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Born Too Soon: Saving Preterm Babies

Mar 25 | 1:30 PM

Most premature babies (>80%) are between 32 and 37 weeks of gestation, and many die needlessly due to a lack of simple care. For babies who cannot breathe at birth, the administration of rapid neonatal resuscitation is crucial to their survival. Extra care for tiny babies, including Kangaroo Mother Care and feeding support, can halve mortality in babies weighing <2000 g. Physicians must manage newborns with signs of infection with safe oxygen administration and supportive care for respiratory complications. Additionally, babies with significant jaundice require supportive care for a swift recovery. On Medflix, Dr. Mondkar, a pioneering figure in India's neonatology landscape, will take us through intriguing neonatal care ideas from her vast experience!

[Music] good evening everyone this is dr rishali from netflix and i would like to welcome you to this amazing very informative session uh born too soon so it's about saving the premature babies the management that is to be done and with us today we have with us uh dr jayashree monker mam is the ex dean professor and head uh at lokman at municipal general hospital scion uh she also is one of the pioneers when it comes to asia's first milk bank uh it the milk bank has been running for the last 30 years she said and they've been helping out a lot of babies and like what i heard from ma'am many like mothers are also ready to donate because this is something which is a very noble cause and the milk bank collects around 800 to 1200 liters annually and at least 3 000 babies need this donor milk every year so that's a huge number and i'm sure ma'am it's it's it must been amazing to do such a noble cause and i mean just reading about it makes us feel good so we are really honored to have you here for this uh talk regarding the same topic that saving the preterm babies with this ma'am i'll just stop my ppt and start with yours yes ma'am it's all yours okay so a very good evening to everyone and i must say it's a great pleasure to be on this uh netflix uh platform and i'd like to thank dr brushali dr who you know invited me to speak on this topic which is very close to my heart and that is saving pre-term lives let me start with a you know as sort of a happy story so to the left of your screen you have priyanka and you see her with her with her newly born baby a newborn baby who's three kilos and uh they're all set to go home the baby is also all dressed up with a nice bonnet and nice uh wrap and all ready to go home but priyanka is going home after a stay of three months in the uh hospital and actually this was during corbid times and therefore this patient is very special to us and the reason why uh you know this baby was in hospital for three months as you can see on the right side is that this is an uh extremely preterm baby the baby was born at 26 weeks of gestational age and the baby required um and his birth weight was 600 grams and uh so obviously for such a tiny baby who's gone so preterm the baby it's you know the it's uh the course is brought with a lot of problems and priyanka's baby was on the ventilator you can see in this picture the baby was on the ventilator and in an incubator almost for the first whole month then moved on to non-invasive ventilation but like it said all's well that ends well and so when you have a nice well-grown baby who's neurologically intact going home it gives pleasure not only to the parents but it also gives us as you know treating clinicians a lot of pleasure and satisfaction so today what i'm going to do in the next 40 minutes is to run you through you know okay run you through sort of problems that these premature babies would uh face and how would we would go about managing them so let's begin with the basics so uh basically uh you know over the last one decade so the past ten years prematurity has emerged as the major cause of neonatal mortality uh before this you know uh i mean i've been working for virtually i'm about 33 years in neonatal 33 plus years almost 40 years in neonatology i would say and first the main causes of death used to be asphyxia used to be uh neonatal sepsis but in the past 10 to 12 years prematurity has now emerged as a major cause for neonatal mortality now if you look at our own country 27 million babies are born in our country each year and out of this 3.5 million babies are born preterm so the highest number of preterm births we have the biggest distinction india has a devious distinction of having the highest number of eternal births every year that is 3.5 million now the neonatal mortality is in the last you know five to seven years with better focus on uh on newborn and pediatric health slowly coming down and the current neonatal mortality is 20 per thousand live works but if you look at this pie chart on the right side and that whole yellow chunk which is uh which is responsible for uh neonatal mortality which gives you the causes of neonatal mortality is because of prematurity so almost 43 percent of the causes of neonatal mortality are because of prematurity and prematurity related issues but the sad part is actually that 80 of these babies are not uh you know that very preterm they're what we call moderate or late freedoms between 32 to 37 weeks of gestation but yet many of them uh die because of lack of just simple essential care and the prime ones being warmed and feeding support and therefore we if you have to make a difference for these babies then we we need to know how to you know manage uh them one way or the other so before i go any further uh uh let's you know like look at what uh prematurity is all about so any baby who's born before 37 completed weeks or before 260 days of intrauterine life would be called a preterm baby now uh there are sort of sub categories of preterm babies so baby was born before 28 weeks of gestation would be called an extremely pre-term baby a baby was born between 28 to 32 weeks of gestation would be called a very pre-term baby that between born between 32 to 34 weeks is a moderate freedom and between 34 to 37 weeks would be a late free time obviously i mean this classification is needed because it makes us understand that the earlier the baby is born the uh the more likely this baby is going to have more many more complications because all these organ systems