Premature Infant 2 Flashcards
Speech and Language (3)
- 20-40% premature infants have language deficits by 2 years
- Puts 2 words together by 2 year corrected age
- Speaks word that can be understood by stranger by 2.5 years
Developmental Screening (4)
- 9, 18, 30, 48 months of age
* *For muscular hypotonia** - MCHAT at 18 months and age 2
- Make referral to EIP as indicated
- Assess school readiness
Cognitive Outcomes (6)
- Deficit in visual motor and visual spatial skills
- Difficulty with self regulation or organization of sensory information
- Higher rate of attention problems
- Learning disabilities
- Hyperactivity, aggressiveness, depression and anxiety
- Much greater risk of seizures
Common medical problems (15)
- Risk of CP; CP can get better with age, around 7 years old
- Strabismus and amblyopia
- Retinopathy of prematurity
- Chronic Lung Disease: 17-54%; high rate of this
- Transient Tachypnea of the newborn
a. Common in late pre-term; generally not a problem - Acute respiratory infections
- Apnea of Prematurity (23%)
- Necrotizing enterocolitis
- GER
- IVH
- Anemia
- Patent ductus arteriosus
- Chronic cardiac insufficiency, cor pulmonale, or CHF
- Hernia
- Undescended testicles
physical assessment of the throat
evaluate suck-swallow, tongue thrust, oral aversion, uvula movement, hyper-hypoactive gag reflex
physical assessment of respiratory tract
a. Rate and retractions
b. Stridor
c. Monitor closely for RSV—wheezing
physical assessment of neck and shoulder
Poor head control, tight scarf sign, difficulty bringing hands to midlines
physical assessment of trunk
a. Arching
b. Decreased range of motion
c. Hypotonia
Physical assessment of extremities (7)
- Hypo/hypertonia
- Passive tone
- Hand to mouth coordination
- Hyperreflexia: how to test
- Clonus
i. Watch for clonus at heel - Testing for Babinski to avoid plantar, gait
- Stress gait by putting penny on nose
i. Will stress trying to keep penny on nose (2-3 y/o)
* Subtle weaknesses as they grow
* Hemiparesis is common
Types of Brain Injury in the Premature Infant (3)
- Periventricular Leukomalacia (PVL)
* #1 cause of cerebral palsy - Intraventricular Hemorrhage (IVH)
* Related to infarctions - Periventricular Hemorrhagic (Infarct PVHI)
* Related to infarctions
Periventricular Leukomalacia (8)
- Necrosis of white matter in the brain.
- It effects 4-15% of VLBW babies
- Most common ischemic brain injury in premature infants
- Watershed injury to periventricular area due to a vascular insult
- 4-26% of preemie with most common in infants <32 weeks or < 1500 gm
- Cerebral palsy with spastic diplegia
a. Most common form
b. With CP, can have normal mental functions/intelligence - Quadriplegia associated with severe PVL
a. Visual impairment
b. Intellectual/developmental impairment - Diagnosis: MRI of brain
Intraventricular Hemorrhage (3)
- Usually occurs in infants < 32 weeks
- Complications of grade 3 to 4 IVH
a. Hydrocephalus
b. Seizures
c. Cerebral palsy
d. Cognitive, sensory, and language delay - May need VP shunt
Periventricular hemorrhagic infarction
Hemorrhagic necrosis of periventricular white matter
Cerebral palsy: overview
Chronic disability of central nervous system origin characterised by aberrant control of movement of posture, appearing early in life and not the result of progressive neurological disease.
