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Prematurity

Presentation

History

In assessing prematurity, gestational age dating by using the mother's history can be unreliable because of uncertainty of the dates. About 20% of women have an uncertain last menstrual period (LMP).

Gestational age assessment begins prenatally with obstetric ultrasonography in the first trimester. Discovery of many fetal anomalies, unsuspected multiple gestation, location of the placenta, and an accurate dating of the pregnancy are additional major benefits of early ultrasonography.

Physical Examination

Confirmation of gestational age in the newborn is based on physical and neurologic characteristics. In 1979, the Dubowitz scoring system for determining gestational age based on neurologic and physical parameters was revised to include 12 items.^[32]The Ballard Scoring System, revised again to include extremely low birth weight (ELBW) infants, remains the main tool clinicians use after delivery to confirm gestational age by means of physical examination.^[2]

The major parts of the anatomy for physical characteristic markers are ear cartilage, sole creases, breast tissue, and genitalia. See the images below.

Preterm infant at 28 weeks' gestation. Note the small amount of ear cartilage and/or flattened pinna.

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Preterm infant at 33 weeks' gestation. Note the increased cartilage, recoil, and outer ridge curving inward.

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A term infant has well-developed cartilage with instant recoil.

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Preterm infant at 28 weeks' gestation. Note the flat sole.

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Preterm infant at 33 weeks' gestation. Note the presence of only an anterior crease.

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Term gestation. Note the multiple creases.

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Preterm infant at 28 weeks' gestation. No breast tissue is present, and the areolae are barely visible.

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Preterm infant at 33 weeks' gestation. The breast tissue is less than 1 cm, and the areolae are raised and/or pigmented.

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The physical examination and evaluation should be performed immediately after stabilization and before the expected weight loss occurs on the first day.

Hittner et al reported that regression of the vascularity of the lens capsule is an excellent tool to confirm a gestational age of 28-34 weeks.^[33]

Neurologic criteria include muscle tone of the trunk and extremities and joint mobility. Reassessing the neurologic criteria 18-24 hours after birth is best to allow for recovery from maternal medication (eg, magnesium sulfate, analgesics), which may decrease tone and responsiveness.

