Premature babies: frequency and causes of premature birth. Anatomical, physiological and neuropsychic characteristics of premature babies
Premature babies- children born in relation to the due date of the end of gestation prematurely.
Premature birth- This is the birth of a child before the end of the full 37 weeks of pregnancy or earlier than 259 days, counted from the first day of the last menstrual cycle (WHO, 1977). A premature baby is premature.
Preterm birth statistics .
Preterm birth rate = 3-15% (on average - 5-10%). Premature birth in 2002 - 4.5%. There is no downward trend in this indicator.
The highest morbidity and mortality are observed among children born prematurely. They account for 50 to 75% of infant mortality, and in some developing countries - almost 100%.
Causes of premature birth
socio-economic (salary, living conditions, nutrition of a pregnant woman);
socio-biological ( bad habits, parents' age, prof. harm);
clinical ( extragenital pathology, endocrine diseases, threat, gestosis, hereditary diseases).
Factors contributing to fetal growth retardation and premature birth (prematurity) can be divided into 3 groups :
absence or insufficiency medical care before and during pregnancy;
level of education (less than 9 grades) - affect the level and way of life, personality traits, material well-being;
low standard of living and, accordingly, material security, and as a result, unsatisfactory living conditions, inadequate nutrition of the expectant mother;
occupational hazards (physically hard, prolonged, monotonous, standing work of a pregnant woman);
extramarital birth (especially with an unwanted pregnancy);
unfavorable ecological situation;
young or elderly age pregnant (less than 18 years old) and first birth over 30 years old);
the father's age is under 18 and over 50 (in Europe);
bad habits (smoking, alcoholism, drug addiction) of both the expectant mother and the father;
short stature, infantile physique of a pregnant woman;
infantilism of the genitals, especially in combination with hormonal disorders (insufficiency corpus luteum, ovarian hypofunction, isthmic-cervical insufficiency) - up to 17% of all premature births;
previous abortions and miscarriages - lead to defective endometrial secretion, collagenization of the stroma, isthmic-cervical insufficiency, increased contractility of the uterus, development in it inflammatory processes(endometritis, synechia);
mental and physical injuries of a pregnant woman (fright, shock, falling and bruising, lifting weights, surgical intervention during pregnancy - especially laparotomy);
inflammatory diseases of the mother of an acute and chronic nature, acute infectious diseases (childbirth at the height of fever, as well as in the next 1-2 weeks after recovery);
extragenital pathology, especially with signs of decompensation or exacerbation during pregnancy: rheumatic diseases hearts, arterial hypertension, pyelonephritis, anemia, endocrine diseases(hypothyroidism, thyrotoxicosis, diabetes mellitus, hyperfunction of the adrenal cortex, etc.), etc. cause disturbance of the uteroplacental blood flow, degenerative changes in the placenta;
genital pathology;
pathology of pregnancy: late gestosis, nephropathy, immunological conflict in the mother-placenta-fetus system;
anomalies in the development of the placenta, umbilical cord;
in vitro fertilization;
multiple pregnancy (about 20% of all premature babies);
fetal diseases: IUI, hereditary diseases, defects fetal development, isoimmunological incompatibility;
the interval between births is less than 2 years.
socio-economic:
socio-biological:
clinical:
Causes of prematurity can be divided according to another principle:
external,
coming from the mother;
associated with the characteristics of the course of pregnancy;
from the side of the fetus.
Prematurity classification
In the ICD X revision in the heading R 07 " Disorders associated with a shortened gestation period, as well as low birth weight " the division of premature newborns is accepted both by weight and by gestational age. The note says: When both birth weight and gestational age have been established, birth weight should be preferred.
Depending on the indicators of gestational age and body weight of a premature baby, 4 degrees of prematurity (3 weeks for each of the first three degrees):
|
Prematurity |
by gestation |
by body weightat birth |
||
|
I degree |
35 weeks - incomplete 37 weeks (up to 259 days) |
2500-2000 grams |
low |
|
|
II degree |
32-34 weeks |
1999-1500 grams |
||
|
III degree |
deeply premature |
29-31 weeks |
1499-1000 grams very low body weight |
|
|
IV degree |
22-28 weeks |
999-500 grams extremely low weight (extremely low weight) |
||
Extreme prematurity- gestational age less than 22 complete weeks (154 complete days).
The line between miscarriage and premature at 22 full weeks (154 full days) of gestation is determined by weight: 499 g - miscarriage, 500 g - premature newborn.
Anatomical, physiological and neuropsychic characteristics of premature babies
Anatomical features of premature babies (external signs of immaturity):
the skin is thin and glossy, dark red, as if translucent;
on the face, back, extensor surfaces of the limbs there is a plentiful primordial fluff - lanugo;
the subcutaneous fat layer is thinned, as a result of which the skin is wrinkled, there is a tendency to swelling of the subcutaneous fat;
body length from 25 cm to 46 cm;
disproportionate physique (the head is relatively large: the large vertical size of the head ranges from ¼ to ⅓ body length, the cerebral skull prevails over the facial; neck and lower limbs short);
low hair growth on the forehead,
the skull is more round, its bones are malleable - the cranial sutures are not closed, the small and lateral fontanelles are usually open;
the auricles are soft, close to the skull;
nails often do not reach fingertips, the nail plates are soft;
the low-lying place of the umbilical cord discharge, below the midpoint of the body;
underdevelopment of the genitals: in girls, the genital gap gapes, that is, the labia minora are not covered by the labia majora (due to underdevelopment of the labia majora and relative hypertrophy of the clitoris), in boys the testicles are not descended into the scrotum (in extremely immature children, the scrotum is generally underdeveloped) ...
Physiological characteristics of the premature body (functional signs of immaturity):
from the sidenervous and muscular systems - depression syndrome:
muscle hypotension, lethargy, drowsiness, delayed reaction to stimuli, weak quiet cry or squeak,
the predominance of subcortical activity (due to the immaturity of the cerebral cortex): movements are chaotic, tremors, hand tremors, clonus of the feet may be noted,
imperfection of thermoregulation (reduced heat production and increased heat transfer: children are easily cooled and overheated, they do not have an adequate temperature rise for the infectious process),
weak expression, rapid extinction or absence of physiological reflexes of the neonatal period,
weak sucking intensity;
from the siderespiratory system :
great lability of the frequency and depth of breathing with a tendency to tachypnea (36 - 72 per minute, on average - 48 - 52), its superficial nature,
frequent respiratory pauses (apnea) of varying duration (5 - 12 seconds);
gasps (convulsive respiratory movements with shortness of breath);
during sleep or rest can be observed: breathing biota type(correct alternation of periods of apnea with periods respiratory movements the same depth), breathing Cheyne-Stokes type(periodic breathing with pauses and a gradual increase and then a decrease in the amplitude of respiratory movements);
primary atelectasis;
cyanoticity;
from the sideof cardio-vascular system :
lower blood pressure in the first days of life (75/20 mm Hg with an increase in the following days up to 85/40 mm Hg;
frequency lability heart rate with a tendency to tachycardia (up to 200 per minute, on average - 140 - 160 beats / min);
the phenomenon of embryocardia (heart rhythm characterized by pauses of the same duration between I and II tone and between II and I tone);
muffled heart sounds, in the first days of life, noises are possible due to the frequent functioning of embryonic shunts (botall duct, oval window);
vascular dystonia - the predominance of activity sympathetic division vegetative nervous system- any irritation causes an increase in heart rate, an increase in blood pressure;
Harlequin's symptom (or Finkelstein's symptom): in the position of the child on the side, an uneven color of the skin is observed: the lower half is pink, the upper half is white, which is due to the immaturity of the hypothalamus, which controls the tone of the skin capillaries;
from the sidedigestive system :
reduced food tolerance: low proteolytic enzyme activity gastric juice, insufficient production of pancreatic and intestinal enzymes, bile acids,
increased permeability of the intestinal wall;
predisposition to flatulence and dysbiosis;
underdevelopment of the cardiac part of the stomach (gaping of the cardia - a tendency to regurgitate);
from the sideurinary system :
low filtration and osmotic function of the kidneys;
from the sideendocrine system :
decreased reserve capacity of the thyroid gland - a tendency to transient hypothyroidism;
from the sidemetabolism and homeostasis - a tendency to:
hypoproteinemia,
hypoglycemia,
hypocalcemia,
hyperbilirubinemia,
metabolic acidosis;
from the sideimmune system :
low level of humoral immunity and nonspecific factors protection.
