MANAGEMENT OF MANAGEMENT OF PRETERM AND PRETERM AND IUGR BABIESIUGR BABIES

Dr.M.Ravindranath ReddyDr.M.Ravindranath Reddy Professor of PaediatricsProfessor of Paediatrics

MANAGEMENT OF PRETERMMANAGEMENT OF PRETERM

1.1. ARREST OF PREMATURE LABOUR ARREST OF PREMATURE LABOUR 2.2. ANTENATAL CORTICOSTEROIDS ANTENATAL CORTICOSTEROIDS 3.3. DELIVERY ROOM MANAGEMENTDELIVERY ROOM MANAGEMENT4.4. NEONATAL MANAGEMENT NEONATAL MANAGEMENT

NEONATAL MANAGEMENTNEONATAL MANAGEMENT

HOME CAREHOME CARE

PLACE OF CAREPLACE OF CARE NICU CARENICU CARE - - BIRTH WT <1800GM.BIRTH WT <1800GM.

- - GEST AGE < 34 WKSGEST AGE < 34 WKS - SICK NEONATE - SICK NEONATE

>34WKS>34WKS>1800GMS>1800GMS

NEONATAL MANAGEMENT NEONATAL MANAGEMENT

1.1. THERMAL REGULATION.THERMAL REGULATION.2.2. OO2 2 THERAPYTHERAPY3.3. PHOTO THERAPYPHOTO THERAPY4.4. PREVENTION OF NOSOCOMIAL INFPREVENTION OF NOSOCOMIAL INF5.5. FLUID & ELECTROLYTE THERAPYFLUID & ELECTROLYTE THERAPY6.6. NUTRITION & NUTRITIONAL SUPPLEMENTSNUTRITION & NUTRITIONAL SUPPLEMENTS7.7. IMMUNIZATION IMMUNIZATION 8.8. DISCHARGE POLICY & FOLLOW UP PROTOCOLDISCHARGE POLICY & FOLLOW UP PROTOCOL9.9. HOME CARE OF PRETERM BABIES.HOME CARE OF PRETERM BABIES.10.10. PREVENTION, EARLY PREVENTION, EARLY & PROMPT MANAGEMENT OF & PROMPT MANAGEMENT OF

COMPLICATIONS COMPLICATIONS

PREVENTION OF NOSOCOMIAL INFECTIONS PREVENTION OF NOSOCOMIAL INFECTIONS

1.1. HAND WASHING HAND WASHING 2.2. EARLY EXCLUSIVE BREAST FEEDING EARLY EXCLUSIVE BREAST FEEDING 3.3. CARE OF UMBILICAL STUMPCARE OF UMBILICAL STUMP4.4. AVOIDING OF UNNECESSARY INTERVENTIONS AVOIDING OF UNNECESSARY INTERVENTIONS

FLUID & ELECTROLYTE THERAPYFLUID & ELECTROLYTE THERAPY

ADDITIONAL ALLOWANCES FOR PHOTOTHERAPY 20 – ADDITIONAL ALLOWANCES FOR PHOTOTHERAPY 20 – 40 ml/kg/day. RADIANT WARMER 40- 80 ml/kg/day.40 ml/kg/day. RADIANT WARMER 40- 80 ml/kg/day.

FLUID IN TAKE SHOULD BE ACCURATELYFLUID IN TAKE SHOULD BE ACCURATELY

RECORDED BY RECORDED BY

ADD ELECTROLYTES AFTER 24-48 HOURS (NaADD ELECTROLYTES AFTER 24-48 HOURS (Na++ 3- 3-5meq/kg/day, K5meq/kg/day, K++ 2 – 3 meq/kg/day) 2 – 3 meq/kg/day)

