Transcript Follow up of the NICU Graduate

FOLLOW UP OF THE NICU
GRADUATE
September 14, 2010
Lynn T. Tran, MD and Jeffrey W. Surcouf, MD
CASE PRESENTATION-O.N.


O.N. is a 27 WGA female who was admitted to the
NICU for prematurity and resp distress. She comes to
you for a F/U clinic visit.
What are some things you want to know?

Maternal labs and prenatal course were noncontributory.

90 day hospital course notable for



Short duration of intubation
 Quick wean to room air
Feeding difficulties
 Reflux treated with Ranitidine
Pt discharged home stable on RA with a prescription for
Ranitidine and Enfacare/EBM ad lib.
O.N. (CONT.)
Previous visits were unremarkable.
 Today, she presents to your office 2 months after
D/C with the mother complaining that she is not
feeding well.


What are some things that you should ask?
Poor feeding (taking appropriate amount with increased
effort and spits)
 Increased fussiness with feeds
 Difficulty sleeping


PE was normal.

What is the diagnosis?
REFLUX

Incidence is high in preemies.

Important to distinguish between functional and pathologic
reflux
Functional
Pathologic
Limited episodes of emesis
Excessive episodes of
emesis
Appropriate wt gain
Poor wt gain
No evidence of esophagitis
Hoarseness, sleep
disturbances, irritability,
hematemesis
No resp sx
Wheezing, recurrent
aspiration, chronic cough,
stridor
No neurobehavioral sx
Sandifer syndrome
No long term effects
Oral aversion, esophageal
stricture, FTT
REFLUX (CONT.)

Frequency:

Mild GER
Term: 40-65%
 Course: 55% resolve by 10 mos; 99% by 2 yrs
 Preemie: similar to term infants


Pathologic:
Term: 6-7%
 Preemies: 3-10%

REFLUX (CONT.)

Risk factors:






Prematurity
Perinatal depression
Sepsis
Congenital anomalies
Neurologic
impairment
h/o ECMO
REFLUX (CONT.)

Pathophysiology






Relaxation of LES
Sluggish esophageal motility
CNS disorder
Increased abd pressure
Decreased gastric compliance
Anatomic

Decreased acute angle of the esophagus into the stomach
Abnormal diaphragmatic activity
 Delayed gastric emptying

REFLUX (CONT.)

Management:

Mild:


Conservative therapy
Moderate to severe:

Pharmacologic therapy
 Histamine-2 antagonists


Proton pump inhibitors


Ranitidine
First line of tx
Omeprazole
Prokinetic


Metoclopramide
Erythromycin
Not routinely used
REFLUX (CONT.)

Diagnostic testing
pH probe
 Modified barium swallow study



Assesses ability to tolerate different formula consistencies
Endoscopy
O.N. (CONT.)

Upon further questioning of the parents, you
realize that the dosage of Ranitidine had not
been increased for the infant’s weight gain.


Ranitidine dose adjusted with improvement in pt’s
sx.
Remember!!!
Course: 55% resolve by 10 mos; 99% by 2 yrs
 Try to let infant outgrow the dose and monitor
clinically for sx

O.N. (CONT.)



During the examination, the mother says,
“Enfamil is so much cheaper and easier to obtain.
Why is my baby still on Enfacare?”
Your response?
Compared to term formula, postdischarge
formulas (Enfacare or Neosure) contains??
 Increased amount of protein with sufficient
additional energy
 Contains extra Ca, P, Zn


Necessary to promote linear growth
Additional vitamins and trace elements
O.N. (CONT.)


“Ok. Since Enfacare is better for my baby, how
long does she have to stay on that formula?”
The AAP recommends:

“The use of postdischarge formula to a postnatal age
of 9 months results in greater linear growth, weight
gain, and bone mineral content compared with the
use of term infant formula.”
O.N. (CONT.)

“What about soy formula?”

The AAP recommends:

Do not use soy formula for:
Preemies weighing < 1800 grams
 Prevention of colic/allergy
 Infants with cow milk protein allergy

O.N. (CONT.)

As the mother is preparing to leave, she
mentions, “My best friend says that my baby
should be on vitamins. What do you think about
that?”
THE AAP RECOMMENDS
Breast Fed
Formula Fed
Vitamin D
400 IU/d
beginning in 1st
few days of life
400 IU/d if
ingesting < 1 L/d
Iron
2 mg/kg/d at 1 mo
until 12 mos
May benefit from
1 mg/kg/d until 12
mos (Most
formulas including
PDF supply 1.8
mg/kg/d)
Calcium
Consider HMF or
MVI
Adequate amounts
in PDF
Fluoride
0.25 mg/d in areas
with < 0.3 ppm for
those > 6 mos
0.25 mg/d in areas
with < 0.3 ppm for
those > 6 mos
CASE PRESENTATION-A.N.


