This is a guest post by Dr. Wossenseged AsratHe will take you on an exploration of the unique journey of preterm babies and the empowering strategies that can help them thrive.

The arrival of a preterm baby is often unexpected and can be accompanied by a whirlwind of emotions for parents and caregivers. However, it is through understanding and embracing the remarkable resilience of these tiny warriors that we can unlock a world of possibilities and provide them with the support they need to overcome the challenges they may face. Join us as we delve into the inspiring stories, research-backed insights, and empowering strategies that can make a profound difference in the lives of preterm babies and their families.

Since the way we tend to define preterm delivery is quite customary. It is very important to set a clear cutoff gestational age from which deliveries below it are defined as  preterm deliveries.

Definitions An infant born after the age of viability but before the completion of 37 weeks of pregnancy is referred to as Preterm Babies. But here too the cutoff week for age of viability is context dependent too. (In US it is defined to be above 22 weeks of gestation, where as in developing nations like Ethiopia it is taken to be above 28 weeks of gestation.)

And according to American Academy of Pediatrics and American College of Obstetricians and Gynecologists again preterm babies will be further classifed as follows:

  • Extremely Preterm (those less than 28 weeks of gestation)
  • Very Preterm (those between 28 weeks and 32 weeks)
  • Moderately Preterm (those between 32 and 34 weeks)
  • Late Preterm (from 34 to 37 weeks)

Birth Weights

Preterm babies tend to weigh smaller as compared to term babies. Since they have not completed their intra-uterine growth fully.

And based on World Health Organization (WHO) on their birth weights again preterm babies will be further classified to as

  • Extremely Low Birth Weight (when birth weight is less than 1000 grams)
  • Very Low Birth Weight (when birth weight between 1000-1500 grams)
  • Low Birth Weight (when birth weight between 1500-2500 grams)

Possible causes for preterm deliveries

Most often ascribing a single cause to a certain preterm delivery is not an easy job. Because there are multiple risk factors contributing to effect the delivery of a baby prior to completion of term dates. In general we can broadly classify the causes to be as 1) Elective preterm deliveries, and 2) Spontaneous preterm deliveries.

Elective Preterm Deliveries

Sometimes Obstetricians might choose to deliver the baby before the completion of term date for certain obstetric indications (Severe Pre-Eclampsia, uncontrolled Gestational Diabetes, active vaginal bleeding causing hemodynamic instability for the mother….) so as to salvage the mother from an impending gross threat to her well-beingness.

 Spontaneous Preterm Deliveries

Whereas in the rest of cases, preterm deliveries might follow a certain speculated risk factor or happens spontaneously for unknown reasons. The following are some known risk factors:
Any history of preterm delivery in the previous pregnancies ( the strongest known risk factor)

  • If the current pregnancy is multiple pregnancy (59% of twin pregnancies and 98% of higher order pregnancies usually will deliver prematurely)
  • Any history of abortion
  • Low maternal body weight
  • Having no antenatal care visits in the current pregnancy
  • Maternal age less than 16 years and older than 35 years
  • Maternal habits (if mother is cigarette smoker, or substance abuser)
  • Untreated infections of the genitourinary system (Bacterial Vaginosis)
  • Any obstetrical co-morbidities (Like high blood pressure, Uncontrolled Gestational Diabetes )
  • The socio-economic status of the mother (though the exact mechanism of it is not clearly delineated till now, but it has been found that mothers from a lower socio-economic profile are at higher risk for preterm deliveries when they get pregnant.)

 Complications seen in Preterm Babies 

Preterm deliveries usually come up with lots of transient and longstanding health related complications. These complications are in one or another way related to the immaturity of the organ-systems of preterm babies. And the rate of these complications is inversely related to the gestational age (the higher the date meaning the closer it gets to term date then the lower the complications will be). Let us examine them in the order of the involved organ-systems.

Cardiac

The most common cardiac pathology that is commonly seen in preterm babies is Patent Ductus Arteriosus (PDA). The ductus arteriosus is one of the fetal shunts which helps in shunting the oxygenated blood from the high resistance pulmonary vessels. But soon after birth with in the first few hours this shunt will close spontaneously. But in preterms it might remain patent. And its incidence increases with increasing prematurity.

Central Nervous System

Poor sucking and swallowing reflexes
Due to the immature development of their nervous systems, preterms are more and more prone to have a poorly coordinated sucking and swallowing reflexes. For that they are at higher risk to aspirate their oral intake in to their lungs and complicate with Aspiration Pneumonia. For that it is highly recommended to feed them with naso-gastric tubes or totally parenteral feeding.

Central Apnea
Newborns have an irregular breathing pattern, meaning they might be apenic in the middle of their regular breathing only to resume by themselves soon after. But pathological apnea is defined as when the cassation of breathing lasts for more than 15-20 seconds.  And preterm babies, in particular, they are at a greater risk to experience central apnea secondary to the immaturity of the respiratory center in their brain.

Intraventricular Hemorrhage
Ventricles are spaces with in the brain parenchyma which serves as a tract for the flow of Cerebrospinal fluids. And in preterm babies the peri-ventricular germinal matrix is prone to hemorrhage. And it might even be complicated with periventricular white matter injury which might lead to cerebral palsy and neurodevelopmental delays.

