Prematurity

PREMATURITY

PREMATURITY

Presentor- Dr. Anusha KattulaDNB(paediatrics)St.Philomena’s

hospital, Bangalore

Moderators- Dr. RajeevDr. Mythili

…….born too soon

• DEFINITION- Liveborn infants delivered before 37 wks(259 days) from the first day of the last menstrual period are termed premature by the WHO

• CLASSIFICATION( by gestational age)

• a) preterm- less than 37 completed wks

• b) late preterm- (34+1)wks-(36+6)wks(238-258 days)

• Birth weight classification

• LBW(low birth weight)-less than 2500 gms

• a) VLBW(very low birth weight)-less than 1500 gms

• b) ELBW(extremely low birth weight)-less than 1000 gms

Why should we be concerned?

• The rate of premature births in India is rising and is presently around 21%

• 3.6 million premature births in India—23.6% of the around 15 million global pre-term births. Of these, 13% are live pre-term births.

• The premature deaths contribute to 16.8% of neonatal mortality rate in India( acc. to NFHS 3)

Differentiating features

Sole- have fine wrinkles, creases are not well formed

• Breast nodule- small or absent

• EAR- preterm ear cartilages are poorly developed, soft and poor recoil

• Hair- wooly and fuzzy

• Skin-skin is thin, gelatinous,shinyand excessively pink, abundant lanugo

• Labia majora widely separated in females

• testes undescended and scrotum poorly developed

• Reflexes are weak-moros,sucking swallowing and grasp

extended posture due to poor tone

new ballard sore

Best- <12hrs( <26 wks)

upto 96 hrs( >26 wks)

Accurate within 2 wks of GA

Overestimates by 2-4 days in 32-37 wks babies

posture

Square window

Arm recoil

Popliteal angle

Scarf sign

Heel to ear

What causes prematurity?

• ETIOLOGY multifactorial and involves complex interaction between fetal, placental, uterine and maternal factors

• Fetal

• Fetal distress

• IUGR

• Multiple gestation

• Erythroblastosis

• Non immune hydrops

• Placental

• Placental dysfunction

• Placenta previa

• Abruptio placentae

• Uterine

• trauma

• Bicornuate uterus

• Incompetent cervix ( premature dilatation)/surgery

• Maternal

• women younger than 16 and older than 35

• Maternal activity

• Prior poor birth outcome

• Inadvertent early delivery

• Preeclampsia

• Chronic medical illness

• Infection

• Drug abuse

• chorioamnionitis

• PROM

• Polyhydramnios

• Iatrogenic/ trauma

How to manage??• PRENATAL CONSIDERATIONS

• Tocolytic therapy in threatened preterm delivery

• Significant role between 25-34 wks of gestation

• No justification after 34 wks

• Beta sympathomimetic drugs

• Time for corticosteroid therapy

• Antenatal steroid therapy( RCOG )

• Reduce RDS(44%), IVH(46%), NEC and

• neonatal death(31%)

• MOA

• In response to glucocorticoid, the fetal lung fibroblast produces a protein, fibroblast-pneumonocyte factor , which in turn stimulates the formation of saturated phosphatidylcholine

• At what GA?- single course between 24-34 wks of GA

• Most effective?-24 hours after and upto 7 days after 2nd dose of corticosteroid

• Reduces neonatal death within 1st 24 hours

• Contraindication-systemic infection- tuberculosis and sepsis

• in chorioamnionitis- can be given but delivery should not be delayed

• Who should receive?

• 1) risk of preterm birth upto 34+6wks

• 2) elective LSCS prior to 38+6 wks

• 3) multifetal pregnancy at risk of preterm

• 4) diabetes mellitus not a C.I

5) Pregnancies with IUGR at risk

• Best dose and route?

• Betamethasone 12 mg given intramuscularly in two doses or dexamethasone 6 mg given intramuscularly in four doses are the steroids of choice

• Betamethasone- 24 hrs apart

• Dexamethasone-12 hrs apart

• Betamethasone- less neonatal cystic periventricular leukomalacia

• larger reduction in RDS

• When repeated?

• Weekly repeated doses- reduction in weight and head circumference

• A single rescue course - initial course was given at less than 26+0 weeks of gestation

• Role of magnesium sulphate

• Commonly used tocolytic

• Reduced rate of cerebral palsy and gross motor dysfunction

• initial infusion of 4 to 6 grams over 15 to 30 minutes, and then a maintenance dose of 2 to 3 grams per hour.

