This document discusses problems faced by late preterm newborns, including respiratory issues, thermoregulation difficulties, and hypoglycemia. It provides epidemiological data on the increasing rates of late preterm births and their associated higher morbidity and mortality compared to full-term infants. Specific problems faced by late preterm infants are outlined, such as transient tachypnea of the newborn, respiratory distress syndrome, and feeding difficulties. Strategies for prevention and management of complications are discussed, including use of kangaroo mother care and dextrose gel to treat hypoglycemia.
Late preterm infants, defined as those born between 34-36 weeks gestation, represent the largest subgroup of preterm births and are at increased risk of morbidity compared to term infants. While many late preterm infants experience only transient problems, they have higher rates of respiratory distress, hypoglycemia, jaundice, feeding difficulties, and temperature instability. Late preterm infants are also at risk for rehospitalization and may experience long-term neurodevelopmental impairments and learning problems. Optimizing care and monitoring for these infants is important given their vulnerabilities despite nearing term gestation.
This presentation is part of and education series to pediatric healthcare providers in Syria and it may be useful to all practitioners working in low resource settings.
This document discusses the care of late preterm infants between 34-36 weeks gestation. It notes that these infants are at higher risk for temperature instability, hypoglycemia, respiratory distress, jaundice, feeding difficulties, and suspected sepsis compared to full term infants. The document provides details on the increased risks for respiratory issues, hypoglycemia, hyperbilirubinemia, infections, and impaired neurodevelopment in late preterm infants. It also outlines recommendations for admission criteria, in-hospital management and monitoring, discharge criteria, and follow-up care for late preterm infants.
Skin to-skin contact and early breastfeedingMahmoudRavari
The document discusses the importance of immediate skin-to-skin contact between mothers and babies after birth. It outlines the 9 instinctive stages babies go through in the first hour of life when placed skin-to-skin with their mothers, including birth cry, relaxation, awakening, activity, crawling, resting, familiarization, suckling, and sleeping. Delaying skin-to-skin contact and breastfeeding initiation has been shown to increase neonatal mortality risk. Immediate skin-to-skin contact provides benefits for both babies and mothers.
This document discusses developmentally supportive care in the NICU. It describes how the NICU environment has transitioned from a technology-oriented space that could overstimulate or deprive infants to one that aims to mimic the womb and support brain development. It outlines principles of developmentally supportive care like NICU design, positioning, handling infants, and parental participation. Interventions like kangaroo care, non-nutritive sucking, massage therapy, and multimodal stimulation are described that aim to properly stimulate infant senses and support physiology and behavior.
This document discusses developmentally supportive care for preterm infants in the NICU. It aims to improve outcomes by supporting brain development, motor skills, sensory systems and family involvement through careful handling, positioning, feeding practices and control of the neonatal environment. Key aspects of care include protecting sleep, minimizing pain and stress, developmental activities like feeding and skin care, family centered care, and providing appropriate light, sound, and a caring staff. This holistic approach can help preterm infants heal and develop normally.
This document discusses guidelines for follow up care of high risk newborns after discharge from the NICU. It outlines the importance of follow up to monitor for growth, development, and health deviations. Criteria for discharge planning are described, including being hemodynamically stable, maintaining temperature, full enteral feeds, parental confidence, and vaccinations. Improving compliance is discussed through informing parents, multi-disciplinary teams, integrating with routine visits, communication, and continuity of care. Risk factors for neurodevelopmental disabilities are outlined. Screenings and assessments recommended before discharge and during follow up include medical exams, neuroimaging, ROP screening, hearing screening, and metabolic screening. Levels of follow up care are assigned based
Late preterm infants, defined as those born between 34-36 weeks gestation, represent the largest subgroup of preterm births and are at increased risk of morbidity compared to term infants. While many late preterm infants experience only transient problems, they have higher rates of respiratory distress, hypoglycemia, jaundice, feeding difficulties, and temperature instability. Late preterm infants are also at risk for rehospitalization and may experience long-term neurodevelopmental impairments and learning problems. Optimizing care and monitoring for these infants is important given their vulnerabilities despite nearing term gestation.
This presentation is part of and education series to pediatric healthcare providers in Syria and it may be useful to all practitioners working in low resource settings.
This document discusses the care of late preterm infants between 34-36 weeks gestation. It notes that these infants are at higher risk for temperature instability, hypoglycemia, respiratory distress, jaundice, feeding difficulties, and suspected sepsis compared to full term infants. The document provides details on the increased risks for respiratory issues, hypoglycemia, hyperbilirubinemia, infections, and impaired neurodevelopment in late preterm infants. It also outlines recommendations for admission criteria, in-hospital management and monitoring, discharge criteria, and follow-up care for late preterm infants.
Skin to-skin contact and early breastfeedingMahmoudRavari
The document discusses the importance of immediate skin-to-skin contact between mothers and babies after birth. It outlines the 9 instinctive stages babies go through in the first hour of life when placed skin-to-skin with their mothers, including birth cry, relaxation, awakening, activity, crawling, resting, familiarization, suckling, and sleeping. Delaying skin-to-skin contact and breastfeeding initiation has been shown to increase neonatal mortality risk. Immediate skin-to-skin contact provides benefits for both babies and mothers.
This document discusses developmentally supportive care in the NICU. It describes how the NICU environment has transitioned from a technology-oriented space that could overstimulate or deprive infants to one that aims to mimic the womb and support brain development. It outlines principles of developmentally supportive care like NICU design, positioning, handling infants, and parental participation. Interventions like kangaroo care, non-nutritive sucking, massage therapy, and multimodal stimulation are described that aim to properly stimulate infant senses and support physiology and behavior.
This document discusses developmentally supportive care for preterm infants in the NICU. It aims to improve outcomes by supporting brain development, motor skills, sensory systems and family involvement through careful handling, positioning, feeding practices and control of the neonatal environment. Key aspects of care include protecting sleep, minimizing pain and stress, developmental activities like feeding and skin care, family centered care, and providing appropriate light, sound, and a caring staff. This holistic approach can help preterm infants heal and develop normally.
This document discusses guidelines for follow up care of high risk newborns after discharge from the NICU. It outlines the importance of follow up to monitor for growth, development, and health deviations. Criteria for discharge planning are described, including being hemodynamically stable, maintaining temperature, full enteral feeds, parental confidence, and vaccinations. Improving compliance is discussed through informing parents, multi-disciplinary teams, integrating with routine visits, communication, and continuity of care. Risk factors for neurodevelopmental disabilities are outlined. Screenings and assessments recommended before discharge and during follow up include medical exams, neuroimaging, ROP screening, hearing screening, and metabolic screening. Levels of follow up care are assigned based
This document discusses neonatal care and discharge planning from neonatal units. It describes three levels of neonatal care from basic special care up to intensive care in a neonatal intensive care unit. It emphasizes the importance of a multidisciplinary approach to discharge planning from the point of admission, identifying a dedicated staff member to coordinate the baby's discharge plan. It also stresses preparing families for meeting the baby's needs at home through training and ensuring integrated support from community health teams after discharge.
The document discusses neonatal pain, including that babies can feel and react to pain, validated scales exist to measure neonatal pain, and developmental aspects of pain perception in newborns. It also outlines non-pharmacological and pharmacological approaches to treating pain in newborns, emphasizing the need for comprehensive pain management strategies that minimize unnecessary pain in neonates.
Respiratory distress is a common problem in newborns. This document discusses the epidemiology, clinical features, assessment, causes and management approaches for several major causes of respiratory distress in newborns, including meconium aspiration syndrome, respiratory distress syndrome, and transient tachypnea of newborn. It provides clinical guidance on evaluating and treating newborns presenting with respiratory distress.
This document summarizes the management of late preterm infants. Key points include monitoring infants for common complications like respiratory distress, hypoglycemia, and feeding difficulties. Supplementation with expressed breastmilk or formula is often needed due to challenges with exclusive breastfeeding. Close follow-up is important to assess growth, development, and prevent future health issues that late preterm infants are at higher risk for. Lifestyle changes and interventions during pregnancy can help prevent preterm births.
Bronchopulmonary dysplasia updates_and_prevention dr falakhagfalakha
The document discusses bronchopulmonary dysplasia (BPD) and strategies for prevention. It notes that BPD results from disrupted alveolar development and remodeling of the airways, vasculature, and smooth muscle. Risk factors include prematurity, genetics, chorioamnionitis, and exposures associated with resuscitation and mechanical ventilation. Strategies discussed to prevent BPD include using lower oxygen concentrations during resuscitation, applying continuous positive airway pressure, and avoiding overinflation and atelectrauma through gentle ventilation techniques. Future research is still needed to develop more evidence-based prevention and treatment approaches for BPD.
This document discusses neonatal hypoglycemia. It begins by explaining glucose physiology in fetuses and the adaptations required at birth. It then defines neonatal hypoglycemia and discusses the various etiologies including endocrine disorders, decreased substrate availability, and increased glucose utilization. Symptoms, screening, and management including prevention, treatment with oral feeds or IV therapy, and treatment of persistent or severe hypoglycemia are covered. The importance of aggressively managing hypoglycemia to prevent neurological damage is emphasized.
This document discusses enteral nutrition in preterm neonates. It notes that providing adequate nutrition to preterm infants is challenging due to immaturity of bowel function and inability to suck and swallow. While parenteral nutrition can provide nutrients, lack of enteral intake can impair gut development and function. The document reviews evidence from several Cochrane reviews on different approaches to enteral feeding in preterm infants, finding insufficient evidence to recommend one approach over others and calling for additional large randomized controlled trials to evaluate effects on important outcomes.
This document discusses neonatal hypoglycemia, including its definition, causes, screening, management, and long-term outcomes. Some key points:
- Hypoglycemia is common in newborns due to immature metabolic pathways and dependence on glucose. It can cause neurological damage if persistent.
- Definitions vary but typically include blood glucose levels below 45 mg/dL, or 36 mg/dL for asymptomatic babies with risk factors.
- Causes include decreased stores, increased utilization, and endocrine disorders like hyperinsulinemia.
