Preterm neonate recent

concepts in management
Dr.N.Saravanan
MD(Pediatrics)DM(Neonatology)
 Objectives
• Classification of preterms
• Antenatal management
• Golden hour management of very preterms
• Recent concepts in RDS management
• Recent concepts in PDA management
• Nutrition management parenteral and enteral
 Classification based on GA
• 39 wks completed- full term
• 37-38 wks- early term
• 34-36 wks- Late preterm
• 32-34 weeks- moderate preterm
• 28-32weeks- very preterm
• Less 28 wks- extreme preterms
• 24-26wks- extrodinary preterms
Extreme preterm
 Antenatal management
• AN Corticosteroids
• AN magnesium sulphate
 AN steroids
• 24-34 wks GA require it
• Even may be beneficial earlier GA
• Dexamethasone preferred-dose 6mg every 12
hrs for 48 hrs
• Betamethasone phosphate acetate salt not
available in India
• 1 2ND course if less than 34 wks and 2 weeks
elapsed
• No contraindications
 AN magnesium sulphate
• Used in less than 32 weeks deliveries
• Evidence shows reduction in Cerebral palsy
• 4gm bolus followed by 1gm hrly till 24 hrs
• No major adverse effects
Golden hour management very preterms

• Thermoregulation
• Gentle resuscitation
• Delayed cord clamping
• Intact cord resucitation
• Surfactant if required
• Caffeine administration
• Securing of iv central and peripheal for TPN
Thermoregulation of very preterm
• Delivery room temperature 23-25*C
• No drying,use of food grade plastic wraps and
resuscitation Under radiant warmer,cap must
• Use of exothermic mattresses in extreme
preterms
• Transport in incubators
 Resucitation of very preterms
• Use O2 blender start with21-30% fio2
• Target spo2 charts should decide further O2
• Use T-piece resucitator which provides peep
• Use delivery room cpap for all extreme
preterms,and very preterms with RD
• Delayed cord clamping 30sec
• No cord milking
• Intact cord rescucuitation is recent trend
Trolley for intact cord resucitation
 Surfactant
• European guidelines followed
• Cpap is initiated early and Babies requiring more
than 30% fio2 oxygen are given surfactant in NICU
• Early selective surfactant therapt is followed
• Poractant is preferred
• Insure is followed
• MIST or LISA Is practiced is expertise is available
• Lung ultrsound increasingly used in decision making
 Caffeine citrate
• Is a must in all extreme preterms
• And very preterms with RD or apnoea
• It reduces incidence of BPD and improves
neurodevelopment outcomes even at 5yrs
follow up.
 Central lines and early tpn
• UVC insertion for very preterms
• UAC for extreme preterms
• Full early TPN from D1 Including
lipid,aminoven,and dextrose -6-12 gir
• Initiation of MEN OR Enteral feeds with
mothers milk
 Continuing respiratory support
• CPAP is continued in stable babies
• Niv ventilation is preferred in 28wks and less
and is helpful in avoiding apnoeas
• Invasive ventilation is avoided as far as
possible and reserved for less than 26 wks
with svere RD or recurrent apnoeas
 ventillation
• Gentle ventilation is carried out SIMV with PS
is usually given,as lung compliance improves
babies are extubated at PIP of 12,and fio2 less
than 30%.
• PDA is a common reason for increasing RD
folowing initial improvement
 HS PDA management
• About 15-40% of very low birth weight infants
have a PDA. In extremely preterm infants (<28
weeks),the incidence is as high as 70-80%.
Pulmonary over circulation can cause a
reduction in lung compliance leading to a
prolonged need for respiratory support
IVH,BPD,and NEC can occur because of ductal steal
phenomenon
 Clinical features of HS pda
• easily palpable dorsalis pedis
• wide pulse pressure (>25 mm of Hg), a hyperactive precordium
• (visible pulsations in more than two rib spaces), systolic murmur
• (ejection systolic; rarely pansystolic or continuous),
• Persistent tachycardia, and are, generally noted on day 3 or 4 of
life.
• In a ventilated neonate, PDA can present with increased
ventilatory
settings, higher FiO, requirement, hypercarbia, metabolic
acidosis,
and recurrent apnea.
BNP CAN BE USED AS A BIOMARKER AS ADD ON TO ECHO
Echo features
 HS PDA echo
• Size >1.5mm
• LA ratio more than 1.4
• Duct flow velocity less 2m/sec
• Descending aorta absent /reversal of flow
• E/A ratio >1
• LVO >320ML/KG/mt
 Management
• Fluid restriction
• Increasing peep
• 'wait and watch' strategy
• seems reasonable in a more mature infant (>28
weeks' GA) who is stable, tolerating feeds, and on
minimal or noninvasive respiratory
• support.? In such cases, fluid restriction and
appropriate ventilatory titration can be coupled with
watchful waiting
 LESS THAN 28WKS
• Paracetamol inhibits prostaglandin production
through inhibition of the peroxidase enzyme.
Moreover, paracetamol has been
• shown efficacious in various situations where
NSAIDs are either contraindicated or have
failed to achieve PDA closure
• DOSE-15mg/kg QID For 3 days
• in neonates <26 weeks, the early targeted
Treatment within 12 hrs with echo features of
signficant PDA, is beneficial, especially in those
with large shunts and needing respiratory
support.
 Enteral NUTRITION
• Ebm mothers own is preferred
• PDHM from milk bank next
• Preterm Formula not preferred in vlbw
• Probiotics have some role when formula is
given in preventing NEC
• In ADEF, MEN IS Started according to following
chart
 ROUTE OF FEEDING
• 34 WEEKS –DBF
• 32-34 WEEKS-Spoon ,or paladai feeds
• Less than 32 weeks-OG feeds
• NNS is started earlier
 Feed advancement
• Very preterm-can advance faster 30ml/kg/day
• Extreme preterm-20ml/kg/day
• HMF is added at 70ml-100ml volume
• Maximum feed volume up to 200ml/kg/day
• BPD babies need restriction to 130ml/kg/day
THANK YOU