DAYDAY <1000.G<1000.G 1000-1500 G1000-1500 G >1500G>1500G

11STST &2 &2NDND 100 – 120100 – 120 80 – 100 80 – 100 60 – 8060 – 80

33RDRD & 4 & 4THTH 130 – 140130 – 140 110 – 120 110 – 120 90 – 10090 – 100

55THTH & 6 & 6THTH 150 -160150 -160 130 – 140 130 – 140 110 – 120 110 – 120

77THTH & 8 & 8THTH 170 – 180170 – 180 150 – 160150 – 160 130 – 140130 – 140

99THTH ON WARDS ON WARDS 190 – 200190 – 200 170 – 180 170 – 180 150 - 160 150 - 160

INTAKE OUTPUT CHART INTAKE OUTPUT CHART

DAILY WT RECORDING DAILY WT RECORDING

SERUM SODIUMSERUM SODIUM

NEONATAL MANAGEMENT NEONATAL MANAGEMENT

1.1. THERMAL REGULATION.THERMAL REGULATION.2.2. OO2 2 THERAPYTHERAPY3.3. PHOTO THERAPYPHOTO THERAPY4.4. PREVENTION OF NOSOCOMIAL INFPREVENTION OF NOSOCOMIAL INF5.5. FLUID & ELECTROLYTE THERAPYFLUID & ELECTROLYTE THERAPY6.6. NUTRITION & NUTRITIONAL SUPPLEMENTSNUTRITION & NUTRITIONAL SUPPLEMENTS7.7. IMMUNIZATION IMMUNIZATION 8.8. DISCHARGE POLICY & FOLLOW UP PROTOCOLDISCHARGE POLICY & FOLLOW UP PROTOCOL9.9. HOME CARE OF PRETERM BABIES.HOME CARE OF PRETERM BABIES.10.10. PREVENTION, EARLY PREVENTION, EARLY & PROMPT MANAGEMENT OF & PROMPT MANAGEMENT OF

COMPLICATIONS COMPLICATIONS

NUTRITION NUTRITION FEEDING FEEDING

TRANSITION PHASE STABLE GROWING PHASE POST DISCHARGE PHASE

PREDOMINANTLY ON IV FLUIDS

FEEDING OPTIONS 1. PRETERM HUMAN MILK +

HMF+FE SUPPLEMENTS

2. LBW FORMULA MILK+ VIT-D,A .B2 + FE SUPPLEMENTS

3. UNDILUTED COW’S MILK + VIT-D, A,B2 FOLATE,ZN_FE SUPPLEMENTS

1. PRETERM HUMAN MILK+ CA,P,VIT-D, A,ZN,FOLATE, FE SUPPLEMTNS.

2. LBW FORMULA MILK +VIT-A, D, FE SUPPLEMENTS

3. UNDILUTED COWS MILK VIT-A, FOLATE _E SUPPLEMENTS

EARLY ENTERAL FEEDING IS RECOMMENDED FOR ALL BABIES EARLY ENTERAL FEEDING IS RECOMMENDED FOR ALL BABIES CI OF ENTERAL FEEDING ARE <1200GMCI OF ENTERAL FEEDING ARE <1200GM

< 30WEEKS< 30WEEKS SICK BABIES (SEVERE BIRHT ASPHYXIA, RDS, SEPSIS, SEIZURES, SICK BABIES (SEVERE BIRHT ASPHYXIA, RDS, SEPSIS, SEIZURES,

APNEIC ATTACKS, ASSISTED VENTILATION)APNEIC ATTACKS, ASSISTED VENTILATION)

METHODS OF FEEDING METHODS OF FEEDING

TROPHIC FEEDS IS RECOMMENDED TO ALL PRETERM TROPHIC FEEDS IS RECOMMENDED TO ALL PRETERM BABIES IRRESPECTIVE OF THEIR CLINICAL STATUS OF BABIES IRRESPECTIVE OF THEIR CLINICAL STATUS OF ABOUT 10ml/kg/day 4-6 HRLY OF EBM. ABOUT 10ml/kg/day 4-6 HRLY OF EBM.

