Issues that Are Associated With the Care of a Pre-Term Neonate Born at 32/ 40 Gestation - Essay Example

Ethical and social issues that are associated with the care and management of a pre-term neonate born at 32/ 40 gestation I. Introduction UnderlyingFactors Low socio-economic class, inadequate antenatal care, lack of access of mothers to clinical advice and services, poor maternal health, certain infections, maternal nutrition status prior and during pregnancy are the most common underlying factors that cause preterm delivery (Delpisheh, et. Al., 2006; Kiss, H. et. Al., 2004; Blondel and Marshal, 1998 ). This means that any of these factors can disrupt the natural process of child’s development in the womb, which will be described later on, and in effect, cause serious future complications if not managed properly. The serious complications that could result from mismanagement could affect the child’s growth, development and survival (Gracey, 2005). Preterm births not only incur developmental and health costs for the child; each preterm birth incurs a cost to the society as well. Petrou (2005), for example, reported that the cumulative cost of hospital admissions of children born at 32-36 weeks gestation to amount to 7,393.78 UK pounds. This is more than a hundred percent greater than the average 3,409.14 UK pounds that term infants incur in hospital admissions. Petrou, et. Al. (2001) gave a report, revealing that preterm and low birth weight infants incur substantial costs to the health sector immediately after the child’s discharge from the hospital. Subsequently, according to the report, preterms impose substantial burden to the families and on different sectors of the society such as education, social services (Petrou, et. Al., 2001). All these costs are associated with the high rates of disability, disease and deaths of those born prematurely (Petrou, S., 2003; Gracey, 2005). Given these issues, particularly the possible future health consequences to the child as well as the societal costs associated with preterm birth, ethical issues such as the value of human life, best interests, deliberate ending of life and withholding of treatment arise (Boyle, et. Al., 2004; Brazier, n.d; Stridsberg, 2005). With the proper understanding of the issue and proper management, however, the guardian or the practitioner need not deal with these ethical dilemmas. Development It is during the last trimester particularly in the eighth and ninth months, that your baby starts a growth spurt. At the end of the term, the baby could be as long as 20 inches and could weigh to about 7.5 pounds. Prior to this, the fetus is only about 14-16 inches long and weighs 2.5 – 3.5 pounds (Your Third Trimester Fetal Development, n.d.), putting on about half a pound every seven days (Your Pregnancy: Month Eight (31-35 weeks), 2004). It is during the last weeks of pregnancy that the growing child develops his immune system. During the eighth month, the mother passes antibodies to the baby to provide him temporary resistance post-partum until he develops his own resistance (Your Pregnancy: Month Eight (31-35 weeks), 2004). The brain is rapidly growing as neurons and synapses continue to develop, and hooked together. At this point, new connections are made. These new connections will give the baby everything he needs to survive as a newborn. These include the ability to suck, swallow, and drink breast milk (Your Pregnancy: Month Eight (31-35 weeks), 2004). The new connections that are made during the last weeks of pregnancy allow the baby to learn easily how to link one’s voice with one’s face (Your Baby’s Developing Brain, 2004). It is during the last trimester that the infant starts to build and store nutrients for himself. It is also during the last eight weeks of pregnancy that normal mineralization of the bones occur (Whitney, et. Al., 2001). It is only during the 37th week that the baby becomes ready to survive on his own (Your Pregnancy: Month Nine (35 weeks-delivery), 2004). II. Body Implications Since growth and development of the fetus are rapid at these stages, it is natural to point out that it is in these stages when nutrient requirements are greatest. As a corollary, a preterm infant is also low-birth-weight, being deprived of placental support at such critical time (Whitney, 2002). Malnutrition may not have teratogenic effects but could result in limited fetal growth and premature birth (Worthington et. Al., 1995). The limitation also extends to the maturity of many body systems. Limited fetal growth and premature birth could also result to an incomplete development of the child’s body systems (Whitney, et. Al., 2002) causing it to be the one of the main causes of infant mortality. (Field, 2003). This is because the infants are subjected to early physical independence before their organs and body systems are actually capable of sustaining itself (Whitney, 2002). Researches have shown that infants who are born prematurely and thus, with low-birth-weight