MAY

“She was born premature at 35 weeks of pregnancy, and is now 4

years old. She likes to play with her brother, Daniel, especially at
the playground. She is ‘fussy’ with her foods and is underweight
for her age. Her medical history states that she has respiratory
problems, is prone to ‘getting’ the flu and needs regular visits to
the Polyclinic for developmental assessment.”

Preterm birth refers to the birth of a baby of less than 37 weeks gestational
age. Premature birth, commonly used as a synonym for preterm birth,
refers to the birth of a premature infant. Because it is by far the most
common cause of prematurity, preterm birth is the major cause of neonatal
mortality in developed countries. Premature infants are at greater risk for
short and long term complications, including disabilities and impediments in
growth and mental development. In humans, whereas the usual definition of
preterm birth is birth before 37 weeks gestation, a "premature" infant is one
that has not yet reached the level of fetal development that generally allows
life outside the womb. In the normal human fetus, several organ systems
mature between 34 and 37 weeks, and the fetus reaches adequate maturity
by the end of this period. One of the main organs greatly affected by
premature birth is the lungs. The lungs are one of the last organs to develop
in the womb; because of this, preemies typically spend the first days/weeks
of their life on a ventilator. Therefore, a significant overlap exists between
preterm birth and prematurity: generally, preterm babies are premature and
term babies are mature. Prematurity can be reduced to a small extent by
using drugs to accelerate maturation of the fetus and to a greater extent by
preventing preterm birth.

Are babies born at 34 to 36 weeks gestation (late preterm) at risk for medical
problems?
Late preterm infants are usually healthier than babies born earlier. More than 99 percent of these
babies survive, though they are:
• 6 times more likely than full-term infants to die in the first week of life (2.8 per 1,000 vs.
0.5 per 1,000)
• 3 times more likely to die in the first year of life (7.9 per 1,000 vs. 2.4 per 1,000)
Late preterm babies often weigh between 4½ and 6 pounds, and they may appear thinner than
full-term babies. These babies remain at higher risk than full-term babies for newborn health
problems, including breathing and feeding problems, difficulties regulating body temperature,
and jaundice . These problems are usually mild. Most of these babies can breast- or bottle-feed,
although some (especially those with mild breathing problems) may need tube-feeding for a brief
time.
A baby’s brain at 35 weeks weighs only two-thirds of what it will weigh at 40 weeks . Because
their brain development is not complete, these babies may be at increased risk for learning and
behavioral problems . Most do not develop serious disabilities resulting from premature birth.
A recent study, however, found that late preterm infants are more than 3 times as likely to
develop cerebral palsy and are slightly more likely to have developmental delays than babies
born full term . Another study found that adults who were born at 34 to 36 weeks gestation may
be more likely than those born full-term to have mild disabilities and to earn lower long-term
wages .

Specific risks for the preterm neonate:

Preterm infants usually show physical signs of prematurity in reverse proportion to the
gestational age. As a result they are at risk for numerous medical problems affecting different
organ systems.
• Neurological problems include apnea of prematurity, hypoxic-ischemic
encephalopathy (HIE), intracranial hemorrhage, retinopathy of prematurity
(ROP), developmental disability, and cerebral palsy.
• Cardiovascular complications may arise from the failure of the ductus
arteriosus to close after birth: patent ductus arteriosus (PDA).
• Respiratory problems are common, specifically the respiratory distress
syndrome (RDS or IRDS) (previously called hyaline membrane disease).
Another problem can be chronic lung disease (previously called
bronchopulmonary dysplasia or BPD).
• Gastrointestinal and metabolic issues can arise from hypoglycemia, feeding
difficulties, rickets of prematurity, hypocalcemia, inguinal hernia, and
necrotizing enterocolitis (NEC).
• Hematologic complications include anemia of prematurity, thrombocytopenia,
and hyperbilirubinemia (jaundice) that can lead to kernicterus.
• Infectious include sepsis, pneumonia, and urinary tract infection
Neonatal care

In developed countries premature infants are usually cared for in a neonatal

intensive care unit (NICU). The physicians who specialize in the care of very
sick or premature babies are known as neonatologists. In the NICU,
premature babies are kept under radiant warmers or in incubators (also
called isolettes), which are bassinets enclosed in plastic with climate control
equipment designed to keep them warm and limit their exposure to germs.
Modern neonatal intensive care involves sophisticated measurement of
temperature, respiration, cardiac function, oxygenation, and brain activity.
Treatments may include fluids and nutrition through intravenous catheters,
oxygen supplementation, mechanical ventilation support, and medications.
In developing countries where advanced equipment and even electricity may
not be available or reliable, simple measures such as kangaroo care (skin to
skin warming), encouraging breastfeeding, and basic infection control
measures can significantly reduce preterm morbidity and mortality.