Morphological signs of prematurity:
large vertical head size (⅓ from body length, in full-term - ¼),
predominance of the size of the cerebral skull over the facial one,
open small and lateral fontanelles and sutures of the skull,
low hair growth on the forehead,
soft auricles,
abundant lanugo,
thinning of subcutaneous fat,
the location of the umbilical ring below the midpoint of the body,
underdevelopment of nails
Functional signs of prematurity:
low muscle tone (frog pose);
weak reflexes, weak cry;
a tendency to hypothermia;
max body weight loss by 4-8 days of life and is 5-12%, is restored by 2-3 weeks;
prolonged physiological (simple) erythema;
physiological jaundice - up to 3 weeks. - 4 weeks;
early adaptation period = 8 days. -14days,
late adaptation period = 1.5 months. - 3 months;
the rate of development is very high: the mass-growth rate is compared by 1 year (compared with full-term), in deeply premature (<1500 г) - к 2-3 годам;
in neuropsychic development, by 1.5 years they catch up with full-term ones, provided that they are healthy. In 20% of cases with a weight of 1500 g and< - поражается ЦНС (ДЦП, эпилепсия, гидроцефалия).
Features of the course of the neonatal period in premature infants
The period of early adaptation in premature babies is 8-14 days, the neonatal period lasts more than 28 days (up to 1.5-3 months). For example, if a child was born at 32 weeks of gestation, then in 1 month of life his gestational age will be 32 + 4 = 36 weeks.
Physiological loss of body weight lasts longer - 4 - 7 days and is up to 10 - 14%, its recovery occurs by 2 - 3 weeks of life.
90 - 95% of premature babies have neonatal jaundice of prematurity, more pronounced and longer than in full-term (can be kept up to 3-4 weeks).
Hormonal crisis and toxic erythema are less common than in full-term patients.
An increase in muscle tone in the flexors usually appears at 1 - 2 months of age.
In healthy premature infants weighing up to 1500 g, the ability to suck appears within 1 - 2 weeks of life, with a weight of 1500 to 1000 g - at 2 - 3 weeks of life, less than 1000 g - by the month of life.
The rate of development of premature babies is very high. Most premature babies catch up with their peers by the age of 1-1.5 years. Children with very low birth weight (less than 1500 grams - deeply premature) usually lag behind in physical and neuropsychic development up to 2-3 years. Organic lesions of the central nervous system (cerebral palsy, hearing, vision, etc.) occur in 20% of very premature infants. At 5-7 years old and 11-14 years old, there may be violations of the harmony of development (growth retardation).
Prevention of premature birth consists of:
socio-economic factors;
family planning;
treatment of extragenital pathology before pregnancy;
treatment of urogenital infections;
consultation in polyclinics “marriage and family”;
infusion of lymph suspension (150ml) during pregnancy or outside of it;
culture of sex life.
PREMATURE BABY- children born between the 28th and 38th weeks of intrauterine development, with a weight (mass) of less than 2500 g, a height of less than 45 cm.
Depending on the weight of the child's body at birth, it is customary to distinguish four degrees of prematurity:
1st degree - body weight 2001-2500 g;
2nd degree - weight 1501-2000 g;
3rd degree - weight 1001-1500 g;
4th degree - weight below 1000 g.
The most common causes of prematurity are previous abortions, multiple pregnancy, complications of pregnancy (see), toxicosis of pregnant women (see), cardiovascular and endocrine diseases, acute and hron, mother's diseases. Causes of prematurity can also be certain occupational injuries, physical and mental trauma during pregnancy, incompatibility of the blood of the mother and the fetus, bad habits of the mother (smoking, alcohol consumption), etc. (see Miscarriage).
External signs of prematurity
The external signs of prematurity include the almost complete absence of subcutaneous tissue (Fig.). For deeply premature babies (weight up to 1500 g), glossy, seemingly translucent, dark red skin is characteristic, collected in wrinkles, abundantly covered on the limbs, back, face with thick fluff (lanugo). The navel is located low, in the lower third of the abdomen. The pupils are covered with the pupillary membrane. Nails are thin, not always reaching the edges of the nail bed. The cartilage of the auricles is very soft. Girls have a wide open purple-red genital fissure due to underdevelopment of the labia majora. Boys have an empty, without testicles, very red scrotum.
In more mature premature babies (1500 g and more), the lack of development of subcutaneous tissue, wrinkles of the skin are also sharply expressed, but the color of the skin is less red, it is rather pale pink. The dense fluff mainly covers the extensor surfaces of the limbs, the back and, to a lesser extent, the face. The nails are thin, but longer, reaching the end of the nail bed. The navel is located slightly higher above the symphysis. Boys have one or both testicles in the scrotum, but they have not descended to the bottom and lie in the upper half of it and easily go into the inguinal rings when pressed on them.
The middle of the body length in newborns N. is located above the navel (in full-term babies it approximately corresponds to the location of the navel). The length of the head at birth, depending on the degree of prematurity, ranges from 1/4 to 1/3 of the height. The skull is rounder than that of full-term newborns, the sutures and the small fontanel are open, the large fontanel is often small due to the displacement of the skull bones. There is a tendency to edema of the subcutaneous tissue, with cooling, scleradema may develop (see. Sclerema, scleredema).
The umbilical cord remains a little later than in full-term (on the 5-7th day of life instead of 3-4 in full-term), the umbilical wound heals by the 7-10th day of life.
None of these external signs taken separately can be considered an unconditional sign of prematurity, only their combination is taken into account.
Functional signs of prematurity
Functional signs of prematurity (physiological - biochemical characteristics of various organs and systems). The functional level of organs and systems of N. d. Is due to their significant morfol, immaturity due to the loss of a certain period of intrauterine development, as well as the characteristics of maturation and development of the child's body in inadequate conditions for him in the new environment.
N. d. With a low body weight at birth (up to 1500 g) are sluggish, drowsy, they have weak or no sucking and swallowing reflexes.
Common features that indicate the immaturity of N.'s organism in the first months of life are low differentiation of responses to external stimuli, rapid exhaustion of excitation processes, insufficient interaction between body systems, and slowness of metabolic adaptation processes. N.'s sense organs are capable of functioning from the first days of life; during this period, almost all the reflexes of innate automatism can be evoked in them - sucking, swallowing, searching, swimming, supporting, walking, Moro's reflex, Talent reflex, Peiper's reflex, Bauer's reflex, etc. (see Newborn).
The early postnatal period in N. is characterized by a more pronounced morfol, and funkts, immaturity of c. n. with., ch. arr. cerebral cortex than in full-term newborns. There are imperfect, generalized reactions, the regulation of which is carried out, probably, at the level of subcortical structures. To manifestations of immaturity of c. n. with. includes a decrease in spontaneous motor activity, muscle hypotonia and hyporeflexia, small and unstable tremors of the limbs and chin, mild athetosis, mild and unstable strabismus, small and unstable horizontal nystagmus, etc. These changes are usually short-lived and last for 2-3 weeks. life. The lower the degree of prematurity, the faster these symptoms disappear. The EEG records slow low-amplitude irregular waves, accompanied by short bursts of regular waves with a frequency of 5-13 Hz, as well as frequent irregular low-amplitude waves of a higher frequency (up to 50 Hz). In many cases, significant portions of the curve are close to the isoelectric line. Only by 1-3 months. of a child's life EEG in its type begins to approach the EEG of full-term newborns. In the first months of life, N. d. The ability to carry out adaptive functions appears: from the 3rd to 8th week of life, conditioned reflexes are developed from various analyzers (see. Conditioned reflex).