have a higher risk of cardiovascular disease, lung disorders, renal diseases and other types of diseases that could manifest itself in adulthood or even earlier (Prenatal Development, n.d.). Preterm infants are at high risk for nutrient imbalances (Subramanian, et. Al., 2006) Since the last weeks of pregnancy are the time when the fetus builds and stores nutrients, its early delivery subjects it to limitations in nutrient stores, and thus physical metabolic maturity, which are necessary to consummate its physical independence. In addition, its premature GI tract promotes further nutrient imbalances as it limits the absorption of nutrients particularly fat, fatty acids and fat-soluble vitamins, iron, zinc and calcium (Whitney, et. Al., 2002; Worthington, et. Al., 1995). Arachidonic Acid and Docosahexanoic Acid (DHA) are very important long-chain fatty acids that are critical in the development of the child, especially brain (Uauy, et. Al., 2001). The transfer of these long-chain fatty acids are then missed out by the preterm infant (Whitney, et. Al., 2002). Children born at this stage, do not undergo normal mineralization of the bones which increases their risk for rickets, particularly, osteopenia. As a rule, the lower the birth-weight of the preterm infant, the higher his probability for this metabolic bone disease (Osteopenia-premature infants, 2005). Care and Management Since the preterm infant is mostly affected developmentally and nutritionally, the care and management of preterm infants should be targeted to compensate for what they lack. In other words, the care and management should be directed to assist the infant in adjusting to the environment; to prevent possible nutritional imbalances through the administration of the nutrients in the safest mode possible; to and to help the infant in catching up with growth. The caloric intake of the infant is very critical. Since it is relatively smaller compared to the full-term, its Basal Metabolic Rate (BMR) is higher which necessitates a proportionally higher caloric needs. In theory, the Total Energy Allowance (TEA) of a preterm infant is 30-50% higher compared to the full-term infant (Worthington, et. Al., 1995). However, the caloric intake must be balanced with nutrients so as not to risk the infant’s immature organs. Particularly, the most critical are the kidneys and the liver. The protein intake of the infant, for example, should be balanced to meet the growth needs and the infant’s high susceptibility to renal malfunction because of immature kidneys. In general, a gradual increase until 3-4 g/kg BW/day is considered a safe threshold of protein intake for the preterm infant, while for the caloric intake the value is 120-240 kcal/kg BW/day (McGuire, et. Al., 2004). In addition, salt intake should be minimized because its underdeveloped kidneys as well as its immature liver increase the risk for edema (McGuire, et. Al., 2004; Whitney, et. Al., 2002; Worthington, et. al., 1995). The infant is also susceptible to hypothermia because of the limited time it is allowed to store fat while inside the womb. This necessitates the regulation of the environment temperature to approximate that in the womb, thus the need for an incubator. A blanket must be provided to wrap the infant’s body in cases when the infant is to be removed from the incubator. All infants are to be handled with care but the case of the preterm infant is relatively more critical and cautious as they are more fragile because of their poorly calcified bones. Preterm infants are also characterized by their high susceptibility to bleeding as a result of their still immature liver, which is responsible for adequate prothrombin formation (Worthington, et. Al., 1995). Minerals such as Iron, calcium and phosphorus must be administered parenterally to supplement the infant’s immediate needs: the iron to prev early anemia; Calcium and phosphorus to promote bone growth and development. Fat soluble vitamins, A, D, E and K are also expected to be low in preterms because of their limited fat deposition. Vitamin D is especially critical to facilitate Calcium absorption and to prevent immature bone development that could increase the predisposition to rickets. Vitamin K is necessary to prevent hemorrhage. As said earlier, the infant is very susceptible to bleeding (Worthington., et. Al., 1995). Vitamin C, although not a fat-soluble vitamin, must also be supplied adequately because this is necessary to avoid the build-up of tyrosine in the blood because of its association with the enzyme involved in tyrosine metabolism. It is also needed in the conversion of folic acid to its active form. Folic acid is necessary for further development of the brain. Another function of Vitamin C is to assist in the absorption of iron and calcium (Worthingthon, et. Al., 1995). The preterm infant is a special case which needs certain considerations in the administration of food. There is a high probability that the infant has a weak