Prematurity is considered to be the birth of a child before the end of the gestational period, that is, between 22 and 37 weeks, with a body weight of less than 2500 g and a length of less than 45 cm.
Premature babies have disorders of thermoregulation, breathing with a tendency to apnea (cessation of respiratory movements), weak immunity and obvious anthropometric and clinical signs.
Degrees
The classification of premature babies by degree is related to the child’s body weight (gestational age is conditional):
1st degree - body weight 2001-2500g. (the period corresponds to 35-37 weeks);
2nd degree - body weight 1501-2000g. (the period corresponds to 32-34 weeks);
3rd degree - 110-1500g. (gestational age 29-31 weeks);
Grade 4 - the baby’s weight is less than 1000g, which corresponds to a gestational age of less than 29 weeks (extremely premature).
Reasons for the birth of premature babies
Causes premature birth numerous and presented on three sides:
Maternal factors:
- chronic diseases of women (pathology of cardio-vascular system, endocrine diseases, kidney pathology):
- acute infections during pregnancy;
- gynecological diseases;
- complicated obstetric history (abortion, cesarean section);
- intrauterine device;
- injuries;
- age (under 17 and over 30);
- Rhesus conflict pregnancy;
- bad habits;
- pathology of the placenta (previa, abruption);
- harmful working conditions;
- complications of pregnancy (preeclampsia).
Paternal factors:
- age (over 50 years);
- chronic diseases.
Fruit factors:
- intrauterine malformations;
- multiple pregnancy;
- erythroblastosis (hemolytic disease);
- intrauterine infection.
Signs
Premature babies have a pronounced clinical picture. There is a disproportion of body parts, the cerebral skull predominates over the facial one. The bones of the skull are soft; in addition to the fontanelles, non-fusion of the cranial sutures is observed. Soft ears are also characteristic.
In premature babies, the subcutaneous fat layer is poorly developed; they cannot “hold” their temperature (instability of thermoregulation). Underdevelopment of the lungs during prematurity is due to the lack of surfactant, which ensures the opening of the pulmonary alveoli during inspiration, which is manifested by respiratory failure and periodic apneas (stopping breathing).
The skin is wrinkled, has a bright red color in the first day, there is a slight muscle tone or its complete absence.
Physiological reflexes (sucking, searching and others) are weakly expressed.
In premature boys, the testicles are not descended into the scrotum, and in girls, the labia majora are underdeveloped. Hypertensive and hydrocephalic syndromes are typical for premature babies.
Due to underdevelopment of the eyelids, bulging eyes (exophthalmos) are pronounced.
There is insufficient liver function, which is manifested by kernicterus. Due to underdeveloped immune system Premature babies are at high risk of infection. Premature babies are prone to spitting up. In addition, in such children the nail plates are underdeveloped and can only reach the middle fingertips.
Therapy for premature babies
A neonatologist is involved in the management and treatment of premature babies.
Children born prematurely require certain living conditions. The ambient temperature should be 25°C and the humidity at least 55-60%. For this purpose, premature babies are kept in incubators (special incubators).
The incubators contain babies weighing less than 2000g. Healthy premature babies are discharged on days 8-10, provided their body weight reaches 2 kg.
If premature baby within 14 days has not reached a weight of 2000 g, he is transferred to the second stage of nursing (carried out in the intensive care unit of the children's department/hospital). Such children are placed in incubators where oxygen is supplied.
Premature babies begin to be bathed at 2 weeks of age (subject to the healing of the umbilical cord). They walk with children when they are 3-4 weeks old and weigh 1700-1800g.
Healthy premature babies are discharged when they reach a weight of 1700g.
Feeding
Feeding your baby with pumped milk breast milk begin 2-6 hours after birth, provided there are no contraindications and the pregnancy is long (34-37 weeks).
Babies who are critically ill or very premature are given parenteral nutrition through a tube (through the mouth or nose) for the first 24-48 hours of life.
They begin to put a baby weighing 1800-2000g to the breast. in the presence of active sucking. On day 1, the volume of one feeding is 5-10 ml, on day 2 10-15 ml, and on day 3 - 15-20 ml.
In addition, premature babies are advised to administer vitamins:
- vikasol (vitamin K) to prevent intracranial hemorrhage;
- ascorbic acid (vitamin C), vitamins B1, B2;
- vitamin E (tocopherol);
- prevention of rickets (vitamin D);
- vitamins B6 and B5, lipoic acid for extreme prematurity;
Consequences of prematurity and developmental prognosis
The prognosis for life in premature babies depends on many factors. Primarily on gestational age and birth weight. If a baby is born at 22-23 weeks, the prognosis depends on the intensity and quality of therapy. The risk of death increases in the following cases:
- antepartum hemorrhage;
- breech birth;
- multiple pregnancy;
- asphyxia during childbirth;
- low temperature of the child;
- respiratory distress syndrome.
Long-term consequences of prematurity (the likelihood of these complications again depends on many factors; under other favorable conditions, these complications are quite rare):
- retardation in mental and physical development;
- cerebral palsy;
- convulsive and hydrocephalic syndromes;
- myopia, astigmatism, glaucoma, retinal detachment;
- tendency to frequent infections;
- hearing impairment;
- violation menstrual cycle, genital infantilism and problems with conception in girls.
Did you have a premature baby? Of course, you are worried and ask a lot of questions, the answers to which, alas, you do not always receive in a timely manner. Meanwhile, knowing your baby’s “weaknesses” will make it easier for you to cope with many situations - for example, feeding or bathing. And a slight weight gain or slight developmental lag between the baby and his peers will not cause concern.
