REVIEW OF COMMON MEDICAL PROBLEMS IN THE NEONATAL INTENSIVE CARE UNIT (NICU)
By Olachi J. Mezu-Ndubuisi, M.D, O.D
1) RESPIRATORY PROBLEMS:
a) What happens when a baby is born?
When a baby is born, he or she no longer has the blood flow from the placenta and now needs to make a transition from life in the womb to the real world through a complex number of major changes in the respiratory and circulatory systems. For the baby to maintain its breaths after birth there needs to be adequate exchange of oxygen in the lungs; and so the lung vessels, chest wall, nerves and muscles need to be well developed so that the lungs are able to meet the needs of the baby with little respiratory effort.
b) Respiratory distress is described by tachpnea (fast respirations more than 60 breaths per minute), nasal flaring, chest retractions and grunting sounds by the baby. Respiratory distress may be present with or without cyanosis (pale or blue color). Peripheral or acrocyanosis is common in the newborn period and is seen by bluish –looking legs or hands in the newborn baby. Central cyanosis, however, is more worrisome and is identified by looking at the newborn baby’s tongue, lips, and trunk. Decreased oxygen saturation, apnea, or both may also be present. Irregular, gasping, or slow respiratory rates of less than 30 breaths per minute are a worrisome sign.
i) Cause: The cause of respiratory distress include: cardiac or central nervous system (CNS) abnormalities, sepsis, infection, and hematologic, metabolic; low Apgar scores, transient tachypnea of the newborn (TTN), respiratory distress syndrome (RDS), persistent pulmonary hypertension, and respiratory failure. Premature babies have more respiratory difficulties than full-term babies. C-section deliveries also increases the likelihood of respiratory problems due to retained lung fluid that occurs when these babies do not take a deep enough breath as they are born. They therefore have a delayed transition time from life in the womb to the outside world.
ii)Management: Infants with respiratory difficulties may need to be observed or transitioned in the nicu for hours to days and treated with oxygen, continuous positive airway pressure [CPAP], and mechanical ventilation as needed. A chest x-ray may be obtained to find out the cause of the respiratory distress. In the newborn, a normal chest x-ray shows complete, uniform aeration of both lung fields.
c) Respiratory Distress Syndrome (RDS): This is seen mainly in premature infants with immature lungs. The incidence of RDS varies inversely with gestational age. It occurs in up to 80% of newborns between 28 and 30 weeks of gestation. The risk of RDS is higher in Caucasians, males, infants of diabetic mothers, second born twins. Pregnancy-induced hypertension, chronic maternal hypertension, administration of corticosteroids to the mother, and premature rupture of membranes reduce the risk.
(i) Cause: It is caused by deficiency of a protein called surfactant in the lungs, which causes the air sacs (alveoli) in the lungs to collapse or to stay unopened preventing adequate air exchange and blood flow in the lungs.
(ii) Signs/Symptoms: The baby presents with respiratory distress as described above. Onset of symptoms is usually within 6 hours of birth, and if left untreated, the baby may gradually worsen over the next 2 to 3 days. Recovery over the next 3 to 5 days following treatment is accompanied by diuresis (increased urine output) of the baby.
(iii) Management: The baby with RDS is treated with oxygen, CPAP, or mechanical ventilation. Some NICUs will administer one or more doses of surfactant to improve oxygen delivery to the baby. Complications of RDs include PDA, air leak syndromes, and bronchopulmonary dysplasia (BPD).
c) Bronchopulmonary Dysplasia (BPD) or Chronic Lung Disease (CLD): This is a condition characterized by inflammation and scarring in the lungs in premature babies when they still need oxygen after 28 days of life due to their underdeveloped lungs. Babies who are born prematurely or have RDS are at risk for bronchopulmonary dysplasia (BPD). Though most infants will recover from BPD and have few health problems as they grow older like, bronchitis; BPD can be a potentially serious condition.
2) APNEA: Apnea is one of the most common respiratory problems in the premature infant that can prolong hospitalization and the need for cardiopulmonary monitoring. It is defined as absence of air flow for at least 20 seconds, or for a shorter period of time if accompanied by bradycardia (a low heart rate less than 100 beats per minute), pale (pallor) or blue color (cyanosis) in the baby.
i) The more premature the baby, the more likely for apnea to occur and the more severe the degree of apnea. Approximately 50% of infants less than 1500 grams birth weight or born before 32 weeks of age have apnea; and may require either medicine or ventilatory support to treat recurrent apneic episodes that are prolonged in duration. Apnea of Prematurity usually resolves between 34 to 36 weeks post-natal age.
ii) Apnea can cause the following things to occur in your baby: Decrease in oxygen delivery and blood flow to your baby; decrease in heart rate; and a decrease in muscle tone.
