Premature infant. Pediatric care for the premature children + Most frequent diseases of premature infants

Question 1

what are the terminology of prematurity ?

Answer 1

extremely preterm = below 28 weeks

very preterm = 28 weeks and less than 32 weeks

moderate preterm = less than 34wks - 32 weeks

late preterm = 34 weeks to less than 37 weeks

—— less than 37 weeks = preterm——-

early term = 37 weeks to less than 39 weeks

term =39-less than 41 weeks

Question 2

preterm babies are usually not SGA correct ?

Answer 2

yes

Question 3

there are morphological characteristics which can helps determine the age of the baby such as?

Answer 3

ballard score
nippes become visible in the 31 gestational week - if visible we know the baby has passed its 31st gestational week

position go the testis in the inguinal canal and scrotum

neurological development

Question 4

what are the aetiology of preterm labour ?

Answer 4

50 percent remain unknown

maternal factors = pr eclampsia 
mother's age lower than 16 or higher than 40 
smoking 
vibration 
alcohol 
drugs 
stress 

anemia , diabetes , hyperthyroidism

uterine anomlais- tumors , cervical insuffieicny , vaginal infections and infection of the cervix

prom- usually infections , placenta previa , twin pregnancy ,

fetus - IUGR ,
multiple fetus
polyhydroaminos - uterine stretch pathway

Question 5

how can we diagnose PROM ?

Answer 5

good test for this is cervical and vaginal fibronectin - substance of basement membrane protein produced but the membrane - when fetal membranes are disrupted - fibronectin is secreted into the vaginal and cervix

A positive fetal fibronectin test at 22 to 24 weeks
predicts more than
half of the
spontaneous preterm
births that occur before 28 weeks.

Question 6

what re the characteristic features of preterm babies ?

Answer 6

small

head bigger to body

translucent skin with visiblee blood vessels

fine lanugo hair

soft pliable ear cartilage

soft bones

closed eyes

listless and inactive

extended extremities

partially developed REFLEX ACTIVITIES- lack of suction reflex

INABILITY TO MAINTAIN BODYTEMP = less body fat

inability to excrete urine

female - prominent clitorious

ABNORMAL BREATHING PATTERNS - shallow and irregular pauses

lower muscle tone

problems feeding - difficulty sucking or coordinated swallowing

Question 7

what are preterm babies dangerously susceptible to ?

Answer 7

no surfactant produced so respiratory distress = hyaline membrane disease or respiratory distress syndrome

immature respiratory centre so cannot breath periodically = apnea

metabolic acidosis

more susceptible to hypoglycaemia

hyperbilirubinemia

heart failure = patent ductus arteriosus

INFECTIONS -sepsis and necrotic enterocolitis

intraventricular haemorrhages

fluid and electrolyte imbalance

RETINOPATHY of prematurity

anemia

Question 8

what are the long term problems for preterm babies ?

Answer 8

bronchopulmonary dysplasia 
delayed growth and development 
mental or physical disability or delay 
increased risk for intellectual disability 
cerebral palsy 
vision and hearing loss = retinopathy

Question 9

what are the standard care given to preterm babies

Answer 9

baby should be dried and effectively covered and warm

electie intubation for extremely low birth weight babies = less tan 1000g

exogenous surfactant given
corticosteroids for lung development through endotracheal tube

ventilator - continuous positive airway pressure

less than 30 weeks old - IV fluid and nasogastric

30-34 = nasogastric / breast feeding

more than 34 = breast feeding or katori

10 percent of daily calories should be derived for protein
40 percent - carbs
5 percent fats

2.5-3.5 mew/kg/per day

vit a recommended for preterm promoting epithelial repair and minimise fibrosis

vit D - prevents rickets

vitamin K 0.5mg should be given intramuscularly
factors 2 , 7 , 9 ,1 administers
prevent haemolytic disease of the new born

immunisation and put in sterile conditions
antibiotics given if there are signs of infection

Question 10

for a preterm baby it is put in a system of neonatal intensive care unit which measure what ?

