Premature Infant

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What is premature birth?

Pregnancy normally lasts about 40 weeks. A baby born 3 or more weeks early is premature. Babies who are born closer to their due dates tend to have fewer problems than babies born earlier. But even those who are born late preterm (closer to 37 weeks) are at risk for problems.

Doctors and nurses often call premature babies "preemies."

Having a premature baby may be stressful and scary. To get through it, you and your partner must take good care of yourselves and each other. It may help to talk to a spiritual advisor, counselor, or social worker. You may be able to find a support group of other parents who are going through the same thing.

Why is premature birth a problem?

When a baby is born too early, his or her major organs are not fully formed. This can cause health problems.

• Babies who are born closer to 32 weeks (just over 7 months) may not be able to eat, breathe, or stay warm on their own. But after these babies have had time to grow, most of them can leave the hospital.
• Babies born earlier than 26 weeks (just under 6 months) are the most likely to have serious problems. If your baby was born very small or sick, you may face hard decisions about treatment.

What causes premature birth?

Premature birth can be caused by a problem with the fetus, the mother, or both. Often the cause is never known. The most common causes include:

• Problems with the placenta.
• Pregnancy with twins or more.
• Infection in the mother.
• Problems with the uterus or cervix.
• Drug or alcohol use during pregnancy.

What kind of treatments might a premature infant need?

Premature babies who are moved to the neonatal intensive care unit (NICU) are watched closely for infections and changes in breathing and heart rate. Until they can maintain their body heat, they are kept warm in special beds called isolettes.

They are usually tube-fed or fed through a vein (intravenously), depending on their condition. Tube-feeding lasts until a baby is able to breathe, suck, and swallow and can take all feedings by breast or bottle.

Sick and very premature infants need special treatment, depending on what medical problems they have. Those who need help breathing are aided by an oxygen tube or a machine, called a ventilator, that moves air in and out of the lungs. Some babies need medicine. A few need surgery.

Breast milk gives your baby extra protection from infection. You can pump breast milk and bring it to the hospital for your baby.

NICU (say "NIK-yoo") nurses can teach you things you'll need to do at home to help your baby.

Does premature birth cause long-term problems?

Before the birth, it is hard to predict how healthy a premature baby will be. Most premature babies don't develop serious disabilities. But the earlier a baby is born, the higher the chances of problems. Work together with your doctor and other health providers to closely watch your baby's development and try to catch any problems early on.

• Most premature babies who are born between 32 and 37 weeks do well after birth. If your baby does well after birth, his or her risk of disability is low.
• Babies most likely to have long-term disability are those who are born before 26 weeks or who are very small, 2.2 lb (1000 g) or less. Long-term problems may include problems with thinking and learning or cerebral palsy.

What can you expect when you take your baby home?

When you're at home, don't be surprised if your baby sleeps for shorter periods of time than you expect. Premature babies are not often awake for more than brief periods. But they wake up more often than other babies. Because your baby is awake for only short periods, it may seem like a long time before he or she responds to you.

Premature babies get sick more easily than full-term infants. So it's important to keep your baby away from sick family members and friends. Make sure your baby gets regular checkups and shots to protect against serious illness. Be current on your immunizations and ask other people who will be near your baby to be immunized too.

Sudden infant death syndrome (SIDS) is more common among premature babies. So make sure your baby goes to sleep on his or her back. This lowers the chance of SIDS.

Delivery of Your Premature Infant

A premature delivery may happen suddenly or after days or weeks of waiting and worrying. If you know you may deliver early, you, your partner, and your doctor can prepare for a premature birth.

The premature delivery

You and your premature infant (preemie) are considered high-risk during preterm labor. This means that you will have less freedom, both to make birth-related decisions and to move about freely. You can expect the following:

• You may need to adjust your birth plan and birthing choices during this birth. You can refuse medicines such as painkillers during preterm labor. But other treatments such as antibiotics or corticosteroids can be important to ensure your infant's chances of good health after birth. Be sure to ask as many questions as you can think of about your medical care. The more you understand about your doctor's decisions, the less anxious you will feel.
• You will be on constant fetal heart monitoring. You also will be checked regularly for changes in heart rate, body temperature, and uterine contractions.
• You will probably deliver vaginally, rather than by cesarean section (C-section), as long as you and your fetus show no signs of distress.

After the premature birth: The infant

As soon as the umbilical cord is cut, the neonatal staff will watch over and stabilize your infant. If your infant is less than 36 weeks' gestation at birth, they may move him or her to the neonatal intensive care unit (NICU) for observation and specialized care. If you deliver in a hospital that has no NICU, your infant may need to be taken to another hospital.

