The Premature Baby Notes

The Premature Baby

Premature = baby born before 37 weeks

• Premature babies viable from 23-24 weeks gestation

  • Mortality is high (10% survive at 23 weeks 25% at 24 weeks)

  • 25% of those who survive have a major disability

  • >32 weeks prognosis is excellent

Complications of prematurity

• Brain

  • Intraventricular haemorrhage

  • Post haemorrhagic hydrocephalus

  • Periventricular leucomalacia

  • Increased risk of cerebral palsy

• Eyes

  • Retinopathy of prematurity

• Temperature control

  • Increased surface are to volume ration = loss of heat

  • Immature skin can’t retain heat and fluid efficiently

  • Less subcutaneous fat = less insulation

• Respiratory

  • Respiratory distress of the newborn (surfactant deficiency)

  • Apnoea + bradycardia

  • Pneumothorax

  • Chronic lung disease

• Cardiovascular

  • Hypotension

  • PDA

• GI

  • Necrotising enterocolitis

  • Reflux

  • Inguinal hernias (high risk of strangulation)

• Metabolic

  • Hypoglycaemia common

    • Must be treated promptly if symptomatic

    • Maintain blood sugar at >2.6mmol/L to prevent neurological damage

  • Hypocalcaemia

  • Electrolyte imbalance

  • Osteopenia of prematurity (Joulies phosphate) – risk of fractures

• Infection

  • Increased risk of sepsis esp. group B strep + coliforms

  • Pneumonia common

  • Infection in lines e.g central venous lines

• Blood

  • Anaemia of prematurity

  • Neonatal jaundice

Respiratory Distress Syndrome

• Causes of respiratory distress

  • Pneumonia

  • Pneumothorax

  • Meconium aspiration

  • Cardiac failure

  • Diaphragmatic hernia

  • CCAM

Signs of RDS

• Tachypnoea

• Intercostal + sternal recession

• Cyanosis

• Expiratory grunting

Investigations

• Diagnosis confirmed by CXR

• Shows ground glass appearance due to alveolar collapse

Management

• Corticosteroids given antenatally to mothers at risk of pre-term delivery can prevent RDS by stimulating surfactant production

• O2 + supporting respiration

  • CPAP

  • ET tube and mechanical ventilation

• Exogenous surfactant can be delivered via ET tube

  • Has decreased mortality of RDS by 40%

• Some babies with RDS develop chronic lung disease of prematurity (broncho-pulmonary dysplasia) and may require long term O2 treatment at home

Necrotising Enterocolitis

• Relatively rare by serious complication of prematurity

• Bowel mucosal ischaemia allows gut micro-organisms to penetrate bowel wall causing severe haemorrhagic colitis

• Establishing full milk feeding too rapidly is a risk factor for NEC as is the presence of congenital heart disease (hypoxia)

Clinical features

• Acute collapse,

• Abdominal distension

• Bile stained vomit

• Bloody diarrhoea

Investigations

• AXR – gas in bowel wall or portal tract

Management

• Stop milk feeds

• Support circulation

• Antibiotics

Surgical – laparotomy required if perforation occurs

- Complications = intestinal strictures + short gut syndrome

Brain Injury

• Pre-term infants especially susceptible to brain injury

• Most important factor in prognosis

• Term babies are also at risk of developing hypoxic-ischaemic encephalopathy (HIE) after an asphyxia insult

Intraventricular haemorrhage

• Occurs in up to 40% of VLBW infants

• Haemorrhage develops in the floor of lateral ventricle and ruptures into the ventricle

  • In 25% of cases the haemorrhage involves the white matter around the ventricle by obstructive venous infarction

  • Carries a high risk of hemiplegic cerebral palsy

  • May be asymptomatic

  • Usually diagnosed by cerebral USS

  • Prognosis depends on extent of IVH + occurance of complications

Post Haemorrhagic Hydrocephalus

• Occurs in...

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