Normally, pregnancy lasts from 37 to 42 Weeks (approximately nine months). Infants born before 37 weeks are considered to be premature. Although a premature baby may not be fully prepared for life outside the womb, he has been completely formed (even fingers, toes, and nails) since he was 12 weeks old! Most of a premature baby's problems result from a lack of time: to acquire the more mature characteristics such as fat, some enzymes, and internal body regulators. The size and frailty of your premature baby may frighten you at first. This will lessen as you visit more often and get to know him. Most parents search for the reason for their child's premature birth and feel some responsibility for it. Was there something they did or didn't do that could have caused it? Often a premature birth cannot be explained or related to anything. Your obstetrician will be able to answer some of your questions and help you sort through this problem. It is important to begin resolving some of' these feelings in your mind early, so you can focus your attention and energy on your baby.
Premature babies look different than full term babies. The most apparent difference is size. They may weigh anywhere from just over one pound to five or six pounds or more, depending on the length of the pregnancy They have less fat than a term baby and smaller muscles. Because of this, they may seem skinny or bony (especially around the ribs). With time they will fill out. Their skin is softer and thinner and may be covered with light hair (lanugo). It will disappear in a few weeks just as it would have inside the uterus. The muscular reflexes are usually acquired late in pregnancy. Because of this, your baby's movements may seem shaky or jerky. He will become increasingly coordinated as he grows older. His sucking and swallowing reflexes usually do not occur in a coordinated fashion until 32 to 34 weeks' gestation. When your baby is ready to digest milk, tube feedings can be given until this sucking and swallowing coordination has been acquired. Meanwhile, you can help him practice with a pacifier.
Prematurity carries with it a wide range of potential problems, from mild to severe. Fortunately, in the last decade there have been great advances made in the understanding of premature babies. Now, the chances are much greater for premature babies to grow up to live happy, healthy lives.
Respiratory Distress Syndrome
The most common difficulty premature babies have is Respiratory Distress syndrome (RDS), also known as Hyaline Membrane Disease (HMD). In this disease, there is a relative lack of surfactant. Surfactant coats the lining of the lungs and allows them to inflate easily and retain air. Surfactant frequently is not present in sufficient amounts until the last month of pregnancy. Insufficient amounts will cause the baby to work harder to take deep breaths. This can be very tiring. Some of the medical help required may be oxygen, CPAP, a ventilator, or adding surfactant into the baby's windpipe (trachea). These treatments will be discussed later in this section. RDS frequently improves between the third and fifth day of life, although these babies may be ill for some time with related problems. Our staff is very familiar with RDS and has much experience helping babies through it. Even when a baby is not ready to be held, he can be comforted by the warm touch of his parent's finger.
Patent Ductus Arteriosus
Before birth, a lot of blood does not need to go to the baby's lungs to pick up oxygen because oxygen is supplied by the mother's bloodstream through the placenta. The blood is directed away from his lungs and to the rest of his body by a vessel called the ductus arteriosus. The ductus arteriosus is located just outside the heart and normally closes shortly after birth because it is no longer necessary. Often, in premature babies it fails to close. This open vessel is called a patent ductus arteriosus (PDA). If the ductus remains open, mild to severe problems can occur. The therapy given will depend on the severity of the problem. Two possible treatments to close a PDA are medication and surgical closure. Usually medication is the preferred treatment and most often is successful. Either will be explained to you before it is begun.
It is normal for premature babies to have an irregular pattern of breathing. At times, they may even stop breathing. If this occurs, the breathing monitor and sometimes the heart monitor alarm and the nurse will help the baby to begin breathing again. She may tickle him or rub his body to remind him to breathe. She may also have to give him breaths of air with the resuscitation bag at his bedside. These "apnea spells" (episodes of stopped breathing) may be caused by many things. Most frequently, they are due to an immaturity of the breathing control center in the brain and will go away in time.
Babies are generally more prone to infection than adults. If the medical team suspects your baby has an infection, tests may be needed. Samples of blood and/or other body fluids may be sent to the laboratory. Tests to detect infection may take many days. Antibiotics may be started right away.
Necrotizing Enter colitis (NEC)
NEC is an infection of the wall of the intestines (gut). It may spread to the blood. Premature babies are prone to this disease. They cannot be fed by usual means, and will need nourishment by vein. Although often mild, some cases are very serious. Surgery is sometimes necessary to repair or remove damaged intestine.
Retinopathy of Prematurity (ROP)
ROP is a problem of the retina (back part of the eye that "sees"). It occurs mostly in very premature infants. Most cases are not severe and get better on their own. However, on occasion, it can threaten vision in one or both eyes, and surgery may be necessary to improve the chance for sight. Cedars-Sinai's NICU is recognized for its low incidence of ROP.
