Transcript Primary Care of the Preterm Infant

Primary Care of the
Preterm Infant
KAREN HUSSEIN, PGY-3
Goals and Objectives
 Identify, understand and manage the ongoing
medical needs of the NICU graduate
 Recognize the key role of the PCP in providing
optimal continuity of treatment by coordinating
transition of care from the neonatologist, providing
direct medical care and facilitating ongoing care of
the infant by subspecialists and other health
professionals
 Review of common screening topics and medical
problems of the NICU graduate
Screening
Question #1
 A premature infant presents to your office for an
initial visit after hospitalization.
 What questions should be asked and topics should
be covered in the initial hospital follow up visit then
subsequent visits?
Initial Visit
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NICU course
Current medications
Medical equipment
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Growth parameters
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Formula and kcal/oz
Type of feeding (oral versus G-tube)
Volume and frequency of feeds
Immunization record
Neonatal screening
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Current weight, length and head circumference as compared to at birth parameters
Vital signs
Nutrition
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Home oxygen
Pulse oximetry
Apnea and bradycardia monitor
Ventilator
Feeding pump
Metabolic and newborn screening
Cranial imaging
Hearing
Ophthalmologic
Specific problems related to infant
Review of NICU discharge summary
Initial Visit
 Evaluation of progress since discharge including
growth
 Time to listen and address the family’s concerns
 Education for family about
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Medical diagnoses
Cardiopulmonary resuscitation
Any medications and/or equipment required in care
 Review future appointments with subspecialty
services , primary care visits and hearing and vision
screening
Subsequent Visits
 Timing depends on infant’s medical condition
 More frequent in the beginning to monitor and establish
adequate growth
 Focus on:
 Routine primary care (ie, immunizations)
 General care directed towards NICU graduate (ie, hearing,
vision and development screening)
 Specific medical problems of the infant
 Consistent care that provides continuity of
information and psychosocial support to family
PREP Question #1
 A 24-week-premature infant who is now 46 weeks of corrected gestational
age is being seen in your office for concerns of decreasing oral intake and
poor weight gain. The infant was discharged to home from the neonatal
intensive care unit 2 weeks ago weighing 2,400 grams. His medical
problems include bronchopulmonary dysplasia that requires diuretics and
gastroesophageal reflux that has been treated with omeprazole. The infant
was sent home feeding a minimum of 45 mL of premature formula
concentrated to 27 calories per ounce orally every 3 hours using a slow flow
nipple. At the first office visit 1 week ago, the infant weighed 2,505 grams
and was described as feeding slowly but taking the minimum volume of
formula daily. Currently, the infant weighs 2,610 g. The mother reports that
the infant is feeding 35 to 45 mL of formula every 3 hours. The mother
describes her son as waking and hungry every 3 hours, although he often
“shuts down” after 10 minutes of feeding and refuses to take more. The
infant does not spit, arch, or turn red with feedings. He passes 2 soft,
brown stools daily. The physical examination is otherwise unremarkable.
When you observe a feeding, the infant has unlabored respiratory effort
and maintains an oxygen saturation of 95%.
PREP Question #1
 Of the following, the MOST appropriate approach to
help with the poor oral intake is to
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A. advance the caloric content of the formula
B. change to a regular-flow nipple
C. consult occupational therapy
D. increase the diuretic dosage
E. initiate oxygen via nasal cannula
Answer
 C. consult occupational therapy
 Consultation with an occupational therapist
experienced with premature infants is recommended
when feeding problems are identified in discharged
premature infants.
 Feeding problems are 7 times more common in
infants born prematurely, with 33% of infants born
at less than 26 weeks’ gestation having continued
feeding issues at 30 months’ corrected gestational
age.