A.N. is a 25 WGA male who was admitted to the NICU
for prematurity and resp distress. He presents to your
office 1 month after D/C.
What are some things you want to know?

Maternal labs were negative but mother suffered
preeclampsia precipitating preterm delivery.

150 day hospital course notable for
Long duration of intubation
 Wean to HFNC then to RA
 Apnea of prematurity
 Treated with Caffeine
 Abnormal sleep study prior to D/C confirming AOP


Pt discharged home stable on RA with a prescription for
Caffeine and with an apnea monitor.
APNEA

Apnea is defined by



How is this different from periodic breathing?


Cessation of air flow > 20 sec
< 20 sec accompanied by bradycardia or cyanosis
Periodic breathing is defined as ≥ 3 respiratory
pauses of ≥ 3 sec with intervening episodes of
respiration < 20 sec
Types
Central
 Obstructive
 Mixed-most common

APNEA OF PREMATURITY

Incidence inversely related to GA
100% between 24-29 WGA
 50% between 30-32 WGA
 25% between 34-35 WGA


Usually begins in 1st 2 DOL

When does it end?

By 37 weeks postmenstrual age in infants delivered ≥
28 WGA

Some infants continue to have apnea beyond 40 weeks
postmenstrual age.
A.N. (CONT.)


During the examination, the mother asks, “When
can I stop using the Caffeine?”
What are some questions that you should ask?





How often has the monitor gone off?
When it has gone off, what did the baby look like?
How abnormal was the sleep study?
What is the corrected gestational age of the baby?
What dose of Caffeine is the baby receiving?
CAFFEINE

Mechanism of action:
Stimulatory effects on the brainstem via increasing cAMP
levels
 May increase diaphragmatic contractility


Dosing:



Therapeutic levels:


Loading dose: 20-25 mg/kg IV/PO
Maintenance: 5-10 mg/kg/d IV/PO Q24
5-25 mcg/ml
Side effects:


Tachycardia, restlessness, vomiting
May worsen reflux
CAFFEINE (CONT.)

Discontinuing Caffeine:

If having events


Consider checking Caffeine level and optimize dose if
subtherapeutic
No events
Trial off of Caffeine
 Continue on home apnea monitor

A.N. (CONT.)

The mother wants to know how long he has to be
on the apnea monitor and states that it is
inconvenient and drives her crazy.
APNEA MONITORS

In general, when should you be able to
discontinue the apnea monitor?
In infants 43 to 46 weeks postmenstrual age or in
older infants after 1 month of clinically irrelevant
events.
 If no recent events, discontinue at least 2-4 weeks
after stopping Caffeine.


If the infant had an abnormal sleep study,
consider repeating the study prior to stopping the
monitor.

This is a clinical decision with no scientific evidence
to support the use of sleep studies or home apnea
monitoring!
APNEA MONITORS (CONT.)
Monitors should not be used for healthy preemies
with a previous hx of AOP.
 Consider monitors for those infants with
persistent apnea being sent home on Caffeine or
in those infants with isolated, infrequent As/Bs.


Alarm settings:

HR:
Low: 60 – 80 bpm
 High: 220 bpm


Apnea:

20 sec
HOME OXYGEN USE

Will need concurrent care with Pulmonology to
help with discontinuing oxygen
CASE PRESENTATION-C.W.


C.W. is a 24 WGA male who was admitted to the
NICU for prematurity and resp distress. He presents
to Developmental Clinic 3 mos after D/C.
What are some things you want to know?

Maternal labs were negative, but mother presented with
preterm labor.

Nearly 1 year hospital course notable for multiple
complications particularly


Grade IV bilateral IVH
Pt discharged home on O2 with seizure medications and
close neurosurgery follow-up.
C.W. (CONT.)

The mother wants to know if it is ok that her
baby is not walking as he is now 13 mos old.

Thoughts?

Consider pt’s corrected age
Majority will correct by 1 year of age
 However, correction for developmental milestones
may be continued until 2 years of age.


What are the risk factors for abnormal
development?
EARLY INTERVENTIONS

Candidates:

High risk infant




Neurologic condition
 IVH
 PVL
 Seizures
Visual impairment
Hearing loss
At risk infant






BW < 1200g
GA < 32 weeks
Total hospital stay > 25d
APGARS < 5 at 5 min
IUGR
SGA
The high risk infant and the at risk
infant have the potential for
abnormal outcomes…normal HUS
does not guarantee normal outcome,
nor does abnormal HUS guarantee
abnormal outcome.
Helping parents understand and
cope with this (must be patient) is
one of the challenges we face.
EARLY INTERVENTION

Can be accomplished through
Developmental clinic
 School based intervention
 Early Steps via parish


Multidisciplinary care
Neurology
 PT/OT/Speech
 Psychology

CASE PRESENTATION-S.W.


