What to Expect the First Year (135 page)

The same breathing problems may occur in young premature babies in infant seats and baby swings, so don't use either without the doctor's approval.

Prematurity is risky business. Tiny bodies are not fully mature, many systems (heat regulatory, respiratory, and digestive, for example) aren't yet fully operative, and not surprisingly, the risk of neonatal illness is increased. As the technology for keeping such babies alive improves, more attention is being given to these common preemie conditions, and completely successful treatment is becoming more and more the norm for many of them. (New treatments are being developed almost daily and so may not be detailed here, so be sure to ask your neonatologist or pediatrician about recent advances.) The medical problems that most frequently complicate the lives of preterm infants include:

Respiratory distress syndrome (RDS).
Because of immaturity, the premature lung often lacks pulmonary surfactant, a liquid that coats the inside of the lungs and helps keep the air sacs (alveoli) in the lungs from collapsing. Without surfactant the tiny air sacs collapse like deflating balloons each time baby breathes out, forcing him or her to work harder and harder to breathe. This is called RDS. Interestingly, babies who have undergone severe stress before birth, usually during labor and delivery, are more likely to have surfactant, since the stress appears to speed lung maturation.

RDS, the most common lung disease of premature infants, was once frequently fatal, but more than 80 percent of babies who develop RDS today survive, thanks to an increased understanding of the syndrome and new ways of treatment. Extra oxygen is given via a plastic oxygen hood, or via continuous positive airway pressure (CPAP), which is administered through tubes that fit into the nose or mouth. The continuous pressure keeps the lungs from collapsing until the body begins producing sufficient surfactant, usually in 3 to 5 days. With severe RDS, a breathing tube is placed in the mouth and the baby is put on a respirator. Artificial surfactant is then administered directly to the baby's lungs via the breathing tube. Sometimes, when lung immaturity is detected in utero, RDS can be prevented entirely by the prenatal administration of a hormone to the mother, to speed lung maturation and production of surfactant.

A mild case of RDS usually lasts for the first week of life, though if the baby must be placed on a respirator, the recovery may be much slower. Babies with severe cases of RDS may be at an increased risk of colds or respiratory illnesses during their first 2 years of life, and may be more likely to experience childhood wheezing or asthma-like illnesses and be hospitalized in their first 2 years.

Bronchopulmonary dysplasia (BPD).
In some babies, particularly those born very small, long-term oxygen administration and mechanical ventilation used to help treat RDS appear to combine with lung immaturity to cause BPD, or chronic lung disease. The condition, which results from lung injury, is usually diagnosed when a newborn still requires increased oxygen after reaching 36 weeks gestation and lung changes (such as scarring) are seen on x-rays. Babies with BPD have to work harder than other babies to breathe, and breastfeeding or bottle-feeding makes them work especially hard. Because they end up using so many calories when they exert themselves to breathe, and because they have a harder time eating, babies with BPD often have nutritional challenges such as poor weight gain.

BPD is a chronic condition, and the only cure is giving it time, since over time, new healthy lung tissue will grow and the symptoms will ease. That's why treatment is only to lessen the symptoms of the condition while the lungs grow and mature. Treatment can include extra oxygen, continued mechanical ventilation, medications such as bronchodilators (to help open the airways) or steroids (to reduce inflammation), and medication to prevent RSV (respiratory syncytial virus;
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) prevention medication. Some babies will require oxygen at home, and all require a high caloric intake to improve growth. Happily, most babies with BPD outgrow their symptoms and lead healthy lives.

Apnea of prematurity.
Though apnea (periods when breathing stops) can occur in any newborn, the problem is much more common among premature infants. Apnea of prematurity occurs when immature respiratory and nervous systems cause preterm babies to stop breathing for short periods. It is diagnosed when a baby has such periods that last more than 20 seconds or shorter ones that are associated with
bradycardia, a slowing of the heart rate. It is also considered apnea if the cessation of breathing is associated with the baby's color changing to pale, purplish, or blue. Almost all babies born at 30 weeks or less will experience apnea.

Apnea is treated by stimulating the infant to start rebreathing by rubbing or patting the baby's skin, administering medication (such as caffeine or theophylline), or using continuous positive airway pressure (CPAP), in which oxygen is delivered under pressure through little tubes into the baby's nose. Apnea of prematurity is not associated with SIDS (Sudden Infant Death Syndrome), and many babies will outgrow it by the time they reach 36 weeks gestation. If a baby has breathing pauses after apnea has been outgrown, it is not considered apnea of prematurity and is more likely caused by some other problem.

Patent ductus arteriosus.
While baby is still in the uterus, a duct called the ductus arteriosus connects the aorta (the artery through which blood from the heart is sent to the rest of the body) and the main pulmonary artery (the one leading to the lungs). This duct shunts blood away from the nonfunctioning lungs and is kept open during pregnancy by high levels of prostaglandin E (one of a group of fatty acids produced by the body) in the blood. Normally, levels of prostaglandin E fall at delivery, and the duct begins to close within a few hours. But in about half of very small premature babies (those weighing less than 3 pounds, 5 ounces), and in some larger babies, levels of prostaglandin E don't drop, and the duct remains open or “patent.” In many cases there are no symptoms, except a heart murmur and a little shortness of breath on exertion and/or blueness of the lips, and the duct closes by itself soon after birth. Occasionally, however, severe complications occur. Treatment with an antiprostaglandin drug (indomethacin) is often successful in closing the duct. When it isn't, surgery will do the job.

