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1. To advance to the next slide, please press the arrow ( ) button on the keyboard This PowerPoint program was created by Alisa Dent, RN, BSN.

2. A Bad Day in the NICU What Do I Need to Know?

4. Infection PDA IVH Reflux NEC ROP Topics to be discussed

5. Infection & Your Baby • Babies can get many types of infections • in blood stream • in lungs • in fluid around brain • UTI • under skin • Infections caused by bacteria, fungi, or viruses. • Infections can start before or after birth.

6. Why do preemies get infections so easily? • Babies have an inexperienced immune system. • Preemies get fewer antibodies from mother. • Preemies have Ivs which can be routes of entry for bacteria. • Preemies are given antibiotics. These kill bacteria most likely to cause infection, but can enable other less common germs to grow more easily.

8. Less active increased apneas new or increased respiratory problems temperature instability Feeding intolerance poor skin color problems with low blood pressure possible seizures How does a baby with an infection act?

9. How will the doctor know if there is an infection? • The doctor may: • Obtain fluid samples from one or more body sites and send to the lab for culture. The lab will see if any type of bacteria grows. • The doctor will also monitor lab values such as the white blood cell count and the CRP value.

10. How is an infection treated? • Bacterial infections are treated with antibiotics. • Your baby may be on more than one antibiotic. • When an infection is caused by a virus or fungus, then a different medication is used. • Your baby may also receive meds to boost immune system.

11. Will there be permanent problems from an infection? • Most of the time infection responds rapidly to antibiotics. • Permanent problems are most likely if the baby has meningitis, or if there has been severe low blood pressure for a long period of time.

12. PDA Patent Ductus Arteriosus

13. What is a patent ductus arteriosus? • Patent means open • The ductus arteriosus is a blood vessel connecting the main vessel leading to the lungs (pulmonary artery) to the main vessel of the body (aorta). • It is NOT an anatomical flaw. • It is a blood vessel that is a normal, necessary part of fetal circulation.

15. Why does a baby have a ductus arteriosus? • Before birth, the mother and the placenta take care of the oxygen needs for fetus. • The fetus does not need to use their lungs, so very little blood needs to go to the lungs. • The ductus arteriosus allows most of the blood bypass the lungs and get to the rest of the body.

16. What happens to the ductus arteriosus after birth? • When breathing starts at birth, and the lungs expand with air, blood flow to the lungs increase. • A sudden rise in the blood oxygen level gives the PDA the message that it is time to close. • The 1st phase of closure should occur within baby’s first few days of life.

17. What if the PDA remains open? • After delivery, when a baby begins breathing, the blood flow shifts direction through the PDA. • Now the blood goes from the aorta to the lungs, adding to the blood that the lungs are getting from the heart. • This is too much blood into the baby’s lungs.

18. What if the PDA remains open? • Fluid in the lung increases and makes it harder for the baby to breathe. • The PDA increases the work load on the heart. • This increased work load for the heart can lead to heart failure if blood flow through the PDA is large.

19. Signs & Symptoms of a PDA • Increase in oxygen requirements and/or help breathing. • Breathing with more difficulty or increase in apneas. • A heart murmur is heard. • The baby’s heart rate increases.

20. Treatment of a PDA • Wait to see if it closes • Medication called Indomethacin can be given. It causes the ductus to narrow. More than 1 course of the medication may be needed. • Decreasing the amount of fluid baby recieves. • A diuretic may be given to decrease amount of fluid in lungs.

21. What happens if medical treatment does not work? • If the ductus will not close with medication,, the PDA can be tied off surgically through an incision through the chest. • This procedure can be done at baby’s bedside by a pediatric surgeon.

22. Will the PDA come back? • Sometimes the drugs only close the ductus for hours or a few days. • A second course may be needed, or surgery may be required. • Once baby is over problems of prematurity and the PDA has gone away, It will NOT come back later in life.

23. IVH Intraventricular Hemorrhage

24. What is Intraventricular hemorrhage? • IVH means bleeding into the normal fluid spaces within the brain or the ventricles. • IVH also refers to bleeding in areas near the ventricles even if the blood is not within them. • The severity or extent of IVH is graded.

25. Ventricle

26. Grading of IVH • Grade I- bleeding confined to the tiny area where it first begins. mild • Grade II- blood is also within the ventricles. mild • Grade III- more blood in the ventricles, usually with the ventricles increasing in size. moderate • Grade IV- the blood is beyond the ventricles, into the brain tissue. severe

27. Why do premature babies get IVH? • The preemie brain is still developing. • The area where IVH usually begins has a very fragile network of tiny blood vessels. • These blood vessels can burst easily causing bleeding. • The more premature or sick the baby, the greater the risk that they will develop IVH. • Babies at greatest risk are those <1000gm.

