Premature infant. Pediatric care for the premature children + Most frequent diseases of premature infants Flashcards
what are the terminology of prematurity ?
extremely preterm = below 28 weeks
very preterm = 28 weeks and less than 32 weeks
moderate preterm = less than 34wks - 32 weeks
late preterm = 34 weeks to less than 37 weeks
—— less than 37 weeks = preterm——-
early term = 37 weeks to less than 39 weeks
term =39-less than 41 weeks
preterm babies are usually not SGA correct ?
yes
there are morphological characteristics which can helps determine the age of the baby such as?
ballard score
nippes become visible in the 31 gestational week - if visible we know the baby has passed its 31st gestational week
position go the testis in the inguinal canal and scrotum
neurological development
what are the aetiology of preterm labour ?
50 percent remain unknown
maternal factors = pr eclampsia mother's age lower than 16 or higher than 40 smoking vibration alcohol drugs stress
anemia , diabetes , hyperthyroidism
uterine anomlais- tumors , cervical insuffieicny , vaginal infections and infection of the cervix
prom- usually infections , placenta previa , twin pregnancy ,
fetus - IUGR ,
multiple fetus
polyhydroaminos - uterine stretch pathway
how can we diagnose PROM ?
good test for this is cervical and vaginal fibronectin - substance of basement membrane protein produced but the membrane - when fetal membranes are disrupted - fibronectin is secreted into the vaginal and cervix
A positive fetal fibronectin test at 22 to 24 weeks predicts more than half of the spontaneous preterm births that occur before 28 weeks.
what re the characteristic features of preterm babies ?
small
head bigger to body
translucent skin with visiblee blood vessels
fine lanugo hair
soft pliable ear cartilage
soft bones
closed eyes
listless and inactive
extended extremities
partially developed REFLEX ACTIVITIES- lack of suction reflex
INABILITY TO MAINTAIN BODYTEMP = less body fat
inability to excrete urine
female - prominent clitorious
ABNORMAL BREATHING PATTERNS - shallow and irregular pauses
lower muscle tone
problems feeding - difficulty sucking or coordinated swallowing
what are preterm babies dangerously susceptible to ?
no surfactant produced so respiratory distress = hyaline membrane disease or respiratory distress syndrome
immature respiratory centre so cannot breath periodically = apnea
metabolic acidosis
more susceptible to hypoglycaemia
hyperbilirubinemia
heart failure = patent ductus arteriosus
INFECTIONS -sepsis and necrotic enterocolitis
intraventricular haemorrhages
fluid and electrolyte imbalance
RETINOPATHY of prematurity
anemia
what are the long term problems for preterm babies ?
bronchopulmonary dysplasia delayed growth and development mental or physical disability or delay increased risk for intellectual disability cerebral palsy vision and hearing loss = retinopathy
what are the standard care given to preterm babies
baby should be dried and effectively covered and warm
electie intubation for extremely low birth weight babies = less tan 1000g
exogenous surfactant given
corticosteroids for lung development through endotracheal tube
ventilator - continuous positive airway pressure
less than 30 weeks old - IV fluid and nasogastric
30-34 = nasogastric / breast feeding
more than 34 = breast feeding or katori
10 percent of daily calories should be derived for protein
40 percent - carbs
5 percent fats
2.5-3.5 mew/kg/per day
vit a recommended for preterm promoting epithelial repair and minimise fibrosis
vit D - prevents rickets
vitamin K 0.5mg should be given intramuscularly
factors 2 , 7 , 9 ,1 administers
prevent haemolytic disease of the new born
immunisation and put in sterile conditions
antibiotics given if there are signs of infection
for a preterm baby it is put in a system of neonatal intensive care unit which measure what ?
there is overhead warmer they eyes are sealed closed closed there is a ventilator a feeding tube = feeding method oxygen saturation monitor Iv pump IV pump with umbilical artery catheter = feeding method PICC line - central line = feeding method ECG and blood pressure monitor / HR temperature monitor bilirubin lights incubator
what is kangaroo care
placing a premature baby in an upright position on the mothers bare chest allowing tummy to tummy contact and planning the premature baby in between the mother’s breast
and baby head is tubers so the ear is above the parents heart
kangaroo care has been shown to help prmature newborn with ?
body temp
allow easy access to breast feeding
increase weight gain - allows the baby total into deep sleep = allows the baby to conserve energy
increased intimacy and attachment
what are the symptoms for necrotising enetrocoitis
poor feeding
blood in stool
vomiting bile
failure to thrive
later on
abdominal discolouration , peritonitis
intestinal perforation
systemic hypotension
what is necrotising enterocolitis ?
