Prematurity Edema of the subcutaneous tissue in premature babies is. Complementary foods for premature babies
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 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 graduation. normal term pregnancy.
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 birth defects development 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. Behind normal weight bodies 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
Appearance of premature babies features, which are directly dependent on the duration of pregnancy. The lower the gestational age, the more such signs and the more pronounced they are. Some of them can be used as additional tests for approximate definition 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 at birth wrinkled, loose skin characteristic of children with intrauterine malnutrition, and later observed in premature patients who, according to different reasons yes-whether a large loss of mass or have a flat weight curve.
- Disproportionate physique. At premature baby relatively large head and torso, short neck and legs, low position 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 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 mild form 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.
Unlike the weights average height boys with a birth weight of up to 1200 g at the age of one year was higher than in 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 in terms of body weight and height are compared with full-term peers, at 5-6 summer age, that is, during 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 psychomotor development catch up with their full-term peers, and by the age of 2 years, 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)
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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 Ilppyo: “ mental development premature babies in the first years of life is noticeably 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 small deviations in neuropsychic development.
According to S. Drillien, almost 30% of premature babies born weighing up to 2 kg have moderate or serious violations 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;
- behind last years Premature babies tend 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)
Premature babies: frequency and causes of preterm 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 37 completed weeks of pregnancy or earlier than 259 days 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, age of parents, 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 :
lack or insufficiency of 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, malnutrition 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;
infantilism of the genital organs, especially in combination with hormonal disorders (insufficiency corpus luteum, hypofunction of the ovaries, 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, an increase in the contractility of the uterus, the development of inflammatory processes(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 uteroplacental blood flow, degenerative changes in the placenta;
genital pathology;
pregnancy pathology: 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, fetal malformations, 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):
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Degrees of prematurity |
by gestation |
by body weightat birth |
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I degree |
35 weeks - incomplete 37 weeks (up to 259 days) |
2500−2000 grams |
low |
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II degree |
32-34 weeks |
1999−1500 grams |
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III degree |
deeply premature |
29-31 weeks |
1499−1000 grams− very low body weight |
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IV degree |
22-28 weeks |
999-500 grams extremely low mass (extremely low mass) |
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Extreme prematurity− gestational age less than 22 full weeks(154 full 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;
the auricles are soft, close to the skull;
nails often do not reach the fingertips, the 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;
frequency lability heart rate with a tendency to tachycardia (up to 200 per minute, on average - 140 - 160 beats / min);
the phenomenon of embryocardia (heart rhythm, characterized by pauses of equal duration between 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:
low 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.
A premature baby is a baby born less than 37 completed weeks of gestation, i.e. before day 260 of pregnancy.
Determining prematurity by weight and height alone is not entirely correct, especially when the length of the pregnancy is difficult to ascertain. This classification method is used to standardize treatment and observation, for the needs of statistics. There are children born with a large weight and height, but with obvious signs of immaturity, which is typical for premature babies. In practice, in addition, it is necessary to take into account a wider range of positions for assessing the actual age of the child.
Signs of prematurity: weak cry of the child, shallow, weakened irregular breathing, insufficient development of the subcutaneous fat layer, in connection with which the skin is red, dry, wrinkled, abundantly covered with fluff; the small and lateral fontanels are open, the auricles are soft and fit snugly to the head, > the nails do not reach the edge of the phalanges of the fingers, the umbilical cord is located below the middle of the body length, the genitals are underdeveloped - in boys, the testicles are not lowered into the scrotum, in girls, the labia minora are not covered large; movements are scanty, hypotonia (reduced tone) of the muscles, physiological reflexes are reduced, even sucking and swallowing reflexes may be absent.
Maturation of the sense organs in preterm infants.
Touch: The system of somatic sensitivity (senses of touch, temperature and pain) develops between 8 and 15 weeks of pregnancy. At 32 weeks of gestation, the fetus always reacts to changes in ambient temperature, touch and pain.
Taste: Taste buds are morphologically mature by the 13th week of pregnancy. At 24 weeks of pregnancy, the fetus already reacts to taste stimuli.
Hearing in the fetus appears at 20 weeks of gestation. At 25 weeks pregnant, the fetus responds to intense vibrational and sound stimuli. Sensitivity and the ability to distinguish sounds in height reach an adult level by the 30th week of pregnancy. In a full-term newborn, they are no different from those in an adult.
Vision. By 24 weeks of gestation, all structures of vision are formed. The reaction of the pupils of the fetus to light appears at a gestational age of 29 weeks. At 32 weeks, it becomes stable. At 36 weeks of gestation, the vision of the fetus is no different from that of a full-term baby. It must be remembered that the vision of even full-term children is 20 times worse than that of adults; it is still fuzzy, vague. The child sees only the outlines of objects (moving and stationary) located at a distance of only 25-30 cm from his eyes. A full-term baby distinguishes between shiny and red objects.
Smell: By 28-32 weeks of gestation, premature babies begin to react to strong odors.
Features of the course of the neonatal period in premature babies.
The course of the neonatal period in premature babies has some features and depends on the degree of physiological maturity.
In premature newborns, lethargy, drowsiness, weak cry, physiological erythema is pronounced.
Physiological jaundice is usually detected somewhat later due to the bright color of the skin and is often delayed up to 3-4 weeks of life.
The umbilical cord in premature babies is thick, juicy, falls off later (by the 8-14th day of life), healing umbilical wound slow.
Many premature babies have edema at the 1-2nd week of life, which are located mostly on the lower extremities and abdomen.
Thermoregulation is not stable enough, a naked child quickly cools, the body temperature can drop below 36 °, and at an elevated ambient temperature, overheating (“couvez fever”) quickly sets in.
The respiratory rate in premature infants is unstable, when moving it reaches 60-80 per 1 min., at rest and during sleep it decreases significantly, prolonged apnea (breathing stops) can be observed, especially during feeding. In preterm infants, pulmonary atelectasis is often observed in the first days of life.
