Transcript Outpatient Follow up Care of Premature Infants Jonathan R. Wispe Section of Neonatology

Outpatient Follow up Care of
Premature Infants
Jonathan R. Wispe
Section of Neonatology
Nationwide Children’s Hospital
ONCE A PREMIE
ALWAYS
A PREMIE
OBJECTIVES
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Understand the long term effects of the
common complications of prematurity
Understand how to correct for prematurity
Recognize normal patterns of postnatal, catchup growth
Implications of intrauterine growth restriction
Importance of Post-discharge nutrition
Terms related to prematurity
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Premature infants: infant < 37 weeks gestation
LBW: birth weight < 2500 g (5 lb 8 oz)
VLBW: birth weight < 1500 g (3 lb 5 oz)
ELBW: birth weight < 1000 g (2 lb 3 oz)
Chronologic age: time since birth
Postconceptional age: time since conception
Corrected age: age corrected for prematurity
HMD
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Hyaline membrane disease (HMD) AKA
respiratory distress syndrome (RDS)
It is a lung disease where there is a deficiency
of surfactant
It is one of the most common causes of
morbidity in preterm infants
The diagnosis is made by clinical features and
radiographic findings
HMD
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Diffuse
reticulograndular
pattern
Air bronchograms
Homogeneous
symmetric or
asymmetric lung fields
HMD - treatment
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Prenatal steroids given before 34 weeks of
age
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Administer to mothers 24 -48 hrs prior to delivery
Steroids increase the production and secretion of
surfactant
Postnatal surfactant therapy
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Synthetic: Exosurf, surfaxin
Natural / animal: Survanta, Curosurf, Infasurf
BPD /CLD
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Persistent pulmonary
insufficiency
O2 requirement beyond
28 days of age or 36
wks postconceptional
age
Abnormal radiographic
findings
BPD /CLD -treatment
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Bronchodilators
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Diuretics
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120 cc/kg/day
Nutrition
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Furosemide (Lasix), Chlorothiazide (Diuril),
hydrochlorothiazide, Spironolactone (Aldactone)
Fluid restrictions
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Albuterol, theophylline
150 cal/kg/day or more
Steroids ??
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Budesonide, dexamethasone
PDA
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Ductus arteriosus is a
vascular connection
between the main
pulmonary artery with
the descending aorta
The incidence of PDA
is inversely related to
the gestational age
PDA
Treatment
 Medical:
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CPAP
Fluid restriction
Diuretics
PRBC transfusion
Indocin / Ibuprofen
Surgical:
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Permanently ligation
A’s and B’s
There are 3 classifications of apnea:
1. Central
2. Obstructive
3. Mixed
Mixed apnea is the most common type seen in
premature infants
A’s and B’s
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There are many causes of apnea and bradycardia
However, majority of infants in NICU have apnea
and bradycardia due to prematurity
Apnea and bradycardia of prematurity usually ceases
by 37 weeks of gestation, but can persist several
weeks past term
Usually, there is no specific cause for apnea and
bradycardia in NICU. It is attributed to immaturity
of respiratory control mechanisms
A’s and B’s -treatment
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Tactile stimulation
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Continuous positive airway pressure
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decrease obstructive and mixed apnea
no effect on central apnea
Methyxanthines
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rubbing the feet
bag and mask ventilation
Aminophylline and Theophylline
Caffeine
Mechanical ventilation
NEC
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NEC is the most
common intestinal
emergency encountered
in the NICU
Prematurity is the only
definite risk factor
identified
The cause is
multifactorial
NEC-treatment
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NPO
NG suction to decompress GI tract
Vigorous IV fluid resuscitation
Respiratory support
Correction of acidosis, anemia,
thrombocytopenia
Empiric IV antibiotics
Complications of NEC
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Stricture formation (25 to 35% of survivors)
Short gut syndrome
Malabsorption, FTT, weight loss
Intra-abdominal abscesses
Cholestasis
Sepsis
Recurrence of NEC
IVH
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The most common type of neonatal intracranical
hemorrhage
Occasionally seen in late preterm and term infants
Classification of IVH
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IVH I – germinal matrix hemorrhage (GMH)
IVH II – GMH + blood in ventricle. No ventricle dilation
IVH III – GMH + blood in ventricle + ventricular dilation
IVH IV – GMH + IVH + ventricular dilation + white
matter involvement
IVH III and IVH IV
IVH and outcome
IVH
outcome
comments
IVH I and II
-1 to 2% risk of CP and MR
The most common
abnormality is spastic
diplegia
IVH III
-cognative & neuromotor
ability are affected
-50% with major disability
Spastic quadriplegia as well
as diplegia
IVH IV
-cognative & neuromotor
ability are affected
-80% with major disability
The most common
abnormality is hemiparesis
Hydrocephalus
Management:
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Lumbar puncture
External reservoir
-if infant is too small for
shunt placement
VP shunt
-is associated with a 10%