A) Types of Apnea: It is important to find out the type of apnea the baby before treatment is considered. There are three types of Apnea:
a) If no respiratory effort and no air flow, it is known as Central Apnea.
b) If reparatory effort is present, but there is no airflow, this is called Obstructive Apnea.
c) If both central and obstructive apneas occur during the same episode, this is termed Mixed Apnea.
iv) Apnea is only a symptom and can be caused by other diseases, and so various possible causes should be investigated and considered especially if it occurs more frequently than expected or at a gestational age it should not occur.
(v) In premature babies, Apnea of Prematurity is commonly seen and is a diagnosis of exclusion (if all other causes are ruled out). It usually resolves by 37 weeks of gestation; but may persist for several weeks past term.
B) Causes of Apnea include: Respiratory Distress Syndrome (RDS); Pulmonary mechanical problems such as Air leak, or Atelectasis ; Intra-ventricular Hemorrhage (IVH); Seizures; Drugs in the mothers body system during delivery ; Infectious causes like Pneumonia, Sepsis, Meningitis, Necrotizing Enterocolitis (NEC); Anemia; Metabolic Abnormalities like Hypoglycemia, Acidosis, Hyponatremia, Hypocalcemia Gastroesophageal Reflux ;; Patent Ductus Arteriosus (PDA); Cold (Hypothermia) or Hot Body Temperatures (hyperthermia) in the baby. Treatment: Institution of interventions should occur in the order of increasing invasiveness and risk.
C) Treatment: Diagnose and treat any initiating causes as above; provide stimulation to the baby, try continuous positive airway pressure (CPAP) using nasal prongs with or without methylxanthine (usually caffeine) treatment. If apnea is severe or other treatments fail, your doctors may decide to start mechanical ventilation on your baby. If apnea persists past term or at discharge of the baby; the doctor may send your baby home with an apnea monitor.
A) NEONATAL SEPSIS: In the newborn baby, this is known as any infection that occurs in the first 28 days of life. During your pregnancy, your obstetrician is frequently checking you and monitoring the baby looking for any signs of infection or sepsis. Typically the conditions that mothers have that increase the chances of their babies having sepsis are: group B strep (GBS) positive cervical cultures; STD’s like Chlamydia, gonorrhea, herpes, HIV, syphilis, or Hepatitis B. These should be screened at the first OB visit to ensure adequate treatment of the mother and prophylaxis (prevention) for the baby. However GBS screening is done between the 35th and 37th week of pregnancy. Other maternal signs or symptoms that may predict infection in the baby are maternal fever, prolonged and/or premature rupture of membranes; premature separation of the placenta from the uterine wall, foul smelling/cloudy amniotic fluid. Usually, when theses are present your Ob will request a consultation with the pediatrician or neonatologist regarding the potential for delivery and/or postpartum complications.
(i) Signs and Symptoms: Signs of Sepsis in the baby include respiratory distress or delayed transition after birth; poor feeding, vomiting; low Apgar Score (heart rate, respiratory rate and effort, skin color, temperature, and activity). An infant with a score less than 7 at five minutes needs to be monitored closely in the neonatal intensive care unit.
(ii)Diagnosis: Workup for neonatal sepsis includes blood tests including blood culture, CBC (complete blood count), CRP (a nonspecific marker of inflammation and possible infection; chest x-ray (esp. if associated with breathing problems) or other radiological studies; lumbar puncture (obtaining spinal fluid to rule out meningitis if there is significant risk of sepsis).
Antibiotics may be started till the blood culture is negative for at least 48 to 72 hrs. In some cases, the pediatrician or neonatologist may decide to treat if there is a high index of suspicion for infection. When babies have sepsis, they may be too sick to feed as well and may require tube feeding of breast milk or formula or may be keep NPO (nothing by mouth) and receive full nutritional support through TPN ( an intravenous mixture of proteins, carbohydrates, and fats). They may also require support of their blood pressure and heart function with medication if they are unstable.
B) MENINGITIS: This is a feared complication of neonatal sepsis. It is common in premature babies and is diagnosed with a spinal tap in babies with signs or symptoms of sepsis; or babies unresponsive to treatment of sepsis with antibiotics. The incidence varies from 2:10,000 to as high as 1:1000.
It can be bacterial, viral, and aseptic meningitis from enteroviral or fungal organisms; and is most often caused by vertical transmission during labor and delivery (transmission from mother to baby). It occurs most frequently in the days following birth and is more common in premature infants than term infants. Neonates are at greater risk of sepsis and meningitis than other age groups because of decreased ability to fight infections. Infants younger than 32 weeks’ gestation receive little of the maternal immunoglobulin received by full-term infants.
