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Late Preterm Infants: Immediate problems after birth

Any baby born before 37 completed weeks of gestation are preterm babies.
Looking at the pathophysiology of babies who are extremly tiny and who are mature, there is a transitional range of babies in between called Late Preterm babies. Late preterm babies are those who are born 34 to 36 weeks and 6 days.
[Late preterm” was defined by participants of the 2005 Workshop on “Optimizing Care and Outcome of the Near-Term Pregnancy and the Near-Term Newborn Infant”  National Institutes of Heath ].

late preterm baby

Term neonates are those who are born between 37 completed weeks of gestation to 41 weeks and 6 days. Those babies who are born between 37 weeks and 38 weeks 6days are Early Term babies. Full Term babies are those who are born after 39 weeks.
Post term newborns are those born after 42 completed weeks of gestation.

preterm definitions

Late Preterm Infants

Late preterm infants are often notrious in any NICUs. They are metabolically and functionally immature and often present with mutitudes of problem, while some of them behave like full mature term infants and transit uneventfully.

Some of the commonly encountered problems in Late preterm neonates are

Respiratory distress

As late preterm babies tend to have delayed cardiopulmonary adaptation to ex-utero environment, they present with Transient Tachypnea of Newborn and Hyaline membrane disease. They are more prone to developing pneumothorax because of secondary lung pathologies like RDS.

PPHN

One of the dreaded complication of any pathology in neonates in Persistent pulmonary Hypertension of Newborn which is rarer in extreme preterms and more common in Late preterm and term babies.

Apnea of Prematurity: 

Although rare, 4-7% of LPT babies can develop apnea due to functional immaturity of the Central nervous system.

Hypothermia

As they have low brown adipose tissue response, late preterms are more prone to Hypothermia.

Jaundice

Jaundice during neonatal period is a frequent problem in LPT infants due to functional immaturity of Liver enzymes. The duration of jaundice is often more prolonged, and peak concentrations of indirect bilirubin frequently are higher than found in term infants. Delayed maturation and lower concentrations of uridine diphosphoglucuronate glucuronosyltransferase, Increased enterohepatic circulation, increased RBC load lead to development of exaggerated neonatal jaundice in this age group.

neonatal jaundice phototherapy

Feeding Problems

Poor Suck-swallow coordination, feeding intolerance and seldom Nectrotizing enterocolitis are seen in these infants.

Metabolic and other Problems

Hypoglycemia, Hypocalcemia and Polycythemia are specifically seen problems in late preterm infants. Polycythemia and hypoglycemia are more common in IUGR infants.
Some of the References Quoted them as: 1. 'Late preterm infants: near term but still in a critical developmental time period.' Kugelman A Pediatrics 2013 
2. 'Late preterm Infants: A population at risk' William A, Pediatrics 2007 Neoreviews: Infant born Late preterm


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Breastfeeding Terminologies

Breastfeeding in newborn should start right after birth as early as possible. Breastfeeding is the nature's rule and has tremendous benefit over artificial feeding.

breastfeeding


Few terminologies are important in regard to Breastfeeding:

Exclusive Breast milk: No food or liquid other than breast milk, not even water, is given to the infant from birth by the mother, health care provider, or family member/supporter.

Total breast milk: No food or liquid other than breast milk, not even water, is given to the infant from birth by the mother, health care provider, or family member/supporter during the past 7 days.

Predominant breast milk: Breast milk, given by the mother, health care provider, or family member/supporter plus 1 or a maximum of 2 feeds of any food or liquid including nonhuman milk, during the past 7 days.

Partial breast milk: Breast milk, given by the mother, health care provider, or family member/supporter plus 3 or more feeds of any food or liquid including nonhuman milk, during the past 7 days.

No breast milk: The infant/child receives no breast milk.

Breast milk includes breastfeeding, expressed breast milk or donor milk and undiluted drops or syrups consisting of vitamins, mineral supplements or medicines.

[Source- The Breastfeeding Committee for Canada Breastfeeding Definitions, March 2004.]


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New National Immunization schedule of Nepal includes Rotavirus vaccine : 2018


The National Immunization schedule of Nepal has included Rota viral vaccine over existing 11 Antigens.

