Dnipropetrovsk Medical Institute of
Conventional and Alternative Medicine
preterm baby –maturity, physical and
physiological characteristics.
Principles of raising a prematurity
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Why Prematurity is an Important Public Health Issue
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Public Health focuses on promoting health
and preventing disease
Primary Prevention
Secondary Prevention
Tertiary Prevention
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Primary Prevention
Decreasing the Rate of Preterm Births
Determining the Factors that Impact Preterm Birth
Social
Biologic
Environmental
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At Risk Populations
Low income women
Women of color
Women younger than 20 and older than 40
Women who were born preterm
Women with a history of previous preterm delivery
Women with multiple pregnancy
Women with uterine/cervical abnormalities
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Other Risk Factors
Smoking, use of alcohol, other substance use
Infection
Stress
Trauma
Unintended pregnancy
Chronic health conditions like diabetes or high blood
pressure
In-vitro conception
History of repeated miscarriages or spontaneous abortions
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Despite a good understanding of risks, there has
been little reduction in the rate of prematurity in
the US
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Secondary Prevention
Improving the Outcome of Premature Infants
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Preterm infants are
at higher risk for
poor health
outcomes than
infants born at
term
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Increased Mortality
Preterm birth and low birth weight are the leading cause
of death in infants younger than one year.
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Infants born before 34 weeks are at greatest risk of
death and long term morbidities
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Increased Morbidity
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Respiratory distress and long term respiratory issues; asthma
Delayed brain development/developmental delay
Cerebral palsy
Epilepsy
Cognitive delay
SIDS/SUIDS
Feeding problems
NICU admission and re-hospitalization
Vision and hearing problems
Autism
Behavior and learning problems
Depression, anxiety, and other mental health issues
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Late Preterm Infants
Mortality
Late preterm infants (34-37) weeks are 6 X more likely to
die in the first week of life and 3X more likely to die in
the first year
Prematurity
Late Preterm Infants
Morbidity
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Respiratory distress
Hypothermia
Sepsis
Hypoglycemia
Inadequate feeding/dehydration
Hyperbilirubinemia
Growth and developmental issues
Immature brain
Prematurity
The fetal brain at 34 weeks weighs only about 65% of
that of a full term infant brain
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The Costs of Prematurity
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Physical/Medical
Developmental
Emotional
Financial
Psychosocial
Educational
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Costs
According to the Institute of Medicine
The annual costs to society are $26.2 billion dollars
$51,600 per infant
$49,033 to employer
The costs are 11 X greater than those of a normal
newborn
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The average 1st year costs for a preterm infant are 10X
than that of a term infant
($32,325 vs $3,235)
The average hospital stay is 9 X longer if the infant is
born preterm
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What is the Role of the Public Health Nurse?
 Improve the health and developmental outcomes of
the premature infant by identifying the physical,
developmental and social/emotional risks
 Implement nursing interventions to reduce the risks
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 Reduce costs
 Reduce disparities
The differences in the rates of disease; incidence,
prevalence, morbidity, mortality, or survival rates in
one population compared to the health of the general
population.
The CaCoon Nurse’s Role in Providing
Services to Preterm Infants
Screening
Assessment
Education/Information
Case Management
Care Coordination
Support/Advocacy
Monitoring
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What skills do you need to provide services to
premature infants and their families?
 Know how to adjust for prematurity
 An understanding of the growth and development of the
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pre-term infant
Understand common medical issues and treatments
Understanding of normal vs abnormal course
Understand infant states, cues, and behaviors
Knowledge of community resources
Ability to provide family centered approach to care
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Adjusting for Prematurity
Determine gestational age in weeks
Subtract the gestational age from 40 weeks
Subtract the weeks of prematurity from the chronological age
Example: JA was born at 32 weeks gestation. Subtract 40-32= 8 weeks
premature
Today JA is 12 weeks old chronologically
12 weeks (actual age) -8 weeks = 4 weeks adjusted age
Adjustment for prematurity should be done until at least 24 months of
age
Terminology
 Low birth weight < 2.5 kg
 Very Low Birth Weight < 1.5 kg
 Extremely Low birth Weight < 1.0 kg
 Premature < 37 weeks
 Immature < 28 weeks
 ELGAN: Extremely Low Gestational Age
Newborn < 26 weeks
 Small for gestational age < 2.5 percentile
infant's maturation
Physiological characteristics of
premature neonates cont….