will be immature but uh what i need to point out is that even the late preterm babies are not taking just because they're late and previously they used to be called near-term babies but near-term sort of implies that you know these babies are almost full-term so shouldn't be having problems but even the late pre-term babies have much more problems in terms of respiratory problems in terms of gender hypoglycemia as compared to their uh term uh to a term counterpart and therefore uh preterm babies do require special attention so what can we do to improve these lot of preterm babies so we would improve these lot of preterm babies by uh you know are there any strategies that we can actually use before the birth of the baby well the best strategy the ideal most strategies if you could prevent preterm birth altogether so we could work towards it but it may not be immediately possible it's like improving the general health of the girl child and you know improving her nutrition and also of course during the pregnancy i give as a good antenatal care good emergency obstetric care would uh help in better out you know reducing premature deliveries to an extent and of also better outcomes in these babies but around delivery i think what are the you know some of the important strategies for managing such babies would be first and foremost in neutral transfer so uh you know it's horrible when a baby has to is born at a small nursing home then he's wanted to pre-term some 800 grammar and then there's a rush for which which and i should should we transfer this baby to and then as you'll there'll be no vacancies all the public hospitals are overcrowded uh we would have sometimes like i was just telling um dr brishali doubling under an instant warmer sometimes even trickling because if we don't give them care then who's going to give them care that they would these babies would die otherwise so uh therefore in neutral transfer you transfer the the mother during as soon as she starts preterm labor to a center which which has a well-equipped nicu so that the babies can be managed appropriately there and the babies do not get destabilized after birth then other strategies which have been found to be very effective are antenatal corticosteroid and antenatal magnesium sulfate administered to mothers during if they have threatened preterm labor then skilled personnel for resuscitation of such tiny preterm babies in the labor room and prevention of labor so i'm going to you know talk a little bit more in detail about these because these are important strategies so um uh until so you know i think one of the best finds of the uh uh 19th uh century that the 19 um in the 19th century would be the the finding that antenatal cortical steroids in the form of beta methods own 12 milligrams uh two doses given 24 hours apart or dexa mil uh method zone six milligrams four doses given uh 12 hours apart so a total of 24 milligrams for both the drugs when given to mothers who are in threatened preterm labor between 24 to 34 weeks of gestational age actually improve outcomes by reducing the incidence of the communist problem that is tiny preterm space of respiratory distress syndrome the risk reduction is by 29 the mortality risk reduction is by 22 besides this other complications that these babies have like intraventricular hemorrhage it is bleeding inside the ventricles of the brain patent ductus arteriosis necrotizing enterocolitis you know dreadful conditions which really uh increase the morbidity as well as the mortality are significantly reduced and uh the best results are seen if uh you know the labor can be delayed by using propellants for about 48 hours but some steroid is always better than nosteroid and the effect of the steroid lasts for about seven days so what happens to those pregnancies where their mothers come in threatened and treated labor but they do not progress further so do we give repeated courses if they're say between 24 to 34 weeks and the answer to this is one more course perhaps maybe may be recommended and this is by the royal college of obstetrics and gynecology uk as well as by the who guidelines they say that one additional course that is a total of 24 milligrams may be repeated especially if the first course was given before 26 weeks of gestational age and you repeat it after uh seven days um during this period as we talked about then they viewed looked at expanded use of antenatal corticosteroids also and uh they looked at whether it would be useful they said 24 to 34 we so beyond 34 weeks in late three terms in the 34 to 36 week babies and the american college of obstetrics and gynecology recommends it for even late freedoms however uh who had done you know a research study called the action 2 trial and they found that it did not make any difference antenatal cortical steroids did not improve the outcome in late preterm labor uh when it was given and therefore the who does not recommend it but elective uh then the royal college of obstetrics and gynecology has used looked at using it in elective caesarean deliveries before uh in early term babies that is before 38 completed weeks simply for the reason that these babies or also when they undergo an elective caesar have more respiratory morbidities and they have found that actually it reduces the nico admissions for respiratory problems in these early term babies also so there is an expanded use but primarily between 24 to 34 weeks as soon as the mother comes in threatened preterm labor it's mandatory to give her her start the course of antenatal steroids and continue the give the full course as far as possible then another strategy which is found to be useful in premature babies is uh antenatal magnesium sulfate and this is found when administered to mothers in threatened preterm labor it is found to improve the neurodevelopmental outcomes of these babies a long-term developmental outcomes and there's a risk reduction of grass motor dysfunction by 39 and cerebral palsy by 30 percent so that's a big you know improvement in these babies because you know the more preterm they are the more they are at risk of brain injury so any strategy that one can use to try to improve their outcomes is welcome and antenatal magnesium sulfate is therefore recommended for neuro protection and uh when the mother is an imminent preterm labor when less than 32 weeks of gestation and uh the dose