Terminology. preterm birth(birth premature baby) are births that occur before the end of the full 37 weeks of pregnancy. The gestational age (gestational age) is conditionally counted from the first day of the last menstrual cycle.

The term post-conceptual age, the estimated total (i.e., gestational plus postnatal) age of the premature baby in weeks since the start of the mother's last menstrual cycle, may be used. For example, a 7-week-old baby (baby 1 month 3 weeks old) born at 25 weeks of gestation is treated as a baby with a post-conceptual age of 32 weeks. In this situation, the term postmenstrual age is sometimes used to describe the same combination of gestational age plus postnatal age. Knowledge of the post-conceptual age of the premature baby in practical work necessary, especially in the first months of life, for a correct assessment of the correspondence of his neurological status (a necessary and important component of the characteristics of the general condition of a premature newborn) to true maturity this child. It is known that muscle tone, the appearance of unconditioned reflexes of the newborn, behavioral reactions have fundamental differences depending on the period of development in weeks.

According to the order of the Ministry of Health of Russia No. 318 dated 04.12.92, the following terminology is recommended:

all children with body weight<2500 г - это новорожденные с малой массой. Среди них выделяют группы:

2 5 0 0 - 1 5 0 0 g - children with low birth weight (LBW);

1 5 0 0 - 1 0 0 0 g-very low body weight (VLBW);

1 0 0 0 g - with extremely low body weight (ELBW).

In order for domestic statistics to be comparable with international criteria in the field of perinatology, Russia, taking into account WHO recommendations, switched to new criteria, which is reflected in the above-mentioned order. Health institutions must register all children born alive and dead, who have a birth weight of 500 g or more, a length of 25 cm or more, with a gestational age of 22 weeks. and more (industry indicators). However, as before, the state statistics of those born alive takes into account only children from 28 weeks. gestation or more (body weight 1 0 0 0 g or more, length 35 cm or more). Of those born alive with a body weight of 5 0 0 - 9 9 9 g, only those newborns who lived 1 6 8 hours (7 days) are subject to registration in the registry office.

Classification. The use of the classification of prematurity by degrees that previously existed in the domestic literature is inappropriate, because the division of children into groups according to body weight in no way reflects the true degree of prematurity (body weight may not correspond to the gestational age). Among premature babies in 18.6-25% of cases (G. M. Dementieva, 1978; M. V. Medvedev, 1998) there are intrauterine growth retardation in asymmetric and symmetrical types. In addition, it is known that in the group of children with a birth weight of less than 2500 g, every third is a full-term newborn.

Currently, when establishing the diagnosis of a premature newborn, the gestational age in weeks at which the given birth occurred (the gestational age of the newborn) is indicated. This concretizes the basic situation, allows you to give a correct assessment of a premature baby and choose the tactics of its management (diagnosis example: premature newborn - 28 weeks).

To assess the compliance of all parameters of the development of a premature baby, the clinical state of all its systems and organs, it is first necessary to know its gestational age. Methods for estimating gestational age are outlined in chapter III.

According to the ratio of body weight and gestational age, both full-term and premature babies are divided into three groups:

large for a given gestational age (GGA);

appropriate for gestational age (GAW);

small for gestational age (SGA).

The idea of ​​this classification is not purely academic interest, it has a deep clinical meaning. Each group has a typical pathology in the neonatal period. Thus, the distribution of children into groups makes it possible to predict the pathology for each child immediately after birth, which is especially important in practical work with small children, in whom the clinical picture of various diseases is often similar. Omitting this part of the data about the newborn, the clinician can take erroneous steps towards understanding the pathology and diagnosing the disease. The most typical example is the interpretation of the syndrome of excitation and / or convulsive syndrome in children with MGV only as a consequence of the posthypoxic state, without taking into account the possible metabolic disorders (hypoglycemia, hypocalcemia) that are characteristic of children who are small by the gestational age, which can also cause arousal syndrome and require urgent measures to prevent damage to the central nervous system. If we rely on this classification (in world practice, it is always used when making a diagnosis of a newborn at any stage of pregnancy), the above diagnosis will be supplemented and will be formed as follows: premature newborn - 28 weeks, MHV (or BGV, GWT).

For postnatal assessment of the correspondence of the physical development of the child to his gestational age, special tables are used (Table 8.1 and Table 3.16).

The rate of preterm birth is highly variable. In most industrialized countries in the last two decades, it is quite stable and amounts to 5-10% of the number of children born. Frequency of premature

births in St. Petersburg - 7.4-6.7% (1999-2002). In the United States, out of 3.7 million babies born annually, 10.8% are children born weighing less than 2500 g, and 1.1% are born earlier than 32 weeks. and with body weight less than 1 2 5 0 g.

The rate of neonatal mortality in premature infants is much higher than that of those born at term and largely depends on the effectiveness of medical care: monitoring of vital functions, proper control of the thermal regime, provision of respiratory support, correction of acidosis and electrolyte disorders, introduction of adequate nutrition, rational prescribing drug therapy and infection prevention.

The survival rate of premature babies directly depends on the gestational age and birth weight. Children weighing 1500 g and below (less than 30-31 weeks of gestation) account for only 1% of all live births, but at the same time, 70% of deaths in the neonatal period (excluding children with congenital anomalies) occur in children with weight body to 1 5 0 0 g. With the accumulation of experience in the intensive treatment of newborn premature babies, a progressive decrease in the mortality rate is noted (Table 8.2).

