Approach to complications of prematurity (late): Clinical sciences

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Introduction 0:00–0:38

Preterm birth before 37 weeks of gestation can result in various complications that increase an infant's morbidity and mortality.
These complications are most common among patients who were born before 32 weeks of gestation or those with very low birth weight under 1500 g.
Late complications of prematurity can develop after the first month of life and because they don't typically cause acute or obvious signs and symptoms, many are identified through screening.
Now, if a pediatric patient presents with a chief concern, suggesting a late complication of prematurity, first, obtain a focused history and physical examination, then review your findings to determine if your patient requires further evaluation.

H&P 0:38–0:54

Let's start by assessing your patient's oxygen requirement. If your patient required supplemental oxygen for 28 days or more, consider bronchopulmonary dysplasia or BPD history will reveal an infant born before 32 weeks of gestation.

Bronchopulmonary dysplasia 0:54–2:33

They may have had a patent ductus arteriosus required mechanical ventilation or had prolonged exposure to hyperoxia. The exam might reveal chest retractions and audible pulmonary rales and when attempting to wean your patient's supplemental oxygen, they will usually become hypoxemic and tachypneic within 60 minutes.
Even though BPD is a clinical diagnosis. You can consider ordering a chest X ray to support the diagnosis determine disease severity and identify complications.
Typically, the chest X ray will reveal diffuse hazy opacifications and hyperinflation with or without cystic luce andies.
This combination of clinical and imaging findings confirms your diagnosis of bronchopulmonary dysplasia. Ok.
Here's your first clinical pearl. In severe cases of BPD disrupted pulmonary vascular development leads to increased pulmonary vascular resistance and ultimately pulmonary hypertension over time.
The right ventricle hypertrophies. In order to maintain cardiac output, these patients can experience pulmonary hypertensive crises during which an acute increase in pulmonary arterial pressure overwhelms, the right ventricle and causes right sided heart failure.
Ok. You'll also assess your patient for signs and symptoms of anemia.

Anemia of prematurity 2:33–3:40

Premature infants are physiologically predisposed to anemia due to limited iron stores, impaired erythropoietin production and a short fetal red blood cell lifespan.
Newborns with anemia may have poor weight gain apneic episodes or a history of frequent lab draws. Keep in mind that some patients are asymptomatic and the anemia might be discovered as an incidental lab finding on physical exam.
Your patient might be hypoxemic, tachypneic or tachycardic and you'll often detect pallor especially on the conjunctivi and the palms of the hands and soles of the feet.
With these signs and symptoms consider anemia of prematurity to confirm the diagnosis. Obtain hemoglobin levels.
A hematocrit and a reticulocyte count. If the hemoglobin and hematocrit are below reference range for age and The reticulocyte count is low diagnose anemia of prematurity.
Next, assess the need to screen for periventricular leukomalacia or PVL. Since P VL is caused by an ischemic injury to the premature brain, these patients may have had a previous episode of hypoxemia or hypotension or they may have been diagnosed with intraventricular hemorrhage sepsis or necrotizing enterocolitis.

Periventricular leukomalacia 3:40–4:55

The physical exam may reveal an uncoordinated suck, swallow, increased muscle tone or spastic diplasia. With these findings consider PVL and order a cranial ultrasound if it shows characteristic white matter injury with or without cysts diagnose PVL.
Now, here's a clinical pearl PVL is often asymptomatic during the first weeks or months of life. So to identify it, you'll need to perform routine screening with cranial ultrasound for all infants with risk factors such as gestational age of 30 weeks of gestation or less.
Order the first ultrasound within the first seven days of life, then again at 4 to 6 weeks of life and at least once more before your patient is discharged from the hospital.
Now, you'll also need to assess your patients risk for osteopenia because intrauterine transfer of minerals occurs most rapidly during the third trimester, preterm.

Osteopenia of prematurity 4:55–6:21

Infants lack the calcium and phosphorus stores required for adequate bone development. And consequently, they're at risk for osteopenia.
Neonates with osteopenia are usually asymptomatic and are identified through routine screening. But in severe cases, they may present with fractures.
Consider screening your patient at 4 to 5 weeks of life if they have risk factors such as gestational age, less than 30 weeks at birth, long term corticosteroid use or long term parenteral nutrition unless there's a fracture.
The physical exam is usually unremarkable. At this point.
You should consider osteopenia of prematurity and order labs including alkaline phosphatase and phosphorus levels. Because bony changes are usually only visible on imaging.
You may also consider obtaining x rays. Typically alkaline phosphatase levels are elevated and phosphorus levels are low.
If you obtain x rays, you may see growth plate widening and poor bone mineralization. With these findings diagnose osteopenia of prematurity.
Now, you should also assess the need to screen for retinopathy of prematurity or ro this late complication of prematurity is caused by ischemic injury to the developing retina which results in abnormal retinal vascularization.

Retinopathy of prematurity 6:21–7:37

If not identified and treated ro can lead to visual impairment or blindness. Rop occurs almost exclusively in infants born before 30 to 32 weeks of gestation and the history may reveal episodes of hypoxemia, hyperoxia or hypotension as well as previous mechanical ventilation.
This history should make you consider rop and obtain a retinal screening examination. Characteristic patterns of abnormal retinal vascularization are diagnostic of retinopathy of prematurity.
Here's a clinical pearl since ROP is typically asymptomatic, it's usually identified by screening the timing of which depends on gestational age at birth for infants born at or before 27 weeks of gestation screen for rop at a postmenstrual age of 31 weeks.
And for those born at 28 weeks or later screen at four weeks of life. Finally, once you've completed all necessary screenings, you'll need to perform ongoing assessments.

Neurodevelopmental impairments 7:37–8:47

As your patient grows to look for neurodevelopmental impairments, premature infants are at an increased risk of intellectual motor or social delays.
And in many cases, a caregiver is the first to identify developmental concerns. You may also identify delays through routine developmental surveillance during infancy or early childhood.
Since neurodevelopmental impairments are often related to brain injury. History may reveal an episode of severe asphyxia or your patient may have been diagnosed with intraventricular hemorrhage, PVL meningitis or seizures depending on the underlying pathology.
Physical exam findings may include macro or microcephaly, muscle tone abnormalities such as hypertonia or spasticity and abnormal posture or body movements.
Any of these should make you consider a neurodevelopmental impairment and arrange for a full developmental assessment as well as hearing and vision screening.
The presence of any deficit confirms a neurodevelopmental impairment. All right.
It's a quick recap. Late complications of prematurity can present after the first month of life.

Review 8:47–9:31

If your patient was born before 32 weeks of gestation and required supplemental oxygen for 28 days or more. Consider BPD if your patient demonstrates signs and symptoms of anemia, evaluate for anemia of prematurity if indicated, screen for PVL with a cranial ultrasound osteopenia of prematurity with alkaline phosphatase and phosphorus levels and retinopathy of prematurity with retinal examination.
Lastly consider neurodevelopmental impairment in all patients born preterm and perform regular developmental assessments including vision and hearing screening.