is magnesium sulphate um intravenously given over 20 minutes uh as soon as the mother is admitted in preterm labor and then continued at one gram per hour intravenously for a period of 24 hours or till labor occurs whichever is earlier and so this would help in yeah definitely neurodevelopmental outcome now what are the common problems that premature babies face so there are a whole host of problems that babies can ha can have especially you know during the early first one to two weeks of life and typically at birth they may not try immediately what we call perinatal depression would require resuscitation hypothermia is a big problem for these babies and if they have hypothermia their outcomes are poorer respiratory distress syndrome is a commonest pulmonary morbidity that they have apnea metabolic problems intracranial bleeds pda and you you and of course feeding difficulties so these are then besides this you know it's not that for once the first two weeks are over life is sort of you know comfortable and now they're going to do and there's not going to be any issues even in the third week in the fourth week of life and thereafter also these tiny preterm babies extremely preterm babies um you know less than 28 weeks would continue to have problems and i'll talk touch up on this briefly later so let's look at what we can do for uh you know managing early problems of these babies what are the strategies for improving outcomes i mean if i were to talk on all these problems which i would like i would be completing one whole textbook because it's all about um you know neonatology is all about trying to include a lot of these preterm babies so i'm going to stress on just about eight to ten of these aspects which are important for good outcomes so the first uh aspect would be labor room stabilization of the prejudge baby now the birth of any preterm baby is what is called a high risk delivery and therefore if uh you know we want to improve outcome of these babies [Music] you know we have there has to be a trained a team which is trained in neonatal resuscitation who's present in the labor room in anticipation once you know that the mother is eminently going to deliver and they have to ensure that all the equipment that is required for you know managing uh preterm resuscitation in the form of an appropriate sized angle bag of 240 ml capacity uh the preterm size base mask of size zero and size zero zero the pre-term size laryngoscope blades of size zero and zero zero endotracheal tubes the smaller sizes two point five and three and of course a labor room cpap device so what is the cpap device cpap device is something that gives continuous positive airway pressure i'll talk about it later in the um a little more in detail in the next slide and of course the second important uh you know strategy in the labor room is prevention of hypothermia so you know when the baby is in neutral or the baby is in a very comfortable environment and actually the baby's temperature is one degree higher than the temperature of the mother and it is surrounded by amniotic fluid and very comfortable when the baby comes out in this cold environment baby loses heat very rapidly by convection convec the ocean conduction radiation evaporation all forms of heat philosopher and the baby can lose heat and there is enough research to show that there is a significant increase in the risk of mortality intraventricular hemorrhage bronchopulmonary dysplasia sepsis oil and retinopathy of prematurity all the typical problems of future newborns again aggravated if the temperature and the mortality is higher if the temperature of the babies is not maintained and the baby suffer from hypothermia so what is the special care that we need to give these babies in the labor room is that um you know all babies who are resuscitated with the term of preterm are resuscitated under an infant former that's the picture that you see in the top right corner and in addition to this for preterm babies particularly less than 32 weeks what you do to help maintain temperature is put them as soon as they're born and they you know you've cut the cord you put them into a plastic bag or a plastic wrap a sterilized plastic wrap even without drying the baby and what we're achieving is we're creating a micro environment for the baby and therefore we're reducing the evaporative heat losses and evaporative heat losses are the one which is associated with a lot of you know heat loss and therefore uh you know predispose the baby to hypothermia so we as you can see i hope you can see it in the lower picture uh that you uh what we actually do is wrap the baby in a plastic wrap and cover the head with the plastic and nurse the baby in what is called a thermal mattress for better temperature regulation and by the time the baby reaches and we remove this plastic wrap only after the baby reaches the nicu and we find that the temperature is in the normal range of 36.5 to 37.5 degree centigrade the baby is nursed under the radiant one more in or in the incubator that's when we would remove the master crack and the third important strategy in the labor room would be respiratory stabilization so when a baby is born and he sort of bleeds immediately these very tiny babies will see them retracting they'll have intercostal retraction subpositive retractions you can see they have difficulty and they have grunting they have allen azer flare they have sternal retractions which shows that they have significant respiratory distress and therefore one of the strategies in the labor room is to give what is called continuous positive airway pressure so let's uh um understand a little bit about this device a continuous positive airway pressure so this cpam devices we say or continuous positive airway pressure is used for the problem of respiratory distress syndrome so respiratory distress syndrome is one of the most common pulmonary morbidities that these babies suffer from immediately after birth actually starting right from the word go and basically it's a prerogative of the tinier preterms babies less than 34 weeks of gestational age at work and particularly if they have received an incomplete course of antenatal corticosteroids and basically what is what causes respiratory distress syndrome is a deficiency of a pulmonary substance called surfactant so surfactant is basically a surface tension reducing agent in the