Anemia of Prematurity - Portal Neonatal

NEC is commonly managed with antibiotics, elimination of oral intake, gastric decompression by
nasogastric tube, and supportive measures to correct complications such as metabolic acidosis,
thrombocytopenia, and hypotension. Surgical intervention may be necessary if evidence of
perforation exists (presence of free air on radiographs) or medical treatment fails. Long-term
complications include those related to bowel resection (short gut syndrome), bowel strictures, and
risk of abdominal adhesions.
Spontaneous bowel perforation often occurs in the first week of life, presenting earlier than a typical
case of NEC. Stark et al showed a strong interaction between postnatal use of dexamethasone and
indomethacin on incidence of perforation (19%) in ELBW infants in a trial designed to determine if a
10-day course of postnatal dexamethasone would reduce the risk of CLD or death.
Intraventricular hemorrhage
A hemorrhage in the brain that begins in the periventricular subependymal germinal matrix can
progress into the ventricular system. Both incidence and severity of IVH are inversely related to
gestational age. ELBW babies are at particular risk for IVH because development of the germinal
matrix typically is incomplete. Any event that results in disruption of vascular autoregulation can
cause IVH, including hypoxia, ischemia, rapid fluid changes, and pneumothorax. Presentation can be
asymptomatic or catastrophic, depending on the degree of the hemorrhage. Symptoms include
apnea, hypertension or hypotension, sudden anemia, acidosis, changes in muscular tone, and
seizures. One commonly used system classifies IVH into 4 grades, as follows:
• Grade I - Germinal matrix hemorrhage
• Grade II - IVH without ventricular dilatation
• Grade III - IVH with ventricular dilatation
• Grade IV - IVH with extension into the parenchyma
IVH is diagnosed using cranial ultrasound, which usually is performed on ELBW infants during the
first week after birth, since most IVHs occur within 72 hours of delivery. Use of antenatal steroids
decreases incidence of IVH, and treatment consists of supportive care. Early administration of
indomethacin also reduces the risk of IVH when used prophylactically in ELBW infants but may affect
urine output and platelet function adversely. Prognosis is correlated with the grade of IVH. The
outcome in infants with grades I and II is good; as many as 40% of infants with grade III IVH have
significant cognitive impairment, and as many as 90% of infants with grade IV IVH have major
neurologic sequelae.
The recent Trial of Indomethacin Prophylaxis in Prematurity (TIPP) demonstrated a decrease in the
incidence of severe grades of IVH but no difference in neurodevelopmental outcomes at age 18-24
months. Thus, the question of using such an approach remains unanswered. The use of antenatal
steroids has been associated with a decreased incidence of IVH in ELBW infants.
Periventricular leukomalacia
Periventricular leukomalacia (PVL) is defined as damage to white matter that results in severe motor
and cognitive deficits in ELBW infants who survive. PVL occurs most often at the site of the occipital
radiation at the trigone of the lateral ventricles and around the foramen of Monro. The origin of PVL is
believed to be multifactorial; the injury possibly results from episodes of fluctuating cerebral blood
flow, which are caused by prolonged episodes of systemic hypertension or hypotension. PVL has
been linked to periods of hypocarbic alkalosis. Recently, PVL also has been associated with
chorioamnionitis. PVL is diagnosed using brain ultrasound in patients aged 4-6 weeks, and it occurs
in 10-15% of ELBW infants. The presence of PVL, particularly cystic PVL, is associated with an
increased risk of cerebral palsy; spastic diplegia is the most common outcome.