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This is an excerpt from "It's Your Baby" by Dr. Saroja Balan. During her thirty years of practice, pediatrician Dr Saroja Balan has met thousands of parents and found herself answering the same questions. While she firmly believes parenting is mostly learning on the job, she knows a little help goes a long way. Written specifically for Indian parents, It's Your Baby is the best support to accompany you on your journey.


Preterm Birth

Being a new parent is already tough, but when the baby is born early (a preterm birth), there are many more challenges. Preterm babies are those born between 24 weeks and 36 weeks of pregnancy. Delivery before 22 weeks is usually termed a miscarriage according to Indian law and a paediatrician will not be called to attend the birth. Between 22 and 24 weeks, the couple, in consultation with the paediatrician or neonatologist, will take a decision on the resuscitation of the baby.

Preterm babies are further divided into:

  •  Late preterm (34 weeks to 36 weeks and 6 days)
  • Moderate preterm (32 weeks to 34 weeks)
  • Very preterm (28 weeks to 32 weeks)
  • Extremely preterm (less than 28 weeks)

According to Indian law, after the 24th week of pregnancy (the stage beyond which the baby is able to survive on its own), aborting a baby is illegal. If a baby is born after 24 weeks, the neonatologist will be called to attend the delivery and all efforts to help the baby survive that transitional period immediately after birth will be made. If the delivery is not imminent, the neonatologist will discuss all the possibilities that can happen after the baby is born. She will explain the different challenges the baby will face over the coming weeks. Most units will have a counselling session with the parents every day, explaining all the things that have happened to the baby and those that are likely to happen over the next few days. Babies born between 37 and 38 weeks are simply called early-term babies.

A neonate is the term used for babies from the period of birth up till 28 days after delivery. Neonates are further divided into:

  • Early neonate (0–7 days)
  • Late neonate (7–28 days)

Special care given to this group of babies is provided by trained doctors called neonatologists in a NICU.

Babies weighing less than 2.5 kg are called low birth weight babies. Usually, premature births are the result of various issues that cause early labour. At other times, it may be because of problems that necessitates the early termination of the pregnancy. Sometimes, there is no obvious cause.

To help reduce the incidence of preterm deliveries, specific care and attention is given to the mother during the pregnancy especially if there are risk factors. This period is called the prenatal period, to denote the period before the time of delivery.

Possible Causes of Preterm Labour

  • Being pregnant with more than one baby: Increased used of IVF and other assisted reproductive techniques (ART) has made multiple births and twin pregnancies very common. So it is important that we identify such pregnancies and provide them with a higher level of care, especially as they need closer monitoring. In multiple births, as the weight of the 2 or 3 babies together is always more than a singleton, the uterus overdistends and leads to preterm labour.
  • Bleeding or other problems in the uterus
  • Infection in the body or in the uterus
  • Stress: This seems to be the reason for many problems lately.

The exact mechanism is unknown but it is a well-known cause of preterm birth. Some types of stress can lead to high blood pressure which leads to preterm labour.

  • Having had a preterm labour or birth before
  • Getting pregnant again within 1 year of delivering a baby
  • Multiple pregnancies like twins and triplets
  • Being younger than 16 and older than 36
  • Chronic health problems like heart disease or kidney disease
  • Smoking and addiction to drugs (like cocaine)
Problems caused by pregnancy:
  • Infections
  • High blood pressure
  • Diabetes
  • Blood-clotting
  • Placental problems

Nowadays, thanks to neonatal intensive care, more and more preterm babies are surviving. Babies born after 28 weeks and weighing more than 1 kg have as much as a 90% chance of survival in a good NICU. A small number of these babies may have long-term health and developmental problems. Babies born earlier than 28 weeks could have more complications than if they were born at term. If your baby has a relatively smooth course in the ICU before discharge, then the chances of her having any long-term problems is very small. But if your baby has complications during her stay in the NICU, then your paediatrician will keep a close watch on your baby’s development in the coming months.

