Peds Prematurity

Front 1

define premature infant

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live born newborn delivered prior tp 37 wks from the first day of last menstrual period

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low birth weight

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< 2500g

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very low birth weight

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1500g

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extremely low birth weight

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<1000

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extremely low gestational age neonate

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<750g and or gestational age 26 wks weeks

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Most common cause of prematurity

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most premature births have no identifiable causes

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what are the maternal, fetal and obstetric causes for prematurity

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maternal: low SES, preeclampsia, infections, chronic medical illness (HTN, renal dz, diabetes), drug use
fetal: multiple gestation, fetal distress (from hypoxia), congenital anomalies
OB: incompetent cervix, polyhydramnios, chorioanionitis, premature rupture of membranes, placenta previa & abruptio placenta

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Common problems in premature newborns

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-respiratory distress syndrome (hyaline membrane z)
-bronchopulmonary dysplasia
-necrotizing enterocolitis
-retinopathy of prematurity
-intraventricular hemorrhage

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Signs of respiratory distress syndrome

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-seen within the first 4 hrs of life
-tachypnea
-grunting
-cyanosis

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Dx of respiratory distress syndrome

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chest x-ray with diffuse reticulogranular or "ground glass" pattern

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Tx for respiratory distress syndrome

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-oxygen, CPAP, intubation, mechanical ventilation
-exogenous surfactant replacement

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how can the production of surfactant be accelerated in the mother

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maternal steroid (betamethasone); best if given 24-48 hrs prior to delivery

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causes of Respiratory distress syndrome

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occurs secondary to insufficiency of lung surfactant due to immaturity of surfactant producing type 2 alveolar cells

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alveolar collapse in respiratory distress syndrome results in what

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atelectasis, intrapulmonary shunting, hypoxemia and cyanosis

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what is bronchopulmonary dysplasia

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chronic lung disease that develops in preterm neonates treated with oxygen and positive pressure ventilation

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what can bronchopulmonary dysplasia lead to

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squamous metaplasia and hypertrophy of small airways

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why do neonates presenting with respiratory distress syndrome receive antibiotics

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because clinically and radiographically RDS and congenital pneumonia are indistinguishable

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What have been shown to reduce the incidence of RDS

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antenatal steroids

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Etiology for bronchopulmonary dysplasia

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-multifactorial
-lung immaturity
-prolonged mechanical ventilation
-Barotrauma (from mechanical ventilation)
-oxygen toxicity to the lungs

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Dx of bronchopulmonary dysplasia

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chest x -ray w/ hyperaeration and atelectasis

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Tx for bronchopulmonary dysplasia

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-supplemental oxygen as needed
-oral steroids
-bronchodilators

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Which neonates are more likely to have bronchopulmonary dysplasia

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-born at 22-32 weeks
-<1000g at birth

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What is the mortality of necrotizing enterocolitis

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20%

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most common site for necrotizing enterocolitis

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terminal ileum and proximal ascending colon

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What are serious sequelae of necrotizing enterocolitis

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-intestinal strictures
-malabsorption
-fistula
-short bowel syndrome

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what is the most common GI emergency in premature infants

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necrotizing enterocolitis

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Dx of necrotizing enterocolitis

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-distended loop of bowels
-abdominal x-ray w/ pneumatosis internalis-air bubbles w/in bowel walls
-air in portal vein
-free air under diaphragm
-occult blood in stool

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Tx for necrotizing enterocolitis

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-discontinue feeds
-NG decompression
-IV fluids
-Antibiotics
-Surgery

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Etiology of necrotizing enterocolitis

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-caused by bowel ischemia and bacterial invasion of intestinal wall
-more common in premature infants treated w/ indomethacin for PDA. Indomethacin may cause splanchnic vasoconstriction

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Signs of nectrotizing enterocolitis

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-intolerance of oral feeding
-abdominal distension
-temperature instability
-respiratory distress
-acidosis, sepsis, shock

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Most common complication of necrotizing enterocolitis

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stricture

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Absolute indication for operative intervention in Necrotizing enterocolitis

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pneumoperitoneum

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what is retinopathy of prematurity

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disease that affects immature vasculature in the eyes of premature infants

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Why is severe retinopathy currently rare

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use of oxygen

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Which neonates are at risk of developing retinopathy of prematurity

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<1500g birth wt or younger than 32 wks gestational age at birth

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Etiology of retinopathy of prematurity

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-caused by proliferation of immature retinal vessels due to excessive use of oxygen
-most common cause is hyperoxia
-

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What is retinopathy of prematurity associated with

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-can cause retinal detachment and blindness in severe cases
-characterized by neovascularization of retina and vascular congestion that can cause retinal detachment and decrease visual acuity

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Dx of retinopathy of prematurity

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ophthalmology evaluation

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Tx for retinopathy of prematurity

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laser surgery

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What is intraventicular hemorrhage

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rupture of germinal matrix blood vessels due to hypoxic or hypotensive injury
-most IVH's occur within 72 hrs after birth

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what are predisposing factors for intraventicular hemorrhage

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prematurity, RDS, hypo- or hypervolemia, shock, bleeding disorders

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what are the signs of intraventricular hemorrhage

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most are asymptomatic
apnea, HTN or hypotension, changes in muscle tone, lethargy, poor suck, seizure, bulging fontanelle

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Dx of intraventricular hemorrhage

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cranial ultrasound

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Tx for intraventricular hemorrhage

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-directed toward correction of underlying conditions (RDS, shock)
-in cases associated w/ hydrocephalus placement of ventriculoperitoneal shunt

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what is the chance of normal survival in US after 24 weeks

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50%

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what is the best choice for feeding for premature infants

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breast feeding

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Ex-preemies should receive which infection prophylaxis

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RSV during RSV season

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what are the special needs for ex-preemies

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-heat loss
-hypoglycemia
-fluid and electrolyte imbalance
-hyperbilirubinemia
-bronchopulmonary dysplasia- wheezing and RSV
-high calorie diet
-routine vaccination