Heart sounds may be muffled, and the heart rate varies depending on the conditions and condition of the child (120-140). With anxiety and an increase in ambient temperature, the heart rate can reach up to 200 beats per 1 minute.
Physiological weight loss is restored by the 2-3rd week of life. Weight gain in the first month is insignificant (100-300 g).
At the 2-3rd month of life, when an intensive weight gain begins, premature babies often develop anemia. With proper nutrition with a sufficient introduction of protein and vitamins, it gradually passes. Decrease in hemoglobin below 50 units. requires special treatment.
A premature baby needs close attention, as in the process of its nursing, a number of problems often arise. First of all, this applies to children born with a body weight of 1500 g or less (“deeply premature”) and, especially, less than 1000 g (“extremely premature”).
In developed countries, premature babies are usually cared for in intensive care units. Pediatricians who specialize in nursing children up to the 28th day of life are called neonatologists.
Particularly worth mentioning is the feeding of premature babies. Children born before 33-34 weeks of gestation, as a rule, are fed through a tube inserted into the stomach, because their sucking and swallowing reflexes are either reduced or completely absent. In addition, coordination of these reflexes is necessary, which develops only by 33-34 weeks of gestational age. The food used is expressed breast milk and / and infant formula specially adapted for such babies. That part of the food that children do not absorb in the digestive tract due to the reduced activity of digestive enzymes and other functional and morphological features of premature babies is administered in the form of separate solutions of proteins, fats and carbohydrates intravenously (parenteral nutrition).
Modern neonatal intensive care includes the most sophisticated methods of temperature control, respiration, heart activity, blood oxygenation and brain function.
Conditions for nursing premature babies.
The group of small children is especially dependent on the influence of external factors. They require ideal nursing conditions in order to achieve not only their survival, but also favorable further development.
One of the most important conditions for nursing premature babies is the optimal temperature regime. Most often, children weighing up to 1500 g are placed in incubators. If a child does not retain its own heat well, then even if it is more than 1500 grams, it can be placed in an incubator.
Immediately after the birth of the child, they are placed in an incubator with an air temperature of 34 to 35.5 degrees (than less mass child, the higher the temperature), by the end of the month the temperature is gradually reduced to 32 degrees. The temperature regime in the couveuse is selected individually. To control the child's body temperature, special temperature sensors can be used, connected to the monitor on one side, and attached to the child's body with a patch on the other.
Also, the thermal regime can be maintained using special changing tables with a source of radiant heat.
Another important condition for nursing is air humidity and in the first days it should be 70-80%. For this purpose, there are special humidifiers in incubators.
The goal of creating conditions favorable for the development of a child receiving intensive care is associated with minimizing adverse effects, as a result of which the prognosis of psychomotor development improves.
Creating favorable conditions for the development of newborns in intensive care units (optimal light regimen, noise elimination, minimizing painful manipulations, tactile stimulation) has a positive effect on the subsequent development of children with serious illnesses.
Newborns are very vulnerable. Their reaction to damaging factors is common, that is, it involves the response of several body systems at once. The elimination of pain and anxiety reduces the need for oxygen in the blood (and, consequently, in the correction of the mode artificial ventilation lungs), reduces its energy costs, improves food tolerance, reduces the duration of hospitalization.
The inclusion of parents in the treatment process reduces in newborns pain and stress reactions and favorably affects subsequent development.
Newborns in intensive care units continue to develop sensory organs. Negative and positive environmental factors affect the conduction of excitation along the nerve pathways.
Critical changes occur in the brain of a premature baby during the period when he is in the intensive care unit (22-40 weeks of gestation):
Environmental influences influence the formation of the important processes listed above during this critical period. If these effects are inadequate, they can irreparably disrupt the process of formation of the nervous system.
A neonate receiving intensive care is exposed to light and sound. The very medical procedures necessary to save his life are a great burden for a premature and seriously ill child. These treatments include sanitation respiratory tract, vibration massage chest, insertion of a gastric tube and feeding through it, vein catheterization, chest x-ray, ultrasound, ophthalmoscopy, daily physical examination, determination of vital signs, hygiene procedures, weighing.
According to rough estimates, a seriously ill newborn is shifted and subjected to various manipulations for care, treatment and condition control more than 150 times a day. Thus, periods of continuous rest do not exceed 10 minutes.
What can reduce this kind of stress?
- Creation comfortable conditions, elimination of noise and bright light, convenient placement in an incubator (incubator) or in a bed.
- Cooperation with parents, strengthening their attachment to the child.
- Use of natural soothing and self-regulating factors: pacifiers, kangaroo care, twins in the same bed (incubator).
- Laying in the midline in a flexor position, swaddling, simulating a limited space in the uterus.
- Conducting several care manipulations in the same period of time to provide the child with longer periods of rest.
Eliminate noise and glare. Prematurity itself is a risk factor for sensorineural hearing loss and deafness. It is detected in 10% of those born prematurely and only in 5% of those born full-term. Noise disrupts the formation of auditory pathways in the central nervous system necessary for the development of speech.
Light levels of less than 6 foot-candles (60 lux) and noise levels of less than 50 decibels (calm, low speech) recommended in intensive care units reduce the risk of hearing loss and improve the subsequent development of seriously ill children. In the intensive care unit, therefore, only calm speech without raising the voice is allowed. It must be remembered that the doors of the incubator must be closed carefully quietly, do not knock on the incubator and other nearby surfaces.
Eyelids do not protect the eyes of newborns. At least 38% white light passes through the eyelids and irritates the child.
Elimination of pain and congestion:
Premature babies are very sensitive to rough touch. They react to such touches with tachycardia, agitation, increased blood pressure, apnea and a drop in hemoglobin oxygen saturation, disorders in the regulation of physiological processes, and insomnia.
However, preterm infants are not able to respond to pain with changes over a long period of time. physiological indicators and behaviour. Their reactions are quickly depleted, so it is difficult to notice them. The scales for assessing the intensity of pain, developed for full-term newborns, are not applicable to preterm infants.
