Okay, let’s talk about
apnea of prematurity.
This happens in
presumably because their brains haven’t
developed enough to remind them to breathe.
This usually goes away as they age.
We define apnea of prematurity as a cessation
of breathing for more than 20 seconds.
Remember, normal newborns may hold their
breath for 15 seconds and that’s just fine.
They’re just a little premature.
Ninety percent of infants who are under
1 kilo will have apnea of prematurity.
It’s a common problem
due to CNS immaturity.
We need to differentiate
this apnea, however,
from things like sepsis or
hypoglycemia or electrolyte imbalances
or bleeds inside the brain
like IVH or seizure.
All of these are possibilities.
So as a result with these
infants, we will monitor them.
We will give them supportive
care and we may provide CPAP
as a way of preventing them from
having significant apneic episodes.
Eventually, we may not want to
have them on a breathing machine
or be giving them the supportive care,
so we would give them caffeine.
Caffeine is effective at reducing
apnea episodes in premature infants.
Let’s switch gears to another
common problem in premature infants
which is necrotizing
enterocolitis or NEC.
This is an ischemic necrosis of
immature intestines in an infant.
This can happen between
1 and 8% of infants
depending on how premature
that group of infant is.
It is associated with
intrauterine growth retardation
or a patent ductus arteriosus.
And it typically happens right
after the first feed.
The baby’s intestine is
pretty much sterile.
As this infant is having a vascular
supply issue with their intestines
or poor blood flow to their intestines,
we introduce food in trophic
amounts, tiny amounts,
to allow the intestines
to start growing.
Shortly thereafter, we’ve also
been introducing bacteria
and some of those bacteria can
somehow get into the intestinal wall
and start growing inside
the intestinal wall.
An x-ray might reveal
air in the wall.
If that goes too far, it can
actually perforate the abdomen
and that can cause peritonitis.
These kids can get very sick.
So again, feeding
intolerance in an infant,
they start having increased
residuals after they feed.
They then develop temperature instability
and that may be our first clue.
Then, they start
having bloody stools
and that is a real clue that
something is going wrong.
We may notice abdominal distension
or discoloration of the abdomen
as you can see in this patient.
In fact, the NICU nurses are usually
measuring abdominal girths in these infants
and will notice when they go up acutely
and say, “Aha! Here’s the problem.”
Patients may develop apnea
just from being sick
and they may develop hypotension
if they become septic.
Labs we get for NEC include a
CBC which may show anemia,
a high white count.
We will often stool occult the stool
just to check and see if
there is blood in the stool.
That can be a clue.
And what’s classic is we get an abdominal
x-ray which shows dilated bowel loops
and may show pneumatosis, air in that portal
tract or air right under the diaphragm.
That’s certainly a key.
So how do we manage NEC?
Unfortunately, some of these
infants can go to surgery,
but first we’ll usually try medical
NEC which means a medical treatment.
What we do is we provide
We will make them NPO.
We may do rectal and gastric
decompression by suction perhaps.
And then we will usually
broad spectrum antibiotics
because the intestines
tend to have a broad
spectrum of bacteria.
Sometimes that will do it,
but other times they go on to get
sicker and it requires surgery.
We hate it when it requires
well, sometimes they only need to
resect a small amount of bowel.
If it’s gone on for a while
or it’s particularly severe,
they have to resect a
large amount of bowel.
Patients who have a large
amount of bowel resection
may go on to develop something
we call short gut syndrome.
This is incredibly
challenging to deal with.
These infants don’t
have enough intestine
to absorb the amount of
nutrients they need.
They may end up on
which eventually leads to
liver failure and death.
Or they may require an
which unfortunately doesn’t
have a great prognosis.
So there are ways we can prevent
infants from getting NEC.
One is slow trophic feeds.
When they’re premature, we start it
really slow and very gradual in moving up
and that allows the intestine to
develop with the trophic feeds.
Those are feeds that are providing
nutrients so that intestine can develop
until it’s ready to
take more full feeds.
The other key is to use breast milk.
For reasons I don’t know,
patients tend to do a little bit better
with breast milk than they do with formula.