2 Main Headline
3 Co-Author: Dr. Srinivas Murthy CL Editor: Dr. Chetan Ginigeri DR. LATHIESH KUMAR KAMBHAM A CSR initiative by Himalaya BabyCare
4 First published in India by HarperVantage 2024 An imprint of HarperCollins Publishers India 4th Floor, Tower A, Building No. 10, DLF Cyber City, DLF Phase II, Gurugram, Haryana – 122002 www.harpercollins.co.in 2 4 6 8 10 9 7 5 3 1 Copyright © Himalaya Wellness Company 2024 Illustrations and photographs © Shutterstock 2024 P-ISBN: 978-93-5489-905-8 E-ISBN: 978-93-5489-935-5 This book and its content represent the author’s viewpoint backed by factual data as reported by the author. Dr. Lathiesh Kumar Kambham asserts the moral right to be identified as the author of this work. This book only intends to provide educational and informational value and is not a substitute for professional medical advice. Readers should consult medical experts for the latest childcare information. The publisher is not liable for the opinions and endorsements shared in the book. All rights, including copyright, are reserved. Reproduction, storage, or transmission of any part of the book requires written consent from the publisher and Himalaya Wellness Company. Printed and bound at Thomson Press (India) Ltd.
5 It all began in 1930 in the forests surrounding Dehradun. Mr. M. Manal, the founder of Himalaya Wellness Company, curiously looked on as villagers fed the roots of a local herb to calm a herd of agitated elephants. This herb was Rauwolfia Serpentina, the inspiration that led to the creation of Serpina®, the world’s first natural antihypertensive drug which was launched in 1934. Mr. Manal embarked upon the journey of uncovering the mysteries of Nature at a time when herb-based healthcare was looked at with skepticism. Fuelled by his vision of bringing the best of nature’s solutions backed by scientific research to people suffering health concerns, he was determined to contemporize Ayurveda through modern technology. With a single hand-operated tableting machine bought after pawning his mother’s bangles, he strode ahead on the road less travelled and full of challenges. It took him four years of extensive research to formulate the first offering, Serpina®, which laid the foundation for Himalaya’s strong foothold in research. In 1955, came the historic breakthrough that established Himalaya as a symbol of trust in the Indian healthcare landscape. Liv.52®, a formulation for liver health, became the best-selling flagship offering and a name synonymous with brand Himalaya. Ever since, as a head-to-heel problem-solving brand, Himalaya has introduced many other iconic products such as Septilin®, Cystone®, Bonnisan®, and Rumalaya® forte, which reinforced the trust of millions of customers, making Himalaya a household name. Broadening horizons, Himalaya diversified into Personal Care, BabyCare, Wellness, and Animal Health while consolidating all portfolios under one umbrella, “Himalaya Since 1930”. Today, Himalaya is a leading global health and personal care brand with close to 500 products sold in over 100 countries – touching millions of lives every day and realizing the promise of Happiness through Wellness in every home and heart. OUR STORY
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7 What do all preemies have in common? Courage, strength, determination, tenacity, perseverance, endurance, spiritedness and the fact that they are all adorable! One of the most gratifying feelings we experience as pediatricians is that of seeing a little preterm outlive the storm of uncertainty and survive to tell a story. As medical science breaks new glass ceilings everyday, doctors become more and more capable of protecting and nurturing new life and witness magic every day. In Premature Birth:A Parental Guide, a neonatologist vocalizes a premature baby’s journey to anxious parents who see the fragile newborn surrounded by medical equipment, tubes, and wires on his/her early entry into this world. The book aims to aid new parents as they wait for their baby or are trying to learn how to hold her/him. It allays some anxieties by sharing knowledge that can be leveraged to ensure the baby reaches her/his true potential. Dr. Lathiesh Kumar Khambam is an expert neonatologist whose influence extends beyond neonatal intensive care creating an ecosystem of collaborative support that includes obstetricians, neonatologists, nurses, physiotherapists, lactation experts, child development specialists, ophthalmologists, biomedical engineers, and retrieval teams. The center of attention, however, is always the baby and the parents. This book is another tool to enhance the ecosystem of family-centered care. As a pediatrician, I understand the role of supportive parents who partner with us doctors to provide care for their baby. Parents will find this book an easy guide to understand the parameters of normal development of a premature baby, and any deviations or delays from it, and what’s possible in advanced neonatal care units today. I congratulate Dr. Lathiesh for making the effort to reach out to the community of preemie parents and wish the book a great success. Dr. Chetan Ginigeri MD (PGI Chandigarh), Fellow PICU (King's College Hospital, London) Consultant Pediatrics & Pediatric Intensive Care Unit ASTER Hospitals, Bengaluru Foreword
8 Babies have always been a top priority at Himalaya BabyCare, and we are committed to bringing wellness and happiness to babies via head-to-heel baby care solutions based on science. We are devoted to offering continued support to moms and parents across the initial critical years of parenthood through education and awareness on baby care, facilities, and amenities to ensure convenient care for babies on-the-go, delivering a hassle-free experience for parents. The period of six to eight weeks post birthing (postpartum) is crucial for the baby and the mother, with mental and emotional care for the mother and overall care for the newborn. Indeed, childbirth is a life-changing event that brings delight to the family. But, at the same time, handling a newborn can be an overwhelming experience for the parents. It could cause unprecedented stress and anxiety as they try to navigate through the unknown terrain of baby healthcare. We believe that interactions and advice of health professionals is critical for new parents. This book is an ongoing effort from Himalaya BabyCare to educate parents on baby care, common health problems in babies, and vaccination schedules. This book’s content is created based on frequently asked questions from parents. With this book, our focus is to be the guiding partner through early parenthood, for a positive and enriching baby experience. Our Purpose
