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PPC3 Exam 1 > Premature Infant 1 > Flashcards

Premature Infant 1 Flashcards

1
Q

LBW, VLBW, ELBW

A

LBW: <2500 grams

VLBW: <1500 grams

ELBW: <1000 grams

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2
Q

Early term vs. Late preterm

A

Early term: 37-38 6/7 weeks

Late preterm: 34 to 36 weeks and 6 days

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3
Q

Growth charts (4)

A
  1. Up to 36 weeks gestation
    a. The Olsen and Bertino charts are the best growth charts to assess appropriate all GAs
    i. Primarily used in the NICU up to 15 weeks
  2. Between 36 to 50 weeks corrected age (10 weeks post-term), the Fenton chart is the best growth chart to assess longitudinal growth in preterm infants over this period
  3. After four to eight weeks post-term, the World Health Organization (WHO) growth charts for normal children can be used.
  4. Fenton Growth Chart
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4
Q

Neonatal Outcome Predictors

A

Put in various facts about a child’s delivery (BW, weeks gestation, etc) and it discusses the % of problems the child may have; both the morbidity and mortality

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5
Q

Gestational Age (2)

A
  1. Gestational age: Estimated time since conception
  2. Corrected age=age corrected for prematurity
    a. Take gestational age (# of weeks in utero)
    i. Born at 31 weeks and seeing him at 4 months = 2 months
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6
Q

Initial management of preterm infant (6)

A
  1. Establish gestational age
  2. Skin to skin contact if stable
  3. Newborns get assessed every 30 minutes until stable for 2 hours and then q 4 hours for the first 24 hours
  4. Support skin to skin contact
  5. Use New Ballard Scale
  6. Plot measurement and determine if SGA, AGA, or LGA
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7
Q

Risks of late preterm infants (7)

A
  1. Respiratory distress
  2. Hypothermia
  3. Sepsis
  4. Hypoglycemia
  5. Feeding difficulties and dehydration
    a. No weight loss of more than 3% per day or 7% by day 7
  6. Hyperbilirubinemia
  7. Developmental, learning, and behavioral challenges
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8
Q

Hospital care (6)

A
  1. Continual Assessment
  2. Newborn screening
    a. 24 hours after feeding
    b. Repeat if done earlier
    c. Assessment for congenital cardiac anomalies with pulse ox assessment
    d. Hearing screening
  3. Review maternal information
  4. Give written material
  5. Automatically get early intervention referral for primary care
  6. Mother’s should be followed for post partum depression
    a. A lot of guilt associated with not having full term baby
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9
Q

When is the baby ready to transition to home care? (6)

A
  1. Stable for 24 hours
  2. No significant emesis
  3. Adequate voiding
  4. At least one stool in 24 hours
  5. No signs of sepsis
  6. Successful feeding for 24 hours without weight loss
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10
Q

When should the first visit in the office occur? (4)

A
  1. Within 2 -4 days following discharge
  2. Subsequent visits vary
  3. More frequent visits for high-risk families-Consider VNS
  4. More to monitor
    a. Bilirubin
    b. Parent’s understanding of feeding plan
    c. Post circumcision care
    d. Developmental care
    i. Protection from overstimulation
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11
Q

First Visit (8)

A
  1. Read through discharge summary
  2. Adaptation to home environment
  3. Parental adjustment
  4. Establish relationship with parent
  5. Reassurance
  6. Get to know the infant well
  7. Advise vitamin D 400 units for all breast feeding infants
  8. Give supplemental iron for newborns
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12
Q

Overstimulation in a preterm infant: cues (9)

A
  1. Limb extension with fingers or toes splaying
  2. Twitches or startles
  3. Arching or limp
  4. Facial grimaces
    a. Jerks similar to seizures
    b. More prone to having seizures due to immature CNS
  5. Abrupt color change
  6. Gaze aversion
  7. Cortical thumb fisting
  8. Irregular breathing
  9. Crying
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13
Q

Assess Safety Risks: Home (7)

A
  1. Drugs or alcohol
  2. Smokers
  3. Domestic violence
  4. Mental health issues
  5. Social service involvement
  6. Screen for maternal mood disorder
  7. Safe sleep practices
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14
Q

Other safety risks to assess for (6)

A
  1. Assess for parent’s knowledge of when to call 911
  2. Infections and immunizations
  3. Provide information about shaken baby syndrome
  4. Coping with crying
  5. Car seat safety
    i. Most NICUs will do car seat safety check
  6. Family support
    i. Refer to VNS, WIC, lactation support, social services
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15
Q

