PREMATURE CHILDREN — the children who were born in terms between the 28th and 38th weeks of pre-natal development with a weight (weighing) less than 2500, less than 45 cm in height.
Depending on the body weight of the child at the birth it is accepted to distinguish four degrees of prematurity:
the 1st degree — the body weight of 2001 — 2500;
the 2nd degree — the weight of 1501 — 2000;
the 3rd degree — the weight of 1001 — 1500 g;
the 4th degree — weight is below 1000.
The previous abortions, polycarpous pregnancy, complications are the most frequent reasons of prematurity pregnancies (see), toxicoses of pregnant women (see), cardiovascular and endocrine diseases, acute and hron, diseases of mother. Physical and mental injuries during pregnancy, incompatibility of blood of mother and a fruit, addictions of mother (smoking, alcohol intake), etc. can be the reasons of prematurity also nek-ry professional harm (see. Nevynashivany pregnancies ).
- 1 External signs of prematurity
- 2 Functional signs of prematurity
- 3 Physical and psychological development
- 4 Features of a course of diseases, their treatment and prevention at premature children
- 5 The organization of medical care and feature of care of premature children in the conditions of maternity hospital and a hospital
- 6 Features of the regime of the premature child and care of it
- 7 Tables
External signs of prematurity
Almost total absence of hypodermic cellulose (fig.) belongs to external signs of prematurity. The lustrous, as if translucent, dark red skin collected in wrinkles, plentifully covered on extremities, a back, a face with a dense down (lanugo) is characteristic of deeply premature children (weight till 1500). The navel is located low, in the lower third of a stomach. Pupils are tightened by a pupillary cover. Eggshell nails, not always reach to the brim a nail bed. Cartilages of auricles very soft. At girls widely open purple-red sexual crack owing to an underdevelopment of big vulvar lips is noted. At boys — empty, without testicles, very red scrotum.
At more mature premature children (1500 and more) insufficiency of development of hypodermic cellulose, rugosity of skin are also sharply expressed, but skin color less red, it is rather light pink. The dense down covers generally extensor surfaces of extremities, a back and in a smaller measure the person. Eggshell nails, but are longer, reach the end of a nail bed. The navel is located slightly above over a symphysis. Boys in a scrotum have one or both small egg but which did not go down to the bottom and lying in its upper half and easily going to abdominal rings during the pressing on them.
The middle of length of a body at newborn N. of is above a navel (at full-term it approximately corresponds to an arrangement of a navel). Length of the head at the birth depending on degree of prematurity makes from 1/4 to 1/3 growth. A skull krugly, than at the full-term newborns, seams and a small fontanel are open, the big fontanel is often small because of the shift of bones of a skull. Tendency to hypostases of hypodermic cellulose is noted, during the cooling the scleredema can develop (see. Sclerema, scleredema ).
The funic rest disappears a bit later, than at full-term (on 5 — the 7th day of life instead of 3 — the 4th at full-term), the umbilical wound begins to live to 7 — to the 10th day of life.
Any of the specified external signs separately cannot be considered as an unconditional sign of prematurity, only their set is considered.
Functional signs of prematurity
Functional signs of prematurity (the physiologist - the biochemical characteristic of various bodies and systems). The function level of bodies and systems H. of is caused their considerable morfol, immaturity owing to loss of a certain period of pre-natal development, and also features of maturing and development of an organism of the child in inadequate conditions of the new environment for it.
N of with low body weight at the birth (till 1500) are sluggish, sleepy, at them are poorly expressed or there are no sucking and deglutitory reflexes.
The common features testimonial of immaturity of an organism of N. of of the first months of life, low differentiation of responses to external irritants, a bystry exhaustion of processes of excitement, insufficient interaction between systems of an organism, slowness of processes of metabolic adaptation are. Sense bodys of N. of are capable to functioning from the first days of life; during this period it is possible to cause almost all reflexes of inborn automatism in them — sucking, deglutitory, search, swimmings, support, walking, Moro's reflex, a reflex of Talent, Peyper's reflex, Bauer's reflex, etc. (see. Newborn ).
