management of preterm, small for gestational age infants: before birth to adolescence exploring the...
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Management of Preterm, Small for Gestational Age
Infants: Before Birth to Adolescence
Exploring the MazeExploring the Maze
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Pediatrician:
You are called to the high risk pregnancy
unit for a consultation:• Primigravida at 25 weeks• Hypertensive: BP = 160/110• 3+ proteinuria on dipstix• Headache• Peripheral oedema with 6kg weight gain in the
past 4 weeks
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Investigations:
• Bloods:• Hb 140g/L• WCC 18,000• Plats 103 x 109/L• MPV: 12.9• Uric Acid 467• AST 25• Albumin 29
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Investigations
• Ultrasound:• EFW: 450g (HC at 5th %ile, AC and FL <1%ile)• AFI 76• Umb arterial doppler: S/D ratio 7.2
• What else do you need to know?
• What are you going to say?
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Obstetrical Determinants of Survival and Handicap
• Antenatal treatment with glucocorticoids: 50% reduction in RDS related mortality in later GA
• Willingness to perform c/section for >800g• C/section for <800g associated with more
handicap• Obstetricians routinely underestimate
neonatal prospects for survival and survival without handicap
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Perinatal Outcomes at 23 -28 wks GA1983-1989
n=1024
Still birth rate
Synnes et al, 1994
0
5
10
15
20
25
30
35
23 24 25 26 27 28
GA
% S
till b
irth
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Perinatal Outcomes at 23 -28 wks GA1993-1997
n=278
Still birth rate
El-Metwally et al 2000
0
10
20
30
40
50
60
70
22 23 24 25
GA
% S
tillb
irths
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LDR Deaths
05
101520253035404550
23 24 25 26 27 28
GA
% L
DR
Dea
ths
Synnes et al, 1994
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LDR Deaths
El-Metwally et al 2000
0
5
10
15
20
25
30
35
40
22 23 24 25
GA
LDR
dea
ths
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Death < 7 days
0
5
10
15
20
25
30
35
40
23 24 25 26 27 28
GA
% D
eath
< 7
day
s
Synnes et al, 1994
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Death 7 - >28 days
0
2
4
6
8
10
12
14
23 24 25 26 27 28
GA
Death
7->
28days
Synnes et al, 1994
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Survival to discharge
0102030405060708090
100
23 24 25 26 27 28
GA
% S
urvi
val t
o D
/C
Synnes et al, 1994
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Survival to discharge
0
10
20
30
40
50
60
70
80
22 23 24 25
GA
% S
urvi
val t
o d/
c
El-Metwally et al 2000
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Management
25 wks gestational age by early u/s
13% still birth 11% LDR death 66% live to NICU
23% death < 7 days 6% death <28 days 6% death >28 days55% survival to d/c
NICU morbidity
66% BPD 18% IVH6% NEC 43% Air leaks 23% Sepsis/Meningitis 55% PDA
Synnes et al, 1994
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Major Morbidity and Mortality vs Birth Weight
0102030405060708090
501-750
741-1000
1001-1250
1251-1500
Birth Weight (grams)
Per
cent Major Morbidity
Mortality
NICHHD, 2001
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18 month outcomes for 25 wks GA
32% impaired
17% CP 13% Blind 2% Deaf 10% Low MDI
Synnes et al, 1994
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Other Factors to Consider
• Multiple gestation
• Gender
• SGA
• Antenatal steroids
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Effect of SGA on Mortality:25 wks GA
0102030405060708090
100
400 600 800 1000 1200
Birthweight (grams)
% M
orta
lity
Synnes et al, 1994
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Cognition and SGA vs AGA
• Significantly greater cognitive and neurologic morbidity in SGA vs AGA
• No differences by birth weight between the groups in cognitive performance or neurologic status
• Cognitive impairment associated with neurologic abnormality in both groups
• Higher incidence of neurologic deficit
in SGA infants greater cognitive impairment in the SGA infants
McCarton et al, 1996
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SGA vs AGA with Neurologic Impairment
Percentage of AGA and SGA preterms with cognitive retardation as a function of neurological status
Cognitive test scores as a function of neurological status at 3 years in AGA and SGA preterms.
