A Preemie is out of the NICU Now What!? Care of the Ex Preterm Neonate

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1 A Preemie is out of the NICU Now What!? Care of the Ex Preterm Neonate Shawn Hollinger, MD FAAP FRCPC Assistant Professor Neonatology Department of Pediatrics Adjunct Professor Obstetrics and Gynecology James H. Quillen College of Medicine East Tennessee State University Disclosure statements I Shawn Hollinger, DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation I Shawn Hollinger, DO NOT anticipate discussing the unapproved/investigative use of a commercial product/device during this activity or presentation Goals By the end of this talk, I hope you will be able to: Discuss the risks of developmental impairment with the families of preterm infants after hospital discharge Discuss the literature regarding nutritional needs of preterm infants post hospital discharge Explain the pro s/con s of home apnea monitors and devise a plan for their discontinuation 1

2 Please select the team that best describes you A. General pediatrician B. Family physician C. Specialist pediatrician D. Nurse E. Resident F. Medical Student G. Other/Just here for the free food 0% 0% 0% 0% 0% 0% 0% General pediatrician Family physician Specialist pediatrician Nurse Resident Medical Student Other/Just here for the free food We are going to start out talking about some important TLAs with respect to premature infants. What is a TLA? A. Transient Leukocyte Adhesion B. Topical Lubricant/Anesthetics C. Thermodynamic Linear Associations D. Three Letter Acronyms E. Therapeutic Laser Applications Transient Leukocyte Adhesion Topical Lubricant/Anesthetic 0% 0% 0% 0% 0% Thermodynamic Linear Associat.. Three Letter Acronyms Therapeutic Laser Application TLAs 2

3 According to the EPIPAGE study, which of these TLAs predicted severe cognitive deficiencies (More than one correct answer) A. Severe IVH (Intraventricular Hemorrhage) B. PVL (Periventricular Leukomalacia) C. BPD (Bronchopulmonary Dysplasia) D. NEC (Necrotizing enterocolitis) E. SES (Socioeconomic status) F. SGA (Small for Gestational age) G. AOP (Anemia of prematurity) 14% 14% 14% 14%14% 14% 14% Severe IVH (Intraventricular He... PVL (Periventricular Leukomalacia) BPD (Bronchopulmonary Dysplasia) NEC (Necrotizing enterocolitis) SES (Socioeconomic status) SGA (Small for Gestational age) AOP (Anemia of prematurity) :30 Intraventricular Hemorrhage (IVH) Definition/Classification Bleeding into the brain s ventricular system thought to arise from changes in perfusion of delicate cellular structures augmented by the immaturity of cerebral perfusion regulation The more premature the baby, the higher the risk Historically classified as Grade 1 4 IVH 3

4 Grades 0, 1 & 2 IVH Outcomes All VLBW infants (<1250 g) are at risk of long term developmental delays (even if no IVH) Grade 1 & 2 IVH have varying reports of long term outcomes in the literature from slight increase risk to no increase risk Multicenter study compared 99 infants with Grade 1 and 2 IVH with 291 that had no evidence of IVH At 18 years of age no significant difference in intelligence, tests of achievement or problem behaviors Wy et al. J Perinatol Jul;35(7): doi: /jp Epub 2015 Feb 5 Grade 3 4 IVH Outcomes Several cohort studies following outcomes of infants found to have Grade 3 and 4 IVH Much more likely to develop post hemorrhagic hydrocephalus (and have shunt placement) Shunt placement does not appear to independently predict poorer NDI Higher chance of CP, cognitive, visual, auditory impairment Most studies from 40 90% [consistently higher with grade 4] Brouwer AJ et al. Neonatology 2014;106: DOI: / Bronchopulmonary Dysplasia (BPD) 4

5 Definitions and Classification For preterm infants defined as the need for supplemental oxygen for at least the first 28 days of life. For those less than 32 weeks gestation at birth classify BPD into mild moderate or severe at 36 weeks gestation New BPD impaired alveolar development lungs are characterized by fewer and larger alveoli NICHD Concensus conference 2001 Bronchopulmonary Dysplasia Lung disease associated with prematurity and arrested alveolar development Things that can help: Improves over time with optimal growth and nutrition Decrease ventilator injury Decrease O2 free radical injury Increased caloric demands Mild fluid restriction Which of the following are true with respect to long term pulmonary outcomes of BPD? (Select ALL THAT APPLY) 25% 25% 25% 25% A. Impaired pulmonary function tests B. Increased risk of re admission to hospital C. Increased risk of pulmonary artery hypertension D. Increased risk of recurrent wheezing Impaired pulmonary function tests Increased risk of re admission.. Increased risk of pulmonary arte.. Increased risk of recurrent whe... :30 5

