In a premature newborn, it is noted. Premature babies - degrees and signs of prematurity in a newborn baby, features of the body and behavior
- these are children born before the due date, functionally immature, with a weight below 2500 g and a body length of less than 45 cm. Clinical signs of prematurity include a disproportionate physique, open sutures of the skull and a small fontanel, a lack of expression of the subcutaneous fat layer, hyperemia of the skin, underdevelopment of the genital organs, weakness or absence of reflexes, weak cry, intense and prolonged jaundice, etc. Nursing premature babies involves the organization of special care - temperature, humidity, oxygenation level, feeding, and, if necessary, intensive care.
To the third group of causes that disrupt the normal maturation of the fetus and cause increased likelihood the birth of premature babies include various extragenital diseases of the mother: diabetes mellitus, hypertension, heart defects, pyelonephritis, rheumatism, etc. Often, premature birth is provoked by acute infectious diseases suffered by a woman in late gestation.
Finally, the birth of premature babies may be associated with pathology and abnormal development of the fetus itself: chromosomal and genetic diseases, intrauterine infections, severe malformations.
Classification of prematurity
Taking into account the indicated criteria (gestational age, body weight and length), 4 degrees of prematurity are distinguished:
I degree of prematurity- delivery occurs at a period of 36-37 weeks of gestation; the body weight of the child at birth is 2500-2001 g, length - 45-41 cm.
II degree of prematurity- delivery occurs at a period of 32-35 weeks of gestation; the body weight of the child at birth is 2001-2500 g, length - 40-36 cm.
III degree prematurenews- delivery occurs at a period of 31-28 weeks of gestation; the body weight of a child at birth is 1500-1001 g, length - 35-30 cm.
IV degree of prematurity- delivery occurs before 28 weeks of gestation; the birth weight of the child is less than 1000 g, the length is less than 30 cm. The term "premature with extremely low body weight" is used in relation to such children.
External signs of prematurity
Premature babies are characterized by a number of clinical signs, the severity of which correlates with the degree of prematurity.
Deeply premature babies with a body weight of II-II degree malnutrition), the child's physique is disproportionate (the head is large and is approximately 1/3 of the body length, the limbs are relatively short). The abdomen is large, flattened with a clearly visible divergence of the rectus muscles, the navel is located in the lower abdomen.
In very premature babies, all fontanelles and sutures of the skull are open, the cranial bones are supple, the brain skull prevails over the facial one. Characterized by underdevelopment of the auricles, poor development of nails (nail plates do not reach fingertips), weak pigmentation of the nipples and areola. The genital organs in premature babies are underdeveloped: in girls there is a gaping of the genital slit, in boys - undescended testicles into the scrotum (cryptorchidism).
Premature babies born at 33-34 weeks of gestation and later are characterized by greater maturity. Their appearance is different pink skin, the absence of a fluff on the face and torso, a more proportional physique (smaller head, higher location of the navel, etc.). In premature babies of I-II degree, the bends of the auricles are formed, the pigmentation of the nipples and areola circles is expressed. In girls, the large labia almost completely cover the genital gap; in boys, the testicles are located at the entrance to the scrotum.
Anatomical and physiological features of premature babies
Prematurity is determined not so much by anthropometric indicators as by the morphological and functional immaturity of vitality. important organs and body systems.
Characteristic features of the respiratory organs in premature babies are the narrowness of the upper respiratory tract, high standing diaphragm, compliance chest, perpendicular arrangement of the ribs relative to the sternum. These morphological features of premature babies cause superficial, frequent, weakened breathing (40-70 per minute), a tendency to apnea lasting 5-10 seconds (apnea of prematurity). Due to the underdevelopment of the elastic tissue of the lungs, the immaturity of the alveoli, and the reduced content of surfactant in premature babies, a syndrome of respiratory disorders easily occurs (congestive pneumonia, respiratory distress syndrome).
Immaturity of cardio-vascular system characterized by pulse lability, tachycardia 120-180 per minute, muffled heart tones, arterial hypotension (55-65/20-30 mm Hg). In the presence of congenital heart defects (open Botall duct, open foramen ovale), murmurs may be heard. Due to the increased fragility and permeability of the vascular walls, hemorrhages easily occur (subcutaneous, into internal organs, into the brain).
