Premature Baby: Hospital Care

Very small premature babies are usually born more than 8 weeks early (after less than 32 weeks of pregnancy). These babies:

• have very red, thin skin and very little fat
• have perfectly formed organs that are not mature enough to work well for several weeks
• need special care in the hospital for at least 3 to 4 weeks and often much longer until they are mature enough to be cared for at home.

Very premature babies may need to be cared for in the hospital until close to their due dates. If they do well, they may be discharged as early as 2 to 4 weeks before their due date. If they have more problems than average, they may stay in the hospital past their due date.

What causes prematurity?

There are many causes of early birth. Sometimes a baby may need to be delivered early because the pregnancy causes a health problem for the mother. Sometimes there is an infection in the birth canal that causes early labor or causes the mother's water to break early. Problems with the mother's cervix or uterus can also cause early delivery. Twins or other multiple births are often born early.

What happens after the baby is born?

Because your baby is so small and premature, your baby will be cared for in the special care nursery (SCN) for many weeks. Many premature infants are sickest right after birth and gradually get better as they get older. However, the very smallest infants may have problems for the first 6 weeks. Ups and downs are a normal part of a premature baby's early life.

• Special beds

  At first the baby is kept on an open warmer, a bed that keeps the baby warm by heating the air. Open warmers are used for babies who have just been born or need a lot of care so that they can be reached and cared for more easily.

  Once the baby's breathing rate is OK, the baby is placed in an Isolette. The Isolette is a plastic box with controlled air temperature to keep the baby warm. Babies grow fastest if they are kept warm. When it is easier for a baby to maintain his own temperature, he is placed in an open crib.

• Monitors

  All babies are attached to a heart and breathing monitor while they are in the SCN. These monitors sound an alarm if there is a big change in the baby's heart or breathing rate. The baby is also attached to a pulse oximeter, which records the oxygen level in the baby's skin. There are also temperature alarms for the warming beds and Isolettes.

• Healthcare providers

  Many people will help care for your baby during her stay in the SCN.

  The neonatologist is a pediatrician who has special training in the care of premature infants. The neonatologist directs the overall care of the baby. Nurses and physician assistants help the neonatologist oversee the baby's progress.

  Nurses deliver most of the hands-on care during each shift. A very sick baby may have one nurse devoted solely to her care. More stable babies may share a nurse with one or two other babies.

  The respiratory therapist oversees the breathing needs of babies who need oxygen or are on ventilators.

  The social worker helps families deal with the emotional stress of having a sick baby.

  The occupational therapist evaluates the infant's developmental progress and plans a developmental program for your child.

  All of these people will be happy to talk with you at any time about your baby.

• Visiting

  Visit your baby as much as you can. Your presence helps the baby grow and get strong. Sometimes the baby is so sick at first that you may not be able to hold him until he is better. You can still hold the baby’s hand, touch, and talk to him. The older and more mature your baby is, the more you will be able to handle and care for him.

What problems do premature babies have?

There are many problems that a preterm baby faces during the first weeks. Most problems of prematurity improve as the baby grows.

Breathing problems

• Respiratory distress syndrome (RDS)

  Many babies born early have not yet started making a substance that helps keep the lungs open when breathing. Babies who have RDS need oxygen and need help with their breathing. A ventilator is used to help the baby breathe.

• Apnea

  Apnea means "forgetting to breathe". Every small premature baby has some apnea. It improves as the brain matures. In the meantime, the baby is given help to keep breathing. Medicine is given to stimulate breathing. A device called a nasal cannula or a nasal CPAP may be used to help give your baby extra oxygen and stimulate breathing. Sometimes the baby is put on a respirator, which breathes for her until she is able to breathe more reliably. Babies who are born 12 weeks or more prematurely may not breathe well for several weeks.

• Chronic lung disease

  Many very preterm babies develop chronic lung problems. These babies may need extra oxygen for weeks to months. Sometimes a baby's lungs fill with extra fluid. If this happens the baby is given diuretics, a medicine that makes the baby urinate more and get rid of extra water.