In addition, remember that any medical prognosis is by no means a final “sentence.” Often, children with seemingly favorable characteristics die or are delayed in development, while children with gloomy prospects survive and grow up healthy in spite of everything.
So you want to know everything about premature babies? We will tell you about the features of physiology, development, nursing, feeding and rehabilitation treatment of babies born much earlier than expected.
As defined by the World Health Organization (WHO)
A baby is considered premature if it is born between 22 and 37 weeks of pregnancy (gestation), weighing between 500 and 2,500 grams and measuring between 25 and 40 centimeters in height.
Premature Baby Day
Celebrated on November 17, which was established in 2009 by the European Foundation for the Care of Newborn Patients.
Degrees of prematurity
Determined depending on weight and the number of completed weeks of pregnancy (gestation) at the time of birth.
I degree
The baby is born at 34-36 weeks and 6 days weighing from 2001 to 2500 grams. The child is quite mature and independently viable. Therefore, as a rule, no special conditions are required. However, sometimes treatment and nursing are necessary - for example, with prolonged jaundice, trauma during childbirth and some other conditions.
II degree
The baby is born at 31-33 weeks and 6 days weighing between 1501 and 2000 grams. Usually, the baby quickly adapts to new living conditions if timely medical care is provided, as well as the creation of appropriate conditions for care and feeding.
III degree
Very early birth at 28-30 weeks of pregnancy with a baby weighing from 1001 to 1500 grams. Many of these children survive, but in the future they require long-term rehabilitation treatment and observation by doctors of various specialties. Sometimes some babies have various diseases, birth defects developmental or genetic abnormalities.
IV degree
Childbirth before 28 weeks of pregnancy with an extremely low baby weight of up to 1000 grams. The baby is immature and completely unprepared for new conditions. One in five babies is born alive, but the likelihood of survival is extremely low. Unfortunately, many children die before reaching the age of one month: of those born before 26 weeks - 80-90% of babies, at 27-28 weeks - 60-70%.
Moreover, such children usually have numerous severe diseases and/or congenital malformations, which significantly worsens the prognosis. The further probable fate of the baby and the need for long-term nursing are explained to the parents. The final decision on the management of a very premature baby is recommended to be made jointly with an obstetrician-gynecologist, neonatologist and parents.
Signs of prematurity
Depends on the number of completed weeks of pregnancy (gestational age) at the time of birth.
Moderate, or I-II degree of prematurity
Baby is mostly active, moves his arms and legs, but his muscle tone is somewhat reduced.
Cardiovascular system of premature infants
In utero, the fetus has a special blood circulation. The fact is that the lungs do not participate in breathing, and oxygen enters the blood from the vessels of the placenta. Arterial blood, once in the baby’s blood vessels, mixes with venous blood and is again distributed throughout the body.
This process is possible thanks to holes, or shunts, between the chambers of the heart and large vessels.
In a full-term baby, after the first breath, the auxiliary openings close. This is how the newborn’s blood circulation is established, ensuring the supply of arterial blood to the organs and tissues.
Due to incomplete tissue maturation in a premature baby, such restructuring occurs much later. In addition, this process is also delayed due to the increased load on the heart and blood vessels: resuscitation (resuscitation) in the delivery room, artificial ventilation, intravenous infusion of solutions.
A premature baby often has congenital heart defects, which significantly worsen his condition.
A child born earlier than expected reacts sensitively to external stimuli (touch, loud sound) by increasing heart rate and increasing blood pressure.
Endocrine system of a premature baby
The adrenal cortex does not produce enough cortisol, a hormone necessary for the baby’s adaptation to life outside the womb and ensuring an adequate response to stress (childbirth). With adrenal insufficiency, the child’s condition quickly deteriorates: blood pressure drops sharply, the amount of urine decreases, and body temperature drops.
The function of the thyroid gland is temporarily reduced (transient hypothyroidism), which leads to a slowdown in the baby’s metabolism. The condition is manifested by a tendency to edema, prolonged jaundice, poor weight gain and various breathing problems.
The gonads produce hormones in insufficient quantities, so the sexual crisis is not pronounced:
- In girls, the mammary glands moderately enlarge and the labia swell, and bloody discharge from the genitals is not pronounced or absent.
- In boys, the scrotum and penis may swell slightly.
Low blood sugar (hypoglycemia)
Often occurs in the first 3-5 days of life, which is due to several factors:
- Insufficient glycogen stores are a form of glucose storage in cells.
- Reduced production of enzymes by the pancreas, which reduces the breakdown and absorption of glucose from the intestines and stomach.
- Increased synthesis of insulin in the pancreas, a hormone that promotes the penetration of glucose into cells.
What are the dangers of hypoglycemia? The maturation of nervous tissue is disrupted, and epileptic seizures (convulsions) and mental retardation may occur in the future.
Immune system of premature babies
There is also a positive aspect in such work of the immune system: in some babies the risk of developing allergic reactions after birth is slightly reduced.
However, as they grow older, on the contrary, the child becomes more susceptible to allergens. May develop allergic reactions and/or diseases: (a combination of protein with iron - to transport oxygen) found in erythrocytes (red blood cells).
- The level of vitamin K is reduced, which is involved in the formation of proteins and some blood factors (for example, prothrombin) responsible for normal blood clotting.
- The ability of platelets (blood cells) to stick together and form blood clots is reduced.
Jaundice in premature babies
In utero the fetus develops fetal hemoglobin, carrying more oxygen to organs and tissues, which is necessary in conditions of mixed blood circulation.
After birth, fetal hemoglobin is rapidly destroyed, forming bilirubin- a toxic pigment that spreads throughout the body with the blood, coloring the skin and mucous membranes in yellow. Bilirubin binds to special proteins that are produced in the liver and is then excreted from the body.