Central nervous system:
immaturity of central nervous system
Poor cough reflex
Uncoordinated sucking and swallowing
Intra ventricular and periventricular hemorrhage
Respiratory system :
Resuscitation difficulties at birth(respiratory distress)
Hyaline membrane disease due to under developed lungs
Breathing is periodic(apnea) and associated with intercostal
recessions due to soft ribs
Pulmonary aspiration(low O2 saturation)
Cont…
Thermo-regulation:
 inability to regulate body temperature
Excess heat loss due to reduced fat layers
There can be cooling or overheating(hypo- and
hyperthermia)
Cardio vascular system :
Under developed heart due to delayed closure of
ductus arteriosus is among preterm infants
Preterm is defined as babies born alive before 37 weeks of
pregnancy are completed.
Epidemiology and causes of
preterm birth
 ƒLabour induction or C/S for maternal or fetal
indications (30‐35%)
 ƒSpontaneous preterm labour with intact membranes
(40‐45%)
 ƒPreterm premature rupture of membranes (PPROM)
(25‐30%) ƒPreterm birth causes one‐third of all infant
deaths
Risk factors for premature birth
Certain medical conditions during pregnancy , such as:
 Infections eg. uterine or cervical abnormalities
 High blood pressure
 Diabetes , alcoholic or smoking
 Obesity or Being underweight before pregnancy
 Short time period between pregnancies (less than 18
months)
 Birth defects in the baby
 Multiple pregnancies: triplets , twins etc
General problems in premature infants
 Feeding: (IV – Gavage)
 Temperature control: (incubator-heated bed)
 Respiratory control: apneas, Respiratory
support CPAP, Artificial ventilation
 Immature lungs – lack of surfactant: Oxygen
suppl, Respiratory support (CPAP, ventilator)
 Immature brain: brain hemorrhage and cysts
 Immunology: risk of infections (antibiotics)
 Organ injury (Brain, Eye, Lung, Intestine, Skin
 Long term consequences
Survival
1940: 50% with BW1500 gram survive
2000: 50% with BW 600 gram survive
Birth weight % Survival after 1 year
350-499 g
14
500-799 g
47
750-999 g
76_______________
Medical Birth Registry 1992-96
Survival
Gestational age weeks
21
22
23
24
25
26
NFR’s Consensus report 1999
Survival %
0-4
0-12
8-36
12-62
31-79
53-85
Sequels
From 1979 to 1994 survival among preterm infatns
with BW 501-800 gr increased from 20 to 59%.
The percentage of children with severe
neurosensory injury was however, unchanged
(O’Shea 1997)
Injury of ELGANs 1972-1990
< 26 uker < 800 gram
Mental retardation 14%
14%
Cerebral palsy
12%
8%
Blindness
8%
8%
Deafness
3%
3%
”Major disability”
22%
24%
Survival increased, however rate of injury was
constant
Lorents JM et al 1998, (meta-analysis including > 4000 children)
Injury of preterm infants
 Eye ( Retinopathy of prematurity ROP
Stage 1-5)
 Brain injury (Intracranial hemorrhage (grade
1-4) Periventricular leukomalacia PVL).
Immature capillaries (plexus Choroides),
hemodynamic changes, intrauterine
inflammation
 Pulmonary ( Bronchopulmonary dysplasia BPD, Chronic lung disease - CLD)
 Intestinal (necrotizing enterecolitis - NEC)
Development and pathogenesis of ROP
Impact of BPD, Brain Injury &
ROP on 18 m Outcome of ELBW
Infants
Overall probability of a
poor outcome @ 18 m
(35%)
“ A simple count of 3 common neonatal morbidities
strongly predicts the risk of later death or disability ”
Schmidt B et al. JAMA. March 2003;289:1121-
School problems
 A Dutch study showed that > 50% with BW < 1500 gram
needed extra support at school
 No relation between Gestational age and injury
 Preterm infants have to be followed-up at least till school
age because these problems have a late debut. Learning
problems picked up around 8 years
ADHD
Hyperactivity
Intellectual problems (arithmetics, solving problems, cognitive
functions)
Short term memory
Coordination problems
Behavioral problems (shy, sport performance, sosialise )
Boys> girs
Low Socioeconomic conditions
Future challenges
 Prevent preterm birth
 Understand relation between intrauterine
conditions and postnatal injury
 Improved nutrition
 Improved technology
 New drugs (antioxidants, anti inflammatory,
etc)
 New insight into the needs and the
psychological development
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Gross motor risks in early screening
Looking at more than milestones
Use the Infant Motor Screen
 Symmetry
 Presence or absence of reflexes
 Tone
 Protective responses
 Vestibular responses
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Interventions
Education/Information
Case Management
Care Coordination
Support
Monitoring
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Education and Information
Current development and what to expect next –normal progression of
development
Activities to foster development
Modifying activities based on infants needs, behaviors, and cues
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Case Management
Identify and remove barriers
Referrals to EI, SSI, OT/PT, Speech, Developmental
clinics or pediatricians
Community services
Infant massage, infant sign language, library
programs, swimming classes
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Care Coordination
Educational staff, medical, neurologist,
ophthalmologist, audiologist, developmental
disabilities
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Support
Family’s understanding of developmental issues
