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Clinical Reference Systems: Pediatric Advisor 10.0
Care of the Very Small Premature Infant
DESCRIPTION
Very small premature babies weigh less than 3 pounds
(1500 grams) and are usually born more than 8 weeks early
(after less than 32 weeks of gestation). These babies:
- have very red, thin skin and very little fat
- have perfectly formed internal and external organs
- have organs that, though perfectly formed, are not mature
enough to function well for several weeks
- need special care in the hospital for at least 3 to
4 weeks and often much longer until they are mature
enough to be cared for at home.
Very premature babies may need to be cared for in the
hospital until close to their due dates. If they have a
smooth course in the hospital (not many setbacks), they may
be discharged as early as 4 to 5 weeks before their due
date. If they have more problems than average, they may
stay in the hospital past their due date.
This handout describes the causes of prematurity, the
hospital's special care nursery, the medical problems a
premature baby may have, and how the baby may be fed. It
also covers when the baby may go home and the special
attention the baby may need during the first year after
birth.
CAUSE
There are many causes of extreme prematurity. Sometimes a
baby may need to be delivered early because the pregnancy is
causing a health problem for the mother. Sometimes there is
an infection in the birth canal that causes early rupture of
the membranes (breaking of the bag of water) or preterm
labor. Abnormalities of the mother's cervix or uterus can
also cause early delivery. Twins are often born early.
There are many treatments for preterm labor to lengthen the
pregnancy. There are also preterm prevention programs,
which identify mothers at high risk and help to prevent
preterm delivery. Medical care during pregnancy (prenatal
care) is very important in helping to prevent babies from
being born too early.
SPECIAL CARE NURSERY (SCN)
- Environment
The special care nursery (SCN) seems to be a noisy and
confusing place when you first enter it. However, with
time you become used to it. The staff in the SCN try to
make your baby as comfortable and secure as possible.
At first the baby is kept on an open warmer, a bed that
keeps the baby warm by heating the surrounding air.
Open warmers are used for babies who have just been born
or need a lot of care so that they can be reached and
cared for more easily.
Once the baby's breathing rate is OK, the baby is placed
in an Isolette. The Isolette is a plastic box with
controlled air temperature to keep the baby warm.
Babies grow fastest if they are kept warm. When it is
easier for a baby to maintain his own temperature and
the baby weighs about 4 pounds (1800 grams), he is
placed in an open crib.
- Monitors
All babies are attached to a heart and respiratory
monitor while they are in the SCN. These monitors sound
an alarm if there is a significant change in the baby's
heart or breathing rate. This alerts the staff to
immediately check the infant. The baby is also attached
to a pulse oximeter, which records the oxygen level in
the baby's skin. In addition, there are temperature
alarms for the warming beds and Isolettes.
- Personnel
Many people will help care for your baby during her stay
in the SCN.
The neonatologist is a pediatrician who has special
training in the care of premature infants. The
neonatologist directs the overall care of the baby.
Nurse practitioners and physician assistants help the
neonatologist oversee the baby's progress.
Nurses deliver most of the hands-on care during each
shift. A very sick baby may have one nurse devoted
solely to her care. More stable babies may share a
nurse with one or two other babies.
The respiratory therapist oversees the breathing needs
of babies who need oxygen or are on ventilators.
The social worker helps families deal with the emotional
stress of having a sick baby.
The occupational therapist evaluates the infant's
developmental progress and plans a developmental program
for your child.
All of these people will be happy to talk with you at
any time about your baby.
- Nursery course
Because your baby is so small and premature, your baby
will be cared for in the SCN for many weeks. Many
premature infants are sickest right after birth and
gradually get better as they get older. However, the
very smallest infants may have a very rocky course for
the first 6 weeks. Many families find that the
experience is like riding a roller coaster. Some days
they are elated with the baby's progress, only to be
disappointed the next day when things are not going very
well. These ups and downs are a normal part of a
premature baby's early life, but they are very hard on
mom and dad.