6 BPD affect on Lungs Long Term Negative affect on PFTs (apparently for life) More likely to have recurrent wheezing More likely to have PAH (Pulmonary Artery Hypertension) Up to 50 % chance of requiring re admission to hospital in the first 2 years of life for treatment of a respiratory infection Up To Date Complications and Long term pulmonary outcomes of BPD Accessed July 2015 BPD Management Post Discharge Frequent hand washing, infection avoidance, RSV prophylaxis if indicated, annual influenza vaccine Strict avoidance to second hand smoke (and anticipatory guidance to pre teens about FIRST hand smoke!) Close adherence to vaccine schedules Up To Date Complications and Long term pulmonary outcomes of BPD Accessed July 2015 Diuretics 6

7 Diuretics Have been shown to improve lung mechanics and decrease support needs for a few days Not been shown to have any clear long term benefit Furosemide has been shown to increase nephrocalcinosis especially with prolonged use HCTZ/Spironolactone is associated with hyponatremia and hypokalemia often requiring dietary supplementation Int J Pediatr. 2012; 2012: Published online 2012 Jan 3. doi: /2012/ Current Pharmacologic Approaches for Prevention and Treatment of Bronchopulmonary Dysplasia Kristen Tropea 1, 2 and Helen Christou 1, 2 * Articles I found Guiding Post Discharge use/monitoring of Na/K and Diuretics Retinopathy of Prematurity (ROP) 7

8 ROP Definitions and Classification Abnormal growth of the retinal blood vessels after preterm birth Zone How far the vessels have grown Stage 1 increased branching of newly formed blood vessels forming a line Stage 2 rapid growth of new vessels leading to a ridge Stage 3 severely abnormal vessel growth with fibrous tissue Stage 4 Partial retinal detachment Stage 5 Complete retinal detachment Plus disease increase in tortuosity of the new blood vessels a concerning sign for speed of growth ROP Long term outcomes Important cause of blindness infants per year in the United States Monitored closely in the NICU (and sometimes after discharge until fully vascularized) If reach threshold, risk of blindness is high and laser treatment is indicated VLBW infants are also at increased risk of strabismus, myopia and amblyopia Recommend screening by an ophthalmologist at 9 12 months Socioeconomic Status (SES) 8

9 Socioeconomic Status EPIPAGE study is one of the largest cohorts followed 2500 French babies weeks Data until age 5 on CP and cognitive function Examined medical and social risks for mild and severe disabilities Parents with low SES was the MAIN predictor for mild cognitive deficiency (3.4 times more likely than those with high SES) Cerebral lesions (IVH, PVL) were the main predictor for severe disabilities along with low SES (2.6 times more likely than high SES) EPIPAGE Beainoet al. Acta Pædiatrica 2011 Apnea of Prematurity Caffeine Up to 85% of infants born <34 weeks have apnea spells attributed to apnea of prematurity (diagnosis of exclusion) CAP trial Well designed RCT Caffeine vs. placebo Useful for successful extubation Useful to decrease apnea episodes No harmful effects on neurodevelopmental outcome (to school age) No studies have examined use past 34 weeks PCA 10% of infants with apnea of prematurity will continue to have apnea after 34 weeks NEOREVIEWS Vol. 14 No. 11 November 1, 2013 pp. e540 -e550 9

10 Home Apnea Monitors Developed to decrease SIDS Have never been show to decrease SIDS Still used in some instances More of a diagnostic tool (to distinguish false CR events and document frequency of true CR events) than a therapeutic tool (to prevent SIDS) Likely never going to get a good study proving/disproving their efficacy UpToDate Use of home cardiorespiratory monitors in infants Accessed May 2015 Home Apnea Monitors Indications are really on a case by case basis Recommended to discuss what a monitor is for and can and can t do (babies have died on a monitor) Recommended to discuss length of use at time of discharge Length of use depends on the indication for use Apnea of prematurity rarely occurs after 43 weeks PCA Risk of SIDS is very low after 6 months Risk of entanglement and strangulation by the wires increased after they begin to roll Generally accepted that after 6 8 weeks of no events should discontinue use UpToDate Use of home cardiorespiratory monitors in infants Accessed May 2015 Osteopenia of Prematurity 10

11 Osteopenia of Prematurity Majority of Calcium and Phosphorous accumulation occurs in the third trimester Vitamin D (deficiency) also plays a role Decreased mechanical factors (kicking on uterine wall) also alter cortical bone growth Risk factors: Decreasing gestational age Furosemide use Corticosteroid use Concurrent illness OOP Treatment Calcium and phosphorous supplementation In most cases nutrient enriched formula contains enough to reach higher RDI Can supplement in a similar way to Na/K Vitamin D supplementation also recommended Typically use Alk Phos, Phosphate to monitor severity of disease (aim for Alk Phos <600 and Phosphate >1.8) How Frequent to monitor??????? Dokos et al. Clin Cases Miner Bone Metab May-Aug; 10(2): Vulnerable Child Syndrome Parents of children with preterm infants often perceive their infants as medically vulnerable High parental perception of child vulnerability is associated with disproportionately high health care utilization Has also been linked to poorer health care outcomes Mothers with high anxiety at time of discharge are more likely to have higher perceptions of vulnerability Small studies showing targeted behavioral therapy for mothers early on are promising for decreasing perceptions of vulnerability Allen et al. Pediatrics Feb;113(2):

