Neonatology and the Premature Infant

Prematurity

Babies born before 37 weeks gestation (10.4% of infants in the USA)

39 weeks gestation (unless medically indicated)

The WHO recommends NOT inducing labor prior to

22 - <25 weeks

Border of viability for neonates

under 28 weeks

Extreme preterm

28-31 6/7 weeks

Very preterm

32-36 6/7 weeks

Moderate to late preterm

37-41 6/7

Term

greater than 42 weeks

Post term

Gestational age (term vs. preterm), amniotic fluid clarity, addition risk factors, plan for umbilical cord management

What are the 4 questions of the pre-delivery report

Is the baby term gestation, is the tone good, is the baby crying

What are the 3 question for time of birth

delay cord clamping for 60 sec (raises hemoglobin, establishes RBC volume), evaluate infant on the mother (keep them together), the infant is warm, stimulate, and dry, airway is clear (bulb suction as needed)

If the answer to the time of birth questions is YES

Start with drying, stimulating and clearing the airway (BIG ONE), if hr is under 100 start PPV, consider intubation or LMA (laryngeal mask airway), if hr under 60 start chest compression, place central line, give emergency meds, determine if baby will stay with family or go to NICU

If the answer to the time of birth questions is NO

Activity (muscle tone, are they moving), Pulse (over 100, less than 100, absent), Grimace (reflex irritability), appearance (skin color - blue vs pink), respiration (cry, irregular or absent)

What is the APGAR Score (1 min and 5 min is required)? Big number good

Meds (Mg, general anesthesia, analgesics/narcotics), placenta previa, placenta abruption, nuchal cord, prolapsed cord

Maternal causes of low APGAR scores

Prematurity, intrauterine growth restriction, infant of a DM mother, hypoxic ischemic encephalopathy, congenital anomalies (congenital diaphragmatic hernia, spinal muscular atrophy, renal agenesis, CNS anomalies)

Neonatal causes of low APGAR scores

intraventricular hemorrhage, Hypoxic ischemic encephalopathy, neonatal abstinence syndrome

Common neurological problems in neonates

Retinopathy of prematurity

Common ophthalmology problems in neonates

RDS, bronchopulmonary dysplasia, aspiration pneumonia

Common respiratory problems in neonates

PDA, congenital cardiac defect, hypotension

Common cardiac problems in neonates

necrotizing enterocolitis, feeding intolerance, failure to thrive

Common FENGI problems in neonates

thrombocytopenia, hyperbilirubinemia, DIC

Common Heme problems in neonates

early onset group B strep sepsis, late onset sepsis

Common ID problems in neonates

Intraventricular Hemorrhage (IVH)

Bleeding within the thin walled capillary bed of the germinal matrix near the lateral ventricles - usually in infants less than 30 weeks and under 1500g (3.3 lbs)

Low birth weight, decreased gestational age (under 32 weeks), chorioamnionitis at delivery (inflammatory response), maternal hypertension (METH), genetic

Prenatal risk factors of IVH

Mode of delivery, neonatal transport (airplane pressure), hemodynamic instability, mechanical ventilation/pneumo, CO2 level shifts, hypoxia, acidosis

Peri/postnatal risk factors for IVH

Antenatal steroids for all mothers at risk for premature delivery

Preventative measures for IVH - prenatal

experienced delivery team, optimized delivery time, decreased stimulation for 1st 96 hours of life (keep flat, no movement), Small baby protocol (no daily weight, keep midline, minimize touch times)

Preventative measures for IVH - peri/postnatal

Asymptomatic, hypotension, bulging anterior fontanelle, apnea, seizures, coma, drop in Hct

Signs and Symptoms of IVH

All infants less than 32 weeks and/or less than 1500 g by day 7 of life at the latest

Screening protocols for IVH

Head u/s

First line imaging for IVH 🏆

bleeding in the germinal matrix - no shadowing on U/S

Grade 1 IVH

Bleeding within the lateral ventricles

Grade 2 IVH

Bleeding within the lateral ventricles (covers 75%) resulting in dilation of the ventricles

Grade 3 IVH

ANY Bleeding within the periventricular white matter

Grade 4 IVH

Blood transfusion (Hct low), respiratory support, Na Supplementation, serial lumbar punctures (draws off CSF to decrease ventricle size → shunts may need to be placed), long term follow up with neurodevelopmental clinic

Supportive care of IVH

low risk for moderate to severe neurodevelopmental delays and cerebral palsy

Long term outcomes of grade 1 and 2 IVH

30-60% risk neurodevelopmental delays or Cerebral palsy; 4x increase risk of death

Long term outcomes of grade 3 and 4 IVH

Respiratory Distress Syndrome (RDS, AKA hyaline membrane deficiency)