This table is currently of historical importance, but is interesting for tracking the rate of decline in mortality of premature babies in the United States (Table 8.2) and comparing this indicator with domestic data (Table 8.3).

The premorbid background of women who gave birth to children with very low body weight and extremely low body weight, the state of health of very premature babies, the principles of therapy in the intensive care unit and long-term results of the development of children in this weight group were studied. The tactics and strategy of medical care for underweight children are shown, the structure and causes of disability in such a group of children are studied, depending on the timing of transfer to specialized departments. In the course of the work performed, it was found that the main cause of disability in children born with very low and extremely low body weight is cerebral palsy (70%) among the entire structure of disability, followed by epilepsy (20%) and retinopathy (10%). The identified changes dictate the need to develop standards for the prevention of these complications.

catamnesis

health status

very low and extremely low body weight

diagnostics

disability

cerebral palsy

1. Premature children in childhood and adolescence: a medical and psychosocial study / A.A. Baranov, V.Yu. Albitsky, S.Ya. Volgina and others - M., 2001. - 188 p.

2. Fedorova L., Vlasova O.A. Perinatal brain damage in children with extremely low birth weight // Perinatal anesthesiology and intensive care of the mother, fetus and newborn: materials of the conference, Yekaterinburg, 1999. - Yekaterinburg, 1999. - P. 381–383.

3. Kurnosov Yu.V., Merzlova N.B., Baturin V.I., Boris G.V. The main causes of disability in children born with very low and extremely low body weight in the Perm region // Modern perinatology: organization, technology and quality: materials of the I International Congress on Perinatal Medicine and the VI Annual Congress of Perinatal Medicine Specialists. - M., 2011. - S. 10.

4. Fedorova L.A. Neurological outcomes of critical conditions of the early neonatal period in premature infants with very low and extremely low birth weight: abstract of the thesis. dis. ... cand. honey. Sciences. - St. Petersburg, 2003. - 21 p.

5. Shabalov N.P. Neonatology. - St. Petersburg: "Special. lit.", 1997. - V.1. – 600 s.

The development of technologies for nursing children with very low and extremely low birth weight has led to a significant decrease in mortality. At the same time, the introduction of new methods of intensive care and resuscitation of newborns, including the use of modern respiratory equipment, the use of non-invasive diagnostic and therapeutic procedures, modern drug therapy, led to the emergence of a number of diseases that were not observed until the middle of the 20th century. This applies to such a specific pathology of premature babies as bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis, which significantly worsen the child's condition both in the acute period and in the long-term period.

The structure of pathology in children with very low and extremely low birth weight who underwent resuscitation changes depending on the improvement of intensive care methods. Thus, the use of a surfactant made it possible to reduce the severity of the syndrome of respiratory disorders and the incidence of bronchopulmonary dysplasia, however, the frequency of neurological disorders in children of this group remains high, which requires further improvement of early diagnosis methods and timely correction to improve the prognosis of their further development. In the periodical literature, there are isolated reports on the study of long-term results of the state of health of very premature babies, in addition, the question of the timing of transporting a very premature baby from remote areas to specialized centers has recently remained debatable, since any transportation, especially a small baby, is associated with a health risk. , and any unfavorable condition (noise, vibration, sound, etc.) can cause gross changes in the central nervous system.

There are 51 municipalities of the first level in the Perm Territory - 42 municipal districts and 6 urban districts with a maximum distance of 350 kilometers from Perm. More than 700 thousand children live in the Perm Territory. In 2011, 36,099 children were born in the region, of which 34,124 (94.5%) were full-term, 1,975 (5.5%) were premature, 227 (11.5%) were born prematurely with VLBW, 95 (4.8%) with ENMT.

Purpose of the work: to study the follow-up of children born with very low and extremely low body weight in the period from 2000 to 2009 and to assess their health status.

Material and research methods

Long-term follow-up was carried out in 64 children out of 216 examined, aged 2 to 10 years of age, born with VLBW and ELBW. All these children were treated in the neonatal intensive care unit of the Perm Regional Children's Clinical Hospital (PKDKB).

The analysis of medical records of 216 premature babies with birth weight from 650-1488 grams with a gestational age at birth from 26 to 34 weeks, born with VLBW and ELBW in the maternity wards of district and central district hospitals of the Perm region, was carried out.

Research results and discussion

Out of 216 very premature newborns with VLBW and ELBW born in the maternity wards of district and central regional hospitals, 64 children aged 2 to 10 years of age were examined during follow-up. 8 children out of 64 born (12.5%) were observed with ELBW, 56 children out of 146 (87.5%) survivors were observed with VLBW. When studying the anamnesis of the life of these children, it was found that all of them were born in the maternity wards of district and central regional hospitals in the Perm Territory, 80 children (37.1%) were transferred to the intensive care unit of the Perm Regional Children's Clinical Hospital (PKDKB) on the first day of life , 136 children (62.9%) were transferred at a later date - on days 2-22 of life. Transportation of newborns was carried out by a team of the resuscitation and advisory center (RCC) of the PKDKB. All children (100%) underwent transportation without a pronounced deterioration in their condition and were hospitalized in the intensive care unit of the RCCH. Two groups were distinguished by body weight: newborns with ELBW - 20 children (9.3%), of which 12 survived (60%), 8 died (40%); The VLWT group included 196 patients (90.7%), of which 146 children (73.4%) were transferred to the next stage of nursing with an improvement in their condition, 50 (26.6%) died.

