Anemia of Prematurity - Portal Neonatal

early administration of high concentrations of lipids may worsen hyperbilirubinemia and
BPD through pulmonary vascular lipid deposition and bilirubin displacement from albumin.
o Excessive glucose loads may increase oxygen consumption, respiratory drive, and
glucosuria. Calcium and phosphorus requirements are greatly increased in preterm
infants. Most mineral stores in the fetus occur during the third trimester, leaving the
extremely preterm infant calcium and phosphorus deficient and at increased risk of rickets.
Supplemental furosemide therapy and limited intravenous calcium use may worsen bone
mineralization and secondary hyperparathyroidism. Vitamin A supplementation may
improve lung repair and decrease incidence of BPD. Supplement trace minerals (ie,
copper, zinc, and manganese) because they are essential cofactors in the AO defenses.
o Early initiation of small amounts of enteral feeds (even if umbilical lines are in place)
followed by slow steady increases in volume appears to facilitate tolerance of feeds. The
most immature and unstable preterm infant often experiences a difficult transition to
complete enteral nutrition. Frequent interruption of feedings secondary to intolerance or
instability complicates the management of these patients. Enteral feeding of breast milk
provides the best nutrition while preventing feeding complications (ie, sepsis, necrotizing
enterocolitis). The energy content of expressed breast milk and formulas can be enhanced
to provide increased energy intake, while minimizing fluid intake. Infants may require 120-
150 kcal/kg of body weight per day to gain weight. Diuretics may often be used to prevent
or treat fluid overload.
• Medical therapies: Often, many different drug therapies are employed to treat infants with
severe BPD. The efficacy, exact mechanisms of action, and potential adverse effects of these
medications have not been definitively established.
o Diuretics
� Furosemide (Lasix) is the treatment of choice for fluid overload in infants with BPD. It
is a loop diuretic that has been demonstrated to decrease PIE and pulmonary
vascular resistance (VR), improving pulmonary function. Daily or alternate day
furosemide therapy improves respiratory function and may facilitate weaning from
PPV, oxygen, or both.
� Adverse effects of long-term Lasix therapy are frequent and include hyponatremia,
hypokalemia, contraction alkalosis, hypocalcemia, hypercalciuria, cholelithiasis, renal
stones, nephrocalcinosis, and ototoxicity. Careful parenteral and enteral nutritional
supplementation is required to maximize the benefits instead of exacerbating the
adverse effects of furosemide. Potassium chloride supplementation is favored over
sodium chloride supplementation in cases of mild hyponatremia or hypokalemia.
� Thiazide diuretics with inhibitors of Aldactone have also been used in infants with
BPD. Several trials of thiazide diuretics combined with spironolactone have shown
increased urine output with or without improvement in pulmonary mechanics in infants
with BPD. In 2000, Hoffman reported that spironolactone administration does not
reduce the need for supplemental electrolyte administration in preterm infants with
BPD. In 1989, Englehardt and colleagues found no effect in pulmonary mechanics in
infants with BPD. Adverse effects include electrolyte imbalance. Long-term efficacy
studies comparing furosemide with thiazide and spironolactone therapy have not been
performed to date.
o Smooth muscle agents (bronchodilators)
� Albuterol is a specific beta2-agonist used to treat bronchospasm in infants with BPD.
Albuterol may improve lung compliance by decreasing airway resistance secondary to
smooth muscle cell relaxation. Changes in pulmonary mechanics may last as long as
4-6 hours.
� Adverse effects include increases in BP and heart rate. Ipratropium bromide is a
muscarinic antagonist that is related to atropine but may have more potent
bronchodilator effects. Improvements in pulmonary mechanics have been
demonstrated in BPD after ipratropium bromide inhalation. Combination therapy of
albuterol and ipratropium bromide may be more effective than either agent alone. Few
adverse effects are noted.
� Cromolyn sodium inhibits release of inflammatory mediators from mast cells. Some
studies have shown a decrease in inflammatory mediators in tracheobronchial
aspirates of infants with BPD who were treated with this drug. Do not use cromolyn to