Preterm Neonate: Case and QnA
Clinical Case of Preterm Neonate
A 26-year-old primigravida presents to the emergency department at 26 weeks and 2 days gestation with preterm premature rupture of membranes (PPROM) and regular contractions. Despite tocolysis attempts, she delivers a male infant weighing 820 grams.
Immediate Postnatal Period:
- Apgar scores: 4 at 1 minute, 6 at 5 minutes
- Respiratory distress evident: grunting, nasal flaring, and intercostal retractions
- Placed on continuous positive airway pressure (CPAP) in the delivery room
- Transferred to NICU for further management
NICU Course:
- Chest X-ray shows diffuse ground-glass opacities consistent with Respiratory Distress Syndrome (RDS)
- Surfactant administered via INSURE (INtubation-SURfactant-Extubation) technique
- Requires intubation and mechanical ventilation on day 2 due to worsening respiratory status
- Umbilical arterial and venous lines placed for monitoring and medication administration
- Started on caffeine for apnea of prematurity prophylaxis
- Total parenteral nutrition initiated
- Cranial ultrasound on day 3 shows grade I intraventricular hemorrhage
Complications and Management:
- Develops patent ductus arteriosus (PDA) on day 5, managed with a course of ibuprofen
- Episodes of feeding intolerance; managed with careful advancement of enteral feeds
- Requires phototherapy for hyperbilirubinemia
- Screened for retinopathy of prematurity (ROP) at 4 weeks of age
Outcome:
The infant is extubated to non-invasive ventilation on day 14 and gradually weaned to room air over the next 4 weeks. He achieves full enteral feeds by 34 weeks corrected gestational age and is discharged home at 38 weeks corrected age, weighing 2100 grams, with close follow-up arranged.
2. Clinical Presentations of Preterm Neonates
1. Respiratory Distress Syndrome (RDS)
- Tachypnea (>60 breaths/minute)
- Grunting
- Nasal flaring
- Intercostal and subcostal retractions
- Cyanosis
- Decreased breath sounds on auscultation
- Oxygen requirement
2. Late-Onset Sepsis
- Temperature instability (hypothermia or hyperthermia)
- Lethargy or irritability
- Poor feeding or feeding intolerance
- Apnea or bradycardia episodes
- Tachycardia
- Hypotension
- Mottled skin or poor perfusion
3. Necrotizing Enterocolitis (NEC)
- Abdominal distension
- Feeding intolerance
- Bilious gastric aspirates or emesis
- Bloody stools
- Lethargy
- Temperature instability
- Apnea or respiratory distress
4. Intraventricular Hemorrhage (IVH)
- Sudden deterioration in clinical status
- Decreased level of consciousness
- Hypotension
- Abnormal eye movements or gaze
- Seizures
- Bulging fontanelle
- Apnea or bradycardia episodes
5. Retinopathy of Prematurity (ROP)
- Usually asymptomatic in early stages
- Abnormal red reflex in advanced cases
- Leukocoria (white pupillary reflex) in severe cases
- Strabismus
- Poor visual tracking
- Nystagmus in advanced stages
3. Viva Questions and Answers Related to Preterm Neonates
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Q: What is the definition of a preterm neonate?
A: A preterm neonate is an infant born before 37 completed weeks of gestation, regardless of birth weight.
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Q: How are preterm infants further classified based on gestational age?
A: Preterm infants are classified as:
- Extremely preterm: <28 weeks
- Very preterm: 28 to <32 weeks
- Moderate to late preterm: 32 to <37 weeks
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Q: What are the main risk factors for preterm birth?
A: Main risk factors include:
- Previous preterm birth
- Multiple gestation
- Cervical insufficiency
- Uterine anomalies
- Maternal infections
- Chronic maternal conditions (e.g., hypertension, diabetes)
- Substance abuse
- Socioeconomic factors
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Q: What is the pathophysiology of Respiratory Distress Syndrome (RDS) in preterm infants?
A: RDS is caused by surfactant deficiency in immature lungs. This leads to alveolar collapse, decreased lung compliance, increased work of breathing, and ventilation-perfusion mismatch, resulting in hypoxemia and respiratory acidosis.
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Q: How is surfactant administered in preterm infants with RDS?
