Going home: Facilitating discharge of the preterm infant Flashcards
What percentage of preterm infants <37 weeks are discharged home directly from tertiary NICUs?
50%
What is prolonged hospitalization associated with?
- Poor parent-child relationships
- Failure to thrive
- Child abuse
- Parental grief
- Feelings of inadequacy in parents
What is the usual GA at discharge for infants born at <34 weeks GA?
37-40 weeks GA
What are the four physiological competencies required for discharge?
- Thermoregulation
- Control of breathing
- Respiratory stability
- Feeding skills and weight gain
What is a risk of overheating?
SIDS
Does transfer to a cot before 1700g have an adverse effect on temperature stability or weight gain?
No
What is apnea of prematurity?
Cessation of breathing for >20s or 10-20s if accompanied by bradycardia (HR <80bpm) or oxygen saturation <80% in infants <37 weeks PMA
How late can apnea of prematurity persist until?
44 weeks PMA
What is the half life of caffeine in neonates?
100h
When is home cardiorespiratory monitoring occasionally considered?
Infants with unusually prolonged and recurrent apnea, bradycardia, and hypoxemia
What are risk factors for recurrence of apneas of prematurity?
<30 weeks GA
Last spell occurred at > 36 weeks PMA
At what time period from the last spell did 96% of preterm infants not experience recurrence of apnea or bradycardia?
Seven days
Note that 13 days were required in infants <26 weeks GA
What percentage of surviving preterm infants with birthweights <1500g receive oxygen beyond 36 weeks PMA?
25%
What complications are associated with high oxygen targets (95-99%) in preterm infants vs. low targets (89-94%)?
- No difference in growth
- No difference in neurodevelopment
- Higher respiratory morbidity (pneumonia, acute exacerbations of CLD, rehospitalizations for pulmonary causes, need for diuretics, methylxanthines and/or oxygen)
- Longer duration of oxygen therapy
- Nonspecific reduction in progression to threshold ROP
- Modest decrease in retinal ablative therapy for severe ROP
What do most centres recommend as a target SaO2 for infants with BPD?
90-95%
What does offering non-nutritive sucking during gavage feeding do?
Significantly shorten LOS and facilitate transition from tube to oral feeding
How does supplementation with cup feeds affect discharge?
Increases the number of babies discharged home fully breastfeeding
Delays discharge by approximately 10 days
What additional nutritional support is required in preterm infants?
- May require hypercaloric feedings
- Iron supplementation for the first year of life
- Vitamin D 400-1000IU/day
What is the recommendations regarding GER?
Usually physiologic with minimal clinical consequences
What factor increase risk of neglect, FTT, and adverse developmental outcomes?
- Low educational level
- Poor SES
- Young maternal age
- Language barriers
- Inadequate housing
- Inadequate prenatal care
- Use of illicit substances or alcohol
- Depression
- Isolation
- Lack of family support
- Unstable parental relationships
- Infrequent family visiting during NICU stay
What should nurseries do re: parents of preterm infants?
- Educate parents about their infant
- Promote parental involvement
- Prepare parents for infant’s transition to home
What factors must be attained for physiologic maturity?
- Maintenance of normal body temperature (~37 degrees) when fully clothed in an open cot
- An apnea-free period of sufficient duration (at least 5-7 days suggested)
- Maintenance of SaO2 >90-95% on RA
- Sustained weight gain
- Successful feeding by breast and/or bottle without major cardiorespiratory compromise
What evaluations must be completed on the preterm infant prior to discharge?
- Provincial newborn screening
- Assessment for RSV prophylaxis and administration as indicated
- Cranial imaging at near term if indicated by GA
- ROP screening, if indicated by GA or BW
- Hearing screening
- Immunizations according to chronological age and provincial/territorial schedule
- Predischarge physical exam incld. wt, lt, HC
What should parents be able to do prior to discharge of a preterm infant?
- Independently and confidently care for their infants
- Provide medications, nutritional supplement, and any special medical care
- Recognize signs and symptoms of illness and respond appropriately, esp. in emergency situations
- Understand the importance of infection control and smoke-free environment
What follow-up should be arranged prior to discharge of a preterm infant?
- identification of and communicatio with the identified primary care MD and providing written or electronic summary of each infants’ birth history and care
- f/u by qualified HCP within 72h
- medical and surgical appointments as required, incld. ROP screening
- Neonatal neurodevelopmental f/u if indicated
- f/u of hearing and newborn screening results
- RSV prophylaxis, if required
- Community resources and supports
- A neonatologists or pediatricians advice and support to PCP as needed