According to one study, three out of four episodes of hypoxia and a drop in hemoglobin oxygen saturation are associated with care and treatment procedures. In addition, in response to them, stress hormones are released. A premature baby who covers his face with his hands gives us a signal that he is experiencing discomfort.
It is very important to try to reduce stress and pain effects.
Non-drug methods for minimizing pain reactions and overload in newborns include the use of a pacifier and a teat with a bottle of water, swaddling that mimics the closed space of the uterus, reducing exposure to light and noise, performing several manipulations at the same time in order to increase the gaps between them and allow the child to rest.
Correct placement of premature babies:
When a baby is in the neonatal intensive care unit, it is important to create an environment that mimics the closed space of the uterus (“nest” made of soft materials).
Neural connections are strengthened by repeated stimulation and weakened by its absence. After birth, a premature baby, having left the closed space of the uterus, ceases to receive constant tactile stimulation from its walls, which supports muscle development. The weak muscles of a premature baby cannot resist gravity. He takes a sprawled pose with limbs extended, abducted and turned outward. Gradually, this posture leads to the formation of abnormal muscle tone and postural (associated with a forced position of the body) deformities.
Thus, the increasing flattening of the skull from the sides leads to a narrowing and lengthening of the head (the so-called scaphocephaly and dolichocephaly). It is due to the thinness and softness of the bones of the skull, which is why it is easily deformed. This deformity of the head apparently does not affect the development of the brain, but makes the child outwardly unattractive and interferes with his socialization. However, with good care, the deformation can be significantly reduced.
Prolonged stay in the same position leads to muscle and skeletal deformities that impair subsequent motor development and the ability to learn. the world, play, master social and other skills.
Giving the newborn the correct posture prevents deformations of the skull, trunk and pelvis, which disrupt and slow down subsequent development. Newborns themselves cannot turn, so attention should be paid to the correct posture. The child should be laid in a collapsed position in the "nest" and regularly turned from one side to the other. It is allowed to lay out premature babies on the stomach, but only under the control of monitoring supervision and personnel.
Premature is considered to be children born in the period from the 22nd to the 37th week of gestation with a body weight of less than 2500-2700 g and a body length of less than 45-47 cm. The most stable indicator is the gestational age.
The fetus is viable (according to WHO definition) with a body weight of 500 g or more, a body length of 25 cm or more, and with a gestational age of more than 22 weeks. National statistics of Russia on miscarriage ( spontaneous interruption pregnancy less than 37 completed weeks) takes full account of these recommendations. Statistics on prematurity (spontaneous or induced termination of pregnancy from the time when the fetus is considered viable) among live births takes into account only children from the 28th week of gestation weighing 1000 g or more and body length 35 cm or more. Of those born alive with a body weight of 500-999 g, newborns who lived 7 days after birth are subject to registration.
The number of premature babies in different countries ranges from 3 to 17%, in Russia - 3-7%. Among prematurely born children, the highest morbidity and mortality are observed. They account for about 75% of infant mortality in our country; in the most economically developed countries - 100%.
CAUSES OF PREMATED BIRTH OF CHILDRENThe main causes of premature birth of children are as follows.
Socio-biological factors.
Parents too young or too old. If old age has a negative effect on gestation due to biological changes in the aging organism, then the birth of premature babies in young mothers is due to unplanned pregnancies.
Miscarriage is influenced by the low level of education of parents and the associated unhealthy lifestyle during pregnancy and a lack of understanding of the importance of constant
medical supervision. Among children born to women who were not observed during the entire pregnancy in antenatal clinic, the perinatal mortality rate is 5 times higher.
Occupational hazards, bad habits, and hard physical labor play an important role in miscarriage. Bad influence Smoking affects the health of the child not only for the mother, but also for the father. Severe malformations in children from men who smoke for many years and / or smokers a large number of cigarettes occur 2 times more often than in children from non-smoking fathers.
Even with a desired pregnancy, the risk of miscarriage in single women is higher than in married women, which is due to social and psycho-emotional factors.
previous abortions. The complete elimination of abortion with the use of effective contraception can reduce the rate of preterm birth by 1/3.
Short intervals between births (less than 2 years) may be the cause of premature delivery.
Mother's illnesses.
pathological course of pregnancy.
DEGREES OF PREMATURITY
There are four degrees of prematurity (Table 4-1).
Table 4-1.Degrees of prematurity
Currently, the diagnosis usually does not indicate the degree of prematurity, but the gestational age in weeks (a more accurate indicator).
SIGNS OF PREMATURITY Clinical signs
The appearance of a premature baby depends on the degree of prematurity.
A deeply premature baby (weighing less than 1500 g) has thin wrinkled skin of dark red color, richly covered with cheese-like grease and fluff (lanugo). simple erythema
lasts up to 2-3 weeks. The subcutaneous fat layer is not expressed, the nipples and areolas of the mammary glands are barely visible; auricles are flat, shapeless, soft, pressed against the head; nails are thin and do not always reach the edge of the nail bed; the navel is located in the lower third of the abdomen. The head is relatively large and is 1/3 of the body length; limbs are short. The sutures of the skull and fontanelles (large and small) are open. The bones of the skull are thin. In girls, the genital slit gapes as a result of underdevelopment of the labia majora, the clitoris protrudes; in boys, the testicles are not descended into the scrotum.
In more mature premature babies, the appearance is different. The skin is pink, there is no fluff on the face (at birth on the 33rd week of gestation), and later on the trunk. The navel is located slightly higher above the womb, the head is approximately 1/4 of the body length. In children born at more than 34 weeks of gestation, the first bends appear on the auricles, the nipples and areola are more visible, in boys the testicles are located at the entrance to the scrotum, in girls the genital slit is almost closed.
