Admission to SCN – A Case Study (Baby B) By: Nicole Stevens

Goals for today Provide background pathophysiology on the main issues that preterm babies face during a stay in SCN Discuss the implications for families who face a baby having a prolonged stay in SCN Also look at the types of babies readmitted from home Hear from Judy Russell (Clinical consultant/lactation) on the feeding issues for mothers with preterm babies and those readmitted from home

Maternal Background Ebony: G2P1 (1 year old boy, alive and well), 21 yrs old; Opos, antibody –ve, rubella low immunity, serology neg. Hx: hyperthyroidism/Graves disease (on carbimazole), GDM (diet controlled), depression, low BMI (17), smoker Routine care through pregnancy, mother reported nil issues. Presented in preterm labour at 32.2wks to BHS Proceeded to Em LUSCS due to breech presentation

Birth/Resuscitation Difficult footling breech extraction (LUSCS) Present for resus: paed reg, SCN nurse, midwife and paed resident ROM/clear liquor at time of LUSCS Apgars: 4@1, 8@5, 9@10 Respirations est. by 5 mins, required IPPV in air then oxygen, then ongoing CPAP in oxygen (30%) for transport.

Admission to SCN Baby B admitted to SCN from theatre BW: 1860g CPAP ongoing via transport prongs IV cannula inserted, blds taken (culture, FBE, CRP, TBG and venous gas) Examined well, not dysmorphic Unknown cause for preterm labour, managed for potential sepsis. Moved to an incubator and managed on CPAP 5 (cm/H2O)/bubble CPAP initially, with minimal oxgyen requirement

Potential Sepsis In the cases of preterm labour, it is usual practice to err on the side of caution and assume it may be an infection that has caused the preterm labour, so the preterm newborn is ‘covered’ with antibiotics until considered safe to cease (min. 48 hrs) Bloods taken for FBE, CRP and culture as IV cannula inserted Commenced on Benzylpenicillin 12/24 and Gentamycin 36/24 CRP results: 26/8 1, 29/8 <1, 3/9 <1 No growth noted on cultures after 5 days FBE results NAD on 3 dates. Received 2 days of IV antibiotics and then ceaed. Nil further episodes of suspected sepsis to date.

Respiratory Distress Syndrome Main risk factor: prematurity, SPTL (no time for steroids) Early evidence of increased WOB, tachypnoea and oxygen requirement (time would prove if it is a differential diagnosis of TTN) Initial cap gas result (at 1hr): pH: 7.086, PCO2: 76.8, Lact: 1.82, HCO3: 25, BE: -7 4.5hrs later: pH: 7.24, PCO2: 55.2, HCO3: 23.7, BE: -4 24hrs later: pH: 7.285, PCO2: 44.2, HCO3: 21.0, BE: -6

Acid Base Balance Baby B presents with a respiratory acidosis, low base excess is ignored because of the significantly elevated PCO2 (makes it a likely error), use HCO3 to interpret metabolic component. Normal Values: Respiratory acidosis (pCO2 >= 50 mmHg, pH < 7.25) Respiratory alkalosis (pCO2 < 35 mmHg, pH > 7.40) Metabolic acidosis (HCO3< 18 mmol/L or B.E. < minus 4.0 mEq/L, pH < 7.25) Metabolic alkalosis (HCO3 > 25 mmol/L or B.E. > plus 4.0 mEq/L, pH > 7.40)

RDS Initially managed on CPAP of 5 cm/H20 Increased to 6cm at approx 7hrs of age due to increase in FiO2 (up to 30% CXR taken – confirming RDS, nil other issues, NGT in place, no pneumothorax Reduced back to 5cm next day (in air) Remained in air and ceased CPAP next morning (just over 41hrs old) Remained off CPAP

Apnoea Baby received 41+hrs of CPAP support 12 hrs after cessation of CPAP, had 2 episodes of apnoea, bradycardia and desaturation requiring stimulation In between episodes had normal observations and respiratory effort Decision made to caffeine load (20mg/kg, IV) Ongoing daily dose at 5mg/kg (IV/oral) also ordered Dose increased to 10mg/kg 2 days later, due to ongoing issues of apnoea At 34wks CA, reduced back to 5mg/kg Likely to be ceased at approx 35 – 36wks CA

Hyperbilirubinaemia Noted to look jaundice on day 2 SBR results: 27/8 at 1215 160/2 (total/direct) Commenced phototherapy 28/8 at 1500 87/3 Ceased phototherapy 29/8 at 1140 112/2 6/9 at 1123 120/5 Nil further monitoring of jaundice levels

Feeding Initially kept NBM, on CPAP, intermittent tachypnoea, so risk of aspiration. Hydration managed with 10% dextrose infusion, initial TBG of 2.0mmol/L (at point of IVC insertion) – infusion commenced and resolved, nil further hypoglycaemia issues Commenced on small amounts of EBM as available and for comfort from 12 hrs of age By 36hrs of age regular 3 x 8 feeds commenced via the NGT and dripped weaned accordingly TFI progressed through usual rates of increase for a preterm baby.

Feeding Ongoing issues with feeding (intolerance) Changes implemented in response: Reduced TFI Increased frequency from 3/24 to 2/24. Fortifier had been commenced when tolerating appropriate of feeds, but vomitting exaccerbated by this, so ceased again Maintained on 2/24 feeds, reduced TFI, and no fortifier until tolerating; now in the process of slowly grading up TFI and extending out to 3/24 again (currently 34.4wks) More in depth baby feeding, lactation advice from Judy Russell!

Summary of Issues Preterm labour & birth/suspected sepsis Respiratory distress (TTN or RDS – time will tell, but likely RDS due to gestation) Hypoglycaemia Apnoea of prematurity Jaundice Feed intolerance