Prematurity Treatment & Management

  • Author: Susan A Furdon, MS, RNC, NNP; Chief Editor: Ted Rosenkrantz, MD   more...
 
Updated: Jan 24, 2012
 

Medical Care

Stabilization in the delivery room with prompt respiratory and thermal management is crucial to the immediate and long-term outcome of premature infants, particularly extremely premature infants. The American Academy of Pediatrics has established guidelines for levels of neonatal care.[9]

Principles of respiratory management are as follows:

  • Recruit and maintain adequate lung volume or optimal lung volume. In infants with respiratory distress, this step may be accomplished with early continuous positive airway pressure (CPAP) given nasally, by mask (Neopuff), or by using an endotracheal tube when ventilation and/or surfactant is administered.
  • Avoid hyperoxia and hypoxia by immediately attaching a pulse oximeter and keeping the oxygen saturation (SaO2) between 86% and 93% by using an oxygen blender.
  • Prevent barotrauma or volutrauma by using a ventilator that permits measurement of the expired tidal volume and by keeping it 4-7 mL/kg.
  • Administer surfactant early (< 2 h of age) when indicated and prophylactically in all extremely premature neonates (< 29 wk).

Many centers are using early CPAP and a relatively permissive approach to ventilation. Research is needed to provide evidence to support an approach that provides the best outcome.

A retrospective analysis studied the first 48 hours in 225 infants of 23-28 weeks gestational age. The study results noted that 140 of these infants could be stabilized with nasal CPAP in the delivery room; 68 with a favorable outcome and 72 with a failed outcome within 48 hours; history or initial blood gas results were poor predictors of subsequent nasal CPAP failure. A threshold fraction of inspired oxygen (FiO2) of greater than or equal to 0.35-0.45 compared with greater than or equal to 0.6 for intubation may shorten the time to surfactant delivery, without a relevant increase in intubation rate.[10]

Thermoregulation

Maintenance of the neutral thermal environment is critical for minimizing stress and optimizing growth of the premature infant. The neutral thermal environment is defined as the environmental temperature in which the neonate maintains a normal temperature and is consuming minimal oxygen for metabolism.

Neonates lose heat by 4 means, as follows:

  1. Evaporation: Evaporation is energy consumed by a fluid as it converts from a liquid to gas. This is primarily in the delivery room. Completely drying the infant is of primary importance in prevention of hypothermia. This step can be omitted if other resuscitative measures are taking place.
  2. Conduction: This is direct transfer of heat from a warm body to a cool object by contact (eg, placing an infant on a cold scale).
  3. Convection: This is the loss of heat from the warm air next to the skin to moving air currents (eg, windchill effect). Double-walled isolettes help to reduce convective heat loss.
  4. Radiation: This is the loss of heat that radiates from a warm body to a cool surface (eg, window, outside wall).

Preterm infants are relatively unable to compensate for cold stress because of a small amount of subcutaneous tissue (insulation) and decreased brown fat to produce heat.

Preterm infants do not shiver. The increased surface area to body mass allows for rapid heat loss, especially from the head.

Decreased posturing ability further diminishes their ability to compensate.

In extremely low birth weight (ELBW) infants, immature skin further complicates thermoregulation due to increased evaporative water loss. (See Extremely Low Birth Weight Infant.)

Consequences of cold stress are increased metabolism with loss of weight or failure to gain weight and increased use of glucose with depletion of glycogen stores and hypoglycemia.

Metabolic acidosis results in a decreased surfactant production and loss of functional alveolar number, which results in hypoxia. The hypoxia causes pulmonary vasoconstriction, and further hypoxia.

Increased oxygen consumption results in hypoxia, anaerobic metabolism, and lactic acid production.

In the intensive care nursery, radiant warmers may be used to compensate for heat loss. Incubators are more efficient than radiant warmers because the heated environment decreases heat loss due to conduction, convection, and radiation. With radiant warmers, consider using plastic wrap and a humidified environment for ELBW infants. New devices function as both an incubator and an overhead warmer to enable access for procedures. In all nurseries, maintain the environmental temperature at more than 70°F (>21°C).

Temperature maintenance is especially critical during neonatal resuscitation, when the same principles apply. (See Neonatal Resuscitation).

Skin care

Premature infants have immature skin, a decreased or absent stratum corneum, decreased cohesiveness between skin layers, increased water fixation, and tissue edema. The immature skin integrity leads to easy injury, transdermal absorption of drugs and other materials in contact with the skin and increased risk for infection.