This diseases are static and may in fact get better
Not a disease that gets worse over time
Inborn errors of metabolism manifestations get worse over time though
Cerebral palsy: etiology (4)
- Prenatal (70%): Infection, anoxia, toxic, vascular, Rh disease, genetic, congenital malformation of brain
- Natal (5-10%): Anoxia, traumatic delivery, metabolic
- Post natal: Trauma, infection, toxic
- Most of these are in utero insults not related to poor delivery
Cerebral palsy: spastic rigidity
Upper motor neuron lesions; increase tone throughout range of movement
Cerebral palsy: hemiplegia, diplegia, paraplegia, quadriplegia, monoplegia
hemiplegia: one side of the body
diplegia: UMNL of all four limbs but legs more than arms. May be symmetric or asymmetric
paraplegia: one leg involement
quadriplegia: equal involvement of arms and legs
monoplegia: one limb
Cerebral palsy: dyskinesia
involuntary movements and changes in muscle tone. Damage to basal ganglia and extrapyramidal pathways
Cerebral palsy: athetosis
Slow writhing movements of limbs. Extension and fanning of fingers and extension of wrist
Cerebral palsy: chorea
Quick jerky movements of trunk and proximal limb muscles
Early sings of CP: Birth History (5)
a. Prematurity.
b. Seizures.
c. Low Apgar
d. Intracranial haemorrhage.
e. Periventricular leukomalacia.
Early signs of CP: other (6)
- Delayed Milestones
2 Abnormal Motor Performance
a. Handedness
i. Preferring one hand over another before age 2 **
b. Reptilian crawl.
i. If mother says baby isn’t crawling normally then it’s a sign of CP
- Toe waking.
- Altered Tone
a. Hypertonia – will feel like “sack of potatoes”
b. Can also be hypotonia
i. But all hypotonics will become hypertonic - Persistence of primitive reflexes.
- Abnormal posturing-Cortical Thumb
Landau Reflex (2)
- Infant will lift head and extend the neck and trunk
2. Present by 6 months
Parachute reflex (2)
- Present by 6-8 months
2. Look for symmetric response
Propping reflex (2)
- Anterior propping when sitting up
* Should proper forward as they first learn to prop - Lateral propping to maintain balance
Cerebral palsy complications (12)
- Spasticity
- Weakness
- Visual compromise
- Deformation
- Increase reflexes
- Hip dislocation*
- Clonus
- Seizures
- Articulation & Swallowing
- Kyphoscoliosis
- Constipation
- Urinary tract infection difficulty
Vision: Retinopathy of prematurity (8)
- Proliferation of abnormal retinal blood vessels
- May regress or worsen to retinal detachment
- Risk factor: >32 weeks and supplemental oxygen
- Eye exam: 4-6 weeks post birth if oxygen exposed
- Premature infants are at increased risk
a. Visual impairment from myopia and strabismus
b. Visual impairment as a result of cortical injury. - Early detection and treatment are key
- Classed by location of the disease in the retina (zone), vascular abnormality (stage), and extent of developing vasculature (clock hour)
- Treated with laser surgery
Nasal deformities (2)
- May have pressure necrosis from NP CPAP prongs or cross bars
- Problems with purulent secretions and infections should be referred to pediatric ENT
Oral tracheal intubation (6)
- Speech irregularities
- Deformities of teeth and arches
- Palatal grooving
- High shaped V palate
- Missing teeth
- Posterior cross bite
Dental vs Dentition
Dental: If birth weight is less than 1500 gram, refer to pediatric dentist after first tooth eruption
Dentition: Onset of tooth eruption is related to corrected age
*Preemies: 20-30 % of enamel defects—enamel hypoplasia or opacities of primary teeth
Chronic and Cardiac Insufficiencies (2)
- Cor pulmonale: Heart is enlarged and less efficient pump, total body fluid overload, compromises pulmonary function
- Recovery of normal cardiac function parallels recovery of pulmonary system
Respiratory System: CLD/BPD (4)
- Incidence is inversely proportional to birth weight and gestational age
- Characterized by increase airway resistance from inflammation of the airway and bronchial hyperresponsiveness
- May have tracheomalacia and/or bronchomalacia
- Many with neurodevelopmental deficits Growth failure
CLD (3)
- Iatrogenic disease: Oxygen toxicity and Barotraumas from pressure ventilation
