PRETERM BIRTH AND LOW BIRTH WEIGHT

 Prematurity and low birth weight (LBW) are closely associated but different
phenomena.
 They are strongly related to neonatal and infant morbidity and mortality.
 Babies born premature and with LBW have an increased risk of developing
health complications and neurodevelopmental impairments, thus affecting
overall development.
 the consequences of prematurity and LBW can extend into adulthood,
resulting in an increased incidence of diseases, including diabetes and
chronic lung disease

DEFINITIONS

PRETERM

 The World Health Organisation (WHO) (2022) defines prematurity or preterm

as babies born alive before 37 weeks of pregnancy are completed.
 Full-term births range from 37 – 41 weeks’ gestation
 Using gestational age, prematurity has been divided into three sub-categories:
o extremely preterm (> 28 weeks),
o very preterm (28 – 32 weeks),
o and moderate to late preterm (32 – 37 weeks) (WHO, 2022).

LOW BIRTH WEIGHT

 LBW is defined as a birth weight of less than 2500 g, regardless of gestational

age.
 A birth weight of less than 1500 g is considered very low, and a birth weight of
less than 1000 g is considered extremely low
 Normal birth weight ranges from 2500 – 4000 g
 As such, a baby with LBW may be born preterm or at term.

STATS

 According to WHO (2022) estimates, 15 million babies are born preterm

yearly, representing an 11% global preterm birth rate
 Of the 15 million preterm births, approximately 84000 occur in South Africa

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  About 1 million children die before the age of five due to complications
associated with preterm births
 socioeconomic factors greatly influence preterm birth rates and the survival of
babies born prematurely.
 Globally, approximately 15-20% of all babies born have low birth weight, of
which 95,6% occur in developing and low and middle-income countries

CAUSES OF PREMATURITY AND LOW BIRTH WEIGHT

 About 25% to 50% of preterm labour and low birth weight cases have no
apparent cause;
 growing evidence shows that infection may be a major contributing factor to
preterm delivery
 the gestational length can be impacted by more localized illnesses of the
vagina and urinary systems as well as generalized infections
 Several risk factors of prematurity have been identified:

Risk Factors of Prematurity

 preterm rupture of the membrane and a complication that occurs during

pregnancy marked by high blood pressure
 The mother’s age also increases the likelihood of preterm delivery, especially
in mothers below the age of 20 years.
 A history of stillbirth, abortion, multiple births, and preterm delivery are other
recognized risk factors.
 Chronic illness, HIV/AIDS, cardiovascular disease in mothers, and anaemia,
educational level, maternal weight
 alcohol consumption during pregnancy, poor prenatal care, poor maternal
nutrition and the use of substances all induce premature labour Infections and
Prematurity
 Periodontal and intra-amniotic infections are the most prominent infections in
pregnancy complications and will be discussed in this section.

Maternal Periodontal Disease

 Periodontal disease is defined as “a chronic infection caused by bacteria that

stimulates the immune-inflammatory response, leading to inflammation

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  Periodontal disease may cause pregnancy complications such as low birth
weight, prematurity, gestational diabetes, and intrauterine growth restriction.
 In pregnant women, periodontal disease starts with a tooth plaque and is
exacerbated by the activity of oestrogen and progesterone, essential
hormones during pregnancy

Intra-amniotic Infection

 Chorioamnionitis is the medical term for inflammation caused by an

intrauterine infection
 Fever, maternal or foetal tachycardia, uterine tenderness, foul-smelling
amniotic fluid, or an increased white blood cell count are all signs of
chorioamnionitis
 The inflammation that occurs in chorioamnionitis may impact the umbilical
cord and the chorionic villi blood vessels, resulting in funisitis and chorionic
vasculitis
 Acute chorioamnionitis denotes an infectious or inflammatory condition of the
chorion, amnion, or both in the pregnant person.
 This suggests that the mother and her foetus are more likely to experience
serious complications

Chorioamnionitis symptoms may include

 a temperature of more than 3 7.8 degrees Celsius, membrane rupture,

maternal or foetal tachycardia, uterine pain, malodorous amniotic fluid, vaginal
discharge (smelling or unpleasant, green, or yellow, itchy, or sore), or
peripheral leucocytosis with no other site of infection (Monga & Blanco, 1995).
 Birth abnormalities can be caused by several reasons, including
environmental influences, inherited factors, and the interplay of the two
 Intrauterine infection is caused by Several biological elements, such as
infection of viruses, toxoplasma gondii, ureaplasma urealyticum, bacteria,
mycoplasma, chlamydia, parasites, and fungus (Zheng et al., 2005).