The National Association of Neonatal Nurses (NANN) and the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) recommended the following areas of newborn skin care, which are based on clinical and laboratory research.

  1. Bathing: Use only water and no soap for infants who weigh less than 1000 g. Decrease the frequency of using cleansers. Only use neutral-pH cleansers.
  2. Disinfectants (eg, povidone-iodine, chlorhexidine): Completely remove these agents after the procedure to decrease transdermal absorption. Isopropyl alcohol use is discouraged because it is relatively ineffective as a disinfectant and is drying to the skin. Alcohol burns, and cracked skin can result.
  3. Adhesives: Minimize their use. Use double-backed silk tape versus tape with strong adhesive properties (Elastoplast). Use hydrogel electrodes. Avoid solvents or bonding agents.
  4. Transepidermal water loss: Place infants born at 30 weeks' gestation in a high-humidity (>70%) environment.
  5. Topical solutions: Review ingredients of any topical solution placed on the skin of a preterm infant. Transdermal absorption can occur. Discourage use of solvents for adhesive removal.
  6. Pectin barriers (eg, DuoDERM extra thin, Restore extra thin): These are recommended. Anchoring devices (umbilical lines) to pectin barriers results in improved skin integrity.

Fluid and electrolyte management

Preterm infants need intense monitoring of their fluid and electrolytes because of their increased transdermal water loss, immature renal function, and other environmental issues (eg, radiant warming, phototherapy, mechanical ventilation).

Expected loss of extracellular water in the first week of life in the term infant is 5% of birth weight, low birth weight (LBW) infant is 10% of birth weight, and in the ELBW infant is 15-20%. Data curves, which Dancis developed in the 1940s, may be useful in monitoring weight loss in each group of infants.

The degree of prematurity and the infant's specific medication problems dictate initial fluid therapy. However, the following general principles apply to all preterm infants:

  • Initial fluids should be a solution of glucose and water. More mature infants can be started at 60-80 mL/kg/d. The most immature infants may need up to 100-150 mL/kg/d. (See Extremely Low Birth Weight Infant.)
  • Environmental aspects of care, eg, radiant warming, phototherapy, and a nonhumidified environment, increase insensible water loss and the need for fluids. Mechanical ventilation, use of double-walled isolettes, and provision of humidity decrease insensible water loss.
  • The glucose infusion rate (GIR) is usually started at 4-6 mg/kg/min. In general, to obtain this rate, a solution of dextrose 10% in water (D10W) should be used initially. The exception is the ELBW infant who should initially be given dextrose 5% in water (D5W) to provide the same GIR and to prevent hyperglycemia.
  • Electrolytes should not be added until 24 hours of age, when urine output is adequate. Electrolytes and calcium should be monitored at 12-24 hours of age depending on the degree on prematurity and other medical issues.
  • Basal needs are sodium is 2-3 mEq/kg/d, potassium 1-2 mEq/kg/d, and calcium 600 mg/kg/d (as calcium gluconate). Urinary losses, which may increase in the most immature of infants and in those exposed to diuretics, dictate the need for supplemental sodium.
  • Infants who develop acute tubular necrosis (ATN) should be treated with fluid restriction that equals insensible water loss plus urine output. Additional fluid is administered by closely and frequently monitoring the output and electrolytes during the post-ATN diuretic phase.
  • Hyponatremia and weight gain should be treated with decreasing fluid administration. Monitoring of urinary electrolyte losses is sometimes helpful in replacement therapy.
  • The patient's weight should be followed up every 24 hours. Results of laboratory monitoring and change in weight dictate changes in fluid and electrolyte support.
Next

Consultations

A developmental specialist might be consulted. The risk of neurodevelopmental problems occurs as gestational age and birth weight decrease.

Hearing screening should be performed on all newborns before they are discharged.

Previous
Next

Diet

Preterm infants born at less than 34 weeks' gestation have poor coordination of the suck and swallow reflexes and decreased intestinal motility. Nutrition in the first several days after birth often is provided intravenously. Even the relatively healthy preterm infant may not reach full enteral nutrition until a week or longer after birth.

Colostrum

If available, colostrum is the preferred initial nourishment.

Colostrum contains digestible proteins, antibody (secretory immunoglobulin A [IgA]), growth factors, and other components that in the aggregate promote intestinal villous growth and influence the intestinal colonization.

