Complications and risks from complications

Premature children encounter too many challenges in the first minutes of their lives. The reason is the immaturity of all organs and systems, leading to the inability of the baby to adapt alone to life outside the womb. It requires special care. The good news is, that in recent years, medicine has undergone significant development. Thanks to this progress, preterm children who previously could not survive, can now be saved and develop as healthy children. The biggest challenge for doctors is treating newborns with a birth weight below 1500 g, and especially under 1000 g. Even if your child is born with such weight, you can be sure that doctors will do everything in their power to make it survive and grow a healthy child.

Premature children have to overcome difficulties associated with breathing, maintaining body temperature, feeding, frequent infections and others. Here comes the role of the medical team of the Department of Neonatology. A "welcome" preparation is done before each premature baby is born –a warm incubator, oxygen or ventilation device, monitor reporting oxygen saturation and heart rate and so on. This is of utmost importance and aims at maximizing the support of vital functions of the baby (breathing, heartbeat) from the first minutes after birth. The primary resuscitation in the delivery room, carried out on unified protocol, is a significant reserve to reduce late complications. Some premature babies (more mature and weighing around and above 2000 g) do well alone and do not require intensive care, prolonged treatment and special care.

Early complications

They occur shortly after birth, in terms of conducted intensive treatment during their stay in the department. Possible complications are: pneumothorax (collapse of the lungs due to air entering the pleura), pneumonia, anemia, brain hemorrhages, severe forms of infections and others. These conditions of the baby require additional treatment, prolonge the stay of the child in the ward, and increase the risk of late damage. If they occur in your baby the neonatologist will explain what changes have occurred in the child's condition, is there any danger to life and its later development, what measures have been taken and in what approximate time limits an improvement could be expected. More often such complications occur in premature infants weighing less than 1500 g and 1000 g. We will focus a little more in detail on some of them, but if you have any questions about your child's condition, do not hesitate to ask your neonatologist.

Lung problems

During pregnancy, the baby develops and matures progressively until it reaches ability to cope with the life outside the womb. The drastic transition from the "water" to "oxygen" life is an impressive challenge requiring immediate adaptation, involving breathing, circulation, thermoregulation, metabolic balance, renal and digestive functions.

Of all organs that have to adapt to life out of the womb, the lung is undoubtedly one where the start of functioning is most impressive, but also the richest of consequences, due to its effect on the function of other organs. This very efficient respiratory system is achieved through the unity of the factors responsible for the correct anatomical and functional maturation.

• Insufficient synthesis of surfactant substance - hyaline membrane disease. The synthesis of surfactant increases after week 24. That is why, premature babies suffer from the lack of it, and this leads to the development of respiratory insufficiency in the first hours and days after birth. The artificial synthesis of surfactant and the therapy with it are considered as a revolution in neonatology. The product is given to infants, who need it through a tube which penetrates into the throat and slowly releases the substance in the lungs.
• Apnoea of the premature birth. Premature babies often show breathing patterns, in which short breaks occur. Sometimes, these breaks can be longer and the babies should be "reminded" to breath with gentle stimulation. Some medications can be used to stabilize the baby's breathing. Sometimes these breaks can be severe enough so that your baby needs a little help in breathing, but in most cases this problem will improve. If your baby is no longer on assisted ventilation, it will be attached to the monitor, which includes an alarm when the pause in breathing prolongs too much.
• Pneumothorax. Sometimes, air may be leaking from damaged air sacs in the lungs, especially if your baby is breathing with the help of assisted ventilation device. Air bubbles may form in the tissues of the lung or around the lungs and cause collapse of the lungs (pneumothorax). Large air pockets can press the lungs and make breathing difficult. In this case, the doctor can insert a tiny tube in the baby's chest to be able to get the air out of there. Local anesthesia is administered during the procedure. Often, a drainage tube is placed in an emergency, so doctors and nurses may not have time to discuss the procedure with you.
• Chronic pulmonary disease. Babies, who have been on assisted ventilation for a long time, may develop chronic pulmonary disease (known as broncho-pulmonary dysplasia or CPD). We will discuss CPD in more detail a little later.
• Meconium aspiration syndrome. One of the reasons babies may need help breathing is the so-called meconium aspiration syndrome. During birth, some babies often inhale a mixture of meconium and amniotic fluid. Meconium is the first feces of the baby, that is thick, sticky and dark green. If your baby has the meconium aspiration syndrome, it may show signs of fatigue, weakness, lethargy and have a slow heartbeat. The trachea of the baby is cleaned from the most of the meconium. This is done by inserting a tube into the trachea of the baby (through the mouth or nose) and the meconium is sucked into it during the extraction. The doctor will continue until clean fluid comes out of the tube without signs of meconium. This can be a serious condition that requires complex and intensive medical care. However, most babies recover within a few days or weeks, depending on how much meconium they have inhaled. Usually there is no permanent damage to the lungs.

