Problems in late preterm babies, iap bps,bangalore,webinar, 20-5-20 - Dr Karthik Nagesh

1. Dr.N.Karthik Nagesh
MD,FRCPCH (U.K.),FNNF
Neonatal Intensive Care Fellowship ( U.K.)
’
• Chairman-HOD , Neonatology & NICUs, Manipal
Hospitals Group, Bangalore
• Chairman – Manipal Advanced Children’s Centre,
Manipal Hospitals, Bangalore
• Professor ( Adjunct)- Pediatrics & Neonatology,
Manipal University
• Past President ‘NNF – Karnataka’
• Past President ‘IAP – Bangalore’

2. PROBLEMS OF THE LATE
PRETERM
NEWBORNS

3. Panelists
 Dr. Pradeep G.C.M , Professor & HOD of
Neonatology,
M.S. Ramaiah Medical College & Hospitals,
Bangalore
 Dr. Vishwanath Kamoji, Consultant Neonatologist
& Pediatrician, Columbia Asia Hospital, Hebbal,
Bangalore
 Dr. Nandini Nagar, Consultant Neonatologist &
Pediatrician, Cloudnine Hospital, Jayanagar,
Bangalore

4. NICU Growth in Karnataka - Three Decad

5. About 1000 SNCUs+NICUs
**India needs 20 000–30 000 level 3 NICU beds and 75
000–100 000 level 2 SNCU beds….

7. EPIDEMIOLOGY
 Every year, an estimated 15 million babies are born
preterm and this number is rising
 Approximately 1 million children die each year due to
complications of preterm birth
 Late preterm births - increasing trend ( about 6-9% of
Births and 71 % of all Preterms).
 Morbidity & Mortality more in late preterms compared to
terms

9. Problems Of The Late Preterms

11. Morbidity of Late Preterm Infants
Sapiro-mendoza CK et al, Pediatrics 2008

13. The Late Preterm – Physiologic
Immaturity
 Transient Tachypnea of the Newborn(TTNB)
 Respiratory Distress Syndrome(RDS)
 Persistent Pulmonary Hypertension(PPHN)
 Respiratory Failure
 Jaundice
 Hypoglycemia
 Thermoregulation Problems
 Feeding Difficulties
 Neuro – Developmental Impairment

15. Adverse neonatal outcome – Early term
Babies

18. NICU admission - by Weeks of gestation
0
5
10
15
20
25
30
35
14
10
12.3
34.8
40 wks-
17/127
39wks-
10/113
38wks-
14/120
37wks-
15/43

19. RDS by weeks of gestation
0
5
10
15
20
25
4.7
4.4
4.1
23.2
40wks-
6/127 39wk
s-
5/113
38wks
-5/120 37 wks-
10/43

21. COMPLICATIONS
 Temperature Instability
 RDS
 Feeding Difficulties
 Hypoglycemia
 Hyperbilirubinemia
 Apnea
 Neonatal Sepsis
 Prolonged Hospital Stay
 Readmission

22. Respiratory issues in late preterm
Prof Pradeep GCM
M.S.Ramaiah Medical College
Bengaluru

23. Introduction
 Studies have consistently shown that late preterm
infants have higher respiratory morbidity and
mortality compared with full-term infants
 Incidence of respiratory distress in late preterm is
28.9% as compared to term( 4.2%)
 35 weeks’ gestation are nine fold more likely, to
have respiratory distress compared with babies
born at term

24. Respiratory Manifestation
Etiology of respiratory distress is diverse and
includes
 Transient tachypnea of the newborn
 RDS
 Persistent pulmonary hypertension
 Apnea

25. Need for Mechanical Ventilation

26. Respiratory Manifestation
 Why late preterm infants are at risk for developing
respiratory distress?

27. Management
 Antenatal Steroids
 Close monitoring for respiratory distress
 Early respiratory support / Surfactant

28. Thank you !

29. ISSUES OF THERMOREGULATION
& HYPOGLYCEMIA IN LATE
PRETERMS
DR PRIYA SHIVALLI
DCH, DNB, FELLOWSHIP IN NEONATOLOGY (IAP)
CONSULTANT NEONATOLOGIST & PEDIATRICIAN
VAGUS SUPERSPECIALITY HOSPITAL
BENGALURU

30. Acute complications of late preterm birth. Wang ML, Dorer DJ, Fleming M, et al.
Clinical outcomes of near-term infants. Pediatrics. 2004;114:372–376.

