Premature infants: aka preemies.

Prematurity is not based just on weight.

LBW are not always considered preemies.

Factors:

• weeks of gestation
• birth weight
• clinical appearance and behavior

Dubowitz and Ballard are charts that help determine gestational age. Based on physical and neurological maturity. Done within the 1st 24 hours of birth to be accurate.

Prematurity is one of the leading causes of death in the neonate.

Pre-term: born before 37 week gestation.

Can also be classified according to weight after 37 weeks.

SGA: newborn in the lowest 10th percentile of weight for gestational age.

AGA: weight falls between the 10th percentile and the 90th percentile.

LGA: above the 90th percentile.

IUGR: intrauterine growth retardation. Used to describe a SGA fetus.

LBW: low birth weight. NB weighing between 1500-2500 grams regardless of the reason.

VLBW: every LBW babies, <1500 grams regardless of gestational age.

Preemie characteristics:

• lot of lanugo
• transparent skin
• ear has less cartilage
• ear has slow or no recoil
• smooth soles of feet
• not a lot of molding
• skin is red
• labia major does not cove minora
• testes may not be descended
• scrotum does not have rugea
• do not lie in flexed position -- have hypotonia
• swallowing and gag reflex may be absent; at risk for aspiration, another risk is an immature cardiac sphincter
• sometimes can’t feed more than 10cc
• immune system is depressed because antibodies did not get transferred; at risk for infection
• cry is low and whiney
• sucking is weak, ineffective or absent

Problems:

• respirations
• thermoregulation
• nutrition
• infection

Also called hyaline membrane disease. Occurs because the lungs are too immature to function properly. Preterm lacks sufficient surfactant. Surfactant keeps alveoli distended after expiration. Preemie will not get enough oxygen and this damages the lung cells. These damaged cells will combine with other substances in the lungs and will form a fibrous substance called hyaline membrane. Membrane lines the alveoli and blocks gas exchange.

Interventions:

Surfactant via endotracheal tube. This helps baby make his own.

Amniocentesis to get L/S ration. If not 2:1, can get an injection of celestone (betamethasone).

Monitor resps, ABG’s and pulse ox.

Oxygen can be given under hood or CPAP (continuous positive airway pressure).

Monitor for S&S of resp distress.

Disease that is associated with high blood concentration of oxygen. Causes vasoconstriction of the eye vessels and can lead to scarring which can lead to retinal detachment. Final stage is called restrolental fibroplasia. Can cause blindness. To prevent: keep oxygen concentration as low as possible. Usually not more than 40%.

Prone to cold stress. Do not have brown fat which is necessary for thermoneogenesis. Very important to keep baby warm. Can lead to metabolic acidosis and hypoglycemia.

Gastric gavage (tube feeding) may be needed with a high calorie formula (20/ounce). Will put NG tube down and feed q2h. Aspirate for residual. Giving too much puts at risk for aspiration. Let them eat for only 20 minutes to conserve energy. May only get face and fanny care and not a whole bath. Cannot be overstimulated. After feeding, place on their right side to promote normal peristalsis.

Prevention is best. Change position to prevent pressure areas. Family must be free of respiratory infections. Strict aseptic technique.

Try to reduce parent anxiety. Preemies are taken right away and bonding does not occur right away. Encourage to touch and talk to baby. Allow them to verbalize their feelings. They sometimes feel guilty.

Hypoglycemia: get a blood sugar. 40-80 is normal. Below 40 is hypoglycemic. S&S = jittery, tremors, twitching, limpness, lethargy, weak high pitch cry (indicated CNS involvement), apathy, convulsions, coma. Other signs: cyanosis, apnea, irregular rapid resps, poor feeding, sweating.

Respiratory distress: diabetic moms are unable to use phospolipids because of their hyperinsulinism. This makes them unable to use lecithin.

NEC. Acute inflammatory disease of the intestines. Found in infants who were hypoxic at birth or premature. Causes poor tissue perfusion to the bowel and bacteria will enter the bowel and necrotic gas pockets form. Causes distention (shiney and tender to touch) of the abdomen. Will have regirgitation and gastric residual. Will get early feedings loaded in sugar which can cause bacteria to grow. Usually occurs within 1st 10 days of life. Diagosed by x-ray. Complication is bowel can perforate. Treatment is to stop formula feeding, put on IV fluids, antibiotics, and may have to have a colostomy. When abdomen is distended, do not tape diaper, no rectal temp, must measure girth.

Vitamin K:

Gets an injection of vitamin K to help with clotting. Need vitamine K to make prothrombin in the liver. Normal bacteria in the stomach is needed to produce vitamin K. The baby has a sterile stomach and must get the injection to prevent bleeding. Will get 0.5mg to 1mg IM in vastis lateralis.

Erythomicin:

Eye prophylaxis is give to prevent blindness. Prevents opthalmus neonatoreum from maternal gonorrhea or chlamydia. Used to use silver nitrate but is does not work on chlamydia. State law.

Hepatitis B vaccine:

Some get Hep B vaccinations. Side effects can be detrimental so some hospitals don’t give it.

Phenylketonuria (PKU):

PKU testing. Inborn error of metabolism. Passed by recessive gene. Both parents have to have it in order for the baby to get it. The NB is not able to oxidize phenylalanine. It builds up in the blood stream and these phenyl ketones will accumulate on the brain. As a result infant may be mentally retarded. This amino acid is found in meat, dairy products, dry beans, nuts and eggs. Phenylalanine cannot be converted to triazine, which is needed to produce melanin. Tested after a milk diet for 24 hours by a heel stick. If error is found, they are put on a special diet until adulthood. Diet should start before baby is 3 weeks old. Lofenalac is a formula used to feed.

Circumcision:

Contraversial issue. In March of 99 the American Academy of Pediatrics took away payment from circumcision. Benefits were thought to include the prevention of cancer, UTI, and STD’s, but there is not enough evidence of this. It is recommended that pain relief be given. Needs consent, NPO and to be restrained.

1. Gomco: bell shaped aparatus placed over the glans and tightened. Will put vasaline gause around glans with antibiotic ointment. Should void within 12 hours. If bleeds, then squirt epinephrine on penis. It is a vasoconstrictor. Teach mom to change vasaline gause after each change of diaper.

2. Plastitube: plastic ring placed between glans and prepuce secured with a suture. Foreskin is cut. Plastic ring falls off within 7-10 days. Also check for bleeding and voiding. Don’t have to use vasaline gause.