Answer 10

there is overhead warmer 
they eyes are sealed closed  closed 
there is a ventilator 
a feeding tube = feeding method 
oxygen saturation monitor 
Iv pump 
IV pump with umbilical artery catheter = feeding method 
PICC line - central line = feeding method 
ECG and blood pressure monitor / HR 
temperature monitor 
bilirubin lights 
incubator

Question 11

what is kangaroo care

Answer 11

placing a premature baby in an upright position on the mothers bare chest allowing tummy to tummy contact and planning the premature baby in between the mother’s breast

and baby head is tubers so the ear is above the parents heart

Question 12

kangaroo care has been shown to help prmature newborn with ?

Answer 12

body temp

allow easy access to breast feeding

increase weight gain - allows the baby total into deep sleep = allows the baby to conserve energy

increased intimacy and attachment

Question 13

what are the symptoms for necrotising enetrocoitis

Answer 13

poor feeding
blood in stool
vomiting bile
failure to thrive

later on
abdominal discolouration , peritonitis
intestinal perforation
systemic hypotension

Question 14

what is necrotising enterocolitis ?

Answer 14

where a portion of the bowel dies it is thought to involve the combination of poor blood flow and infection of the intestines

Question 15

how can we prevent necrotising enetroclitis

Answer 15

use breast milk

probiotics

Question 16

when is the typical onset of enterocolitis ?

Answer 16

after 4 weeks of life

generally inversely proportional to the gestational age of the baby birth

Question 17

how is the diagnosis of necrotising enterocolitis ?

Answer 17

radiography

transillumination of the abdomen

Bells stages of disease
stage 1 = mild symptoms such as apnea , lethal , bradycardia , temp instability
abdominal distension , increased gastric residual bloody stools
no radiological signs

stage 2
mild to moderate symptoms
additional intestinal signs : absent bowel sound and abdominal tenderness

radiologic - pneumatosis intestinal or portal venous gas

lab =metabolic acidosi , thrmbocytopenia

stage 3
hypotension
peritonitis and striking abdominal distension
radiology = pneumoperitoneum

lab test = metabolic and resp acidosis
DIC

US = bowel gas , sentinel loop

Question 18

what is the treatment for necrotising colitis ?

Answer 18

bowel rest by stopping oral  feeding, 
gastric decompression with nasogastric tube suction , fluid repletion to correct electrolyte abnormalities
parenteral nutrition always 
antibiotic therapy 
mechanical ventilation 

supine and left lateral decubitus abdominal X-rays should be performed every six hours

As an infant recovers from NEC, feeds are gradually introduced. “Trophic feeds” or low-volume feeds (<20 ml/kg/day) are usually initiated firs

Question 19

Where the disease is not halted through medical treatment alone, or when the bowel perforates what is the course of action in NE

Answer 19

emergency surgery to resect the dead bowel is generally required, although abdominal drains may be placed in very unstable infants as a temporizing measure

In the case of an infant whose bowel is left in discontinuity, the surgical creation of a mucous fistula or connection to the distal bowel may be helpful as this allows for re-feeding of ostomy output to the distal bowel. This re-feeding process is believed to improve bowel adaptation and aid in advancement of feeds.

Question 20

some children may suffer what whenextensive portions of the bowel had to be removed in NE ?

Answer 20

short bowel syndrome = malabsorption disorder

Question 21

a patent ductus arteriousus creates what type of shunt ?

and what are the signs and symptoms ?

diagnosis ?

Answer 21

left to right shunt

signs and symptoms depends on the size of the shunt

pulse can be bounding , systolic murmur audible ,
apnea , bradycardia , increased oxygen requirement

echocardiography - doppler through ultrasound

Question 22

what are the main problems in the left to right shunt in PDA?

Answer 22

HYPERperfusion in lung circulation = pulmonary haemorrhages

HYPOperfusion of system circulation to gut and brain = NEC

heart failure - increase volume load on left side of heart = bounding pulses , hyperactive pericardium , murmur , cardiomegaly

Question 23

patent ductus arteriosuus closes physiologically in premature babies?

Answer 23

yes however they are more delayed especially if there is respiratory distress syndrome

normally the physiological closure is within 24 hours and the anatomical closure several weeks later

= arterial hypoxemia and reduced response to oxygen prevents the fast closure of ductus arteriosusu in children

Question 24

what can treat this closure of ductus arteriosus?

