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PRIMARY CARE OF THE EX- PREMATURE INFANT

PRIMARY CARE OF THE EX- PREMATURE INFANT. Therapeutical success and what next??. DR HATEM KHAMMASH MBBS, FRCPc, FAAP MAKASSED ISLAMIC HOSPITAL. Learning Objectives. Growth and nutrition Immunization calendar Screening Newborn Hearing Vision Neurodevelopment Common medical problems

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PRIMARY CARE OF THE EX- PREMATURE INFANT

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  1. PRIMARY CARE OF THE EX- PREMATURE INFANT Therapeutical success and what next?? DR HATEM KHAMMASH MBBS, FRCPc, FAAP MAKASSED ISLAMIC HOSPITAL

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

  3. Health Data – PalestineMOH reports (2009-2010) • Number Live Birth (2009) 116,595 54.2% West Bank & 45.8% Gaza. • 6.7 % born with birth weight less than 2500 gm (2010 ) 7800 infants • 1.1 % born with birth weight less than 1500 gm 1280 infants

  4. Growth & Nutrition (FACTS) • Premature birth is a major disruption at a time when the fetus should be growing rapidly. • Premature infants are often subjected to additional metabolic stressors. • To provide continued nutritional care after discharge from the NICU is to support optimal growth, development, and nutritional status. • Nutrient reserves in premature infants are suboptimal after discharge. • Poor postnatal growth, especially of the head, is associated with an increased risk of neurodevelopment impairment and poorer cognitive outcomes

  5. For each gestational age category, the postnatal study growth curve was shifted to the right of the reference curve Problem of chronic under nutrition and poor growth 99% of ELBW and 97% of VLBW had weights <10th percentile at 36 wks PMA Postnatal Growth of Premature Infants

  6. Human Milk for Premature Infants • Preferred feeding for ELBW/VLBW • Nutritional value • Immunologic and antimicrobial components • Contains hormones and enzymes • Once growth is established, nutritional needs of the preterm infant exceed the content of human milk for protein, Ca, P, Mg, Na, Co, Zn and vitamins

  7. Human Milk for Premature Infants • Unsupplemented HM • Associated with slower growth rate • Nutritional deficiencies: hyponatremia, hypoproteinemia, osteopenia, Zn deficiency • Infants discharged with subnormal weight for CA should be supplemented • ??? continued use of HMF

  8. Post-discharge Formula for Premature Infants • Nutrient-enriched formula for preterm infants after hospital discharge – post discharge formula (PDF) • Materna sensitive 22 cal, Neosure 22 cal • Intermediate in composition between preterm and term formulae • Compared to term formula, PDF contains • Increased amount of protein with sufficient additional energy • Contains extra Ca, P, Zn - necessary to promote linear growth • Additional vitamins and trace elements

  9. Post discharge enriched formulas should be used for feeding of preterm infants(esp. less than 1250 grams) • Enriched formula should be continued until the infant is 9 to 12 months corrected age. • Preterm infants , with special conditions (CLD etc…) may require continued specialized formula use beyond 12 months corrected age

  10. Postdischarge Formula for Premature Infants • Use of PDF after discharge in preterm infants  improved growth, with differences in weight and length • AAP recommendations 1. Use of PDF vs term formulas to 9mos chronological age  greater linear growth, weight gain and bone mineral content 2. Iron and vitamin fortified  no other supplements 3. If average intake 150ml/k/day  +Iron 1mg/k/day until 12 mos

  11. 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

  12. 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

  13. 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)

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

  15. Hepatitis B

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

  17. CDC Bronchiolitis Mortality Study: LBW as a Risk Factor • Multiple cause-of-death and linked birth/infant death data for 1996-1998 were used to examine bronchiolitis-associated infant deaths. Deaths were compared to surviving infants. • Birthweight <2500 g was a key risk factor for bronchiolitis-associated death, even when taking into account other factors (including GA): Birthweight Odds Ratio (95% CI) <1500 g 25.5 (14.6, 44.6) 1500-2499 g 4.6 (3.2, 6.8) 2500 g Referent Holman R, Shay D, et al. Pediatr Infect Dis J, 2003; 22: 483-9

  18. 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

  19. 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

  20. تعليمات استعمال دواء (Abbosynagis) PALIVIZUMAB يعطى الدواء لعلاج وقائي للتلوث بواسطهRSV في كل حاله من الحالات التاليه: أ) الخدج والصغار الذين ولدوا خدج ولم يكملوا السنتين والمصابين بإمراضرئويه مزمنة ويحتاجون إلى الأكسجين (الدواء داخل في سلة العلاج) ب) الخدج والصغار الذين ولدوا خدج ولم يكملوا السنة والمصابين في مرض رئوي مزمن BPD والتي شخصت لديهم بعد تصوير أشعة للصدر عادية وعلامات إكلينيكيه في عمر معدل 36 أسبوع حمل واحتاجوا للعلاج من التالي: أكسجين، مدرات، كورتيزون وجميعها شاملة في سلة العلاج. ج) الخدج ومن ولد خدج ولم يكملوا السنة إذا ولدوا قبل أن ينهوا 32 أسبوع حمل + 6 أيام شامله في سلة العلاج العلاج يعطى في الأشهر من نوفمبر وحتى مارس من كل سنه

  21. تعليمات استعمال دواء (Abbosynagis) PALIVIZUMAB د) للاولاد الذين يعانون من امراض قلب منذ الولادهCongenital Heart Disease 1) اولاد يأخذون علاج لقلة تدفق الدم 2) اولاد مع ضغط دم مرتفع رؤوي متوسط حتى خطير 3) اولاد مع امراض قلب من قلة الاكسجين هـ) الاولاد الذين لم يكملوا السنة وولدوا بوزن اقل من 1 كغم وبدون التعلق في اسبوع الولادة شاملة في سلة العلاج و) الاولاد الذين لم يكملوا السنة ويعانون من امراض رئويه مزمنه وصعبه وبدون التعلق باسبوعالولاده. الامراضالرئويهالمزمنه توصف بانهاالامراض التي تحتاج الىاكسجين في الاسبوع 36 للحمل. المرض الرئوي المزمن الصعب توصف بالولد الموجود في بدايه موسم RSV حيث يكون محتاجاً لعلاج مزمن باحدالتاليه: الاكسجين، المدرات، المنشطات بالاستنشاق، موسعات الشعب بالاستنشاق والمنشطات

  22. Screening • Newborn • Hearing • Vision • Neuro-developmental

  23. Newborn Screening • VLBW infants and those ≥ 3 weeks of hospitalization with congenital hypothyroidism may have a delayed rise in TSH • Recommendations 3rd specimen at 4 – 6 weeks or just prior to hospital discharge (Swedish performs this at 30 days PMA)

  24. 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

  25. 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

  26. 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

  27. 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

  28. 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

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

  30. 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

  31. Chronic Medical Problems Anemia of prematurity 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. 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)

  34. 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)

  35. 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

  36. 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

  37. 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

  38. 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

  39. 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)

  40. 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

  41. Psychosocial Issues • Post-partum depression • Higher rates • Associated with poor child developmental outcomes • Refer to parent support groups????

  42. Take Home Points • Immunize based on chronologic age • Give AboSynagis 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 ophth at 6 – 12 mo • Monitor for neurodevelopment 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

  43. Take Home Points Screen for anemia at 2 mos, 6 mos, 12 months CLD common in prematurity – low threshold Apnea of prematurity –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

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