Long term sequelae

Most children even if born very preterm adjust very well during childhood and adolescence. As
survival has improved, the focus of interventions directed at the newborn has shifted to reduce
long-term disabilities, particularly those related to brain injury. Some of the complications
related to prematurity may not be apparent until years after the birth. A long-term study
demonstrated that the risks of medical and social disabilities extend into adulthood and are
higher with decreasing gestational age at birth and include cerebral palsy, mental retardation,
disorders of psychological development, behavior, and emotion, disabilities of vision and
hearing, and epilepsy. Also it was shown that higher levels of education were less likely to be
obtained with decreasing gestational age at birth. People born prematurely may be more
susceptible to developing depression as teenagers. Some of these problems can be described as
being within the executive domain and have been speculated to arise due to decreased
myelinization of the frontal lobes. Throughout life they are more likely to require services
provided by physical therapists, occupational therapists, or speech therapists. Further long-term
studies are needed to get a better picture about the sequelae of preterm birth.
Problems faced by premature babies:
Breathing problems

Around one premature baby in 10 has a breathing problem, and the earlier she's born, the more
likely this is. Possible reasons include:

• Small, immature lungs

• Weak breathing muscles

• A soft ribcage
• 'Stop-breathing' (apnoea) attacks

• Respiratory distress syndrome

• A hole in the membrane around a lung, making it collapse (pneumothorax)

• Brain damage

• Pneumonia

Untreated breathing problems lead to a shortage of oxygen (hypoxia) which, if prolonged, severe
or untreated, can damage various parts of the body, such as the eyes, ears or brain. Staff watch
for hypoxia by monitoring a baby's breathing and heart rate and measuring blood gas levels.
They also help prevent or correct it with extra oxygen, CPAP and, if necessary, ventilation.

Respiratory distress syndrome (RDS):

This develops in four out of five babies born before 36 weeks, generally
within the first four hours of life, and overall it affects about 12,000 babies a
year in the UK. Delaying premature labour so a mother can receive steroids
reduces the risk, possibly by stimulating the baby's production of surfactant
(see below).

Surfactant
A baby's lungs begin to make surfactant from 22 weeks of pregnancy, and at
34:36 weeks there's a big rise in production. This fatty substance is a
lubricant which keeps the tiny air spaces open and helps a baby breathe. A
baby born before 36 weeks may not make enough for a few days after birth.
This leads to the rapid, grunting breathing characteristic of RDS. Three in
four babies with RDS need ventilation.

Infections

Premature babies are much more likely to develop infections (for example,
pneumonia and gastroenteritis) because their immune systems are relatively
immature. Breastfeeding reduces this risk.

How diet can boost your child’s immune system?

• Drink Water
Encourage your child to drink plenty of water. The human body is 70% water and it
needs a continuous fresh supply to work properly. Water helps the smooth passage
of waste out of the body: infrequent bowel movements weaken the immune system.

* Offer water as the first choice of drink.

* Replace cola or other sugary caffeinated drinks with slightly diluted

unsweetened fruit juice.

• Eat Fresh Fruit and Vegetables

You probably know that fruit and vegetables are high in vitamin C but they're also
rich in antioxidants. Both vitamin C and antioxidants help boost immunity.

• Eat Fish
Now we know that fresh or frozen oily fish, such as salmon, mackerel and herring,
contain omega 3 fats, which are valuable immune system boosters. Eat oily fish at
least twice a week if possible.

• Eat Seeds
Sunflower, pumpkin and particularly flax seeds are very good sources of nutrients -
after all they contain everything that is needed for the creation of a new plant! If
your child is a reluctant eater, seeds can be ground to a powder and sprinkled onto
food.

Underweight:
• He/she may simply be not taking enough energy (calories) in his/her diet. Some children have
fast metabolisms and are very active. If his/her diet does not keep pace with the amount of
calories he/she is burning off during the day he/she will lose weight. If he/she goes through
prolonged periods of fussy eating (also called "selective eating"), this can also cause him/her to
lose weight, which can be very distressing for all involved.

• He/she may be losing too many calories. This could be caused by temporary illness - e.g. a
tummy bug which has caused sickness and diarrhoea. Diarrhoea may also lead to malabsorption
of foods - which means that his/her body cannot absorb the nutrients from foods into his/her
bloodstream, causing him/her to lose weight.

• Children who have been unwell, or who have chronic infections or heart disease may also need
increased calories. Occasionally, being underweight can be a sign of an underlying medical
condition, which is why it is important to contact your doctor if you are concerned about your
child's weight.

Your doctor will refer your toddler to a paediatrician should he feel that your child is showing
any signs of illness. Whatever the cause of your child's weight loss, it may help if you increase
your child's calorie intake.

