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low birth weight infant (preterm infant)

Includes: preterm infants, also see preterm delivery Monitor: - SaO2 Radiology: - avoid pneumograms for predischarge assessment of prolonged apnea of prematurity [9] - avoid daily chest radiographs without indications for intubated infants - avoid screening with term-equivalent or discharge brain MRIs in preterm babies [9] Complications: - in-hospital mortality for infants born at 22-28 weeks of gestation = 26% - respiratory distress syndrome - bronchopulmonary dsyplasia - necrotizing enterocolitis - very low birth weight infants (mean of 1179 g) vs normal infants (mean 3279 g) may sustain small, but persistent cognitive deficits, suggested by: a) lower IQ scores (87 vs 92) b) lower rate of graduation from high school (74% vs 83%) c) higher rate of neurosensory impairment (10% vs 1%) d) increased risk of hospitalization for psychiatric disease in young adulthood [2] (RR = 1.3-2.7) - 42% of surviving premature infants (< 27 weeks gestation) have normal neurodevelopment at 2.5 years of age [4] - 31-25% of infants born at 22-24 weeks gestation survive - 52-57% without neurodevelopmental impairment [15] - survival without neurodevelopmental impairment increased from 16% in 2000-2003 to 20% in 2008-2011 [15] primarily due to an increase in survival; no change in the rate of survival with neurodevelopmental impairment [15] - severe dermatitis in very preature infants - very premature infants catabolize zinc rapidly & cannot store it [3] - prolonged elevations of plasma insulin (into adolescence) - may be risk factor for development of insulin resistance & type 2 diabetes [6] Management: - target SaO2 is 91-95% [11] - kangaroo care in preterm infants (infant skin to maternal skin contact) is associated with better cognition, sleep, & executive function at 10 years of age [5] - preterm infants breast fed during the 1st month of life have better school-age neurodevelopmental outcomes [13] - supplemental enriched donor milk, compared to preterm infant formula is not associated with improved neurodevelopmental status at 18 months [14] - active treatment in the NICU increases survival in infants 22-24 weeks of gestation but not at 25-26 weeks [8] - avoid antireflux medications for treating symptomatic GERD or apnea & desaturation in preterm babies [9] - avoid antibiotic therapy for > 48 hours to rule out bacterial infection in asymptomatic preterm infants [9] - inhaled budesonide (200 ug/puff) within 24 hours of birth associated with less bronchopulmonary dsyplasia but similar or possibly higher mortality [10] - recombinant human erythropoietin of uncertain benefit - 500 U/kg every other day for the first 2 weeks reduces moderate/severe disability at 18 months [12] - 3000 IU/kg as 3 IV doses administered at < 3, 12-18 & 36-42 hours of life does not improve 2-year neurodevelopmental outcomes [12]