where a portion of the bowel dies it is thought to involve the combination of poor blood flow and infection of the intestines
how can we prevent necrotising enetroclitis
use breast milk
probiotics
when is the typical onset of enterocolitis ?
after 4 weeks of life
generally inversely proportional to the gestational age of the baby birth
how is the diagnosis of necrotising enterocolitis ?
radiography
transillumination of the abdomen
Bells stages of disease
stage 1 = mild symptoms such as apnea , lethal , bradycardia , temp instability
abdominal distension , increased gastric residual bloody stools
no radiological signs
stage 2
mild to moderate symptoms
additional intestinal signs : absent bowel sound and abdominal tenderness
radiologic - pneumatosis intestinal or portal venous gas
lab =metabolic acidosi , thrmbocytopenia
stage 3
hypotension
peritonitis and striking abdominal distension
radiology = pneumoperitoneum
lab test = metabolic and resp acidosis
DIC
US = bowel gas , sentinel loop
what is the treatment for necrotising colitis ?
bowel rest by stopping oral feeding, gastric decompression with nasogastric tube suction , fluid repletion to correct electrolyte abnormalities parenteral nutrition always antibiotic therapy mechanical ventilation
supine and left lateral decubitus abdominal X-rays should be performed every six hours
As an infant recovers from NEC, feeds are gradually introduced. “Trophic feeds” or low-volume feeds (<20 ml/kg/day) are usually initiated firs
Where the disease is not halted through medical treatment alone, or when the bowel perforates what is the course of action in NE
emergency surgery to resect the dead bowel is generally required, although abdominal drains may be placed in very unstable infants as a temporizing measure
In the case of an infant whose bowel is left in discontinuity, the surgical creation of a mucous fistula or connection to the distal bowel may be helpful as this allows for re-feeding of ostomy output to the distal bowel. This re-feeding process is believed to improve bowel adaptation and aid in advancement of feeds.
some children may suffer what whenextensive portions of the bowel had to be removed in NE ?
short bowel syndrome = malabsorption disorder
a patent ductus arteriousus creates what type of shunt ?
and what are the signs and symptoms ?
diagnosis ?
left to right shunt
signs and symptoms depends on the size of the shunt
pulse can be bounding , systolic murmur audible ,
apnea , bradycardia , increased oxygen requirement
echocardiography - doppler through ultrasound
what are the main problems in the left to right shunt in PDA?
HYPERperfusion in lung circulation = pulmonary haemorrhages
HYPOperfusion of system circulation to gut and brain = NEC
heart failure - increase volume load on left side of heart = bounding pulses , hyperactive pericardium , murmur , cardiomegaly
patent ductus arteriosuus closes physiologically in premature babies?
yes however they are more delayed especially if there is respiratory distress syndrome
normally the physiological closure is within 24 hours and the anatomical closure several weeks later
= arterial hypoxemia and reduced response to oxygen prevents the fast closure of ductus arteriosusu in children
what can treat this closure of ductus arteriosus?
echocardiography done when there is congestive heart failure with all the symptoms that persists heart failure to ratio between left atrium and aortic root diameter ratio normal is 0.86 if it is more than 1 or 1.1 early treatment started with indomethacin
inhibitors of prostaglandin such as ASA (cogulative effects and bilirubin displacement ) or indomethacin (renal function :( ) closure of persistant ductus arteriosus
surgical ligation
what re the signs for respiratory distress syndrome ?
increased resp rate - tachypnea - more than 60 breaths per min
chest wall recession - sternal and subcostal undraping
tachycardia
expiratory grunting = to create positive pressure
nasal flaring
cyanosis
prolonged periods of apnea
is respiratory disease is treated or not the acute symptoms lasts how many days ?
2-3 days
first day child worsens
second day - baby remarkably stable
resolution on the third day
what can be differential diagnosis to respiratory distress syndrome ?
acute respiratory distress syndrome - widespread inflammation of the lungs
how can we diagnose respiratory distress syndrome ?
bell shaped chest
chest x ray - decreased lung volume , absence of thymus - after 6 hrs
in pregnancy over 30 weeks fetal lung maturity checked by amniocentesis
L/S ratio and PG - phosphatidylglycerol
less than 2:1 and absence of PG means there is no lung maturity
surfactant an albumin ratio
less than 35 indicates immature lungs
greater than 55 inidicates mature surfactant production
what is the treatment for respiratory distress syndrome ?
