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7/20/2015
1
Shawn Hollinger, MD FAAP FRCPC
Assistant Professor Neonatology ‐ Department of Pediatrics
Adjunct Professor Obstetrics and Gynecology
James H. Quillen College of Medicine
East Tennessee State University
A PreemieisoutoftheNICU–NowWhat!?
CareoftheEx‐PretermNeonate
• I Shawn Hollinger, DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation
• I Shawn Hollinger, DO NOT anticipate discussing the unapproved/investigative use of a commercial product/device during this activity or presentation
Disclosurestatements
By the end of this talk, I hope you will be able to:
• Discuss the risks of developmental impairment with the families of preterm infants after hospital discharge
• Discuss the literature regarding nutritional needs of preterm infants post hospital discharge
• Explain the pro’s/con’s of home apnea monitors and devise a plan for their discontinuation
Goals
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PleaseselecttheteamthatbestdescribesyouA. General pediatrician
B. Family physician
C. Specialist pediatrician
D. Nurse
E. Resident
F. Medical Student
G. Other/Just here for the free food
General pediatrician
Family physician
Specialist pediatrician
Nurse
Resident
Medical Student
Other/Just here for the free food
0% 0% 0% 0%0%0%0%
WearegoingtostartouttalkingaboutsomeimportantTLAswithrespecttoprematureinfants.WhatisaTLA?A. Transient Leukocyte Adhesion
B. Topical Lubricant/Anesthetics
C. Thermodynamic Linear Associations
D. Three Letter Acronyms
E. Therapeutic Laser Applications
Transient Leukocyte Adhesion
Topical Lubricant/Anesthetic
Thermodynamic Linear Associat..
Three Letter Acronyms
Therapeutic Laser Application
0% 0% 0%0%0%
TLAs
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AccordingtotheEPIPAGEstudy,whichoftheseTLAspredictedseverecognitivedeficiencies(Morethanonecorrectanswer)A. Severe IVH (Intraventricular
Hemorrhage)B. PVL (Periventricular
Leukomalacia)C. BPD (Bronchopulmonary
Dysplasia)D. NEC (Necrotizing enterocolitis)E. SES (Socioeconomic status)F. SGA (Small for Gestational age)G. AOP (Anemia of prematurity) Se
vere IVH (Intraventricular He...
PVL (Periventricular Leukomalacia)
BPD (Bronchopulmonary Dysplasia)
NEC (Necrotizing enterocolitis)
SES (Socioeconomic status)
SGA (Small for Gestational age)
AOP (Anemia of prematurity)
14% 14% 14% 14%14%14%14%
:30
IntraventricularHemorrhage(IVH)
Definition/Classification
• Bleeding into the brain’s ventricular system – thought to arise from changes in perfusion of delicate cellular structures augmented by the immaturity of cerebral perfusion regulation
• The more premature the baby, the higher the risk
• Historically classified as Grade 1 – 4 IVH
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Grades0,1&2IVH‐ Outcomes
• All VLBW infants (<1250 g) are at risk of long term developmental delays (even if no IVH)
• Grade 1 & 2 IVH have varying reports of long term outcomes in the literature – from slight increase risk to no increase risk
• Multicenter study compared 99 infants with Grade 1 and 2 IVH with 291 that had no evidence of IVH
• At 18 years of age no significant difference in intelligence, tests of achievement or problem behaviors
Wy et al. J Perinatol. 2015 Jul;35(7):511‐5. doi: 10.1038/jp.2014.244. Epub 2015 Feb 5
Grade3– 4IVHOutcomes
• Several cohort studies following outcomes of infants found to have Grade 3 and 4 IVH
• Much more likely to develop post hemorrhagic hydrocephalus (and have shunt placement)
• Shunt placement does not appear to independently predict poorer NDI
• Higher chance of CP, cognitive, visual, auditory impairment –Most studies from 40 ‐90% [consistently higher with grade 4]
Brouwer AJ et al. Neonatology 2014;106:296–303 DOI: 10.1159/000365127
BronchopulmonaryDysplasia(BPD)
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DefinitionsandClassification
• For preterm infants defined as the need for supplemental oxygen for at least the first 28 days of life.
