Recently we observed yet another World Prematurity Day on November 17.Due to the adverse complications faced by premature baby long been sidelined health officials across the world have this year decided to share their knowledge and resources concerning the pre term baby which will enable the baby to grow and develop to its fullest potential.
The Sunday Observer spoke to the Senior Lecturer, Department of Paediatrics, University of Colombo and Consultant Neonatologist, University Unit, De Soysa Hospital for Women, Colombo, Dr. Nishani Lucas to find out more about the risks faced by babies born too early, how such risks could be minimised, and advice on how parents can play a vital role in giving their baby a new lease of life.
Excerpts.
Q. On November 17, urgent health issues concerning pre term babies took centre stage when neonatologists across the world observed another World Prematurity Day. For the benefit of uninformed readers, could you explain what prematurity is vis a vis full term pregnancy?
Dr. Nishani Lucas
A. A full-term pregnancy can be described as a pregnancy that goes on for 37 – 42 weeks gestation i.e., around 10 months duration, where the baby’s organ system reaches enough maturity to face the outside world, in comparison to prematurity, where the baby is born before completion of 37 weeks gestation, thereby interrupting the maturation process and being born prior to attaining full maturity, hence the term pre – maturity.
Q. What are the most common causes and risk factors that lead to premature births?
A. While the exact reasons for preterm birth have not been identified for more than half the cases, individual or family history of preterm birth have been identified to be a strong risk factor along with young or advanced maternal age, short interpregnancy intervals, low maternal body mass index, multiple pregnancy, pre-existing non communicable disease, hypertensive disease of pregnancy and infections according to Lancet, one of the most prestigious medical journals.
Q. Is the age of the mother at the point of delivery a risk factor to consider? For example if the mother is over 35 will her chances of delivering a premature baby especially if it is her first child, be greater than a younger mother? Why?
A. Yes, the age of the mother is certainly a risk factor. Mothers aged 40 years and more, as well as mothers younger than 25 , have been found to be at higher risk of preterm birth. While spontaneous preterm birth is the most common reason in younger women, the need to induce preterm delivery due to the use of assisted reproduction techniques, placenta previa, hypertensive disease, gestational diabetes and medical illness appear to be the reasons leading to preterm birth in older women.
Q. What about the genetic factor? If there is a family history of prematurity what are the chances of a new mother delivering a child prematurely?
A. History of preterm birth as well as family history increases the risk of preterm birth.
Q. Does the age of the father count? If he is also an older man will the chances of the baby being born preterm be greater due to less sperms?
A. Yes, increased paternal age increases the risk of preterm birth (fathers over 35 years of age, especially over 45 years of age.) A decline in testosterone as well as sperm degradation due to aging appear to decrease the sperm number as well as damage the sperm, decreasing fertilisation potential as well as increases the risk of preterm birth, congenital heart disease, cleft palate, childhood cancers, psychiatric and cognitive disorders as well as autism.
Q. Having a pre existing condition like diabetes – will it lead to a greater chance of having a preterm baby?
A. Yes, it will.
Q. I understand that babies born too early are often exposed to numerous health complications . Do you agree? If so, could you spell out some of the main health issues they face ? For example, can premature birth affect the brain ? Bones? immune system? IQ?
A. Yes, I agree. They have difficulty in breathing due to immature lungs and they are at higher risk of infection as well as bone demineralisation, bleeding inside their brain due to immature blood vessels and hypoxic brain injury during artificial ventilation.
Q. What about retinal damage to the eyes causing retinal blindness?
A. Retinopathy of prematurity is a preventable cause of blindness in preterm babies. It is due to the growth of abnormal blood vessels in the preterm, which is exacerbated by exposure to high oxygen levels. Minimising the use of oxygen while avoiding hypoxia is a key element in its prevention. In addition, early detection and treatment prevents its progression to blindness. Hence the Sri Lankan health policy mandates that preterm babies less than 34 weeks gestation are assessed by an eye surgeon within the neonatal unit at 3 weeks of age.
Q. How can these complications be prevented? Do our hospitals have sufficient facilities?
A. Complications can be prevented with good neonatal care. State hospitals are equipped with facilities equivalent to that present in the private sector. Preterm births are attended by skilled and experienced medical personnel, who provide immediate respiratory support with continuous positive airway pressure, minimising the use of oxygen followed by intratracheal surfactant and intravenous nutrients. Early provision of breast milk, skin to skin care, early stimulation, meticulous hand hygiene, strict antibiotic policy while confining visiting only to parents, are some other measures undertaken by our hospitals to optimise the care of preterm babies.
