Premature Baby Assessment
Premature Baby Assessment
Premature Baby Assessment
Prematurity is defined by the gestational age at which infants are born. Previously, any
infant weighing < 2.5 kg was termed premature. Although premature infants tend to be
small, this weight-based definition is incorrect because many infants weighing < 2.5 kg are
mature or postterm and postmature and small for gestational age; they have a different
appearance and different problems.
In 2015, 9.63% of births in the US were premature (decreased from 10.44% in 2007). Of
these, 71% were late preterm and 29% (2.76% of births) occurred at < 34 weeks .
Premature infants, even late preterm infants who are the size of some full-term infants, have
increased morbidity and mortality compared to full-term infants due to their prematurity.
Gestational age
Gestational age is loosely defined as the number of weeks between the first day of the
mother's last normal menstrual period and the day of delivery. More accurately, the
gestational age is the difference between 14 days before the date of conception and the date
of delivery. Gestational age is not the actual embryologic age of the fetus, but it is the
universal standard among obstetricians and neonatologists for discussing fetal maturation.
Birth prior to 37 weeks gestation is considered premature. Premature infants are further
categorized as
Premature infants tend to be smaller than term infants. The Fenton growth charts provide a
more precise assessment of growth vs gestational age (see Figure: Fenton growth chart for
preterm boys and see Figure: Fenton growth chart for preterm girls).
Premature infants are categorized by birthweight:
Etiology
Elective
Spontaneous
Cigarette smoking
Younger or older maternal age (eg, < 16 years, > 35 years)
Untreated infections (eg, bacterial vaginosis, intra-amniotic infection [formerly
chorioamnionitis])
Multiple gestation (eg, twins, triplets)
Cervical insufficiency (formerly cervical incompetence)
Preeclampsia
Placental abruption
Certain congenital defects (fetuses with structural congenital heart defects are nearly
twice as likely to be delivered prematurely as fetuses without congenital heart
defects)
Multiple gestation is an important risk factor; 59% of twins and > 98% of higher-order
multiples are delivered prematurely. Many of these infants are very premature; 10.7% of
twins, 37% of triplets, and > 80% of higher-order multiples are delivered at < 32 weeks ( 1).
Socioeconomic factors
Low socioeconomic status
It is unclear how much risk these socioeconomic factors contribute independent of their
effect on other risk factors (eg, nutrition, access to medical care).
Complications
Cardiac
The overall incidence of structural congenital heart defects among premature infants is low.
The most common cardiac complication is
Apneic episodes
Intraventricular hemorrhage
Developmental and/or cognitive delays
Infants born before 34 weeks gestation have inadequate coordination of sucking and
swallowing reflexes and need to be fed intravenously or by gavage.
Immaturity of the respiratory center in the brain stem results in apneic spells (central
apnea). Apnea may also result from hypopharyngeal obstruction alone (obstructive apnea).
Both may be present (mixed apnea).
The periventricular germinal matrix (a highly cellular mass of embryonic cells that lies over
the caudate nucleus on the lateral wall of the lateral ventricles of a fetus) is prone to
hemorrhage, which may extend into the cerebral ventricles (intraventricular hemorrhage).
Infarction of the periventricular white matter (periventricular leukomalacia) may also occur
for reasons that are incompletely understood. Hypotension, inadequate or unstable brain
perfusion, and blood pressure peaks (as when fluid or colloid is given rapidly IV) may
contribute to cerebral infarction or hemorrhage. Periventricular white matter injury is a
major risk factor for cerebral palsy and neurodevelopmental delays.
Premature infants, particularly those with a history of sepsis, necrotizing enterocolitis,
hypoxia, and intraventricular and/or periventricular hemorrhages, are at risk of
developmental and cognitive delays (see also Childhood Development). These infants
require careful follow-up during the first year of life to identify auditory, visual, and
neurodevelopmental delays. Careful attention must be paid to developmental milestones,
muscle tone, language skills, and growth (weight, length, and head circumference). Infants
with identified delays in visual skills should be referred to a pediatric ophthalmologist.
Infants with auditory and neurodevelopmental delays (including increased muscle tone and
abnormal protective reflexes) should be referred to early intervention programs that provide
physical, occupational, and speech therapy. Infants with severe neurodevelopmental
problems may need to be referred to a pediatric neurologist.
Eyes
Ocular complications include
Retinopathy of prematurity (ROP)
Myopia and/or strabismus
Retinal vascularization is not complete until near term. Preterm delivery may interfere with
the normal vascularization process, resulting in abnormal vessel development and
sometimes defects in vision including blindness (ROP). Incidence of ROP is inversely
proportional to gestational age. Disease usually manifests between 32 weeks and 34 weeks
gestational age.
