Read What to Expect the First Year Online
Authors: Heidi Murkoff
Overall, better than two out of three babies born prematurely will turn out to be perfectly normal, and most of the others will have only mild to moderate disabilities. Most often the baby's IQ will be normal, though preterm infants do have an increased risk of learning challenges. The risks of permanent development issues are much greater for those who are born at 23 to 25 weeks and/or weigh less than 25 ounces. Still, of the 40 percent of these infants who survive, more than half do well.
As your baby grows, it will be important to keep in mind that she will have some catching up to do before her development reaches the normal range for her birth age. Her progress is likely to follow more closely that of babies of her adjusted age (see next question). If she was very small, or had serious complications during the neonatal period, she is very likely to lag behind her corrected age mates, too, particularly in motor development.
It may also be slower going in the neuromuscular department. Some preemies may not lose those telltale newborn reflexes such as the Moro, tonic neck, or grasp reflexes (
click here
) as early as term infants do, even taking adjusted age into account. Or their muscle tone may be weak, in some cases causing the head to be floppy, in other cases causing the legs to be stiffer than normal and the toes to point. Though such signs may signal something's wrong in full-term babies, they're usually nothing to worry about in pretermers (but do have them evaluated by the doctor).
Slow developmental progress is definitely to be expected in a preemie, and is not usually a cause for concern. If, however, your baby seems not to be making any progress week to week, month to month, or if she seems unresponsive (when she's not ill), speak to her doctor. If a problem is discovered, the early diagnosis could lead to early treatment, which may make a tremendous difference in the long term.
Wondering whatâif anythingâyou should tell your older child about your new premature baby? Your first impulse might be to try to protect a big sib (especially one who's still pretty young) by not saying much at all about the baby's condition. But even very young children pick up more than the adults around them usually give them credit forâand without comforting context, stress signals can be especially unsettling and scary. Why is everyone distracted? Why are routines being disrupted? Why are mommy and daddy so stressed out? And where is the baby if it's not still in mommy's belly? The imagined can actually be more frightening for a young child than the realityâand what he or she doesn't know can hurt more than it has to.
Instead, give your older child some very basic facts about what's going on with the new baby. Explain that the baby came out of mommy too soon, before growing enough, and has to stay in a special crib in the hospital until he or she is big enough to come home. With the hospital's okay, take your older child for an initial visit, and if it goes well and he or she seems eager, visit together regularly. Big sibs who are still little are just as likely to be fascinated by the wires and tubes as they are to be scared, particularly if adults set the right toneâconfident and cheerful rather than nervous and somber. Having the new older sib bring a present to place in the isolette will help him or her feel a part of the team caring for the new baby. If your older child would like to, and if you have the staff's permission, let him or her scrub up and then touch the baby through the portholes. Encourage the brand new big brother or sister to sing, talk to, and make eye contact with his or her brand new sibling. This early bonding, even through isolette walls, can help your older child feel closer to the baby when that homecoming finally takes place. Big sib seems to want nothing to do with this extra tiny, extra needy new member of the family? That's fine, too. As always, follow your child's lead.
In the meantime, keep routines as close to “normal” as possible, and make sure that anyone who is caring for your older child is familiar with favorite foods, books, music, toys, games, and of course, bedtime as usual. During times of change and stressâwhich your preemie's stay in the NICU will inevitably beâthe same-old, same-old will be particularly comforting to a young older sibling.
Even once they've reached the age of full-term babies, preemies continue to need some special care. As you prepare to take your baby home, keep these tips in mind:
⢠Read the month-by-month chapters in this book. They apply to your preterm baby as well as to full-termers. But remember to adjust for your baby's corrected age.
⢠Keep your home warmer than usual (but not overheated), at least 72°F or so, for the first few weeks that your baby is at home. The temperature regulating mechanism is usually functioning in premature infants by the time they go home, but because of their small size and greater skin surface in relation to fat, they may have difficulty keeping comfortable without a little help. In addition, having to expend a great many calories to keep warm could interfere with weight gain. If your baby seems unusually fussy, check the room temperature to see if it's warm enough. Feel baby's arms, legs, or the nape of the neck to be sure it isn't too cool in the room. But don't go overboard by overbundling your little baby. It's dangerous for a baby to be dressed too warmly while sleeping. Again, feel baby's arms, legs, or the nape of the neck to be sure he or she is at the right temperatureânot too cool and not too warm.
⢠Buy diapers made for preemies. You can also buy baby clothes in preemie sizes. Just don't buy too manyâbefore you know it, they'll be outgrown.
⢠Ask the doctor if you should sterilize bottles, if you're giving them, between feedings by boiling them or running them through a hot dishwasher. Though sterilizing after each feeding may be an unnecessary precaution for a term baby, the doctor might recommend it for your preemie, who is more susceptible to infection. Continue for a few months, or until baby's doctor tells you it's no longer necessary. Sterilizing between uses might also be a must-do with breast pump parts, so ask the doctor about that as well. Microwave bags designed for sterilizing baby feeding equipment can make the job easier.
⢠Feed frequently ⦠and patiently. The smaller the baby, the tinier the tummyâwhich means that preemies may need a refill as often as every 2 hours (timed from the beginning of one feed to the start of the next). Feeding can be slowgoing, too, especially with breastfed preemiesâwho may not be able to suckle as efficiently as full-termers. They may take longerâas long as an hourâto drink their fill at each feed. Let your extra-little one take all the time he or she needs to feed.
⢠Feed extra ⦠if your doctor tells you to. Some preemies need a little extra boost in the calorie department, so the doctor might suggest you add a small amount of extra formula powder to fortify bottles, or to include a small amount of cereal in the bottle after a certain age. Reminder: Don't do this unless specifically recommended by the doctor for your bottlefed baby.