lungs it um you know it lines the air fluid interfaces of the alveoli and it reduces the surface tension and thus it prevents the alveolar also opposing each other at the end of expert exploration is passive and the air moves out a fair amount of air moves out from the lungs but air always has to be present in the alveolar if they collapse and opening the alveoli with each breath becomes difficult and the typical example is when you blow a balloon when you start to blow a balloon you have to put a lot of pressure but once it there's a little bit of air that goes in then distending the balloon is easier so the same way there has to be some air that remains in the alveoli to keep them distended and then breathing becomes easy and the work of breathing becomes lesser so when these preterm babies have a surfactant deficiency they start manifesting with respiratory stress right from birth this distress becomes uh progressive with intercostal subpositive retractions grunting and the babies become cyanos if you put them in a pulse oximeter you you'll find that they're not maintaining their saturations and you need to give them oxygen and oxygen also doesn't work because they have not been able to open up the album and if you allow them you know to sort of uh remain unattended too then they would tie around and the babies would going to respiratory failure stop breathing and they would actually end up losing these babies and so these pictures as you can see uh at the top right you have a baby who you can see the lower chest uh retraction so you might have to imagine them or you know you might have to zoom to see that the muscles are pulled in in the lower intercostal spaces the second picture shows you the type 2 alveolar cell pin cell where the surfactant is generally produced and the third is the typical x-ray of respiratory distress syndrome which we don't see very commonly these days and this is typically called a white and lung because the alveoli are so active that there is no aeration of the lungs as such we don't see this commonly because we start labor room cpap and that we prevent the alveoli from acting like a at your electrical image so basically management of rds like i said is labor room cpap so uh so basically it's very uh you can either give cpap by putting the baby on the ventilator or by using a simple device as you can see at the bottom of this picture that is what is called a uh uh the cpap device so it consists of you know the air oxygen blender uh that the top you know the top part where the air and oxygen mixes and you uh you sort of decide how much fio2 the baby requires the oxygenation the baby requires depending on the saturation the lower the saturation the higher the oxygen you would have to a fraction of oxygen you would have to give but this air oxygen mixture then comes to the lower part which is called a humidifier where the air oxygen mixture gets warmed up and then it goes to these tubings that you can see i wish i don't have a pointer unfortunately um on this platform but these tubings are called the uh uh the uh the inspiratory tubing and through this interspiratory tubing the gas is delivered to the uh uh to the interface uh through the interface to the baby now we use two interfaces as you can see the top right is the nasal prong interface and below you can see a nasal mask which fits snugly over the uh the nose of the baby so we prefer to use a nasal mass rather than nasal problems because the nasal plants can actually sometimes damage the news now uh what happens is that this um this system has two limbs and inspiration and the exploration the expiratory limb goes to this you know bubble cpap generator what you see to the you know to the left side of the picture that funnel thing and the thing believes it and basically it is a the the exploited tubing goes into a column into a column of water and the length of the column under water is the cpap generating pressure so if you keep five centimeters under water you're giving the baby five centimeters of continuous descending pressure so when the air flows it's sort of a back pressure effect that is created refers to the inspiratory limb out into the expiratory limit because of that vertical underwater column it actually creates a you know sort of a back pressure effect and that causes distension of the alveoli so the benefit of sita is is that it's much more non-invasive what it's doing is you're you're not intubating the baby putting an endotracheal tube in the lungs and then connecting to the baby to the ventilator which has its own problems yes it is needed but if we could manage you know if we give it early and the baby escapes with uh uh you know with um with cpap then the long-term outcomes pulmonary outcomes are likely to be given better and it's this combination of early cpap with early rescue surfactant which has become a game changer as far as management of these um uh you know these tiny babies are concerned so today we have surfactant which is uh easily available for babies uh it can be it's uh you know um bohinde developed a derived natural surfactant or oscillating developing actions uh surfactant and uh uh so and this surfactant has to be given intratriggerly so we normally would give surfactant if the oxygen requirements are high and uh if of about 30 on a cpap of 6 centimeters of water then now there are two methods of giving in previously we used to give it by intubating the baby and then giving the surfactant in rapidly exhibiting the baby and putting the baby back on so this is called um in short technique let's intubate surfactant and rapid extubation to cpap and about recently in the past five to seven years they've used a simpler uh technique and a better technique that is just using a thin catheter as you can see in the lower picture the there's a thin catheter which is passed into the trachea and the surfactant is administered to that the benefit of using the same catheter is that throughout the procedure you can continue the continuous positive airway pressure in these babies so that is what makes a you know difference with these babies and basically when you use this technique and this is called lesser invasive visa or the less invasive surfactant administration technique and it is seen to improve the outcome of these babies in terms of chronic lung disease or bpd it reduces the mortality it reduces the need for