FOLLOW UP OF THE NICU GRADUATESeptember 14, 2010

Lynn T. Tran, MD and Jeffrey W. Surcouf, MD

CASE PRESENTATION-O.N. O.N. is a 27 WGA female who was admitted to the

NICU for prematurity and resp distress. She comes to you for a F/U clinic visit.

What are some things you want to know?

Maternal labs and prenatal course were noncontributory.

90 day hospital course notable for Short duration of intubation

Quick wean to room air Feeding difficulties

Reflux treated with Ranitidine

Pt discharged home stable on RA with a prescription for Ranitidine and Enfacare/EBM ad lib.

O.N. (CONT.)

Previous visits were unremarkable. Today, she presents to your office 2 months

after D/C with the mother complaining that she is not feeding well. What are some things that you should ask?

Poor feeding (taking appropriate amount with increased effort and spits)

Increased fussiness with feeds Difficulty sleeping

PE was normal.

What is the diagnosis?

REFLUX Incidence is high in preemies.

Important to distinguish between functional and pathologic reflux

Functional Pathologic

Limited episodes of emesis

Excessive episodes of emesis

Appropriate wt gain Poor wt gain

No evidence of esophagitis

Hoarseness, sleep disturbances, irritability, hematemesis

No resp sx Wheezing, recurrent aspiration, chronic cough, stridor

No neurobehavioral sx Sandifer syndrome

No long term effects Oral aversion, esophageal stricture, FTT

REFLUX (CONT.)

Frequency: Mild GER

Term: 40-65% Course: 55% resolve by 10 mos; 99% by 2 yrs

Preemie: similar to term infants Pathologic:

Term: 6-7% Preemies: 3-10%

REFLUX (CONT.)

Risk factors: Prematurity Perinatal depression Sepsis Congenital

anomalies Neurologic

impairment h/o ECMO

REFLUX (CONT.)

Pathophysiology Relaxation of LES Sluggish esophageal motility CNS disorder Increased abd pressure Decreased gastric compliance Anatomic

Decreased acute angle of the esophagus into the stomach

Abnormal diaphragmatic activity Delayed gastric emptying

REFLUX (CONT.)

Management: Mild:

Conservative therapy Moderate to severe:

Pharmacologic therapy Histamine-2 antagonists

Ranitidine Proton pump inhibitors

Omeprazole Prokinetic

Metoclopramide Erythromycin

Not routinely used

First line of tx

REFLUX (CONT.)

Diagnostic testing pH probe Modified barium swallow study

Assesses ability to tolerate different formula consistencies

Endoscopy

O.N. (CONT.)

Upon further questioning of the parents, you realize that the dosage of Ranitidine had not been increased for the infant’s weight gain. Ranitidine dose adjusted with improvement in

pt’s sx.

Remember!!! Course: 55% resolve by 10 mos; 99% by 2 yrs Try to let infant outgrow the dose and monitor

clinically for sx

O.N. (CONT.)

During the examination, the mother says, “Enfamil is so much cheaper and easier to obtain. Why is my baby still on Enfacare?”

Your response?

Compared to term formula, postdischarge formulas (Enfacare or Neosure) contains?? Increased amount of protein with sufficient

additional energyContains extra Ca, P, Zn

Necessary to promote linear growth

Additional vitamins and trace elements

O.N. (CONT.)

“Ok. Since Enfacare is better for my baby, how long does she have to stay on that formula?”

The AAP recommends: “The use of postdischarge formula to a postnatal

age of 9 months results in greater linear growth, weight gain, and bone mineral content compared with the use of term infant formula.”

O.N. (CONT.)

“What about soy formula?”

The AAP recommends: Do not use soy formula for:

Preemies weighing < 1800 grams Prevention of colic/allergy Infants with cow milk protein allergy

O.N. (CONT.)

As the mother is preparing to leave, she mentions, “My best friend says that my baby should be on vitamins. What do you think about that?”

THE AAP RECOMMENDSBreast Fed Formula Fed

Vitamin D 400 IU/d beginning in 1st few days of life

400 IU/d if ingesting < 1 L/d

Iron 2 mg/kg/d at 1 mo until 12 mos

May benefit from 1 mg/kg/d until 12 mos (Most formulas including PDF supply 1.8 mg/kg/d)

Calcium Consider HMF or MVI

Adequate amounts in PDF

Fluoride 0.25 mg/d in areas with < 0.3 ppm for those > 6 mos

0.25 mg/d in areas with < 0.3 ppm for those > 6 mos

CASE PRESENTATION-A.N. A.N. is a 25 WGA male who was admitted to the

NICU for prematurity and resp distress. He presents to your office 1 month after D/C.

