Pakistan’s First Parenting Magazine

When Your Baby is Born Early

How to take care of your premature child

By Dr. Zack Boukydis

When babies are born early, or premature, there is a recognition by parents and professionals that the baby could be vulnerable and may need ‘special care’ in order to survive, develop and have a good life.

A general definition for a premature baby is that they are born earlier than 37 weeks gestational age, weighing less than 2,500 grams at birth.  Depending on how early the baby is born, and the circumstances of the mother’s pregnancy and the birthing process, the baby may be especially vulnerable. Parents are often worried about how their baby can survive and what will be their child’s quality of life.

Organized Care for Premature Babies

Depending on the resources available in a particular region, or a particular country, a baby born premature may be taken to a hospital with a ‘special care’ or ‘neonatal intensive care’ unit. These units may use knowledge and technical understanding developed in a relatively new field of medicine called neonatology (the care of vulnerable newborn babies; especially premature babies). The basic needs of a premature baby often include:

  1. Keeping warm; this can be accommodated by placing the baby in a special bed looking somewhat like a plastic box called an ‘incubator; or by being on mother’s, father’s (or other’s) body (called skin-to-skin, or kangaroo care).
  2. Help with breathing; sometimes with special equipment called a respirator or an oxygen mask to provide the correct mix of oxygen and other gases that can enter a baby’s developing lungs and be absorbed into the baby’s blood stream.
  3. Nutrition; when a pre-term baby is very young special nutrition may be given through an intravenous line (into the baby’s vein). Slightly older babies may receive special formula or mother’s milk through a tube that goes through their nostrils to the back of the mouth (if they are too young to suck well); and as older pre-term babies begin to suck they may begin to suck on their mother’s breast or from a bottle.
  4. Helping the baby’s immune system to fight off infections, special medications may help with infections; the mother’s milk has been shown to help prevent infections.
  5. Loving care; especially from their mother, father, or other family members who may hold the baby in skin-to-skin contact; or visit the baby in an incubator, touch the baby and speak to it. Nurses and doctors who love their work and love babies can also provide loving care.

A Brief Overview of Premature Baby`s Development

Many people who have a premature baby wonder what their child’s development will be like. One can be aware of the developmental milestones of a full-term baby, but does not know what to expect when the baby is born early. It is important to remember that every baby is unique. Also depending on what kind of special care or treatment your baby is receiving, or what conditions your baby may have, he or she may follow a different course of development. He or she may have periods where development appears slower because, for instance your baby may need a lot of assistance with breathing. At times like these, it is possible that a lot of the baby’s energy is devoted to the effort of breathing and processing oxygen in his or her body and there can be less energy to fuel the next step of development.

With these considerations in mind, I indicate the progression so that many parents may have more understanding of what the world of a developing premature baby is like.

26-28 weeks gestational age

  • Have some periods of steady rhythmic breathing.
  • Can have some tremors and startles, but more ability to control the movement of their arms and legs over time.
  • There can be noticeable attempts to self soothe (hand to mouth, crossing legs, assuming a flexed posture, grasping parents’ finger, a tube or a blanket).
  • Some cry ‘attempts’, and brief high-pitched cries; alterations in ‘states of consciousness’; i.e. sleep, drowsy, fussy, very brief period of focused eyes open; hyper-alertness (strained looking), roving eye movements (sometimes eyes are coordinated, sometimes not). Mostly the baby needs to sleep, with brief awake periods.
  • Can hear and respond to sounds (parents voice, singing, rhythmic melodies)
  • Starting to establish deep restful sleep; and 24 hour daily patterns of waking and sleeping.
  • Mostly uncoordinated sucking and swallowing; but some sucking in or suction with appropriate lip shape around mother’s nipple (may not be ready for bottle feeding; if mother can’t breastfeed); a time of learning to suck, and coordinate sucking, swallowing and breathing.
  • Often most stable on mother/father’s chest; usually respond well to a loving hand on or beside his or her body or head.