Gastrointestinal tract
Gastrointestinal complications include
Necrotizing enterocolitis
Feeding intolerance is extremely common because premature infants have a small stomach,
immature sucking and swallowing reflexes, and inadequate gastric and intestinal motility.
These factors hinder the ability to tolerate both oral and nasogastric feedings and create a
risk of aspiration. Feeding tolerance increases over time, particularly when infants are able
to be given some enteral feedings.
Necrotizing enterocolitis usually manifests with bloody stool, feeding intolerance, and a
distended, tender abdomen. Necrotizing enterocolitis is the most common surgical
emergency in the premature infant. Complications of neonatal necrotizing enterocolitis
include bowel perforation with pneumoperitoneum, intra-abdominal abscess formation,
stricture formation, short bowel syndrome, septicemia, and death.
Infection
Infectious complications include
Sepsis
Meningitis
Sepsis or meningitis is about 4 times more likely in the premature infant, occurring in
almost 25% of very low-birthweight infants. The increased likelihood results from
indwelling intravascular catheters and endotracheal tubes, areas of skin breakdown, and
markedly reduced serum immunoglobulin levels (see Perinatal Physiology : Neonatal
immunologic function).
Kidneys
Renal complications include
Metabolic acidosis
Growth failure
Renal function is limited, so the concentrating and diluting limits of urine are decreased.
Late metabolic acidosis and growth failure may result from the immature kidneys’ inability
to excrete fixed acids, which accumulate with high-protein formula feedings and as a result
of bone growth. Sodium and bicarbonate are lost in the urine.
Lungs
Pulmonary complications include
Hypoglycemia
Hyperbilirubinemia
Metabolic bone disease (osteopenia of prematurity)
Hypothermia
Premature infants have an exceptionally large body surface area to volume ratio. Therefore,
when exposed to temperatures below the neutral thermal environment, they rapidly lose
heat and have difficulty maintaining body temperature. The neutral thermal environment is
the environmental temperature at which metabolic demands (and thus calorie expenditure)
to maintain normal body temperature (36.5 to 37.5° C rectal) are lowest.
Diagnosis
Fetal ultrasonography
When periods are regular and recorded contemporaneously, the menstrual history is
relatively reliable for establishing gestational age. Ultrasonographic measurements of the
fetus in the 1st trimester give the most accurate estimate of gestational age.
Ultrasonographic estimates are less accurate later in pregnancy; 2nd and 3rd trimester
ultrasonographic results should rarely be used to revise those done during the 1st trimester.
After delivery, newborn physical examination findings also allow clinicians to estimate
gestational age, which can be confirmed by the new Ballard score.
Along with appropriate testing for any identified problems or disorders, routine evaluations
include pulse oximetry, complete blood count, electrolytes, bilirubin level, blood culture,
serum calcium, alkaline phosphatase, and phosphorus levels (to screen for osteopenia of
prematurity), hearing evaluation, cranial ultrasonography (to screen for intraventricular
hemorrhage and periventricular leukomalacia), and screening by an ophthalmologist for
retinopathy of prematurity. Weight, length, and head circumference should be plotted on an
appropriate growth chart at weekly intervals.
Complications
The incidence and severity of complications of premature infants increase with decreasing
gestational age and birthweight. Some complications (eg, necrotizing
enterocolitis, retinopathy of prematurity, bronchopulmonary dysplasia, intraventricular
hemorrhage) occur primarily in infants delivered at < 34 weeks.
Symptoms and Signs
The premature infant is small, usually weighing < 2.5 kg, and tends to have thin, shiny,
pink skin through which the underlying veins are easily seen. Little subcutaneous fat, hair,
or external ear cartilage exists. Spontaneous activity and tone are reduced, and extremities
are not held in the flexed position typical of term infants.
In males, the scrotum may have few rugae, and the testes may be undescended. In females,
the labia majora do not yet cover the labia minora.
Reflexes develop at different times during gestation. The Moro reflex begins by 28 to 32
weeks gestation and is well established by 37 weeks. The palmar reflex starts at 28 weeks
and is well established by 32 weeks. The tonic neck reflex starts at 35 weeks and is most
prominent at 1 month postterm.
Evaluation
Monitoring in a neonatal intensive care unit (NICU)
Growth and nutrition: Weight should be monitored closely, particularly in the first
days of life when there is a contraction of the extracellular volume; dehydration with
severe hypernatremia may develop. Weight, length, and head circumference should
be assessed weekly and plotted on an appropriate growth chart.