During the first hours and days, your infant will adjust to living outside of the maternal "life-support system." This is a time when birth defects and complications of prematurity often become apparent.

After the premature birth: The mom

While the neonatal staff attends to your infant, the obstetric staff will care for you. Depending on your condition, this will take at least a few hours. Meanwhile, your birth partner may want to go with your infant to the NICU.

Before your breast milk comes in (3 or 4 days after childbirth), you will be asked to decide whether you plan to breastfeed or bottle-feed your premature infant. Formula does not give your infant added protection from early infection, so strongly consider pumping milk for your infant for at least the first weeks of life. If you decide to breastfeed, expect at first to pump milk for feedings until your infant is mature enough to feed orally.

• Breast milk contains antibodies that help protect your vulnerable infant against early, serious infections, including sepsis and necrotizing enterocolitis, as well as ear and upper respiratory infections during early childhood.
• The benefits of breast milk over formula include better nutrient absorption, digestive functioning, and nervous system development.
• Both specialized formula and breast milk can offer your infant excellent nutrition.
• Pumping and breastfeeding can be one of the most beneficial and rewarding things you do for your premature infant. But it may also be hard and exhausting. If you cannot breastfeed, decide not to breastfeed, or find that you have to discontinue doing so, formula feeding will meet your infant's nutritional needs.

Your hospital's lactation consultant can be very helpful with pumping and breastfeeding questions and problems, both before and after the birth.

Taking Care of Yourselves

If your premature infant is moved to the neonatal intensive care unit (NICU), you may become overwhelmed with new emotions and information. You and your loved ones may handle issues and feelings differently, and it may create a strain on your relationships.

Thinking of yourself and your relationships may not be easy when you are under a lot of stress. But your child or children depend on you to be physically and emotionally able to care for them.

Take a quiet moment and focus on yourself. Ask yourself, "How am I doing? What do I need right now?" Try to take time to get enough rest, food, exercise, and fresh air and sunlight. Do you have someone you can talk to: a partner, friend, parent, spiritual advisor, or counselor? If any of these basic needs aren't being met, make them a top priority.

• Arrange for and accept as much help from friends and family as you can.
• Keep a journal of your thoughts and feelings.
• Visit with a friend, spiritual advisor, counselor, or social worker. It helps to talk about how you feel.
• If your hospital has a support group for NICU parents, try it out. Sometimes the best possible support comes from people who are going through the same issues that you are.
• See a mental health professional or go to the emergency room right away if you are having thoughts of hurting yourself or another person. Such thoughts can sometimes arise due to postpartum depression, severe stress, or both.
  • Depression: Managing Postpartum Depression
• Watch for signs of depression, anxiety, or post-traumatic stress disorder. Seek help if you have symptoms.

The Premature Newborn

A premature infant's health at birth is influenced by many things, including:

• Gestational age at birth.
• Weight at birth.
• Maternal illness and medical treatment during pregnancy.
• Congenital birth defects.

Most infants born at 36 and 37 weeks' gestation are mature enough to be discharged from the hospital with the mother. But many premature infants need care in the neonatal intensive care unit (NICU). Hospital care will be needed for:

• Underdeveloped lungs.
• Inability to breathe continuously (apnea of prematurity).
• Inability to maintain body heat.
• Inability to feed orally.

While in the NICU or at home, many premature infants also need treatment for jaundice, infection, and anemia.

The Sick Premature Infant

Many premature infants are resilient and surprise everyone by overcoming great odds. Expect that your infant can progress for several days but may then have a medical setback.

Premature infants are more likely than others to get an infection. And organs that have not had time to mature can cause a number of problems.

The more premature a newborn is, the greater is the baby's risk of having medical problems.

Infants born at 23 to 26 weeks' gestation are extremely underdeveloped and have a much higher risk of death or disability. Parents of these infants are likely to be faced with difficult medical decisions. Infants who have reached their 32nd week of development before birth are less at risk than those who are born earlier.

Babies born at 34 to almost 37 weeks' gestation are called late preterm infants. Although they are not as likely to have as many problems as infants who are born earlier, they are at risk for breathing problems, high blood pressure in the lungs, and other short-term and long-term problems.

Getting to Know the Neonatal Intensive Care Unit (NICU)

If your premature infant (preemie) is admitted to the neonatal intensive care unit (NICU) after birth, you will find out about new technologies, new medical words, and new rules and procedures.

You will depend on the NICU staff members, including neonatologists and nurses, to know how to care for your infant and to be your teachers. With their help, you can quickly learn about your infant's needs and what you can do for your infant. Throughout your infant's stay in the NICU, you will want to keep open communication with the staff.

