management of preterm LBW.pptx

Management of Preterm And Low Birth Weight
Dr. Raheel Ahmed FCPS Pediatrics
Children Hospital, Chandka Medical College Larkana

Definitions
Prevalent
Etiology
Assessment of gestational age
Problems of prematurity
Management
Antenatal (Prevention)
Natal (Delivery room care)
Post natal (after birth care)
Prognosis
Discharge criteria
Definitions
Term?
Preterm?
Immature?
LBW? VLBW?ELBW? ILBW?
SGA?
IUGR?
Gestational Age
Full-term
infant born after 37 completed menstrual weeks of pregnancy
Preterm (or premature) infant
infant born before 37 completed weeks of gestation
Late preterm infant (a recently identified category)
infant born between 34 and 36 weeks gestation
Moderately preterm infant
infant born between 32 and 34 completed weeks of gestation
Very preterm infant/ Early preterm
infant born before 32 completed weeks of gestation
Immature < 28 weeks
ELGAN: Extremely Low Gestational Age Newborn < 26 weeks


Weight
Low birth weight (LBW)
infant who weighs less than 2,500 grams at delivery
Very low birth weight (VLBW)
infant who weighs less than 1,500 grams at delivery
Extremely low birth weight (ELBW)
infant who weighs less than 1,000 grams at delivery
Incredible Low birth weight
infant who weighs less than 750 grams at delivery

1. Management of Preterm And Low Birth Weight Dr. Raheel Ahmed FCPS Pediatrics Children Hospital, Chandka Medical College Larkana

2. Definitions Prevalent Etiology Assessment of gestational age Problems of prematurity Management Antenatal (Prevention) Natal (Delivery room care) Post natal (after birth care) Prognosis Discharge criteria

3. Definitions Term? Preterm? Immature? LBW? VLBW?ELBW? ILBW? SGA? IUGR?

4. Full-term infant born after 37 completed menstrual weeks of pregnancy Preterm (or premature) infant infant born before 37 completed weeks of gestation Late preterm infant (a recently identified category) infant born between 34 and 36 weeks gestation Moderately preterm infant infant born between 32 and 34 completed weeks of gestation Very preterm infant/ Early preterm infant born before 32 completed weeks of gestation Immature < 28 weeks ELGAN: Extremely Low Gestational Age Newborn < 26 weeks Gestational Age Sources: Iams JD, Creasy RK. Preterm labor and delivery, Chapter 34. In: Maternal-Fetal Medicine: Principles and Practice, 5th ed., 2004; Davidoff MJ et al. Semin Perinatol 2006;30:8-15.

5. Weight Low birth weight (LBW) infant who weighs less than 2,500 grams at delivery Very low birth weight (VLBW) infant who weighs less than 1,500 grams at delivery Extremely low birth weight (ELBW) infant who weighs less than 1,000 grams at delivery Incredible Low birth weight infant who weighs less than 750 grams at delivery Source: Iams JD, Creasy RK. Preterm labor and delivery, Chapter 34. In: Maternal-Fetal Medicine: Principles and Practice, 5th ed., 2004.

6. Classification of newborns by birth weight and gestational age.

7. Low birthweight is less than 2,500 grams (5 1/2 pounds). Preterm is less than 37 completed weeks gestation. Source: National Center for Health Statistics, 2003 natality file. Prepared by the March of Dimes Perinatal Data Center, 2006. Overlap in LBW, Preterm & Birth Defects, U.S., 2003 Low Birthweight Births 7.9% Preterm Births 12.3% Birth Defects ~3-4% Among LBW: 2/3 are preterm Among preterm: more than 43% are LBW (some preterm are not LBW)

8. Definitions Prevalent Etiology Assessment of gestational age Problems of prematurity Management Antenatal (Prevention) Natal (Delivery room care) Post natal (after birth care) Prognosis Discharge criteria

9. Prevalent Worldwide ranges from 5-18%. 15 million infant born preterm around the globe. 60% occur in South Asia, Sub Saharan Africa Pakistan is 4 th number after India, China and Nigeria. Annually increase in number, 748100 annually (Dawn News2015) Pakistan: Ranges from 11.4% to 22.8%

10. All Preterm Births by Gestational Age , Preterm is less than 37 completed weeks gestation. Source : National Center for Health Statistics, 2003 natality file. Prepared by the March of Dimes Perinatal Data Center, 2006. (34 Weeks) (33 Weeks) (32 Weeks) (<32 Weeks) (35 Weeks) (36 Weeks ) 71% of PTB is at 34, 35, 36 weeks

11. Preterm Births United States, 1983-2003 Preterm is less than 37 completed weeks gestation. Source: National Center for Health Statistics, 2003 final natality data. Prepared by March of Dimes Perinatal Data Center, 2006. Percent Healthy People Objective 28 Percent Increase

