A brief presentation for preterm infant management.

1. Preterm Infant
Capt Aung Pyace Phyoe

2. Outline
1. Introduction
2. Defination and Terminology
3. Etiology
4. Prenatal consultation
5. Delivery room care
6. Care in NICU
7. Management of the Late Preterm Infant
8. Management of common complications in preterms
9. Discharge from hospital
10. Immunization
11. Follow up

3. Introduction
- unique group of patients in the neonatal intensive care unit (NICU).
- these infants are so physiologically immature.
- estimated 15 million babies are born too early every year.
- 10.6% of all live births globally were preterm.
- the leading cause of death in children under the age of 5 years.

4. 2018 Infant mortality rate in Myanmar - 38.5 deaths per 1,000
live births (WHO)

5. 1. Defination and Terminology
- babies born alive before 37 weeks of pregnancy are completed.
Classification (Gestation)
• extremely preterm >28 weeks
• very preterm 28 - 32 weeks
• moderate to late preterm 32 - 37 weeks
Classification (Birth Wt)
• Micropreemie <800 g
• Extremely low birthweight < 1000 g
• Very Low birthweight < 1500 g
• Low Birthweight < 2500 g

6. Definition of AGA, SGA and LGA
• AGA – between 10th and 90th percentile for gestation age
• SGA – 2 SD below the mean weight for gestational age or below 10th
precentile
• LGA – 2 SD above the mean weight or above 90th percentile for
gestational age

7. Other age terminology
A. Chronological age (or postnatal age). The time elapsed since birth.
B. Postmenstrual age. Gestational age plus chronological age,
expressed in weeks , preferred term to describe premature infants in
the perinatal period.
C. Corrected age The chronological age minus the number of weeks
born before 40 weeks’ gestation

8. 2. Etiology
• Unknown - 40%
• Foetal - Fetal distress, multiple gestation, erythroblastosis,
nonimmune hydrops.
• Placental - Placental dysfunction, placenta previa, abruptio placenta.
• Maternal -Preeclampsia, bicornuate uterus, chronic medical illness,
infection, drug abuse

9. 3. Prenatal consultation
• Member – Parent, Neonatologist, OG, other healthcare team.
• Things to discuss
• Tx option.
• survival rate - (6% at 22 completed weeks, 26% at 23 weeks, and 55% and
72% at 24 and 25 weeks)
• short- and long-term complications.

10. 4. Delivery room care
Delayed cord clamping - 30 to 60 seconds.
Thermoregulation
• Room temperature 25°C to 26°C.
• Polyethylene wrap or bag, thermal mattress, hat.
Respiratory support
• Breathing spontaneously and has a heart rate >100 beats/min CPAP(4-6 cm
H2O) – to prevent lung collapse.
Transport
• As soon as possible
• Prewarmed portable incubator equipped with blended O2 and CPAP availability.

11. *** approach to resuscitation is similar
to that in more mature infants***

13. 5. Care in NICU
• Maturity assessment
• Temperature and humidity control
• Fluids and electrolytes
• Blood glucose
• Nutrition for the metabolically stable infant
• Respiratory support
• PDA
• Transfusion
• Skin care
• Other special considerations for the ELBW infant

14. Maturity assessment

16. Temperature and humidity control
- Tiny infant has a relatively large skin surface area and minimal energy
reserves, constant neutral thermal environment is essential.
- Increase env; temp  increase heat loss, O2 consumption, metabolic
stress.
- To maintain minimal evaporative heat loss - best environmental
humidity is 80%.
Incubators and hybrid incubators
• Prewarmed double-walled incubators.
• Standard - hybrid humidified incubators.

17. Humidification
Use a respiratory care humidification unit
- to minimize insensible fluid losses and hypothermia.
- maintains airway temperature as close as possible to 35°C.
- fluids used for humidification should be changed every 24 hours.
 Minimize nosocomial infection in humidified environments
- Do not allow nonmedical items, change linens regularly.
- Change bed every 7 to 10 days.

