Problems of preterm infants after discharge

Sensory processing disorders in premature infants

Introduction. Children born prematurely have an increased risk of immediate medical complications, as well as socioemotional, cognitive, linguistic and sensory processing disorders later in life. Studies have examined the effects of prematurity on developmental outcomes, such as cognition, however, there is a need for a more detailed examination of sensory processing disorders in preterm infants. Not only is prenatal neurosensory development interrupted in utero, but these children may also experience intense stimulation in the neonatal unit, which can further alter the development and function of the sensory system. Objective. The paper presents an overview of research on sensory processing disorders in premature infants, with special emphasis on the impact of the environment of the neonatal unit. Method. Insight into the relevant literature was performed by specialized search engines on the Internet and insight into the electronic database. Results. Sensory processing disorders affect 39% to 52% of newborns born prematurely, with some evidence to suggest that children born before 32 weeks are most at risk. The literature to date has consistently reported difficulties in sensory modulation of preterm infants, within the tactile, vestibular, auditory, oral, and visual domains. Conclusion. Sensory processing disorders in preterm infants appear to occur as a result of their immature neurological and biological system and being in the environment of a neonatal intensive care unit, which is unable to meet the sensory needs of preterm infants. Altered sensory experiences, during periods of neurodevelopmental vulnerability and fragility, can result in sensory processing disorders, which may include enhanced responses or less response to stimuli (hyper or hyposensitivity).

Analysis of sensory processing in preterm infants

BACKGROUND

Premature birth suggests condition of biological vulnerability, predisposing to neurological injuries, requiring hospitalization in Neonatal Intensive Care Units, which, while contributing to increase the survival rates, expose infants to sensory stimuli harmful to the immature organism.

AIMS

To evaluate the sensory processing at 4 and 6months' corrected age.

SUBJECTS AND METHODS

This was a descriptive cross-sectional study with a sample of 30 infants divided into an experimental group composed of preterm infants (n=15), and a control group composed of full-term infants (n=15). The infants were assessed using the Test of Sensory Functions in Infants.

RESULTS

The preterm infants showed poor performance in the total score of the test in reactivity to tactile deep pressure and reactivity to vestibular stimulation. When groups were compared, significant differences in the total score (p=0.0113) and in the reactivity to tactile deep pressure (p<0.0001) were found.

CONCLUSION

At 4 and 6months of corrected age, the preterm infants showed alterations in sensory processing. These changes were most evident in reactivity to tactile deep pressure and vestibular stimulation.

Two-year outcomes of a randomized controlled trial of inhaled nitric oxide in premature infants

BACKGROUND AND OBJECTIVES

The European Union Nitric Oxide trial was designed to assess the potential benefits of inhaled nitric oxide (iNO) compared with placebo in infants with respiratory failure. This follow-up study evaluated respiratory, neurodevelopmental, and other outcomes for infants entered into the European Union Nitric Oxide trial to age 2 years.

METHODS

In a multicenter, randomized, double-blind study, preterm infants born at <29 weeks' gestation with moderate respiratory failure were allocated to receive iNO (5 ppm) or placebo for 7 to 21 days. Subjects underwent assessments at 1 and 2 years corrected for prematurity.

RESULTS

At 36 weeks' postmenstrual age, 696 of 792 infants were alive; 4 in the iNO arm subsequently died before age 2 years compared with 7 in the control arm. We evaluated 95% of the survivors at 12 months and 90% at 2 years. In the iNO arm, 244 of 363 (67.2%) infants had survived without disability at age 2 years compared with 270 of 374 (72.2%) who received placebo (P = .094). Mean (SD) cognitive composite scores (Bayley Scales of Infant and Toddler Development, third edition) were 94 (13) in the iNO group and 95 (14) in the placebo group; in the iNO group, 19% scored <85 and 9.5% developed cerebral palsy compared with 13.3% and 9%, respectively. There were no significant differences in hospitalizations overall or due to respiratory illness in use of home oxygen therapy or respiratory medications, in growth, or in other health outcomes.

CONCLUSIONS

At 2 years of age, low-dose (5 ppm) iNO started early (<24 hours after birth) for a median of 20 days did not affect neurodevelopmental or other health outcomes.