How Your Preterm Baby Looks

  • The earlier your baby arrives, the smaller your baby will be. The head will appear larger in relation to the body.
  • She will have less fat. So her skin will look thinner and may appear transparent. You might even be able to see her blood vessels through the skin.
  • She will be covered with fine hair called lanugo, more on her back and shoulders.
  • Her features will appear sharper and less round than a full-term baby. She might not have any vernix caseosa – the cheesy white material that covers term babies, mainly in the third trimester. This layer protects the newborn baby’s skin helping it to adapt to postnatal life.
  • Your baby may not cry very loudly or very much, depending on how early she has arrived and what problems she may have been born with. This will be discussed in detail in this chapter.
  • As these babies have hardly any layer of fat, they have difficulty in maintaining normal body temperature. Hence, they may need an incubator or radiant warmer to keep them warm.

NICU This is where your baby will stay for a few days or even a few weeks. Most neonatal units will allow parents to visit and, as the baby becomes more stable, parents may be asked to participate in the care of the baby.

Equipment in the NICU

Incubator The incubator is meant to mimic as much as possible the environmental conditions that your baby enjoyed while in the womb. The incubator provides your baby with the optimal growing environment – the right amount of warmth, humidity and oxygen so that she can grow.

Babies less than 1 kg will usually be looked after in an incubator, as humidity is important to maintain the balance of sodium and potassium in the little body. Hence, the baby’s treatment is conducted within the incubator so that he doesn’t have to come out and be exposed to the risk of infection. His temperature will be monitored constantly and the heating adjusted so that all the calories that are given to him will be used mainly for growth.

Infant warmer In some neonatal units, infant warmers or open-care systems are used. They provide easy access to babies, hence may be used for looking after sicker babies who are not stable and who need procedures done to them. Bigger preterm babies who don’t need much humidity can also be managed under an infant warmer. The temperature of the infant warmer can be adjusted to optimise the condition of the baby in relation to the temperature of the room.

Ventilator Through major improvements in technology, ventilators minimise lung damage in preterm babies. Small puffs of oxygenated breath are provided by the ventilator to the baby, according to her needs. These machines are calibrated to support the baby’s breath and also provide a breath when there is no spontaneous breath by the baby. As the baby’s lungs improve and mature, the support is slowly reduced – this process is called weaning. For some babies, it can happen in a couple of days, while the very small ones may take a few weeks.

Phototherapy unit The phototherapy system shines a warm blue light over your baby that helps to break down bilirubin, which is then passed out harmlessly in the stool. Your baby may need a few days under the light. The more premature the baby, the longer they will spend under these lights. This has been discussed earlier in the chapter on jaundice in the newborn.

Infusion pumps The infusion pump is used to provide fluids, nutrients and medicines to your baby through an intravenous cannula placed in a vein. The cannula is a small tube placed in the baby’s vein through which dextrose and other fluids run into the body. These machines are so calibrated that they can provide even very small doses without error. Some babies may need more than one pump at a time as they may need fluids and multiple medication like antibiotics and pain relief medicines at the same time.

Monitors As soon as your preterm baby arrives, she will be hooked on to one of these monitors with the help of wires or probes that help to monitor the heart rate, breathing rate and oxygen levels in the blood. These parameters are important – they help the nurses and doctors looking after your baby provide optimal care and indicate if things are going wrong.

X-rays and ultrasound X-rays are done to monitor the progress of internal organs, especially the lungs, and help chart out the best treatment plan for your baby. Ultrasound imaging is a common bedside procedure done in the NICU. It can give doctors a clearer picture of internal organs like the brain, heart, lungs and liver. There is no radiation involved and it is painless. Serial ultrasound can be done to chart the course of the problem.

Procedures in the NICU

Intravenous (IV) Lines Intravenous lines or cannulae are used to provide fluids and medication to the baby. These lines may be placed in the umbilicus, arm, leg and even the scalp. Once the line is inserted, it will not cause pain. Sometimes they are inserted into deeper veins in the neck or groin so that they last longer. These are called peripherally inserted central catheters (PICC) or central venous catheters.

Arterial Lines An arterial line is a cannula or plastic tube called a catheter line placed in one of the arteries either in the umbilicus, arm or leg. This helps the staff monitor the blood pressure as well as take frequent blood samples. An infusion of normal saline with a small amount of heparin is run through it to prevent it from blocking.

Eye tests All babies less than 1.5 kg of weight and below 32 weeks of age get regular eye tests. The first check-up happens 2 weeks after birth or when the baby reaches 32 weeks corrected age, whichever is sooner. (If your baby was born at 28 weeks and is now 4 weeks old, the corrected age is 32 weeks.) Drops will be put in the baby’s eyes to dilate the pupils for the examination. These examinations are done to rule out retinopathy of prematurity which is a potentially blinding disease seen in premature babies or babies who have experienced a particularly stormy neonatal period. <see page 249>.

