Premature Baby & Predicting Outcomes Flashcards
What is prematurity?
- More than 24 weeks but less than 37 weeks gestation
- 5-9% of births
How are premature babies classified?
By gestation & weight
- Low birth weight = <2500g
- Very low birth weight = <1500g
- Extremely low birth weight= <1000g
What are the causes of pre-term labour & delivery?
- Infection or inflammation
- Utero placental ischaemia or haemorrhage
- Uterine overdistension
- Stress
- Other immunologically mediated processes
- Precise mechanism cannot be established in most cases
What are the pregnancy-related risk factors for pre-term labour & delivery?
- Pre-eclampsia: high BP & protein in urine after 20th week of pregnancy
- Premature rupture of amniotic membranes
- Infection: UTI, infection of amniotic membrane, placenta
- Weakened cervix that begins to dilate early
- Birth defects of uterus
- Poor nutrition
- History of preterm delivery
What are the other factors that increase risk of pre-term labour & delivery?
- Age of the mother (<16 or >35)
- Use of tobacco, cocaine, or amphetamines
- Lack of prenatal care
- Low SES
- Diabetes
- Renal disease
- Cardiorespiratory disease
- Polyhydramnios
What are the baby-related risk factors for pre-term labour & delivery?
- Multiple pregnancy: 15% preterm infants are multiple births
- Anomalies
- Intrauterine foetal death
- Infection
What can organ immaturity in premature babies result in?
- Food intolerance
- Poor immunity
- Poor thermoregulation
- Heart and lung problems
- Neurological insults
- Ophthalmic lesions
- Kidney immaturity
- Metabolic disturbances
- Lack of survival reflexes (suck, swallow, cough, gag)
What are some of the lung-related complications of prematurity?
- Surfactant
- Respiratory distress syndrome (RDS)
- Chronic lung disease
What is surfactant?
- A slippery substance (phospholipid) in the lungs
- Helps the lungs fill with air & keeps the alveoli from
deflating at low volumes - Protects lung surface from epithelial injury, infection &
capillary leakage
Why is surfactant a complication of prematurity?
- Present from 24 weeks but not in large enough quantity
- 28-30 weeks with assistance
- 34 weeks for spontaneous first breath
What is respiratory distress syndrome (RDS)?
- Aka hyaline membrane disease (HMD)
- Stiff lungs difficult to inflate and ventilate
- Pulmonary interstitial emphysema (PIE): Alveolar air leak
- Pneumothorax (alveolar rupture)
- Pneumonia (collapse +/- consolidation)
What is chronic lung disease?
- AKA bronchopulmonary dysplasia (BPD)
- O2 required at 28 days old
What are some of the treatments for lung-related complications?
- Maternal corticosteroids & artificial surfactant: Benefit to baby lungs & possibly gut maturity
- Magnesium sulphate: treats maternal preeclampsia
& reduces rate of CP in early childhood - Improving ventilation
What are some of the strategies for improving ventilation in premature babies?
- Quick intubation for artificial surfactant & then extubation & Bubble CPAP asap
- Gentler ventilation modes, HFOV, targeted O2
- Careful positioning plans, V/Q matching
What are some of the brain-related complications of prematurity?
- Periventricular leukomalacia (PVL)
- Peri/intra ventricular haemorrhage
What is periventricular leukomalacia (PVL)?
- White matter lesion
- Injury to oligodendrocytes in periventricular area
- Site of injury affects the descending corticospinal tracts, visual radiations & acoustic radiations.
What is the cause of PVL?
Hypotension, ischemia & coagulation necrosis at watershed zones of MCA
What are some of the initial symptoms of PVL?
- Decreased tone in lower extremities
- Increased tone in neck extensors
- Apnea and bradycardia events
- Irritability
- Pseudobulbar palsy with poor feeding
- Clinical seizures
What are the longer term outcomes for PVL?
- Mild PVL: Spastic diplegia CP most common
- Severe PVL: Quadriplegic CP most common, varying degrees of intellectual & developmental impairment
What is a peri/intra ventricular haemorrhage?
Haemorrhage in the fragile capillary network supplying the germinal matrix
What are the grades of peri/intra ventricular haemorrhages?
- Grade I: Subependymal region &/or germinal matrix
- Grade II: Subependymal hemorrhage with extension into lateral ventricles without ventricular enlargement
- Grade III: Subependymal hemorrhage with extension into lateral ventricles with ventricular enlargement
- Grade IV: Intraparenchymal haemorrhage
What is necrotising enterocolitis?