Mature breast milk

Mature breast milk replaces transitional milk by 10-12 days after birth.

The caloric density varies among mothers based in part on the mother's nutritional status.

For ELBW infants, breast milk is often inadequate to sustain growth.

Most calories are contained in lactose (35%) and fat (50%). In the more preterm infants, lactase activity is low which may contribute to less-than-optimal digestion of lactose and absorption of carbohydrate. This improves with gestational age.

Calcium, sodium, potassium, and trace mineral levels are insufficient to meet the needs of the preterm infant. Therefore, minerals, protein, carbohydrates, and lipids are often added to breast milk to support optimal growth in the form of commercially available breast milk fortifiers.

Approximately 120-150 cal/kg/d are required for growth. Small preterm infants with increased metabolic needs due to complications such as bronchopulmonary dysplasia may require as much as 180 cal/kg/d to grow.

Formula

Preterm formulas have been developed to address the specific needs and digestive abilities of the preterm infant.

The typical formula contains more easily digested glucose polymers (50% of carbohydrates) and medium chain triglycerides that minimize the need for active lipase activity.

Although preterm formula contains more calcium and phosphorus than breast milk, osteopenia of prematurity and poorly mineralized primary teeth remain clinically significant problems. Poor early intravenous nutrition and the use of diuretics often exacerbate these problems. Increased sodium compensates for poor renal retention.

The formulas contain additional trace minerals and vitamins.

Previous
Proceed to Medication
 
 
Contributor Information and Disclosures
Author

Susan A Furdon, MS, RNC, NNP  Neonatal Clinical Nurse Specialist/Nurse Practitioner, Department of Pediatrics, Albany Medical Center

Susan A Furdon, MS, RNC, NNP is a member of the following medical societies: National Association of Neonatal Nurses and Sigma Theta Tau International

Disclosure: March of Dimes Grant/research funds Speaking and teaching; Abbott Grant/research funds Speaking and teaching; Ikara Consulting fee Consulting

Coauthor(s)

David A Clark, MD  Chairman, Professor, Department of Pediatrics, Albany Medical College

David A Clark, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Pediatric Society, Christian Medical & Dental Society, Medical Society of the State of New York, New York Academy of Sciences, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Specialty Editor Board

Ted Rosenkrantz, MD  Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine

Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Pediatric Society, Connecticut State Medical Society, Eastern Society for Pediatric Research, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Arun K Pramanik, MD, MBBS  Professor of Pediatrics, Director of Neonatal Fellowship, Louisiana State University Health Sciences Center

Arun K Pramanik, MD, MBBS is a member of the following medical societies: American Academy of Pediatrics, American Thoracic Society, National Perinatal Association, and Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

Carol L Wagner, MD  Professor of Pediatrics, Medical University of South Carolina

Carol L Wagner, MD is a member of the following medical societies: American Academy of Pediatrics, American Chemical Society, American Medical Women's Association, American Public Health Association, American Society for Bone and Mineral Research, American Society for Clinical Nutrition, Massachusetts Medical Society, National Perinatal Association, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Chief Editor

Ted Rosenkrantz, MD  Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine

Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Pediatric Society, Connecticut State Medical Society, Eastern Society for Pediatric Research, and Society for Pediatric Research

Disclosure: Nothing to disclose.

References

  1. Barton L, Hodgman JE, Pavlova Z. Causes of death in the extremely low birth weight infant. Pediatrics. Feb 1999;103(2):446-51. [Medline].

  2. Ballard JL, Khoury JC, Wedig K, et al. New Ballard Score, expanded to include extremely premature infants. J Pediatr. Sep 1991;119(3):417-23. [Medline].

  3. Creasy RK, Gummer BA, Liggins GC. System for predicting spontaneous preterm birth. Obstet Gynecol. Jun 1980;55(6):692-5. [Medline].

  4. [Best Evidence] Robertson CM, Howarth TM, Bork DL, Dinu IA. Permanent bilateral sensory and neural hearing loss of children after neonatal intensive care because of extreme prematurity: a thirty-year study. Pediatrics. May 2009;123(5):e797-807. [Medline].

  5. Kent AL, Wright IM, Abdel-Latif ME. Mortality and Adverse Neurologic Outcomes Are Greater in Preterm Male Infants. Pediatrics. Jan 2012;129(1):124-131. [Medline].