Growth
 At risk for inadequate growth due to increased caloric and
nutrient requirements and feeding skills
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Swallowing problems
Oral motor dysfunction
Hypersensitivity
Delayed feeding skill development
Oral aversion problems
 Plot growth curves and developmental milestones according
to corrected age for the first two years of life
 Initiate corrective measures
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Changes in the composition, volume, caloric density and mode of feeding
 Evaluate for contributing conditions (ie, gastroesophageal
reflux or feeding disorders)
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Prompt referral to a feeding specialist and/or nutritionist
Immunization
 At increased risk for vaccine-preventable infections
 AAP recommends that medically stable preterm
infants should receive full immunization based upon
their chronological age consistent with the
schedule and dose recommended for full-term
infants
 May have been started in the NICU but delays are
common, especially in unstable infants, so it is
important to obtain an immunization record
 Consider RSV prophylaxis with Palivizumab
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Please see dedicated CCC presentation for more details
PREP Question #2
 A 2-year-old boy who has a history of premature
birth has been diagnosed with hearing loss. He was
born at 28 weeks’ gestation and required 2 weeks of
mechanical ventilation. After discharge, he required
home oxygen therapy for 3 months. His mother asks
if any medications could have contributed to his
hearing loss.
PREP Question #2
 Of the following, the medication exposure MOST
likely to contribute to hearing loss is
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A. amphotericin B
B. caffeine
C. cefotaxime
D. chlorothiazide
E. furosemide
Answer
 E. furosemide
 The AAP Joint Committee on Infant Hearing Year 2007 position
statement has identified risk factors for children with congenital or
acquired hearing loss that include
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Neonatal Intensive Care Unit (NICU) hospitalization greater than 5 days,
Extracorporeal membrane oxygenation (ECMO)
Mechanical ventilation
Hyperbilirubinemia requiring exchange transfusion
Exposure to ototoxic medications, such as aminoglycosides (gentamicin and
tobramycin) or loop diuretics (eg, furosemide)
 Furosemide-induced ototoxicity can be either transient or
permanent.
 Aminoglycosides appear to potentiate the ototoxic effects of
furosemide and, as such, it is recommended that efforts be made to
avoid simultaneous use of aminoglycoside and loop diuretics.
Hearing
 Estimated prevalence of bilateral sensorineural
hearing loss is 1-2 per 1000 newborns in the US, but
is 10-20 times higher among premature infants
 Recommended to have automated auditory
brainstem response as screening test for hearing
 Follow up audiological evaluation during the first
year of life or sooner if needed is critical to ensure
the timely diagnosis on late-onset hearing loss
 Infants with other risk factors, such as meningitis or
cytomegalovirus, should have follow up testing
performed soon after discharge
Vision
 At increased risk for long-term ophthalmologic
abnormalities including
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Retinopathy of prematurity (ROP)
Strabismus
Reduced visual acuity
Myopia
Amblyopia
Anisometropia
Retinal detachment
Neurodevelopment
 At increased risk for developmental delays and disabilities
 Motor impairment and/or tone abnormalities
 Cerebral palsy
 Learning delay or disability
 Borderline low-average intelligence quotients (IQs)
 Autism or autism spectrum disorders
 Attention-deficit hyperactivity disorder (ADHD)
 Specific neuropsychological deficits (ie, visual motor integration,
executive dysfunction)
 Behavior problems (ie, internalizing problems, social difficulties)
 Risk is increased with decreasing gestational age
 Need to identify and refer at-risk infants for further
evaluation and early intervention services
 Follow up with family to ensure infant is receiving appropriate
services specific to developmental needs (PT, OT, ST for
feeding, Early Steps)
Psychosocial Issues
 Bringing home a NICU graduate can be very
challenging to parents because of social, financial
and psychological stresses
 Siblings and spouses may feel neglected by the
infant’s needs
 Need to screen for these stressors
 Provide support services
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Home health nursing visits
Early child intervention services
Support groups
Social work services
Child protective services
Car Seats and Beds
 To prevent morbidity and mortality caused by motor
vehicle accidents
 Premature infants can be at increase risk for
cardiopulmonary compromise while in car seats
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Greater decreases in oxygen saturation
More frequent episodes of desaturation, bradycardia and
apnea
Greatest risk with infants with pre-discharge weights < 2000g
Need car seat challenge prior to discharge if at risk
 Please see dedicated CCC presentation for more
details
Dental
 Increased risk of dental problems
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Enamel hypoplasia
Increased risk for dental carries
Delayed tooth eruption
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Based upon adjusted postmenstrual age between 3-10 months
Tooth discoloration
Palatal groove
Tooth malalignment
If prolonged intubation, may develop V-shaped palate, posterior
cross bites, deformed incisal edges and missing teeth
 Recommend first visit by 12 months of age
 Fluoride exposure via water recommended after 6
months of age
Common Problems of the
NICU Graduate
PREP Question #3
 A mother brings her 7-week-old infant in for his first
health supervision visit after being discharged from
the neonatal intensive care unit. The infant was
delivered at 31 weeks’ gestation because of placental
abruption. He was intubated for 4 days after delivery
and received 3 doses of surfactant for respiratory
distress syndrome. He subsequently required oxygen
by high flow nasal cannulae for 1 week. He has been
in room air since that time and results of his chest
radiograph are normal. His mother is worried that
her infant has moderate to severe chronic lung
disease.