9 We understand that your precious little one's delicate skin needs special care. Keeping this in mind and your baby's safety at the forefront, we have thoughtfully crafted a range of baby care products based on the Ayurvedic discipline of Kaumarabhritya. Our products are gentle, research-based, and free from harsh chemicals, formulated to help nourish and protect your baby's skin. Himalaya BabyCare Gentle • Safe • Researched
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11 Table of Contents Out Too Early! ���������������������������������������������������������� 12 The Early Battles in the World Outside the Womb ������������������������������������������������������������������ 18 The Home for the First Few Anxious Days ������������������������������������������������������������� 24 A Long Wait ��������������������������������������������������������������� 38 Feeding Your Premature Baby: Everything You Need to Know ����������������������������� 44 From Just Survival to Intact Survival ��������������������� 56 OMG! So Tiny! ���������������������������������������������������������� 62 To Treat the Outside, We Need to Look Inside ���������������������������������������������������������������� 68 Finally…Homebound! ���������������������������������������������� 72 New Challenges, New Life, New Roller Coaster at Home ������������������������������������������������������ 76 Protect, Preserve, and Enhance ����������������������������� 84 Vaccination ����������������������������������������������������������������� 86 Paving the Road to the Future ������������������������������� 88 The Outliers ��������������������������������������������������������������� 90
12 Have you welcomed your baby a little early? Babies usually require full-term or 40 weeks to develop completely inside the mother’s womb. However, sometimes they are born earlier and are referred to as ''preterm'' or ''premature'' babies. Such babies require special care as soon as they are born. As parents, you will face several challenges during this journey, but you are not alone. The healthcare providers will assist you throughout the process to ensure a positive outcome for your newborn. This chapter will help you understand more about preemies (premature babies) and briefly discuss the major health issues faced by them. When is a baby considered preterm or premature? Usually, a normal pregnancy lasts up to 40 to 42 weeks from the first day of your last menstrual period (LMP). However, when a baby is born early, 1. Out Too Early!
13 i.e., before 37 weeks of pregnancy, the birth is considered preterm or premature. So, in terms of days, it means that the baby is born less than 259 days after the first day of your LMP. How are babies categorized based on their birth weight? Newborns weighing between 2.5 and 3.99 kg are considered to have a normal birth weight (BW). However, there can be considerable variations among different ethnic communities and groups. According to their birth weights, babies can have: < 2.5 kg < 1.5 kg < 1 kg
14 Do all premature babies have a low weight at birth? In most cases, premature babies are born with low birth weight. This can be because a baby’s growth in the womb is closely related to the duration of the pregnancy. This is another reason that most preterm babies are likely to be smaller in size. However, there are exceptions. For example, a 34-week-old preterm baby weighing 2.5 kg is considered premature but not low birth weight. Given below is a classification of the degree of prematurity based on the weeks of pregnancy. Categories Weeks of Pregnancy Extreme preterm 24 weeks to 28 weeks Moderate preterm 28+1 weeks to 32 weeks Early preterm 32+1 weeks to 33+6 weeks Late preterm 34+0 weeks to 36+6 weeks Full-term 37 weeks to 42 weeks Post-term More than 42 weeks
What causes preterm delivery, and can it occur again? About 50 percent of women who have preterm deliveries go into labor for unknown reasons. The risk factors for preterm delivery include the following: Statistically, a woman who has had a preterm delivery earlier stands a 25-50 percent chance of having another one. However, for many women, preterm delivery is a one-time event. 15 Problems with the uterus Short span between pregnancies Physical injury or trauma Younger (<16 years of age) or older (>35 years of age) mothers Chronic health conditions in the mother such as diabetes or high blood pressure Multiple miscarriages or abortions Infections in the genital tract Being underweight or overweight Previous history of preterm birth Twin or multiple pregnancies Conception through in vitro fertilization (IVF) Smoking or use of illicit drugs
16 Is it my fault that the baby was born prematurely? No one is at fault for the baby's early birth. Most of the time even the doctors do not know the cause as preterm births are spontaneous. How do I manage high blood pressure (pre-eclampsia) during pregnancy? Pre-eclampsia affects 5-7 percent of all pregnant women and usually occurs during the first pregnancy. It is characterized by high blood pressure, protein in the urine, and water retention leading to rapid weight gain. High blood pressure (pre-eclampsia) can be managed with blood pressure medications, ample bed rest, and a nutritious diet. If these measures do not improve the condition, an elective preterm delivery is necessary. How long will my baby stay hospitalized? The hospital stay depends on the degree of prematurity and on the medical complications that may arise during the period. Usually, a baby goes home once proper independent feeding is established, and the baby reaches 34 to 35 weeks of gestational age. This means that a baby born before 28 weeks, may need to be hospitalized for 6 to 8 weeks, whereas a baby born at 34 weeks may go home within a week.
