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Outpatient Care of the NICU Graduate

Outpatient Care of the NICU Graduate. Nhu Hang, R3 and Sonal Patel, R2 March 1, 2011. Learning Objectives. Immunization calendar Screening Newborn Hearing Vision Neurodevelopmental Growth and nutrition Common medical problems Psychosocial issues. Background.

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Outpatient Care of the NICU Graduate

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  1. Outpatient Care of the NICU Graduate Nhu Hang, R3 and Sonal Patel, R2 March 1, 2011

  2. Learning Objectives • Immunization calendar • Screening • Newborn • Hearing • Vision • Neurodevelopmental • Growth and nutrition • Common medical problems • Psychosocial issues

  3. Background • ~4 million births in the US each year • 12.5% born < 37 weeks GA (500,000 infants) • 2% born < 32 weeks GA

  4. Definitions • Preterm: < 37 weeks GA • Late preterm: 34 – 37 weeks GA • Very preterm: < 32 weeks GA • Extremely preterm: < 25 weeks GA • LBW: < 2500 grams • VLBW: < 1500 grams • ELBW: < 1000 grams • Corrected age: chronological age - # weeks born premature • PMA (post-menstrual age): GA + chronological age

  5. Immunizations • AAP: medically stable preterm infants should receive full immunizations based upon their chronological age • Hepatitis B • RSV

  6. Hepatitis B

  7. RSV • Increased risk for significant morbidity and mortality • Immunization with palivizumab (Synagis) leads to decreased rates of RSV-related hospitalizations

  8. RSV Immunization Recommendations (AAP) • CLD of prematurity, < 24 months: immunize if medical therapy within 6 months before the start of RSV season, give maximum of 5 monthly doses • CHD, < 24 months: immunize if hemodynamically significant CHD, give maximum of 5 monthly doses • Congenital abnormalities of the airway or neuromuscular disease, < 12 months: immunize, give maximum of 5 monthly doses

  9. RSV Immunization Recommendations (AAP) • Prematurity • Born at < 29 weeks GA, < 12 months: immunize, give maximum of 5 monthly doses • Born at 29 – 31 6/7 weeks GA, < 6 months: immunize, give maximum of 5 monthly doses • Born at 32 – 34 6/7 weeks GA: immunize if born < 3 months before the onset or during the RSV season AND either attends day care or has a sibling younger than 5 years of age, give maximum of 3 monthly doses until they reach 3 months of age

  10. Screening • Newborn • Hearing • Vision • Neurodevelopmental

  11. Newborn Screening • VLBW infants and those ≥ 3 weeks of hospitalization with congenital hypothyroidism may have a delayed rise in TSH • Recommendations (WA State DOH): 3rd specimen at 4 – 6 weeks or just prior to hospital discharge (Swedish performs this at 30 days PMA) • Other recommendations (WA State DOH) • 1st specimen PRIOR to transfusions, hyperalimentation, steroids, antibiotics • If transfused before 1st specimen -> 3rd specimen at 4 – 6 weeks post transfusion • If given steroids -> subsequent specimen at 7 – 10 days post therapy

  12. Hearing Screening • Increased risk for hearing loss (2% compared to 0.2%) including auditory neuropathy • Recommendations (Joint Committee on Infant Hearing/AAP) • Hearing screening with ABR (auditory brainstem response) – Swedish performs this on ALL newborns • If they fail -> refer to audiologist

  13. Hearing Screening • Recommendations (continued) • Reassessment by 24 – 30 months of age for those at increased risk regardless of newborn screening • NICU stay of > 5 days or with • ECMO therapy • Mechanical ventilation • Ototoxic drugs (aminoglycosides, loop diuretics) • Hyperbilirubinemiarequiring exchange transfusion • TORCHES, meningitis • Craniofacial anomalies • Syndromes associated with hearing loss, neurodegenerative syndromes, sensory motor neuropathies • Some argue for repeat screening at 6 months