The early post-natal period at N. is characterized by more expressed morfol, and funkts, immaturity of c. N of page, hl. obr. bark of big cerebral hemispheres, than at the full-term newborns. Imperfect, generalized reactions, regulation take place to-rykh it is carried out probably at the level of subcrustal structures. To manifestations of immaturity of c. the N of page belongs decrease in a spontaneous physical activity, a hypomyotonia and a hyporeflexia, a small and non-constant tremor of extremities and a chin, unsharply expressed athetosis, slight and non-constant squint, a small and non-constant horizontal nystagmus, etc. These changes usually happen short-term and keep for 2 — 3 weeks of life. The degree of prematurity is less, the these symptoms disappear quicker. On EEG the slow low-amplitude irregular waves which are followed by short flashes of regular waves with a frequency of 5 — 13 Hz, and also frequent irregular low-amplitude waves of more high frequency are registered (to 50 Hz). In many cases considerable sites of a curve are close to the isoelectric line. Only by 1 — 3 month of life of the child of EEG on the type begins to approach EEG of the full-term newborns. In the first months of life N. of have an ability to carry out adaptive functions: with 3 — the 8th week of life conditioned reflexes from various analyzers are developed (see. Conditioned reflex ).
Intracranial pressure at N. of of the first 3 months of life is in limits of 70 — 90 mm w.g. (at full-term — 80 — 100). Cerebrospinal liquid normal transparent with unsharply expressed xanthochromia that is caused by high-permeability of walls of vessels of a brain; at children 3 — the 4th degree of prematurity the xanthochromia is expressed more sharply, than at children of the 1st and 2nd degree of prematurity. Concentration of bilirubin does not exceed 0,1 — 0,3 mg / 100 ml. The cytosis is low, to 30 — 33 cells in 1 mkl, generally find lymphocytes. Reaction to the Panda positive (+ or ++); concentration of crude protein on average 70 — 90 mg / 100 ml (globulin of 12 — 39 mg / 100 ml), albumine of 28 — 57 mg / 100мл, fibrinogen of 0,10 mg / 100 ml, concentration of ammonia to 50 mg / 100 ml, and nitrogen of ammonia to 32 mg / 100 ml. Concentration of sodium fluctuates from 296 to 336 mg / 100мл, potassium — from 10,7 to 14,4 mg / 100 ml, calcium — from 3,7 to 8,0 mg / 100 ml. Level of chlorides averages 600 — 800 mg / 100 ml, sugar of 40 — 70 mg / 100 ml (on average 56,3 mg / 100 ml), gland of 82,5 mkg / 100 ml.
Regulation of processes of heat generation and a thermolysis is very imperfect (heat generation is reduced, the thermolysis is increased). Sweating at newborn N. of is absent owing to what they easily overheat. Rectal temperature at N. is lower than of the first 10 days of life, than at the full-term newborns; it makes 36,6 — 37,1 °, to monthly age reaches 37,2 °. The day-night rhythm of body temperature at N. of appears only after 3 months of life.
Features of breath of N. of are caused by immaturity of c. N of page. The respiration rate fluctuates in wide limits (36 — 82 in 1 min.) and depends on degree of prematurity: the big respiration rate is noted at children with smaller body weight. Breath at N. of to 11/2 — 2 months of life uneven on a rhythm and depth, is interrupted by respiratory pauses and convulsive breaths. Transition of irregular breath in periodic is often observed (see. Breath, pathology ). The muscular exercise in the form of reflex movements in 5 — 7 sec. conducts to a short-term stop or sharp delay of breath; the normal type of reactions — increase of breath on a muscular exercise is established usually by 40th day of life. Breath becomes regular (uniform on the frequency and amplitude of respiratory movements) only to 3 — to the 4th month of life.
Funkts, are expressed to feature of cardiovascular system at N. in dominance of sympathetic department of century of N of page; any irritations cause increase of cordial reductions, strengthening of sonority of tones and increase in the ABP.
Pulse rate of N. of depends on body weight at the birth a little and in the first 3 months of life 120 — 150 beats/min equal on average. During the crying pulse rate can reach 200 ud! min. Urezheniye of pulse to the figures making less than 80 beats/min testifies to explicit pathology. The ABP depends on body weight at the birth, degree of prematurity, age and funkts, conditions of an organism of the child; on the first month of life maximal pressure averages 65,6 and minimum — 24,4 mm of mercury. High-permeability of walls of capillaries is inherent to N of.
The low voltage of teeth and a deviation of an electrical axis of heart are characteristic of N.'s ECG of to the right. All teeth are well-marked. The interval P — Q is on average equal 0,10 sec., the interval Q — R — S fluctuates from 0,04 to 0,1 sec., the QRS T complex — from 0,23 to 0,35 sec. At nek-ry children the expressed arrhythmia with an urezheniye of number of cordial reductions in the period of a respiratory pause is observed.
