WHAT IS PREMATURITY? Introduction and Definition Prematurity is a term used to describe when a baby is born early.

Most pregnancies last around 40 weeks but some are shorter and some are longer. Babies that are born between 37 weeks and 42 weeks are called full term. Babies that are born before 37 weeks are called premature or preterm. They are affectionately known as preemies. More than half a million (500,000) babies are born prematurely in the US each year. About 70% of those babies are born between 34 and 36 weeks and are known as late preterm births. Babies born between 32 and 33 weeks are known as moderately preterm and are 13% of all premature babies. Ten percent are born between 28 and 31 weeks, and six percent at less than 28 weeks. These are known as very preterm babies. They are very small and may not be ready to survive outside the womb. (Martin 2006). Even though all premature babies are at risk for health problems, those born before 32 weeks face the highest risk. Babies that are born prematurely face a number of problems, including low birth weight, respiratory and breathing difficulties, and underdeveloped organs and organ systems. Babies born before term tend to have low birth weight (LBW), which means they weigh less than 2,500 grams (about 5 pounds, 8 ounces). Very low birth weight (VLBW) describes an infant that weighs less than 1,500 grams (about 3 pounds, 5 ounces). LBW and VLBW infants are at higher risk than other infants for a variety of problems, including cerebral palsy, sepsis (a type of blood infection), chronic lung disease, and death. These infants are also at higher risk for hypothermia, or low body temperature, which can be dangerous. Prematurity is not a disability itself, but a condition that is a major cause of both intellectual and physical disabilities and other chronic health problems. Sadly, prematurity is also the leading cause of death for newborns. Those who survive may face lifelong problems including:

Intellectual disabilities, such as mental retardation or learning difficulties Cerebral palsy Breathing and respiratory problems, such as chronic lung disease Vision and hearing loss, and Feeding and digestive problems.

Some babies will require special care and spend weeks or months hospitalized in a neonatal intensive care unit (NICU). The NICU is a special, caring environment for sick and premature babies, with specialized equipment designed for infants and a hospital staff who have special training in newborn care. There is currently no cure for prematurity, but researchers are working on ways to prevent these early births. Modern medicine has made it possible for some of the very smallest babies to survive and many children, particularly those who are late pre-term births, often catch up to their peers by the time school starts.

For those babies who were born very early and may have continuing problems, there are different treatment options available such as early intervention, therapy, medications, surgery, education, and support.

WHO DOES PREMATURITY AFFECT? Epidemiology/Pathogenesis Any woman can have a baby prematurely. Most preterm births are spontaneous, meaning they just happen. Although the causes of preterm labor are not fully understood, researchers believe that preterm labor may be triggered by the bodys response to certain infections. But in about 40% of cases, doctors cannot determine why the baby was born before term. Preterm babies are higher for black infants (18%) and Native Americans (14%) than for Hispanics (12%), whites (11%) and Asians (10%). Black infants were two times more likely than Asian infants to be born premature, and prematurity is the leading cause of infant death for black infants. (National Center for Health Statistics). Preterm births are also more common for women carrying twins, triplets or other multiples. Multiple births are 6 times more likely to be preterm than single babies. Women who are very young, such as 20 years old and under, or much older, over 40, have the highest rates of preterm births. ((National Center for Health Statistics). Researchers believe there are several reasons for disparities between African-American women and other groups but more investigation is needed. Some of the disparities can be attributed to differences both the quality of care received within the health care delivery system and access to health care, including preventive and curative services. Social, political, economic and environmental exposures may also result in differences in underlying health status and must be explored more fully by researchers. WHAT CAUSES PREMATURITY? Etiology/Pathogenesis/Risk Factors There are some known risk factors for premature birth. But even if a woman does everything right during pregnancy, she still can have a premature baby. The known risk factors are:

Carrying more than one baby (twins, triplets, quadruplets or more). Having a previous preterm birth. Problems with the uterus or cervix. Chronic health problems in the mother, such as high blood pressure, diabetes, and clotting disorders. Certain infections during pregnancy. Cigarette smoking, alcohol use, or illicit drug use during pregnancy.