In a full-term baby Bilirubin levels rarely reach high levels and are eliminated from the body within a few days or two weeks.
In a premature baby this process is delayed due to the immaturity of the liver, insufficient production of bile acids, narrow bile ducts of the liver and gall bladder.
An increase in bilirubin levels is dangerous because it, being a toxic substance, leads to impaired respiration in cells and the formation of proteins. Most of all, bilirubin “loves” fat cells and nervous tissue.
Physiological weight loss
After birth, all babies “lose weight” for several reasons:
- During childbirth, metabolism in the body and energy consumption by tissues increases.
- Childbirth is stressful for the baby, leading to fluid loss through sweat and breathing.
- The original stool, meconium, is passed.
The child has nothing to make up for losses from the outside, since not enough colostrum and energy enter the body. The baby begins to consume its own “reserves” of brown fat accumulated during intrauterine development.
Weight restoration happens in different terms. In full-term babies - by 7-10 days of life. With a moderate degree of prematurity - usually after the second week of life, with deep - the third or fourth week. The process is influenced by numerous factors: conditions of nursing and feeding, the presence or absence of diseases and some other points.
urinary system
The exchange of salts and water in premature babies is unstable, so they are equally prone to both the formation of edema and dehydration. In addition, the kidney tissue where urine production occurs is also immature, which further contributes to water retention in the body.
Therefore, premature babies often develop early edema- even during intrauterine development, in the first hours or days of life. They are soft, spread throughout the body and disappear in the first or second week of life.
Late edema occur in the second or third week of life, indicating problems with nutrition, a decrease in the amount of protein in the body, or the presence of a disease in the child. The swelling is dense to the touch and is located in the lower third of the abdomen, feet, legs and pubis.
Given the characteristics of organs and tissues, a premature baby needs help to adapt to new living conditions and survive.
A child born at a gestational age of 22-37 weeks (154-259 days from the first day of the last menstrual period) with a body weight of less than 2,500 g and a length of less than 45 cm is considered premature. A newborn with a birth weight of 500 g who has made at least just one breath. Depending on body weight at birth, there are 4 degrees of prematurity:
I degree – 2001-2500;
II degree – 1501-2000;
III degree – 1001-1500 g;
IV degree – 1000 g or less.
Birth weight is not an absolute indicator of prematurity. Thus, 1/3 of newborns weighing less than 2500 g are full-term, and 4-5% of premature infants have a body weight exceeding 2500 g. The main criterion for prematurity is gestational age (intrauterine development period, gestatio - pregnancy, carrying). Based on gestational age, there are 4 degrees of prematurity:
I degree – gestation period 36-35 weeks;
II degree – gestation period 34-32 weeks;
III degree – gestation period 31-29 weeks;
IV degree – gestation period 28-22 weeks.
Prematurity- a concept that relates exclusively to the neonatal period. The frequency of birth of premature babies in various regions of the country is 5-12%. The mortality rate of premature babies is 20 times higher than the mortality rate of full-term babies.
Anatomical and physiological features(AFO) premature baby
Morphological signs of prematurity: The appearance of premature babies has a number of signs that are directly dependent on the stage of pregnancy. The shorter the child’s gestational age, the more pronounced they are and the more of them there are. Some
signs are used to determine gestational age. These include: skin, ears, nipple areolas, furrows on the feet, sexual characteristics.
A very premature baby has thin, wrinkled skin of a dark red color, abundantly covered with fluff (lanugo). The auricles are soft and adjacent to the skull; at a short gestation period, they lack relief and are shapeless as a result of underdevelopment of cartilage tissue. The areolas of the nipples are underdeveloped, less than 3 mm, and with severe prematurity they may not be detected. The furrows on the feet are sparse, short, shallow, appear at the 37th week of pregnancy, and at the 40th week of gestation they become numerous. The scrotum in boys is empty, the testicles are located in the inguinal canals, or in abdominal cavity. Girls are characterized by genital gaping
gaps - the labia majora do not cover the labia minora, the hypertrophied clitoris is clearly visible.
A premature baby is small in size and has a disproportionate build. The weight-height ratio is 30-50. Relatively large head (1/3 of the body), short neck and legs, umbilical ring located closer to the womb. The brain skull predominates over the facial skull. The sutures of the skull and fontanels are open. The subcutaneous fat layer is not expressed. Nails do not reach fingertips.
Functional signs of prematurity. Premature babies are characterized by immaturity of all organs and systems, the severity of which depends on the duration of pregnancy. Neurological signs of prematurity are muscle hypotonia, decreased
physiological reflexes (sucking, swallowing, sucking movements inhibit breathing, cause respiratory pauses, cyanosis) and motor activity, imperfect thermoregulation (reduced heat production and increased heat transfer), weak cry of the child, decreased activity of digestive enzymes. Children are periodically restless, there is intermittent tremor of the chin and limbs, and a tendency to convulsions. Breathing is 40-90 respiratory movements per minute, uneven in rhythm and depth, interrupted
convulsive sighs and pauses (apnea) lasting up to 10-15 seconds, which is more often observed in very premature infants with hypoxic lesions of the central nervous system. With a longer cessation of breathing, asphyxia (suffocation) may develop (insufficient development of the alveoli, the capillary network of the lungs, reduces the content surfactant and, which leads to insufficient expansion of the lungs, the persistence of fetal atelectasis, and the development of hemodynamic disorders in the lungs, which determine breathing patterns. Therefore, premature babies make up the main percentage of newborns who develop respiratory distress syndrome).