(i) Signs and symptoms: Temperature instability, episodes of apnea or bradycardia, hypotension, feeding difficulty, hepatic dysfunction, and irritability alternating with lethargy; Respiratory symptoms; neurologic symptoms are stupor and irritability, seizures; bulging anterior fontanel; extensor posturing; focal cerebral signs including gaze deviation and hemiparesis; cranial nerve palsies. Nuchal rigidity (neck stiffness) is the least common neurologic sign in neonatal bacterial meningitis, occurring in fewer than 25% of affected neonates (Volpe, 2001). The typical neck stiffness with meningitis is seen in older kids, not newborns.
(ii) Management: The cerebrospinal fluid (CSF) needs to be examined in the baby if meningitis is suspected. Usually in any newborn that sepsis is considered, the CSF sample is also obtained to rule out meningitis. Broad spectrum antibiotics will be started while awaiting the CSF results. Neurologic complications include vision impairment, hydrocephalus, involvement of other cranial nerves, deafness or hearing impairment, seizures and brain abscess.
C) NEONATAL PNEUMONIA: Infants can be infected in various ways in utero, during delivery or after delivery. If infected fluid is swallowed or aspirated, it can cause pneumonia. The incidence of pneumonia is less than 1% in full term infants; but as high as 10% in premature infants.
(i) Signs and Symptoms: Infants with pneumonia have respiratory distress as well as more generalized symptoms of infection, including poor feeding, temperature instability, jaundice, and lethargy.
(ii) Management: It is difficult to tell the symptoms of pneumonia and infection apart in the newborn infant, so any newborn baby that is suspected to be very ill will be screened for both sepsis and pneumonia. Pneumonia screening is done by your baby’s doctor ordering a chest x-ray and some blood work like Complete blood count (CBC), C-reactive protein (CRP) and blood culture; and spinal fluid should be obtained. Depending on the condition of the baby or presence of maternal risk factors like fever, discharge, prolonged rupture of membranes or chorioamnionitis in the mother, the pediatrician or neonatologist may cover the baby with broad spectrum antibiotics (like ampicillin and gentamycin0 while waiting for the results of the blood work. Pneumonia treatment may last from 7 to 10 days, sometimes longer depending on the baby’s condition.
4) NUTRITION AND FEEDING YOUR NICU BABY:
Breast milk is the best food for all babies and provides essential nutrients and helpful immunity to fight infections especially in premature or sick babies. But in the event that breast milk is not available or an option for the baby, there are specially made formulas for premature babies that have extra nutrients and calories to help them grow and your nicu will let you know which one is appropriate for your baby. Babies who are premature usually have ineffective sucking mechanism or are still unable to co-ordinate sucking, swallowing and breathing at the same time. Thus, these infants are not able to fully breast feed or suck a bottle. Moreover, sick term or near term babies, though bigger may be too weak ,sick , or unstable to feed orally especially if they are breathing too fast or have respiratory problems. Most of the time, it is safe and encouraged to feed premies with small amounts of formula or breast milk through a tube (gavage) as a way to introduce nutrients into the intestines to stimulate it to grow and mature faster; even if the baby needs intravenous fluids.
i) Intravenous feeding (IV): They may need to be initially fed through a catheter inserted in their vein. The site of the intravenous line (IV) can be the umbilical vessels, arm, leg veins, or sometimes scalp area. The IV solution will typically contain dextrose (a form of glucose or sugar); and most NICUs will wait 24 hours before adding electrolytes. Recent studies have shown that adding protein early in the IV solution (even on day of birth) helps improve the baby’s nutrition and growth.
Parenteral nutrition should be used when enteral feedings are not possible due to surgical conditions which preclude feeding or when enteral feedings are inadequate as in cases of severe prematurity, prolonged feeding intolerance and intractable diarrhea. Total Parenteral Nutrition (TPN) is a complex iv solution that contain numerous nutrients, minerals and electrolytes and is usually started within 24 to 48 hrs of birth. Premature babies or babies that cannot feed orally for a few days or weeks will be likely getting most of their nutritional needs from TPN. When on TPN, your baby’s doctor or nurse practitioner will order blood chemistry tests frequently to ensure a healthy and safe balance of electrolytes in the tpn.
ii) Gavage Feeding: This is used for introducing the baby’s gut or intestines to breast milk or formula gradually. A tube is inserted through the nose or mouth that typically ends in the stomach or sometimes in the intestines. The tube may be left in at all times or inserted at each feeding and removed at the end of each feeding. A baby may be on full gavage feeds or may be on some gavage feeds and iv solution. As gavage feeds are increased, the iv solution is decreased. Usually anywhere from 30 weeks to 33 weeks, the baby will be introduced to sucking on the breast or a bottle and amount of oral feeds increased till the baby can feed on demand. Then, the intravenous or gavage feeds are discontinued.
When your baby gets to full feeds, usually more calories may be given by fortifying the breast milk or formula in order to increased weight gain. A baby should gain an average of 20 to 30 grams a day.