- Visiting
The SCN staff welcome parents and families to visit
their babies as often as possible because the family's
presence is very important for the baby's growth and
recovery. Sometimes the baby is so sick at first that
you may not be able to hold him until he is better.
However, touching, holding his hand, talking, and
watching are always welcome. The nurse will be your
best guide as to how much stimulation your baby can take
at one time. The older and more mature your baby is,
the more you will be able to handle and care for him.
Phone calls are a good way to keep in touch with the
nursery staff and are welcome at any time, day or night.
EXPECTED PROBLEMS
There are many problems that a preterm baby faces during the
first weeks. The nursery staff expect these problems to
occur and watch for them. Most problems of prematurity
improve as the baby grows.
- Respiratory problems
- Respiratory distress syndrome (RDS)
Many babies born prematurely have not yet started
making surfactant. Surfactant is a substance that
helps keep the lungs open when we breathe. Babies
who have RDS need oxygen and need help with their
breathing until the lungs make surfactant. A
ventilator is used for 5 to 7 days to help the baby
breathe. The baby is given artificial surfactant to
to help him breathe until the lungs make their own
surfactant.
- Apnea
Apnea means "forgetting to breathe" and every small
premature baby has some apnea. Apnea occurs because
the brain is still immature. It improves as the
brain matures. In the meantime the baby is given
help to keep breathing. Medication (for example,
aminophylline or caffeine) is given to stimulate
breathing efforts. Sometimes the baby is placed on a
respirator, which breathes for her until she is able
to breathe more reliably. Babies who are born
12 weeks or more prematurely may not breathe reliably
for several weeks.
- Chronic lung disease
Many very preterm babies develop chronic lung
problems. These lung problems result from the
underdevelopment of the lungs and inflammation of the
lungs caused by RDS, oxygen, and respirators. These
babies may need extra oxygen for weeks to months.
Sometimes a baby's lungs fill with extra fluid. If
this happens the baby is given diuretics, a medicine
that makes the baby urinate more and get rid of extra
water. Occasionally the baby is given steroids in
low doses to help reduce inflammation.
Most children outgrow these lung problems during the
first several months of life. Some children may
continue to have a tendency for wheezing and
infections, but this usually improves with each
passing year.
- Feedings
Getting the baby to grow is the single most important
thing to be done to help him outgrow the problems of
prematurity. This means feedings are very important.
At first the baby may be too weak or have too much
trouble breathing to nurse or feed from a bottle.
However, there are ways the baby can get fluids and
calories for growth without nursing. Later, when he is
stronger, he can nurse.
- Intravenous fluids (IVs)
Your baby will be given intravenous fluids (IVs)
immediately after birth. This IV fluid contains
sugar to give the baby energy. When a baby has
serious breathing problems, he is not well enough to
begin feedings right away.
All babies lose weight during the first days of life
because their bodies get rid of extra water. Once
the baby is given food (either by IV or milk
feedings), he will begin to gain weight slowly. The
smallest babies may take several weeks to regain
their birth weight.
- Hyperalimentation
After several days, if milk feedings cannot be
started, your baby will begin receiving
hyperalimentation fluids. These are fluids given
intravenously (IV). They contain sugar, protein,
minerals, and fats. These fluids will give your baby
calories to start growing.
Very small premature babies often need several weeks
of hyperalimentation before they are ready to begin
milk feedings. These very small babies may need a
central line for hyperalimentation. A central line
is an IV line that is placed in a central vein in the
body--for example, in the neck or groin. With it the
baby can be given higher concentrations of sugar and
calories.
- Milk feedings
Feeding methods: When the baby is ready, milk
feedings are begun. All babies of this size are too
small and weak to suck on the breast or bottle.