Intracranial pressure in N. for the first 3 months. life is within 70-90 mm of water. Art. (full-term - 80-100). The cerebrospinal fluid is normally transparent with mild xanthochromia, which is due to the high permeability of the walls of the cerebral vessels; in children of the 3-4th degree of prematurity, xanthochromia is more pronounced than in children of the 1st and 2nd degree of prematurity. The concentration of bilirubin does not exceed 0.1-0.3 mg / 100 ml. Cytosis is low, up to 30-33 cells in 1 μl, mainly lymphocytes are detected. Pandey's reaction is positive (+ or ++); total protein concentration on average 70 - 90 mg / 100 ml (globulin 12-39 mg / 100 ml), albumin 28-57 mg / 100 ml, fibrinogen 0.10 mg / 100 ml, ammonia concentration up to 50 mg / 100 ml, and ammonia nitrogen up to 32 mg / 100 ml. Sodium concentration ranges from 296 to 336 mg / 100 ml, potassium - from 10.7 to 14.4 mg / 100 ml, calcium - from 3.7 to 8.0 mg / 100 ml. The level of chlorides averages 600-800 mg / 100 ml, sugar 40-70 mg / 100 ml (average 56.3 mg / 100 ml), iron 82.5 μg / 100 ml.
The regulation of the processes of heat generation and heat transfer is very imperfect (heat generation is reduced, heat transfer is increased). Sweating in newborns N. d. Is absent, as a result of which they easily overheat. Rectal temperature in N. for the first 10 days of life is lower than in full-term newborns; it is 36.6-37.1 °, reaching 37.2 ° by the age of one month. The daily rhythm of body temperature in N. d. Appears only after 3 months. life.
Features of breathing of N. are caused by immaturity of c. n. with. The respiratory rate varies widely (36-82 per minute) and depends on the degree of prematurity: a higher respiratory rate is observed in children with less body weight. Breathing in N. d. Up to 11 / 2-2 months. life is uneven in rhythm and depth, interrupted by respiratory pauses and convulsive breaths. The transition of irregular breathing to periodic breathing is often observed (see Respiration, pathology). Muscle load in the form of reflex movements after 5 - 7 sec. leads to a short stop or a sharp slowdown in breathing; normal type of reactions - increased breathing rate for muscle load is usually established by the 40th day of life. Breathing becomes regular (uniform in frequency and amplitude of respiratory movements) only by 3-4 months of life.
Funkts, features of the cardiovascular system in N. d. Are expressed in the predominance of the sympathetic section of century. n. with.; any irritation causes an increase in heart rate, an increase in the sonority of tones and an increase in blood pressure.
N.'s pulse rate depends little on body weight at birth and in the first 3 months. life is equal to an average of 120-150 beats / min. When crying, the pulse rate can reach 200 beats! Min. A decrease in the pulse rate to numbers less than 80 beats / min indicates a clear pathology. BP depends on the body weight at birth, the degree of prematurity, age and function, the state of the child's body; in the first month of life, the maximum pressure averages 65.6 and the minimum - 24.4 mm Hg. Art. N. d. Is characterized by high permeability of the walls of the capillaries.
For N.'s ECG, low voltage of teeth and deviation of the electrical axis of the heart to the right are characteristic. All teeth are well defined. The P-Q interval is on average 0.10 seconds, the Q - R - S interval ranges from 0.04 to 0.1 seconds, the QRS T complex - from 0.23 to 0.35 seconds. In some children, pronounced arrhythmia is observed with a decrease in the number of heart contractions during the respiratory pause.
N.'s digestive system also has a number of features. Proteolytic activity of gastric juice and enzymatic function of glands went. - kish. tract are significantly reduced in comparison with full-term newborns. The pH of gastric juice at the height of digestion reaches 4.4, however, even with a high degree of prematurity in the gastric juice there is a significant amount of rennet that curdles milk. From the first days of life, good resorption of proteins is noted, the need for which is very high due to the rapid growth of N. d. Fats are absorbed poorly, while the need for them as a source of energy is very high. The permeability of the intestinal wall in N. for substances of both a bacterial nature and those formed during the digestion of food is increased. N. d. Has a low ability of the kidneys to osmotic concentration, which indicates the imperfection of the osmoregulation system (see. Osmotic pressure). There is a low level of filtration in the glomeruli, limited ability to remove excess water, almost complete reabsorption of sodium entering the renal tubule system. This is due to morfol, kidney immaturity: the predominance of juxtamedullary and midcortical nephrons with relatively short nephron loops (Henle loops). In children with a birth weight above 1500 g under the age of 2 months. in cases of dehydration, the osmolarity of the blood rises from 492 to 658 my / l, as a result of which signs of the so-called. anhydrous fever (dehydration).
Indicators of nonspecific resistance (titer of properdine, phagocytic activity of leukocytes, etc.) in N. d. Are lower than in full-term. The ability to develop specific immunity is also reduced, the IgG content in the umbilical cord blood at birth is lower than in full-term ones.
The nature of special physiological conditions, reflecting the period of adaptation after birth, in premature babies. The processes of adaptation in N. d. In the first days of life proceed slowly, and the less mature the child is, the longer and harder the period of adaptation proceeds. At N. d. More often than at full-term, such conditions as metabolic acidosis (see), hypoglycemia (see), hyperbilirubinemia (see), disturbances of water-salt metabolism (see) are observed.
In healthy N. of the first 20 days of life, compensated metabolic, less often respiratory and mixed acidosis is most often observed. In N. d. With a birth weight of more than 1500 g, indicators of the acid-base state are normalized by the end of the 1st month. life, N. d. with a body weight below 1500 g at this age and even at an older age often still retain signs of compensated acidosis, and sometimes an increase in acidotic shifts, which is accompanied by the accumulation of pyruvic acid, a decrease in glucose content and an increase in the activity of enzymes serum glycolysis. This is the so-called. late, by definition of Kildberg (P. Kildeberg), type of acidosis At N. d.
The acid-base state of blood plasma in healthy N. d. Is characterized by the following parameters: pH - 7.37; pCO 2 - 36.3 mm Hg. Art .; BB (plasma buffer bases) - 21.5 meq / l of blood; BE (base surplus) -3.3 meq / l (see Acid-base balance).
The content of the most important electrolytes (potassium and sodium) in the intercellular fluid and in erythrocytes in N. d. Is subject to significant fluctuations. This, apparently, largely explains the wide range of fluctuations in the concentration of osmotically active substances in the blood serum. The range of fluctuations in blood osmolarity in N. d. Under normal conditions of nursing and feeding is from 252 to 354 mosm / l, fluctuations are more pronounced in children who had a body weight of up to 1500 g at birth.
Fiziol, N.'s erythema remains longer than in full-term patients. Fiziol, jaundice is also often protracted, due to the immaturity of hepatocytes, in particular the glucuronyltransferase system, which binds free bilirubin. Free bilirubin accumulates in the nerve cells of the brain, rich in lipids, thereby disrupting the phosphorylation processes, as a result of which the formation of high-energy compounds (see) - ATP is delayed, which leads to bilirubin intoxication. The development of bilirubin encephalopathy is facilitated by a number of states characteristic of N. for: 1) hypoglycemia (since glucose is a substrate of uridine diphospho gluconic acid, necessary for binding free bilirubin); 2) hypoalbuminemia (in this case, the connection of bilirubin with protein decreases and the toxic effect of bilirubin on nerve cells increases); 3) hypoxia, which increases the permeability of cell membranes for bilirubin; 4) dehydration, leading to an increase in the concentration of bilirubin.
Sexual crisis in N. occurs much less frequently than in full-term newborns, the mammary glands, as a rule, do not secrete colostrum-like secretions.
Physical and neuropsychic development
In N. of all degrees of prematurity, there is a low increase in body weight in the first month. life due to greater than full-term loss of the original body weight. In N. d., The loss of initial weight is 9-14% in relation to the body weight at birth (in full-term 5-6%, less often 8%). The greater the body weight of a premature baby at birth, the faster it will regain its original weight. The less the child weighed at birth, the more intensively his body weight increases in the first year of life (Table 1). The monthly increase in growth in N. of all degrees of prematurity in the first year of life averages 2.5-3 cm. Head circumference in the first 2 months. life is on average 3-4 cm larger than the chest circumference; by the year, depending on the degree of prematurity, the head circumference is 43-46 cm, the chest circumference is 41-46 cm.
By 3 years of life, N.'s weight and height. In most cases approach the corresponding indicators of full-term peers.
