Premature babies: frequency and causes premature birth. Anatomical, physiological and neuropsychic features of premature babies
premature babies- children born in relation to the established end of gestational age 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.
premature birth statistics .
The frequency of preterm birth = 3–15% (average − 5–10%). Premature births in 2002 - 4.5%. There is no downward trend in this indicator.
Among prematurely born children, the highest morbidity and mortality are observed. They account for 50 to 75% of infant mortality, and in some developing countries - almost 100%.
Causes of preterm birth
socio-economic (salary, living conditions, nutrition of a pregnant woman);
socio-biological ( bad habits, parent's age, prof. harmfulness);
clinical (extragenital pathology, endocrine diseases, threat, preeclampsia, hereditary diseases).
Factors contributing to fetal growth retardation and preterm labor (prematurity) can be divided into 3 groups :
absence or insufficiency medical care before and during pregnancy;
level of education (less than 9 classes) - affect the level and lifestyle, personality traits, material well-being;
low standard of living and, accordingly, material security, and as a result, unsatisfactory living conditions, inadequate nutrition of the expectant mother;
occupational hazards (physically difficult, prolonged, monotonous, standing work of a pregnant woman);
extramarital birth (especially with unwanted pregnancy);
unfavorable ecological situation;
young or elderly age pregnant (less than 18 years old) and first birth over 30 years old);
father's age is under 18 and over 50 (in Europe);
bad habits (smoking, alcoholism, drug addiction) of both the future mother and father;
short stature, infantile physique of a pregnant woman;
genital infantilism, especially in combination with hormonal disorders (corpus luteum insufficiency, ovarian hypofunction, isthmic-cervical insufficiency) - up to 17% of all preterm births;
previous abortions and miscarriages - lead to inadequate secretion of the endometrium, collagenization of the stroma, isthmic-cervical insufficiency, increased contractility of the uterus, the development of inflammatory processes in it (endometritis, synechia);
mental and physical injuries of a pregnant woman (fright, shocks, falls and bruises, weight lifting, surgical interventions during pregnancy - especially laparotomy);
inflammatory diseases of the mother of an acute and chronic nature, acute infectious diseases (delivery 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 a violation of the uteroplacental blood flow, degenerative changes in the placenta;
genital pathology;
pathology of pregnancy: late gestosis, nephropathy, immunological conflict in the mother-placenta-fetus system;
anomalies in the development of the placenta, umbilical cord;
in vitro fertilization;
multiple pregnancy (about 20% of all premature babies);
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:
environmental,
coming from the mother;
associated with the peculiarities of the course of pregnancy;
from the side of the fetus.
Classification of prematurity
In ICD X revision under heading R 07 " Disorders associated with the shortening of pregnancy, as well as low birth weight" The division of premature newborns is accepted 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 a premature baby, 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 |
deeply premature |
29-31 weeks |
1499−1000 grams− very low body weight |
|
|
IV degree |
22-28 weeks |
999-500 grams extremely low mass (extremely low mass) |
||
Extreme prematurity− gestational age less than 22 completed weeks (154 completed days).
The line between miscarriage and premature at 22 full weeks(154 full days) of gestation is determined by weight: 499 g - miscarriage, 500 g - premature newborn.
Anatomical, physiological and neuropsychic features of premature babies
Anatomical features of premature babies (external signs of immaturity):
the skin is thin and glossy, dark red, as if translucent;
on the face, back, extensor surfaces of the limbs there is an abundant primordial fluff - lanugo;
the subcutaneous fat layer is thinned, as a result of which the skin is wrinkled, there is a tendency to edema of the subcutaneous fat;
body length from 25 cm to 46 cm;
disproportionate physique (the head is relatively large: the large vertical size of the head ranges from ¼ to ⅓ of the body length, the brain skull prevails over the facial one; the neck and lower limbs are short);
low forehead hair growth
the skull is more round, its bones are pliable - non-closure of cranial sutures, small and lateral fontanelles are usually open;
auricles are soft, close to the skull;
nails often do not reach fingertips, nail plates are soft;
low-lying place of discharge of the umbilical cord, below the midpoint of the body;
underdevelopment of the genital organs: in girls, the genital slit gapes, i.e., the labia minora is not covered by the labia majora (due to 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 features of the body of a premature baby (functional signs of immaturity):
from the sidenervous and muscular systems - depression syndrome:
muscle hypotension, lethargy, drowsiness, delayed response to stimuli, a weak, quiet cry or squeak,
the predominance of subcortical activity (due to the immaturity of the cerebral cortex): movements are chaotic, shudders, hand tremors, stop clonus may be noted,
imperfection of thermoregulation (reduced heat production and increased heat transfer: children easily cool and overheat, they do not have an adequate temperature increase for an infectious process),
weak severity, rapid extinction or absence of physiological reflexes of the neonatal period,
weak sucking intensity;
from the siderespiratory system :
great lability of the 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 seconds);
gasps (convulsive respiratory movements with difficulty inhaling);
during sleep or rest may be observed: breathing Biot 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 a decrease in the amplitude of respiratory movements);
primary atelectasis;
cyanosis;
from the sideof cardio-vascular system :
lower blood pressure in the first days of life (75/20 mm Hg with an increase in the following days to 85/40 mm Hg;
lability of heart rate with a tendency to tachycardia (up to 200 beats per minute, on average - 140 - 160 beats / min);
the phenomenon of embryocardia (heart rhythm, characterized by pauses of equal duration between I and II tone and between II and I tone);
muffled heart tones, in the first days of life, noises are possible due to the frequent functioning of embryonic shunts (botall duct, oval window);
vascular dystonia - the predominance of the activity of the sympathetic division of the autonomic nervous system - any irritation causes an increase in heart rate, an increase in blood pressure;
Harlequin symptom (or Finkelstein symptom): in the position of the child on the side, uneven skin coloration is observed: the lower half Pink colour, upper - white, which is due to the immaturity of the hypothalamus, which controls the state of skin capillary tone;
from the sidedigestive system :
reduced food tolerance: 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 - a tendency to regurgitation);
from the sideurinary system :
low filtration and osmotic function of the kidneys;
from the sideendocrine system :
decrease in the reserve capacity of the thyroid gland - a tendency to transient hypothyroidism;
from the sidemetabolism and homeostasis − propensity to:
hypoproteinemia,
hypoglycemia,
hypocalcemia,
hyperbilirubinemia,
metabolic acidosis;
from the sideimmune 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 ones - ¼),
the predominance of the size of the brain skull over the facial,
open small and lateral fontanelles and sutures of the skull,
low forehead hair growth
soft ears,
plentiful lanugo,
thinning of subcutaneous fat,
the location of the umbilical ring below the midpoint of the body,
underdevelopment of nails
Functional signs of prematurity:
short muscle tone(frog pose);
weakness of reflexes, weak cry;
tendency to hypothermia;
max weight loss by 4-8 days of life and is 5-12%, is restored by 2-3 weeks;
prolonged physiological (simple) erythema;
physiological jaundice - up to 3 weeks. - 4 weeks;
period early adaptation= 8days -14 days,
period of late adaptation = 1.5 months. - 3 months;
the rates of development are very high: the mass-growth index is compared to 1 year (compared to full-term ones), in very preterm infants (<1500 г) - к 2-3 годам;
in neuropsychic development, by the age of 1.5, they catch up with full-term ones, provided that they are healthy. In 20% of cases with a mass of 1500 g and< - поражается ЦНС (ДЦП, эпилепсия, гидроцефалия).