putting the baby on mechanical ventilation and problems such as intraventricular hemorrhage and mortality so this really early cpap and early rescue surfactant has become a game changer for managing such waves of course there'd be a small proportion of babies would need to be ventilated but these babies would uh would need to be ventilated and uh generally if there is cpap failure we would and as described by this criteria we would actually go ahead and ventilate these babies now uh other common early problems in these babies are hypoglycemia and if the blood sugar drops this can be really a brain damaging problem and therefore we need to monitor these babies for hypoglycemia similarly neonatal jaundice occurs in all babies but in preterm babies the peak tends to be higher and it stays on for a longer period of time and since the blood brain barrier is immature in these babies actually what could happen to these babies is it could uh damage the brain and therefore we need to aggressively monitor the bilirubin levels of these babies and another major cause for death in these babies is sepsis so preterm babies very often will die of sepsis and uh therefore it's very important for us to be constantly monitoring and the problem is that you know the manifestations of sepsis uh you know babies preterm babies have a very limited repertoire of of manifesting and therefore they would require um you know it's difficult to even diagnose that they have uh clinical sepsis and therefore one needs a low index of system there's also not one single test which says that okay if this is positive this means that the baby definitely has sepsis yes blood culture is diagnostic but um hardly about 40 to 60 percent of babies would have a positive blood culture and therefore we need a high index of suspicion for a sepsis and a low threshold for starting antibiotics but the flip side is that we could land up with multiple drug resistant organisms so we have to do that try to work start it at the the drugs at the right time give it for the right period of time de-escalate as soon as the babies are better and use narrow or you know spectrum drugs and use what are called care bundles so prevention of ventilators acquired pneumonias prevention of hospital acquired bloodstream infections which is called antimicrobial stewardship so all this would be required to prevent deaths due to urinary sepsis but the most important aspect of managing these babies is the nutrition of the babies and you know for the bigger preterm babies it's not too bad initially we will encourage the mothers to express their own milk and then we would uh first be the bartender spoon or by gavash by putting in an enteroclastic tube but for the tiny preterm babies it has been rightly being said that that the birth of a extremely preterm baby is a nutritional emergency because on one side the american academy of pediatrics recommends that these babies um and um oppose italy also their growth should be um similar to that of a of a you know baby in utero of a comparable gestational age whereas on the other hand basically the postnatal growth is different from in tri trend growth and most babies will lose after as much as 15 percent of their birth weight and they can regain their birth weight only by about uh 14 to 21 uh days of life and therefore uh uh you know the initial period itself you know they they're losing out the benefits and added to that are all the multiple problems in terms of you know high metabolic needs immaturely of the gi system and the catabolic effects of the disease processes that they have like respiratory distress sepsis chronic lung disease and therefore what happens is they develop a cumulative deficiency of protein and energy and they get what is called extra uterine growth restriction which has a lot of its own problems so if we have to optimize the growth of these preterm babies what we need to do is early aggress the strategies that we use as early aggressive parental nutrition so we give them uh amino acids and lipids starting at a slightly higher dose and right from day one and also what is very important is early aggressive internal nutrition so we start early full feeding these babies you know any baby more than 30 weeks we're always looking out there can we start this baby right on full piece from day one and if you're not able to do that at least what are called minimal electro nutrition to stimulate the gut to start you know functioning better and the second important strategy is using mother's own milk or if that is not available then pasteurized donor human milk if uh this thing is if uh rather than using for uh formula preterm formula or term formula and these babies because formula feeds are associated with much more problems and then once we get the babies on to fulfill sometimes we have to enhance their growth by fortification of milk and regular growth monitoring of these babies throughout to see that they're growing uh properly and prevent intra extraordinary restriction so basically what are the benefits of using mother's own milk and if that is not available the next best alternative would be using pasteurized donor human milk and pasteurized donor human milk uh so today there is enough evidence to say that when you use human milk then the babies tolerate their feeds better they have lesser sepsis they have lesser you know worrisome problems like necrotizing enterocolitis uh retinopathy of prematurity and many complications are avoided they have a shorter hospital stay and have better neurodevelopmental outcomes so therefore that is very important and therefore when mother's own milk is not available then the next best alternative is pasteurized donor human look i like to tell this group over here that we at cyan hospital uh have been running a human milk bank which is not in the first in india but the first in asia uh over the first in asia for uh and we've been running the milk bank for the past 33 years so it's basically having uh you know mothers who are uh you know uh motivating the mothers helping them with their own lactation problems and sort of convincing them to donate most of the milk and we reach out to about you know three thousand babies uh largely pre-term babies that sometimes bigger you know sometimes they return babies particularly within the first few days after the birth when their mothers do not have enough milk to get