Best Practices for Nurturing Preterm and Low-birth Weight Babies
Nurturing newborns in South Sudan series: Essential intendance for the pocket-sized infant
Introduction
"Nurturing newborns in South Sudan" is a serial of clinical guidance reviews on newborn care for the South Sudan context. The first office of this serial focused on essential care of the newborn giving standard recommendations for the birth, delivery and care of all newborns not in need of emergency lifesaving care immediately after birth.[1] In one case out of danger, these newborns should receive the essential care bundle. The 2d part of this series reviews essential care for babies who are born 'small'. Babies who are born preterm (earlier 37 weeks gestation) and those with depression birth weight (less than ii.5kg) autumn under this category of 'small'.
The complications, interventions and intendance for preterm and low birth weight are broad and cannot be comprehensively covered in this newspaper. In a later on review, we will focus on priority interventions and care for preterm and depression nascency weight babies reviewing topics similar assessment and management of jaundice and diagnosis and treatment of seizures amidst others.
Defining the 'small infant' and risk factors
In this commodity, babies are defined every bit "small-scale" based on whether they have low birth weight and/or were built-in preterm. Low nascency weight babies are classified as: low birth weight <2.5kg irrespective of gestational age, very low nascence weight < 1.5kg and extremely depression nascence weight <1.0kg.[2] Premature or preterm babies are generally defined as babies born before 37 completed weeks of gestation[two] and are further classified equally: extremely preterm <28 weeks, very preterm- 28 to 32 weeks and moderate to late preterm 32 to 37 weeks.
There are several take a chance factors for preterm nativity and low nascency weight and these include: previous birth of a small-scale babe, multiple pregnancy, tobacco use and substance abuse, maternal infections, chronic medical conditions in the mother such equally hypertension and diabetes mellitus, pregnancy complications necessitating early delivery and curt intervals between pregnancies (less than eighteen months).[3] Young historic period of the mother and poor nutrition are additional gamble factors. Sometimes the cause of a small baby is unknown and some babies, with minor parents, will be born pocket-size. A few preterm babies may not have a low birth weight - for example if they are built-in big for gestational age due to maternal diabetes mellitus - but they will feel problems like to those of pocket-size babies due to their prematurity.
Prematurity
More than one in x babies are born prematurely equating to nigh 15 meg babies per year worldwide. This number continues to ascension. Complications related to preterm births caused about one million deaths among children less than 5 years one-time in 2015, making it the leading cause of decease and morbidity in this age grouping.[4] Beyond the newborn period, babies born prematurely experience disabilities related to learning, vision and hearing and neuromotor complications like cerebral palsy.[five,6]
The preterm nativity rate in Due south Sudan increased from 12.0% in 2014[7] to about xiii.0% as reported in 2017- a total of 59,000 babies. Among those children born prematurely, about 2,700 of them were built-in as 'extremely premature' - that is less than 28 weeks gestation. About ane,300 of these were dumb preterm survivors and there were four,600 straight preterm kid deaths per year. There are limited information on prematurity and its run a risk factors in South Sudan but a high boyish birth rate at 158 per 1000 girls is reported.[viii]
About half of the children built-in before 32 weeks in low resource settings similar S Sudan practise not survive and all the same low-cost effective interventions that would relieve approximately 75% of these newborns are available. These interventions include kangaroo intendance for thermal and breastfeeding support in babies less than 2kgs, antenatal steroids to stimulate lung maturity, magnesium sulphate for neuroprotection, antibiotics, safe oxygen use and midwife led continuity of intendance for newborns, the latter leading to a 24% reduction in the run a risk of preterm births.[half-dozen]
There are existing national policies for kangaroo care and antenatal corticosteroids use in South Sudan but none for specific intendance of the preterm, safe oxygen use and use of continuous positive airway force per unit area machines[eight] which, despite availability in some facilities, the necessary infrastructure for use and maintenance is lacking.[nine]
Identification, cess and classification of pocket-size babies
Identifying if a infant is term or preterm helps to accurately interpret animate, feeding and activeness to determine whether the problems are due to prematurity or danger signs and to make preparations for their specialized care or intervention at birth, delivery and in the disquisitional beginning weeks of life. More important than just identifying if an infant is small is being able to apace classify them as well or unwell to ensure that they receive appropriate care and lifesaving treatment in a timely manner.[10]
Preparation and assessment of adventure for the birth of a small infant should be made for all significant women.[11] Effigy 1 shows how to appraise the gamble for the birth of a small babe in significant women through three steps: Assess, Review and Human action.