31.  Hypothermia is more common than we think
– A silent killer!
 In low income and middle income countries (LMICs)
prevalence in community settings ranges from 11%-
92%, in hospital setting ranges from 8%- 85%.
 Independently associated with increased mortality 1.6
to 1.9 times.
 Hypothermia can cause a Healthy baby to become ill
and a sick baby to deteriorate dramatically.

32. PREDISPOSING FACTORS
IN LATE PRETERMS
 Larger surface area per unit body weight
 Decreased thermal insulation due to lack of
subcutaneous fat
 Reduced brown adipose tissue (Nonshivering
thermogenesis)
 Decreased tone

35. NEONATAL ENERGY TRIANGLE

36. Prevention and Management
 In Delivery room
 Thermoneutral environment
 Kangaroo mother care
 Clothing / Swaddling
 Incubators / Radiant warmer
 Polyethylene plastic wraps
If Temp <36deg C
Swaddle baby and cover
head with a cap
If after 30 mins, <36degC
Place under radiant
warmer
If still <36degC
Shift to NICU
Further evaluation and
treatment
Measure temperature every hour for first 6hrs
Then minimum of every 6hrs until discharge

38. KANGAROO MOTHER CARE
BENEFITS
Improved survival
Temperature regulation
Physiologic stability
Reduced Sepsis
Pain reduction
Sleep organisation
Improved growth
Improved breastfeeding
Early discharge
Increased IQ

39. The Effects of Skin-to-Skin Care on Late Preterm and
Term Infants At-Risk for Neonatal Hypoglycemia
Arpitha Chiruvolu, Kimberly Miklis and Veeral Tolia
Pediatrics May 2018, 142
ABSTRACT
Objective: The objective of this study was to evaluate the effects of prolonged
skin-to-skin care (SSC) during blood glucose monitoring (12–24 hours) in late
preterm and term infants at-risk for neonatal hypoglycemia (NH).
Study design: We conducted a retrospective pre- and postintervention study. We
compared late preterm and term infants at-risk for NH born in a 1-year
period before the SSC intervention, May 1, 2013, to April 30, 2014 (pre-SSC)
to at-risk infants born in the year following the implementation of SSC
intervention, May 1, 2014, to April 30, 2015 (post-SSC).
Results: The number of hypoglycemia admissions to neonatal intensive
care unit among at-risk infants for NH decreased significantly from 8.1%
pre-SSC period to 3.5% post-SSC period (P = 0.018). The number of infants
receiving intravenous dextrose bolus in the newborn nursery also
decreased significantly from 5.9% to 2.1% (P = 0.02). Number of infants
discharged exclusively breastfeeding increased from 36.4% to 45.7%, although
not statistically significant (P = 0.074).
Conclusion: This SSC intervention, as implemented in our hospital, was
associated with a significant decrease in newborn hypoglycemia
admissions to neonatal intensive care unit. The SSC intervention was safe

40. EMBRACE -
WARMER
BEMPU –Monitors
temperature with alarm

41. HYPOGLYCEMIA IN LATE
PRETERMS
 Incidence of hypoglycemia is inversely proportional to
gestational age
 Glucose levels fall 1-2 hrs after birth
 In late preterm infants:
Immature hepatic glycogenolysis
Decreased adipose tissue lipolysis
Deficient hepatic gluconeogenesis and ketogenesis
Hepatic enzyme immaturity

43. DEFINITION OF HYPOGLYCEMIA

44. DEFINITION
 Operational threshold
Blood glucose level of < 40 mg/dL
 WHO – BGL OF < 45 mg/Dl
 Transitional Neonatal Hypoglycemia- TNH
Normal physiological adaptation to postnatal life.

45. SCREENING
‘AT RISK’ Neonate
 Preterm <37 weeks
 Small for gestational age (SGA)
 Large for gestational age (LGA)
 Infant of diabetic mother (IDM)

46. TIME SCHEDULE OF BLOOD GLUCOSE
MONITORING
CATEGORY OF INFANTS TIME SCHEDULE
At risk neonates 2, 6, 12, 24, 48 and 72 hrs of life
Sick neonates ( sepsis, asphyxia,
polycythemia, shock during acute
phase of illness )
Every 6 – 8 hrly
Neonates on parenteral nutrition Initial 72hrs: every 6-8hrs
After 72hrs: once a day
AIIMS PROTOCOL 2019

47. DIAGNOSIS
 Point of care-Glucometer
Measures whole blood glucose
Error prone
 Lab glucose estimation – plasma glucose level
( 10-15% more than whole BGL)
Glucose oxidase method, Fluoride tubes preferred
 Continuous glucose monitoring sensor (CGMS)
Experimental