Morphological signs of CNS immaturity in premature infants are weak differentiation of gray and white matter, smoothness of the brain sulci, incomplete myelination of nerve fibers, and poor vascularization of the subcortical zones. Muscle tone in premature babies is weak, physiological reflexes and motor activity are reduced, the reaction to stimuli is slowed down, thermoregulation is impaired, there is a tendency to both hypo- and hyperthermia. During the first 2-3 weeks premature baby transient nystagmus and strabismus, tremors, winces, clonus of the feet may occur.
In premature babies, functional immaturity of all parts of the gastrointestinal tract and low enzyme-excretory activity are noted. In this regard, premature babies are prone to regurgitation, the development of flatulence, dysbacteriosis. Jaundice in premature babies is more intense and lasts longer than in full-term newborns. Due to the immaturity of the liver enzyme systems, the increased permeability of the blood-brain barrier, and the rapid breakdown of red blood cells, premature infants can easily develop bilirubin encephalopathy.
Functional immaturity of the kidneys in premature infants leads to changes in the electrolyte balance (hypocalcemia, hypomagnesemia, hypernatremia, hyperkalemia), decompensated metabolic acidosis, a tendency to edema and rapid dehydration with inadequate care.
The activity of the endocrine system is characterized by a delay in the formation of the circadian rhythm of hormone release, rapid depletion of the glands. In premature babies, there is a low synthesis of catecholamines, transient hypothyroidism often develops, in the first days of life a sexual crisis rarely occurs (physiological mastitis, physiological vulvovaginitis in girls).
Premature babies develop early anemia more rapidly than full-term babies, there is an increased risk of developing septicemia (sepsis) and septicopyemia (purulent meningitis, osteomyelitis, ulcerative necrotic enterocolitis).
During the first year of life, the increase in body weight and length in premature babies occurs very intensively. However, according to anthropometric indicators, premature babies catch up with their peers born at term only by 2-3 years (sometimes by 5-6 years). lag in psychomotor and speech development in premature babies depends on the degree of prematurity and concomitant pathology. In a favorable scenario for the development of a premature baby, alignment occurs in the 2nd year of life.
Further physical and psychomotor development of premature babies may be on par with their peers or be delayed.
Among premature babies, neurological disorders are more common than among full-term peers: astheno-vegetative syndrome, hydrocephalus, convulsive syndrome, vegetative-vascular dystonia, cerebral palsy, hyperactivity, functional dyslalia or dysarthria. Almost a third of premature babies have a pathology of the organ of vision - myopia and astigmatism of varying severity, glaucoma, strabismus, retinal detachment, optic nerve atrophy. Premature babies are prone to frequent repeated acute respiratory viral infections, otitis media, against which background hearing loss may develop.
Women who were born prematurely adulthood often suffer from menstrual irregularities, signs of sexual infantilism; they may be at risk of miscarriage and premature birth.
Features of caring for premature babies
Babies born prematurely need special care. Their phased nursing is carried out by neonatologists and pediatricians, first in the maternity hospital, then in the children's hospital and polyclinic. The main components of caring for premature babies are: ensuring optimal temperature and humidity conditions, rational oxygen therapy and metered feeding. In premature babies, constant monitoring of the electrolyte composition and CBS of the blood, monitoring of the gas composition of the blood, pulse and blood pressure is carried out.
Very premature babies are placed immediately after birth in incubators, where, taking into account the condition of the child, a constant temperature (32-35 ° C), humidity (in the first days about 90%, then 60-50%), oxygenation level (about 30%) are maintained. Premature babies of I-II degree are usually placed in heated beds or in ordinary beds in special boxes, where the air temperature is maintained at 24-25°C.
Premature babies who are able to support themselves normal temperature bodies that have reached a body weight of 2000 g, with good epithelialization umbilical wound may be discharged home. The second stage of nursing in specialized departments of children's hospitals is indicated for premature infants who have not reached 2000 g in the first 2 weeks, and for children with perinatal pathology.