The results of the studies showed that all mothers (100% of cases) had somatic diseases (anemia, hypertension, endemic goiter, vegetovascular dystonia, chronic gastritis), the presence of urogenital infections was noted in 77.1% of cases and ARVI and aggravated obstetric anamnesis was revealed in all women. The course of pregnancy, creating a risk of fetal hypoxia, was established in 75.7% of cases. Such a frequency of pathology of pregnancy, apparently, caused the onset of preterm birth due to disorders of the immune-endocrine status and disorders of the immunobiological relations between mother and fetus in conditions of chronic hypoxia.

All newborns who were in the intensive care unit underwent complex etiopathogenetic therapy aimed at eliminating the manifestations of multiple organ failure, ensuring adequate gas exchange, stabilizing central and peripheral hemodynamics, and maintaining adequate cerebral perfusion.

In order to stabilize central hemodynamics and maintain adequate cerebral perfusion pressure, volemic and catecholamine support (dopamine, dobutrex, adrenaline) was performed. Thus, dopamine was used in 163 children (75.5%), dobutamine was used in 89 (41.2%) children, adrenaline titration was carried out in rare cases, in particular, in refractory septic shock in 7 (3.2%). The use of inotropic drugs varied from 1 to 26 days, at a starting dose of 3 to 20 µg/kg/min.

Respiratory therapy was performed using all modern methods used in neonatology. In 10 newborns (5%) against the background of decompensated respiratory failure and hypoxemia, high-frequency ventilation of the lungs (HF IVL) was used.

Symptomatic therapy included pain relief, prescription of antibacterial, hemostatic and immunomodulatory drugs. The main drugs used in the intensive care unit were antibacterial, antiviral, antifungal drugs. Antibacterial drugs were used both in the escalation scheme and in the descalation scheme, depending on the severity of the child's condition, the underlying and concomitant diagnosis. With an uncomplicated infectious history in the mother, a combination of third-generation cephalosporins + aminoglycosides was initially used. The change of antibacterial drugs was carried out according to all criteria for the effectiveness of antimicrobial protection. During treatment, each child with VLBW and ELBW received 1-5 antibiotic regimens in various combinations. According to the frequency of use, cephalosporins were most often used in combination with aminoglycosides.

Antiviral therapy was used in 136 children (62.9%), in the last 2 years we have been using antiviral drugs for both therapeutic and prophylactic purposes. The most commonly used drug is viferon. Recently, the practice has included the use of immunoglobulins (immunovenin, pentaglobin, prescribed according to generally accepted schemes). Antifungal drugs were used in 59 children with VLBW and ELBW (27.3%) for therapeutic and prophylactic purposes; for prevention, an antimycotic drug was prescribed if the child had leukocytosis for a long time without an obvious focus of infection, a long time spent on mechanical ventilation, ELBW at birth. The main drugs were diflucan, amphotericin B.

In the group of children with ELBMT, the average body weight at birth was 876.75 ± 14.21 g, at the time of transfer - 1321.87 ± 12.54 g, body length - 34.87 ± 1.74 cm. minute was 3.25 ± 1.0 points, at the 5th minute the score changed slightly and amounted to 4.25 ± 0.7 points. In this group of children, there was a later hospitalization in the intensive care unit (5 children, which amounted to 62.5%, were hospitalized over 7 days of life), which was associated with an extremely difficult condition at birth, and the treatment of such a child was carried out on the spot until stabilization of the state and the emergence of transportability criteria. 6 children (75%) were transported to mechanical ventilation, 2 (25%) - to oxygen therapy. Significant changes in respiratory therapy have appeared since the use of surfactant preparations, all children transported on oxygen therapy received endotracheal surfactant at the point of treatment, and therefore invasive ventilation was not required.

At discharge from the hospital, each child born with ELBW had an average of 5.5 diseases. The main diagnoses at discharge in the children we observed in the follow-up were: respiratory distress syndrome in 3 patients (37.5%), bronchopulmonary dysplasia and perinatal damage to the central nervous system (PPCNS) were equivalent in 2, which amounted to 25%; neonatal sepsis in 1 (12.5%). Among the most frequent complications were intraventricular hemorrhages, periventricular lecomalacia, which later led to the disability of the child.

The average body weight of children born with VLBW was 1295.58 ± 34.72 g, at the time of transfer it was 1526.73 ± 15.2 g. The mean number of illnesses at discharge did not differ significantly compared to children born with ELBW. The structure of the main diagnoses during transfer was presented as follows: intrauterine pneumonia of various origins in 27 children (18.5%), respiratory distress syndrome - in 38 (26%), early and late neonatal sepsis - in 8 (5.5%) , undifferentiated localized intrauterine infection - in 14 (9.6%), PCNS - in 48 (32.8%), bronchopulmonary dysplasia - in 6 (4.1%).

According to health groups, 6 out of 8 children (75%) born with ELBW were assigned to group III, health groups II and IV were assigned to 1 child (12.5). 3 children (37.5%) were recognized as disabled in childhood, the main causes were cerebral palsy (ICP) in 2 children (25%), severe retinopathy in 1 (12.5%). The rest of the children (62.5%) had functional abnormalities in the internal organs with a favorable prognosis of the disease, such as mild BPD, partial atrophy of the optic nerves, mild neuropsychiatric retardation, pathology of early age in the form of anemia, underweight, ophthalmopathology .

