World Premature Day
The 17th of November every year is dedicated to those born into this world a little bit earlier than expected.
I’m sure many of us know of someone or have had children of their own who, often due to medical issues, have had to expedite their pregnancy and receive a caesarean section. If you could ask these people how their experience was I’m sure they would say “scary” “we didn’t know what was going to happen” “the baby is so tiny” but “we are happy the baby is alive and healthy“ or unfortunately the baby didn’t make it. The trauma associated with the process is indescribable whether the outcome was positive or negative.
Today, we look into some stats, some premature infant considerations in anaesthesia and perhaps how to be a caring caregiver ?
The brass tax
Approximately 15 million babies are born preterm each year around the world. This equates to roughly 1 in 10 babies are premature. In South Africa, around 84000 babies are born premature and of this 10% do not survive. In South Africa, 8/100 babies are premature and that ranks us world wide as 24th in countries whose newborn deaths are due to complications of prematurity. If we remember back to our public health lectures one of the sustainable development goals of which South Africa is a signatory is in fact to reduce neonatal deaths. The goal is to reduce neonatal deaths to 12 per 1000 live births. South Africa unfortunately is failing to largely improve its prematurity death rate.
Prematurity itself carries a higher risk of mortality and morbidity due to both short and long term complications which include:
- Respiratory distress syndrome / apnea of prematurity
- Necrotizing enterocolitis
- Sepsis
- Intraventricular hemorrhage
- Feeding difficulties
- Auditory and visual deficiencies
There are numerous other complications but these are the common ones. Improved antenatal and post natal care practices can go a long way to improve outcomes with regard to the above.
Anaesthetic considerations
It would be remiss to not talk about bit about some anaesthetic considerations as well. While this is not a comprehensive talk, perhaps consider it as a reminder for one of Dr Siyaka's morning meetings !
In summary, the considerations of the premature neonate:
- CNS: Intraventricular heamorrhage - cerebral palsy- greater risk of bleed due to changes in blood flow, blood pressure and serum osmolality.
- RESP: Foetal lung immaturity-surfactant production- may need ventilation support - leads to chronic lung disease / bronchopulmonary dysplasia. Anaesthsia cause ventilation mismatches leading to hypoxia. Apnoea of prematurity- pause in breathing of 20 seconds/ less and 20 seconds with bradycardia and cyanosis- related to gestational age- decreasing incidence as child grows consideration up to 60 weeks post conceptual age - exacerbated by almost anything that affects normal homeostasis. require monitoring for 24 hours in high dependency unit
- CVS: Greater risk of cardiovascular collapse- poor diastolic function- LV less compliant and cardiac output depends on HR. Small blood volumes - minor bleeding can cause hypovolaemia.congenital cardiac defects - PDA often present with significant L-R shunting
- Temperature: Very thin epidermis- can lead to fluid and temperature loss- skin injury from light trauma
- Renal: Function is related to gestational age- decreased bicarbonate reabsorption - normal acidosis of prematurity- ADH response is blunted- hyponatremia is common
- Glucose homeostasis: Liver stores of glycogen limited- lipolysis and ketogenesis limited - strict glucose monitoring
Procedures common to premature infants
PDA ligation
Laparotomy for NEC
Inguinal hernia repair
ophthalmic operations
CSF drainage for VP shunt
CT / MRI investigations
How to be a better human
Often the mothers with the premature infant is coming for their first caesarean section. The Gynae has just said that the baby is in trouble and we need to act fast. The mother is dealing with both the stress of the surgery as well as the outcome of the baby. Medical terms are being thrown at her and she has absolutely no clue what they mean. Here comes us, the anaesthetist at 1 am, grumpy overworked and lack of caffeine in hand. We say, “ We going to put a needle in your back but it’s not painful, just sit still…”
While this is not wrong and yes often the best anaesthetic, one must remember that often it is us that can really make the experience positive in a negative situation. Talking to the patient, reassurance, guided information and managing expectations is all at the head side of the bed. If the patient feels like they are part of the team, the motivation to do what you ask, not to complain about small pains or discomforts really does come so much easier and they will thank you at the end of the day.
Personal Note
This is a topic close to my heart as I also had a premature baby.
Hudson Davies was born 1.3kg @ 32 weeks due to complications of PET and placental insufficiency leading to intrauterine growth restriction. He spent 70 days in ICU and received many invasive lines.
The worst was seeing him pull out his feeding tube everyday and having it replaced! As a doctor, knowing and googling all the complications that might happen on a daily basis was enough to go crazy.
Today, Hudson is a healthy happy child with a weight of 8kg and no complications thus far from his stay in ICU. He received the best care from Mediclinic midstream ICU and continues to follow up there. However, he was lucky, he received the best care possible. South Africa, as said earlier, has many premature births and vast majority does not receive such care. It’s an ongoing fight which we must win and we as a medical community must improve.
If the only thing you learnt reading this is to please wash your hands around premature babies and ensure top notch aseptic technique, then it’s a win. Please consider supporting premature baby drives and charity events.
Consider donating to a deserving foundation
Feziwe