5) NECROTIZING ENTEROCOLITIS (NEC): is the most common gastrointestinal medical and surgical emergency that mainly affects premature infants and newborns. NEC affects close to 10% of infants who weigh less than 1500 g. The mortality rates (or risk of death) from NEC in preterm infants who have extremely (<1000g) is 35-50%. Infants that have very low birth weigh (<1500g) who are diagnosed with NEC have a mortality rate of 10 to 30%.
Although it is more common in premature infants, it can also be observed in term and near-term babies. The average age of onset has been reported to be 13 to 20 days for babies born at less than 33 weeks estimated gestational age (EGA), 5 days for babies born after 34 weeks’ gestation; and term infants can develop NEC as early as the first 1-2 days of life. Studies have shown that babies who are breastfed have a lower incidence of NEC than formula-fed babies.
(i) Cause: NEC is a caused by multiple factors believed to be preceded by an ischemic or toxic event that causes damage to the immature gastrointestinal mucosa; inflammation of the intestinal tissues, the release of inflammatory mediators all of which lead to variable degrees of intestinal damage. Introducing feeds into the gut allows for bacterial growth at which time the damaged mucosa is invaded by gas-producing bacteria. This process may lead to necrosis or bowel death, which can cause perforation of the bowel or sepsis. NEC affects the GI tract and, in severe cases, can cause profound impairment of multiple organ systems.
(ii) Signs and Symptoms: Initial symptoms may be subtle and can include one or more of the following: Feeding intolerance increased gastric residuals and delayed gastric emptying, abdominal distention, abdominal tenderness, decreased bowel sounds, blood in stools, stomach wall redness or dark color (advanced stages), and visible intestinal loops on the abdomen. Systemic signs are nonspecific and can include any combination of the following: Increased apneas and bradycardias, Lethargy, decreased peripheral perfusion (poor leg or arm color), shock or low blood pressure (in advanced stages); coagulopathy (profuse bleeding)
(iii) Lab Work: The doctors or nurse practitioners may order certain labs that may indicate signs of NEC like CBC, Blood culture, CRP. Abdominal x-rays may show dilated loops of bowel, pneumatosis intestinalis (air in the wall of the bowel), free abdominal air (a sign of perforation of the bowel), and other signs of systemic infection, including shock and acidosis.
(iv) Treatment: Treatment should be started as soon as NEC is suspected. It includes withholding feeds and making the baby NPO (nothing by mouth) for a period of time usually 7-10 days or longer, thus, requiring them to receive TPN. A nasogastric (NG) tube is inserted to provide intermittent suction for decompression. IV fluids are used to correct any electrolyte abnormalities. Due to need for prolonged parenteral nutrition, central venous catheters may be placed like a PICC line or Broviac line. These however have certain risks and complications like blood clots and infections. Clinically, these babies are very difficult to distinguish from infants with sepsis. Serial abdominal x-rays are ordered every few hours to monitor the baby for intestinal perforation. Broad spectrum antibiotics are started since bacteria are also responsible for NEC. Medical management is successful in about 80% of these patients; but surgery is indicated when medical management fails or perforation of the intestines occurs or is suspected.
(a)Prolonged TPN and absence of nutrition in the gut can cause liver problems or cholestasis and other metabolic complications.
(b) In severe cases of NEC, the bowel may be dead or perforated requiring surgery to resect or cut off part of the dead bowel. In undetected, NEC can be a potential life-threatening condition and progresses fast. So often, your baby’s feedings may be stopped, held or slowed if there are any suspicions of feeding intolerance or NEC.
(c)Depending on the location and extent of the bowel removed, long-term problems can include the need for ileostomy and/or colostomy ( the intestines are guided outside the abdomen and its contents empty into a pouch for a period of time), repeated surgical procedures to reanantomose (reconnect ) parts of bowel or remove more segments of bowel.
(d)Other problems from surgery are short gut and malabsorption syndromes, failure to thrive due to suboptimal nutrition, and multiple hospitalizations.
(e)Some babies will need liver or intestinal transplant.
6) CARDIAC PROBLEMS
(A)Murmurs: Heart murmurs may be heard in your newborn baby and are not always a cause for concern. They may be heard shortly after birth and may persist for days or weeks; or sometimes through childhood. If they are not associated with any color changes or cyanosis, feeding difficulty or breathing problems, they are usually innocent murmurs; and your baby’s doctor will reassure you. Murmurs associated with illness in the baby or worrisome symptoms will be investigated with an echocardiogram of the heart (echo) to determine the cause.
(B) PDA: Patent ductus arteriosus (PDA) is a heart problem that occurs soon after birth in some babies; and is the sixth most common congenital heart defect, occurring in 5 to 10 percent of all children with congenital heart disease.