Features of the course of the neonatal period in preterm infants
The period of early adaptation in premature babies 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 weight loss lasts longer - 4 - 7 days and amounts to 10 - 14%, its recovery occurs by 2 - 3 weeks of life.
90-95% of preterm babies have neonatal jaundice of prematurity, more pronounced and longer than full-term (can be held up to 3-4 weeks).
Hormonal crisis and toxic erythema are less common than in term infants.
An increase in muscle tone in the flexors usually appears in 1-2 months of life.
In healthy premature babies weighing up to 1500 g, the ability to suckle appears within 1–2 weeks of life, with a weight of 1500 to 1000 g – at 2–3 weeks of life, less than 1000 g – by the month of life.
The rate of development of premature babies is very high. Most premature babies catch up with their peers by 1-1.5 years in terms of weight and height. 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 babies, there are organic lesions of the central nervous system (cerebral palsy, hearing, vision, etc.).
Prevention of preterm birth consists of:
socio-economic factors;
family planning;
treatment of extragenital pathology before pregnancy;
treatment of urogenital infection;
consultation in polyclinics “marriage and family”;
transplantation of lymph suspension (150 ml) during or outside of pregnancy;
sex culture.
Today, premature births are common. In most developed countries, this indicator is relatively stable and amounts to 5-10% of the total number of children born.
The prognosis for life in premature babies depends on many factors. First of all, from the gestational age and birth weight. In the case of the birth of a child in the period of 22-23 weeks, the prognosis depends on the intensity and quality of therapy.
Long-term consequences of prematurity (the likelihood of these complications again depends on many factors; under other favorable conditions, these complications are quite rare). Among premature babies, the risk of mental and physical disability is higher than among full-term babies.
The concept of prematurity.
A premature baby is a baby born before the end of the normal gestational age.
Usually, it is customary to refer to premature babies whose birth weight is less than 2500 g. However, the definition of prematurity only by birth weight does not always correspond to reality. Many children born prematurely have a body weight of more than 2500 g. This is more often observed in newborns whose mothers have diabetes.
At the same time, among full-term infants born at 38-40 weeks of gestation, there are children whose birth weight is less than 2000 g and even 1500 g. These are primarily children with congenital malformations and intrauterine diseases, as well as from multiple pregnancies and sick mothers. Therefore, it is more correct to consider the duration of pregnancy as the main criterion for determining prematurity. On average, as you know, a normal pregnancy lasts 270-280 days, or 38-40 weeks. Its duration is usually calculated from the first day after the last menstruation until the onset of childbirth.
A baby born before 38 weeks of gestation is considered premature. According to the International Nomenclature (Geneva, 1957), children with a birth weight of more than 2500 g are diagnosed with prematurity if they were born before 37 weeks.
Babies born at 38 weeks' gestation or more, regardless of birth weight (more or less than 2500 g), are full-term. In controversial cases, the issue of full-term is decided on the basis of a combination of signs: gestational age, body weight and height of the child at birth.
Childbirth before 28 weeks of gestation is considered a miscarriage, and a newborn with birth weight less than 1000 g (from 500 to 999 g) is considered a fetus. The concept of "fetus" persists until the 7th day of life.
The degree of prematurity of children (intrauterine malnutrition)
The degree of intrauterine malnutrition is determined by the lack of body weight. For normal body weight, we conditionally accept the lower limit of the limit corresponding to the given gestational age indicated above. The ratio of body weight deficit to the minimum body weight for this gestational age in percent shows the degree of intrauterine malnutrition.
We single out 4 degrees of intrauterine malnutrition: with I, the body weight deficit is 10% or less; with II - from 10.1 to 20%; with III - from 20.1 to 30% and with IV - over 30%. Here are some examples:
- A child weighing 1850 g was born at 35 weeks. The mass deficit is (2000-1850): 2000 X 100=7.5%. Diagnosis: prematurity of the 1st degree, intrauterine malnutrition of the 1st degree.
- A child weighing 1200 g was born at 31 weeks. The mass deficit is (1400-1200): 1400 X 100 = 14.3%. Diagnosis: prematurity III degree, intrauterine malnutrition II degree.
- A child weighing 1700 g was born at 37 weeks. The mass deficit is (2300-1700): 2300 X 100 = 26%. Diagnosis: prematurity of the 1st degree, intrauterine malnutrition of the 3rd degree.
- A child weighing 1250 g was born at 34 weeks. The mass deficit is (1800-1250): 1800 X 100 = 30.5%. Diagnosis: prematurity II degree, intrauterine malnutrition IV degree.