During the first 1.5 years of life, the rates of neuropsychic development in practically healthy N. d. In comparison with full-term are delayed; the formation of the main neuropsychic reactions is, as it were, shifted in time to a later age stage. The degree of this shift depends on the degree of prematurity expressed in weeks, i.e., gestational (intrauterine) age and body weight at birth.
In N. d. For 0.5-2 months. later than in full-term, visual and auditory concentration, purposeful hand movements, the ability to sit, stand and walk appear; a few months later they start talking.
The formation of neuropsychic reactions in healthy N. d., In addition to the degree of prematurity and body weight at birth, are also influenced by perinatal "risk factors" - Burdened obstetric history of the mother, fetal hypoxia during childbirth. In the first year of life, the rates of neuropsychic development in ND, who had the syndrome of oppression of c in the neonatal period, were reliably more delayed. n. with. (see Birth trauma).
Features of the course of diseases, their treatment and prevention in premature babies
Due to the immaturity of a number of organs and systems, and the anatomical and physiological characteristics of the organism, N. d. Has a higher morbidity and a peculiar course of a number of diseases than in full-term ones.
Intracranial birth trauma, perinatal posthypoxic encephalopathy, in the pathogenesis of a cut, as a rule, lies the hypoxia of the brain of the fetus and newborn, manifested by adynamia, puffy atony, areflexia, rough and frequent tremors of the extremities and athetosis. At the same time, there is vertical nystagmus, a symptom of the "setting sun" (rolling of the eyeballs, reaching such a degree when only part of the iris is visible), pronounced persistent squint, convulsions, etc. In children with a birth weight of up to 1500 g, symptoms of depression of c prevail. n. with. (hypo- or weakness, hypo- or areflexia), in children with heavy weight - signs of excitation of c. n. with. (motor restlessness, muscle hypertonicity, etc.).
Hemolytic disease of newborns in N. d. Proceeds more severely than in full-term. The almost complete absence of subcutaneous tissue leads to a later wedge, manifestation of jaundice, which can lead to untimely treatment of this disease.
Changes in the blood do not always correspond to the severity of the disease; pronounced anemia, erythrocytosis, leukocytosis, characteristic of hemolytic disease in full-term newborns, may be absent in N. d. In children of the 1st and 2nd degree of prematurity with hemolytic disease, changes in the blood are similar to those in the blood of sick full-term newborns. Biliru-binovaya intoxication of c. n. with. in children with prematurity of the 3-4th degree, it occurs with a relatively low level of indirect bilirubin in the blood - 9.0-12.0 mg / 100 ml. The prognosis of hemolytic disease of newborns in N. is more difficult than in full-term (see. Hemolytic disease of newborns).
Sepsis in N. with a low body weight (up to 1500 g) at birth occurs 3.5 times more often than in children with a large body weight. At N. the umbilical sepsis is more common, to-ry is characterized by a subacute current. From the moment of infection of the child to the first manifestations of the disease, a latent period often passes, equal to an average of 20 days. The first manifestations of the disease are lethargy, poor sucking, the appearance or increased regurgitation, pale skin with a gray tint, flattening of the body weight curve or cessation of weight gain. In the midst of the disease, a state of toxicosis sets in, regurgitation intensifies, the skin acquires a dirty gray tint, a network of saphenous veins is pronounced on the abdomen, polyadenia is observed in some children, and anemia grows. Temperature reaction is usually absent. The liver enlarges, jaundice appears. At N. d. Sepsis is more often complicated by pneumonia, edges are characterized by a wavy current with a meager wedge, manifestations. The most severe complication of sepsis is ulcerative necrotizing enterocolitis with perforation of ulcers and the development of peritonitis. Sepsis at N. d. Often ends lethally (see. Sepsis).
N.'s pneumonia begins gradually. There is a general lethargy of the child, hypotension, hyporeflexia, phenomena prevail respiratory failure and intoxication. Signs of impaired peripheral circulation appear very early (marbling of the skin, etc.). Breathing 20-75 in 1 min., Usually superficial, sometimes moaning, less often - foam at the mouth. There is a tympanic shade of percussion sound in the front and its dullness in the paravertebral parts of the chest, crepitant wheezing, attacks of cyanosis (see Pneumonia, in children).
Rickets develops in N. d. Earlier than in full-term ones - by 1-2 months. life. Its occurrence is facilitated by a number of factors caused by the immaturity of the body of a premature baby (weak bone mineralization, reduced fat resorption, reduced reabsorption of phosphates in the kidneys). The disease progresses rapidly and proceeds, as a rule, acutely. A feature of rickets in N. is the absence of a period of neuro-vegetative disorders (see. Rickets).
Anemia. In healthy N. d. In the first 2-3 months. life often occurs so-called. early anemia (Hb - 50 units and below), associated with increased hemolysis of erythrocytes and relative insufficiency of the hematopoietic system. At the 4th month. life, hemolysis is significantly reduced and red blood counts spontaneously improve; therefore N.'s early anemia does not require special treatment.
Late anemia of prematurity (arising in the second half of life) is almost always iron-deficient in nature, which is due to the depletion of iron stores received from the mother, insufficient assimilation of iron from food, and an increased need for iron in comparison with full-term babies due to more intense processes increase in body weight and blood volume.
Treatment of all the listed diseases is similar to their treatment in full-term children, however, when carrying out therapy, one should take into account the specificity of the reactions of N.'s body to certain l-ech. measures (rapid depletion of compensatory-protective forces). It is necessary to avoid or carefully prescribe stimulating therapy (blood transfusion, administration of gamma globulin, etc.), after a cut a short-term effect can be observed, followed by exhaustion of the main fiziol, processes and deterioration of the child's condition.
Prophylaxis
In the prevention of all N.'s diseases, the fight against miscarriage, antenatal protection of the fetus (see), the correct management of childbirth (see), prevention of birth trauma matters. To prevent N.'s anemia, proper nutrition and measures to combat anemia of the mother are necessary, the appointment of the correct regimen of care and feeding of the newborn. In the prevention of pneumonia in N. d. Timely resuscitation measures at the birth of children in asphyxia are important. In case of respiratory disorders in N. d. With a high degree of risk of developing an inflammatory process in the lungs, it is advisable to administer antibiotics in the first days of life.
Specific prophylaxis of rickets with vitamin D 2 in N. should begin no later than 10-15 days of life. The daily dose of vitamin D2 should not exceed 15,000 IU, the total prophylactic dose should not exceed 400,000 IU per month. Carrying out general UFO is strictly individual, depending on the season of the year. In the prevention of rickets in N. d. A large role belongs to the correct care, regimen, rational feeding with the inclusion of foods containing vitamin D, the appointment of a complex of vitamins.
N. d. With a previous intracranial birth trauma with diseases of acute respiratory infections may experience convulsive seizures during the period of a rise in temperature. gymnastics, etc.).
Great care and utmost care should be exercised when prescribing and carrying out N. for preventive vaccinations. All vaccinations should be carried out in a gentle manner (see Vaccination). Children who have undergone asphyxia or intracranial birth trauma at birth are given preventive vaccinations (DPT, measles) at the age of 1 year - 1 year 6 months. and even later.
Organization of medical care and features of care for premature babies in a maternity hospital and a hospital
Immaturity of N.'s organism (especially those born to sick mothers) and rapid exhaustion of the main fiziol, processes necessitate the organization for them during the first 1.5-2 months. life of a sparing regime, providing for a sharp limitation of fluctuations in temperature and humidity of the environment, exposure to tactile, sound, light and other stimuli. The main requirement for caring for N. d. Is the strictest observance of all the rules of asepsis and antiseptics.
To prevent the phenomena of secondary asphyxia, the primary treatment of all N. d. After birth is carried out on a special changing table with heating. N. d. With body weight at birth of St. 2000 g is transferred to special wards for premature children of the maternity hospital (see). With satisfactory weight gain and good general condition (sucking, active movements, etc.), such children can be discharged from the maternity hospital to the pediatric area, subject to active home patronage (discharge times are individual and depend on the condition of the child).