- At-risk babies should be screened at birth and every few hours. Treatment involves glucose boluses and intravenous infusions to maintain safe blood glucose levels.
This document discusses the infant of a diabetic mother. It begins with an introduction stating that diabetes is a common complication of pregnancy and risks to the infant have decreased but still exist. It then covers pathophysiology, epidemiology, complications, management, and prognosis. Key points include: fetal macrosomia is a risk; hypoglycemia is common due to hyperinsulinemia; other risks include hypocalcemia, hypomagnesemia, and congenital heart defects. Management involves monitoring glucose and electrolytes along with imaging tests. Treatment focuses on maintaining normal glucose during labor and delivery along with early breastfeeding to prevent hypoglycemia. Prognosis is generally good but neurodevelopmental risks exist if maternal glucose control was
This document discusses neonatal transport, including the best method of in-utero transfer when high-risk delivery is anticipated. It outlines indications for neonatal transport when in-utero transfer is not possible or the sick neonate requires care beyond what is available. The document also describes common problems that can occur during transport such as hypothermia and how to ensure the neonate is stable before and during the transfer using a transport protocol that includes equipment, medications, monitoring, and maintaining temperature, blood sugar, blood pressure, and airway stability.
This document discusses the identification and transport of sick neonates. It begins by outlining signs of health at birth and danger signs that indicate illness. Some key danger signs include lethargy, respiratory distress, cyanosis, convulsions, and excessive weight loss. The document emphasizes the importance of early detection and treatment of sick newborns to prevent high mortality. It provides guidance on assessing vital signs and identifying potential illnesses in newborns. Finally, it covers best practices for stabilizing, caring for, and transporting sick neonates in a safe manner to the appropriate medical facility for treatment. The overall goal is to get the right baby, to the right facility, using the right transport methods and personnel, while providing
This document discusses developmental care for high-risk neonates in neonatal intensive care units (NICUs). It outlines how the NICU environment can negatively impact infant development, and how developmental care aims to decrease neonatal stress and allow for optimal neurobehavioral growth. Developmental care includes practices like kangaroo mother care, non-nutritive sucking, and massage therapy. The document calls for upgrading pediatric nursing education, research, and clinical practice to better implement developmental care models and improve outcomes for high-risk infants.
1) Neonatal shock is characterized by an imbalance between oxygen delivery and demand, leading to tissue hypoxia. Myocardial dysfunction, abnormal vasoregulation, and hypovolemia are common causes.
2) Pathophysiology includes an immature myocardium with fewer contractile elements and higher basal contractility, as well as complex vascular smooth muscle tone regulation. Relative adrenal insufficiency also contributes.
3) Clinical assessment of shock includes vital signs, perfusion markers like capillary refill time and lactate, and echocardiography to evaluate cardiac function and filling. Goal-directed management targets normalization of these parameters.
The document discusses pain in preterm and term neonates. It states that the pain system is intact and functional in both populations. Behavioral responses like facial expressions and cry characteristics can indicate pain. The development of sensory receptors and connections allow pain to be processed by 20 weeks gestation. While neonatal pain may not be recalled, it can have long term impacts on brain development and later health and behavior. Effective pain assessment and management are important to provide neonatal patients.
This document discusses the case of a term male infant born without complications who experienced episodes of hypoglycemia. At 2 hours of age he was jittery with a blood glucose of 35 mg/dL and improved after feeding. On the second day of life he again had low glucose of 35 mg/dL. At 2 weeks he presented with fussiness, jitteriness, staring spells, somnolence, and seizures with glucose less than 10 mg/dL, requiring IV glucose treatment. He continued having recurrent hypoglycemic episodes over the following weeks.
This document provides guidance on managing a neonate with respiratory distress, including defining the severity, identifying the etiology, initial management with oxygen therapy and supportive care, and the various modes of respiratory support including CPAP, NIV, HHHFNC, IMV, and HFOV. The goal of respiratory support is to optimize oxygenation and ventilation while avoiding lung injury through use of the lowest effective pressures and tidal volumes. Clinical assessment and arterial blood gases are important to monitor the adequacy of respiratory support and make adjustments as needed.
Premature and low birth weight children's growth and development must be closely monitored. Embryonic and early childhood structural brain development is a slow process that last through the toddler stage. Embryonic gyrification, sulcation, and production of myelin is essential to brain development. Brain tissue requires more than 40 weeks of optimal gestational conditions. During the third trimester grey matter undergo corticle folding, while white matter undergo changes in tissue organization and maturation. The frontal lobe is especially vulnerable to fetal nutrient deficiency during this critical period. Stakeholders must also monitor infants and toddlers who are born early term (37-38 weeks gestation) since their brain tissue is also underdeveloped. Parents, physicians, and child-care providers are encouraged to assess preterm children's cognitive, learning, movement, language, and social emotional domains. Preterms should also receive visuospatial, neuromuscular skeletal and working memory assessments in addition to cognitive, learning, language, and social emotional assessments. Early intervention is the key to rehabilitation.
This document summarizes a presentation on follow-up care for high-risk newborns. It discusses the medical home framework and components of health and developmental follow-up. Key points include:
- High-risk infants requiring ongoing care include preterms and those with special health care needs or technology dependence.
- Follow-up includes primary care, specialty care, developmental surveillance, and addressing family concerns from infancy through adulthood.
- Transition points for parents include concerns in the first 3 months after discharge and needs changing from ages 3 months to 1 year, 1-3 years, preschool, and beyond.
- Barriers to care include limited provider familiarity with complex conditions, insufficient reimbursement, and
This document discusses the importance of follow-up care for high-risk newborns after discharge from the NICU. It outlines that follow-up should include regular medical examinations to monitor growth and development, screening tests, and neurobehavioral assessments. Follow-up care is most intensive for high-risk infants born prematurely or with very low birth weight, and can involve multiple specialists. The long-term goal is to identify any disabilities or delays early and provide intervention to prevent or reduce impairments.
1) Hypoglycemia is common in newborns, affecting 1-3 per 1000 live births, with risk decreasing with increasing gestational age.
2) Significant neurodevelopmental deficits can occur in neonates who experience prolonged hypoglycemia. Studies in monkeys and infants show neuronal injury, particularly in parieto-occipital cortex and other regions.
3) There is no consensus on the definition and threshold for treating hypoglycemia. Guidelines generally recommend treating if blood glucose is less than 50 mg/dL in symptomatic newborns or less than 36 mg/dL in at-risk but asymptomatic newborns.
This document discusses neonatal care and discharge planning from neonatal units. It describes three levels of neonatal care from basic special care up to intensive care in a neonatal intensive care unit. It emphasizes the importance of a multidisciplinary approach to discharge planning from the point of admission, identifying a dedicated staff member to coordinate the baby's discharge plan. It also stresses preparing families for meeting the baby's needs at home through training and ensuring integrated support from community health teams after discharge.
The document discusses neonatal pain, including that babies can feel and react to pain, validated scales exist to measure neonatal pain, and developmental aspects of pain perception in newborns. It also outlines non-pharmacological and pharmacological approaches to treating pain in newborns, emphasizing the need for comprehensive pain management strategies that minimize unnecessary pain in neonates.
Respiratory distress is a common problem in newborns. This document discusses the epidemiology, clinical features, assessment, causes and management approaches for several major causes of respiratory distress in newborns, including meconium aspiration syndrome, respiratory distress syndrome, and transient tachypnea of newborn. It provides clinical guidance on evaluating and treating newborns presenting with respiratory distress.
This document summarizes the management of late preterm infants. Key points include monitoring infants for common complications like respiratory distress, hypoglycemia, and feeding difficulties. Supplementation with expressed breastmilk or formula is often needed due to challenges with exclusive breastfeeding. Close follow-up is important to assess growth, development, and prevent future health issues that late preterm infants are at higher risk for. Lifestyle changes and interventions during pregnancy can help prevent preterm births.
Bronchopulmonary dysplasia updates_and_prevention dr falakhagfalakha
The document discusses bronchopulmonary dysplasia (BPD) and strategies for prevention. It notes that BPD results from disrupted alveolar development and remodeling of the airways, vasculature, and smooth muscle. Risk factors include prematurity, genetics, chorioamnionitis, and exposures associated with resuscitation and mechanical ventilation. Strategies discussed to prevent BPD include using lower oxygen concentrations during resuscitation, applying continuous positive airway pressure, and avoiding overinflation and atelectrauma through gentle ventilation techniques. Future research is still needed to develop more evidence-based prevention and treatment approaches for BPD.
This document discusses neonatal hypoglycemia. It begins by explaining glucose physiology in fetuses and the adaptations required at birth. It then defines neonatal hypoglycemia and discusses the various etiologies including endocrine disorders, decreased substrate availability, and increased glucose utilization. Symptoms, screening, and management including prevention, treatment with oral feeds or IV therapy, and treatment of persistent or severe hypoglycemia are covered. The importance of aggressively managing hypoglycemia to prevent neurological damage is emphasized.
This document discusses enteral nutrition in preterm neonates. It notes that providing adequate nutrition to preterm infants is challenging due to immaturity of bowel function and inability to suck and swallow. While parenteral nutrition can provide nutrients, lack of enteral intake can impair gut development and function. The document reviews evidence from several Cochrane reviews on different approaches to enteral feeding in preterm infants, finding insufficient evidence to recommend one approach over others and calling for additional large randomized controlled trials to evaluate effects on important outcomes.
This document discusses neonatal hypoglycemia, including its definition, causes, screening, management, and long-term outcomes. Some key points:
- Hypoglycemia is common in newborns due to immature metabolic pathways and dependence on glucose. It can cause neurological damage if persistent.
- Definitions vary but typically include blood glucose levels below 45 mg/dL, or 36 mg/dL for asymptomatic babies with risk factors.
- Causes include decreased stores, increased utilization, and endocrine disorders like hyperinsulinemia.
- At-risk babies should be screened at birth and every few hours. Treatment involves glucose boluses and intravenous infusions to maintain safe blood glucose levels.
