Presenter: Robin Baweja MD PGY-3

Topic: Care of the Premature Infant

Date: March 2, 2010
Introduction:
Prematurity is defined as birth that occurs before 37 completed weeks of gestation. It is associated with 1/3 of all infant deaths in the US. Associated with diseases such as CP, vision impairment and hearing impairment. Complications of prematurity are the underlying reasons for the higher rate of infant mortality and morbidity. There are both short-term complications and long-term sequelae in patients that survive and are discharged from the NICU

Key Definitions of Premature Infants: Defined as GA or weight
Late Preterm Birth – GA between 34 and less than 37 weeks

Very Preterm Birth – GA less than 32 weeks

Extremely Preterm Birth – GA at or below 25 weeks

Low Birth Weight – BW less than 2500 grams

Very Low Birth Weight – BW less than 1500 grams

Extremely Low Birth Weight – BW less than 1000 grams

Short term complications of Prematurity: NICU based

Respiratory Distress

PDA

Bronchopulmonary Dysplasia

Late Onset Sepsis

Grade III – IV Intraventricular Hemorrhage

Necrotizing Enterocolitis

Periventricular Leukomalacia

ROP

Long Term Complications of Prematurity: Outpatient Based

Neurodevelopmental Disabilities – impaired cognitive skills, motor deficits, sensory impairments, vision and hearing losses, behavioral problems.

Chronic Health Issues – RSV, asthma, feeding intolerance, surgical issues, poor weight gain, small head circumference, Strabismus, Umbilical Hernia, BPD, Apnea of prematurity, SIDS, GER, Anemia of prematurity, amblyopia, CP, Hydrocephalus, Inguinal Hernias

Care for the Prematurity Infant:

Although most NICU graduates are discharged from the NICU when their adjusted gestational age is near or at term, they differ in their medical needs compared to normal term infants.

AAP guidelines state the following in regards to the role of the primary care physician.
Communication with the neonatologist and family during the NICU stay. Transfer of medical records to the PCP. This decreases confusion for the parent regarding transfer of care.
PCP will determine further management of care in regards to outpatient vs inpatient care.
PCP needs to have knowledge of the existing medical problem and the ability to detect new problems as they arise. For example, premature infants are more at risk for developing hearing loss, ROP, developmental delay.
Need to have ongoing coordination with subspecialists. Need to know how to utilize community services. Outpatient Management:
i) Initial Visit: Review NICU’s course, current medications and medical equipment. Discharge summary is essential to include in chart. Evaluation of patient’s progress. Time to listen to parent’s concerns and address your knowledge of the child’s medical conditions. Review future appointments.

ii) Growth: NICU graduates are risk for inadequate growth and poor nutrition. Require frequent follow-up. First 4 months – average weight gain 20-30 g/day. Between 4 and 8 months – 14 g/day. 8-12 months – 11-12 g/day. Catch-up growth is the greatest between 36-40 weeks after conception and may continue to age 7. Breast milk is still adovocated as the best source of nutrition, however, may need preterm or transitional formula.

iii) Immunization: AAP recommends that medically stable preterm infants should receive full immunization based upon their chronological age consistent with the sceduale and dose recommended for normal full term infants. ( Hep B, Influenzae, RSV )

iv) Screening:
Hearing – done before discharge in the NICU, must be repeated at 5-6 months if there are risk factor. If SNHL is reported, must be get a formal audiologic assessment and followed by a multidisciplinary team. (speech, audiologists ect.)

Vision – ROP common in VLBW and ELBW, presents at 32 weeks gestation, peaks at 38-40 weeks and begins to regress by 46 weeks. Initial screening should be done by 4-6 weeks and additional intervals at 1-3 weeks until retinal vessels have matured. Compliance is imperative.
Neurodevelopmental: PCP should be able to utilize screening tools if accessible. Be familiar with community resources. Vulnerable Child Syndrome (parents could be overprotective, abnormal separation difficulties, sleep problems, poor developmental outcome )

v) Daycare: May be unstable to be placed in formal daycare. Specialized needs such as CPR training, feeding sceduale, should be familiar with premature infant.

vi) Car Seats: Increased risk of cardiopulmonary compromise while in car seats. Increase risk of apnea, desaturation, and bradycardia while in car seat. Tested in the NICU for 90 -120 minutes while monitoring HR, RR and O2 saturation. May need car padding to support head and neck. Must be rear-facing. Apnea monitor/oxygen tank needs to be tucked under the seat