The alimentary system of N. of also has a number of features. Proteolytic activity of a gastric juice and enzymatic function of glands went. - kish. a path are considerably reduced in comparison with the full-term newborns. pH of a gastric juice at height of digestion reaches 4,4, however even at big degree of prematurity in a gastric juice there is in a significant amount a rennin curdleing milk. From the first days of life the good resorption of proteins is noted, requirement in to-rykh is very big owing to rapid growth of N. of. Fats are acquired badly whereas the need for them as in an energy source is very big. Permeability of an intestinal wall at N. of for substances both bacterial character, and formed in the course of digestion of food, is increased. At N. observes low ability of kidneys to osmotic concoction that testifies to imperfection of system of osmoregulation (see. Osmotic pressure ). The low size of filtering in balls, limited ability to removal of excess of water, almost full reabsorption of the sodium coming to system of renal tubules is noted. It is caused morfol, immaturity of kidneys: dominance of the yukstamedullyar-ny and srednekortikalny nephrons having rather short nephronic loops (Henle's loops). At children with body weight at the birth higher than 1500 aged up to 2 months in cases of dehydration osmolarity of blood increases from 492 to 658 mine owing to what symptoms of so-called anhydrous fever (dehydration of an organism) can develop.
Indicators of nonspecific resistance (a caption a proper dyne, phagocytal activity of leukocytes, etc.) at N. are lower than, than at full-term. Ability to development of specific immunity is also reduced, the maintenance of IgG in umbilical blood at the birth lower, than at full-term.
Character of the special physiological states reflecting the period of adaptation after the birth at premature children. Processes of adaptation at N. of in the first days of life proceed in a slowed-up way, and the less mature is the child, the longer and heavier the period of adaptation proceeds. N. have more often than at full-term, such states are observed as metabolic acidosis (see), hypoglycemia (see), hyperbilirubinemia (see), disturbances water salt metabolism (see).
At healthy N. of the first 20 days of life most often observe the compensated metabolic, the respiratory and mixed acidosis is more rare. At N. over 1500 indicators of an acid-base state are normalized by with body weight at the birth by the end of 1 month of life, N. have with body weight lower than 1500 at this age and even in more senior quite often signs of a compensated acidosis, and sometimes and strengthening of atsidotichesky shifts still remain that is followed by accumulation pyroracemic to - you, decrease in content of glucose and increase in activity of enzymes of glycolysis in blood serum. It is so-called late, by P. Kildeberg's definition, type of acidosis At N.
The acid-base condition of a blood plasma at healthy N. is characterized by the following parameters: pH — 7,37; pCO 2 — 36,3 mm of mercury.; VV (the buffer bases of plasma) — 21,5 mekv/l blood; VE (excess of the bases) — 3,3 mekv/l (see. Acid-base equilibrium ).
Content of the major electrolytes (potassium and sodium) in intercellular liquid and in erythrocytes at N. to is subject to considerable fluctuations. Apparently, also the broad range of fluctuations of concentration of osmotically active agents in blood serum in many respects is explained by it. In usual conditions of nursing and feeding makes a limit of fluctuations of osmolarity of blood at N. from 252 to 354 mosm/l, fluctuations are expressed more at the children who had at the birth body weight to 1500 Mr.
Fiziol, the erythema at N. of remains is longer, than at full-term. Fiziol, jaundice has also long character more often that is caused by immaturity of hepatocytes, in particular the glyukuroniltransferazny system which is carrying out binding of free bilirubin. Free bilirubin collects in the nervous cells of a brain rich with lipids, breaking thereby processes of phosphorylation owing to what education is late vysokoergichesky connections (see) — ATP that leads to bilirubinovy intoxication. Development of bilirubinovy encephalopathy is promoted by a number of of states, characteristic of N.: 1) a hypoglycemia (as glucose is substrate uridindifosfo gluconic to - you, necessary for binding of free bilirubin); 2) a hypoalbuminemia (at the same time communication of bilirubin with protein decreases and toxic impact of bilirubin on nervous cells increases); 3) the hypoxia promoting increase in permeability of cellular membranes for bilirubin; 4) dehydration leading to increase in concentration of bilirubin.
Sexual crisis of occurs at N. considerably less than at the full-term newborns, mammary glands, as a rule, do not excrete a molozivopodobny secret.
Physical and psychological development
At N. is noted by of all degrees of prematurity a low increase of body weight for the 1st month of life at the expense of bigger, than at full-term, losses of initial body weight. At N. of loss of initial weight makes 9 — 14% in relation to body weight at the birth (at the full-term 5 — 6%, 8% are more rare). The more the body weight of the premature child at the birth, the quicker occurs is recovered iye initial weight. The less the child at the birth weighed, the weight of his body on the first year of life (tab. 1) increases more intensively. The monthly increase of growth at N. of of all degrees of prematurity on the first year of life averages 2,5 — 3 cm. The circle of the head in the first 2 months of life on average is more than circle of a breast on 3 — 4 cm; by a year depending on degree of prematurity the circle of the head is equal to 43 — 46 cm, a circle of a breast — 41 — 46 cm.