This document discusses the infant of a diabetic mother. It begins with an introduction stating that diabetes is a common complication of pregnancy and risks to the infant have decreased but still exist. It then covers pathophysiology, epidemiology, complications, management, and prognosis. Key points include: fetal macrosomia is a risk; hypoglycemia is common due to hyperinsulinemia; other risks include hypocalcemia, hypomagnesemia, and congenital heart defects. Management involves monitoring glucose and electrolytes along with imaging tests. Treatment focuses on maintaining normal glucose during labor and delivery along with early breastfeeding to prevent hypoglycemia. Prognosis is generally good but neurodevelopmental risks exist if maternal glucose control was
This document discusses neonatal transport, including the best method of in-utero transfer when high-risk delivery is anticipated. It outlines indications for neonatal transport when in-utero transfer is not possible or the sick neonate requires care beyond what is available. The document also describes common problems that can occur during transport such as hypothermia and how to ensure the neonate is stable before and during the transfer using a transport protocol that includes equipment, medications, monitoring, and maintaining temperature, blood sugar, blood pressure, and airway stability.
This document discusses the identification and transport of sick neonates. It begins by outlining signs of health at birth and danger signs that indicate illness. Some key danger signs include lethargy, respiratory distress, cyanosis, convulsions, and excessive weight loss. The document emphasizes the importance of early detection and treatment of sick newborns to prevent high mortality. It provides guidance on assessing vital signs and identifying potential illnesses in newborns. Finally, it covers best practices for stabilizing, caring for, and transporting sick neonates in a safe manner to the appropriate medical facility for treatment. The overall goal is to get the right baby, to the right facility, using the right transport methods and personnel, while providing
This document discusses developmental care for high-risk neonates in neonatal intensive care units (NICUs). It outlines how the NICU environment can negatively impact infant development, and how developmental care aims to decrease neonatal stress and allow for optimal neurobehavioral growth. Developmental care includes practices like kangaroo mother care, non-nutritive sucking, and massage therapy. The document calls for upgrading pediatric nursing education, research, and clinical practice to better implement developmental care models and improve outcomes for high-risk infants.
1) Neonatal shock is characterized by an imbalance between oxygen delivery and demand, leading to tissue hypoxia. Myocardial dysfunction, abnormal vasoregulation, and hypovolemia are common causes.
2) Pathophysiology includes an immature myocardium with fewer contractile elements and higher basal contractility, as well as complex vascular smooth muscle tone regulation. Relative adrenal insufficiency also contributes.
3) Clinical assessment of shock includes vital signs, perfusion markers like capillary refill time and lactate, and echocardiography to evaluate cardiac function and filling. Goal-directed management targets normalization of these parameters.
The document discusses pain in preterm and term neonates. It states that the pain system is intact and functional in both populations. Behavioral responses like facial expressions and cry characteristics can indicate pain. The development of sensory receptors and connections allow pain to be processed by 20 weeks gestation. While neonatal pain may not be recalled, it can have long term impacts on brain development and later health and behavior. Effective pain assessment and management are important to provide neonatal patients.
This document discusses the case of a term male infant born without complications who experienced episodes of hypoglycemia. At 2 hours of age he was jittery with a blood glucose of 35 mg/dL and improved after feeding. On the second day of life he again had low glucose of 35 mg/dL. At 2 weeks he presented with fussiness, jitteriness, staring spells, somnolence, and seizures with glucose less than 10 mg/dL, requiring IV glucose treatment. He continued having recurrent hypoglycemic episodes over the following weeks.
This document provides guidance on managing a neonate with respiratory distress, including defining the severity, identifying the etiology, initial management with oxygen therapy and supportive care, and the various modes of respiratory support including CPAP, NIV, HHHFNC, IMV, and HFOV. The goal of respiratory support is to optimize oxygenation and ventilation while avoiding lung injury through use of the lowest effective pressures and tidal volumes. Clinical assessment and arterial blood gases are important to monitor the adequacy of respiratory support and make adjustments as needed.
Premature and low birth weight children's growth and development must be closely monitored. Embryonic and early childhood structural brain development is a slow process that last through the toddler stage. Embryonic gyrification, sulcation, and production of myelin is essential to brain development. Brain tissue requires more than 40 weeks of optimal gestational conditions. During the third trimester grey matter undergo corticle folding, while white matter undergo changes in tissue organization and maturation. The frontal lobe is especially vulnerable to fetal nutrient deficiency during this critical period. Stakeholders must also monitor infants and toddlers who are born early term (37-38 weeks gestation) since their brain tissue is also underdeveloped. Parents, physicians, and child-care providers are encouraged to assess preterm children's cognitive, learning, movement, language, and social emotional domains. Preterms should also receive visuospatial, neuromuscular skeletal and working memory assessments in addition to cognitive, learning, language, and social emotional assessments. Early intervention is the key to rehabilitation.
This document summarizes a presentation on follow-up care for high-risk newborns. It discusses the medical home framework and components of health and developmental follow-up. Key points include:
- High-risk infants requiring ongoing care include preterms and those with special health care needs or technology dependence.
- Follow-up includes primary care, specialty care, developmental surveillance, and addressing family concerns from infancy through adulthood.
- Transition points for parents include concerns in the first 3 months after discharge and needs changing from ages 3 months to 1 year, 1-3 years, preschool, and beyond.
- Barriers to care include limited provider familiarity with complex conditions, insufficient reimbursement, and
This document discusses the importance of follow-up care for high-risk newborns after discharge from the NICU. It outlines that follow-up should include regular medical examinations to monitor growth and development, screening tests, and neurobehavioral assessments. Follow-up care is most intensive for high-risk infants born prematurely or with very low birth weight, and can involve multiple specialists. The long-term goal is to identify any disabilities or delays early and provide intervention to prevent or reduce impairments.
1) Hypoglycemia is common in newborns, affecting 1-3 per 1000 live births, with risk decreasing with increasing gestational age.
2) Significant neurodevelopmental deficits can occur in neonates who experience prolonged hypoglycemia. Studies in monkeys and infants show neuronal injury, particularly in parieto-occipital cortex and other regions.
3) There is no consensus on the definition and threshold for treating hypoglycemia. Guidelines generally recommend treating if blood glucose is less than 50 mg/dL in symptomatic newborns or less than 36 mg/dL in at-risk but asymptomatic newborns.
Neonatal Outcome In Pregnancy Induced Hypertensive Mothers – A Tertiary Care ...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Neuroprotection strategies for newborns ,2018 - Dr Karthik Nageshkarthiknagesh
This document provides information about Dr. N. Karthik Nagesh, his qualifications and experience in neonatology. It then summarizes his presentation on strategies for perinatal neuroprotection in newborns. These include antenatal steroids, magnesium sulfate, delayed cord clamping, therapeutic hypothermia, caffeine, kangaroo care and investigational therapies like melatonin and erythropoietin. The goal is to help newborns, especially preterms and those with birth asphyxia, have intact survival by preventing brain injury. Future areas of research discussed include preventing preterm birth and better identifying babies at risk of hypoxic ischemic encephalopathy.
This document discusses the case of a preterm baby born at 28 weeks and 2 days gestation who experienced respiratory distress syndrome, apnea of prematurity, sepsis, and grade 1 germinal matrix hemorrhage but was eventually discharged home on oxygen and follow up care. The baby was treated with CPAP, caffeine, antibiotics, phototherapy, and other supportive care measures over 38 days in the NICU.
This document discusses strategies to prevent kernicterus, a type of brain damage caused by severe neonatal jaundice. It identifies several key areas for improvement, including better lactation support, follow-up within 48 hours of discharge, and parent education. A systems-approach is recommended to optimize newborn jaundice management through improved identification of at-risk newborns, characterization of jaundice levels, and community surveillance to achieve safety standards and prevent future cases of kernicterus.
Preterm Birth Interventions_James Litch_10.16.13CORE Group
Prevention of Preterm Birth and Complications outlines key definitions, numbers, and interventions related to preterm birth. It begins with defining preterm birth as babies born alive before 37 completed weeks of pregnancy. It then presents a strategic three-phase approach and discusses how preterm birth is connected to other maternal and child health outcomes. The document reviews evidenced-based interventions to manage preterm birth like antenatal corticosteroids and antibiotics for premature prelabor rupture of membranes. It also discusses interventions for caring for preterm newborns and ways to prevent preterm birth like birth spacing and treating infectious diseases.
This document discusses neonatal hypoglycemia, including definitions, risks, screening and management. Key points:
- Hypoglycemia is associated with increased mortality and neurological impairments if untreated.
- Risks include prematurity, IUGR, infant of diabetic mother. Screen high risk babies within 1 hour of life and all others at 3-4 hours.
- Treatment includes feeding every 3 hours, IV glucose if needed. Persistent hypoglycemia may indicate underlying metabolic disorders requiring further testing and management.
- Long term studies are still needed to better understand outcomes of treated vs untreated neonatal hypoglycemia in developing countries.
This document provides protocols for various neonatal conditions presented by Dr. Nishant Prabhakar and moderated by Dr. M. Lazarus on 6/12/2016. It includes guidelines on hyperbilirubinemia, neonatal seizures, hypoglycemia, and neonatal sepsis. For hyperbilirubinemia and sepsis, it outlines risk factors, diagnostic criteria, treatment guidelines including phototherapy and antibiotic protocols. For other conditions, it summarizes evaluation and management recommendations from sources such as the American Academy of Pediatrics and AIIMS.
Dr Sujoy Dasgupta was invited to deliver a lecture at BOGSCON (The Annual Conference of Bengal Obstetric and Gynaecological Society) held at Kolkata in December 2019
This document compares the use of intravaginal misoprostol tablets and intracervical dinoprostone gel for cervical ripening and labor induction. A study of 200 women found that dinoprostone gel resulted in a shorter mean induction to delivery interval, more spontaneous vaginal births, and fewer C-sections and instrument-assisted deliveries than misoprostol. Neonatal outcomes were similar between the two groups, with most babies experiencing no complications. The study concluded that dinoprostone gel is more effective than misoprostol for cervical ripening and labor induction in nulliparous and primiparous women at term with an unfavorable cervix.