The cardiovascular system. The pulse is labile from 100 to 180 beats per minute. Any irritants cause increased heart rate, increased sonority of tones, and increased blood pressure (due to the predominant influence of the sympathetic department). Blood pressure does not exceed 60-70 mm Hg. Thermoregulation in a premature baby is imperfect. Children quickly cool down and also quickly overheat. In children with low body weight, heat loss is increased due to a relatively larger body surface, a too thin subcutaneous fat layer and immaturity of thermoregulation centers. The peculiarity of the temperature reaction is manifested in the fact that when overheated, the body temperature can rise to 40 degrees, and in response to external infections, premature infants may not respond with an increase in temperature.
Digestive system. The volume of the stomach in the first 10 days of a premature infant is 3 ml/kg
multiplied by the number of days. Proteins are well absorbed, but fats are poorly absorbed. The permeability of the intestinal wall is significantly increased, and the enzyme-secreting function of the intestine is reduced. The liver is functionally even more immature than that of full-term infants. small stomach volume, decreased secretion and activity of digestive enzymes, poor development of the intestinal muscle wall, decreased immunoglobulin A promotes the development of dysbacteriosis.
Sucking and swallowing reflexes are poorly developed. There is often a lack of coordination between sucking and swallowing. There is a tendency to regurgitation, vomiting, flatulence, and constipation. The absence of a cough reflex promotes aspiration of food.
Kidneys. Reduced filtration function, increased urinary sodium excretion and poor water reabsorption, limited ability to remove excess water from the body. Daily diuresis by the end of the first week ranges from 60 to 145 ml, the frequency of urination is 8-15 times a day.
Hematopoietic system. Lower levels of hemoglobin and red blood cells, fetal hemoglobin remains at a high level for a long time. Almost all preterm infants less than 30 weeks' gestational age are anemic. Increased permeability and fragility of blood vessels (due to vitamin K deficiency) contribute to the occurrence of cerebrovascular accidents and hemorrhages.
Due to imperfect immunity, premature babies are prone to infectious diseases.
Borderline physiological states are unique in premature infants: physiological erythema, loss of initial body weight, and jaundice are more pronounced and prolonged. Mild jaundice may be accompanied by severe bilirubin encephalopathy. Sexual crisis is much less common than in full-term babies and is less pronounced. Primary leukocyte crossover is 7-15 days later. Transient fever easily occurs due to non-compliance with drinking regime and overheating. The umbilical cord remnant falls off later than in full-term babies (on the 5th-7th day of life), the umbilical wound heals by 12-15 days, with mass
less than 1000 kg - 1-2 weeks later.
Features of development of premature babies
I. Physical development of premature infants
1. Characterized by higher rates of increase in body weight during the first year of life compared to children born at term. The exception is the first month of life, when there is a low increase in body weight due to a greater loss of initial weight than in full-term infants. In premature infants, initial weight loss is 9-14% of birth weight. They double their body weight by 2-3.5 months, triple by 4-6 months, and by one year their weight increases 4-7 times.
2. The monthly increase in height in premature infants is on average 2.5-3 cm. Growth in the first year increases by 27-38 cm. Despite the high rates of growth and development, in the first 2-3 years of life, premature infants in terms of body weight and growth lag behind their peers born full-term. And only by the age of 3, the body weight and length of these children approach the corresponding indicators for full-term children.
3. In children with grades I-II prematurity, teeth erupt at 6-9 months, grades III-IV - 8-10 months.
4. Head circumference at birth is 3-4 cm larger than chest circumference. By 3-5 months sizes
are compared, then the chest circumference is greater than the head circumference.
5. Subsequently, the periods of the 1st and 2nd extension in premature infants occur 1-2 years later than in full-term infants.
II. Neuropsychic development of premature infants
During the first years of life, the rate of psychomotor development of children is delayed, the formation of leading lines of nervous mental development shifted in time to a later age stage. This lag depends on the degree of prematurity and is more pronounced in children with degrees III-IV prematurity. In these children, the appearance of psychomotor skills at 1-2 years is delayed by 2-3 months.
In children with II degree of prematurity for 1-1.5 months
By the end of the 1st year of life, the majority of children with degree I prematurity catch up with their full-term peers in psychomotor development, and by the age of 2 years, extremely preterm children are compared with them. Delayed mental development of a child born ahead of schedule, may be due to dysfunction of the sensory organs. Thus, pathology of the visual organs (myopathy, astigmatism, strabismus) occurs in 25%, hearing loss of varying degrees in 4% of children born prematurely.
In premature infants (due to unfavorable intrauterine conditions, fetal hypoxia, etc.)
psychoneurological disorders in the form of neuropathic psychopathic personality traits are observed. Neurological changes are more common: vegetative-vascular disorders, hypertensive-hydrocephalic syndrome, convulsive syndrome, cerebral palsy. By the age of 4-7 years, the manifestation of neuropsychiatric symptoms may disappear or remain in the form of mild clinical signs of central nervous system damage: unstable mental condition, negativism reactions, anxiety, fussiness, insomnia, loss of appetite, difficulty in eating solid food. An unfavorable course with the formation of persistent and complex psychopathological syndromes is possible. However, most premature babies have normal mental development. Among the premature there are many famous people: Darwin, Newton, Voltaire, Hugo, Napoleon, Yesenin, Mironov, etc.
Organization of medical care for premature babies
The problem of caring for premature babies is extremely complex, since children are not yet mature enough to exist outside the mother’s body. To preserve the viability of premature babies, it is necessary to create special conditions both at the time of birth and during the subsequent adaptation of the child. For this purpose, assistance to premature babies is provided in stages:
Stage I of nursing – providing intensive care and treatment in the maternity hospital;
Stage II – nursing in a specialized department;
Stage III of nursing – dispensary observation in a children's clinic.