Answer 24

echocardiography done when there is congestive heart failure with all the symptoms that persists heart failure to ratio between left atrium and aortic root diameter ratio normal is 0.86 if it is more than 1 or 1.1 early treatment started with indomethacin

inhibitors of prostaglandin such as ASA (cogulative effects and bilirubin displacement ) or indomethacin (renal function :( ) closure of persistant ductus arteriosus

surgical ligation

Question 25

what re the signs for respiratory distress syndrome ?

Answer 25

increased resp rate - tachypnea - more than 60 breaths per min chest wall recession - sternal and subcostal undraping tachycardia expiratory grunting = to create positive pressure nasal flaring cyanosis prolonged periods of apnea

Question 26

is respiratory disease is treated or not the acute symptoms lasts how many days ?

Answer 26

2-3 days first day child worsens second day - baby remarkably stable resolution on the third day

Question 27

what can be differential diagnosis to respiratory distress syndrome ?

Answer 27

acute respiratory distress syndrome - widespread inflammation of the lungs

Question 28

how can we diagnose respiratory distress syndrome ?

Answer 28

bell shaped chest chest x ray - decreased lung volume , absence of thymus - after 6 hrs in pregnancy over 30 weeks fetal lung maturity checked by amniocentesis L/S ratio and PG - phosphatidylglycerol less than 2:1 and absence of PG means there is no lung maturity surfactant an albumin ratio less than 35 indicates immature lungs greater than 55 inidicates mature surfactant production

Question 29

what is the treatment for respiratory distress syndrome ?

Answer 29

CPAP- continuous positive airway pressure intravenous fluid to stabilise the blood sugar and blood blood pressure if the baby shows signs of worstenng - endotracheal tubing or put in mechanical ventilation CPAP exogenous pulmonary surfactant given through the breathing tube extracorporeal membrane oxygenation = cannot be placed until over 2KG because small blood vessels for cannulation giving higher vascular resistance

Question 30

in severe RDS what is the problem ?

Answer 30

bronchopulmonary dysplasia

Question 31

there are four grades of intraventricular haemorrhages what are they ?

Answer 31

grade 1 - germinal matrix bleeding where there are tender vessels grade 2 - bleeding occurs inside the ventricles grade 1 and two are small amounts bleeding grade 3 and 4 grade 3 - the blood presses the brain tissue the ventricles are enlarged with he blood grade 4 the bleeding is directly involved with the brain tissue - intraparenchymal haemorrhage most severe being uniltarel hemorrhagic infraction = resulting in hemiplegia = paralysis of one side of the body here blood clots can form and reduce the drainage of cerebrospinal fluid giving hydrocephalus

Question 32

what are the symptoms in intraventricular haemorrhages

Answer 32

apnea change in blood pressure and heart rates decreased muscle tone decreased reflexes excessive sleep seizures and abnormal movements

Question 33

how is the diagnosis done of intraventricula hemorrhegae ?

Answer 33

all babies born before 30 weeks should have ultrasoundd of the head

Question 34

what is the treatment for intravenetricular haemorrhages ?

Answer 34

no way to stop the bleeding give diuretics streptokinase therapy most recently combo of drainage , irrigation and fibrinolytic therapy = DRIFT therapy blood transfusion given to maintain blood pressure if fluid builds ip to point that there is cancer - a spinal tap done to relive the pressure surgery needed to place a tube shunt to drain the fluid from the brain

Question 35

what is the prognosis of intravenetricular haemorrhages ?

Answer 35

less tan half the baby with low grade intraventricular haemorrhages have long term problems severe problems leads to developmental delays and problems controlling movement and one third with severe bleeding die

Question 36

how can we prevent intraventricular hemorrhegs ?

Answer 36

give corticosteroids to pregnant women - develop lungs - reduce RDS risk - therefore reduce IVH risk umbilical cords are not clamped right away have less risk for IVH

Question 37

most intravenetricular haemorrhages occurs when after birth and what increases its chances

Answer 37

after 72 hours extracorporeal membrane oxygenation congenital cytomegalovirus

Question 38

surfactant is produced by which type of pneumocystis ? and what triggers its release

Answer 38

type 2 = premature infants pneumocystis not fully mature cortisol = adrenal gland not fully functional

Question 39

where does the term hyaline membrane disease come from in respiratory distress syndrome ?