Neonatal hypoglycemia is a common metabolic problem in newborns that can cause neurological injury if left untreated. The Sugar Babies trial was a randomized controlled trial conducted in New Zealand that compared the effects of administering 40% dextrose gel or placebo gel to newborns at risk of hypoglycemia. The trial found that fewer babies in the dextrose gel group failed treatment compared to the placebo group. Babies receiving dextrose gel were also less likely to need additional intravenous dextrose treatment or to be admitted to the NICU specifically for hypoglycemia. The study demonstrated that dextrose gel provides an effective first-line treatment for neonatal hypoglycemia.
This document defines prematurity and related terms like low birth weight (LBW), small for gestational age (SGA), very low birth weight (VLBW), and extremely low birth weight (ELBW). It discusses the public health importance of prematurity, describing the high rates of prematurity globally and associated increased mortality. The document outlines maternal and fetal risk factors for prematurity and methods for differentiating preterm and SGA infants. It also provides extensive details on potential health complications in preterm infants and recommendations for management and prevention.
This document discusses preventing preterm labour. It begins by providing statistics on the incidence of preterm birth in various locations. It then discusses the magnitude of the problem, highlighting the high costs of preterm birth. Several studies on outcomes of extremely preterm infants are summarized. The document is then organized into sections on primary, secondary, and tertiary prevention of preterm labour. Key points are made about various risk factors and diagnostic tools, as well as treatments such as progesterone, cerclage and antibiotics.
Screening for and treatment of asymptomatic bacteriuria in high-risk pregnant women reduces the risk of preterm birth. However, routine screening of all pregnant women in the first trimester with urine culture is not currently recommended due to the low prevalence of asymptomatic bacteriuria in the general pregnant population and the costs of universal screening.
approach to evidence based antenatal Fetal survellianceDr Praman Kushwah
This document discusses evidence-based approaches to antenatal Doppler fetal surveillance. It begins by outlining the objectives and aims of fetal surveillance, including identifying fetuses at risk of hypoxia and improving perinatal outcomes. It then describes various methods of fetal surveillance, including daily fetal movement counts, non-stress tests, biophysical profiles, and Doppler velocimetry. The document discusses the indications and measurements of Doppler indices for the uterine, umbilical, and middle cerebral arteries. It reviews recent evidence showing that Doppler ultrasound in high-risk pregnancies can reduce perinatal deaths and interventions without increasing them in low-risk pregnancies. The document concludes by emphasizing that not all pregnancies require surveillance and that monitoring
This document discusses respiratory disorders in newborns. It begins by defining respiratory distress and noting that it affects 4-7% of neonates and is responsible for 30-40% of NICU admissions, with higher rates in preterm infants. The main causes of respiratory distress are discussed as transient tachypnea of the newborn, respiratory distress syndrome, pneumonia, meconium aspiration syndrome and persistent pulmonary hypertension of the newborn. Diagnosis involves assessing respiratory rate, retractions, oxygen saturation and chest x-rays. Management involves supportive care, surfactant replacement therapy and managing complications.
Screening for gestational diabetes an update by dr alka mukherjee nagpur ms i...alka mukherjee
Gestational Diabetes Mellitus (GDM) is defined as any glucose intolerance with the onset or first recognition during pregnancy. This definition helps for diagnosis of unrecognized pre-existing Diabetes also. Hyperglycemia in pregnancy is associated with adverse maternal and prenatal outcome. It is important to screen, diagnose and treat Hyperglycemia in pregnancy to prevent an adverse outcome. There is no international consensus regarding timing of screening method and the optimal cut-off points for diagnosis and intervention of GDM. DIPSI recommends non-fasting Oral Glucose Tolerance Test (OGTT) with 75g of glucose with a cut-off of ≥ 140 mg/dl after 2-hours, whereas WHO (1999) recommends a fasting OGTT after 75g glucose with a cut-off plasma glucose of ≥ 140 mg/dl after 2-hour. The recommendations by ADA/IADPSG for screening women at risk of diabetes is as follows, for first and subsequent trimester at 24-28 weeks a criteria of diagnosis of GDM is made by 75 g OGTT and fasting 5.1mmol/l, 1 hour 10.0mmol/l, 2 hour 8.5mmol/l by universal glucose tolerance testing. Critics of these criteria state that it causes over diagnosis of GDM and unnecessary interventions, the controversy however continues. The ACOG still prefer a 2 step procedure, GCT with 50g glucose non-fasting if value > 7.8mmol/l followed by 3-hour OGTT for confirmation of diagnosis. In conclusion based on Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study as mild degree of dysglycemia are associated with adverse outcome and high prevalence of Type II DM to have international consensus It recommends IADPSG criteria, though controversy exists. The IADPSG criteria is the only outcome based criteria, it has the ability to diagnose and treat GDM earlier, thereby reducing the fetal and maternal complications associated with GDM. This one step method has an advantage of simplicity in execution, more patient friendly, accurate in diagnosis and close to international consensus. Keeping in the mind the diversity and variability of Indian population, judging international criteria may not be conclusive, thus further comparative studies are required on different diagnostic criteria in relation to adverse pregnancy outcomes
This document outlines fetal growth restriction (FGR), including its causes, diagnosis, and management. FGR refers to a fetus that has failed to reach its growth potential and can be diagnosed based on measurements below the 10th percentile. It is a leading cause of stillbirth and newborn complications. Diagnosis involves frequent ultrasounds to monitor fetal size, proportions, and Doppler blood flow. Management depends on the severity and includes surveillance, dietary changes, medications to improve placental function, and timing of delivery. The goal is to balance fetal risks with the benefits of maintaining the pregnancy.
This document presents two case scenarios for discussion at a seminar on acute kidney injury in newborns. The first case involves a preterm, low birth weight baby with late onset sepsis who develops increased serum creatinine and decreased urine output after being treated with antibiotics. The second case involves a preterm baby with bilateral hydroureteronephrosis who develops oliguria, rising serum creatinine, and hypertension despite treatment. The document asks how each baby would be diagnosed and managed.
Similar to Problems in late preterm babies, iap bps,bangalore,webinar, 20-5-20 - Dr Karthik Nagesh (20)
Surfactant journey,nnk,oct 2017 - Dr Karthik Nageshkarthiknagesh
This document summarizes Dr. Karthik Nagesh's experience with surfactant therapy in India, beginning in the early 1990s. It describes some of Dr. Nagesh's early experiences using surfactant procured from other countries to treat neonatal respiratory distress syndrome. It then outlines how surfactant therapy became more established in India through clinical trials, workshops to educate others, and the eventual commercial availability of surfactants in India. The document provides several cases that demonstrated the benefits of surfactant therapy for reducing the need for oxygen and ventilation support.
Preterm immunisation 2018,6 oct ,south neocon- Dr Karthik Nageshkarthiknagesh
Preterm infants are at increased risk of morbidity and mortality from vaccine-preventable diseases. However, routine immunization of preterms is often delayed. The document discusses evidence that preterm infants can mount protective immune responses to vaccines according to their chronological age. While antibody levels may sometimes be lower in preterms, the majority achieve levels associated with protection. The safety and efficacy of individual vaccines in preterms is reviewed. The benefits of vaccinating medically stable preterms according to routine schedules outweigh potential risks like transient apnea.
Preterm immunisation 2018 - Dr Karthik Nageshkarthiknagesh
This document discusses vaccination in preterm infants. It notes that preterm infants are at higher risk of morbidity and mortality from vaccine-preventable diseases. However, vaccination of preterms is often delayed. The document summarizes evidence that preterm infants can mount protective immune responses when vaccinated according to their chronological age, regardless of gestational age or birth weight. It addresses specific concerns about the safety and efficacy of various vaccines in preterm populations such as BCG, polio, hepatitis B, pertussis and others. Overall, the document advocates for vaccinating medically stable preterm infants according to routine schedules in order to provide them protection from serious diseases.
Niv current trends karthik nagesh,2019 - Dr Karthik Nageshkarthiknagesh
This document provides an overview of various modes of non-invasive ventilation that can be used to support respiration in neonates, including advantages and disadvantages. It discusses nasal continuous positive airway pressure (NCPAP), nasal intermittent positive pressure ventilation (NIPPV), high flow nasal cannula (HFNC) therapy, nasal high frequency oscillatory ventilation (nHFOV), and neurally adjusted ventilatory assist (NAVA). The document summarizes the physiological rationale and evidence from studies comparing the different non-invasive modalities. It provides guidance on clinical situations where each mode may be indicated. The overall focus is on using the least invasive respiratory support possible to minimize lung injury and risk of chronic lung disease in preterm neon
Lung protective strategies,2019 - Dr Karthik Nageshkarthiknagesh
This document provides an overview of advances in neonatal respiratory care from the 1970s to present day. It discusses the evolution of ventilatory care including the introduction of surfactant replacement therapy in the 1980s, high frequency oscillatory ventilation and nitric oxide therapy in the 1990s, and the increased use of non-invasive respiratory support methods like nasal continuous positive airway pressure, nasal intermittent positive pressure ventilation, and high flow nasal cannula in the 2000s and beyond. The principles of care for extremely low birth weight infants in the first week of life are also outlined, focusing on ventilation strategies to minimize lung injury and optimize outcomes.
Jaundice 2019, salem cme - - Dr Karthik Nageshkarthiknagesh
This document discusses bilirubin encephalopathy (kernicterus) and the bilirubin-induced neurological dysfunction (BIND) spectrum. It covers the pathogenesis, risk factors, clinical features, evaluation, management with phototherapy, and guidelines for phototherapy in term and preterm infants. Key points include the need to prevent excessive bilirubin levels to avoid encephalopathy, the use of total serum bilirubin or transcutaneous bilirubin measurements to guide treatment, and following AAP guidelines for phototherapy thresholds based on gestational age and risk factors.