The main goal of stage I is to save the child’s life. In the first hours and days after birth, intensive therapy is provided, if necessary, and careful care and monitoring are provided. Special attention is paid to compliance with the sanitary and epidemiological regime. Healthy babies with a birth weight of more than 2000 g are discharged home from the maternity hospital, all other premature babies are transferred to a specialized department for the second stage of nursing.
The main area of work of the specialized department is treatment and rehabilitation. Therapeutic measures aimed at eliminating hypoxia, cerebrovascular accidents, jaundice, pneumopathy, preventing anemia, rickets, malnutrition.
Discharge from the department of the second stage of nursing is approached individually. The main criteria are:
– absence of diseases;
- restoration of initial body weight and its satisfactory increase;
— normal level hemoglobin;
- favorable home environment.
All information about the child is transferred to the children's clinic on the day of discharge.
The determining criterion for prematurity is gestational age. Options physical development and even the degree of morphological and functional maturity are not criteria for diagnosing prematurity, since they may not correspond to gestational age. Premature babies often have a birth weight of more than 2500 g.
Currently, there are no degrees of prematurity. When formulating a diagnosis, the gestational age (in days or weeks) and the nature of body weight at birth are indicated (low - 2499-1500 g, very low - 1499-1000 g, extremely low - 999-500 g).
Assessment of physical development indicators.
Assessment of physical development indicators of premature, full-term and post-term infants is carried out using percentile tables or average statistical indicators (stigmatic deviations). Parameters of physical development such as body weight and length, head circumference, chest, and abdomen are assessed.
Assessment of the degree of morphological and functional maturity. The maturity of a newborn child is determined by a combination of morphological (clinical) and functional signs in relation to gestational age.
Maturity is understood as the readiness of the child’s organs and systems to ensure its extrauterine existence.
A healthy, full-term baby whose morphological and functional state of organs and systems corresponds to its gestational age is considered mature. All premature babies are immature in relation to full-term babies. At the same time, they may be quite functionally mature for their gestational age, but their organs and systems are unable to ensure existence in extrauterine life. Among full-term newborns, immature ones can also be found. These are children whose morphological and functional maturity is below their gestational age. Gestational age is determined by obstetricians-gynecologists during an objective examination of the pregnant woman (fetal movement, height of the uterine fundus, date of the last menstruation, ultrasound diagnostics).
The degree of morphological maturity of an infant is determined by a complex external signs:
body proportions, density of skull bones and size of fontanelles, presence of vernix lubrication at birth, development of mammary glands, shape of ears, condition skin, performing the nail plate on the nail bed, etc.
In 1971, Petruss proposed an assessment table for the degree of maturity, which includes five external morphological characteristics: 1) auricle; 2) diameter of the nipple areola; 3) striations of the feet; 4) external genitalia; 5) skin color (table). Each of these signs is scored from 0 to 2 points. The resulting sum of points is added to 30. The final result corresponds to the degree of morphological maturity of the newborn child. If it matches the gestational age, then the baby is mature for its gestational age. All premature babies are immature; at the same time, they may be functionally mature enough for their gestational age, but are incapable of extrauterine life.
Newborn Maturity Score Chart
| Signs | |||
| Leather | Red, swollen, | Red, | Pink |
| thin | pasty | ||
| Auricle | Formless, | Availability | solid, |
| soft | curl and from | formalized | |
| absence of anti- | |||
| curl | |||
| Striations | 1-2 lines in the distal | 1/2 distal | Almost |
| stop | nom department | department | fully |
| Breast | pink dot | Diameter | Diameter |
| areola nipple | areola nipple | ||
| less than 5 mm | more than 5 mm | ||
| External | Testicles in inguinal | Testicles at the entrance | Testicles in |
| genitals | channels | into the scrotum | scrotum |
| in boys | |||
| External | Minor genitalia | Equal size | Large |
| genitals | lips predominate | big and | labia |
| in girls | over the big ones | minor reproductive organs | cover |
| genital gaping | lips | small | |
| cracks, hypertrophy | |||
| clitoris |
The functional maturity of a newborn child is determined by the maturity of vital systems:
· Central nervous system - the presence and severity of sucking, swallowing and other reflexes during the newborn period, maintaining one’s own body temperature at an adequate ambient temperature;
· respiratory organs - correct breathing rhythm, absence of attacks of apnea and cyanosis;
· cardiovascular system - correct heart rhythm, no microcirculation disorders, normal functioning of other organs and systems
Functional characteristics of the premature infant's body
| System | Functional Features |
| Nervous Respiratory Circulation Digestive Urinary Immune | Depression syndrome: lethargy, drowsiness, weak cry, decreased muscle tone and physiological reflexes; imperfection of thermoregulation Primary atelectasis of the lungs, lability of frequency and depth of breathing, frequent apnea Lability of heart rate, vascular dystonia, noise due to the functioning of fetal communications Decreased tolerance to food, increased permeability of the intestinal mucosa Low filtration, reabsorption, concentration and secretory functions Low level of cellular and nonspecific protective factors |
Features of the neonatal period in premature infants.
Premature children have features of the manifestation of some borderline conditions. The maximum physiological loss of body weight is observed by the 4-7th day of life and can be 5-12%, body weight restoration occurs by 2-3 weeks of life. Physiological jaundice can last up to 3-4 weeks. The manifestation of a sexual crisis is uncharacteristic for premature infants. Toxic erythema is possible in premature infants with a gestational age of 35 to less than 37 weeks. The neonatal period in premature infants lasts more than 28 days (up to 1.5-3 months). If a child was born at 32 weeks gestation, then at 1 month of life his gestational age will be 32 + 4 = 36 weeks.