18. Monitoring and maintenance of body temperature.
1. Maintain axillary skin temperature of 36.0°C to 36.5°C.
- Mode - servo-control, manual control.
- electronic thermometers.
2. Record skin temperature.
- servo-control skin probe.
- record skin temperature and environmental temperature every hour until the skin
temperature is stable (36.0–36.5°C)
- Thereafter 2-hour intervals.
3. Record the incubator humidity.
- every hour until it is stable and then every 2 hours.
4. Weigh low birthweight infants for management of fluids and electrolytes
after the third day of life.
5. Other heat-conserving practices - knit hats, fetal positioning, and air
boost curtains
6. Accessory items for infant care must be prewarmed - intravenous (IV)
fluids, stethoscope, saline lavages, and any other.

19. Hypothermia (skin temperature <36°C)
- Set the warmer 0.4°C higher than infant’s temperature.
- Not faster than 1°C/hr.
- Rapid rewarming  core body temperatures >37.5°C  increased
insensible water losses, increased O 2 consumption, apneic episodes,
increased incidence of intraventricular hemorrhage (IVH), deviations in
vital signs, and a detrimental effect on neurodevelopment.
Hyperthermia (skin temperature >37.0°C)
- 0.4°C lower than the infant’s skin temperature
- If increased temperature persists  pathologic conditions - sepsis,
intraventricular hemorrhage, or mechanical overheating.
- Do not turn off the warmer.

21. Fluids and electrolytes
Intravenous fluid therapy
• Insensible water loss
• Age
• Additional fluid
Infusion of fluid
• Umbilical artery catheter (0.5 normal saline (NS) + 0.5 U heparin/mL)
• Umbilical venous catheter (0.5 U heparin/mL)
• Broviac or percutaneous central venous catheters (0.5 U heparin/mL)
• Radial arterial line/posterior tibial arterial line (2 U heparin/mL + 0.5 N/S)
• For catheter flushes, use the same fluids as those infused as IV fluids
• do not use N/S to avoid excessive sodium
• do not use hypotonic saline like (<0.45 NS or <5% dextrose) to avoid red
cell haemolysis.

23. Monitoring of fluid therapy
• at least twice daily during the first few days of life.
• body weight
• urine output
• blood pressure measurements
• serum sodium
• Hematocrite
• physical examination

24. Hemodynamic monitoring
• valuable tool in assessing fluid status
• HR -140 to 160 beats/min
->160 beats/min  hypovolemia, pain, inadequate ventilation,
anemia, sepsis, or hyperthermia.
-<100 beats/min  hypoxia or medication
• Arterial blood pressure
-infant’s mean arterial pressure at or equal to the gestational age
during the first 48 hours

25. Electrolyte
Sodium (132–138 mEq/L)
• may begin to decrease in the postdiuretic phase.
• sodium chloride should be added to the IV fluids (3–8 mEq/kg/d of sodium)
• prediuretic phase
-hyponatremia  fluid overload
-hypernatremia  dehydration(excessive insensible water loss)
• Thereafter
-hypernatremia  (a) premature addition of sodium in the
prediuretic phase, or (b) dehydration, or (c) excessive Na+ intake.
- hyponatremia  (a) fluid overload, or (b) inadequate Na+ intake, or
(c) excessive Na+ loss

26. Potassium
• prediuretic phase - no potassium need.
• during the first 48 hours after birth -prone to increased serum potassium
levels of ≥5 mEq/L. (range 4.0–8.0 mEq/L)
(a) Relative hypoaldosteronism
(b) Shift of intracellular potassium to the extracellular space due to
an immature Na+/K+-ATPase pump
(c) Immature renal tubular function
(d) Lack of arginine
• K+ >6 mEq/L –close electrocardiogram (ECG) monitoring, acid-base status,
and urine output
- Albuterol metered-dose inhaler (4 puffs every 2 hours; 1 puff
= 90 µg)
• K+ >7 mEq/L -insulin, sodium bicarbonate, and calcium gluconate.
• 3–6 days after birth - add supplemental K+ to IV fluids (Begin with 1 to 2
mEq/kg/d),
• Measure serum K+ every 6 to 12 hours until the level is stabilized