Features of premature babies
The appearance of premature babies has distinctive features that are directly dependent on the gestational age. The lower the gestational age, the more such signs and the more pronounced they are. Some of them can be used as additional tests to estimate gestational age.
- Small sizes. Low growth and reduced nutrition are characteristic of all premature infants, with the exception of children born weighing over 2500 g. corresponds to the length of the body, they just look petite. The presence of wrinkled, flabby skin at birth is typical for children with intrauterine malnutrition, and later observed in premature patients who, for various reasons, gave a large weight loss or have a flat weight curve.
- Disproportionate physique. A premature baby has a relatively large head and torso, short neck and legs, and a low navel. These features are partly due to the fact that the growth rate of the lower extremities increases in the second half of pregnancy.
- Severe hyperemia of the skin. More characteristic of fruits.
- Expressed lanugo. Small premature babies have soft fluffy hair not only on the shoulders and back, but abundantly cover the forehead, cheeks, thighs and buttocks.
- Gaping of the genital slit. In girls, due to the underdevelopment of the labia majora, the genital gap gapes and the clitoris is clearly visible.
- Empty scrotum. The process of lowering the testicles into the scrotum occurs in the 7th month of uterine life. However, for various reasons, it may be delayed. In very premature boys, the testicles are often not descended into the scrotum and are located in the inguinal canals or in the abdominal cavity. Their presence in the scrotum indicates that the gestational age of the child exceeds 28 weeks.
- Underdevelopment of fingernails. By the time of birth, the nails, even in the smallest children, are quite well formed and completely cover the nail bed, but often do not reach the fingertips. The latter is used as a test to assess the degree of nail development. According to foreign authors, the nails reach the fingertips at 32-35 weeks of gestation, and at more than 35 weeks they protrude beyond their edges. According to our observations, the nails can reach the tips of the fingers as early as the 28th week. Assessment is carried out in the first 5 days of life.
- Soft ear shells. Due to the underdevelopment of cartilage tissue in small children, the auricles often tuck inward and stick together.
- The predominance of the brain skull over the facial.
- The small spring is always open.
- Underdevelopment of the mammary glands. Premature babies do not have physiological breast engorgement. The exception is children whose gestational age exceeds 35-36 weeks. Breast engorgement in children weighing less than 1800 g indicates intrauterine malnutrition.
Characteristics of premature babies.
When evaluating any premature baby, it should be noted to what extent it corresponds to its gestational age, which can only be attributed to the prematurity itself, and which is a manifestation of various pathological conditions.
The general condition is assessed on a generally accepted scale from satisfactory to extremely severe. The severity criterion is primarily the severity of pathological conditions (infectious toxicosis, CNS damage, respiratory disorders). Prematurity itself in its "pure" form, even in children weighing 900-1000 g, in the first days of life is not a synonym for a serious condition.
The exception is fruits with a body weight of 600 to 800 g, which on the 1st or 2nd day of life can produce quite a favorable impression: active movements, good tone of the limbs, a rather loud cry, normal skin color. However, after some time, their condition deteriorates sharply due to respiratory depression, and they die rather quickly.
Comparative characteristics are carried out only with premature babies of a given weight category and gestational age. If preterm infants of IV-III degree do not have depression syndrome, severe neurological symptoms and significant respiratory disorders, their condition can be regarded as moderate or a more streamlined wording can be used: “the condition corresponds to the degree of prematurity”, “the condition basically corresponds to the degree prematurity."
The latter means that the child, in addition to prematurity, has moderate manifestations of atelectasis or a mild form of encephalopathy.
Premature babies tend to worsen their condition as the clinical manifestation of pathological syndromes occurs several hours or days after birth. Some doctors, in order to avoid reproach for underestimating the child, indiscriminately regard almost all premature babies as severe, which is reflected in the stencil entry: “The condition of the child at birth is severe. The severity of the condition is due to the degree of prematurity and its immaturity. Such a record, on the one hand, does not contribute to clinical thinking, and on the other hand, does not provide sufficient information for an objective assessment of the child at the subsequent stages of nursing.
The maturity of the newborn means the morphological and functional correspondence of the central nervous system to the gestational age of the child. The standard of maturity is a healthy full-term baby. Compared to him, all premature babies are considered immature. However, each gestational age of a premature baby has its own degree of maturity (gestational maturity). When a developing fetus is exposed to various damaging factors (infectious and somatic diseases of the mother, toxicosis of the pregnant woman, criminal intervention, etc.), the maturity of the child at birth and in subsequent days may not correspond to his age. In these cases, we should talk about gestational immaturity.
The concepts of "mature" and "healthy" newborn are not identical. The child may be sick, but his maturity is to match his true age. This applies to pathological conditions that are not accompanied by CNS depression. In severe pathology, it makes no sense to determine the maturity of a child.
The determination of maturity is carried out not only at the birth of a child, but also in the following days, during the 1-3rd week of life. However, during this period, functional CNS depression is often due to postnatal pathology (infectious toxicosis), therefore, in our presentation, the concept of "gestational immaturity" is interpreted more broadly. It reflects the morphological underdevelopment of the brain, as well as the functional damage to the central nervous system of intrauterine and postnatal origin. More precisely, we determine not so much gestational maturity as the correspondence of a given child to premature babies of similar body weight and age.
For comparative characteristics, motor activity, the state of muscle tone and reflexes of the newborn, the ability to maintain body temperature, and the severity of the sucking reflex can be used. Under equal conditions, they can also start sucking earlier and more actively.
In addition to immaturity, severe hypoxia, various CNS lesions, and infectious toxicosis have a depressing effect on the sucking reflex. The combination of these factors leads to the fact that many premature babies are unable to suck from the horn for a long time. The duration of this period in children weighing 1800 g or more usually does not exceed 2.5-3 weeks, in children weighing 1250-1700 g - 1 month and in children weighing 800-1200 g - 1'/ 2 months.
A more prolonged absence of suckling, which cannot be explained by a generalized or indolent infection, goes beyond mere gestational immaturity and should be alert for organic CNS damage, even if there are no neurological symptoms at this time.
Inhibition of sucking in children who have previously actively sucked is almost always associated with the appearance of a focus of infection.