Several methods of tube feeding allow dripping the
milk into the stomach or intestine without stressing
the baby. Gavage feedings involve passing a tube
through the mouth or nose and into the stomach. Milk
is dripped in by gravity. Because most small
premature babies are fed every 3 hours, the tube may
be taped in place so that it does not have to be put
into the stomach each time the baby is fed. Very
small babies may be fed small amounts continuously so
the stomach is never overfilled. A feeding tube that
passes through the nose and the stomach and into the
intestine is called a nasojejunal tube. It allows
milk to be fed directly into the intestine and avoids
filling the stomach.
Kinds of milk: Several kinds of milk may be used to
feed your premature baby. Some nurseries encourage
mothers to pump their breasts so breast milk is
available for their babies. Breast milk is easily
digested by the baby and contains factors that may
protect against infection. Other nurseries use
formulas that have been especially designed for
premature babies or formulas that are very easily
digested. Your baby's physician will talk with you
about which kind of milk he or she thinks is best for
your baby.
Feeding by breast or bottle: Premature babies are
not able to suck and swallow until they reach a
gestational age of 32 weeks. When a baby becomes big
and strong enough and has developed a strong,
coordinated suck, bottle- and breast-feedings are
possible. At first the baby will tire quickly and
may not take very much of the feeding. With time the
baby will learn to feed well from a nipple.
- Feeding intolerance
The premature baby's intestinal tract often doesn't
work very well at first. The baby's stomach may
empty very slowly, and it may be hard for the infant
to pass bowel movements. The baby may vomit often
because of looseness of the valve between the stomach
and esophagus (gastroesophageal reflux). It is easy
for the baby to get distended (the bowel gets filled
with gas). These are all signs that the intestinal
tract is immature.
The amount of milk a baby is fed is usually increased
very slowly. It is important to make sure that the
baby can manage each increase well. There may be
many starts and stops in the feeding process. The
baby's intestinal function improves as she gets
older. It may be several weeks before the very
smallest infants can take full milk feedings.
- Necrotizing enterocolitis (NEC)
Necrotizing enterocolitis is a serious intestinal
infection, which some premature babies get. When a baby
gets necrotizing enterocolitis, the feedings don't pass
through the intestine well and there is blood in the
bowel movements. If this infection is suspected, x-rays
are taken of the baby's intestines, feedings are
stopped, and the baby is given antibiotics. If the baby
does have necrotizing enterocolitis, antibiotics are
continued and the baby is not fed for 7 to 10 days.
Sometimes surgery is necessary if the intestines are
seriously affected by the infections. Once the baby has
begun to recover from the infection and possibly
surgery, he will be fed with IV hyperalimentation fluids
until he is ready to start milk feedings again.
- Infection
Premature babies cannot protect themselves against
infections very well because their defenses are weak.
The early signs of infection can be very subtle, but
once infected, the baby can get sick very quickly. For
this reason your physician will look closely for signs
of infection whenever there is an important change in
the baby's behavior and will treat with antibiotics very
readily. Examples of such changes include increasing
apnea spells, other changes in breathing behavior, and
poor digestion of feedings. Your baby may have several
courses of antibiotics during his hospital stay.
- Intraventricular hemorrhage (IVH)
Very premature infants are at risk for bleeding in the
brain (intraventricular hemorrhage). Several
ultrasounds of your baby's head during the first week
will be used to look for any sign of bleeding. If
bleeding occurs, your physician will continue to follow
for any sign of complications with ultrasound.
- Retinopathy of prematurity (ROP)
While inside the mother, the baby lives in a low-oxygen,
dark place: the uterus. After birth, the baby is
exposed to more oxygen and light. The eye responds to
these changes by growing extra blood vessels. This
process is called retinopathy of prematurity. The
younger the baby is, the more sensitive the retina (back
of the eye) is. Every baby who is born at a gestational
age less than 28 weeks will have some retinopathy. This
blood vessel growth begins around 6 weeks after birth
and usually increases until 10 to 12 weeks after birth.