- Common GI complication
- Death of intestine tissue
- Causes abdominal bloating, blood in stool, diarrhoea, vomiting etc
What is the treatment for necrotising enterocolitis?
- Halting regular feedings
- Relieving gas in the bowel by inserting a tube in the stomach
- Giving IV fluids & antibiotic
medicines - Monitoring
When is surgery required for necrotising enterocolitis?
- If there is a hole in the intestines
- Inflammation of the abdominal wall
- Remove dead bowel tissue
- Perform a colostomy or ileostomy
- The bowel is reconnected after several weeks or months when the infection has healed
What environmental complications are associated with prematurity?
- Noxious sensory inputs for preterm infant can contribute to neuronal disorganisation
- Physiological stability required for social interaction & functional motor patterns
- Favour for extensor muscles
- Muscular & osteo-articular deformities & acquired muscle shortening
- Midline foot/leg posture also affected
How are flexor muscles affected by the environment in prematurity?
- < 31 weeks: immature mm fibres & NMJs, diminished flexor tone
- Uterine wall limits arcs of limb movements & encourages flexed resting postures
- Once born, environment favours extensor muscles (gravity, equipment)
Which muscles are commonly affected by deformities and acquired muscle shortening in prematurity?
- SCM, shoulder girdle, biceps trapezoid muscle (acquired torticollis)
- Abduction & ER muscles of shoulder
- Blocks active movements, allowing ungainly & non-functional movements to develop
- Passive & active muscle insufficiencies
How is the midline foot/leg posture affected in prematurity?
- ER/wide abduction of hips
- Lack of pelvic elevation
- May affect developmental milestones up to 6 years
How is motor development affected by prematurity?
- Infants born <32 weeks have delayed motor development during the 1st year of life
- Slower to attain motor skills e.g. rolling, sitting, standing, walking
- Prevalence of CP increases with decreased gestational age
What other impairments are associated with prematurity?
- Reduced gross/fine motor control
- Reduced balance/coordination
- Fine motor
- Learning difficulties: concentration, behavioural problems, abstract reasoning, processing multiple tasks
What techniques can be used by physio to help an infant find a calm, quiet & organised state?
- Positioning to foster flexion
- Midline placement of the infants limbs
- Using slow transitional movements
- Sucking
- Contained & supportive touch
What strategies can physio used to treat premature babies?
- Assessment
- Positioning and Nesting
- Swaddling
- Handling Advice
- Neurodevelopmental Physio Exercises
What are the aims of developmentally supportive positioning?
- Place in positions that mimic the joint position & limb alignment in utero
- Introduced as early as possible
- 3/4 prone +/- postural support role
- Sidelying with hands/knees midline
- Prone with pelvic elevation for midline hip flexion & nil hip ER
- Supine with nesting deep enough to support knees into midline & hip flexion
What are the benefits of positioning?
- Facilitate contained exploratory movements & maintain joint integrity
- Increased coordinated spontaneous midline movements
- May be beneficial for self-regulatory abilities & stress behaviours
- Maintaining skin integrity
- Assisting with head shaping
- Prevention of acquired torticollis
What is a developmental nest?
- Knees & hips flexed facing same direction
- Shoulders supported into flexion with hands in midline
- May contribute to better coordinated midline-oriented movements
- Gives resistance to early movement to assist fibre type differentiation
What are the benefits of swaddling?
- Fosters self-regulation
- Gentle flexion of legs & arms without eliminating small arcs of spontaneous movement
- Facilitates neuromuscular development
What are some of the neurodevelopmental physio exercises?
- Pick up from sidelying
- Sidelying: chin tuck, head control arm and hand movements
- Hand to hand
- Foot to foot
- Pelvic rocking
- Cycling with resistance
- Head positioning
- Prone time over a roll, on lap
- Supported upright sitting
- Handling positions
- Symmetry
What are some of the problems for families post-discharge?
- Poor growth
- Pneumonia wheezing asthma
- Bronchiolitis
- Chronic lung disease
- GORD
- Complex nutritional & gastro disorders
- Inguinal hernias
- Re-admission to hospital in first year increased 4 times
What are the aims of assessment at 34 weeks?
- To compare infant performance with age expectations to indicate need for intervention
- Educate parents re: infant’s motor development
- Plan intervention prepare for referral
What is the Lacey Assessment of the Preterm Infant (LAPI)?
- Monitors developing motor skills & postures
- Predicts normal motor development or CP at 3 years
What does assessment after discharge involve?
- Growth & development follow-up clinic
- Screening for developmental delay at periodic intervals
- Assessment of movement, speech, language, feeding, growth
- Prediction of motor development
- Ensuring intervention is targeted