Long-term results of observation of 58 children born with VLBW showed that cerebral palsy was the main cause of disability in 14 patients (70% of the total disability), epilepsy and severe neuropsychiatric retardation were recognized as the cause of disability in 2 children (20%), respectively. , sensorineural hearing loss and retinopathy of the 5th degree were equally diagnosed in 1 child (5%).

The distribution by health groups was as follows: II - 15 children (25.8%) III - 22 (37.9%), IV - 15 (25.8%), V - 4 (10.5%). Thus, the most common cause of disability in very preterm infants born with VLBW and ELBW is cerebral palsy.

Recently, the issue of the timing of transporting a very premature baby from remote areas to specialized centers has been debatable, since any transportation, especially a small baby, is associated with a health risk, and any adverse condition (noise, vibration, sound, etc.) can cause gross changes in the central nervous system.

The first group included 14 children transported to our department at the age of the first day of life from the districts of the Perm Territory to the department at birth in the group with VLBW (average weight 1276 ± 12.3 g) - 19 children; in the group with ENMT (mean weight 876 ± 5.4 g) - 2 children. The age of children is from 2 to 9 years (4.5 ± 1.3 years).

Assessment of the health group: II - 5 (23.8%), III - 9 (42.9%), IV - 7 (33.3%) - the main cause of disability is cerebral palsy. The structure of functional deviations is shown in Table. 1. As follows from the table, the most common pathology in children born with very low and extremely low body weight was the pathology of the nervous system, delayed neuropsychic development, compensated hydrocephalus that did not require surgical treatment and without signs of impaired vital functions. All such children undergo regular medical examinations by a neuropsychiatrist for the purpose of favorable adaptation. On the part of the cardiopulmonary system, there are deviations such as a ventricular septal defect in the muscular part. Of the diseases of early age, the course of atopic dermatitis is noted. On the part of the pulmonary system in children, there is a mild course of BPD, obstructive bronchitis. On the part of the organs of vision, pathology was detected in the form of strabismus, myopia. All long-term and frequently ill children were classified as pathology of the immune system.

Table 1

Structure of functional deviations of II and III health groups, n = 7

The second group included 30 children transported for a period of 2-7 days of life. The age of children is from 2 to 10 years (4.8 ± 1.7 years). Birth weight in the VLBW group (mean weight 1165 ± 11.4 g) - 27 children; in the group with ENMT (average weight 859 ± 5.2 g) - 3 children. Health group score: II - 9 (30%), III - 12 (40%), IV - 6 (20%), V - 2 (10%). Disability was established in 10 children, the causes of which were: cerebral palsy in 5 children (50%), retinopathy in 2 (20%), deafness in 1 (10%), severe neuropsychiatric retardation in 2 (20%). The structure of functional deviations is presented in table. 2.

table 2

Structure of functional deviations of II and III health groups, n = 19

The third group included children taken to specialized centers at the age of more than 7 days of life. Initially, such a group of children was in an extremely serious condition and was not transportable for various reasons. Catamnesis was studied in 16 children. The age of the children ranged from 3 to 11 years. Among children - born with VLW - 13, with ELBW - 3. The distribution by health groups revealed group II in 2 (12.5%), III - in 7 (43.8%), IV - in 3 (8.7% ), V - in 4 (25%). Disability have 7 children (43.7%). The main reason is cerebral palsy. The structure of functional deviations is presented in table. 3.

Table 3

Structure of functional deviations, n = 9

The main cause of disability in children born with VLBW and ELBW is damage to the central nervous system of varying severity and compensation. The main cause is cerebral palsy - 32.7% among the total number of children observed in the catamnesis and 70.8% in the general structure of disability.

1. The main causes of disability were cerebral palsy in 24.1% of children, which accounted for 70% of the total number of disabilities; epilepsy and gross mental retardation were recognized as the cause of disability in 3.5% of children, respectively, which accounted for 20% of the total disability structure, sensorineural hearing loss and grade V retinopathy were equally diagnosed in 1.7% of children - 10% of the total.

2. Long-term results of observation showed that the main cause of disability in children born with ENMT and VLBW is cerebral palsy, so measures are needed to reduce this pathology among premature newborns.

3. The largest proportion in children born with ELBW in the composition of functional abnormalities were changes in the central nervous system in the form of delayed neuropsychic development, compensated hydrocephalus, which further requires the supervision of a neurologist for more favorable adaptation and improved quality of life

4. A direct relationship has been established between unfavorable somatic, neurological and functional outcomes in children with extremely low birth weight with critical conditions of the early neonatal period, specific somatic pathology of the mother.

5. The main task of resuscitation care is the successful nursing of children with extremely low birth weight, ensuring not only their survival, but also ensuring a satisfactory quality of life, the absence of disability.

Reviewers:

Illek Ya.Yu., Doctor of Medical Sciences, Professor, Head of the Department of Children's Diseases, Kirov State Medical University, Kirov;

Krasavina N.A., Doctor of Medical Sciences, Associate Professor of the Department of Pediatrics FPC and teaching staff, State Budgetary Educational Institution of Higher Professional Education "PSMA named after ak. E.A. Wagner, Ministry of Health of the Russian Federation, Perm.

The work was received by the editors on February 14, 2013.

