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Common Problems of Premature Babies

Portsmouth Hospitals NHS Trust

Common Problems

The following conditions may occur with premature babies. This does not mean that your baby will develop these conditions.

Anaemia

What is Anaemia?

Anaemia is caused from having too few red blood cells. These cells are responsible for carry oxygen around the body.
Babies can get anaemic for a variety of reasons, but the common causes are:

  • they make few new red blood cells in the first few weeks of life
  • their red blood cells have a shorter life than that of adults  
  • blood is taken for different blood tests

Anaemia may not always need to be treated especially if your baby is not sick. Eventually your baby will make more red blood cells, and as they grow, may be given an additional source of iron to assist the body to make red blood cells.
If the anaemia needs to be treated this is usually by a transfusion of red blood cells. This blood is obtained from blood bank where it has been meticulously screened.

Apnoea and Bradycardia

Apnoea is a pause in breathing that:

  • usually lasts for longer than 15-20 seconds
  • usually associated with baby’s colour changing and 
  • a slowing of the heart rate to less than 100bpm(bradycardia)

In premature babies in particular, they have an immature respiratory centre in the brain. As your baby grows their breathing will become more regular and therefore apnoeas will occur less and less. Apnoeas may also be caused or increased by other situations eg, infection, insufficient oxygen and unstable temperatures to name a few.

Your baby may only require some stimulation or medication to stimulate their breathing. If apnoeas are worsening then they may require assistance with their breathing, ranging from CPAP to Mechanical ventilation.

Apnoea of prematurity is a result of immaturity. Once baby gets older the apnoeas resolve, and will not return. If they continue to have pauses in breathing it may be due to some other problem which will be investigated.

Blood Sugar

When babies are sick they may suffer from too low or too high a blood sugar. We check blood sugar levels by pricking the baby's heel and taking a drop of blood and testing it.  If the blood sugar is too low we will give more sugar. This may be by intravenous fluids or if the baby is feeding we may give the feeds earlier, more often and more amount. If the blood sugar is too high and the baby is being fed by intravenous fluids we will decrease the amount of sugar in the fluids, or if needed give the baby some insulin.

Once the baby is feeding regularly, blood sugar problems rarely occur.

Baby’s Weight

Almost all babies loose weight before they begin to gain weight. Weight loss is usually about 5-15% of the baby’s birth weight. Much of the weight loss is loss of water because the baby is no longer surrounded by fluid. Sometimes very sick babies gain weight in the first few days. This is not a real weight gain; it is retention of water. As the baby’s condition improves, the baby will loose weight. Usually a baby does not regain their birth weight until two or more weeks of age.

Infection

Babies are susceptible to many kinds of infection due to their immature immune system. They do not have the antibodies to fight the infection. Infection of the blood stream and general infection is known as sepsis, when it occurs in the fluid surrounding the brain it is called meningitis, in the urine it is a urinary tract infection (UTI), in the lungs it can be pneumonia. They can also get infection of the skin.

Infections can be caused by bacteria, viruses, or fungi. They can be acquired at any time, in utero, at delivery, or in the nursery.

Babies may or may not display signs of infection, some of these may be:

  • less active or alert 
  • increasing number of apnoeas and bradycardias 
  • unstable body temperature may be too high or too low 
  • poor feeding or increased vomiting 
  • poor colour
  • low blood pressure 
  • breathing problems

To test for infection we will take some blood for culture, we may even need to take urine or spinal fluid as well. We may also send blood to be tested for high or low white blood cells.

Bacterial infections will be treated with antibiotics. Invariably we will start these antibiotics before getting the final results back as a precautionary measure. Viral and fungal infections are treated with different drugs.
Usually babies respond quickly to antibiotics and have no permanent problems from the infection.