NICU technology

First you'll learn to scrub up before visiting your infant's bedside. When you're there, you may be surprised by the number of machines and instruments surrounding your child. Remember that because of these machines your premature infant has a much greater chance of doing well than ever before.

At a minimum, your infant will be warmed and watched over with equipment that includes:

• An isolette or overhead heater.
• A temperature probe, to keep track of body temperature.
• A heart monitor, to keep track of breathing and heart rate.
• A pulse oximeterto keep track of how much oxygen is in the blood.

If your infant has additional medical needs, other tests and equipment also may be used, including:

• A transcutaneous oxygen and/or carbon dioxide monitor, to constantly measure these levels in the blood without using a needle.
• An intravenous (IV) site, for giving medicine, fluids, and feedings.
• An umbilical catheter, for giving medicine, fluids, and feedings, and for drawing blood.
• A ventilator, for help with breathing.
• Continuous positive airway pressure (CPAP), for help with breathing. (This is usually for mild to moderate apnea of prematurity and mild lung problems or for weaning from a ventilator.
• A cranial ultrasound, to check for brain bleeding or damage, usually between days 3 and 7 after birth.
• A chest X-ray, to check for lung damage. It may also be used to check the positioning of an endotracheal tube if one is used to assist with breathing.
• An abdominal X-ray. This is to check the intestines for necrotizing enterocolitis and to check the position of the umbilical catheter.
• An echocardiogram, to check the heart for congenital heart defects or patent ductus arteriosus.
• Phototherapy, to help treat jaundice.

Your role in your infant's care

At first sight, you may question whether and even how to touch your tiny infant. Unless your newborn is very sick or immature, you will be allowed to touch and possibly hold him or her. But your infant's nurse or doctor will first need to show you how to work around the technology and to alert you to your infant's special needs. When visiting with your premature newborn, remember that:

• A premature infant has limited energy for recovering and growing. Try not to wake your infant from sleep.
• A premature newborn's brain isn't quite ready for the world. Be alert to signs that your infant is being overstimulated, such as a change in heart rate or a need to turn away from you. This can be triggered by your gaze, voice, or touch, or by sound and light in the room.
• A stable, more mature preemie will thrive on periods of cuddling (kangaroo care), infant massage, and calming music.

If you're not able to hold or help your infant, you can give him or her an immunity boost by providing breast milk. Regardless of whether you plan to breastfeed or bottle-feed later on, pumped breast milk for tube-feeding reduces your infant's risk of infection.

As your infant grows stronger, you will be able to take on more caregiving tasks. These range from holding and feeding to changing diapers and bathing. You can count on the NICU nurses to teach you and answer your questions. If you are breastfeeding, you may be asked to spend the night with your infant to find out if he or she is strong enough to nurse around the clock.

Taking Your Baby Home

Your premature infant is considered ready to go home when he or she is able to:

• Take all feedings by nipple and continue to gain weight.
• Maintain body heat in an open infant bed.
• Breathe well. (An infant whose lungs have suffered damage may be sent home with portable oxygen.)
• Have normal breathing and a normal heart rate for a week. (An infant who is otherwise mature enough yet still stops breathing sometimes or has lung disease or other breathing problems may be sent home with a device to monitor his or her breathing.)

Some infants are ready to go home as early as 5 weeks before their due date. Other infants, usually those who have had medical problems, may be sent home later.

Preparing to go home

As your infant's discharge from the hospital approaches, you may feel excitement, impatience, and a new kind of anxiety. Responsibility for your infant's care, which has so recently required lots of technology and medical training, is now being transferred to you. You can best prepare yourself by learning:

• Infant cardiopulmonary resuscitation (CPR), as taught by a certified instructor.
• How to safely transport your infant in the car.
• Basic infant care skills.
• How to handle the medicine or medical equipment, if any, that will be needed at home.

You will also want to:

• Discuss your questions and concerns with the neonatal intensive care unit (NICU) staff, your baby's doctor, and a discharge planner. A discharge planner can help make sure that your baby will get the right care after leaving the hospital.
• Make an appointment with your baby's doctor for a few days after your infant's homecoming. Weekly medical checks after discharge are especially important for a premature infant, as well as reassuring for you.
• Be current on your immunizations, and ask other people who will be near your baby to be immunized too. It's okay to get routine immunizations while you are breastfeeding. They do not harm your baby.

If home-based health care and support are available to you, take advantage of them. Home-based services spare you and your infant the physical and emotional stress of traveling to numerous appointments.