Although researchers know more than ever before about what leads to preterm delivery, there is still a long way to go in developing treatments to prevent it. The current focus of research includes developing better screening tests to identify women destined to deliver early, and treatments that can be used early on to stop or slow the events leading to prematurity. CAN PREMATURITY BE PREVENTED? A woman may be able to reduce her risk for preterm delivery by visiting her health care provider before pregnancy and, once pregnant, seeking early and regular prenatal care. Visiting the doctor before a planning to have a baby, known as a preconception visit, is especially crucial for women with chronic disorders, such as diabetes and high blood pressure, which sometimes can contribute to preterm birth. When a woman receives proper prenatal care, problems often can be identified early and treated, helping to reduce the risk for preterm birth. A woman may want to make healthier lifestyle choices, such as avoiding alcohol, smoking and illicit drugs beginning before pregnancy and throughout pregnancy. She should try to reach a healthy weight before pregnancy because women who are overweight or underweight are at increased risk for premature delivery. One new treatment may help prevent a subsequent preterm delivery in women who have already had a premature baby. This treatment is currently recommended only for women with a previous spontaneous (not induced) preterm birth who are currently pregnant with one fetus. Studies show that treatment with the hormone progesterone (called 17P) reduces the risk for preterm delivery by about one-third in these women. (DeFonseca 2003). When a doctor suspects that a woman may deliver preterm, he may suggest treatment with corticosteroid drugs. Corticosteroids help the babys lungs mature more quickly to significantly reduce the risk of complications. (Dalziel 2006). The doctor will give the pregnant woman two or more shots containing these drugs. Treatment is most effective when administered at least 24 hours before delivery. The doctor also may suggest treatment with medications (called tocolytics) that may postpone labor (often for only a couple of days). Even this short delay can give the doctor time to treat the pregnant woman with corticosteroids and arrange for delivery in a hospital with a NICU that can give appropriate care to a premature infant, which could make a lifesaving difference for the baby. However, it is important to remember that even if a woman does everything right, she may still have a premature baby. More research still is needed to understand the risk factors for premature birth, such as how family history, genetics, lifestyle, and environment may interact to put some women at greater risk for a premature delivery.

WHAT PUTS A CHILD AT RISK FOR PREMATURITY? Children are at risk for prematurity based on factors affecting the mother. Children that are multiples, such as one of twins, triplets, or more, are at higher risk than single babies. In more than 40% of the cases, doctors do not know why the baby was born premature. HOW IS PREMATURITY DIAGNOSED? Prematurity is diagnosed by the gestational age of the fetus. The term gestational age means how many weeks the baby has been growing inside its mother. A full term pregnancy is 38 to 42 weeks. Those babies born between 34 and 36 weeks are known as late preterm births. Babies born between 32 and 33 weeks are known as moderately preterm. The very littlest babies are born between 28 and 31 weeks, and even some at less than 28 weeks. These are known as very preterm babies. They are very small and may not be ready to survive outside the womb. The baby will be taken to the neonatal intensive care unit (NICU) for specialized care and treatment of any health problems. COMMON HEALTH PROBLEMS ASSOCIATED WITH PREMATURITY Babies that are born prematurely are at high risk for a number of complications. These are the most common complications seen immediately after the birth. Even though many of these complications can be diagnosed and treated, they can often lead to long-lasting difficulties as the baby grows. Hypothermia. Babies who are born too small and too soon often have trouble controlling their body temperature because they dont have enough body fat to prevent the loss of heat. This is known as low body temperature or hypothermia. Babies in the NICU are placed in an incubator or warmer right after birth to help control their temperature. A tiny thermometer taped to the babys stomach senses her body temperature and regulates the heat in the incubator. Maintaining a normal body temperature will help the baby grow faster. Respiratory distress syndrome (RDS): A serious breathing problem that affects mainly babies born before 34 weeks of pregnancy. RDS can result from several situations. The first is that the babys lungs arent fully developed. Sometimes a type of medication known as corticosteroids is given to these infants to help the lungs mature more quickly. If a woman is at risk of delivering her baby before 34 weeks, corticosteroids may be given to her to try to prevent the baby from developing RDS. RDS may also occur if the lungs are missing an important material called surfactant. Surfactant is a slick coating covering the lining of the lungs. Babies dont make enough surfactant to be able to breathe outside the womb until a certain point in their development. Most babies born prematurely have only about

5% of the surfactant that they need. Fortunately, they can receive replacement surfactant to coat the lungs and allow for easier breathing. Sometimes this can prevent RDS from occurring at all and in other cases; the replacement surfactant can save the babys lungs from long-term damage. A doctor may suspect a baby has RDS if she is struggling to breathe. A lung Xray and blood tests often confirm the diagnosis. Along with surfactant treatment, babies with RDS may need additional oxygen and mechanical breathing assistance to keep their lungs expanded. They may receive a treatment called continuous positive airway pressure (CPAP), which delivers pressurized air to the baby's lungs. The air may be delivered through small tubes in the baby's nose, or through a tube that has been inserted into his windpipe. CPAP helps a baby breathe, but it does not breathe for him. The sickest babies may temporarily need the help of a respirator to breathe for them while their lungs mature.