Figure 1. Preparation and cess of risk for the birth of a small-scale baby for all meaning women. Source: Soma GJ.People images adapted from smart.servier.com.
Identification of the pocket-sized babe
Later on birth, all babies should be assessed to determine if they are small and this can be washed by measuring their weight and clinically examining for features of prematurity, come across Table i.[11]
Tabular array i. Identification of features of prematurity
| Term Poor Growth | Preterm / Premature | |
| Pes | Length >8cm Creases all over sole | Length <8cm Few creases on sole |
| Ear | Good recoil | Thin slow recoil |
| Peel | Opaque, loose with folds | Thin, translucent |
| Genitalia | Testes in scrotum, wrinkled Labia closed | Testes high Scrotum smoothen Labia open up |
Assessment and classification of wellness or danger signs in the modest baby
After cess and identification as 'pocket-size', all small babies should be classified as either well or unwell inside 90 minutes to inform further care. This can be delayed for upwards to four hours if the baby has feeding difficulties and any of the danger signs (Table 2).
Table 2. Classification of the 'small infant' and danger signs
| The WELL small-scale babe | DANGER SIGNS | The UNWELL small infant |
|
|
|
Classification is based on the babe'due south weight, temperature, and examination (Tabular array 2). Babies less than 1,500 grams are near always premature and often will demand special care such as intravenous fluids at higher level facilities. Small babies have better outcomes when built-in at facilities that accept the capacity for use of antenatal steroids, resuscitation, and oxygen, and breathing and thermoregulatory back up and are under the care of a skilled wellness workers.[ten,eleven]
Essential intendance and special considerations for the small-scale infant
The pocket-sized baby needs extra attention in all the steps of essential newborn care and routine ongoing cess, led by their mothers/caregivers with assistance of wellness cadres. The small-scale 'well' babe volition require only elementary supportive care at and after delivery.
These babies should be dried with a clean, dry out towel, maintained in peel to skin contact with the mother (kangaroo care), covered to maintain heat, with breastfeeding initiated inside the get-go hour to prevent hypoglycaemia.[12,13,14,15] These supportive measures have proven to be price effective and easy to be implemented if acceptable training is done in a country like South Sudan. Other special considerations are outlined below.
Prenatal steroids and magnesium sulphate
Premature infants with very low and farthermost depression birth weight are at higher take chances of respiratory distress syndrome. This risk can be reduced by the apply of intramuscular dexamethasone, ii doses of 12mg 24 hours autonomously for pregnant mothers at risk of premature delivery.[13,16,17] The other benefits for babies with prenatal steroid apply are a pregnant reduction in bloodshed and intraventricular cerebral haemorrhage.
Magnesium sulphate( intravenously at a loading dose of 4g in 200 mls of normal saline given slowly in 20 to thirty minutes, so 1g/60 minutes until delivery or for 24 hours, whichever came first)is likewise proven to take a neuroprotective role when given to a mother anticipating a preterm baby delivery (≤32 weeks of gestation).[13]
String clamping and cord care
Delayed cord clamping for i to three minutes significantly increases the haemoglobin level for both term and preterm babies and reduces the risk of anaemia in infancy. Premature babies attain ameliorate circulatory stability, accept reduced risk of intraventricular cerebral bleeding, reduced chance of necrotizing enterocolitis, and less late-onset sepsis after delayed cord clamping.[17,18]
Application of chlorhexidine (4%) to the umbilical cord stump for the first calendar week after nascency is recommended for infants born at domicile in settings with high mortality (xxx or more than deaths per one,000 live births) while dry cord care is suitable for babies built-in in a controlled surround such as hospitals and primary health intendance centres. The mother should be educated on personal hygiene measures like mitt washing when caring for the infant.[12,xiv]
Thermal intendance
Small babies who are well and clinically stable should receive kangaroo care starting immediately after birth and continued at all the times, day and night, aiming at a core body temperature of 36-37oC with the anxiety warm and pinkish. In case the caretaker (mother or anyone who is committed to care for the babe) is unable to provide kangaroo care, other methods of warming the baby tin be used such as placing in a clean and disinfected radiant warmer or incubator.[12,14] Effigy 2 demonstrates kangaroo care.[19]
Figure ii. How to hold the baby for kangaroo care. Adjusted with permission from Earth Health System (WHO). Source: Kangaroo mother care. A practical guide. (WHO.[19] People images adjusted from smart.servier.com.