27. Calcium
- Hypocalcemia <8 mg/dL
- Symptomatic hypocalcemia is treated with calcium salts
- Usually happens on 2nd day of life

28. Blood glucose
- Should give 4–6 mg/kg/min GIR with amino acid
- Hypoglycemia - <40 mg/dL for first 48 hours
- thereafter < 50 mg/dL
- an inadequate glucose infusion rate or a
physiologic lack of glycogen stores, sepsis, cold
stress, or hyperinsulinemia)
- Hyperglycemia - >150 mg/dL
- increased glucose infusion rate, sepsis, necrotizing
enterocolitis (NEC), intraventricular hemorrhage
(IVH), or a stress response

29. Nutrition for the metabolically stable infant
• Parenteral nutrition - started on admission and continued until the infant is receiving
sufficient enteral feeding.
-GIR of 4 to 6 mg/kg/min; amino acids - started at 2.5 g/kg/d, increased by 0.5
g/kg/d to a maximum of 3.5 to 4 g/kg/d.
• Intravenous lipids (20%) -started by 24 hours of age; start with 1 to
2 g/kg/d, increase to 3 g/kg/d in 24 hours if triglyceride level is <200 mg/dL.
-Septic and thrombocytopenic infants require caution.
• Early feeds of small amounts of breast milk or premature formulas (10–20 mL/kg/d)
-can promote gut development, characterized by increased gut growth, villous
hypertrophy, digestive enzyme secretion, and enhanced motility
-incidence of infection, NEC, and retinopathy of prematurity is decreased when
breast milk is used

30. Respiratory support
Endotracheal intubation
• Type of endotracheal tube (ETT)
a. <500 to 1000 g. 2.5 mm ID.
b. 1000 to 1250 g. 3.0-mm ID
• Mechanical ventilation
Rate - 20-60 / min
Inspiratory time (IT) - 0.3 – 0.5 s
PIP - 12-20 cm H2O
Mean airway pressure - <8 cm H2O
FIO2 - as required per initial PO2 values
Flow rate - 6-8 L/min
• Nasal CPAP (nCPAP)
• High-flow nasal cannula

31. Monitoring respiratory status
1. Oxygenation
• Blood gas sampling
-Desired ABG (a) PaO2 . 45–60 mm Hg
(b) PaCO2 . 35-45 mm Hg
(c) pH. 7.35–7.45 is acceptable.
• Continuous O2 monitoring
2. Chest radiograph
• Indications i. Abnormal change in blood gas values
ii. Adjustment of the ETT (to confirm proper positioning)
iii. Sudden change in the infant’s status
iv. Significant increase in O2 requirement or frequent desaturations

32. Suctioning
• as-needed basis.
a. Breath sounds - Wet or diminished breath sounds
b. Blood gas values - significant increase in PaCO2  ETT malposition,
secretions blocking the airway passages, inadequate ventilation, prior
bicarbonate/acetate administration, or pain.
c. Airway monitoring - By using airflow sensors and continuous
computer graphic screen displays.
d. Visible secretions in the ETT
e. Loss of chest wall movement

33. Extubation
1. Preextubation. - use of caffeine citrate loading  improves respiratory
drive and reduced length of time on mechanical ventilation, neuroprotective
effects when started at birth.
2. Indications - mean airway pressure of 6 cm H2 O and a low (30%) Fio2
-Most infants >26 weeks and 700 g birthweight can be
extubated in the first 72 hours.
Other indications for extubation:
a. Ventilator rate ≤10 breaths/min
b. Regular spontaneous respiratory rate
3. Postextubation care - breathing patterns, respiratory effort, auscultation
of the chest, monitoring of vital signs, and blood gas analysis.
-After extubation, placed on CPAP or HFNC with blended O2.
-extubation to nasal prong or mask CPAP has beneficial effects on
respiratory function and the prevention of atelectasis.