mortality rate
-shunt malformation or
infection may be as high as
70%
P
P age:
age: 2
2 of
of 2
22
2
IIM
M :: 4
4
PVL
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An ischemic lesion leading
to areas of necrosis in
periventricular white
matter
Typically a bilateral lesion
White matter is damaged
and descending motor
tracts are affected
All infants with PVL
should be monitored
closely for
neurodevelopmental
sequelae
ROP
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Is a disease of prematurity
where there is an
incomplete vascularization
of retinas
Classification of ROP
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Zone I to III (location)
Stage 1 to 5 (severity)
Clock hours (extent of
involvement of disease)
+ /- plus disease (tortuosity
of the vessels)
ROP
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The incidence and severity of ROP increase with
decreasing gestational age
Most cases of ROP resolve spontaneously
 scarring of retina may occur later
Some will require laser surgery to prevent retinal
detachment
A F/U visit is based on the retinal findings
 Once ROP has resolved, F/U for refractive errors
ROP
Surgery:
Cryotherapy
 Laser surgery
 Scleral buckle and
vitrectomy
The goal is to prevent
retinal detachment
which leads blindness
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Prior to discharge
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maintain body temperature
take feeds orally and gain
adequate weight (20 to 30
grams per day)
have mature and stable
cardiopulmonary function
Have appropriate
immunizations
Have sensorineural
assessment
Growth
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The growth pattern is a
valuable indicator of an
infant’s well-being
Growth parameters should
be plotted on standard
curves according to the
infant’s ADJUSTED AGE
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Adjust the age until infant is
2-3 years
After that, age difference is
insignificant
CORRECTION FOR
PREMATURITY
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Example:
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Baby was born at 26 weeks gestation
14 weeks premature (3.5 months)
Now seeing at “1 year of age”
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Chronologic age
Need to plot weight and development for 8.5
months
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Corrected age
GROWTH CHARTS
GROWTH CHARTS:GIRLS
HEAD GROWTH
PATTERNS OF GROWTH
Healthy LBW, AGA infants experience catch-up
growth during the first 2 years of life.
• Maximal growth occurs between 36 and 40
weeks of gestational age
• Little catch-up growth after age 3
PATTERNS OF BRAIN GROWTH
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Head growth is usually the first parameter to
demonstrate catch-up growth
Rapid head growth must be distinguished
from pathologic growth caused by
hydrocephalus
Insufficient brain growth indicates poor brain
growth and identifies an infant at risk for
developmental disability
PATTERNS OF GROWTH
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Growth velocities for height and weight vary
considerably
Important to evaluate weight gain in
comparison to gains in length
Low weight for length (or declines in all
parameters) indicates inadequate nutrition
GROWTH OF SGA INFANTS
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Strongly determined by cause of growth
retardation
As a group, SGA infants don’t grow as well
If they have catch-up growth, it starts by 8 to
12 months adjusted age.
At least 50% are < 50% at age 3
Growth of SGA INFANTS
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Symmetric SGA infants are at the greatest risk
OFC percentile at or below weight percentile
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Less likely to experience catch-up growth
Very high risk for neuro-developmental
abnormalities
NUTRITIONAL REQUIREMENTS
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Nutritional requirements of the preterm infant
exceed the needs of the term infant at the
same adjusted gestational age
Increased needs may persist for the first year
of life, even if there are no exceptional
medical problems
Chronic disease greatly increases calorie and
protein requirements
Growth
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Catch-up growth generally occurs during the
first 2 years of life
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Maximal growth velocity occurs between 36 to
44 weeks postconception
Little catch-up growth occurs after 3 yrs
Head circumference is the first parameter to
show catch-up growth
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differentiate hydrocephalus vs catch-up growth is
important
POST DISCHARGE NUTRITION
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Preterm infant has increased nutritional needs for:
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Protein
Minerals
Calories
Needs to be supplemented until baby is at least 46
weeks post-conceptional age
Needs can be met by:
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Fortification of breast milk
Use of specific formulas
Nutrition
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Health preterm infants need 110 to 130 cal/k/day
Infants with chronic disease may need 200 cal/k/day
Need appropriate caloric distribution:
 Carbohydrates- fats-protein: 40-50-10
More then 24 cal formula can cause hyperosmolar
dehydration
Solid food should be introduced at 4 to 6 months
corrected aged
Cow’s milk at 1 year corrected age
Nutrition
20 cal vs 22 cal formula
 more calories per 30cc
 20 cal vs 22 cal
 better calcium/phosphorous ratio
 1.5 vs 1.8
 More protein per 100cc
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Other electrolytes
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1.4 g vs 2.1 g
more sodium, chloride, copper
The duration of 22 cal formula ???
