Care of the Premature Infant:Past Success, Future challenges : Care of the Premature Infant: Past Success, Future challenges Steven A. Ringer, MD,PhD Brigham and Women’s Hospital Harvard Medical School Boston, Massachusetts, USA


The Newborn is a unique patient: The Newborn is a unique patient Immediately prior to birth, patient is a fetus Dependent on maternal health Subject to diseases or factors that affect the mother Inaccessible to direct care The course before and during birth determines newborn health and ability to thrive


The Newborn is a unique patient: The Newborn is a unique patient There is no independent past medical history Babies can not talk! Caregivers depend on information received from the caregiver of the mother Communication and discussion are important


Maternal history important to baby: Maternal history important to baby Preexisting maternal diseases: Diabetes Hypertension Maternal infection Unusual occurrences during gestation Abnormal growth Unusual maternal complaints Abnormalities in fetal behavior


The premature newborn:Special problems: The premature newborn: Special problems Respiratory immaturity Temperature control Infection Nutrition Hyperbilirubinemia


Respiratory Immaturity and Hyaline Membrane Disease: Respiratory Immaturity and Hyaline Membrane Disease A primary defect is complete or partial surfactant deficiency Anticipation of premature delivery can reduce the incidence and severity of disease Maternal therapy with corticosteroids is very effective The Obstetrician’s care affects the baby


Antenatal Corticosteroids: Antenatal Corticosteroids A single course (48 HOURS) will: Reduce the risk of hyaline membrane disease by at least 50% Reduce mortality by at least 50% Reduce the incidence of intraventricular hemorrhage Possibly reduce the risk of necrotizing enterocolitis


Steroids and surfactant: Steroids and surfactant Where exogenous surfactant is available, steroids and surfactant provide additive beneficial effects Without surfactant, steroid therapy is still extremely useful: At gestational ages above 30-32 weeks, the risk of serious HMD is practically eliminated


Slide9: Steroids and Surfactant


Respiratory Immaturity: Respiratory Immaturity With maternal steroid therapy, risk of HMD above 30-32 weeks gestation is close to zero The impact of surfactant is primarily in babies born at less than 30-32 weeks, or Those born without benefit of antenatal steroids Partnership between Obstetrics and Pediatrics can save babies- Focus on those born > 30-32 weeks


Temperature Control: Temperature Control A problem of immaturity and thermodynamics Immature skin and nervous systems have trouble retaining body heat High surface area:body weight ratio dramatically increases heat loss


Temperature Control has evolved: Temperature Control has evolved Machines can help: Warmers and Incubators Mothers are warm and always present! Small babies can be kept warm by mother or father Works even for very tiny infants, very effective for babies >1500-1800 gm Useful even when no other modality available


Infection: Infection Neonatal infection remains a disease with extremely high mortality: 85 % or higher Mortality highest for smallest babies- especially those <1500 gm Infection at or immediately after birth is a function of maternal infection Successful care of the baby depends on care before and during birth


Infection: Infection Vigilance for signs of maternal infection Treatment of mother with antibiotics during labor if there are signs of infection Augmentation of labor Communication at birth to baby’s caregivers Early start to therapy can cure! AVOID EXTREMELY BROAD SPECTRUM ANTIBIOTICS


Neonatal Infection : Neonatal Infection Most common organisms are gram negatives, mostly E Coli. In US, Group B Streptococcus is most common Listeriosis does occur Initial antibiotic combination depends on local flora, Ampicillin and Gentamicin is good choice


Additional Issues: Additional Issues Hydration: Must ensure adequate hydration, as judged by perfusion,blood pressure, urine output Nutrition: The lower the gestational age, the smaller the initial feedings, slower the advance Human milk is preferred


Additional Issues: Additional Issues Hyperbilirubinemia Common Higher levels in males, blood group mismatch Levels up to 425 mmol/l safe in term healthy infants Lower levels dangerous in prematures- 170 mmol/l for 1 kg, 340 mmol/l for 2 kg


The timeline of success: The timeline of success Early advances in newborn care included improved thermo-regulation and hydration Survival improved above 2000 gram BW Treatment of infection improved after 1950 Penicillin, ampicillin, oxacillin aminoglycosides


The timeline of success: The timeline of success 1965- Survival possible at 2000-2500 gm, less common at lower BW 1975- Survival possible at 1200-1500 Most small babies died Respiratory support developing 1980- Survival at 1000 gm Improved respiratory support, IV hydration


The timeline of success: The timeline of success 1988-89- Improved survival (85-90%)and outcome at BW > 1000g Improved ventilators, improved fluid and parenteral nutrition 1992-94- Very high survival at BW >1000 g, improving survival at 500-1000g Outcome at <800 g remains questionable


The timeline of success: The timeline of success The progress to improved survival and enhanced outcome has been iterative, depending on both breakthroughs in care, scientific discoveries, and increasing clinical experience Along the way, serious mistakes have been made, often in widespread fashion Sulfa drugs, post-natal steroids, different modes of ventilation,benzyl alcohol preservatives and others


The timeline of success: The timeline of success The keys to success have been: Communication among neonatologists A willingness to try new things, and to give up old or outmoded therapies Thoughtful physicians with the desire to improve the survival and outcome for smaller babies Serious problems still exist: Outcomes for smallest babies are far from universally good Many babies 24-26 weeks gestation have serious lifelong disabilities


The Challenge for Vietnam: The Challenge for Vietnam Resources are limited Experience with the infants of very low gestational age is limited Communication between physicians sometimes difficult because of geography, structure BUT: The physicians are thoughtful and educated The desire for improvement is present Other caregivers will come here to help!


The Challenge for Vietnam: The Challenge for Vietnam The iterative process has begun, survival at lower gestational ages is possible Resources can be expanded at low cost by using antenatal steroids, CPAP Mistakes in therapy will be avoided here- this will enhance and quicken advances


The Challenge for Vietnam: The Challenge for Vietnam Success depends on collaboration and discussion between physicians Widespread exposure to international help Realistic national goals are needed- e.g. “90% survival at a chosen gestational age by 2007” Harsh but honest decisions needed to effectively set goals: Is there a birthweight or gestational age below which resuscitation and care will not be offered?


The Challenge for Vietnam: The Challenge for Vietnam With increasing speed, progress will be made National goals should change as advances are achieved Collegial interaction and communication are the cornerstones of success