Newborn Hearing Test Newborn babies have their ears checked on discharge from the hospital or a few days after going home. These hearing tests aim to rule out congenital nerve deafness. A failed test does not necessarily mean your baby has a serious hearing problem, but close monitoring, follow-ups and advanced screening may be necessary.

Blood Transfusions When babies are ill, they need to have a lot of blood tests done. Sometimes they may lose blood around the time of delivery. Newborn babies, especially premature babies, are unable to make enough blood to replace these losses. So anaemia may develop and the baby may need a blood transfusion. This is done through a vein for 3–4 hours. Some sick preterm babies may need multiple transfusions over the course of their stay in the NICU.

Problems of Preterm Babies

Respiratory and Lung Problems Many babies admitted to the NICU have some degree of breathing problems. It may range from needing extra oxygen in mild cases to needing ventilatory support. The ventilatory support may be either by continuous positive pressure ventilation (CPAP) or assisted ventilation.

Respiratory Distress Syndrome (RDS) This is the most common condition that affects premature babies. It is due to immature lungs which are deficient of a substance called surfactant. Surfactant is a substance that coats the small air sacs in the lung and allows them to open and close with minimum effort. It is produced in the developing lung from 20 weeks gestation onwards, but the greatest production happens 6 weeks before term. If there is a chance of preterm labour, then mothers are given a steroid injection to mature the lungs and increase the production of surfactant. Lack of surfactant will make breathing much harder. The signs are that the baby breathes much faster than normal for his age and with greater effort. There will be indrawing of the muscles of the ribcage (retractions) and you will hear a moan or grunt every timethe baby breathes. This grunt is the body trying to keep the air sacs from fully collapsing with each breath. Respiratory distress will usually worsen over the first 72 hours and then slowly start to improve as the immature lung increases its production of surfactant. Nowadays, surfactant can be instilled in the lung immediately after birth through the endotracheal tube or breathing tube.

Medical Solutions

Mechanical Ventilation A ventilator is a machine that can help premature babies breathe or even completely take over the process of breathing. For this, a plastic tube called the endotracheal tube is passed via the mouth into the trachea. It is fixed in place with the help of tape and is connected to the ventilator. The nurse and doctor will adjust the settings depending on how much help the baby requires with the breathing. As the babies’ lungs improve, the settings of the ventilator are reduced till it is time to come off the machine. This process is called weaning. Depending on the baby, this process may take from a few hours to several days. Some babies who are very sick may not do very well on the conventional ventilator and will have to be shifted to a different form of ventilation called high frequency oscillatory ventilation (HFOV). The HFOV delivers very small breaths at a very high rate and it will seem like the chest wall is vibrating.

Continuous Positive Pressure Ventilation (CPAP) This machine continuously blows warmed moist air and oxygen into the baby’s lung under a slight positive pressure. The air and oxygen can be delivered by soft tubes placed in the nose called nasal prongs or by a mask fitted over the nose. The prong or mask is held in place by beingtied to a cap on the baby’s head. In this form of ventilation, the baby isdoing all the breathing himself, but the positive pressure delivered by the machine prevents his lungs from collapsing completely with every breath, therefore making breathing easier. You can use CPAP right from birth or as a transition from the ventilator to breathing on his own. It is not uncommon for babies to need CPAP off and on for a few weeks as the lungs grow and mature. In some units, they use a heated humidified high flow nasal cannula (HHHFNC). This delivers a high concentration of oxygen and some degree of positive pressure. Its ease of use and less trauma to the nose make it popular.

Nasal Oxygen Some babies need low levels of oxygen when they come off the ventilator or CPAP. This can be given by placing tiny tubes in the nostrils called nasal prongs. Some babies may need this extra oxygen for a long time and occasionally may be discharged needing oxygen.

Nitric Oxide Nitric oxide is a gas that is naturally produced by the body and helps relax blood vessels. In some cases it is needed to help difficult ventilation by relaxing the blood vessels in the lung. The gas is put directly into the lungs via the breathing circuit of the ventilator.

