Snapshot A 1-day-old newborn boy is being evaluated in the neonatal intensive care unit for dyspnea. The patient was born to a 16-year-old girl at 29 weeks of gestation by spontaneous vaginal delivery. The patient’s mother did not attend any prenatal appointments. Her medical history is significant for cocaine use. On exam, the patient appears cyanotic and tachypneic. There is grunting, nasal flaring, and accessory muscle use. A chest radiograph is obtained. (Neonatal respiratory distress syndrome) Introduction Overview clinical definition preterm infants are defined by gestational age less than 37 weeks demographics 5-18% of births worldwide preterm birth complications are a leading cause of death for patients < 5 years of age worldwide risk factors morbidity and mortality in preterm infants increase with decreasing birth weight and gestational age Neonatal Respiratory Distress Syndrome Neonatal respiratory distress syndrome (NRDS) demographics > 50% of infants born at < 28 weeks of gestation < 5% of infants born at > 37 weeks of gestation pathogenesis deficiency of pulmonary surfactant sufficient pulmonary surfactant concentration not reached until 35-36 weeks of gestation causes alveolar collapse Presentation symptoms usually present soon after birth tachypnea nasal flaring grunting accessory muscle use cyanosis Imaging chest radiograph atelectasis increased linear densities/opacities air bronchograms tubular outline of airways Studies arterial/venous blood gas respiratory and metabolic acidosis hypoxia Treatment prevention antenatal glucocorticoids stimulates infant lung maturation recommended for pregnant women < 34 weeks of gestation at risk of preterm delivery within 7 days first-line nasal continuous positive airway pressure (CPAP) with positive end-expiratory pressure (PEEP) if severe intratrachael surfactant and intubation Complications bronchopulmonary dysplasia patent ductus arteriosus (PDA) Bronchopulmonary Dysplasia Bronchopulmonary dysplasia (BPD) demographics infants born < 32 weeks of gestation who required prolonged mechanical ventilation especially consider if still requiring oxygen past original due date pathogenesis barotrauma oxygen toxicity Presentation persistent symptoms of NRDS increasing oxygen demand Imaging chest radiograph atelectasis Studies arterial/venous blood gas respiratory and metabolic acidosis hypoxia echocardiogram monitor for development of pulmonary hypertension (i.e., increased pulmonary artery pressure or right heart strain) Treatment controlled oxygenation Complications pneumothorax Anemia of Prematurity Anemia of prematurity pathogenesis erythropoiesis normally decreases after birth due to increased tissue oxygenation following the onset of breathing and ductus arteriosus closure in preterm infants, this occurs earlier (~3-12 weeks post-birth) and with more severity impaired production of erythropoietin reduced red blood cell life span blood loss from iatrogenic blood sampling Presentation often asymptomatic poor weight gain tachycardia increased episodes of apnea Studies labs low hemoglobin low hematocrit low reticulocyte count normal mean corpuscular volume (MCV) peripheral smear normocytic and normochromic RBCs Treatment iron supplementation blood transfusions as needed Intraventricular Hemorrhage Intraventricular hemorrhage (IVH) demographics majority are newborns who have a birth weight < 1500 g are born at < 32 weeks of gestation pathogenesis fragile germinal matrix increased risk of bleeding into the ventricular system of the brain Presentation symptoms appear usually 0-5 days of birth lethargy seizure cranial nerve abnormalities hypotonia apnea bulging anterior fontanelle head circumference enlargement does not increase until severe Imaging cranial ultrasound Treatment supportive care if severe serial lumbar punctures diuretics ventriculo-peritoneal shunt Complications cerebral palsy developmental delay Hypothermia Hypothermia pathogenesis large body surface relative to size inability to produce enough heat Presentation temperature < 37°C cyanosis lethargy Treatment slowed warming Other Complications Patent ductus arteriosus (PDA) Retinopathy of prematurity (ROP) Necrotizing enterocolitis (NEC) Neurological disorders cerebral palsy developmental delay Hypo- and hyperglycemia Increased risk of infections Growth impairment