PREP Question #3
 Of the following, the MOST appropriate information
to provide to the mother is that infants who have
chronic lung disease
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A. are born at less than or equal to 26 weeks’ gestation
B. have chest radiographs with severe fibrosis and
hyperventilation
C. have received a minimum of 5 days of assisted ventilation
D. maintain normal postnatal lung development
E. require supplemental oxygen at 36 weeks’ corrected
gestation
Answer
 E. require supplemental oxygen at 36 weeks’
corrected gestation
 The most commonly used definition of the “new BPD,”
currently referred to as chronic lung disease (CLD), is the
requirement of oxygen at 36 weeks’ corrected gestation.
 With the improvement in ventilator management and the
incorporation of therapeutic modalities such as prenatal
corticosteroids and surfactants into daily practice, the
underlying mechanism for CLD is believed to be an arrest
of normal lung development due to premature birth.
 The radiographs of CLD often do not reveal the fibrosis
and hyperinflation that was characteristic of infants
diagnosed with BPD in the past.
Respiratory
 Most common problem is bronchopulmonary dysplasia (BPD) or
chronic lung disease (CLD) of prematurity
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Respiratory disease with requirement of supplemental oxygen at 36 weeks
postmenstrual age and persistent abnormalities on chest radiographs
At discharge, baseline studies include respiratory and heart rate, blood pressure,
oxygen requirement, chest radiograph and echocardiogram to assess for presence
of pulmonary hypertension
May continue to require supplemental oxygen, medications (ie, diuretics,
electrolyte supplements and bronchodilators) and increased caloric needs
Most often allowed to outgrow diuretic dose and slow wean of home oxygen
Morbidities include acute respiratory exacerbations, pulmonary edema, upper
and lower respiratory tract infections, cardiac problems (ie, cor pulmonale and
pulmonary hypertension) and growth failure
Typically improves by two years of age
 At risk for reactive airway disease and respiratory infections (ie,
RSV and other virus or bacterial infections)
 Be alert for late-onset sequelae of prolonged intubation (subglottic
stenosis)
Apnea of Prematurity
 Approximately in 25% of premature infants
 Most outgrow by postmenstrual age of 40 weeks
 Some will continue to have apnea and may be
discharge home on methylxanthine therapy (ie,
caffeine) or apnea monitors
 Timing to discontinue these interventions is
multifactorial, usually determined by the
subspecialist or NICU follow up clinic
Question #2
 What is the second most common cause of childhood
blindness?
Retinopathy of Prematurity
 Second most common cause of childhood blindness
 Treatment can reduce morbidity
 Indicated in all infants with birth weight < 1500 g or
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gestational age less than 31 weeks
Also indicated in infants whose clinical course places them at
increased risk as determined by the neonatologist
Typically presents at approximately 32 weeks gestation
Peaks at 38 to 40 weeks
Beings to regress by 46 weeks
Initial retinal screening 4-6 weeks after birth
Additional examinations at intervals of 1-3 weeks until retinal
vessels have fully matured
PREP Question #4
 You are the primary care physician for newborn
twins born at 33 weeks’ gestation and discharged
from the neonatal intensive care unit after a 4-week
stay. They required oxygen for 3 days after birth, but
little other respiratory support. They were diagnosed
with gastroesophageal reflux disease. They have
occasional episodes of coughing and gagging without
color change. They are otherwise well.