Family resources and strengths
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Social Emotional Development
Preterm infants are at significant risk for later
relationship issues. These risks are related to:
Maternal/family experience
Infant’s experience in the NICU
Financial impact
Infant cues and behaviors
Ongoing stress when infant transitions to the home
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Maternal Experience
Interrupted pregnancy leads to crisis birth
Crisis leads to anxiety and fear
May also experience feelings of guilt, grief or loss
Attachment behaviors are developed in a technical
environment that doesn’t foster nurturing
Infant is probably less socially responsive and harder
to soothe
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Maternal outcomes
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Depression
Disengagement
Symptoms similar to PTSD
Over-involved and protective
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Infant’s Experience
Immature brain and nervous system
NICU environment
Unusual stimulation and pain
Cues and behavior patterns may be difficult for caregiver to understand
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Infant Outcomes
Insecure attachment
Anxiety
Internalizing problems
Difficulty developing social relationships
Increased risk for abuse and neglect
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The longer the NICU
stay, the higher the
likelihood of issues
related to maternal
infant interaction
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Interverventions
Screening
ASQ-SE; screening for maternal depression; screening
for attachment issues
Assessment
Maternal infant interaction; parents knowledge of
cues, behaviors, infant state
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Education
Improve Parent
Understanding
 Cues
 Behaviors
 Infant states
 Temperament
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Variations in behavior, sleep states, and cues should
guide all parent interactions.
The parent’s role is to meet the infant’s needs. Parents
who are empathetic and responsive foster a sense of
trust which strengthens the infant’s attachment and
sense of security.
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Modifying the
Environment
Help the parent learn to
respond sensitively to the
infant’s ability to handle
various levels of light,
noise, and activity and
adjust the infant’s
environment as needed for
the infant
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Providing Appropriate Timing
Foster positive interactions by helping the parent learn
to adjust to the infant’s needs by pacing interactions
and avoiding activity that overwhelms the infant
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Maintaining and Ensuring Continuity and
Predictability
Support the parents in their efforts to maintain
consistency in the in infant’s routine and daily
activities.
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Supporting the Infant’s Attempts at Self Regulation
Help the parent learn to recognize the
infant’s fatigue levels.
Assist parent to develop skills that support and facilitates
the infant’s ability to calm itself.
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Supporting Movement and Positioning and
Providing Appropriate Support During All
Handling
Assist the parent to learn how to provide smooth, gentle,
slow handling, how to move in rhythm with the infant,
and how to effectively position the infant
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Supporting the Infant’s Management of Sleep Wake
Cycles
Teach normal sleep wake cycles and help the parent
develop positive behaviors that facilitate the infant’s
level of alertness, smooth state changes, engagement
opportunities, and opportunities for self-calming
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Case Management
Referral for maternal mental health support
Referral to programs that support positive
attachment-mother baby group
Infant mental heath programs ???
Referrals to services to reduce stressors
Financial referrals SSI/DD programs
Parenting support programs
Respite
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Care Coordination
Care conferences with other in home programs, services,
child care provider to
explore ways to foster and support attachment
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Support
Help family identify support systems
Assist family to find other community supportschurch, work, school
Empathy for the family’s situation/beliefs
Active listening to the parent
Activities to support attachment, ie, kangaroo care,
infant massage, breastfeeding
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Monitoring
Repeat screenings and assessments
Follow up with referrals
Skills building behaviors
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Nursing Systems ASSESSMENT
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Cardiovascular
Respiratory
Gastrointestinal
Elimination
Vision and Hearing
Neuromuscular
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Risk Assessment
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Feeding and Nutrition
Infection
Unintentional Injury
Intentional Injury
Exposure to toxins (second hand smoke)
Dental
Attachment and Bonding
Parenting
Coping
Basic Needs