Feeding premature babies should begin in the first hours of life. Children with absent sucking and swallowing reflexes are fed through a gastric tube; if the sucking reflex is sufficiently pronounced, but the body weight is less than 1800 g, the child is fed through the nipple; children weighing over 1800 g may be breastfed. The frequency of feeding premature babies I-II degree 7-8 times a day; III and IV degree - 10 times a day. Calculation of food is made according to special formulas.
Premature babies with physiological jaundice should receive phototherapy (general UV). As part of the rehabilitation of premature babies at the second stage, communication between the child and the mother, skin-to-skin contact, is useful.
Clinical examination of premature babies
After discharge, children born prematurely need constant supervision by a pediatrician during the first year of life. Examinations and anthropometry are carried out weekly in the first month, once every two weeks - in the first half of the year, once a month - in the second half of the year. In the first month of life, premature babies should be examined by a pediatric surgeon, pediatric neurologist, pediatric orthopedic traumatologist, pediatric cardiologist, pediatric ophthalmologist. At the age of 1 year, children need to consult a speech therapist and a child psychiatrist.
From 2 weeks of age, premature babies need the prevention of iron deficiency anemia and rickets. Preventive vaccinations for premature babies are carried out according to an individual schedule. In the first year of life, repeated courses of baby massage, gymnastics, individual wellness and tempering procedures are recommended.
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% in our country. infant mortality; 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.
too young or too elderly age parents. 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 low level parental education and related unhealthy lifestyle during pregnancy and lack of understanding of the importance of continuous
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. 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.
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, nipples and areola mammary glands barely noticeable; auricles are flat, shapeless, soft, pressed against the head; nails are thin and do not always reach the edge 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. Leather Pink colour, 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. Babies born at more than 34 weeks' gestation show the first curves at 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 infants are characterized by muscle hypotension, decreased physiological reflexes, decreased motor activity, impaired thermoregulation, and weak crying. 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).
Laboratory research
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 of 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 the maternity hospital and in a 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 in the future of all modern methods care and treatment. 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 the individual characteristics of the 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. The optimum air temperature in the room is 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
Peculiarities of feeding 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 satisfactory general condition, a sufficiently pronounced sucking reflex and a body weight at birth of more than 1800 g can be applied 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.
Prematurity is the birth of a child before the end of the gestational period, that is, in the period from 22 to 37 weeks, with a body weight of less than 2500 g and a length of less than 45 cm.
In premature babies, there are disorders of thermoregulation, breathing with a tendency to apnea (cessation of respiratory movements), weak immunity and overt anthropometric and clinical features.
Degrees
The classification of premature babies by degrees is related to the body weight of the child (the gestational age is conditional):
1 degree - body weight 2001-2500g. (term corresponds to 35-37 weeks);
2 degree - body weight 1501-2000g. (term corresponds to 32-34 weeks);
3 degree - 110-1500gr. (gestational age 29-31 weeks);
Grade 4 - the weight of the child is less than 1000 g, which corresponds to a gestational age of less than 29 weeks (extremely premature).
Reasons for the birth of premature babies
The causes of preterm birth are numerous and presented from three sides:
Maternal factors:
- chronic diseases of a woman (pathology of the cardiovascular system, endocrine diseases, kidney pathology):
- acute infections during pregnancy;
- gynecological diseases;
- aggravated obstetric history (abortion, caesarean section);
- intrauterine device;
- trauma;
- age (under 17 and over 30);
- Rh-conflict pregnancy;
- bad habits;
- pathology of the placenta (previa, detachment);
- harmful working conditions;
- complications of pregnancy (preeclampsia).
Paternal factors:
- age (over 50 years);
- chronic diseases.
fruit factors:
- intrauterine malformations;
- multiple pregnancy;
- erythroblastosis (hemolytic disease);
- intrauterine infection.
signs
Premature babies have a pronounced clinical picture. There is a disproportion of body parts, the brain skull prevails over the facial one. The bones of the skull are soft, in addition to the fontanelles, non-fusion of the cranial sutures is observed. Soft ears are also characteristic.
