Care of the NICU Graduate / RSV prophylaxis / Early Intervention
Dr. Heidi Beutler Your first patient today is a newborn. She was born 2 months ago at 28 weeks gestation with a birth weight of 926 grams. She was discharged home from the hospital last week. Today she weighs 2045 grams. She is taking Neosure 22 cal/oz formula, and appears well.
1) How much should she weigh when she sees you a week from today?
2) Her mother has been pumping breast milk but could not give it to her baby
until now because she was taking medications. She wants to give her baby
only breast milk from now on. Is that ok?
3) The NICU forgot to give the mother prescriptions for vitamins. Should she be taking them? Which ones, and how much?
Your second patient is the twin brother of the first patient. He weighed 810 grams at birth and needed CPAP and oxygen for RDS for the first 3 weeks of life. He received IV antibiotics for 10 days for presumed sepsis. A head ultrasound showed a right-sided grade II intraventricular hemorrhage, which was unchanged prior to discharge. Today he weighs 1900 grams, and his head circumference is 34 cm. On exam he seems to have an inguinal hernia.
1) The NICU was too busy to make his follow-up appointments. Which ones should be made, and when?
2) When he comes back to see you in a week, what should his head circumference be?
3) Can you give him (and his sister) vaccines today?
4) It’s May 15. Should these twins get palivizumab in October, and if so, how will you arrange for this?
The mother asks you whether the twins will be normal, since they were premature.
1) What can you tell her about neurodevelopmental outcomes at this time?
2) Are they eligible for Early Intervention, and how do you arrange for it?
REFERENCES
The most comprehensive and current (2007) review:
Michael P Sherman, MD, FAAP, et al, “Follow-up of the NICU Patient” http://www.emedicine.com/ped/topic2600.htm
And:
The AAP’s 2004 “Follow-up Care of High Risk Infants,” is a report of a symposium called to define optimal methods to assess the outcome of high-risk infants, identify gaps in knowledge about the neurodevelopmental outcome of high-risk infants, and prioritize research efforts in response to these gaps.
http://pediatrics.aappublications.org/cgi/reprint/114/5/S1/1377
Other references on more specific topics:
Growth and Nutrition:
including updated growth charts for premature infants http://www.biomedcentral.com/1471-2431/3/13
Breastfeeding the preterm infant:
http://www.bfmed.org/ace-files/protocol/NicuGradProtocol.pdf
Reis BB, Hall RT, Schanler RJ, et al. Enhanced growth of preterm infants fed a new powdered human milk fortifier: A randomized, controlled trial. Pediatrics. Sep 2000;106(3):581-8
Vohr BR, Poindexter BB, Dusick AM, et al. Beneficial effects of breast milk in the neonatal intensive care unit on the developmental outcome of extremely low birth weight infants at 18 months of age. Pediatrics. 118(1):e115-23.
RSV prophylaxis:
Meissner HC, Long SS. Revised indications for the use of palivizumab and respiratory syncytial virus immune globulin intravenous for the prevention of respiratory syncytial virus infections. Pediatrics. Dec 2003;112(6 Pt 1):1447-52. [Medline].
Immunizing the preterm infant:
Saari TN. Immunization of preterm and low birth weight infants. American Academy of Pediatrics Committee on Infectious Diseases. Pediatrics. Jul 2003;112(1 Pt 1):193-8.
Retinopathy of Prematurity guidelines:
http://pediatrics.aappublications.org/cgi/content/full/117/2/572
BPD:
Jobe AH. The New BPD. NeoReviews. 2006;7(10):e531-45
Neurodevelopmental Outcomes:
Aylward GP, Neurodevelopmental outcomes of infants born prematurely. J Dev Behav Pediatr. 2005 Dec;26(6):427-40.
Marlow N, Wolke D, Bracewell MA. Neurologic and developmental disability at six years of age after extremely preterm birth. N Engl J Med. Jan 6 2005;352(1):9-19.
Patra K, Wilson-Costello D, Taylor HG. Grades I-II intraventricular hemorrhage in extremely low birth weight infants: effects on neurodevelopment. J Pediatr. Aug 2006;149(2):169-73.
Woodward LJ, Anderson PJ, Austin NC, et al. Neonatal MRI to predict neurodevelopmental outcomes in preterm infants. N Engl J Med. 355(7):685-94.
And finally,
Early Intervention:
http://www.nyc.gov/html/doh/html/earlyint/earlyint.shtml
(includes a downloadable form used to refer a child for E.I.)
http://www.health.state.ny.us/community/infants_children/early_intervention/
hot off the press:
http://www.nyc.gov/html/doh/downloads/pdf/chi/chi27-2.pdf
