Pediatrics [NICU]

Intro
The neonatal intensive care unit (NICU) is a special beast. Many
of the general issues encountered are already covered in other
sections. This topic covers what’s outstanding - primarily
problems related to prematurity.

Bronchopulmonary dysplasia (BPD)

This is a difficult concept, but think of BPD (child) as AIP or Look for supplemental oxygen use in the premature infant to
DPLD (adult). BPD is the chronic consequence of an acute diagnosis BPD. Stage severity by oxygen use at 36 weeks
problem. If you understand sepsis in adults, where most of this gestational age.
comes from (and realize this is pulm crit care level stuff), you
know that ARDS is a bad thing that happens. Consider reviewing
Pulm ARDS or the next level content ARDS to try to understand
the details.

In ARDS there are bad lungs. ARDS is acute. Then lungs scar.
That leads to DPLD – a broad category of lung disease –
specifically with the name AIP. DON’T look up the names. Just
understand that acute bad stuff (fluid) leads to chronic bad stuff “Old BPD” – Pulmonary fibrosis, extreme differences in alveolar
(scarring). inflation, pulmonary hypertension.

BPD in kids is DPLD in adults. Respiratory Distress Syndrome “New BPD” – Disruption of alveolarization (larger and fewer in
of the Newborn (RDS) is ARDS in adults. But why they happen number).
is different.

In the newborn, undeveloped lungs haven’t made enough

lubricant, called surfactant. Some alveoli get stuck together and
fail to open (called “derecruitment”). There’s so much chatter Prevent with avoidance of prematurity and excessive fluid
right now about this disease that YOU, and MS3, can’t possibly administration. Antenatal steroids may help.
contribute to the conversation. Don’t try. Focus on the bolded
concepts in this section.

RDS is talked about in neonatal resuscitation. It’s imperative to

give oxygen and lung protective strategy ventilation. However, Use surfactant. Use it early.
if an infant was born at < 32 weeks AND continues to require
oxygen at day 28, they probably have BPD.

Once there is chronic disease, there’s little that can be done. Lung
scarring can’t be reversed. Emphysema, interstitial lung disease
(also called DPLD) etc. are all possible. The goal, then is to
prevent the transition of RDS to BPD.

Lung-protective ventilatory strategies, decreasing the FiO2, and

diuresis are all things done for RDS; they’re the same things done
for ARDS. But the only things that really work (other than luck)
are ante-natal steroids and perinatal surfactant.

The bottom line is this: prevent premature birth, give steroids

before baby is born if they’re preterm, then give surfactant after
they’re born.

© OnlineMedEd. http://www.onlinemeded.org
 Pediatrics [NICU]

Retinopathy of prematurity (ROP)
The normal development of retinal vasculature is interrupted by Caused by neovascularization of the retina. This leads to bleeding
premature birth. The capillary growth that’s supposed to happen and scarring causing distortion and detachment of retina.
(vascularization) stops, but the growth of capillaries in general
doesn’t, leaving us with abnormal growth of capillaries
(neovascularization). This is represented on a spectrum of
problems (there are 5 stages) ranging from a thin line of active Avoid excessive oxygen administration in premature infants to
disease (1) to retinal detachment (5). save their eyes.

Prematurity is the thing that causes retinopathy of prematurity. Serial examinations are needed to detect appropriate time for
But it’s worsened by high oxygen delivery (like RDS-BPD intervention (if needed).
spectrum). Regardless, every premature neonate is going to be
screened for ROP with an ophthalmologic exam.
Lasering of the eyes is primary treatment.
Primary treatment is laser photocoagulation. While mild disease
may regress on its own, remember, “if ROP, zap with laser.” The
consequence is glaucoma.

Intraventricular hemorrhage (IVH)
The intraventricular lining (germinal matrix) is highly vascular
and susceptible to BP changes. This lining usually involutes at
34 weeks. So if a neonate is born before 34 weeks, they have this
thing that can easily bleed and is sensitive to changes in blood
pressure (either high or low). So there’s a premature neonate with
all its problems (like sepsis, RDS, BPD), it gets pumped full of
fluids, TPN, and pressors, and wham! brain bleed.
Immature lining of ventricles ruptures prior to its physiologic
involution (~34 weeks). Made worse with inability to regulate
cerebral blood flow in the neonate.
Screen with IVH. No need for advanced imaging.
Long-term sequelae vary. Younger gestational age and larger
areas of bleeding give worse prognosis: MR, CP, Seizures

Screen every premature neonate < 30 weeks (it’s fair to say up

to 34) with a cranial ultrasound. The younger the baby, the
worse is it. The worse it is, the worse the consequences. It’s a
brain bleed so it’s essential to manage intracranial pressures;
baby may need a craniotomy or VP shunt. Because it ruins the
brain, hydrocephalus, cerebral palsy, intellectual disability, or
seizures (anything with the brain) is a possible consequence.

Premature infants <30 weeks typically undergo a cranial

ultrasound around one week of life to evaluate for hemorrhage.
Follow-up imaging is done at 36-40 weeks. Once found, IVH is
placed in 4 grades (1-4) based on increasing severity (and
percentage of ventricular volume occupied).

Necrotizing Enterocolitis
We talk about this in other sections. But because it’s one of the
“big 4” of neonatal care, we’re discussing it again. Just remember
if there’s a premature infant and bloody bowel movement, rule
out NEC first. On the test, look for the buzz term pneumatosis
intestinalis or air in the wall of the bowel (they mean the same
thing) on an X-ray. From there, it’s NPO, IV abx, and TPN to
help baby grow. Surgery may be required, leading to short gut
syndrome.

© OnlineMedEd. http://www.onlinemeded.org