Risk Factors of Low Birth Weight

 Low birth weight shares some of the risk factors with prematurity,

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  including maternal age; mothers below 20 and above 30 years are at an
increased risk of having babies with low birth weight
 The mother's weight is another recognized risk; about 40% of birth weight is
inherited from both parents,
 with the mother's weight significantly influencing the baby's birth weight.
 That explains why mothers weighing below 45kg usually have small babies
 smoking during the gestational period places the baby at risk of having low
birth weight
 since the chemical substances present in cigarettes have an adverse impact
on the growth of the foetus
 Chromosomal abnormalities, including deletions, translocations, and
duplications, affect foetal growth.
o Moreover, trisomy 21, 18 and Turner’s syndrome are chromosomal
anomalies that cause growth retardation of the foetus
o Preterm delivery itself is a risk for low birth weight.
o Iron comprises hormonal and neurological regulation of pregnancy;
o therefore, low iron consumption results in inadequate iron delivery to
the foetus causing insufficient oxygenation of the foetus, which results
in poor foetal growth and development
 Socioeconomic status is another risk factor for low birth weight since it
determines access to education and health institutions.
o Pregnant mothers from a low socioeconomic background are often
uninformed about nutrition good for them and the foetus,

COMPLICATIONS ASSOCIATED WITH PREMATURITY AND LOW BIRTH

WEIGHT

 The primary issue related to preterm birth and LBW

 concerns the complications of prematurity and LBW sustained by children
 and the subsequent consequences of these complications on the child’s
survival and development.
 Preterm birth and LBW are the leading cause of newborn death.
 While the majority of preterm and LBW infants survive without major
neurodevelopmental complications,

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  a minority of these infants will experience significant neurodevelopmental
problems
 In premature individuals, neurological deficits occur due to the disruption of
the gestation period.
 The gestation period serves as a critical period for brain development.
o In particular, rapid brain growth and development occur between 30
and 32 weeks of gestation
 When this gestation period is disturbed, infants are exposed to external
factors including inflammation, medication, and infection.
 “These external factors “disturb the structural and functional maturation of the
brain and result in high rates of neurologic morbidity” (Wallois, 2020, p. 1).

Neurological deficits occur in children of significantly low-birth weight due to the

reduced total brain volume,

 which translates to a disturbance in the development of specific brain regions.

 Thus, preterm and LBW babies have an increased risk of developmental
disabilities such as cerebral palsy, autism spectrum disorder (ASD), cognitive
and sensory impairments, attention deficit hyperactivity disorder (ADHD), and
behavioural and social problems (Behrman & Butler, 2007).

A brief discussion of the complications will follow.

Visual Impairment

 A common visual impairment of prematurity is retinopathy of prematurity

(ROP)
 Retinopathy causes blood vessels to grow abnormally in the retina, the light-
sensitive nerve tissue that lines the inside back wall of the eye.
 The only available treatments are surgical, done under general anaesthesia,
with the infant “asleep.”
 The procedures to treat retinopathy of prematurity include Laser
photocoagulation.
 This procedure stops the abnormal growth of blood vessels through the retina.
ROP is one of the significant causes of childhood blindness