In PDA, there is an abnormal flow of blood between two of the major arteries near the heart: the aorta and the pulmonary artery. Before birth, these two arteries are normally connected by a blood vessel called the ductus arteriosus, which is an important part of the baby’s circulation in the womb. Usually, this ductus closes within 72 hrs to a few days or weeks after birth; but in premature babies, it may stay open longer causing extra blood to flow into the lungs from the heart and cause severe respiratory problems.
(a) Lab findings: A chest x-ray shows an enlarged heart and increased pulmonary markings. Echo reveals more detailed anatomy of the PDA and gives an estimate of the pulmonary artery pressures.
(b) Treatment: It may be treated by restricting the amount of fluids the baby is getting; or sometimes medications like indomethacin (indocin) or ibuprofen are given to the baby. If repeated treatments with medications fail or there is severe respiratory (e.g. a high oxygen requirement) or cardiac compromise, the ductus may be surgically ligated.
7) JAUNDICE: This is a condition where the skin and the sclera (white of the eye) have a yellow color caused by excess amount of bilirubin in the blood. Bilirubin is produced by the normal breakdown of red blood cells; and would normally be circulated through the liver and excreted as bile through the intestines. But when bilirubin builds up faster than the liver can break it down or body can excrete it, it causes the yellow discoloration on the skin.
Jaundice is very common in newborns, especially premature babies, because they make more bilirubin than adults do since they have more turnover of red blood cells; or due to their liver still being immature.
High levels of bilirubin can be toxic to the body tissues and brain damage, cerebral palsy, and deafness. The American Academy of Pediatrics (AAP) recommends that all infants should be checked for jaundice shortly after birth usually within a few days of birth. In babies who are very jaundiced and with high levels of bilirubin, it may be necessary to place them under a special blue light called phototherapy which breaks down the bilirubin into a more soluble form that can be easily excreted by the baby.
(A)Types of Jaundice and Treatment
i) Physiological (normal) jaundice: this is mild jaundice that occurs as a result of the immaturity of the baby’s liver and appears in newborns 2 to 4 days of age and disappears when the baby is about one to two weeks old. Usually this requires no treatment, but the pediatrician may still draw the bilirubin levels to determine how high it is. Very high levels in the first 24 to 48 hrs may need to be treated with phototherapy.
ii) Breastfeeding jaundice: jaundice can occur when a breastfeeding baby is not getting enough breast milk because the baby is having a difficult time with the breastfeeding or because the mother’s milk is not yet “in”. This means that the baby is not getting enough to drink and is therefore not able to excrete the bilirubin fast enough. In the hospital, lactation specialists or nurses can assist the mother with getting the baby to latch on well to the breast; or sometimes, the mother may need to supplement breastfeeding with some formula till her milk is “in”. This usually controls the jaundice and it resolves without treatment. In very jaundiced babies, getting a bilirubin level may be needed to be safe.
iii) Breast milk jaundice: In 1% to 2% of breastfed babies, jaundice may be caused by substances produced in their mother’s breast milk that can cause the bilirubin level to rise and this prevents the excretion of bilirubin through the intestines. It may start after the first 3 to 5 days and slowly improves over 3 to 12 weeks. Usually, no treatment is needed.
iv) Jaundice of prematurity: occurs frequently in premature babies since they are even less ready to excrete bilirubin well. Jaundice in premature babies needs to be treated at a lower bilirubin level than in full term babies in order to avoid complications.
v) Blood group incompatibility (Rh or ABO problems): This occurs when a baby has a different blood type than its mother, and the mother produces antibodies that destroy the infant’s red blood cells. This causes a rapid buildup of bilirubin in the baby’s blood causing the baby’s skin to be jaundiced. Jaundice from ABO Incompatibility can begin as early as the first day of life and is usually treated by phototherapy and serial measurements of the bilirubin level in the baby. Rhesus incompatibility (Rh) can cause a severe form of jaundice in babies with the rhesus antigen if there mothers do not have the antigen but have been previously exposed to it in a prior pregnancy. Rh problems in babies can now be prevented with an injection of Rh immune globulin to the mother within 72 hours after delivery, which prevents her from forming antibodies that might endanger any subsequent babies.
8)ANEMIA: Anemia can occur due to inadequate production of red blood cells, a shorter red blood cell life span, and blood loss. After birth, all infants have a decrease in their hemoglobin level (a component of their red blood cells). In full term infants, a physiologic and usually asymptomatic anemia occurs at the age of 8-12 weeks, and in premature babies, this anemia can occur earlier (4 to 10 weeks) and can be more severe; but resolves by 3 to 6 months. Your baby in the NICU will get frequent heel pricks to test for the hemoglobin and hematocrit level, sometimes this is done weekly.
(i) Clinical Signs and Symptoms: Inadequate weight gain and poor growth; pale skin, decreased activity, tachycardia (fast heart rate);a murmur; poor feeding and growth.