  6. Dubowitz LM, Dubowitz V, Goldberg C. Clinical assessment of gestational age in the newborn infant. J Pediatr. Jul 1970;77(1):1-10. [Medline].

  7. Hittner HM, Hirsch NJ, Rudolph AJ. Assessment of gestational age by examination of the anterior vascular capsule of the lens. J Pediatr. Sep 1977;91(3):455-8. [Medline].

  8. Fritz MA. Infertility treatment and the multifetal gestation epidemic: too much of a good thing. Contemporary OB-GYN. 2002;65-90.

  9. [Guideline] Stark AR. Levels of neonatal care. Pediatrics. Nov 2004;114(5):1341-7. [Medline].

  10. Fuchs H, Lindner W, Leiprecht A, Mendler MR, Hummler HD. Predictors of early nasal CPAP failure and effects of various intubation criteria on the rate of mechanical ventilation in preterm infants of < 29 weeks gestational age. Arch Dis Child Fetal Neonatal Ed. Sep 2011;96(5):F343-7. [Medline].

  11. [Best Evidence] Roberts G, Anderson PJ, De Luca C, Doyle LW. Changes in neurodevelopmental outcome at age eight in geographic cohorts of children born at 22-27 weeks' gestational age during the 1990s. Arch Dis Child Fetal Neonatal Ed. Mar 2010;95(2):F90-4. [Medline].

  12. Carlo WA, McDonald SA, Fanaroff AA, et al. Association of antenatal corticosteroids with mortality and neurodevelopmental outcomes among infants born at 22 to 25 weeks' gestation. JAMA. Dec 7 2011;306(21):2348-58. [Medline].

  13. Allen MC, Alexander GR, Tompkins ME, Hulsey TC. Racial differences in temporal changes in newborn viability and survival by gestational age. Paediatr Perinat Epidemiol. Apr 2000;14(2):152-8. [Medline].

  14. Allen MC, Alexander GR, Tompkins ME, Hulsey TC. Racial differences in temporal changes in newborn viability and survival by gestational age. Paediatr Perinat Epidemiol. 2000;14(2):152-8. [Medline]. [Full Text].

  15. Alme AM, Mulhern ML, Hejkal TW, et al. Outcome of rtinopath of prematurity patients following adoption of revised indications for treatment. BMC Ophthalmol. Nov 2008;13:8:23. [Medline].

  16. Anand KJ, Hall RW, Desai N, et al. Effects of morphine analgesia in ventilated preterm neonates: primary outcomes from the NEOPAIN randomised trial. Lancet. May 2004;363:1673-1682. [Medline].

  17. Andres RL, Day MC. Perinatal complications associated with maternal tobacco use. Semin Neonatol. Aug 2000;5(3):231-41. [Medline].

  18. Barrington KJ, Finer NN. Inhaled Nitric Oxide for Respiratory Failure in Preterm Infants. Cochrane Database System. January 2006;25:CD000509. [Medline].

  19. Beckerman KP. Protease inhibitor treatment of HIV-1-infected women may protect against extreme prematurity and very low birth weight. J Infect Dis. Oct 2007;196:1270-1271. [Medline].

  20. Bell EF. Preventing Necrotizing Enterocolitis: What Works and How Safe. Pediatrics. January 2005;115:173-174. [Medline].

  21. Bell EF. When to transfuse preterm babies. Arch Dis Child Fetal Neonatal Ed. Nov 2008;93:F469-473. [Medline].

  22. Bernstein IM, Horbar JD, Badger GJ, et al. Morbidity and mortality among very-low-birth-weight neonates with intrauterine growth restriction. The Vermont Oxford Network. Am J Obstet Gynecol. Jan 2000;182(1 Pt 1):198-206. [Medline].

  23. Bhandari V, Bergqvist LL, Kronsberg SS, et al. Morphine Administration and Short-Term Pulmonary Outcomes Among Ventilated Preterm Infants. Pediatrics. August 2005;116:352-359. [Medline].

  24. Borna S, Saeidi FM. Celecoxib versus magnesium sulfate to arrest preterm labor: randomized trial. J Obstet Gynaecol Res. Oct 2007;33:631-634. [Medline].

  25. Boulet SL, Schieve LA, Nannini A, et al. Perinatal outcomes of twin births conceived using assisted reproduction technology: a population-based study. Hum Reprod. Aug 2008;23:1941-1948. [Medline].