- Excessive bronchial secretions, narrowed airways, ineffective O2 and CO2 exchange
- Severe forms: oxygen dependence, increased work of breathing, vulnerable to infections
Transient Tachypnea (5)
- Most common respiratory disorder seen in late preterm
a. Delayed reabsorption of fetal alveolar fluid
i. Used to be thought squeeze through birth canal did it
ii. Now recognize that fluid production decreases before vaginal delivery
iii. Large premature, term or late preterm infant born via C/s section with no history of labor or infant of diabetic mother. - Usually within 2-3 hours of birth
- Can be as late as 12 to 24 hours
- Slight tachypnea with RR 60-80
- Mild labored with nasal flaring and grunting
Acute respiratory infections (2)
- Preemies are more susceptible to pneumonia
* Do not let any children with colds/sick be around premies - Catastrophic outcomes in CLD with RSV
Respiratory Complications: Bronchopulmonary Dysplasia (4)
- “Chronic lung disease following respiratory failure”
- Etiology: barotrauma, inflammation and oxygen exposure
- Increased susceptibility to pulmonary infections
- Persists until adolescence
Respiratory Complications: Bronchopulmonary Dysplasia – What could you have done? (3)
- Provided higher caloric diet
- Bronchodilators, Lasix, oxygen and treat infections
- Palivizumab – RSV monoclonal antibody
Management of CLD/BPD (7)
- Bronchodilators
- Diuretic
- Oxygen
- Antibiotics when needed
- Immunize with Synagis/flu vaccine
- Excellent nutrition with high calories and nutrients
- MCT oil .25 to 1 gm per ounce of formula Consult dietician, OT, speech therapy
a. Speech therapy//make sure they are not aspirating
Management of Apnea with Prematurity (5)
- Periodic breathing with pathologic apnea in premature infants
- 40% are central, 50% are mixed, 10% are obstructive
- Usually ceases by 37 weeks
- Pharmacological management with caffeine
- Preemies may be discharged on meds
Persistent Pulmonary Hypertension of Newborn (PPNH) (3)
- Syndrome of acute respiratory failure
- Failure to achieve a normal decrease in PVR that occurs at birth with a variable degree of right to left shunting of venous blood across the fetal chambers (PDA, PFO)
- Characterized by systemic hypoxemia and elevated pulmonary arterial pressure in the absence of congenital defects.
Gastroesophageal Reflux: Overview (6)
- Manifests as regurgitation, apnea, aspiration pneumonia, worsening BPD/CLD
- Increased incidence in premature
- Theophylline and caffeine exacerbate GER symptoms
- Regurgitation, apnea, irritability, bradycardia, or Respiratory Distress syndrome (RDS)
- Potential morbidity
a. Pneumonia
b. Respiratory distress
c. Esophagitis - Use of PPI not recommended
Gastroesophageal Reflux: Manifestations (3)
- Premature infants: hypotonic LES, delayed emptying and decreased compliance of stomach
- Vomiting after feeds, spells, cough
- Sandifer syndrome: arching of back, rigid neck, opisthotonus
Gastroesophageal Reflux: Conservative Treatment (2)
- Thickened feeds, frequent small feeds, positioning the infant
- Medical Treatment: Ranitidine, PPI’s and prokinetic are used without approval for use
Premature and GER (3)
- Infants with very low birth weight (VLBW)
- H2RAs often given for GER or to prevent stress-induced gastritis
- H2RA use in significant association with necrotizing enterocolitis
NEC (6)
- Destructive process of small bowel
- Occur in 5 of 100 VLBW live births
- 1 of 1000 live births
- Ileocecal region is most commonly involved*
- Up to 15% necrosis of bowel
- Risk of short bowel syndrome due to resection
Inguinal Hernia (5)
- Appear as bulge in the groin, scrotum or labia
a. Parent should immediately go to ED if they see this - Greater risk of strangulating with premature infants
- Surgical repair to prevent incarceration (within the first six months)
- Prompt referral
- Educate about when to go to the ED
Car seat safety (3)
- Observe child in care seat if child is at risk for respiratory problems
- Air travel should be delayed until 6-8 weeks past due date
- All infants with cardiac and apnea monitor should make sure that equipment has adequate battery life
