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Mike Devoe, MD 7/31/2010 Dr Mike DeVoe D Mik D V NE TN Regional Perinatal Center Now. Minimum 2 page order set Are we being inundated with preterm infants? y Regional Perinatal Center data, 2007 y Regional Births, TN 5225 VA 3245 y LBW Births TN 525+ VA 360+ y NICU y 500 + admissions 2009 y ALOS – 17 days y Trends y y y Increased admissions for Neonatal Abstinence Syndrome (NAS) Preterm delivery rate unchanged Increase in “Late Preterm” rate 2007 2007 2007 TEENAGE 2007 2007 LBW 2007 VLBW INFANT MORT. # BIRTHS PREG. RATE Unmarried % # BUCHANAN 202 30.9 79 16 7.9 6 3.0 1 5.0 DICKENSON 203 26.2 63 22 10.8 6 3.0 GRAYSON 157 26.3 55 16 10.2 1 0.6 2 12.7 CITY/COUNTY LEE # % 265 36 9 36.9 86 15 57 5.7 NORTON CITY 45 36.7 23 6 13.3 RUSSELL 298 11.1 84 20 6.7 04 0.4 3 11 3 11.3 2.0 5 16.8 SCOTT 207 21.6 2 9.7 351 30.6 144 43 12.3 5 1.4 4 11.4 468 25.5 159 48 10.3 7 1.5 2 4.3 22 183 8.7 1 6 SMYTH 551 18 RATE TAZEWELL WASHINGTON 69 # 8 10 3.9 47 8.5 WISE 498 32.6 190 56 11.2 10 2.0 3 6.0 SW VA Region 3245 27.3 1135 307 9.6 60 1.8 1.8 25.0 3 7.5 5.4 VIRGINIA 107,261 27.2 38,281 9,344 8.6 1,899 1.7 760 7.7 Mike Devoe, MD 7/31/2010 TEENAGE COUNTY # BIRTHS PREG. RATE ADEQ. PRE- LBW VLBW INFANT MORT. Unmarried NATAL CARE # % # % # RATE CARTER 561 20 38.3 68.6 52 9.3 9 1.6 2 3.6 GREENE 753 30.2 41.7 65.7 53 7.2 9 1.2 2 2.7 HANCOCK 86 6.6 25.6 70.9 11 12.9 1 1.2 - * HAWKINS 635 22.3 36.9 64.1 45 7.3 6 0.9 4 6.3 JOHNSON 188 32.2 35.1 71.8 18 9.6 7 3.7 2 10.6 SULLIVAN 1707 32.3 41.8 66.2 168 9.8 35 2.1 20 11.7 UNICOI 180 19.9 37.2 70.0 13 7.2 4 2.2 3 16.7 WASHINGTON 1415 25.1 36.2 75.3 128 9.0 24 1.7 14 9.9 36.6 68.9 488 9.0 95 1.7 47 8.5 27.8 42.8 60.9 8176 9.4 1514 1.7 718 8.3 NE TN REGION 5525 TENNESSEE 86661 Outcomes y Vermont Oxford: y International outcomes database, > 800 NICU’s y Comparative outcomes to similar size and complexity NICU y State comparisons available through TIPQC state data reporting subset through Vermont Oxford y “real‐time” outcomes available on line y Annual summaries for planning, y Identifying the outliers And how are we doing locally? (What are “our” problems we are turning over to you?) y How do we know our outcomes? y What are our goals? y What factors hinder accomplishment of our goal of optimal outcomes i l y Subspecialty access y Ophthalmology, neurology, orthopedics y Funding issues y Some insurers will not reimburse for follow‐up y “Lost to Follow up” Mike Devoe, MD 7/31/2010 With all of the improvements in NICU care like surfactant, improved ventilation strategies, why are we still seeing “BPD” BPD/CLD: Proposed Etiologies Normal Lung Development y Pulmonary Immaturity y Oxygen Toxicity y Barotrauma/Volutrauma y Vitamin Deficiencies y Failed Antioxidant Protection y Genetic Predisposition y Excess Fluid Administration y Patent Ductus Arteriosus y Chronic Infection y y y Canalicular Period 16 to 26 weeks Saccular Period 26 to 36 weeks Ureaplasma Chlamydia Cytomegalovirus Alveolar Period 36 to 41 weeks (Non‐human, Primate Lung Sections) Presented by K Stenmark, MD:ICRV, 2003 Incidence of BPD/CLD y Worldwide, the incidence of bronchopulmonary dysplasia (BPD) and chronic lung disease (CLD) is reported to range from 14% to 43% of premature infants, depending on population studied. y The incidence of CLD/BPD is inversely related to birth weight and gestational age. y Definitions vary greatly, and this has made estimates of disease incidence difficult to ascertain. Fanaroff AA, et al. Am J Obstet Gynecol. 1995;173:1423‐31 CLD: Clinical Manifestations y Symptoms of CLD: y Chronic, recurrent pulmonary exacerbations y Cough y Wheeze y Tachypnea y Respiratory distress Mike Devoe, MD CLD: Typical Chest X‐ray Findings Radiographic Abnormalities of Chronic Lung Disease (CLD): Hyperinflation Hazy appearance consistent with fib i /i t titi l fibrosis/interstitial changes Linear‐reticular opacities Cystic elements (emphysematous bullae) Scoring systems vary from institution to institution CT scans are thought by some to be better than plain films for diagnosis and monitoring changes 7/31/2010 NICU Discharge management y Oxygen requirement stable for 1 wk prior to discharge y Low flow 100% cannula system for home use y