  14. Vision Screening • Increased risk for long-term ophthalmologic problems • Retinopathy of prematurity (ROP) • Developmental vascular proliferative retinal disorder that occurs in the retina of preterm infants with incomplete retinal vascularization • Presents at ~34 weeks PMA, advances irregularly until 40 - 45 weeks PMA • Resolves spontaneously in the majority of infants • However, is the second most common case of childhood blindness

  15. Vision Screening • Recommendations (AAP) • Screening criteria (one of the following): • BW < 1500 grams • Born at ≤ 32 weeks GA • BW between 1500 – 2000 grams or > 32 weeks GA whose clinical course puts them at higher risk • Evaluation schedule • 4 – 8 weeks after birth depending on GA • Additional examinations at intervals of 1 – 3 weeks per ophthalmology • Other common ophthalmologic abnormalities: reduced visual acuity, strabismus, myopia • Referral to ophthalmology at 6 – 12 months

  16. Neurodevelopmental Screening • Impaired neurodevelopmental outcomes • Cognitive skills • Motor deficits (fine and gross motor) and CP • 45% of children with CP were premature • 9 – 12% of ELBW and VLBW infants are diagnosed with CP • Sensory impairment (vision, hearing) • Behavioral and psychological problems • ADHD, anxiety, depression • Rates of disabilities increases with decreasing BW and GA

  17. Neurodevelopmental Screening • Neurologic exam • Tone • Lower extremity extensor tone • Head lag • Shoulder girdle • Truncal tone • Reflexes

  18. Neurodevelopmental Screening • Developmental evaluation should be based on corrected age until at least 24 months • Refer to an early intervention program (EIP) if there are any concerns • Swedish NICU grads are encouraged to get PT/OT evaluation by 6 months regardless

  19. Growth • Weigh at PCP’s office, 24 – 72 hrs after discharge • Frequency of visits: every 1 – 2 weeks • Careful in labeling a preterm infant FTT (failure to thrive) • Rather than < 5%ile, should apply to those falling off their growth curve

  20. Catch-up Growth • “catch-up growth”: reaching 5th – 10th percentile on standard growth chart (eg. CDC) • Accelerated growth rate results in “catch-up” • Initially in head circumference, then weight and length… • However, pay attention to growth velocity • eg, If OFC is b/t 75th – 97th percentile, but height/weight is b/t 3rd and 25th – consider why? • OFC that is > 3 std deviations below the mean – high risk for developmental disability in future

  21. Growth • Consider cranial u/s for signs/symptoms hydrocephalus • Widely spaced sutures • Tense fontanel • Irritability • Alterations in nl behavior/activity level • Frequent downward deviation of eyes “sunsetting” • (esp if had grade III or IV IVH)

  22. Which Growth Chart to use? • For LBW infants (<2500g), CDC growth charts adequate (plot by corrected age) • For VLBW (<1500g), may use Infant Health and Development Program (IHDP, 1990) growth charts more accurate • Correct chart should be established by NICU Nutritionist • May stop using corrected age after age 2 or 2.5 years

  23. Nutrition • 24 kcal/30 mL (1 fl oz) -- until weight 1.8 – 3.5 kg • Then 22 kcal/oz formula / supplemented BM • until catch-up growth or 12 mos corrected age • AAP goal: 137 – 165 kcal/kg/day for catch-up growth • Then, average caloric needs: 100 – 120 kcal/kg/day • Avg daily weight gain: 20 – 30 g/ day

  24. Nutrition – Breast Fed • Human breastmilk = safest/ideal source of nutrition for ALL infants (including VLBW) • usual caloric concentration = 20 kcal/oz • By time of discharge, mother should pump to build-up milk supply ~50% greater than baby will need. • Most complete transition to exclusive nipple feeding after discharge • Should incorporate frequency of nippling into supplementation plan -- enhances milk supply! • Be careful of fatigue

  25. NUTRITION – Assessing Adequacy • Early breastfeeding state that the infant should breastfeed a minimum of 10-12 times in a 24 hour period.* • Diapers: > 5 wet diapers per day. • Breastmilk fortifiers NOT recommended once reaches weight of 2500 grams or greater. • Signs of effective breast feeding effectively: • rhythmic sustained suckling • audible swallow • softening of the maternal breast • maternal signs of milk ejection.