A: Surfactant is typically administered via endotracheal tube using one of these methods:
- INSURE (INtubation-SURfactant-Extubation) technique
- LISA (Less Invasive Surfactant Administration) or MIST (Minimally Invasive Surfactant Therapy)
- During mechanical ventilation for infants already intubated
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Q: What are the indications for mechanical ventilation in preterm infants?
A: Indications include:
- Severe respiratory distress unresponsive to non-invasive support
- Recurrent apnea unresponsive to CPAP and caffeine
- pCO2 >65 mmHg with pH <7.20
- FiO2 >0.6 to maintain target saturation
- Cardiovascular instability or shock
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Q: What is bronchopulmonary dysplasia (BPD), and how is it diagnosed?
A: BPD is a chronic lung disease of prematurity. It's diagnosed based on oxygen dependency at 36 weeks postmenstrual age or at discharge for infants born at <32 weeks gestation. Severity is classified based on the level of respiratory support required.
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Q: How do you manage patent ductus arteriosus (PDA) in preterm infants?
A: Management of PDA includes:
- Conservative management (fluid restriction, diuretics)
- Pharmacological closure (ibuprofen or indomethacin)
- Surgical ligation for refractory cases
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Q: What is necrotizing enterocolitis (NEC), and what are its risk factors in preterm infants?
A: NEC is a severe gastrointestinal emergency characterized by intestinal inflammation and necrosis. Risk factors include prematurity, formula feeding, rapid advancement of feeds, hypoxic-ischemic events, and altered gut microbiome.
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Q: How do you diagnose and manage necrotizing enterocolitis?
A: Diagnosis is based on clinical, laboratory, and radiographic findings. Management includes:
- NPO (nil per os) status
- Nasogastric decompression
- Broad-spectrum antibiotics
- Supportive care (fluid resuscitation, respiratory support)
- Serial abdominal examinations and radiographs
- Surgical intervention if perforation or clinical deterioration occurs
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Q: What are the stages of intraventricular hemorrhage (IVH) in preterm infants?
A: IVH is graded according to the Papile classification:
- Grade I: Subependymal hemorrhage
- Grade II: Intraventricular blood without ventricular dilatation
- Grade III: Intraventricular blood with ventricular dilatation
- Grade IV: Intraparenchymal hemorrhage
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Q: How do you prevent and manage intraventricular hemorrhage in preterm infants?
A: Prevention strategies include:
- Antenatal corticosteroids
- Delayed cord clamping
- Careful fluid management
- Minimal handling
- Maintaining stable cerebral perfusion
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Q: What is retinopathy of prematurity (ROP), and how is it screened?
A: ROP is a vasoproliferative disorder of the developing retina in preterm infants. Screening is done by ophthalmoscopy, starting at 31 weeks postmenstrual age or 4 weeks after birth, whichever is later, for infants born <30 weeks or <1500g. The frequency of subsequent exams depends on the findings.
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Q: How do you manage apnea of prematurity?
A: Management includes:
- Caffeine citrate as first-line pharmacological therapy
- Proper positioning and handling
- Maintaining thermoneutrality
- Respiratory support (e.g., CPAP) if frequent or severe
- Treating underlying causes (e.g., sepsis, anemia)
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Q: What are the nutritional requirements of preterm infants, and how are they met?
A: Preterm infants have high nutritional needs for growth and development. These are met through:
- Early initiation of parenteral nutrition
- Gradual introduction and advancement of enteral feeds
- Use of human milk (preferably mother's own milk) fortified with human milk fortifier
- Preterm formula when human milk is unavailable
- Supplementation of vitamins (especially vitamin D) and iron
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Q: How do you manage hyperbilirubinemia in preterm infants?
A: Management includes:
- Regular monitoring of serum bilirubin levels
- Phototherapy based on gestational age-specific treatment thresholds
- Exchange transfusion for severe cases
- Treating underlying causes (e.g., hemolysis, sepsis)
- Ensuring adequate hydration and nutrition
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Q: What are the short-term and long-term complications of preterm birth?
A: Short-term complications include RDS, IVH, NEC, sepsis, and PDA. Long-term complications can include:
- Neurodevelopmental impairment
- Chronic lung disease (BPD)
- Visual and hearing impairments
- Growth failure
- Cognitive and behavioral problems
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Q: How do you assess neurodevelopmental outcomes in preterm infants?
