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

1. 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.

2. 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

3. 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

4. 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.

5. 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

6. 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

7. 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.

8. 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
   The approach depends on the infant's clinical status, echocardiographic findings, and gestational age.

9. 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.

10. 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

11. 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

12. 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
    Management involves supportive care, serial cranial ultrasounds, and treatment of complications such as post-hemorrhagic hydrocephalus.

13. 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.

14. 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)

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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
    Complications:
    • Catheter-related bloodstream infections
    • Thrombosis
    • Catheter malposition or migration
    • Pleural or pericardial effusion
    • Air embolism
    • Mechanical complications during insertion

24. 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

25. 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

26. 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

27. 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