their own babies so this picture that you see is the milk bank as it stood in 1989 and this is our current state of the art human movement today we are recognized as a zonal reference center by the government of india for promoting milk banking and we help you know hospitals who want to start milk banks of their own and now uh now if we want our babies to grow then uh as per the intrauterine you know growth rate then basically uh what we're expecting is a weight gain once they've regained their birth weight a daily weight gain of 15 to 20 grams per kilogram per day a length of increase of 0.71 centimeter meter a week and a head sucker print circumference of 0.71 centimeters and if we have to achieve that then we have to ensure that the energy intake of these babies is around 110 to 135 kilocalories the protein intake is 3.5 to 4 4.5 grams per kilogram per day and they have adequate intake of calcium phosphorus and vitamin d and all the multivitamins for proper growth so therefore uh now if we have to uh you know use unfortified human milk for these uh babies the unfortified human milk by the time you know preterm milk is a little richer than proteins and uh calories but by about three weeks uh the concentration comes back to term human blood and therefore unfortified human milk would provide about 67 calories per 100 ml and 1.1 grams of protein per 100 ml so if we have to give these babies 4 grams 110 to 135 kilocalories per kg would actually have to feed them 200 to 290 to 340 ml per kg and that's really large volumes and babies wouldn't be able to tolerate them and therefore we have to fortify the milk by by multi-component fortification which gives additional calories proteins calcium phosphorus and multivitamins and nutrition and which babies are candidates you know for milk fortification of human milk could be all elbw and some of the blvw babies about the 30 week gestational age babies or very low birth weight babies who are not who after reaching full feeds and full feeds is about 150 to 180 ml per kilogram per day if they're still not growing well then we would fortify the human men now we could start fortification in the extremely low birth or the extremely low gestational age babies at about when they reach feeds of 50 to 80 ml per kilogram per day so as to avoid all the problems of growth restriction metabolic bone disease anemia from happy and so on and so forth and uh when we do this then by the growth of these babies would be fortification would help in better growth and this table is just to show you that when you fortify the milk then uh with full fortification then we are able to uh achieve uh if you look at the last column a calorie can take a 144 kilo calories per kg and a protein and take about 3.9 grams per kg per day with adequate calcium phosphorus and other uh so basically um right from the throughout the course in the hospital we need to monitor these babies and because we want to prevent them from getting extra uterine growth restriction extraction growth restriction we define as the if the weight particularly is less than the 10 percentile by the time the baby reaches 36 weeks so by the time of discharge then the baby is said to be growth restricted and we are worried about growth restriction because it causes a lot of short-term as well as long-term problems in terms of short-term problems extra training so they don't grow well if they don't have enough nutrition then they're more likely to have developed sepsis more likely to stay longer on the ventilator or have a prolonged ventilatory course have problems of of chronic lung disease eye problems and metabolic bone problems and uh but on the other side the flip side is at the rapid catch-up growth and if they basically uh grow very very fast and small fat equation then when they become adults they get what is called the metabolic syndrome of obesity hypertension diabetes mellitus etc so again it's a tight joke now not all babies would require uh formula feeding would require a fortification of milk but all babies would pretend babies would require supplements of vitamins of calcium phosphorus and of iron at the time of once they're on full feeds and on discharge now beyond first two weeks of life also i said these babies can have a lot of problems they can have uh you know prolonged ventilation a problem called chronic lung diseases as you can see in this x-ray at the bottom uh this is a really bad lung disease and they can stay on the ventilator for long and then have difficulty in growing so it's a kind of a vicious cycle similarly another dreaded complication is an interstellar complication and you can see the abdominal look at this condition uh in the top right picture which is called necrotizing enterocolitis and that really is a setback if babies develop it and they can they would require very often would require even intestinal resection so we have to monitor them for uh you know bleeding inside the brain that's intraventricular hemorrhage the retinopathy of prematurity is a retinal disorder that these babies develop because of hypoxic and hyperoxide changes and before because of the adverse effects of that and therefore we have to start monitoring these babies looking at the retina of these babies by director of the scope every week uh starting from all three weeks of age till the retina becomes mature and if you find that there is rop and if it's an advancing rop what you call a aggressive posterior type 1 rp then interventions will be done by the ophthalmologist so similarly we need to you know see that the calcium phosphorus levels are okay and that the babies are not developing metabolic bone disease and not developing what is called anemia of prematurity now another very important strategy is what is called developmentally supportive care so when the these tiny babies are in the nicu the an ico environment all our care practices should be such that they focus on physiological stability of the baby on decreasing the stress responses in the baby protecting the baby's sleep promoting uh behavioral strain behavioral state regulation and basically ensuring better long-term neurodevelopmental outcomes and this can be done by uh you know one is allowing the mothers to participate in the care of the baby so we allow free entry of the mothers into the neonatal unit and they handle their babies they talk to their babies and sort of you