According to our data, children weighing up to 1200 g in the first 2 months of life increase their height by 1-2 cm per month, children with a larger weight - by 1-4 cm.
The increase in head circumference in premature babies of all weight categories in the first half of the year averages 3.2-1 cm per month, and in the second half of the year - 1-0.5 cm. During the first year of life, the head circumference increases by 15-19 cm and in at the age of 1 year, on average, it is 44.5-46.5 cm [Ladygina V. E., 1972].
Physical development of premature babies
Of interest is the physical development of the smallest children with a birth weight of 800 to 1200 g. According to our data, the average body weight of these children at the age of one year is 8100 g, with the most frequent fluctuations from 7500 to 9500 g. Comparing weight indicators at the age of one year Depending on the gender, we did not observe in children with a birth weight of up to 1200 g a difference between the body weight of boys and girls.The average weight gain for the 2nd year of life in children with a birth weight of 800 to 1200 g, according to our data, is 2700 g, and at 2 years of age their weight is on average 11000 g with the most frequent fluctuations from 10,000 up to 12,000
The average body weight for boys at the age of 2 years is 11,200, and for girls, 10,850 g.
The rate of increase in height in children with a birth weight of 800 to 1200 g is also quite high. According to our data, children in this weight category increase their initial height by 2-2.2 times by a year, reaching an average of 71 cm with fluctuations from 64 to 76 cm. During the first year of life, they grow on average by 38 cm with fluctuations from 29 to 44 cm.
In contrast to weight indicators, the average height of boys with a birth weight of up to 1200 g at the age of one year was higher than that of girls - 73 and 69.5 cm, respectively.
During the 2nd year of life, children with a birth weight of 800 to 1200 g, according to our data, increase their height by an average of 11 cm and reach 81 cm at 2 years of age, with fluctuations from 77 to 87 cm.
Interesting data were obtained by R. A. Malysheva and K. I. Kozmina (1971) in the study of the physical development of preterm infants at an older age. Examining children aged 4 to 15 years, they found that after 3-4 years of life, premature babies are compared in body weight and height with full-term peers, at 5-6 years of age, i.e. in the period of the first " stretching”, they again, according to these indicators, especially in body weight, begin to lag behind full-term children. By the age of 8-10 years, growth rates level off again, but the difference in body weight between full-term and premature boys remains.
With the approach of puberty, the same pattern repeats itself: the second "stretching" in premature babies occurs 1-2 years later. In full-term boys, growth between 11 and 14 years increases on average by 20 cm, in girls - by 15 cm, in premature babies, these figures are respectively less - 16 and 14.5 cm. Full-term boys increase body weight during this period by an average of 19 kg, girls - 15.4 kg, premature babies - by 12.7 and 11.2 kg, respectively.
Teething in premature babies, it starts at a later date. There is a correlation between body weight at birth and the time when the first teeth appear. According to some data, in children with a birth weight of 2000 to 2500 g, the eruption of the first teeth begins at 6-7 months, in children weighing from 1501 to 2000 g - at 7-9 months and in children weighing from 1000 to 1500 g - at 10-11 months. According to our data, in children with a birth weight of 800 to 1200 g, the first teeth appear at the age of 8-12 months, on average - at 10 months.
In conclusion, let's touch on a question that often arises among doctors of children's clinics: should all premature babies be considered as children with malnutrition in the first year of life.
The physical development of premature babies has its own characteristics and depends on body weight at birth, previous diseases and constitutional features of the child. Assessment of body weight indicators should be carried out only in comparison with those in healthy premature babies of this weight category. Therefore, it is completely wrong to regard a child born with a weight of 950 g, in which at the age of one year it is equal to eight kg, to regard as a patient with malnutrition. Diagnosis: prematurity in such a child explains the temporary lag in physical and psychomotor development.
Psychomotor development of premature babies: consequences
Basic psychomotor skills in most premature babies appear later than in full-term babies. The lag in psychomotor development depends on the degree of prematurity and is more pronounced in children weighing up to 1500 g. bodies from 1501 to 2000 - for 1 - 1 1/2 months.
By the end of the first year, most children with a birth weight of 2001 to 2500 g catch up with their full-term peers in psychomotor development, and by the age of 2, deeply premature ones are compared with them.
Data on the psychomotor development of premature babies by months are presented in Table. 1.
Table 1 Some indicators of psychomotor development in premature babies in the 1st year of life, depending on body weight at birth (data from L. 3. Kunkina)
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||
Thus, in terms of psychomotor development, premature babies are compared with their full-term peers earlier than in terms of height and body weight.
However, in order for a child to develop well, a lot of individual work must be done with him (massage, gymnastics, display of toys, colloquial speech).
In long-term ill preterm infants and in children who were deprived of the necessary individual care, the lag in psychomotor development is more pronounced.
Consequences of prematurity, prognosis (catamnesis)
The prospect of nursing premature babies largely depends on their further psychomotor development. In this regard, early and long-term prognosis is of great importance.
The literature on this issue is contradictory. This is primarily due to the unequal contingent of the examined children, the difference in the tests used to determine the usefulness of the child, as well as the number of specialists (neurologist, psychiatrist, ophthalmologist, speech therapist) involved in the examination.
Some authors are very pessimistic about the neuropsychic development of premature babies. As an example, let us cite the statement of the prominent Finnish scientist Ilppö: “The mental development of premature babies in the first years of life lags behind the norm. Unfortunately, a significant proportion of these intellectual defects persist for life. Premature babies are much more likely to show more or less severe mental disability. Intellectual disorders are often combined with hemiplegia, paraplegia, Little's disease ”(Fanconi G, Valgren A, 1960). In the studies of many authors, there is a large percentage of severe CNS lesions in non-term infants.
R. A. Malysheva et al., examining 255 premature babies aged 3-4 years, 32 of them (12.6%) had severe organic lesions of the central nervous system and 50% had slight deviations in neuropsychic development.
According to S. Drillien, almost 30% of premature babies born weighing up to 2 kg have moderate or severe impairments in psychomotor and physical development.