A: Assessment includes:
- Regular neurological examinations during NICU stay
- Cranial ultrasound and MRI imaging
- Standardized developmental assessments (e.g., Bayley Scales of Infant and Toddler Development)
- Long-term follow-up with multidisciplinary teams
- Monitoring of motor, cognitive, language, and behavioral development
- Early intervention programs when delays are identified
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Q: What is the role of antenatal corticosteroids in preterm birth management?
A: Antenatal corticosteroids:
- Accelerate fetal lung maturation
- Reduce the incidence and severity of RDS
- Decrease the risk of IVH and NEC
- Improve overall survival rates
- Are recommended for women at risk of preterm delivery between 24 and 34 weeks gestation
- Typical regimen: Betamethasone 12 mg IM, two doses 24 hours apart
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Q: How do you manage temperature regulation in preterm infants?
A: Temperature management includes:
- Immediate drying and wrapping after birth
- Use of radiant warmers or incubators
- Maintaining neutral thermal environment (36.5-37.5°C core temperature)
- Humidity control in incubators for extremely preterm infants
- Kangaroo care when stable
- Monitoring for and treating hypothermia or hyperthermia
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Q: What are the principles of fluid and electrolyte management in preterm infants?
A: Key principles include:
- Higher fluid requirements due to higher insensible water losses
- Careful monitoring of fluid balance, weight, and electrolytes
- Gradual increase in fluid intake over the first week of life
- Sodium restriction in the first few days of life
- Potassium supplementation after establishing adequate urine output
- Calcium and phosphate supplementation for bone mineralization
- Adjusting fluid management in conditions like PDA or BPD
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Q: How do you diagnose and manage early-onset sepsis in preterm infants?
A: Diagnosis and management include:
- High index of suspicion based on risk factors and clinical signs
- Blood cultures before starting antibiotics
- Empiric antibiotic therapy (typically ampicillin and gentamicin)
- Lumbar puncture if clinically indicated
- Supportive care (respiratory support, fluid management, inotropes if needed)
- Monitoring of clinical status and laboratory parameters
- Antibiotic duration based on culture results and clinical course
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Q: What are the indications for and complications of central line placement in preterm infants?
A: Indications:
- Long-term parenteral nutrition
- Administration of hyperosmolar solutions or irritant medications
- Frequent blood sampling
- Poor peripheral access
- Catheter-related bloodstream infections
- Thrombosis
- Catheter malposition or migration
- Pleural or pericardial effusion
- Air embolism
- Mechanical complications during insertion
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Q: How do you manage persistent pulmonary hypertension of the newborn (PPHN) in preterm infants?
A: Management strategies include:
- Optimize oxygenation and ventilation
- Maintain normal blood pressure and tissue perfusion
- Inhaled nitric oxide (iNO) therapy
- Consider sildenafil in refractory cases
- Treat underlying conditions (e.g., sepsis, pneumonia)
- ECMO in severe cases, if available and appropriate
- Avoid acidosis, hypothermia, and excessive handling
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Q: What are the current recommendations for oxygen saturation targets in preterm infants?
A: Based on recent large trials (BOOST-II, COT, SUPPORT):
- For infants <28 weeks gestation: Target 90-95% after initial stabilization
- Avoid hyperoxia (saturation >95%) due to increased risk of ROP
- Avoid prolonged hypoxia (saturation <85%) due to increased risk of NEC and mortality
- Individualize targets based on clinical condition and postnatal age
- Use oxygen blenders and pulse oximetry for precise oxygen delivery and monitoring
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Q: How do you assess and manage pain in preterm infants?
A: Pain management includes:
- Use of validated pain assessment tools (e.g., PIPP, N-PASS)
- Non-pharmacological measures (e.g., sucrose, non-nutritive sucking, skin-to-skin care)
- Minimizing painful procedures and clustering care activities
- Local anesthetics for minor procedures
- Judicious use of opioids for severe pain or invasive procedures
- Regular reassessment and adjustment of pain management strategies
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Q: What are the principles of developmentally supportive care in the NICU?
A: Key principles include:
- Minimizing environmental stressors (noise, light)
- Promoting sleep and circadian rhythms
- Positioning to promote physiological flexion and midline orientation
- Encouraging parent-infant bonding and involvement in care
- Implementing kangaroo care when appropriate
- Providing individualized care based on infant cues and behaviors
- Supporting non-nutritive sucking and oral feeding readiness