The First Weeks at Home

As you and your premature infant adjust to being at home, you will gradually establish a routine together. During the first weeks at home, consider these important points:

• Sleeping and wakefulness. Because their brains aren't as fully developed at birth as full-term newborns, premature infants:
  • Sleep more than full-term infants do but for shorter periods of time. Expect that you may be awakened frequently at night until 6 months after your due date.
  • Are seldom awake for more than brief periods until about 2 months after their due date. It may seem like a long time before your infant responds to your presence.
• Fussiness and hypersensitivity. It's normal for full-term infants to cry for up to 3 hours a day by 6 weeks after their due date. Most premature infants will do the same and then some. Your premature infant may be easily disturbed by too much light, sound, touch, or movement or by too much quiet after living in the noisy NICU. If so, gradually create a more calming environment, swaddle your infant in a blanket, and hold him or her as much as possible. When you swaddle your baby, keep the blanket loose around the hips and legs. If the legs are wrapped tightly or straight, hip problems may develop.
• Sleeping position. Laying your infant on his or her back reduces the risk of sudden infant death syndrome (SIDS), which is more common among premature infants than full-term infants.
• Feedings. Your infant probably will come home on a hospital feeding schedule, which will tell you how often to nurse or bottle-feed at home. To avoid infant dehydration, never go longer than 4 hours between feedings. Small feedings may help reduce spitting up. If you see signs of reflux during or after feedings, such as spitting up a lot, talk to your infant's doctor.
• Nutrition. Your infant's doctor may recommend adding iron, vitamins, or supplemental formula to a breastfed diet. Adding iron is typical treatment for all premature infants (preemies), because they lack the iron stores that full-term infants have at birth. Some preemies simply need extra energy and vitamins from formula (given in addition to breast milk) to keep up their growth.
• Exposure to diseases and smoke. Your premature infant needs more protection than a full-term infant, particularly due to immature lungs at birth.
  • Keep your infant away from sick family members and friends as well as from enclosed public places during his or her first two winter seasons.
  • Don't allow tobacco smoke near your infant.
• Protection from serious illness (immunizations and RSV antibody). With the exception of the hepatitis B vaccine, the preemie's schedule for childhood immunizations is the same as for a full-term infant, figured from the date of birth (chronological age). In addition, the doctor may suggest that your baby get injections of RSV antibody in the winter, to help reduce the risk of problems from respiratory syncytial virus (RSV) infection.
• Child care. You may need to find child care for times when you need a break or for when you return to work or other tasks. Avoid group child care if your baby is at high risk for infection, especially in the fall and winter when viral illnesses tend to spread. You'll likely need to keep your baby out of group child care until he or she is on a routine schedule. For more information about child care options, see the topic Choosing Child Care.
• Hearing and vision screening. Premature infants are at greater risk of hearing loss. Those born at or before 30 weeks or weighing less than 1500 g (3.3 lb) are more likely to develop a vision problem called retinopathy of prematurity.
  • Your infant's hearing will have been assessed in the NICU. But be alert to new or increased hearing problems during your child's first 5 years of life.
  • Vision screening is recommended for infants born at or before 30 weeks, whose birth weight was below 1500 g (3.3 lb), or who have serious medical conditions. The first screening is recommended between 4 and 7 weeks after birth.^{footnote 1}

Looking Ahead to the Childhood Years

Your infant's "age"

Age is both a measure of time and a marker of development. Unlike with a full-term infant, a premature infant's age and development can be defined in different ways. This can be confusing. When following your premature infant's growth and development, it can be helpful to know the difference between the following "ages":

• Gestational age is the same as the length of your pregnancy. If your baby was born at 32 weeks, that is his or her gestational age. This is sometimes called the baby's postconceptual age.
• Chronological age is measured from the day of birth. Your child's birthdays are celebrations of his or her chronological age.
• Corrected age is your child's chronological age minus the amount of weeks or months he or she was born early. For example, if your 1-year-old was born 3 months early, you can expect him or her to look and act like a 9-month-old (corrected age). You may find this figure to be most reassuring when following your child's growth and development for the first 2 years after birth.

Your infant's development

During your child's first 2 years of life, he or she will appear to be developmentally behind full-term children of the same age. But you can expect your infant and young child to achieve the same sequence of developmental milestones as any other child.

Expect that your premature infant's "lag" in development will catch up at about age 2. As your child grows into the preschool years, a 2- to 4-month difference in age or development blends right in among a group of preschoolers. For more information about preschoolers, see the topic Growth and Development, Ages 2 to 5 Years.

As your child begins formal schooling, be alert for signs of learning problems. Learning, reading, and math disabilities due to prematurity may first become apparent during the early school years.