AGE <1200G<30WKS

1200-1800G30 -34WKS

>1800G>34WKS

INITIAL IVF GAVAGE BREAST FEEDING

AFTER 1-3DAYS GAVAGE KATORI/ SPOON BREAST FEEDING

LATER 2-4 WKS KATORI /SPOON BREAST FEEDING BREAST FEEDING

4- 6 WKS BREAST FEDING BREAST FEDING BREAST FEDING

TYPES OF FEDINGTYPES OF FEDING

NASO GASTRIC OR OROGASTRICNASO GASTRIC OR OROGASTRIC

TRANS PYLORIC FEEDINGSTRANS PYLORIC FEEDINGS

GATROSTOMY FEEDINGGATROSTOMY FEEDING

TOTAL PARENTERAL NUTRITIONTOTAL PARENTERAL NUTRITION

INDICATIONS-INDICATIONS- 1)BABIES WEIGHING <18OOgms AND NOT EXPECTED 1)BABIES WEIGHING <18OOgms AND NOT EXPECTED

TO RECEIVE SIGNIICANT ENTERAL NUTRITION FOR >5 DAYSTO RECEIVE SIGNIICANT ENTERAL NUTRITION FOR >5 DAYS

2) BABBIES WEIGHING MORE THAN 1800GMS AND NOT 2) BABBIES WEIGHING MORE THAN 1800GMS AND NOT EXPECTED TO RECEIVE SIGNIICANT ENTERAL NUTRITION >7 EXPECTED TO RECEIVE SIGNIICANT ENTERAL NUTRITION >7

DAYSDAYS 3)VLBW BABIES WITH SEVERE SYSTEMIC ILLNESS3)VLBW BABIES WITH SEVERE SYSTEMIC ILLNESS

4)ELBW BABIES4)ELBW BABIES

AMOUNT & FREQUENCY OF ENTERAL FEEDS(<1.5kg) AMOUNT & FREQUENCY OF ENTERAL FEEDS(<1.5kg) 1.1. BEGIN AT 30ml/Kg/day ON 1BEGIN AT 30ml/Kg/day ON 1STST DAY & BALANCE AMOUNT BY DAY & BALANCE AMOUNT BY

IVFIVF2.2. FIRST FEED GIVEN AT 2 HRS THEN 2-3 HRLYFIRST FEED GIVEN AT 2 HRS THEN 2-3 HRLY3.3. INCREEASE BY 15 ml/Kg every day depending on tolerance INCREEASE BY 15 ml/Kg every day depending on tolerance 4.4. Maximum 180 – 200ml/kg/ day BY 7-10 DAYS Maximum 180 – 200ml/kg/ day BY 7-10 DAYS

TOLERANCE OF FEEDS:TOLERANCE OF FEEDS:

RAPID ENHANCEMENT OF MORE THAN 25-50ml/kg/day IS RAPID ENHANCEMENT OF MORE THAN 25-50ml/kg/day IS ASSOCIATED WITH HIGHER RISK OF NECASSOCIATED WITH HIGHER RISK OF NEC

MONITORED BY MONITORED BY 1.1. PREFEED ASPIRATE PREFEED ASPIRATE 2.2. ABDOMINAL GIRTHABDOMINAL GIRTH3.3. STOOLS SHOULD BE SCREENED FOR OCCULT BLOOD & STOOLS SHOULD BE SCREENED FOR OCCULT BLOOD &

REDUCING SUBSTANCESREDUCING SUBSTANCES

CRITERIA FOR ADEQUATE FEEDING :CRITERIA FOR ADEQUATE FEEDING :

1.1. SATISFACTORY WEIGHT GAIN SATISFACTORY WEIGHT GAIN 2.2. AVERAGE LINEAR GROWTH AROUND 1cm/wkAVERAGE LINEAR GROWTH AROUND 1cm/wk3.3. HEMATOCRIT SHOULD BE MAINTAINED AROUND 40% HEMATOCRIT SHOULD BE MAINTAINED AROUND 40% 4.4. URINE OSMOLALITY SHOULD VARY BETWEEN 150-300 m osm/kg URINE OSMOLALITY SHOULD VARY BETWEEN 150-300 m osm/kg

& baby SHOULD VOID AT LEAST 1ML/KG/HR OF URINE & baby SHOULD VOID AT LEAST 1ML/KG/HR OF URINE

NUTRIENT SUPPLEMENTS NUTRIENT SUPPLEMENTS

PROTEINS: PROTEINS: 3 – 4gm/kg/day3 – 4gm/kg/dayFATS:FATS: 3 – 4gm/kg/day3 – 4gm/kg/dayCARBOHYDRATESCARBOHYDRATES 10- 12gms/kg/day10- 12gms/kg/dayMINARALSMINARALS CALCIMUMCALCIMUM -250mg/kg/day-250mg/kg/day