Preterm infants are characterized by muscle hypotension, decreased physiological reflexes, motor activity, violation of thermoregulation, weak cry. A deeply premature baby (less than 30 weeks of gestation) lies with outstretched arms and legs; sucking, swallowing and other reflexes are absent or weakly expressed. Body temperature is unstable (it can drop to 32-34? C and rises easily). At birth after the 30th week of gestation, a premature baby is found to have partial flexion of the legs at the knee and hip joints; sucking reflex is good. In a child born at 36-37 weeks of gestation, flexion of the limbs is complete, but unstable; a distinct grasping reflex. A premature baby in the first 2-3 weeks of life may have a non-permanent tremor, non-rough and non-permanent strabismus, horizontal nystagmus with a change in body position.
Premature boys and girls do not differ in anthropometric parameters, since these differences are formed in the last month of pregnancy (full-term boys are larger than girls).
Features of internal organs
Morphological and functional immaturity of the internal organs is also in line with the degree of prematurity and is especially pronounced in very preterm infants.
Breathing in premature babies is superficial with significant fluctuations in respiratory rate (from 36 to 76 per minute), with a tendency to tachypnea and apnea lasting 5-10 seconds. In children born at less than 35 weeks of gestation, the formation of surfactant is impaired, which
ry prevents the collapse of the alveoli on exhalation. They develop SDR more easily.
Heart rate in premature babies is characterized by high lability (from 100 to 180 per minute), vascular tone is reduced, systolic blood pressure does not exceed 60-70 mm Hg. Increased permeability of the vascular walls can lead to impaired cerebral circulation and cerebral hemorrhage.
Due to the insufficient maturity of the renal tissue, its function to maintain acid-base balance is reduced.
All gastrointestinal enzymes necessary for the digestion of breast milk are synthesized, but are characterized by low activity.
In preterm infants, there is no relationship between the intensity of jaundice and the degree of transient hyperbilirubinemia, which often leads to an underestimation of the latter. The immaturity of the liver and the associated insufficient activity of the enzyme glucuronyl transferase, increased permeability of the blood-brain barrier (BBB), as well as the rapid breakdown of erythrocytes can lead to the accumulation of indirect bilirubin in the blood in the first days of life and the development of bilirubin encephalopathy, even at a relatively low concentration of bilirubin (170-220 µmol/l).
In the first days of life, premature babies are more likely than full-term babies to have hypoglycemia, hypoproteinemia, hypocalcemia, hypomagnesemia, hyperkalemia, and decompensated metabolic acidosis. The content of erythrocytes and Hb at birth is almost the same as in full-term, but the content of HbF is higher (up to 97.5%), which is associated with intense hemolysis. From the second day of life, red blood indicators change at a faster pace than in full-term ones, and at the age of 6-8 weeks, a typical deviation in the hemogram appears for premature babies - early anemia of prematurity. The leading cause of anemia is considered to be low production of erythropoietin. The content of leukocytes is the same as in full-term children, however, the presence of young forms up to promyelocytes is typical. The first crossing of granulocytes and lymphocytes occurs the later, the greater the degree of prematurity (with III degree - by the end of the first month of life).
PECULIARITIES OF THE DEVELOPMENT OF PREMATURE CHILDREN Physical development
The physical development of preterm infants is characterized by a higher rate of increase in body weight and length during the first year.
life. The smaller the weight and length of the body of a premature baby at birth, the more intensively these indicators increase during the year.
By the end of the first year of life, body weight increases as follows: with prematurity IV degree 8-10 times, III degree - 6-7 times, II degree - 5-7 times, I degree - 4-5 times. Body weight increases unevenly. The first month of life is the most difficult period adaptation, especially for a very premature baby. The initial body weight decreases by 8-12% (in full-term children by 3-6%); recovery is slow. With a gestation period of less than 32 weeks, body weight often reaches its initial values only by the end of the first month of life and begins to increase more intensively from the 2nd month.
The body length of a premature baby by the end of the first year of life is 65-75 cm, i.e. increases by 30-35 cm, while in a full-term one, the body length increases by 25 cm.
Despite the high rates of development, in the first 2-3 years of life, premature babies lag behind their peers who were born full-term. Alignment occurs after the third year of life, often at 5-6 years. In the future, in children born prematurely, asthenia and infantilism are often observed, but indicators of physical development characteristic of full-term peers are also possible.
psychomotor development
In psychomotor development, healthy premature babies compare with their full-term peers much earlier than in physical development. Children with II-III degree prematurity begin to fix their eyes, hold their heads, roll over, stand up and walk on their own, pronounce the first words 1-3 months later than full-term ones. Premature babies "catch up" with full-term peers in terms of psychomotor development in the second year of life; with prematurity I degree - by the end of the first year.
FEATURES OF NURSING PREMATURENursing of premature babies is carried out in two stages: in maternity hospital and specialized department. Then the child comes under the supervision of the clinic.
All over the world, great importance is attached to the "soft nursing of premature babies" with the limitation of intensive care, stressful situations, pain. After the birth of a premature baby, it should be placed in a sterile warm diaper (“optimum comfort”). Cooling immediately after birth, while still in the delivery room, often dooms all further care to failure. So, if the body temperature of a premature baby only once dropped to 32? C
and below, mortality reaches almost 100%, even with the correct use of all modern methods of care and treatment in the future. In the first days of life, very premature babies or premature babies in a serious condition are kept in incubators. They maintain a constant temperature (from 30 to 35? C, taking into account individual features child), humidity (on the first day up to 90%, and then up to 60-55%), oxygen concentration (about 30%). The body temperature of the child can be maintained in a heated crib or in regular crib with the help of heating pads, since the longer the stay in the incubator, the greater the likelihood of infection of the child. Optimum temperature air in the room - 25? C. It is necessary to support the adaptive reactions of the child by instilling native mother's milk into the mouth from a pipette, heated diapers, prolonged stay on the mother's chest (like "kangaroo"), a calm voice nurse, stroking movements of her hands.
Only 8-10% of healthy premature babies with a birth weight of more than 2000 g are discharged home from the maternity hospital. The rest are transferred to specialized institutions for the second stage of nursing.
