Severely Premature Babies Require Lots More Care
(Extra Stimulation Can Help Their Development)
9 December 2003
Q. Our grandson was born almost three months early. He
was kept in the newborn intensive care nursery for over a
month. His lungs were very immature and he was placed on a
ventilator for about three weeks. He is much better now,
although he is still in the hospital and requires some oxygen.
The doctors and nurses are trying to get him to gain weight.
Our daughter has just started to nurse him, although most of
his feedings are still given through a feeding tube. When
they asked me to hold him, I was really scared because he
looked so tiny and fragile. The doctors said that other than
having some damage to his lungs, he is a perfectly normal
baby. However, I am still very concerned about him. Can you
tell us what we can do to help our grandson grow and develop
normally?
A. You must be a very proud grandmother, congratulations!
Thanks to advances in medical technology over the past few
decades, most premature babies like your grandson are able to
survive and actually do very well, although they do face more
challenges than healthy full-term babies.
Neonates that are born more than two months early (gestational
age less than 32 weeks) have a fairly high chance of developing
an immature lung condition called RDS (respiratory distress
syndrome). Because of their premature birth, the alveoli (or
tiny air-sacs in the lungs) are not able to produce a substance
called surfactant. Surfactant is very much like dish-washing
detergent. If you recall, detergents make bubbles in water
by reducing the surface tension. In a similar way, surfactant
keeps the alveoli open and distended, and allows absorption
of oxygen from the air and removal of carbon dioxide produced
by other parts of the body.
Without surfactant, the alveoli would collapse and the baby
would have difficulty breathing. One of the major advances
in newborn medicine is the development of artificial surfactant
that can be given to premature babies through a tube inserted
into their trachea (or windpipe). The surfactant will coat
the inside lining of alveoli, allowing them to gradually open
and function normally for the exchange of oxygen and carbon
dioxide.
Unfortunately, many premature babies still require the assistance
of a machine called ventilator to help them to breathe. The
ventilator keeps the alveoli open and provides additional
oxygen that the child may require. Some babies have to stay
on the ventilator for days, weeks, and occasionally even
months. As a result, some premature babies develop a lung
condition called broncho-pulmonary dysplasia (BPD), likely
from a combination of pressure from the ventilator and extra
oxygen.
Because of BPD, some premature babies may require supplementary
oxygen for weeks or months after birth. Fortunately, this
kind of lung damage can improve over time. Although sensitive
lung function test can show a difference between older children
who have had BPD compared with those that were born at full-term,
these children can still participate in almost all childhood
activities, including sports. However, children with BPD are
more susceptible to viral and bacterial infections of the
lungs (especially when they are still very young), and they
are also more prone to develop asthma.
Because of their susceptibility to infections, it is most
important to avoid giving bad germs to these premature babies.
Good hand-washing is an effective method that everyone should
practise. I always recommend exposing these babies to as few
people as possible, since some may carry germs that they don't
even know. Don't bring him to baby showers; your daughter
can bring lots of pictures for everyone to see. I am not
trying to make everybody paranoid, but one should avoid
unnecessary exposure to germs. If weather is good, you and
your daughter can take him out for walks, even shopping, as
long as he doesn't go to crowded places or being handled by
lots of people.
Another important thing that your family can do is getting
influenza vaccine (more commonly called flu shot). There are
influenza outbreaks each winter in North America, affecting
every community large and small. During these outbreaks, many
children get sick, and some schools have to be closed. These
outbreaks also occur in senior homes and manors. Influenza
kills thousands of people every year, mostly seniors, and
occasionally young adults and children, especially those who
have pre-existing medical conditions.
Premature babies, especially those who have BPD, are very
susceptible to influenza. You can prevent your grandson from
getting infected by making sure that everyone in his household,
as well as close relatives who would look after him, to get
immunized with the flu shot. Children over six months of age
can be immunized. Therefore, if your grandson has older
siblings, they should get vaccinated to prevent them from
picking up the virus in school or play groups and bringing it
home to their little brother. The protection from flu shot
is not complete, but it does reduce the severity of disease,
and hopefully decrease the amount of virus that your tiny
grandson gets exposed to.
