NICU Case Study Mary Pate-Bennett UTK Dietetic Intern April 18, 2013 Infant B was a 23 5/7 week

gestation, 580g premature infant with in utero drug exposure to IV opana and cocaine. Exam showed pulmonary hyperplasia and a patent ductus arteriosis (PDA). Bronchopulmonary Dysplasia developed early on. The PDA was ligated on day 20 and the infant responded well and is healing. Currently, Infant B is being treated with Diflucan for a fungal infection which could potentially be Malasessezia furfur, derived from the lipid emulsion, or candida- yeast infection. TPN was started on admission and a peripherally inserted central catheter (PICC) line was placed immediately after birth. TPN was gradually increased to 2.6 g/kg/day protein, using a pediatric amino acid solution, and a 1.1g/kg/day fat, with 8% dextrose solution providing 54 kcal/kg/day. EN feedings were started on day 8 at 1.5 ml/hour continuous feeds through a continuous nasogastric gavage (CNG) tube. Expressed breast milk is currently being used at a rate of 14 ml/day. Stool output has been an average of 2 per day.

The infant was born at 23 weeks which marks the beginning of the perinatal period. At this point, the spinal cord, brain, ears, arms, hands, feet, lungs, kidneys, lymphatic system have all been formed, but are not well developed. The heart beats and can be heard with a stethoscope. Nipples and hair have formed. Pancreas is formed. Face is well formed. Tooth buds appeared in 10th week. Genitals appear well differentiated (in this case, uterus and vagina are formed). Red blood cells are being produced in the spleen and liver. Urine forms and is being discharged in the amniotic fluid. Lanugo covers the body. Bones have formed, but are still soft. The baby can hear. Sucking motions are made with the mouth and swallowing occurs. Eyelids are formed and will stay closed until the 28th week. Meconium is made and is present in the intestinal tract. Liver and pancreas are producing fluid secretions. Eyebrows and eyelashes are present. Footprints and fingerprints begin to form. Alveoli are being formed in the lungs. Nails appear on fingers and toes.

Further Development- what is to come: 23-25 weeks o Bone marrow begins to make red blood cells. o Rapid eye movements begin. o The tongue begins to develop taste buds. o The infant is regularly sleeping and waking. o Real hair is growing on their head (instead of the Lanugo) o The uterus and ovaries are in place, complete with a lifetime supply of eggs. o The lower airways of the lungs develop, but are not producing surfactant. o Fat storage begins. o Fetus will respond to parents voice, with movement.

26 weeks o Eyelashes and eyebrows are well formed. o All eye parts are developed. o Footprints and fingerprints are more developed. o Air sacs are formed in the lungs. They are beginning to form surfactant. o Fingernails are developing. 27 -30weeks o Rapid Brain Development o Development of the nervous system to control some bodily functions o Opening and closing of the eyelids o Cochleae are developed, but will not be fully functioning until 18 months after birth o Respiratory system, immature, but able to perform gas exchange o Red blood cells are now developing in the bone marrow. 31-34 weeks o Rapid increase of body fat o Pupils of eyes can constrict, dilate and detect light entering the eyes. o Rhythmic breathing movements, but lungs are still not fully mature. Practicing breathing. o Thalamic brain formation- for motion o Full development of bones, although still soft and pliable o Fetus begins to store phosphorus, calcium and iron from the intestinal tract. o The CNS is now able to regulate body temperature. o Toenails are visible. o Lanugo slowly begins to disappear. 35 weeks o Lanugo disappears more quickly o Body fat increases o Fingernails reach the end of the fingertips 36-40 weeks o Lanugo is gone except on the upper arms and shoulders. o Fingernails extend beyond fingertips. o Small breast buds are present on both sexes. o Head hair is now coarse and thick. o At week 37, the organs are ready to work on their own.

Because of such an early delivery, some of the risks for a prenatal infant include: Apnea of prematurity Hypoxic-ischemic encephalopathy (HIE) Pulmonary interstitial emphysema Pulmonary hemorrhage Cerebral palsy Intraventricular hemorrhage (IVH) Retinopathy of prematurity (ROP) Patent ductus arteriosis (PDA) Respiratory distress syndrome (RDS) Bronchopulmonay dysplasia (BPD Necrotizing enterocolitis (NEC) Periventricular leukomalacia (PVL) Cytomegalovirus (CMV) Infection.

With these high risks, some of the potential long-term outcomes include: Behavioral problems Delayed growth and development Mental or physical disability or delay Vision loss or blindness Cerebral Palsy Hearing loss Higher risk of depression as Adolescents Epilepsy Dental problems Infections, Asthma and Feeding issues The infant is critically ill and has a poor prognosis.