• Contraindicated in mothers with myasthenia gravis

• PRENATAL CONSIDERATIONS-

• Should be delivered in a facility with high risk obstetrical service and level 3 NICU

• Prenatal administration of glucocorticoids to the mother even if there is no time for full course

• ETHICS- counselling should include discussions regarding survival rate and both short and long term complications

• Determining parental wishes when viability is questionable

• Defining limits of parental choice; need for caregiver parent teamwork

DELIVERY ROOM MANAGEMENT

• Resuscitation-

Thermoregulation-a

polythene wrap or bag used to prevent

heat loss (<29 wks)

Respiratory support-the NRP recommends availability of pulse oximetry, blended O2 and low saturation protocol

88-92%-<30 weeks 92-95%->30 wks

• Breathing spontaneously with distress,cyanosis and HR>100- CPAP of 4-6 cms water to prevent atelectasis

T-piece resuscitator- flow controlled and pressure limited

advantages

• Consistent pressure

• Control of PEEP and PIP

• Reliable delivery of 100% O2

• No fatigue

disadvantages

• Compressed gas supply

• Pressures should be set up prior

• Changing inflation pressure during resuscitation- difficult

• Risk of prolonged inspiratory time

Targeted saturations

1 min 60-65%

2 min 65-70%

3 min 70-75%

4 min 75-80%

5 min 80-85%

10 min 85-95%

• Transport –in prewarmed incubator with blended O2 and CPAP facility

• Temperature and humidity control- with neutral thermal environment

• A. incubators and hybrid incubators-prewarmed double wall incubators

• B. humidification-warm humidification within incubator

• 1) use a respiratory care humidifcation unit- inline humidification of ventilator gas circuits

• 2) minimize nosocomial infection in humidified environment

• C. monitoring and maintenance of body temperature

• 1) maintain axillary skin temperature of 36.0⁰C to 36.5⁰C

• 2) record skin temperature

• 3) record the incubator humidity

• 4) weigh LBW infants once daily for management of fluids and electrolytes

• FLUIDS AND ELECTROLYTES

• Intravenous fluid therapy- baseline fluid needs inversely proportional to GA and birth weight

• VLBW- more fluid losses during first week-upto 150ml/kg/day

• first day of life- according to guidelines

• second and subsequent days of life- depends on changes in body weight,renal function and serum electrolyte concentration

• Additional fluid during phototherapy-increased by 10-20ml/kg/day

• restriction of fluid intake- prevention and treatment of PDA,renalinsufficiency and BPD

Birth weight(g) IWL(ml/kg/day)

1000-1,250 56

1251-1500 46

>1500 26

Birth weight(kg)

Fluid rate(ml/kg/day)

<24hrs 24-48 hrs >48 hrs

1-1.5 kg 80-100 100-120 120-160

>1.5 60-80 80-120 120-160

• Infusion of fluids-UAC or double lumen UVC replaced by PICC or peripheral arterial lines if needed

• monitoring fluid therapy- based on body weight, urine output , heart rate and arterial BP

electrolyte values- should be monitored atleast twice daily

• 1) SODIUM-initially Na levels are sufficient

• decrease in post diuretic phase(3-5days)-Na added in fluids(3-8 meq/kg/d)

• Hyponatremia in prediuretic phase- fluid overload

• Hypernatremia in prediuretic phase-dehydration

• 1) hypernatremia Na >150mEq/l- a) premature addition of Na in prediuretic phase b) dehydration c) excessive Na intake

• 2) hyponatremia Na <130 mEq/l- a) fluid overload b) inadequate Na intake c) excessive Na loss

• POTASSIUM –

• During first 48 hrs- increased serum K levels of >5mEq/l(4-8meq/l)

reason-a) relative hypoaldosteronism

b) Immature Na+K+ATPase pump

c) immature renal tubular function

d) lack of arginine, a precursor to insulin

• 2) K > 6mEq/l- close ECG monitoring T-wave changes and rhythm disturbances along with electrolyte trends, acid base status and urine output

• acidosis treated

• albuterol MDI

• >7- insulin, NaHCO3 and Ca gluconate

• 3) 3-6 days after birth- when K reaches 4mEq/l add K to IVF

• start wit 1-2 meq/kg/d

• CALORIES-ENERGY- 70-80 kcal/kg/day-maintenance of body weight

• additional calories-growth(25 kcal/kg/day)

