TWO PATIENTS IN ONE
( continued from page 9 )
and blood pressure , is more likely to get through the first week of hospitalization without a significant intraventricular hemorrhage . 10 As a rule of thumb , most premature infants who have not had an advanced intracranial bleed by five days of life , without a major hypotensive or sepsis event later , is unlikely to have one thereafter . 11 Just as important , stabilization allows an opportunity for the infant to start and steadily advance enteral feeding – the precursor of the ultimate potential cure-all for even the most premature and sickest infants : growth . During this period , total parenteral nutrition may help limit weight loss . But only with fortified breast milk or concentrated premature formula can premature infants reach the nutritional goals necessary to outgrow their pulmonary disease . Of course , the more premature an infant , the more associated problems there are to overcome during this acute phase . The effect of a patent ductus arteriosus ( PDA ), anemia of prematurity , apnea of prematurity , hyperbilirubinemia and the need for prolonged intravenous access are the five most common problems that are routinely endured .
With stability , growth and sometimes help from postnatal steroids , most premature infants are eventually able to work themselves down on respiratory support to nasal cannula or even room air . They are tolerating fortified feeds through a nasogastric or nasojejunal tube demonstrating steady growth but not ready to orally feed . They remain in an isolette for supplemental heat . Except for the ever-present threat of sepsis or worse , necrotizing enterocolitis ( NEC ), the “ feeding and growing ” phase of prematurity is mundane – and that is the way neonatologists like it . During this period , any significant changes are usually not good . Although a respite for neonatologists , some families have difficulty during this period and may develop what staff often refer to as “ NICU-itis ”. After making it through weeks of touch and go situations when every little detail was painstakingly adjusted , measured and double-checked , families may have a hard time letting go of the micro-management of the acute phase of care . It is hard on parents to wait for further growth and , more importantly neurologic maturity , to move forward . They may worry that “ nothing is being done ” to speed up a natural process that has its own timeline . This understandable impatience , combined with unaddressed trauma , may decay into a conflictual relationship with physicians or staff , often pitting one against the other . 12
The final phase of NICU care for the premature infant centers on successfully overcoming the criteria for discharge . This phase is also known by the recurrent question families ask , “ How do we get out of here ?” Usually , rapid neurologic and homeostatic maturity starts at 34 to 36 weeks corrected gestation as the proverbial “ light bulb ” comes on . Problems such as poor oral feeding skills , temperature instability , apnea of prematurity and lagging growth , which have been grudgingly improving , often seem to become non-issues almost overnight .
Typically , premature infants are ready for discharge when they can demonstrate two to three days of oxygenating well on low flow wall oxygen or room air , taking all feeds by mouth , staying warm in open crib , showing no signs of apnea and demonstrating adequate weight gain . For most premature infants , its seems that one of these five criteria is usually a stubborn hang-up that can add days and sometimes weeks to their hospitalization . In the past , skilled home neonatal nursing care was available to help decrease the length of stay , but for multiple reasons , these once commonplace services are now virtually nonexistent . First-time parents or those taking home infants who require complex medical care are encouraged to stay with their baby in “ Care by Parent ” rooms adjacent to the NICU prior to discharge , which despite the gestational age at presentation and owing to neurologic maturity , occurs between 36 to 38 weeks corrected age for most infants .
There are few other times in medicine in which families know , that even with a positive outcome , they are destined for nearly 100 days of hospitalization . Few parents are prepared for the burden implied by such a prolonged length of stay . In contrast , time , and the growth and maturity that come with it , is the secret weapon of the neonatologist , helping them to overcome many of the most challenging cases . Neonatologists are akin themselves to gardeners caring for a sprouting that was planted too early . We hope that early dutiful care , followed by a prolonged period of closely monitored growth and directional staking , will overcome even the roughest of starts , ending in a sturdy tree that no one ever realized was premature to begin with .
References
1
https :// www . aamc . org / what-we-do / mission-areas / health-care / workforce-studies / interactive-data / number-people-active-physician-specialty-2019
2
Bell , E . F ., et al . Mortality , in-hospital morbidity , care practices , and two-year outcomes for extremely preterm infants in the United States , 2013-2018 . Journal of the American Medical Association . 2022 .
3 https :// www . acog . org / clinical / clinical-guidance / committee-opinion / articles / 2017 / 08 / antenatal-corticosteroid-therapy-for-fetal-maturation
4
Age Terminology During the Perinatal Period , Committee on Fetus and Newborn Pediatrics ( 2004 ) 114 ( 5 ): 1362 – 1364
5 https :// www . merckmanuals . com / professional / pediatrics / respiratory-problems-in-neonates / pulmonary-air-leak-syndromes
6 https :// www . uptodate . com / contents / long-term-neurodevelopmental-outcome-of-preterm-infants-epidemiology-and-risk-factors
7 https :// www . nichd . nih . gov / research / supported / EPBO
8
Wendy F . Hensel , The Disabling Impact of Wrongful Birth and Wrongful Life Actions , 40 Harv . Civil Rights-Civil Liberties L . Rev . 141 ( 2005 )
9
Jeng , Mei-Jy ; Lee , Yu-Sheng ; Tsao , Pei-Chen ; Soong , Wen-Jue . Neonatal air leak syndrome and the role of high-frequency ventilation in its prevention . Journal of the Chinese Medical Association : November 2012 - Volume 75 - Issue 11 - p 551-559
10
Ballabh , P . Pathogenesis and Prevention of Intraventricular hemorrhage . Clin . Perinatol . 41 , 47 – 67 ( 2014 )
11
Parodi , Govaery , et al . Cranial ultrasound findings in preterm germinal matrix haemorrhage , sequelae and outcome . Pediatric Research volume 87 , pages 13 – 24 ( 2020 )
12 https :// handtohold . org / nicu-emotional-health /
Dr . Cohen practices neonatal-perinatal medicine with Norton ’ s Children Neonatology .
10 LOUISVILLE MEDICINE