Jaundice

Jaundice is a yellow colour of the skin and whites of the eyes in newborn babies. The yellow colour is due to the presence of bilirubin. Bilirubin is produced when red blood cells get old and are broken down by the body. Normally this is done in the liver and then placed in the intestine so it can come out in the stool.
Babies who are more likely to become jaundiced include: 

  • premature babies due to immature organs
  • babies with a different blood type from their mother

Low and moderate levels of jaundice are not harmful. Very high levels can be harmful, and may cause brain damage. Baby’s bilirubin level will be tested if they become jaundiced, by taking a small amount of blood from a heel prick. This test may be referred to as an SBR or bilirubin level.

If the bilirubin level is high enough to need treatment, your baby will be undressed and placed under phototherapy lights or on a phototherapy blanket in an incubator. This light is a high intensity light that helps break down the bilirubin in the skin. The eyes of your baby will be covered to protect them from so much light.
Phototherapy will continue until the bilirubin level has reached a safe level, usually only a few days but sometimes may be for more than a week.

If your baby's bilirubin gets close to harmful levels, the doctor can do an Exchange Transfusion. This procedure involves replacing the baby's blood containing bilirubin with blood from blood bank.

Respiratory Distress Syndrome

Respiratory Distress Syndrome (RDS) is the most common lung disease of premature infants, due to their incomplete lung development and insufficient Surfactant in the lungs.
Babies with RDS may display the following:

  • rapid breathing
  • retractions or pulling in of the ribs and centre of the chest with each breath
  • grunting
  • flaring or widening of the nostrils with each breath

Your baby will be placed in an incubator to keep him/her warm. They will be attached to a monitor by small leads attached to your baby's chest. He/she will need extra oxygen. The air we breathe is 21% oxygen. He/She will need more oxygen to stay pink. This can be given into the incubator or it may be necessary to give your baby CPAP (Continuous Positive Airway Pressure). This is oxygen delivered under a small amount of pressure usually through little tubes that fit into the nostrils of the nose.

If the RDS is worse, he/she may need to be intubated, where a breathing tube (endotracheal tube) is inserted into his/her windpipe. Once intubated, your baby will be placed on a ventilator to help them breathe. Your baby may be given surfactant, a drug that replaces the substance your baby's lungs lack, and which reduces the tension on the surface of the lungs and makes breathing easier for the baby. This is given down the endotracheal tube.

Your baby may need catheters (small pieces of tubing) placed into their umbilical cord stump. These catheters are used to give the baby intravenous (by vein) fluids, medications and to obtain blood for testing.

For each baby the course is different. Usually the baby's get a bit worse for a few days and then gradually require less and less oxygen. In more severe cases there is an improvement after a few days to a week but the improvement may be slower and some babies may need extra oxygen and even the ventilator for days to weeks.

As your baby gets better, his/her breathing will become easier, less oxygen will be required and if they are on CPAP or ventilator will gradually be weaned off it.

If the disease has been severe possible problems in the future may include:

  • increased severity of colds or other respiratory infections, particularly in the first few years
  • increased sensitivity to such irritants as smoke and pollution
  • greater likelihood of wheezing or other asthma-like problems in childhood
  • may have injury or scarring of the lungs if the RDS was severe, called Bronchopulmonary Dysplasia (BPD)

Patent/Persistant Ductus Arteriosus (PDA)

This problem is fairly common in premature babies, but is rare in babies born at term. The incidence tends to decrease as the birth weight and gestational age increases.

The ductus arteriosus is a small pathway between the two major blood vessels leading from the baby's heart. These two major blood vessels are called the pulmonary artery and the aorta.

When the baby is in the uterus it needs to have a ductus arteriosus as it has a completely different circulation, getting its oxygen from the placenta, to the lungs. After the baby is born, the lungs expand, the baby starts to breathe and the blood receives oxygen from the lungs. Therefore the ductus arteriosus is no longer needed.

The pulmonary artery is now responsible for carrying blood without oxygen away from the heart, to the lungs, where it is replenished with oxygen. The aorta is the major artery of the body and carries blood with oxygen to every part of the body.