Children with a birth weight of 1500 g and below, with a pronounced violation of thermoregulation, as well as children with a large body weight, but with any pathology, immediately after primary treatment, are placed in a closed incubator (see) with t ° 34-32 ° , edges is regulated depending on the body temperature of the child (when measuring it in the anus, it should be from 36.6 to 37.1 °). Oxygen should be constantly supplied to the incubator at the rate of 2 liters per minute. The humidity in the jug is set to 80%, by the end of the 1st week. its life is reduced to 60-50%. Such children should be transferred from the maternity ward to the intensive care wards or to special wards for N. d. Of the maternity hospital, where they are again placed in the incubator (in order to avoid hypothermia and asphyxia, children should be transferred from the ward to the ward with heating pads and an oxygen pillow). On the 7-8th day of life, N. d. Is transported in a specially equipped car for transporting premature babies (equipped with a transport chamber, in which heated and humidified oxygen is supplied, and served by specially trained nurses) to a special department of the hospital for N or to the department of pathology of newborns in children's hospitals, where they are treated and nursed until complete recovery and until the body weight of a premature baby reaches 2500 g (on average, these periods are about 45-47 days). In order to avoid cross-infection, patients N. should be in a boxed ward, where it is necessary to create an optimal temperature regime and humidity, since cooling or overheating contributes to pneumonia. Terms of shifting N. d. From the container to the crib depend on their condition. At first, N. d. In the bed is warmed with heating pads.
Feeding
N. d., Especially in the first weeks of life, should receive breast milk or expressed donor breast milk. Natural feeding ensures maximum success in nursing these children. Human milk contributes to the predominance of bifidobacteria in the intestines of infants (see), which prevent the growth of putrefactive intestinal flora, and contains substances that contribute to the formation of fiziol, immunity in a newborn (see. Breast milk, Colostrum).
For N. d., Born in a relatively satisfactory condition and with a body weight above 2000 g, it is advisable to appoint the first feeding after 8-12 hours. after birth. With a child's body weight up to 2000 g, provided that it is in an incubator where the required temperature and humidity is maintained, it is not applied to the breast during the entire time of stay in maternity hospital(5 - 7 days), and fed with a probe or nipple (depending on the condition of the child and the presence of a sucking reflex); the first feeding is also prescribed after 8-12 hours. after birth.
When choosing a feeding method, they are guided mainly by the degree of functions, maturity of the premature baby, his general condition, sucking, swallowing activity and body weight indicators. With weak sucking and the absence of a swallowing reflex, feeding is carried out using a thin polyethylene probe. As a rule, children with a body weight of less than 1300 g during the first 1.5-2 weeks. life is fed through a tube, because at the same time they are less tired. When the baby's condition improves and the sucking movements become more active, some of the tube feedings are gradually replaced with nipple feeding. This combined method is usually used to feed children with a body weight of 1300-1500 g in the first 2-3 weeks of life. In the future, gradually feeding through a tube is eliminated and switched to feeding from the nipple.
The question of feeding N. by breast is decided strictly individually. If the child's condition is satisfactory and he sucks well from the nipple without getting tired, the amount of food assigned to him, gains weight, he is applied to the breast. This corresponds approximately to the 3rd week. life.
The child should be kept at the breast for no more than 15-20 minutes. Since N. d. When sucking quickly get tired, deep sleep, into which they fall through a certain time after the start of sucking, is not a sign of saturation.
After checking the amount of milk being sucked out by weighing the baby before and after breastfeeding, it should be fed to normal with expressed breast milk from the nipple. If the mother has flat or large nipples and the baby does not breastfeed, feed from the breast through a special pad. The very act of sucking plays a big fiziol, the role of increasing the secretion of the digestive glands in the child and stimulating lactation in the mother.
To calculate the amount of milk required by N. d., Use the method of calorie calculation. In the first 3 days of life, the caloric content of food for N. d. Is from 40 to 60 kcal per 1 kg of body weight per day, which in terms of colostrum is 35 g; by the 7-8th day of life - 70-80 and by the 10-14th day - 100-120 kcal per 1 kg of body weight per day.
For the convenience of calculating the amount of milk required by a child in the first 10 days of life, Rommel's formula is used, according to a cut, for every 100 g of the child's weight, as many grams of milk are assigned as there are days for the child, plus 10. The calorie content of food calculated using this formula is slightly higher ...
By the age of one month N. should receive (per 1 kg of body weight per day): 135 - 140 kcal; from about 2 months of age, children born with a body weight of more than 1500 g, the calorie content is reduced to 130-135 kcal; children born with a body weight of up to 1500 g, up to 3 months. should get 140 kcal; at 4-5 months -130 kcal.
Both an increase and a decrease in the caloric content of food should be made not only depending on the age of the child, but always taking into account his condition, food tolerance and the intensity of the increase in body weight. With mixed and artificial feeding, the calorie content of food should be 10-15 kcal higher than with natural feeding.
Premature babies should receive 200 ml of liquid per 1 kg of body weight per day, therefore, in addition to the daily amount of milk, it is necessary to introduce liquid. Excluding from the daily amount of liquid consumed by the child, then, a cut he receives with milk (87.5 ml in every 100 ml of milk received), a volume of liquid is obtained, which must be introduced as a drink (use 5% solution glucose or Ringer's solution diluted with water with the addition of 5 or 10% glucose solutions). The liquid is introduced in small portions between feedings, either during the night break, or added to a portion of milk.
In the first days of N.'s life, it is necessary to feed more often: first, 12-10 feeding times are prescribed, then gradually they switch to more rare feeding with a 3-hour break between feedings and a 6-hour night break. Usually, the transition to feeding with 3-hour breaks is carried out by the 5-8th day of life, taking into account the condition of the child. From the 2nd week. life, as a rule, 7 meals a day are accepted.
With natural feeding, the most favorable indicators of nitrogen metabolism are provided with the introduction of the following amount of protein with food: at the age of 2 weeks - 2 - 2.5 g per 1 kg of body weight, up to 1 month - 2.5-3 g per 1 kg , older than 1 month 3-3.5 g per 1 kg of body weight per day. When artificial feeding using adapted milk formulas, for example. "Baby", the amount of protein required for N. d. At the age of up to 2 weeks is 2.5-3 g per 1 kg of body weight, up to 1 month - 3-3.5 g per 1 kg and older 1 months - 3.5-4 g per 1 kg of body weight per day.
With artificial feeding without the use of adapted milk mixtures (using dilution of cow's milk, kefir), the amount of protein per 1 kg of body weight should be 4.0-4.5 g per day. Proteins in N.'s diet are usually calculated on the due weight.
The need for fat in a premature baby is from 5.0 to 6.5 g per 1 kg of body weight per day and does not depend on the type of feeding. The calculation of dietary fat is based on the child's current weight. When correcting fat in the diet of a premature baby, it is necessary to remember that it is not well absorbed and tolerated by the body of a premature baby.
The amount of carbohydrates in the diet of a premature baby should be from 13 to 15 g per 1 kg of body weight per day for any type of feeding.
In case of insufficient weight gain, it is necessary to correct the diet for the protein component.
For this purpose, you can carefully introduce cottage cheese (usually by the age of one month), starting from * / 2 teaspoons per day, rubbing it well with breast milk. You can also add kefir to breast milk.
In the absence or insufficient amount of breast milk from the mother, N. d. Is fed with dry adapted mixtures "Baby", "Vitalakt", "Biolakt", the composition of which is close to breast milk. The "Baby" mixture is prescribed in the first 2 months. life, in the future they switch to the "Kid" mixture. However, preference is given to fermented milk mixtures - "Biolakt", "Narine", "Boldyrgan", etc. (see Lactic acid products, Milk mixtures).
For 1 month. life enter ascorbic acid 0.01 g 3 times a day. Vitamins B2, B6 are prescribed 0.001 g 2 times a day. The timing of the introduction of fruit and vegetable juices and homogenized vegetable and fruit purees, as well as complementary foods, are prescribed from 4.5-5 months. according to the general rules of feeding infants (see Feeding children).
Weaning is carried out according to generally accepted rules for 11 - 12 months. life of a child.
Features of the regimen of a premature baby and caring for him in the pediatric area
To ensure continuity in work between a children's clinic, a maternity hospital and children's hospitals, when N. is discharged, the epicrisis reflects the features of the course of the neonatal period in a child, a wedge, the diagnosis, the treatment carried out, and also recommendations for further honey are given. supervision in the pediatric area.
