South County Doulas

Babies who are born prematurely often have two ages:

• Chronological age is the age of the baby from the day of birth -- the number of days, weeks, or years old the baby is.
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• Adjusted age is the age of the baby based on his due date. Healthcare providers may use this age when they evaluate the baby's growth and development. So, if a baby is 6 months old, but was born two months early, his adjusted age is 4 months.

What should you say when someone asks your baby's age?

This is up to you. You can say, "He's 6 months old, but he was born two months early. That's why he looks like a 4-month-old." Or you can say, "He's 6 months old" and leave it at that.

Remember: When people ask about your baby, they're usually trying to be kind, not nosy.

When will your baby catch up developmentally?

Most premature babies "catch up" to their peers, developmentally, in two to three years. After that, any differences in size or development are most likely due to individual differences, rather than to premature birth. Some very small babies take longer to catch up.

When can you stop using your preemie's adjusted age?

You can stop adjusting your baby's age when it feels most comfortable to you.

How do I calculate my baby's adjusted age?

Here's one example:

Chronological age: 20 weeks

The number of weeks your baby was premature: 6 weeks

Subtract the number of weeks premature from the chronological age: 20 weeks minus 6 weeks equal 14 weeks. 14 weeks is your baby's adjusted age.

Divide your baby's adjusted age in weeks by 4 to determine your baby's adjusted age in months: 14 divided by 4 equals 3 1/2 months

There may be a number of practical problems, as well. Even if insurance pays the medical costs, the extra needs can pose a financial burden. Along with the double expense for equipment, clothing and childcare, there is the expense of frequent trips to the hospital. If one baby is severely ill or disabled, he or she may be sent to a high-risk center for specialized care while the other twin remains in the birth hospital. In that event, you must get from one to the other for daily visits. Or if one baby is home, you must leave that tiny newborn to go visit the sick one.

These are problems with which a hospital social worker can help you cope. Social workers may refer you to agencies that might provide transportation, for example, or help you arrange child care for siblings at home. If friends offer to help, let them know specifically what they can do-- pick up and babysit your older child, give you a ride, or prepare a meal.

The combination of all these stresses is likely to strain your relationship with your partner. Try to make time for each other -- go out for breakfast, see a movie, or just walk around the block together. You need to take good care of yourselves so you can take good care of the babies. If the pressure of the situation becomes too great, ask the hospital social worker about support groups and/or counseling.

Keeping open the lines of communication with doctors and nurses will help you feel connected to the babies. Visit as often as you can. Ask questions and participate in the care as much as is medically feasible.

One very important thing mothers can do is pump breast milk and bring it in regularly. Even if babies are unable to nurse, they can get the nutritional benefits of human milk and their mother will be maintaining her milk supply until they can breastfeed. 

If you plan to breastfeed at home, nurses can do a lot of teaching, especially if you are a first-time mother who needs to learn various positions for nursing two babies at once, and how to get the babies sucking when their reflexes are weak. However, not all nurses know how to teach mothers of twins. If your twin-related questions are not being answered by hospital staff, you can get specific advice from TWINLINE phone counselors or publications.

If one twin has a chronic condition and must stay in the hospital much longer than the other one, a developmental delay may occur. Even with stimulation from the nursery staff, the hospitalized baby is at a disadvantage because he or she can't get to know you very well in a hospital setting. To counteract this and facilitate bonding, some hospitals occasionally allow a pass for a baby who is medically stable to visit home for a day. Ask your babies' doctor if this is possible. A home visit is especially important if older siblings have not been allowed to come to the Intensive Care Nursery. They need to be reassured that their newborn sister or brother is alive and growing. Remember that preemies, in general, will be developmentally behind for a time. If they come home at three months, they'll be more like newborns than three month olds.

Before your twins leave the hospital, be sure you have had some practice caring for your babies and been taught to use any special equipment they may need. Ideally, you and the staff should develop discharge plans together, based on the reality of your home situation. The discharge plan helps you understand the care the babies need-how and when to administer medication, what signs to look for, and when it's necessary to call the pediatrician, as well as routine wellbaby care.

Follow-up appointments for the babies to come back to the hospital to be checked should be made before discharge. You may also want to arrange for visits by a public health nurse-a free county service in many communities. It works best when the nurse meets you in the hospital or makes a home visit before the arrival of the babies. PHN's do a home assessment and can suggest the best placement of furniture, for example. Their role is not to give hands-on care but rather to offer support, educate parents, provide community referrals and act as a communication link between pediatricians and parents.