Differential Diagnoses

American College of Obstetricians and Gynecologists. Practice bulletin no. 159: Management of preterm labor. Obstet Gynecol. 2016 Jan. 127 (1):e29-38. [QxMD MEDLINE Link].
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Backes CH, Markham K, Moorehead P, Cordero L, Nankervis CA, Giannone PJ. Maternal preeclampsia and neonatal outcomes. J Pregnancy. 2011. 2011:214365. [QxMD MEDLINE Link]. [Full Text].
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Sibai BM, Caritis S, Hauth J, Lindheimer M, VanDorsten JP, MacPherson C, 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. 2000 Feb. 182 (2):364-9. [QxMD MEDLINE Link].
Kogan MD, Alexander GR, Kotelchuck M, et al. Trends in twin birth outcomes and prenatal care utilization in the United States, 1981-1997. JAMA. 2000 Jul 19. 284 (3):335-41. [QxMD MEDLINE Link].
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Boulet SL, Schieve LA, Nannini A, et al. Perinatal outcomes of twin births conceived using assisted reproduction technology: a population-based study. Hum Reprod. 2008 Aug. 23 (8):1941-8. [QxMD MEDLINE Link].
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Creasy RK, Gummer BA, Liggins GC. System for predicting spontaneous preterm birth. Obstet Gynecol. 1980 Jun. 55 (6):692-5. [QxMD MEDLINE Link].
Kent AL, Wright IM, Abdel-Latif ME, for the New South Wales and Australian Capital Territory Neonatal Intensive Care Units Audit Group. Mortality and adverse neurologic outcomes are greater in preterm male infants. Pediatrics. 2012 Jan. 129 (1):124-31. [QxMD MEDLINE Link].
Roberts G, Anderson PJ, De Luca C, Doyle LW, for the Victorian Infant Collaborative Study Group. 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. 2010 Mar. 95 (2):F90-4. [QxMD MEDLINE Link].
Carlo WA, McDonald SA, Fanaroff AA, et al, for the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Association of antenatal corticosteroids with mortality and neurodevelopmental outcomes among infants born at 22 to 25 weeks' gestation. JAMA. 2011 Dec 7. 306 (21):2348-58. [QxMD MEDLINE Link].
Ventolini G, Neiger R, Mathews L, Adragna N, Belcastro M. 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. 2008 Feb. 25 (2):79-83. [QxMD MEDLINE Link].
Finer NN, Horbar JD, Carpenter JH. Cardiopulmonary resuscitation in the very low birth weight infant: the Vermont Oxford Network experience. Pediatrics. 1999 Sep. 104 (3 pt 1):428-34. [QxMD MEDLINE Link].
Barton L, Hodgman JE, Pavlova Z. Causes of death in the extremely low birth weight infant. Pediatrics. 1999 Feb. 103 (2):446-51. [QxMD MEDLINE Link].
Dees E, Lin H, Cotton RB, Graham TP, Dodd DA. Outcome of preterm infants with congenital heart disease. J Pediatr. 2000 Nov. 137 (5):653-9. [QxMD MEDLINE Link].
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. 2009 May. 123 (5):e797-807. [QxMD MEDLINE Link].
Werner EF, Han CS, Savitz DA, Goldshore M, Lipkind HS. Health outcomes for vaginal compared with cesarean delivery of appropriately grown preterm neonates. Obstet Gynecol. 2013 Jun. 121 (6):1195-200. [QxMD MEDLINE Link].
Pittman G. Vaginal delivery safer for many preemies: study. Reuters Health Information. Available at http://www.medscape.com/viewarticle/803871. May 8, 2013; Accessed: June 5, 2013.
Dubowitz LM, Dubowitz V, Goldberg C. Clinical assessment of gestational age in the newborn infant. J Pediatr. 1970 Jul. 77 (1):1-10. [QxMD MEDLINE Link].
Hittner HM, Hirsch NJ, Rudolph AJ. Assessment of gestational age by examination of the anterior vascular capsule of the lens. J Pediatr. 1977 Sep. 91 (3):455-8. [QxMD MEDLINE Link].
Conde-Agudelo A, Romero R. Cervical phosphorylated insulin-like growth factor binding protein-1 test for the prediction of preterm birth: a systematic review and metaanalysis. Am J Obstet Gynecol. 2016 Jan. 214 (1):57-73. [QxMD MEDLINE Link].
Conde-Agudelo A, Romero R. Predictive accuracy of changes in transvaginal sonographic cervical length over time for preterm birth: a systematic review and metaanalysis. Am J Obstet Gynecol. 2015 Dec. 213 (6):789-801. [QxMD MEDLINE Link].
Hummler H, Fuchs H, Schmid M. Automated adjustments of inspired fraction of oxygen to avoid hypoxemia and hyperoxemia in neonates - a systematic review on clinical studies. Klin Padiatr. 2014 Jul. 226 (4):204-10. [QxMD MEDLINE Link].
Waitz M, Schmid MB, Fuchs H, Mendler MR, Dreyhaupt J, Hummler HD. Effects of automated adjustment of the inspired oxygen on fluctuations of arterial and regional cerebral tissue oxygenation in preterm infants with frequent desaturations. J Pediatr. 2015 Feb. 166 (2):240-4.e1. [QxMD MEDLINE Link].
van Kaam AH, Hummler HD, Wilinska M, et al. Automated versus manual oxygen control with different saturation targets and modes of respiratory support in preterm infants. J Pediatr. 2015 Sep. 167 (3):545-50.e1-2. [QxMD MEDLINE Link].
Van Zanten HA, Kuypers KLAM, Stenson BJ, Bachman TE, Pauws SC, Te Pas AB. The effect of implementing an automated oxygen control on oxygen saturation in preterm infants. Arch Dis Child Fetal Neonatal Ed. 2017 Sep. 102 (5):F395-9. [QxMD MEDLINE Link].