A. Janus-Kukulska and S. Lis, in a study of 67 children with a birth weight of up to 1250 g, aged 3 to 12 years, half of them found a lag in physical and mental development, 20.9% were found to have severe CNS lesions .
Attention is drawn to the frequency of various lesions of the organ of vision. In studies by A. Janus-Kukulskaya and S. Lis, 39% of children weighing up to 1250 g at birth were found to have various visual defects: myopia, strabismus, astigmatism, optic nerve atrophy, retinal detachment. Other researchers also point to a high percentage of congenital myopia (30%) in premature babies [Grigorieva VI et al., 1973].
K. Rare et al. (1978), studying the follow-up of 43 children born weighing up to 1000 g, 12 of them were found to have severe eye damage, including 7 - retrolental fibroplasia (RLF) and 2 - complete loss of vision.
S. Saigal et al. (1982) in a study of 161 children with a birth weight of up to 1500 g, RLF was found in 42 children, in 12 of them it proceeded in a severe form.
At the same time, other authors note a more favorable outcome in the follow-up examination of premature babies. In the observations of N. R. Boterashvili, the frequency of CNS lesions varied depending on the degree of prematurity from 3.8 to 8.5%. L. 3. Kunkina, studying together with a neurologist 112 premature babies aged 3 years, 4 of them (3.6%) found a delay in neuropsychic development, 7 (6.2%) had neurotic reactions in the form anxiety, sleep disorders, logoneurosis, and in 2 (1.7%) - epileptiform seizures [Kunkina L. 3., 1970].
J. Hatt et al. (1972), observing 26 children with a birth weight of 1250 g or less at the age of 2 to 12 years, 77.8% of them noted normal mental development.
S. Saigal et al. (1982) studied follow-up for 3 years in 184 children born weighing up to 1500 g. 16.8% had neurological disorders, including 13% - cerebral palsy.
According to A. Teberg et al. (1977) and K. Rare et al. (1978), among children with a birth weight of 1000 g or less, 67.5-70% had no deviations in the neurological status.
Analyzing the literature data and our own material, we can note the following:
- Premature infants are significantly more likely than full-term infants to have organic lesions of the central nervous system.
They are caused by the pathology of the prenatal period, complications in childbirth and damaging factors in the early postnatal period (hyperoxemia, hyperbilirubinemia, hypoglycemia);
- preterm infants with a gestational age of less than 29 weeks and a body weight of less than 1200 g, due to underdevelopment of the retina, have a greater predisposition to the development of RLF. It is in this contingent of children that this pathology is mainly observed;
- in recent years, premature babies have a tendency to increase the incidence of cerebral palsy. By the way, this is typical for full-term children. This trend can be explained by two reasons: firstly, there are now more opportunities to save a pregnancy that occurs with the threat of termination; secondly, progress in organizing specialized care for newborns and the creation of resuscitation services in maternity hospitals contribute to the survival of children with asphyxia. - this and intracranial hemorrhages;
- The prospects for the psychophysical development of premature babies largely depend on how pathogenetically substantiated and sparing (iatrogenic factors) the therapy was at the 1-2nd week of life and how early and consistently rehabilitation assistance was provided at subsequent stages.
Due to the fact that mild forms of cerebral palsy are not detected immediately, and often only in the second half of the first year of life, and some pathology of vision is not diagnosed by pediatricians at all, after discharge from the department of premature babies with a burdened anamnesis and weighing up to 1500 g should be observed by a neurologist, as well as undergo an examination by an ophthalmologist.
Based on the above, premature babies should remain under the systematic supervision of neonatologists from the moment of birth until the period when their health is out of danger, and the body becomes ready for independent life.
Doctor of Medical Sciences, Alexander Ilyich Khazanov(Saint Petersburg)
A full-term newborn is born defenseless and requires vigilant care. If we are talking about a baby who saw the world much earlier than the time allotted by nature, then the risks and troubles increase many times over. According to statistics, 8-12% of children are born long before the expected date. Nursing them is a complex process that involves a number of specialists. A positive attitude and the right actions of parents are of great importance. Consider the features of the condition of premature babies and the main recommendations for caring for them.
A newborn is considered premature if it was born before the 37th week of pregnancy, that is, before the 260th day of intrauterine development (gestation). At the same time, its weight is in the range from 0.5 to 2.5 kg, and its height is from 25 to 40 cm. Depending on the term of birth and body weight, 4 degrees of prematurity are distinguished:
- 1st - term - 35-37 weeks, weight - 2.001-2.5 kg, the child is mature and viable, in some cases treatment is required (with jaundice, birth trauma);
- 2nd - term - 32-34 weeks, weight - 1.501-2.0 kg, when assisted, the baby quickly adapts to external conditions;
- 3rd - term -29-31 weeks, weight - 1.001-1.5 kg, most children survive, but they need long-term rehabilitation;
- 4th - term - less than 29 weeks, weight - up to 1.0 kg, the baby is not ready for independent life, the prognosis is unfavorable - 60-70% of babies die within 30 days.
Nursing a premature baby in a medical facility
According to WHO standards, newborns with a body weight of at least 500 g and the presence of a heartbeat are subject to nursing. The earlier the child was born, the more difficult his condition. Prematurity of the first and second degree is called moderate, the third and fourth - deep. In addition to the above parameters, when developing nursing tactics, doctors pay attention to the severity of signs of immaturity of the body, the main ones are:
- irregular weakened breathing;
- dry wrinkled skin with a reddish tint due to underdevelopment of subcutaneous fat;
- weak cry;
- lanugo (fluff) on the body;
- nail plates do not completely cover the phalanges;
- umbilical cord below the center of the abdominal wall;
- all fontanelles are open;
- the genitals are underdeveloped;
- meager movements due to reduced muscle tone;
- disproportionate sizes of body parts - a large head, short limbs;
- physiological reflexes are not expressed.
In the case of moderate prematurity, some of these signs are absent. It also happens that the baby's body weight is more than 2.5 kg, but there are manifestations of immaturity of the body.