By 3 years of life the weight and N.'s growth by in most cases approach the corresponding indicators of the full-term peers.
For the first 1,5 years of life rates of psychological development in almost healthy N. of in comparison with full-term are detained; formation of the main psychological reactions is as if shifted in time for later age stage. Extent of this shift depends on degree of the prematurity expressed in weeks i.e. gestational (pre-natal) age and body weight at the birth.
N. have for 0.5 — 2 months later, than at full-term, visual and acoustical concentration, purposive movements of hands, ability to sit, stand and go appears; several months later they begin to speak.
Formation of psychological reactions at healthy N. of, in addition to degree of prematurity and body weight at the birth, is influenced by also perinatal «risk factors» — Burdeness of the obstetric anamnesis of mother, a hypoxia of a fruit in labor. Rates of psychological development in N.D. which had a syndrome of oppression of c in the period of a neonatality are authentically more detained on the first year of life. N of page (see. Birth trauma ).
Features of a course of diseases, their treatment and prevention at premature children
owing to immaturity of a number of bodies and systems, and anatomo-physiological features of an organism at N. observes higher, than at full-term, incidence and a peculiar current of a number of diseases.
The intracranial birth trauma, perinatal post-hypoxemic encephalopathy, in a pathogeny a cut, as a rule, lies a hypoxia of a brain of a fruit and the newborn, is shown by an adynamia, a pyshechny atony, an areflexia, a rough and frequent tremor of extremities and an athetosis. At the same time the vertical nystagmus, a symptom «setting the sun» (the rolling of eyeglobes reaching such degree when only a part of an iris is visible), the expressed persistent squint, spasms, etc. is noted. At children with body weight at the birth till 1500 symptoms of oppression of c prevail. the N of page (hypo - or an adynamia, hypo - or an areflexia), at children with a big weight is signs of excitement of c. N of page (motive concern, hyper tone of muscles, etc.).
The hemolitic disease of newborns at N. of proceeds more hard, than at full-term. Almost total absence of hypodermic cellulose conducts to later a wedge, to display of jaundice that can lead to untimely therapy of this disease.
Changes in blood not always correspond to weight of a disease; sharply expressed anemia, the hyperglobulia, a leukocytosis characteristic of a hemolitic disease at the full-term newborns, at N. of can be absent. At children 1 — the 2nd degree of prematurity with a hemolitic disease of change in blood are similar to changes in blood at the sick full-term newborns. Biliru-binovy intoxication of c. the N of page at children at prematurity 3 — the 4th degree comes at rather low level of an indirect bilirubin in blood — 9,0 — 12,0 mg / 100 ml. The forecast of a hemolitic disease of newborns at N. of heavier, than at full-term (see. Hemolitic disease of newborns ).
Sepsis at N. of with low body weight (till 1500) at the birth arises by 3,5 times more often than at children with big body weight. At N. of umbilical sepsis meets more often, to-ry it is characterized by a subacute current. From the moment of infection of the child to the first displays of a disease often there passes the eclipse period equal on average to 20 days. The first displays of a disease — slackness, bad suction, emergence or increase of vomiting, blanching of integuments with a gray shade, flattening of a curve of body weight or the termination of increase of weight. In the heat of a disease there comes the condition of toxicosis, vomiting amplifies, integuments get a dirty-gray shade, on a stomach the network of saphenas is brightly expressed, at a part of children the polyadenia is observed, anemia accrues. Temperature reaction, as a rule, is absent. The liver increases, jaundice develops. At N. sepsis is complicated by pneumonia more often, edges the wedge, manifestations is characterized by a wavy current with scanty. The heaviest complication of sepsis — an ulcer and necrotic coloenteritis with perforation of ulcers and development of peritonitis. Sepsis at N. quite often comes to an end with letalno (see. Sepsis ).
Pneumonia at N. begins gradually more often. The general slackness of the child, hypotonia, a hyporeflexia is noted, the phenomena of respiratory insufficiency and intoxication prevail. Very much early signs of disturbance of peripheric circulation appear (a mramornost of integuments, etc.). Breath 20 — 75 in 1 min., usually superficial, sometimes groaning, is more rare — foam at a mouth. The tympanic shade of a percussion sound in lobbies and its obtusion in juxtaspinal departments of a thorax, crepitant rattles, attacks of cyanosis is noted (see. Pneumonia, at children ).
