm labor
 prenatal education of the symptoms of preterm labor
 early identification and treatment of preterm labor