Toddlers have small tummies and yet can be very active, so if your toddler is slow to gain
weight, you may have to increase the calorie content of what he/she is eating without increasing
the quantity. There are several ways to do this:

• Ensure that all dairy foods are full-fat rather than low-fat, e.g. yoghurt, fromage frais, cheese.

• Try adding a small amount of soft vegetable margarine or vegetable oil, butter or double cream
to savoury foods. Half a teaspoon of margarine or butter can be added to a savoury dish of meat
and vegetables without your child being aware of it.

• Use mashed potato as a base to which you can add margarine, grated cheese, or baked beans.

• Use mayonnaise or salad cream as a dip for raw vegetables.

• Try giving your toddler avocado, which is high in calories and full of vitamins and other
nutrients and can be made into a dip or mashed into potato.

• Give your toddler some mashed banana with full-fat yoghurt or fromage frais as a dessert.

Your toddler may eat more by having mid-meal snacks, but make sure that these are savoury
snacks where possible, as sweet foods can reduce his appetite for the next meal and possibly
cause tooth decay.

Resist the temptation to give your toddler an extra bottle or drink of milk during the night as this
may become a permanent habit and will usually result in your child having less appetite for
solids during the day.

Don't use high fibre foods such as wholemeal pasta and brown rice as it can reduce his/her ability
to absorb essential vitamins and minerals.

It could be helpful to give your toddler a vitamin supplement specially formulated for toddlers if
your child is breastfed or drinking cow's milk as his/her main drink. (Toddlers who are drinking
formula milk do not need extra vitamins as formula already has vitamins added to it). This could
increase the amount of iron absorbed from his/her diet, which in turn could increase his/her
appetite.

Children need to feel relaxed and comfortable to enjoy food and eat well. Try to have regular
mealtimes and eat at a table as a family whenever you can. Although you may be feeling very
anxious, resist the temptation to put pressure on your toddler to eat. Turn the TV off and
concentrate on eating and chatting as a family, making mealtimes a sociable time.

Remember that toddlers have short attention spans and will quickly get bored with sitting at the
table, so many toddlers will eat more food in the day if they can have five or six small meals
rather than three large meals.

As your toddler gets older start to involve him/her in food preparation and in buying foods. Don't
forget to offer him/her a wide variety of tastes, including foods which you may not enjoy
yourself.
Developmental Assessment:
• Why is it important?
It is crucial to detect any developmental delay or disorder in a child early. This is because
early interventions improve the outcome of treatment. Developmental delays can have
significant negative effects on the child. Depending on the area of developmental delay, the
affected child may encounter speech and language difficulties, behavioural and learning
problems. There is a range of what is considered “normal development”. Some babies or
children may accomplish certain tasks or reach a specific developmental milestone earlier or
later than others. Therefore, parents should work together with your healthcare providers to
help your child grow and develop his/her full potential. You are advised to consult your
doctor or nurse if you have concerns
about your child's development.

• Is your child developing normally?

It is crucial to have your child checked to see if he/she is developing normally. Early detection
means early intervention to help him/her overcome or deal with any difficulties that he/her may
have.
• What is developmental assessment?
It is a structured evaluation of your child’s physical, emotional social, language, and intellectual
development.
• When should you bring your child for developmental assessments?
Developmental assessments are done at 3 months, 9 months, 18 months, 3 years and 4 years of
age at the polyclinics.
• What are the signs that my child has developmental delays?
You know your child best. Keeping the developmental assessments appointment at the polyclinic
is important.

You will be advised by the nurse on how to complete the developmental questionnaire in your
child’s health booklet. You should consult the doctor if you are worried. The most obvious signs
that parents would notice are delays in walking and talking.

By 12 to 15 months, your toddler should be able to communicate his basic wants and needs, even
if he is not speaking actual words yet.

By 15 months he should be able to speak at least a few simple words "Mama," "Dada".

By 18 months your child should be able to walk.

By 19 to 24 months:
Display self conscious emotions but the intensity depends on monitoring and encouragement of
adults.
 Adds more words in the vocabulary for talking about feelings.
 Learns to tolerate absence of familiar caregiver.
 Can use words to describe peer's behaviors.
 Learns to use own name or personal pronouns to describe self.
 Can sort self others into categories based on age, sex, and other characteristics.
 Starts to develop self control.
By 2-3 years:
 Begins to develop self concept and self esteem.
 Understands causes, effects and behavioral signs of basic emotions.
 Learns to cooperate.
 Empathy increases.

By 3-4 years:
 Improves emotional self-regulation.
 Experiences self-conscious emotions often.
 Decreases non social activities and plays interactively more often.
 Forms first friendship.
 Begins to prefer same-sex playmates.