Care of late preterm infant sandip

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Care of late preterm

Care of late preterm

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  • Until recently, we have classified infants by GA in : Preterm, Term and post-term, however due to difference in their physiology, development, morbidity, mortality and long term outcome, we are using a new terminology to describe the GA: preterm, LPT, ET and term.
  • Why there has been an increase in this 2 groups? We really don’t know, but it seems to be multifactorial.

Transcript

  • 1. CARE OF LATE PRETERM INFANT SANDIP GUPTA PGT ,PEDIATRICS
  • 2. • Is multifactorial: • Increased surveillance and medical interventions • Inaccurate gestational age estimates • Presumption of fetal maturity at 34 weeks’ gestation • ART • Increased rates of elective cesarean sections and inductions of labor • Maternal and physician concerns about complications of vaginal delivery and subtle changes in medical thresholds for cesarean birth
  • 3. COMMON PROBLEMS  Temprature instability  Hypoglycemia  Respiratory distress  Apnea  Jaundice  Feeding difficulty  Dehydration  Suspected sepsis
  • 4. RESPIRATORY • Late preterm infants: 28.9% respiratory distress at birth compared to 4.2% of term infants. • It was found that for incidence of respiratory distress increases with every week less than 39 wk, • 30/1000 @34 wks to 14/1000@35wks to7.1/1000 @36 wks.
  • 5. CAUSES  TTN  RDS  PPHN  APNEA
  • 6. GI SYSTEM: NUTRITION  Feeding problems: neuronal immaturity, decreased oromotor tone, sleepier,have less stamina.  Nutritional experts recommend 34-35 wks LPT receive nutrient rich milk(22kcal/oz) with higher protein(1.9g/dl),calcium, phosphate, Zn,trace elements ,vitamins.  TPN: more adept to handle aminiacids( start @ 2g/kg/d maintain @ 2.5-3g/kg/d).  Use of lipids in LPT infants to prevent essential fatty acid deficiency in infants with increased PVR& respiratory disease should be avoided in critical stages of illness.
  • 7. HYPOGLYCEMIA  Often missed, occurs 3times more .  Decreased glycogen storage & feeding     difficulty,compensatory mechanism not fully developed. Severe hypoglycemia is a risk factor for neuronal cell death & poor neurodevelopmental outcomes. Routine testing of bl.sugar in LPT infant. Glucose requirement 6-8mg/kg/hr. Demand may increase in coexisting sepsis, asphyxia ,cold stress.
  • 8. HYPERBILIRUBINEMIA  Most common condition requiring evaluation,t/t,      readmission. Rehospitalisation for jaundice higher in preterms(4.5% vs 1.2% in terms. Newman et al(1999) in their study showed that neonates born at 36wks have 8 times more risk of TSB>20mg% when compared to those born at 41wks or later. Hepatic immaturity& overall immaturity of GUT function & motility. LPT are at a greater risk of kernicterus at bilirubin level equal to or lower than that of a term baby. AAP recommends that all newborns should be assessed for risk of developing hyprbilirubinemia by using predischarge TSB or TCB
  • 9. INFECTIONS  More susceptibility to infection due to immunological immaturity.  Congenital, Early & Late .  Research shows that LPT undergo testing for sepsis more often than term infants(36.7%12.6%)& receive antibiotics more often & for a longer duration.  This may be because 1/3rd of preterm deliveries occur due to PPROM, as well as due to their presentation with respiratory distress, hypoglycemia ,hypothermia.
  • 10. THERMOREGULATION  Manifests as tachypnea,apnea, poor feeding,poor color,& metabolic acidosis.  Hypothermia can respiratory transition exacerbate hypoglycemia which can mimick sepsis.  Physiological immaturity of thermoregulation :brown & white adipose tissue, body surface area.  LPT have decrease hormone for brown fat meatabolism(prolactin,norepinephrin,T3,cortisol).
  • 11. NEURODEVELOPMENT  Research shows that LPTs & early term neonates have risk for development through 1st 5yrs of life.  During final few wks brain maturity is still in progress.  These aspects include maturing oligodendroglia,neuronal arborisation, connectivity, maturation of neurotransmitter system & accounts for 30% of brain growth in last few weeks.  brain of LPT still immature , the cerebral cortex still smooth sulci& gyri are not fully formed,myelination & neuronal connectivity is still incomplete.
  • 12. HOSPITALISATION  ADMISSION CRITERION:It is recommended that       all newborns born before 35wks& or having birth wt<2300gm should be admitted to atransitional nursery & should be monitored for vitals,feeding abilities, thermoregulation & other problems. HOSPITAL MANAGEMENT: Physical exam Gestational age estimation Vitals monitoring & pulse oximetry Feeding plan & assessment of breastfeeding. Scrrening for hypoglycemia & tcb.
  • 13. DISCHARGE CRITERIA  Should not be discharged before 48hrs  Vitals normal for 12hrs before discharge.  Passage of 1 stool spontaneously.  Adequate urine output.  24hrs of successful breastfeeding.  Wtloss >7% in 48hrs should be assesed further before discharge.  Risk assessment plan for infant discharged before72 hrs.
  • 14. FOLLOW UP  Brought back to their pediatrcian for a checkup.  Growth monitoring & developmental assessment.  Early intervention.