Rickets develops at N. of earlier, than at full-term — on 1 — 2 months of life. Its emergence is promoted by a number of the factors caused by immaturity of an organism of the premature child (a weak mineralization of bones, a reduced resorption of fat, the lowered reabsorption of phosphates in kidneys). The disease quickly progresses and flows, as a rule, sharply. Feature of rickets at N. of is lack of the period of neurovegetative frustration (see. Rickets ).
Anemia. Healthy N. of in the first 2 — 3 months of life often have a so-called early anemia (Hb — 50 units and below) connected with an increased hemolysis of erythrocytes and relative insufficiency of system of a hemopoiesis. Hemolysis considerably decreases by 4 months of life, and indicators of red blood spontaneously improve; therefore early anemia of N. of does not demand special treatment.
Late anemia premature (arising in the second half of the year of life) has almost always iron deficiency character that is caused by exhaustion of the reserves of iron received from mother, insufficient assimilation of the iron arriving with food, and the need for iron increased in comparison with the full-term children because of more intensive processes of increase in body weight and volume of blood.
Treatment of all the list of lenny diseases is similar to their treatment at the full-term children, however during the performing therapy it is necessary to consider specifics of reactions of an organism of N. of to these or those l-ech. actions (bystry exhaustion of compensatory and protective forces). It is necessary to avoid or to carefully appoint the stimulating therapy (hemotransfusion, administration of gamma-globulin, etc.), after a cut the short-term effect with the subsequent exhaustion of the main fiziol, processes and an aggravation of symptoms of the child can be observed.
In prevention of all diseases of N. of matters fight against not incubation of pregnancy, antenatal protection of a fruit (see), correct maintaining childbirth (see), prevention of a birth trauma. The healthy nutrition and measures for fight against anemia of mother, purpose of the correct mode of leaving and feeding of the newborn are necessary for the prevention of anemia of N. of. In prevention of pneumonia at N. of timely holding resuscitation actions at the birth of children in asphyxia is important. At disorders of breath at N. of with a big risk degree of development of inflammatory process in lungs introduction of antibiotics in the first days of life is reasonable.
Specific prevention of rickets by means of vitamin D 2 at N. shall begin not later 10 — the 15th day of life. The daily dose of D2 vitamin shall not exceed 15 000 ME, the general preventive dose — no more than 400 000 ME within a month. Carrying out the general Ural federal district strictly individually depending on a season of year. In prevention of rickets at N. of the big role belongs to the correct leaving, the mode, rational feeding with inclusion of the products containing vitamin D, to purpose of a complex of vitamins.
N. of with the postponed intracranial birth trauma at diseases of acute respiratory infections can have convulsive attacks during rise in temperature, Such children need to be preserved especially carefully against recurrent respiratory diseases and to hold recreational events (strict observance of the mode, sufficient stay on air, massage, gymnastics and so forth).
Big care and extreme attentiveness should be shown at appointment and N.'s carrying out of of preventive inoculations. All inoculations should be carried out by the sparing method (see. Vaccination ). Do to the children who had asphyxia or an intracranial birth trauma, preventive inoculations at the birth (AKDS, protivokorevy) at the age of 1 year — 1 year 6 months and even later.
The organization of medical care and feature of care of premature children in the conditions of maternity hospital and a hospital
Immaturity of an organism of N. of (which were especially born at sick mothers) and a bystry exhaustion of the main fiziol, processes cause the necessity of the organization for them within the first 1,5 — 2 months of life of the sparing mode providing sharp restriction of temperature variations and humidity of the environment, influence of tactile, sound, light and other irritants. The main requirement at care of N. of — the most strict observance of all rules of an asepsis and antiseptics.
For the prevention of the phenomena of secondary asphyxia roughing-out of all N. of after the birth is carried out on a special swaddling little table with heating. N of with body weight at the birth of St. 2000 transfer to special chambers for premature children's department maternity home (see). At a satisfactory increase of weight and a top general condition (suction, the active movements, etc.) such children can be written out from a maternity home on the pediatric site on condition of active patronage at home (terms of an extract are individual and depend on a condition of the child).