48. J Pediatr, 2010 Aug;157(2):198-202.e1.
Continuous Glucose Monitoring in Newborn Babies at
Risk of Hypoglycemia
Deborah L Harris1, Malcolm R Battin, Philip J Weston, Jane E Harding
Abstract
Objective: To determine the usefulness of continuous glucose monitoring in babies at risk of neonatal hypoglycemia.
Study design: Babies >/=32 weeks old who were at risk of hypoglycemia and admitted to newborn intensive care received
routine treatment, including intermittent blood glucose measurement using the glucose oxidase method, and blinded
continuous interstitial glucose monitoring.
Results: Continuous glucose monitoring was well tolerated in 102 infants. There was good agreement between blood and
interstitial glucose concentrations (mean difference, 0.0 mmol/L; 95% CI, -1.1-1.1). Low glucose concentrations (<2.6 mmol/L)
were detected in 32 babies (32%) with blood sampling and in 45 babies (44%) with continuous monitoring. There were 265
episodes of low interstitial glucose concentrations, 215 (81%) of which were not detected with blood glucose measurement.
One hundred seven episodes in 34 babies lasted >30 minutes, 78 (73%) of which were not detected with blood glucose
measurement.
Conclusion: Continuous interstitial glucose monitoring detects many more episodes of low
glucose concentrations than blood glucose measurement. The physiological significance of these
previously undetected episodes is unknown.

49. AAP GUIDELINES

50. TABLE TO CALCULATE GLUCOSE INFUSION RATE IN
NEONATES

52. Lancet 2013 Dec 21;382(9910):2077-83.
Dextrose Gel for Neonatal Hypoglycaemia (The Sugar Babies Study): A
Randomised, Double-Blind, Placebo-Controlled Trial
Deborah L Harris1, Philip J Weston2, Matthew Signal3, J Geoffrey Chase3, Jane E Harding4
Abstract
Background: Neonatal hypoglycaemia is common, and a preventable cause of brain damage. Dextrose gel is used to reverse
hypoglycaemia in individuals with diabetes; however, little evidence exists for its use in babies. We aimed to assess whether
treatment with dextrose gel was more effective than feeding alone for reversal of neonatal hypoglycaemia in at-risk babies.
Methods: We undertook a randomised, double-blind, placebo-controlled trial at a tertiary centre in New Zealand between Dec
1, 2008, and Nov 31, 2010. Babies aged 35-42 weeks' gestation, younger than 48-h-old, and at risk of hypoglycaemia were
randomly assigned (1:1), via computer-generated blocked randomisation, to 40% dextrose gel 200 mg/kg or placebo gel.
Randomisation was stratified by maternal diabetes and birthweight. Group allocation was concealed from clinicians, families, and
all study investigators. The primary outcome was treatment failure, defined as a blood glucose concentration of less than 2·6
mmol/L after two treatment attempts. Analysis was by intention to treat. The trial is registered with Australian New Zealand
Clinical Trials Registry, number ACTRN12608000623392.
Findings: Of 514 enrolled babies, 242 (47%) became hypoglycaemic and were randomised. Five babies were randomised in
error, leaving 237 for analysis: 118 (50%) in the dextrose group and 119 (50%) in the placebo group. Dextrose gel reduced the
frequency of treatment failure compared with placebo (16 [14%] vs 29 [24%]; relative risk 0·57, 95% CI 0·33-0·98; p=0·04). We
noted no serious adverse events. Three (3%) babies in the placebo group each had one blood glucose concentration of 0·9
mmol/L. No other adverse events took place.
Interpretation: Treatment with dextrose gel is inexpensive and simple to administer. Dextrose
gel should be considered for first-line treatment to manage hypoglycaemia in late preterm and
term babies in the first 48 h after birth.

53. ADDITIONAL EVALUATION
Recurrent/Resistant Hypoglycemia
 Refractory Hypoglycemia (>12mg/kg/min GIR)
 Prolonged hypoglycemia ( >7days)
Critical lab sample (<40mg/dL)
Insulin, Cortisol, Betahydroxy butarate, FFA
Ammonia , Lactate,
Urine ketones, reducing substances,
GH, TSH, TMS, Urine GCMS
Genetic testing - SUR1, KiR6.2 mutations
18F-fluoro- L- DOPA PET scan- pancreas

54. Management of Resistant
Hypoglycemia
 Hydrocortisone -5mg/kg/day BD IV
 Diazoxide – 5-15mg/kg/day TDS PO
 Octreotide -5-35mcg/kg/day TDS SC
 Glucagon -0.2mg/kg SC/IM
 Nifedepine
 Sirolimus
 Surgery