Other problems faced by the premature babies are related to:

• Inability to maintain their own body temperature: these children are kept in an incubator, which provides them with optimal ambient temperature and humidity. In infants under 1500 g and especially under 1000 g, the time of the incubator stay is longer - weeks, even months.
• Immaturity and easy vulnerability of the brain structures: the reason for the more frequent cerebral lesions in premature infants weighing less than 1000-1500 g. The most common neurological complications are brain haemorrhage and the formation of cysts. We will discuss this issue in detail later.
• Incomplete development of the retina: retinal maturation continues in unusual conditions (lack of complete darkness, air), and the developing structures are exposed to higher concentrations of oxygen, assisted ventilation, etc.
• Immaturity of the immune system: the immune system of premature babies is immature and this is the reason for more frequent and more severe forms of infection. Complications in premature infants were observed more frequently in those born before weeks 32-34 / weighing below 1500 g. Their frequency significantly increases in premature babies under week 30 and weighing under 1000 g. The existence of aggravating factors during pregnancy, birth and after that also affect the condition of the newborn after birth, the morbidity and the late complications.

Major risk factors for the occurrence of complications in premature infants:

• Abnormal pregnancy.
• Birth weight and gestational age - the lower the weight and gestational age, the greater the risk for damages.
• Incomplete development and immaturity of all organs and systems of the premature baby - lungs, brain, gastrointestinal tract, kidneys, retina, etc. Their further development and maturation continues in a totally different environment and under conditions of intensive methods of resuscitation and complex treatment.

Late complications

Bronchopulmonary dysplasia (BPD)

Chronic pulmonary disease - develops in part of the preterm children. The incidence of the disease higher at gestational age under 30 weeks and weight less than 1500 g. Children weighing less than 1000 g are with the biggest.

• What factors predispose to the development of this disease? There are many circumstances that can affect and cause the development of bronchopulmonary dysplasia. Among the main reasons are: pulmonary immaturity (due to premature birth), presence of lung disease (hyaline membrane disease), which is more severe and requires longer and more intensive assisted ventilation of the child. The action of the oxygen, which is necessary for the treatment can cause specific changes in the lung. The premature baby has immaturity and low levels of protective enzymes. Therefore, it is more vulnerable to oxygen. A number of other factors also have an impact and meaning: infection during the birth of the child or developed later, feeding the sick child prematurely and many others. While presented with all these factors, not all at-risk children develop BPD.
• What is the disease like? Babies are diagnosed with bronchopulmonary dysplasia, if they are constantly on oxygen after reaching 36 gestation weeks (4 weeks before term), and chest X-ray confirms that there are changes in the lungs typical of this type of disease. They have rapid and difficult breathing, expend energy for the respiratory movements, eat harder and their weight gain is less than optimal.
• What can be done to reduce and / or prevent the development of BPD? Prevention of premature birth, effective primary resuscitation in the delivery room, treatment with surfactant, using the lowest possible concentrations of oxygen and so on. The main rule is to conduct an effective complex intensive care, maximum sparing for the child.
• How should I care for the child and who will do the follow-up? Besides the information during treatment, parents receive guidance on nutrition and child care at discharge. The disease, the treatment, the condition at discharge are described in the medical history. This information is important for the GP of the baby. Follow-up and treatment of children with BPD is carried out by a team –a GP (general practitioner), a pediatric pulmonologist, a neonatologist, a pediatric cardiologist. The family is also part of the team. They carry out specific and continuous home treatment. Parents are informed of the need to ensure a non-smoking environment and timeliness of mandatory immunizations. In recent years, a specific prevention of RSV infections carried out for these children. You will be informed about it by your neonatologist, who will carry out this prevention in the autumn-winter season together with the GP. In the majority of cases, the result is a gradual improvement of clinical symptoms and lung function is normalized the age of 2. In some cases, an asthma may develop later on.

