Prematurity and High-Risk Infants

Original Editor - Robin Tacchetti based on the course by Krista Eskay
Top Contributors - Robin Tacchetti and Jess Bell

Introduction

Prematurity is a significant healthcare problem with estimates of 15 million preterm births annually according to the World Health Organization (WHO). Preterm births are further categorised by gestational period:

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

Risk of Preterm Birth

Preterm infants are at an increased risk for neurodevelopmental disorders and delayed growth. Developing neurological sequelae from prematurity includes cerebral palsy, decreased intelligence and delayed neurodevelopment. The rate of 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 throughout life. Pravia et al., (2020) details below the risk and management of a preterm birth on each body system:

Body System	Pulmonary
Risk	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

Body System	Renal
Risk	Chronic kidney disease
Management	Monitor blood pressure regularly Avoid nephrotoxins Control blood pressure (consider an angiotensin-converting enzyme inhibitor if hypertension medication is needed) Limit salt intake Consider periodic urine microalbumin screening, renal ultrasonography

Body System	Cardiovascular
Risk	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

Body System	Endocrine
Risk	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

Body System	Central Nervous System
Risk	Autism Mood disorders Intellectual disabilities
Management	Be alert to need for early evaluation and support

Prevention

Knowing all of the potential sequelae of preterm birth, prevention if possible is key. When prevention is not possible, understanding the best ways to handle preterm birth and care for the newborn are essential to attain the best possible outcome. Below are suggestions by the Global Action Report on Preterm Birth to reduce the risk, manage and care for premature birth.

Management of Pregnant Women at Higher Risk of Preterm Birth

• Identify and treat hypertensive disease in pregnancy
• Monitor multiple pregnancies
• Administration of progesterone to prolong pregnancy
• Identify and treat structural abnormalities (e.g., cervical cerclage, cervical pessary)
• Promote antenatal and skilled delivery care for all women
• Smoking cessation and reducing exposure to secondhand smoke and other pollutants
• 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

Management of Women in Preterm Labor:

• Tocolytics to slow down labor
• Antenatal corticosteroids to reduce mortality in the newborn
• Antibiotics to prevent infection
• Provision of magnesium sulphate for neuro-protection of the newborn

Care of the Premature Baby

• Essential and extra newborn care, especially feeding support
• Neonatal resuscitation
• Thermal care (maintain baby's body temperature)
• Kangaroo Mother Care (skin-to-skin contact with mother or another family member to provide stable warmth and to encourage frequent and exclusive breastfeeding)
• Chlorhexidine cord care (umbilical cord cleaning)
• Comprehensive neonatal intensive care, where capacity allows

Resources

• Understanding Newborn Behaviour
• Infant Development
• Infant Terminology and Reflexes