Lal M, Tin W, Sinha S. Automated control of inspired oxygen in ventilated preterm infants: crossover physiological study. Acta Paediatr. 2015 Nov. 104 (11):1084-9. [QxMD MEDLINE Link].
Dargaville PA, Sadeghi Fathabadi O, et al. Development and preclinical testing of an adaptive algorithm for automated control of inspired oxygen in the preterm infant. Arch Dis Child Fetal Neonatal Ed. 2017 Jan. 102 (1):F31-6. [QxMD MEDLINE Link].
Plottier GK, Wheeler KI, Ali SK, et al. Clinical evaluation of a novel adaptive algorithm for automated control of oxygen therapy in preterm infants on non-invasive respiratory support. Arch Dis Child Fetal Neonatal Ed. 2017 Jan. 102 (1):F37-F43. [QxMD MEDLINE Link].
[Guideline] Barfield WD, Papile LA, Baley JE, et al, for the American Academy of Pediatrics Committee on Fetus And Newborn. Levels of neonatal care. Pediatrics. 2012 Sep. 130(3):587-97. [QxMD MEDLINE Link]. [Full Text].
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 Arch Dis Child Fetal Neonatal Ed</i>. 2011 Sep. 96 (5):F343-7. [QxMD MEDLINE Link].
Manley BJ, Owen LS, Doyle LW, et al. High-flow nasal cannulae in very preterm infants after extubation. N Engl J Med. Oct 10 2013. 369(15):1425-33. [QxMD MEDLINE Link].
American Academy of Pediatrics, Committee on Fetus and Newborn. Respiratory support in preterm infants at birth. Pediatrics. 2014 Jan. 133 (1):171-4. [QxMD MEDLINE Link]. [Full Text].
Fox S. AAP backs CPAP plus selective surfactants in premies. Medscape Medical News. Available at http://www.medscape.com/viewarticle/818416. December 30, 2013; Accessed: January 5, 2014.
DeMauro SB, Douglas E, Karp K, et al. Improving delivery room management for very preterm infants. Pediatrics. 2013 Oct. 132 (4):e1018-25. [QxMD MEDLINE Link].
Fox S. Delivery room guidelines improve outcomes for preemies. Medscape Medical News. Available at http://www.medscape.com/viewarticle/811032. September 16, 2013; Accessed: September 23, 2013.
Engmann C, Wall S, Darmstadt G, Valsangkar B, Claeson M, for the participants of the Istanbul KMC Acceleration Meeting. Consensus on kangaroo mother care acceleration. Lancet. 2013 Nov 30. 382 (9907):e26-7. [QxMD MEDLINE Link].
Eliakim A, Litmanovitz I, Nemet D. The role of exercise in prevention and treatment of osteopenia of prematurity: an update. Pediatr Exerc Sci. 2017 Oct 10. 1-6. [QxMD MEDLINE Link].
Darmstadt G, Paul V, Al Jaifi NH, et al, for the Guideline Development Group. WHO recommendations for care of the preterm or low-birth-weight infant. Geneva: World Health Organization; 2022. [Full Text].
Bergh AM, Gupta S, Rao S. Programmatic implementation of kangaroo mother care: a systematic synthesis of grey literature. medRxiv. April 5, 2023. Available at https://www.medrxiv.org/content/10.1101/2023.04.05.23288153v1.full.pdf. Accessed: May 8, 2023.
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Zhang R, Bo T, Shen L, Luo S, Li J. Effect of dexamethasone on intelligence and hearing in preterm infants: a meta-analysis. Neural Regen Res. 2014 Mar 15. 9 (6):637-45. [QxMD MEDLINE Link]. [Full Text].
Capone K, Sriram S, Patton T, et al. Effects of chromium on glucose tolerance in infants receiving parenteral nutrition therapy. Nutr Clin Pract. 2017 Jun 1. 884533617711162. [QxMD MEDLINE Link].
Kapoor V, Glover R, Malviya MN. Alternative lipid emulsions versus pure soy oil based lipid emulsions for parenterally fed preterm infants. Cochrane Database Syst Rev. 2015 Dec 2. 12:CD009172. [QxMD MEDLINE Link].
Abrams SA, for the American Academy of Pediatrics Committee on Nutrition. Calcium and vitamin d requirements of enterally fed preterm infants. Pediatrics. 2013 May. 131 (5):e1676-83. [QxMD MEDLINE Link].
Hand L. Guidelines: Preterm infants require vitamin D supplement. Medscape Medical News. Available at http://www.medscape.com/viewarticle/803253. April 29, 2013; Accessed: May 9, 2013.
Ohls RK, Christensen RD, Kamath-Rayne BD, et al. A randomized, masked, placebo-controlled study of darbepoetin alfa in preterm infants. Pediatrics. 2013 Jul. 132 (1):e119-27. [QxMD MEDLINE Link].
Hand L. Darbepoetin reduces transfusion needs in preterm infants. Medscape Medical News. Available at http://www.medscape.com/viewarticle/806369. June 17, 2013; Accessed: June 24, 2013.
Von Kohorn I, Ehrenkranz RA. Anemia in the preterm infant: erythropoietin versus erythrocyte transfusion--it's not that simple. Clin Perinatol. 2009 Mar. 36 (1):111-23. [QxMD MEDLINE Link].
Bernstein IM, Horbar JD, Badger GJ, Ohlsson A, Golan A. Morbidity and mortality among very-low-birth-weight neonates with intrauterine growth restriction. The Vermont Oxford Network. Am J Obstet Gynecol. 2000 Jan. 182 (1 pt 1):198-206. [QxMD MEDLINE Link].
Borna S, Saeidi FM. Celecoxib versus magnesium sulfate to arrest preterm labor: randomized trial. J Obstet Gynaecol Res. 2007 Oct. 33 (5):631-4. [QxMD MEDLINE Link].
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Foix-L'Helias L, Marret S, Ancel PY, et al, for the EPIPAGE Study Group. 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. 2008 Jan. 115 (2):275-82. [QxMD MEDLINE Link].
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. 2005 Mar. 115 (3):681-7. [QxMD MEDLINE Link].
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Media Gallery

