Premature babies - or those who have had intrauterine growth restriction (IUGR) - are more prone to the ailments that can affect all newborn infants because many of their physiological systems are not yet fully developed. Many of these problems are neither life-threatening, nor have long-term sequelae. However, some of them can also develop into a severe condition if not treated effectively and promptly.

Respiratory tract problems

These are the most frequently encountered problems associated with prematurity. Most of them are relatively mild and easily managed but, on occasions, they can be life-threatening. If in doubt refer urgently to hospital. More than a half of extremely low birthweight (ELBW) children are readmitted to hospital at least once in the first 1-2 years of life, mostly as a result of respiratory illnesses, including lower respiratory tract infections;¹ these rates are 2-3 times the rates of readmission of normal birthweight children. Respiratory syncytial virus also increases the risk of rehospitalisation, especially in very premature infants.

Periodic breathing

Apnoeic attacks

• Anaemia (see below)
• Gastro-oesophageal reflux
• Hypoglycaemia
• Cerebral bleeding
• Infection
• Electrolyte disturbance

Management:

• The infant should be gently massaged during an attack to stimulate breathing and given O₂ if saturation levels do not rise quickly.
• Constant monitoring is required including using an apnoea monitor.⁶
• Caffeine or aminophylline are often effective in preventing attacks but, where these fail, assistance via continuous positive airway pressure or even artificial ventilation may be needed.

Respiratory distress syndrome (RDS)

See Infant Respiratory Distress Syndrome article.
RDS is characterised by:

• Rapid breathing
• Grunting
• Recession of sternum/rib margins

The most common cause is hyaline membrane disease associated with the failure to produce surfactant.^7,8 It is treated by assisted ventilation and the administration of artificial surfactant.

Gastrointestinal problems

Gastro-oesophageal reflux

• It can be confirmed by imaging or by monitoring lower oesophageal pH.

Management

• Raising the infant's head and thickening the milk with antacid/alginate.⁹

Distended abdomen

This is mainly seen after 7-10 days and is due to trapped gas.
Changing the feeding schedule usually cures the problem.
Also be aware that it may reflect more serious disorders such as:

• Sepsis
• Congenital gastrointestinal anomalies
• Obstruction due to milk curd
• Impacted faeces

Anaemia

• If anaemia is causing significant problems it can be treated with either a blood transfusion or by using erythropoetin. There may be a statistically significant increased risk of retinopathy of prematurity (ROP) with early EPO treatment.^10,11
• Untreated, normal Hb starts to return at 4-6 weeks of age if full-term.
• Anaemia is often seen later, associated with iron and folate deficiency and can be prevented by supplementation. However, some research suggests supplementation may have adverse effects.¹²

Jaundice

• Significant jaundice is defined according to gestational and postnatal age and is found with levels at 240 μmol/L at 4 days in preterm infants and 290 μmol/L in the term infants.¹⁴
• Small babies are particularly at risk of kernicterus with levels as low as 250-300 μmol/L depending on the degree of prematurity.
• Treatment is with phototherapy at an early stage, or exchange transfusions if severe.¹⁵

Oedema

Oedema with pitting is commonly seen in the face, hands and feet and genitalia.

• It usually slowly disappears of its own accord but a more severe form is associated with respiratory distress syndrome, heart failure and hydrops fetalis.

Infections

An impaired immune response makes infections both more common in preterm infants and more difficult to diagnose with atypical presentations.
Atypical signs include:

• Falling temperature
• Lethargy
• Jaundice
• Pallor
• Feeding problems
• Vomiting

Miscellaneous problems

Common ones include (click on links to go to related articles):

• Maldescended testes.
• Umbilical and inguinal hernias.
  • The latter need surgical correction as they may strangulate.
• Strawberry marks.
• Delayed neurological development.
  • Small for gestational age (SGA) infants have been found to have significantly retarded neurological development compared with average for gestational age (AGA) infants from 2 months onwards.^8,16
  • However, good growth in the following months is associated with a similar improvement in development.
  • Disability is highest in children born at 24-28 completed weeks of gestation - 49%.¹⁷

Document references

1. Doyle LW, Ford G, Davis N; Health and hospitalistions after discharge in extremely low birth weight infants. Semin Neonatol. 2003 Apr;8(2):137-45. [abstract]
2. Kelly DH, Shannon DC; Periodic breathing in infants with near-miss sudden infant death syndrome. Pediatrics. 1979 Mar;63(3):355-60. [abstract]
3. Tin W; Oxygen therapy: 50 years of uncertainty. Pediatrics. 2002 Sep;110(3):615-6.
4. Finer NN, Higgins R, Kattwinkel J, et al; Summary proceedings from the apnea-of-prematurity group. Pediatrics. 2006 Mar;117(3 Pt 2):S47-51. [abstract]
5. Nimavat DJ et al; Apnea of Prematurity, eMedicine, Oct 2009
6. No authors listed; Apnea, sudden infant death syndrome, and home monitoring. Pediatrics. 2003 Apr;111(4 Pt 1):914-7. [abstract]
7. McClure P et al; Hyaline Membrane Disease, eMedicine, May 2009
8. Saigal S, Doyle LW; An overview of mortality and sequelae of preterm birth from infancy to adulthood. Lancet. 2008 Jan 19;371(9608):261-9. [abstract]
9. Schwarz SM et al; Gastroesophageal Reflux, eMedicine, Jan 2010
10. Aher SM, Ohlsson A; Early versus late erythropoietin for preventing red blood cell transfusion in preterm and/or low birth weight infants. Cochrane Database Syst Rev. 2006 Jul 19;3:CD004865. [abstract]
11. Quiram PA, Capone A Jr; Current understanding and management of retinopathy of prematurity. Curr Opin Ophthalmol. 2007 May;18(3):228-34. [abstract]
12. Domellof M; Iron requirements, absorption and metabolism in infancy and childhood. Curr Opin Clin Nutr Metab Care. 2007 May;10(3):329-35. [abstract]
13. Hansen TWR; Neonatal Jaundice, eMedicine, Mar 2010
14. Sarici SU, Serdar MA, Korkmaz A, et al; Incidence, course, and prediction of hyperbilirubinemia in near-term and term newborns. Pediatrics. 2004 Apr;113(4):775-80. [abstract]
15. Dennery PA, Seidman DS, Stevenson DK; Neonatal hyperbilirubinemia. N Engl J Med. 2001 Feb 22;344(8):581-90.
16. Ounsted M, Moar VA, Scott A; Neurological development of small-for-gestational age babies during the first year of life. Early Hum Dev. 1988 Mar;16(2-3):163-72. [abstract]
17. Larroque B, Ancel PY, Marret S, et al; Neurodevelopmental disabilities and special care of 5-year-old children born before 33 weeks of gestation (the EPIPAGE study): a longitudinal cohort study. Lancet. 2008 Mar 8;371(9615):813-20. [abstract]

Internet and further reading

• Postnatal care: Routine postnatal care of women and their babies, NICE Clinical Guideline (2006)
• Ross MG et al; Fetal growth restriction, eMedicine, Feb 2010
• No authors listed; Preterm birth: what can be done? Lancet. 2008 Jan 5;371(9606):2.
• Goldenberg RL, Culhane JF, Iams JD, et al; Epidemiology and causes of preterm birth. Lancet. 2008 Jan 5;371(9606):75-84. [abstract]
• Iams JD, Romero R, Culhane JF, et al; Primary, secondary, and tertiary interventions to reduce the morbidity and mortality of preterm birth. Lancet. 2008 Jan 12;371(9607):164-75. [abstract]

Acknowledgements