FEATURES OF PREMATURE FEEDING
Feeding characteristics of preterm infants are due to their increased need for nutrients due to intensive physical development, as well as functional and morphological immaturity of the gastrointestinal tract, and therefore food should be introduced carefully. Even deeply preterm infants should be fed already in the first hours of life due to the catabolic orientation of metabolism, hypoproteinemia and hypoglycemia.
With parenteral nutrition, the child's intestines are quickly colonized by conditionally pathogenic microflora. At the same time, the permeability of the mucous membranes of the gastrointestinal tract increases, which contributes to the generalization of the infectious process. Parenteral nutrition is resorted to only in extremely severe conditions in very premature babies and for a limited period of time. It is more expedient for such children to prescribe round-the-clock drip administration of native mother's milk.
For children with a gestational age of more than 28 weeks, as well as for all preterm infants with SDR, a weak sucking reflex, breast milk is administered through a gastric tube. With a satisfactory general condition, a sufficiently pronounced sucking reflex and a body weight at birth of more than 1800 g, it is possible to apply to the breast in 3-4 days. Preterm infants with a birth weight of less than 1500 g are breastfed from the third week of life. In the absence of milk from the mother, specialized mixtures are prescribed for premature babies.
(for example, "Nenatal", "preNAN", etc.) Upon reaching a body weight of 2500-3000 g, the child is gradually transferred to conventional substitutes for women's milk.
Nutrition calculations are made in accordance with the need of the child's body per 1 kg of body weight per day: 1-2 days of life - 30 kcal, 3rd day - 35 kcal, 4th day - 40 kcal, then daily 10 kcal more up to the 10th day of life; on the 14th day - 120 kcal, from the 21st day of life - 140 kcal.
When determining the volume of food, one should take into account the individual characteristics of the child: very premature babies from the 2nd month sometimes absorb the volume of breast milk corresponding to 150-180 kcal/kg.
LONG-TERM CONSEQUENCES OF PREMATUREAmong premature babies, the risk of mental and physical disability is higher than among full-term babies.
Severe neuropsychiatric disorders in the form of cerebral palsy, intellectual decline, hearing and vision impairment, epileptic seizures occur in 13-27% of premature babies.
Premature babies are 10-12 times more likely to have malformations. They are characterized by a disproportionate development of the skeleton, mainly with deviations towards asthenia. Many of them have an increased risk of "school maladjustment" in the future. Among those born prematurely, attention deficit hyperactivity disorder is more often observed.
In women who were born very premature, in the future, menstrual irregularities, signs of sexual infantilism, the threat of abortion and premature birth are often observed.
Despite the above, at proper care and rational nutrition, premature babies usually grow up healthy and become full members of society.
PREVENTIVE BIRTH OF CHILDRENPrevention of premature birth of children provides for the protection of the health of the expectant mother; prevention of medical abortions, especially in women with menstrual irregularities and neuroendocrine diseases; creation of favorable conditions for pregnant women in the family and at work; timely identification of risk groups and active monitoring of the course of pregnancy in these women.
Premature babies are those born between the 28th and 38th weeks of intrauterine development with a body weight of 2500 g or less and a length of 35-45 cm.
What is the weight of a premature baby?
A fetus weighing less than 1000 g, born at a gestational age of less than 28 weeks, is regarded as a miscarriage.
When determining the signs of prematurity, indicators of physical development and gestational age (length of pregnancy) are taken into account, since newborns, premature and full-term, can be born with a body weight that does not correspond to gestational age. For example, body weight may be reduced due to intrauterine malnutrition or intrauterine growth retardation (small children for a given gestational age), as well as increased, which is observed in those born to mothers with diabetes mellitus. Given the large range of indicators characterizing prematurity, for practical purposes, the latter is divided into four degrees. The degree of prematurity reflects the maturity of the newborn, the possibility of adapting it to the external environment, the frequency and characteristics of pathology, and the likelihood of survival. So, they make a diagnosis of prematurity:
degree of prematurity - body weight of the child at birth 2500 - 2001
degree of prematurity - body weight of the child at birth 2000-1501
degree of prematurity - body weight of the child at birth 1500-1000 g.
degree of prematurity - body weight of a child at birth up to 1000 g.
The frequency of preterm birth in different countries varies widely (from 3.1 to 16.6%). There is no downward trend in this indicator. Among prematurely born children, there is the highest morbidity (birth trauma of the central nervous system, sepsis, pneumonia, rickets, anemia, malnutrition) and the highest mortality. Up to 75% of all newborn deaths are premature. Therefore, the priority medical workers in the fight to reduce morbidity and infant mortality is the prevention of prematurity. And in the event of its occurrence, the provision of proper care for premature newborns.
Reasons for the birth of premature babies
The main causes of premature birth of children are as follows:
Socio-biological factors. Parents too young or too old. If old age has a negative effect on gestation due to biological changes in the aging body, then the birth of premature babies in young mothers is due to unplanned pregnancies.
Miscarriage is influenced by the low level of education of parents and the associated unhealthy lifestyle during pregnancy and a lack of understanding of the importance of constant medical supervision. Among children born to women who were not observed during the entire pregnancy in the antenatal clinic, the level of perinatal mortality is 5 times higher.
Occupational hazards, bad habits, and hard physical labor play an important role in miscarriage. Not only the mother, but also the father has a negative impact on the health of the child. Severe malformations in children from men who smoke for many years and / or smoke a large number of cigarettes occur 2 times more often than in children from non-smoking fathers.
Causes of prematurity in children
The causes of prematurity can be various factors that disrupt the intrauterine development of the fetus and the physiological course of pregnancy. Babies are often born prematurely to mothers with infectious diseases, including latent ones. Premature birth can cause mycoplasma infection, cytomegaly, diseases caused by herpes viruses, adenoviruses and other pathogens that pass through the placental barrier, damage the placenta and disrupt its function.