Alterações orais em crianças prematuras e de baixo peso ao nascer: a importância da relação entre pediatras e odontopediatras

OBJETIVO: Apresentar uma revisão de literatura sobre as alterações orais em crianças prematuras e de baixo peso ao nascer. FONTES DE DADOS: Foram selecionados artigos em inglês e português, desde 1976 até 2009, pesquisados no PubMed, Lilacs e na Bibliografia Brasileira de Odontologia (BBO), além de livros e consensos nacionais e internacionais. As palavras-chave utilizadas foram: "prematuro", "recém-nascido de baixo peso", "cárie dentária", "hipoplasia do esmalte dentário", "manifestações bucais e "dentição primária". Selecionaram-se artigos avaliando incidência, prevalência e etiologia das alterações orais, além de revisões de literatura e relatos de casos clínicos. SÍNTESE DOS DADOS: As alterações orais mais comuns em crianças prematuras e de baixo peso ao nascer são os defeitos no esmalte dentário (hipoplasias e hipocalcificações), a predisposição ao desenvolvimento de lesões de cárie dentária, as alterações na cronologia de erupção dentária e as alterações no palato com consequente aparecimento de maloclusão. Outras alterações também são relatadas, como diferenças nas dimensões das coroas dentárias e na espessura e porosidade do esmalte dentário. A interação entre pediatras e odontopediatras é fundamental no manejo dessas crianças. CONCLUSÕES: O conhecimento das alterações orais em crianças pré-termo e de baixo peso ao nascer por parte dos pediatras e odontopediatras favorece a atuação multidisciplinar com o objetivo de educar, prevenir e atenuar as possíveis mudanças físicas e dentárias nessas crianças.

[Development and evaluation of an e-learning program for mothers of premature infants]

PURPOSE

It has been attempted to support mother of premature infants by providing information of premature infant care using e-learning because premature infants need continuous care from birth to after discharge.

METHOD

The e-Learning Program for mother of premature was developed with Xpert, Namo web editor, Adobe Photoshop, and PowerPoint and applied for 4 weeks from 4 to 30 September 2006.

RESULT

1) We found that the contents of information which premature infants' need when being in the hospital and after discharge were the definition of a premature infant, orientation of NICU, care of premature infants, care of premature infants' common diseases, the connection of healthcare resources, exchange of information, and the management of rearing stress. 2) The program content consisted of cause of premature birth, comparison to full-term baby, physiology character, orientation of NICU, common health problems, follow up care, infection control, feeding, normal development physically and mentally, weaning method, and vaccination.

CONCLUSION

Considering the results, this program for mother of premature is a useful means to provide premature-care information to mothers. This information can be readily accessible and can be varied and complex enough to be able to help mothers to the information and assistance they require.

Vulnerable: a concept analysis

TOPIC

In spite of the significance of vulnerable as a phenomenon that affects the human condition, its essence remains complex and elusive.

PURPOSE

A conceptual analysis to clarify knowledge of this concept to explore the common and scientific usage.

SOURCES OF INFORMATION

A comprehensive and systematic review from bibliographic and abstract databases and online searches.

CONCLUSIONS

Findings contributed to the definition of vulnerable as a highly individualized dynamic process of being open to circumstances that positively or negatively influence outcomes, a definition based on a synthesis of knowledge concerning vulnerable, and offers a reconceptualization that expands its use in nursing scientific theory, research, and clinical practice.

The changing face of bronchopulmonary dysplasia: Part 2. Discharging an infant home on oxygen

Transitioning an infant with bronchopulmonary dysplasia (BPD) home on oxygen is a complex process. It requires an interdisciplinary team, with clear but flexible discharge criteria, and a coordinated process to manage the complexity. In "The Changing Face of Bronchopulmonary Dysplasia: Part I" (Advances in Neonatal Care, December 2002, pp 327-338), the evolving nature of BPD was presented, along with new diagnostic criteria, a description of the risk factors and clinical profile of this condition, and a discussion of preventative strategies as well as the medical and neurodevelopmental outcomes. "The Changing Face of Bronchopulmonary Dysplasia: Part 2. Discharging an Infant Home on Oxygen" provides strategies to support families during the pivotal transition home on oxygen and other related technologies. The use of a systematic interdisciplinary discharge planning process, guided by clear criteria for discharge, is presented. An outline of the comprehensive discharge teaching, home care, and multispecialty follow-up that are necessary to ensure a safe and smooth transition into the community to avoid repeat or unnecessary rehospitalizations and to enhance outcomes is provided. Medical fragility persists in infants with BPD, placing additional stress on families. Pragmatic strategies to provide intensive parent support throughout the process are offered.

