Premature children are the children who were born before the term of childbirth, functionally unripe, weighing below 2500 and body less than 45 cm long. Clinical signs of prematurity include a disproportionate constitution, open seams of a skull and a small fontanel, not expressiveness of a hypodermic and fatty layer, hyperaemia of integuments, an underdevelopment of genitals, weakness or lack of reflexes, weak shout, intensive and long jaundice, etc. Nursing of premature children means the organization of special leaving - temperature condition, humidity, level of oxygenation, feeding, if necessary – performing intensive therapy.
The children who are given rise during the period from 28 to 37 week the pregnancies having the body weight of 1000-2500 and length of a body of 35-45 cm are considered as premature. Gestation term is considered the steadiest criterion; anthropometrical indicators, owing to their considerable variability, belong to conditional criteria of prematurity. Annually as a result of spontaneous premature birth or artificially induced termination of pregnancy on late terms premature 5-10% of children of total number of newborns are born.
By definition of WHO (1974), the fruit is considered viable at gestational term more than 22 weeks, body weight from 500 g, body length from 25 cm. In a domestic neonatology and pediatrics the fruit birth before the 28th week of a gestation having body weight less than 1000 and length less than 35 cm is regarded as a late abortion. However, if such child was born live and lived after the birth not less than 7 days, it is registered as premature. Level of neonatal mortality among premature children is much higher than that among the full-term babies, and considerably depends on quality of delivery of health care the first minutes and days of life of the child.
All reasons leading to the birth of premature children can be united in several groups. The social and biological factors including too early or advanced age of parents (is younger 18 and 40 years are more senior), addictions of the pregnant woman, insufficient food and unsatisfactory living conditions, professional harm, an adverse psychoemotional background, etc. concern to the first group. The risk of a premature rodorazresheniye and the birth of premature children is higher at the women who were not planning pregnancy and neglecting medical maintenance of pregnancy.
The second group of the reasons is made by the anamnesis and the pathological course of the real pregnancy burdened obstetric and gynecologic at future mother. Here the greatest value abortions in the anamnesis, mnogoplody have, gestoza, a hemolytic disease of a fruit, a premature otsloyka of a placenta. Intervals between childbirth can serve as the reason of the birth of premature children short (less than 2 years). Quite often premature children are born at the women resorting to extracorporal fertilization, however it is connected not with the fact of use of VRT, and it is rather – with the "female" factor interfering fertilization in the natural way. Adversely gynecologic diseases and malformations of genitals affect incubation of pregnancy: tservitsit, the endometritis, ooforit, fibroma, endometriosis, a two-horned saddle uterus, a uterus hypoplasia, etc.
Various ekstragenitalny diseases of mother concern to the third group of the reasons breaking normal maturing of a fruit and causing the increased probability of the birth of premature children: diabetes, hypertension, heart diseases, pyelonephritis, rheumatism, etc. Often premature birth is provoked by the acute infectious diseases transferred the woman on late terms of a gestation.
At last, the birth of premature children can be connected with pathology and abnormal development of the fruit: chromosomal and genetic diseases, pre-natal infections, heavy malformations.
Taking into account the designated criteria (term of a gestation, weight and length of a body) allocate 4 degrees of prematurity:
The I degree of prematurity – a rodorazresheniye occurs on the term of 36-37 weeks of a gestation; the body weight of the child at the birth makes 2500-2001, length – 45-41 cm.
The II degree of prematurity - a rodorazresheniye occurs on the term of 32-35 weeks of a gestation; the body weight of the child at the birth makes 2001-2500, length – 40-36 cm.
The III degree of prematurity - a rodorazresheniye occurs on the term of 31-28 weeks of a gestation; the body weight of the child at the birth makes 1500-1001, length – 35-30 cm.
The IV degree of prematurity - a rodorazresheniye occurs before 28 weeks of a gestation; the body weight of the child at the birth makes less than 1000, length – less than 30 cm. Concerning such children the term "premature with extremely low body weight" is used.
