Clinical tips: premature babies


premature baby in humidicrib

Premature babies need extra care—particularly regarding how they take medications, write Jarrod McMaugh and Carlene McMaugh

Babies are considered to be pre-term or premature if they are born before 37 weeks gestation. further differentiation is made for children born before 28 weeks, 28 to 31 weeks, and 32 to 36 weeks, due to the maturity of different organs.

Just as children cannot be considered as ‘small adults’ for the purposes of medication dosing calculations, premature babies should not be considered the same as other babies when advising parents about medications.

The physiology of children born at different times prior to the full gestation period will vary significantly, while the presence of developmental issues will add a further layer of complexity. Pharmacists need to consider these issues when providing advice to their parents.

When discussing the health of a child who is born premature, it is common to discuss their birth age and their gestational age. Some conditions require a consideration of when a child would have been born, while other considerations are based on their age since birth.

The overriding consideration is that a child who was born preterm may not be able to take medications in the same way as other children their age. While weight and age are two of the main factors we consider when advising patients on safe use of medications in children, for those who were born preterm, pharmacists need to consider other factors as well.

A discussion with the child’s neonatologist may be necessary when a medication is being used for the first time, if the parents have not already been advised.

Absorption and elimination of medications

The digestive tract of a child who is born preterm may be underdeveloped to an extent that alters their ability to absorb medications adequately.

Liver function and kidney function may also be affected to a degree that requires dose adjustment due to altered elimination and metabolism.

Gut Microbiome

The microbiome that lives in our bowel is developed over a lifetime of exposure to different sources.

For a preterm baby, the microbiome may be drastically altered due to exposure to antibiotics in the NICU, and reduced exposure to the mother’s microbiome during birth or if breastfeeding is interrupted.

This may impact on the way the digestive tract and immune system develops.

Feeding

Breastfeeding will always be the recommended form of nutrition for premature babies due to the nutritional and immunological benefits this provides.

Just as the baby may not be fully developed at the time of birth, mothers may not be producing milk at the time of delivery.

While not a consequence of premature birth, other issues like cleft palate/lip may impact on feeding.

Skin

Our skin is the largest organ in our body; it is generally impermeable, protecting us from external substances, toxins, and pathogens.

For a baby, the surface area of the skin is proportionally larger and more permeable. This is pronounced in a premature child.

As a result, the ability to absorb medications from topical products may be enhanced.

Vaccinations

Vaccinations are provided to children who are born pre-term based on their birth age, rather than their gestational age.

Due to the potential of coming in to contact with various childhood illnesses, children will be vaccinated on the same schedule as other children born at the same time, with consideration given to other health issues that may impact on the appropriateness of each vaccination.

Lungs and breathing

Children who are born early will have some impact on lung function. For instance, surfactant production to reduce surface tension is usually affect, while apnoeas may be present due to neurological involvement.

Impact on pharmacist advice

It is important to remember that parents will likely have a higher-than-normal level of health literacy when it comes to their child, but as health professionals we should not allow their knowledge and familiarity with their child to override any concerns we may have with the appropriateness of a medication or a dose.

For pharmacists working in a specialised hospital setting, there is a lot of support due to input of neonatologists and the use of dosing protocols for specialised medication regimens to support a child to survive and thrive after an early birth.

For community pharmacists and hospital pharmacists working outside of a neonatal setting, there needs to be a consideration of the general issues associated with early birth, as well as the specific issues for each individual.

Keeping this point in mind – and remembering that this article barely scratches the surface – will ensure pharmacists can provide the best individualised advice to parents with children who are born pre-term.

Jarrod McMaugh is a community pharmacy practitioner with Capital Chemist in the northern suburbs of Melbourne. He has extensive experience in developing and delivering professional services in the community pharmacy setting.

Carlene McMaugh has worked in the healthcare field for over 20 years in varied roles and as a pharmacist for ten years including three years working as a pharmacist in the UK. She currently works in Capital Chemist Coburg and in the pharmaceutical industry.

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