Answer 39

proteinaceous exudate from hypoxemia

Question 40

what are the complications for respiratory distress syndrome ?

Answer 40

pneumothorax intracerebral hemorrhage bronchopulmonary dysplasia from artificial ventilation

Question 41

what is pneumothorax ? and what are the types of pneumothorax ?

Answer 41

A pneumothorax occurs when some of the tiny air sacs (alveoli) in a baby's lung become overinflated and burst. This causes air to leak into the space between the lung and chest wall (pleural space) -------------- spontaneous = resolves without tretammnet , no respiratory distress syndrome either loculated - sealed off , resolved without treatment tension positive pressure - creates a ball/valve mechanism

Question 42

what causes pneumothorax in premature infants ?

Answer 42

respiratory distress syndrome in premature babies and when the baby needs a ventilator the extra positive pressure can burst the alveoli for these air scare not able to expand easily due to the decrease of surfactant meconium aspiration syndrome pneumonia = all needing mechanical ventilation resuscitation

Question 43

what are the symptoms in pneumothorax ?

Answer 43

``` hype resonance on the affected side irritability cyanosis tachycardia tachypnea flair of nostrils grunting in breathing restlessness chest and admonimal muscle retraction aid in breathing ```

Question 44

what is the diagnosis for pneumothorax ?

Answer 44

transillumination - pockets of air will show up as lighter areas chest X ray = lungs are wide because no air in it = elapsed alveoli from respiratory distress pleura is black

Question 45

what is the treatment for pneumothorax ?

Answer 45

oxygen mask given tension pneumothorax (As air builds up in the chest, it can push the heart toward the other side of the chest. This puts pressure on both the lung that hasn't collapsed and the heart.) chest drain decompression by needle catheter and then insert a chest tube

Question 46

how can we prevent pneumothorax

Answer 46

mechanical ventilation is always at the lowest possible

Question 47

what is hypothermia bad for neonates ?

Answer 47

hypoglycaemia failure to thrive mortality increases

Question 48

why're preterm babies especially vulnerable to hypothermia ?

Answer 48

large surface area compares to mass = convection heat loss then heat generated skin is thin and heat permeable they have little subcutaneous fat for insulation organs are not fully functional to produce heat metabolically Poorly developed metabolic mechanism for responding to thermal stress (e.g. no shivering) Greater body water content

Question 49

what are the ways there can be heat loss in neonates

Answer 49

Evaporation: when amniotic fluid evaporates from the skin. from skin and breathing or sensible (sweating). * Conduction: when the newborn is placed naked on a cooler surface, such as table, scale, cold bed. The transfer of heat between two solid objects that are touching * Convection: when the newborn is exposed to cool surrounding air or to a draft from open doors, windows or fans, the transfer of heat from the newborn to air or liquid * Radiation: when the newborn is near cool objects, walls, tables, cabinets, without actually being in contact with them. The transfer of heat between solid surfaces that are not touching.

Question 50

how do babies produce heat ?

Answer 50

metabolic process muscle activity - restlessness and crying flexed position yo decrease surface area peripheral vasoconstriction non shivering thermogenesis - metabolism of brown fat produce heat thermal receptors -- hypothalamus -- synthetic nervossystem and NE release to brown fat found in kidney , adrenal gland , head , neck , heart

Question 51

consequence of hypothermia in children

Answer 51

cold --- activation of non shivering thermanogensis --- metabolism of brown fat --- increased o2 consumption -- increased resp rate --- pulmonary vasoconstriction -- tissue hypoxia -- peripheral vasoconstriction --- anaerobic metabolism -- metabolic acidosis metabolism of brown fat -- increased glucose use -- hypoglycaemia

Question 52

how many degrees is hypothermia ?

Answer 52

ewborn’s axillary temperature drops below 36.3°C

Question 53

what are the signs and symptoms for hypothermia ?

Answer 53

Acrocyanosis and cool, mottled, or pale skin • Hypoglycemia • Bradycardia • Tachypnea, restlessness, shallow and irregular respirations apnea, metabolic acidosis Decreased activity, lethargy, hypotonia Feeble cry, poor feeding

Question 54

how do we manage hypothermia ?

Answer 54