12. Definitions Prevalent Etiology Assessment of gestational age Problems of prematurity Management Antenatal (Prevention) Natal (Delivery room care) Post natal (after birth care) Prognosis Discharge criteria

13. Etiology Bacterial vaginosis Smoking Nutritional factors: folate , calcium, iron Anemic Mother Asymptomatic bacteriuria Depression Domestic violence Inter-pregnancy interval Periodontal disease History of PTD Occupational risk factors Substance abuse Maternal stress Other vaginal infections: yeast, trich , GC/ Chlam Mother age: <18y, >40y years Chronic illness like diabetes, HTN, renal disease Maternal causes

14. Preterm Births by Maternal Age, United States, 2003 Preterm is less than 37 completed weeks gestation Source: National Center for Health Statistics, 2003 final natality data. Prepared by March of Dimes Perinatal Data Center, 2006. Percent

15. Etiology Uterine causes Bicornuate uterus Placenta previa , Abruptio placentae , placental dysfunction PROM Iatrogenic

16. FETAL CAUSES Fetal distress Multiple gestation Chromosomal disorders like Down syndrome Intrauterine infections like syphilis, taxoplasmosis . Erythroblastosis , Non-immune hydrops Etiology

17. Definitions Prevalent Etiology Assessment of gestational age Problems of prematurity Management Antenatal (Prevention) Natal (Delivery room care) Post natal (after birth care) Prognosis Discharge criteria

18. Assessment of gestational age Assessment tool – Mother menstrual history Prenatal U/S Postnatal maturation examination New Ballard Score Rapid visual assessment

19. Rapid visual assessment of gestational age

20. General : Weight daily , height, foc vitals Respiratory : note retractions -- grade & location Note grunting especially expiratory pneumothorax --diminished sounds on one side pulse ox Assessment

21. Silverman Score re: respiratory distress Low score= 0 distress High score= severe distress

22. Assessment Guidelines : (continued) Cardiovascular : note murmurs --location & amplitude. Apex beat -if on wrong side may indicate dextrocardia / diaphragmatic hernia . Assess Peripheral pulses . Note mottling if poor peripheral perfusion

23. Assessment Guidelines : Gastrointestinal: Abd . Distention , loops of bowel seen. Feeding tolerance - regurge , gastric aspirate ac. Blood in stools( + hemoccult test) Genitourinary: daily weight for hydration. Weigh diapers on gram scale for output. Assess for Ambiguous genitalia, preterm genitalia

24. Neurological : jittery -- immature CNS or hypoglycemia. Reflexes , head circumference, fontanels soft & flat Temperature : skin temp vs air temp S kin : irritation from all monitoring equipment/probes/IV’s/heel sticks; preterm “look” of skin: translucent, waxy Assessment Guidelines :

25. Definitions Incidence Etiology Assessment of gestational age Problems of prematurity Management Antenatal (Prevention) Natal (Delivery room care) Post natal (after birth care) Prognosis Discharge criteria

26. Problems of prematurity Immediate (Acute) Hypothermia Hypoglycemia/ Hypocalcemia RDS, Apneic Spells IVH Liver immaturity: Jaundice+ Kernicterus Infections NEC PDA  heart failure Feeding problems Anemia of Prematurity Retinopathy of prematurity Rickets(metabolic bone disease of prematurity) Long term problems Chronic Lung disease(BPD) Poor growth Cerebral Palsy Post hemorrhagic hydrocephalus Learning problems Deafness Mental sub normality

27. Problems of prematurity

28. Definitions Prevalent Etiology Assessment of gestational age Problems of prematurity Management Antenatal (Prevention) Natal (Delivery room care) Post natal (after birth care) Prognosis Discharge criteria

29. Management Antenatal/ prenatal management Encourage for Good nutrition Iron and folic acid for anemia Avoid smoking Improve ability of women to successfully use contraception-- Longer inter-pregnancy interval Treatment of underlying treatable cause

30. Causes Treatment Bacterial vaginosis Vaginal cream Oral antibiotics: MTZ/ clindamycin Rescreening Depression Screen at 1 st visit and 3 rd trimster Psychotherapy SSRI except Paxil Asymptomatic Bacteruria Urine Dr: 10 5 csf/ml Amoxicillin/ cephalexin / nitrofurantoin H/o PTB Weekly IM inj17 alpha hydroxyprogesterone caproate 250mg. begin 16-20 weeks and continue until 36 weeks Prevention of RDS Dexamethasone 12mg at 12hr interval 2 doses

31. Delivery room care Every preterm delivery should be attended by pediatrician. Proper resuscitation at birth Early stabilization of vital signs Prevention of hypothermia, hypoglycemia in delivery room <1 kg  electively intubate/ CPAP, shift to icu 1-1.5kg  shifted to NICU for observation. bCPAP >1.5 kg  KMC position and early breastfeeding/NG feeding and observe for complications Management

