Common medical and surgical problems - Office Care of the Premature Infant, part 2

Author: David E. Trachtenbarg, Thomas B. Golemon
Date: May 15, 1998

Advancements in the care of premature infants have led to increased survival of these infants, and family physicians frequently provide care to these infants following their discharge from the hospital. Premature infants present many challenges to the family physician. Medical problems originating in the initial weeks of life may require care for months or years. Other conditions may manifest clinically later in infancy or in childhood, necessitating an attitude of continual alertness and attentiveness on the part of the physician. A summary of recommendations for office care is given in Table 1.

TABLE 1 Office Data to Obtain in Follow-up Care of Premature Infants

Infant's age Office data to obtain1 week after GROWTH AND DEVELOPMENT discharge Review prenatal and hospital information; note medications and special formula. Identify risk factors for developmental delay. Record length, weight and head circumference on graph; perform physical examination. NUTRITION Review diet (note any hypercaloric formula), feeding pattern and typical 24-hour day. SCREENING Assess need for community services (WIC, visiting nurse, respiratory therapy, rehabilitation, etc.); immunization status (especially hepatitis B if weight > 2,000 g [4 lb, 6 oz]). Check on use of infant car seat. Answer questions.2 to 4 weeks GROWTH AND DEVELOPMENT after discharge Record length, weight and head circumference on premature growth chart; look for catch-up growth (first head, then weight, then length). NUTRITION Review diet, feeding and typical 24-hour day. Add vitamins and iron. Weight-gain goal is 1 oz per day; calorie requirement is usually 100 kcal per kg per day. SCREENING Special testing and consultations (such as audiology, ophthalmology, pneumographs, pulmonary clinic); immunizations: hepatitis B.2 to 4 months GROWTH AND DEVELOPMENT after discharge Record length, weight and head circumference on premature growth chart; physical examination; developmental testing at regular Intervals. NUTRITION Review diet, feeding and typical 24-hour day. SCREENING Review medications, blood tests, reports from special clinic, and special needs. Immunizations: by chronologic age.4 to 6 months GROWTH AND DEVELOPMENT after discharge Record length, weight and head circumference on premature growth chart,- physical examination. NUTRITION Review diet, feeding and typical 24-hour day. SCREENING Review medications, updates from special clinics, blood work needs. Immunizations: hepatitis B, influenza.6 to 12 months GROWTH AND DEVELOPMENT after discharge Continue recording growth on premature chart through age 2; continue developmental screening. NUTRITION Diet should advance normally unless problems exist, such as swallowing difficulties or reflux. SCREENING Monitor medication needs and any blood levels as needed.Infant's age Comments1 week after discharge First week is the most stressful; support and encourage mother; be available. Use growth chart for premature infants. Follow infant's course weekly until stable growth is documented. Cover after-hours availability.2 to 4 weeks after discharge Watch for normal head growth versus hydrocephaly; suspicion of hydrocephaly is higher with history of intraventricular hemorrhage. Increased calories required in chronically ill infants, such as those with bronchopul -monary dysplasia; up to 200 kcal per kg per day may be required. May need to check serum theophylline or anticonvulsant levels. Check home adaptation. Follow weekly or biweekly as needed.2 to 4 months after discharge Continued catch-up growth, especially of the head. Watch for hyperosmolar problems with high-calorie formula. Consider acellular pertussis vaccine; use full doses for immunizations.4 to 6 months after discharge Continue developmental testing at each visit. In general, solids may be added to diet at four months after due date. Influenza immunization may be given in season to infants >6 months of age, especially those with chronic lung disease, as well as to persons in contact with infant.6 to 12 months after discharge Catch-up growth is usually achieved by 2 to 3 years of age; some may never catch up. May switch from formula to whole milk at 1 year of age. Note any clinic reports available.

WIC = Women, Infants and Children's Program.

Abnormalities found on screening frequently require consultation with other specialists. Coordination of health care for timely intervention and follow-up is an important role for the family physician, who also must be sensitive to issues of parental support and cost containment. This second part of a two-part article reviews some of the most common medical and surgical problems encountered during the office care of infants born prematurely.

Common Medical Problems Anemia

Factors that lead to anemia in premature infants include the following: (1) lower iron stores than those in term infants, (2), lower erythropoietin production compared with that in term infants and (3) frequent blood sampling, which can reduce an infant's blood volume by up to 10 percent within a few days of frequent sampling.[1] Anemia usually reaches its nadir at one to three months of age, when hemoglobin values of 7 g per dL (70 g per L) are not uncommon in premature infants.

During office visits, signs and symptoms such as tachycardia, tachypnea, pallor, lethargy, poor feeding, poor weight gain and apnea with bradycardia may indicate the presence of anemia. If these signs and symptoms develop, the blood count should be checked. Routine hemoglobin determinations may be considered for infants with hemolytic disease, such as ABO or Rh incompatibility. Although hematocrit levels below 25 percent are often poorly tolerated,[2] the need for transfusion should be based on the patient's signs and symptoms rather than on a specific hematocrit level. Infants with large left-to-right shunts usually benefit from a hematocrit level of greater than 40 percent.[3]

Iron supplementation reduces the level and duration of anemia.[4,5] Starting between two weeks and two months of age, iron supplementation in a dosage of 2 to 4 mg per kg per day for 12 to 15 months is recommended.[6,7] Ferrous sulfate drops contain 25 mg of elemental iron per mL, and the usual 0.6-mL dose contains 15 mg.