Immunizations: General (4)

A
  1. AAP recommends immunizations according to chronological age
  2. Rotavirus must be given between 6 weeks and 14 weeks and 6 days
  3. Hepatitis B: after 2.0 kg—get at discharge or after one month of age
    a. Within first 24 hours, all baby’s should receive HepB vaccine
  4. Cocooning around the infant
    a. Pertussis immunization
    i. Any care taker must have pertussis vaccine
    b. Influenza immunizations
    i. Anyone that comes into contact with baby must have flu vaccine
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16
Q

Synagis (Palivizumab) (3)

A
  1. 15mg/kg monthly—100 mg vials-up to 5 doses
  2. All infants < 29 weeks gestational age at birth
  3. All infants less than 32 weeks gestational age
    i. Chronic lung disease of prematurity (defined as 21% oxygen for at least 28 days after birth
    ii. Infants with hemodynamically significant heart disease
17
Q

RSV Monoclonal Antibody (3)

A
  1. Infants in which palivizumab should be considers
    i. Pulmonary abnormality
    ii. Neuromuscular disability with inability to clear secretions in lower airway
    iii. Children < two years of age that are immunocompromised
  2. Infants who may need palivizumab until 2nd year
    i. Supplemental oxygen in the first 28 days and continue to require medical intervention
  3. 15 mg/kg intramuscularly in anterolateral thigh—November to April
18
Q

Premie Energy Requirements (6)

A
  1. Higher need in preterm infants due to comorbidities such as BPD
    a. If they are breathing more quickly then they require more calories
  2. 105 to 130 kcal/kg/day
    a. Some of these infants require 180kcal/kg/day due to work of breathing
  3. Breast milk fortifiers used for preterm infants
  4. Preterm transition formula 22cal/oz.
    a. Neosure/Enfacare 22 cal/oz formula
    i. Regular formula is 20cal/oz
  5. Keep until 1 year of life adjusted age
  6. No soy due to low phosphate and risks associated with metabolic bone disease
    a. Cannot have soy formulas!
19
Q

Growth (5)

A
  1. Daily weight gain of 15-20 gm./day
  2. Length by 1.1 cm per week until term then .75 cm for 3 months, down to .5 from 3-6 months
  3. Head circumference: .5 cm week until 3 months
  4. .25 cm from 3-6 months
  5. 1.25 cm/week or more: hydrocephalus
    a. Will need neurology referral
20
Q

Vitamin D requirements (5)

A
  1. Prohormone essential for normal absorption of Calcium from gut
  2. Rickets if deficient
  3. Dark skinned infants who are breastfed and infants born to mom who are vitamin D
  4. 400 units per day if >1500 gm
  5. 200 units per day if < 1500 gm
21
Q

High risk for rickets (7)

A
  1. Born at <27 weeks gestation
  2. Birth weight <1000 grams
  3. Severe bronchopulmonary dysplasia with use of loop diuretics (eg: furosemide) and fluid restriction
  4. Long-term steroid use
  5. History of necrotizing enterocolitis
  6. Failure to tolerate formulas or human milk fortifiers with high mineral content
22
Q

Symptoms of Rickets (12)

A
  1. Irritability
  2. Delay in gross motor development and bone pain
  3. Widening of the wrists and ankles
  4. Genu varum or valgum
  5. Prominence of the costochondral junction (rachitic rosary)**
  6. Delayed closure of the fontanelles
  7. Craniotabes
  8. Frontal bossing
  9. Dental eruption delay –
    Dental hypoplasia
  10. Poor quality dental enamel
  11. Poor growth
  12. Increased susceptibility to infections
23
Q

Screening for Vitamin D deficiency (3)

A
  1. Alkaline phosphatase can be used as screen as it will be markedly elevated
    a. >1000 but can be 800 to 1000
  2. Screening the serum APA and serum phosphorus at 4 to 6 weeks after birth in VLBW infants followed by biweekly monitoring is appropriate.
  3. Typically, the APA will peak at 400 to 800 IU/L and then decrease in VLBW infants who do not develop rickets.
24
Q

Nutritional Needs of Premature Infants (4)

A
  1. If CLD needs high concentrate formula— can’t tolerate volume.
    a. Concentrated formula can cause diarrhea though
  2. Daily multivitamins .5 to 1.0 ml until taking (750ml) or 25 ounces per day or until body weight is 3.5 to 4.0 kg
  3. Vitamin D: 400 IU per day if over 1500gm
  4. Iron supplement: 2 mg/kg/day in breast feed infant receiving unfortified human milk up until age 12 months**
    a. Iron stores are done in third trimester and iron is critical to brain growth so they need supplementation
25
Q