34. Surfactant
• early administration of surfactant during the first 4 hours of life to
decrease chronic lung disease
• Administration criteria - absence of antenatal steroids, increased
oxygen demand >30%, and a radiograph consistent with surfactant
deficiency.
Vitamin A
• for decreasing chronic lung disease in ELBW infants
• begin the first week of life
• 5000 IU intramuscularly [IM] 3 times per week for 4 weeks.

35. PDA
• Overhydration must be avoided.
• Up to 30% of PDAs spontaneously close.
• indomethacin or ibuprofen in hemodynamically significant PDA
Transfusion
• Keep the hematocrit between 35% and 40%.
• Lower values may be acceptable if the infant is asymptomatic.

36. Skin Care
• Minimal use of tape
• Zinc-based tape can be used
• hydrogel adhesive
• Use of humidity helps maintain skin integrity until skin is mature (2–3 weeks)
Treatment of skin breakdown
1. Clean skin breakdown/excoriated area with warm sterile water, leaving open to
air.
2. Apply topical antibiotic over broken-down infected areas, leaving open to air.
3. Apply transparent dressings over excoriated areas.
4. Administer IV antibiotics if necessary.

37. Other special considerations for the ELBW infant
• Infection – C&S, antibiotics, chemoprophylaxis with fluconazole (Start 48 to
72 hours after birth and give 3 mg/kg IV twice a week for 4 to 6 weeks or
until IV access is no longer necessary.)
• CNS haemorrhage – cranial USG in first 7 days
• Hyperbilirubinemia – SB 2 times a day, Phototherapy and exchange
transfusion
• Pain - physiologic(heart rate, O2 saturation, respiratory rate, blood
pressure, facial expression, vocalization, and motor activity), behavioral
(facial expression, vocalization, and motor activity)
• Social problems
• Developmental issues - Minimal stimulation, positioning, Kangaroo care,
environmental issue, parental education.

38. Management of the Late Preterm Infant
• Respiratory morbidity
• Length of stay
• Jaundice
• Poor feeding
• Temperature instability
• Hypoglycemia
• Infectious morbidity
• Sudden infant death syndrome (SIDS) and apnea
• Readmission
• Respiratory syncytial virus (RSV) infection
• Long-term outcomes

39. Management of common complications in preterms

40. Respiratory Distress Syndrome (Hyaline Membrane Disease)
• occurs primarily in premature infants
• Surfactant deficiency (decreased production and secretion) is the primary
cause of RDS
• Asphyxia, hypoxemia, and pulmonary ischemia.
• Asso:with hypovolemia, hypotension, and cold stress
CLINICAL MANIFESTATIONS
• rapid, shallow respirations
• tachypnea
• prominent (often audible) grunting,
• intercostal and subcostal retractions
• nasal flaring and
• Death d/t alveolar air leaks (interstitial emphysema, pneumothorax),
pulmonary hemorrhage, or IVH.

41. Investigation
• x-ray of the chest
• blood gas
• a lung profile
(lecithin:sphingomyelin
ratio and phosphatidylglycerol
level)

42. Prevention
• Administration of betamethasone to women 48 hr before the delivery
of fetuses between 24 and 34 wk of gestation
• reduces the incidence, mortality, and morbidity of RDS.
Treatment
• Early supportive care
• frequent monitoring
• Warm humidified oxygen
• CPAP
• mechanical ventilation
• Multidose endotracheal instillation of exogenous surfactant
• Inhaled nitric oxide (iNO)

43. Apnoea of prematurity
• Pause in breathing for >20s or shorter ass with O2 desaturation,
bradycardia, pallor and reduced tone.
• common problem in preterm infants.
• Idiopathic apnea of prematurity
• (-)identifiable predisposing diseases
• Most common pattern– mixed type
• Dependent on gestational age
• occurs on the 2nd–7th day of life

44. Potential Causes of Neonatal Apnea and Bradycardia

45. TREATMENT
• cardiorespiratory monitors
• Gentle tactile stimulation
• suctioning, repositioning, and bag and mask ventilation.
• Oxygen,CPAP.
• Drugs (theophylline, caffeine citrate , Doxapram)
• Transfusion of packed red blood cells
• antireflux medications ---GOR