arm chain” is a set of interlinked procedures to be performed at birth and during the next few hours and days after birth in order to minimize heat loss in all newborns ``` warm delivery room immediate drying skin to skin contact brest feeding - within one hour appropriate clothing and blanket keep mother and newborn together for 24 hours a day in warm room warm transportation ```

Question 55

how is the severity of hypothermia measured inneonats ?

Answer 55

mild = 35--36.3 degrees moderate = 32 -34.9 degrees severe below 32

Question 56

for mild hypothermia what is done to treat it ?

Answer 56

skin to skin contact in warm room place cap on newborn head cover mother and newborn in warm blankets

Question 57

what is the treatment for moderate hypothermia ?

Answer 57

radiant heater | warm incubator

Question 58

what is the treatment for severe hypothermia

Answer 58

warm incubator

Question 59

how can we deliver nutrition whenpretm infants cannot swallow

Answer 59

nasogastric tube - and mothers breast milk breast milk needs to ne supplemented with phosphate and protein calories and calcium

Question 60

when is parenteral nutrition needed

Answer 60

typically when the birth weight is below 1kg

Question 61

why s breast milk the most advisable for nutrition

Answer 61

passive immunity through IgA cows milk based formula = NE cannulation - septicaemia increase

Question 62

when taking care of preterm babies iron what needs to be considered

Answer 62

iron is transferred to the fetus in the last trimester and therefore can have low iron stress this can also be in addition to inadequate erythropoietin repose iron supplements are given

Question 63

why do preterm infant have increased risk for infection

Answer 63

because IgG is the only antibody transferee through placenta and also mostly in the last trimester = increased infection in pretty in addition PROM is caused due to cervical inflammation which can spread o the premature newborn can be nosocomial - hospital derived since they are exposed to catheters and mechanical ventilation and long hospital stays

Question 64

intraventricular haemorrhage is also caused by ?

Answer 64

perinatal asphyxia

Question 65

retinopathy of prematurity is also called retrolental fibroplasia and terry syndrome has what pathophysiology

Answer 65

disorganised growth of genital blood vessels which may result in scarring and retinal detachment By the fourth month of pregnancy, the fetal retina has begun to develop vascularization. Such formation of blood vessels appears to be very sensitive to the amount of oxygen supplied, either naturally or artificially. the blood vessels grow from the retina outwards and this process is complete few weeks before full term of delivery the blood vessels conintue to grow normally ROP does not occur however continue to grow abnormally with fibrovascular proliferation ROP occurs and cause haemorrhages when the blood and abnormal vessels are reabsorbed it may give rise to multiple bad like membranes which can pull up the rentina and eventually lead to blindness

Question 66

what are the risk factors of retinopathy of prematurity ?

Answer 66

in preterm babies(esp below 32 weeks) relieving neonatal intensive care in which oxygen therapy is used FOR THE lungs the direct growth of the blood vessels is related to relatively low areas of oxygen VERY low birth weight = 35 percent less than 1500g infection

Question 67

people with ROP have what complications ?

Answer 67

strabismus , glaucoma , cataracts and shortsightedness myopia in later life

Question 68

what is the cause of bronchopulmonary dysplasia in neonates ?

Answer 68

``` treated with long term oxygen or supplemented oxygen mechanical ventilation RDS abnormal lung development antenatal infection ``` which is needed in low birth weight and preterm infants

Question 69

what re the signs and symptoms of BPD ?

Answer 69

feeding problems - oral tactile hypersensitivity after prolonged intubation hypoxemia hypercapnia crackles wheezing hyperinflation

Question 70

what s the pathophysiology of BPD what is the definition of BPD ?

Answer 70

BPD is a chronic respiratory disease oxygen conc more than 40 percent is toxin to the neonatal lung prolonged high oxygen delivery causes necrotising bronchitis and alveolar septa injury with inflammation and scarring this is due to the generation of superoxides and hydrogen peroxides and oxygen radicals which disrupt the membrane lipids resulting in hypoxemia -------- BPD is oxygen dependance at 36 weeks post conceptual age accompanied by clinical and radiographic findings due to failure RDS resolving

Question 71

how do you diagnose BPD ?