28-30 weeks

  • Have longer periods of rhythmic breathing; their body is slowly gaining the ability to stay warm for short periods away from their parent’s body or a heated isolette.
  • There is more stability in their ability to control the movement of their arms and legs; sometimes have average muscle tone, and periods with hypo tonicity (less than average tone; legs or arms appear loose; can’t hold head up) and hyper tonicity (more than average tone; legs and arms can be out straight, fingers spread out; back may be arched rather than flexible).
  • There are noticeable attempts to self soothe (see list above).
  • There can be the beginning of some rhythmic crying; alterations in state; sleep, drowsy, fussy, some brief periods of focused eyes open (eyes bright, coordinated and‘taking in’ your face); still has hyper alertness; some roving eye movements.
  • Slowly establishing a predictable sleep/wake cycle.
  • Mome infants have sucking and swallowing; but must be held quietly, in a quiet place (with soft, or no voice; no active talking and looking); they can be vulnerable to other sounds, or bright lights in the room while attempting to suck, and can lose coordinated sucking and swallowing.

30-32 weeks

  • Have longer periods of rhythmic breathing; their body has some ability to stay warm for short periods away from their parent’s body or heated isolette.
  • There is more stability in the ability to control physical movement of arms and legs; more periods of average muscle tone; less times of being jittery; still have some periods of alteration between hypo and hyper tonicity.
  • There are more successful attempts to self-soothe and more frequent efforts to self-soothe.
  • There is the onset of rhythmic crying; able to cry with more ‘volume’; alterations in state; sleep, drowsy, fussy, longer periods of focused eyes open (starting to be able to turn eyes to a slowly moving face); still can have some hyper alertness; some roving eye movements.
  • Baby can have, or learn a predictable sleep/wake cycle.
  • More infants (not all) have sucking and swallowing with steady breathing while sucking; but vulnerable to other sensory input (see above) while attempting to suck; this is often the time when bottle feeding is initiated; many infants can have steady rhythmic sucking on mother’s breast.

32-34 weeks

  • Able to have steady breathing; even while being physically moved; able to tolerate and keep steady temperature for short periods away from parent’s body or the incubator.
  • Longer periods of stability in muscle tone and physical movement of arms and legs; less periods of alteration between hypo and hyper tonicity; can use steady arms and bending (flexing) fingers to explore parent’s skin, or sheets and blankets.
  • More and increasingly successful attempts to self soothe.
  • Longer periods of rhythmic crying mixed with fussing; fussing or crying is ‘clearer’ (parents can tell more easily when their baby is hungry) alterations in state; sleep, drowsy, fussy, longer periods of focused eyes open; can hold a steady ‘gaze’; looks at stable, bright, or high contrast objects; can move both eyes and head to briefly follow a moving face, or moving object; still may have some hyper alertness; some roving eye movements.
  • Can briefly turn toward sounds and voices.
  • Developing more predictable sleep/wake cycle.
  • More infants (not all) have sucking and swallowing; but vulnerable to other noises, bright lights, etc.  While attempting to suck, many infants are successful in starting and maintaining steady breast or bottle-feeding.

34-36 weeks

  • Able to tolerate longer periods away from parents’ body or isolette; may be moved to an open crib (depending on their ability to breathe well).
  • More stability in the ability to move arms and legs; use of hands for exploration; less periods of alteration between hypo and hyper tonicity.
  • Many successful attempts to self soothe.
  • Longer periods of rhythmic crying mixed with fussing; more predictable changes of state; can have a well established deep sleep; longer periods of focused eyes open; can hold a steady ‘gaze’; looks and following stable, bright, or high contrast objects and parents’ face; brief hyper alertness; some roving eye movements (especially when stressed); is able to track or follow moving objects; turn toward sounds/voices.
  • More predictable sleep/wake cycle.
  • More infants (not all) have sucking and swallowing; but are still vulnerable to noises and bright lights while sucking; many more infants are successful in starting and maintaining breast or bottle-feeding.
  • Some Guidelines for Loving Interaction with Your Baby