The most important thing you can do for yourself is to get some help when the babies come home. You may have spent three months shuttling between hospitals and then take home two sick babies on apnea monitors or oxygen, or with other special needs. Here is what one mother told us. "Against better advice, we didn't get enough help. In retrospect, I would have done whatever I could to get high school kids, or somebody else that wouldn't have cost a lot, to give me a break. And I wouldn't have been so reluctant to ask friends to help. The exhaustion of caring for preemie twins is cumulative. If you can stop it from happening, you'll feel better and everything will be better."

However you can manage it, try to get some "respite"-regular in-home help with the care of the children, which allows mom a break to leave for awhile or take a nap, knowing that someone will care for the babies and the house. Relief from baby care and housework is imperative if your family is to get through the babies' next two years-the high-risk period. During that time, the babies are very prone to respiratory infections and doctors continue to evaluate what their long-term medical future will be.

If you can afford it, hire regular household help or pay for the services of a visiting nurse. Find out if your insurance policy covers visiting nurses. Some families have even taken out loans to pay for child care and declare that having this aid during the difficult early months was well worth the expense.

If hired help is out of the question, try to arrange paternity leave for the twins' father or enlist extra support from relatives and friends. This can work fine if it's regular and dependable. The discharge planning and teaching should include anyone who will be caring for the babies. When no such support is available, ask the hospital to arrange for a public health nurse to keep in touch with you.

The premature arrival of twins or more is a very stressful situation for any family. Parents who make it through the first year of caring for tiny, needy infants with their sanity and close relationships intact are to be congratulated!

You're concentrating on your baby now, but remember that you have special needs, too. Taking good care of yourself will help you take the best care of your preemie.

• Allow plenty of time to heal. You may need more time to recover from the rigors of childbirth than you imagined. Eat a healthy diet, and get as much rest as you can. When your health care provider gives you the OK, make time for exercise, too. Even brisk walks through the hospital hallways or courtyard may lift your spirits.
• Acknowledge your emotions. Expect to feel joy, excitement, sadness, anger and frustration — sometimes all on the same day. Remember that you and your partner or spouse may react to stress and anxiety differently, but you both want what's best for your baby. Support each other through respect, understanding and compromise.
• Expect to feel overwhelmed. You're under a tremendous amount of strain. You may celebrate successes one day, only to experience setbacks the next. Give yourself permission to take it one day at a time.
• Take a break when you need it. Your baby needs you, but it's important to balance time at the hospital with time for yourself and the rest of your family.
• Accept help from others. Allow friends and loved ones to care for any other children, prepare food, clean the house or run errands. Let them know what would be most helpful.
• Keep a journal. Record the details of your baby's progress, as well as your own thoughts and feelings. Include pictures of your baby.
• Seek support. Surround yourself with understanding friends and loved ones. Talk with other NICU parents. Consider joining a local support group for parents of preemies, or check out online communities. Seek professional help if you're feeling depressed or you're struggling to cope with your new responsibilities.

Warmth

Premature babies lack the body fat necessary to maintain their body temperature, even when swaddled with blankets. Therefore, incubators or radiant warmers are used to keep the babies warm. Incubators are made of transparent plastic, and they completely surround an infant to keep him or her warm, decrease the chance of infection, and limit water loss. Radiant warmers are electrically warmed beds open to the air. These are used when the medical staff needs frequent access to the baby for care.

Nutrition and Growth

So, what are premature babies fed? Breast milk is an excellent source of nutrition, but premature infants are too immature to feed directly from the breast or bottle until they're 32 to 34 weeks gestational age. Most premature infants have to be fed slowly because of the risk of developing necrotizing enterocolitis (NEC), an intestinal infection unique to preemies. Breast milk can be pumped by the mother and fed to the premature baby through a tube that goes from the baby's nose or mouth into the stomach.

Breast milk has an advantage over formula because it contains proteins that help fight infection and promote growth. Special fortifiers may be added to breast milk (or to formula if breastfeeding isn't desired), because premature infants have higher vitamin and mineral needs than full-term infants. Nearly all premature babies receive additional calcium and phosphorus either by adding fortifier to breast milk or directly through special formulas for preemies. The baby's blood chemicals and minerals, such as blood glucose (sugar), salt, potassium, calcium, phosphate, and magnesium, are monitored regularly, and the baby's diet is adjusted to keep these substances within a normal range.

Hyperbilirubinemia

A common treatable condition of premature babies is hyperbilirubinemia, which affects 80% of premature infants. Infants with hyperbilirubinemia have high levels of bilirubin, a compound that results from the natural breakdown of blood. This high level of bilirubin causes them to develop jaundice, a yellow discoloration of the skin and whites of the eyes. Although mild jaundice is fairly common in full-term babies (about 60%), it's much more common in premature babies. Extremely high levels of bilirubin can cause brain damage, so premature infants are monitored for jaundice and treated quickly, before bilirubin reaches dangerous levels. Jaundiced infants are placed under special lights that help the body eliminate bilirubin. Rarely, blood exchange transfusions are used to treat severe jaundice.