Bibliographic link

BASIC DEFINITIONS AND CONCEPTS,

CHARACTERIZING THE NEONATAL PERIOD OF LIFE

Under the term "gestational age" understand the number of completed weeks that have elapsed between the first day of the last menstrual period (and not the expected day of conception) and the date of delivery, regardless of whether the pregnancy ended with a live birth or a stillbirth.

In the absence of data on the last menstrual period, the estimate of gestational age is based on available clinical studies.

live birth(World Health Organization, 1974) - the complete expulsion or removal of the product of conception from the mother's body, regardless of the duration of pregnancy, and the fetus after such separation breathes or shows other signs of life, such as heartbeat, pulsation of the umbilical cord or voluntary movements of the muscles, regardless of whether the umbilical cord has been cut and whether the placenta has separated. Each product of such a birth is regarded as a live birth.

Since January 1993, Russia has adopted this definition of live birth (previously, the criterion for live birth was the presence of spontaneous breathing), and this entails the need for resuscitation of all children (fetuses) who have any of the four signs of life at birth: spontaneous breathing, heartbeat, pulsation umbilical cord, spontaneous movement of muscles.

Stillbirth is the death of the product of conception before its complete expulsion or removal from the mother's body, regardless of the duration of pregnancy. Death is indicated by the absence of breathing in the fetus after such separation or any other signs of life, such as heartbeat, umbilical cord pulsation, or voluntary muscle movements.

Birth weight is considered the result of the first weighing of the fetus or newborn, recorded after birth. This weight should preferably be established within the first hour of life before significant postnatal weight loss occurs.

Measurement of the length of the body of a newborn (fetus) with a very low birth weight and with an extremely low body weight at birth must be carried out with its extended position on a horizontal stadiometer.

Regardless of gestational age, based on the result of the first weighing, the following categories of children are distinguished:

- baby with low birth weight a child of any gestational age, having at birth a body weight of less than 2500 g;

- very low birth weight baby a child of any gestational age, having at birth a body weight of less than 1500 g;

- a child with extremely low birth weight - a child of any gestational age who weighs less than 1000 g at birth.

preterm birth It is customary to consider childbirth occurring at a gestational age of up to 37 weeks (up to 260 days of pregnancy).

Due to the peculiarities of obstetric tactics and nursing of children born at different gestational ages, it is advisable to allocate the following intervals:

Premature birth at 22-27 weeks;

Premature birth at 28-33 weeks;

Premature birth at 34-37 weeks of gestation.

Premature baby- a child born at a gestational age of less than 37 completed weeks, i.e. up to 260 days of pregnancy.

Classification of prematurity by degrees is impractical, tk. the division of children into groups by body weight in no way reflects the true degree of prematurity(body weight may not correspond to gestational age). Among premature babies, in 18.6-25% of cases, intrauterine growth retardation occurs in asymmetric and symmetrical types. In addition, it is known that in the group of children with a birth weight of less than 2500 g, every third is a full-term newborn.

Regardless of body weight, preterm infants are usually morphofunctionally immature.

Post-conceptual age is a term used to characterize premature babies, calculated as the sum of the duration of the gestational and postnatal period.

Thus, 6 weeks after birth, the post-conceptual age of a child with a gestational age of 27 weeks would be 33 weeks.

full-term baby- born at a gestational age of 38 to 42 weeks of gestation, i.e. between 260 and 294 days of pregnancy. Most full-term newborns have a body weight of more than 2500 g and a body length of more than 46 cm, however, in 10% of newborns, both lower and higher indicators of body weight and body length are noted.

Postterm baby- born at 42 weeks of gestation or more, i.e. on the 295th day of pregnancy and later. The mass and length of his body can significantly exceed the indicators of full-term children, however, in some cases, relatively low anthropometric indicators are encountered, which is associated with progressive placental insufficiency.

Morphological signs of postmaturity - dryness, peeling, maceration of the skin, meconium staining of the umbilical cord, membranes of the placenta, the presence of ossification nuclei of the proximal epiphysis of the tibia and humerus.

« Small for gestational age"- a term that has now been replaced by the concept of intrauterine growth retardation (IUGR).

IUGR- a syndrome that appears in the prenatal period and is characterized by a slowdown, stop or negative dynamics of the size of the fetus and is manifested in the newborn by a decrease in body weight (as an integral indicator of the size of the fetus) by two or more standard deviations (or below the 10th centile) compared to the due for gestational age (i.e. the gestational age at which the baby was born).

« Big for gestational age" - a baby who has a body weight above 90% of a centel for his gestational age.

childbirth- a complex, multi-link unconditioned reflex, actively aimed at expelling the fetal egg from the uterine cavity, after the fetus has reached viability.

Average duration of labor normally 7-18 hours, in primiparous -7-14 (10-12) hours, in multiparous - 6-12 (6-8) hours.

Quick delivery- childbirth lasting less than 6 hours.

Rapid delivery- childbirth lasting 4 hours or less.

protracted labor- childbirth more than 18 hours.

Rapid, rapid, prolonged labor are pathological.

Normally, the duration of the second stage of labor in primiparas is 30-60 minutes, in multiparous 15-20 minutes.

perinatal period, according to the definition given in the Tenth Revision of the International Classification of Diseases and Causes of Death (ICD-10), begins at 22 completed weeks of pregnancy (154 days) and ends on the 7th full day after delivery.