A deficiency of surfactant resulting in high surface tension in lungs, premature infants are at the greatest risk (surfactant by type II alveolar cells is not expressed until week 20)

prematurity, infant of DM mother, surfactant inactivation (aspiration of blood or meconium), lung inflammation

Risk factors for RDS

antenatal steroids

Prenatal preventative measures for RDS

Tachypnea (60+), nasal flaring (increased air intake), grunting (increased PEEP), intercostal retractions (increased lung volume), tachycardia, cyanosis, apneic episode with progression

Signs and symptoms of RDS

Diffuse ground grass on CXR, CO2 over 60, PaO2 decreased, BD increased, loss of A lines and pleural line abnormalities on U/S

Diagnostics of RDS

Non-invasive positive pressure ventilation (may require intubation if apnea present, watch the pressures if you give surfactant), surfactant administration (within the 1st 6 hours, must be intubated), nasal CPAP is 1st line

Treatment of RDS - patient specific

CO 60+, FiO2 30+%

Rules for surfactant administration - maintain SpO2 above 90%

Bronchopulmonary dysplasia

A long term outcome of RDS, that is defined by required oxygen support and/or mechanical ventilation at 28 days of life or 36 weeks corrected gestational age - may require home oxygen or tracheostomy

Ductus arteriosus

Diverts blood from the pulmonary arteries to the aorta bypassing the lungs

decrease in the circulation of PGs and increase in O2

What causes the closure of the ductus ateriosus?

Prematurity, low birth weight, RDS (pressure in lungs may pop it open), diuretic usage, genetics, rubella 2nd trimester

Risk factors for PDA

volume overload that is affecting the lungs

Indications for treating a PDA

antenatal steroids

Preventative measures for PDA

Asymptomatic; washing machine, holosystolic murmur, failure to thrive, pulmonary over circulation, persistent need for respiratory support, widened pulse pressure (ductals steal), DOE, fatigue, cyanosis, clubbing

Signs and Symptoms of PDA

Echo

Diagnostics for PDA

NSAIDs (indomethacin (watch bowel), tylenol, ibuprofen (watch kidneys)), Ligation (bedside procedure), Piccolo (preterms under 700g)

Treatment for PDA

CoA, severe pulmonary HTN, R-L shunting

CARDIO REMINDER - When are we NOT closing a PDA (give PGs)

favorable if that’s the only thing, surgical management may lead to greater mortality risk

Long term outcomes of PDA

Necrotizing enterocolitis (NEC)

A disorder characterized by ischemic necrosis of the intestinal mucosa, severe inflammation, invasion of enteric gas forming organisms, and dissection of gas into the bowel wall - most common GI emergency in preterms

Under 32 weeks, RDS, PDA, other comorbidities, ductal steal (poor perfusion), corticosteroids, ibuprofen, hyperosmolar formula

Risk factors for NEC

Feeding intolerance (most common), distended abd (measure after every feed), apnea, desaturations, bradycardia, hypothermia, bloody stool, dusky abd, lethargy

Signs and Symptoms of NEC

Dilated bowel loops (ileus), pneumatosis intestinalis (railroad tracks), free air (football sign),

KUB X-ray findings for NEC - confirm with U/S

Kidney, ureter, bladder X-rays, CBC (thrombocytopenia, leukocytosis), blood cultures, evidence of DIC

Diagnostics for NEC

NPO place replogle (specialized drain), Abx (pip-tazo), fluid management, serial KUBs

Gameplan for mild to moderate NEC

surgical consult, exploratory surgery with removal of dead bowel

Gameplan for severe NEC (presence of free air)

accounts for 10% of NICU deaths, 42% mortality in infants under 750 g (1.6 lbs), poor long term growth

Outcomes in NEC

PDA, RDA, NEC, prematurity

Risk factors for failure to thrive (a failure to gain weight appropriately)

licensed dietician

Failure to thrive is most appropriately managed by a…

Optimal growth is 20-30g/kg/da - fortification of formula or breast milk

treatment plan for failure to thrive

calcium 150-220 mg/kg/day, phosphorus 75-140 mg/kg/day, vitamin D 400 IU/day, Iron 3-6 mg/kg/day

Optimization of vitamins and minerals in failure to thrive

Hep B (if over 2000 g), DTAP, PCV13, IPV, NO ROTOVIRUS

Vaccines recommended in the NICU

All infants get Beyforus (RSV monoclonal antibody), try to convince the family to get vaxxed as well

RSV prophylaxis

monitor growth, coordinate care, vaccinations, neurodevelopmental assessment, social concerns/obstacles

It is recommended that all preterm infants follow up in a NICU specific clinic during the 1st 2 years of life to…