Animate back up
The modest baby who is unwell is more likely to accept breathing problems at or immediately after birth and will require resuscitation and respiratory support. Such newborns will nowadays with clinical features of respiratory distress syndrome (tachypnoea, expiratory grunt, intercostals and sub-costal recession and cyanosis) due to a deficiency of surfactant which helps to keep the alveoli open.Continuous positive airway pressure therapy for newborns with respiratory distress syndrome should be started with cautionas soon as the diagnosis is fabricated;aiming at oxygen saturations of >90% just <95% because excess oxygen tin can cause injury to the lungs, encephalon and optics.
Small babies with respiratory distress will require further specialized intendance including temperature maintenance, and Iv antibiotics (equally it is hard to exclude pneumonia as a crusade of respiratory distress); they may besides demand to be nil by mouth and receive maintenance 4 fluids.[12,fourteen]
Premature babies are at risk of apnoea which is defined as pauses in animate for more 15 to 20 seconds or pauses for less than 15 seconds but with a slow eye rate (<100 beats per minute) or low oxygen saturation level <80% for ≥four seconds) due to immaturity and/or low of the central respiratory drive to the muscles of respiration.[20] Pocket-sized babies should be started on caffeine citrate/aminophylline for prevention/handling of apnoea. Mothers who care for their babies using kangaroo intendance can place their babies when they have abnormal animate (including apnoea)if provided with suitable grooming. In addition, kangaroo care is reported to subtract apnoea episodes in babies born preterm.[21]
Direction of infections
Premature babies are at loftier risk of infection such as sepsis, pneumonia, meningitis, omphalitis due to their underdeveloped immunity. Clean cord care equally described in a higher place and hygiene while caring for the baby will go a long way to reducing infections. Babies who display danger signs or who are at risk of infection(due to premature rupture of membranes or maternal infection)should be treated with ampicillin (or penicillin) and gentamicin as the first line antibiotic treatment for at to the lowest degree 10 days.[12,fourteen]
Feeding
Low birth weight babies who are stable and have stiff suckling reflexes should be allowed to breastfeed. Early feeding will forestall hypoglycaemia which is common with small-scale babies and it necessitates monitoring at least half-dozen-hourly for the first day of life.
Small-scale babies unable to breastfeed should be given expressed breast milk with a loving cup and spoon. The babe who is unable to feed from a loving cup and spoon should be given intermittent bolus feeds through a gastric tube. The enteral feeds are increased gradually past 20-30mls/kg/twenty-four hour period to a maximum of 180mls/kg/24-hour interval calculated based on the highest weight the baby had attained.[12]
Smaller babies are at college risk of feeding issues and necrotizing enterocolitis. Enteral feeds should exist given in boluses and preferably every 2-iii hours. This should brainstorm on the get-go day with 10-15mls/kg/day of enteral feeds (trophic feeds) with the remaining fluid requirement met by intravenous fluids (10% dextrose).
On the second and further days enteral feeds should exist increased by 20-xxx mls/kg/day, and the remaining fluid requirement should contain dextrose 10% and electrolytes.[12,14] The aim should exist to institute feeding within 5-vii days so the IV drip can exist removed (Tabular array three).
Tabular array 3. A proposed plan for Four fluids and enteral feeds for preterm babies
| Mean solar day | Full feeds+ Four fluids | IV fluid | Expressed chest milk / formula milk |
| 1 | 60mls/kg/day | Dextrose 10%; 50mls/kg/24-hour interval | 10mls/kg/day |
| ii | 90mls/kg/twenty-four hour period | dextrose 5%+ ½ normal saline; 50 mls/kg/24-hour interval | 40mls/kg/day |
| 3 | 120mls/kg/day | dextrose 5%+ ½ normal saline; 50mls/kg/day | 70mls/kg/day |
| four | 150mls/kg/day | dextrose v%+ ½ normal saline; fifty mls/kg/solar day | 100mls/kg/day |
| 5 | 150mls/kg/solar day | dextrose 5%+ ½ normal saline; 20 mls/kg/day | 130mls/kg/day |
| 6 | 150mls/kg/day | 150mls/kg/solar day | |
| 7 | 180mls/kg/twenty-four hour period | 180mls/kg/twenty-four hours |
Other routine care: eye intendance, vitamin K, HIV prophylaxis
Cleaning both eyes and the application of tetracycline eye ointment are part of essential care to forestall infections such as ophthalmia neonatorum or bacterial conjunctivitis (Come across table four). Vitamin K should also be given, just at a much lower dose of 0.5mg IM for babies who counterbalance less than ane.5kg.Vitamin Grand prevents haemorrhagic affliction of the newborn.[12,fourteen]