  Most children outgrow these lung problems during the first several months of life. Some children may continue to have problems with wheezing and infections, but usually get better as they get older.

Feedings

Feedings are very important. At first the baby may be too weak or have too much trouble breathing to nurse or feed from a bottle. However, there are ways the baby can get fluids and calories for growth without breast or bottle-feeding. Later, when he is stronger, he can breast or bottle-feed.

• Intravenous fluids (IVs)

  Your baby will be given IV fluids right after birth. This IV fluid contains sugar to give the baby energy. When a baby has serious breathing problems, he is not well enough to start feedings right away.

  All babies lose weight during the first days of life as their bodies get rid of extra water. Once the baby is given food (either by IV or milk feedings), he will begin to gain weight slowly. The smallest babies may take several weeks to regain their birth weight.

• Hyperalimentation

  Hyperalimentation fluids contain sugar, protein, fat, minerals, and vitamins. These fluids are given by IV to supply the calories your baby needs to start growing.

  Your baby will slowly switch from hyperalimentation fluids to milk feedings over several days to weeks.

  Very small premature babies often need several weeks of hyperalimentation before they are ready to take all their milk feedings. Because their veins are very small and thin and wear out quickly, the very smallest babies need a special IV that is placed in a central vein in the body. A central line allows the baby to be given higher concentrations of sugar and calories for growth.

• Milk feedings

  Feeding methods:

  All babies of this size are too small and weak to suck on the breast or bottle. Several methods of tube feeding allow dripping the milk into the stomach or intestine without stressing the baby. Gavage feedings involve passing a tube through the mouth or nose and into the stomach. Milk is dripped in by gravity. Because most small premature babies are fed every 3 hours, the tube may be taped in place so that it does not have to be put into the stomach each time the baby is fed. Very small babies may be fed small amounts continuously so the stomach is never overfilled. A feeding tube that passes through the nose and the stomach and into the intestine is called a nasojejunal tube. It allows milk to be fed directly into the intestine and avoids filling the stomach.

  Milk for premature infants:

  Breast milk: Your breast milk is a very important food for your baby. It has many important factors that protect your baby against infection and it is also easily digested. Because your premature baby can not nurse you will need to pump your breasts to provide breast milk for your infant. Your nurse can help show you how to pump milk. Your breast milk may be "fortified" with extra protein and calories to help your baby grow faster.

  Premature formulas: There are formulas made specifically for small premature infants. These formulas contain extra protein, calories, and minerals to stimulate growth in a very tiny baby.

  Special formulas: Sometimes a baby needs a special formula because of an allergy to milk protein or because he cannot absorb nutrients from his intestine.

  Feeding by breast or bottle:

  Premature babies are not usually able to suck, swallow, and breathe at the same time until they reach a gestational age of 34 weeks. Even then they may be very weak and tire quickly when trying to suck. Babies need to learn how to suck, swallow, and breathe all at the same time. This takes many feedings to practice. Do not get discouraged if it takes several weeks for your baby to learn what to do.

Breast-feeding is harder than bottle feeding for a premature baby to master. The baby often has to suck harder to get milk out from the breast than the bottle. But as your baby gets stronger and bigger, breast-feeding will get easier for you and your baby. Your nurse and the lactation consultant can help you practice breast-feeding with your baby. Most of the time a baby will go home taking both breast and bottle-feedings and will switch to full breast-feeding over several weeks.

• Feeding problems

  The premature baby's intestinal tract often doesn't work very well at first. The baby's stomach may empty very slowly, and it may be hard for the infant to pass bowel movements. The baby may vomit often because of looseness of the valve between the stomach and esophagus. It is easy for the baby’s bowel to get filled with gas. These are all signs that the intestinal tract is immature.

  The amount of milk a baby is fed is usually increased very slowly. It is important to make sure that the baby can manage each increase well. There may be many starts and stops in the feeding process. It may be several weeks before the very smallest infants can take full milk feedings.