Calcium and Vitamin D in Premature Infant (4)

A
  1. Biochemical monitoring of very low birth weight infants in hospitalization.
  2. Vitamin D should be provided at 200 to
  3. 400 IU/day both during hospitalization and after discharge from the hospital.
  4. Infants with radiologic evidence of rickets should have efforts made to maximize calcium and phosphorus intake by using available commercial products
26
Q

Risk factors for Rickets (8)

A
  1. Born at less than 27 weeks gestation
  2. Birth weight under 1000 gm
  3. Long term parental nutrition
  4. Bronchopulmonary dysplasia with loop diuretic and fluid restriction
  5. Long term steroid use
  6. History of NEC
  7. Failure to tolerate formula and fortifiers with high mineral content
  8. Risk For Rickets:
    a. 10% to 20% of hospitalized infants with birth weight <1000 g have radiographically defined rickets (metaphyseal changes) despite current nutritional practices
    b. Rickets is defined by radiographic findings, not by any biochemical findings.
    i. Was 50% prior to use of milk fortifiers and changes in composition of formula
27
Q

Risk factors for low bone mass (4)

A
  1. Significant decrease in height during the prepubertal years of former very low birth
  2. Weight (VLBW) infants exposed to dexamethasone for the treatment of bronchopulmonary dysplasia
  3. Dalziel et al. demonstrated that prenatal steroid use did not affect peak bone mass.
  4. Slower fetal growth, rather than preterm birth, predicted lower peak bone mass
28
Q

Management of Preterm Infant and Calcium and Vitamin D

A
  1. In infants who weight less than 1800 to 2000 gm, they must have fortifiers for breast milk or pretermformula
  2. If rickets develops, must have X-ray every 5-6 weeks until resolved
  3. Monitor alkaline phosphatase weekly or biweekly
  4. Handle infant gently!
29
Q

Growth in VLBW Infants: AGA Infants (2)

A
  1. Will grow normal or faster rate –> Higher rate of obesity later in life
  2. Take longer to catch up
    a. 24 months for weight
    b. 18 months for head circumference
    c. Growth spurt at 38-48 weeks after conception
    d. Again at 6-9 months
    e. Most catch up by 2-3 years
30
Q

Feeding problems (5)

A
  1. Tonic bite reflex
  2. Tongue thrust
  3. Hyperactive gag reflex
  4. Oral hypersensitivity; From nasogastric or orogastric tubes
  5. Refer problems to speech therapy with specialty in oral motor problems or PT with similar interest
31
Q

Growth and feeding (3)

A
  1. Reassess at every visit in terms of need for supplement or fortification
  2. Start solids no earlier than six months
  3. If the infant is on formula, but not taking 800cc of formula a day, needs to supplement the infant with Vitamin D
32
Q

Breastfeeding <1500 grams (6)

A

Fortifier to add protein and minerals:

  1. Well tolerated
  2. 1.1 g protein/4 packets
  3. Added iron to reduce the need for additional iron supplementation
  4. Includes fat and essential fatty acids
  5. Low osmolality
  6. Iron 2 mg/kg/day
33
Q

Anemia of preterm infant (2)

A
  1. Worse at 4-8 weeks with hgb 7-10 g/dl
    * Regular term infants do this at 8 weeks, but premies do this much earlier*
  2. Expect to see Hgb at 9-10 and Hct at 27-30
    * This is a normal physiological drop of hct
34
Q

Anemia of preterm infant symptoms (7)

A
  1. Tachypnea
  2. Tachycardia
  3. Pallor; Look at conjunctiva, palms and color of lips
  4. Lethargy
  5. Apnea with bradycardia
  6. Poor feeding with weight loss
  7. Elevated lactic acid
35
Q

Anemia of preterm infant management (3)

A
  1. Iron fortified formula
  2. Supplemental iron
  3. Transfusion in extreme case
36
Q

Family Support (6)

A
  1. Higher rate of maternal depression
  2. Depressed mom more likely to have poor child developmental outcome
  3. Needs education and support
  4. Edinburgh Postpartum Depression Scale
    a. This must be done at every well-child visit up to 6 months of age
  5. Concept of chronic sorrow in mother’s of preterm infants with multiple problems
  6. Refer to early intervention—must follow up with family

PPC3 Exam 1 (13 decks)

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