Small babies born to HIV positive mothers should receive dual prophylaxis with AZT (twice daily) and NVP (in one case daily) for the first 6 weeks of their life. Those who are high hazard of acquiring HIV infection should continue infant prophylaxis for an additional 6 weeks (total of 12 weeks of infant prophylaxis) using either AZT (twice daily) and NVP (one time daily) or NVP.[12,fourteen]
Tabular array four. Dosages and routes of administration for commonly used drugs for newborns
| Drug | Daily/Maintenance/ initial dose | Maximum dose/ loading dose | |
| 1 | Caffeine citrate (oral/IV) (Iv is given over 30mins) | 5mg/kg | 20mg/kg |
| 2 | Aminophylline (IV) (IV is given over 15-30mins) | two.5mg/kg 12 hourly, | 6mg/kg |
| 3 | Vitamin K (IM) | 0.4mg/kg for premature baby and 1mg for term baby | |
| four | Tetracycline middle ointment | Practical in both eyes at nativity | |
| 5 | Ampicillin (IV/IM) | 50mg/kg 12 hourly in the beginning week of life Weeks ii-4 of life every 8 hours | |
| 6 | Benzyl penicillin (4) | 50000 IU/kg 12 hourly Weeks 2-iv of life, every 6hours | |
| 7 | Gentamicin (IV/IM) | iii-4mg/kg once a solar day | |
| viii | Cefotaxime | 50mg/kg 12 hourly in first calendar week of life Weeks 2-iv of life every 8 hours Note: Age Specific doses: Less than 29 weeks (extreme preterm); give -12 hourly if less than 28 days of life and -8 hourly if more than 28 days of life If 30-36 weeks (moderate to tardily preterms); give -12 hourly for the outset 2 weeks of life and - 8 hourly after 2 weeks of life | |
| 9 | Ceftriaxone/ (IV/IM) | 50mg/kg 12 hourly |
Immunization
Infants built-in prematurely or with low birth weight should be vaccinated using the same schedules as those recommended for full term infants, with the exception of the hepatitis B vaccine due to the reduced immune response in infants less than 2,000 kg.[12,fourteen,22]
Postnatal visits and follow upward care
Babies with low nascence weight tin be discharged when they have no danger signs or signs of infection, are gaining weight on breast feeding alone, can maintain their temperature in the normal range 36-37oC in an open cot and the female parent is confident and able to accept care of the baby. The suitable weight for discharge is 1.8 kg and higher up because at this fourth dimension the babe should be able to suckle the breast well. Before discharge caregivers should exist counselled thoroughly on exclusive breast feeding, keeping the infant warm (kangaroo intendance), and the danger signs for seeking urgent medical care.[12]
Babies with low birth weight should take regular follow upwardly upon discharge from the hospital/health centre weekly until their weight is iii kg.[12] Weight gain should be calculated, modalities of feeding and feeding challenges should be discussed, assessment of wellbeing and danger signs should exist done, and the neurodevelopment assessment (after correcting for the gestation age) should be carried out at whatsoever bespeak of intendance.[12] Community health workers (through the Southward Sudan Boma Health Initiative) if trained should provide home based follow up care for low birth-weight babies on kangaroo care discharged from health facilities.[23] Caregivers need continued friendly psychosocial back up and their readiness to intendance for these pocket-size babies should always be assessed and praised.[24]
Further strategies to reduce the run a risk of delivery of small babies
The post-obit strategies are vital in reducing the numbers of babies who are born minor.[three]
- Providing women access to wellness care before and between pregnancies,
- Identifying women at risk for preterm delivery and offering constructive treatments to foreclose preterm nascency,
- Preventing unintended pregnancies and waiting at least 18 months between pregnancies.
Conclusion
Beyond ensuring pocket-size babies survive and thrive, it is important to empower families and caregivers to be able to intendance confidently for their babies at home, ensuring proper psychosocial support and regular follow upward at the health facility. As with all other newborns, assessment for danger signs should be made at every visit.[one]
Through this review, we have seen that there are low cost and high impact interventions for essential intendance for pocket-size babies that are vital for increasing their chances of survival and which can be implemented in South Sudan. Continuous health educational activity and training on these interventions volition go a long way in increasing their coverage.
Acknowledgements: We thank our reviewer and Nancy MacKeith for assist in preparing this paper.
We received no funding and have no conflicts of interest.