Often preterm birth occurs as a result of severe somatic diseases, vegetative dystonia, anemia of the pregnant woman. Infantilism and anomalies in the development of the female genital area, neuro-endocrine pathology, immunological incompatibility in antigenic systems also predispose to this. Premature babies are born with multiple pregnancies.
Great importance have previous medical abortions, which cause functional and morphological changes in the endometrium and an increase in uterine contractility, chromosomal aberrations, the age of the pregnant woman and her bad habits, occupational hazards.
Signs of premature newborns
Clinical signs of a premature baby
The appearance of a premature baby depends on the degree of prematurity.
Signs of very premature babies
A very premature baby (weighing less than 1500 g) has the following signs: thin wrinkled skin of dark red color, abundantly covered with cheese-like grease and fluff (lanugo). Simple erythema lasts up to 2-3 weeks.
The subcutaneous fat layer is not expressed, the nipples and areolas of the mammary glands are barely visible; auricles are flat, shapeless, soft, pressed against the head; nails are thin and do not always reach the edge of the nail bed; the navel is located in the lower third of the abdomen. The head is relatively large and is 1/3 of the body length, the limbs are short. The sutures of the skull and fontanelles (large and small) are open. The bones of the skull are thin. In girls, the genital gap gapes as a result of underdevelopment of the labia majora, the clitoris protrudes, in boys, the testicles are not lowered into the scrotum.
Signs of more mature premature babies
In more mature premature babies, the appearance and signs of prematurity are different. Here are their signs: the skin is pink, there is no fluff on the face (at birth at the 33rd week of gestation), and later on the trunk. The navel is located slightly higher above the womb, the head is approximately 1/4 of the body length. In children born at more than 34 weeks of gestation, the first bends appear on the auricles, the nipples and areola are more visible, in boys the testicles are located at the entrance to the scrotum, in girls the genital slit is almost closed.
Premature babies are characterized by such signs as muscle hypotonia, decreased physiological reflexes, decreased motor activity, impaired thermoregulation, and a weak cry. A deeply premature baby (less than the 30th week of gestation) lies with outstretched arms and legs, sucking, swallowing and other reflexes are absent or weakly expressed. Body temperature is unstable (it can drop to 32-34 ° C and rises easily). At birth after the 30th week of gestation, a premature baby is found to have partial flexion of the legs at the knee and hip joints; sucking reflex is good.
In a child born at a period of 36-37 weeks. gestation, flexion of the limbs is complete, but unstable, a distinct grasping reflex is evoked. A premature baby in the first 2-3 weeks of life may have a non-permanent tremor, non-rough and non-permanent strabismus, horizontal nystagmus with a change in body position.
Premature boys and girls do not differ in anthropometric parameters, since these differences are formed in the last month of pregnancy (full-term boys are larger than girls).
Features of internal organs in premature babies
Morphological and functional immaturity of the internal organs is also in line with the degree of prematurity and is especially pronounced in very preterm infants.
Breathing in premature babies is superficial with significant fluctuations in respiratory rate (from 36 to 76 per minute), with a tendency to tachypnea and apnea lasting 5-10 seconds. In children born at less than 35 weeks of gestation, the formation of surfactant is impaired, which prevents the collapse of the alveoli on exhalation. They develop SDR more easily.
Heart rate in premature babies is characterized by high lability (from 100 to 180 per minute), vascular tone is reduced, systolic blood pressure does not exceed 6070 mm Hg. Increased permeability of the vascular walls can lead to impaired cerebral circulation and cerebral hemorrhage.
Due to the insufficient maturity of the renal tissue, its function to maintain acid-base balance is reduced.
All gastrointestinal enzymes necessary for the digestion of breast milk are synthesized, but are characterized by low activity.
In preterm infants, there is no relationship between the intensity of jaundice and the degree of transient hyperbilirubinemia, which often leads to an underestimation of the latter. The immaturity of the liver and the associated insufficient activity of the enzyme glucuronyl transferase, increased permeability of the blood-brain barrier (BBB), as well as the rapid breakdown of erythrocytes can lead to the accumulation of indirect bilirubin in the blood in the first days of life and the development of bilirubin encephalopathy, even at a relatively low concentration of bilirubin (170-220 µmol/l).
Laboratory studies of a premature baby
In the first days of life, premature babies are more likely than full-term babies to have hypoglycemia, hypoproteinemia, hypocalcemia, hypomagnesemia, hyperkalemia, and decompensated metabolic acidosis. The content of erythrocytes and Hb at birth is practically the same as in full-term ones, but the content of HbF is higher (up to 97.5%), which is associated with intense hemolysis.
From the second day of life, red blood indicators change at a faster pace than in full-term ones, and at the age of 6-8 weeks, a typical deviation in the hemogram appears for premature babies - early anemia of prematurity. The leading cause of anemia is considered to be low production of erythropoietin.
Features of the development of premature babies
Physical development is characterized by a higher rate of increase in body weight and length during the first year of life. The lower the body weight and length of a premature baby at birth, the more intense the increase in these indicators during the year. By the end of the first year of life, the body weight of a premature baby increases as follows:
with a newborn weighing 800-1000 g - 8-10 times
"" "" 1001 - 1500 g "6-7"
"" "" 1501-2000 "5-7"
"" "" 2001-2500 "4-5"
In the same age period, the growth of a premature baby is 65–75 cm, i.e., it increases by 30–35 cm.
Body weight increases unevenly. The first month of life is the most difficult period of adaptation, especially for a very premature baby. His initial body weight decreases (for a full-term one by 5-7%); recovery is slow: in preterm infants with signs of III-IV degree, body weight often reaches the initial figures only by the end of the 1st month of life and begins to increase more intensively from the 2nd month.
Despite the high rates of development, in the first 2-3 years of life, premature babies lag behind their peers who were born full-term in terms of body weight and height. In the future, in children born prematurely, asthenia and infantility are more often observed, but a number of children have indicators of physical development corresponding to full-term peers.