In premature babies, the subcutaneous fat layer is poorly developed, they cannot “keep” the temperature (thermoregulation instability). The underdevelopment of the lungs in prematurity is due to the lack of a surfactant, which ensures the opening of the pulmonary alveoli on inhalation, which is manifested by respiratory failure and periodic apnea (breathing stops).
The skin is wrinkled, has a bright red color on the first day, there is a weak muscle tone or its complete absence.
Physiological reflexes (sucking, searching and others) are weakly expressed.
In premature boys, the testicles are not lowered into the scrotum, and in girls, the labia majora are underdeveloped. Hypertensive and hydrocephalic syndromes are characteristic of premature babies.
Due to the underdevelopment of the eyelids, bulging eyes (exophthalmos) are expressed.
There is insufficient liver function, which is manifested by nuclear jaundice. Due to underdeveloped immune system premature babies are at high risk of infection. Premature babies are prone to spitting up. In addition, these children have underdeveloped nail plates and can only reach the middle of the fingertips.
Therapy for premature babies
A neonatologist is involved in the management and treatment of premature babies.
Children born before term require certain conditions of existence. The ambient temperature should be 25°C and the humidity should be at least 55-60%. For this purpose, premature babies are kept in incubators (special incubators).
Infants weighing less than 2000 g are kept in incubators. The discharge of healthy premature babies is carried out on the 8-10th day, provided that their body weight reaches 2 kg.
If premature baby has not reached a weight of 2000 g within 14 days, he is transferred to the second stage of nursing (carried out in the intensive care unit of the children's department / hospital). Such children are placed in incubators where oxygen is supplied.
Bathing premature babies begins at 2 weeks of age (subject to healing of the umbilical cord residue). They walk with children when they are 3-4 weeks old and weigh 1700-1800g.
The discharge of healthy premature babies is carried out when they reach a weight of 1700g.
Feeding
Feeding a baby with expressed breast milk begins 2-6 hours after birth, provided there are no contraindications and long term pregnancy (34-37 weeks).
Children who are in serious condition or very preterm are given parenteral nutrition through a tube (through the mouth or nose) during the first 24-48 hours of life.
A child weighing 1800-2000g begins to be applied to the breast. with active sucking. On day 1, the volume of one feeding is 5-10 ml, on day 2 10-15 ml, and on day 3 - 15-20 ml.
In addition, premature babies are shown the introduction of vitamins:
- vikasol (vitamin K) to prevent intracranial hemorrhage;
- ascorbic acid (vitamin C), vitamins B1, B2;
- vitamin E (tocopherol);
- prevention of rickets (vitamin D);
- vitamins B6 and B5, lipoic acid with deep prematurity;
Consequences of prematurity and developmental prognosis
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. The risk of death increases in the following cases:
- prenatal bleeding;
- childbirth in breech presentation;
- multiple pregnancy;
- asphyxia in childbirth;
- low temperature of the child;
- respiratory distress syndrome.
Long-term consequences of prematurity (the likelihood of these complications again depends on many factors; under other favorable conditions, these complications are quite rare):
- lag in mental and physical development;
- cerebral palsy;
- convulsive and hydrocephalic syndromes;
- myopia, astigmatism, glaucoma, retinal detachment;
- tendency to frequent infections;
- hearing impairment;
- menstrual disorders, genital infantilism and problems with conception in girls.
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 the full 37 weeks of pregnancy or earlier than 259 days counted from the first day of the last menstrual cycle (WHO, 1977). A prematurely born child is premature.
premature birth statistics .
The frequency of preterm birth = 3–15% (average − 5–10%). Premature births in 2002 - 4.5%. There is no downward trend in this indicator.
Among prematurely born children, the highest morbidity and mortality are observed. They account for 50 to 75% of infant mortality, and in some developing countries - almost 100%.
Causes of preterm birth
socio-economic (salary, living conditions, nutrition of a pregnant woman);
socio-biological (bad habits, parent's age, prof. harmfulness);
clinical (extragenital pathology, endocrine diseases, threat, preeclampsia, hereditary diseases).