Hypothermia for neonates, india , ppt - Dr Karthik Nageshkarthiknagesh
This document discusses hypoxic ischemic brain injury in newborns. It describes the pathophysiology as primary energy failure caused by hypoxia/ischemia leading to immediate neuronal death, and secondary energy failure hours to days later caused by reperfusion injury and free radical formation, leading to delayed apoptotic cell death. Whole body cooling is described as an effective therapeutic intervention to reduce brain injury if initiated within 6 hours of the hypoxic ischemic insult and maintained at 33.5°C for 72 hours. The benefits, methods, and monitoring of therapeutic hypothermia are summarized.
Hie treatment, 2019, kar pedicon,davangere - Dr Karthik Nageshkarthiknagesh
Erythropoietin shows promise for reducing brain damage from neonatal hypoxic-ischemic encephalopathy (HIE). Several clinical trials have found that erythropoietin administered to infants with HIE results in less MRI-detected brain injury and improved neurodevelopmental outcomes. A current phase III trial is evaluating whether high-dose erythropoietin given with therapeutic hypothermia can reduce death or disability in infants with moderate to severe HIE. Erythropoietin appears to be a safe and potentially effective adjunctive treatment for HIE, but larger trials are still needed to determine optimal dosing and administration strategies.
Fungal sepsis,final,nnf kerala,kims,2019 - Dr Karthik Nageshkarthiknagesh
This document summarizes key information on fungal infections in newborns. It finds that invasive candidiasis is most common in extremely low birth weight infants. Risk factors include central lines, prolonged antibiotic use, and TPN. Diagnosis relies on detecting Candida in blood or other sterile sites. Early treatment with antifungals like amphotericin B or fluconazole is important to prevent complications. Prophylaxis with fluconazole may benefit high-risk infants to reduce invasive infections.
Erythropoetin in hie,iap neocon, pune,2018 - Dr Karthik Nageshkarthiknagesh
Erythropoietin shows promise for reducing brain injury in neonatal hypoxic ischemic encephalopathy (HIE). Clinical trials show that high doses of erythropoietin given with therapeutic hypothermia may result in less MRI-detected brain injury and improved motor outcomes at 1 year for infants with HIE. A current phase III trial is evaluating whether high dose erythropoietin can reduce death or neurodevelopmental disability when given with hypothermia. Additional studies are still needed to determine the optimal dosing, timing, and duration of erythropoietin administration for HIE treatment, especially in low and middle-income countries.
Dengue article kn 2019 - Dr Karthik Nageshkarthiknagesh
1) The document discusses ethical considerations regarding medical treatment decisions for infants with conditions like anencephaly that cannot be benefited by available therapies. It argues that not providing predictably futile treatments in such cases can be ethically and legally justified.
2) It references a 1983 report from the President's Commission that discussed situations where parents may want treatment even if deemed futile by physicians, and that providers should respect such requests if they don't cause suffering. Individual providers could decline if they found the treatment personally offensive.
3) The second document discusses the possibility of missing neonatal dengue cases transmitted from infected mothers. It describes two cases where screening at birth was negative but infants later developed severe dengue symptoms. It
Current status of neonatal intensive care in india, karthik nagesh n,archives...karthiknagesh
The document summarizes the current status of neonatal intensive care in India. It finds that while neonatal intensive care has grown significantly in India over the last decade due to increased private sector investment and some government initiatives, there remains a large disparity between care available to wealthy, urban populations and poor, rural populations. The government has launched programs to expand basic newborn care services, but more investment is still needed to bridge this gap and achieve national targets for reducing neonatal mortality rates, particularly in rural areas that still lack even basic newborn care services. Overall, neonatal intensive care has advanced in India but major inequities persist in access to lifesaving care for newborns.
hhhfnc 2019,karneocon,vijayapura - Dr Karthik Nageshkarthiknagesh
High Flow Nasal Canula (HFNC) therapy in Neonates - Applications discusses the use of HFNC therapy in neonates as an alternative to invasive ventilation and CPAP. It provides an overview of the evidence and clinical settings where HFNC is indicated. It describes how HFNC works and guidelines for its use. The document also discusses some of the problems with more invasive forms of ventilation and how HFNC aims to provide respiratory support in a less invasive manner.
Bind neuro neocon 2018 - Dr Karthik Nageshkarthiknagesh
This document discusses bilirubin-induced neurologic dysfunction (BIND) and chronic bilirubin encephalopathy. It covers the diagnosis and outcomes of these conditions, as well as prevention strategies. Some key points:
- BIND represents a spectrum of minor neurologic manifestations that can occur with moderate hyperbilirubinemia exposure. It includes subtle processing disorders, disturbances in visual-motor skills, and speech/language abnormalities.
- Risk factors for BIND/encephalopathy include prematurity, hemolysis, complications, and individual infant vulnerability. Diagnosis involves assessments of neuromotor signs, muscle tone, reflexes, and neurobehavior over time.
- Prevention strategies include promoting
Approaches to non invasive respiratory support in preterm - Dr Karthik Nageshkarthiknagesh
This document discusses various approaches to non-invasive respiratory support for preterm infants, including nasal continuous positive airway pressure (NCPAP), high-flow nasal cannula (HFNC), nasal intermittent mandatory ventilation (NIMV), and neurally adjusted ventilatory assist (NAVA). While non-invasive approaches can reduce the need for intubation and invasive ventilation, none have been shown to decrease the risk of bronchopulmonary dysplasia. The benefits and risks of each approach are described.
Bpd,nnf kerala,march 2019 - Dr Karthik Nageshkarthiknagesh
This document provides information about Dr. N. Karthik Nagesh, including his professional designations, affiliations, awards, publications, and special interests in neonatal intensive care and respiratory disorders. It also includes summaries of current strategies for the prevention and management of bronchopulmonary dysplasia (BPD) in preterm infants, such as the use of antenatal steroids, continuous positive airway pressure (CPAP), minimal invasive surfactant therapy, targeted volume ventilation, and inhaled steroids.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
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- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
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3. Panelists
Dr. Pradeep G.C.M , Professor & HOD of
Neonatology,
M.S. Ramaiah Medical College & Hospitals,
Bangalore
Dr. Vishwanath Kamoji, Consultant Neonatologist
& Pediatrician, Columbia Asia Hospital, Hebbal,
Bangalore
Dr. Nandini Nagar, Consultant Neonatologist &
Pediatrician, Cloudnine Hospital, Jayanagar,
Bangalore
7. EPIDEMIOLOGY
Every year, an estimated 15 million babies are born
preterm and this number is rising
Approximately 1 million children die each year due to
complications of preterm birth
Late preterm births - increasing trend ( about 6-9% of
Births and 71 % of all Preterms).
Morbidity & Mortality more in late preterms compared to
terms
22. Respiratory issues in late preterm
Prof Pradeep GCM
M.S.Ramaiah Medical College
Bengaluru
23. Introduction
Studies have consistently shown that late preterm
infants have higher respiratory morbidity and
mortality compared with full-term infants
Incidence of respiratory distress in late preterm is
28.9% as compared to term( 4.2%)
35 weeks’ gestation are nine fold more likely, to
have respiratory distress compared with babies
born at term
24. Respiratory Manifestation
Etiology of respiratory distress is diverse and
includes
Transient tachypnea of the newborn
RDS
Persistent pulmonary hypertension
Apnea
29. ISSUES OF THERMOREGULATION
& HYPOGLYCEMIA IN LATE
PRETERMS
DR PRIYA SHIVALLI
DCH, DNB, FELLOWSHIP IN NEONATOLOGY (IAP)
CONSULTANT NEONATOLOGIST & PEDIATRICIAN
VAGUS SUPERSPECIALITY HOSPITAL
BENGALURU
30. Acute complications of late preterm birth. Wang ML, Dorer DJ, Fleming M, et al.
Clinical outcomes of near-term infants. Pediatrics. 2004;114:372–376.
31. Hypothermia is more common than we think
– A silent killer!
In low income and middle income countries (LMICs)
prevalence in community settings ranges from 11%-
92%, in hospital setting ranges from 8%- 85%.
Independently associated with increased mortality 1.6
to 1.9 times.
Hypothermia can cause a Healthy baby to become ill
and a sick baby to deteriorate dramatically.
32. PREDISPOSING FACTORS
IN LATE PRETERMS
Larger surface area per unit body weight
Decreased thermal insulation due to lack of
subcutaneous fat
Reduced brown adipose tissue (Nonshivering
thermogenesis)
Decreased tone
36. Prevention and Management
In Delivery room
Thermoneutral environment
Kangaroo mother care
Clothing / Swaddling
Incubators / Radiant warmer
Polyethylene plastic wraps
If Temp <36deg C
Swaddle baby and cover
head with a cap
If after 30 mins, <36degC
Place under radiant
warmer
If still <36degC
Shift to NICU
Further evaluation and
treatment
Measure temperature every hour for first 6hrs
Then minimum of every 6hrs until discharge
37.
38. KANGAROO MOTHER CARE
BENEFITS
Improved survival
Temperature regulation
Physiologic stability
Reduced Sepsis
Pain reduction
Sleep organisation
Improved growth
Improved breastfeeding
Early discharge
Increased IQ
39. The Effects of Skin-to-Skin Care on Late Preterm and
Term Infants At-Risk for Neonatal Hypoglycemia
Arpitha Chiruvolu, Kimberly Miklis and Veeral Tolia
Pediatrics May 2018, 142
ABSTRACT
Objective: The objective of this study was to evaluate the effects of prolonged
skin-to-skin care (SSC) during blood glucose monitoring (12–24 hours) in late
preterm and term infants at-risk for neonatal hypoglycemia (NH).
Study design: We conducted a retrospective pre- and postintervention study. We
compared late preterm and term infants at-risk for NH born in a 1-year
period before the SSC intervention, May 1, 2013, to April 30, 2014 (pre-SSC)
to at-risk infants born in the year following the implementation of SSC
intervention, May 1, 2014, to April 30, 2015 (post-SSC).
Results: The number of hypoglycemia admissions to neonatal intensive
care unit among at-risk infants for NH decreased significantly from 8.1%
pre-SSC period to 3.5% post-SSC period (P = 0.018). The number of infants
receiving intravenous dextrose bolus in the newborn nursery also
decreased significantly from 5.9% to 2.1% (P = 0.02). Number of infants
discharged exclusively breastfeeding increased from 36.4% to 45.7%, although
not statistically significant (P = 0.074).