External signs of prematurity
A number of clinical signs which expressiveness correlates with prematurity degree is characteristic of premature children.
Deeply premature children having body weight a hypotrophy of the II-II degree), the child's constitution disproportionate (the head big also makes about 1/3 from length of a body, an extremity rather short). The pot-belly spread with obviously noticeable divergence of direct muscles a navel is located in the lower part of a stomach.
Deeply premature children have all fontanels and seams of a skull are open, cranial bones pliable, the brain skull prevails over front. The underdevelopment of auricles, poor development of nails (nail plates do not reach finger-tips), weak pigmentation of nipples and okolososkovy circles is characteristic. Genitals at premature children are underdeveloped: at girls the gaping of a sexual crack is noted, boys have not omission of testicles in a scrotum (kriptorkhizm).
The premature children who are given rise on term 33-34 weeks of a gestation later are characterized by a bigger maturity. Their appearance differs in pink color of integuments, lack of a down on a face and a trunk, more proportional constitution (the smaller head, higher arrangement of a navel and so forth). At premature children of the I-II degree bends of auricles are created, pigmentation of nipples and okolososkovy circles is expressed. At girls big vulvar lips almost completely cover a sexual crack; at boys testicles are located at an entrance to a scrotum.
Anatomo-fiziologichesky features of premature children
Prematurity is defined not so much by anthropometrical indicators, how many morfofunktsionalny immaturity of vitals and systems of an organism.
Characteristics of respiratory organs at premature children are the narrowness of the top airways, high standing of a diaphragm, a thorax pliability, a perpendicular arrangement of edges concerning a breast. These morphological features of premature children cause the superficial, frequent, weakened breath (40-70 in min.), tendency to lasting 5-10 seconds ( premature). Owing to an underdevelopment of elastichesky tissue of lungs, immaturity of alveoluses, the reduced content of surfactant premature children easily have a syndrome of respiratory frustration (stagnant pneumonia, a respiratory distress syndrome).
Immaturity of cardiovascular system is characterized by lability of pulse, tachycardia 120-180 in min., a priglushennost of warm tones, arterial hypotonia (55-65/20-30 mm of mercury.). In the presence of congenital heart diseases (the opened Botallov Canal, an open oval window) noise can be listened. Owing to the increased fragility and permeability of vascular walls easily there are hemorrhages (hypodermic, in internals, in a brain).
The weak differentiation of gray and white substance, smoothness of furrows of a brain, incomplete miyelinization of nervous fibers, the grown poor vaskulyarization of subcrustal zones are morphological features of immaturity of TsNS at premature children. A muscular tone at premature children weak, physiological reflexes and physical activity are lowered, reaction to irritants is slowed down, thermal control is broken, there is a tendency as to hypo - and a hyperthermia. In the first 2-3 weeks at the premature child can arise passing and squint, a tremor, starts, stop.
At premature children functional immaturity of all departments of digestive tract and low fermentovydelitelny activity is noted. In this regard premature children are predisposed to vomiting, development of a meteorizm, dysbacteriosis. Jaundice at premature children is expressed more intensively and remains longer, than at the full-term newborns. Owing to immaturity of fermental systems of a liver, the increased permeability of a hematoencephalic barrier and rough disintegration of erythrocytes at premature children bilirubinovy encephalopathy can easily develop.
Functional immaturity of kidneys at premature children leads to change of electrolytic balance (a gipokaltsiyemiya, a gipomagniyemiya, a gipernatriyemiya, a giperkaliyemiya), to dekompensirovanny metabolic acidosis, tendency to developing of hypostases and bystry dehydration at inadequate leaving.
Activity of endocrine system is characterized by a delay of formation of a circadian rhythm of release of hormones, bystry exhaustion of glands. At premature children low synthesis of catecholamines is noted, the tranzitorny hypothyroidism often develops, in the first days of life sexual crisis is seldom shown (physiological mastitis, physiological vulvovaginit at girls).