The rate of development of premature babies is very high. In most of them, weight and height indicators by the end of the 1st year of life are compared with those of full-term peers; in very premature children (less than 1500 g) - by 2-3 years. IN neuropsychic development by 1.5 years of age, premature children catch up with their full-term peers, provided that they are healthy. It must be taken into account that 60-80% of very premature children have organic damage to the central nervous system (cerebral palsy, hydrocephalus, schizophrenia, epilepsy), damage to hearing, vision, etc.
Stages of nursing premature babies.
Nursing of premature babies is carried out in institutions where special conditions are created. It can be 2-stage: maternity hospital - home. Premature infants with a body weight of 2300 (2200) g or more, whose condition is satisfactory at the time of discharge, are nursed in a 2-stage manner; the infants steadily gain weight and maintain body temperature. Such children are discharged from the maternity hospital on the 7-8th day of life.
Less mature and sick premature babies are cared for according to a 3-stage system: maternity hospital - specialized departments for nursing premature babies - home.
Transfer to specialized departments is carried out on the 3rd day without infectious or acute surgical pathology. The duration of nursing in two stages is from 1 to 3 months.
Nursing of premature newborns at stage I (maternity hospital):
1) creation of optimal temperature conditions. In the children's ward where premature babies are cared for, it is necessary to maintain a temperature of 24-26 (28) °C. Body temperature premature newborn should be within 36.4-37.0 °C. Methods of caring for premature babies - crib, heating pad or incubator. Children born with asphyxia, with birth trauma, with a body weight of 2000 g or less, unable to maintain their own body temperature, with edema and aspiration syndromes, with respiratory distress syndrome (RDS) stage II-III, in severe conditions are placed in the incubator. caused by various pathologies of the neonatal period;
2) ensuring rational feeding. Premature babies are breastfed, bottle-fed, tube-fed, parenterally. Indications for feeding through a tube are: regurgitation, slow weight gain, RDS 5 points, mechanical ventilation, extensive congenital defects of the hard and soft palate, low sucking and swallowing reflexes or lack thereof.
Parenteral nutrition is prescribed for vomiting, flat or negative weight curve, intestinal paresis, if the residual volume of food before feeding is more than 1 ml/kg, for surgical pathology of the gastrointestinal tract, etc. To calculate the amount of nutrition for premature infants when feeding from a bottle or through a tube, use the following formulas:
· Romel: (u + 10) x mass, g: 100; 4 per feeding: 3 x t x p, where t is body weight; and - day of life. The given formulas are used until the 14th day of life;
· Khazanova: from 0 to 2 weeks - 1/7 body weight, g, from 2 to 4 weeks - 1/6 body weight, from 4 weeks - 1/5 body weight, g;
If premature babies are on artificial or mixed feeding, the following infant formulas are recommended: “Robolact” or “Linolak” in the 1st week of life for premature infants weighing 1500 g or less, followed by a transition to adapted formulas (“Prepilti”, “Pregumana”, “Novolakt-MM”, “Enfalact” "). From 1.5-2 months it is necessary to include fermented milk mixtures (up to 40%) in the diet of premature babies. When a premature baby weighs 2000 g or more, the first complementary food is introduced 1-2 weeks earlier than for full-term infants; with a weight of less than 1500 g, the first complementary foods are introduced 1-2 months later in relation to their full-term peers. According to WHO recommendations, premature babies under 6 months should be exclusively breastfed;
3) prevention of infection. Measures to prevent infection include: compliance with the sanitary and epidemiological regime, giving colostrum in the delivery room, culture of flora from the external auditory canal, culture of blood and meconium for sterility, feeding with native or breast milk with the addition of lysozyme, prescribing eubiotics. Premature babies with a high developmental risk infectious pathology antibacterial therapy and immunoglobulin are prescribed
human. Change of oxygen tents, nasal catheters, breathing circuits is carried out every 12 hours, incubators - 72 hours.
Objectives of stage II (specialized department):
1) provision of medical and preventive care; 2) carrying out sanitary educational work; 3) rehabilitation (medicinal, orthopedic, speech therapy, social).
Objectives of stage III (clinic):
1) clinical examination; 2) rehabilitation; 3) sanitary educational work.
Clinical examination. A premature baby is examined within 1 day from the date of discharge. In the 1st month of life, a premature baby is examined weekly by a local pediatrician, and examined once by the head of the department. During the 1st half of life, the premature baby is examined 2 times a month at home. From the 2nd half of the year - once a month in a clinic. During clinical observation, an assessment of physical and neuropsychic development is carried out.
· Weight gain:
1st month Stage I-II - 400 g Stage III-IV - 300 g;
2-10th I-II - 700 g III-IV - 600 g;
11-12th month 141 stage - 500 g IYU stage - 400 g.
Body height:
I quarter 3-5 cm;
II quarter 3-2.5; W-D/quarter 1-1.5 cm.
· Increase in head circumference: up to 3 months 1.5-2 cm;
from the 4th month no more than 1 cm. Rehabilitation:
· preservation breastfeeding;
· 4 increasing the immunological reactivity of the body (gymnastics, massage, walks in the fresh air, hardening);
· prevention of rickets and iron deficiency anemia;
· prevention of infections (individual vaccination calendar);
Premature babies: frequency and causes of premature birth. Anatomical, physiological and neuropsychological characteristics of premature infants
Premature babies− children born in relation to the established end of gestation prematurely.
Premature birth is the birth of a child before the end of the full 37 weeks of pregnancy or earlier than 259 days counted from the first day of the last menstrual cycle (WHO, 1977). A prematurely born child is premature.