Conclusion: This SSC intervention, as implemented in our hospital, was
associated with a significant decrease in newborn hypoglycemia
admissions to neonatal intensive care unit. The SSC intervention was safe
41. HYPOGLYCEMIA IN LATE
PRETERMS
Incidence of hypoglycemia is inversely proportional to
gestational age
Glucose levels fall 1-2 hrs after birth
In late preterm infants:
Immature hepatic glycogenolysis
Decreased adipose tissue lipolysis
Deficient hepatic gluconeogenesis and ketogenesis
Hepatic enzyme immaturity
44. DEFINITION
Operational threshold
Blood glucose level of < 40 mg/dL
WHO – BGL OF < 45 mg/Dl
Transitional Neonatal Hypoglycemia- TNH
Normal physiological adaptation to postnatal life.
45. SCREENING
‘AT RISK’ Neonate
Preterm <37 weeks
Small for gestational age (SGA)
Large for gestational age (LGA)
Infant of diabetic mother (IDM)
46. TIME SCHEDULE OF BLOOD GLUCOSE
MONITORING
CATEGORY OF INFANTS TIME SCHEDULE
At risk neonates 2, 6, 12, 24, 48 and 72 hrs of life
Sick neonates ( sepsis, asphyxia,
polycythemia, shock during acute
phase of illness )
Every 6 – 8 hrly
Neonates on parenteral nutrition Initial 72hrs: every 6-8hrs
After 72hrs: once a day
AIIMS PROTOCOL 2019
47. DIAGNOSIS
Point of care-Glucometer
Measures whole blood glucose
Error prone
Lab glucose estimation – plasma glucose level
( 10-15% more than whole BGL)
Glucose oxidase method, Fluoride tubes preferred
Continuous glucose monitoring sensor (CGMS)
Experimental
48. J Pediatr, 2010 Aug;157(2):198-202.e1.
Continuous Glucose Monitoring in Newborn Babies at
Risk of Hypoglycemia
Deborah L Harris1, Malcolm R Battin, Philip J Weston, Jane E Harding
Abstract
Objective: To determine the usefulness of continuous glucose monitoring in babies at risk of neonatal hypoglycemia.
Study design: Babies >/=32 weeks old who were at risk of hypoglycemia and admitted to newborn intensive care received
routine treatment, including intermittent blood glucose measurement using the glucose oxidase method, and blinded
continuous interstitial glucose monitoring.
Results: Continuous glucose monitoring was well tolerated in 102 infants. There was good agreement between blood and
interstitial glucose concentrations (mean difference, 0.0 mmol/L; 95% CI, -1.1-1.1). Low glucose concentrations (<2.6 mmol/L)
were detected in 32 babies (32%) with blood sampling and in 45 babies (44%) with continuous monitoring. There were 265
episodes of low interstitial glucose concentrations, 215 (81%) of which were not detected with blood glucose measurement.
One hundred seven episodes in 34 babies lasted >30 minutes, 78 (73%) of which were not detected with blood glucose
measurement.
Conclusion: Continuous interstitial glucose monitoring detects many more episodes of low
glucose concentrations than blood glucose measurement. The physiological significance of these
previously undetected episodes is unknown.
52. Lancet 2013 Dec 21;382(9910):2077-83.
Dextrose Gel for Neonatal Hypoglycaemia (The Sugar Babies Study): A
Randomised, Double-Blind, Placebo-Controlled Trial
Deborah L Harris1, Philip J Weston2, Matthew Signal3, J Geoffrey Chase3, Jane E Harding4
Abstract
Background: Neonatal hypoglycaemia is common, and a preventable cause of brain damage. Dextrose gel is used to reverse
hypoglycaemia in individuals with diabetes; however, little evidence exists for its use in babies. We aimed to assess whether
treatment with dextrose gel was more effective than feeding alone for reversal of neonatal hypoglycaemia in at-risk babies.
Methods: We undertook a randomised, double-blind, placebo-controlled trial at a tertiary centre in New Zealand between Dec
1, 2008, and Nov 31, 2010. Babies aged 35-42 weeks' gestation, younger than 48-h-old, and at risk of hypoglycaemia were
randomly assigned (1:1), via computer-generated blocked randomisation, to 40% dextrose gel 200 mg/kg or placebo gel.
Randomisation was stratified by maternal diabetes and birthweight. Group allocation was concealed from clinicians, families, and
all study investigators. The primary outcome was treatment failure, defined as a blood glucose concentration of less than 2·6
mmol/L after two treatment attempts. Analysis was by intention to treat. The trial is registered with Australian New Zealand
Clinical Trials Registry, number ACTRN12608000623392.
Findings: Of 514 enrolled babies, 242 (47%) became hypoglycaemic and were randomised. Five babies were randomised in
error, leaving 237 for analysis: 118 (50%) in the dextrose group and 119 (50%) in the placebo group. Dextrose gel reduced the
frequency of treatment failure compared with placebo (16 [14%] vs 29 [24%]; relative risk 0·57, 95% CI 0·33-0·98; p=0·04). We
noted no serious adverse events. Three (3%) babies in the placebo group each had one blood glucose concentration of 0·9
mmol/L. No other adverse events took place.
Interpretation: Treatment with dextrose gel is inexpensive and simple to administer. Dextrose
gel should be considered for first-line treatment to manage hypoglycaemia in late preterm and
term babies in the first 48 h after birth.
54. Management of Resistant
Hypoglycemia
Hydrocortisone -5mg/kg/day BD IV
Diazoxide – 5-15mg/kg/day TDS PO
Octreotide -5-35mcg/kg/day TDS SC
Glucagon -0.2mg/kg SC/IM
Nifedepine
Sirolimus
Surgery
55. Neonatal Hypoglycemic Brain Injury
NHBI involves
particularly parieto-
occipital cortex and
subcortical white
matter
56. JAMA Pediatr. 2017 Oct; 171(10): 972–983.
Association of Neonatal Glycemia With Neurodevelopmental Outcomes at 4.5 Years
Christopher J. D. McKinlay, PhD,1,2 Jane M. Alsweiler, PhD,1,2 Nicola S. Anstice, PhD,3 et al1, for the Children With Hypoglycemia
and Their Later Development (CHYLD) Study Team
Abstract
Importance
Hypoglycemia is common during neonatal transition and may cause permanent neurological impairment, but optimal intervention thresholds are unknown.
Objective
To test the hypothesis that neurodevelopment at 4.5 years is related to the severity and frequency of neonatal hypoglycemia.
Design, Setting, and Participants
The Children With Hypoglycemia and Their Later Development (CHYLD) Study is a prospective cohort investigation of moderate to late preterm and term
infants born at risk of hypoglycemia. Clinicians were masked to neonatal interstitial glucose concentrations; outcome assessors were masked to neonatal
glycemic status. The setting was a regional perinatal center in Hamilton, New Zealand. The study was conducted from December 2006 to November 2010.
The dates of the follow-up were September 2011 to June 2015. Participants were 614 neonates born from 32 weeks’ gestation with at
least 1 risk factor for hypoglycemia, including diabetic mother, preterm, small, large, or acute illness. Blood and masked interstitial
glucose concentrations were measured for up to 7 days after birth. Infants with hypoglycemia (whole-blood glucose concentration <47 mg/dL) were treated to maintain blood glucose
concentration of at least 47 mg/dL.
Exposures
Neonatal hypoglycemic episode, defined as at least 1 consecutive blood glucose concentration less than 47 mg/dL, a
severe episode (<36 mg/dL), or recurrent (≥3 episodes). An interstitial episode was defined as an interstitial glucose
concentration less than 47 mg/dL for at least 10 minutes.
Main Outcomes and Measures
Cognitive function, executive function, visual function, and motor function were assessed at 4.5 years. The primary outcome was neurosensory impairment, defined as poor performance in one
or more domains.
Results
In total, 477 of 604 eligible children (79.0%) were assessed. Their mean (SD) age at the time of assessment was 4.5 (0.1) years, and 228 (47.8%) were female. Those exposed to neonatal
hypoglycemia (280 [58.7%]) did not have increased risk of neurosensory impairment (risk difference [RD], 0.01; 95% CI, −0.07 to 0.10 and risk ratio [RR], 0.96; 95% CI, 0.77 to 1.21). However,
hypoglycemia was associated with increased risk of low executive function (RD, 0.05; 95% CI, 0.01 to 0.10 and RR, 2.32; 95% CI, 1.17 to 4.59) and visual motor function (RD, 0.03; 95% CI, 0.01
to 0.06 and RR, 3.67; 95% CI, 1.15 to 11.69), with highest risk in children exposed to severe, recurrent, or clinically undetected (interstitial episodes only) hypoglycemia.
Conclusions and Relevance
Neonatal hypoglycemia was not associated with increased risk of combined neurosensory impairment at 4.5 years but was
associated with a dose-dependent increased risk of poor executive function and visual motor function, even if not detected
clinically, and may thus influence later learning. Randomized trials are needed to determine optimal screening and intervention
thresholds based on assessment of neurodevelopment at least to school age.
57. TAKE HOME MESSAGES
Late preterms experience temperature instability and
hypoglycemia mostly in initial 48 hrs.
Ineffective thermoregulation in the late preterm infant
predisposes the infant to significant complications.
Encourage early breast feeding within 1hr of birth and
screen for hypoglycemia for 48hrs-72hrs.
Early recognition and management prevent short and
long term morbidity and mortality.
Need to create awareness among health care
providers.
59. Jaundice and dehydration in
late preterm neonates
Dr. Nandini Nagar
Consultant neonatologist and pediatrician
Cloudnine hospital, Jayanagar, Bangalore
60. Why worry about jaundice in late
preterm neonates?
