Prematurity Preterm neonate

P07.3

DESCRIPTION

Neonate born before 37 completed weeks of pregnancy.

GENERAL AND SUPPORTIVE MEASURES

  • Admit unwell/unstable infants to neonatal high/intensive care facility.
  • Temperature control:
    • Kangaroo mother care: Initiate if baby is well and vital signs are stable.
    • Provide a neutral thermal environment (incubator or infant crib with overhead heater) and keep ambient temperature at 26–28°C.
    • Keep infants temperature, axilla or skin of anterior abdominal wall, at
    • 36.2–36.8°C.

Table for neutral thermal environment for age and body mass

Neutral Thermal Environment

Age Temperature for body mass range
< 1 200 g
± 0.5°C 		‎≥1 200– 1500 g ± 0.5°C ‎≥1 500– 2 500 g ±1°C ‎≥2 500 g ±1.5°C
0–12 hours 35 34.0 33.3 32.8
12–24 hours 34.5 33.8 32.8 32.4
2–4 days 34.5 33.5 32.3 32.0
4–14 days 33.5 32.1 32.0
2–3 weeks 33.1 31.7 30.0
3–4 weeks 32.6 31.4
4–5 weeks 32.0 30.9
5–6 weeks 31.4 30.4
  • Monitor to prevent or detect early the diseases/complications of prematurity:
    • respiratory rate,
    • haematocrit,
    • blood pressure,
    • bilirubin,
    • blood gas,
    • blood glucose,
    • acid-base status,
    • electrolytes,
    • calcium, magnesium,
    • hydration status, and
    • growth parameters.
  • Nutritional support:
    • Give naso/orogastric tube feedings to infants with audible bowel sounds and no complications/diseases of prematurity.
    • Preferably use own mother’s expressed breast milk, pasteurised donor breast milk or pre-term formula. Give small frequent bolus feeds, 1, 2 or 3 hourly or continuous naso/orogastric tube feeds (alternatives: cup, dropper, spoon, syringe).
    • Monitor gastric emptying by aspirating the stomach before each feed.
    • Consider stopping enteral feeding if:
      • aspiration of 3 mL or more of gastric contents before the next feed,
      • vomiting,
      • abdominal distension,
      • diarrhoea, or
      • ileus.
    • IV alimentation if enteral feeds are contraindicated or not tolerated.
  • IV fluids to ensure adequate hydration, electrolyte and mineral intake, and normoglycaemia (blood glucose ≥ 2.6 mmol/L) until enteral (tube or oral) intake is satisfactory.
    • Discontinue IV fluids gradually to avoid reactive hypoglycaemia.
    • Discontinue the infusion when several oral feedings have been retained.
    • If renal function is compromised, use potassium-free solution.

Fluid requirements for a healthy preterm infant

Day of life mL/kg/24 hours
1 70
2 90
3 110
4 130
5 and onwards 150

Some infants may require fluid volumes up to 200 mL/kg/24 hours after day 6.

  • Hospital discharge if:
    • clinically well,
    • able to breastfeed or formula feed,
    • able to maintain body temperature, and
    • usually > 1.8 kg.
  • Follow-up visits to assess growth parameters, neurodevelopment, hearing and vision.

MEDICINE TREATMENT

To maintain haematocrit at 40% or Hb ±13 g/dL for the first 2 weeks of life:

  • Packed red cells, IV, 10 mL/kg.

To maintain oxygen tension in the blood at 60–80 mm Hg:

  • Oxygen, humidified via head box, or nasal cannulae.
    • Oxygen therapy should be utilised to maintain oxygen saturation of haemoglobin at of 90-94%; use pulse oximeter.

At birth

  • Vitamin K, IM, 0.5–1 mg.
  • Immunise according to EPI schedule according to chronological age.
  • Iron and multivitamin supplementation from the third week of life.

Prophylaxis

  • Iron (elemental), oral, 2–4 mg/kg/24/hours.
    • Ferrous lactate 1 mL = 25 mg elemental iron.
    • Multivitamin, oral, providing at least vitamin D, 400–800 IU and vitamin A, 1 250–5 000 IU per 24 hours.

Continue with iron and vitamin supplementation until the infant is on a balanced diet.

REFERRAL

Presence of one or more of the following complications that cannot be managed at the facility:

  • Respiratory distress and/or apnoea attacks requiring ventilatory support.
  • PDA with cardiac failure not responding to medical management.
  • Necrotising enterocolitis requiring surgical intervention.
  • Jaundice with serum unconjugated bilirubin level in the exchange transfusion zone.
  • Septicaemic infants or infants with infections not responding to therapy.
  • Pulmonary and/or intraventricular haemorrhage.
  • Feeding difficulties where the underlying cause is unclear.
  • Infants requiring hyperalimentation if parenteral nutrition is not available at the hospital.
  • Convulsions not responding to treatment.
  • Congenital abnormalities requiring surgical intervention.
  • Hypoglycaemia not responding to treatment.
  • For eye examination/hearing screening:
    • infants less than 1.5 kg,
    • infants < 32 weeks gestation,
    • infants who received prolonged respiratory support/oxygen,
    • infants with recurrent apnoea, and
    • infants with an unstable clinical course.