know that helps actually helps improve outcomes in these babies then the second thing that we can do is what is called clustering of care now typically what happens is you know all healthcare providers are on their own uh the nurse wants to finish off the feeding she wants to change the diapers the doctor wants to finish the blood collection so the reports are available before the seniors come for rounds and therefore the baby gets disturbed uh you know repeatedly so rather than disturbing them if the care is clustered you know and based on the um and the interventions are based on the cues that the baby gives then uh that would actually give the baby more time to rest and more time to heal and more time to grow better similarly nesting so you know in youtube the babies are you know have this comfortable environment they can their feet can touch the uterine wall so they have a feeling of security and suddenly when they come out into the open they sort of fling their limbs and therefore you nest them you know by giving them a sort of boundary and that also helps in better neurodevelopmental outcome things like swaddling the babies holding the babies down when they are restless you know with your hands and giving them sort of a comforting touch and of course kangaroo mother care are some of the strategies of what we call developmentally supported care and kangaroo mother care today has been proved to be a very very good interventional strategy it's associated with a whole host of benefits in terms of cardio recipe stability in terms of better growth of babies in terms of lesser complications in babies lesser duration of hospital stay better breastfeeding rates and early hospital discharge so if you can see the bottom left picture that's the kangaroo care bag we put the baby in you put the baby open with a cap and with a diaper into this bag and put the baby in skin to skin contact with the mother inside her gown turning the head to one side placing the baby between the breasts and there is hardcore evidence you know to say that kangaroo mother care is associated with 40 percent reduction the risk of mortality it it reduces risk 65 reduction in the risk of infections and the of hypothermia which is a dreaded complication for these babies and better uh overall growth of these babies so how do we prognosticate these babies obviously the prognosis would depend upon mortality and the long-term outcomes and uh this would be obviously inversely related to the gestational aids of the baby as well as to the birth weight the smaller the chest the earlier they are born and the smaller their birth weights the more would are likely to be complications and we need to uh you know sort of um [Music] we need to counsel these parents on a daily basis virtually so every day after our rounds we'll talk to these uh their parents and you know apprise them of the condition of their baby and price them of water what would be the likely you know things that they are likely to face during the hospital's day and after this thing and then we would finally discharge these babies once they're maintaining their temperature they're stable they're off antibiotics and off their medications they're breastfeeding well and mother is confident of managing their emanation immunization has been initiated and the follow-up plan has been explained and the danger signals that when to report back immediately have been explained to these mothers that's the time that we would now uh continue to consider discharging and of course if the babies are extremely low birth weight then anywhere between four they are only after they've crossed their weight of 1400 to 1800 grams and some units would say two kilos before they would send the babies home so i'd like to end by saying that uh the strategies to improve improve preterm care would be in neutral transfer to a center or with a well-equipped nicu antenatal corticosteroids and magnesium sulfate labor room stabilization particularly with you know effective resuscitation and continuous positive airway pressure uh device early cpap and early rescue surfactant with lisa aggressive and dental feeding of these babies appropriate fortification of milk prevention of stress sepsis at whatever you know hand washing being the most important step growth monitoring of these babies and regular monitoring for rop and ivh and all the problems would we would result in a you know good outcome in these babies and babies leaving our nic will nest with intact outcomes so uh thank you for a patient hearing uh i uh are there any questions i'd be happy to do anything thank you so much ma'am [Music] so it was a very nice session so to summarize basically like you explain management of rds the benefits of cpap and indication for ventilation as well as how important is kangaroo mother care so i'm sure our audience has learned a lot we'll take up the questions uh dr muthu is asking that much or mycosis as a causative organism in preterm babies can you please share your experience uh we don't really see much of mycosis thankfully you know we do see fungal infections and typically the fungal infections are candidal infections and those can be reasonably easily treated but they can cause a chronic illness in babies but we don't thankfully don't see even you know very fortunately in this forward era most of our babies have escaped totally touch wood but they've escaped very rarely the babies have had you know problems and that the pediatric h2 could have and uh we've also successfully breastfed all these babies when they're born of go with positive mothers with all infection ipc you know infection prevention measures and most of them are successfully braced [Music] we do have one raise and i'll just accept the request dr swati gaway i am accepting your request please turn on your audio video hello yeah hello hi mam swati here nice to see you here it was a very nice topic and nicely explained i just want to know the long term effects of extremely premature babies like that 600 grammar you had shown a priyanka's baby so whatever long-term effects so it depends on what kind of problems they've had if they've not had severe intraventricular hemorrhage if they've not had uh you know very bad bro only dysplasia if they've grown well if they've not shown significant extra uterine growth restriction then the outcomes are pretty good for these babies but definitely