(ii) Treatment: Usually, unless the baby is having worrisome symptoms, anemia in the newborn may not be treated right away. When your baby gets to full feeds, oral iron supplementation may be started. Blood transfusions may be needed in sick babies or those on high level of oxygen on the ventilator to increase the oxygen carrying capacity of their red blood cells. Blood transfusions should be used with caution and only when necessary because of risk of transfusion reactions which can be life-threatening and risk of transmitting infectious diseases through transfusions.
9)Persistent pulmonary hypertension of the newborn (PPHN) : is a disorder of the heart and lungs that occurs when increased resistance in the lung vessels makes them unable to relax like they should when the baby takes its first breaths after birth. This prevents adequate oxygen to flow to the heart and the rest of the body and results in diversion or shunting of blood flow in the lungs to the rest of the body circulation through persistence of a vessel that connects the heart to the lung( ductus arteriosus) or opening between the two upper chambers of the heart (foramen ovale). Therefore these babies have high blood pressure in their lungs and cannot breathe well.
Babies with congenital heart defects or birth defects are at risk for PPHN. This condition is most often associated with perinatal asphyxia in 50-70% of reported cases; and is usually noted in term or near term infants. Other conditions associated with this syndrome include hypoglycemia (low blood sugar) and sepsis.
(i)Signs and Symptoms: The baby presents clinically with cyanosis, tachypnea and respiratory distress, but with minimal retractions during the first day of life. The infant’s chest x-ray may be normal or demonstrate various abnormalities compatible with aspiration, pneumonia, diaphragmatic hernia, or hyaline membrane disease. Low blood pressure is a finding in advanced disease due to heart failure. The diagnosis is confirmed with an echo.
1. Babies with PPHN often need oxygen and a ventilator may be used to help them breathe.
2. Blood pressure and perfusion need to be maintain
3. A trial of Nitric oxide(NO) gas may be given to the babies through a breathing tube. This treatment may help the blood vessels in the lungs to relax and improve breathing.
10) Respiratory Syncytial Virus (RSV) is a major cause of respiratory illness affecting the lungs and airway passages in young children that can lead to life-threatening illness, especially in premature babies and kids with diseases that affect the lungs, heart, or immune system.
RSV is very contagious, and can be spread by coughing or sneezing droplets that contain the virus. It can also be spread by contaminated hands and surfaces; and spreads fast through daycares and schools. Most kids by the age of 2 yrs are infected with RSV, and it is difficult to distinguish it initially from a common cold. RSV often occur from late fall through early spring. The illness may last a week or longer, but some cases may last several weeks.
To prevent serious RSV-related respiratory disease, at-risk kids can be given a monthly injection of a medication consisting of RSV antibodies during peak RSV season; and repeated in subsequent years as long as the child is at high risk for severe RSV.
Two medications RespiGam® and Synagis® (palivizumab) are currently FDA-approved for prevention of Respiratory Syncytial Virus disease in high risk infants.
(i)The following children are at risk for severe RSV infection and will benefit from prophylaxis:
• Infants with significant respiratory illness within the last 6 months and who are <2 years of age at the onset of the RSV season.
• Infants born at <28 weeks gestation who are <12 months at the onset of the RSV season.
• Infants born at 28-32 weeks gestation who are <6 months at the onset of the RSV season.
• Infants born at 32-35 weeks gestation who are <6 months old at the onset of the RSV season and have at least two risk factors (exposure to environmental air pollutants; child care attendance; school-aged siblings; congenital airway abnormalities; severe neuromuscular disease; persistent hospitalization on an inpatient ward; Native American Indian)
• Infants <2 years of age at the onset of the RSV season with significant congenital heart disease.
11) Periventricular Hemorrhage- Intraventricular Hemorrhage (PVH-IVH) : is a significant cause of both morbidity and mortality in infants who are born prematurely. It is caused by bleeding of the capillaries (tiny blood vessels) in the area of the baby’s developing brain called germinal matrix. Fluctuations of blood flow in the brain as a result of rapid changes in blood pressure and some metabolic abnormalities, or rapid infusion of volume to the baby, can lead to increased bleeding of the capillaries in or around the ventricles (fluid-filled chambers in the brain). Prematurity is the most important risk factor for IVH.
PVH-IVH is diagnosed primarily through the use of brain imaging studies, usually cranial ultrasound. Because PVH-IVH can occur without clinical signs, screening and serial examinations are necessary for the diagnosis.
PVH-IVH can be classified into 4 grades of severity based on their ultrasound appearance with grade I being mild bleed and grade 4 is the most severe bleeding with dilation or widening of the ventricles.
• Grade I – Minimal to mild bleeding within the germinal matrix.
• Grade II – Mild Bleeding in the ventricles without enlargement.
• Grade III – Moderate Bleeding in the ventricles causing enlargement.