The main causes of preterm birth:
- nutritional deficiencies in the mother's diet;
- lack of medical care;
- stress factors;
- bad habits and addictions of a woman;
- exposure to toxic substances, including in the workplace;
- the age of the mother is under 18 and over 35, the father is under 18 and over 50;
- more than three abortions in history;
- pregnancy earlier than one year after childbirth;
- chronic diseases of the mother;
- physical injury;
- immunological conflict;
- infections and chromosomal abnormalities of the fetus, and so on.
Condition features
A child born prematurely is not ready for independent life. The rate of adaptation depends on the maturity of the organism and the severity of the course of childbirth. In most cases, such babies, up to a certain age, lag behind their peers in development and show an increased tendency to certain diseases.
nervous system
By the 28th week of pregnancy, all the nerve endings and nodes, as well as the brain, are formed in the baby. But myelin, the substance responsible for the transmission of impulses, does not fully cover them. In a full-term baby, the process of myelination of fibers takes 3-5 months.
In a child born prematurely, the maturation of the nervous system may be delayed. As a result, there are difficulties with sucking, swallowing, breathing, reacting to external stimuli, and so on.
The stronger the degree of prematurity, the weaker the unconditioned reflexes.
The cerebral cortex in premature babies is poorly formed. Some structures are underdeveloped, such as the cerebellum, which is responsible for coordinating movements. The walls of the brain vessels are weakened, so there is a risk of ischemia (lack of oxygen) and hemorrhages.
thermoregulation
In children born prematurely, the processes of preserving and dissipating heat are imperfect. They are easily supercooled (body temperature drops below 36°) and overheated under the influence of external conditions. Reasons for this:
- lack of subcutaneous fat;
- immaturity of the thermoregulation center in the brain;
- immaturity of the sweat glands.
The increased risk of overheating/hypothermia persists for up to 6 months. The mechanism of thermoregulation is finally formed by the age of 8.
System digestion
The digestive system of premature newborns is characterized by some features:
- reduced motor activity of the gastrointestinal tract, food passes slowly;
- enzymes are not produced enough, products are poorly digested, and fermentation occurs;
- due to the low acidity of digestive juices, the intestinal microflora is disturbed;
- the stomach has a small volume;
- sphincter at the border with the esophagus is weak.
As a result, babies suffer from bloating, intestinal colic, defecation disorders, frequent, profuse regurgitation, lack of vitamins and minerals.
The nutrition of such a child in the first days of life is carried out through a special probe.
Hearing And vision
With deep prematurity, the child reacts to sound stimuli only by blinking and moving the limbs. He begins to turn his head to the sound in about 1-1.5 months.
The vision of these children is poorly developed. Most of the time they lie with their eyes closed. Babies born at 30-32 weeks of gestation can hold their eyes on bright objects and turn towards a light source.
The vascular network of the retina is formed in the last month of pregnancy. Premature babies are at high risk of retinopathy, a retinal lesion that can lead to visual impairment and blindness. With timely treatment, the condition is corrected.
Respiratory system
Narrow airways, immaturity of the respiratory center of the brain, a highly located diaphragm - these and other factors make it impossible for a premature baby to fully breathe independently. In the waking state, he breathes very often (60-80 times per minute), but not deeply. In sleep, the frequency decreases, sometimes there are episodes of apnea - respiratory arrest, while the nasolabial triangle and fingers turn blue.
With deep prematurity, atelectasis (falling) of individual sections of the lungs can be observed. This is due to an insufficient amount of surfactant - a substance that is formed from 23 to 36 weeks of gestation and is designed to open the pulmonary vesicles during the first breath. As a result, respiratory disorders occur, which are often accompanied by an infection (pneumonia).
Some children have bronchopulmonary dysplasia after being connected to a ventilator. In the future, this is fraught with frequent acute respiratory infections.
Cordially — vascular system
Normally, after the first spontaneous breath, the shunts between the heart chambers and large vessels are closed in the child, thanks to which blood circulation was ensured during fetal development. In babies born prematurely, the process of restructuring the circulatory system occurs in the first months of life. In addition, the heart and blood vessels experience increased stress due to ongoing rehabilitation measures. Quite often congenital malformations are found.
The baby's heart sounds are muffled, the average heart rate is 120-140 beats per minute. The body reacts to any external influence with a jump in pressure and an increase in the frequency of contractions - up to 200.
Endocrine system
When born prematurely, all elements of the endocrine system do not function fully:
- Adrenals. Cortisol deficiency leads to a decrease in the adaptive capabilities of the body and an inadequate response to stress factors. With severe adrenal insufficiency, the baby's body temperature decreases and blood pressure drops.
- Thyroid. There is transient hypothyroidism (decreased activity of the organ). As a result, the metabolism slows down, swelling occurs, jaundice is prolonged, and so on.
- Ovaries and testicles. Due to the lack of hormones, the sexual crisis is mild.
- Pancreas. Excess insulin synthesis and meager glycogen stores lead to low blood sugar levels. Hypoglycemia is a dangerous violation of the maturation of the nervous tissue.
Bone system
In premature babies, the bones are fully formed, but the process of their mineralization is incomplete. For this reason, the risk of hip dysplasia is high.
Due to the deficiency of calcium and phosphorus, early prevention of rickets is advisable. It consists in the appointment of vitamin D from the age of 2 weeks.
urinary system
The immaturity of the renal tissue and the instability of water-salt metabolism predispose children to the formation of edema. Usually they appear in the first days of life and disappear in 1-2 weeks. Later firm swelling in the lower body may indicate nutritional problems or disease. In addition, it should be borne in mind that the baby can quickly develop dehydration.
hematopoietic system
The tendency to anemia in preterm infants is associated with the rapid destruction of fetal hemoglobin and the immaturity of the bone marrow. In addition, there is an increased risk of bleeding due to a lack of vitamin K and a decrease in the ability of platelets to stick together.
immune system
Most of the antibodies and immunoglobulins the child receives from the mother at 32-35 weeks. Premature babies have a marked lack of protective factors. Their immune system functions poorly: immunoglobulins and lymphocytes are almost not produced.