Transient Tachypnoea of Newborn When babies are in the womb, their lungs are filled with fluid. During delivery, most of the fluid is pushed out of the lungs or reabsorbed into the blood stream so that the baby can start to breathe. If, for any reason, some of this fluid remains in the lung, the baby will have rapid breathing after birth. This results in transient tachypnoea of newborn (TTN). This is more commonly seen in term or near-term babies than in preterm babies. Treatment may involve giving supplemental oxygen or more assistance with breathing. It usually improves over the first few hours or days of life. Generally, the baby will not be fed or fed smaller volumes through a tube placed through the mouth or nose into thestomach, until her breathing has slowed to the normal range of 40 to 60 per minute.

Apnoea and Bradycardia All newborns tend to have an irregular breathing pattern with episodes of very quick breathing followed by a pause. Premature babies may also have an immature breathing centre and so might ‘forget to breathe’, which is called apnoea. Apnoea may also be accompanied by bradycardia where the heart rate slows down. These episodes can be quite frightening for parents but are seldom a real risk to your baby. An alarm sounds instantly as the problem occurs, and nursing staff helps at once by gently patting the baby’s back or rubbing the soles of his feet to remind him to breathe. Caffeine is a medicine given to babies to stimulate their breathing. It is usually given till 34 weeks’ gestation,but some babies may need to take it for longer. If they don’t respond to these methods, they may need more assistance with breathing like CPAP or ventilation.

Chronic Lung Disease This is usually a lung condition that is seen in very premature babies who have been on mechanical ventilation or CPAP or even oxygen for RDS. Some babies experience spasms or tightening of their airways similar to that in asthma. It is often difficult to wean her from CPAPand oxygen and establish full feeds. Some of these babies are started on diuretics. As the baby grows, new, undamaged lung tissue will grow, improving her condition.

Pneumothorax This is otherwise called an air leak, because air leaks from damaged parts of the lung into the space surrounding the lung. The good lung then becomes compressed and breathing becomes harder. The baby will need extra oxygen or, if on the ventilator, the requirements will increase. Usually, a small tube is placed through the chest wall to remove the collected air so that the collapsed lung can re-expand. She will be given either a local anaesthetic or a pain-relieving medicine before the procedure. Some newborns, generally larger babies, may have a spontaneous pneumothorax after birth. This will usually settle by giving extra oxygen, intravenous fluids and rest.

Persistent Pulmonary Hypertension of Newborn (PPHN) Term or post-term babies are most prone to PPHN. It happens when the newborn’s circulatory system does not adapt to breathing outside the womb. The pressure in the lungs remains very high and blood bypasses the lungs via a blood vessel called ductus arteriosus. When the blood bypasses the lungs, it does not get oxygenated. Causes may include a difficult birth process, even infection picked up prior to delivery, meconium aspiration syndrome or birth asphyxia. The treatment involves trying to lower the pressure in the lung. This can be achieved by adequate ventilation and high levels of oxygen, and sometimes nitric oxide.

Meconium Aspiration Syndrome Meconium is the first stool passed by babies. It is thick and sticky and dark green or black in colour. Sometimes, when a baby experiences problems prior to delivery, she may pass meconium in the womb. So when the baby gasps in the womb, she inhales this meconium-laden amniotic fluid. The inhaled meconium irritates her airways and makes it difficult for her to breathe. Mild cases may only need oxygen but severe cases will need ventilation.

Jaundice Jaundice is the term used to describe the yellowish discolouration of the skin and whites of the eyes caused by the building up of a natural pigment called bilirubin. Newborns are constantly making new red blood cells and the old ones are being broken down. One of the waste products of this process is bilirubin. Bilirubin is processed by the liver into an easily disposable form and then eliminated from the body in the stool. Bilirubin is the end product of destruction of red blood cells and further processed in the liver. Babies who are jaundiced become sleepy and are difficult to feed. When your baby’s doctor tells you that she has jaundice, it means her skin has a yellow tint. Where does this yellow colour come from? This is not the same jaundice that adults get which is caught from eating contaminated food (hepatitis A) or caught from the blood of an infected person (hepatitis B and C) through transfusions, surgery or dental work. Some babies make bilirubin faster than they can get rid of it, causing the bilirubin to build up in the body and make the skin appear yellow. The yellow colour is most visible in daylight. Sunlight usually breaks down this excess bilirubin, but the baby has to be placed in direct sunlight with no clothes on. Given the fragile nature of these babies, technology steps in.