55. Neonatal Hypoglycemic Brain Injury
NHBI involves
particularly parieto-
occipital cortex and
subcortical white
matter

56. JAMA Pediatr. 2017 Oct; 171(10): 972–983.
Association of Neonatal Glycemia With Neurodevelopmental Outcomes at 4.5 Years
Christopher J. D. McKinlay, PhD,1,2 Jane M. Alsweiler, PhD,1,2 Nicola S. Anstice, PhD,3 et al1, for the Children With Hypoglycemia
and Their Later Development (CHYLD) Study Team
Abstract
Importance
Hypoglycemia is common during neonatal transition and may cause permanent neurological impairment, but optimal intervention thresholds are unknown.
Objective
To test the hypothesis that neurodevelopment at 4.5 years is related to the severity and frequency of neonatal hypoglycemia.
Design, Setting, and Participants
The Children With Hypoglycemia and Their Later Development (CHYLD) Study is a prospective cohort investigation of moderate to late preterm and term
infants born at risk of hypoglycemia. Clinicians were masked to neonatal interstitial glucose concentrations; outcome assessors were masked to neonatal
glycemic status. The setting was a regional perinatal center in Hamilton, New Zealand. The study was conducted from December 2006 to November 2010.
The dates of the follow-up were September 2011 to June 2015. Participants were 614 neonates born from 32 weeks’ gestation with at
least 1 risk factor for hypoglycemia, including diabetic mother, preterm, small, large, or acute illness. Blood and masked interstitial
glucose concentrations were measured for up to 7 days after birth. Infants with hypoglycemia (whole-blood glucose concentration <47 mg/dL) were treated to maintain blood glucose
concentration of at least 47 mg/dL.
Exposures
Neonatal hypoglycemic episode, defined as at least 1 consecutive blood glucose concentration less than 47 mg/dL, a
severe episode (<36 mg/dL), or recurrent (≥3 episodes). An interstitial episode was defined as an interstitial glucose
concentration less than 47 mg/dL for at least 10 minutes.
Main Outcomes and Measures
Cognitive function, executive function, visual function, and motor function were assessed at 4.5 years. The primary outcome was neurosensory impairment, defined as poor performance in one
or more domains.
Results
In total, 477 of 604 eligible children (79.0%) were assessed. Their mean (SD) age at the time of assessment was 4.5 (0.1) years, and 228 (47.8%) were female. Those exposed to neonatal
hypoglycemia (280 [58.7%]) did not have increased risk of neurosensory impairment (risk difference [RD], 0.01; 95% CI, −0.07 to 0.10 and risk ratio [RR], 0.96; 95% CI, 0.77 to 1.21). However,
hypoglycemia was associated with increased risk of low executive function (RD, 0.05; 95% CI, 0.01 to 0.10 and RR, 2.32; 95% CI, 1.17 to 4.59) and visual motor function (RD, 0.03; 95% CI, 0.01
to 0.06 and RR, 3.67; 95% CI, 1.15 to 11.69), with highest risk in children exposed to severe, recurrent, or clinically undetected (interstitial episodes only) hypoglycemia.
Conclusions and Relevance
Neonatal hypoglycemia was not associated with increased risk of combined neurosensory impairment at 4.5 years but was
associated with a dose-dependent increased risk of poor executive function and visual motor function, even if not detected
clinically, and may thus influence later learning. Randomized trials are needed to determine optimal screening and intervention
thresholds based on assessment of neurodevelopment at least to school age.

57. TAKE HOME MESSAGES
 Late preterms experience temperature instability and
hypoglycemia mostly in initial 48 hrs.
 Ineffective thermoregulation in the late preterm infant
predisposes the infant to significant complications.
 Encourage early breast feeding within 1hr of birth and
screen for hypoglycemia for 48hrs-72hrs.
 Early recognition and management prevent short and
long term morbidity and mortality.
 Need to create awareness among health care
providers.