In the first weeks of life, the baby is defenseless against pathogenic microorganisms, while there is a tendency to generalize infectious processes. Vaccination of children is carried out according to a special schedule starting from 6 or 12 months.
In children born prematurely, a prolonged course of jaundice, increased intracranial pressure, and motor disorders are often observed. In addition, the risk of cerebral palsy, epilepsy and developmental delay is high.
Dynamics masses body
Weight loss occurs in all children after birth, but in full-term babies it is 5-8% of the initial weight, and in premature babies it is 5-15%. The subsequent dynamics depends on the general condition of the body and living conditions. Approximate rates:
- the initial weight is restored for 2-4 weeks of life, weight gain in the first month - 100-300 g;
- by 2-3 months, the mass doubles, and by 12 - increases by 4-8 times;
- growth during the first year of life becomes more by 27-38 cm, then 2-3 cm is added every month.
Specificity behavior
The degree of activity of the baby depends on the maturity of his body. If the baby was born before 28 weeks, then he sleeps most of the day. When touched, he may wake up and begin to move, grimace, but after a few minutes he falls asleep again. In the first degree of prematurity, the child is able to wake up on his own and stay awake for a longer time, as well as scream clearly and loudly.
In the first months of life, children cry a lot and are easily excited under the influence of stimuli, it is difficult for them to calm down. Hypo- or hypertonicity of the muscles is often observed.
The pace of neuropsychic development of premature babies is slowed down: later they begin to sit down, crawl, walk, talk. In the absence of serious pathologies, they "catch up" with their peers by 18-24 months. But fatigue and emotional instability may persist.
nursing
The process of nursing a premature baby can be divided into two stages: stay in the hospital and at home.
Hospital
Neonatologists are responsible for nursing babies. Immediately after birth, the child enters the intensive care unit or intensive care unit. If he cannot breathe on his own, he is put on a ventilator and injected with surfactant to open his lungs. Oxygenation can be performed, as well as the introduction of fluids and medications through catheters. Constant monitoring of vital signs is carried out.
The baby is placed in an incubator (incubator), where the air temperature is 33-35 ° and humidity is 70-95%. Indicators are selected individually depending on the degree of prematurity. As the condition improves, they decrease. Air parameters in the ward: temperature - 25°, humidity - 55-60%. The baby loses heat very easily. When changing clothes, heated changing tables and warm diapers are used. In the incubator, the child can spend from 3-4 days to 7-8 weeks.
In the process of nursing, it is very important to create the most favorable environment, minimizing stressful and traumatic factors, since premature babies are very sensitive. They react violently to any stimulus by several body systems at once, which negatively affects their condition. Main directions:
- noise reduction;
- protection from intense light sources;
- careful conduct of all medical procedures;
- tactile contact with the mother, if possible - laying on the chest, touching, stroking;
- soft swaddling, simulating being in the uterus;
- periodic change in body position to prevent bone deformities and abnormal muscle tone.
The period of stay in the hospital, as a rule, is equal to the period that the baby did not have enough for the full completion of intrauterine development.
House
Basic conditions for discharge of a child:
- the possibility of self-sucking;
- the ability to maintain body temperature;
- weight more than 2 kg and constant weight gain;
- healing of the umbilical wound;
- compliance with blood counts.
A premature baby needs careful handling, but do not be too zealous: be afraid to touch him and wrap him up carefully. It is better to practice loose swaddling so that the baby can move his arms and legs. Warm and heavy blankets are not needed, it is better to use lightweight textiles.
It has been scientifically proven that if you wear a premature baby in a sling, then he quickly adapts to new conditions.
The optimum air temperature in the room where the child is located is 25 °. Do not leave him naked for longer than 3-4 minutes. Gradually, the duration of air baths can be increased to 10-12 minutes, spending them 3-4 times a day.
The water environment is ideal for the baby. It needs to be bathed every day, especially if there is diaper rash. In the first weeks, the desired water temperature is 36-37 °. Then it can be gradually reduced to 32 °. This will encourage hardening.
Very useful massage for children. In the first weeks, this may be a slight stroking of the abdomen. When the baby's weight reaches 3 kg, you can move on to a general massage, adding elements of gymnastics to it. Sessions should be conducted by an experienced specialist.
Walking is allowed provided that the weight of the crumbs is more than 2.1 kg. The duration of the first promenade is 5-10 minutes. Then the duration can be increased to 30-40 minutes 2-3 times a day. In bad weather, it is worth "walking" on the balcony by opening the window. It is important to properly dress the baby so that he does not overheat and does not freeze.
Monthly with the baby it is necessary to go to the pediatrician. During the first year, 2-3 times you need to visit an orthopedist, surgeon, ENT, ophthalmologist. The child's neuropathologist should be shown every 3 months. It is very important to visit doctors in a timely manner in order to detect the slightest deviations at the initial stage.
Nutrition
Proper nutrition is a key point in nursing premature babies. If the baby does not have swallowing and sucking reflexes, he is fed through a tube. In some cases, these automatisms are present, but there are problems with coordination of movements. The way out of the situation is feeding from a syringe without a needle, bottle or spoon. Children weighing 1.8-2 kg are applied to the mother's breast, which are able to actively suck. In any case, in the first days, saline, glucose and vitamins (K, C, E, group B) are administered intravenously to babies. Nutrient solutions may also be given.
The ideal food for premature babies is mother's milk. If direct attachment to the breast is not possible, then the woman should express herself. In case of shortage or absence of milk, special mixtures with an increased level of protein and increased energy value are used. Almost every baby food manufacturer has products designed for premature babies. It is necessary to buy the mixture on the recommendation of a doctor.
After discharge from the hospital, it is advisable to purchase an electronic scale and clearly monitor the amount of milk / formula eaten at each feeding, as well as the dynamics of the baby's weight. Children quickly get tired of sucking, it is worth giving them the opportunity to rest. They should be applied to the chest on demand. With artificial feeding, it is necessary to maintain intervals of 3 hours. The input of complementary foods is carried out according to an individual scheme.