Children with body weight at the birth of 1500 and below, with sharply expressed disturbance of thermal control, and also children with big body weight, but with any pathology right after roughing-out are placed in closed couveuse (see) with t ° 34 — 32 °, edges it is regulated depending on the body temperature of the child (at measurement in an anus it shall make it from 36,6 to 37,1 °). In the couveuse oxygen at the rate of 2 l in 1 min. shall move constantly. Humidity in the couveuse is installed to 80%, by the end of 1 week of life it is reduced to 60 — 50%. Such children should be transferred from delivery room to chambers of an intensive care or in special chambers for N. of a maternity home where they are placed in the couveuse again (in order to avoid overcooling and asphyxia of children should be transferred from department to department with hot-water bottles and an oxygen cushion). On 7 — the 8th days of life of N. of transport in specially equipped car for transportation premature (equipped with the transport couveuse, in to-ry the warmed-up and moistened oxygen moves, and serviced by specially trained paramedical staff) in special department-tsy for N. or in department of pathology of newborn children's hospitals where they are treated and nurse to an absolute recovery and until the body weight of the premature child does not reach 2500 (these terms average apprx. 45 — 47 days). In order to avoid a cross infection sick N. shall be in the boxed chamber where it is necessary to create an optimum temperature schedule and humidity since cooling or overheating promote a disease of pneumonia. Terms of a rearrangement of N. from the couveuse in a bed depend on their state. At first N. in a bed warm hot-water bottles.
N., especially in the first weeks of life, shall receive maternal breast milk or the decanted donor breast milk. Natural feeding provides the maximum success in nursing of these children. Women's milk promotes dominance in intestines of babies bifidobacteria (see), antiblastic putrefactive flora of intestines, also contains the substances promoting formation at the newborn fiziol, immunity (see. Breast milk , Colostrum ).
For N. of which were born in rather satisfactory condition and with body weight it is higher than 2000, it is reasonable to appoint the first feeding in 8 — 12 hours after the birth. At the body weight of the child till 2000 on condition of stay it in the couveuse where the necessary temperature and humidity is maintained, it is not put to a breast during the whole time of stay in a maternity home (5 — 7 days), and raise by means of the probe or a pacifier (depending on a condition of the child and existence of a sucking reflex); the first feeding is appointed also in 8 — 12 hours after the birth.
At the choice of a method of feeding are guided generally by degree funkts, a maturity of the premature child, his general condition, activity of suction, swallowing and indicators of body weight. At weak sucking and lack of a deglutitory reflex feeding is made by means of the thin polyethylene probe. As a rule, children with body weight during the first 1,5 — 2 weeks of life are fed less than 1300 via the probe since at the same time they get tired less. When the condition of the child improves and the sucking movements become more actively, a part of feedings via the probe gradually replace with feeding from a pacifier. By such combined method usually raise children with the body weight of 1300 — 1500 in the first 2 — 3 weeks of life. Further gradually feeding via the probe is excluded and passed to feeding from a pacifier.
The issue of N.'s feeding by is resolved by a breast strictly individually. If satisfactory and it well exhausts a condition of the child from a pacifier, without getting tired, the amount of food appointed to it, puts on weight, it is put to a breast. Approximately it corresponds 3rd week of life.
It is necessary to hold the child at a breast no more than 15 — 20 min. As N. of at suction quickly get tired, a deep sleep, in to-ry they fall through a nek-swarm time after the beginning of suction, is not a sign of saturation.
Having checked amount of the exhausted milk by weighing of the child before feeding by a breast, it needs to be finished feeding to norm the decanted breast milk from a pacifier. If mother has flat or big nipples and the child does not take a breast, it is necessary to feed him from a breast through a special slip. The act of suction plays big fiziol, a role, increasing secretion of digestive glands at the child and stimulating a lactation at mother.
For calculation of amount of milk, necessary N., use method of caloric calculation. In the first 3 days of life the caloric content of food for N. makes from 40 to 60 kcal on 1 kg of body weight a day that in terms of colostrum makes 35 g; to 7 — to the 8th day of life — 70 — 80 and to 10 — to the 14th day — 100 — 120 kcal on 1 kg of body weight a day.
For convenience of calculation of amount of the milk demanded to the child in the first 10 days of life use Rommel's formula, on a cut so many grams of milk how many to the child of days, plus 10 are appointed to each 100 g of weight of the child. Caloric content of the food calculated by this formula slightly higher.
To monthly age of N. of shall receive (on 1 kg of body weight a day): 135 — 140 kcal; approximately from 2-month age to the children who were born with body weight more than 1500, caloric content is reduced to 130 — 135 kcal; the children who were born with body weight till 1500 up to 3 months shall receive 140 kcal; in 4 — 5 months — 130 kcal.