  26. Plan for Breastfeeding • Minimum daily milk intake is prescribed in mL at the time of hospital discharge. • Obtain accurate infant scale (in grams) for home. • Keep records of pre- and post- weights & duration for each feeding. • If consumes less than the prescribed amount, a supplementary bottle feeding given (EBM preferred) to make up deficit. • “nipple plus gavage” • When gaining weight steadily, frequency of test weights may be reduced. • Daily weights may be recommended for a few weeks to assure adequate intakes.

  27. Nutrition – Formula Fed

  28. Factors affecting growth & nutrition • Preterm birth • Prolonged/complicated NICU course • Neurodevelopmental deficits • Congenital structural • GI: malabsorption, GERD, feeding difficulty • Chronic lung disease of prematurity (BPD) • Congenital Heart Disease • Poor feeding technique • Neglect / Abuse • Genetics (size of parents)

  29. Nutrition – Micronutrients • Multivitamins – 0.5 – 1 mLof standard MVI qday, until reaches weight of 5 kg (11 lbs) • Iron – 2-4 mg/kg of iron per day • Folate – 50 micrograms/day (until 2.5 kg) • Fluoride – if water not fluoridated, 0.25 mg/d (2 wks – 2 yrs old) • Vitamin D – 200 – 400 IU / day (formula vs breastfed)

  30. Introducing Solid Foods • When: • Consistently consuming: > 960 mL (32 oz) per day for 1 week • Infant weighs 6 – 7 kg • Corrected age is at least 4 months • Oral-motor “readiness”

  31. Chronic Medical Problems • Anemia of prematurity • GERD • Chronic lung disease of prematurity • Apnea of prematurity • SIDS • Surgical • Dental

  32. ANEMIA of PREMATURITY • Baseline Hct when discharged – may need follow-up sooner • Screen for Anemia of prematurity at 2 mos, 6 mos and 12 mos of age • Nadir for Hgb: 7 – 10 g/dL at 4 – 8 wks after birth; 11 g/dL at 8 – 12 wks in Term infants • AOP typically occurs at 3 to 12 weeks after birth in infants less than 32 weeks gestation

  33. GERD • Mild reflux: • thicken formula w/ rice cereal (30mL/120mL or 2 tbsp/4fl oz), enlarge nipple hole • Maintain upright position – ? wedge • Moderate Reflux: • Medications: H2 blocker, PPI (lansoprazole) • N-D tube – if causing recurrent respiratory issues, may use as diagnostic tool* • Severe Reflux: usually require surgical correction (Nissen fundoplication?)

  34. Chronic Lung Disease of Prematurity • Formerly: Bronchopulmonary dysplasia (BPD) • 50 -80% of infants born weighing < 900g • Discharge/ Baseline: RR, HR, BP, SpO2, CXR, echo • Usual meds: • Bronchodilators (questionable role) • Diuretics (usually thiazide, since loops can cause nephrolithiasis) • Supplemental O2, with home oximetry • Inhaled Steriods (when appropriate) • Antibiotics (when appropriate)

  35. Chronic Lung Disease of Prematurity • If on diuretics - will need to monitor serum electrolytes • High readmission rates - esp first 2 yrs of life • Complications: • Acute respiratory exacerbations • Upper & Lower Respiratory Infections • Cardiac issues (cor pulmonale, pulmonary Htn) • Growth failure (increased caloric needs)

  36. Apnea of Prematurity • “Respiratory pause for > 20 seconds, or pause w/ bradycardia, change in tone, abnl mov’t, O2-desat” • ~ 25% premature infants develop AoP • usually central apnea in origin due to immature brain • May have methylxanthine (caffeine) w/ apnea monitor* • Usual dose: loading: 10 – 20 mg/kg per dose, and maintenance: 5 – 10 mg/kg per dose