58. THANK YOU

59. Jaundice and dehydration in
late preterm neonates
Dr. Nandini Nagar
Consultant neonatologist and pediatrician
Cloudnine hospital, Jayanagar, Bangalore

60. Why worry about jaundice in late
preterm neonates?
Bilirubin levels in late preterm neonates peaks later (at 7 days rather than 5 days)
Stays elevated longer
Reacher higher mean levels as compared to term neonates (207 micromol/L vs 190
micromol/L)
Risk of BIND is higher at lower levels of serum bilirubin as compared to term neonates
Risk of BIND doubles for every week below 37 weeks
Exclusive breastfeeding increases the risk of extreme hyperbilirubinemia (428
micromol/L) by a factor of 6
Safe discharge of the late preterm infant. R K Whyte, Canadian Pediatric Society, Fetus and Newborn
Committee. Pediatr Child Health.2010 Dec; 15(10):655-660

61. Feeding difficulties in late
preterm - dehydration
 Late preterm babies adapt quickly to enteral feeds
BUT
 Deglutition, peristaltic function and sphincter function may be immature
in the esophagus, stomach and intestines
 Lead to poor coordination of sucking and swallowing
 Delay in establishment of breast feeding
 Excessive weight loss/poor weight gain in the first week - dehydration

62. Comparison of short-term
outcomes
 Jaundice requiring phototherapy (18% in late preterm vs 2.5% in term)
 Hypoglycemia (6.8% vs 0.4%)
 Respiratory distress (4.2% vs 0.1%)
 Sepsis (0.4% vs 0.04%)
 IVH (0.2% vs 0.02%)
Short-term neonatal outcome in low-risk, spontaneous, singleton, late preterm deliveries. Melamed N,
et al. Obstet Gynecol. 2009; 114 (2 Pt 1): 253

63. Increased risk of
jaundice and BIND
 Decreased capacity to handle
unconjugated bilirubin
 Decreased hepatic uptake
 Decreased uridine
diphosphoglucuronate glucuronosyl
transferase (UGT) activity
 Increased enterohepatic circulation
 Delayed postnatal maturation of
hepatic bilirubin uptake and
conjugation
 Delayed establishment of enteral
feeding

64. Copyrights apply

65. Copyrights apply

66. BIND
 pontine brainstem
 oculomotor nuclei
 globus pallidus
 auditory pathways
 Hippocampus
 Diencephalon
 subthalamic nuclei
 Cerebellum
 vermis
- disordered visual gaze (eg,
limitations of upward gaze)
- sensorineural hearing
impairment gait abnormalities
(choreoathetoid cerebral palsy)
- speech and language disorders
- Subtle neuromotor signs are
associated with a range of
processing disorders due to
visuo-oculomotor, auditory,
speech, and expressive language
disturbances

67. MRI brain changes
 MRI brain
imaging shows
hyperintense
signals in T1
weighted
sequences in
the globus
pallidus, that
then shifts to
bilateral
hyperintense

68. Copyrights apply

69. predisposed to
significant
hyperbilirubinemia
and other morbidity
 LAMBS study (Elaine M Boyle et al, ADC, 2015) – Neonatal outcomes and delivery of
care for infants born late preterm or moderately preterm: a prospective population-
based study
 Tonse Raju et al, Pediatrics, 2006 – Optimising care and outcome for late preterm
(near-term) infants: A summary of the workshop sponsored by the NICHHD
 Tonse Raju, Pediatrics, 2017 – The “Late Preterm” Birth – Ten Years Later (under
Pediatric perspectives)
 Kumar C et al, J neonatal biology, 2014 – Late Preterm and Early Term Neonates: A
New group of high-risk newborn in neonatology with varied complications

70. Incidence, course and prediction of
significant hyperbilirubinemia (study
from Turkey)
 219 term and 146 near term newborns
 6th hour and daily bilirubin checked until day 7
 Late preterms had a 2.4-fold higher risk of developing significant
hyperbilirubinemia
 Day 5 and day 7 serum bilirubin levels were significantly higher in the near-term
group
Incidence, course and prediction of hyperbilirubinemia in near-term and term newborns. Sarici SU, et
al. Pediatrics. 2004; 113(4):775

72. - Prospective cohort study including neonates
>35 weeks gestation over a period of 6 months
from Mar to Aug in 2011
- Risk factors for significant hyperbilirubinemia
were identified and serum bilirubin was tested at
36 – 48 hours of age, before discharge
- Excluded – NICU admission for any acute
illness, Blood group incompatibility, congenital
anomalies, those who received IV antibiotics
- 486 infants were included in the final analysis,
of which 14% developed significant
hyperbilirubinemia

73.  On univariate analysis, serum total bilirubin, gestational age and percentage of weight
loss were predictive of significant hyperbilirubinemia
 On multiple logistic regression, pre-discharge bilirubin had better predictive ability than
GA and % of weight loss
 Most of the late preterms who had jaundice had significant hyperbilirubinemia, and it
was statistically significant