Factors contributing to fetal growth retardation and preterm labor (prematurity) can be divided into 3 groups :
absence or insufficiency medical care before and during pregnancy;
level of education (less than 9 classes) - affect the level and lifestyle, personality traits, material well-being;
low standard of living and, accordingly, material security, and as a result, unsatisfactory living conditions, inadequate nutrition of the expectant mother;
occupational hazards (physically difficult, prolonged, monotonous, standing work of a pregnant woman);
extramarital birth (especially with unwanted pregnancy);
unfavorable ecological situation;
young or old age of the pregnant woman (less than 18 years old) and the 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;
pathology of pregnancy: late gestosis, nephropathy, immunological conflict in the mother-placenta-fetus system;
anomalies in the development of the placenta, umbilical cord;
in vitro fertilization;
multiple pregnancy (about 20% of all premature babies);
fetal diseases: IUI, hereditary diseases, defects fetal development, isoimmunological incompatibility;
the interval between births is less than 2 years.
socio-economic:
socio-biological:
clinical:
Causes of prematurity can be divided according to another principle:
environmental,
coming from the mother;
associated with the peculiarities of the course of pregnancy;
from the side of the fetus.
Classification of prematurity
In ICD X revision under heading R 07 " Disorders associated with the shortening of pregnancy, as well as low birth weight" The division of premature newborns is accepted both by weight and by gestational age. The note says: When both birth weight and gestational age are established, birth weight should be preferred.
Depending on the indicators of gestational age and body weight of a premature baby, 4 degrees of prematurity (3 weeks for each of the first three degrees):
|
Degrees of prematurity |
by gestation |
by body weightat birth |
||
|
I degree |
35 weeks - incomplete 37 weeks (up to 259 days) |
2500−2000 grams |
low |
|
|
II degree |
32-34 weeks |
1999−1500 grams |
||
|
III degree |
deeply premature |
29-31 weeks |
1499−1000 grams− very low body weight |
|
|
IV degree |
22-28 weeks |
999-500 grams extremely low mass (extremely low mass) |
||
Extreme prematurity− gestational age less than 22 completed weeks (154 completed days).
The line between miscarriage and premature at 22 full weeks (154 full days) of gestation is determined by weight: 499 g - miscarriage, 500 g - premature newborn.
Anatomical, physiological and neuropsychic features of premature babies
Anatomical features of premature babies (external signs of immaturity):
the skin is thin and glossy, dark red, as if translucent;
on the face, back, extensor surfaces of the limbs there is an abundant primordial fluff - lanugo;
the subcutaneous fat layer is thinned, as a result of which the skin is wrinkled, there is a tendency to edema of the subcutaneous fat;
body length from 25 cm to 46 cm;
disproportionate physique (the head is relatively large: the large vertical size of the head ranges from ¼ to ⅓ of the body length, the brain skull prevails over the facial one; the neck and lower limbs are short);
low forehead hair growth
the skull is more round, its bones are pliable - non-closure of cranial sutures, small and lateral fontanelles are usually open;
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 is pink, the upper half is 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.
Raise muscle tone in the flexors they usually appear 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, disappears later (by the 8-14th day of life), the healing of the umbilical wound is 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). For anxiety and fever environment the heart rate can reach up to 200 beats per 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 requires close attention, since a number of problems often arise in the process of nursing it. 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 low birth weight group is particularly affected by exposure to external factors. They demand ideal conditions nursing, in order to achieve not only their survival, but also a 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 (the smaller the weight of the child, the higher the temperature), by the end of the month the temperature is gradually reduced to 32 degrees. Temperature regime in the couveuse are 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 medical procedures include airway debridement, chest vibration massage, gastric tube insertion and feeding, vein catheterization, chest x-ray, ultrasound, ophthalmoscopy, daily physical examination, 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 by middle line in a flexor position, swaddling, imitating 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 unable to long period time to respond to pain with change 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 manipulations in care and medical 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 pacifier with a bottle of water, swaddling that imitates closed space uterus, reducing exposure to light and noise, performing several manipulations at the same time in order to increase the gaps between them and give the child a 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. Weak muscles 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 to a newborn 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.
