EMERGING ISSUES IN NEONATES
Dr. Sandeep Kadam, (MD, DM)*
Neonatologist. KEM Hospital, Pune.*
Chronic lung disease: Chronic lung disease is defined as oxygen dependence beyond 36 weeks post-conceptional age with abnormal Chest X-ray. Broncho-pulmonary dysplasia, described by Northway included preterms with mechanical ventilation who had prolonged oxygen dependence at 28 days post-conceptional age. However, chronic lung disease is a preferred term.

Any disorder that produces an acute lung injury and/or requires treatment with positive-pressure mechanical ventilation and high concentrations of inspired oxygen during the initial weeks of life predisposes the infant to development of chronic lung disease.

Addition to RDS, conditions that have resulted in CLD include pneumonia/sepsis, meconium aspiration pneumonia, pulmonary hypoplasia, persistent pulmonary hypertension, tracheoesophageal fistula, congenital diaphragmatic hernia.

Risk factors:
  1. Extreme Prematurity
  2. Mechanical Ventilation
  3. Oxygen

The risk is directly proportional to the severity of initial lung disease, duration of mechanical ventilation, and oxygen administration and is inversely proportional to birth weight and gestational age.
Clinical features
  1. Tachypnea
  2. Recessions
  3. Relative hypoxia and CO2retention
  4. Areas of collapse and hyperinflation
  5. Bronchial hyper reactivity and wheezing attacks
  6. Pulmonary hyperinflation
  7. Growth failure

Treatment: Prevention is the key.

Antenatal steroids, Gentle ventilation and early use of CPAP are the key. Avoid preterm delivery and minimize barotraumas and volutrauma. Babies should be nursed in prone position. Correct anemia and gastro-esophageal reflex. Steroids in postnatal period should be avoided due to increased risk of cerebral palsy. Nutrition includes at least 150 kcal/kg/day and more lipids and less carbohydrate with use of MCT oil.

CLD may be associated with longterm neurodevelopment handicaps.

Fungal Sepsis: With advances in neonatal care and more and smaller babies being admitted in the NICU, fungal infections have emerged as a significant cause of mortality.

Fungal sepsis is seen in 9 percent of all late-onset infections in the neonatal intensive care unit. Fungal colonization is part of a commensal relationship in human. But in the immunocompromised host, fungi often invade the skin, mucosa, tissues and bloodstream causing significant damage and mortality. Premature infants can be considered immunocompromised causing hosts, with defects in every in every arm of the immune system and hence at increased risk of fungal sepsis, Fungal invasion may occur through the skin, respiratory tract, gastrointestinal tract, vascular catheter, or infected infusate.

Risk factors: Risk factors such as younger gestational age, prior administration of antibiotics, parenteral nutrition, steroids, days of intubation, and duration of hospitalization is associated with fungal colonization.

Factors that contribute to poor outcome with fungal sepsis in VLBW infants include the immature immune system, end organ dissemination, fungal adherence to indwelling vascular catheters, diagnostic difficulties and delay, as well, as limited effectiveness and delayed initiation of antifungal therapy. Identification of fungus in blood culture is difficult possibly due to slow growth, low density of organisms, and the small amount of blood collected for culture.

Clinical Presentation: The signs and symptoms of candidal infection are similar to those any type of sepsis in neonates, with increased ventilatory requirements, apnea, bradycardia, temperature instability, and abdominal distention. Clinical presentation includes thrombocytopenia and end organ dissemination such as endocarditis, renal, liver, brain abscesses, and endophthalmitis.

The evaluation of infants with fungal sepsis in addition to cerebrospinal fluid and urine cultures.

Fungi implicated in neonatal disease commonly are Candida albicans, Candida parapsilosis Malassezia further, Aspergillus flavors, Aspergillus fumigatus and Candida glabrata.

Treatment: Fluconazole and Amphotericin B are main stay in the therapy of neonatal fungal sepsis and they appear to be safe and effective.
Key Messages
  1. Chronic lung disease is an emerging problem in preterms, with increasing oxygen requirements beyond 36 weeks post conceptional age and an abnormal Chest X-ray.
  2. Barotrauma and volutrauma are mainly responsible, hence gentle ventilation is the key.
  3. Avoid routine use of steroids, as they may cause adverse neuro developmental outcomes.
  4. Fungal sepsis is an important cause of morbidity and morality in preterms.
  5. Prematurity, prolonged antibiotics, ventilation and TPN may be associated with fungal sepsis.
  6. Early identification and treatment have better outcomes.
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