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FOCUS ON PREMATURITY

 

Prematurity remains a public health problem

 

A recent report by the World Health Organization (WHO) states that each year, about 15 million babies in the world are born preterm (before 37 completed weeks of gestation), more than 1 in 10 babies (1). Preterm birth complications are the leading cause of death among children under 5 years of age, responsible for nearly 1 million deaths in 2013, and for many others, remain the legacy of physical, neurological or learning problems (1).

 

More than 60% of preterm births occur in Africa and South Asia, but preterm birth is truly a global problem as it has been shown an increase in preterm birth rates over the past 20 years in the lower-income and higher-income countries (1).

 

The definition of preterm birth was once defined as birth weight less than 2500 grams. As recommended by the WHO, preterm is defined as babies born alive before 37 completed weeks of gestation, regardless of the child's birth weight if it is at least 500 g.

 

There are sub-categories of preterm birth, based on gestational age (1):

  • extremely preterm (less than 28 weeks)
  • very preterm (28 to less than 32 weeks)
  • moderate to late preterm (32 to less than 37 weeks)

 

Preterm birth occurs for a variety of reasons (12-16):

  • related to socioeconomic status: age (under 20 or over 40 years), weight (thinness or obesity), smoking, precarious situation or physical violence ;
  • according to the mother's medical history: uterine malformations, history of preterm delivery (before 34), history of late miscarriages, psychological state of the mother (stress, depression, trauma) ;
  • associated with infectious factors such as local infections (eg urinary and genital infections) or general infections (eg flu)
  • related to pregnancy itself: multiple pregnancies (twins, triplets ... ), maternal stress or hyperactivity, complications (premature rupture of membranes that protect the fetus or placental bleeding disorders, hypertension ... ) .

 

 

The consequences of prematurity are well known

 

The survival of premature babies is very dependent on gestational age. Indeed, the survival of premature babies less than 24 weeks remains an exceptional event, whereas the survival of premature babies over 29 weeks admitted in neonatal unit is greater than 90% (3). Very premature babies are more likely than full-term infants to have multiple health problems in the first years of life. Thus, 40% of them are readmitted during the first year of life, against 10 % in children born at term (3). The primary cause of these hospitalizations is a respiratory disease. Retinopathy, once common, is only seen in 3-5 % of cases. 

 

The major medical concerns involving premature infants are also well known (3). Among very preterm infants, 5-10 % of them suffer from cerebral palsy and 40% from minor neuromotor deficits. Cognitive disorders, learning disorders, lowered IQ, the overall risk of mental deficiency are increased in extreme preterm (3). In EPIPAGE French survey (Etude EPIdémiologique sur les Petits Ages GEstationnels - Epidemiological Study on Small gestational ages), behavioral problems at the age of three years are two times more prevalent than in full-term children, although deafness, deemed common in premature, is rare ( 0.5%) in the EPIPAGE investigation, as well as severe visual deficits (3).

 

 

Moderate prematurity and Respiratory Distress Syndrome (RDS)

 

The moderate prematurity however, should not be trivialized. The outcome of moderate and late preterm infants is actually studied only in recent years. Estimation of their real consequences remains imperfect and long term prognosis contains many uncertainties. All current gravity is due to disabilities which express later: hearing disorders, visual impairments, alterations of eye-hand coordination skills, attention deficit disorders, psychological troubles and school difficulties (4)

 

Late-preterm infants are 7 times more likely to have newborn morbidity than term infants (22% vs 3%). The newborn morbidity rate doubled in infants for each gestational week earlier than 38 weeks (5).

 

Late preterm birth, compared with term delivery, was associated with increased risk of respiratory distress syndrome and other respiratory morbidity (6). Thus, respiratory distress syndrome is the leading should not be underestimated in late preterm.

 

Furthermore, in a recent Swedish study, it has been shown that moderately preterm infants still have substantially increased risks for neonatal morbidity with 28% of respiratory distress, 16% of hypoglycemia, 15% of bacterial infection and 59% of hyperbilirubinemia (7, 8).

 

In terms of neurological development, the risk of cerebral palsy decreases since the 1990s but it remains 6-7 times higher among children born between 32 and 36 weeks than at term (9). Difficulties finally make it necessary academic support in more than one in two premature children, especially in mathematics (10, 11).

 

 

 (1) OMS ed. Arrivés trop tôt: rapport des efforts mondiaux portant sur les naissances prématurées. Genève: OMS; 2012:1–12.

 (2) Mackay DF, Nelson SM, Haw SJ, Pell JP. Impact of Scotland's Smoke-Free Legislation on Pregnancy Complications: Retrospective Cohort Study. Lanphear BP, ed. PLoS Med. 2012;9(3):e1001175.

 (3) Zupan Simunek V. Le devenir des prématurés en 2008 en France. Journées Parisiennes de Pédiatrie: 2008:1–9.

 (4) Senterre T, Beauduin P, Dubru JM, Rigo J. [Care and follow-up of premature infants after discharge]. Rev Med Liège. 2008;63(4):199–207.