• AAP-105-130 kcal/kg/day

start with 5-10% dextrose

• A) hypoglycemia <40mg/dl for first 48 hrs, then <50mg/dl

• causes- lack of glycogen stores,sepsis,coldstress,hyperinsulinemia

• B) hyperglycemia >150mg/dl- osmotic glycosuria

• causes- sepsis, NEC,IVH,stress response

maintain glucose infusion- 1.5 mg/kg/min

Carbohydrate-4-8mg/kg/min

• advanced at 1-2 mg/kg/min

• max- 11-12 mg/kg/min

CALCIUM- monitored daily

hypocalcemia usually occurs on 2nd day

• hypocalcemia <7mg/dl

• acute treatment-100-200 mg/kg/dose i.v-10-30 min

• maintenance- 200-800mg/kg/d Q6H—IV/PO

• NUTRITION FOR METABOLICALLY STABLE INFANT

• A) parenteral nutrition- on admission with GIR 6-8

• aminoacids start at 3-3.5g/kg/d increase by 0.5g/kg/d ----max 3.5-4g/kg/d

• intravenous lipids(20%)- start by 24 hrs-0.5-1g/kg/d increase by 0.5g/kg/d upto 3g/kg/d

Monitor TG levels - <200mg/dl

• C) trophic feeds/ gut priming ( minimal enteral nutrition)

• (10-20ml/kg/d)-EBM/ formula/ pasteurized donor human milk

• Start asap- by 2-3 days

• Benefits-

• Improved gut hormones

• Less feeding intolerance

• Earlier progression to full enteral feeds, fewer days on PN

• Improved weight gain and Ca and P retention

gut development,Villous hypertrophy, digestive enzyme secretion, enhanced motility

• Breast milk is best option

• Contraindications

• Severe hemodynamic instability

• Suspected or confirmed NEC

• Evidence of ileus

• Clinical-intestinal pathology

Feeding problems

• Difficulty in self feeding

• In coordination of sucking and swallowing

• Abdominal distension

• Regurgitation and aspiration

Feeding advancements• Use full strength, 67kcal/100 ml human milk or preterm formula

• The initial volume- atleast 24 hrs prior to advancement

• 80ml/kg/day reached- feeds Q2-3H

• More rapid advancement- 100ml/kg/day

• Do not exceed increments-15 ml/kg every 12 hours

• Volume goal-140-160 ml/kg/dayBirth weight (g) Initial rate (ml/kg/day) Volume increase (ml/kg

every 12 hours)

1001-1250 10-20 10

1251-1500 20-30 10-15

1501-1800 30 15

1801-2500 30-40 15-20

• Caloric density:

• For human milk fed babies- caloric density advanced by 6-12 kcals/100 ml- HMF

• Maintained for 24hrs before advancement schedule

• As enteral feeds are increased- IV fluids reduced accordingly

RESPIRATORY ISSUES

Poor development of respiratory muscles- CPAP or ventilator support

a) Perinatal depression-special care

air-oxygen mixtures, oximetry monitoring, prevent heat loss

apnea secondary to respiratory insufficiency

perinatal infection

b) RDS- due to surfactant deficiency

• Perinatal asphyxia in premature infants can acutely impair surfactant production

• Antenatal corticosteroid therapy

• APNEA

• Due to developmental immaturity of central respiratory drive

• REM sleep predominates in preterm infants

• Chemoreceptor response

• In preterms-hypoxia-transient hyperventilation-hypoventilation-apnea

• Ventilatory response to increased CO2 is decreased

• Active reflexes- by stimulation of posterior pharynx, lung inflation, fluid in larynx or chest wall distortion

• Ineffective ventilation- impaired coordination of respiratory muscles

• Nasal obstruction

• inhibitory neurotransmitters

• MONITORING AND EVALUATION

• For atleast 1 week- heart rate , desaturations

• Bradycardia, cyanosis, airway obstruction

• Tactile stimulation, ventilation with bag and mask

• Other causes ruled out- infection, impaired oxygenation, metabolic disorders, drugs, temperature instability,intracranial pathology

• Evaluation – history,physical examination, ABG, CBC, GRBS, Ca and SE

• TREATMENT-

• Specific therapy

• Supplemental O2

• Avoid reflexes

• Positioning

• Nasal CPAP- <32 to 34 wks, residual lung disease

• CAFFEINE- a methylxanthine

• -respiratory centre stimulation

• -antagonism of of adenosine

• -improvement of diaphragmatic contractility

• Reduces rate of BPD

• All infants <1250 gms

• Prior to extubation

• Loading dose- 20mg/kg of caffeine citrate oral/i.v- 30 min

• Maintenance dose-5-8 mg/kg OD- 24 hrs after 1st dose

• Serum levels- 5-20mcg/ml- therapeutic

• Discontinued-34-36 wks if no apneic spells for 5-7 days

• Risks- weight gain was less during 1st 3 weeks

• Severe apneas, bradycardia,PCV<25%- PRBCs transfusion

• Mechanical ventilation

• NEUROLOGIC

• Perinatal depression

• ICH- from fragile involuting vessels

• Maintain stable perfusion – maintain normal BP, volume , electrolytes, blood gases

