Premature/ Lowbirh weight  baby could be admitted to neonatal care for a number of reasons, including when they:

1. are born early (premature)
2. premature Lungs of the babies.
3. are very small and have a low birthweight
4. have an infection
5. have jaundice
6. had a very difficult birth
7. are waiting for, or recovering from, complex surger
8. if they need ventilatory support

Apart from this problems premature/Low birth weight babies may have varities of complication which we deals in NICU highly advanced equipments with skilled neonatal team of doctors and nursing stuff we provide best care.

 

For all newborns admitted to a neonatal intensive care unit (premature babies and sick full-term infants), care can be divided into two general components: supportive (i.e., care required to maintain as near to normal homeostatic function as possible) and reactive (i.e., treatment started in response to illness or change in an infant’s health). Broadly, supportive care encompasses the following:

Respiratory support;
Cardiovascular support;
Nutritional support.
Reactive care generally involves treatment of complications, namely:

1. Neurological issues (e.g., seizures);
2. Patent ductus arteriosus;
3. Necrotising enterocolitis;
4. Retinopathy of prematurity.

Respiratory support
The fetal lung is not structurally mature until around 35 weeks’ gestation. Respiratory failure can be caused by incomplete lung development or surfactant deficiency, and is a major cause of morbidity and mortality in preterm infants. The initial support given depends on the gestational age at birth and clinical condition of the infant. The earlier the gestation at birth, the higher the likelihood that prolonged respiratory support will be required. There are various aspects of mechanical and pharmacological respiratory support.

Ventilation
Ventilation is used to support infants who are unable to breathe effectively for themselves. It can be invasive (the baby is attached to a ventilator via an endotracheal tube) or non-invasive (the baby is connected to a pressure support system via nasal prongs or a soft facemask). Although ventilation is the mainstay of non-pharmacological human respiratory support, its efficacy can be enhanced by the use of certain medicines, outlined below.

Surfactant replacement therapy
Pulmonary surfactant is produced in the lungs, but is often deficient in premature babies. Early administration of surfactant (via an endotracheal tube) for infants who are likely to be surfactant deficient reduces their initial oxygen and ventilation requirements. It also reduces the incidence of respiratory distress syndrome (RDS), pneumothorax, pulmonary interstitial emphysema and death. Surfactant therapy is also used in full-term neonates who have meconium aspiration syndrome. The surfactants used in the UK are poractant alfa and beractant, which are modified and purified from porcine lung and bovine lung, respectively. Natural surfactants have a more rapid onset of action, and are associated with improved survival, compared with the synthetic products that were used in the past. Antenatal corticosteroid use reduces the incidence of neonatal RDS by promoting surfactant production. A combination of antenatal corticosteroid administration and postnatal surfactant replacement therapy has been demonstrated to improve neonatal lung function more than either treatment alone.

Postnatal corticosteroids
The use of corticosteroids in the neonatal period can facilitate weaning from intensive ventilatory support. However, they are used sparingly due to adverse effects on cognitive and motor development. Children who are treated with dexamethasone after premature birth have been shown to perform significantly worse in cognitive and motor testing at school age compared with preterm infants who are not treated with corticosteroids. Corticosteroid use is also associated with an increase in risk of secondary infection.

Hydrocortisone appears to be an effective alternative to dexamethasone, with fewer long-term adverse effects (neurological, neuro-endocrine and cardiovascular). However, trial numbers are small and blinded randomised controlled trials are needed to confirm these findings.

Caffeine
Neonatal apnoea due to immaturity of the cerebral respiratory centre can delay progression from invasive to non-invasive respiratory support. Caffeine —a respiratory stimulant — can be used for babies with neonatal apnoea to facilitate respiratory weaning earlier than might otherwise be achieved, and may even allow a premature baby to avoid the need for invasive support at all. A loading dose achieves therapeutic serum caffeine levels quickly; smaller subsequent doses, given once or twice daily, maintain serum levels until the respiratory centre is fully mature (at 33–34 weeks’ corrected gestation,. The “Caffeine therapy for apnoeas of prematurity” study showed that infants who received caffeine were weaned from invasive ventilation a week earlier than those who received placebo. Moreover, fewer babies who received caffeine required supplemental oxygen at 36 weeks’ corrected age. There is 1mg of caffeine base in 2mg of caffeine citrate so, to avoid errors, it is important that clinicians indicate whether a dose is prescribed in terms of caffeine base or caffeine citrate. The British National Formulary for Children recommends that the dose is prescribed in terms of caffeine base.