All N. d. Constitute a group of increased risk, threatened by morbidity. The high-risk group includes children with a birth weight of less than 1500 g, as well as N. d. Who underwent in the neonatal period infectious diseases, in particular sepsis, pneumonia, etc., as well as children with intracranial birth trauma. N. d., Early transferred to artificial feeding, require special attention.
The pediatrician of the polyclinic and the nurse visit the child at home on the very first day after he is discharged from the maternity hospital or hospital. For 1 month. a child's life, a pediatrician should examine him once a week, at the age of 1 to 6 months - once every 2 weeks, in the second half of life - once a month.
Children whose body weight at birth was less than 1750 g, up to 7 months. lives are under nursing care, carried out 2 times a month. More mature N. d. The nurse visits 2 times a month up to 4 months. life, after 4 months. life (if the child is in a satisfactory condition) - once a month (see Patronage).
Medical supervision for N. d. Includes an assessment of physical and neuropsychic development, control over feeding and its correction.
In the second year of life and thereafter, the number of preventive medical supervision depends on the state of health, physical and neuropsychic development of the child. It should be remembered that N. d. In the second year of life has a tendency to develop anemia. In this connection, they are recommended to do a blood test once a quarter. Specialists of various profiles (orthopedic surgeon, neuropathologist and ophthalmologist) should examine the child for 1 month. life, and then again at least 2 times a year. All N. d. With identified pathology should be under dispensary supervision by specialists of the appropriate profile.
When N. is found at home, first of all, you should maintain the required temperature in the room (within 22-24 °). The room where the child is located should be ventilated as often as possible.
Children with prematurity of the 1st and 2nd degree do not need a very warm wrap, they dress them the same way. as full-term, however, a warm, but not hot, heating pad is placed under the blanket. Children with prematurity of 3-4 degrees are dressed warmer (a blouse with a hood and sewn-on sleeves at the ends, a diaper, a diaper made of a bike, a fleece blanket and an envelope made of paper fabric with a quilted quilted jacket or folded fleece blanket). Heating pads are placed on three sides, the water temperature in which should not be higher than 60 °, and on top of everything they wrap the child with a flannel or flannel or thin woolen blanket. The air temperature under the bottom blanket should be 28-33 ° C. If the child has a coldness during a walk and the forehead becomes cold, then a thin layer of cotton wool is placed in the cap or hood.
You can not restrict the baby's breathing with tight swaddling. In order for all parts of the lungs to breathe evenly, it should be periodically turned from one side to the other. By the end of the 1st month. life, most N. d. usually ceases to need special warming. If a child has a normal body temperature, and he is sweating, therefore, he is hot and needs to be wrapped less.
N. d. Are taken out for a walk after the permission of the doctor, having put a heating pad in a blanket. In winter, when the air temperature is 7-10 °, children are taken out into the street at the age of no earlier than 3 months. life.
In the absence of contraindications, starting from the age of 3 weeks - 1 month, N. should be placed on the stomach for 1-2 minutes. 3-4 times a day. At the age of 1 - 1.5 months. in the daily regimen include stroking massage, from 3 to 6 months - other massage techniques, passive exercises with their constant complication. In the second half of the year, the complex of physical exercises includes active exercises in an increasing volume (see Gymnastics for young children).
The basis of correct nursing and education of N. d. Is a clear physiologically grounded regime. When prescribing the regimen, the body weight at birth, age, and condition of the child are taken into account (Table 2).
Tables
Table 1. THE AVERAGE MONTHLY BODY WEIGHT GAIN IN PREMATURE CHILDREN DEPENDING ON THE BODY WEIGHT AT BIRTH (according to V. E. Ladygina)
|
Age, months |
Body weight at birth, g |
|||
|
Average monthly weight gain, g |
||||
Table 2. MODES FOR PREMATURE CHILDREN OF THE FIRST YEAR OF LIFE DEPENDING ON BODY WEIGHT AT BIRTH AND AGE (at home)
|
Age, months |
Mode (number of feedings and sleep) depending on the baby's body weight at birth |
|
|
body weight at birth 1550-1750 g |
birth weight 1751 - 2500 g |
|
|
7 feedings every 3 hours; daytime sleep - 2.5 hours 4 times, each wakefulness - 15-20 minutes; night sleep - 6-7 hours. |
Up to 2-2.5 months 7 feeds every 3 hours, then 6 feeds every 3.5 hours; daytime sleep - 2-2.5 hours 4 times, each wakefulness - 30-40 minutes; night sleep - 6-7 hours. |
|
|
3-4 to 6-7 |
6 feedings every 3.5 hours; daytime sleep - 2-2.5 hours 4 times, each wakefulness - 30-40 minutes. (after 5 months - sleep for 2 hours 15 minutes 4 times, each wakefulness - up to 1 hour); night sleep - 6-7 hours. |
Up to 5 months 6 feeds every 3.5 hours, then 5 feeds every 4 hours; daytime sleep - 2.5 hours 3 times, each wakefulness - up to 1.5 hours; night sleep - 6-7 hours. |
|
6-7 to 9-10 |
5 feedings every 4 hours; daytime sleep - 2 hours 15 minutes - 2.5 hours 3 times, each wakefulness - 1.5-2 hours; night sleep - 6-8 hours. |
5 feedings every 4 hours; daytime sleep - 2 hours 3 times, each wakefulness - up to 2 hours; night sleep - 6-8 hours. |
|
9-10 to 1 year old |
5 feedings every 4 hours; daytime sleep - 2 hours 3 times; each wakefulness - 2-2 hours 15 minutes; night sleep - 6-8 hours. |
5 feedings every 4 hours; daytime sleep for 1.5-2 hours 3 times, each wakefulness - 2.5 hours; night sleep - 6-8 hours. |
|
Note. Children with a birth weight of 1000-1500 g rarely get to the pediatric area earlier than 3-4 months of life; at this age, they, as a rule, need a regimen similar to the regimen for N. d. with a birth weight of 155 0 -175 0 g. |
||
Bibliography: Afonina L. G. and Dauranov I. G. Immunological changes in premature infants with intracranial injury, Vopr. okhr. mat. and children., v. 20, no. b, p. 42, 1975; Afonina L. G., Mikhailova 3. M. and T and and-e in N. A. The state of immunological reactivity of premature infants with sepsis, there she, t. 19, No. 8, p. 21, 1974; Gulkevich Yu. V. Perinatal infections, Minsk, 1966, bibliogr .; Ignatieva RK Questions of statistics of prematurity, M., 1973;
Novikova E. Ch. And Polyakova G. of the item Infectious pathology of the fetus and newborn, M., 1979, bibliogr .; Novikova E. Ch. And Tagiev N. A. Sepsis in premature babies, M., 1976, bibliogr .; Novikova E. Ch. And others. Premature babies, Sofia, 1971; Fetus and newborn, ed. L. S. Persianinova, p. 199, M., 1974; Stephanie DV and Veltischev Yu. E. Clinical immunology of childhood, L., 1977, bibliogr .; X and z and N about in AI Premature children, L., 1977, bibliogr .; Bozhkov LK Physiology and pathology in a child's miscarriage, Sofia, 1977; A handbook of pre-natal pediatrics for obstetricians and pediatricians, ed. by G. F. Bats-tone a. o., Philadelphia, 1971.
The problem of the neuropsychic development of a child, due to its enormous social significance, is always in the focus of attention of doctors and teachers.
Weight-based orientation in group selection for outcome analysis is convenient for neonatologists. However, obstetricians, when making the most important decisions on planned delivery, are guided by the period of intrauterine development. The perinatologist's choice of the right tactics is becoming increasingly important as an increasing number of children born at 28 weeks of gestation and less survive without gross neurological damage thanks to the development of perinatal intensive care. Therefore, it is necessary to have data on the outcomes of premature babies, depending on the timing of their intrauterine development.
L.W. Doyle, D. Casalaz (2001) published the results of follow-up observations up to 14 years of 351 children born with extremely low body weight in Victoria (Australia) in 1979-1980. 88 children survived to the age of 14 - 25%. Of those who survived, 14% had a severe disability, 15% had a moderate disability and 25% had a mild one. 46% were normal, but half of them had reduced intellectual capacity compared with the control group of children born with normal body weight. Cerebral palsy was diagnosed in 10% of survivors, blindness - in 6%, deafness - in 5%. The authors note that when comparing the incidence of disability in children at the age of 2, 5, 8 and 14 years old, its steady increase was noted as the child grows up.