What are some things you want to know?

Maternal labs were negative but mother suffered preeclampsia precipitating preterm delivery.

150 day hospital course notable for Long duration of intubation

Wean to HFNC then to RA Apnea of prematurity

Treated with Caffeine Abnormal sleep study prior to D/C confirming

AOP

Pt discharged home stable on RA with a prescription for Caffeine and with an apnea monitor.

APNEA Apnea is defined by

Cessation of air flow > 20 sec < 20 sec accompanied by bradycardia or

cyanosis

How is this different from periodic breathing? Periodic breathing is defined as ≥ 3 respiratory

pauses of ≥ 3 sec with intervening episodes of respiration < 20 sec

Types Central Obstructive Mixed-most common

APNEA OF PREMATURITY

Incidence inversely related to GA 100% between 24-29 WGA 50% between 30-32 WGA 25% between 34-35 WGA

Usually begins in 1st 2 DOL

When does it end? By 37 weeks postmenstrual age in infants

delivered ≥ 28 WGA Some infants continue to have apnea beyond 40 weeks

postmenstrual age.

A.N. (CONT.)

During the examination, the mother asks, “When can I stop using the Caffeine?”

What are some questions that you should ask? How often has the monitor gone off? When it has gone off, what did the baby look

like? How abnormal was the sleep study? What is the corrected gestational age of the

baby? What dose of Caffeine is the baby receiving?

CAFFEINE Mechanism of action:

Stimulatory effects on the brainstem via increasing cAMP levels

May increase diaphragmatic contractility

Dosing: Loading dose: 20-25 mg/kg IV/PO Maintenance: 5-10 mg/kg/d IV/PO Q24

Therapeutic levels: 5-25 mcg/ml

Side effects: Tachycardia, restlessness, vomiting May worsen reflux

CAFFEINE (CONT.)

Discontinuing Caffeine: If having events

Consider checking Caffeine level and optimize dose if subtherapeutic

No events Trial off of Caffeine Continue on home apnea monitor

A.N. (CONT.)

The mother wants to know how long he has to be on the apnea monitor and states that it is inconvenient and drives her crazy.

APNEA MONITORS

In general, when should you be able to discontinue the apnea monitor? In infants 43 to 46 weeks postmenstrual age or

in older infants after 1 month of clinically irrelevant events.

If no recent events, discontinue at least 2-4 weeks after stopping Caffeine.

If the infant had an abnormal sleep study, consider repeating the study prior to stopping the monitor. This is a clinical decision with no scientific

evidence to support the use of sleep studies or home apnea monitoring!

APNEA MONITORS (CONT.)

Monitors should not be used for healthy preemies with a previous hx of AOP.

Consider monitors for those infants with persistent apnea being sent home on Caffeine or in those infants with isolated, infrequent As/Bs.

Alarm settings: HR:

Low: 60 – 80 bpm High: 220 bpm

Apnea: 20 sec

HOME OXYGEN USE

Will need concurrent care with Pulmonology to help with discontinuing oxygen

CASE PRESENTATION-C.W.

C.W. is a 24 WGA male who was admitted to the NICU for prematurity and resp distress. He presents to Developmental Clinic 3 mos after D/C.

What are some things you want to know?

Maternal labs were negative, but mother presented with preterm labor.

Nearly 1 year hospital course notable for multiple complications particularly

Grade IV bilateral IVH

Pt discharged home on O2 with seizure medications and close neurosurgery follow-up.

C.W. (CONT.)

The mother wants to know if it is ok that her baby is not walking as he is now 13 mos old.

Thoughts?

Consider pt’s corrected age Majority will correct by 1 year of age However, correction for developmental

milestones may be continued until 2 years of age.

What are the risk factors for abnormal development?

EARLY INTERVENTIONS Candidates:

High risk infant Neurologic condition

IVH PVL Seizures

Visual impairment Hearing loss

At risk infant BW < 1200g GA < 32 weeks Total hospital stay > 25d APGARS < 5 at 5 min IUGR SGA

The high risk infant and the at risk infant have the potential for abnormal outcomes…normal HUS does not guarantee normal outcome, nor does abnormal HUS guarantee abnormal outcome.

Helping parents understand and cope with this (must be patient) is one of the challenges we face.

EARLY INTERVENTION

Can be accomplished through Developmental clinic School based intervention Early Steps via parish

Multidisciplinary care Neurology PT/OT/Speech Psychology

CASE PRESENTATION-S.W. S.W. is a 27 WGA male that was admitted to the

NICU for prematurity and resp distress. On initial D/C follow up, infant was noted to be gaining weight and doing well.