Despite the fact that the perinatal period ends with the first week of life, the clinical manifestations of diseases that have arisen at this time can persist for several months, and their adverse effects - for many years of life.

Perinatal diseases occur as a result of exposure to the fetus of pathogenic factors closely related to extragenital and obstetric pathology of the mother.

The perinatal period is divided into three periods: antenatal, intranatal and early neonatal.

Antenatal period begins with the formation of the zygote and ends with the onset of childbirth. From an ontogenetic point of view, it is advisable to divide the antenatal period into embryonic, early fetal and late fetal.

Various adverse factors affecting the human body in the antenatal (embryonic) period can lead to congenital malformations and spontaneous abortion in the early stages.

Adverse effects on the fetus in the early fetal period often lead to a decrease in the mass of organs and tissues of the fetus, as well as placental hypoplasia. The most typical clinical manifestation of intrauterine diseases in this period is a symmetrical form of intrauterine growth retardation (IUGR) and severe insufficiency of uteroplacental circulation.

Various adverse effects on the fetus in the late fetal period lead to disruption of the processes of morphofunctional maturation of the fetus. Chronic insufficiency of uteroplacental circulation is accompanied by the development of an asymmetric form of IUGR, immune and infectious factors cause acute congenital diseases - hemolytic disease of the newborn (HDN), hepatitis, pneumonia, myocarditis, encephalitis, etc.

Intranatal period calculated from the onset of labor to the birth of the child. Despite its short duration, this period is extremely important for the health of the fetus and newborn, since complications of the birth process lead to adverse consequences in the form of severe fetal asphyxia and birth trauma.

neonatal period starts from the moment of birth and ends 28 completed days after birth.

Within the neonatal period, there are early neonatal period (from birth to 6 days 23 hours and 59 minutes of life) and late neonatal period (7 days - 27 days 23 h 59 min).

In the early neonatal period certain antenatal factors (biochemical consequences of chronic intrauterine hypoxia of the fetus, cytopathogenic effect of antibodies (AT) of the mother during an immune conflict, an infectious process associated with congenital infection), as well as factors that have arisen in the neonatal period (hypothermia, deficiency surfactant, nosocomial infection, etc.).

APGAR SCORE (CLINICAL AND LABORATORY CRITERIA)

Criteria for assessing a newborn by Apgar

If the Angar score is less than 7 points 5 minutes after birth, it is necessary to continue assessing the child's condition according to Apgar every 5 minutes until reaching 7 points.

Indicators of the acid-base state of the umbilical cord blood of healthy newborns

pH concentration in healthy full-term and preterm infants in the neonatal period

Intracellular and extracellular buffer systems, excretory functions of the lungs and kidneys contribute to maintaining the pH of arterial blood in the range of 7.35–7.45.

Indicators of pO2 and pCo2 in the blood of healthy full-term and preterm infants in the neonatal period

* Indicators of arterial blood.

** Indicators of capillary blood.

WWTP monitoring can be carried out in various ways. The most invasive, but also the most accurate method is to determine the gas composition of arterial blood. If the child has no indications for catheterization of arterial vessels, blood is taken from a vein or capillaries.

pH, pO2 and pCo2 levels in healthy newborns

in arterial, venous and capillary blood

Criteria for the gas composition of the blood in full-term newborns:

● Hypoxemia - p a O 2< 60 мм рт.ст.

● Hyperoxemia - p a O 2 > 80 mm Hg.

● Respiratory acidosis - p a CO 2 >45 mm Hg. and pH<7,35, дефицит оснований (BE, ммоль/л) выше -5.

● Respiratory alkalosis - p a CO 2<35 мм рт.ст. и pH>7,45.

Assessment of the state of children according to Apgar and Zalinga (laboratory indicators

arterialized capillary blood)

(E. Saling, 1972)

INDICATORS OF PHYSICAL DEVELOPMENT,

MATURITY CRITERIA FOR NEWBORNS

“See these kids? They were born at 24 and 25 weeks with a body weight of only 500 and 600 grams, ”Oleg Ionov, head of the neonatal intensive care unit, points to two adjacent boxes.

“Imagine - the child had to be in the womb for another half of the term. After birth, he is completely unadapted to life - he cannot breathe on his own, and all body systems are not ready to accept mother's milk, ”Oleg Ionov lifts the cape on the box, showing a tiny body that looks more like a realistic doll than a living child.

Director of the Center Gennady Tikhonovich Sukhikh with colleagues

Oleg Ionov opens transparent boxes with babies especially for us. Most of the time they are covered with thick cloaks so that the visual system matures in the twilight. The situation on the other side of the glass should resemble the mother's womb as much as possible. Inside the box should be dark, warm and quiet.

According to WHO recommendations, the infant's viability limit starts at 500 g. Previously, this figure was twice as much - a fetus less than 1000 g, roughly speaking, was considered a miscarriage. Nevertheless, today children are successfully discharged from the intensive care unit of newborns, who at birth did not even reach the cherished 500 grams.

The neonatal intensive care unit is more like the location of a science fiction movie. Here, no one fusses and runs around with medicines. Almost all the work is done by machines. Nurses come into the room to record physiological data and make sure everything is going according to plan. The plan itself is developed by a team of doctors - individual for each patient. And depending on the physiological changes, it is constantly adjusted.

“Our center has good results not just because we use good medicines or good equipment, but because we have developed the right system - when to use this or that method, when to switch from one to another, when to use this medicine, and nothing else,” lists the components of successful work Oleg Ionov.