Optimal diuretic therapy, chlorthiazide and aldactone y Bronchodilator therapy as needed y Inhaled steroid therapy as needed I h l d id h d d y No immediate medication changes for several days prior to discharge y Pulse oximetry by home health on prn checks, y Ideal O2 saturation range 82‐95% y Check at rest and with feeds y Pediatric Pulmonary follow up 4‐6 weeks post discharge y RSV prophylaxis per AAP risk criteria Hansell DM. Eur Respir J. 2001;17:1294‐313; Lynch DA, et al. Am J Roentgenol 1999;173:713‐8 Pediatric Management, BPD y Pulse oximeter checks at each visit (82‐95%) y Adjust diuretic therapy for weight gain y Serum electrolytes q 2‐4 weeks while on diuretics, may need addition of NaCl or KCl feeding supplement y Office visits for wheezing, aggressive treatment y Majority of patients off oxygen and diuretic therapy within 6 mos of NICU discharge y Nutrition, Nutrition, Nutrition y May have need for increased caloric intake but with volume restriction. “dense” formula use (up to 30 cal.oz = 1 cal/ml) Apnea and Monitoring y NICHD Consensus group 2006 y “No consensus has been reached regarding the definition, diagnosis, or treatment of apnea of prematurity” y Available technology is rarely used to document real time events y The observational period after therapy is unknown y There is an infrequent association between GER and apnea y Definition: y The cessation of breathing for more than 20 sec or apnea or the cessation of breathing for less than 20 sec if it is accompanied by bradycardia or oxygen desaturation PEDIATRICS Vol. 117 No. 3 March 2006, pp. S47‐S51 (doi:10.1542/peds.2005‐0620H) Mike Devoe, MD Apnea Types y Central Apnea: Cessation of airflow and effort y Obstructive apnea: cessation of airflow, effort preserved y Mixed y Periodic Breathing: periods of irregular respiration for as long as 20 sec followed by apnea periods of 10 sec or less, at least 3 times in succession y 2‐6% of time in healthy term newborns y Up to 25 % of time in preterm infants y Most commonly occurs in active sleep y Pathophys: y Prolonged brainstem conduction times in apnea patients y Usually occurs in REM sleep y Blunting of CO2 response in preterm infants 7/31/2010 Apnea management, post discharge y Monitoring indicated for infants with persistent apnea despite medical therapy y Indications for home monitoring: y “clinically significant apnea” or ALTE y Recording monitoring documenting apnea y GER with apnea y Sib of SIDS, per NIH consensus, only after 2 SIDS related deaths occur in a family y NICU Monitoring done for: y Apnea episodes within 1 week of discharge, despite medication y GER with apnea within last week prior to discharge y NOT routinely used for patients being discharged on oxygen therapy with “stable” oxygen requirement prior to discharge y Obstructive airway anomaly, Pierre Robin, Trach patients, etc y Incidence: up to 70 % of all preterms < 34 weeks Apnea, out pt mgmt y EDUCATION: y Prenatal and postnatal Tobacco use y Prone sleeping position Apnea Monitoring y Weaning: y For patients discharged on medication and monitoring y No significant apnea for 1‐2 weeks y Pacifier use y Discontinue medication by 8 wks post discharge y Soft Bedding g y Monitor additional 4 weeks y “Co‐bedding” y Discontinue monitor if no further significant apnea events y Illnesses in infants with BPD y Monitor Downloads y Valuable only if monitor is used y Performed monthly y Troubleshooting: y Genetic Factors y Duration of Monitoring: y Usually minimum of 6 weeks y Medication use: y Maintain therapeutic dosing, 5 mg/kg y Levels not necessary y Don’t let patient “outgrow” the dose – either therapeutic or no dosing y y y Loose leads Monitor alarms set too high, decrease low HR alarm to 60 by 4 months if still in use Interference, artifact common Mike Devoe, MD 7/31/2010 Hearing and vision difficulty Vision/Hearing y Retinopathy of Prematurity y Oxidant injury to developing retinal vessels y Oxygen therapy, transfusions, iron therapy, nutrition? y Vascular development not complete until 42‐44 weeks Vascular development not complete until 42 44 weeks y Protocol, y NICU: Beginning at about 42 days age, ROP check per Vanderbilt Ophthalmology y Recheck every two weeks until vessels mature y Laser