Outpatient%20Follow%20up%20Care%20of%20%20%20%20%20%20%20%20%20Premature%20Infants

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Outpatient Follow up Care of
Premature Infants

• Jonathan R. Wispe
• Section of Neonatology
• Nationwide Childrens Hospital

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• ONCE A PREMIE
• ALWAYS
• A PREMIE

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OBJECTIVES

• Understand the long term effects of the common
  complications of prematurity
• Understand how to correct for prematurity
• Recognize normal patterns of postnatal, catch-up
  growth
• Implications of intrauterine growth restriction
• Importance of Post-discharge nutrition

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Terms related to prematurity

• Premature infants infant lt 37 weeks gestation
• LBW birth weight lt 2500 g (5 lb 8 oz)
• VLBW birth weight lt 1500 g (3 lb 5 oz)
• ELBW birth weight lt 1000 g (2 lb 3 oz)
• Chronologic age time since birth
• Postconceptional age time since conception
• Corrected age age corrected for prematurity

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HMD

• 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

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HMD

• Diffuse reticulograndular pattern
• Air bronchograms
• Homogeneous symmetric or asymmetric lung fields

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HMD - treatment

• Prenatal steroids given before 34 weeks of age
• Administer to mothers 24 -48 hrs prior to
  delivery
• Steroids increase the production and secretion of
  surfactant
• Postnatal surfactant therapy
• Synthetic Exosurf, surfaxin
• Natural / animal Survanta, Curosurf, Infasurf

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BPD /CLD

• Persistent pulmonary insufficiency
• O2 requirement beyond 28 days of age or 36 wks
  postconceptional age
• Abnormal radiographic findings

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BPD /CLD -treatment

• Bronchodilators
• Albuterol, theophylline
• Diuretics
• Furosemide (Lasix), Chlorothiazide (Diuril),
  hydrochlorothiazide, Spironolactone (Aldactone)
• Fluid restrictions
• 120 cc/kg/day
• Nutrition
• 150 cal/kg/day or more
• Steroids ??
• Budesonide, dexamethasone

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PDA

• 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

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PDA

• Treatment
• Medical
• CPAP
• Fluid restriction
• Diuretics
• PRBC transfusion
• Indocin / Ibuprofen
• Surgical
• Permanently ligation

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As and Bs

• There are 3 classifications of apnea
• 1. Central
• 2. Obstructive
• 3. Mixed
• Mixed apnea is the most common type seen in
  premature infants

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As and Bs

• 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

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As and Bs -treatment

• Tactile stimulation
• rubbing the feet
• bag and mask ventilation
• Continuous positive airway pressure
• decrease obstructive and mixed apnea
• no effect on central apnea
• Methyxanthines
• Aminophylline and Theophylline
• Caffeine
• Mechanical ventilation

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NEC

• NEC is the most common intestinal emergency
  encountered in the NICU
• Prematurity is the only definite risk factor
  identified
• The cause is multifactorial

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NEC-treatment

• NPO
• NG suction to decompress GI tract
• Vigorous IV fluid resuscitation
• Respiratory support
• Correction of acidosis, anemia, thrombocytopenia
• Empiric IV antibiotics

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Complications of NEC

• Stricture formation (25 to 35 of survivors)
• Short gut syndrome
• Malabsorption, FTT, weight loss
• Intra-abdominal abscesses
• Cholestasis
• Sepsis
• Recurrence of NEC

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IVH

• The most common type of neonatal intracranical
  hemorrhage
• Occasionally seen in late preterm and term
  infants
• Classification of IVH
• 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

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IVH III and IVH IV
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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
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Hydrocephalus

• Management
• 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

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PVL

• 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

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ROP

• Is a disease of prematurity where there is an
  incomplete vascularization of retinas
• Classification of ROP
• Zone I to III (location)
• Stage 1 to 5 (severity)
• Clock hours (extent of involvement of disease)
• /- plus disease (tortuosity of the vessels)

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ROP

• 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

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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

• 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

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Growth

• The growth pattern is a valuable indicator of an
  infants well-being
• Growth parameters should be plotted on standard
  curves according to the infants ADJUSTED AGE
• Adjust the age until infant is 2-3 years
• After that, age difference is insignificant

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CORRECTION FOR
PREMATURITY

• Example
• Baby was born at 26 weeks gestation
• 14 weeks premature (3.5 months)
• Now seeing at 1 year of age
• Chronologic age
• Need to plot weight and development for 8.5
  months
• Corrected age

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GROWTH CHARTS
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GROWTH CHARTSGIRLS
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HEAD GROWTH
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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

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PATTERNS OF BRAIN GROWTH

• 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

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PATTERNS OF GROWTH

• 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

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GROWTH OF SGA INFANTS

• Strongly determined by cause of growth
  retardation
• As a group, SGA infants dont grow as well
• If they have catch-up growth, it starts by 8 to
  12 months adjusted age.
• At least 50 are lt 50 at age 3

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Growth of SGA INFANTS

• Symmetric SGA infants are at the greatest risk
• OFC percentile at or below weight percentile
• Less likely to experience catch-up growth
• Very high risk for neuro-developmental
  abnormalities

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NUTRITIONAL REQUIREMENTS

• 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

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Growth

• Catch-up growth generally occurs during the first
  2 years of life
• 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
• differentiate hydrocephalus vs catch-up growth is
  important

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POST DISCHARGE NUTRITION

• Preterm infant has increased nutritional needs
  for
• Protein
• Minerals
• Calories
• Needs to be supplemented until baby is at least
  46 weeks post-conceptional age
• Needs can be met by
• Fortification of breast milk
• Use of specific formulas

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Nutrition

• 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
• Cows milk at 1 year corrected age

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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
• 1.4 g vs 2.1 g
• Other electrolytes
• more sodium, chloride, copper
• The duration of 22 cal formula ???
• 9 months vs. 2 months vs term

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Nutrition

• 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
• Vitamin D supplement - 200 IU/L
• can supplement with powder formula

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Development

• 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
• Prolonged hospitalization
• Impact of medical condition
• Developmental milestones of premature infants
  usually fall between chronological age and
  adjusted age
• The impact of prematurity in preterm infants
  without neurologic insult lessens over time

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Development

• 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

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Development

• 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

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Immunizations

• Preterm infants should be immunized at the usual
  chronologic age
• 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

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Immunizations-RSV

• 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

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AAP Guideline for RSV prophylaxis

• Infants lt 2 yrs of age and with CLD who required
  medical therapy within 6 months of RSV season
• Infants lt 28 weeks and lt 12 months at the start
  of RSV season
• Infant 29 to 32 weeks and lt 6 months of age at
  the start of RSV season
• 32 to 35 weeks and lt 6 months at start of RSV
  season and with risk factors

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Immunization hepatitis B

• 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
  )

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IMMUNIZATIONS

• Rotovirus
• Influenza

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Anemia of prematurity

• 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

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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

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Home apnea monitor

• If the family agrees to have home apnea monitor,
  infant can
• follow up in the apnea clinic, or
• follow up with the primary physician
• download the monitor
• review the strips
• stop the monitor if no A Bs
• 
  

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Vision

• ROP
• 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
• Higher incidence in preterm infants

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Hearing

• Initial screening
• EOAE - evoked otoacoustic emission
• ABR - auditory brainstem response
• If infant passes initial hearing screening, this
  does not rule out acquired or progressive hearing
  loss
• 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

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BIG POINTS

• 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