Magnetic resonance imaging and the neonate

Over the past decade, advances in neuroimaging have given birth to a new field of diagnostic pediatric neurologic assessment that includes magnetic resonance imaging (MRI). This invaluable tool helps medical professionals to resolve many clinical and research questions related to neonatal neurodevelopment that other imaging technology cannot explain. Nurses and others who accompany infants to MRI would benefit from a better understanding of early neurodevelopment and of the neuroimaging procedure. Knowing the advantages and disadvantages of MRI techniques can help nurses be better patient advocates, parent liaisons, and caregivers to infants having MRI scans.

Developmental progression of feeding skills: an approach to supporting feeding in preterm infants

Infants born prematurely, with congenital or acquired medical conditions, or who have extended stays in the neonatal intensive care unit (NICU) are at higher risk of developing feeding and nutritional problems than are full-term, healthy newborns. Because of the complex nature of feeding, it is necessary to have a thorough understanding of the developmental nature of this skill. The importance of recognizing stability in the physiologic, motor and state systems and using stability to determine both readiness to begin nipple feeding and progress in feeding, is discussed. Intervention strategies to promote stability leading to successful feeding are also described. Viewing infant feeding from a developmental skill acquisition perspective can guide the caregiver in determining how challenging it is for the infant, and therefore is useful in supporting the progression of feeding.

Delayed childbearing and its impact on population rate changes in lower birth weight, multiple birth, and preterm delivery

OBJECTIVE

This study quantified the impact of delayed childbearing (maternal age greater-than-or-equal to 35 years) on population rate changes in low birth weight (LBW; < 2500 g), preterm delivery (< 37 weeks), multiple births, and small for gestational age (SGA; < 10th percentile) in Alberta, Canada, between 1990 (N = 42 930) and 1996 (N = 37 710).

METHODS

Data were obtained from the provincial notification of a live or stillbirth. Analyses included relative risk estimates and chi(2) tests for trend. Potential confounding attributable to in vitro fertilization was investigated.

RESULTS

The proportion of births to women greater-than-or-equal to 35 years of age was 8.4% in 1990 and 12.6% in 1996, a 51.2% increase. Among these women, LBW delivery increased 11%, and preterm delivery increased 14%. Delayed childbearing accounted for 78% of the change in LBW rate in the population and 36% of the change in preterm delivery rate in the population. Provincial multiple birth rates increased by 15% for twins and 14% for triplets. Delayed childbearing accounted for 15% of the twin increase and 69% of the triplet increase. When in vitro fertilization pregnancies were excluded, the change was 43% for preterm rates, 100% for LBW, 14% for twins, and 9% for triplets. Delayed childbearing did not contribute to changes in singleton SGA deliveries.

CONCLUSIONS

The findings suggest that the recent increase in LBW and preterm delivery is partly related to the population phenomenon of delayed childbearing. Maternal age was not related to changes in SGA, suggesting that the age effect is through pregnancy complications that lead to preterm delivery and LBW. Prospective parents should be informed about the higher risk for neonatal morbidity associated with delayed childbearing. Health care providers should be aware of the impact of delayed childbearing on health care resources.

Primary care of the premature infant discharged from the neonatal intensive care unit

Premature infants require varying degrees of newborn intensive care and have a wide range of physical and developmental outcomes. Subsequent ambulatory care for these infants is often complex. Although tertiary hospitals often provide multidisciplinary follow-up clinics, the pediatric nurse practitioner (PNP) responsible for primary care has a unique opportunity to influence the lives of these special babies and their families. While the basic principles of well child care and health maintenance apply to this special population, there are several inherent challenges. The transition from neonatal intensive care unit (NICU) to home can be stressful for families. Infants born prematurely often have unpredictable behavior and present with cues that are vague and unclear to caregivers. Growth must be monitored adjusting for prematurity, and nutrition must be tailored to the physical and developmental level of the infant. Assessments of development, vision, and hearing must also be adjusted for prematurity. Fortunately, the majority of premature infants discharged from the NICU thrive and develop normally. However, some will experience medical problems and developmental delay. Knowledge of complications common to premature infants will be helpful to the PNP providing primary care. These include difficulties of growth and feeding, gastroesophageal reflux, apnea and bradycardia, chronic lung disease, fine and gross motor abnormalities, and other learning problems. Providing care to the NICU graduate is one of the challenges faced by PNPs in primary care, but one that is both rewarding and enjoyable.