CPAP- continuous positive airway pressure
intravenous fluid to stabilise the blood sugar and blood blood pressure
if the baby shows signs of worstenng - endotracheal tubing
or put in mechanical ventilation
CPAP
exogenous pulmonary surfactant given through the breathing tube
extracorporeal membrane oxygenation = cannot be placed until over 2KG
because small blood vessels for cannulation giving higher vascular resistance
in severe RDS what is the problem ?
bronchopulmonary dysplasia
there are four grades of intraventricular haemorrhages what are they ?
grade 1 - germinal matrix bleeding where there are tender vessels
grade 2 - bleeding occurs inside the ventricles
grade 1 and two are small amounts bleeding
grade 3 and 4
grade 3 - the blood presses the brain tissue the ventricles are enlarged with he blood
grade 4 the bleeding is directly involved with the brain tissue - intraparenchymal haemorrhage
most severe being uniltarel hemorrhagic infraction = resulting in hemiplegia = paralysis of one side of the body
here blood clots can form and reduce the drainage of cerebrospinal fluid giving hydrocephalus
what are the symptoms in intraventricular haemorrhages
apnea
change in blood pressure and heart rates
decreased muscle tone
decreased reflexes
excessive sleep
seizures and abnormal movements
how is the diagnosis done of intraventricula hemorrhegae ?
all babies born before 30 weeks should have ultrasoundd of the head
what is the treatment for intravenetricular haemorrhages ?
no way to stop the bleeding
give diuretics
streptokinase therapy
most recently combo of drainage , irrigation and fibrinolytic therapy = DRIFT therapy
blood transfusion given to maintain blood pressure
if fluid builds ip to point that there is cancer - a spinal tap done to relive the pressure
surgery needed to place a tube shunt to drain the fluid from the brain
what is the prognosis of intravenetricular haemorrhages ?
less tan half the baby with low grade intraventricular haemorrhages have long term problems
severe problems leads to developmental delays and problems controlling movement and one third with severe bleeding die
how can we prevent intraventricular hemorrhegs ?
give corticosteroids to pregnant women - develop lungs - reduce RDS risk - therefore reduce IVH risk
umbilical cords are not clamped right away have less risk for IVH
most intravenetricular haemorrhages occurs when after birth and what increases its chances
after 72 hours
extracorporeal membrane oxygenation
congenital cytomegalovirus
surfactant is produced by which type of pneumocystis ? and what triggers its release
type 2 = premature infants pneumocystis not fully mature
cortisol = adrenal gland not fully functional
where does the term hyaline membrane disease come from in respiratory distress syndrome ?
proteinaceous exudate from hypoxemia
what are the complications for respiratory distress syndrome ?
pneumothorax
intracerebral hemorrhage
bronchopulmonary dysplasia from artificial ventilation
what is pneumothorax ?
and what are the types of pneumothorax ?
A pneumothorax occurs when some of the tiny air sacs (alveoli) in a baby’s lung become overinflated and burst. This causes air to leak into the space between the lung and chest wall (pleural space)
spontaneous = resolves without tretammnet , no respiratory distress syndrome either
loculated - sealed off , resolved without treatment
tension positive pressure - creates a ball/valve mechanism
what causes pneumothorax in premature infants ?
respiratory distress syndrome in premature babies
and when the baby needs a ventilator the extra positive pressure can burst the alveoli for these air scare not able to expand easily due to the decrease of surfactant
meconium aspiration syndrome
pneumonia
= all needing mechanical ventilation
resuscitation
what are the symptoms in pneumothorax ?
hype resonance on the affected side irritability cyanosis tachycardia tachypnea flair of nostrils grunting in breathing restlessness chest and admonimal muscle retraction aid in breathing
what is the diagnosis for pneumothorax ?
transillumination - pockets of air will show up as lighter areas
chest X ray = lungs are wide because no air in it = elapsed alveoli from respiratory distress
pleura is black
what is the treatment for pneumothorax ?
oxygen mask given
tension pneumothorax (As air builds up in the chest, it can push the heart toward the other side of the chest. This puts pressure on both the lung that hasn’t collapsed and the heart.) chest drain decompression by needle catheter and then insert a chest tube
how can we prevent pneumothorax
mechanical ventilation is always at the lowest possible
what is hypothermia bad for neonates ?
hypoglycaemia
failure to thrive
mortality increases
why’re preterm babies especially vulnerable to hypothermia ?
large surface area compares to mass = convection heat loss then heat generated
skin is thin and heat permeable
they have
little subcutaneous fat for insulation
organs are not fully functional to produce heat metabolically
Poorly developed metabolic mechanism for responding to thermal stress (e.g. no
shivering)
Greater body water content
what are the ways there can be heat loss in neonates
Evaporation: when amniotic fluid evaporates from the skin. from skin and breathing or sensible (sweating).