Both increase, and decrease in caloric content of food shall be made not only depending on age of the child, but it is obligatory taking into account his condition, portability of food and intensity of increase of body weight. At the mixed and artificial feeding the caloric content of food shall be 10 — 15 kcal higher, than at natural feeding.
Premature children shall receive a day 200 ml of liquid on 1 kg of body weight therefore in addition to daily amount of milk it is necessary to enter liquid. Excluding from daily amount of the liquid consumed by the child, a cut he receives with milk (87,5 ml in each 100 ml of the received milk), receive the volume of liquid, to-ry it is necessary to enter in the form of drink (solution of glucose or Ringer's solution diluted with water with addition 5 or 10 of % of solutions of glucose use 5%). Liquid is entered in the small portions between feedings, or during a night break, or added to a portion of milk.
In the first days of life of N. of it is necessary to feed more often: in the beginning appoint 12 — 10-times feeding, then gradually pass to more rare feeding with a 3-one-hour break between feedings and a night break for the 6th hour. Usually transition to feeding with 3-hour breaks is carried out to 5 — to the 8th day of life, howling the accounting of a condition of the child. From the 2nd week of life 7-times feeding is accepted, as a rule.
At natural feeding optimum indicators of a nitrogen metabolism are provided at introduction with food of the following amount of protein: aged to 2 weeks — 2 — 2,5 g on 1 kg of body weight, up to 1 month — 2,5 — 3 g on 1 kg, are more senior 1 month 3 — 3,5 g on 1 kg of body weight a day. At artificial feeding with use of the adapted milk mixes, e.g. «Baby», amount of the protein necessary for N. for aged to 2 weeks, makes 2,5 — 3 g on 1 kg of body weight, up to 1 month — 3 — 3,5 g on 1 kg and are more senior 1 month — 3,5 — 4 g on 1 kg of body weight a day.
At artificial feeding without use of the adapted milk mixes (use cultivation of cow's milk, kefir) the amount of protein on 1 kg of body weight shall make 4,0 — 4,5 g a day. Squirrels in N.'s diet of usually expect the must weight.
The need for fat at the premature child makes from 5,0 to 6,5 g on 1 kg of body weight a day and does not depend on a type of feeding. Calculation of fat in a diet is made on the existing weight of the child. Carrying out correction of fat in a diet of the premature child, it is necessary to remember its insufficiently good comprehensibility and portability an organism of the premature child.
The amount of carbohydrates in a diet of the premature child shall make from 13 to 15 g on 1 kg of body weight a day at any kind of feeding.
At an insufficient increase in weight it is necessary to carry out correction of food on a proteinaceous component.
For this purpose it is possible to enter carefully cottage cheese (usually to monthly age), since */2 teaspoons a day, having well pounded it with breast milk. It is possible to add to breast milk also kefir.
At absence or insufficient amount of breast milk at N.'s mother of raise the dry adapted blends «Baby», «Vitalakt», «Biolakt», the structure to-rykh is brought closer to breast milk. The mix «Baby» is appointed in the first 2 months of life, further passed to the mix «Kid». However preference is given to acidified milk formulas — «Biolakt», Na-rine, Boldyrgan, etc. (see. Lactic products , Milk mixes ).
On 1 month of life enter ascorbic to - that 0,01 g 3 times a day. Vitamins of V B2, B6 appoint 0,001 g 2 times a day. Terms of administration of fruit and vegetable juice and the homogenized vegetable and fruit purees, and also a feeding up are appointed from 4,5 — 5 months by the general rules of feeding of babies (see. Feeding of children ).
The excommunication from a breast is carried out by the standard rules on 11 — 12th month of life of the child.
Features of the regime of the premature child and care of it
For ensuring succession in work between children's policlinic, maternity hospital and children's hospitals at N.'s extract of in an epicrisis affect features of a current of the neonatal period at the child the pediatric site, a wedge, the diagnosis, the carried-out treatment, and also recommendations about further medical observation on the pediatric site are made.
In total N. make the group of the increased risk threatened on incidence. Children with body weight at the birth enter into group of a high risk less than 1500, and also N. which transferred in the period of a neonatality infectious diseases, in particular sepsis, pneumonia, etc., and also children with an intracranial birth trauma. The special attention is required by N. early transferred to artificial feeding.
The pediatrician of policlinic and the nurse visit the child at home in the first day after its extract from a maternity home or a hospital. On 1 month of life of the child the pediatrician shall examine it once a week, aged from 1 up to 6 months — 1 times in 2 weeks, in the second half of the year of life — once a month.
