NICU Graduate and Special Needs Children

1. NICU Graduate and Special Needs Children Chapters 118 and 138

2. Considerations for Special Needs Kids brought to ED • Their size may be large or small for age and a Broslow tape may not be appropriate • Caregivers are often invaluable as they should know the baseline vitals and much about the child's disease process • They may have different vitals that are “their” baseline • Consider pacemaker and vent settings

3. Cerebral Palsy • “Describes a collection of nonprogressive disorders of movement and posture originating from an injury sustained by the developing brain within the first 3-5 years of life” • Often associated with other CNS disorders • Classified by motor abnormality, distribution, and degree of involvement

4. CP causes for ED presentation • Seizures • Respiratory compromise • Gastrointestinal including feeding tubes • Dehydration • Pain or cutaneous complications from ortho braces

5. Meningomyelocele and Neural Tube Defects • Neurogenic bowel/bladder dysfxn • Contractures • Scoliosis • Hydrocephalus • Chiari II malformation • Tethering of the spinal cord • Cognitive Impairment • Spinal cord syrinx • Vesiculoureteral reflux • UTI • Constipation • Growth failure • Latex allergy • GERD • Respiratory compromise • Seizures Just to name a few

6. Meningomyelocele Neural tube defects

7. Meningomyelocele Complications • Recurrent UTI • Due to colonization, only tx symptomatic UTI • If unable to self-cath, consult Urology due to possibility of a false lumen • Chiari II malformation • Malformation of the cerebellum, hindbrain & stem • May present with apnea, vision changes, motor incoordination, upper ext weakness and headache

8. Autism • Mostly an impairment of social interaction • No different that the “normal” child • Some assoc with tuberous sclerosis • May have difficulty with exam and getting labs due to communication difficulty

9. Mental Retardation and Developmental Delay • Familiarize yourself with the medical complications for the various syndromes • Parents/caregivers will have invaluable knowledge about disorder as well as know the baselines

10. Down Syndrome • Pneumonia • Otitis media • Atlanto-occipital instability • Congenital heart defect • AV canal defects • Vent/atrial septal defect • Tetralogy of Fallot • Patent ductus • Pulmonary htn and CHF • Gastro • GERD • Esophageal atresia • Tracheoesophageal fistula • Pyloric stenosis • Meckels • Hirschrungs • Imperforate anus

11. Spinal Cord Injury • Autonomic dysreflexia: • Sweating, flushing, pounding heart, htn, bradycardia and piloerection • TX: empty bladder, disimpact rectum, discontinue painful procedures and repositioning

12. Techno-dependent Kids • Tracheostomy care • Mechanical ventilation • Feeding tubes • VP shunts • Urinary diversions

13. A few “little” facts • *Infants should be evaluated based on corrected gestational age, not their chronologic age • At 40wks: • Resp rate is 30-40bpm, if bronchopulmonary dysplasia is present 60-70bpm • Heart rate120-160bpm, lower if sleeping • Hematocrit 20-25% lower due to physiologic anemia

14. Cold Stress • Environmental temperatures vs little SubQ fat • Not capable of shivering • Increase metabolism of brown fat • Consumes oxygen and leads to hypoglycemia Consider turning up thermostat in room Consider use of a heat lamp from OB

15. Hypoglycemia • Glucose testing is necessary for all premature infants presenting with acute illness • Multifactorial: • Increased glucose consumption • Cold stress • Poor enteral intake • Suboptimal glycogen stores If BGL is <45 treat with IV D10W at 100mg/kg per day

16. Hypertension • Normal range is age dependent, but should be considered if > 120/75 • Occurs in 9% of premies • Causes: • Thromboembolic renal artery occlusion • Bronchopulmonary dysplasia

17. Fractures • Usually occur prior to initial discharge due to osteopenia • Fractures of the long bones and ribs most common • Will be found subsequently as healing fractures on x-ray • Good idea to compare to previous films before misinterpretation as child abuse

18. Failure to Thrive • May be due to ongoing chronic disease or dysfunctional parenting • Should consume at least 150ml/kg/day of standard formula and consistently gain 20-30g/d • Compare to discharge weight • Diagnostic eval and admit • *Prematurity is not an adequate explanation for FTT

19. Immunizations • AAP recommends using the same immunization schedule as full term infants in most cases

20. Bronchopulmonary Dysplasia • Sequela of prematurity, hylanine membrane disease, and mechanical ventilation • Features: tachypnea, hypercarbia, suboptimal oxygenation, and reactive airway disease • Severe ds: pulmonary htn, pulmonary edema, cor pulmonale • Cornerstone of tx: oxygen and nutrition

21. Acute deterioration in BPD • Manifested by: • Increased resp rate and effort • Poor feeding • Decreased oxygenation If assoc with CHF, may notice peripheral edema and excessive weight gain If anemic, may see pallor and not cyanosis

22. Bronchopulmonary Dysplasia

23. Causes of BPD • Pulmonary edema or CHF • Anemia • Dehydration • Gastroenteritis • Diuretic therapy • Respiratory infection • RSV especially! • Bronchospasm • Exposure to cigarette smoke • Sepsis • Aspiration • Gastroesophageal reflux • Incoordinate sucking or swallowing

24. Evaluation of a BPD patient • CBC with diff • Arterial blood gas • Normally have a compensated respiratory acidosis with PCO2 of 50-70mmHg • Appropriate cultures • CXR with old for comparison *Diuretics are the cause if the resp acidosis is worse and the pt is hypochloremic due to retention of bicarb and 2* increase in PCO2

25. Therapy of BPD • Treat underlying cause of deterioration • OXYGEN • If need for bronchodilator therapy • Admit for observation • Likely to require mechanical ventilation

26. Apnea and Home Apnea Monitors • Studies demonstrate that the majority of alarms are due to monitor malfunction and not change in resp status • Admit all that: • Were witnessed apneic episodes • Cyanosis or bradycardia • Required intervention ie stimulation or mouth-mouth Causes same as with deterioration but include cardiac dysrhythmia , seizure and hypoglycemia

27. Posthemorrhagic Hydrocephalus • Intraventricular hemorrhage not uncommon to neonate premies • Hydrocephalus can be a complication and the pt is usually discharged with a VP shunt • If return is due to obstruction: tense fontanel and vomiting • If due to infection: poor feedings, lethargy, irritability, fever and vomiting

28. Posthemorrhagic Hydrocephalus

29. Eval and Tx of hydrocephalus • Head circumference comparison to previous • Head CT or US • Empiric antibiotics • Neurosurgical consultation

30. Expected Home Death • Usually parents are given instruction by discharging physician to bring child to ED for death pronouncing • A letter is often brought delineating diagnosis and appropriate ED guidance • Do not make futile attempts at resuscitation • Request autopsy permission