  26. Chiswick M. Infants of borderline viability: ethical and clinical considerations. Semin Fetal Neonatal Med. Feb 2008;13:8-15. [Medline].

  27. Clarke P, Mitchell SJ, Wynn R, et al. Vitamin K prophylaxis for preterm infants: a randomized, controlled trial of 3 regimens. Pediatrics. Dec 2006;118:e1657-1666. [Medline].

  28. Cole CH. Prevention of Prematurity: Can We Do It in America?. Pediatrics. Aug 1985;76:310-312. [Medline].

  29. Connolly G, Byrne P. Teenage pregnancies and risk of late fetal death and infant mortality. Br J Obstet Gynaecol. Nov 1999;106(11):1230. [Medline].

  30. Cotter AM, Garcia AG, Duthely ML, et al. Is antiretroviral therapy during pregnancy associated with an increased risk of preterm delivery, low birth weight, or stillborn?. J Infect Dis. May 2006;193:1195-1201. [Medline].

  31. Crowther CA, Haslam RR, Hiller JE, et al. Neonatal Respiratory Distress Syndrome after Repeat Exposure to antenatal corticosteriods: a randomised controlled trial. Lancet. Jun 2006;367:1913-1919. [Medline].

  32. Dees E, Lin H, Cotton RB, et al. Outcome of preterm infants with congenital heart disease. J Pediatr. Nov 2000;137(5):653-9. [Medline].

  33. Doron MW, Veness-Meehan KA, Margolis LH, et al. Delivery room resuscitation decisions for extremely premature infants. Pediatrics. Sep 1998;102(3 Pt 1):574-82. [Medline].

  34. Doyle LW, Davis PG, Morley CJ, et al. Outcome at 2 years of age of infants from the DART study: a multicenter, international, randomized, controlled trial of low-dose dexamethasone. Pediatrics. April 2007;119:716-721. [Medline].

  35. Doyle LW, Halliday HL, Ehrenkranz RA, et al. Impact of Postnatal Systemic Corticosteroids on Mortality and Cerebral Palsy in Preterm Infants: Effect Modification by Risk for Chronic Lung Disease. Pediatrics. March 2005;115:655-661. [Medline].

  36. Durnwald CP, Walker H, Lundy JC, et al. Rates of Recurrent Preterm Birth by Obstetrical History and Cervical Length. Am J Obstet Gynecol. September 2005;193:1170-1174. [Medline].

  37. El-Metwally D, Vohr B, Tucker R. Survival and neonatal morbidity at the limits of viability in the mid 1990s: 22 to 25 weeks. J Pediatr. Nov 2000;137(5):616-22. [Medline].

  38. Escobar GJ, Clark RH, Greene JD. Short-Term Outcomes of Infants Born at 35 and 36 Weeks Gestation: We Need to Ask More Questions. Seminars in Perinatology. February 2006;30:28-33. [Medline].

  39. Fanaroff AA, Stoll BJ, Wright LL, et al. Trends in Neonatal Morbidity and Mortality for Very Low Birthweight Infants. American Journal of Obstetrics and Gynecology. February 2007;196:e1-8. [Medline].

  40. Finer NN, Horbar JD, Carpenter JH. Cardiopulmonary resuscitation in the very low birth weight infant: the Vermont Oxford Network experience. Pediatrics. Sep 1999;104(3 Pt 1):428-34. [Medline].

  41. Foix-L'Helias L, Marret S, Ancel PY, et al. Impact of the use of antenatal corticosteroids on mortality, cerebral lesions and 5-year neurodevelopmental outcomes of very preterm infants: the EPIPAGE cohort study. BJOG. January 2008;115:275-282. [Medline].

  42. Furdon SA, Lapitsky J, Diven S, Horgan MJ. Effect of standardized approach to the care of the extremely low birthweight infant. J Nurs Care Qual. Aug 1997;11(6):42-51. [Medline].

  43. Gracey K, Talbot D, Lankford R, Dodge P. Family teaching toolbox. Nasal cannula home oxygen. Adv Neonatal Care. Apr 2003;3(2):99-101. [Medline].

  44. Groh-Wargo S, Hovasi Cox J. Nutritional Care for High-Risk Newborns. 3rd ed. Los Angeles, CA: Bonus; 2000.

  45. Gross SJ, Anbar RD, Mettelman BB. Follow-up at 15 Years of Preterm Infants from a Controlled Trial of Moderately Early Dexamethasone for the Prevention of Chronic Lung Disease. Pediatrics. March 2005;115:681-687. [Medline].