Comprehensive primary care follow-up for premature infants

Advances in perinatal and neonatal care have led to an increased incidence of survival of premature infants. Although most premature infants have normal outcomes, they are at increased risk for morbidity and mortality and require comprehensive primary care follow-up after they are discharged from the hospital. This article will review guidelines for general follow-up of premature infants and the associated problems related to prematurity. General follow-up is performed by the pediatric nurse practitioner, with subspecialty consultant referrals as needed. Knowledge of the problems of prematurity and treatment regimes will assist the pediatric nurse practitioner in providing high-quality care to these high-risk infants.

Effects of in vitro fertilization on low birth weight, preterm delivery, and multiple birth

PURPOSE

To quantify the contribution of in vitro fertilization (IVF) on changes in the rates of low birth weight (LBW), preterm delivery, very low birth weight, and multiple births during the past 3 years.

METHODS

Data on IVF pregnancies from 1994 to 1996 within Alberta were reviewed. Population data were obtained from the Provincial notice of a live or stillbirth.

RESULTS

The IVF component of increased LBW rate in the province was 17.8% for infants <2500 g and 43.5% for those born <1500 g. IVF accounted for 10.5% of the provincial rate increase in deliveries <37 weeks' gestation and 66.2% of those <30 weeks' gestation. IVF accounted for 21.4% of the twins and all of the sets of triplets in the province.

CONCLUSION

During a 3-year period IVF has affected the incidence of LBW, preterm delivery, and multiple birth. IVF is a substantial contributor to changes in very low birth weight and delivery before 30 weeks, which is partly related to multiple births.

The role of the neonatal nurse practitioner in post NICU follow-up

This descriptive correlational study explored the role of neonatal nurse practitioners (NNPs) in postneonatal intensive care unit follow-up. A random sample of 505 NNPs completed a researcher-developed instrument pretested for reliability and validity. There was overwhelming agreement (96%) that a role exists for NNPs in follow-up. In total, 52% felt qualified to provide follow-up and 22% were currently in the role. NNPs with previous primary care experience (P = 0.010) were more involved in follow-up. NNPs with additional certification (P = 0.016) or previous primary care experience (P = 0.003) felt more qualified to provide follow-up care. Facilitators and barriers to the role were identified by NNPs providing follow-up care.

Environmental impact of the NICU on developmental outcomes

The neonate, especially the premature one, is both dependent on and vulnerable to the intensive care environment to support physiologic and neurobehavioral organization. Concerns about this environment have led to suggestions that it may be a major contributing factor in the persistent incidence of behavioral and learning problems among preterm infants. By modifying the neonatal intensive care environment to provide a more developmentally supportive milieu, we can better meet the infant's physiologic and neurobehavioral needs, support the infant's emerging organization, and foster growth and development.

Premature birth and the changing composition of newborn infectious disease mortality: Reconsidering “exogenous” mortality

Linked death and birth records from San Antonio, Texas reveal that infectious infant mortality is increasingly a function of premature birth and low birth weight. Between 1935 and 1944, 4% of infectious infant deaths had associated causes involving prematurity and related conditions; by 1980, 25% of infectious infant deaths involved prematurity and more than 40% of those infants weighed less than 2,500 grams. The shift in birth-weight composition results almost entirely from an increase in very low-weight births. Under conditions of advanced perinatal technology, infectious infant mortality should no longer be viewed as wholly exogenous. These findings further undermine the contemporary relevance of the exogenous-endogenous distinction.

Neonatal Follow-Up Care: Implications for Home Health Care

Through changes in technology and medicine, the population of the intensive care nursery (ICN) has become more acute, along with new challenges for the home care provider. The follow-up care of these infants is multifaceted. They have medical, technical, developmental, financial, and psychosocial issues that affect them as well as their families and community. These issues may become evident in the form of a crisis, postdischarge, or may remain chronic and long term. The home health care nurse is in a unique position to facilitate, report, educate, and provide compassionate care for these infants and their families as well as connect them to their community. This article discusses some of the issues facing the ICN infant and family postdischarge and suggests home care interventions. It is followed by a three-part tool that may be used to assess an infant's ICN course, home assessment, and infant assessment.