17 How will my preterm baby develop in the long run? Overall, premature babies have a positive outcome. Most babies born after 34 weeks develop normally and may have less complications if any. Preterm babies below 32 weeks may develop issues that need to be discussed with the attending doctor. SUMMARY The birth of a preterm baby is both a moment of happiness as well as concern for parents. However, with the right information and support from your doctor, you can be better equipped to navigate such times. Preterm birth can result in various short-term complications. However, most preterm babies are healthy, and are ready to go home within a couple of weeks after additional care and support. For any concerns or queries related to your baby, feel free to reach out to your doctor.
18 Main Headline Since preterm babies arrive early in the world, they are not well-equipped to handle life outside the womb. Their bodies are fragile and prone to short and long-term health problems. Usually, the earlier a baby is born, the higher the chances of complications. Premature babies born before 7 months or 28 weeks need extended specialized Neonatal Intensive Care Unit (NICU) care for multiple complications which might develop during the growth phase. While some complications occur immediately after birth, others can appear even after the baby reaches three to six months of age. 2. The Early Battles in the World Outside the Womb
19 Let us now better understand the problems premature babies can face during the initial few weeks or months of their lives. Temperature regulation Premature babies lack the necessary fat required to generate enough energy and maintain their body heat. Hence, they may have trouble maintaining the right body temperature. Therefore, to help regulate the baby’s body temperature between 36.5-37.5˚C, she/ he is kept in special incubators or servo-controlled warmers after birth. Breathing and respiration For babies born before 30 weeks of pregnancy, the respiratory system might not have developed fully which might result in breathing issues. In such a case, the treatment requires giving small doses of a special medication which helps to gradually improve the condition as the babies grow older and resolves by the time they turn 35 weeks old. Brain If a baby is born prematurely, there are chances of internal bleeding in the brain. The bleeding is mostly mild and does not affect the baby. Regular brain ultrasounds are done
20 while the baby is in the NICU to detect any bleeding. Heart Premature babies may be born with a heart defect. Patent ductus arteriosus (PDA), where an opening does not close off on its own, is a common heart defect that can be diagnosed and treated effectively. It’s important to speak to your baby’s cardiologist regarding the situation before deciding on the treatment line. Intestinal Poorly developed intestines make it difficult for preterm babies to digest milk given orally. Although breast milk is better tolerated than formula milk, starting the feeding too early is not recommended. Interestingly, studies have shown that small amounts of mother’s milk, can, in fact, reduce the risk of any complications. That is why mothers are asked to express milk for their babies from the first day they are admitted to the NICU. Liver Most preterm babies develop jaundice during their first week or two, resulting in the yellowing of the baby’s skin. Most of the time this is harmless, a
21 temporary condition that disappears on its own or with appropriate treatment, which includes placing the baby under special bilirubin lights. Kidneys Preterm babies have troubl e remov ing body toxins and have poor concentrations of body fluids; hence, they should be given fluids as frequently as possible. Bones Preterm babies tend to have lower calcium and phosphorus levels and are recommended supplements until they are one year old. Passive exercises to strengthen the bones are also carried out when the baby is in the NICU. Blood Preterm babies are more likely to develop "anemia" when compared to fullterm babies. They may require blood transfusions, especially if the babies weigh less than 1.5 kg, as part of their treatment.
22 Immune system Due to their reduced ability to fight infections, preterm babies are kept in a sterile environment, like that of their mother’s womb. Moreover, extra care needs to be taken to prevent infections in the first few weeks after discharge from the hospital. Skin Preterm babies have very thin and delicate skin that is prone to injuries. This is primarily because of lower fat deposits below the skin and fewer cells on the skin surface. Oil applications through light massages help strengthen the skin and prevent abrasions, infections, and loss of water through evaporation in babies. Vision All preterm babies, especially those who weigh less than 1.8 kg or are below 32 weeks of age, need to
23 be checked at regular intervals for vision-related problems. Hearing Almost all premature babies undergo a hearing test to check for hearing loss. Behavioral and psychological problems Preterm babies can develop behavioral and psychological problems, which must be confirmed by child psychologists upon diagnosis. The child may also be required to take an IQ assessment between the ages of three to five years to identify any learning difficulties. Summary In this chapter, we discussed the challenges preterm babies face once they get exposed to the outside world. This information will equip you to understand what your baby is going through, and the type of care being administered. However, your treating doctor will be able to help you with the right information.