Electrolyte balance: Serum electrolytes, glucose, calcium, and phosphate levels need
to be periodically measured, particularly in infants receiving parenteral fluids and/or
nutrition (eg, very premature and extremely premature infants).
Central nervous system infection: Lumbar puncture is typically reserved for infants
with clear signs of infection and/or seizures, a positive blood culture, or an infection
that is not responding to antibiotics.
Intraventricular hemorrhage: Screening cranial ultrasonography is indicated at 7 to
10 days in premature infants < 32 weeks and in older premature infants with complex
courses (eg, cardiorespiratory and/or metabolic instability).
Because premature infants are at risk of apnea, oxygen desaturation, and bradycardia while
in a car seat, the American Academy of Pediatrics currently recommends that before
discharge all premature infants have their oxygen saturation monitored for 90 to 120
minutes while seated in the car seat that they will use after discharge. However, there are no
agreed-upon criteria for passing or failing the test, and a recent report from the Canadian
Paediatric Society (CPS) found that the car seat test had poor reproducibility and did not
predict risk of mortality or neurodevelopmental delay. Thus, the CPS does not recommend
routine testing before discharge (1). Given the concerns about the car seat test, a common-
sense approach to car travel is for a newly discharged premature infant to be observed by a
non-driving adult during all car seat travel until the infant has reached the due date and has
remained consistently able to tolerate being in the car seat. Because the infant's color needs
to be observed, travel should be limited to daylight hours. Long trips should be broken up
into 45- to 60-minute segments so that the infant can be taken out of the car seat and
repositioned.
After discharge, extremely preterm and very preterm infants should receive careful
neurodevelopmental follow-up and appropriate early referral to intervention programs as
needed for physical, occupational, and language therapy.
Prognosis
Prognosis varies with presence and severity of complications, but usually mortality and
likelihood of complications decrease greatly with increasing gestational age and
birthweight (see Figure: Survival and survival without severe impairment in extremely low-
birthweight infants).
Observed and maximal potential rates of survival (top) and survival without severe
impairment (bottom) in extremely low-birthweight infants. (Adapted from Tyson JE, Parikh
NA, Langer J, et al: Intensive care for extreme prematurity—moving beyond gestational
age. The New England Journal of Medicine 358:1672–81, 2008.)
Treatment
Supportive care
Parents should be encouraged to visit and interact with the infant as much as possible
within the constraints of the infant’s medical condition. Skin-to-skin contact between the
infant and mother (kangaroo care) is beneficial for infant health and facilitates maternal
bonding. It is feasible and safe even when infants are supported by ventilators and
infusions.
Feeding
Feeding should be by nasogastric tube until coordination of sucking, swallowing, and
breathing is established at about 34 weeks gestation, at which time breastfeeding is strongly
encouraged. Most premature infants tolerate breast milk, which provides immunologic and
nutritional factors that are absent in cow’s milk formulas. However, breast milk does not
provide sufficient calcium, phosphorus, and protein for very low-birthweight infants
(ie, < 1500 g), for whom it should be mixed with a breast milk fortifier. Alternatively,
specific premature infant formulas that contain 20 to 24 kcal/oz (2.8 to 3.3 joules/mL) can
be used.
In the initial 1 or 2 days, if adequate fluids and calories cannot be given by mouth or
nasogastric tube because of the infant’s condition, IV parenteral nutrition with protein,
glucose, and fats is given to prevent dehydration and undernutrition. Breast milk or preterm
formula feeding via nasogastric tube can satisfactorily maintain caloric intake in small,
sick, premature infants, especially those with respiratory distress or recurrent apneic spells.
Feedings are begun with small amounts (eg, 1 to 2 mL every 3 to 6 hours) to stimulate the
gastrointestinal tract. When tolerated, the volume and concentration of feedings are slowly
increased over 7 to 10 days. In very small or critically sick infants, total parenteral
hyperalimentation via a peripheral IV or a percutaneously or surgically placed central
catheter may be required for a prolonged period of time until full enteral feedings can be
tolerated.
Hospital discharge
Premature infants typically remain hospitalized until their medical problems are under
satisfactory control and they are
Most premature infants are ready to go home when they are at 35 to 37 weeks gestational
age and weigh 2 to 2.5 kg. However, there is wide variation. Some infants are ready for
discharge earlier and some require longer stays in the hospital. The length of time the infant
stays in the hospital does not affect the long-term prognosis.
Preterm infants should be transitioned to the supine sleeping position before hospital
discharge. Parents should be instructed to keep cribs free of fluffy materials including
blankets, quilts, pillows, and stuffed toys, which have been associated with an increased
risk of sudden infant death syndrome (SIDS).