• Grade IV – Severe Bleeding or hemorrhage in the brain substance or parenchyma.
(i)Signs and symptoms: Most babies are asymptomatic or may show subtle signs that are often overlooked like: a sudden unexplained drop in hematocrit levels (anemia) along with findings related to anemia (e.g., pallor, poor perfusion); metabolic acidosis, glucose instability, respiratory acidosis, apnea, decreased tone, and stupor;, signs of respiratory distress like retractions and tachypnea, and altered mental status (e.g., decreased responsiveness, coma). Other neurological signs that may be seen include fullness of the fontanels, seizures, and posturing. Progression can be rapid and may result in shock and death.
(ii)Management: Any presenting electrolyte abnormality should be corrected. Immediate relief of pressure in the ventricles may need to be performed with a spinal tap or ventricular tap (directly through the soft spot on the head); but this is short-lived and may need to be repeated until surgery can be done. A shunt may be placed to drain excess cerebrospinal fluid into the abdominal cavity in the case of associated hydrocephalus.
(iii)Complications: Sequelae of PVH-IVH include life-long neurological deficits, such as cerebral palsy, developmental delay, mental retardation and seizures. Though the knowledge that your baby has IVH can be devastating, remember that premies are still developing and their brains have a lot of resilence. As long as your baby is stable or clinically improving significantly, he may recover from a brain bleed with little or no sequelae.
12) NEURO-DEVELOPMETAL OUTCOMES:
Families and caregivers of preterm infants and those threatened with preterm delivery face two heart-aching unknowns: Will my child survive? And if so, will there be any long-term developmental problems? These considerations guide the parents and clinicians in their decision making about how aggressive to be in treating premature babies.
Between 20 and 32 weeks after conception, there is rapid brain growth and development occurring in the unborn baby; thus illness, under nutrition, and infection during this time may compromise neurodevelopment leading to serious neuromotor problems (mainly cerebral palsy), visual and hearing impairments, learning difficulties, psychological, behavioral, and social problems.
Significant advances in perinatal and neonatal medicine in the last decade have resulted in increased survival of extremely premature infants. Survival rates for infants born in tertiary perinatal and neonatal care centers in the US increase with each week of gestational age of the baby. Note that factors like twin pregnancy, male sex, severe IUGR, placental insufficiency from pre-eclampsia or other conditions after placental blood flow may reduce the rates below.
(i)Reported survival rates varies based on the gestational age:
a.22 wks range from 0% to 21%.
b. 23 wks range from 5% to 46% and
c. 24 weeks range from 40% to 59%.
d. 25 weeks range from 60% to 82% and
e. 26 weeks from 75% to 93%, respectively.
(ii) The survival rate also varies with birth weights ranges:
a. From 501 g (1.1 lb)to 1500 g (3.3 lb) is 85%.
b. 501 to 750 grams (1.10-1.65 lb) is 55%.
c. 751 to 1000 g is 88%
d.1001 to 1250 g (2.2-2.75 lb) : 94%
e. 1251 to 1500 g: 96%.
Majority of extremely premature infants who do survive will be free of major disability. Studies of infants < 750 to 1,000 grams birth weight anticipate that approximately half of all extremely premature survivors will have one or more subtle neurodevelopmental disabilities in the school and teenage years.
(iii) Prevalence of neuromotor and sensory findings at 18 months in extremely low birth weight (elbw) infants:
a. Abnormal neurological examination—25% .
• Cerebral palsy—17%
• Seizure disorder—5%
• Hydrocephalus with shunt—4%.
b. Any vision impairment—9%
• Unilateral blindness—1%
• Bilateral blindness—2%
• Needs hearing aids—3%
(iv)Out-patient Follow-up of NICU Graduates:
(a)When your baby is getting ready to be discharged you will hear about the NICU follow-up clinic; if not, do ask your baby’s doctor, nurse practitioner or case manager about it. This is a clinic that co-ordinates all the neuro-developmental and health needs of the babies that have been discharged from the NICU. In the nicu follow-up clinic, you will be seen by a multi-disciplinary team including neonatologist, developmental pediatrician, physical and occupational therapists, psychologists; and you will have access to any other services your baby may require like audiology, nutrition, etc. During the visit your child’s sub-specialty appointments like cardiology, eye appointments, surgery etc are reviewed.
Your NICU may have a clinic affiliated with them or may recommend one for your baby on discharge. It is therefore important that all premature babies on discharge from the NICU get regular neurodevelopmental assessments; sometimes every 3 months to ensure that the baby is reaching his or her milestones. If not, during the neurodevelopmental visit, any problems with low tone (hypotonia) or increased tone (hypertonia) of the muscles can be identified. Physical Therapy is recommended for any tone abnormality and can be given weekly, bi-weekly or monthly depending on severity.