Along with the understanding of pre-term baby development, here are a few guidelines for loving interaction with your baby. Because premature babies are less mature than full-term babies, they cannot handle sensory input (listening, seeing, and being moved) all at the same time.  The general rule is “softer” and “less” (only one) ‘active input of touching, looking and speaking’. It is best to start out with very soft, rhythmic voice and gentle touching (or for a very early baby, holding your baby’s hand, or resting your hand beside your baby’s body). At first, watch you’re baby, watching closely is central to what we mean by listening to your early born baby. When it is possible to hold your baby, especially if this is during skin-to-skin contact, the issue is simpler- you softly hold your baby, sometimes speaking quietly and singing to it.

Pre-term babies are constantly trying to balance responding to, and seeking out stimulation, with protecting itself from too much stimulation. By watching closely, you can begin to listen to your baby and learn when he/she is remaining steady and ready (with regular breathing, good skin color) for you to ‘engage’ her, and when she is protecting herself (turning her head from too much stimulation, putting her hand or arm over her face; sometimes showing stronger stress signs such as grimacing, looking very tired; change of breathing patterns, and getting paler or duskier skin color).

It takes some time of watching, listening, and learning how much and what types of interaction your baby likes. What sometimes makes this especially challenging (to look and listen to a young premature baby) is that they may have events going on in their body, rather than your efforts to interact with them, which may cause the ‘stress signs’ to occur.  Sometimes parents misinterpret these changes; and can even ‘take it personally: ‘I didn’t do it right’ or even ‘she doesn’t like me’.  Your baby came from you, physically and spiritually. She is joined to you in love. She cannot ‘not like’ you. She is showing that it is ‘too much stimulation’ for her; but she still loves you and needs you. One of the beauties of skin-to-skin contact, especially with a young premature baby is that you hold them, providing your loving warmth and you and your baby can take your time to get to know each other in the way I am talking about here. It is with slightly older premature babies, especially after 32 weeks gestational age, that some of these suggestions about interaction (face to face while being held) may be especially relevant.

How to Rally, How to Endure?

As a psychologist working with families with premature babies and parents, I want to say some things that may be helpful to parents who have given birth to a premature baby.

With many technical advances in the care of premature babies, there is also widespread recognition that parents are important for the baby during hospital care. I encourage parents to be with their baby, to hold their baby (have as much skin-to-skin contact as possible), to breastfeed their baby and to care for their baby as much as they can. Some hospitals and professionals support parents, some are neutral, and some are consumed by the difficult job of caring for the babies and don’t feel they have the resources for supporting the parents. Also, as babies are unique, each family situation is unique. Some parents live too far from a hospital while some may have other children or family members to care for. Therefore, while I will continue to advocate for parents loving and caring for their babies in hospitals, I want to care for parents who can have limited or no contact with their baby. What I have seen over the years is that babies are resilient and can live through the early hospitalization. But sadly, some babies pass on, related to the illnesses of prematurity. Certainly, while it matters that babies are held, what matters most is that babies are held in heart, and in mind. With support and self-respect, I trust that parents have the inner resources to find their way in the often difficult situation of having a premature baby in a hospital. What matters for many parents is that they recognize, sometimes immediately, sometimes over time, that their baby has a deep will to live. If parents can feel this for themselves they can find extra inner resources to care for and have hope for their baby. One mother puts it this way; “she is small and seems so helpless; and hanging on a delicate balance between living and dying; but I can sense her inner light, and now I can find myself rallying, finding my way through my fear and depression to be with her as her momma.”

In many areas, there are networks of parents with premature babies. Parents group in the hospital or in the community, and some hospitals have staff that can put current parents in touch with a parent who has left the hospital with their baby, and who would be willing to meet, listen to the current parent, and offer their experience.

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