The Very Low Birth Weight Infant

Dana Rivera, M.D.

Delivery

A 800 gram female infant at 26 weeks

Precipitous vaginal delivery to 22 yr old G3P1 with suspected placental abruption

Resuscitation

Baby pale, no respiratory effort, HR 60 Requires intubation with PPV with gradual

increase in HR Transferred to NICU Perfusion remains poor with pallor

ETT size selection– < 1kg: 2.5– 1-2 kg: 3.0– 2-3 kg: 3.5– > 3 kg: 4

Position?– between clavicles

and carina

Umbilical lines?

UVC– Intrathoracic IVC

– Just above diaphragm UAC

– High: T6-9, T7-10

– Low: below L3

Initial Hours

Diagnosis

BPD

IVH

PDA

ROP

ROS

SDS

AOP

NEC

Surfactant Deficiency SyndromeSigns and Symptoms

Respiratory distress– tachypnea– grunting – retractions – flaring– coarse breath sounds– mixed acidosis– hypoxia

CxR:

ground glass

underinflation

air bronchograms

Surfactant Deficiency SyndromePhysiology

Made by? – Type II pneumocytes

Detected by? – ~23 weeks, inadequate until ~32 weeks

Made of?– 70-80% phospholipids

Works by?– Prevents high surface tension

Laplace’s Law

Pressure = 2x tension/ radius

If surface tension equal smaller alveolus empties into larger alveolus

Surface tension of different sized alveoli not constant- smaller alveoli have lower surface tension

Surfactant Deficiency SyndromeManagement

Prevention Respiratory support Surfactant replacement

– Side effects

Antibiotics Maintain Hct

Day # 2

NPO, placed on IVF or TPN??

Total fluid goal greater or less than term infant?? Why?

Determining ongoing fluid needs??

Day #4

Increased ventilator support overnight

ABG: 7.22/50/50/16/-7

Murmur

Diagnosis

BPD

IVH

PDA

ROP

ROS

SDS

AOP

NEC

Patent Ductus ArteriosusSigns and Symptoms

Murmur Widened pulse pressure Hyperactive precordium Bounding pulses Metabolic acidosis

PDA- Pathophysiology

LR shunt– Pulmonary congestion– L-sided overload– CHF

Diagnosis– ECHO

PDA- Management

– MedicalFluid restrictionDiureticsIndomethacin

– Contraindications

– SurgicalMedical failureCritical statusContraindication to indomethacin

Day #6

S/P indomethacin without complications; f/u ECHO reveals closed ductus

Weaned to low ventilator support (IMV15, 15/4, 30%)

Nurses report episodes of bradycardia (60s) which respond to bagging– What are you thinking?

Diagnosis

BPD

IVH

PDA

ROP

ROS

SDS

AOP

NEC

Apnea of Prematurity

Cessation of breathing > 15 sec duration with desaturation/ bradycardia

Central, obstructive, mixed

Methylxanthine tx– Caffeine

Caffeine

Stimulates medullary respiratory center

Increased sensitivity to CO2

Enhanced diaphragmatic contractility

Diuretic

Enhanced catecholamine response

– Increased cardiac output/ HR

Increased glucose (glycogenolysis)

GER

Day #7

What is the one test you should order today??

Diagnosis

BPD

IVH

PDA

ROP

ROS

SDS

AOP

NEC

Intraventricular HemorrhageSigns and Symptoms

Catastrophic– bulging fontanelle– posturing– seizures– apnea– hypotension– metabolic acidosis– drop in Hct– death

Saltatory– Cycle of deterioration and

recovery

Silent: 50%

Intraventricular hemorrhage (IVH)Pathophysiology

Germinal matrix– Developmental area of

brain

– Periventricular b/w caudate nucleus and thalamus

– Provides neurons/ glial cells

– Richly vascularized/ loose supportive stroma

– Dissipates by term

– Poor control of cerebral blood flow

IVH

Grade I– Germinal matrix only

(subependymal) Grade II

– Intraventricular/ normal ventricles

Grade III– IVH + dilated ventricles

Grade IV– IVH + parenchymal bleed

Screening head u/s– < ~34 weeks

Management– Supportive,

ventricular taps, reservoirs, VP shunts

Prognosis

Day #14

2 spits yesterday of small amount of formula

10cc bilious residual this am on premature formula (16cc q3hr)

Diagnosis

BPD

IVH

PDA

ROP

ROS

SDS

AOP

NEC

NEC- Signs and Symptoms

Abdominal – distension, tenderness,

discoloration, mass

Feeding intolerance– Vomiting (bilious), gastric

residuals, heme (+)/ bloody stools

Systemic– Lethargy, apnea, poor

perfusion, temp instability

Labs – reflect sepsis– leukocytosis/ leukopenia,– L shift– thrombocytopenia– acidosis – hypo/hyperglycemia– hypoxia/hypercapnea

NEC- radiograph

Pneumatosis intestinalis

thickened bowel wall

sentinel loop

“soap bubble” appearance (RLQ)

NEC

Pneumoperitoneum

Portal venous air

NEC- Pathophysiology

Onset?– 3-10 days (24hr-3mo)

Where?– Jejunum, ileum, colon

What?– Bowel necrosis,

edema, hemorrhage, perforation

Etiology?– Multifactorial– GI dysmotility/ stasis– Partially digested formula

substrate for bacterial proliferation

– Mucosal injury/ bacterial invasion

– Mesenteric ischemia– Inflammatory mediators

NEC- Management

Medical– Bowel rest– Decompression– Broad spectrum Abx– Serial radiographs– Fluid/ nutritional support– Blood product support– BP support– Respiratory/metabolic

support

Surgical– Pneumoperitoneum, fixed

abdominal mass, persistently dilated loop, abdominal discoloration, persistent clinical deterioration

– Resection of necrotic bowel with ostomy

– Peritoneal drain

Day # 38

S/P NEC, no perforation, feedings resumed after 10 days bowel rest with elemental formula, reached full feeds 4 days ago

Now extubated, remains oxygen dependent

Diagnosis

BPD

IVH

PDA

ROP

ROS

SDS

AOP

NEC

Chronic lung disease (CLD or BPD)

Treatment with oxygen >21% for at least 28 days plus—

Mild BPD: Breathing room air at 36 weeks postmenstrual age (PMA) or discharge

Moderate BPD: Need for <30% oxygen at 36 weeks PMA or discharge

Severe BPD: Need for 30% oxygen and/or positive pressure (ventilation or continuous positive airway pressure) at 36 weeks PMA

BPD- Pathophysiology

Day #38

What should have been ordered by now??

Diagnosis

BPD

IVH

PDA

ROP

ROS

SDS

AOP

NEC

Retinopathy of prematurity (ROP)

Risk factors?– Prematurity, oxygen exposure

Vasoconstriction vaso-obliteration neovascularization

Classification– Stages 1-5– Zones I-III

ROP- Stages & Zones

1: Demarcation line 2: Ridge formation 3: Neovasculariztion/

proliferation 4: Partial retinal detachment 5: Complete retinal

detachment

Plus disease– Tortuous arterioles,

dilated venulesHigher stage, lower zone-

worse disease state

ROP screening

< 1500gm or 32 weeks

Selected infants >1500gm, > 32 weeks

AAP policy statement– Pediatrics 117(2), 2/06

Gestational age Postmenstrual Chronologic

22 31 9

23 31 8

24 31 7

25 31 6

26 31 5

27 31 4

28 32 4

29 33 4

30 34 4

31 35 4

32 36 4

Who is the most famous person affected by ROP?