- Conduction: when the newborn is placed naked on a cooler surface, such as table, scale, cold bed. The transfer of heat between two solid objects that are touching
- Convection: when the newborn is exposed to cool surrounding air or to a draft from open doors, windows or fans, the transfer of heat from the newborn to air or liquid
- Radiation: when the newborn is near cool objects, walls, tables, cabinets, without actually being in contact with them. The transfer of heat between solid surfaces that are not touching.
how do babies produce heat ?
metabolic process
muscle activity - restlessness and crying
flexed position yo decrease surface area
peripheral vasoconstriction
non shivering thermogenesis - metabolism of brown fat produce heat thermal receptors – hypothalamus – synthetic nervossystem and NE release to brown fat found in kidney , adrenal gland , head , neck , heart
consequence of hypothermia in children
cold — activation of non shivering thermanogensis — metabolism of brown fat — increased o2 consumption – increased resp rate — pulmonary vasoconstriction – tissue hypoxia – peripheral vasoconstriction — anaerobic metabolism – metabolic acidosis
metabolism of brown fat – increased glucose use – hypoglycaemia
how many degrees is hypothermia ?
ewborn’s axillary temperature drops below 36.3°C
what are the signs and symptoms for hypothermia ?
Acrocyanosis and cool, mottled, or pale skin
• Hypoglycemia
• Bradycardia
• Tachypnea, restlessness,
shallow and irregular respirations
apnea,
metabolic acidosis
Decreased activity, lethargy, hypotonia
Feeble cry, poor feeding
how do we manage hypothermia ?
arm chain” is a set of interlinked procedures to be performed at birth and during the next few hours and days after birth in order to minimize heat loss in all newborns
warm delivery room immediate drying skin to skin contact brest feeding - within one hour appropriate clothing and blanket keep mother and newborn together for 24 hours a day in warm room warm transportation
how is the severity of hypothermia measured inneonats ?
mild = 35–36.3 degrees
moderate = 32 -34.9 degrees
severe below 32
for mild hypothermia what is done to treat it ?
skin to skin contact in warm room
place cap on newborn head
cover mother and newborn in warm blankets
what is the treatment for moderate hypothermia ?
radiant heater
warm incubator
what is the treatment for severe hypothermia
warm incubator
how can we deliver nutrition whenpretm infants cannot swallow
nasogastric tube - and mothers breast milk
breast milk needs to ne supplemented with phosphate and protein calories and calcium
when is parenteral nutrition needed
typically when the birth weight is below 1kg
why s breast milk the most advisable for nutrition
passive immunity through IgA
cows milk based formula = NE
cannulation - septicaemia increase
when taking care of preterm babies iron what needs to be considered
iron is transferred to the fetus in the last trimester and therefore can have low iron stress
this can also be in addition to inadequate erythropoietin repose
iron supplements are given
why do preterm infant have increased risk for infection
because IgG is the only antibody transferee through placenta and also mostly in the last trimester = increased infection in pretty
in addition PROM is caused due to cervical inflammation which can spread o the premature newborn
can be nosocomial - hospital derived since they are exposed to catheters and mechanical ventilation and long hospital stays
intraventricular haemorrhage is also caused by ?
perinatal asphyxia
retinopathy of prematurity is also called retrolental fibroplasia and terry syndrome has what pathophysiology
disorganised growth of genital blood vessels which may result in scarring and retinal detachment
By the fourth month of pregnancy, the fetal retina has begun to develop vascularization. Such formation of blood vessels appears to be very sensitive to the amount of oxygen supplied, either naturally or artificially.
the blood vessels grow from the retina outwards and this process is complete few weeks before full term of delivery the blood vessels conintue to grow normally ROP does not occur however continue to grow abnormally with fibrovascular proliferation ROP occurs and cause haemorrhages
when the blood and abnormal vessels are reabsorbed it may give rise to multiple bad like membranes which can pull up the rentina and eventually lead to blindness
what are the risk factors of retinopathy of prematurity ?
in preterm babies(esp below 32 weeks) relieving neonatal intensive care in which oxygen therapy is used FOR THE lungs
the direct growth of the blood vessels is related to relatively low areas of oxygen
VERY low birth weight = 35 percent
less than 1500g
infection
people with ROP have what complications ?
strabismus , glaucoma , cataracts and shortsightedness myopia in later life
what is the cause of bronchopulmonary dysplasia in neonates ?
treated with long term oxygen or supplemented oxygen mechanical ventilation RDS abnormal lung development antenatal infection
which is needed in low birth weight and preterm infants
what re the signs and symptoms of BPD ?
feeding problems - oral tactile hypersensitivity after prolonged intubation
hypoxemia
hypercapnia
crackles wheezing
hyperinflation
what s the pathophysiology of BPD
what is the definition of BPD ?