these babies are at risk compared to the you know moderate returns of the late three terms and they could have long-term neurodevelopmental adverse outcomes in the form of motor problems in the form of a little bit of a you know mental sub normality yeah or have school related problems what is also formative you know educational uh issues once they go to school so that would be same so the yes compared to the red key terms definitely there would be some issues in these videos but many of them also do that okay thank you thank you mom thank you so much ma'am next question is um can you please share some seeing care bundles to prevent hospital acquired infection so i think the single most uh important uh you know bundle uh is not mundo but processes hand washing or hand hygiene so every one i mean there are if you look at the who website they'll give you the moments of five moments of hand hygiene that when you come into the unit before you're touching your baby um when you're doing a sterile procedure after touching a baby and uh you know when you're touching a sterile equipment or hand washing at each hand washing or hand hygiene you know at every step and there is a fixed method by which it should be done and that is one of the first most important uh you know care for these babies secondly the important thing is feeding care so encouraging mothers to breastfeed so you know direct transfer of milk from mother to baby but when milk has to be expressed then all the uh sterility of the equipment so the vatis and spoons have to be autoclaved uh the container into which the mother is expressing her milk has to be um steel container if we're using milk pumps for expression then we use a fresh uh you know milk expression set for each um each mother to express out on milk and we would still you know sort of disinfect it before it is used for uh again over there and each mother should preferably have her own set or when we use the hospital grade electrical pumps we have about uh you know 10 to 20 sets which we send to the unit and they are paired sets so they express more from both grace so and we would send them back to the milk bank for washing and uh sterilization so we don't use the same one for for more than one mother that's the feeding bundles then of course when you are uh iv insertion long line insertion so the nurses also have a role to play the doctors have a very important role to play and once the iv line is in place when they are handling the iv how it is handled is extremely important because these are the the sites through which catheter you know induced infections can occur so uh and then of course skin care of these babies so preventing uh them from getting abrasion of skin when you fix a probe the temperature probe or the heart rate monitors or whatever they come when you're taking them off see that the skin because the skin is so fragile it could come off so uh before very careful skin care of these babies so there are a lot of you know each aspect is virtually a care bundle that is necessary thank you so much ma'am hyundai is asking what is the approximate cost for a cpap machine uh cpap with the blender uh and the humidifier comes for about 1.5 to 2 lakhs and you need humid warming and humidification because you know otherwise it could dry out the respiratory epithelium and actually predisposes babies to bronchi dysplasia so if you look at it in terms in comparison to a ventilator uh then definitely these bubble seepable devices are very much better uh there's another question by dr subramaniam that's ignore hfow in preterm uh high frequency oscillation is something that we do use in three terms as a rescue modality so if the baby is really doing uh you know i mean they have been they have been tried also as primary modality in our own institution we use high frequency oscillatory ventilation as a secondary modality if conventional ventilation has also failed so if the baby is not maintaining saturations or if the baby has what is called you know any syndromes in the form of pulmonary interstitial emphysema sometimes if they have a pneumothorax and they're not saturating well on conventional ventilation then we might move them to high frequency oscillatory ventilation now when there is persistent hypoxemia then ecmo that is a extracorporeal membrane oxygenation is another option we don't have it in our own unit there are there are a few units in mumbai which do have ecmo and then one would have to transport it uh transfer the baby to such a center now the important thing is uh i mean equals i think we use more for uh would be used more for babies who have decision pulmonary hypertension especially in association with conditions like congenital diaphragmatic hernias or sometimes primary pph and which is not very common i mean you don't see one in three four years prime media but cdh related to pphs are not uncommon and sometimes i mean if you have atmospheric money has an equals i think of what is also so if you have this ecmo then it could help a few more babies definitely oh okay great thank you so much ma'am for explaining that and we are at the end of the questions as well we have very positive comments uh often we missing saying very nice session dr ho mari sharma says it was a very nice they have learned a lot very informative session so yes i resonate with all our audiences comments that yes it was a very nice session uh you explained it very easy i mean in a very good uh easy to understand terms that how to take care because managing a preterm baby is way too complicated lots of emotions at play as well as parents are there and the pressure is i mean yes yes so it's too much to handle for the doctors as well so i hope this presentation and the guidance from you would help our doctors manage the pre-term babies well and thank you so much ma'am it was an honor to have you here with us on medflix and thank you to all doctors as well thank you very much thank you so much

BEING ATTENDED BY

Dr. Murtuza Zozwala & 503 others

SPEAKERS

dr. Jayashree Mondkar

Dr. Jayashree Mondkar

Ex Dean, Professor &Head | I/ C Mothers Milk Bank (Retd) | Department Of Neonatology |LTMMC & LTMGH, Sion Hospital, Mumbai

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dr. Jayashree Mondkar

Dr. Jayashree Mondkar

Ex Dean, Professor &Head | I/ C Mothers Milk ...

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