Terminology regarding preterm age

Gestational age is the time elapsed between the first day of the last normal menstrual period and the day of delivery. It is defined in weeks and days, for example 25 weeks and 2 days would be expressed as 25+2. Corrected gestational age is calculated as the gestational age plus the chronological age of the infant. For example, a baby born at 25 weeks and 2 days, who is now 1 week and 4 days old, would have a corrected gestational age of 26 weeks and 6 days, expressed as 26+6.

Cardiovascular support
Cardiovascular support in sick neonates is usually started on the basis of clinical and echocardiographic assessment. Examples of such support include the use of vasopressors and fluid administration for neonates with sepsis and the use of cardioselective inotropes following perinatal asphyxial myocardial damage. Historically, a combination of dopamine and dobutamine has been used first line, with adrenaline added if required. A one-off dose of hydrocortisone can begiven if inotrope resistance occurs. Other inotropes can also be used in specific clinical circumstances; choice of drug will depend on action and receptor profile. Vasoconstrictive drugs may have undesirable side effects in flow-sensitive, maturing organs (e.g., brain, kidney) and therefore the risks and benefits of their use must be weighed up.

There is a lack of consensus about how measurement of cardiovascular status can be reproduced reliably to predict long-term outcome.

Nutritional support
Poor nutritional status can have a negative impact on the survival of preterm infants, and is linked with an increased risk of necrotising enterocolitis, septicaemia, impaired growth and poor cognitive outcome.

Stores of every major nutrient are built up by a foetus in the later stages of a normal pregnancy; therefore, infants born preterm have not undergone this process. A preterm baby weighing 1kg has sufficient energy stored to survive for two to three days; death occurs if nutritional replacement is not supplied during and after this period.

The metabolic demands of preterm infants are high from the moment of delivery. However, it is not possible to start most preterm infants on enteral feeds alone because the immature gut will not tolerate the quantities that would be required to provide complete nutrition. Total parenteral nutrition is often used as a nutritional bridge between birth and the time from which enteral feeds alone can provide full nutrition, or for those who are nil-by-mouth.

Breast milk is the most complete form of nutrition for infants over 1.5kg. It reduces the risk of necrotising enterocolitis and infections, and improves cognitive outcome. Colostrum is the first milk produced by the mother and it contains antibodies which provide passive immunity for the neonate and first protection against pathogens. Mature breast milk contains high levels of prebiotics and probiotics (promoting the growth of “good” gut bacteria, which help immune function) as well as optimal amounts of fat, carbohydrate and salt.

Although expressed breast milk is the best milk to give enterally to any preterm infant, it will not fully meet the nutritional demands of very preterm infants even if given in large volumes. In these situations, breast milk fortifier can be added to boost the protein and calorie content of the breast milk[8]. In situations where expressed breast milk is not available, preterm-specific formulas should be used; standard baby formulas do not meet the needs of preterm infants.

Vitamin and mineral supplementation
 Phosphate is essential for bone growth and mineralisation, and deficiency occurs frequently in preterm infants. Preterm infants fed exclusively on breastmilk, which is relatively phosphate-poor, should receive an oral phosphate supplement. Plasma phosphate levels should be checked frequently to guide supplementation.

Vitamin D is important for bone mineralisation and many other physiological processes. In preterm neonates, all vitamin D must be obtained from dietary sources. Most infants receiving milk feeds will require some form of vitamin D supplementation, normally administered in a combination multivitamin product. For preterm infants with symptomatic anaemia who are in neonatal intensive care units, iron supplementation is used infrequently because these babies will often receive blood transfusions. However, breast-fed preterm infants will commonly be discharged home on oral iron supplements to prevent iron deficiency anaemia developing at home during the first year of life. Formula milk is manufactured with additional iron content and therefore ex-preterm babies discharged on formula feeds generally do not require supplementation. 

Neurological issues
Pain and sedation
Morphine is used for two main indications in the neonatal intensive care unit: as an analgesic and, sometimes, as a sedative for invasively ventilated infants.

Analgesia may be required for severe or sustained pain (in this case it is given by infusion) or for the treatment of short-term pain (in which case it is administered as bolus doses). In any circumstance, morphine should only be used when necessary and babies should be monitored for respiratory depression. Infants should be weaned from the drug as soon as possible to avoid development of tolerance.

Paracetamol can be used as an alternative to morphine for the treatment of short-term pain and has the advantage of not causing respiratory depression. Oral sucrose or breast milk can be given before a painful procedure — evidence shows that the baby will cry less during the procedure, although the mechanism of action for this is unclear. Suckling on a dummy can have the same effect. Oral sucrose can be used in preterm infants, though caution should be exercised in extremely preterm infants, those weighing less than 1.5kg and those who are not fully enterally fed. Preterm babies who are unwell or who have a history of necrotising enterocolitis should not receive sucrose analgesia. Sucrose is not recommended for babies older than one month because it has not been shown to be effective for these patients