Statistics on premature births .
Preterm birth rate = 3−15% (average − 5−10%). Premature births in 2002 – 4.5%. There is no downward trend in this indicator.
Preterm births have the highest morbidity and mortality rates. They account for 50 to 75% of infant mortality, and in some developing countries - almost 100%.
Causes of premature birth
socio-economic (salary, living conditions, nutrition for the pregnant woman);
socio-biological (bad habits, parents' age, prof. harmful);
clinical (extragenital pathology, endocrine diseases, threat, gestosis, hereditary diseases).
Factors contributing to fetal growth restriction and premature birth (prematurity) can be divided into 3 groups :
lack or insufficiency of medical care before and during pregnancy;
level of education (less than 9 grades) - influence the level and lifestyle, personality characteristics, material well-being;
low standard of living and, accordingly, material security, and as a consequence, unsatisfactory living conditions, inadequate nutrition of the expectant mother;
occupational hazards (physically difficult, prolonged, monotonous work of a pregnant woman in a standing position);
out-of-wedlock childbirth (especially with an unwanted pregnancy);
unfavorable environmental conditions;
young or elderly age pregnant (less than 18 years old) and first birth over 30 years old);
father's age is under 18 years and over 50 years (in Europe);
bad habits (smoking, alcoholism, drug addiction) of both the expectant mother and father;
short stature, infantile physique of a pregnant woman;
infantilism of the genital organs, especially in combination with hormonal disorders (insufficiency of the corpus luteum, ovarian hypofunction, isthmic-cervical insufficiency) - up to 17% of all premature births;
previous abortions and miscarriages - lead to inadequate secretion of the endometrium, collagenization of the stroma, isthmic-cervical insufficiency, increased contractility of the uterus, and the development of inflammatory processes in it (endometritis, synechiae);
mental and physical trauma of a pregnant woman (fright, shock, falling and bruising, heavy lifting, surgical interventions during pregnancy - especially laparotomy);
inflammatory diseases of the mother of an acute and chronic nature, acute infectious diseases (childbirth at the height of fever, as well as in the next 1-2 weeks after recovery);
extragenital pathology, especially with signs of decompensation or exacerbation during pregnancy: rheumatic heart disease, arterial hypertension, pyelonephritis, anemia, endocrine diseases (hypothyroidism, thyrotoxicosis, diabetes mellitus, hyperfunction of the adrenal cortex, etc.) etc. cause disruption of uteroplacental blood flow, degenerative changes in the placenta;
genital pathology;
pathology of pregnancy: late gestosis, nephropathy, immunological conflict in the mother-placenta-fetus system;
abnormalities in the development of the placenta and umbilical cord;
in vitro fertilization;
multiple pregnancy (about 20% of all premature pregnancies);
fetal diseases: IUI, hereditary diseases, defects fetal development, isoimmunological incompatibility;
the interval between births is less than 2 years.
socio-economic:
socio-biological:
clinical:
Causes of prematurity can be divided according to another principle:
external environmental,
coming from the mother;
related to the characteristics of the course of pregnancy;
from the side of the fetus.
Classification of prematurity
In ICD X revision in section R 07 “ Disorders associated with shortened gestational age and low birth weight" It is customary to divide premature newborns both by weight and by gestational age. The note says: When both birth weight and gestational age are established, birth weight should be preferred.
Depending on the indicators of gestational age and body weight of the premature baby, they are divided into 4 degrees of prematurity (3 weeks for each of the first three degrees):
|
Degrees of prematurity |
by gestation |
by body weightat birth |
||
|
I degree |
35 weeks - incomplete 37 weeks (up to 259 days) |
2500−2000 grams |
low |
|
|
II degree |
32−34 weeks |
1999−1500 grams |
||
|
III degree |
very premature |
29−31 weeks |
1499−1000 grams− very low body weight |
|
|
IV degree |
22−28 weeks |
999−500 grams− extremely low weight (extremely low weight) |
||
Extreme prematurity− gestational age is less than 22 full weeks (154 full days).
The line between miscarriage and prematurity at 22 full weeks(154 full days) of gestation is determined by weight: 499 g - miscarriage, 500 g - premature newborn.
Anatomical, physiological and neuropsychological characteristics of premature infants
Anatomical features of premature babies (external signs of immaturity):
the skin is thin and glossy, dark red in color, as if translucent;
there is abundant original down on the face, back, and extensor surfaces of the limbs − lanugo;
the subcutaneous fat layer is thinned, as a result of which the skin is wrinkled, and there is a tendency to swelling of the subcutaneous fat;
body length from 25 cm to 46 cm;
disproportionate body build (the head is relatively large: the large vertical size of the head ranges from ¼ to ⅓ of the body length, the cerebral skull predominates over the facial skull; the neck and lower limbs are short);
low hair growth on the forehead,
the skull is more round, its bones are pliable - non-fusion of cranial sutures, the small and lateral fontanelles are usually open;
the ears are soft and fit tightly to the skull;
nails often do not reach the fingertips, the nail plates are soft;
low-lying place of origin of the umbilical cord, below the midpoint of the body;
underdevelopment of the genital organs: in girls, the genital gap is gaping, i.e., the labia minora are not covered by the labia majora (due to the underdevelopment of the labia majora and relative hypertrophy of the clitoris); in boys, the testicles are not lowered into the scrotum (in extremely immature children, the scrotum is generally underdeveloped) .
