Prematurity and High-Risk Infants

Introduction

Prematurity is a significant healthcare problem occurring on over 10% of live birth every year. The World Health Organization (WHO) estimates there are 15 million preterm births every year. The WHO categorizes preterm birth into the following three categories:

• extremely preterm (< 28 weeks)
• Very preterm (28–32 weeks)
• Moderate to late preterm (32–36 weeks)

Complications of Preterm Birth

Preterm infants have an increased risk for neurodevelopmental disorders and delayed growth with some developing neurological sequelae such as cerebral palsy, decreased intelligence and delayed neurodevelopment.Neurodevelopment and growth in preterm infants can be affected by:

• gestational age
• birth weight
• length of hospitisation
• Apgar score
• cardiopulmonary resuscitation (CPR)
• ventilation
• breastfeeding

Infants born at an earlier gestational age are at a higher risk for complex medical conditions, recurrent hospitisations and neurodevelopmental impairments. Developmental delays and chronic diseases that result from preterm birth may persist into adulthood and consequently, require a heavy burden on the patients, families and healthcare system.

Complications

The third trimester of pregnancy is marked by rapid organ maturation and growth. Without proper organ development, preterm infants are at an increased risk for chronic respiratory, cardiac, renal and endocrine systems disorders later in life. The following paragraphs as described by Pravia et al., (2020) delineate each system increased risk for disease due to prematurity and management recommendations.

Pulmonary

Risks:

• Obstructive disease,
• Pulmonary hypertension

Management:

• Evaluate previous asthma diagnosis

• Consider baseline pulmonary function testing

• Avoid smoking, maintain healthy weight, promote exercise

• Keep current on influenza and Pneumococcus vaccinations

Renal

Risks:

• Chronic kidney disease

Management:

• Monitor blood pressure regularly

• Avoid nephrotoxins

• Control blood pressure (consider an angiotensin-converting enzyme inhibitor if a hypertension medication is needed)

• Limit salt intake

• Consider periodic urine microalbumin screening, renal ultrasonography

Cardiovascular

Risks:

• Hypertension
• Ischemic heart disease
• Congestive heart failure
• Peripheral vascular disease

Management:

• Monitor blood pressure regularly

• Avoid smoking
• Maintain healthy weight
• Promote exercise

• Consider baseline echocardiogram with appropriate cardiovascular risk assessment

Endocrine

Risks:

• Diabetes
• Metabolic syndrome
• Obesity
• Osteoporosis

Management:

• Monitor blood glucose
• Body mass composition, lipids

• Maintain healthy body weight and abdominal girth

• Ensure appropriate calcium and vitamin D supplementation

• Promote weight-bearing exercise
• Limit medications associated with causing metabolic abnormalities, dyslipidemia, worsening bone density

Central Nervous System

Risks:

• Autism
• Mood disorders
• Intellectual disabilities

Management:

• Be alert to need for early evaluation and support

Prevention

Knowing the potential sequelae, there are numerous ways to help prevent preterm birth and how to benefit an infant born prematurely. The Global Action Report on Preterm Birth lists overall ways to reduce preterm birth rate and benefit the preterm infants:

• Identification and treatment of malaria, tuberculosis and HIV
• Behavioral and social support
• Financial interventions
• Nutritional interventions including calcium supplementation

Management of Pregnant Women at Higher Risk of Preterm Birth

• Identification and treatment of hypertensive disease in pregnancy
• Monitoring multiple pregnancies
• Administration of progesterone to prolong pregnancy
• Identification and treatment of structural abnormalities (e.g., cervical cerclage, cervical pessary)
• Management of women in preterm labor including:
• Tocolytics to slow down labor
• Antenatal corticosteroids to reduce mortality in the newborn
• Antibiotics for pprom to prevent infection
• Provision of magnesium sulphate for neuro-protection of the newborn Community interventions:
• Promote antenatal and skilled delivery care for all women
• Smoking cessation and reducing exposure to secondhand smoke and other pollutants Policy interventions:
• Policies to support safe motherhood and universal access to antenatal care
• Workplace policies regulating working hours and strenuous working conditions
• Professional and hospital policies to regulate infertility treatments and to reduce cesarean birth rates and early induction of labor