75. Copyrights apply

76. Copyrights apply

77. Indications to treat in late
preterms without risk factors
Phototherapy
indications
 24 hours of age: >10 mg/dl (171
micromol/L)
 48 hours of age: >13 mg/dl (222
micromol/L)
 72 hours of age: >15 mg/dl (257
micromol/L)
Exchange transfusion
indications
 24 hours of age: >16.5 mg/dl (282
micromol/L)
 48 hours of age: >19 mg/dl (325 micromol/L)
 >72 hours of age: >21 mg/dl (359
micromol/L)
Courtesy: UptoDate

78. Indications to treat in late
preterms with risk factors
Phototherapy indications
 24 hours of age: >8 mg/dl (137
micromol/L)
 48 hours of age: >11 mg/dl (188
micromol/L)
 72 hours of age: >13.5 mg/dl (231
micromol/L)
Exchange transfusion
indications
 24 hours of age: >15 mg/dl (257
micromol/L)
 48 hours of age: >17 mg/dl (291
micromol/L)
 >72 hours of age: >18.5 mg/dl (316
micromol/L)
Courtesy: UptoDate

79. Phototherapy
 Exposure to light of wavelength 425 – 475 nm
 Mechanisms of action: Structural isomerization of bilirubin to lumirubin
(major), photo-oxidation to polar molecules, photoisomerization to a less
toxic bilirubin isomer
 Results in a decline in bilirubin by 2 – 3 mg/dl within 4 – 6 hours
 Greater the spectral power (irradiance X BSA), faster the drop in bilirubin
 Irradiance of white lights is 8 – 10 microW/cm2/nm, and that of blue LED
lights is 30 - 35 microW/cm2/nm

80. Monitoring during and after
phototherapy
 Feeding – breast feeding, EBM, donor
milk, formula
 Continuous NG feeds
 Hydration status, urine output
 Temperature – LED lights do not
cause much overheating
 Fibre-optic biliblanket can be used
during feeding, or in conjunction with
LED lights
 Rebound hyperbilirubinemia

83. Double volume exchange
transfusion
 Very rarely performed nowadays
 In a tertiary care NICU with facilities for central
line insertion and ventilation
 Whole blood required, or red cells of maternal
blood group reconstituted with plasma (or O
negative red cells with AB negative plasma)
 Crossmatched, irradiated blood that is negative
for all known microorganisms like CMV, HIV, Hep
B and C, and syphilis
 Central lines, preferably UVC, UAC or UVC alone
 5 – 10 ml aliquots
 SBR falls to ½ to ¾ of the pre-exchange value

84. IVIG
 In infants with Rh isoimmune hemolytic disease, in whom SBR is rising despite
phototherapy, or is within 2 – 3 gm/dL of the threshold for exchange transfusion
 Dose – 0.5 to 1 gm/kg over 2 hours
 Can be repeated if indicated after 12 hours

85. Hearing
screening
 Hearing screening preferably using BERA is
necessary for neonates that have been treated
for significant hyperbilirubinemia, as it can lead
to sensorineural hearing loss.

86. Key points
 Late preterm neonates are at a higher risk of
delayed establishment of enteral feeding and
dehydration
 Greater risk of significant hyperbilirubinemia and
BIND
 Support early breast feeding, lactation nurses to
help
 Have a low threshold for EBM, donor milk,
formula
 Fortify EBM
 Continuous NG feeds is a good option if there’s
excessive weight loss and jaundice
 Delay discharge from hospital

87. Thank You
BENGALURU CHENNAI MUMBAI
PUNE
GURUGRAM NAVI MUMBAI CHANDIGARH NOIDA
Our Locations
Website
http://cloudninecare.com/

88. Feeding, Nutrition and
Neurology
Late preterm INFANTS

89. Feeding- Hypothetical case
 34 week old LSCS for PIH 1.6 kg mild respiratory
distress. Normal Doppler's
 How many would start on D10 or TPN with as initial
fluid.
 How many would wait for Mother’s milk, for how long.
 Would you commence on NG or direct breast feeds
as distress resolves?