24 Main Headline The neonatal intensive care unit (NICU) is a specialized area with equipment to care for newborn babies. Most often, premature and low-birthweight babies need to be in the NICU before they can be discharged for home. When a baby is admitted to the NICU, some of the key functions the specialized staff perform are to ensure that the baby’s temperature is stabilized, they are provided breathing support if required and that infection is prevented. The number of people who can enter the NICU is restricted. It is kept sterile and low on noise so that the babies undergoing treatment remain healthy and comfortable. 3. The Home for the First Few Anxious Days
25 Which babies need NICU care? NICU care is required for the following babies: Premature babies A baby is called preterm or premature when she/ he is born before 37 weeks of pregnancy. The more preterm a baby is, the more specialized medical care they need, and the longer they stay in the NICU. Full-term babies that are sick Some full-term babies may require special medical care due to conditions like jaundice, seizures, infection, respiratory distress, or low blood glucose levels. Babies with birth defects Some babies are born with birth defects or "congenital anomalies" that require special NICU care. There are several birth defects like heart disease, obstruction in the intestines, kidney disease, and more that require immediate surgery followed by special medical care and observation in the NICU.
26 Babies under observation/monitoring In some cases, babies may need to be closely monitored as they may experience difficulty in breathing, poor feeding, or low levels of activity. These babies will also be kept in the NICU and given special treatment. Are there different levels of neonatal care? Newborn care in the NICU varies from baby to baby depending on their requirement. The different levels of care are explained below: Level 1 This is when babies are kept with their mothers, but daily checkups are done to ensure that the baby is doing well and is not suffering any ailments. Level 1 care includes monitoring blood glucose levels, providing warmth, administering vitamin K, cord care, and early establishment of feeding. Level 2 Some babies require extra medical care than daily routine checks. In such cases where babies require antibiotics, IV fluids, or phototherapy for jaundice,
27 they are admitted to Level 2 care. Sometimes, babies who improve after receiving Level 3 care are also kept in Level 2 until they are ready for discharge. Babies at this level are given milk through feeding tubes and are kept here until they are ready for breastfeeding/oral feeding. Level 3 Level 3 of the NICU is for babies who require critical care. These babies have an extremely low birth weight (ELBW) and require ventilation and surgical intervention. How is the layout of the NICU? The high-dependency room (HD) is where babies in critical condition are kept.
28 The low-dependency room (LD) is where babies who require close monitoring are admitted. These babies may require oxygen support or phototherapy (a baby is kept in special blue or white light to treat jaundice). The mother’s room is specially designed for the mother’s stay while the baby is in the NICU. Many hospitals provide this room at a nominal cost. The feeding room is where the mother can spoonfeed or breastfeed the baby, provide kangaroo care as well as express milk, and complete sterilization. Rooming-in is where the baby and mother stay before they go home. This provides the mother with an opportunity to initiate breastfeeding and for both to get comfortable with each other.
29 Who comprises the NICU staff? A Neonatologist is a pediatrician who specializes in newborn care. Your baby’s neonatologist is trained to handle complex conditions associated with prematurity and sickness and directs your baby’s treatment. Junior Doctors/Registrars are the ones providing the required medical care and monitoring your baby based on instructions provided by senior doctors. They work in shifts and update all the charts. They make decisions for the baby’s well-being in the absence of senior doctors. Fellows are trained and experienced pediatricians practicing to become neonatologists.
30 Staff Nurses are trained to care for preterm and sick babies and complete the baby’s routine care like bathing, cleaning, and diaper changes. They also monitor and record the baby’s vitals, attend to the equipment attached to your baby, and keep you updated on the care being provided. A Nutritional/Lactation Expert supports the mother in establishing breastfeeding, expressing the milk required by the baby, and ensuring that the baby receives the feed at the right time. They also provide advice and emotional support to the mother and baby till they are comfortable nursing by themselves. Coordinators manage the administration and billing department of the NICU. Once the baby is ready
31 for discharge, coordinators manage the discharge process to ensure a seamless experience. Physiotherapists are trained to provide care to babies in the NICU who have breathing difficulties or muscle problems. Are there any NICU rules that need to be followed? Parents are expected to follow the NICU guidelines and cooperate with the NICU staff to ensure that their baby’s safety and well-being are the top priority. Visits • The NICU is a restricted area as the babies inside have low immunity and are prone to infection. • Mothers are free to visit their baby at any time, provided no procedure is being performed on the baby. • Fathers are allowed a certain number of visits. • All other relatives are advised to meet the baby after discharge, if not at the allocated visiting hours.
32 What precautions need to be followed before entering the NICU? Hygiene: Strict hygiene protocols including handwashing, removal of footwear, and use of gowns and more, should be followed by parents entering the NICU. They are restricted from the area in case they have any infections like a cold, cough, or fever to prevent the baby from contracting any of the illnesses. Jewelry: No jewelry should be worn when the mother visits the baby in the NICU to avoid injuries and the risk of infection. Parents are also advised not to carry any accessories including mobile phones and watches when visiting the baby. Privacy: Parents should interact with their babies while respecting others’ privacy. It is a daunting time for anyone whose babies are in the NICU, and it’s not advised to pry on another baby’s condition, or come in contact with him/her. Photography: Photographs should be limited and parents are only allowed to take pictures of their own baby. Photographs are to be taken without the flash and with prior consent from the staff.
