Prematurity: Complications  Respiratory distress syndrome  Bronchopulmonary dysplasia  Apnea of prematurity  Patent ductus arteriosus  Intraventricular hemorrhage  Periventricular leukomalacia  Necrotizing enterocolitis  Sepsis  Anemia  Retinopathy of prematurity

Respiratory Distress Syndrome  Etiology Anatomic immaturity of the lung Anatomic immaturity of the lung Increased interstitial and alveolar lung fluid Increased interstitial and alveolar lung fluid Surfactant deficiency Surfactant deficiency

Courtesy of Professor Louis De Vos 17 Weeks

Courtesy of Professor Louis De Vos 22 Weeks

Courtesy of Professor Louis De Vos 25 Weeks

 CXR: poor aeration, ground-glass appearance, homogenous, air bronchograms

Respiratory Distress Syndrome  Management: Prevention - antenatal steroids Prevention - antenatal steroids Positive pressure ventilation Positive pressure ventilation Oxygen Oxygen +/- Surfactant (requires intubation) +/- Surfactant (requires intubation)

Pressure (cmH 2 0) Volume (ml)

Bronchopulmonary Dysplasia  Respiratory symptoms, x-ray abnormalities, and O2 req’t for > 28 d and persisting at 36 wks corrected GA   Pathophysiology: Disturbed alveolarization with increased alveolar- to-capillary distance and decreased alveolar-to- capillary ration Secondary to: Lung inflammation Mucociliary dysfunction Airway narrowing Hypertrophied airway smooth muscle Alveolar collapse Constriction of pulmonary vascular bed

Bronchopulmonary Dysplasia  Management: Prevention: IM Vitamin A, Caffeine Prevention: IM Vitamin A, Caffeine NUTRITION NUTRITION Oxygen +/- ventilation Oxygen +/- ventilation +/- Diuretics +/- Diuretics +/- Steroids: systemic, inhaled +/- Steroids: systemic, inhaled +/- Bronchodilators +/- Bronchodilators  Prognosis: Increased respiratory illnesses in childhood Increased respiratory illnesses in childhood Decreased long-term lung function Decreased long-term lung function BUT, fine in the playground by pre-school age (usually …) BUT, fine in the playground by pre-school age (usually …)

Apnea of Prematurity  Central, obstructive, or mixed  Majority of <32 weeks  Treat with: Adequate positioning Adequate positioning Oxygen Oxygen Methylxanthines (i.e. Caffeine) Methylxanthines (i.e. Caffeine) CPAP CPAP Ventilation if necessary Ventilation if necessary

Patent ductus arteriosus  Seen in >60% of 60% of <1000 g babies  Management strategies: Preload/afterload reduction Preload/afterload reduction Adequate oxygenation Adequate oxygenation Optimize pH Optimize pH Indomethacin/Ibuprofen Indomethacin/Ibuprofen Surgery (PDA ligation) Surgery (PDA ligation) Conservative management Conservative management  Prognosis: Multiple associations (NEC, CLD, etc …) but no proven causation Multiple associations (NEC, CLD, etc …) but no proven causation

Metabolic Problems of Prematurity  Hypoglycemia  Fluid/electrolyte imbalance  Hypocalcemia/hypomagnesemia  Hyperbilirubinemia  Hypothermia

Intraventricular hemorrhage  Common in < 1500 gm babies  Usually evident in 1st week of life  Reasons: highly vascularized germinal matrix highly vascularized germinal matrix less basement membrane to capillaries less basement membrane to capillaries abnormal cerebral autoregulation abnormal cerebral autoregulation  Prognosis: Good - small amounts of bleeding in the ventricles Good - small amounts of bleeding in the ventricles Poorer - large amount intraparenchymally or if post- hemorrhagic hydrocephalus Poorer - large amount intraparenchymally or if post- hemorrhagic hydrocephalus

Periventricular leukomalacia  Pathophysiology: Ischemic lesion to watershed area around ventricles in premature infants Ischemic lesion to watershed area around ventricles in premature infants Link to inflammation? Link to inflammation? Most often shows up 3-4 wks after delivery Most often shows up 3-4 wks after delivery  Prognosis: Correlated with cerebral palsy Correlated with cerebral palsy

Necrotizing Enterocolitis  1-5% NICU admissions  Multi-factorial etiology: Feeds, Prematurity, Ischemia, Infection Feeds, Prematurity, Ischemia, Infection  Diagnosis: clinical and radiologic  Treatment: Decompression (NPO, NG tube) Decompression (NPO, NG tube) Antibiotics Antibiotics Surgery prn Surgery prn  Prognosis: 30% mortality if <1500 g 30% mortality if <1500 g

Sepsis  Suboptimal immune function in preemies plus poor skin barrier, indwelling catheters  GBS and coliforms cause early onset sepsis < 5-7 days of life < 5-7 days of life  Nosocomial sepsis common in prems Most common = coagulase negative staphylococcus Most common = coagulase negative staphylococcus Fungi can also be problematic in > 1 week of life Fungi can also be problematic in > 1 week of life

Anemia of Prematurity  Reasons: decreased hemoglobin at delivery decreased hemoglobin at delivery decreased RBC survival decreased RBC survival blunted erythropoietin response blunted erythropoietin response IATROGENIC IATROGENIC  Treatment: prevention prevention iron supplementation iron supplementation transfusion transfusion EPO EPO

Retinopathy of Prematurity  40-70% NICU survivors < 1000 g  Etiology: vasoconstriction leading to abnormal vascular proliferation vasoconstriction leading to abnormal vascular proliferation  Diagnosis: Screening Screening  Treatment: Close monitoring, laser if necessary Close monitoring, laser if necessary

Long Term Outcomes – 24 weeks Local survival ( )~ 60% Risk of severe disability: very low IQ, unable to walk, blindness and/or deafness ~ 15-20% of survivors Risk of moderate disability: low IQ, walk with aid, impaired vision and/or correctable hearing loss ~ 20-30% of survivors Deafness~ 2% of survivors Blindness1-10% of survivors Overall, chance of being ‘normal’ or mildly impaired ~ 50-65% of survivors

Disorders of gestation length or of growth n Small for gestational age: <2SD below n Large for gestational age: >2SD above n Prematurity: <37 weeks gestation n Postmaturity: >42 weeks gestation