One of the general important factors affecting the condition and further development of the nervous system is the quality of perinatal intensive care before childbirth, as well as the rapid onset and continuous implementation of neonatal supervision and intensive care. Further improvement in outcomes depends on the choice of a strategy aimed at eliminating the adverse effects of perinatal factors (respiratory failure, hypoxia, hypothermia, etc.).
Many studies of different years have shown that peri- and intraventricular hemorrhages of severe degree, periventricular leukomalacia, convulsive seizures, hyperbilirubinemia, prenatal bleeding in the mother, delay in the restoration of the initial body weight after physiological loss lead to an increased incidence of disorders of the nervous system in premature infants. and postnatal growth retardation of the child.
With regard to cerebral palsy in premature infants, the following data are available. The reported incidence of cerebral palsy among surviving premature infants in recent years has been inconsistent. Thus, in one of the regional studies, it is reported that after the introduction of intensive neonatal care among children born with a body weight of less than 2000 g, the number of survivors (without cerebral palsy) increased by 101 children for every 1000 survivors, and the number of children with subsequently developed severe disabilities increased. only 5 for every 1000 survivors (Stanley, Atkinson, 1981). In Sweden, it has been estimated that cerebral palsy develops in only one out of every 40 additionally rescued with intensive neonatal care (Hagberg et al., 1984). In addition, this study noted that the increase in the incidence of cerebral palsy occurred mainly among children with birth weights of 2001-2500. Therefore, the contribution made by surviving children with EBMT to the total number of children with cerebral palsy should not be overestimated.
Data based on long-term observation (about
15 years) published by Timothy R., La Pine et al. (1995). Children weighing less than 800 g (420-799 g, gestational age 22-28 weeks) were observed. Three groups were compared: those born in 1977-1980, in 1983-1985 and in 1986-1990.
The annual intake of these children doubled from 1977 to 1990. Survival rates increased - 20, 36 and 49%, respectively (especially among children weighing less than 700 g). At the same time, the frequency of severe neurological disorders did not differ significantly over these three periods - 19%, 21%, and 22%, respectively. During all three periods, damage to the nervous system occurred more often in boys. The average level of cognitive ability for these periods also did not differ - 98, 89 and 94. The authors conclude that a progressive increase in survival does not lead to an increase in neurodevelopmental disorders.
According to the data available to date, there is no doubt that there is a high probability of a completely successful outcome in mental development in children with EBMT. However, it is necessary to take into account some peculiarities. In the process of development in this group of children, there is a violation of synchronicity, more often the lag of psychomotor development from mental development. When assessing with psychometric tests, one should focus on the age of the premature baby, adjusted for the term of prematurity, which helps to mitigate undue anxiety.
For reliable prediction of distant outcomes of mental development, the socio-economic environment (education, occupation and income of parents, their active position) is of particular importance. Premature babies are especially susceptible to external influences, and through appropriate intervention, their intellectual development can be enhanced. Studies using social and sensory stimulation have shown that enriched programs led to improved scores on intelligence tests. This is at the heart of the work of the so-called "institutions of early intervention", under the supervision of which premature babies must necessarily be in order to receive active all-round assistance in their development.
Severe visual impairments, which occur in premature infants with VLBW in 5-6% of cases, are more often caused by retinopathy of premature infants; there may be cases of optic nerve atrophy (often associated with cerebral palsy) and caused by a generalized disease of the fetus of an infectious or genetic nature.
Recently, there has been a tendency towards a decrease in the incidence of deafness associated with damage to the auditory nerve in surviving children with VLBW. In the group of children with EBMT, it is 2%. It is very important to diagnose hearing loss early in order to begin possible correction.
According to the structure of somatic pathology, in the process of further development of premature babies, in the first place are respiratory diseases, then disorders of the nervous system, anemia, infectious diseases and disorders of the digestive system. However, respiratory diseases in children with VLBW are observed more often only up to 2 years of age, and from 2 to 8 years, such a relationship has not been established (Kitchen W. et al., 1992). Children with IUGR are more likely to get sick. So, according to A.A. Baranov et al. (2001), at an early age 24% of children with IUGR and only 1.2% of children with GBS suffered pneumonia.
In recent years, due to significant advances in neonatology (in particular in such areas as neonatal resuscitation, improvement and development of new methods of nursing, etc.), the survival rate of premature babies has increased as with critically low birth weight, on the one hand. and with perinatal lesions, on the other.
Premature babies are at a high risk of developing somatic, neurological disorders in them in the future, which forms the basis for the occurrence of various kinds of deviations in mental development. The data accumulated by foreign statistics indicate that among premature babies:
- Cerebral palsy was diagnosed in 16% of cases; the percentage of this disease turned out to be quite stable and was adopted as an indicator of the prevalence of cerebral palsy in surviving premature infants;
- mental retardation was diagnosed in 20% of cases; in 21% of cases, the level of intellectual development was below normal (in the United States, this category of children is called "persons with borderline intellectual abilities"); in 10% of cases, blindness or deafness was observed;
- in 1/3 of cases there was a combination of disabling disorders (for example, cerebral palsy and mental retardation);
- in 50% of cases at the age of 6-8 years, the intellectual development of children corresponded to the norm (according to T. Montgomery, 1996).
Domestic and foreign authors note that the following biological factors have a significant effect on the early mental development of premature infants: histological age, morphofunctional immaturity, birth weight, neurological disorders (E.P. Bombardirova, 1979; V. Krall et al., 1980 ; S. Grigoroiu, 1981; S. Goldberg et al., 1986; J. Watt, 1986; D. Sobotkova et al., 1994; A.E. Litsev, 1995; Yu.A. Razenkova, 1997).
The aim of this work was to study the features of early mental development of premature infants with critically low birth weight and perinatal CNS damage.
For this, the scales of intellectual and motor development of children were used. early age N. Bailey's test (1993). This test was chosen on the basis that, firstly, it is well standardized and, secondly, it allows you to compare the value of standard points received by the child both with his own, but obtained at a different age, and with the values obtained by the group. peers.
The subjects were 24 premature babies with a critical body weight of 900 to 1500 grams. The histological age of these infants ranged from 25 to 36 weeks (mean histological age = 29.7 weeks). The chronological ages of these children ranged from 2 months 13 days to 13 months 6 days (mean chronological age = 20 weeks). Boys accounted for 42% (n = 10), girls - 58% (n = 14). All children had a history of a diagnosis of perinatal encephalopathy of varying severity.
After discharge from the hospital, the children were followed-up. The examination of children was carried out on an outpatient basis together with doctors, a neonatologist and a neurologist.
results
The results of the test performed by the children were compared with the standard values corresponding to their chronological age, on the one hand, and the corrected age, on the other. Adjusted age is the difference between the chronological age of the baby and the time (number of weeks) the baby is premature. For example, the chronological age of a child at the time of examination is 5 months. 6 days, the histological age of the child is 27 weeks. The term of prematurity is 40 weeks. (average duration of pregnancy) minus 27 weeks. = 13 weeks (3 months 1 week). The adjusted age would be 5 months in this case. 6 days - 3 months 7 days = 1 month 29days In the group as a whole, the mean values of the index of intellectual development (M = 59.6) and the index of motor development (M = 61.7), calculated for the chronological age of children, were lower than the average value of the norm by approximately 2 2/3 standard deviations (SD = 15 ). These values correspond to indicators of significant developmental delay.
Calculated for the adjusted age of children, the average value of the IQ (M = 89) is below the average for the norm by approximately 2/3 standard deviations; and the average value of the index of motor development (M = 93) is lower than the average value for the norm by 1/3 standard deviation. Both of these values are within the normal range. (see Histogram 1).
Bar graph 1. Average value of intellectual and motor development for the group as a whole
Analysis of individual data obtained for chronological age shows that intellectual development of only 8.9% of children corresponds to the norm, the bulk of children - 80% fall into the group of significant delay and 11% of children - in the group of average delay. A similar distribution of children by development groups is observed in motor development: 10.2% - corresponds to the norm, 82% - a significant delay, and 7.8% - an average delay. That is, we see that the bulk of children fall into the group of significant delay.
