Tip 55b: fluid losses in preterm babies

Babies <1.5kg commonly require:

  • high infusion rates (80-100ml/kg/day) of 10% dextrose on day 1
  • diligent review of their fluid balance and clinical picture with reduction in fluids if required (e.g. hyponatraemia)
  • delayed sodium supplementation until a significant diuresis has occurred (usually after day 1-2).

References: Hartnoll, G., 2003. Basic principles and practical steps in the management of fluid balance in the newborn. Seminary in Neonatology8: 307-313.

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Tip 55a: fluid requirements in preterm babies

The insensible losses in preterm babies, from evaporation and respiratory tract, can reach 40-60ml/kg/day, even when nursed in 90% humidity, and can be much larger (up to 140ml/kg/day).

Reference: Hartnoll, G., 2003. Basic principles and practical steps in the management of fluid balance in the newborn. Seminary in Neonatology8: 307-313.

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Tip 50: surfactant for RDS

Using surfactant early (<2h age vs. late) in preterm infants with RDS requiring ventilation leads to reduced:

  • pneumothorax (RR 0.69)
  • pulmonary interstitial emphysema (RR 0.60)
  • neonatal mortality (RR 0.84)
  • chronic lung disease at 36 weeks’ gestation (RR 0.69).

Reference: Bahadue, F.L., Soll, R., 2012. Early versus delayed selective surfactant treatment for neonatal respiratory distress syndrome. Cochrane Database of Systematic Reviews, Issue 11. Art. No: CD001456. 6 RCTs.

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Fun 4: communication

Badger was supposed to record the first conversation with new parents within 24 hours but couldn’t make his paws work the controls  😦

Badger dictaphone

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Tip 49: respiratory distress syndrome (RDS)

“For babies with RDS to have the best outcomes, it is essential that they have optimal supportive care, including:

  • maintenance of normal body temperature
  • proper fluid management
  • good nutritional support
  • appropriate management of the ductus arteriosus
  • support of the circulation to maintain adequate tissue perfusion.”

Reference: Sweet, D.G., Carnielli, V., Greisen, G., et al., 2013. European Consensus Guidelines on the Management of Neonatal Respiratory Distress Syndrome in Preterm Infants – 2013 Update. Neonatology; 103:353-368. DOI: 10.1159/000349928.

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Tip 48: herpes simplex virus (HSV) infection

There are three main presentations of neonatal HSV:

1. Disseminated disease involves lungs, liver, adrenal glands, skin, eyes, and brain

2. Skin, eyes and/or mouth (SEM) disease

3. Central nervous system disease. Symptoms are generally non-specific and only 2/3 have associated skin lesions. There are NO pathognomic skin lesions in neonates.

The first two present earliest, generally at 10–12 days of life, whereas CNS disease presents during the second or third week of life.

Reference: Thompson, C., Whitley, R., 2011. Neonatal Herpes Simplex Virus Infections: Where Are We Now? Adv Exp Med Biol; 697: 221–230.

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Tip 47: PEEP from the first breath

Studies have shown a ~50% reduction in surfactant administration in 25-28 week gestation babies who receive early PEEP during resuscitation/stabilisation. Also, less supplemental oxygen is required. However, the risk of pneumothorax is increased and there is no overall reduction in mortality or chronic lung disease (CLD).

References:

Sweet, D.G., Carnielli, V., Greisen, G., et al., 2013. European Consensus Guidelines on the Management of Neonatal Respiratory Distress Syndrome in Preterm Infants – 2013 Update. Neonatology; 103:353-368. DOI: 10.1159/000349928.

Morley, C.J., et al. Nasal CPAP or intubation at birth for very preterm infants. N Engl J Med; 358(7): 700-8. DOI: 10.1056/NEJMoa072788. RCT, 610 infants.

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