BPD is a chronic respiratory disease
oxygen conc more than 40 percent is toxin to the neonatal lung
prolonged high oxygen delivery causes necrotising bronchitis and alveolar septa injury with inflammation and scarring this is due to the generation of superoxides and hydrogen peroxides and oxygen radicals which disrupt the membrane lipids
resulting in hypoxemia
BPD is oxygen dependance at 36 weeks post conceptual age accompanied by clinical and radiographic findings due to failure RDS resolving
how do you diagnose BPD ?
chest x ray show widespread opacification and sometimes cystic changes by phases
lung opacification
then cysts
then areas of overdistenton and atelectasis
then spongelike appearance
and in histopathopoligy BPD reveal interstitial edema , atlesctasisi , mucosal metaplsao , interstitial fibrosis an necrotising obliterative bronchitis
for neonates treated with more than 21% oxygen for at least 28 days
for gestational age less than 32 weeks :
mild = breathing room air at 36 weeks moderate = need 30 percent of oxygen at 36 weeks severe = need more than 30 percent oxygen or positive air pressure CPAP at 36 week
for gestational age 32 weeks or older
mild = breathing room air at postnatal age of 56 or at discharge
moderate = need less that 30 percent oxygen 56 days postnatally or at discharge
severe need 30 percent or more oxygen with or without CPAP 56 days postnatal age
what is the clinical management of BPD ?
to reduce oxygen toxicity and barotrauma ventilator settings are reduced to lower the partial pressure of pa02 to 50 mmhg and higher paco2 = 50 to 75mmhg)
dexamethasone therapy reduce inflammation and improve pulmonary function
steriods given to babies less than 8 days old can prevent
however risk of neurodevelopment sequels such as cerebral palsy outweighs the benefits
= low dose may be given
oxygen therapy - CPAP or high flow nasal cannula therapy
what are other common problems that premature infants also low birth weight baby developmentalp ?
low birth weight babies develop cerebral palsy but more common is learning disabilities
learning difficulties risk is at greatest off born before 26 gestational week
fine motor skills difficulties
concentration
behavioural problems
to try and prevent retrolental fibroplasia what Pa02 do we give premature babies
keep it 50-80mmhg
what are the clinical managmnet of BPD ?
oxygen dependance hypercapnia compensatory metabolic alkalosis pulmonary hypertension failure to thrive
what s the complication of BPD ?
right sided heart failure
when having mechanical ventilation with BPD what is a common occurrence with these positive air pressure which can worsen BPD ?
barotrauma
what are the complications of BPD?
hyperinflation reactive airways developmental delay higher risk or severe respiratory syncytial virus pneumonia higher risk for asthma
what is pulmonary dysmaturity or wilson mikety syndrome ?
affecting premature infants or SMALL for gestational age of less than 1.5kg
and occurs 1-5 weeks after birth
chronic lung disease that closely related to bronchopulmonay dysplasia
alveoli that have failed to grow and multiple not due to RDS
what is the symptoms of wilson mikety syndrome
cyanosis , dyspnea , wheezing , hyperinflation , corpulmonale , failure to thrive
what is the diagnosis of wilson mikety syndrome
chest x ray
lung cysts - interstitial emphysema
diffuse infiltrats
hyper inflated lungs
flattened diaphragm
what is the treatment for wilson mikety syndrome
give oxygen therapy
diuretics
what is pneumopericardum ?
air enters the pericardial cavity
LIFE THREATENING
recognised in preterm neonates associates with severe lung pathology after vigorous lung resuscitation or in the presence of assisted ventilation
why is pneumopericardium life threatening ?
lead to cardiac tamponade and death
what are the signs and symptoms of pneumopericardium ?
dyspnea
cyanosis = heart is an ineffectual pump
chest pain
pluses paradoxes
becks triad when cardiac tamponade
muffled heart sounds
hypotension , rased jugular venous pressure
how do we diagnose pneumopericardium ?
halo around the heat
When air and fluid mix together in the pericardial sac, a tinkling sound superimposed over a succussion splash is heard. This is known as a “Bruit de Moulin”,
Air between the anterior parietal pericardium and the thoracic cage may also give rise to the “Hamman’s Sign” – which is a crunching sound typically heard on auscultation of the chest, but may sometimes be heard even with the unaided ear.