Autism Spectrum Disorders

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  Autism spectrum disorder (ASD) is a neurodevelopmental disorder defined by
extensive impairments in the ability to socialise and communicate,
 along with restricted and repetitive patterns of behaviours and interests.
 These symptoms appear during early developmental periods and are usually
lifelong (Matheis et al., 2018).
 Though it may be challenging to detect, the precise age of onset for ASD has
been eliminated, making it necessary for the condition’s symptoms to appear
during infancy or early childhood and recognises that the disorder may only
entirely manifest later on in one’s life, when need of social interaction increase
(Maye, Kiss & Carter, 2016).
 Sharma et al. (2018) deduced that although findings determining aberrations
in particular functional tracts continue to be subject to constant revision,
recent neurobiological findings of behavioural functioning in ASD point to
altered brain connectivity as a key feature of its pathophysiology.
 Furthermore, Mamidala et al. (2013) were able to conclude that labour
difficulties, preterm birth, neonatal jaundice, delayed birth cry, and birth
asphyxia were found to be linked with ASD after perinatal and neonatal risk
variables were examined.
 This is due to the fact that, infants that are born prematurely are more
susceptible to developing health issues such respiratory distress syndrome,
hypoxic-ischemic encephalopathy, and intraventricular haemorrhage, which
can impact brain development and raise the chance of ASD (Mamidala et
al.2013).

Cerebral Palsy

 Cerebral Palsy (CP) is defined as “a group of permanent disorders of the

development of movement and posture, causing activity limitations, that are
attributed to non-progressive disturbances that occurred in the fetal or infant
brain” (Graham, 2016, p. 1).
 Symptoms of CP include exaggerated reflexes, floppy or rigged limbs and
involuntary motions (appears in early childhood). These motor deficiencies
are often accompanied by “disturbances in perception, cognition,
communication, and behaviour” (Graham, 2016, p. 1).

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  Symptoms of CP occur throughout the individual’s lifespan and have no
definitive cure. Graham (2016, p. 4) states, “In approximately 90% of cases,
 cerebral palsy results from destructive processes that injure healthy brain
tissue, rather than from abnormalities in brain development.”
 This suggests that preterm birth and LBW are processes that damage the
healthy brain tissue of infants and are not processes inherently characterised
by abnormal brain development.
 Brain damage is most likely to occur in infants born prematurely for several
reasons, including brain bleeds – the earlier a baby is born, the higher the risk
of bleeding in the brain, also known as intraventricular haemorrhage.
 Cerebral palsy can result from varying combinations of lesions in the cerebral
cortex, the hemispheric white matter, the basal ganglia and the cerebellum.
 Long-term treatment would include physical therapy, other therapy, drugs, and
occasionally surgery.

While preterm and LBW children have an increased risk of all types of CP, the most
common type is spastic diplegia (Behrman & Butler, 2007).

 Spasticity is identified by magnified reflexes, tight t muscle tone, and

restricted motion around a joint(s).
 Spasticity of the two lower extremities with no or minor involvement of the
arms represents spastic diplegia.
 While most children with this type of CP undergo physical therapy and
medical procedures (such as orthopaedic surgery), many children are
adequately functional when they attend school (Behrman & Butler, 2007).

There is significant variation in the functional consequences ranging from lifelong

disability, such as the inability to walk, to more minor impairments, such as abnormal
muscle tone (Colvin et al., 2007).

Cognitive Impairment

 Research indicates that preterm babies have a spectrum of structural brain

abnormalities associated with cognitive, learning, and behavioural disabilities
 found that low birth weight children scored very low on tasks involving
abstract non-verbal reasoning, perceptual organisation, and mathematical
tasks, which may indicate issues with working memory.

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  Schneider et al. (2004) found that preterm children were likelier to have lower
IQ test scores and struggle with math and reading skills than full-term
children.
 These children might have trouble with academic subjects like math, reading,
and writing and might need special education services to succeed in school.

Social and Behavioural Problems

 Early social development, such as responsive smiling and recognition of

family members, may occur later for preterm children compared to term
children.
 Additionally, imaginative and interpersonal play may also be delayed.
 Studies from various counties have found that extremely LBW children of
school age have a higher incidence of behavioural problems, mainly related to
attention, socialising, and information processing (Colvin et al., 2004).
 These children might have trouble establishing and maintaining relationships,
controlling their emotions, and displaying acceptable social behaviours.
 This may lower their quality of life and cause isolation, anxiety, and
depression.

