Outpatient Follow up Care of Premature Infants

1. Outpatient Follow up Care of Premature Infants Jonathan R. Wispe Section of Neonatology Nationwide Children’s Hospital

2. ONCE A PREMIE ALWAYS A PREMIE

3. 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

4. Terms related to prematurity • 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

5. 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

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

7. 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

8. BPD /CLD • Persistent pulmonary insufficiency • O2 requirement beyond 28 days of age or 36 wks postconceptional age • Abnormal radiographic findings

9. 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

10. 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

11. PDA Treatment • Medical: • CPAP • Fluid restriction • Diuretics • PRBC transfusion • Indocin / Ibuprofen • Surgical: • Permanently ligation

12. 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

13. A’s and B’s • 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

14. A’s and B’s -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

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

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

17. 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

18. 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

19. IVH III and IVH IV

20. IVH and outcome

21. 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%

22. 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

23. 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)

24. 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

25. ROP Surgery: • Cryotherapy • Laser surgery • Scleral buckle and vitrectomy The goal is to prevent retinal detachment which leads blindness

26. 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

27. Growth • 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 • Adjust the age until infant is 2-3 years • After that, age difference is insignificant

28. 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

29. GROWTH CHARTS

30. GROWTH CHARTS:GIRLS

31. HEAD GROWTH

32. 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

33. 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

34. 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

35. GROWTH OF SGA INFANTS • 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

36. 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

37. 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

38. 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

39. 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

40. 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 • Cow’s milk at 1 year corrected age

41. 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 Nutrition

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. AAP Guideline for RSV prophylaxis • 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

49. 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 )

50. IMMUNIZATIONS • Rotovirus • Influenza