Cerebral complications

Brain hemorrhages (you will hear them also called intraventricular, ICH, or bleeding in the brain ventricles). The developing brain of the baby has plenty of blood vessels. Sometimes, these blood vessels rupture, causing bleeding in the brain. Short bleeding does not cause long term problems. Bleeding in the brain is classified according to its severity. First and second degree are mild and moderate bleeding - their prognosis is good. The third and fourth stages are the most serious – the late prognosis for them is the better, the sooner the haemorrhage if found out, the better it has been followed up and the timely the treatment was initiated. The increased bleeding can restrict the flow of blood to other parts of the brain, which means that they will not get enough oxygen.

Risk factors

Premature birth is an independent risk factor, especially if it is caused by conditions during pregnancy, leading to fetal distress. Preterm infants (especially with weight below 1500 g and 1000 g) are characterized with immaturity of the brain and brain vessels.

Under an ongoing intensive treatment, the brain of premature babies is very vulnerable due to incomplete development. This creates conditions mostly for intraventricular haemorrhage - unilaterally or bilaterally. Their diagnosis and monitoring begins in the department. At discharge, you will receive information about the condition and the need for check-ups, tests and consultations. The follow-up is clinical and neurological, and with ultrasound examination - TFU (transfontanelle ultrasound). It is performed by a neonatologist and / or a pediatric neurologist.

Formation of brain cysts (the medical term for this problem is a periventricular leukomalacia or PVL). Sometimes, examinations show that parts of the brain had not received enough oxygen. If these parts die, a pocket full of fluid, called a cyst, is formed in the place of brain tissue. How this will affect the baby depends on how many the cysts are, how big they grow, what areas of the brain are affected. This is a specific damage to the central nervous system, typical of premature babies, especially those born before week 31. It occurs in 10-15% of children under week 31 and only in 1% of those over 33 weeks. These changes in the brain may occur before birth, during birth and after it, or later due to various diseases of the child. Again, the main prerequisite for the occurrence of these changes is the immaturity of the brain. The child's condition is monitored by transfontanelleultrasound (TFU). Long-term prognosis depends on the severity of the cysts. In the most severe forms, deviations in the locomotor and / or mental development are expected. This is the most common cause of development of CP (Cerebral Palsy).

Follow-up, treatment and rehabilitation in these children is carried out by a team of specialists: a neonatologist, a pediatric neurologist, a physiotherapist, a therapist, eventually a psychologist. Early start of physical rehabilitation is important to prevent delays in motor development.

The terminology can be confusing. Do not hesitate to ask your doctor to explain the situation in a more simple and comprehensible language.

Hydrocephalus is more often a consequence of heavy bleeding. Hydrocephalus is an increase in the amount of CSF (cerebrospinal fluid) and the expansion of the ventricular system (brain ventricles). The leakage may be progressive, i.e. rapid growth of head circumference and progressive enlargement of the ventricular system. In these cases, after consultation with the neurosurgeon, a surgical treatment is carried out. In other cases, the follow-up shows retention or slow increase in time of the ventricular dilatation, which is more favorable.