THE LIFETIME TRAJECTORY

 Preterm children continue to have a high prevalence of neurological issues

that result in impairment, with a distinct gestation-related gradient.
 General cognitive deficits persist in very preterm/very low birth weight or
extreme preterm/ extremely low birth weight even after adjusting for
socioeconomic factors or excluding children with neurosensory impairment.
 Studies of premature and LBW children report that children from higher
socioeconomic backgrounds show significant gains over time
 However, record linkage studies indicate higher disability rates and
hospitalisations for psychiatric problems in very preterm and extremely
preterm young adults.
 it has long been hypothesised that greater prenatal risk is linked to psychosis
(Murray & Fearon, 1999), while preterm samples have been too small to test
this idea adequately.

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Similarly, lower educational achievement has been reported when comparing
preterm individuals to controls.

 Preterm children drop out of school early, are less likely to complete high
school, and are more unlikely to earn a college degree.
 However, most research indicated that employment rates do not generally
change regarding gestation, although lower gestational age was connected
with poor job-related income and obtaining social assistance (Bohnert &
Breslau, 2008; Lindström et al., 2009).
 Young people born prematurely are less likely to move away from their
parent’s house, begin living with a partner, or begin having children (Cooke R,
2004; Moster et al., 2008).
 However, some studies did not discover this difference (Saigal et al., 2006).
 The disparities in forging romantic connections are most likely caused by
preterm adults’ higher levels of shyness, lower levels of extraversion,
decreased sensation seeking, decreased peer interactions, and lower levels
of risk-taking (drinking, smoking, and engaging in criminal activity), (Cooke R,
2004; Hack et al., 2004; Lindström et al., 2009; Saigal et al., 2006; Schmidt et
al., 2008). Functional abnormalities persist into adulthood in most domains,
particularly in very preterm and extremely preterm infants. It is essential to
remember that most preterm children enjoy adaptable lives and have jobs
despite the higher risk. Early and middle childhood are regularly assessed as
having lower life quality for those who are very preterm and extremely preterm
(Zwicker & Harris, 2008). Nevertheless, as people become older (in
adolescence and early adulthood), the disparities from their full-term
counterparts are smaller or even disappear (Hack, 2009; Saigal & Tyson,
2008), despite the functional deficiencies for very/extremely preterm people
continuing to occur more frequently as they age (Saigal & Rosenbaum, 2007).

NEUROIMAGING

Research conducted by Wood et al. (2008) and Hints and O’Shea (2008) found that
abnormal ultrasounds during the neonatal phase do not accurately predict many
neuropsychological, behavioural, and cognitive outcomes. This is supported by
Cooke and Abernethy (1999), who found that adolescents that suffered preterm

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severe brain abnormalities on MRIs did not show any difference in IQ, motor function
or frequency of ADHD compared to their counterparts with normal prenatal brain MRI
scans. As a result, the psychological developmental outcome of children who survive
VLBW either does not correlate with traditional markers of perinatal brain injury or
only does so poorly. Contrarily, LBW might be associated with the development of
important brain regions and overall brain growth (Abernethy et al., 2002).

On the other hand, it is important to note that findings suggest that preterm birth
poses a significant risk to brain development and an even greater risk to acquired
brain injury (Wolke, 2011). “At 24 weeks old (6.5 months), the baby’s brain is initially
comprised entirely of white matter (as this is located in the deep parts of the brain),
which aids in information communication between the various sections of the brain.
In the next 16 weeks, the baby’s brain begins to develop grey matter, which is in
charge of information processing. As the grey matter develops and the brain folds on
itself, its surface area dramatically increases (Kapellou et al., 2006).

Kapellou et al. (2006) also mention that the earlier the preterm birth, the greater the
brain development disruption is, and boys are more likely to be affected than girls.
Nagy et al. (2009) found that brain development disruption causes the development
of a different brain with altered white and grey matter. These differences can also be
seen in childhood and adolescence in many cases. Lastly, the degree of brain
growth disruption before term may also predict delayed development two years later
(Kapellou et al., 2006). If these results are accurate, it may be able to track brain
development after birth to identify which infants may require developmental support
in the future.