 9 months vs. 2 months vs term
Nutrition
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Breast fed preterm infants at home
 less calories per 30cc
 human milk fortifier available to increase calories
 very expensive
 not available in the stores
 do not have adequate calcium, vitamin D, iron for preterm
infants
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Vitamin D supplement - 200 IU/L
can supplement with powder formula
Development
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It is important to use corrected age when assessing
premature infants developmental milestones
Most premature infants will experience temporary
delays in development. This is due to:
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Prolonged hospitalization
Impact of medical condition
Developmental milestones of premature infants
usually fall between chronological age and adjusted
age
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The impact of prematurity in preterm infants without
neurologic insult lessens over time
Development
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Development proceeds from cephalic to caudal and
proximal to distal
Developmental milestones:
 Motor skills (gross and fine)
 Language skills (expressive and receptive)
 Social skills
 Cognitive skills
 Adaptive skills
Development
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Back to sleep campaign
 Recommend- supine position to decrease
incidence of SIDS
 Infants lack the practice of flexion
Importance of flexion
 Need a balance between flexion and extension
 Important to have tummy time (prone
position) when infant is awake
 Avoid Johnny jumpers, walkers, exersaucer
Immunizations
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Preterm infants should be immunized at the
usual chronologic age
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example:
 28 weeks now 60 days old (2 month-old)
 PCA = 36 weeks
 due for DTaP, Hib, hep B, IPV, Prevnar
Vaccine dosages should not be reduced for
preterm infants
Follow immunization schedule as
recommended by AAP
Immunizations-RSV
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RSV is the leading cause of hospitalization in infants
under one year of age
Hand washing helps control the spread of RSV
Risk factors are: day care attendance, school age
sibling, lack of breast feeding, multiple births,
passive smoke exposure, birth within 6 months of
RSV season
Synagis (monoclonal RSV antibody) is administered
at 15 mg/kg IM monthly during RSV season, usually
October/November to April/May. There is regional
and seasonal variations
AAP Guideline for RSV prophylaxis
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Infants < 2 yrs of age and with CLD who
required medical therapy within 6 months of
RSV season
Infants < 28 weeks and < 12 months at the
start of RSV season
Infant 29 to 32 weeks and < 6 months of age
at the start of RSV season
32 to 35 weeks and < 6 months at start of
RSV season and with risk factors
Immunization – hepatitis B
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Preterm infants born to mothers not tested during pregnancy
for HBsAg
 Determine maternal HBsAg ASAP
 Infant should receive hep B vaccine within 12 hrs of life
 Preterm infants less than 2kg at birth should receive
HBIG if maternal HBsAg status cannot be determined
with in 12 hrs of life
 Full term infants: may delay HBIG for 7 days
 The initial vaccine dose should not be counted as part of
immunization series. ( a total of 4 doses )
IMMUNIZATIONS
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Rotovirus
Influenza
Anemia of prematurity
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Nadir of anemia occurs at 1-3 months of age
Hg of 7g/dl is not uncommon
Need to monitor signs & symptoms of anemia
F/U H/H until it is increasing
Iron supplementation reduces the level and
duration of anemia
Iron supplementation:
 2 to 4 mg/k/day for 12 to 18 months
Home apnea monitor
Infant with mild A & B & off caffeine in NICU can:
1. discharge home with apnea monitor
 train care taker CPR
 24 hours available medical assistance
 24 hours available equipment service
2. stay in the hospital for 5 to 10* day apnea free period
before discharging an infant home without home
apnea monitor
Darnall, Pediatrics 1997
Home apnea monitor
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If the family agrees to have home apnea monitor,
infant can:
 follow up in the apnea clinic, or
 follow up with the primary physician
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download the monitor
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review the strips
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stop the monitor if no A & B’s
Vision
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ROP
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Causes blindness in 1 to 4 %
F/U with an ophthalmologist until complete
vascularization. Then, F/U at 1-2 years of age
There are cases of late detachment reported
F/U later for strabismus, amblyopia, refractive
error
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Higher incidence in preterm infants
Hearing
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Initial screening
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If infant passes initial hearing screening, this does
not rule out acquired or progressive hearing loss
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EOAE - evoked otoacoustic emission
ABR - auditory brainstem response
F/U if there are any concerns
F/U 9 to 12 months if there are any other risk factors
If infant fails hearing screening, F/U 3 months of age
 Early intervention if infant is diagnosed with any
hearing loss
BIG POINTS
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Baby is not OK just because they are home
Correct growth and development for
prematurity
Give shots on time
Nutrition, nutrition, nutrition
Early recognition and intervention