An Update on Neonatal Transitions in Care and Nutritional Requirements for the General Practitioner Doug Cunningham, MD Professor of Pediatrics/Neonatology Division of Neonatology, Department of Pediatrics, College of Medicine, University of Kentucky Faculty Disclosure I have no financial disclosures, or other disclosures to make, referable to my presentation today. Educational Need/Practice Gap Practice guidelines for newborn infants, especially preterm and sick newborn term infants, change frequently. The general practitioner is challenged to maintain awareness and to keep abreast of changes as practiced in the neonatal intensive care unit from which infants enter his or her practice. This presentation seeks to provide some current information to meet those needs. 1
Objectives Upon completion of this educational activity, you will be able to: 1. Identify expected growth trajectories for preterm and term infants. 2. Identify current nutritional recommendations for preterm and term infants in the first month of life. 3. Identify developmental expectations of preterm and term infants in the first 12 months of life. 4. Identify immunizations needed by preterm and term infants in the first year of life. 5. Identify the current treatment modalities of the neonatal abstinence syndrome for newborn preterm and term infants. Expected Outcomes That physicians caring for infants in the first year of life will find information within this presentation to be of benefit for their patients: For monitoring growth trajectories For monitoring nutritional goals For monitoring developmental outcomes For offering infectious disease protection through immunization For management options when faced with continued NAS treatment challenges I. Neonatal growth expectations Preterm infants Chronological age v. post conceptual age Late preterm infants Intrauterine growth restriction Catch up growth Appropriate Sustained Accelerated Term infants Delayed Neurodevelopmental impairment Appropriate Excessive Loss of expected adiposity rebound phenomenon m 2
Growth Potential Realization Indices and Neonatal Growth Assessment Scores AGA SGA IUGR GPRI = HC, AC, thigh circ., Wt., and CHL NGAS=0 =AGA, LBW>20=IUGR, LBW<20 SGA IUGR: ICD 10 ICD 10; P05.2 or P05.9 (formerly ICD 9; 764.9) Reference is to birth weight; 10 th percentile typically, but not limited to Considered pathological: Maternal disease, placenta abnormality, fetal ultrasound findings P05.2 fetal malnutrition, not SGA P05.9 slow fetal growth, or fetal growth retardation 3
SGA: ICD 10 ICD 10; P05.1 (formerly ICD 9; 764) Reference is to birth weight; 10 th percentile Most will be healthy, such as: Constitutional SGA, by paternity or ethnicity Multiparous maternal status Multiple gestation Idiopathic short stature IUGR Symmetric vs. Asymmetric SYMMETRIC ASYMMETRIC Baschet AA, et al. In: Obstetrics. Gabbe, Neibyl & Simpson, eds; 2007. Adiposity rebound 4
Adiposity rebound II. Nutritional goals Preterm Protein 3 4g/kg/da Preterm human milk v. proprietary formula Protein varies: Preterm human milk = 2.1 2.4 g/kg/da at 100 120 cal/kg/da Formulas for preterm infants = 3.0 3.3g/kg/da at 100 cal/kg/da Term Breast feeding! Mature human milk 110 120 cal/kg/da: Protein =1.4 g/kg/da 6% of daily calories Fats = 3.9 g/kg/da 52% of daily calories CHO = 7.2g/kg/da 42% of daily calories II. Nutritional graphics Post discharge formulas Volume Protein g Similac Neosure Advance (Abbott) 22kcal/oz 134 ml 2.8 g Enfacare Lipil (Mead Johnson) 22kcal/oz % energy 11 % 11 % Fats g 5.5 g 5.3 g % energy 49 % 47 % CHO g 10.1 g 10.4 g % energy 40 % 42 % 5
III. Follow up for infants suspect for neurodevelopmental delays Clinic for evaluations: Nurse practitioner clinic coordinator Nurse research/data coordinator Social worker Speech specialist Occupational/Physical therapists nutritionist General pediatrician Neonatologist Developmental specialist Clinical psychologist Child life specialist ilit Early childhood education specialist III. Development: observations in UK NICU Clinic Head lag Slip through Astasis Hip abduction Ankle dorsiflexion Deep tendon reflexes Asymmetric tonic neck reflex Tonic labyrinthine reflex Equilibrium in sitting Protective extension Fisting Shoulder retraction Tonic extension Scissoring equinus IV. Neonatal immunizations Vaccine/ Birth 1 month 2 months 4 months 6 months 12 mos. age Hepatitis Hep B Hep B, Hep B Hep B, Hep B B or or Rotavirus RV RV Dipth,Pert DaTP DaTP DaTP DaTP ussis, Tetn H. Influ B HiB HiB HiB Pn coccal PCV PCV PCV PCV Polio(Salk) IPV IPV IPV Influenza Influ. MMR MMR Varicella Varicella Hepatitis A Hep A; first dose 6
IV. Neonatal immunization preterm (2000g or less) Hepatitis B Mother is HBsAG positive: give HBIG + HepB w/in 12 hours Do not count Hep B at 12 hr as first does of vac. series Follow w/ 3 doses Hep B at 1, 2 6 mos. If mother HBsAg negative at time of birth, initial HepB can be delayed until just prior to discharge See also: <www.cdc.gov/hepatitis/hbv/vaccchildren.htm> V. Neonatal abstinence syndrome Premature infants Of all NAS infants 20 25% will preterm Comparison of NAS preterm to term for clinical signs and outcome? Term infants Overall incidence in KY is estimated to be 23% are substance exposed Substance affected is less and dependent upon maternal substance abuse and timing V. NAS treatment Options: Environmental and supportive measures Opioids (morphine, methadone, buprenorphine, tinc. of opium) Phenobarbital Benzodiazepines clonidine 7
V. NAS after discharge management: Parent education Breast feeding encouraged, if on methadone wean HIV testing (prior to discharge) Hepatitis i C testing (if mother +, test at 18 mos.) Methadone taper after discharge Prescription control Follow up appt. weekly Supply of methadone to be brought to clinic Wean by 0.02 0.05mg weekly of biweekly Objectives Upon completion of this educational activity, you will be able to: 1. Identify expected growth trajectories for preterm and term infants. 2. Identify current nutritional recommendations for preterm and term infants in the first month of life. 3. Identify developmental expectations of preterm and term infants in the first month of life. 4. Identify immunizations needed by preterm and term infants in the first year of life. 5. Identify the current treatment modalities of the neonatal abstinence syndrome for newborn preterm and term infants. questions? end doug.cunningham@uky.edu Office telephone 859 323 2662 8