• For those less than 32 weeks gestation at birth – classify BPD into mild moderate or severe at 36 weeks gestation
• “New BPD” – impaired alveolar development – lungs are characterized by fewer and larger alveoli
NICHD Concensus conference 2001
• Lung disease associated with prematurity and arrested alveolar development
• Things that can help:• Improves over time with optimal growth and nutrition
• Decrease ventilator injury
• Decrease O2 free radical injury
• Increased caloric demands
• Mild fluid restriction
Bronchopulmonary Dysplasia
Whichofthefollowingaretruewithrespecttolong‐termpulmonaryoutcomesofBPD?(SelectALLTHATAPPLY)
A. Impaired pulmonary function tests
B. Increased risk of re‐admission to hospital
C. Increased risk of pulmonary artery hypertension
D. Increased risk of recurrent wheezing
Impaired pulmonary function tests
Increased risk of re‐admission ..
Increased risk of pulmonary arte..
Increased risk of recurrent whe...
25% 25%25%25%
:30
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BPDaffectonLungsLong‐Term
• Negative affect on PFTs (apparently for life)
• More likely to have recurrent wheezing
• More likely to have PAH (Pulmonary Artery Hypertension)
• Up to 50 % chance of requiring re‐admission to hospital in the first 2 years of life for treatment of a respiratory infection
Up To Date – Complications and Long‐term pulmonary outcomes of BPD‐ Accessed July 2015
BPDManagementPostDischarge
• Frequent hand‐washing, infection avoidance, RSV prophylaxis if indicated, annual influenza vaccine
• Strict avoidance to second hand smoke (and anticipatory guidance to pre‐teens about FIRST hand smoke!)
• Close adherence to vaccine schedules
Up To Date – Complications and Long‐term pulmonary outcomes of BPD‐ Accessed July 2015
Diuretics
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• Have been shown to improve lung mechanics and decrease support needs for a few days…
• Not been shown to have any clear long term benefit
• Furosemide has been shown to increase nephrocalcinosisespecially with prolonged use
• HCTZ/Spironolactone is associated with hyponatremia and hypokalemia often requiring dietary supplementation
Diuretics
Int J Pediatr. 2012; 2012: 598606.Published online 2012 Jan 3. doi: 10.1155/2012/598606 Current Pharmacologic Approaches for Prevention and Treatment of BronchopulmonaryDysplasia Kristen Tropea
1, 2and Helen Christou
1, 2 *
ArticlesIfoundGuidingPostDischargeuse/monitoringofNa/KandDiuretics
RetinopathyofPrematurity(ROP)
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ROP– DefinitionsandClassification
• Abnormal growth of the retinal blood vessels after preterm birth
• Zone – How far the vessels have grown • Stage 1 – increased branching of newly formed blood vessels forming a line
• Stage 2 – rapid growth of new vessels leading to a ridge• Stage 3 – severely abnormal vessel growth with fibrous tissue
• Stage 4 – Partial retinal detachment
• Stage 5 – Complete retinal detachment
• Plus disease – increase in tortuosity of the new blood vessels – a concerning sign for speed of growth
ROPLongtermoutcomes
• Important cause of blindness – 400‐600 infants per year in the United States
• Monitored closely in the NICU (and sometimes after discharge –until fully vascularized)
• If reach “threshold”, risk of blindness is high and laser treatment is indicated
• VLBW infants are also at increased risk of strabismus, myopia and amblyopia – Recommend screening by an ophthalmologist at 9‐12 months
SocioeconomicStatus(SES)
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SocioeconomicStatus
• EPIPAGE study is one of the largest cohorts followed – 2500 French babies 22 – 32 weeks
• Data until age 5 on CP and cognitive function
• Examined medical and social risks for mild and severe disabilities
• Parents with low SES was the MAIN predictor for mild cognitive deficiency (3.4 times more likely than those with high SES)
• Cerebral lesions (IVH, PVL) were the main predictor for severe disabilities along with low SES (2.6 times more likely than high SES)
EPIPAGE – Beaino et al. Acta Pædiatrica 2011
ApneaofPrematurity
• Up to 85% of infants born <34 weeks have apnea spells attributed to apnea of prematurity (diagnosis of exclusion)
• CAP trial – Well designed RCT• Caffeine vs. placebo