Eyes

Retinopathy of Prematurity

The vascularization process of the retina would not get finalized till the completion of full term gestation. Preterm birth interferes with the normal vascularization and angiogenesis of these retinal vessels which could cause visual defects or even blindness.

Strabismus and Myopia

Gastrointestinal System

Feeding intolerance

Preterms have a smaller stomach and immature gastric and intestinal motility. These factors will impair their tolerance to the oral and nasogastric tube feedings.

Necrotizing Enterocolitis (NEC)

It is the most common surgical emergency in preterm babies. The three factors which contribute for the development of necrotizing enterocolitis are enteral feeding (especially with formula), prematurity, compromised blood flow to the gut. And usually the newborns will present with bloody stool, distended and tender abdomen and feeding intolerance. Being fed human breastmilk, mother’s own breastmilk or donor pasteurized human milk, is protective against NEC.

Infectious Complications

Preterms are found to be 4 times more likely to develop sepsis and meningitis as compared to that of term neonates. And predisposing risk factors are reduced serum immunoglobulin,  the presence lf indwelling intravascular cathethers and endotracheal tubes and areas of skin breakdown which might serve as a portal of entry for pathogenic micro-organisms.

Respiratory System

Preterm babies are more prone to develop respiratory distress for multiple reasons. The common clinical presentations will be fast breathing, audible grunting, flaring of ala nasi, bluish discoloration of the lips, retractions of the intercostal spaces. On top of other common etiologies what is a pecuilar cause of respiratory distress in preterm babies is Respiratory Distress Syndrome (RDS). It is secondary to surfactant deficiency which leads to alveolar collapse and atelectasis.

Some of these preterm babies will be weaned off from the respiratory support with in short period of time but others could develop chronic lung disease (Bronchopulmonary Dysplasia) and might need prolonged respiratory support.

Metabolic Complications

Neonatal Hypoglycemia

It is very common for premature babies to have low blood sugar (glucose) levels.

Neonatal Hyperbillirubinemia (Neonatal Jaundice)

Decreased maturiy of the hepato-billiary system and decreased intestinal motility will play their part for the development of neonatal jaundice on top of other risk factors which are shared with term babies, like some types of blood group incompatibility with mother.

Temperature Regulation

Hypothermia

Preterm babies have exceptionally large body surface area to volume ratio; therefore when exposed to the external environment they will rapidly lose their body heat and have a difficulty in maintaining their body temperature.

But all the aforementioned complications will not occur in all preterms despite the clinical conditions, some preterms might not have any of them.

Holistic Management of Preterm Babies

Emotional Support for Parents

Parents should be encouraged and supported to visit their newborns despite the clinical condition of the baby. Direct skin to skin contact (Kangaroo Care) is greatly beneficial to maintain their body temperature and to foster the bonding between the mother and their newborn babies.

Feeding should be through nasogastric (NG) tube or directly through Intravenous route  until 34 weeks  and then after direct breast feeding will be encouraged unless there is another contraindication for doing so. However breast milks dont contain adequate calcium, phosphorus and and proteins for those with very low birth weight (Less than 1500 grams) for whom breast milk fortifiers or special preterm formula milks could be used too as an alternative.

Breast milk is not only a source of nourishment for preterm babies but also plays a crucial role in their overall health and well-being. One significant benefit of breast milk is its ability to help prevent necrotizing enterocolitis (NEC), a serious and potentially life-threatening condition that affects the intestines of preterm infants. Breast milk is rich in essential nutrients, antibodies, and beneficial bacteria that help strengthen the baby’s immune system and protect against NEC. By promoting exclusive breast milk feedings, we can greatly reduce the risk of NEC and give preterm babies the best possible start in life.

Skin-to-skin contact, also known as kangaroo care, has numerous benefits for both premature babies and their mothers. One remarkable advantage is that it actually stimulates the secretion of milk in the mother’s breast. The close physical contact and warmth between mother and baby during skin-to-skin care triggers hormonal responses that promote milk production. This intimate bonding experience not only enhances the mother-baby connection but also ensures an adequate supply of breast milk, which is vital for the growth and development of premature infants.

Addressing all the medical complications with appropriate medical management before facilitating discharge from the NICU.

Prevention

Eventhough it will be difficult to eliminate the risk of preterm deliveries but there are certain interventions which help to decrease the risk.

  • Adjusting modifiable maternal risk factors
  • Starting antenatal care as early as possible once you know you are pregnant
  • Arresting preterm labor with tocolytics
  • Giving antenatal steriods to hasten fetal lung maturity 48 hrs prior to delivery.

As we come to the end of our dedicated exploration into the world of preterm babies, we hope that you have found this blog to be a valuable resource filled with insightful information and empowering strategies. Our intention has been to shed light on the unique journey of preterm infants and provide support and guidance to their families. Remember, you are not alone in this journey. Whether you are a parent, caregiver, or simply someone seeking knowledge, we encourage you to continue seeking out resources, connecting with others, and advocating for the well-being of these remarkable warriors.

Together, we can make a difference and give preterm babies the love, care, and opportunities they deserve. Thank you for joining us on this meaningful journey.

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