References
- Soma GJ. Nurturing newborns in Due south Sudan series : Essential care of the newborn. 2020;13(3):99–103.
- World Health Organization. Born too soon. The Global Action Study on Preterm Nativity. 2012 https://www.who.int/pmnch/media/news/2012/201204_borntoosoon-report.pdf
- New York Times. Inside a Neonatal Dispensary in Southward Sudan : 'In Some Ways, Information technology Felt Wrong to Exist Hither'. https://www.nytimes.com/2018/08/28/insider/south-sudan-neonatal-clinic.html
- World Health Organization. Preterm birth. WHO Fact Canvas. https://www.who.int/news-room/fact-sheets/particular/preterm-birth
- Colvin M, McGuire Due west, Fowlie Prisoner of war. Neurodevelopmental outcomes after preterm birth BMJ. 2004 Dec xi; 329(7479): 1390–1393. doi: ten.1136/bmj.329.7479.1390
- Centers for Disease Control and Prevention C. Premature Birth. 2017; 2017–ix.https://www.cdc.gov/reproductivehealth/features/premature-nativity/alphabetize.html
- USAID. Every Preemie Scale. Status of preterm and low birth weight demographics, risk factors and wellness system responsiveness in USAID'S 23 MCH priority countries. https://www.everypreemie.org/wp-content/uploads/2016/05/SummaryProfile_4.29.pdf
- USAID. Every Preemie Scale- South Sudan land profile for preterm and low nascency weight. 2017;(1). https://www.everypreemie.org/wp-content/uploads/2019/07/SouthSudan_7.5.xix.pdf
- World Wellness Organization. Care of the preterm and low birth weight newborn. (Nov 2018):v–7. https://www.who.int/maternal_child_adolescent/newborns/prematurity/en/
- American University of Pediatrics. Essential Intendance for Small Babies Provider Guide. 2015. 7-17p.
- American Academy of Pediatrics. Essential Care for Small Babies Facilitator Guide. 2015.3-8p.
- World Wellness Organization. Pocket book of hospital intendance for children: guidelines for the management of common childhood illnesses. World Health Organization 2013; 45-72.
- Globe Health Organization. WHO recommendations on interventions to improve preterm birth outcomes. www.who.int/reproductivehealth
- World Health Organisation. WHO recommendations on newborn health: guidelines approved by the WHO Guidelines Review Commission. World Health Organization; 2017.
- World Health Organisation. WHO recommendations on postnatal intendance of the mother and newborn. Earth Health System; 2014.
- Kemp MW, Newnham JP, Challis JG, Jobe AH, Stock SJ. The clinical utilise of corticosteroids in pregnancy. Hum Reprod Update. 2016; 22(2):240–59.
- Heike R, Gillian ML, Gyte José L, Díaz-Rossello LD. Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm nativity on maternal and infant outcomes. Cochrane Syst Rev-Interv. 2019; 5–7.
- Leante Castellanos JL, Pérez Muñuzuri A, Ruiz Campillo CW, et al. Recomendaciones para el cuidado del cordón umbilical en el reciénnacido. An Pediatría. 2019; 90(6):401.e1-401.e5.
- World Health Organization. Kangaroo mother intendance. A applied guide. 2003. one–54 p. https://www.who.int/publications/i/item/9241590351
- Zhao J, Gonzalez F, Mu D. Apnea of prematurity: from crusade to handling. European Journal of Pediatrics. 2011 Sep 1;170(ix):1097-105
- Montealegre-Pomar A, Bohorquez A, Charpak Due north. Systematic review and meta-assay suggest that Kangaroo position protects against apnoea of prematurity. ActaPaediatrica. 2020 Jul;109(7):1310-6.
- Earth Health Organization. Summary of WHO Position Papers - Recommendations for Routine Immunization Table one : Summary of WHO Position Papers - Recommendations for Routine Immunization. 2018 Dec:1–xi.
- Lutwama GW, Kok M, Jacobs E. An exploratory written report of the barriers and facilitators to the implementation of community health worker programmes in disharmonize-affected South Sudan.
- Petty J, Whiting L, Green CF J. Parents' views on preparation to care for extremely premature infants at habitation. 2018. https://pubmed.ncbi.nlm.nih.gov/29975481/
Source: http://www.southsudanmedicaljournal.com/archive/may-2021/nurturing-newborns-in-south-sudan-series-essential-care-for-the-small-baby.html
0 Response to "Best Practices for Nurturing Preterm and Low-birth Weight Babies"
Post a Comment