• Head USG at 5-7 days

• CARDIOVASCULAR

• A) hypotension-

• hypovolemia

• cardiac dysfunction

• sepsis induced vasodilation

• B) PDA- between 24-48 hrs of birth

• pulmonary over circulation and diastolic hypotension

• PDA- monitor clinically

• ECHO –to r/o other structural defects, confirm PDA

• over hydration avoided

• 30% PDA’s – close spontaneously

• hemodynamically significant- indomethacin/ ibuprofen

• persistent or recurrent PDA- second dose

• recurrence of PDA with L-R shunt- surgical ligation

• HEMATOLOGIC-

• A) anaemia- exaggeration of normal physiologic anaemia

• no treatment required

• TRANSFUSION- low RBC volume, low hematocrit <40%

• transfusion guidelines

• B) Hyperbilirubinemia- prematurity is a risk factor

• 10-12 on 5th day-15 mg/dl

• - keep SBR <10 mg/dl

• monitor SBR twice daily

• exchange transfusion if > 12mg/dl

• Gastrointestinal- increased risk of NEC

• formula feeding is an additional risk factor

• breast milk- protective

• gradual increments in feeds

• Renal- immature kidneys-low GFR

• cant handle water, solute and acid loads

• SKIN CARE- zinc based tape, hydrogel adhesive

• minimal handling

• -hydrogel skin probe with min. size

• -rotation of oximeter probe

• -BP cuffs and urine bags- min usage

• SPECIAL CONSIDERATIONS-

• A) INFECTION

• 1) cultures- delivery in infected environment-blood and CSF cultures

• surveillance skin cultures

• 2) antibiotics- septic risk-empiric ampicillin and gentamicin

• 3) nosocomial infection- immature immune system, poor skin integrity, extended stay

• hand hygiene, bacitracin to nares

• D) pain- should be assessed as 5th vital sign

• several multidimensional pain assessment scales

• 1) PIPP-Premature Infant Pain Profile

• HR and Spo2

• 2) CRIES-Crying,Requires O2 for Spo2< 95%,Increased vital signs,expression,sleepless

• 3) NIPS- Neonatal Infant Pain Scale

• 4) Neonatal Pain,Agitation,and Sedation scale( N-PASS)

• SOCIAL PROBLEMS- parents invited in infant’s care- parent infant bonding

• Parent conferences involving physician, social worker and primary nurse

• DEVELOPMENTAL ISSUES

• 1)minimal stimulation- stressors like noise, light and activity minimized

• 2)positioning- flexed position

• change in position every 4 hrs

• 3) KMC- promotes behavioral state organization

• parental attachment/confidence

• support growth and development

• 4) environmental issues- decrease ambient noise

• cyclic lighting- circadian rythms

• 5) parental education- family centred care

• containment techniques,calming interactions

Prophylactic therapy

• VITAMIN A- decreases CLD

• start in first week-5000IU i.m—3 times/wk for 4 weeks

•

• SURFACTANT- during first 4 hrs- to reduce CLD

• CPAP in delivery room> prophylactic surfactant

• criteria- absence of AN steroids, increased O2 demand>30%, CXR supportive

FOLLOW UP CARE

• Respiratory syncytial virus –most important cause of respiratory infection in premature infants

Good hand hygiene, avoid passive cigarette smoking exposure

• Influenza vaccine- when older than 6 months

• air travel – not recommended for BPD infants

supplemental O2- if PaO2 <80mm Hg

• Immunizations-same schedule as term infants with exception of hepatitis B

• Medically stable,thriving infants- hep B as early as 30 days of age regardless of gestational age or b.wt

• Rotavirus-not given until NICU discharge

• Growth – infants with BPD –increased caloric needs

• Abnormal or delayed oral motor development and oral aversion

• If growth failure persists even after excess calorie intake GERD and GH deficiency should be ruled out

• Gastrostomy tube- severe feeding problems

• Anaemia- supplemental iron(2-3mg/kg) for first 12-15 months of life

• Multivitamin drops- 2 weeks of age

• Rickets- higher risk infants- long term parenteral nutrition, furosemide and fat malabsorption

• All breast fed infants- 400 IU of vit D along with calcium 200mg/kg at time of discharge

• Metabolic screening at 3-4 weeks of age

• Sensory issues-

• Opthalmologic follow up- infants with severe ROP- increased risk of significant vision loss or blindness