sucking and swallowing reflex, for example. Then, this case demands not bottle-feeding, nor breast feeding initially, but parenteral or tube feeding. In any case however, breast milk is still recommended for its long-chain fatty acid components which are very critical for the brain development. In addition, the preterm milk is well-suited for the preterm infant because it contains just enough concentrations of protein for the infant’s needed growth. Still, the preterm milk must be supplemented with Calcium and Phosphorus to approximate the growth rate that has been bypassed by premature delivery (Whitney, et. Al., 2002; Worthington, et. Al, 1995). The infant’s immature lungs would also necessitate that no food must be administered for about 24 hours after birth until the respiration stabilizes and until edema subsides. The infant’s immature GI tract, as well as its small stomach capacity, only allows small feedings. To provide for his relatively high energy requirements, feedings should be done frequently. If formulas will be used to feed the infant, these must be with MCTs such as butterfat and corn oil to adjust for the infant’s poor fat tolerance. Charting and monitoring of weight must be done to observe progress and adjust management strategies (Whitney, et. Al., 2002; Worthington, et. Al., 1995). III. Conclusion The topic of preterm infant encompasses many different issues from its social causes, to the ethical dilemmas and proper management. The social causes and ethical dilemmas, however could be, although not easily, resolved by proper management pre- and post- delivery. Proper health care practices of the mother, for example could prevent premature delivery while the possibility of any health defects that could manifest during the adulthood (or earlier) could be prevented if both the family and the health care providers cooperate to incorporate knowledge to the promotion and advocacy of the preterm infant’s normal development. Works Cited Blondel and Marshal. (1998). Poor antenatal care in 20 French districts: risk factors and pregnancy outcome. J. Epidemiol. Community Health 52:501-506 Boyle, et. Al. (2004). Ethics of refusing parental requests to withhold or withdraw treatment from their premature baby. J Med Ethics. 30: 402-405. Brazier, M. (n.d.). How to Treat Premature Infants. The Scientist: Magazine of the Life Sciences. Volume 20 Issue 12 p.22. Delpisheh, et. Al. (2006) Socio-economic status, smoking during pregnancy and birth outcomes: an analysis. Child Health Care. 10: 140-148 Field, et. Al. (2002). Extreme prematurity in the UK and Denmark: population differences in viability. Archives of Disease in Childhood Fetal and Neonatal Edition. 87:F172 Gracey, M. (2005). Nutrition of the Preterm Infant. Atlas Books. Retrieved 02 Jan 2006 from http://www.atlasbooks.com/marktplc/rr01415.htm Kiss, H. (2004). Antenatal infection screening reduced preterm delivery. BMJ. 329:371 McGuire, et. Al., (2004). Feeding the Preterm Infant. BMJ. 329;1227-1230 Osteopenia-premature infants. (2005). Medline Plus. Retrieved 02 Jan 2006 from http://www.nlm.nih.gov/medlineplus/ency/article/007231.htm. Petrou., et. Al (2001). The long-term costs of preterm birth and low birth weight: results of a systematic review. Child: Care, Health and Development. Volume 27 Issue 2 Page 97 Petrou S. (2003). Economic consequences of preterm birth and low birth weight. British Journal of Obstetrics and Gynaecology. 110 (20): 17-23. Petrou S. (2005). The economic consequences of preterm birth during the first ten years of life. British Journal of Obstetrics and Gynaecology. 112(Suppl 1): 10-15. Prenatal Development. (n.d.). [Online Notes]. Retrieved 02 Jan 2006 from http://web.uvic.ca/psyc/mueller/psyc435a/Week%202%20Lecture%20Notes.pdf. Stridberg. (2005). Making The Best Decisions When Faced With The Risks Of Premature Delivery. Medical News Today. East Sussex: MediLexicon International, Ltd. Subramanian, et. Al. (2006). Extremely Low-birth-weight Infants. Emedicine. Retrieved 02 Jan 2006 from http://www.emedicine.com/ped/topic2784.htm. Uauy, et. Al. (2001). Essential Fatty Acids in Visual and Brain Development. Pubmed. 36(9):885-95. Whitney, et. Al (2002). Understanding Normal and Clinical Nutrition. USA: Wadsworth Learning. Worthington, et. Al. (1995). Nutrition Throughout the Life Cycle. Europe: McGraw-Hill. Your Baby’s Developing Brain. (2004) Mead Johnson Nutritionals. Retrieved 02 Jan 2006 from http://www.expectalipil.com/braindevelopment.html.  Your Pregnancy: Month Eight (31-35 weeks). (2004). Mead Johnson Nutritionals. Retrieved 02 Jan 2006 from http://www.expectalipil.com/fetal_dev_8.html. Your Pregnancy: Month Nine (35 weeks-delivery). (2004) Mead Johnson Nutritionals. Retrieved 02 Jan 2006 from http://www.expectalipil.com/fetal_dev_9.html Your Third Trimester Fetal Development. (n.d.). Palo Alto Medical Foundation. Retrieved 02 Jan 2006 from http://www.pamf.org/pregnancy/third/fetal.html. 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