⢠Ask the doctor about a multivitamin and iron supplement. Preemies can be at greater risk of becoming vitamin deficient than full-termers and may need this extra insurance.
⢠Don't start solids until your doctor gives the go-ahead. Generally, solids are introduced to a preterm infant when his or her weight reaches 13 to 15 pounds, when more than 32 ounces of formula is consumed daily for at least a week, and/or when adjusted age is 6 months. Occasionally, when a baby is not satisfied with just formula or breast milk, solids may be started as early as 4 months adjusted ageâassuming your baby is developmentally ready.
⢠Relax. Without a doubt, your baby has been through a lotâand so have you. But once your little bundle is home, try to put the experience behind both of you. As great as the impulse may be to hover or overprotect, aim instead to treat your preemie like the normal, healthy baby he or she is now.
“Our son, who was born nearly 2 months early, seems very far behind compared with other 4-month-olds. Will he ever catch up?”
Your little guy's probably not “behind” at all. In fact, he's probably just where a baby conceived when he was should be. Traditionally, a baby's age is calculated from the day he was born. But this system is misleading when assessing the growth and development of premature infants, since it fails to take into account that at birth they have not yet reached term. Your baby, for example, was just a little more than minus 2 months old at birth. At 2 months of age he was, in terms of gestational age (calculated according to his original due date), equivalent to a newborn. At 4 months, he's more like a 2-month-old. Keep this in mind when you compare him with other children his age or with averages on development charts. For example, though the average baby may sit well at 7 months, your child may not do so until he's 9 months old, when he reaches his seventh-month corrected age. If he was very small or very ill in the newborn period, he's likely to sit even later. In general, you can expect motor development to lag more than the development of the senses (vision and hearing, for example).
Experts use the gestational age, usually called adjusted or corrected age, in evaluating a premature child's developmental progress until he's 2 to 2½ years old. After that point, the 2 months or so differential tends to lose its significanceâthere isn't, after all, much developmental difference between a child who is 4 years old and one who is 2 months shy of 4. As your baby gets older, the gap between his adjusted age and his birth age will likely diminish and finally disappear, as will any developmental differences between him and his peers (though occasionally, extra nurturing may be needed to bring a preemie to that point). In the meantime, if you feel more comfortable using his adjusted age with strangers, go ahead (they'll never know the difference). Certainly do so when looking at your baby's developmental progress.
You can encourage motor development by placing your baby on his tummy, facing outward toward the room rather than toward the wall, as often and for as long as he'll put up with it (but only when he is carefully supervised). Since preemies and low-birthweight babies spend most of their early weeks, sometimes months, on their backs in isolettes, they often resist this “tummy-to-play” position, but it's a necessary one for building arm and neck strength. Tummy time on your tummy or chest may be more fun for both of you ⦠plus you'll both reap the benefits that come from such kangaroo care if you do it skin-to-skin.
For most of your premature baby's first 2 years, his or her adjusted age will be the one that counts most, except in one area: immunizations. Most of a baby's vaccine schedule isn't delayed because of prematurity, so instead of receiving vaccines according to gestational age, he or she will receive them according to birth age. In other words, if your baby was born 2 months early, he or she will still get those first shots at age 2 monthsânot age 4 months.
There is, however, one exception. The hepatitis B vaccine is not given to a premature infant at birth (as it is for full-termers). Instead, doctors will wait until the baby weighs in at a minimum of 4 pounds, 6 ounces.
Don't worry about your tiny baby's immune system not being mature enough or able to produce antibodies to the vaccines. Researchers have found that at 7 years, even children who were born extremely small have antibody levels similar to other children the same age.
“My baby seems way too small for the infant car seat. Wouldn't she be safer in my arms?”
It's not only unsafe but illegal for a baby (premature or full-term) to ride in somebody's arms rather than in a car seat. Every baby, no matter how tiny, must be buckled up safely, securely, and snugly each and every time she's in a moving vehicle. But parents of low-birthweight babies often find that their especially little babies seem lost in a standard rear-facing infant car seat. The AAP recommends the following when choosing and using a car seat for your preemie:
⢠Select a car seat that will fit your baby. Choose an infant car seat, not a convertible seat, and look for one that has less than 5½ inches from the crotch strap to the seat back. This will help keep your baby from slouching. Also,
look for one that measures less than 10 inches from the lowest harness strap position to the seat bottom so that the harness won't cross over your baby's ears.
⢠Make it fit even better. Use the newborn insert that comes with the car seat (most infant seats include one) to cocoon your baby. If baby still seems too small to fit, roll a towel or small blanket and arrange it so that it pads the seat at the sides of her head. And if there's still a big gap between your baby's body and the harness, use a folded towel or blanket to fill it in (but don't place one under baby).
Also consider having a certified car seat installation technician check how your preemie fits into her car seatâto make sure she's getting the support she needs and is seated safely, as well as to show you how to make any necessary adjustments. (Search on
nhtsa.gov/apps/cps/index.htm
for a location near you.)
Some premature babies have trouble breathing in the semipropped position the seat requires. One study has shown that these infants may show a decreased oxygen supply while riding in a car seat, and that this deficit may last for as long as 30 minutes or more afterward. Some may also experience short periods of apnea (breathing cessation) in car seats. Make sure your baby is observed and monitored in the car seat by the hospital staff before going home. If she does experience breathing problems in a car seat, it's best to limit the amount of auto travel you do with her for the first month or two at home (or use an approved car bed), especially if she has had spells of apnea previously. Ask her doctor about monitoring her breathing when she's in an ordinary car seat, at least for a while, to see if she is experiencing any problems.