At premature children more in high gear, than at full-term, early anemia develops, there is an increased risk of development of a septitsemiya (sepsis) and a septikopiyemiya (purulent meningitis, osteomyelitis, an ulcer and necrotic enterokolit).
Within the first year of life increase of weight and length of a body at premature children happens very intensively. However on anthropometrical indicators premature children catch up with the peers born in time only by 2-3 years (sometimes by 5-6 years). Lag in psychomotor and speech development in premature children depends on degree of prematurity and the accompanying pathology. At the favorable scenario of development of the premature child alignment happens on the 2nd year of life.
Further physical and psychomotor development of premature children can go on an equal basis with peers or be late.
Among premature children more often than neurologic violations occur among the full-term peers: asteno-vegetative syndrome, hydrocephaly, convulsive syndrome, vegeto-vascular dystonia, cerebral palsy, hyperactivity, functional dislaliya or dizartriya. Almost pathology of an organ of vision – short-sightedness and an astigmatism of various degree of expressiveness, glaucoma, squint, an otsloyka of a retina, an atrophy of an optic nerve is found in a third of premature children. Premature children are inclined to frequent repeated SARS, otitises against the background of what relative deafness can develop.
The women who were born premature in adulthood often suffer from violations of a menstrual cycle, signs of sexual infantility; at them the threat of spontaneous termination of pregnancy and premature birth can be noted.
Features of care of premature children
The children born by premature need the organization of special leaving. Their stage-by-stage nursing is carried out by experts of a neonatologama and pediatricians at first in maternity hospital, then in children's hospital and policlinic. The main components of care of premature children are: providing optimum temperature moisture conditions, rational kislorodoterapiya and the dosed feeding. At premature children constant control of electrolytic structure and BRAIDS of blood, monitoring of gas composition of blood, pulse and HELL is exercised.
Deeply premature children right after the birth are located in couveuses where taking into account a condition of the child the constant temperature (32-35 °C), humidity (in the first days about 90%, then 60-50%), the oxygenation level (about 30%) is maintained. Premature children of the I-II degree are usually placed in beds with heating or in usual beds in special boxes where the air temperature of 24-25 °C is maintained.
The premature children capable to independently maintain normal body temperature, the reached body weights of 2000 having a good epitelization of an umbilical wound can be written out home. The second stage of nursing in specialized offices of children's hospitals is shown the premature, not reached in the first 2 weeks of body weight 2000, and to children with perinatal pathology.
Feeding of premature children it is necessary to begin already during the first hours lives. Children with absent sosatelny and glotatelny reflexes receive food via the gastric probe; if the sosatelny reflex is expressed enough, but body weight less than 1800 – the child is raised through a pacifier; children with body weight can be attached over 1800 to a breast. Frequency rate of feedings of premature children of the I-II degree of 7-8 times a day; III and IV degrees - 10 times a day. Calculation of food is made on special formulas.
Premature children with physiological jaundice, have to receive phototherapy (the general Ural federal district). Within rehabilitation of premature children at the second stage communication of the child with mother, contact "skin to skin" is useful.
Medical examination of premature children
After an extract the children born by premature need constant observation of the pediatrician within the first year of life. Surveys and anthropometry are carried out weekly in the first month, 1 every two weeks – in the first half of the year, once a month - in the second half of the year. On the first month of life premature children have to be examined by the children's surgeon, the children's neurologist, the children's traumatologist-orthopedist, the children's cardiologist, the children's ophthalmologist. At the age of 1 year consultation of the logopedist and children's psychiatrist is necessary for children.
From 2 weeks age premature children need prevention of iron deficiency anemia and rickets. Preventive inoculations to premature children are carried out according to the individual schedule. On the first year of life repeated courses of baby massage, gymnastics, the individual improving and tempering procedures are recommended.