S.W. is a 27 WGA male that was admitted to the
NICU for prematurity and resp distress. On initial
D/C follow up, infant was noted to be gaining weight
and doing well.
What are some things you want to know?

Maternal labs were negative, but mother presented with
placental abruption.

2.5 month hospital course





Short intubation period
Prolonged use of supplemental O2 via HFNC
Stage 2 Zone 2 ROP
Multiple courses of Abx due to sepsis
Pt discharged home on RA and PolyViSol with Fe.
S.W. (CONT.)

Upon perusal of the D/C Summary you note:

Newborn screen was drawn on DOL 1 and was found
to be normal.
Does this reassure you?
 What else should you be asking?


Hepatitis B was given prior to discharge.

BAER was equivocal.
NEWBORN SCREENING

New state of Louisiana recommendations

Premature, LBW, or sick infants
Upon admit to the NICU
 Hemoglobins, GALT, biotinidase enzymes and provide
baseline amino acids and acylcarnitines
 48-72 hours of age
 Only if 1st NBS collected < 24 hours of age
 28 days of age or upon discharge
 Thyroid, later onset CAH and homocystinuria in
preemies

NEWBORN SCREENING (CONT.)

Term infants
All should be screened prior to discharge but no later than 7
days of age.
 However, risk of false negatives if screened < 24 hrs of age.
 Repeat between 1-2 wks of age but no later than 3 wks of
age

NEWBORN SCREENING (CONT.)

If a specimen is collected after a blood
transfusion, repeat testing should be performed:

3 days after transfusion


To detect congenital hypothyroidism, CAH and metabolic
disorders detected by MS/MS
And 90 days after last transfusion

To detect sickle cell disease, biotinidase
deficiency, galactosemia and cystic fibrosis
NEWBORN SCREENING (CONT.)

What about feeds?
Some programs recommend waiting 48-72 hrs after
PN
 Based on the new recommendations, the timing of
feeds does not matter.

IMMUNIZATIONS

Medically stable preemies should receive all
routine vaccinations at the same chronologic age
as recommended for full term infants.
IMMUNIZATION SCHEDULE
CATCH UP IMMUNIZATION
SCHEDULE
IMMUNIZATIONS

Palivizumab (Synagis)


1st dose given during 1st week of November
5th (last) dose given in March

Indications:

Infants with chronic lung dz ≤ 24 mos of age who receive tx
within 6 mos before the start of RSV season (max of 5 doses)

GA ≤ 28 WGA who are ≤ 12 mos of age at start of RSV season

≥ 28 WGA or ≤ 32 WGA who are ≤ 6 mos of age at the start of
RSV season (max of 5 doses)

> 32 WGA or ≤ 35 WGA who are ≤ 3 mos of age or born during
RSV season with risk factors (max of 3 doses)
 Daycare OR
 School aged siblings (< 5 yrs)
www.cdc.gov
S.W. (CONT.)

In addition to Developmental Clinic, what other
appointments should you make for this infant?
Audiology
 Ophthalmology

HEARING SCREEN



All infants should receive BAER or OAE in the NICU
prior to D/C.
Infants should have repeat screens at 12 months of
age if < 32 WGA.
F/U every 6 months after the last hearing screen until
3 yrs of age if at risk for late onset or progressive
hearing loss







In utero infection
Hyperbilirubinemia
ECMO
PPHN
Syndromes
Head trauma
Prolonged use of ototoxic medications
FINAL THOUGHT


Infants are discharged from the NICU with
potentially obvious, treatable medical problems.
The parents, however, may be left with lessobvious emotional difficulties due to having an
NICU graduate.
FINAL THOUGHT

Parents experience, among others:






Guilt
Fatigue
Anxiety and emotional disturbances
Financial difficulties…time away from work, medical expenses
Marital stress
Family stress…what do you tell older siblings?

These feelings don’t go away immediately on discharge.

Some families cope better than others.

As the PCP, it is important to understand these feelings
and to support not only the patient, but the family as well.
It is important to know where to refer these families if they
need more support.
REFERENCES
http://www.cdc.gov
 http://www.dhh.louisiana.gov/offices/?ID=263
 Brodsky, D. and Ouellette, M. Primary Care of
the Premature Infant. Saunders Elsevier: 2008.
 Chandran, L. and Gelfer, P. Breastfeeding: The
Essential Principles. Pediatrics in Review.
November 2006: 409-417.
 Gomella, T. Neonatology. McGraw-Hill: 2004.
 Kleinman, K. Pediatric Nutrition Handbook.
American Academy of Pediatrics: 2009.
 Vanderbilt, D. et al. The Do’s in Preemie
Neurodevelopment. Contemporary Pediatrics.
September 2007: 84-92.