Apnea. Premature babies sometimes stop breathing for 20 seconds or more. This interruption in breathing is called apnea, and it may be accompanied by a slow heart rate. Premature babies are constantly monitored for apnea. If the baby stops breathing, a nurse will stimulate the baby to start breathing by patting him or touching the soles of his feet. Bleeding in the brain (IVH): Most common in babies born before 32 weeks of pregnancy. Bleeding in the brain is called intraventricular hemorrhage (IVH). It can cause pressure in the brain and brain damage. The bleeds usually occur in the first three days of life and generally are diagnosed with an ultrasound examination. Most brain bleeds are mild and resolve themselves with no or few lasting problems. More severe bleeds can cause the fluid-filled structures (ventricles) in the brain to expand rapidly, causing pressure on the brain that can lead to brain damage (such as cerebral palsy and learning and behavioral problems). In such cases, surgeons may insert a tube into the brain to drain the fluid and reduce the risk of brain damage. In milder cases, drugs sometimes can reduce fluid buildup. IVH also is associated with a risk for developing cerebral palsy. Patent ductus arteriosus (PDA): A heart problem that is common in premature babies. Untreated, it can lead to heart failure. Before birth, a large artery called the ductus arteriosus lets the blood bypass the lungs because the fetus gets its oxygen through the placenta. The ductus normally closes soon after birth so that blood can travel to the lungs and pick up oxygen. When the ductus does not close properly, it can lead to heart failure. PDA can be diagnosed with a specialized form of ultrasound (echocardiography) or other imaging tests. Babies with PDA are treated with a drug that helps close the ductus, although surgery may be necessary if the drug does not work. Necrotizing enterocolitis (NEC): Some premature babies develop this potentially dangerous intestinal problem usually two to three weeks after birth. It can lead to feeding difficulties, abdominal swelling and other complications. NEC

can be diagnosed with imaging tests, such as X-rays, and blood tests. Affected babies are treated with antibiotics and fed intravenously (through a vein) while the bowel heals. In some cases, surgery is necessary to remove damaged sections of the intestine.

Retinopathy of prematurity (ROP): An eye problem that occurs mainly in babies born before 31 weeks of pregnancy. In severe cases, treatment is needed to help prevent vision loss. The smaller a baby is at birth, the more likely that baby is to develop ROP. This disorderwhich usually develops in both eyesis one of the most common causes of visual loss in childhood and can lead to lifelong vision impairment and blindness. About 14,00016,000 of premature infants are affected by some degree of ROP. The disease improves and leaves no permanent damage in milder cases of ROP. About 90 percent of all infants with ROP are in the milder category and do not need treatment. However, infants with more severe disease can develop impaired vision or even blindness. About 1,1001,500 infants annually develop ROP that is severe enough to require medical treatment. About 400600 infants each year in the US become legally blind from ROP. ROP is diagnosed during an examination by an ophthalmologist (eye doctor). Most cases are mild and heal themselves with little or no vision loss. In more severe cases, the ophthalmologist may treat the abnormal vessels with a laser or with cryotherapy (freezing) to protect the retina and preserve vision.

Jaundice. Premature babies are more likely than full-term babies to develop jaundice because their livers are too immature to remove a waste product called bilirubin from the blood. In addition, premature infants may be more sensitive to the ill effects of excess bilirubin. Babies with jaundice have a yellowish color to their skin and eyes. Jaundice often is mild and usually is not harmful; however, if the bilirubin level gets too high, it can cause brain damage. This generally can be prevented because blood tests show when bilirubin levels are too high, so the baby can be treated with special lights (phototherapy) that help the body eliminate bilirubin. Occasionally, a baby may need a blood transfusion. Anemia. Premature infants often are anemic, which means they do not have enough red blood cells. Normally, the baby stores iron during the later months of pregnancy and uses it late in pregnancy and after birth to make red blood cells. Infants born too soon may not have had enough time to store iron. Babies with anemia tend to develop feeding problems and grow more slowly; anemia also can worsen any heart or breathing problems. Anemic infants may be treated with dietary iron supplements, drugs that increase red blood cell production or, in severe cases, blood transfusion. Chronic lung disease (also called bronchopulmonary dysplasia or BPD). Chronic lung disease most commonly affects premature infants who require ongoing treatment with supplemental oxygen. The risk of BPD is increased in babies who still need oxygen when they reach 36 weeks after conception (weeks

of pregnancy plus weeks after birth adding up to 36 or more weeks). These babies develop fluid in the lungs, scarring and lung damage, which can be seen on an Xray. Affected babies are treated with medications that make breathing easier and are slowly weaned from the ventilator. Their lungs usually improve over the first two years of life. However, many children develop chronic lung disease resembling asthma.