Children, body weight to-rykh at the birth made less than 1750, up to 7 months of life are under the sisterly patronage which is carried out 2 times a month. More mature N. the nurse visits 2 times a month up to 4 months of life, after 4 months of life (at satisfactory condition of the child) — once a month (see. Patronage ).
Medical overseeing of N. of includes assessment of physical and psychological development, control of feeding and its correction.
On the second year of life and in the subsequent the number of preventive medical observations depends on the state of health, physical and psychological development of the child. It is necessary to remember the life of tendency to development of anemia in N. of remaining on the second year. in this connection 1 quarterly they are recommended to do blood test. Specialists of various profiles (the surgeon-orthopedist, the neuropathologist and the oculist) shall examine the child on 1 month of life, and then repeatedly not less than 2 times a year. In total N. of with the revealed pathology shall be under dispensary observation at specialists of the corresponding profile.
At N.'s finding of in house conditions first of all it is necessary to maintain necessary temperature in the room (within 22 — 24 °). The room where there is a child, should be aired as often as possible.
Children with prematurity 1 — the 2nd degree do not need very warm wrapping, dress them also. as full-term, however under a blanket put a warm, but not hot hot-water bottle. 3 — 4-n degrees dress children with prematurity more warmly (a jacket with a hood and sleeves which are sewn up on the ends, a diaper, a diaper from a baize, a flannelette blanket and an envelope from fustian matter with the quilted quilted jacket or the put flannelette blanket). From three parties hot-water bottles, water temperature in put to-rykh shall be not higher than 60 °, and over everything wrap up the child with a flannelette or flannel or thin woolen blanket. Air temperature under the lower blanket shall be 28 — 33e. If at the child during walk is Nov and a forehead become cold, then in a cap or a hood enclose a thin coat of cotton wool.
It is impossible to constrain breath of the child hard swaddling. That all sites of lungs evenly breathed, it should be overturned periodically from one side on another. By the end of 1 month of life N.'s most usually ceases to need special warming. If the child has standard temperature of a body, and he sweats, therefore, it hot and it needs to muffle up less.
N of take out to walk after permission of the doctor, having put a hot-water bottle in a blanket. In the winter at air temperature — 7 — 10 ° children are taken out on the street aged not earlier than 3 months of life.
In the absence of contraindications, since age of 3 weeks — 1 month, N. should put on a stomach for 1 — 2 min. 3 — 4 times a day. At the age of 1 — 1,5 month include the stroking massage in a day regimen, from 3 — 6 months — other methods of massage, passive exercises with their constant complication. In the second half of the year include in a complex of physical exercises in the increasing volume active exercises (see. Gymnastics for children of early age ).
A basis of the correct nursing and N.'s education by is accurate physiologically reasonable mode. At purpose of the mode consider body weight at the birth, age, a condition of the child (tab. 2).
&Table 1.nbsp; The AVERAGE MONTHLY INCREASE of BODY WEIGHT AT PREMATURE CHILDREN DEPENDING ON BODY WEIGHT AT the BIRTH (according to V. E. Ladygina)
Table 2. The MODES FOR PREMATURE CHILDREN of the FIRST YEAR of LIFE DEPENDING ON BODY WEIGHT AT the BIRTH AND AGE (in house conditions)
Bibliography: Afonina L. G. and Dauranov I. G. Immunological shifts at premature children with an intracranial injury, Vopr. okhr. mat. also it is put., t. 20, No., page 42, 1975; Afonina L. G., Mikhaylov 3. M and T and and-e in N. A. Sostoyaniye of an immune responsiveness of patients with sepsis of premature children, there she, t. 19, No. 8, page 21, 1974; Gulkevich Yu. V. Perinatal infections, Minsk, 1966, bibliogr.; Ignatyeva R. K. Questions of statistics of prematurity, M., 1973;
Novikova E. Ch. and Polyakov G. of the item. Infectious pathology of a fruit and newborn, M., 1979, bibliogr.; Novikova E. Ch. and Tagiyevn.A. Sepsis at premature children, M., 1976, bibliogr.; Novikova E. Ch., etc. Premature children, Sofia, 1971; The Fruit and the newborn, under the editorship of L. S. Persianinov, page 199, M., 1974; Stefani D. V. and Veltishchev Yu. E. Clinical immunology of children's age, L., 1977, bibliogr.; X and z and N about in A. I. Premature children, L., 1977, bibliogr.; L. K. Fiziologiya's gods and pathology on nedonosenoto children, Sofia, 1977; A handbook of pre-natal paediatrics for obstetricians and paediatricians, ed. by G. F. Bats-tone a. o., Philadelphia, 1971.