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What is Prematurity?

Introduction
This article will discuss some aspects of prematurity in South Africa, such as reasons for and risk of prematurity, stimulation and follow-up of the premature infant and premature baby feeding.

Definitions

A baby born before 37 weeks of the pregnancy being completed is regarded as premature and when born before 28 weeks the baby is extremely preterm. This prematurity can also be classified according to the weight of the baby at birth. Low birth weight (LBW) is a baby with a birth weight between 1 500 and 2 500 grams. Very low birth weight (VLBW) is a baby with a birth weight of less that 1 500 grams. An extremely low birth weight (ELBW) baby is regarded as a baby weighing less than 1 000 grams at birth. The chronological age (birth age) refers to the premmies age from the day she was actually born. After 40 weeks, the term gestational age will be replaced with corrected age. This is her chronological age (age from the day she was born) that has been adjusted by deducting the time she was premature.

The causes
Prematurity can be caused by a variety of medical conditions during pregnancy as well as certain lifestyle conditions. The likelihood for giving birth to premature babies increase when expecting multiples. In case of malnutrition of the pregnant mom, the baby may also be born too early.

Other reasons may include pre-eclampsia and HELLP syndrome. A condition more often seen is premature rupture of membranes, which may result in oligohydramnios and infection. Bleeding of the placenta may also be a reason for premature delivery, such as in placenta-previa, placenta abruption, or injury to the abdomen in case of a motor vehicle accident. Finally, fetal abnormalities might also be cause for premature birth.

Other risk factors include previous preterm birth, miscarriage or multiple abortions, urinary tract infections, vaginal infections, sexually transmitted infections and possibly other infections. History of kidney disease, uterus and cervical abnormalities, such as cervical incompetence, diabetes, clotting disorders, being pregnant with a single fetus after in vitro fertilization (IVF), being underweight before pregnancy and low weight gain during the pregnancy. Also contributing to prematurity is obesity, short time period between pregnancies (less than 6-9 months between birth and the beginning of the next pregnancy) and intrauterine growth restriction. Increased caesarean births and induction also seems to contribute to prematurity.

Lifestyle and environmental risks that may put mothers at greater risk for preterm labour include: late or no prenatal care, smoking during pregnancy, drinking alcohol, using illegal drugs, physical environment such as lead paint, crowding and pollution; domestic violence, including physical, sexual or emotional abuse, lack of social support, long working hours with long periods of standing and stress. More mothers have high-profile jobs that may cause unnoticed physical and emotional stress. High levels of stress hormones, cortisol, cross the placenta and may result in prematurity and fussy, irritable babies. Due to the improvements in the medical science it is more often possible to prevent miscarriages and this may lead to lengthening the pregnancy until the baby is viable, however premature.

Statistics
According to UNICEF 22% of all low-birth weight infants born in developing countries are born in Africa. They state that the number of low-birth weight babies is more than double the number born in developed regions, South Africa rating at a level of 14.6%. This percentage may increase to as much as 25% in the public sector. The mortality rate of premature babies is three times higher than in newborns.

Challenges/risks

A premature baby is not just a very small baby. Premmies are at risk since the support and protection of the womb is abruptly removed while the immature organs still need to continue their development, especially the brain.

Immature lungs and brain cause some complications of preterm birth. This includes temperature instability, feeding difficulties, breathing problems (Respiratory Distress Syndrome and chronic lung problems), tachypnea of the newborn, retinopathy of prematurity, necrotising enterocolitis and jaundice. The premature infant is also at risk for physiological, emotional, neurosensory, developmental and psychosocial development problems due to the extrauterine demands made on the central nervous system (CNS) that is not yet prepared for this environment. Premature babies may also be at risk for hearing loss due to immature development and exposure to a compromising environment, such as the NICU and noisy incubators, infections in utero, high bilirubin levels, treatment with certain antibiotics and severe asphyxia, caused by periods of too little oxygen.

Later developmental problems may include mental and neurological problems, such as cerebral palsy, visual, hearing, and motor deficits, poor emotional regulation, as well as emotional vulnerability and difficulties with self-regulation and self-esteem. Attention problems and language delays leading to learning disabilities, lower IQ, impaired executive function and attention deficit disorders. Prematurity may also lower the fatigue thresholds that may influence activities of daily living, distractibility, impulsivity, concentration difficulties, spatial processing disturbances, language comprehension and speech problems. Premature babies experience more health problems, such as asthma, upper and lower respiratory infections and ear infections. Premature babies may be at risk for these developmental problems, but that is not a given that all premmies will experience all these problems, if any.

Conclusion
Prematurity in South Africa is a growing phenomenon. An average of 14% of all babies in South Africa are born premature and therefore it is important that all healthcare professionals are knowledgeable regarding their potential challenges, development that may be at risk and most importantly how to manage these babies and their parents. The next articles on prematurity will focus on the stimulation and follow-up of the premature baby as well as the how to manage the baby once she is ready to go home.


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