Then the blood vessels begin to go away.
If the blood vessels grow too much, there can be pulling
on the retina, which may cause the retina to separate
from the back of the eye. In its worst form,
retinopathy can cause severe problems with vision or
even blindness.
Every baby born more than 8 weeks early will be examined
by an ophthalmologist (eye specialist). The first exam
will be 6 weeks after birth. The exams will continue
until the blood vessels have gone away. If the blood
vessel growth starts to cause problems, treatment with a
laser or freezing (cryosurgery) can be performed to
prevent separation of the retina from the back of the
eye.
- Anemia
Every preterm baby becomes anemic (has too few red blood
cells) during the first 2 months of life. The baby
loses blood from frequent blood tests and when her red
blood cells get old. She cannot make new blood to
replace the lost blood until 2 months after birth. Most
babies who are sick and need frequent blood tests, or
who weigh less than 3 pounds (1500 grams) at birth, will
need a blood transfusion to keep the blood count normal.
Your physician will talk to you about the need and
reason for transfusion when the time comes and about the
risks and benefits of transfusion.
Preterm babies are given extra iron in their diet so
when their bodies can make blood, they have plenty of
iron for making new red blood cells.
GOING HOME
Each baby recovers and grows at a different rate so it is
hard to have a firm rule for when a baby can leave the
hospital. Generally we can say, however, that a baby is
ready to go home when he can keep his temperature in an open
crib, take all his feedings from the bottle or breast, and
has been free of apnea spells for a week. Sometimes it
seems that the baby will never be ready to go home, and then
suddenly you are told that he will be ready in a day or so.
If you need to have special equipment at home, the SCN staff
will help you arrange for it. The nurses and physicians
will teach you everything you need to know about caring for
your baby at home.
If you visit your baby frequently in the hospital, you will
learn how to feed and care for your baby long before he is
ready to go home. It is very important for your
pediatrician to see your baby often after discharge from the
hospital. Someone in the SCN will make sure that you have
an appointment with a pediatrician after discharge.
LONG-TERM OUTCOME
Most very premature babies grow up to be normal, healthy
children. However, low-birth-weight babies are at greater
risk for developmental problems than babies that are not
premature. Premature babies also may require special
medical attention during their first year of life.
- Pediatric follow-up
Premature babies need to see their pediatrician often
after they leave the hospital. The pediatrician needs
to make sure that they are gaining weight well. It is
also very important that they receive their childhood
immunizations to protect them against infection.
Premature babies with chronic lung problems may need to
be examined often to be sure that they do not have
problems with wheezing or lung infections. It is not
uncommon for these babies to go back to the hospital if
they get a bad cold that causes wheezing and trouble
with breathing. It is less likely after the first year.
Visits to the pediatrician will become less frequent as
your baby gets older and healthier.
- Neurodevelopmental follow-up
A very small premature baby should be examined at a
special clinic that follows the baby's growth and
progress. If a child shows signs of developmental
problems, special education or therapy programs may help
the child's development.
- Vision and hearing
All very small premature babies should have their eyes
examined for retinopathy. They should also have vision
exams regularly. Children who were premature may be at
increased risk for eye muscle problems and may need
glasses.
All premature babies should have their hearing tested at
least once during their first year to make sure they do
not have hearing problems.
- Care at home
Once home, your baby will still need special care, such
as more frequent feedings. However, you will see that
she quickly begins to grow and become very healthy and
strong. This will reassure you that your baby is
recovering and will be normal.
As is true for all babies, do not expose your baby
unnecessarily to children or adults with colds or the
flu. Babies with chronic lung disease may be very
susceptible to upper respiratory infections. For this
reason taking your child to a group day-care home or
center may not be advisable in the first year.
As your baby grows you can treat him more and more like
a normal infant. Try not to be overprotective as she
becomes increasingly independent and adventurous. Your
pediatrician will be able to guide you as your baby
grows and thrives.
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