Apnea

Apnea is another common health problem among premature babies. During an apnea spell, a baby stops breathing, the heart rate may decrease, and the skin may turn pale, purplish, or blue. Apnea is usually caused by immaturity in the area of the brain that controls the drive to breathe. Almost all babies born at 30 weeks or less will experience apnea. Apnea spells become less frequent with age.

In the NICU, all premature babies are monitored for apnea spells. Treating apnea can be as simple as gently stimulating the infant to restart breathing. However, when apnea occurs frequently, the infant may require medication (most commonly caffeine or theophylline) and/or a special nasal device that blows a steady stream of air into the airways to keep them open.

Anemia

Many premature infants lack the number of red blood cells necessary to carry adequate oxygen to the body. This complication, called anemia, is easily diagnosed using laboratory tests. These tests can determine the severity of the anemia and the number of new red blood cells being produced.

Premature infants may develop anemia for a number of reasons. In the first few weeks of life, infants don't make many new red blood cells. Also, an infant's red blood cells have a shorter life than an adult's. And the frequent blood samples that must be taken for laboratory testing make it difficult for red blood cells to replenish. Some premature infants, especially those who weigh less than 1,000 grams, require red blood cell transfusions.

Low Blood Pressure

Low blood pressure is a relatively common complication that may occur shortly after birth. It can be due to infection, blood loss, fluid loss, or medications given to the mother before delivery. Low blood pressure is treated by increasing fluid intake or prescribing medications. Infants who have low blood pressure due to blood loss may need a blood transfusion.

Respiratory Distress Syndrome

One of the most common and immediate problems facing premature infants is difficulty breathing. Although there are many causes of breathing difficulties in premature infants, the most common is called respiratory distress syndrome (RDS). In RDS, the infant's immature lungs don't produce enough of an important substance called surfactant. Surfactant allows the inner surface of the lungs to expand properly when the infant makes the change from the womb to breathing air after birth. Fortunately, RDS is treatable and many infants do quite well. When premature delivery can't be stopped, most pregnant women can be given medication just before delivery to hasten the production of surfactant in the infant's lungs and help prevent RDS. Then, immediately after birth and several times later, artificial surfactant can be given to the infant if needed. Although most premature babies who lack surfactant will require a breathing machine, or ventilator, for a while, the use of artificial surfactant has greatly decreased the amount of time that infants spend on the ventilator.

Bronchopulmonary Dysplasia

Bronchopulmonary dysplasia (BPD) is a common lung problem among premature infants, especially those less than 1,000 grams (2.2 pounds) at birth. The exact mechanism for this disease is still unclear, but extreme prematurity, severe RDS, infections before and after birth, and the prolonged use of oxygen and/or a ventilator needed to treat a lung disease all play a major role in the development of BPD. Preemies are often treated with medication and oxygen for this condition.

Infection

Infection is a big threat to premature infants because they're less able than full-term infants to fight germs that can cause serious illness. Infections can come from the mother before birth, during the process of birth, or after birth. Practically any body part can become infected. Reducing the risk of infection is why frequent hand washing is necessary in the NICU. Bacterial infections can be treated with antibiotics. Other medications are prescribed to treat viral and fungal infections.

Patent Ductus Arteriosus

The ductus arteriosus is a short blood vessel that connects the main blood vessel supplying the lungs to the aorta, the main blood vessel that leaves the heart. Its function in the unborn baby is to allow blood to bypass the lungs, because oxygen for the blood comes from the mother and not from breathing air. In full-term babies, the ductus arteriosus closes shortly after birth, but it frequently stays open in premature babies. When this happens, excess blood flows into the lungs and can cause breathing difficulties and sometimes heart failure. Patent ductus arteriosus (PDA) is often treated with a medication called indomethacin or ibuprofen, which is successful in closing the ductus arteriosus in more than 80% of infants requiring these medications. However, if medical therapy fails, then surgery may be required to close the ductus.

Retinopathy of Prematurity

The eyes of premature infants are especially vulnerable to injury after birth. A serious complication is called retinopathy of prematurity (ROP), which is abnormal growth of the blood vessels in an infant's eye. About 7% of babies weighing 1,250 grams (2.75 pounds) or less at birth develop ROP, and the resulting damage may range from mild (the need for glasses) to severe (blindness). The cause of ROP in premature infants is unknown. Although it was previously thought that too much oxygen was the primary problem, further research has shown that oxygen levels (either too low or too high) play only a contributing factor in the development of ROP. Premature babies receive eye exams in the NICU to check for ROP.

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