Infections. Premature babies have immature immune systems that are inefficient at fighting off bacteria, viruses and other organisms that can cause infection. Serious infections that are commonly seen in premature babies include pneumonia (lung infection), sepsis (blood infection) and meningitis (infection of the membranes surrounding the brain and spinal cord). Babies can contract these infections at birth from their mother, or they may become infected after birth. Infections are treated with antibiotics or antiviral drugs.

TREATMENT There is no one treatment that will work for every premature baby. The treatment interventions depend on the individual problems. While your baby is in the NICU, the health care team will use a variety of treatments to keep your baby healthy and thriving. Once your baby goes home, treatment will depend on any specific needs your baby may have. What are the medical treatment options? Some of the medical treatment options that are used for complications of prematurity include: Antibiotics or antiviral drugs to help treat infections Blood transfusions to treat anemia or jaundice Surfactant and oxygen treatments to help prevent lung damage Equipment such as monitors and incubators to help warming and breathing

What are the surgical treatment options? Some of the surgical treatment options that are used for complications of prematurity include: Inserting a tube into the brain to reduce fluid build up in the case of bleeding (IVH) Surgery to close the ductus artery to prevent heart failure Surgery to remove damage sections of the intestine in cases of severe enterocolitis Laser surgery or cryotherapy (freezing) to preserve vision in cases of severe retinopathy

What are the non-medical treatment options? Once your baby comes home, there are different types of interventions that can be used depending on any continuing complications. As your baby grows and develops, you may find you need to turn to early interventions that may include: Physical therapy Occupational therapy Respiratory therapy Speech and language therapy Vision and hearing aids

WHAT HAPPENS OVER TIME TO PREMATURE BABIES? WILL THERE BE IMPROVEMENT? DOES IT GET WORSE? (Prognosis and Complications) A premature birth presents a wide range of possible complications and conditions. Each baby is unique, and will have a different set of circumstances surrounding the birth. Sometimes, only time will tell what lasting complications, if any, a baby will have; in other situations, problems are obvious from the very beginning. For severe complications of prematurity, such as cerebral palsy, vision or hearing loss, or intellectual disabilities, the condition itself may not improve. You can still give your baby a high quality of life through early intervention services, adaptive devices, and other methods of treatment. For other complications, particularly in those babies born late preterm, these may improve as your baby grows. Many studies have been done to determine the long-term effects of low birth weight and prematurity through school age and adolescence (Botting et.al. 1998, 1997; Hoy et. al. 1988; Marlowe et. al. 2005; Saigal et. al. 2000) but more are needed. Some children catch up to their peers by school age; others have lingering difficulties that are easily overcome, and still others have greater challenges.

WHAT QUESTIONS SHOULD I ASK? Since so many things are uncertain when a baby is born prematurely, its natural to have questions. Its important to be as informed as possible about your babys condition and the impact it may have on the future. You are a key element of your babys treatment team. You may want to know everything thats going on right away, or you may want some time just to be with your baby and ask questions later. Sometimes there are no definite answers to your questions, but learning what you can do to in the moment can help relieve some of the anxiety and uncertainty. Questions you may want to ask include:

How is my baby doing today? Has anything changed? What caused this condition? What are you doing to treat it? What types of tests are being given to my baby and what information will they provide? Will there be any long-term complications? How can I prepare for that? How will I be informed of any major change in my baby's condition? What can I do to take care of my baby? How long will my baby need to stay in the NICU? What can I do for my baby at home? What resources and services will we need once we leave the hospital?

WHAT RESOURCES ARE AVAILABLE TO PATIENTS AND FAMILIES? American Academy of Pediatrics http://www.aap.org/sections/perinatal/families.html Centers for Disease Control (CDC) http://www.cdc.gov/features/prematurebirth/ Kids Health http://kidshealth.org March of Dimes www.marchofdimes.org
National Dissemination Center for Children with Disabilities (NICHCY) www.nichcy.org

National Institute of Child Health and Human Development (NICHD) www.nichd.nih.gov

REFERENCES

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