surgery if progressions y F/U at 6 mos with ped/general ophthlamology Hearing Defecits y Etiologies: y Genetic (Conexin Gene) y Hypoxic encephalopathy T i (bili bi ibi i ) y Toxins (bilirubin, antibiotics, etc) y Structural anomaly y Inner/outer ear y Testing Protocols y OAE vs ABR y If fail x2, TEIS referral, BAER, audiology, genetic screen Mike Devoe, MD 7/31/2010 Nutrition: Nutrition y At risk groups as identified y Use of growth curves for preterm infants, corrected for gestational age y Use of preterm formulas for trace mineral, calcium, U f f l f i l l i vitamin intake for all infants < 35 weeks gestation, continue through 6 mos post discharge y Supplemental Vitamin use, polyvisol w,w/out iron y Nutritional concerns: y Failure to follow growth curves y Assessment: y Strict I/O, caloric estimates l y Type of intake y Unusual outputs? y Higher energy requirement y y y Post surgical Respiratory exacerbations Congestive cardiac disease Nutrition Basics y Neosure or Enfacare until 6‐9 months y If excessive wt increase, verify no cereal addition to bottle, etc y May also mix neosure to 20 cal/oz If breastfeeding at least 2 neosure feeds/day y If breastfeeding, at least 2 neosure y No soy formula, low bioavailabililty of calcium and phosphours y If feeding intolerance is documented, may switch to pregestimil, alimentum or nutramigen y PolyViSol for all breast fed infants and all bottle fed infants until taking 1 liter of term formula/day y Wait to introduce solids until infant is at least developmentally 4‐6 mos of age Nutrition – problem solving 101 y Plot growth as age adjusted, if not following curve: y Ensure adequate caloric intake y y y 0‐4 mos – breast fed 10‐12 feeds/day, bottle 16‐24 oz; 24‐36 oz 4 6 mos breast fed 8‐10 feeds/day, bottle 26‐40 oz 4‐6 mos – breast fed 8 10 feeds/day bottle 26 40 oz 6‐8 mos – breast fed 6‐8 feeds/day, bottle 24‐32 oz, ½ cup cereal, 3‐4 tbsp/day veggies, fruits, meats 1‐2 tbsp/day y If intake is adequate on good intake of solids, can give avocados, vegetable oil, y Increase formula concentration to 24‐27 cal/oz y R/O aspiration, stool loss Periventricular Leukomalacia Mike Devoe, MD 7/31/2010 IVH/PVL, local data Developmental Outcome, things to watch for ETSU NICU Follow up y Multidisciplinary y Neonatology y Peds certified physical therapy D l l h l f i y Developmental psychology for testing y Audiology y Speech/Language y Perinatal Nutrition y Others as needed Pediatrics 2004; 113:594– 600; quality of life, Known Risk factors: y y y y Very Low Birth weight Asphyxia, (multisystem, acidosis) BPD (oxygen @ 36 weeks) Neurologic: y Microcephaly, TORCH y Neonatal Seizures y Meningitis y IVH y PVL y Psychosocial Issues: (substance abuse, abuse) y Special Needs (monitors, oxygen, tracheotomy, g‐tube Mike Devoe, MD 7/31/2010 F/U clinic y Goal: provide a central location for appropriate evaluation and referral for neonates post NICU discharge y Resource for primary care providers in the area p y p y Appropriate feedback to primary care y No treatment is done in the clinic y Diagnosis and referral only with appropriate agencies y No primary care in clinic y 1st visit at 2‐3 mos post discharge, then q 2‐6 mos, dependent on patient needs through age 2 yrs F/U clinic, types of assessment y Nutrition: y Audiology y Speech/language y PT y Developmental Fig 2. Timeline: child outcomes Summary y Corrected Gestational Age: up through 9 mos y Plot growth curves and developmental milestones y Immunize based on chronological age, RSV y Screen for nutrition problems, especially patients with severe IUGR, BPD y Assess tone abnormalities y Use outside resources y Pediatrics 2004;114:1377‐1397 Care connection, TEIS, neonatal follow up clinic y Watch for y Inguinal hernias y Late onset hydrocephalus y Intestinal stenosis post NEC y Maintain medications appropriate for weight y “Premie” formula for 6 mos post discharge Copyright ©2004 American Academy of Pediatrics Mike Devoe, MD Summary y Corrected gestational age: 9‐18 mos y Plot growth and development y Screen for tone and motor delay y Reassess hearing status y Screen for language milestones y Ophthalmology evaluation, especially with history of BPD y Immunizations, RSV and influenza per guidelines 7/31/2010