The first months of the life of a child born prematurely is a difficult period for his parents. At this time, it is extremely important to trust the professionalism of doctors, as well as give your baby your love by talking to him and touching him. Modern technologies allow to nurse very premature babies. Up to 2-3 years, they may lag behind their peers in development, but over time, all problems are smoothed out. The main thing is to take care of the child and pay maximum attention to his needs.
According to the recommendations of the World Health Organization, a premature baby is considered who was born between 22 and 37 completed weeks(154-259 full days, counting from the first day of the last menstruation) regardless of body weight and height at birth.
Specialists divide all prematurely born children into several groups depending on the gestational age at the time of their birth (gestational age, or gestational age of the fetus).
- late premature baby - a baby born between 34 and 36 weeks of pregnancy;
- moderately premature - in the period from 32 to 34 weeks of pregnancy;
- deeply premature - up to 32 weeks of gestation;
- extremely, or extremely premature - up to 28 weeks.
It is important for doctors to know the gestational age at the time of the birth of the baby, as this allows them to anticipate the occurrence of many problems and ensure adequate medical care for both the woman and the child.
Also, premature and underweight babies are divided into several groups depending on body weight at birth. A small child is considered to be of any gestational age, whose birth weight was less than 2500 g. This category includes the vast majority of premature babies. Depending on the weight at birth, newborns are distinguished:
- with normal weight 2500-3999 g
- with low weight<2500 г
- with very low weight<1500 г
- extremely low birth weight infants<1000 г
The gestational age of a newborn child can be determined using an appropriate scoring system, taking into account the total assessment of neuromuscular and physical maturity. To date, the most commonly used scale is Ballard (Ballard scale, JL Ballard, 1991), which allows you to determine the gestational age of the child in the range from 20 to 44 weeks.
Using this scale, the period of intrauterine development of a newborn can be determined with an accuracy of up to 2 weeks. When establishing the degree of maturity, the gestational age at which the birth occurred is necessarily taken into account. Assessment on the Ballard scale is carried out immediately after the stabilization of the child's condition.
In addition to determining the gestational age, it is also important for doctors to assess the intrauterine development of the baby. Indeed, even with a full-term pregnancy, it happens that the growth and development of a newborn child at the time of his birth lags behind the gestational age. In order to assess the intrauterine development of a child, it is necessary to compare the anthropometric indicators of the child at birth (body weight, body length and head circumference) with the corresponding standards for his gestational age according to the percentile curves of intrauterine development.
The following tables show the mean birth weight, length, and head circumference of preterm infants at different gestational periods for each gender.
|
Weight, length and head circumference by gestational age for boys |
||||
|
Gestational age |
Length |
Head circumference |
||
|
40 weeks |
3.6 kg |
51 cm |
35 cm |
|
|
35 weeks |
2.5 kg |
46 cm |
32 cm |
|
|
32 weeks |
1.8 kg |
42 cm |
29.5 cm |
|
|
28 weeks |
1.1 kg |
36.5 cm |
26 cm |
|
|
24 weeks |
0.65 kg |
31 cm |
22 cm |
|
|
Weight, length and head circumference by gestational age forgirls |
||||
|
Gestational age |
Length |
Head circumference |
||
|
40 weeks |
3.4 kg |
51 cm |
35 cm |
|
|
35 weeks |
2.4 kg |
45 cm |
31.5 cm |
|
|
32 weeks |
1.7 kg |
42 cm |
29 cm |
|
|
28 weeks |
1.0 kg |
36 cm |
25 cm |
|
|
24 weeks |
0.6 kg |
32 cm |
21 cm |
|
All premature babies have a characteristic appearance that indicates their immaturity:
disproportionate physique;
- the cerebral skull predominates over the facial, the bones of the skull are soft, pliable, the small and lateral fontanelles are not closed;
- the skin is covered with a cheese-like lubricant, the subcutaneous fat layer is thinned, vellus hair on the body (lanugo), short hair on the head;
- soft ear and nasal cartilages, nails do not go beyond the fingertips, the umbilical ring is located closer to the pubis, in boys the testicles are not lowered into the scrotum, in girls the clitoris and labia minora are not covered by large ones;
- muscle tone and motor activity are reduced;
- a prematurely born child is usually drowsy, lethargic, weakly screams; movements are uncoordinated, chaotic;
- in very premature babies (gestational age less than 32 weeks), physiological reflexes are absent or weakly expressed.
The lower the gestational age of the child and his body weight at birth, the more vulnerable he is and the more effort on the part of medical professionals and parents is necessary for nursing him. For example, in children born between the 32nd and 36th weeks of pregnancy rarely have serious problems, and only in exceptional cases they may need short-term respiratory support in the form of mechanical ventilation. However, these babies may have problems maintaining temperature and feeding. Very often they need additional warming, for which they are placed in an incubator or heated bed. It is also difficult for them to breastfeed on their own and they need to be supplemented with expressed breast milk through a tube or in an alternative way (using a syringe without a needle, a spoon, a cup). The optimal method of warming and nursing for such children is the "mom-kangaroo" method. Nevertheless, despite the immaturity of organs and systems, the chance to survive and grow and develop safely in the future in this category of children is quite high.
Children, born at 23-25 weeks, have a lower survival rate - 25-75%, depending on the gestational age and concomitant conditions. Also, due to severe immaturity, most of these children in the future have a high risk of developmental disorders (weak muscle tone, movement disorders, hearing and vision loss, learning and behavioral problems).
Modern methods of emergency care and nursing of premature babies, born between 26 and 28 weeks of gestation, allow most children to save lives, but they have a higher risk of developing disability than children of older gestational age.
In children born between 28 and 32 weeks, due to lung immaturity, will have more severe problems with spontaneous breathing and are more likely to need assisted ventilation (CPAP) or mechanical ventilation. Also, this category of children is more likely to have other problems associated with immaturity: they are more vulnerable to infection, cerebrovascular accident, hemorrhage, nonspecific enterocolitis (NEC), development of vision problems (retinopathy). Nursing them requires more time, effort, patience and resources. However, with the current level of neonatal care, the chance of survival for such children is quite high - 95-98%. And many of these children grow up absolutely healthy in the future.
