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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 Ballard Score: How to use it correctly

Assessment of gestational age can be made postnatally by either Dubowitz Score or New Ballard Scoring system. In sick infants, examination of Anterior lens canpsule vascularity with a +20D lens can be useful in assessing gestation and it needs to be carried out within 24 hours of birth.

Dr Jeanne L Ballard developed a scoring system based on neurological maturity and physical maturity to assess gestational age of babies. We are all well aware of the charts and scoring system but still many of us are not able to score appropriately and assign gestation age accurately.

Here is the chart-

New Ballard Score


You can use online calculator as well
Download New ballard score here

The video below demonstrates the procedure of assessment.




When is the appropriate time to perform New Ballard score?
Performed between 30 minutes to 96 hours, ideally within 24 hours. However, studies have debated its validity up to 7 days.
For preterm babies < 26 weeks, it must be done in first 24 hours because on second day babies may suffer from consequences of prematurity.

In such a case, you have two options: Perform the remainder of the neuromuscular criteria, then assign a similar score to the popliteal angle and heel to ear. Wait 24 to 48 hours or until flexor tone has returned to the hamstrings and gluteus muscles, and repeat the assessment For breech deliveries, there may be flexor fatigue in 1st 24 hours so, NBS is performed after 24-48 hours to avoid lower score for lower limbs.

Assigning score and gestational age
For scores between numbers on the grid, we interpolate as follows:
25 = 34 weeks
26 = 34 weeks
27 = 34 weeks
28 = 35 weeks
29 = 35 weeks
30 = 36 weeks

Record only completed weeks of gestation and not partial weeks.
If weeks by exam fall within 2 weeks of KNOWN maternal dates, preferably confirmed by early ultrasound, then the maternal dates are more likely correct.
If weeks by exam are greater than 2 weeks outside of maternal dates in either direction, then the clinical gestational assessment is more likely correct.

References:
New Ballard Score, expanded to include extremely premature infants. Ballard JL et Al.
http://www.ballardscore.com/
Essential Neonatology- Mathur
Validity of New Ballard Score until 7th day of postnatal life in moderately preterm neonates.
Sasidharan K et Al


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Pediatric OPD is a Challenge: Treating the Child and Meeting Parents expectations

Scenario

"A concerned mother brings her 3 yr child to the Outpatient Clinic, the child has had fever for 1 day, running nose and cough for 2 days. There are no other serious complains and findings on examination are all normal, except for running nose and low grade fever. A case of common cold that is very common in childhood.

The mother is really concerned about the child contacting  Pneumonia , well there were no symptoms as such and pediatrician counsels her on that, but she wants an antibiotic for safe-side. Doctor explains the condition and hazards of erroneous use of Antibiotics, she is convinced.

She is equally concerned about the cough. She has been giving the child Anti-tussive from Over-the-counter prescription that is pandemic in our country. Doctor advice her to stop the drug as current research does not recommend its use in below four years children. She is not convinced this time, in-spite of counselling"

In such a Scenario either doctor keeps trying to convince her, either he loses the follow-up or he has to go with the flow an prescribe Anti-tussives and Vitamins as the trend is in Private practice.

Pediatric OPD

Pediatrics is a bit different subject to doctors in many sense. Specially in Pediatric out patient department or in private clinics, doctors will often find a mildly ill child but more skeptical parents who might constantly test you with their queries and doubts.

Pediatrics is different in that , not just treatment of the sick child is important but also meeting of the parents expectations, counselling them well and taking them in confidence. Often doctors meet lot of patient who already on Antibiotics for Viral URTI , so the dilemma sets in- to continue or to stop the medication. The trend in the private practice is so wide-spread that antibiotics are prescribed for cases without any indications. The fault is not just in doctors here but in parents as well who often switch doctors when doctor prescribes less drugs. However its what the nature of care-taker is, they always want to be on the safe side, while unknowingly they may be harming the child.