Infection

Premature babies cannot protect themselves against infections very well because their defenses are weak. Once infected, the baby can get sick very quickly. For this reason your baby will be watched closely for signs of infection. If the doctor suspects an infection, your baby will be treated with antibiotics. Your baby may have several courses of antibiotics during his hospital stay.

Bleeding in the brain

Very premature infants are at risk for bleeding in the brain. An ultrasound of your baby's head will be done during the first week and then again at 36 to 40 weeks gestational age to check and follow-up for any sign of bleeding.

Eye problems

While inside the mother, the baby lives in a low-oxygen, dark place: the uterus. After birth, the baby is exposed to more oxygen and light. The eye responds to these changes by growing extra blood vessels. This process is called retinopathy of prematurity. The younger the baby is, the more sensitive the retina (back of the eye) is. Every baby who is born at less than 28 weeks of pregnancy will have some retinopathy. This blood vessel growth starts around 6 weeks after birth and usually increases until 10 to 12 weeks after birth. Then the blood vessels start to go away.

If the blood vessels grow too much, they pull on the retina. This can cause the retina to separate from the back of the eye. In its worst form, retinopathy can cause severe problems with vision or even blindness.

Every baby born more than 10 weeks early will be examined by an eye specialist. Some babies that are born at greater than 30 weeks gestational age will also be screened if they have certain other risk factors. The first exam will be 4 to 8 weeks after birth. The exams will continue until the blood vessels have gone away. If the blood vessel growth starts to cause problems, treatment with a laser or freezing (cryosurgery) can be done to keep the retina from separating from the back of the eye.

Anemia

Every preterm baby has too few red blood cells during the first 2 months of life. The baby loses blood from blood tests and when her red blood cells get old. She cannot enough make new blood to replace the lost blood until 2 months after birth. Most babies who are sick and often need blood tests, or who weigh less than 2 and a half pounds at birth, will need a blood transfusion to keep the blood count normal.

Preterm babies are given extra iron in their diet. This makes sure that they have plenty of iron for making new red blood cells when their bodies are able to do so.

When can my baby go home?

Each baby recovers and grows at a different rate. There is no firm rule for when a baby can leave the hospital. Generally, a baby is ready to go home when he can keep his temperature in an open crib, take all his feedings from the bottle or breast, and has been free of apnea spells for a week.

If you need to have special equipment at home, the SCN staff will help you arrange for it. They will teach you everything you need to know about caring for your baby at home.

What follow-up care does my child need?

Most very premature babies grow up to be normal, healthy children. However, low-birth-weight babies are at greater risk for developmental problems than babies that are not premature. Premature babies also may need special medical attention during their first year of life.

• Follow-up

  It is very important for your healthcare provider to check your baby often after going home from the hospital. The pediatrician needs to make sure that they are gaining weight well. It is also very important that your baby gets childhood immunizations to protect them against infection.

  Premature babies with chronic lung problems may need to be checked often to be sure that they do not have problems with wheezing or lung infections. It is not uncommon for these babies to go back to the hospital if they get a bad cold that causes wheezing and trouble with breathing. This is less likely after the first year.

• Vision and hearing tests

  All very small premature babies should have their eyes examined for retinopathy. They should also have their vision checked regularly after they go home from the hospital. As they grow up, they may have eye muscle problems and may need glasses to correct this problem.

  All premature babies should have their hearing tested at least once during their first year to make sure they do not have hearing problems.

• Care at home

  Once home, your baby will still need special care, such as more frequent feedings. However, you will see your baby quickly grow and get healthy and strong.

  As is true for all babies, do not expose your baby to children or adults with colds or the flu. Babies with chronic lung disease are more likely to get upper respiratory infections. It may not be a good idea to take your child to a group day-care home or center in the first year.

  As your baby grows you can treat him more and more like a normal infant. Try not to be overprotective.