33 Are there any counseling sessions provided? Counseling sessions by the doctor updating the parents on the well-being and progress of their baby is the best form of communication to provide positive consolation. During the counseling sessions, doctors provide all the facts and hide no information from the parents to help them cope with the situation. What rights do parents of a premature baby have? It’s not uncommon for parents to hesitate to ask for information from doctors. Here are some of the rights you have as parents of a preemie: Right to information: As parents, you have the right to ask for information about your baby’s health, finances, or any other support you may need while your baby is in the NICU. Right to a second opinion: In case you feel that your baby is not showing signs of improvement or wish to take a second opinion from another doctor, you have the right to ask your current doctor to share your baby’s medical records. Right to see medical records: As parents, you have all the right to see your baby’s medical records, but only in your doctor’s presence.
34 Right to choose treatment option: If there are multiple treatment courses for the baby, doctors provide all the necessary options, timelines, and outcomes to parents, and they are free to choose what they think will be the treatment course that benefits the baby the most. Please ensure that you have enough time and information to make your decision, and don’t hesitate to ask your doctor any questions you may have. Follow-up instructions: When the baby is ready to be discharged, as parents you should gather all the required information to appropriately care for your baby and ask your doctors any questions you’re seeking answers to. Please keep in mind all the follow-up instructions provided and ensure that your baby is brought in for future appointments, screening tests, sonography, and vaccinations as per schedule. In case you have any queries, please reach out to your doctor, and she/he will be happy to assist you.
35 SUMMARY Seeing your baby in the NICU can be stressful, especially when she/he is surrounded by a multitude of high-tech equipment. However, it is rewarding to know that your baby is receiving round-the-clock care and is growing stronger every day. When babies are in the NICU, parents often feel they cannot do much, but that's not the case. Parents are welcome to visit their baby in the NICU and provide emotional support to establish a sense of security and comfort for their newborn. Oral feeding, breastfeeding, gentle stroking, massages, singing, and providing developmentally supportive care are things parents can provide their babies.
36 Main Headline
37 Himalaya & the Science of BabyCare Bringing the best of Nature's care for babies by contemporizing Ayurveda with modern technology
38 The wait for parents to hold the baby outside of the NICU can be daunting and emotional. Although both parents experience the joy of welcoming their newborn, they are also surrounded by uncertainties and overwhelming information about their baby’s health and progress as their baby strives to overcome the most difficult first few days or weeks of life. They not only have to support each other emotionally but also must take care of the hospital formalities. In addition, the mothers also require special attention to their health and recovery. During this time, support in any form from your loved ones including family and friends can bring relief and care. 4. A Long Agonizing Wait
39 Different Types of Concerns Parents May Need to Address Concerns regarding physical recovery: Mothers undoubtedly experience a lot of physical stress during preterm delivery with the recovery period being longer than a full-term delivery. If the mother has undergone a cesarean section, then the stitches can be painful and can cause discomfort even while performing simple tasks like moving or sitting. This can become even more challenging if the NICU is not in the vicinity of the area where the mother has been admitted. Financial stress: Often, parents are unprepared to handle the sudden financial requirement to care for the preterm baby. Since most parents plan for the needs of a full-term baby, handling and arranging finances can be stressful as preterm babies need specialized care and medications. How should parents cope with the concerns and stress of a preterm baby? When parents learn that their premature baby requires NICU care, they need to understand the importance of specialized care and try managing the anxiety and maintain a positive outlook. Now, this is easier said than done, but you can practice managing the following tips to handle these difficult times.
40 a) Accept and communicate: It is advisable that parents accept their baby’s condition as soon as possible and avoid straying into thoughts about the endless possibilities of what if their baby had been born full-term. Vocalizing your worries and questions to your doctors will help you understand the situation and handle the uncertainties more effectively. b) Ensure good care: Pregnancy and delivery put a lot of stress on the mother’s body, especially in the case of preterm delivery. It is important to prioritize the mother’s health and take the required rest, medication, and nutrition as advised by the doctor. This will also help with lactation as most babies are introduced to feeding during their NICU stay.
41 c) Understand your doctors and the NICU: Parents need to understand how the NICU works as their babies can spend anywhere from a few days to a few months there. Do not hesitate to get more information on the guidelines, different team members involved in taking care of your baby, the treatment being provided to your baby, the timings for the availability of senior doctors, and any other information that may help you manage your stress. d) Consider counseling: Usually, the counseling sessions are given by senior doctors wherein they update the parents on the progress of their
42 baby, positively impacting their parents. This is the most important form of communication between the doctor and the parents and is the best time to get answers to all your queries. It is advised to inform the doctor of the preferred language of communication at the beginning of the counseling session in order to make good use of the session.