• Useful for successful extubation
• Useful to decrease apnea episodes
• No harmful effects on neurodevelopmental outcome (to school age)
• No studies have examined use past 34 weeks PCA
• 10% of infants with apnea of prematurity will continue to have apnea after 34 weeks
Caffeine
NEOREVIEWS Vol. 14 No. 11 November 1, 2013 pp. e540 -e550
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• Developed to decrease SIDS
• Have never been show to decrease SIDS
• Still used in some instances
• More of a diagnostic tool (to distinguish false CR events and document frequency of true CR events) than a therapeutic tool (to prevent SIDS)
• Likely never going to get a good study proving/disproving their efficacy
HomeApneaMonitors
UpToDate – Use of home cardiorespiratory monitors in infants – Accessed May 2015
• Indications are really on a case‐by‐case basis• Recommended to discuss what a monitor is for and can and can’t do (babies have died on a monitor)
• Recommended to discuss length of use at time of discharge
• Length of use depends on the indication for use• Apnea of prematurity rarely occurs after 43 weeks PCA
• Risk of SIDS is very low after 6 months
• Risk of entanglement and strangulation by the wires increased after they begin to roll
• Generally accepted that after 6‐8 weeks of no events should discontinue use
HomeApneaMonitors
UpToDate – Use of home cardiorespiratory monitors in infants – Accessed May 2015
OsteopeniaofPrematurity
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• Majority of Calcium and Phosphorous accumulation occurs in the third trimester
• Vitamin D (deficiency) also plays a role
• Decreased mechanical factors (kicking on uterine wall) also alter cortical bone growth
• Risk factors:• Decreasing gestational age
• Furosemide use
• Corticosteroid use
• Concurrent illness
OsteopeniaofPrematurity
• Calcium and phosphorous supplementation
• In most cases nutrient enriched formula contains enough to reach higher RDI
• Can supplement in a similar way to Na/K
• Vitamin D supplementation also recommended
• Typically use Alk Phos, Phosphate to monitor severity of disease (aim for Alk Phos <600 and Phosphate >1.8)
• How Frequent to monitor???????
OOP‐ Treatment
Dokos et al. Clin Cases Miner Bone Metab. 2013 May-Aug; 10(2): 86–90.
VulnerableChildSyndrome
• Parents of children with preterm infants often perceive their infants as medically vulnerable
• High parental perception of child vulnerability is associated with disproportionately high health care utilization
• Has also been linked to poorer health care outcomes
• Mothers with high anxiety at time of discharge are more likely to have higher perceptions of vulnerability
• Small studies showing targeted behavioral therapy for mothers early on are promising for decreasing perceptions of vulnerability
Allen et al. Pediatrics. 2004 Feb;113(2):267‐73
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Nutrition
• Difficult to attain normal intrauterine growth in the NICU
• Recommended intakes not always achieved due to feeding intolerance or adverse events
• VLBW and ELBW infants often discharged around 35‐36 weeks weighing between 1800‐2200 grams
Nutrition
Aggett et al. Journal of Pediatric Gastroenterology and Nutrition 2006; 42: 596‐603
SpecificNutrientDeficienciesCalcium and PhosphorusIronZincWater soluble vitaminsFat soluble vitaminsLCPUFAs
Enhanced visual developmentNeurodevelopment
Shah et al. Pediatric Clinics of North America 2009; 56: 1069‐1083
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ImportanceofHumanMilk
Human milk is the gold standard of which all formulas are based
Universally recommended over formula
Research shows that provider encouragement of human milk is effective regardless of social and ethnic background
Studies show that parents will decide to provide breastmilk almost immediately after learning how critical breastmilk is in the management of the NICU infant
Meier et al. Clinics in Perinatology 2010; 37: 217‐245
FeedingthePretermInfant
Small studies show that preterm infant fed exclusively unfortified EBM at discharge may have nutritional deficiencies
Decreased bone mineral content at 6 months corrected age
Lower calcium, protein and phosphorus intake
Schanler found decreased BMC 1 year postdischarge.