Q. Are parents allowed to be part of this process?
A. Yes of course. Parents play an essential role in providing breast milk, skin to skin care as well as early stimulation by touching and talking to baby.
Q. It has been said that breastfeeding is a powerful tool in boosting a preterm baby’s immunity levels and chances for survival. Is this true? If so how?
A. Transfer of immunity (factors including immunoglobulins) from the mother across the placenta, occur mainly after 28 weeks of gestation which would be missed by a baby born preterm. This results in preterm babies having a decreased immunity. However, breastmilk facilitates the continuation of transfer of immune mediators including immunoglobulin and cellular factors. Therefore, breastfeeding a preterm baby increases their immunity and increases their chances for survival.
Q. The global theme for this year is “small actions BIG IMPACT”: immediate skin to skin care for every baby everywhere”. What is its significance in terms of improving the chances of preterm babies so that they may realise their fullest potential?
A. A baby is sterile at birth. The first contact gives the first exposure to microorganisms. Friendly microorganisms present in the community and present on the mother’s skin would result in the baby being colonised by friendly bacteria in contrast to being colonised by unfriendly and harmful hospital microorganisms present on all animate surfaces in the delivery room.
Q. With regard to skin to skin contact being promoted as a powerful therapy , does this apply to all mothers? Isn’t there a likelihood of the mother transmitting her infection to the baby ? Since we are in the midst of a Covid 19 outbreak as well as risks of exposure to new equally contagious diseases and re emerging diseases like TB, do you recommend that infected mothers be allowed to provide skin to skin and breast feed their babies?
A. Skin to skin therapy is a very powerful therapy that improves the survival of all newborns, especially for those born preterm, through colonisation with friendly bacteria, preventing hypothermia, establishing breastfeeding, increasing bonding, decreasing the heart rate and respiratory rate, thereby decreasing hospital stay and improving neurodevelopment.
Skin to skin therapy and breastfeeding should be carried out in mothers with Covid 19, or other contagious diseases as breastmilk transfers the protective antibodies formed by the mother to the baby, thereby protecting the baby from infection. The risk of transmission can be minimised reducing the risk of droplet transmission by practicing hand hygiene and wearing a mask.
Q. Does that mean Skin to skin care and breastfeeding should be continued despite the mother having infectious diseases like TB.
A. Yes, except for those with untreated open pulmonary TB, who are the only infectious category. Baby should be separated from the mother until completion of the first 2 weeks of anti TB treatment, while receiving expressed breast milk, after which skin to skin care can be resumed.
Q. I understand that consultant paediatricians also collaborated with the Health Ministry sometime back to put out new improved guidelines regarding the welfare of new or babies? Are these guidelines available to all health officials in the department?
A. Yes, the latest National Guidelines on Newborn care prepared by neonatologists and paediatricians in collaboration with Family Health Bureau were released by the Ministry of Health in 2020. They are freely available online in the Family health Bureau website under ‘guidelines’ released in 2020.
Q. Are there guidelines for mothers and parents too?
A. Although there are no guidelines for parents at present, the National Newborn Guidelines of 2020, provide guidance for the health care workers on conducting a predischarge meeting with the preterm baby’s parents and other caregivers, specifying how to care for the baby after discharge (National Newborn Guidelines, 2020, Volume 1, page 92). This includes the importance of hand washing and minimal handling, dangers of suffocation during co-sleeping, safety of feeding and risk of aspiration, early stimulation and avoiding screen time as well as identifying danger signs like feeding difficulty, fast or difficult breathing, fever or cold to touch as well as if the mother feels that the baby is unwell which would warrant urgent admission to hospital, as well as making contingency plans to reach the hospital,
hands on training on basic resuscitation and first aid for choking and including importance and plan of follow up.
Q. Do you have a special word of advice to all mothers out there on how they can play an important role in protecting and preventing their preterm babies from any complications that may impede his/her chances of enjoying a healthy life in the future?
A. Not only for mothers but for fathers too. Be there for your preterm baby. Come to the neonatal unit as soon as you can and be there for your baby. Baby benefits from seeing you, hearing you, smelling you, skin to skin contact and your gentle touch. Please provide breastmilk for your baby as soon as possible, as it helps them to overcome their weak immune system and get off intravenous fluids as well as intravenous lines, thereby decreasing their risk of infection. Provide skin to skin care as soon as, and as frequently as possible, due to the above-mentioned advantages. Wash hands before handling the baby and restrict contact only to immediate family. Minimise visitors after discharge, and comply with the follow up plan as well as with the medical advice so that their eyes are screened for retinopathy, multivitamins and iron supplements are continued till 2 years of age and that they receive early stimulation to optimise their neurodevelopment.