90. Feeding- Hypothetical case
 This we are considering as a singleton.
 Gets compounded when you consider Twins and
Triplets
 The majority of them would not go to term, and are
born around 32-36 weeks for various reasons

91. Feeding
 Preterm infants have functional taste receptors from
18 weeks’ gestation and flavors perception from
around 24 weeks’ gestation This may be bypassed by
the NG route
 Suck swallow and breathing coordination- 33-34
weeks

92. Feeding: Energy requirement
Dextrose Vs PN
 IV Infusions-27% of LP infants vs 5% of term , very
few LP and ET babies will receive parenteral nutrition
support^
 PN Vs 10% dextrose in LP infants while waiting for
maternal milk supply to meet demand and for full
enteral feeds to be tolerated *
 Each day of parenteral support in LP infants has been
reported to predict an increase in time to achieve full
oral feeds of 2 h (hazard ratio: 0.92; 95% CI: 0.89–
0.95).
^Wang ML, Dorer DJ, Fleming MP, Catlin EA. Clinical
outcomes of near-term infants. Pediatrics 2004;114:372–6.
*Alexander T, Bloomfield FH. Nutritional management of moderate–late
preterm infants: survey of current practice. J Paediatr Child Health 2018 Aug
27. https:// doi.org/10.1111/jpc.14201.

93. Feeding: Which milk?
 Breast milk
 Donor Breast milk
 Formula??
 Encourage early BF- within the first hour if possible
 Encourage Kangaroo Mother care, stimulation of milk
production through regular expressing

94. Feeding : Problems
HYPOGLYCEMIA – is one of the commonest reasons for
additional nutritional support in LP infants.
 3-4 x higher than term babies and recurrent
 50% of hepatic glycogen stores, a key source of glucose
in the immediate newborn period, are deposited between
36 and 40 weeks gestation- which these babies lack!
HYPERNATREMIA-
 More common in LP than term babies for the same
reasons, associated with wt loss and feeding difficulties.
 Need to be managed appropriately as discussed

95. Feeding: Immediate Problems
3
months
Oromotor
dysfunction
Avoidant
feeding Most
commonly
Choking
Spitting
1
year
of
life
Improved,
but persist
Admission to NICU vs Nursery fared worse with more later admissions

96. FLAMINGO study
 “Feeding in Late And Moderately preterm Infants
Nutrition and Growth Outcomes (FLAMINGO): a cohort
study with an embedded RCT, double-blind trial in
formula-fed infants to investigate the effects of a new
infant formula on growth and body composition.”
 140 subjects in the RCT, with an anticipated 250 subjects
in the cohort study. Each subject will be included from
randomisation until study end for a maximum of 25
months, comprising of a 6-7 month intervention period in
the RCT and a follow up period until a corrected age of
24 months of age. Recruitment is expected to be
completed in April 2022.
 Aim to see if early provision of a different formula makes
a difference to these babies Supported by Danone / Nutricia

97. Feeding: ESPGHaN
Recommendations
Breast feed &
support
Hypoglycemia
IVF/ TPN
Robust
Unit
Policies Rooming in
/care
Temp control/
BEMPU
Discharge
policies- May
need to be
individualised
Further

98. Feeding: Vitamins/ Minerals
 AAP/ ESPGHAN Recommendations
 Fe for six months
 Vit D through early childhood
• MULTIVITS
• CALCIUM
PHOSPHATE
• Vit D
At full feeds/
2 weeks
•IRON
At 4-6 weeks
• FORTIFIERS
esp <1500g
For adequate
calories

99. Brain growth and development
Occurs in very specific orders and time frames.
It also occurs at different rates during different gestational ages,
which creates critical periods of development during which
cells are susceptible to insults or injuries.
Injury in critical period of growth and differentiation can change
the trajectory of brain development, resulting in different
patterns of brain injury and repair which manifest as
unique neurologic outcomes.
Brain growth has been shown to be altered simply by being
born preterm, as evidenced by studies showing differences in
magnetic resonance imaging (MRI) between late preterm and
FTI* .
*Walsh JM, Doyle LW, Anderson PJ, et al. Moderate and late preterm birth: effect on
brain size and maturation at term-equivalent age. Radiology 2014;273:232–40.

100. Brain growth and development
The late preterm brain is still
immature and more likely to
experience noxious stimuli from
medical complications after birth
such as RDS, sugars,apneas
hyperbilirubinemia etc
Evidence from animal models
reveals that these factors can
promote or precipitate neuronal cell
death in the immature brain*. There
is some evidence that it is unable to
defend against such toxicities.
*Bhutta AT, Anand KJ. Abnormal cognition and behavior in preterm neonates
linked

101. MRI*
38-44 week
 Measures of brain size, BPD, and other brain structures
such as the deep grey nuclei, cerebellum, and corpus
callosum were smaller in MLPT infants than in full-term
infants
 Measures of the extra-axial spaces, namely
interhemispheric distance and superior extra-axial distance,
were significantly larger in MLPT infants than in control
infants (P , .001), suggesting the presence of larger
cerebrospinal fluid volumes in MLPT infants.
 With regard to brain maturation, MLPT infants had less
mature gyral folding and less complete myelination of the
posterior limb of the internal capsule at term-equivalent
age.
*Walsh JM, Doyle LW, Anderson PJ, et al. Moderate and late preterm birth: effect on
brain size and maturation at term-equivalent age. Radiology 2014;273:232–40.

