Paediatrics: Chronic lung disease of prematurity

Chronic lung disease of prematurity

As the quality and outcome of neonatal intensive care for premature babies has improved, more and more infants with chronic lung disease (CLD) are being seen. There are a variety of lung conditions that affect premature babies and necessitate mechanical ventilation;.

·  Respiratory distress syndrome.

·  Neonatal pneumonia.

The following can affect newborn of any gestational age:

·  Meconium aspiration.

·  Diaphragmatic hernia.

·  Pulmonary hypoplasia.

·  Alveolar capillary membrane dysplasia.

·  Interstitial lung disease.

·  Surfactant protein deficiency.

On follow-up in the paediatric clinic you may see oxygen-dependency due to any of these conditions. CLD in this context is defined as abnormal CXR and use of supplementary oxygen beyond 28 days.

Management

In many respects the approach to managing oxygen-dependent infants with compromised lung function is very similar to caring for infants with CF. A multisystem and multidisciplinary team approach is needed. This should include home and community liaison—the neonatal unit nurse spe-cialist and health visitor are particularly helpful.

Nutritional support and therapy

·  Weight gain and growth: these should be monitored and, if there is a problem with inadequate intake, consult a dietician for advice.

·  Gastrostomy: procedure sometimes required to enable full feeding.

·  Gastro-oesophageal reflux (GOR): the ‘flat’ position of the diaphragm, lung hyperinflation, and tachypnoea promote the development of vomiting and GOR. The lungs need to be protected and adequate feeding needs to be ensured. Initially try medical therapy. If these measures fail, fundoplication and gastrostomy feeds are required.

·  Vitamins: appropriate vitamin supplements are used until the child is thriving well (i.e. vitamin compound drops, folic acid, iron).

Antimicrobial therapy

·  Vaccination: all immunizations should be up-to-date. Children on steroids may be at risk if given live or attenuated immunization (e.g. BCG, mumps, measles, and rubella (MMR)).

·  Antibiotics: viral illness may result in significant deterioration in CLD. Take sputum, throat swab, and nasopharyngeal aspirate for viral and bacterial cultures. Have a low threshold for using antibiotics.

·Antivirals: aerosolized ribavirin may be required for severe respiratory syncytial virus bronchiolitis although its benefit is controversial. Patients should have had prophylaxis.

Obstructive airway disease

Wheeze is a common symptom in infants with CLD. Asthma treatments are often used in these children.

Oxygen therapy

The ultimate aim of supervision of these patients is to withdraw oxygen in a safe and timely manner. The target oxygen saturation (SpO₂) in patients on supplemental oxygen via nasal cannulae is 92%. Withdrawal is appro-priate when the infant is clinically well, gaining weight, and has an SpO₂ consistently above 92% with an oxygen requirement 0.1L/min. Children can be weaned from continuous low flow oxygen to night-time and naps only, or remain in continuous oxygen throughout the 24hr until the child has no requirement at all. Oxygen equipment should be left in the home for at least 3mths after the child has stopped using it. If this is in a winter period, it is usually left until the end of winter.