  46. [Best Evidence] Halliday HL, Ehrenkranz RA, Doyle LW. Early (< 8 days) postnatal corticosteroids for preventing chronic lung disease in preterm infants. Cochrane Database Syst Re. Jan 2009;21:CD001146. [Medline].

  47. Hellgren K, Hellstrom A, Jacobson L, et al. Visual and cerebral sequelae of very low birth weight in adolescents. Arch Dis Child Fetal Neonatal Ed. Jul 2007;92:F259-264. [Medline].

  48. Hodnett ED. Support during pregnancy for women at increased risk. Cochrane Database Syst Rev. 2000;(2):CD000198. [Medline].

  49. Holditch-Davis D, Merrill P, Schwartz T, et al. Predictors of wheezing in prematurely born children. J Obstet Gynecol Neonatal Nurs. May-Jun 2008;37:262-273. [Medline].

  50. Horbar JD, Badger GJ, Carpenter JH, et al. Trends in mortality and morbidity for very low birth weight infants, 1991-1999. Pediatrics. Jul 2002;110(1 Pt 1):143-51. [Medline].

  51. Huxley R, Owen GG, Whincup PH, et al. Is Birth Weight a Risk Factor for Ischemic Heart Disease in Later Life?. Am J Clin Nutr. May 2007;85:1244-1250. [Medline].

  52. Johnston CC, Stevens B, Pinelli J, et al. Kangaroo Care is Effective in Diminishing Pain Response in Preterm Neonates. Arch Pediatr Adolesc Med. November 2003;157:1084-1088. [Medline].

  53. Juul SE, McPherson RJ, Bauer LA, et al. A phase I/II trial of high-dose erythropoietin in extremely low birth weight infants: pharmocokinetics and safety. Pediatrics. Aug 2008;122:383-391. [Medline].

  54. Klaus MH, Fanaroff AA. Care of the High-Risk Neonate. 5th ed. Philadelphia, PA: WB Saunders; 2001.

  55. Kogan MD, Alexander GR, Kotelchuck M, et al. Trends in twin birth outcomes and prenatal care utilization in the United States, 1981-1997. JAMA. Jul 19 2000;284(3):335-41. [Medline].

  56. Kraybill EN. Ethical issues in the care of extremely low birth weight infants. Semin Perinatol. Jun 1998;22(3):207-15. [Medline].

  57. Kulmala T, Vaahtera M, Ndekha M, et al. The importance of preterm births for peri- and neonatal mortality in rural Malawi. Paediatr Perinat Epidemiol. Jul 2000;14(3):219-26. [Medline].

  58. Larsson PG, Fahraeu L, Carlsson B, et al. Late miscarriage and preterm birth after treatment with clindamycin: a randomised consent design study according to Zelen. BJOG. Jun 2006;113:629-37. [Medline].

  59. Lin HC, Su BH, Chen AC, et al. Oral Probiotics Reduce the Incidence and Severity of Necrotizing Enterocolitis in Very Low Birth Weight Infants. Pediatrics. January 2005;115:1-4. [Medline].

  60. Lindstrom K, Winbladh B, Haglund B, et al. Preterm Infants as Young Adults: A Swedish National Cohort Study. Pediatrics. July 2007;120:70-77. [Medline].

  61. Linhart Y, Bashiri A, Maymon E, et al. Congenital anomalies are an independent risk factor for neonatal morbidity and perinatal mortality in preterm birth. Eur J Obstet Gynecol Reprod Biol. May 2000;90(1):43-9. [Medline].

  62. Lund C, Kuller J, Lane A, et al. Neonatal skin care: the scientific basis for practice. Neonatal Netw. Jun 1999;18(4):15-27. [Medline].

  63. Maguire CM, Veen S, Sprij AJ, et al. Effects of basic developmental care on nenoatal morbidity, neuromotor development, and growth at term age of infants who were born at < 32 weeks. Pediatrics. Feb 2008;121:e239-245. [Medline].

  64. Mahomed K, Bhutta Z, Middleton P. Zinc supplementation for improving pregnancy and infant outcome. Cochrane Database Syst Rev. Apr 2007;2:CD000230. [Medline].

  65. Malloy MH, Freeman DH. Respiratory distress syndrome mortality in the United States, 1987 to 1995. J Perinatol. Oct-Nov 2000;20(7):414-20. [Medline].