102. MRI*
38-44 week
*Walsh JM, Doyle LW, Anderson PJ, et al. Moderate and late preterm birth: effect on
brain size and maturation at term-equivalent age. Radiology 2014;273:232–40.

103. MRI*
38-44 week
*Walsh JM, Doyle LW, Anderson PJ, et al. Moderate and late preterm birth: effect on
brain size and maturation at term-equivalent age. Radiology 2014;273:232–40.

104. neurodevelopment
36%
• Dev delay
• Disability
50%
• Risk of SEN
in school
10 x
• As many
children than
EPT
Compared to Full term Infants

105. Early outcomes
@ CGA 2 yrs
 Compared to FTI, LPI performed worse in cognitive,
language, and motor domains, with greatest disparity
in the language domain. They also showed evidence
of poorer social–emotional competence.
 Remain at a greater risk of Speech and Language
delay
 Generally LPI do not automatically qualify for early
intervention
 Many researchers have hypothesized that the worse
neurodevelopmental outcomes of LPI may have to do
with their more complicated medical courses
compared to FTI.

106. SCHOOL AGE outcomes
 LPI scored lower in reading in kindergarten and first
grade.
 Children delivered late preterm had a 30% higher
adjusted odds of needing special and individualised
education plan than those born full term.
 Low IQs, Language skills.
 Less attention span

107. ADOLESCENT AND ADULT
outcomes
 Mainly from Sweden, Denmark – 25-50 yrs
old
 Difficult to extrapolate considering the leaping
advances of neonatology in those years.

108. Neurodev-Unanswered queries
Are delays time
bound or
permanent
Is there an
opportunity to
intervene for
better outcomes.
Which LPIs are at
highest risk
Are there specific
delays that are
common or are
they global

109. General Measures in Improving
Neurodevelopment in the preterm
 Design of space with room for KMC
 Light – have a dark or QUIET TIME / no
procedure time
 Sound- Speak in low tone. Alarms, telephone
tones, creaky cupboards / Incubator pots and
doors/to be adjusted to minimise sund.
 Activity level- Maintain Calm, quite and soothing
atmosphere
 Olfactory inputs- remove noxious and unfamiliar
senses- spray/ nicotine / scents

110. General Measures in Improving
Neurodevelopment in the preterm
 Bed / Clothes- Nesting/ swaddling.
 Positioning- support and facilitate physiologically
well-aligned positions whether the infant is on the
back, tummy or side.
 Feeding and Burping- From early on time the
infant’s feeding to be supportive of the infant’s
sleep and wake cycles so that the infant may
learn to recognize feelings of hunger and
satiation. Support the parent to breastfeed the
infant.
 Bloods- Sucrose / breast feeding
 Medical equipments- tapes/ NG/ Nasal canula to

111. Issues in LPT
 Short Term Morbidities
 Health Care Costs
 Hospital Stays
 Re-Hospitalization

112. DISCHARGE CRITERIA
 Vital signs normal for 12hrs before discharge
 Passage of 1 stool spontaneously
 Adequate urine output
 24 hours of successful breast feeding
 If wt loss >7% in 48hr- further assessment before
discharge
 Risk assessment plan for jaundice for infants
discharged within 72hr of birth
 Mother & caregivers demonstrate competency in
care of the infant

113. READMISSION AFTER DISCHARGE
FEEDING
DIFFICULTIES
SUSPECTED
SEPSIS
HYPERBI
LIRUBINE
MIA

114. How do Antenatal Steroids Work?
Science
 Accelerate development of pneumocytes, thus improving lung
mechanics (maximal lung volume, compliance) and gas
exchange
 Increases surfactant production
 Induction of surfactant release, absorption of alveolar fluid,
increase lung antioxidant enzymes
Reduction in RDS, moderate to severe RDS
Reduction in Intraventricular hemorrhage, Necrotising
enterocolitis, mortality, systemic sepsis

115. LPT – Way Forward !
 ‘Evidence Based’ Practice Guidelines
 Accurate Dating – Pregnancy, Fetal Maturity
 Antenatal Steroids – Extended use ( NNT-35)