Physiological characteristics of the premature infant’s body (functional signs of immaturity):
from the outsidenervous and muscular systems − depression syndrome:
muscle hypotonia, lethargy, drowsiness, slow reaction to stimuli, weak quiet cry or squeak,
predominance of subcortical activity (due to immaturity of the cerebral cortex): movements are chaotic, shudders, hand tremors, foot clonus may be noted,
imperfection of thermoregulation (reduced heat production and increased heat transfer: children easily become cold and overheat, they do not have an adequate increase in temperature for the infectious process),
weak expression, rapid extinction or absence of physiological reflexes of the newborn period,
weak sucking intensity;
from the outsiderespiratory system :
great lability of frequency and depth of breathing with a tendency to tachypnea (36 - 72 per minute, on average - 48 - 52), its superficial nature,
frequent respiratory pauses (apnea) of varying duration (5 – 12 sec);
gasps (convulsive breathing movements with difficulty inhaling);
During sleep or rest, you may experience: breathing Biota type(correct alternation of periods of apnea with periods of respiratory movements of the same depth), breathing Cheyne-Stokes type(periodic breathing with pauses and a gradual increase and then decrease in the amplitude of respiratory movements);
primary atelectasis;
cyanotic;
from the outsideof cardio-vascular system :
lower blood pressure in the first days of life (75/20 mm Hg, increasing in subsequent days to 85/40 mm Hg;
lability of heart rate with a tendency to tachycardia (up to 200 per minute, on average – 140 – 160 beats/min);
the phenomenon of embryocardia (heart rhythm characterized by pauses of equal duration between the 1st and 2nd sounds and between the 2nd and 1st sounds);
muffled heart sounds; in the first days of life, murmurs are possible due to the frequent functioning of embryonic shunts (botal duct, oval window);
vascular dystonia - predominance of activity of the sympathetic department of the autonomic nervous system - any irritation causes increased heart rate, increased blood pressure;
Harlequin's symptom (or Finkelstein's symptom): when the child is positioned on his side, uneven coloring of the skin is observed: the lower half Pink colour, the upper one is white, which is due to the immaturity of the hypothalamus, which controls the state of the tone of the skin capillaries;
from the outsidedigestive system :
reduced tolerance to food: low proteolytic activity of gastric juice enzymes, insufficient production of pancreatic and intestinal enzymes, bile acids,
increased permeability of the intestinal wall;
predisposition to flatulence and dysbacteriosis;
underdevelopment of the cardiac part of the stomach (gaping of the cardia - tendency to regurgitation);
from the outsideurinary system :
low filtration and osmotic function of the kidneys;
from the outsideendocrine system :
decreased reserve capacity of the thyroid gland - a tendency to transient hypothyroidism;
from the outsidemetabolism and homeostasis − tendency to:
hypoproteinemia,
hypoglycemia,
hypocalcemia,
hyperbilirubinemia,
metabolic acidosis;
from the outsideimmune system :
low level of humoral immunity and nonspecific protective factors.
Morphological signs of prematurity:
large vertical size of the head (⅓ of the body length, in full-term babies - ¼),
predominance of the size of the brain skull over the facial one,
open small and lateral fontanelles and sutures of the skull,
low hair growth on the forehead,
soft ears,
abundant lanugo,
thinning of subcutaneous fat,
the location of the umbilical ring below the midpoint of the body,
underdevelopment of nails
Functional signs of prematurity:
low muscle tone (frog pose);
weak reflexes, weak cry;
tendency to hypothermia;
max loss of body weight by 4-8 days of life is 5-12%, restored by 2-3 weeks;
prolonged physiological (simple) erythema;
physiological jaundice – up to 3 weeks. - 4 weeks;
period early adaptation= 8 days -14 days,
late adaptation period = 1.5 months. - 3 months;
the pace of development is very high: the weight-height indicator is compared by 1 year (compared to full-term ones), in very premature infants (<1500 г) - к 2-3 годам;
in neuropsychic development by 1.5 years they catch up with full-term ones, provided that they are healthy. In 20% of cases with a weight of 1500 g and< - поражается ЦНС (ДЦП, эпилепсия, гидроцефалия).
Features of the neonatal period in premature infants
The period of early adaptation in premature infants is 8-14 days, the neonatal period lasts more than 28 days (up to 1.5 - 3 months). For example, if a child was born at a gestational age of 32 weeks, then at 1 month of life his gestational age will be 32 + 4 = 36 weeks.
Physiological loss of body weight lasts longer - 4 - 7 days and amounts to 10 - 14%, its restoration occurs by 2 - 3 weeks of life.
In 90 - 95% of prematurely born children there is neonatal jaundice of prematurity, more pronounced and longer-lasting than in full-term ones (can last up to 3-4 weeks).
Hormonal crisis and toxic erythema are less common than in full-term infants.
An increase in muscle tone in the flexors usually appears in 1–2 months of life.
In healthy premature infants weighing up to 1500 g, the ability to suck appears within 1 - 2 weeks of life, with a weight from 1500 to 1000 g - at 2 - 3 weeks of life, less than 1000 g - by a month of life.
The rate of development of premature babies is very high. Most premature children catch up with their peers in terms of height by 1-1.5 years. Children with very low birth weight (less than 1500 grams - very premature) usually lag behind in physical and neuropsychic development up to 2-3 years. In 20% of very premature children, there are organic lesions of the central nervous system (cerebral palsy, damage to hearing, vision, etc.). At 5–7 years and 11–14 years, disturbances in the harmonious development (growth retardation) may be observed.
Prevention of premature birth consists of:
socio-economic factors;
family planning;
treatment of extragenital pathology before pregnancy;
treatment of urogenital infection;
consultation in “marriage and family” clinics;
replanting of lymph suspension (150 ml) during or outside of pregnancy;
culture of sexual life.