  66. March of Dimes. Peristats. Available at www.marchofdimes.com/peristats/. Accessed Oct 1, 2006.

  67. Marret S, Marpeau L, Zupan-Simunek V, et al. Magnesium sulfate given before very-preterm birth to protect infant brain: the randomised controlled PREMAG trial*. BJOG. Mar 2007;114:310-318. [Medline].

  68. Martin JA, Hamilton BE, Sutton PD, et al. Births: Final Data for 2006. National Vital Statistics Reports. Jan 2009;57:1-104.

  69. Martin JA, Kung HC, Mathews TJ, Hoyert DL, Strobino DM, Guyer B, et al. Annual summary of vital statistics. 2006. Pediatrics. 2008;121(4):788-801. [Medline].

  70. McCall EM, Alderdice FA, Halliday HL, et al. Interventions to prevent hypothermia at birth in preterm and/or low birthweight infants. Cochrane Database Syst Rev. Jan 2008;1:CD004210. [Medline].

  71. Meirowitz NB, Ananth CV, Smulian JC, Vintzileos AM. Effect of labor on infant morbidity and mortality with preterm premature rupture of membranes: United States population-based study. Obstet Gynecol. Apr 2001;97(4):494-8. [Medline].

  72. Mercer B, Milluzzi C, Collin M. Periviable birth at 20 to 26 weeks of gestation: proximate causes, previous obstetric history and recurrence risk. Am J Obstet Gynecol. September 2005;193:1175-1180. [Medline].

  73. Mestan KK, Marks JD, Hecox K, et al. Neurodevelopmental Outcomes of Premature Infants Treated with Inhaled Nitric Oxide. N Engl J Med. July 2005;353:23-32. [Medline].

  74. Moore ML. Preterm Labor and Birth: What Have We Learned in the Past Two Decades. J Obstet Gynecol Neonatal Nurs. Sept.-Oct. 2003;32:638-49. [Medline].

  75. Murakami Y, Jain A, Silva RA, et al. Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP): 12-month experience with telemedicine screening. Br J Ophthalmol. Nov 2008;92:1456-1460. [Medline].

  76. Ohlsson A, Aher SM. Early erythropoietin for preventing red blood cell transfusion in preterm and/or low birth weight infants. Cochrane Database Syst Rev. Jul 2006;19:CD004863. [Medline].

  77. Osborn DA, Evans N. Early Volume Expansion for Prevention of Morbidity and Mortality in Very Preterm Infants. Cochrane Datatbase System. 2004;2:CD002055. [Medline].

  78. Peltoniemi OM, Kari MA, Tammela O, et al. Randomized trial of a single repeat dose of prenatal betamethasone treatment in imminent preterm birth. Pediatrics. Feb 2007;119:290-298. [Medline].

  79. Pool V, Iskander J. Saftey of Influenza Vaccination During Pregnancy. Am J Obstet Gynecol. April 2006;194:1200. [Medline].

  80. Rautava L, Lehtonen L, Peltola M, et al. The effect of birth in secondary- or tertiary-level hospitals in Finland on mortality in very preterm infants: a birth-register study. Pediatrics. Jan 2007;119:e257-263. [Medline].

  81. Raydo LL, Reu-Donlon CM. Putting Babies "Back to Sleep": Can we do better?. Neonatal Network. 2005;24:9-16.

  82. Robertson CMT, Watt M-J, Yasui Y. Changes in the Prevalence of Cerebral Palsy for Children Born Very Prematurely Within a Population-Based Program Over 30 Years. JAMA. June 2007;297:2733-2740. [Medline].

  83. Romero R. Prevention of spontaneous preterm birth: the role of sonographic cervical length in identifying patients who may benefit from progesterone treatment. Ultrasound Obstet Gynecol. October 2007;30:675-686. [Medline].

  84. Rudge MV, Calderon IM, Ramos MD, et al. Perinatal outcome of pregnancies complicated by diabetes and by maternal daily hyperglycemia not related to diabetes. A retrospective 10-year analysis. Gynecol Obstet Invest. 2000;50(2):108-12. [Medline].

  85. Schieve LA, Cohen B, Nannini A, et al. A population-based study of maternal and perinatal outcomes associated with assisted reproductive technology in Massachusetts. Matern Child Health J. Nov 2007;11:517-525. [Medline].