PHOSPORUSPHOSPORUS -125mg/kg/day-125mg/kg/dayIRONIRON - <1000gm-3-4mg/kg/day- <1000gm-3-4mg/kg/day

> 1000gm- 2-3mg/kg/day> 1000gm- 2-3mg/kg/dayVITAMINS:VITAMINS:

VIT AVIT A 120-420mg/day120-420mg/dayVIT KVIT K 0.5 – 1mg AT BIRTH0.5 – 1mg AT BIRTHVIT DVIT D 500 -2000 IU/DAY500 -2000 IU/DAYVIT EVIT E 0.5 -0.60.5 -0.6 mg/100kclmg/100kcl

VACCINATION IN LBW BABIESVACCINATION IN LBW BABIES

IF LBW IS NOT SICK, VACCINATION SCHEDULE IS SAME AS IF LBW IS NOT SICK, VACCINATION SCHEDULE IS SAME AS FOR NORMAL BABIESFOR NORMAL BABIESA SICK LBW BABY SHOULD RECEIVE THESE VACCINES ON A SICK LBW BABY SHOULD RECEIVE THESE VACCINES ON RECOVERYRECOVERY

DISCHARGE POLICYDISCHARGE POLICY::MOTHER SHOULD BE MENTALLY PREPARE & PROVIDED WITH MOTHER SHOULD BE MENTALLY PREPARE & PROVIDED WITH ESSENTIAL TRAINING ESSENTIAL TRAINING BABY SHOULD BE STABLE, MAINTAINING HIS BODY BABY SHOULD BE STABLE, MAINTAINING HIS BODY TEMPERATURE, SHOULD NOT HAVE ANY COLD STRESS TEMPERATURE, SHOULD NOT HAVE ANY COLD STRESS BABY SHOULD HAVE DAILY STEADY WEIGHT GAIN VELOCITY BABY SHOULD HAVE DAILY STEADY WEIGHT GAIN VELOCITY OF AT LEAST 10gm/kgOF AT LEAST 10gm/kgHOME CONDITIONS SHOULD BE SATISFACTORY HOME CONDITIONS SHOULD BE SATISFACTORY

FOLLOW UP PROTOCOL FOLLOW UP PROTOCOL

THE FOLLOWING PARAMETERS SHOULD BE CLOSELY THE FOLLOWING PARAMETERS SHOULD BE CLOSELY MONITORED AND FOLLOWED MONITORED AND FOLLOWED

1.1. COMMON INFECTIVE ILLNESSES, REACTIVE AIR WAY COMMON INFECTIVE ILLNESSES, REACTIVE AIR WAY DISEASE, HYPERTENSION, RENAL DYSFUNCTION DISEASE, HYPERTENSION, RENAL DYSFUNCTION GASTROESOPHAGEAL REFLUX.GASTROESOPHAGEAL REFLUX.

2. 2. FEEDING AND NUTRITION.FEEDING AND NUTRITION.3.3. IMMUNIZATIONS IMMUNIZATIONS 4.4. PHYSICAL GROWTH, NUTRITIONAL STATUS, ANEMIA, PHYSICAL GROWTH, NUTRITIONAL STATUS, ANEMIA,

OSTEOPENIA/RICKETS.OSTEOPENIA/RICKETS.5.5. NEUROMOTOR DEVELOPMENT, SEIZURESNEUROMOTOR DEVELOPMENT, SEIZURES6.6. EYES: ROP, VISION AND STRABISMUS.EYES: ROP, VISION AND STRABISMUS.7.7. HEARING HEARING 8.8. BEHAVIOUR PROBLEMS, LANGUAGE DISORDER AND BEHAVIOUR PROBLEMS, LANGUAGE DISORDER AND

LEARNING DISABIILITIES LEARNING DISABIILITIES

MANAGEMENT OF COMPLICATIONS MANAGEMENT OF COMPLICATIONS

1.1. NOSOCOMIAL INFECTIONSNOSOCOMIAL INFECTIONS2.2. HYPOTHERMIA HYPOTHERMIA 3.3. REPIRATORY DISTRESREPIRATORY DISTRES

a. HMDa. HMDb. SEPSIS/PNEUMONIA b. SEPSIS/PNEUMONIA C. TRANSIENT TACHYPNEA OF NEWBORN C. TRANSIENT TACHYPNEA OF NEWBORN D. ASPIRATION SYNDROMESD. ASPIRATION SYNDROMESE. NON-PULM CAUSESE. NON-PULM CAUSES