Hard breathing

As soon as the baby is born, a whole nursing technology is launched. Given the age and comorbidities for a tiny patient, possible risks and a number of appropriate drugs are calculated, because without the help of doctors, premature babies cannot even take their first breath.

“We immediately give him lung surfactant, a natural drug that partially transforms immature lungs into mature ones. This is a complex mechanism that allows you to open the lungs of a child, because they bear little resemblance to the lungs of an adult,” says Oleg Ionov.

From the delivery room to the resuscitation room, the child is brought on respiratory support and then, depending on the severity, he is switched either to a ventilator (when the breathing tube is directly in the trachea) or transferred to non-invasive respiratory support.

“It looks like this,” Oleg Ionov points to one of the boxes. - You see, the baby breathes on his own, but he has cannulas in his nose, they also inhale and exhale, but at the same time, the child controls most of the work of breathing. Moreover, now the devices are smart, with the help of special sensors they feel how the child wants to breathe, and adjust to it.”

Instead of mom

Just imagine: the child received in the womb all the necessary amino acids, fats, carbohydrates, microelements - and suddenly this connection was broken. The task of doctors is to calculate what substances and in what volume the baby should receive now, and how this data should change as it grows (or, conversely, its absence). This painstaking analysis is the art of neonatologists.

“In the department, under sterile conditions, we create special combined nutrient mixtures, which are then connected to the child. Then we examine his blood, see if the child absorbs everything well. After that, we make a correction, and if everything goes well, we try to feed the child through the mouth,” explains Oleg Ionov. – Gradually, we adapt the baby to formulas for premature babies or to breast milk, that is, we increase the dose of what is given through the mouth and reduce the dosage of what is given through the veins. We evaluate how the baby grows and compare it with certain tables.

“We can adjust the calorie content and even the protein concentration of milk. There are special technologies and preparations that enrich breast milk, because breast milk during prematurity has a very low protein content,” says Oleg Ionov, pointing to a structure hanging on the wall. - For example, now the feeding is over. You see special syringe pumps, they are inclined, because in breast milk, this is also a whole technology, fat floats up. And in order for the child to receive everything, including fats, so that they do not remain in the adapter, you need to know at what angle to put this syringe.

The task of doctors is to constantly monitor the condition of small patients, check with growth tables, adjust the ratio of nutrients in mixtures, monitor the development of all organs and systems, track pain impulses and many other aspects that make up the work of a neonatologist. The work is titanic, but the results are more than worth the effort, especially when another patient is discharged from the department.

One of the components of nursing a premature baby with an extremely low body weight is adequate feeding. There is no doubt that it is the organization of rational feeding of premature babies that plays one of the decisive roles in the complex of measures that ensure their physiological, physical and motor development. Biologically complete nutrition allows you to ensure the normal functioning of the digestive system, the favorable course of metabolic processes, the physiological development of immunocompetence and positive dynamics from hematological, microbiological and some other indicators.

In the city children's hospital No. 7 of the city of Barnaul, a child was admitted to the intensive care unit for newborns with a weight of 488 grams. From the anamnesis it is known that he was born from the third pregnancy, the third birth by an emergency caesarean section, with a gestational age of 23-24 weeks, the transverse position of the fetus, premature detachment of the placenta. The woman in the consultation was not observed. There is a burdened obstetric and gynecological history: I pregnancy - the child died at 4 months from decompensated hydrocephalus; II - twins - stillborn. From the pathology of the mother - hepatitis B, chronic pyelonephritis, smokes up to 10 cigarettes a day. The child was born with a weight of 530 grams, in a transverse presentation by caesarean section, body length 27 cm, head circumference 21 cm, chest circumference 17 cm Apgar score 5-6 points. The condition at birth is extremely difficult. The maximum weight loss on the fifth day was 7.9% (42 grams). Probe feeding 4.0-6.0 ml 8 times a day. He was admitted to the intensive care unit with anthropometric parameters: weight - 488 grams, body length - 28 cm, head circumference - 22.5 cm, chest circumference - 19.3 cm.

Severe condition. The skin is icteric with perioral and periorbital cyanosis, with a marbled pattern. The subcutaneous fat layer is thinned. Soft tissue turgor is significantly reduced. Frog pose (Fig. 1). Diffuse hypotension. Mucous membranes are clean, pale. In the lungs, breathing is weakened, the participation of auxiliary muscles in the act of breathing. Heart sounds are rhythmic, muffled, soft systolic murmur at Botkin's point. The abdomen is moderately swollen. The liver is palpable up to 1.5 cm from under the edge of the costal arch, the spleen is not palpable. Intestinal peristalsis is weakened. Pisses freely. Chair mushy 1-2 times, dark brown.

Results of laboratory research methods:

Complete blood count - hemoglobin 94 g / l, erythrocytes - 3.14x10 12 / l, platelets - 350x10 9 / l, leukocytes - 12.0x10 9 / l, leukocyte formula: e - 4%, n - 1%, c - 51%, l - 41%, m - 3%.

Urinalysis: protein - 0.3 g/l, leukocytes - 3-4 per field of view, bacteria ++++.

Biochemical analysis of blood: total protein - 57 g / l, albumins - 37 g / l, globulins - 20 g / l, glucose - 2.3 mmol / l, cholesterol - 45 μmol / l, total bilirubin - 130 μmol / l, direct - 4 µmol, indirect 128 µmol/l, ALT - 35 U/l, AST - 40 U/l.