  86. Schreiber MD, Gin-Mestan K, Marks JD, et al. Inhaled Nitric Oxide in Premature Infants with the Respiratory Distress Syndrome. N Engl J Med. November 2003;349:2099-2107. [Medline].

  87. Schulte J, Domingues K, Sukalac T, et al. Declines in low birth weight and preterm birth among infants who were born to HIV-infected women during an era of increased use of maternal antiretroviral drugs: Pediatric Spectrurm of HIV Disease, 1989-2004. Pediatrics. Apr 2007;119:e900-906. [Medline].

  88. Sibai BM, Caritis S, Hauth J, et al. Risks of preeclampsia and adverse neonatal outcomes among women with pregestational diabetes mellitus. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. Am J Obstet Gynecol. Feb 2000;182(2):364-9. [Medline].

  89. Simoes EA, Groothuis JR, Carbonell-Estrany X, et al. Palivizumab prophylaxis, respiratory syncytial virus, and subsequent recurrent wheezing. J Pediatr. Jul 2007;151:34-42, 42e1. [Medline].

  90. Smith GN, Walker MC, Ohlsson A, et al. Randomized double-blind placebo-controlled trial of transdermal nitroglycerin for preterm labor. Am J Obstet Gynecol. Jan 2007;196:e1-8. [Medline].

  91. Stevens B, Yamada J, Ohlsson A. Sucrose for Analgesia in Newborn Infants Undergoing Painful Procedures. Cochrane Database System Rev. 2004;3:CD001069. [Medline].

  92. Stupin JH, David M, Siedentopf JP, et al. Emergency cerclage versus bed rest for amniotic sac prolapse before 27 gestational weeks. A retrospective, comparative study of 161 women. Eur J Obstet Gynecol Reprod Biol. July 2008;139:32-37. [Medline].

  93. Suzuki K, Tanaka T, Kondo N, et al. Is maternal smoking during early pregnance a risk factor for all low birth weight infants?. J Epidemiol. May 2008;18:89-96. [Medline].

  94. [Best Evidence] Tyson JE, Kennedy KA. Trophic Feedings for Parenterally Fed Infants. Cochrane Database Syst Rev. July 2005;3:CD000504. [Medline].

  95. van Wassenaer AG, Westera J, Houtzager BA, et al. Ten-year follow-up of children born at < 30 weeks' gestational age supplemented with thyroxine in the neonatal period in a randomized, controlled trial. Pediatrics. November 2005;116:e613-618. [Medline].

  96. Ventolini G, Neiger R, Hood DL, et al. Changes in the threshold of fetal lung maturity testing and neonatal outcome of infants delivered electively before 39 weeks gestation: implications and cost-effectiveness. J Perinatol. May 2006;26:264-267. [Medline].

  97. Ventolini G, Neiger R, Mathes L, et al. Incidence of respiratory disorders in neonates born between 34 and 36 weeks of gestation following exposure to antenatal corticosteroids between 24 and 34 weeks of gestation. Am J Perinatol. February 2008;25:79-83. [Medline].

  98. Westrup B, Bohm B, Lagercrantz H, et al. Preschool Outcome in Children Born Very Prematurely and Cared for According to the Newborn Individualized Care and Assessment Program (NIDCAP). Acta Paediatr. April 2004;93:498-507. [Medline].

  99. Wright VC, Schieve LA, Reynolds MA, et al. Assisted Reproductive Technology Surveillance-United States, 2001. MMWR Surveill Summ. April 2004;53:1-20. [Medline].

  100. Ziadeh SM. The outcome of triplet versus twin pregnancies. Gynecol Obstet Invest. 2000;50(2):96-9. [Medline].

 
Previous
Next
 
Preterm infant at 28 weeks' gestation. Note the small amount of ear cartilage and/or flattened pinna.
Preterm infant at 33 weeks' gestation. Note the increased cartilage, recoil, and outer ridge curving inward.
A term infant has well-developed cartilage with instant recoil.
Preterm infant at 28 weeks' gestation. Note the flat sole.
Preterm infant at 33 weeks' gestation. Note the presence of only an anterior crease.
Term gestation. Note the multiple creases.
Preterm infant at 28 weeks' gestation. No breast tissue is present, and the areolae are barely visible.
Preterm infant at 33 weeks' gestation. The breast tissue is less than 1 cm, and the areolae are raised and/or pigmented.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.