4.4. PATENT DUCTUS ARTERIOSUSPATENT DUCTUS ARTERIOSUS5.5. CHRONIC LUNG DISEASE CHRONIC LUNG DISEASE 6.6. NECNEC7.7. IVHIVH8.8. RETINOPATHY OF PREMATURITY RETINOPATHY OF PREMATURITY 9.9. NUTRITION DISORDERS NUTRITION DISORDERS

HYALINEMEMBRANE DISEASE HYALINEMEMBRANE DISEASE

PATENT DUCTUS ARTERIOSUS:PATENT DUCTUS ARTERIOSUS:IN TERM BABY NO ROLE FOR PHARMIACOLOGICAL IN TERM BABY NO ROLE FOR PHARMIACOLOGICAL

CLOSURE AND CONTROL OF CHF FOLLOWED BY SURGICAL CLOSURE AND CONTROL OF CHF FOLLOWED BY SURGICAL LIGATION.LIGATION.IN PRETERM BABY INDOMETHACIN OR IBUPROFEN IS USED FOR IN PRETERM BABY INDOMETHACIN OR IBUPROFEN IS USED FOR PHARMACOLOGICAL CLOSURE ALONG WITH MEASURES TO PHARMACOLOGICAL CLOSURE ALONG WITH MEASURES TO CONTROL CHCONTROL CH

PRENATAL MANAGEMENT

PREVENTION OF PREMETURITY INTERVENTIONS TO DECREASE THE SEVERITY OF HMD (ANTENATAL STEROIDS)

PERIPARTUM MANAGEMENT

TO MINIMIZE FACTORS THAT INCREASE THE SEVERITY OF HMD (PERINATAL ASPHYXIA, HYPOTHERMIA, HYPOXIA

INTERVENTTIONS THAT DECREASES THE SEVERITY OF HMD (PROPHYLACTIC) SURFACTANT, EARLY CP AP)

NEONATOL MANAGEMENT

SPECIFIC MANAGEMENT (RESCUE SURFACTANT) SUPPORTIVE MANAGEMENT (RESPIRATORY SUPPORT FOR RESPIRATORY FAILURE)INTERVENTIONS THAT DESREASES THE SEVERITY OF HMD(FLUID, NUTRITION,

ASEPISIS, MINIMIZE HANDLING)

NECNECMEDICALMEDICAL

STOP ENTERAL FEEDS STOP ENTERAL FEEDS KEEP THE GIT DECOMPRESSED KEEP THE GIT DECOMPRESSED IV FLUIDS IV FLUIDS INSTITUTE TPN IN STAGE IIA, IIB AND III INSTITUTE TPN IN STAGE IIA, IIB AND III MAINTAIN TISSUE PERFUSSION USING SYMPATHOMIMETIC MAINTAIN TISSUE PERFUSSION USING SYMPATHOMIMETIC AGENTS AGENTS PLASMA OR BLOOD TRANSFUSION PLASMA OR BLOOD TRANSFUSION INJ. VITAMIN K IF BLEEDING INJ. VITAMIN K IF BLEEDING CORRECT METABOLIC ACIDOSEDCORRECT METABOLIC ACIDOSEDSTART ANTIBIOTICSSTART ANTIBIOTICS

INDICATIONS FOR SURGERY-INDICATIONS FOR SURGERY- ABS. IND - GI PERFORATION/FULL THICKNESS NECROSISABS. IND - GI PERFORATION/FULL THICKNESS NECROSIS RELAT.IND - RELAT.IND -

PROGNOSIS OF PRETERM LBW BABYPROGNOSIS OF PRETERM LBW BABY

IT IS DIRECTLY RELATED TO BIRTH WEIGHT OF THE CHILD IT IS DIRECTLY RELATED TO BIRTH WEIGHT OF THE CHILD AND QUALITY OF THE NEONATAL CAREAND QUALITY OF THE NEONATAL CARE