Normally the ductus arteriosus is functionally closed by 10-15hours after birth and is anatomically closed 5-7 days after birth.

If you have been told that your baby has a patent ductus arteriosus (PDA) or referred to as "a duct", it means that the ductus arteriosus has either not closed at birth or has opened (become patent) again after birth.

A PDA after birth means that the blood will be able to flow across the duct from the aorta into the pulmonary artery, which will increase the blood flow through the lungs, and may cause a strain on the heart and lungs.

It may be found that your baby will be needing more oxygen than before, having apnoeas and bradycardias more often, a heart murmur may be found when the doctors listen, changes may be seen on x-ray or it can be seen on echocardiogram (an ultrasound picture of the heart)

In many cases the PDA will close itself and not cause any problems. If it does not close then a drug may be given, to help close it. The number of doses required varies with each baby. If the PDA does not close then the duct may need surgery. This is a simple operation called a Ductal Ligation, where the ductus is tied off.

Reflux

Many babies bring up some milk or are slightly sick after a feed. Reflux occurs quite frequently in premature babies because their muscle tone is not strongly developed.

Not all babies who develop reflux will be sick in this way. This makes it harder for doctors and nurses to diagnose. Listening to the history of the symptoms and signs displayed by the baby, often gives the doctors and nurses clues to whether reflux is occurring.

Babies with reflux may show the following:

  • frequent vomiting after a feed
  • back arching due to reflux of the acidic stomach contents into the food tube (oesophagus)
  • crying 
  • restlessness
  • failure to gain weight or weight loss, due to the constant vomiting of feeds

Babies with reflux but who are not vomiting, may display the following:

  • arching of their back
  • screaming and crying
  • going off feeding
  • fighting the teat
  • frequent feeding – i.e. taking only small amounts approximately an ounce of feed nearly every hour

Other tests may be carried out to assist in the diagnosis of reflux. One such test is a Barium Swallow, which requires a series of x-rays. This may not show anything if the reflux was not occurring at the time of the x-ray.

Treatment will depend on the severity of the reflux and how much trouble it is causing your baby.

Mild reflux tends to improve on its own with age and often gets a little better when the baby is able to wean onto more solid food. We would advise you not to start solids until your baby is at least 17 weeks old from birth.

Reflux is often worse when a baby is lying flat and it can help if you position your baby so that their head is gently raised during the day, particularly during and after feeds. Never attempt to let your baby sleep directly on a pillow which could be dangerous. Kangaroo care or holding your baby upright after feeding may also help. Changing the nappy before feeds makes vomiting less likely than doing so when his/her tummy is full.

Feeding your baby with slightly smaller volumes of milk given at more frequent internals may also be helpful.

If despite positioning your baby’s reflux continues he/she may require medication. These medicines either reduce the severity of the reflux by improving the downward movement of the food tube and stomach, or by reducing acidity so that the reflux is less damaging to the lining of the food tube (oesophageal lining).

The following are the more commonly used drugs:

Domperidone (Motilium ®) – strengthens the stomach muscles and speeds up stomach empyting
Rantidine (Zantac ®) – lowers the acid in the stomach
Omeprazole (Losec ®) – is a more powerful acid-lowering drug

Medication often has to be continued for many months. Therefore as your baby continues to grow we will need to adjust your baby’s medication depending on his/her weight. This is important particularly if the symptoms come back, your baby may have outgrown their medication. If the medication appears not to be working as well, most of these drugs have a minimum and maximum dose level and the amount may need to be adjusted.

Gradually your baby’s medication will be stopped when the reflux has improved.

Occasionally it may be recommended that your baby have a thickener, usually added to their feed to help reduce the effect of reflux. The thickener works by making the feed more solid once in the stomach and therefore it is harder to regurgitate up. One such thickener is Thick and Easy (available on prescription only), added just before a feed or mixed in advance when feeds are prepared and stored. The amount to add may need to be adjusted according to your baby’s symptoms.

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