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.

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Author

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

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

Disclosure: Nothing to disclose.

Coauthor(s)

David A Clark, MD Professor and Martha Lepow Chairman of Pediatrics, Professor of Obstetrics and Gynecology, Albany Medical College; Director, Children's Hospital at Albany Medical Center

David A Clark, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Nutrition, American Forestry Association, American Pediatric Society, Capital District Pediatric Society, Christian Medical and Dental Associations, European Society for Paediatric Research, Eastern Society for Pediatric Research, Floyd W Denny Pediatric Alumni Society, Medical Society of the State of New York, New York Academy of Sciences, Society for Pediatric Research

Disclosure: Nothing to disclose.

Specialty Editor Board

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, DCH, FAAP, FIAP, FRCP Professor of Pediatrics, LSU Health, Louisiana State University School of Medicine in Shreveport

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

Disclosure: Nothing to disclose.

Chief Editor

Dharmendra J Nimavat, MD, FAAP Associate Professor of Clinical Pediatrics, Department of Pediatrics, Division of Neonatology, Southern Illinois University School of Medicine; Staff Neonatologist, Clinical Director, NICU Regional Perinatal Center, HSHS St John's Children's Hospital

Dharmendra J Nimavat, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Association of Physicians of Indian Origin

Disclosure: Nothing to disclose.

Additional Contributors

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 Pediatric Society, Eastern Society for Pediatric Research, American Medical Association, Connecticut State Medical Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

Prematurity Clinical Presentation

History

Physical Examination

References

Tables

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