Phototherapy is a process by which this bilirubin in the skin is broken down so that it can be excreted in the urine and stool. The phototherapy can be given by an overhead blue light or a bili blanket, a flat rectangular pad on which the baby is placed. This will not get hot and cause any discomfort to the baby. She will be given eye pads to protect her eyes from the light.

Sepsis Preterm babies are more prone to infection. This may be because:

  • Protective substances called immunoglobulins normally cross the placenta during the final weeks of pregnancy and babies that are born early may not have had enough time to receive them.
  • The normal responses to fight infection are poorly developed in preterm babies.
  • The extra lines and tubes that are placed in them as part of treatment can pose the risk of infection.

It is important that the treating team is always on the lookout for early signs and symptoms of infection. If infection is suspected, then blood will be taken for some tests including a blood culture. A lumbar puncture, which involves taking fluid from the spinal canal to rule out meningitis, will also be done along with looking for infection in the urine. Antibiotics are given straightaway, as the test results may take up to 48 hours to come. The treating team’s aim is to prevent infection at all costs. Hand hygiene is the most important step to prevent infection in the NICU. You may be asked to frequently wash your hands and use hand sanitisers before and after touching your baby.

Low Blood Pressure When premature babies are sick, they frequently have problems maintaining their blood pressure. This is usually treated by giving extra fluids through an intravenous cannula or medication or even by giving blood.

Low Blood Sugar Blood sugar is one parameter that is frequently monitored in premature babies. It can be too high or too low. This is easily corrected by changing the concentration of sugar (dextrose) in the baby’s IV fluids. Blood sugar levels are usually checked from a heel prick sample. Variations in blood sugar may be an early sign of sepsis in a preterm baby.

Necrotising enterocolitis (NEC) This is an inflammatory bowel disease affecting some newborns and premature babies. The reason why some babies develop NEC is not fully understood but it usually happens when there is reduced blood supply to the premature baby’s bowel. This disease is staged from mild to severe. Treatment includes withholding feeds for up to 2 weeks or longer and giving intravenous fluids and antibiotics to help the intestine heal. Parenteral nutrition, a special drip which contains carbohydrates, protein and fat, is given till the baby can tolerate milk again. Although potentially a very serious complication, most infants given the right treatment will recover. A small number of infants who develop this problem will require surgery.

Breast milk has been shown to reduce the incidence of this condition and for this reason we strongly encourage you to consider expressing breast milk for your baby. Probiotics have also been shown to reduce the risk of NEC, which is why most premature babies will be given probiotics.

Retinopathy of Prematurity (ROP) This is a condition where there is growth of abnormal vessel in the retina of the premature baby. Most babies don’t require any treatment but need regular monitoring. Moderate or severe ROP will need treatment. The ophthalmologist may inject a special substance into the eye or your baby may need laser therapy to destroy the abnormal blood vessels. Usually, this is done under sedation and some medicine for pain is also given. Even after the treatment, the baby will need regular check-ups. Long-term outcome depends on the severity of the condition with severe cases requiring spectacles (for short sightedness). These babies need to be reviewed weekly or fortnightly till the retina matures, usually around 44 weeks post conceptual age.

Intraventricular Haemorrhage (IVH) This refers to bleeding into the natural spaces (ventricles) in the brain. Premature babies are more prone to this kind of bleeding as their blood vessels are very fragile. If the bleed is small, the baby may not show any signs or symptoms and it is only detected during routine ultrasound scans. These small bleeds are reabsorbed by the body just like a bruise. Larger bleeds may leave behind damaged tissue. An IVH may occur in as many as 60% of babies less than 1 kg but they are usually small and don’t leave any residual effects. Larger ones could have both short- and long-term problems.

Patent Ductus Arteriosus In the womb, the blood circulating in the baby’s heart follows a certain route. This is referred to as foetal circulation, where it bypasses the lungs. This is because the lungs are filled with fluid and the baby doesn’t need to use her lungs as she gets her oxygen supply from her mother through the placenta. After delivery, once the connection to the placenta is cut, blood is redirected to the lungs as the baby needs to breathe in oxygen herself. The patent ductus arteriosus is a blood vessel that connects the pulmonary vein with the aorta. This structure which is useful in foetal life is supposed to spontaneously close after birth. If this remains open, the heart has to work harder and the baby develops breathing problems. She may need oxygen and sometimes ventilation too. A heart murmur may be heard, her pulse may be very easily felt but an ultrasound of the heart (echocardiogram or ECHO) is usually needed to confirm the diagnosis. Most of the time just reducing the amount of fluid given to the baby and a medication given to close the duct is all that is needed. Occasionally, a surgery may be needed to close the duct.