McCarton et al, 1996
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Patient DR• Resuscitated by resident with bag and mask positive pressure
ventilation with 100% FiO2
• Pediatrician arrived at 1-2 minutes age
• Infant was pink and crying without intubation
• Neonatologist arrived at 10 minutes of age and full treatment was decided to be undertaken
• Infant intubated in DR and transported to NICU
• Apgars 6/7/8
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Postpartum History
• Vitals: temp 34.8 HR 144 RR 52
• Weight 480 g (<5%)
• Length 28.5 cm (<5%)
• HC 22 cm (5%)
• Bruises over scalp buttocks
• Hct 39%
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NICU Course
• Respiratory – HMD ventilated 25 days with 105 days O2– BPD noted on day 27– Apnea x 54 days treated with aminophylline
• CNS: normal cranial u/s
• OPHTHO: ROP grade 2 on day 64
• GU: bilateral inguinal hernia repair
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NICU Course
• FEN/MET– Hyperglycemia day 9 with insulin drip– Umbilical artery catherization, TPN– Osteopenia of prematurity day 38– Low T4 associated prematurity
• HEME:– Anemia of prematurity and iatrogenic loss– Multiple blood transfusions
• GI: jaundice peak 7.8mg/dl onset day 2• ID: suspected sepsis x 2
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Impact of NICU Practices on the Developing Brain
• Excess free radicals—O2, iron• High frequency ventilation with low lung volume?• Hypocarbia/hypercariba or rapidly changing PaCO2 levels?• Caffeine?• Postnatal steroids• Indomethacin ok?• Dopamine?• Sulfite preservatives?• High osmalality drugs?• Anesthetics and pain meds: fentanyl vs. morphine, versed?• Stimulation: visual, auditory, pain• Hyperthermia
Gressens et al, 2002
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Discharge
• 42 ½ weeks gestational age• 113 days chronological age• 2440g • HC 35 cm• Length 43 cm• Meds: vits
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4 months follow-up
• Growth– 3400g (<3%) – length 51.9cm (<3%) – HC 40cm (10%)
• Scars: right nasal notching, heel scars
• Neurodevelopmental exam: – some decrease truncal tone – poor head control
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8 months corrected age
• Growth <5%– 5780g– Length 61.6cm– HC 42.7cm
• Neurodevelopmental exam: – Slight decreased tone and strength– Poor balance– Immature uncoordinated grasp– Minimal vocalizations– Crab-crawls – Not pulling to stand
• Eye exam normal
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18 months corrected age
• Growth (<5%)– 7590g– Length 72.5cm– 45.8cm
• Neurodevelopmental exam: Bayley = 17month – Strongly right-handed– Babbling, using a few words– Abnormal movement: scooting on bottom using left arm– High activity, low persistence and short attention
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3 years • Growth
– 10.74 kg (-2.74 SD)– 88.4cm (-2.66 SD)– 47.5cm (-2.65 SD)
• Neurodevelopment– Soft, hoarse voice referred to
ENT for evaluation– Better expressive than receptive
language– Difficulty following longer directions– Peabody motor scales 31 months:
balance problems, right hand dominant, immature fine pincer
– Stanford-Binet low average
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4 ½ years• Growth
– 11.8kg (-2.98 SD)– 96.2cm (-2.32 SD)– HC 47.8cm (-2.64 SD)– Bone age 4 years at 4 years 10 months
• PET tubes• Neurodevelopment: “bounced around the
room”– High pain tolerance– Slight incoordination– Right side preference– Cognition: 77% verbal; performance 8%– Nonverbal: 16%– Visual-motor: 9%– Visual-Motor Integration: 14%
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8 years• Growth:
– 23 kg (-1.19 SD)– Height 121cm (-1.69 SD)– HC 49.7cm (-1.64 SD)
• Neurodevelopment: recommend learning assistance– Right-side dominant– Tight hamstrings– Brisk reflexes– Poor balance– Average cognitive, poor non cognitive– Poor recall of visual patterns/spelling– Poor arithmetic– Poor pencil use
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14 years
• Growth– 48.3kg (-2.38 SD)– 153.1cm (-1.39 SD)– 51.5cm (-2.43 SD)
• Neurodevelopment– Psyched eval: complex learning problem especially
with math– Poor output and distractible– Difficulty keeping on task– Verbal within normal range, better comprehension
than expression– Performance 10%
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Outcomes in Young Adulthood: Educational disadvantage associated with VLBW
persists to early adulthood
• 20 year outcomes for 242 survivors mean 29.7 wks, 1179g vs. 233 controls with normal birth weight
• 51% normal IQs• Fewer high school grads: 74% v 84% (p<0.04)• Less postsecondary study: 30% v 53% (p<0.04)• Subnormal height: 10% v 5% (p<0.04)• Neurosensory impairments: 10% v 1% (p<0.001)
Hack et al NEJM 2002