32. Management : After birth care

33. Management After birth care Maintain thermoneutral environment Goal is to keep maxillary temp. 36.5 - 37.5 C. Maintain temperature of nursery in range of 25-30c Providing immediate care - dry quickly, cover head with cap, replace wet blankets Preventing heat loss. Methods: Incubator Radiant heater KMC position Wrapping the baby

34. Fetus to Newborn Neurological adaptation: Thermoregulation Methods of heat loss Evaporation – wet surface exposed to air Conduction – direct contact with cool objects Convection- surrounding cool air - drafts Radiation – transfer of heat to cooler objects not in direct contact with infant

35. Effects of Cold Stress Increased oxygen need Decreased surfactant production Respiratory distress Hypoglycemia Metabolic acidosis Jaundice

36. Incubator setting Humidity 70% Temprature : >2 kg  31-33c 1.5-2kg  32-34c 1.0-1.5kg 32-35c <1kg  35-37c

37. Maintenance of fluid and electrolyte Premature needs more fluids as compared to terms Monitor for hypoglycemia, hypo- hypernatremia , hypokalemia Day of life Fluid requirement ( ml/kg/d) 1 60-80 2 80-100 3 100-110 4 120-130 5 and onward 150-180

38. NUTRITION Suck reflex : appears 32-34 weeks gestation, but cannot coordinate suck, swallow, breathe until 36 wks. Premies have poor muscle tone in lower esophageal sphincter so regurge a lot , which may lead to aspiration or vagal response of apnea Premies need calories to GROW, KEEP WARM, & to HEAL

39. Nutrition (cont’d) “Minimal enteral feedings” also called priming the gut: 0.5cc/hr of breastmilk per infusion pump to stimulate GI tract, even though most nutrition still given parenterally Breastmilk is still STRONGLY advocated Methods: Gavage feeding Spoon cup feeding Breastfeeding

40. Measuring gavage tube length. Auscultation for placement of gavage tube.

41. Nutrition Every preterm infant must receive vitamins in addition to breastmilk Vit K prophlaxis 1mg vit K at birth Vit E in dose of 25IU/day should be given to babies less than 1.5 kg or having prolong illness Iron supplementations should be started at age of 4-8 weeks at dose of 2mg/kg/d

42. Protection from infection Strict aseptic measure: Proper hand washing Cleaning of preterm Proper cord care Incubator cleaning

43. NEONATAL SKIN CARE Preterm skin is thinner, delicate, and lacks “ RETE PEGS” which anchor epidermis to dermis. Puts premies at great risk for skin tears. Limit use of adhesive tape, band aids. Do NOT use adhesive remover! Rather use warm water to remove sticky tape. Warm heels before heel sticks .

44. Skin injury r/t poor care

45. Definitions Prevalent Etiology Assessment of gestational age Problems of prematurity Management Antenatal (Prevention) Natal (Delivery room care) Post natal (after birth care) Prognosis Discharge criteria

46. Prognosis Its depends upon gestational age and birth weight In developed countries, the survival rate for 24 weeks gestation is 25%, but marked disability 5-10% of babies with less than 1500g BW have major handicap such as cerebral palsy, developmental delayed, blindness or deafness.

47. Discharge criteria A preterm infant should be taking feeding by nipple Baby should be gaining weight 10-3g/d Temprature should be stabilized in open cot There should be no recent episode of apnea or bradycardia There should be no parental drug administration; it may be converted to oral.

48. و باپ چاہتے ہوں کہ ان کی اولاد پوری مدّت رضاعت تک دودھ پیے ، تو مائیں اپنے بچّوں کو کامل دو سال دودھ پلائیں ۔ اس صورت میں بچے کے باپ کو معروف طریقے سے انہیں کھانا کپڑا دینا ہوگا ۔ مگر کسی پر اس کی وسعت سے بڑھ کر بار نہ ڈالنا چاہیے ، نہ تو ماں کو اس وجہ سے تکلیف میں ڈالا جائے کہ بچّہ اس کا ہے ، اور نہ باپ ہی کو اس وجہ سے تنگ کیا جائے کہ بچّہ اس کا ہے ۔ ۔ ۔ ۔ دودھ پلانے والی کا یہ حق جیسا بچے کے باپ پر ہے ، ویسا ہی اس کے وارث پر بھی ہے۔ ۔ ۔ ۔ لیکن اگر فریقین باہمی رضا مندی اور مشورے سے دودھ چھڑانا چاہیں ، تو ایسا کرنے میں کوئی مضائقہ نہیں ۔ اور اگر تمہارا خیال اپنی اولاد کو کسی غیر عورت سے دودھ پلوانے کا ہو ، تو اس میں بھی کوئی حرج نہیں بشرطیکہ اس کا جو کچھ معاوضہ طے کرو ، وہ معروف طریقے پر ادا کر دو ۔ اللہ سے ڈرو اور جان رکھو کہ جو کچھ تم کرتے ہو ، سب اللہ کی نظر میں ہے Thank You Surat – ul-Baqara Ayat # 233