46. Bronchopulmonary dysplasia (BPD)
• chronic lung disease
• caused by high levels of oxygen for long periods of time or with
prolonged treatment of respiratory distress syndrome using a
ventilator
• need for supplemental oxygen at 36 wk after conception

47. Diagnostic Criteria
FEATURES
OF ALL BPD
ADDITIONAL
FEATURES OF
MILD BPD
ADDITIONAL
FEATURES OF
MODERATE BPD
ADDITIONAL
FEATURES OF
SEVERE BPD
<32 wk gestational age at
birth. Oxygen requirement
for at least 28 days.
Breathing room air at 36
wk PMA or at discharge,
whichever comes first.
<30% supplemental oxygen
at 36 wk PMA or at
discharge, whichever
comes first.
>30% supplemental oxygen
and/or positive pressure
ventilation at 36 wk PMA or
at discharge, whichever
comes first.
>32 wk gestational age at
birth. Oxygen requirement
for at least 28 days
Breathing room air at 56
days of life or at discharge,
whichever comes first.
<30% supplemental oxygen
at 56 days of life or at
discharge, whichever comes
first.
>30% supplemental oxygen
and/or positive pressure
ventilation at 56 days of life
or at discharge, whichever
comes first.

48. Treatment
• nutritional support
• fluid restriction
• drug therapy
• maintenance of adequate oxygenation
• prompt treatment of infection
long-term prognosis
• weaned from oxygen before discharge –good
• Ventilator dependent (>6moth)—10-25% mortality

49. Anemia of prematurity
• Occurs at 1–3 mo after birth
• hemoglobin levels below 7–10 g/dL
• C/f-- pallor, poor weight gain, decreased activity, tachypnea,
tachycardia, and feeding problems
Causes
• blood tests,
• shortened RBC survival,
• rapid growth, and
• the physiologic effects of the transition from fetal to neonatal life.
Treatment
• Blood transfusion
• Recombinant human erythropoietin (r-HuEPO) with oral iron and
possibly vitamin E

50. Intraventricular hemorrhage (IVH)
• 32 weeks are highly susceptible
• Causes - trauma or asphyxia
• Asso: with DIC, isoimmune thrombocytopenia, and neonatal vitamin K deficiency
Treatment
• no treatment for IVH
• anticonvulsant drugs for Seizures
• transfusion with packed RBC or FFP for Anemia and coagulopathy
• VP shunt for posthemorrhagic hydrocephalus

51. Extent of IVH

52. Periventricular leukomalacia (PVL)
• Most common ischemic brain injury in premature infants.
• Occurs in the border zone at the end of arterial vascular distributions
and in the white matter adjacent to the lateral ventricles.
Diagnostic ---periventricular echodensities or cysts detected by cranial
USG.
• premature infants with PVL who develop cerebral palsy (CP),
intellectual impairment, or visual disturbances.

53. Hypoxic Ischemic Encephalopathy (HIE)
• acute problem
• swelling and irritation of the brain caused by lack of oxygen to the
brain.
• mild cases -- completely recovers
• more severe cases --permanent brain damage.
Causes
• asphyxial injury (in abruptio placenta, cord compression,
preeclampsia, or chorioamnionitis)
• Postnatal—(persistent pulmonary hypertension of the newborn,
cyanotic congenital heart disease, sepsis, and meningitis)

54. • Prognosis
• nearly 40% of infants who neonatal encephalopathy----delay deve:
• Asso: with severe hearing impairment
• Apgar scores 3/5 min or less at birth and signs of neonatal encephalopathy---
motor impairement and seizure
• onset of seizures --within the first 24 hours after birth

55. Patent ductus arteriosus
• causes abnormal blood flow between the aorta and pulmonary artery.
• Normal fullterm--closes within 3 days after birth
• 80% of preterm neonates <750 g—patent
• Asso: with increased morbidity and mortality.
Clinical manifestation
• dynamic, precordial impulse
• full pulses,
• widened pulse pressure,
• Hepatomegaly
• high parasternal systolic murmur