43 e) Spend time with your baby: Parents are encouraged to visit their baby in the NICU to provide support and a sense of comfort and security to their newborn. Oral feeding, breastfeeding, gentle stroking, massages, and singing can go a long way in developing a bond with your baby. SUMMARY It may be difficult to take care of yourself while your baby is in the NICU because your sole focus is tending to your baby’s needs. You and your partner may have different feelings and coping mechanisms. However, it is important to keep in mind that if you are healthy and in positive spirits, you will have more energy to spend quality time with your baby which will eventually help you and your partner.
44 Usually, full-term and normal birthweight babies require very little assistance for breastfeeding. However, premature babies have difficulties sucking and swallowing during breastfeeding, and that is why they require to be fed using a tube or a spoon. Also, preterm babies require additional supplements to make up for the nutritional deficiency. Since they have underdeveloped digestion and poor tolerance to feed, they may experience vomiting and abdominal bloating, which means they need to be monitored when they are being fed. While feeding preterm babies, the aim is to gain the ideal weight that they may have if they were still inside the mother’s womb. 5. Feeding Your Premature Baby: Everything You Need to Know
45 1. What are the different ways to feed premature babies? a) Total parenteral nutrition (TPN): Parenteral nutrition, often called total parenteral nutrition, is a medical term for infusing a specialized form of food through a vein (intravenously). The goal of the treatment is to correct or prevent malnutrition. b) Tube feeding or gavage feeding: It involves using an oral or nasal tube to provide small amounts of milk directly to the baby’s stomach. c) Breastfeeding: Transition from tube feeding to breastfeeding occurs when the baby shows signs of being ready to suckle, i.e., when she/ he opens or closes her/his mouth during a
46 tube feed. It is advisable to have your baby by the breast when they are being tube-fed to maintain skin-to-skin contact. When the baby latches on to the mother’s breast before or during tube feeds, it is an indication of establishing oral feeding. Once the baby shows improved suckswallow reflex coordination, your doctor will recommend initiating oral feeds using a spoon. This can gradually be increased based on the baby’s ability to accept oral feed and the corresponding weight gain. Depending on how early your baby was born, she/he may require several weeks before initiating breastfeeding. 2. What are the benefits of providing breastmilk to my baby? During the first six months of your baby’s life, breastmilk is the perfect food for her/him as it contains all the required nutrients including
47 protein, fat, carbohydrates, and vitamins and minerals which support the baby’s growth and development. Moreover, it is easily digestible and offers many benefits to both the baby and the mother. a) Benefits for the baby • Increases immunity and prevents infections: Breast milk has anti-infective properties that help strengthen your baby’s immune system and keep allergies and infections at bay. • Easy to digest: As breast milk is easy to digest, your baby will have reduced chances of having stomach issues, diarrhea, and constipation. • Improves the effectiveness of vaccines: It has been observed that breastfed babies have a better antibody response when they are vaccinated. • Protects against specific illnesses: While you breastfeed your baby, he/she receives your white blood cells and other immune factors, making them less susceptible to specific illnesses including pneumonia and sepsis. • Improves brain development: Breast milk is naturally rich in a special type of omega-3 fatty acid, DHA (Docosahexaenoic acid) which supports your baby’s brain and eye development. Studies have shown that
48 babies who receive breast milk at an early age have better cognitive functions as they grow. Studies have also shown that breastfed babies have higher IQs later in life. b) Benefits for the mother • Helps faster healing: When you breastfeed your baby, the release of oxytocin helps reduce post-delivery blood loss. Oxytocin causes uterine contraction which helps with postpartum bleeding. • Improves bonding: Breastfeeding is a great way to bond and establish non-verbal communication with your baby. This also provides a sense of reassurance and comfort to your baby. • Lowers the risk of some cancers: Studies have shown that mothers who breastfeed their babies are at a lower risk of breast and ovarian cancer.
49 3. General guidelines on breastfeeding The World Health Organization (WHO) recommends mothers exclusively breastfeed their babies for the first six months of their life. It is recommended to start complementary feeding for preterm babies once they weigh over 5 kg or reach a corrected gestational age of five months and above. 4. Fortification of mother’s milk to provide additional nutrients for your premature baby Although breast milk is designed to meet the nutritional needs of a full-term baby, additional minerals, proteins, and vitamins may need to be added to the breast milk when feeding a premature baby. The human milk fortifier (HMF) is a powder added to expressed breast milk and is offered to the baby via tube feeding. Milk fortification is generally stopped once the baby starts directly breastfeeding.