Occasionally, air will "leak" from the baby's lungs into a space between the lung and the chest wall. This trapped air prevents the lung from fully expanding. If large enough, this will cause difficulty breathing and the air may need removal by placing either a needle (for one time removal) or a plastic tube (for continuous removal) in the chest. The tube may need gentle suction to draw out the trapped air. This tube is left in place until the air is removed and the lung is no longer leaking air. This may take a few or many days.
Occasionally, while still in the mom, babies may pass stool (meconium). If the baby breathes it into his lungs (aspirates), it can cause difficulty breathing. Treatment for this problem may include placing a tube into the baby's lungs and cleaning them out with suction. The baby may need oxygen, chest therapy and even the help of a ventilator. The body clears the last traces naturally.
Jaundice (yellowing of the skin) is a common problem in babies. It occurs when a pigment called bilirubin enters the blood. Bilirubin is formed by the normal breakdown of red blood cells. Bilirubin is cleared by the liver and removed from the body. A baby's liver may not be able to perform this job efficiently. A blood test can be done to check the amount of bilirubin in the blood. If it is more than the normal amount, treatment will be started. Light of a specific wave-length and intensity (phototherapy or bililights) will help lower the bilirubin. We will keep your baby's eyes covered with small eye patches and allow his body to be completely exposed to light. Usually a few days of this treatment will resolve the jaundice. Rarely, the jaundice may be severe enough to require an exchange transfusion. (The baby's blood, which is high in bilirubin, would be slowly replaced by donated blood low in bilirubin.
Intraventricular Hemorrhage (IVH)
IVH is bleeding in the area of the normal hollow spaces (ventricles) of the brain. Sometimes the bleeding is so minor that it does not get into the ventricles at all, but only causes minor blood clots at their edges. At other times, bleeding can get into the hollow spaces themselves or even extend into the brain. The most common hemorrhages are minor and do little if any harm. The bleeding is graded from 1-4. Grades 1 and 2 are usually minor. Grades 3 and 4 also can result in little or no harm, but with these grades of hemorrhages the baby's development must be observed more closely, as there is an increased possibility of brain damage. Babies are tested for this by ultrasound of the head. Sometimes more than one test is needed. At times other studies such as Computed Tomography (CT scan) or Magnetic Resonance Imaging (MRI scan) are needed.
It is common for twins, triplets, or quadruplets to need some time in the NICU before going home. Often, this is because they are born prematurely. Sometimes, they have special medical problems related to their growth in the womb together. Also, birth defects are more common in multiple births. Parenting multiples is challenging. You will have to plan for extra clothing, supplies, space, and help you may need when they come home. You will also have two (or three or four) times the emotional ups and downs of the NICU. It may be difficult to keep track of information on more than one baby at the same time. If one baby is having a problem, it may be difficult to be happy for the one/others doing well. Also, it is not unusual for one baby to go home before the other. Visiting may become more difficult when you have one new baby at home and one in the hospital. Many parents find it helpful to keep a journal or notes about each baby, so that things do not get confused. Getting the support of other parents of multiples, who can understand this complex time, often helps parents. These other parents can share things that helped them when they were dealing with more than one baby at once. Your social worker or the parent liaison can help you contact a parent-to-parent volunteer or an organization for parents of multiples in the community.
Infants with Congenital Defects (Defect Present at Birth)
There are 4 million live births in the United States each year. Of these, 1 in every 33 babies is born with a defect. These defects may vary from simple to life threatening. Sometimes the defect needs quick correction while at other times surgery is best delayed. These decisions are made on an individual basis, by a team. The team includes parents, social worker, geneticist, pediatrician, surgeon, physical therapist, etc. Genetics is involved to educate the family and the health care team about several aspects of care. Often, more than one birth defect may be present. Thus, several tests may be needed to make sure that no occult (hidden) defect is overlooked. The most common organ to be affected by a defect at birth is the heart. Infants born with congenital heart disease (Heart defect present at birth)
Infants Born with Congenital Heart Disease (Heart Defect Present at Birth)
Some babies are born with problems in the form or function of their heart. The heart is responsible for pumping blood to all parts of the body. The healthy heart has four chambers which each serve a specific function. The heart receives "used blood" from the body, pumping it to the lungs for oxygen. It then receives "fresh blood" from the lungs, and sends it out to the body again. When any part of the heart or its major vessels is abnormal or does not function well, medical or surgical treatment may be necessary. A variety of tests will help to determine the specific problem in the heart. Some problems can be treated easily, while others may be very complex and life threatening. When a heart problem is suspected or diagnosed, a cardiologist and a cardiac surgeon, if needed, will be added to the team. They will be able to give you more details about your baby's heart and what treatments may be needed.
(Pictures from L-R; Cole Doyle one day old born at 31 wks; Wyatt Doyle two days old born at 31 wks under phototherapy lights for jaundice)