 (5) Shapiro-Mendoza CK, Tomashek KM, Kotelchuck M, et al. Effect of Late-Preterm Birth and Maternal Medical Conditions on Newborn Morbidity Risk. Pediatrics. 2008;121(2):e223–e232.

 (6) Consortium on Safe Labor, Hibbard JU, Wilkins I, et al. Respiratory morbidity in late preterm births. JAMA. 2010;304(4):419–425.

 (7) Altman M, et coll. Neonatal Morbidity in Moderately Preterm Infants: A Swedish National Population-Based Study. J Pediatr. 2011 ; 158 (2) : 239-44.

 (8) Engle WA, Tomashek KM, Wallman C, and the Committee on Fetus and Newborn. “Late-Preterm” Infants: A Population at Risk. Pediatrics. 2007;120(6):1390–1401.

 (9) Himmelmann K, et coll. The changing panorama of cerebral palsy in Sweden. X. Prevalence and origin in the birth-year period 1999–2002. Acta Paediatr 2010 ; 99 (9) : 1337-43.

 (10) Pritchard VE, Clark CAC, Liberty K, Champion PR, Wilson K, Woodward LJ. Early school-based learning difficulties in children born very preterm. Early Hum Dev. 2009;85(4):215–224.

 (11) Larroque B, Ancel P-Y, Marchand-Martin L, et al. Special Care and School Difficulties in 8-Year-Old Very Preterm Children: The Epipage Cohort Study. PLoS ONE. 2011;6(7):e21361.

 (12) HAS. Grossesse à risque : orientation des femmes enceintes entre les maternités en vue de l’accouchement. Recommandations. Décembre 2009.

 (13) HAS. Comment mieux informer les femmes enceintes. Recommandations pour les professionnels de santé. Avril 2005.

(14) HAS. Mesure de la longueur du canal cervical du col de l’utérus par échographie par voie vaginale : Intérêt dans la prévision de l’accouchement prématuré spontané, juillet 2010.

 (15) Amri F, Fatnassi R, Negra S, Khammari S. Prise en charge du nouveau-né prématuré. Journal de pédiatrie et de puériculture 2008 ; 21 : 227-231.

 (16) Laugier J, Rozé JC, Siméoni U, Saliba E, Soins aux nouveau-nés avant, pendant et après la naissance. Masson 2ème édition, 2006.

 

 

 

CARE FOR THE PREMATURE BABY

 

Progress in the care of preterm infants

 

Thanks to technological and therapeutic advances, babies are increasingly surviving premature birth at earlier gestational ages. But, the frequency of mid-term and long-term sequelae has increased among survivors, especially in extreme preterm infants (those born before 28 weeks of pregnancy) (1).

 

Neonatology, obstetrics and anesthesia are areas of medicine in which the advances have been spectacular (1), with improved fetal monitoring and improved neonatal management including surfactant, antenatal glucocorticoid therapy, and less aggressive mechanical ventilation (1).

 

Since 1998, the organization of care throughout France has resulted in the identification of high-risk pregnancies to allow the transfer in suitable maternity. Similarly, cooperation between obstetricians and paediatricians has been established between the various maternity and neonatal intensive care unit (NICU) (1)

 

The Humanization of Care concern is considered a priority, and this humanization features including in-depth reflection with parents about medical decisions before and after birth, and the implementation of developmental care ( NIDCAP for Newborn individualized Developmental Care and Assessment Program) (1, 2).

 

 

A support from the delivery room  

 

The objectives of the delivery room resuscitation are to ensure adequate ventilation and maintain a good hemodynamic balance. The respiratory resuscitation is a priority.

 

Among the specific recommendations in the management of the extreme preterm appear early surfactant administration, and an initial oxygenation (3).

 

The care of the newborn in delivery room is based primarily on the assessment of the child’s state. The three criteria are the effectiveness of the respiratory movements, heart rate and staining (3). Apgar score at 1, 3 and 5 minutes after birth, can assess the initial state of the newborn and its evolution, and determines if there's an immediate need for extra medical or emergency care.

 

In all guidelines respiratory resuscitation is today the priority in the first minutes. Non invasive positive pressure ventilation and early use of exogeneous surfactant are the recent advances for the care of very premature baby in delivery room (4). Alveolar growth is essential to ensure an adequate respiratory function from the lungs. This complex process is initiated at the end of fetal life, but occurs mostly after birth in very premature infants (5).

 

 (1) Salle B, Sureau C. Le prématuré de moins de 28 semaines, sa réanimation et son avenir. Bull Acad Natle Med. 2006;190:1261–1274.

(2) Als H, Duffy FH, McAnulty G, et al. NIDCAP improves brain function and structure in preterm infants with severe intrauterine growth restriction. J Perinatol. 2012:1–7.

(3) Mitanchez D, Gold D. Quelle réanimation pour quel prématuré ? 51e Congrès national d’anesthésie et de réanimation; 2009:1–11.

(4) Chabernaud JL. Aspects récents de la prise en charge du nouveau-né en salle de naissance. Arch Pediatr. 2005;12(4):477–490. Aspects récents de la prise en charge du nouveau-né en salle de naissance

(5) Bourbon J. Développement alvéolaire normal et pathologique (revue). Rev Fr Allergol. 2005;45(7):503–508.