Surveys show that most car seats are not installed optimally, so a check of the car seat by a
certified car seat inspector is recommended. Inspection sites can be found here. Some
hospitals offer an inspection service, but casual advice provided by an uncertified hospital
staff member should not be considered equivalent to inspection by a certified car seat
expert.
The American Academy of Pediatrics recommends that car seats be used only for vehicular
transportation and not as an infant seat or bed at home.
Prevention
Although early and appropriate prenatal care is important overall, there is no good evidence
that such care or any other interventions decrease the incidence of premature birth.
The use of tocolytics to arrest premature labor and provide time for prenatal administration
of corticosteroids to hasten lung maturation is discussed elsewhere (see Preterm Labor :
Treatment).
Key Points
There are many risk factors for premature birth but they are not present in most
cases.
Although women who have consistent prenatal care have a lower incidence of
preterm birth, there is no evidence that improved prenatal care or other interventions
decrease the incidence of premature birth.
More Information
Child car seat inspection station locator
Late Preterm Infants
An infant born between 34 and 36 6/7 weeks gestation is considered late preterm.
Complications
Although clinicians tend to focus on the more dramatic and obvious manifestations of
problems of infants born < 34 weeks gestation, late preterm infants are at risk of many of
the same disorders (see complications of premature infants). Compared to term infants, they
have longer hospital stays and higher incidence of readmission and diagnosed medical
disorders. Most complications relate to dysfunction of immature organ systems and are
similar to, but typically less severe than, those of infants born more prematurely. However,
some complications of prematurity (eg, necrotizing enterocolitis, retinopathy of
prematurity, bronchopulmonary dysplasia, intraventricular hemorrhage) are uncommon in
late preterm infants. In most cases, complications resolve completely.
Complications more common among preterm infants include the following:
Central nervous system: Apneic episodes (see Apnea of Prematurity)
Gastrointestinal tract: Poor feeding due to delayed maturation of the suck and
swallow mechanism (primary reason for prolonged hospital stay and/or readmission)
There are variations in practice in the care of late preterm infants, particularly with respect
to the gestational age and/or birthweight at which infants are routinely admitted to a NICU.
Some hospitals routinely admit infants < 35 weeks gestation to the NICU, whereas others
may have a cutoff of < 34 weeks. Still other hospitals have a discretionary approach.
Regardless of the location of the infant, all late preterm infants need close monitoring of the
following:
Temperature: There is a high risk of hypothermia, and some late preterm infants
may need to be in an incubator. The infant's temperature should be routinely
assessed. For infants who are in the mother's hospital room, the temperature of the
room should be maintained at 22 to 25° C (72 to 77° F) similar to that recommended
for newborn care areas.
Weight: Depending on the infant's intake, there may be excessive weight loss,
dehydration, and hypernatremia. The infant should be weighed daily and the percent
weight loss should be calculated and tracked. Electrolytes should be checked if the
weight loss exceeds 10%.
Feedings and intake: Late preterm infants may breastfeed or bottle feed poorly and
take insufficient amounts of milk. Nasogastric feeding assistance is commonly
needed, particularly in infants who are 34 weeks gestation. Because the mother's milk
may take 1 to 4 days to come in, supplementation with donor milk or formula may be
necessary. The amount of milk that the infant receives as well as either the number of
wet diapers or the urine output (calculated as mL/kg/hour) should be tracked.
Respiratory issues typically resolve without long-term sequelae. Apneic episodes typically
resolve by 37 to 38 weeks gestation and almost always by 43 weeks.
Late preterm infants can be stressed by the metabolic demands of maintaining a normal
core temperature of 36.5 to 37.5° C (97.7 to 99.5° F), which roughly corresponds to an
axillary temperature of 36.5 to 37.3° C (97.7 to 99.1° F). The environmental temperature at
which metabolic demands (and thus calorie expenditure) to maintain body temperature in
the normal range are lowest is the thermoneutral temperature. A normal core temperature
can be maintained at lower environmental temperatures at the cost of increased metabolic
activity, so a normal core temperature is no assurance that the environmental temperature is
adequate. Once the core temperature falls below normal, the environmental temperature is
below what is called the thermoregulatory range and therefore far below the thermoneutral
range. In clinical practice, a room with a temperature of 22.2 to 25.6° C (72 to 78° F)
combined with skin-to-skin contact under blankets, swaddling with multiple blankets, and
wearing a hat may provide a thermoneutral environment for a large and somewhat more
mature late preterm infant. Smaller and less mature late preterm infants usually require an
incubator for a period of time to provide a thermoneutral environment.