Shah et al. Pediatric Clinics of North America 2009; 56: 1069‐1083Schanler et al. Pediatric Research 1992; 6: 583‐586
FeedingthePretermInfant
Fortification can be achieved by adding enriched formula powder to EBM or substituting a number of feeds with enriched formula
Fortification of at least half of the milk for 12 weeks after hospital discharge may be an effective strategy in addressing early discharge nutrient deficits and poor growth.
Tudehope et al. The Journal of Pediatrics 2012; 162: S72‐S80
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FeedingthePretermInfant
No studies have examined the impact on long‐term health outcomes of supplementation of human milk with formula
Studies with term healthy infants show that higher IQ scores and protection from infections, eczema, and adult‐onset morbidities are dependent on a dose‐response manner with human milk
Meier et al. Clinics in Perinatology 2010; 37: 217‐24
FeedingthePretermInfant
ESPGHAN Committee on Nutrition (2006) suggest nutrient‐enriched formula to term‐corrected age and even 52 weeks post‐conception among infants with less than normal weight for post‐conceptional age
Aggett PJ et al (2006) J Pediatr Gastroenterol Nutr 42(5):596‐603.
EnrichedFormulas
Enriched formulas may improve short‐term growth parameters in premature infants but have not been shown to improve long‐term growth or development
However many studies are limited by the preterm infants at most nutritional risk are underrepresented or excluded.
O’Connor et al. American Family Physician 2009; 79: 565‐570Lapillonne et al. The Journal of Pediatrics 2012; S90‐S100
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EnrichedFormulas
Infants fed nutrient‐enriched formulas usually eat less volume
Nutrient‐enriched formulas do not alter the quantity of growth but does improve the quality of growth
Growth
Body Composition
Bone mineralization Lapillonne et al. The Journal of Pediatrics 2012; 16S: S90‐S100Cooke et al. Pediatric Research 2010; 67: 660‐664Amesz et al. Journal of Pediatric Gastroenterology and Nutrition 2010; 50: 200‐207
• Various practices used• Until reaches the 3rd Percentile
• Until reaches 50th Percentile
• Until reaches 3.5kg
• Until 9 months
• Until reaches birth weight channel on growth curve
• Preemie toolkit I find useful!!
• https://www.preemietoolkit.com/pdfs/E_PhysicalExaminationAssessment/Recommendations‐for‐Postdischarge.pdf
HowLongtouseNutrientEnrichedFeeds
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• Deficiency in preterm infants is very common and can have serious side effects
• Supplementation is affordable and well tolerated
• Iron overload/toxicity is nearly impossible at the doses used for supplementation
• Recommended for breastfed infants <2500 g at birth until 1 year of age
• Recommended for formula fed infants <2500 g at birth until drinking 32 oz per day of iron fortified formula
Iron
NEOREVIEWS Vol. 1 No. 4 April 1, 2000 pp. e61 -e68
• Surprisingly little data
• Few studies with methodological flaws
• The few (weak) studies point towards ad lib feeds leading to better weight gain, earlier hospital discharge
• None looked at post‐discharge
AdliborScheduledFeeds?
Adv Neonatal Care. 2004 Aug;4(4):216-25. An integrated review of the literature on demand feedings for preterm infants. Crosson DD1, Pickler RH.
Earlyintervention
• Highest risk patients may be referred by NICU at time of discharge home
• Early identification and treatment of developmental delays improves outcomes
• Free services – anybody can refer
• If concerned ‐ REFER
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NICUHighRiskFollowupClinic
• Multidisciplinary developmental screening for NICU babies at high risk of developmental delays
• Long afternoon for families
• Screening clinic, goal is to ensure community resources are maximized
TeamScoresPoints Team Points Team
Questions?