50 5. Expressed breast milk (EBM) When you express milk, you take the milk out of your breast for your baby. Premature babies require breast milk but may not be able to suckle and have an adequate amount of feed. In such cases, the mothers can express their breast milk and store it for the baby’s needs. When mothers start expressing breast milk as soon as possible, it helps them maintain a good milk supply. 6. What are the different ways of expressing breast milk? The medical staff or your doctor will help you understand how to express your breast milk. a) Using the hand • Wash or clean your hands, and find a private and relaxing spot. • Place a warm towel on your breasts, or gently massage them. • Take your hand and position it on your breast in the C-hold by placing your thumb on the top of your breast and your fingers
51 underneath it, so it forms a C. Your thumb and your fingers should be one to two inches behind your nipple. • Place a collection bottle under your breast and position it in a way that your nipple is directly above the container. • Gently push your breast back and bring your thumb and fingers forward using a rolling motion. Following a rhythm will help express the milk faster. • Ensure that you are gentle and that the process is pain-free. b) Using a manual breast pump Manual breast pumps consist of a breast shield that is attached to a pump handle and a collection bottle. Get yourself comfortable and find a quiet and private place to express your breast milk. Here is how you can use a manual breast pump: • Place the breast shield over your breast with your nipple at the center. • Gently squeeze the pump handle and set a rhythm. • Pump until your milk flow stops, switch to the other breast, and repeat. C) Using an electric breast pump You can also use an electric breast pump. It works similar to the manual one but has a regulator to help express the milk. Here is how you can use an electric breast pump. • Place the breast shield over your breast with your nipple at the center.
52 • Start the pump with low suction and gradually increase the level so that you are comfortable. • Pump until your milk flow stops, switch to the other breast and repeat. 7. Non-nutritive sucking (NNS) Non-nutritive sucking is when a baby is sucking just for comfort, but she/he is full. This is generally done when the baby is currently being tube-fed. NNS can be performed several times a day. It helps the baby to develop early breastfeeding skills of coordinating their sucking, swallowing, and breathing. It helps the mother increase milk production and reduce the time she spends in the hospital. 8. Kangaroo mother care (KMC) This is a skin-to-skin contact method that
53 promotes parent-child bonding, especially when premature babies weigh less than 2 kg. KMC involves the mother holding her premature baby, who is dressed only in a diaper, between her bare breasts, mimicking how a kangaroo carries its baby. This contact helps the baby stay warm and allows close interaction with the mother. You can talk to your doctor about the right time to start KMC. a) Benefits of KMC KMC can help both the mother and the baby. For babies: It has been observed that babies on KMC gain weight more quickly, have rapid brain development, have a stable heart rate, breathing, and oxygen levels, and sleep for longer periods. They are also more alert, cry less, are more successful at breastfeeding, and may get discharged from the hospital sooner. For parents: KMC has helped reduce the stress levels of the parents and promote parent-infant bonding. KMC makes parents more confident in caring for their baby and facilitates earlier breastfeeding. 9. Formula feeding If you are unable to breastfeed your baby, she/ he can be provided with the required nutrition using an infant formula. Holding and talking to your baby, and making eye contact while he/she is being formula-fed will also help in developing a bond between the mother and the child.
54 10.When is the right time to end feeding? The right time to end the feeding session is when your baby begins to lose interest; let the nipple fall out of the mouth and let the baby become more relaxed. In case the baby loses interest in less than 15 to 20 minutes of feeding, you should encourage the baby to finish the feeding as the baby may not be full. Avoid feeding your baby for longer than 30 minutes, as she/he will get tired. Moreover, how quickly the baby learns to suck properly varies. There are chances the baby may not pay much attention to you as she/he is busy learning how to take the feed.
55 SUMMARY Although your baby will not start breastfeeding as early as full-term babies, it is important to understand that your breast milk is making her/him stronger and getting them closer to going home. Kangaroo mother care, regular massages, and non-nutritive sucking are all different and effective ways for you to bond with your baby and encourage her/him to start breastfeeding as soon as possible.
56 Premature babies spend a significant amount of time in the NICU after they are born. Developmentally supportive care (DSC) is provided to minimize the gap between the mother’s womb and the NICU environment so that the baby’s neurodevelopment is not affected. DSC comprises some core elements that aim to optimize healing and growth in premature babies by minimizing stress and increasing the period of resting. These five core elements include: • Providing an ideal NICU environment • Sound or protected sleep • Assessment and appropriate management of stress and pain • Providing family-centered care • Developing infant care practices or activities The advancements in medical sciences and neonatal care have significantly improved the survival of premature babies. Neonatal care is now focused on "intact survival". 6. From Just Survival to Intact Survival
57 1. Ideal physical environment The NICU environment strives to provide the best medical care possible to the premature baby while taking the family’s privacy needs and emotional support into consideration. a) Light exposure: The more premature the baby, the more sensitive to light they will be – but, in all cases, continuous bright lighting should be avoided. Babies who are younger than 28 weeks of gestational age require continuous dim lighting. Once babies reach 28 to 30 weeks of age, they are exposed to controlled artificial light in the day and dim lighting at night to help them understand the concept of day and night. b) Noise exposure: The NICU has low noise levels as preterm babies still require functional maturation of the inner ear. High noise levels may cause damage. Preterm babies are at a much higher risk of developing hearing loss and, hence, healthcare providers and parents are advised to be mindful of the sound levels inside the NICU.