PREP Question #4
 Of the following, the BEST advice to give the parents
is to place the twins in
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A. prone sleep position
B. side sleep position
C. sitting devices, such as car seats, during sleep
D. sleep positioners to keep their heads elevated
E. supine sleep position
Answer
 E. supine sleep position
 Except in a very few instances, supine is the safest sleep
position for an infant including those with
gastroesophageal reflux.
 The safest place for an infant to sleep is on a firm, wellfitted mattress in an approved crib, bassinet, or play yard
free of other objects and located in the parents’ room.
 Current American Academy of Pediatrics
recommendations extend beyond “Back to Sleep” to
address other sleep environment factors.
 Bed sharing, while controversial, is not recommended,
and even twins should sleep on separate sleep surfaces.
Sudden Infant Death Syndrome (SIDS)
 Death of an infant less than one year of age that
remains unexplained despite a thorough
investigation
 At greater risk than term infants with a peak risk at
50-52 weeks postmenstrual age
 No evidence that home apnea monitors decrease the
risk
 Screen at each visit to ensure families are following
AAP recommendations of supine (back) sleeping
position and ask about location of sleeping
Gastroesophageal Reflux
 Common in premature infants and in those with CLD,
neurological impairment or congenital defects (ie,
tracheoesophageal fistulas or diaphragmatic hernias)
 Monitor for complications including
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Poor weight gain due to decreased caloric intake
Apnea and bradycardia
Aspiration
Choking
Esophagitis
Laryngospasms
Discomfort
Nectrotizing Enterocolitis
 Complications
 Need for ostomy care
 Malabsorption
 Intestinal dysmotility
 Need for parenteral nutrition despite enteral feedings
 Cholestasis
 Infections of the ascending biliary tract
 Biliary calculi
 Late partial or complete bowel obstruction
 Short bowel syndrome
 Dumping syndrome
 Growth failure
 Fluid imbalance and electrolyte abnormalities
 Need for follow up with pediatric surgery and/or
gastroenterologist
PREP Question #5
 A 6-week-old male infant is brought to your office for a routine visit. He
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was born at 29 weeks’ gestational age with a birth weight of 1,250 grams to
an 18-year-old mother who did not receive prenatal care until the third
trimester. The baby’s blood type is O positive and his mother’s is B positive.
He had neonatal hyperbilirubinemia and received phototherapy for 1 week.
He is tolerating his feeds of 22-kcal/oz formula and his weight is now 2,265
grams. His temperature is 37.0°C, his pulse rate is 130/min, respiratory
rate is 30 breaths/min, and blood pressure is 80/55 mm Hg. He is alert and
in no apparent distress. His sclerae are anicteric, his oral mucosa is pink
and moist, his lungs are clear to auscultation, and there is no cardiac
murmur or hepatosplenomegaly. The mother is concerned that he looks
pale. The following are the results of his complete blood cell count:
White blood cell count, 12,500/μL (12.5 × 109/L)
Hemoglobin, 8.5 g/dL (85 g/dL)
Mean corpuscular volume, 99 μm3 (99 fL)
Platelet count, 389 × 103/μL (389 × 109/L)
Indirect (unconjugated) bilirubin, 1.0 mg/dL (17.1 μmol/L)
PREP Question #5
 Of the following, the MOST appropriate assessment
of this patient would be that he has a
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A. macrocytic anemia due to folate deficiency
B. microcytic anemia due to iron deficiency
C. normal hemoglobin for a preterm infant
D. normocytic anemia due to ABO incompatibility
E. normocytic anemia due to chronic inflammation
Answer
 C. normal hemoglobin for a preterm infant
 Normal hemoglobin concentration (Hb) and mean corpuscular
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volume (MCV) vary with age, highest in the neonate and decline
significantly by 1 year of age.