Although it has been postulated that vitamin E reduces hemolysis and is frequently diminished in premature infants, vitamin E supplementation does not affect hemoglobin concentration, reticulocyte count or red blood cell morphology.[8] Although erythropoietin is used in some neonatal intensive care units (NICU) in the treatment of anemia of prematurity, it is not routinely recommended.

Developmental Disabilities

One of the greatest fears of parents of a premature infant is mental retardation. Ten to 20 percent of infants with a birth weight under 1,500 g (3 lb, 5 oz) have developmental disabilities.[9] Developmental disabilities may range from severe mental retardation and cerebral palsy to a learning disability demonstrable only when the child reaches school age. Developmental disabilities are commonly caused by one of two complications of prematurity: intraventricular hemorrhage or periventricular leukornalacia.

[15.] Rekha S, Battu RR. Retinopathy of prematurity: incidence and risk factors. Indian Pediatr 1996; 33:999-1003.

[16.] American Academy of Pediatrics, American Association for Pediatric Ophthalmology and Strabismus, American Academy of Ophthalmology. Screening examination of premature infants for retinopathy of prematurity. A joint statement. Pediatrics 1997;100:273.

[17.] Hillemeier AC. Gastroesophageal reflux: diagnostic and therapeutic approaches. Pediatr Clin North Am 1996;43:197-212.

[18.] American Academy of Pediatrics Task Force on Infant Positioning and SIDS. Positioning and sudden infant death syndrome (SIDS): update. Pediatrics 1996;98:1216-8.

[19.] Cisapride. In: Gelman CR, Sayre NK, Rumack BH, et al., eds. Drugdex[R] Drug Evaluations. Vol. 95. Englewood, Colo.: Micromedex, Inc., 1998.

[20.] Rigatto H. Apnea. Pediatr Clin North Am 1982; 29:1105-6.

[21.] Finer NN, Barrington KJ, Hayes BJ, Hugh A. Obstructive, mixed and central apnea in the neonate: physiologic correlates. J Pediatr 1992;121: 943-50.

[22.] Malloy MH, Hoffman HJ. Prematurity, sudden infant death syndrome, and age of death. Pediatrics 1995;96:464-71.

[23.] Kurlak LO, Ruggins NR, Stephenson TJ. Effect of nursing position on incidence, type, and duration of clinically significant apnoea in preterm infants. Arch Dis Child Fetal Neonatal Ed 1994;71:F16-9.

[24.] Yuksel B, Greenough A, Gamsu HR. Respiratory function at follow-up after neonatal surfactant replacement therapy Respir Med 1993;87(3):217-21.

[25.] Hagan R, Minutillo C, French N, Reese A, Landau L, LeSouef P. Neonatal chronic lung disease, oxygen dependency, and a family history of asthma. Pediatr Pulmonol 1995;20:277-83.

[26.] Robertson CM, Etches PC, Goldson E, Kyle JM. Eight-year school performance, neurodevelopmental, and growth outcome of neonates with bronchopulmonary clysplasia: a comprehensive study. Pediatrics 1992;89:365-72.

[27.] Scherer LR 3d. Surgical management. In: Douglas Jr, Gleason CA, Lipstein SU, eds. Hospital care of the recovering NICU infant. Baltimore: Williams & Wilkins, 1991:187-96.

[28.] Disorders and anomalies of the scrotal contents. In: Behrman RE, Kliegman RM, Arvin AM, eds. Nelson Textbook of pediatrics. Philadelphia: Saunders, 1996:1378-80.

[29.] Inguinal hernias. In: Behrman RE, Kliegman RM, Arvin AM, eds. Nelson Textbook of pediatrics. Philadelphia: Saunders, 1996:994-6.

[30.] Scherer LR 3d. Surgical management. In: Jones MID, Gleason CA, Lipstein SU, eds. Hospital care of the recovering NICU infant. Baltimore: Williams & Wilkins, 1991.

[31.] Volpe JJ. Brain injury in the premature infant-current concepts. Prev Med 1994;23:638-45.

[32.] Fujimoto S, Yamaguchi N, Togari H, Wada Y, Yokochi K. Cerebral palsy of cystic periventricular leukomalacia in low-birth-weight infants. Acta Paediatr 1994;83:397-401.

[33.] Hack M, Merkatz IR, Gordon D, Jones PK, Fanaroff AA. The prognostic significance of postnatal growth in very low-birth-weight infants. Am J Obstet Gynecol 1982;143:693-9.

[34.] Paludetto R, Mansi G, Rinaldi P, De Luca T, Corchia C, De Curtis M, et al. Behavior of preterm newborns reaching term without any serious disorder. Early Hum Dev 1982;6:357-63.

This is the second part of a two-part article on office care of premature infants. Part I, on monitoring growth and development, appeared in the last issue (Am Fam Physician 1998; 57:2123-30).

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