Bilirubin levels in late preterm neonates peaks later (at 7 days rather than 5 days)
Stays elevated longer
Reacher higher mean levels as compared to term neonates (207 micromol/L vs 190
micromol/L)
Risk of BIND is higher at lower levels of serum bilirubin as compared to term neonates
Risk of BIND doubles for every week below 37 weeks
Exclusive breastfeeding increases the risk of extreme hyperbilirubinemia (428
micromol/L) by a factor of 6
Safe discharge of the late preterm infant. R K Whyte, Canadian Pediatric Society, Fetus and Newborn
Committee. Pediatr Child Health.2010 Dec; 15(10):655-660
61. Feeding difficulties in late
preterm - dehydration
Late preterm babies adapt quickly to enteral feeds
BUT
Deglutition, peristaltic function and sphincter function may be immature
in the esophagus, stomach and intestines
Lead to poor coordination of sucking and swallowing
Delay in establishment of breast feeding
Excessive weight loss/poor weight gain in the first week - dehydration
62. Comparison of short-term
outcomes
Jaundice requiring phototherapy (18% in late preterm vs 2.5% in term)
Hypoglycemia (6.8% vs 0.4%)
Respiratory distress (4.2% vs 0.1%)
Sepsis (0.4% vs 0.04%)
IVH (0.2% vs 0.02%)
Short-term neonatal outcome in low-risk, spontaneous, singleton, late preterm deliveries. Melamed N,
et al. Obstet Gynecol. 2009; 114 (2 Pt 1): 253
63. Increased risk of
jaundice and BIND
Decreased capacity to handle
unconjugated bilirubin
Decreased hepatic uptake
Decreased uridine
diphosphoglucuronate glucuronosyl
transferase (UGT) activity
Increased enterohepatic circulation
Delayed postnatal maturation of
hepatic bilirubin uptake and
conjugation
Delayed establishment of enteral
feeding
66. BIND
pontine brainstem
oculomotor nuclei
globus pallidus
auditory pathways
Hippocampus
Diencephalon
subthalamic nuclei
Cerebellum
vermis
- disordered visual gaze (eg,
limitations of upward gaze)
- sensorineural hearing
impairment gait abnormalities
(choreoathetoid cerebral palsy)
- speech and language disorders
- Subtle neuromotor signs are
associated with a range of
processing disorders due to
visuo-oculomotor, auditory,
speech, and expressive language
disturbances
67. MRI brain changes
MRI brain
imaging shows
hyperintense
signals in T1
weighted
sequences in
the globus
pallidus, that
then shifts to
bilateral
hyperintense
69. predisposed to
significant
hyperbilirubinemia
and other morbidity
LAMBS study (Elaine M Boyle et al, ADC, 2015) – Neonatal outcomes and delivery of
care for infants born late preterm or moderately preterm: a prospective population-
based study
Tonse Raju et al, Pediatrics, 2006 – Optimising care and outcome for late preterm
(near-term) infants: A summary of the workshop sponsored by the NICHHD
Tonse Raju, Pediatrics, 2017 – The “Late Preterm” Birth – Ten Years Later (under
Pediatric perspectives)
Kumar C et al, J neonatal biology, 2014 – Late Preterm and Early Term Neonates: A
New group of high-risk newborn in neonatology with varied complications
70. Incidence, course and prediction of
significant hyperbilirubinemia (study
from Turkey)
219 term and 146 near term newborns
6th hour and daily bilirubin checked until day 7
Late preterms had a 2.4-fold higher risk of developing significant
hyperbilirubinemia
Day 5 and day 7 serum bilirubin levels were significantly higher in the near-term
group
Incidence, course and prediction of hyperbilirubinemia in near-term and term newborns. Sarici SU, et
al. Pediatrics. 2004; 113(4):775
71.
72. - Prospective cohort study including neonates
>35 weeks gestation over a period of 6 months
from Mar to Aug in 2011
- Risk factors for significant hyperbilirubinemia
were identified and serum bilirubin was tested at
36 – 48 hours of age, before discharge
- Excluded – NICU admission for any acute
illness, Blood group incompatibility, congenital
anomalies, those who received IV antibiotics
- 486 infants were included in the final analysis,
of which 14% developed significant
hyperbilirubinemia
73. On univariate analysis, serum total bilirubin, gestational age and percentage of weight
loss were predictive of significant hyperbilirubinemia
On multiple logistic regression, pre-discharge bilirubin had better predictive ability than
GA and % of weight loss
Most of the late preterms who had jaundice had significant hyperbilirubinemia, and it
was statistically significant
77. Indications to treat in late
preterms without risk factors
Phototherapy
indications
24 hours of age: >10 mg/dl (171
micromol/L)
48 hours of age: >13 mg/dl (222
micromol/L)
72 hours of age: >15 mg/dl (257
micromol/L)
Exchange transfusion
indications
24 hours of age: >16.5 mg/dl (282
micromol/L)
48 hours of age: >19 mg/dl (325 micromol/L)
>72 hours of age: >21 mg/dl (359
micromol/L)
Courtesy: UptoDate
78. Indications to treat in late
preterms with risk factors
Phototherapy indications
24 hours of age: >8 mg/dl (137
micromol/L)
48 hours of age: >11 mg/dl (188
micromol/L)
72 hours of age: >13.5 mg/dl (231
micromol/L)
Exchange transfusion
indications
24 hours of age: >15 mg/dl (257
micromol/L)
48 hours of age: >17 mg/dl (291
micromol/L)
>72 hours of age: >18.5 mg/dl (316
micromol/L)
Courtesy: UptoDate
79. Phototherapy
Exposure to light of wavelength 425 – 475 nm
Mechanisms of action: Structural isomerization of bilirubin to lumirubin
(major), photo-oxidation to polar molecules, photoisomerization to a less
toxic bilirubin isomer
Results in a decline in bilirubin by 2 – 3 mg/dl within 4 – 6 hours
Greater the spectral power (irradiance X BSA), faster the drop in bilirubin
Irradiance of white lights is 8 – 10 microW/cm2/nm, and that of blue LED
lights is 30 - 35 microW/cm2/nm
80. Monitoring during and after
phototherapy
Feeding – breast feeding, EBM, donor
milk, formula
Continuous NG feeds
Hydration status, urine output
Temperature – LED lights do not
cause much overheating
Fibre-optic biliblanket can be used
during feeding, or in conjunction with
LED lights
Rebound hyperbilirubinemia
81.
82.
83. Double volume exchange
transfusion
Very rarely performed nowadays
In a tertiary care NICU with facilities for central
line insertion and ventilation
Whole blood required, or red cells of maternal
blood group reconstituted with plasma (or O
negative red cells with AB negative plasma)
Crossmatched, irradiated blood that is negative
for all known microorganisms like CMV, HIV, Hep
B and C, and syphilis
Central lines, preferably UVC, UAC or UVC alone
5 – 10 ml aliquots
SBR falls to ½ to ¾ of the pre-exchange value
84. IVIG
In infants with Rh isoimmune hemolytic disease, in whom SBR is rising despite
phototherapy, or is within 2 – 3 gm/dL of the threshold for exchange transfusion
Dose – 0.5 to 1 gm/kg over 2 hours
Can be repeated if indicated after 12 hours
85. Hearing
screening
Hearing screening preferably using BERA is
necessary for neonates that have been treated
for significant hyperbilirubinemia, as it can lead
to sensorineural hearing loss.
86. Key points
Late preterm neonates are at a higher risk of
delayed establishment of enteral feeding and
dehydration
Greater risk of significant hyperbilirubinemia and
BIND
Support early breast feeding, lactation nurses to
help
Have a low threshold for EBM, donor milk,
formula
Fortify EBM
Continuous NG feeds is a good option if there’s
excessive weight loss and jaundice
Delay discharge from hospital
87. Thank You
BENGALURU CHENNAI MUMBAI
PUNE
GURUGRAM NAVI MUMBAI CHANDIGARH NOIDA
Our Locations
Website
http://cloudninecare.com/
89. Feeding- Hypothetical case
34 week old LSCS for PIH 1.6 kg mild respiratory
distress. Normal Doppler's
How many would start on D10 or TPN with as initial
fluid.
How many would wait for Mother’s milk, for how long.
Would you commence on NG or direct breast feeds
as distress resolves?
90. Feeding- Hypothetical case
This we are considering as a singleton.
Gets compounded when you consider Twins and
Triplets
The majority of them would not go to term, and are
born around 32-36 weeks for various reasons
91. Feeding
Preterm infants have functional taste receptors from
18 weeks’ gestation and flavors perception from
around 24 weeks’ gestation This may be bypassed by
the NG route
Suck swallow and breathing coordination- 33-34
weeks
92. Feeding: Energy requirement
Dextrose Vs PN
IV Infusions-27% of LP infants vs 5% of term , very
few LP and ET babies will receive parenteral nutrition
support^
PN Vs 10% dextrose in LP infants while waiting for
maternal milk supply to meet demand and for full
enteral feeds to be tolerated *
Each day of parenteral support in LP infants has been
reported to predict an increase in time to achieve full
oral feeds of 2 h (hazard ratio: 0.92; 95% CI: 0.89–
0.95).
^Wang ML, Dorer DJ, Fleming MP, Catlin EA. Clinical
outcomes of near-term infants. Pediatrics 2004;114:372–6.
*Alexander T, Bloomfield FH. Nutritional management of moderate–late
preterm infants: survey of current practice. J Paediatr Child Health 2018 Aug
27. https:// doi.org/10.1111/jpc.14201.
93. Feeding: Which milk?
Breast milk
Donor Breast milk
Formula??
Encourage early BF- within the first hour if possible
Encourage Kangaroo Mother care, stimulation of milk
production through regular expressing
94. Feeding : Problems
HYPOGLYCEMIA – is one of the commonest reasons for
additional nutritional support in LP infants.
3-4 x higher than term babies and recurrent
50% of hepatic glycogen stores, a key source of glucose
in the immediate newborn period, are deposited between
36 and 40 weeks gestation- which these babies lack!
HYPERNATREMIA-
More common in LP than term babies for the same
reasons, associated with wt loss and feeding difficulties.
