Ребенок, родившийся раньше чем через 38—40 недель, считается недоношенным. Недоношенность может быть обусловлена различными причинами:

  1. патология половых органов и беременности — недостаточно развитая матка или наличие у нее дефектов, острые и хронические воспалительные заболевания матки и придатков, многоплодие, многоводие, токсикозы беременности, плохие условия питания плода в связи с предшествующими абортами;
  2. экстрагенитальные заболевания и хронические инфекции матери, травмы живота, нервные потрясения, патология сердечно-сосудистой, эндокринной системы, заболевания почек и т. д. Не менее чем в 1/3 случаев причину недоношенности установить не удается.

Различают 4 степени недоношенности:

  1. Вес от 2001,0 до 2500,0
  2. Вес от 1501,0 до 2000,0
  3. Вес от 1000,0 до 1500,0
  4. Вес ниже 1000,0—800,0

Кроме недоношенности существует понятие незрелости. Определение зрелости плода имеет большое клиническое значение. Болышшстзо недоношенных детей являются и незрелыми. В литературе есть сообщения, когда рождались дети раньше срока, но со всеми признаками зрелого плода. С другой стороны, нередко рождаются доношенные дети с признаками незрелости. Особенно часто это отмечается при многоплодной беременности, диабете. Обычно же незрелость плода зависит от степени недоношенности. О зрелости новорожденного можно судить по функциональному состоянию органов и систем, по адаптационным механизмам к внешнесредовым условиям.

Основные признаки незрелости — рост менее 45 см, вес ниже 2500,0, красноватый цвет кожи, пушок, покрывающий почти все тело, недоразвитые ногти, мягкие, прилегающие плотно к черепу хрящи ушных раковин. Середина тела располагается выше пупка, у мальчиков яички не спущены в мошонку, у девочек зияющая половая щель, отсутствие ядер окостенения в нижнем эпифизе бедра, слабые движения конечностей, слабый крик и др.

Дыхание недоношенных детей неправильное, с разной амплитудой, часто поверхностное, аритмичное. Периодически после кормления могут наступать приступы асфиксии, основными причинами которых являются незрелость дыхательного центра и малые размеры легочных альвеол. Отмечается количественная недостаточность фактора натяжения (сурфактанта). У таких детей легко развиваются ателектазы и пневмонии.

Незрелость со стороны органов пищеварения может выражаться в отсутствии сосательного, а иногда и глотательного рефлексов. Вследствие этого возможны аспирация пищи и развитие аспирационной пневмонии. Слизистые желудочно-кишечного тракта выделяют мало секрета. На них часто обнаруживаются кровоизлияния, а иногда изъязвления дистрофического характера. Ферментативная активность пищеварительных соков низкая, в связи с чем у недоношенных особенно часто отмечаются диспепсии.

Общая сопротивляемость у таких детей чрезвычайно низкая. Они очень склонны к септическим заболеваниям.

Недоношенные и незрелые дети могут достичь должной степени зрелости и в дальнейшем развиваться, как их сверстники, при правильном уходе и вскармливании с учетом незрелости их организма.

Уход за недоношенными детьми

Учитывая особую опасность переохлаждений недоношенных и незрелых детей, следует с самого начала установить особый контроль за микроклиматом такого ребенка. Наиболее подходящие температурные условия для незрелого ребенка можно создать в кювезе. Они бывают разных конструкций. В кювезе можно поддерживать заданную температуру, влажность воздуха и необходимое количество кислорода, а вмонтированная кварцевая горелка создает возможность облучать ребенка ультрафиолетовыми лучами.

Если подобные кювезы отсутствуют, могут быть использованы кроватки-грелки с электрическим подогревом. В крайнем случае можно прибегнуть к примитивной кроватке-корзине с грелками. Важно, чтобы вокруг ребенка температура была 30—35°.

Уже в родильном зале недоношенный ребенок после обработки его под рефлектором должен быть запеленан в теплые стерильные пелепки и помещен в кювез. Выхаживаются таким образом дети со II, III и IV степенью недоношенности. Температурный режим в 1-ю неделю (под контролем температуры тела)—32—34°, затем постепенно снижается до 30° и ниже. В первые 2 суток влажность — 95—100%, к 4—5-м суткам— 69%. Насыщенность кислородом не должна превышать 38%.

Все необходимые манипуляции по уходу — осмотр, поворачивание, пеленание и подмывание лучше делать на специально оборудованном, утепленном пеленальном столике или в кювезе.

При нарушении дыхания и появлении приступов цианоза, что нередко наблюдается в первые дни во время кормления или манипуляций, вводятся средства, возбуждающие дыхательный центр, этимизол, 0,6%-ный раствор подкожно 2-3 раза в день, а также кофеин, кордиамин и др.