  37. Apnea of Prematurity • Majority will outgrow AoP, by the time they are corrected age 40-44 wks • usually okay to stop Tx once 43 wks adjusted age, and free of extreme episodes (outgrow dose of caffeine) • would consult pulmonologist or neonatologist on decision to stop

  38. SIDS • 95% occur before 6 mos of age, majority b/t 2 – 4 mos of life • In premature infants, peak risk is b/t 50 – 52 wks chronologic age • RECOMMEND sleeping on back • Home apnea/bradycardia monitoring have NOT been shown to decrease rates for SIDS in preterm or general pediatric population

  39. Surgical • Umbilical hernias • Up to 75% of VLBW versus 10 – 30% of term infants • Most resolve by age 3 and rarely incarcerate • Refer to surgery if present after age of 4, >2 cm in size (unlikely to close), associated with abdominal pain, or signs of incarceration • Inguinal hernias • Risk factors: male, prolonged mechanical ventilation , lower BW, parenteral nutrition • 7% of preterm versus 0.1 – 0.2% of term infants • Rate of incarceration twice as high (18 – 31%) • Refer to surgery

  40. Dental • Increased risk of • Delayed tooth eruption • Enamel hypoplasia with increased risk for dental caries • Tooth discoloration • Palatal groove • Tooth malalignment • First dental visit by 12 months of age • Supplement with fluoride • Start at 40 weeks PMA • If concentration of fluoride is < 0.3 ppm give 0.25 mg/d (2 weeks – 2 years)

  41. Psychosocial Issues • Vulnerable Child Syndrome • Problems • Feeding problems • Difficulty in separating from the mother • Overindulgence and over-permissiveness • Interventions • Encourage families to normalize the caretaking of the infant and to be firm • Educate families about developmental delays • Refer to an EIP

  42. Psychosocial Issues • Post-partum depression • Higher rates • Associated with poor child developmental outcomes • Refer to an EIP • Refer to parent support groups • Washington State Medical Home for special needs kids: http://medicalhome.org/physicians/checklist_tools.cfm#provider • Seattle Children's - Children w/Special Needs website - Resources by County: http://cshcn.org/washington-resource-lists-county

  43. Take Home Points • Immunize based on chronologic age • Give Synagis if indicated • 3rd newborn screen if VLBW or ≥ 3 wk NICU stay • Hearing screening with ABR, consider referral to audiology at 6 mo (but at least by 24 – 30 mo) • Close F/U for ROP, refer to ophtho at 6 – 12 mo • Monitor for neurodevelopmental problems (check tone, use corrected age), refer to EIP • Frequent visits for catch up growth • Breastfeeding is possible, work with nutritionist • Supplement with Fe 4mg/kg, Vit D, MVI

  44. Take Home Points • Screen for anemia at 2 mos, 6 mos, 12 months • CLD common in prematurity – low threshold • Apnea of prematurity – d/w pulmonologist when stopping caffeine • Umbilical and inguinal hernias – refer to surgery if indicated • 1st dental appt by 12 months, ensure adequate fluoride • Monitor for and address vulnerable child syndrome and PPD • Provide support to parents/families

  45. References • AAP. Policy statement – Hearing assessment in infants and children: recommendations beyond neonatal screening. 2009. • AAP. Policy statement – Modified recommendations for use of palivizumab for prevention of respiratory syncytial virus. 2009 • AAP. Policy statement – Principles and guidelines for early hearing detection and intervention programs. Joint committee on infant hearing. 2007. • AAP. Policy state – Screening examination of premature infants for retinopathy of prematurity. • Bernbaum, et al. Preterm infant care after hospital discharge. Pediatr Rev. 1989;10:195-206. • LaHood, et al. Outpatient care of the premature infant. Am Fam Physician. 2007;76:1159-1164. • McCourt, et al. Comprehensive primary care follow-up for premature infants. J Pediatr Health Care. 2000;14:270-279. • Verma, et al. Continuing care of NICU graduates. Clin Pediatr. 2003;42:299-315. • http://depts.wa.edu/growing/index.html • http://www.doh.wa.gov/ehsphl/phl/newborn/Pubs/SpecialConsiderations.pdf • UpToDate

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