IMPLICATIONS FOR CLINICAL PRACTICE

Wolke (2011) found that costs for initial neonatal treatments are very high, with much
higher costs for treatment the earlier a child is born, with the possibility for repeat
hospitalisations. For those that require special schooling, this also comes at a high
cost compared to those in mainstream schools. Wolke (2011) also states that pre-
neonatal complications and diagnostics from MRIs have poor predictions. All these
have implications for clinicians. Firstly, preterm and LBW babies must be followed up
in the first two years of their lives so that clinicians can identify problems with their
development and start supporting them and their parents (Wolke, 2011). This way,

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clinician involvement will be increased. Secondly, clinicians should aim to be aware
of whether children with cognitive and behavioural impairments were born
prematurely or with low birth weight; thus, their assessments should ask about
prematurity (Wolke, 2011). Since causes of prematurity and low birth weight in part
also have to do with maternal well-being, pregnant women should have access to
prenatal care, and sonar scans must be routinely done to check if there are signs of
complications that may arise that may lead to early delivery of a baby or cause
uterine restrictions leading to low birth weight babies.

APPROACHES TO INTERVENTION

Preterm babies are at a higher risk of impaired neurodevelopment. The primary goal
is to create an early intervention program for extremely premature newborns that
families can use continuously at home and to measure the impact of early parental
stimulation on the development of cognitive and motor skills. To lessen stress among
parents of prematurely delivered infants and improve the neurodevelopment
outcomes for their children during childhood, any early intervention for a high-risk
preterm newborn must concentrate on the parent-infant relationship, the
environment, and behavioural attitudes.

Most of the research came up with interventions that would be viable for families to
use at home continuously. Further research revealed that various intervention
programs employ multisensory and motor stimulations such as gym, auditory, visual,
vestibular, and tactile stimulations. Various interventions for use in the neonatal
intensive care unit (NICU) or other hospital nurseries have been developed. These
consist of (3) a mix of parent- and infant-focused programs, (2) parent-focused
training programs, and (1) infant-focused sensory stimulation activities.

The emphasis, duration, intensity, and, in some cases, goals of these programs
varied. Infant morbidity and death are increased by prematurity and low birth weight.
Several intervention strategies, discussed below, have been created to address
these challenges:

• Antenatal corticosteroid therapy has been found to minimise the risk of

respiratory distress syndrome and intraventricular haemorrhage in premature
newborns. (Roberts et al., 2017).

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• Nutritional support: Adequate nutrition is critical for premature newborns’
growth and development. For premature newborns, enteral feeding with human milk
or formula is advised (Eidelman et al., 2012).

• Skin-to-skin contact between the mother and her premature newborn is called
kangaroo care. This method has been demonstrated to boost infant weight gain,
reduce infection risk, and promote mother-infant bonding. (Boundy et al., 2016).

• Neonatal intensive care units (NICUs) serve preterm and low birth weight
newborns with specialised medical and nursing care. NICUs have been found to
increase newborn survival rates and decrease problems (Barfield et al., 2012).

• Developmental care strategies have been demonstrated to improve

neurodevelopmental outcomes in preterm infants, such as posture, sound, and light
management (Als et al., 2019).

Early data from small-scale intervention trials for preterm children in the 1970s and
1980s suggested that early intervention, by supporting parenting, would be
beneficial. Educational support could help children’s cognitive and behavioural
development (Wolke, 1991).

Thus, interventions beginning within hours of admission to reduce iatrogenic effects

of treatment (e.g., frequent handling, high noise and light, pain induction) and their
adverse effects on physiological outcomes (e.g., hypoxia) have been proposed (Als
et al., 1994) and tested in a variety of usually small-sample intervention studies.
However, meta-analyses have proven unconvincing thus far (Ohlsson, 2009).
Although many of these interventions were helpful, their effects were limited to the
first year or two of life, influencing cognitive development or inter-actional
behaviours.

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