58 2. Sound sleep Sound sleep for preterm babies is very crucial as it helps in their brain development. Babies often require longer periods of sleep. This is why the NICU has carefully controlled auditory and visual stimulation to not disturb the baby’s sleep. 3. Assessment and management of pain and stress Premature babies can get easily stressed with simple procedures such as feeding, diaper changing, daily care, and recording of vitals. If the baby is stressed, there can be changes in her/his breathing, oxygen levels, heart rate, and skin color. Parents, especially mothers, play a very important role in reducing the baby’s stress. The mother’s touch, skin-to-skin contact, kangaroo mother care, and breast milk help soothe the baby and impart a pain-relieving effect. Minor stress due to pain during the procedures can be managed by providing the baby with some oral sucrose or breast milk.
59 4. Family-centered care to help mothers and baby Family-centered care focuses on involving the parents in caring for the baby right from birth until the time they go home. 5. Supportive care practices to help premature babies in their overall development and growth a) Position and handling: The muscles of a premature baby are not as strong as those of a full-term baby. If your baby is not supported well, she/he usually lies with her/his arms and legs extended. These postures may lead to delays in motor development. To help premature babies, they are provided nesting. A nest provides boundaries for babies to push and rest against. High boundaries help babies get their hands and feet toward the midline position. b) Providing mother’s milk: All babies require their mother’s milk for energy and nourishment. Encouraging the mother to express milk, understand and respond to their baby’s cues and behaviors for feeding, and participate in developing their baby’s feeding plan, allows them
60 to provide milk to their babies until they are ready for breastfeeding. c) Sound stimulation to help soothe babies: Studies have shown that the physiological stability of babies and the speed of their weight gain improve when they are exposed to soft and soothing music. Parents can also strengthen their bond by making the baby listen to voice recordings of themselves and family members regularly. d) Visual stimulation: It is important to provide visual stimulation to the baby and to encourage her/him to develop eye-to-eye contact. You can also use pictures and bright toys of various colors and sizes to provide visual stimuli. e) Stimulation of the sense of smell: Premature babies are soothed and stimulated by the scent of their mother. When the mother and the baby have ample skin-to-skin contact, it stimulates and develops the baby's sense of smell. This helps them to identify their mother and root to the nipple for breast milk. f) Touch and hearing development: One of the first senses that the baby
61 develops is touch. The baby should be provided stimulation by positioning the baby in a way that allows her/him to self-soothe. This should be followed by speaking to the baby in a soft voice and gently touching the baby's head or back. You should also encourage your baby to grab the edge of the blanket or your finger and provide an opportunity for rooting and non-nutritive sucking. Stimulation in the form of KMC, touch therapy, and Indian traditional massage therapy are also quite beneficial to the baby. SUMMARY Providing medical care in the NICU alone is not sufficient for your baby to grow healthy. Along with providing various stimuli like light exposure, protected sleep, and an optimum NICU environment, parents should also be involved in caring for the baby. The familycentered developmentally supportive care that includes talking to the baby, providing KMC, and breastfeeding, helps in improving your relationship with your baby. In this way, you will also help make your baby feel safe and secure as she/he gets ready to go home.
62 1. Common growth concerns Some of the common concerns that bother parents of premature babies include: • Why is my baby more fragile and smaller than expected? • Why has my baby lost significant weight during the first week after birth? • Will my baby grow up normally or remain small and fragile for the rest of her/his life? • How can my baby grow better? Since most preterm babies are not able to achieve complete growth inside the mother’s womb, they usually weigh less than 2.5 kg at birth. When the baby is in the NICU, she/he is regularly monitored to ensure that maximum growth potential is reached. However, parents constantly worry about the growth of their preemies. So, let us address those concerns. 7. OMG! So Tiny…
2.The importance of growth Optimal growth supports tissue formation of various major organs. It also af fects the baby's immune system and ability to protect against infections. Babies who achieve optimal growth learn to feed independently at an early stage and can go home sooner. This is why ideal nutrition should be provided to premature babies to improve their growth. 3. Growth in the baby’s first week of life Premature babies tend to have excess water in their bodies which they lose over the first few days after birth. This is quite common and results in weight loss. In case the baby loses greater than one percent of weight per day, it is an indication of dehydration, and the baby may require more fluid intake. Premature babies begin gaining weight after 10 days of birth and may attain normal weight within two to three weeks. 63
64 4. Growth beyond the second week Although premature babies may grow slower than full-term babies, they tend to catch up as the feeding increases. Once the baby reaches normal feeding, breast milk may be fortified to provide more nourishment. It is important to understand that premature babies do not grow the same way in the NICU as they would have if they were inside their mother’s womb. A baby's length and head circumference are also measured and tracked regularly. If the growth chart has parallel lines, it means that the baby is growing well. 5. Catch-up growth Catch-up growth is rapid growth in infants or young children who were born prematurely. It is difficult to predict how much catch-up growth
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