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| Intro
| | == Introduction == |
| | ''Advances in perinatal and neonatal care have led to improved survival in preterm infants [1,2,3]. The survival rate is approximately 50% in infants aged 24 weeks, but it is 80% to 90% in infants aged 28 weeks and 95% in those aged 32 weeks in the United States [4]. However, preterm birth also increases the risk of chronic diseases and developmental delays that may persist into adulthood and, consequently, require higher levels of health care [5]. Overall, encouraging the growth and development of surviving premature infants is crucial, along with efforts to increase survival rates.'' |
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| 15 million preterm births per year; 80% between 32-37 weeks
| | ''Premature infants are a high-risk group for delayed growth and neurodevelopmental disorders, and some have neurological sequelae, such as delayed neurodevelopment, decreased intelligence, and cerebral palsy [6,7]. Factors affecting the growth and neurodevelopment of premature infants include birth weight, gestational age, Apgar score, cardiopulmonary resuscitation (CPR) at birth, breastfeeding, ventilation, or length of hospitalization, among others [''<ref>Kang SR, Cho H. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8004188/ Research trends of follow-up care after neonatal intensive care unit graduation for children born preterm: a scoping review. International journal of environmental research and public health]. 2021 Mar 22;18(6):3268.</ref> |
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| Review of preterm causes:
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| # maternal infection, particular ethnicities, black ethnicities, multiple births, or some substance uses, including caffeine
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| less thank 28 weeks- need neonatal ICU
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| re born around that 28-week age, what we find is that some of these infants are going to have a lot of issues with their lungs, potentially some issues with their eyes. And then you can see down here at 30 weeks, we have that flexor tone that really starts to develop. So that's why a lot of these preterm babies look very hypotonic. They look very gravity dependent. They don't have that nice flexor tone, that tucked in posture, because they haven't really had an opportunity to develop it yet. And then as late as 38 weeks, there is still myelination happening in the brain. And that's really what's helping that connectivity and the signals that are being sent from one part of the brain to the other and from the brain to the body. So when we don't have that good myelination, we're not really having effective signals that are getting sent from different parts of the brain to the body in reverse as wel
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| womb vs nicu
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| womb: quiet, muffled, consistent temp, no pain, darm
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| nicu: fighting gravity cause no flexion posture, loud noises (machines), potential iv and other lines in them, painful procedures, ha e to breathe, temp changes, artificial scents, sounds very loud to infant and can cause damage to ear, light, disrupted sleep
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| sounds
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| AAP less than 45 decibels consistent, no more than 65 decibel to be exposed to
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| average nicu sound 49 but at times can go to 57 can damage ear
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| premature babies 2-10% having hearing disorders compared to 0.1% in term babies
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| stress
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| use an isolettevs open crib
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| put a blanket over isolette coverhelp muffle sound
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| eyes
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| before 32 weeks cant control how much light comes into eye
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| blanket over isolette
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| shade their eyesduring assessment and interventions
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| cyclic lighting
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| plan PT around awake time
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| NICU care:
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| # o there are four different levels of ICU care in the NICU depending on how much care a baby needs. So it goes from level one all the way up to level four. So level one is really just your newborn nursery. Some mild sort of support that the baby might need all the way up to you know, the most complex critically-ill patients. These are really hospitals that are going to be able to have surgical subspecialties. They're going to have a lot of medical subspecialties. And another thing that they're going to be able to provide is ECMO, which we'll talk a little bit more about soon.
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| Pyramid:
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| autonomic, motor, state
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| stress then? So we're going to look at this at each of these different levels. So, autonomic, physiologic, motor, movement, and behavioural. So some things you might see are flailing during an assessment, grimacing, furrowed brows, yawning, their hand coming out with fingers splaying. So all of these are really signs that say, stop. I need to take a break because I am not regulating my state. So physiologic indicators of stress can include circumoral cyanosis. So what this refers to is a little bluish tinge or colouration surrounding the baby's mouth or lips. This means that they're not getting good oxygen perfusion. We might also see skin colouration changes, so this could be something like mottling, which looks like a lacy or a blotchy appearance to the skin. We might find that the baby becomes more pale, or blue, or cyanotic, or red. We would see a change because this shows that there's changes in perfusion to the skin. We might also see changes in heart rate. So their heart rate really spikes up, or really decreases or changes in the respiratory rate and rhythm. Other indicators of stress can include coughing and sneezing. If you see that a baby is starting to yawn, it might look cute, but it's actually an indicator of stress. We might find that they're gagging and vomiting, that they have hiccups, or that they have a bowel movement. So again, these are some of those more nuanced things that might look sweet and cute from the outside, but are really actually indicators that that baby is stressed and you need to take a step back. You need to stop handling them to allow them to self-regulate.
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| that you might see a baby doing that show that that baby is stressed and again, you need to take a step back, take a break. They are not appropriate for interacting with at that time are some posturing of the upper or lower extremities. And what we really mean by this is kind of this sort of salute or stop sign where the arm will come out. We'll also see what looks like sitting in air, we'll call it. So those legs will extend out in front of them and the hips flexed. And that shows that's that kind of increase in tone where that baby is posturing. You might find that they start to splay their fingers. So that hand will come out, those fingers will separate, or that they'll kind of cover their face with that kind of stop sign. So you'll see that splaying of not only the fingers, but sometimes the toes too as they extend their legs out. Another one is arching. So when that back really arches that neck extends, thoracic extension that's often a sign that that baby is very poorly regulated. You might also find that they go into a lower tone. So they might become more flaccid rather than some of these higher tone arching, fingers splaying, sitting in air sorts of movement. Their movements become less organised as well, so you might find that they become more fidgety or jerky or shaky in their movements, whereas before we would see kind of these smooth changes in position. You'll also see that they might grimace or thrust their tongue out.
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| Some behavioural indicators of stress include things that would be a little bit more common that you would know to see that that baby is upset. So that they'd be irritable, that they'd be restless, they're crying and inconsolable. They might have changes in their level of alertness, so they're either extra alert, their eyes are really wide. Or they might be less alert. They're really not interacting with you. They're looking away from you, so that gaze aversion. They might be kind of moving their eyes from one thing to the next, but not really able to focus or attend to you or have a sort of glassy-eye appearance.
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| o see is that low muscle tone. So when these babies are born early, they aren't able to develop that physiologic flexion. So you're more likely to see a splayed-out frog-leg position, arms abducted wide, not moving their arms, or their legs, or their head against gravity very effectively. And the level of hypotonia is often related to how premature they are. We're also going to see atypical primitive reflexes. So all of those reflexes that we talked about testing just previously are going to be absent or diminished or potentially inconsistent. So again, think about when they start to present. And if you have a baby born before that, you might not see those reflexes or they might look very atypical. We're also going to see less movement. So often that spontaneous, generalised movement that we typically see in newborns will be often minimal and there's less variety to it. And it's not uncommon to see some of that arching position that their pelvis really isn't quite as mobile. That they hyperextend their neck, they have scapular elevation, and often these sorts of postures and positions are associated with some of the difficulties with breathing, immobility due to the need for ventilation. So they really aren't able to get into these optimal physiologic flexion positions because of the fact that they have so much assistance for just life sustaining measures.
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| LOTS OF CONDITIONS
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