Seizures When a baby has abnormal movements of her arms, legs or eye, she may have had a seizure. There are many reasons why a baby may have a seizure: for example, infection, brain injury, metabolic or endocrine causes. Most babies will need medication to stop the seizure. An ultrasound of the brain will be done along with a test called electroencephalogram (EEG). Some babies may even need an MRI scan. Long-term outcome depends on the cause and severity of the seizure. She will be followed up long term to see how she grows and develops.

Neonatal Encephalopathy Sometimes during pregnancy, prior to or during birth, there may be a reduction in the oxygen supply to the baby from the placenta. This can affect all of baby’s organs, but especially the brain, leading to brain injury (neonatal encephalopathy).

There are different degrees of brain injury and the long-term outcome depends on the severity of injury.

Remedy: Total body cooling Recent evidence has shown that total body cooling can limit the degree of brain injury caused by neonatal encephalopathy. In this process, the body temperature which normally is 37°C (98.6°F) is cooled down to 33.5°C (92.3°F). The baby’s temperature is kept at this level for 72 hours and thereafter rewarmed to 37°C over the next 12 hours. The cooling is started as soon as possible and the baby is placed on a special mattress. While on treatment, he will be monitored closely and given pain relief. He will not be fed and will be given IV fluids instead. Sometimes, if there is a problem with his breathing, he may need to be ventilated. The period of cooling gives the brain a chance to recover from the injury. There are set guidelines which your doctor will follow to see which babies can be offered cooling as treatment.

Nutrition for Preterm Babies Premature and/or ill infants are often too weak to suck from the breast. These babies need special ways of feeding, such as tube feeding or intravenous fluids till they are ready to suck efficiently. All babies lose weight after birth and it can be up to 10% of their birth weight. Sometimes, babies who are not fed milk or are very sick may lose more weight or are slow to regain their birth weight, but this usually resolves with time. Thereafter, they start to gain weight steadily and gain about 150 gm a week for the first 3 months of their life, once they’re on full feed. Anything more than this is a bonus!

Intravenous Feeding The first issue for premature and/or ill infants is to regulate breathing and heart rate. At this time, digesting milk may be a problem and it may take a few days for the stomach to tolerate milk. Glucose and nutrients are given intravenously through a cannula. As mentioned earlier, they may be placed in the umbilicus or belly button or in a vein in the arm or leg. Sometimes it may need to be placed in the scalp (when werun out of veins in the arms and legs), for which a small area in the scalp is shaved off. Sometimes a PICC line may be inserted through a vein in the arm or leg. These can be left in place for a longer period of time. Some babies who cannot tolerate feed for various reasons, or babies who have had bowel surgery, may need to be given parenteral nutrition which comprises carbohydrates, protein and fat along with multivitamins and trace elements. This is provided intravenously.

Expressing Breast Milk If you had planned on breastfeeding your baby, you can do so even if your baby is premature. As premature babies cannot suck directly from the breast for various reasons, breast milk can be expressed or pumped with either a pump or by hand. This collection should be done in a sterile way. The nurse then feeds this to the baby with a tube placed right through the nose and into the stomach. Breast milk is the best milk for your baby because it meets her nutritional needs, is more easily digested, offers protection from infection and encourages growth and development of the gut. It is important that you start expressing as soon as possible after delivery, ideally within 6 hours. By expressing milk regularly, at least every 3 hours in the day and at least once at night (7 to 8 times a day), you will stimulate your milk supply in the same way as a baby sucking. This will help in establishing your breast milk supply and maintaining it till it is time for your baby to feed directly. You can express by hand or use a breast pump. It’s better if you express by hand in the beginning and at the end of each session. You need to wash your hands properly and also wash and sterilise parts of the pump after each session. It is important to label the milk with the date and time before you give it to the nurse in charge of your baby. Sometimes, if you have problems with the amount of milk that you express, you may be given a medicine to increase the output. It’s important that you maintain a sterile technique when expressing the milk which is then stored in the refrigerator. It cannot be stored for longer than 24 hours in the refrigerator. This milk is then carried to the hospital in an ice bucket. If for any reason the mother is unable to express, there are breast milk banks that have milk donated by other mothers. This milk is heattreated, tested and stored.