12 Nutrition Nutrition Difficult to attain normal intrauterine growth in the NICU Recommended intakes not always achieved due to feeding intolerance or adverse events VLBW and ELBW infants often discharged around weeks weighing between grams Aggett et al. Journal of Pediatric Gastroenterology and Nutrition 2006; 42: Specific Nutrient Deficiencies Calcium and Phosphorus Iron Zinc Water soluble vitamins Fat soluble vitamins LCPUFAs Enhanced visual development Neurodevelopment Shah et al. Pediatric Clinics of North America 2009; 56:

13 Importance of Human Milk Human milk is the gold standard of which all formulas are based Universally recommended over formula Research shows that provider encouragement of human milk is effective regardless of social and ethnic background Studies show that parents will decide to provide breastmilk almost immediately after learning how critical breastmilk is in the management of the NICU infant Meier et al. Clinics in Perinatology 2010; 37: Feeding the Preterm Infant Small studies show that preterm infant fed exclusively unfortified EBM at discharge may have nutritional deficiencies Decreased bone mineral content at 6 months corrected age Lower calcium, protein and phosphorus intake Schanler found decreased BMC 1 year postdischarge. Shah et al. Pediatric Clinics of North America 2009; 56: Schanler et al. Pediatric Research 1992; 6: Feeding the Preterm Infant Fortification can be achieved by adding enriched formula powder to EBM or substituting a number of feeds with enriched formula Fortification of at least half of the milk for 12 weeks after hospital discharge may be an effective strategy in addressing early discharge nutrient deficits and poor growth. Tudehope et al. The Journal of Pediatrics 2012; 162: S72 S80 13

14 Feeding the Preterm Infant No studies have examined the impact on longterm health outcomes of supplementation of human milk with formula Studies with term healthy infants show that higher IQ scores and protection from infections, eczema, and adult onset morbidities are dependent on a dose response manner with human milk Meier et al. Clinics in Perinatology 2010; 37: Feeding the Preterm Infant ESPGHAN Committee on Nutrition (2006) suggest nutrient enriched formula to termcorrected age and even 52 weeks postconception among infants with less than normal weight for post conceptional age Aggett PJ et al (2006) J Pediatr Gastroenterol Nutr 42(5): Enriched Formulas Enriched formulas may improve short term growth parameters in premature infants but have not been shown to improve long term growth or development However many studies are limited by the preterm infants at most nutritional risk are underrepresented or excluded. O Connor et al. American Family Physician 2009; 79: Lapillonne et al. The Journal of Pediatrics 2012; S90 S100 14

15 Enriched Formulas Infants fed nutrient enriched formulas usually eat less volume Nutrient enriched formulas do not alter the quantity of growth but does improve the quality of growth Growth Body Composition Bone mineralization Lapillonne et al. The Journal of Pediatrics 2012; 16S: S90 S100 Cooke et al. Pediatric Research 2010; 67: Amesz et al. Journal of Pediatric Gastroenterology and Nutrition 2010; 50: How Long to use Nutrient Enriched Feeds Various practices used Until reaches the 3 rd Percentile Until reaches 50 th Percentile Until reaches 3.5kg Until 9 months Until reaches birth weight channel on growth curve Preemie toolkit I find useful!! nt/recommendations for Postdischarge.pdf 15

16 Iron Deficiency in preterm infants is very common and can have serious side effects Supplementation is affordable and well tolerated Iron overload/toxicity is nearly impossible at the doses used for supplementation Recommended for breastfed infants <2500 g at birth until 1 year of age Recommended for formula fed infants <2500 g at birth until drinking 32 oz per day of iron fortified formula NEOREVIEWS Vol. 1 No. 4 April 1, 2000 pp. e61 -e68 Ad lib or Scheduled Feeds? Surprisingly little data Few studies with methodological flaws The few (weak) studies point towards ad lib feeds leading to better weight gain, earlier hospital discharge None looked at post discharge Adv Neonatal Care Aug;4(4): An integrated review of the literature on demand feedings for preterm infants. Crosson DD 1, Pickler RH. Early intervention Highest risk patients may be referred by NICU at time of discharge home Early identification and treatment of developmental delays improves outcomes Free services anybody can refer If concerned REFER 16

17 NICU High Risk Follow up Clinic Multidisciplinary developmental screening for NICU babies at high risk of developmental delays Long afternoon for families Screening clinic, goal is to ensure community resources are maximized Team Scores Points Team Points Team Questions? 17