Need to be managed appropriately as discussed
96. FLAMINGO study
“Feeding in Late And Moderately preterm Infants
Nutrition and Growth Outcomes (FLAMINGO): a cohort
study with an embedded RCT, double-blind trial in
formula-fed infants to investigate the effects of a new
infant formula on growth and body composition.”
140 subjects in the RCT, with an anticipated 250 subjects
in the cohort study. Each subject will be included from
randomisation until study end for a maximum of 25
months, comprising of a 6-7 month intervention period in
the RCT and a follow up period until a corrected age of
24 months of age. Recruitment is expected to be
completed in April 2022.
Aim to see if early provision of a different formula makes
a difference to these babies Supported by Danone / Nutricia
97. Feeding: ESPGHaN
Recommendations
Breast feed &
support
Hypoglycemia
IVF/ TPN
Robust
Unit
Policies Rooming in
/care
Temp control/
BEMPU
Discharge
policies- May
need to be
individualised
Further
98. Feeding: Vitamins/ Minerals
AAP/ ESPGHAN Recommendations
Fe for six months
Vit D through early childhood
• MULTIVITS
• CALCIUM
PHOSPHATE
• Vit D
At full feeds/
2 weeks
•IRON
At 4-6 weeks
• FORTIFIERS
esp <1500g
For adequate
calories
99. Brain growth and development
Occurs in very specific orders and time frames.
It also occurs at different rates during different gestational ages,
which creates critical periods of development during which
cells are susceptible to insults or injuries.
Injury in critical period of growth and differentiation can change
the trajectory of brain development, resulting in different
patterns of brain injury and repair which manifest as
unique neurologic outcomes.
Brain growth has been shown to be altered simply by being
born preterm, as evidenced by studies showing differences in
magnetic resonance imaging (MRI) between late preterm and
FTI* .
*Walsh JM, Doyle LW, Anderson PJ, et al. Moderate and late preterm birth: effect on
brain size and maturation at term-equivalent age. Radiology 2014;273:232–40.
100. Brain growth and development
The late preterm brain is still
immature and more likely to
experience noxious stimuli from
medical complications after birth
such as RDS, sugars,apneas
hyperbilirubinemia etc
Evidence from animal models
reveals that these factors can
promote or precipitate neuronal cell
death in the immature brain*. There
is some evidence that it is unable to
defend against such toxicities.
*Bhutta AT, Anand KJ. Abnormal cognition and behavior in preterm neonates
linked
101. MRI*
38-44 week
Measures of brain size, BPD, and other brain structures
such as the deep grey nuclei, cerebellum, and corpus
callosum were smaller in MLPT infants than in full-term
infants
Measures of the extra-axial spaces, namely
interhemispheric distance and superior extra-axial distance,
were significantly larger in MLPT infants than in control
infants (P , .001), suggesting the presence of larger
cerebrospinal fluid volumes in MLPT infants.
With regard to brain maturation, MLPT infants had less
mature gyral folding and less complete myelination of the
posterior limb of the internal capsule at term-equivalent
age.
*Walsh JM, Doyle LW, Anderson PJ, et al. Moderate and late preterm birth: effect on
brain size and maturation at term-equivalent age. Radiology 2014;273:232–40.
102. MRI*
38-44 week
*Walsh JM, Doyle LW, Anderson PJ, et al. Moderate and late preterm birth: effect on
brain size and maturation at term-equivalent age. Radiology 2014;273:232–40.
103. MRI*
38-44 week
*Walsh JM, Doyle LW, Anderson PJ, et al. Moderate and late preterm birth: effect on
brain size and maturation at term-equivalent age. Radiology 2014;273:232–40.
104. neurodevelopment
36%
• Dev delay
• Disability
50%
• Risk of SEN
in school
10 x
• As many
children than
EPT
Compared to Full term Infants
105. Early outcomes
@ CGA 2 yrs
Compared to FTI, LPI performed worse in cognitive,
language, and motor domains, with greatest disparity
in the language domain. They also showed evidence
of poorer social–emotional competence.
Remain at a greater risk of Speech and Language
delay
Generally LPI do not automatically qualify for early
intervention
Many researchers have hypothesized that the worse
neurodevelopmental outcomes of LPI may have to do
with their more complicated medical courses
compared to FTI.
106. SCHOOL AGE outcomes
LPI scored lower in reading in kindergarten and first
grade.
Children delivered late preterm had a 30% higher
adjusted odds of needing special and individualised
education plan than those born full term.
Low IQs, Language skills.
Less attention span
107. ADOLESCENT AND ADULT
outcomes
Mainly from Sweden, Denmark – 25-50 yrs
old
Difficult to extrapolate considering the leaping
advances of neonatology in those years.
108. Neurodev-Unanswered queries
Are delays time
bound or
permanent
Is there an
opportunity to
intervene for
better outcomes.
Which LPIs are at
highest risk
Are there specific
delays that are
common or are
they global
109. General Measures in Improving
Neurodevelopment in the preterm
Design of space with room for KMC
Light – have a dark or QUIET TIME / no
procedure time
Sound- Speak in low tone. Alarms, telephone
tones, creaky cupboards / Incubator pots and
doors/to be adjusted to minimise sund.
Activity level- Maintain Calm, quite and soothing
atmosphere
Olfactory inputs- remove noxious and unfamiliar
senses- spray/ nicotine / scents
110. General Measures in Improving
Neurodevelopment in the preterm
Bed / Clothes- Nesting/ swaddling.
Positioning- support and facilitate physiologically
well-aligned positions whether the infant is on the
back, tummy or side.
Feeding and Burping- From early on time the
infant’s feeding to be supportive of the infant’s
sleep and wake cycles so that the infant may
learn to recognize feelings of hunger and
satiation. Support the parent to breastfeed the
infant.
Bloods- Sucrose / breast feeding
Medical equipments- tapes/ NG/ Nasal canula to
111. Issues in LPT
Short Term Morbidities
Health Care Costs
Hospital Stays
Re-Hospitalization
112. DISCHARGE CRITERIA
Vital signs normal for 12hrs before discharge
Passage of 1 stool spontaneously
Adequate urine output
24 hours of successful breast feeding
If wt loss >7% in 48hr- further assessment before
discharge
Risk assessment plan for jaundice for infants
discharged within 72hr of birth
Mother & caregivers demonstrate competency in
care of the infant
114. How do Antenatal Steroids Work?
Science
Accelerate development of pneumocytes, thus improving lung
mechanics (maximal lung volume, compliance) and gas
exchange
Increases surfactant production
Induction of surfactant release, absorption of alveolar fluid,
increase lung antioxidant enzymes
Reduction in RDS, moderate to severe RDS
Reduction in Intraventricular hemorrhage, Necrotising
enterocolitis, mortality, systemic sepsis
115. LPT – Way Forward !
‘Evidence Based’ Practice Guidelines
Accurate Dating – Pregnancy, Fetal Maturity
Antenatal Steroids – Extended use ( NNT-35)
Editor's Notes
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.
Although survival of MLPT babies is excellent, these babies constitute a much larger proportion of the health care burden related to prematurity than do extremely preterm babies
Nutritional guidelines and requirements for late or moderately preterm (LMPT) infants are notably absent although they represent the largest population of preterm infants.
Although survival of MLPT babies is excellent, these babies constitute a much larger proportion of the health care burden related to prematurity than do extremely preterm babies
If you say one thing and you colleague says anything else, you are not alone. These differences are seen world wide, with physicians commencing on Iv fluids, gradually increasing the NG feeds and then to oral feeds in varying combinations depending on the baby’s clinical condition.
Whilst waiting for full milk feeds to be tolerated, there are no data on whether the provision of dextrose alone is sufficient, despite the inevitable catabolism and accumulating nitrogen deficit , or whether babies should receive parenteral nutrition containing protein. All of these approaches are in use around the world.
These difficulties in feeding delay their discharge from the hospital.
What the parents see is a well formed baby with beautiful 10 tiny fingers and toes, rosy cheeks and a normally breathing baby- they want to go home! And that is despite you spending time with them explaining issues related to feeding.
Most nutrition guidelines provide recommendations for more preterm (< 32/40) or very low birth weight neonates (< 1500 g) but few provide nutritional recommendations for LP and ET babies !! There is little evidence regarding whether PN is more beneficial than 10% dextrose in LP infants while waiting for maternal milk supply to meet demand and for full enteral feeds to be tolerated but its use in LP infants appears to be rare *
MLPT babies inevitably experience a delay between birth and the establishment of full enteral feeds due to immature suck/swallow/breathe coordination, immature gut motility, and delayed supply of sufficient breastmilk.
In absence of breast feeds they can be offred feeds via palada/ cup to help with suck/ swallow coordination.
These infants are also prone to develop nutritionally related neonatal morbidities such as hypoglycaemia, poor feeding, dehydration and malnutrition in the early neonatal period
In utero, there’s a constant supply of glucose which is abruptly halted when the cord is cut.
Compared with their term-born peers, it observed that infants born LMPT were at increased risk of oral motor problems, such as chewing, biting, and swallowing, and refusal/picky eating, such as selective eating, eating too little or too slowly, or having a poor appetite at 2 y corrected age.
Mothers of LMPT preterm infants should receive qualified, extended lactation support, and frequent follow-up. Health care providers should remain vigilant for evidence of poor breast milk transfer and
infant problems related to poor intake.
Individual feeding plans should also include special considerations to compensate for immature feeding skills and difficulties in establishing lactation and breastfeeding.
Iron- <2500 g - 1 to 2 mg/kg/d & < 2000 g should receive 2 to 3 mg/kg/d - up to 6 months age.
LMPT infants require a daily vitamin D supplement of at least 400 IU/d throughout early childhood.
Most of the research into brain sequelae of preterm birth has been in children and young adults born very preterm (ie, , 32 weeks of gestation at birth) yet the burden of prematurity is mostly in moderate and late preterm (MLPT) infants (those born with ges- tational ages between 32 weeks and zero days and 36 weeks and 6 days), who account for approximately 80% of all preterm births (3,4).
This demonstrates that LPI have academic challenges that persist through elementary school.