28. How will the doctors know if my baby has IVH? • Most of time- no outward signs of bleeding. • Occasionally babies have seizures or sudden decrease in red blood cell count. • Babies at risk for IVH will have a head ultrasound. • If IVH is noted on ultrasound, the baby may have the test repeated at intervals to monitor ventricular size and extent of hemorrhage.

29. How is IVH treated? • There is no specific treatment for IVH. • Surgery will not prevent or cure the bleeding.

30. What are the complications of IVH? • Complications are most common with grades III & IV. • The most frequent complication of IVH is Hydrocephalus or too much fluid collecting in the ventricles. • This extra fluid can cause: • the baby’s head to grow more rapid than normal • pressure on baby’s brain

31. Why does a baby develop hydrocephalus? • The brain has 4 ventricles. • Fluid, cerebral spinal fluid (csf), is made in the 2 larger ventricles & travels out of the brain to spinal cord and outer brain. • The fluid is then absorbed into the body from outside the brain.

32. Why does a baby develop hydrocephalus? • Abnormal amounts of fluid collect in the ventricles when: • the fluid cannot get out due to a clot blocking a channel • irritation from the blood and scarring prevent absorption of the fluid.

33. The Flow of Cerebral Spinal Fluid CSF CSF ventricle Spinal column

34. Hydrocephalus

35. Treating Hydrocephalus • In order to treat hydrocephalus, a way for the CSF to escape from the brain. • This may include: • Frequent LPs • Reservoir placed in one of the larger ventricles called a VAD. • A shunt is placed in one of the larger ventricles and drains into the abdomen called a ventriculo-peritoneal shunt.

36. What is a VAD? • A VAD stands for ventricular access device. • A tube is surgically placed into one of the larger ventricles and it connects to a chamber. • This chamber is placed under the scalp. • The CSF can be withdrawn from the chamber with a needle. • Temporary solution.

37. What is a VP shunt? • VP shunt stands for ventriculo-peritoneal shunt. • A VP shunt is placed surgically when baby is large enough usually 4-5 pounds. • A tiny tube is placed into a ventricle that attaches to a larger piece of tubing. The tubing continues under the skin, down the neck and chest and into baby’s abdomen.

38. Ventriculo-Peritoneal Shunt

39. Can IVH cause brain injury? • Grades I & II IVH usually do not cause identifiable brain injury- the blood is slowly absorbed by the body. • Grade III are at increased risk for brain damage, but most are normal or near normal. • Grade IV or those treated for hydrocephalus are at very high risk for permanent brain injury.

40. How will I know if my baby will have long term problems? • This can be determined only over time by monitoring development. • It is VERY important to have premature babies development followed carefully after discharge. • If baby has grade III-IV IVH, may be eligible for a developmental intervention program- ask nurse or social worker.

41. Gastroesophageal Reflux

42. What is reflux? • Reflux is when liquid from the stomach comes back up into the esophagus (food pipe). • It may come all the way back to the mouth causing the baby to “spit up”. • Reflux is common in babies under 1 year of age. It is even more common in preemies due to underdeveloped muscles.

43. Why is reflux a problem? • Reflux is a problem because the liquid from the stomach is mixed with stomach acid. • This acid can cause irritation to the esophagus. • Also, milk that is spit up can not help baby grow.

44. Gastroesophageal Reflux

45. How does a baby with reflux act? • Spitting up often • Apneas more frequent with desaturation. • Fussing or coughing after feeds • Arching of back or crying • Poor growth • More difficult breathing

46. How does the doctor know my baby has reflux? • Clinical signs & symptoms • A test where the baby swallows barium while a special X-ray machine views what is happening to the barium. • Medications to help with reflux may be given to see if there is a decrease in amount of symptoms.

47. How is reflux treated? • Positioning- baby is placed on tummy with head of bed elevated. • Feeding changes- May thicken milk with cereal or give smaller amounts more frequent. • Medicines can be given to reduce acid & improve muscle coordination. • Surgery may be done if other treatments fail.

48. How long will my baby have reflux? • Usually reflux improves slowly and is much better or gone by a year of age. • Some babies may go home on medications for reflux.

49. NEC Necrotizing Enterocolitis

50. What is necrotizing enterocolitis? • NEC is an intestinal disease of the newborn, almost exclusively affecting preemies. • NEC is an inflammation causing destruction to the bowel. • NEC may involve only the inner lining or the entire thickness of the bowel. • It involves various amounts of bowel.