Retinopathy of prematurity (ROP).
The blood vessels in the eyes are not fully developed until about 34 weeks gestation. When babies are born too early, the immature blood vessels in the retinas sometimes begin to grow too quickly, damaging the retina. Retinopathy of prematurity (ROP) is the name for the improper growth of the blood vessels on the retina and the damage caused by that growth. In most preemies, the growth of the retinal blood vessels will slow down on its own, and vision will develop normally. The incidence of ROP increases as birthweight decreases. More than half of babies born weighing less than 2 pounds, 12 ounces (1,250 grams) will develop ROP, most often mild. Severe retinopathy of prematurity is largely a problem of those babies born before 28 weeks.

Most cases of ROP will get better on their own, requiring no treatment, and the babies will recover with no lasting visual problems. But since ROP can sometimes lead to scarring and distortion of the retina, increased risk of nearsightedness, wandering eye, involuntary rhythmic movements of the eye, and even blindness, a newborn with ROP will be seen by a pediatric ophthalmologist. Infants with severe ROP may require treatment (laser therapy, cryotherapy, or surgery) to stop the progression of the abnormal vessels.

Intraventricular hemorrhage (IVH).
IVH, or bleeding in the brain, is extremely common among premature infants because the vessels in their developing brains are very fragile and can bleed easily. Intraventricular hemorrhage most often affects preemies weighing less than 3 pounds, 5 ounces, usually within the first 72 hours of life. The most severe hemorrhages (which affect only 5 to 10 percent of extremely premature babies) require close observation to correct any further problems that develop—for example, hydrocephalus (blockage of spinal fluid). Regular follow-up ultrasounds are usually ordered for such hemorrhages until they are resolved. Unfortunately, there is no way to stop an intraventricular hemorrhage once it has begun. In mild cases (and most cases are), the blood is absorbed by the body. In a less mild case, the treatment targets symptoms of the bleed instead of the bleed itself. The good news is that in most mild cases the follow-up ultrasound of the head is normal and the baby's development is normal for a preterm baby.

Necrotizing enterocolitis (NEC).
NEC is a condition where the intestines become infected and can begin to die. If the disease is not treated promptly, a hole can form through the bowel wall, spilling the bowel's contents into the abdominal cavity. No one knows for sure what causes NEC, but because the more premature a baby is, the greater the risk of NEC, doctors speculate that the intestines of very premature babies are not developed enough to completely handle digestion. Delaying feedings doesn't seem to prevent the condition, but babies fed breast milk usually are at less risk of NEC (breast milk has protective factors that encourage good intestinal development and reduce the amount of harmful bacteria in the intestines). The symptoms of this serious bowel disease include abdominal distension, vomiting, apnea, and blood in the stool. A baby with necrotizing enterocolitis is usually put on intravenous feedings (to let the bowels rest) and antibiotics (to treat the infection). If there is serious deterioration of the intestine, surgery is usually performed to remove the damaged portion. Unfortunately, preemies who are medically or surgically treated for NEC may have growth delays, trouble absorbing nutrients, and trouble with their livers and gall bladders. NEC also seems to increase the risk of developmental delays.

Anemia.
Many premature infants develop anemia (too few red blood cells) because their red blood cells (like those of all babies) have a shorter life than red blood cells of adults, they make few new red blood cells in the first few weeks of life (like all infants), and the frequent blood samples that must be taken from the baby to do necessary laboratory tests make it difficult for red blood cells to replenish. Anemia is also more common in preemies because they missed out on the transfer of iron from their moms that happens during the last weeks of pregnancy and because the bone marrow process that makes new red blood cells is immature in preemies.

Mild anemia may not need treatment if the number of red blood cells is enough to carry oxygen to meet the baby's needs. More serious anemia is usually treated by blood transfusions, iron supplementation, and limiting the amount of blood drawn to only what is necessary. Since preemies, whether they're anemic or not, are born with low levels of iron, they are usually given iron supplements to help build up the reserves necessary to produce red blood cells.

Infection.
Premature infants are most vulnerable to a variety of infections because they are born before the transfer of disease-fighting antibodies from the mother that normally occurs toward the end of pregnancy. Preemies also have an immature immune system, making it more difficult to fight germs, including those that are inadvertently introduced via feeding tubes, IV lines, and blood tests. Among the infections preemies are more likely to come down with are pneumonia, urinary tract infections, sepsis (infection of the body or bloodstream), and meningitis. Babies whose blood, urine, or spinal fluid cultures come back positive for signs of infection are treated with a full course of IV antibiotics, which usually helps resolve the infection and puts baby on the right track back to health again.

Jaundice.
Premature babies are much more likely to develop jaundice than are full-term infants. Also, their bilirubin levels (the measure of jaundice) are likely to be higher and the jaundice longer lasting. Read about the condition
here
.

Hypoglycemia.
Premature and low-birthweight babies often have low blood sugar or hypoglycemia. But since the brain depends on blood glucose
as its main source of fuel, it's crucial that a baby's blood sugar gets regulated as soon as possible so that it doesn't lead to serious (and rare) complications such as brain damage. Problem is, hypoglycemia may not be obvious in newborn babies because the symptoms are hard to pinpoint. Luckily a simple blood test for blood glucose levels can diagnose hypoglycemia, and treatment is straightforward and works well. Treatment includes a rapid-acting source of glucose, which may be as simple as giving baby a glucose/water mixture intravenously or early feedings of formula or breast milk, if baby is well enough to feed. Breast milk is considered as beneficial as formula in treating hypoglycemia. Blood glucose levels are closely monitored after treatment to see if the hypoglycemia occurs again, and if it does, treatment will resolve the issue once again with no long-lasting negative results.