Related

intrauterine growth retardation/restriction preterm delivery

General

infant developmental disorder

References

  1. Journal Watch 22(4):30, 2002 Hack M et al, Outcomes in young adulthood for very-low-birth-weight infants. N Engl J Med 346:149, 2002 PMID: 11796848 - McCormick MC & Richardson DK Premature infants grow up. N Engl J Med 346:197, 2002 PMID: 11796855
  2. Nosarti C et al Preterm Birth and Psychiatric Disorders in Young Adult LifePreterm Birth and Psychiatric Disorders Arch Gen Psychiatry. 2012;():610-617 PMID: 22660967 http://archpsyc.jamanetwork.com/article.aspx?articleID=1171951
  3. Centers for Disease Control and Prevention Notes from the Field: Zinc Deficiency Dermatitis in Cholestatic Extremely Premature Infants After a Nationwide Shortage of Injectable Zinc - Washington, DC, December 2012 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6207a5.htm
  4. Serenius F et al. Neurodevelopmental outcome in extremely preterm infants at 2.5 years after active perinatal care in Sweden. JAMA 2013 May 1; 309:1810. PMID: 23632725
  5. Feldman R et al. Maternal-preterm skin-to-skin contact enhances child physiologic organization and cognitive control across the first 10 years of life. Biol Psychiatry 2013 Oct 3 http://www.biologicalpsychiatryjournal.com/article/S0006-3223(13)00764-6/abstract - Stein MT Skin-to-Skin Contact Between Mother and Preterm Baby Reduces Mortality. Physician's First Watch, Dec 22, 2015 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org - Boundy EO, Dastjerdi R, Spiegelman D et al Kangaroo Mother Care and Neonatal Outcomes: A Meta-analysis. Pediatrics. Jan 2016. EPub 2015 Dec 23 PMID: 26702029 http://pediatrics.aappublications.org/content/early/2015/12/22/peds.2015-2238
  6. Wang G et al. Preterm birth and random plasma insulin levels at birth and in early childhood. JAMA 2014 Feb 12; 311:587 PMID: 24519298
  7. Patel RM et al. Causes and timing of death in extremely premature infants from 2000 to 2011. N Engl J Med 2015 Jan 22; 372:331 PMID: 25607427 http://www.nejm.org/doi/full/10.1056/NEJMoa1403489
  8. Rysavy MA et al. Between-hospital variation in treatment and outcomes in extremely preterm infants. N Engl J Med 2015 May 7; 372:1801 PMID: 25946279 http://www.nejm.org/doi/full/10.1056/NEJMoa1410689
  9. Ho T, Dukhovny D, Zupancic JA et al Choosing Wisely in Newborn Medicine: Five Opportunities to Increase Value. Pediatrics. July 20, 2015 PMID: 26195536 http://pediatrics.aappublications.org/content/early/2015/07/15/peds.2015-0737
  10. Bassler D et al. Early inhaled budesonide for the prevention of bronchopulmonary dysplasia. N Engl J Med 2015 Oct 15; 373:1497 PMID: 26465983 http://www.nejm.org/doi/full/10.1056/NEJMoa1501917 - Schmidt B. No end to uncertainty about inhaled glucocorticoids in preterm infants. N Engl J Med 2015 Oct 15; 373:1566. PMID: 26465990 http://www.nejm.org/doi/full/10.1056/NEJMoa1501917
  11. The BOOST-II Australia and United Kingdom Collaborative Groups. Outcomes of two trials of oxygen-saturation targets in preterm infants. N Engl J Med 2016 Feb 10 PMID: 26863265 http://www.nejm.org/doi/full/10.1056/NEJMoa1514212
  12. Natalucci G et al Effect of Early Prophylactic High-Dose Recombinant Human Erythropoietin in Very Preterm Infants on Neurodevelopmental Outcome at 2 Years. A Randomized Clinical Trial. JAMA. 2016;315(19):2079-2085 PMID: 27187300 http://jama.jamanetwork.com/article.aspx?articleid=2521968 - Song J, Sun H, Xu F et al Recombinant Human Erythropoietin Improves Neurological Outcomes in Very Preterm Infants. Annals of Neurology. 2014 PMID: 27130143 http://onlinelibrary.wiley.com/doi/10.1002/ana.24677/pdf
  13. Belfort, MB, Anderson PJ, Nowak VA et al Breast Milk Feeding, Brain Development, and Neurocognitive Outcomes: A 7-Year Longitudinal Study in Infants Born at Less Than 30 Weeks' Gestation. J Pediatr 2016. July 26. PMID: 27480198 http://www.jpeds.com/article/S0022-3476(16)30411-5/pdf
  14. O'Connor DL, Gibbins S, Kiss A et al Effect of Supplemental Donor Human Milk Compared With Preterm Formula on Neurodevelopment of Very Low-Birth-Weight Infants at 18 Months: A Randomized Clinical Trial. JAMA. 2016; 316(18):1897-1905 PMID: 27825008 http://jamanetwork.com/journals/jama/fullarticle/2579868 - Colaizy TT Donor Human Milk for Very Low-Birth-Weight Infants. JAMA. 2016;316(18):1875-1876 PMID: 27824996 http://jamanetwork.com/journals/jama/fullarticle/2579868
  15. Younge N et al. Survival and neurodevelopmental outcomes among periviable infants. N Engl J Med 2017 Feb 16; 376:617 PMID: 28199816 - Shah PS. Neonatal intensive care - the only constant is change. N Engl J Med 2017 Feb 16; 376:694. PMID: 28199815
  16. National Perinatal Association Multidisciplinary Guidelines for the Care of Late Preterm infants. http://www.nationalperinatal.org/lptguidelines/pdf/NPALatePretermGuidelines-11-12.pdf