56. Gastrointestinal System
• not have fully developed digestive systems and processing food
• highly susceptible to inflammation of the lining of the intestines as
well as many other possible infections

57. Necrotizing enterocolitis (NEC)
• common gastrointestinal disorder of premature infants.
• etiology - unknown
• multifactorial,
• major risk factors --prematurity, enteral formula feeding, intestinal hypoxia/ischemia and
bacterial colonization
Clinical features
• Apnea
• Bradycardia
• Diarrhea
• Lethargy
• fluctuating body temperature.
• advanced cases may show fluid in the peritoneal cavity, peritonitis, or shock.

58. Diagnosis of NEC (X ray)
• Characterized by a bubbly. appearance of gas in the walls of the intestine
(pneumatosis intestinalis),
• large veins of the liver
• the presence of air outside of the intestines in the abdominal cavity.

59. Diagnosis of NEC (X ray)

60. • Treatment of NEC includes:
• stopping feeds
• nasogastric drainage
• intravenous fluids or fluid replacement and nutrition
• Systemic antibiotic
• frequent examinations and X-rays of the abdomen
• surgery

61. Infections
• 3- to 10-fold >incidence of infection than full-term
• D/t
• Maternal genital tract infection ,
• intra-amniotic infection ,
• immune dysfunction,
• prolonged intravenous access

62. • Early onset--Birth to 7 days usually <72 hr
• Organisms –
• GBS
• E coli
• Listeria monocytogenes
• Other gram (-) organism(Pseudomonas,Klebsiella,HIB)

63. • Late onset-- 7 to 90 days
• Orgnisms
• Staph.epidermidis
• E.coli
• Other Gram(-) org.(serratia,Enterobacter,Citrobacter
• Staph.aureus
• GBS and Candida albicans
• Nosocomial -- >30 days
• Antifungal prophylyxis with 2nd line AB

64. DISCHARGE FROM THE HOSPITAL
• Tolerate oral feeding
• Growth occurring at steady increments of approximately 30 g/day
• Temperature should be stabile
• no recent episodes of apnea or bradycardia
• Change IV to oral drugs
• CPR training for parents
• Before discharge - ROP assessment, hearing assessment.
• Exclude anaemia
• Body weigh - 1,800-2,100 g

65. Retinopathy of prematurity
• Risik factors - Transient hyperoxemia, hyop or hypercapnia, extreme
prem, apnoea, anaemia , sepsis, IVH, Lactic acidosis, hypoxia,
exchange transfusion
• due to the under-development of the blood vessels to the retina.
• initial screening examinations --bet: 4 and 6 weeks of chronological
age or 31 and 33 weeks of postconceptional age.
• Screen all infants born < 1.5 kg

68. Hearing
• hearing deficit increases with the degree of prematurity
• due to injury, infection or a congenital defect
• assess hearing before infants leave the NICU
• to follow up for several months afterwards
• Missed diagnosis of hearing problems significantly worsened symptoms
• Sensorineural hearing loss
• prenatal infections,
• Asphyxia
• genetic factors.
• Conducted hearing loss
• obstructions such as wax, fluid
• Rupture / puncture of the ear drum
• Auditory Brainstem Response should be done just before DC
• If abnormal, recheck should be done on 40 week post natal age or 1 month
later

69. Immunization
• According to EPI at the appropriate chronological age
• Hep-B vaccine – as early as 30 days of age regardless of gestational
age or birth weight
• Chronic lung disease – influenza vaccine at 6 month, also family
members.

70. Follow up schedule
• Up to 2 year of age
• Plan – monthly up to 6 mth
- 3 monthly up to 1 year of age
- 6 monthly up to 2 year of age
• Growth monitoring
- Length, weight, OFC
-Developmental assessment

71. References
• Gomella Neonatology 8th edition
• Cloherty 8th edition
• Rennie and Roberton’s Textbook of Neonatology
• Nelson Text book of pediatrics 21st edition
• MPS Guideline (3rd edition)

72. THANK YOU!!!