HEART

The heart forms early during foetal development - it is one of the first structures visible on a prenatal ultrasound. But in order for it to work optimally outside the womb, the heart relies on a dramatic shift in blood flow during the first few hours and days of life.

The heart is divided into two halves: the right side receives oxygen-depleted blood from the body and pumps it to the lungs, where it gets oxygenated; the left side receives the oxygenated blood from the lungs and pumps it out to the body. In the womb, a baby does not get oxygen by breathing through the lungs.

Rather, his oxygen comes from his mother's blood via the placenta and the umbilical cord. Instead of going through the right side of the heart and out to the lungs (as is the case in the normal baby after birth), the blood in the foetus goes through the right side of the heart and then joins the blood being pumped through the left side out to the body. One piece of tissue responsible for redirecting the

foetus blood flow is called the ductus arteriosus. This connection closes within the first two to three days after birth so that blood can flow through the lungs effectively. A ductus arteriosus that stays open too long after birth is called a patent ductus arteriosus (PDA).

Premature babies have a much higher risk of PDA than do full term babies. The problems associated with PDA range from a heart murmur to low oxygen levels. Often signs of a PDA are visible on chest X-rays. A premature baby will be watched closely for a PDA, and if he has one, it can be closed using medicine or surgery. The medicine is called indomethacin. It is effective some of the time, but it cannot be used in a baby with poorly functioning kidneys.

Because some premature babies are slow to gain normal kidney function, indomethacin is not always an option. The surgical procedure is called a ligation. The tissue is tied off or closed with a staple. As soon as either of these measures works, the blood no longer flows through the PDA and normal circulation begins.

GASTROINTESTINAL TRACT
The gastrointestinal (GI) tract becomes fairly functional around 34 weeks of gestation. Before then, a baby will likely have some difficulty coordinating a suck and swallow, digesting normally, and moving her bowels. Therefore a premature baby often needs help receiving nutrition.

A very premature baby will be unable to tolerate any food by mouth. Instead she will need to have fluids given through an IV. When the fluids are continued for an extended period of time (longer than a couple of days), they are mixed with minerals and vitamins to maximize nutrition. This formulation is called TPN, or total parenteral nutrition.

Eventually a premature baby will begin to take formula or pumped breast milk. The point at which this will happen depends on the circumstances of each child. The feedings are typically started using not a bottle but rather a small feeding

tube (called a nasogastric tube, or NG tube) that is inserted through the nose and passed into the stomach.

The tube is kept in place until bottle feedings are started; otherwise trauma would be incurred every time a baby needed to be fed (the tube would have to be passed eight to twelve times a day). The feedings initially may be given continuously, with very small amounts of formula or breast milk dripping aroundthe-clock into the stomach. Once the baby can tolerate this, the feeding schedule will be changed to bolus feeds, whereby the baby gets larger amounts of formula or breast milk every two to three hours. Once she can handle this, bottle- or breast-feeding will be tried. The process of slowly shifting a baby's feeding pattern is called advancing feeds.

Some premature babies require more calories than breast milk or standard formula provide. Breast milk and formula contain 20 calories per ounce. There are also fortified formulas with 22 or 24 calories per ounce. Though these formulas help with weight gain, they are not always well tolerated by babies.

Sometimes a baby must be formula-fed (for instance, when there is no pumped breast milk available), but the GI tract is too immature to break down or absorb certain components of formula. For these babies, there are formulas that have pre-digested fatty acids or additives that provide extra amounts of what the baby needs.

A premature baby is at increased risk of infection of her GI tract. The infection is different from the GI infections of older babies and children - those that typically cause vomiting and diarrhoea. Rather, these infections occur because the blood flow to a premature GI tract can be irregular. When a segment of bowel does not receive enough blood flow, that area can be injured from lack of oxygen. When the bowel is injured, bacteria living in that area can multiply. This is called necrotizing enterocolitis, or NEC. It is a serious infection, requiring antibiotics and sometimes surgery. If left untreated, NEC can cause sepsis. Feedings by NG tube or by mouth must be stopped until the NEC has resolved.

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