Children with II - III degree of prematurity begin to fix their gaze, hold their head, roll over, stand up and walk on their own, pronounce the first words 1 - 3 months later than their full-term peers and catch up with them during the 2nd year of life (children with 1 degree of prematurity to end of year 1).
What does a premature baby look like?
Eyes. If your baby was born before the 26th week of pregnancy, his eyes may be tightly closed.
Genitals. Your child may have underdeveloped genitals. In boys, this will show up in the presence of testicles; in girls, that the labia majora (the outer labia of the vulva) will not be large enough to cover the labia minora (the inner labia of the vulva) and the clitoris, and a patch of skin may be visible from the vagina (don't worry, it will disappear over time) .
Extreme thinness. Your premature baby may look shriveled and skinny because his body lacks the layers of fat that usually accumulate towards the end of pregnancy (after 30-32 weeks). When he starts to gain weight, this fat will appear, and he will begin to look more like a normal full-term baby.
Transparent skin. Accumulations of fat also affect the skin color of a premature baby. Veins and arteries are clearly visible through the skin, and the skin has a pinkish-purple hue regardless of the child's race. (This is because skin pigmentation usually appears after the eighth month of pregnancy.)
Lack of hair. Severely premature babies may not have any body hair at all, except for a soft fluff. On the other hand, babies who were not born much prematurely may be covered - with a thin fluff that covers the body. This down can be especially abundant on the back, upper arms, and shoulders.
Lack of nipples. Usually, nipples appear after the 34th week of pregnancy, so your baby may not have nipples if he was born before this time. However, some babies have fully formed circles, the dark circles that usually surround the nipples.
Low muscle tone. Premature babies are less able to control their bodies than full-term babies. If you put the child on his back), his limbs may tremble or sag. Severely premature babies sometimes hardly move at all: their movements are limited to slight stretching or clenching of fists. Babies who are born before the 35th week of pregnancy may lack the muscle tone needed to assume the fetal position that is common for full-term babies.
Underdeveloped lungs. Premature babies have more breathing problems than full-term babies because their lungs aren't fully developed. Fortunately, as a baby's lungs mature, they can continue to develop outside of the mother's uterus.
Comment: If your baby is born between the 22nd and 25th weeks of pregnancy, you should be prepared for the fact that he will be more like a fetus in the womb than a normal newborn. His eyes may still be tightly closed, his skin may look shiny, translucent, and too tender to touch. His ears may be soft and folded in places where the cartilage has not yet hardened. You will notice how much your baby will change in the coming weeks, how his skin will become thicker and how his eyes will open for the first time. He will begin to resemble a normal newborn.
Assessing the Development of Premature Babies
When analyzing the development of a premature infant in the first year of life, the period of prematurity is subtracted from the age of the child (if the period of prematurity is 2 months, then the development of a 7-month-old child is estimated as 5-month-old). When assessing the development of a premature child of the second year of life, half of the prematurity period is subtracted from the child's age (if the period of prematurity is 2 months, then the development of a 14-month-old child is estimated as 13-month-old). After a premature baby reaches the age of 2 years, its development is assessed without adjusting for prematurity.
Let's find out how the development of premature babies is assessed.
Signs of Speech Disorders and Delayed Development of Language Skills in Preschool Children
- 6 months - does not respond or responds inadequately to sound or voice;
- 9 months - does not respond to the name;
- 12 months - cessation of babbling or no babbling at all;
- 15 months - does not understand the words "no" and "bye-bye", does not respond to them;
- 18 months - does not pronounce other words, except for "mom" and "dad";
- 2 years - does not make two-word phrases;
- after 2 years - still uses "childish" jargon and imitates sounds excessively;
- 2.5 years - the child's speech is incomprehensible even to family members;
- 3 years - does not amount to simple sentences;
- 3.5 years - the child's speech is understandable only to family members;
- 4 years - persistent articulation errors (in addition to the sounds R, S, L, W);
- 5 years - has difficulty compiling structured sentences;
- after 5 years - a noticeable permanent violation of the fluency of speech (stuttering);
- 6 years - Unusual shyness, reversal of words, difficulty with selection suitable words when talking.
At any age - monotony of pronounced sounds or hoarseness of voice.
Signs of impaired cognitive function
- 2-3 months - does not show much interest in relation to the mother;
- 6-7 months - does not turn his head towards the fallen object;
- 8-9 months - does not show interest when they try to play hide-and-seek with him;
- 12 months - does not look for a hidden object;
- 15-18 months - does not show interest in cause-and-effect games;
- 2 years - does not divide surrounding objects into categories (for example, animals are one thing, cars are another);
- 3 years - does not know his full name;
- 4 years - can't tell which of the two lines is shorter and which is longer;
- 4.5 years - does not know how to consistently count;
- 5 years - does not know the names of letters, colors of objects;
- 5.5 years - does not know the date of his birth and home address.
Caring for premature newborns
Features of feeding and care
Feeding premature babies has significant features. These features are due to the increased need for nutrients due to intensive physical development, as well as the morphological and functional immaturity of the gastrointestinal tract, requiring careful introduction of food.
The beginning of feeding a child is determined by the state and degree of his prematurity. The method of feeding is determined depending on the severity of the condition.
With the I degree of prematurity, the child can begin to feed with breast milk or its substitutes after 6-9 hours, with the II degree - after 9-12 hours, with the III degree - after 12-18 hours, the fetus - after 24 - 36 hours. During this period 5% glucose solution is administered in 3 - 5 ml every 2-3 hours. Longer "starvation" is undesirable, as it leads to hypoglycemia, hyperbilirubinemia, hypoproteinemia, increases metabolic acidosis.
Children with III-IV degree prematurity, as well as all premature infants with respiratory distress syndrome, asphyxia, a weak sucking reflex, receive breast milk through a gastric tube, permanent or disposable (the permanent tube is changed every 3-4 days for sterilization and prevention of bedsores). With a satisfactory general condition and a sufficiently pronounced sucking reflex, the first 3-4 days are fed through the nipple. Before this period, it is not advisable to apply to the breast, since breastfeeding is difficult. physical activity and secondary asphyxia or intracranial hemorrhage may occur.