• <1500 gms, <30 weeks

• <26 wks- 6 wks

• 27-28 wks-5 wks

• 29-30 wks-4 wks

• >30 wks-3 wks

• Examined every 2 wks until retina is mature

• They can also have refractive errors, amblyopia, strabismus, anisometropia

• All VLBW- follow up with ophthalmologist by 8-10 months of age and then annually or again at 3 yrs of age

• Hearing follow up- hearing loss in 2% to 11% of VLBW infants-both sensorineural and conductive hearing loss

• BERA/OAE before discharge

Screening – neonatal period and 1 yr

• Auditory dys-synchrony(auditory neuropathy) and central auditory processing problems

• Dental problems- enamel hypoplasia and discoloration

• palate and alveolar ridge deformation

• dentist- first 18 months

• NEURODEVELOPMENTAL OUTCOMES- intracranial hemorrhage(parenchymal) or periventricular white matter injury-neuromotor and cognitive delay

• visuomotor problems,visual field deficits

• complete neurodevelopmental examination before discharge

neuromotor problems- CP-7%-12% in VLBW infants

• most common-spastic diplegia

• referral for early intervention programs- at time of discharge

• social development- autism

• Emotional and behavourial health

• 1) sleep problems

• 2) behavior problems- hyperactivity or ADHD, less socially competent

• special educational programs, psychotherapy services

•

MANAGEMENT OF LATE PRETERM INFANT

• COMPLICATIONS

• A)respiratory distress syndrome- 21% (33wks),7.3%(35-36wks), 0.6%(37-42wks)

• deprived of normal hormonal changes that promote clearance of lung fluid

• B) length of stay- jaundice and poor feeding

• C) jaundice- hepatic immaturity, bilirubin induced hepatic dysfunction(BIND)

• D) poor feeding-suck swallow co-ordination and intestinal motility-immature

• Lactation failure

• E) temperature instability

• F)hypoglycemia-10-15%- delay in activity of hepatic glucose phosphate

• poor intake- exacerbates gluconeogenesis

• SIDS and apnea- immature autonomic nervous system

• (33-36k weekers- twice likely to die of SIDS than term)

• H) readmission-twice likely

• jaundice and infection

• J) RSV- incomplete lung development,impaired immunity

• risk equal to early preterms

• AAP recommends pavilizumab- upto 35 wks only

When is infant ready for discharge??

• A sustained pattern of weight gain(15-25 gm)

• Adequate maintenance of normal temperature fully clothed

• Competent feeding by breast or pallada without cardiorespiratory compromise

• Physiologically mature and stable cardiorespiratory function

• Appropriate immunisations

• Appropriate metabolic screening

• An apnea free period(5-7days)

• New born screening

• Hematologic status assessed and appropriate therapy given

• Nutritional risks assessed and therapy dietary modification

• Hearing evaluation

• Fundoscopic examination

• Neurodevelopmental and neurobehavioral status assessed and explained to parents

• Review of hospital course completed

• Unresolved medical problems identified

• Predischarge physical examination

• Plans for follow-up monitoring and treatment

• Family and parents:

• Determine family’s caregiving and psychosocial readiness

• Pre discharge education-safe sleep practices and SIDS prevention

• Parents should be able to- independently and confidently care for their infant;

• provide medications, nutritional supplements and any special medical care;

• recognize signs and symptoms of illness and respond appropriately, especially in emergency situations; and

• understand the importance of infection control measuresand a smoke-free environment.

• Follow up plan

• Communicated and understood by parents

• Communication with identified primary care physician

• Summary of infants birth history and care

• follow-up by a qualified health care professional within 72 h

• medical and surgical follow-up appointments as required, including ROP screening

• neonatal neurodevelopmental follow-up, if indicated;

• follow-up of hearing and newborn screening results

• community resources and supports; and

• a neonatologist’s or paediatrician’s advice and support to the primary care physician, as needed.

• November 17th is World Prematurity Day

• November 17th has been established as World Prematurity Day. On this day, efforts are made to increase awareness of the health risks associated with preterm birth and how to reduce them.

• MARCH OF DIMES

• The March of Dimes Foundation is a United States nonprofit organization that works to improve the health of mothers and babies

• Founded in 1938

• In 2003, the March of Dimes launched the Prematurity Campaign to address the crisis and help families have full-term, healthy babies. they’re funding lifesaving research and speaking out for legislation that improves care for moms and babies. Worldwide, 15 million babies are born prematurely each year. In 2008, they expanded the campaignglobally.

THANK YOU