During the first week after birth, hemoglobin production decreases
by a factor of 10 because of a sudden increase in tissue oxygenation,
causing a marked decrease of plasma erythropoietin.
This leads to a decrease in Hb known as the physiological anemia of
infancy, which occurs at around 6 to 8 weeks of age in full-term
infants.
In healthy preterm infants, this nadir can be exaggerated and is
known as the physiologic anemia of prematurity.
Although the term anemia is used, the decrease in hemoglobin is
normal and expected; therefore, physiological anemia of infancy is
not a true disease state.
Anemia of Prematurity
 At risk for anemia that occurs earlier and is more
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severe than physiologic anemia in term infants
Nadir for hemoglobin is 7-10 g/dL at 4-8 weeks
compared with 11 g/dL at 8-12 weeks in term infants
Treatment with iron supplementation (2 mg/kg/day
or in multivitamin) results in lower rate of iron
deficiency and iron deficiency anemia
Less additional supplementation needed if receiving
iron-fortified formula versus exclusively
breastfeeding
Symptomatic infants need red blood cell transfusion
Neurologic
 Intraventricular hemorrhage (IVH), grades I-IV
 Posthemorrhagic hydrocephalus occurs in 35% of infants with
IVH and risk increases with severity (ie, grades III and IV)
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Early or late-onset
Obstructive, communicating or both
Transient or sustained
Slow or rapid progression
Shunt placement may be required with need for monitoring for
malfunction or infection
 Postmeningitic hydrocephalus
 Periventricular leukomalacia
 Ischemic infarction of the white matter, most commonly adjacent to
lateral ventricle
 Seizures
 Common etiologies: hypoxic-ischemic injury, direct cerebral trauma,
intracranial hemorrhage, metabolic abnormalities, malformations and
infections
PREP Question #6
 An infant develops abdominal distention and bilious
vomiting at 36 hours after birth. The 3.9-kg infant was
born at 37 weeks of gestation to a mother with type 1
diabetes mellitus. The prenatal course was
unremarkable, with negative carrier testing for cystic
fibrosis. According to the mother, the infant has been
breastfeeding and has had 4 wet diapers and 1 small
smear of meconium. Examination reveals an
uncomfortable infant with a distended, firm abdomen
that is slightly tender to deep palpation. The rectum
appears to be externally patent with an anal wink. A
radiograph is obtained.
PREP Question #6
PREP Question #6
 Of the following, the MOST likely cause of the
infant’s findings is
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A. anorectal malformation
B. Hirschsprung disease
C. meconium ileus
D. neonatal small left colon syndrome
E. pneumatosis coli
Answer
 D. neonatal small left colon syndrome
 An infant of a diabetic mother is at risk for
hypoglycemia, hypocalcemia, polycythemia and
neonatal small left colon syndrome.
Question #3
 What are some of the common surgical procedures
performed on infants in the NICU?
Common Surgical Procedures
 Surgical bowel resection secondary to necrotizing
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enterocolitis (NEC) and/or intestinal perforation
Gastrostomy tube placement
Fundoplication
Ventriculo-peritoneal shunts
Tracheostomy
Cardiac surgeries
Umbilical hernia repair due to incarceration
Inguinal hernia repair
Discuss care for surgical areas and follow up with
surgical specialties
References
 Committee on Fetus and Newborn (2008). Policy statement:
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Hospital discharge of the high-risk neonate. Pediatrics,
122(5), 1119-1126.
Stewart, J. (2014). Care of the neonatal intensive care unit
graduate. Retrieved from http://www.uptodate.com.
Woods, S. & Riley, P. (2006). A role for community health
care providers in neonatal follow-up. Paediatr Child Health;
11(5), 301-302.
Andrews, B., Pellertie, M., Myers, P. & Hagerman, J. (2014).
NICU follow-up: Medical and developmental management
age 0 to 3 years. Neoreviews, 15(4), e123-e132.
Sherman, M.P. (2013). Follow-up of the NICU patient.
Retrieved from http://emedicine.medscape.com/.
AAP PREP Questions