Coprogram - mushy, black, pH - 5.0, mucus +++, fatty acids +++, leukocytes 0-1 in the field of view.

Blood for intrauterine infections - antibodies to the herpes simplex virus IgG in a titer of 1:100, avidity - 42%.

Instrumental research methods were also carried out:

Ultrasound of the internal organs - hypotension of the pelvis of the left kidney, signs of immaturity of the left kidney.

Neurosonoscopy - intraventricular hemorrhage of the 1st degree on the left. Periventricular ischemia throughout.

ECHO-KG - open oval window 3 mm.

Pediatric surgeon - hip dysplasia.

A neurologist is an undifferentiated intrauterine infection with damage to the central nervous system (CNS) and internal organs. Benign intracranial hypertension. Typical epiparaxisms. A combined form of delay in psycho-emotional and pre-speech development. Syndrome of hyperexcitability. Consequences of perinatal damage to the CNS of posthemorrhagic genesis.

Ophthalmologist - retinopathy of prematurity.

During the period of stay in the hospital, the child received the following treatment: therapeutic nutrition with breast milk substitutes, humidified oxygen, transfusion of washed red blood cells twice, cefotaxime, hydrochlorothiazide + triamterene (Triampur compositum), glycine, folic acid, furosemide (Lasix), magnesium sulphate, vitamins D and E, iron chloride (Hemofer), Bifidumbacterin.

Food was administered through a nasogastric tube. Taking into account the early term of the birth of the child, the mother did not have breast milk, therefore, Alfare® formula based on complete protein hydrolysis was prescribed as a breast milk substitute. Calculation of nutrition was carried out by the caloric method. Feeding with this mixture was carried out for 2.5 months until reaching a weight of 1355 grams. Daily gains averaged 11.6 grams. Of the functional disorders of the gastrointestinal tract, regurgitation was noted, which was assessed by a point system and did not exceed 1-2 points. According to the ESPGHAN guidelines, the intensity of regurgitation was assessed on a five-point scale, reflecting the combined characteristics of the frequency and volume of regurgitation.

0 points. Absence of regurgitation.

1 point More than 5 regurgitations per day with a volume of more than 3 ml.

2 points. More than 5 regurgitations per day up to 1/2 the amount of the mixture per feeding in less than half of the feedings.

3 points. More than 5 regurgitations per day up to 1/2 of the amount of the mixture introduced in one feeding, not more often than in half of the feedings.

4 points. Regurgitation of small volume for 30 minutes or more after each feeding.

5 points. Regurgitation from 1/2 to the full volume of the mixture in at least half of the feedings.

The character of the stool was assessed according to the Bristol scale and was rated as type 6.

Upon reaching a weight of 1355 grams, the child was switched to the PreNan® formula, intended for feeding premature and small babies. Feeding continued until the weight of 2062 grams was reached. Subsequently, until the child was discharged from the hospital, the child was fed with an adapted mixture of Nestogen® 1, in a volume of 55.0-65.0 ml 7 times a day for two months.

Physical development: at 1 month - weight 691 grams, at 2 months - 1022 grams, at 3 months - 1590 grams, by 4 months - 2062 grams.

The child was discharged at the age of 6 months (Fig. 2), in a moderate condition due to neurological symptoms, with anthropometric data: weight 2680 grams, body length 45 cm, head circumference 36 cm, chest circumference 31 cm. The skin is pale pink, clean. In the lungs, puerile breathing. Heart tones are rhythmic, medium sonority. The abdomen is soft. Stool type 6 according to the Bristol scale, yellow, up to 2-3 times a day. No regurgitation syndrome was noted.

In dynamics, the results of the survey:

Complete blood count - hemoglobin - 92 g / l, erythrocytes - 3.5x10 12 / l, leukocytes - 9.0x10 9 / l, leukocyte formula: e - 2%, s - 24%, l - 68%, m - 6 %, platelets - 508x10 9 / l.

Biochemical blood test - total protein - 66.0 g / l, albumins - 46 g / l, globulins - 19.3 g / l, glucose - 3.6 mmol / l, total bilirubin - 14.7 μmol / l, direct 1.0 µmol/l, indirect 13.7 µmol/l.

Urinalysis - leukocytes 2-3 in the field of view, specific gravity - 1009, epithelium - a large number.

Coprogram - yellow, mushy, fatty acids +.

Thus, adequate feeding with modern breast milk substitutes (Alfare®, PreNan®, Nestogen® 1), intended for different stages of nursing, helps to correctly adjust nutrition and helps prevent the aggravation of diseases and the involvement of other organs and systems in the pathological process, as well as restore weight body.

Literature

Yatsyk G.?V., Studenikin V.?M., Skvortsova V.?A. Feeding newborns: A guide to neonatology. M.: MIA, 1998. S. 205-214.

Vandenplas Y. Current concepts and issues in the management of regurgitations in infants: a reapprisal // Acta Paediatr. 1996 Vol. 85. P. 531-354.

T. S. Ardatova*
Yu. F. Lobanov*, Doctor of Medical Sciences, Professor
T. Yu. Borisenko**
A. V. Ilyukhin**
T. E. Strelnikova**
O. S. Balakhnina**

*Altai State Medical University,
**MUZ Children's City Hospital No. 7, Barnaul