What are some things you want to know?

Maternal labs were negative, but mother presented with placental abruption.

2.5 month hospital course Short intubation period Prolonged use of supplemental O2 via HFNC Stage 2 Zone 2 ROP Multiple courses of Abx due to sepsis

Pt discharged home on RA and PolyViSol with Fe.

S.W. (CONT.)

Upon perusal of the D/C Summary you note: Newborn screen was drawn on DOL 1 and was

found to be normal. Does this reassure you? What else should you be asking?

Hepatitis B was given prior to discharge.

BAER was equivocal.

NEWBORN SCREENING

New state of Louisiana recommendations Premature, LBW, or sick infants

Upon admit to the NICU Hemoglobins, GALT, biotinidase enzymes and

provide baseline amino acids and acylcarnitines 48-72 hours of age

Only if 1st NBS collected < 24 hours of age 28 days of age or upon discharge

Thyroid, later onset CAH and homocystinuria in preemies

NEWBORN SCREENING (CONT.)

Term infants All should be screened prior to discharge but no later

than 7 days of age. However, risk of false negatives if screened < 24 hrs of

age. Repeat between 1-2 wks of age but no later than 3

wks of age

NEWBORN SCREENING (CONT.)

If a specimen is collected after a blood transfusion, repeat testing should be performed: 3 days after transfusion

To detect congenital hypothyroidism, CAH and metabolic disorders detected by MS/MS

And 90 days after last transfusion To detect sickle cell disease, biotinidase

deficiency, galactosemia and cystic fibrosis

NEWBORN SCREENING (CONT.)

What about feeds? Some programs recommend waiting 48-72 hrs

after PN Based on the new recommendations, the timing

of feeds does not matter.

IMMUNIZATIONS

Medically stable preemies should receive all routine vaccinations at the same chronologic age as recommended for full term infants.

IMMUNIZATION SCHEDULE

CATCH UP IMMUNIZATION SCHEDULE

IMMUNIZATIONS Palivizumab (Synagis)

1st dose given during 1st week of November 5th (last) dose given in March

Indications: Infants with chronic lung dz ≤ 24 mos of age who receive

tx within 6 mos before the start of RSV season (max of 5 doses)

GA ≤ 28 WGA who are ≤ 12 mos of age at start of RSV season

≥ 28 WGA or ≤ 32 WGA who are ≤ 6 mos of age at the start of RSV season (max of 5 doses)

> 32 WGA or ≤ 35 WGA who are ≤ 3 mos of age or born during RSV season with risk factors (max of 3 doses) Daycare OR School aged siblings (< 5 yrs)

www.cdc.gov

S.W. (CONT.)

In addition to Developmental Clinic, what other appointments should you make for this infant? Audiology Ophthalmology

HEARING SCREEN All infants should receive BAER or OAE in the

NICU prior to D/C. Infants should have repeat screens at 12 months

of age if < 32 WGA. F/U every 6 months after the last hearing screen

until 3 yrs of age if at risk for late onset or progressive hearing loss In utero infection Hyperbilirubinemia ECMO PPHN Syndromes Head trauma Prolonged use of ototoxic medications

FINAL THOUGHT

Infants are discharged from the NICU with potentially obvious, treatable medical problems.

The parents, however, may be left with less-obvious emotional difficulties due to having an NICU graduate.

FINAL THOUGHT Parents experience, among others:

Guilt Fatigue Anxiety and emotional disturbances Financial difficulties…time away from work, medical

expenses Marital stress Family stress…what do you tell older siblings?

These feelings don’t go away immediately on discharge.

Some families cope better than others.

As the PCP, it is important to understand these feelings and to support not only the patient, but the family as well. It is important to know where to refer these families if they need more support.

REFERENCES http://www.cdc.gov http://www.dhh.louisiana.gov/offices/?ID=263 Brodsky, D. and Ouellette, M. Primary Care of

the Premature Infant. Saunders Elsevier: 2008. Chandran, L. and Gelfer, P. Breastfeeding: The

Essential Principles. Pediatrics in Review. November 2006: 409-417.

Gomella, T. Neonatology. McGraw-Hill: 2004. Kleinman, K. Pediatric Nutrition Handbook.

American Academy of Pediatrics: 2009. Vanderbilt, D. et al. The Do’s in Preemie

Neurodevelopment. Contemporary Pediatrics. September 2007: 84-92.