(b)Ask your pediatrician about the Infants and Toddlers Program in your community. It is a free program that can be co-ordinated through NICU follow-up clinics or NICU’s before discharge. The therapists come to your home to provide physical, occupational therapy etc. depending on the needs on your child. They can also identify any handicaps or developmental tasks or areas your child may need help with. They are also a great support system for families as they have play dates or social support gatherings with other parents that have nicu babies.
13) Retinopathy of Prematurity (ROP) :
Is one of the leading causes of blindness in children all over the world. It is a proliferative disease that affects immature retinal blood vessels in premature infants. It varies from a mild form with no minimal visual deficits to a more aggressive form with new blood vessel formation (neovascularization), which can progress to retinal detachment and blindness. Increased survival of preemies in the past few decades has led to increase in the number of babies who require ROP screening. Approximately, 27,000 infants of extremely low birth weight are born annually, of which 74% will survive. ROP occurs in 16% of all premature births. Incidence of ROP is inversely proportional to birth weight. It occurs in 65.8% of infants < 1500gms and in 81.6% of infants < 1000gms. Annually 500 -700 children become blind due to ROP in the U.S.
(i) RISK FACTORS for ROP: High levels of supplemental Oxygen, weight less than 1500gms; Respiratory distress Syndrome; concurrent illness; anemia; seizures; sepsis; High CO2 levels; multiple Apnea/ Bradycardia; Mechanical Ventilation (especially duration of intubation); blood transfusions; Intraventricular hemorrhage; multiple prenatal maternal factors (heavy smoking, diabetes, pre-eclampsia)
(ii) INTERNATIONAL CLASSIFICATION OF ROP
1. Stage describes the extent and degree of retinal scarring.
• Stage 0: Mildest form.
• Stage 1: Demarcation Line
• Stage 2: Intraretinal line
• Stage 3: Ridge with extraretinal fibrovascular proliferation
• Stage 4: Subtotal retinal detachment (partial).
• Stage 5: Total Retinal Detachment.
2. Zone : Location relative to the optic nerve and affected area of the retina.
• Zone I: Area centered on the optic disc and extending from the disc to twice the distance between the disc and the macula.
• Zone II: A ring, concentric to Zone I, extending to the edge of the retina on the side of the eye toward the nose.
• Zone III: The remaining crescent area of the retina toward the side and away from the nose.
(iii) TREATMENT OF ROP: Treatment should generally be done within 72 hours of determination of treatable disease to minimize the risk of retinal detachment.
• Observation: Stage 1 and 2.
• Laser Photocoagulation: Eliminates abnormal vessels to prevent retinal detachment (RD). Stage 3
• Cryotherapy: Uses a cold probe on the sclera and causes freezing on the retinal surface. Used in Stage 3.
• Scleral Buckle: A silicone band is tightened around the equator to produce a slight indentation on the inside of the eye. This prevents the vitreous gel from pulling on the retinal scar tissue, and allows the retina to flatten back. Done in Stage 4 & 5 ROP.
• Vitrectomy: Done only in Stage 5. Vitreous is removed and replaced with saline in order to maintain the shape and pressure of the eyeball.
(iv) COMPLICATIONS OF ROP:
a. Despite progress in ROP treatment, it still poses a significant risk (about 2.1%) of blindness to infants <1,251 grams even with aggressive treatment.
b. 20% will develop strabismus or refractive error by 3yrs of age causing loss of depth perception.
c. Incidence of glaucoma (10%)
d. Retinal Detachment (3%).
e. 5.1% of preemies with birth weight < 1251 grams will have vision of 20/200 or worse after 5 and 1/2 yrs of follow-up. Thus, infants < 32wks or <1500g get follow-up care every 6 months whether or not ROP is present.
(v) Recommendations for Screening of premature infants for ROP
a. Infants with a birth weight < 1500 g or GA of 30 weeks or less
b. Selected infants with a birth weight 1500 – 2000 g or GA> 30 wks with an unstable clinical course, including those requiring cardio respiratory support and who are believed by neonatologist to be at high risk.
c. The incidence of any degree of ROP among infants with a GA > 30 weeks has been estimated to be at least 2%. On average, neonates require from 2 to 9 ROP exams. One examination is sufficient only if it unequivocally shows the retina to be fully vascularized in each eye.
(vi) Duration of Follow-up: How long do you keep screening infants for ROP if they are at risk? This should be based on the gestational age of the baby and the severity of retinal findings seen. The eye exams are done until full retinal vascularization and no ROP is seen, OR FULL REGRESSION. Most kids with significant disease are seen for serial exams over months and years depending on their severity.
Written By Olachi Mezu-Ndubuisi, MD, OD
Excerpt from Making the NICU a home and safe haven – a manual of neonatal care for parents and staff. © Black Academy Press, Inc; 2009.
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