Eye problems in premature children

More common in premature children are: impaired visual function, reduced visual acuity, strabismus, retinopathy of the premature baby.

Retinopathy of the premature baby

It is a violation of the development of the blood supply of the immature retina. has The degree of immaturity is essential for the emergence of retinopathy - gestational age and the weight at birth, taking into account the role of other factors such as oxygen, anemia, infections and others. The disease may go with mild and reversible damage to the retina, but in other cases it could be heavy and requiring treatment. There are five different stages, according to the severity of the disease. Prompt and specific treatment is needed in cases of III-rd to the V-th stage of the disease.

Which premature babies undergo mandatory eye exam?

• premature infants born weighing less than 1500 g or of gestational age below 32 weeks.
• children of mechanical ventilation longer than 72 hours or oxygen treatment more than 30 days.

When, by whom and how is the examination performed?

• First check up at the age of 4-6 weeks by a pediatric ophthalmologist.
• The frequency of subsequent examinations is determined by the ophthalmologist.

How is the examination carried out?

• With indirect ophthalmoscopy after pupil dilatation. It is performed by a pediatric ophthalmologist. The examination is short and painless.
• The examination with digital retinal camera (RetCam) is gaining more importance as the primary method in premature babies. Before the examination, local anesthesia and eye drops to dilate the pupils are administered.

Basic methods of treatment in the more severe forms of retinopathy are cryotherapy, laser therapy, and surgical treatment. Preventing retinopathy is limited to prevention of prematurity. The most important tool in this disease is the effective screening of premature infants and the early and adequate treatment. The universally conducted eye screening for designated categories of premature newborns is a fact in our country.

Damage to hearing in extremely preterm infants

It is more often in premature infants born weighing less than 1500 g. Deviations in hearing can be identified by the treating neonatologist or an ENT specialist. The examination is painless and within 5-10 minutes with the respective device. Thanks to the "Bulgarian Christmas 2014" initiative, most NICUs are equipped with specialized devices to examine the hearing of the newborn. This allows for early detection of abnormal hearing and timely treatment.

Anemia of the premature child

It occurs more frequently in babies born before week 32. This is late anemia. It develops at the end of the first month after birth. The peak of the hemoglobin fall is at postnatal week 3-12. It is found with a blood sample requested by a pediatrician or a neonatologist. Prophylaxis and / or treatment with iron preparations, or vitamins is carried out, eventually transfusion, performed in a hospital.

Growth and development

The growth and development in premature children are important indicators to be monitored after discharge of the child. They are assessed against the corrected age (to be read on the day of the term rather than from the actual date of birth).

Monthly assessment of the weight, height, head circumference, fontanelles, in accordance with the growth curves for premature infants. Healthy premature babies go through a period of accelerated growth in the first months. They quickly reach their peers. Children, born weighing less than 1500g, and especially those under 1000 g, can not catch up with their peers in growth until the third year. Follow-up is done by your pediatrician. You have the right to an examination and consultation with a neonatologist either as you wish or a referral by a GP.

Herniations

They are more common in premature babies.

Umbilical herniation

It rarely requires surgery. It is usually corrected with dressing and subsequent development of the muscles of the anterior abdominal wall.

Inguinal herniations

The incomplete descent of testicles in boys facilitates their emergence. They are often bilateral and quite large, but rarely lead to incarceration (entrapment). Most modern authors recommend early correction of the defect, i.e. an early consultation and follow-up by a pediatric surgeon is mandatory. Your pediatrician or neonatologist will refer you to a pediatric surgeon for check up.

Conclusion

Today, in the conditions of modern neonatology, there are opportunities for timely and effective response of the majority of the identified deviations of premature children. A good collaboration of many specialists: a pediatrician (general pediatric care and prevention), a neonatologist, a pediatric neurologist, a pediatric pulmonologist, an ophthalmologist, an ENT specialist, a psychologist, and so on is needed to carry out the best possible and efficient follow-up of premature children.