Breast Milk Fortifier Preterm babies need extra protein, minerals and vitamins over and above what is contained in breast milk. We can add these fortifiers in the expressed breast milk to provide these extra additives.

Probiotics Probiotics are healthy bacteria that live in the gut. They help to keep the gut healthy and prevent the growth of harmful bacteria in the intestine. They are fragile, easily killed by antibiotics, and are replaced by harmful bacteria. As probiotics are less plentiful in the gut of premature babies as compared to older children and adults, they are given probiotics each day.

Tube Feeding Even after your baby can manage to digest milk, it may be some time before she can suck directly from the breast. The sucking reflex usually matures around 33 to 35 weeks’ gestation. In the meantime, he will befed through a soft fine plastic tube passed through the nose or mouthinto the stomach. A syringe is attached to the tube and milk is placed in the syringe. Gravity gradually pulls the milk into the stomach. At first only 1 to 2 ml of feed are given 2 hourly and it is built up slowly, as tolerated by the baby. Once the baby reaches 32 weeks, the cup or breastfeeding is attempted. Cup feeding has been traditionally done by mothers using a paladai in Kerala and a jheenuk in Bengal. The nifty cup, made of silicone, now used in western units, is an adaptation of this. This paladai feeding is a stop-gap method in the transition to breast feeding. Once the baby is mature, around 33 to 34 weeks, he can be put directly to the breast and cup and spoon feeding can be reduced slowly. As they get older, it is very difficult to feed with a cup, as the baby gets very active. Babies also need the satisfaction of sucking, which is part of their development.

Feeding Your Baby As soon as your baby is well enough, you will be able to breastfeed her yourself. The nursing staff will help you with this and most units will encourage breastfeeding. Initially she may feed every 2 hours and may get tired after a few minutes; you may then need to give the rest of the feed with the cup. The nurses will show you how to latch and recognize feeding cues. Sometimes it may take a little while to establish breastfeeding, so don’t give up – it’s worth all the trouble.

Preparing for Home – Preterm Babies There is no place like home. Your baby will be ready to come home when he is breastfeeding or cup feeding, maintaining her temperature in a cot and gaining weight. He must also be free from apnoea and bradycardia and off the medicine caffeine. Some parents may choose to ‘room in’, where they stay in a room with the baby overnight. This will give the parents an opportunity to become familiar with the baby’s specific needs, knowing that the staff is close by in case you need help. Many parents are apprehensive at the thought of taking the baby home. Remember that the staff will not discharge your baby if they do not think the baby is ready for home. You should not worry as the hospital and doctor are only a phone call away.

Vaccinations Preterm babies need immunisations like all other babies to protect them from certain diseases that can cause serious illness or even death. Immunisation is a safe and effective way to protect your baby and works by causing the baby’s immune system to produce antibodies to fight diseases. For vaccination purposes, the actual age of the baby is used, not the corrected age. By this I mean, if your baby was born at 32 weeks and discharged at 34 weeks of age, the baby can be given the first set of vaccine 6 weeks after discharge when the baby will be 40 weeks post conceptual age. The corrected age is used when we are talking about developmental milestones in preterm babies. For vaccination, your doctor will try and sync your baby’s vaccine into the Indian vaccination schedule. All the vaccines are similar to the vaccination schedule for term babies and have been discussed in the vaccination chapter.

Best Sleeping Position The best sleeping position for your baby is on her back. When in the ICU under a warmer, she may have been placed on her tummy to ease her breathing problems. Once she is in a cot, she should always be placed on her back. Even if she vomits, she will not choke when lying on her back. You can turn the baby’s head to one side. She should be placed on her back and her feet near the foot of her cot or basket. The covers should be tucked below her shoulders so that they don’t slip over her head. It is best not to share your bed with the baby, especially if you smoke or have consumed alcohol. You can feed on your bed but take her back to her cot to sleep. Caring for a preterm baby can be more demanding than caring for a full-term baby. So you need to eat well and get enough rest. If you have other children, spend time with them as well. Get help from others.

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