At the hospital, his doctors likely have arranged for your
grandson to receive another vaccine called Synagis. This is
not a true vaccine; it is a high tech antibody against the
Respiratory Syncytial Virus (RSV). This antibody is produced
in mouse, and then modified to resemble human antibody. RSV
is another very serious respiratory virus that causes epidemics
across North America every winter. Children are especially
susceptible, and it spreads through daycares, kindergartens,
and schools. Adults can be infected also, although they are
less likely to get seriously ill. Premature babies, especially
those who have BPD, can get very sick when infected with RSV.
Your grandson will need the Synagis once a month, from October
or November until April to May, depending on the presence of
RSV in your community.
It is also important to remember that regular childhood
vaccination is just as important for your grandson as in
full-term babies. There should be no delay in getting these
vaccinations, and the doctors and nurses likely have given
him his first regular immunization already.
In addition to these routine vaccines, I want to let you know
about two new vaccines that may benefit your grandson. These
vaccines are called Prevnar and Menjugate. Both vaccines are
recommended for children at 2, 4, and 6 months of age. Prevnar
protects children from serious infections caused by 7 most
common strains of Pneumococcus, while Menjugate protects
against group C Meningococcus. Unfortunately most provincial
programs do not include these vaccines in their routine
immunization schedule because they are rather expensive. If
you are interested to learn more about these vaccines, you
can read about them in two previous columns that I have written
(March 5 and April 40, 2002).
I should mention here that clean air at home is extremely
important for premature babies, especially those with BPD.
Not only that no one should smoke in the house, if any parent
or adult smokes, he or she should seriously consider quitting
even before your grandson goes home. Those who smoke carry
significant amount of cigarette smoke on their body and clothing
for a long time. The smoke will irritate the bronchial tubes
of your grandson. We have seen healthy young children coming
into the hospital with difficulty breathing because their
parents smoke. Just imagine what would happen to your grandson
with his damaged bronchial tubes, they will be further damaged
by cigarette smoke.
I am glad to hear that your daughter is trying to nurse him.
This is the best gift any mother can give to their children
that no one else can. Although many formulas have been
manufactured, even for premature babies, none of them is as
good as the mother's breast milk. If possible, she should
try to nurse him for as long as one year, although after the
first four to six months, he can start to take solid food
gradually.
One important aspect in caring for premature babies is to
ensure that they develop normally. Full-term babies are
nurtured in their mothers' wombs for around 40 weeks. During
the last few weeks of gestation, large amount of important
nutrients pass through the placenta and umbilical cord to the
foetus. The brain of these babies are fairly well developed,
with most of the brain cells already present, and nerve fibres
connecting each other through numerous synapses.
The brains of premature babies are less well developed when
they are first born, and they are also more susceptible to
injuries during the first few weeks of life. It is reassuring
to hear that your grandson doesn't have any brain injury so
far. Moreover, premature babies are slower to develop than
full-term babies. It is important to stimulate his brain's
development by touching his skin, talking or singing to him,
even when he is sleeping. I would recommend lots of cuddling
and rocking, it will not spoil him, but instead will help to
stimulate his brain and give him the comfort and security that
all babies need (this applies to normal healthy newborns too).
Playing tape recordings of lullabies can be useful. Most
premature babies can catch up to full-term babies in growth
and development between one to two years of age.
Lastly, I should mention here about sleeping position. It is
important to keep your grandson on his back when he is sleeping.
Premature babies are more susceptible to crib death or sudden
death syndrome (SIDS) than full-term babies; sleeping on the
back can prevent it from happening. However, when he is awake,
he can be put on the belly so that he can exercise his arms
and legs.
I hope you have gained some insight into the care of your
grandson. He may look tiny and fragile; however premature
babies can grow and develop to their natural potential. That
is, if he has tall parents, he can grow to be just as tall,
or even taller. Being tiny at birth does not limit a child's
potential. Most premature babies can finish high school, and
even go to college and university. The most important thing
is the nurture that he gets at home from his parents and
grandparents, as well as other care-takers, including his
teachers. The saying that it takes a whole village to raise
a child is still very true these days.
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