THE RISK OF NEIRODEELOPMENTAL HANDICAPS IS THE RISK OF NEIRODEELOPMENTAL HANDICAPS IS INCREASED 3-FOLD FOR LBW BABIES INCREASED 3-FOLD FOR LBW BABIES

THEIR PHYSICAL GROWTH CORRELATES BETTER WITH THEIR PHYSICAL GROWTH CORRELATES BETTER WITH THEIR CONCEPTIONAL AGE RATHER THAN AGE CALCULATED THEIR CONCEPTIONAL AGE RATHER THAN AGE CALCULATED FROM THE DATE OF BIRTH.FROM THE DATE OF BIRTH.

MANAGEMENT OF IUGR BABYMANAGEMENT OF IUGR BABY

1.1. PREGNANCY PREGNANCY 2.2. DELIVERYDELIVERY

EARLY DELIVARY IS INDICATIVE IN ARREST OF FETAL EARLY DELIVARY IS INDICATIVE IN ARREST OF FETAL GROWTH AND PULMONARY IMMATURITY GROWTH AND PULMONARY IMMATURITY SUCTIONING OF GLOTIC AREA UNDER DIRECT VISION IF SUCTIONING OF GLOTIC AREA UNDER DIRECT VISION IF BABY IS MECONIUM STAINEDBABY IS MECONIUM STAINEDBABY SHOULD BE SCREEN FOR ANY CONGENITAL BABY SHOULD BE SCREEN FOR ANY CONGENITAL MALFORMATIONS.MALFORMATIONS.

3.3. IN THE NURSERY IN THE NURSERY BREAST FEEDING SHOULD BE INTITIATED IMMEDIATELY BREAST FEEDING SHOULD BE INTITIATED IMMEDIATELY AFTER BIRTH AFTER BIRTH SYMPTOMATIC POLYCYTHEMIA SHOULD BE MANAGED SYMPTOMATIC POLYCYTHEMIA SHOULD BE MANAGED WITH PARTIAL EXCHANGE WITH PLASMA OR WITH PARTIAL EXCHANGE WITH PLASMA OR PHYSIOLOGICAL SALINE.PHYSIOLOGICAL SALINE.

PROGNOSIS OF IUGR BABIESPROGNOSIS OF IUGR BABIES

DEPENDS UPON DURATION AND SEVERITY OF DEPENDS UPON DURATION AND SEVERITY OF INTRAUTERINE ENVIRONMENTAL CONSTRAINTS, INTRAUTERINE ENVIRONMENTAL CONSTRAINTS, POSTNATAL PHYSICAL GROWTH MAY BE POSTNATAL PHYSICAL GROWTH MAY BE RETARDED RETARDED

THE HYPOPLASTIC BABIES REMAIN PERMANENTLY THE HYPOPLASTIC BABIES REMAIN PERMANENTLY PHYSICALY AND MENTALLY HANDICAPPED PHYSICALY AND MENTALLY HANDICAPPED

MALNOURISHED SFD HAVE HIGH INCIDENCE OF MALNOURISHED SFD HAVE HIGH INCIDENCE OF MINIMA BRAIN DYSFUNCTION,LEARNING MINIMA BRAIN DYSFUNCTION,LEARNING DISABILITIES AND SUBOPTIMAL PHYSICAL DISABILITIES AND SUBOPTIMAL PHYSICAL GROWTHGROWTH

PREVENTIONPREVENTION OF LBW BABIES OF LBW BABIES

IMPROVEMENT IN FEMALE LITERACYIMPROVEMENT IN FEMALE LITERACY

AVOIDANCE OF EARLY MARRIAGE AND TEENAGE AVOIDANCE OF EARLY MARRIAGE AND TEENAGE PREGNANCYPREGNANCY

ENSURING INTER PREGNANCY INTERVAL OF ATLEAST 3 ENSURING INTER PREGNANCY INTERVAL OF ATLEAST 3 YEARSYEARS

GOOD QUALITY ANTENATAL CAREGOOD QUALITY ANTENATAL CARE

IMPROVEMENT IN NUTRITION DURING PREGNANCY ,etc.IMPROVEMENT IN NUTRITION DURING PREGNANCY ,etc.

THANK UTHANK U