Следует избегать и перегреваний ребенка как в кювезе, так и вне его. На что могут указывать краснота кожи, беспокойство ребенка и повышение температуры тела. Если ребенок в первые недели находится в закрытом кювезе, то затем его лучше поместить в открытый кювез с обогревом и только после этого содержать в кроватке в помещении с температурой воздуха 22—26. Ванны ребенку (независимо от степени недоношенности) после отпадения пуповинного остатка необходимо проводить ежедневно с температурой воды 38-40°. Показания к выкладыванию недоношенного новорожденного из кювезов — удержание нормальной температуры тела при температуре в кювезе 20—30°.

В настоящее время во многих городах созданы специализированные отделения по выхаживанию недоношенных детей.

Прогулки на открытом воздухе в безветренную погоду или на закрытой от ветра веранде можно начинать, когда вес ребенка достигнет 2800,0—3000,0.

Кормление недоношенных и незрелых детей

Вскармливание недоношенных и незрелых детей — исключительно трудная и ответственная задача. Затруднения связаны с незрелостью желудочно-кишечного тракта, низкой ферментативной активностью пищеварительных соков, повышенной проницаемостью кишечной стенки, что способствует проникновению в русло крови из кишечника ядовитых продуктов неполного расщепления пищи, бактериальных токсинов и др., низкой толерантностью к пище, особенно к жирам.

В то же время количество пищи для недоношенных как по содержанию энергетических веществ (углеводов и жиров), так и пластических (белков и солей) должно быть относительно большим, ибо у них более высокая, чем у доношенных детей, энергия роста. Затруднения во вскармливании у них обусловлены слабым сосанием, а то и отсутствием сосательного, а у более недоношенных — и глотательного рефлекса.

Для успешного преодоления трудностей во вскармливании крайне необходимым продуктом питания является грудное, и в частности материнское молоко. Режим кормления строится индивидуально в зависимости от степени незрелости ребенка.

При I степени недоношенности детей кормят из рожка сцеженным грудным молоком через 12 часов после рождения. В зависимости от состояния ребенка, силы сосания его прикладывают к груди матери на 2—3-й сутки.

При кювезном методе выхаживания детям со II и III степенью недоношенности проводится режим голода и жажды. Длительность его будет зависеть от состояния ребенка—24—48 часов. Для детей, родившихся в асфиксии, с внутричерепной родовой травмой, этот период может удлиняться до 72 часов. После голода и жажды ребенку в 1-е сутки дается 5%-ный раствор глюкозы по 5—7 мл 7 раз, во 2-е сутки — глюкоза с добавлением 5—7 мл молока, на 3-й количество молока увеличивается, а глюкозы уменьшается, и только на 4—5-е сутки ребенок получает молоко без глюкозы. Дети кормятся через зонд 7—8 раз (через 3 часа).

Показанием к прикладыванию к груди детей со II и III степенью недоношенности является активное сосание из рожка, при условии если ребенок высасывает положенную ему норму.

При относительно хорошей энергии новорожденного число кормлений сокращается, однако переводить на 6-кратное кормление до достижения веса 4000—4000 г не рекомендуется.

Недоношенный ребенок быстро устает даже при кормлении из бутылочки. Только более крепкие дети, с весом 1500—2000 г и более, при прикладывании к груди сосут достаточно энергично. При определенной осторожности кормление грудью такого ребенка несколько раз в день может быть полезным как для него, так и для лучшего опорожнения груди матери. Важно внимательно следить, чтобы ребенок не переутомлялся, в результате чего может появиться вялость, приступ цианоза. При ослаблении сосания лучше прервать кормление грудыо, дать младенцу подышать кислородом и докормить его с ложечки.
При кормлении с ложечки, пипетки или из бутылочки сцеженным молоком нельзя допускать возможности аспирации молока. Чтобы избежать этого рекомендуется кормление через зонд. Хотя этот метод афизиологичный, а зонд раздражает слизистую носоглотки, к нему приходится прибегать, особенно если ребенок глотает вяло или глоточный рефлекс совершенно отсутствует. Техника кормления через зонд довольно проста. Для этой цели применяют мягкий нелатоновый катетер № 13—15. Такой катетер после стерилизации и охлаждення вводится ребенку через рот или нос в желудок и соединяется со шприцем или небольшой стеклянной воронкой, куда наливается нужное количество подогретого до температуры тела женского молока. До и после кормления через зонд необходимо ребенку дать подышать кислородом в течение 1—2 минут.

Исключительно важно правильно рассчитать количество молока, необходимого недоношенному ребенку. Для расчета количества молока в первые 10 дней жизни новорожденного широко используется формула Роммеля:

Y = n+10

где Y — количество молока в мл, необходимое на каждые 100 г веса тела, n — число дней жизни новорожденного.

Расчет количества пищи можно вести и по ее калорийности. Она должна составлять: к 7—8-му дню — 30—60 кал на 1 кг веса, к 10— 14-му дню — 100—120 кал, к месячному возрасту— 135—140 кал на 1 кг веса.

Калорийность пищи, рассчитанная в первые 10 дней жизни по формуле Роммеля, несколько выше приведенных цифр. После 10-го дня необходимое количество молока должно составлять приблизительно 1/5 веса ребенка.

Если вам понравилась статья поделитесь ссылкой с друзьями в социальных сетях:


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