Erroneous and Erratic use of Antibiotics have led to Antibiotic resistance.There was a time when Penicillin was Jack of All, a shot of it could treat almost everything,today plain Penicillin rarely can treat any condition. These are the outcomes.

Meeting the Expectations of Parents

What parents generally expect is that their child should be well with a day of treatment, which is rarely a possibility, because most antibiotics take at-least 24-48 hours to get working. Counselling about the need and expected time of resolution can convince the parents to be more patient.

They want all their Queries fulfilled and all their doubt cleared. Because they are on behalf of a child patient who cannot express many things and they are guardian to such delicate human beings. Show then the empathy and that you care equally for the welfare of the child. Be patient and answer all the queries they have. Doctors should put themselves in the place of parents and try to fulfill their queries.

They may search for your qualifications and experience , face them confidently and without hesitations. Getting angry at it will not mask the thing, but will cause you to lose a rapport and trust.

They always want best among the pediatrician to treat the child, so they may test you with several questions, doctor must let them know that you are equally good and take them in confidence.

And last of all, ethically don't give up and prescribe medications to satisfy the parents, do it only when you know it is required. And the question is " Is this a possibility?"

I may not be totally right as I have a long journey to go, if you have a different opinion, I welcome your feedback.


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Studying pediatrics - is it easy?

Pediatrician

Pediatrics is a domain of Medicine that deals with child health, illness and well-being . The word "children " may itself may be hard for many doctors, but pediatrics isn't simply about a word. Here the word "Children" includes - neonates, infants, toddlers, shool-age children and adolescents. Every age group has own horizon.

Why studying pediatrics needs a lot of determination and interest?

As we all know, children are not easy to deal with and many people don't have the patience , passion and rest find it hard to built a rapport with children.

Children are scared of white coat and the hospital environment. As soon as they enter, they begin to resist and doctor may have hard time getting his or her co-operation.






Signs are more important than symptoms in pediatrics. Children may not give a subjective complains, instead doctor has to detect his problem. All small children do is cry. A pediatrician has to find a meaning out of his cry.Sometimes it may be a simple colic to as bad as an intussusception or meningitis.

Most difficult thing is the change in biophysiology in children. Right from birth there is daily to monthly change in vitals, clinical findings, reflexes, behavior. Without proper experience detecting an abnormality might be impossible. Pediatric residents have pockets full of growth charts, reference values and drug dosings.

Even the management is totally different in newborn and older children.

Maintainance fluid requirement , nutritional requirement, dose dosing and interval, whether the drug can be used in children, drug formulations- syrup, drops, DT ect makes it mandatory for residents to carry a drug dosage formulation books. There is no fixed dose as in adults.




Another difficult part is the growth and development part. I have seen even pediatrician surrender to this domain. It is a mighty domain and is a core pediatric subject. Even we are pissed off when we encounter a developmental problem case. It is a matter of dedication and patience.

The next is , Congenital anomaly, dysmorphology and spectra of genetic and metabolic diseases that are an

add on to medicine. Dysmorphology is an unrewarding subject. You are a detective and you find the culprit but its unpunishable at most times.There is always a differential when a child is not growing, seriously or recurrently ill or has other problems and it is this part.

The adolescents to say aren't a different species, but its time when they act different. Aggression, rage, frustration, emotions are all exaggerated during this time and taking them in confidence and giving them the right path is the real challenge.

The most important thing is, it is the most sensitive field in medicine. Everyone value children dearer than their life. When a child is critically ill, counselling the parents is harder than the treatment. Breaking a bad news is a different story. Lot of mishaps have occured.

Last but not the least, no matter how ever you are, you have to act funny.

Still, the children make your everyday special. You cannot be a pediatrician and sad. There is only one option. They dazzle you no doubt. So treating these gift of god is a novel job. Pediatrics however difficult may it be, is worth it.

I may be missing points. you are always welcomed to add in.


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