Answer 71

chest x ray show widespread opacification and sometimes cystic changes by phases lung opacification then cysts then areas of overdistenton and atelectasis then spongelike appearance and in histopathopoligy BPD reveal interstitial edema , atlesctasisi , mucosal metaplsao , interstitial fibrosis an necrotising obliterative bronchitis ------------ for neonates treated with more than 21% oxygen for at least 28 days for gestational age less than 32 weeks : ``` mild = breathing room air at 36 weeks moderate = need 30 percent of oxygen at 36 weeks severe = need more than 30 percent oxygen or positive air pressure CPAP at 36 week ``` -------- for gestational age 32 weeks or older mild = breathing room air at postnatal age of 56 or at discharge moderate = need less that 30 percent oxygen 56 days postnatally or at discharge severe need 30 percent or more oxygen with or without CPAP 56 days postnatal age

Question 72

what is the clinical management of BPD ?

Answer 72

to reduce oxygen toxicity and barotrauma ventilator settings are reduced to lower the partial pressure of pa02 to 50 mmhg and higher paco2 = 50 to 75mmhg) dexamethasone therapy reduce inflammation and improve pulmonary function steriods given to babies less than 8 days old can prevent however risk of neurodevelopment sequels such as cerebral palsy outweighs the benefits = low dose may be given oxygen therapy - CPAP or high flow nasal cannula therapy

Question 73

what are other common problems that premature infants also low birth weight baby developmentalp ?

Answer 73

low birth weight babies develop cerebral palsy but more common is learning disabilities learning difficulties risk is at greatest off born before 26 gestational week fine motor skills difficulties concentration behavioural problems

Question 74

to try and prevent retrolental fibroplasia what Pa02 do we give premature babies

Answer 74

keep it 50-80mmhg

Question 75

what are the clinical managmnet of BPD ?

Answer 75

``` oxygen dependance hypercapnia compensatory metabolic alkalosis pulmonary hypertension failure to thrive ```

Question 76

what s the complication of BPD ?

Answer 76

right sided heart failure

Question 77

when having mechanical ventilation with BPD what is a common occurrence with these positive air pressure which can worsen BPD ?

Answer 77

barotrauma

Question 78

what are the complications of BPD?

Answer 78

``` hyperinflation reactive airways developmental delay higher risk or severe respiratory syncytial virus pneumonia higher risk for asthma ```

Question 79

what is pulmonary dysmaturity or wilson mikety syndrome ?

Answer 79

affecting premature infants or SMALL for gestational age of less than 1.5kg and occurs 1-5 weeks after birth chronic lung disease that closely related to bronchopulmonay dysplasia alveoli that have failed to grow and multiple not due to RDS

Question 80

what is the symptoms of wilson mikety syndrome

Answer 80

cyanosis , dyspnea , wheezing , hyperinflation , corpulmonale , failure to thrive

Question 81

what is the diagnosis of wilson mikety syndrome

Answer 81

chest x ray lung cysts - interstitial emphysema diffuse infiltrats hyper inflated lungs flattened diaphragm

Question 82

what is the treatment for wilson mikety syndrome

Answer 82

give oxygen therapy | diuretics

Question 83

what is pneumopericardum ?

Answer 83

air enters the pericardial cavity LIFE THREATENING recognised in preterm neonates associates with severe lung pathology after vigorous lung resuscitation or in the presence of assisted ventilation

Question 84

why is pneumopericardium life threatening ?

Answer 84

lead to cardiac tamponade and death

Question 85

what are the signs and symptoms of pneumopericardium ?

Answer 85

dyspnea cyanosis = heart is an ineffectual pump chest pain pluses paradoxes becks triad when cardiac tamponade muffled heart sounds hypotension , rased jugular venous pressure

Question 86

how do we diagnose pneumopericardium ?

Answer 86

halo around the heat When air and fluid mix together in the pericardial sac, a tinkling sound superimposed over a succussion splash is heard. This is known as a “Bruit de Moulin”, Air between the anterior parietal pericardium and the thoracic cage may also give rise to the “Hamman’s Sign” – which is a crunching sound typically heard on auscultation of the chest, but may sometimes be heard even with the unaided ear.