The opposite picture is observed for the data obtained for the adjusted age, however, even there, despite the fact that the average values of the indices of intellectual and motor development for the group as a whole fall within the normal range, a detailed analysis of individual data shows that the intellectual development of 68.9% of children corresponds to normal, 17.8% of children fall into the group of medium delay, 2.2% - into the group of significant delay, and 11.1% - into the group of advanced development. Motor development is normal in 82% of children; 7.7% of children fall into the group of average delay, 2.6% - into the group of significant delay, and 7.7% - into the group of advanced development.
A longitudinal study showed that with age, there is a change in the percentage of children by development group. For example, the results obtained for the adjusted age show that the intellectual development of children at the first examination corresponds to the age of 47.8%, lags behind in 39.1%, and is ahead of 13.1%; on the second examination: corresponds - in 46.2% and lags behind - in 53%; on the third examination: corresponds to - in 12.5%, lags behind - in 37.5% and ahead - in 50% of children.
Thus, we see that the intellectual development of premature babies in the first year of life is uneven. One and the same child at different age periods can fall into different developmental groups. Similar data were obtained regarding motor development. So on the first examination, 40% of children fall into the norm group for the adjusted age, 25% are behind their age, and 25% are ahead. On the second survey, 70% of children are already age-appropriate, 10% are lagging behind and 20% are ahead of their adjusted age. In the third survey, 37.5% are age-appropriate, 37.5% are lagging behind and 25% are ahead of their adjusted age. The unevenness of both intellectual and motor development of the studied category of children is clearly visible in Histogram 2.
Bar graph 2. Average values of intellectual and motor development of children in the group as a whole
The most pronounced decrease in the level of intellectual and motor development of children is observed at the age of 3-4 months. and 6-7 months, which is consistent with the data obtained in the study by Yu.A. Razenkova, in which the author, based on the slowdown in the rate of CPD in children, singles out these age periods as critical groups for children at increased risk. Analysis of individual data shows that another characteristic feature of the mental development of this group of children is the asynchrony of motor and intellectual development, which is observed in 65% of children.
The analysis of the effect of the severity of perinatal encephalopathy (PEP) on the intellectual and motor development of premature infants in the first year of life did not reveal significant differences between children with mild, moderate and severe PEP (the indices of motor development are 100.75; 97.7; 96.18, and the indices of intellectual development - 95.1; 96.3; 88.9, respectively). All of these values are within the normal range for the adjusted age of children (see Bar Chart 3).
Bar graph 3. Influence of AED severity on the intellectual and motor development of premature infants in the first year of life
conclusions
- Thus, we see that when assessing the mental development of premature babies, it is necessary to take into account the degree of their prematurity. The indicators of motor and intellectual development of these children, as a rule, lag behind those of full-term children and from their chronological age by about the term of prematurity.
- A favorable prognostic sign for the intellectual and motor development of premature infants with critically low birth weight and perinatal CNS damage may be the convergence of the values they obtain for chronological and corrected age.
- The characteristic features of the mental development of the studied category of premature infants are the unevenness and asynchrony of intellectual and motor development in the first year of life.
- Montgomery, T. Follow-up of high-risk newborns with an assessment of their neurological status // Pediatrics. - 1995. - No. 1. - S. 73-76.
- Petrukhin, A.S. Perinatal pathology // Pediatrics. - 1997. - No. 5. - S. 36-41.
- Soloboeva Yu.S., Cherednichenko L.M., Permyakova G.Ya. Actual problems of perinatology. - Yekaterinburg, 1996 .-- S. 221-223.
- Shabalov, I.P. Neonatology. - T.2. - M., 1997.
Most young parents panic if their baby is born prematurely. They worry not only about the health and physical condition of their child, but also about his further mental and mental development. Therefore, in this article we will consider what is special about newborns born prematurely.
What babies are considered premature
Doctors call premature babies who are born between the 28th and 37th weeks of pregnancy. In most cases, the height of such a child ranges from 35-46 cm, and the weight is 1-2.5 kg.
Physiological signs
Premature babies outwardly differ from babies born on time not only in their miniature size, but also in other features:
- the parietal and frontal tubercles are enlarged;
- the facial skull is much smaller than the cerebral;
- large anterior fontanelle;
- there is no subcutaneous fat layer;
- the auricles are soft and easy to deform;
- the growth of vellus hair is observed on the body;
- legs are shorter.
Functional signs
In children born prematurely, all systems and organs are still underdeveloped, especially the central nervous system. Often these children have respiratory arrhythmias, which can lead to respiratory arrest and death. In a full-term baby, the lungs straighten out with the first cry and remain in this state, while in a premature baby, straightened lungs can fall off again. Due to the underdevelopment of the digestive system and the lack of enzymes necessary to digest food, the child often has abdominal pain, constipation, regurgitation and vomiting. An unformed thermoregulatory system leads to the fact that premature babies very quickly and easily overheat or overcool.
Development
If the baby was born prematurely, but in general he is healthy, then he will develop at a rapid pace, trying to catch up with his peers in terms of indicators. According to statistics, children born with a weight of 1.5 to 2 kg double their weight by the age of three months, and by the year they increase it by 4-6 times. The growth of the child also occurs intensively, in the first year of life, the premature baby grows by 27-38 cm, and by the age of one year it reaches 70-77 cm.The head circumference increases by 1-4 cm by six months, and by 12 months by another 0.5 -1 cm.
Psyche... If at birth the child weighed less than 2 kg, then he will have a lag in psychomotor development. Moreover, if the baby does not receive proper care or is often sick, then the lag will worsen.
Activity and tension... In the first two months of their life, premature babies sleep almost all the time, they get tired quickly and move little. After this time, the activity of the baby increases, and along with it, the tension of the limbs also increases. The baby's fingers are almost always clenched into a fist, they can be unclenched with difficulty. To relieve stress, it is necessary to carry out special exercises with the child.
Health... Babies born prematurely and lagging behind their peers in development have weak immunity and often get sick. They are especially prone to otitis media, intestinal disorders, and respiratory infections.
The underdevelopment of the nervous system is reflected in the behavior of the child: sometimes he sleeps for a long time, and sometimes he suddenly wakes up screaming, shudders and gets scared when the lights are turned on or sharp sounds, loud conversation of others.
Care
Immediately after birth, premature babies are placed in a special ward, in which optimal conditions are created for them. Particularly heavy babies are in incubators. In the early days, young mothers can only watch their crumbs through the glass wall of the chamber. If the condition of the newborn is satisfactory, then after a few days the doctors allow the woman to take the child in her arms, and recommend how to communicate with him as much as possible: talk, sing songs, stroke the back, arms, and legs. Such emotional contact contributes to a faster mental and physical development of the child. Even if the baby does not particularly react to mother's actions, this does not mean that he does not feel anything and does not notice, it just does not yet have enough strength to show his reaction. After 3-5 weeks of constant communication with the child, the woman will see the first result of her efforts.
A premature baby will develop faster if stimulated. To do this, you can hang bright toys over his crib, let him listen to the recording of the voices of his relatives or quiet calm music.
Norm of Conduct
The behavior of premature babies is not the same as that of their peers. They quickly get tired and concentrate hard, so when dealing with such a baby, you need to alternate exercises that require mental stress with physical exercises or outdoor games. Each task should be divided into several stages, and consistently monitor their implementation. If a child, born prematurely, lags behind peers in development, then he needs regular supervision from a psychologist.
Alarming symptoms
Parents should not panic if their baby is often naughty, he has signs of apathy and lethargy. Premature babies can thus react to any changes in the world around them, for example, to changes in the weather.
However, there are signs that the baby is not doing well:
- painful reaction, crying, screaming, convulsions at the sound or touch of an adult in a baby older than 1.5-2 months;
- lack of a reciprocal look in an infant older than 2 months, if he has normal vision.
The listed symptoms may indicate such a mental illness as early childhood autism. Many deeply premature babies are at risk. Therefore, if you notice signs of illness in your baby, immediately consult a doctor, psychiatrist or psychologist for advice.
Loading ...