Premature babies weighing less than 1500 g are applied to the breast from the 3rd week of life. Nutrition calculations are made in accordance with the need of the child's body per 1 kg of body weight per day: 1-2nd day of life - 30 kcal, 3rd day - 35 kcal, 4th day - 40 kcal and then daily 10 kcal more up to 10th day; on the 14th day - 120, from the 21st day - 140 kcal. When caring for premature newborns and when determining the amount of nutrition, the individual characteristics of the newborn should be taken into account: very premature babies from the 2nd month of life sometimes absorb the amount of breast milk corresponding to 150-180 kcal / kg. Most preterm infants, being breastfed, develop well.
Children with insufficient weight gain at the end of the 1st month are sometimes prescribed a concentrated supplement in the form of cottage cheese, whole kefir with 5% sugar. In addition, most preterm infants receive parenteral solutions of glucose and albumin. From the 2nd month of life, instead of drinking, they give vegetable broth, as well as fruit and vegetable juices. Instead of breast milk during nursing premature baby milk mixtures can be used.
Care of premature babies
Nursing of premature babies is carried out in 2 stages: in the maternity hospital and in a specialized department for newborns. Then the child comes under the supervision of the clinic. In the maternity hospital, mucus is aspirated from the upper respiratory tract in order to prevent aspiration from the upper respiratory tract. In the first days and weeks of life, very premature babies or premature babies in serious condition are kept in incubators ("incubators"). They maintain a temperature of 30 to 35 ° C (taking into account the individual characteristics of the child), humidity on the first day up to 90%, and then up to 60 - 55%, the oxygen concentration is about 30%. The body temperature of a premature baby can also be maintained in a heated crib or using heating pads in a regular crib. The optimum temperature in the room should be around 24 C.
Oxygen therapy is carried out, the balance of acids and bases is corrected by introducing glucose solutions with ascorbic acid and cocarboxylase. The elimination of hypoglycemia, hypoproteinemia is provided with the help of glucose and albumin solutions. In case of urgent need, plasma transfusions and blood transfusions are carried out.
Most babies with grade III-IV prematurity receive antibiotics during nursing. The indications for their appointment are the severe general condition of the child, purulent-inflammatory diseases in the mother, premature rupture amniotic fluid, childbirth outside medical institution.
What should be the care of a premature baby?
The main features of the body of a premature baby are very poor thermoregulation and shallow breathing. The first can lead to a drop in the child's body temperature to 35 degrees or a rise to 40, the second to oxygen starvation or even respiratory arrest.
As soon as the doctors decide that the baby's condition is satisfactory, the mother and baby are discharged home, having previously provided important instructions on hygiene, clothing, walking and bathing the premature baby.
It is very important to protect such a child from people who are carriers colds, ARI and SARS. For premature babies, both overheating and hypothermia are vitally dangerous. The temperature in the room where the child is located should not fall below 22 degrees, under the covers - at least 33 degrees. The temperature of the water for bathing should be higher than for a full-term baby (not lower than 38 degrees), while the bathroom should also be warm enough - not lower than 24 degrees.
From the foregoing, it is clear that caring for a premature baby includes constant monitoring of his body temperature. He needs warmer clothes than his full-term counterpart. It is very important to constantly change the air in the room, while airing it is worth taking the child out of the room.
The child is gaining weight
As soon as the weight of the child exceeds three kilograms, it can be taken out for walks. You should not go outside if the air temperature in the street is below minus 5 - for a child up to a month, below minus 10 - for a child up to a year. Walks should be started from 5-10 minutes, and gradually increase the walk time to 2-3 hours (leave immediately after feeding and walk until the next feeding).
Another problem is that the baby simply cannot suckle at the breast, and therefore is forced to eat from a bottle (and sometimes there is no strength for this). As soon as the child is strong enough to be able to suckle, you should completely switch to breast-feeding. This will help you quickly gain the desired weight and catch up with your peers in development.
Only 8-10% of premature babies are discharged home from the maternity hospital - these are healthy children with a birth weight of more than 2000 g. The rest are transferred to specialized institutions for the second stage of nursing. In these institutions, children receive the necessary treatment, hygienic baths, they are prevented from rickets and anemia. The complex of therapeutic measures includes massage and gymnastics. A healthy premature baby can be discharged home when he reaches a body weight of more than 2000 g, its positive dynamics and a good sucking reflex.
Proper development premature babies are facilitated by timely care for a premature newborn, a favorable home environment, individual sessions, games, massage and gymnastics, rational nutrition.
Long-term consequences of prematurity
Children born prematurely usually grow up healthy and become full members of society. It is known that I. Newton, Voltaire, Rousseau, Napoleon, C. Darwin, Anna Pavlova were born prematurely. However, among such a contingent of children, the percentage of mentally and physically handicapped children is higher than among those born on time. Gross neuropsychiatric disorders in the form of cerebral palsy, intellectual decline, hearing and vision impairment, epileptic seizures are observed in 13-27% of prematurely born. These indicators are especially high in the group of those who were born very premature, among them children who are later restless, suffering from uncertainty, night terrors are more often observed. In preterm births, a disproportionate development of the skeleton is more often noted, mainly with a deviation towards asthenia.
In recent years, doctors of various specialties have been studying the developmental features of children born prematurely. It has been established that in women who were born very preterm, menstrual irregularities, defective generative function, signs of sexual infantilism, threatened miscarriage and premature birth are more often noted.
Prevention of premature birth of children includes:
- Protecting the health of the expectant mother from the very early childhood;
- Prevention of medical abortions, especially in women with menstrual disorders and neuroendocrine diseases;
- Creation of favorable conditions for a pregnant woman in the family and at work;
- Timely detection of pregnant women with the threat of preterm birth and monitoring the course of pregnancy in them.