Rota virus is the leading cause of Acute viral diarrhea in children and leads to substantial mortality and morbidity. The vaccine is given Orally  at 6 and 10 weeks.


About Fractional dose of IPV : As an alternative to the intramuscular injection of a full dose of IPV, countries may consider using fractional doses (1/5 of the full IPV dose) via the intradermal route.In the context of an IPV shortage, countries should consider instituting a 2-dose fractional dose schedule, where feasible, 
fIPV has been introduced at 6 and 14 weeks in our schedule as recommended by WHO.


New immunization schedule Nepal

IPV vs fIPV


Also read the Old Schedule-2014 


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Interpreting Pedigree chart to recognize pattern of inheritance


One of the problem faced by students is solving a pedigree chart and recognizing pattern of inheritance, which is even important in day to day clinical practice.

Inheritance that needs to be differentiated in pedigree can be

Mendelian ( Single Gene defect )
 Autosomal Dominant
Autosomal Recessive
X linked

Non traditional inheritance like
Mitochondrial inheritance

In a Step Wise approach

1. Identify whether pattern of inheritance is Autosomal or Sex linked.
If only Males are affected , it is likely X linked inheritance ( Recessive, X linked dominant disorders are very rare)
If both males and females are equally affected, it is Autosomal inheritance


2. Determine whether the disorder is dominant or recessive.
If only Affected parent transmit the disease , it is Dominant disorder
If non-affected parent transmit the disease, it is Recessive disorder.
In other words,
If the disorder is dominant, one of the parents must have the disorder.
If the disorder is recessive, neither parent has to have the disorder because they can be heterozygous.

If disease skips generations, it is likely Recessive disorder.



Rules of Inheritance: Understanding Mendelian disorder by Dr Sulabh Shrestha

Understanding Mendelian inheritance - Epomedicine




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Umbilical Infection in Neonate leading to Septic shock: Case


A Preterm neonate of 33 weeks gestation deteriorated on day 2 with septic shock and decreased urine output rapidly over 12 hours. Baby was pale and CRT was prolonged. A Workup was sent and Emperical Antibiotics were started. Baby needed Inotrope support and improved over next 24-48 hours. On day 4, redness was seen around umbilical area and was indurated and tender on palpation.
A diagnosis of Omphalitis was made, Swab culture was sent from the base of cord and Cloxacillin was added. Local dressing was done and local antiseptic ointment was applied.



Over next 2 days, the redness decreased along with induration. Umbilical stump still had not fallen off . Treatment was continued.



After the cord fell off, the redness and induration subsided but pus discharge was seen as umbilicus was manipulated everytime.  Swab culture was sent. As abdomen was distended, an sonogram of abdomen was done to look for internal extension, including screening for collection in fascia and liver. USG was normal. Inj Vancomycin was added and cloxacillin was stopped.


Finally, baby showed drastic improvement. Distension of abdomen subsided and umbilicus looked healthy.  Finally baby was discharged. Although no cultures were positive, empirical antibiotics for  Staph aureus was administered for 14 days duration.




Discussion

Although Omphalitis is superficial infection of umbilical cord, a dreaded scenario is when there is rapid extension of infection to fascia, muscles and peritoneum of abdomen leading to necrotizing fascitis, myonecrosis and peritonitis. Systemic spread can lead to sepsis and shock rapidly like in this condition. Common organism leading to this conditions are Staph aureus, Streptococcus and gram negative organisms like Klebsiella and Proteus. MRSA are reported in cases of omphalitis. Application of dung, human milk and herbs to cord can lead to infection by Clostridium.

Risk factore for Omphalitis, include Septic delivery, PROM, chorioamnionitis, umbilical vessel catheterization which were all absent in this case. Baby was Low birth weight and was another risk factor for omphalitis. 

Mean age of onset in preterm is 3-5 days and in term babies it is 5-9 days.

Treatment:
A combination therapy for Gram +ve and -ve agents
Inj Vancomycin and an aminiglycoside is preferred drug for emperical use.
If extension to internal structure is suspected addition of metronidazole or clindamycin may be needed.

Surgical consultation for complicated cases.


Complications:
Necrotizing fascitis
Myonecrosis
Pertitonitis and abdominal abscess
Liver abscess
Portal vein thrombosis.








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