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4/4/92 — Preemies at Home, Day 8

April 4, 2011

Here's our big girl, looking almost like a full-term newborn. This is a long post that includes a few notes from the home care nurses, followed by the discharge notes from Dr. Gardner (the head of the ISCU) to Dr. Lum, our pediatrician and Molly's new doctor. The notes may be a bit tedious to you, but to me they are a fascinating synopsis of her first months of life. In just a few pages, Dr. G had to explain everything Molly had been through to prepare Dr. Lum to take over her case. Not many babies come with a full blown medical resume — 132 days and countless life-or-death moments summed up in 10 paragraphs. I became hooked on "medical speak" during our NICU stay, but I'm still amused to read Dr. G's description of her final examination as "unremarkable". Hardly. I've translated most of the heavy jargon in brackets, but when in doubt, check the Glossary Page.

Home Nursing Notes

Today Isaac had an apneic episode with bradycardia at 1:10 a.m. while burping. He was lethargic for two to three minutes with a heart rate drop that required stimulation (patted on the back) to bring out. Molly had one apneic episode at 1:40 a.m. while she was sleeping. Her heart rate was OK (140s) when ascultated. Nasal cannula out?

Discharge notes for Molly from Dr. Gardner to Dr. Lum:

Molly Bearman was hospitalized in our Infant Special Care Unit for November 17, 1991 – March 10, 1992 because of preterm birth at 24 3/7 weeks gestation. Her hospital course was complicated by respiratory failure and the development of chronic lung disease associated with patent ductus arteriosus and atrial septal defect.

This infant was a second twin born at Evanston Hospital to a 31 years old primiparous [woman pregnant for the first time] mother whose pregnancy was accomplished by GIFT and was complicated by chronic bleeding throughout pregnancy. The mother was hospitalized one week before delivery because of increased vaginal bleeding and uterine contractions and was treated with bed rest and tocolysis [delaying of labor, in this case with drugs]. On the day of delivery increased uterine contractions [resulted in early delivery]. The infant was intubated promptly after delivery and was treated with exogenous surfactant [surfactant not produced internally, but introduced from an external source] once her condition was stable. Apgar scores were 2 and 7 and one and five minutes.

At the time of admission, the infants weight was 750 gm, length 30 cm, and head circumference 21 cm. There were no anomalies or dysmorphic features. The infant’s color was pink while she was ventilated with 30% oxygen and there was fairly good air exchange throughout the lung fields. Her size and physical findings were consistent with a gestational age of 24 to 25 weeks. A brief summary of her hospital course follows.

Cardiorespiratory

The infant received prophylactic treatment with exogenous surfactant in the surfactant comparison trial. [This was one of several studies in which Molly and Isaac were participants.] She initially required minimal oxygen supplementation and minimal assisted ventilation. During the third week requirement for increasing supplemental oxygen and assisted ventilation prompted treatment with Decadron [a corticosteriod] which was followed by a decreased oxygen requirement and was continued for a total of six weeks. The infant was extubated on the 37th day and subsequently required nasal cannula oxygen ranging from 22% to 30% throughout the remainder of the hospital stay in order to maintain adequate oxygenation. Treatment with theophyllin was initiated on the tenth day to assist in weaning from the ventilator and was continued because of episodes of apnea and bradycardia. Theophyilline was discontinued two weeks prior to discharge without episodes of apnea or bradycardia. Chest x-ray initially showed only minimal granularity of the lung fields and subsequently showed increasing opacity progressing to typical changes of moderately severe bronchopulmonary dysplasia. There was a slight improvement in the appearance of the chest x-ray during the last month of hospitalization and chest x-rays obtained prior to discharge continued to show bilateral areas of increased opacity with areas of increased lucency. The heart size was normal.

The murmur of a patent ductus was noted during the first week. The first echocardiogram on November 26 demonstrated the presence of a large patent ductus arteriosus with a patent foramen ovale or atrial septal defect [see Glossary]. She was treated with Indomethacin beginning on November 29 and a repeat echocardiogram on December 3 showed only a minimal left-to-right patent ductus and a repeat echocardiogram on December 17 showed similar findings. A second course of Indomethacin was begun on January 9 and echocardiograms on January 14 and January 28 continued to show the presence of a small ductus shunt plus a left-to-right atrial shunt. Her most recent echocardiogram was on March 10 and continued to show the presence of a left-to-right patent ductus with an atrial septal defect.

Nutrition

The infant received hyperalimentation from the third day of life to the 35th day. Gavage feedings were begun on the 25th day and were tolerated well. The infant progressed at a satisfactory rate to taking nipple feedings and all feedings had been taken by nipple through the last 10 days. There was satisfactory weight gain throughout the hospital stay.

Infectious Disease

There were no documented episodes of bacterial infection [unlike with Ike!]. The infant was treated with Ampicillin and Gentamicin during the first three days and antibiotic therapy was discontinued when the blood cultures and cultures of tracheal aspirate were negative. She was again treated with Ampicillin and Vancomycin, or Vancomycin and Getamicin, on three occasions for three or four days when there were clinical signs suggestive of sepsis and antibiotic therapy was discontinued when blood cultures were negative.

Retinopathy of Prematurity

The initial opthalmology examination showed extremely immature development of the retinal vasculature and on subsequent examinations progressed to Stage III bilaterally on February 17. The most recent examination on March 10 showed regression of the retinal changes to Stage II bilaterally and follow-up examination in two weeks was recommended.

Screening Examinations

Cranial ultrasonography performed serially through the hospitalization showed no abnormalities. Neonatal metabolic screen was normal. We were unable to schedule an Auditory Evoked Brainstem Response during the week prior to discharge and asked the parents to schedule this examination on an outpatient basis. DTP and HIB immunizations were given on January 17, 1992.

At the time of discharge, Molly’s weight was 1860 gm, length 43 cm and head circumference 31 cm. Her color was pink while she was receiving minimal oxygen supplementation and there was good air exchange throughout the lung fields. There was a continuous murmur consistent with a patent ductus. Her examination was other wise unremarkable. She was discharged home to receive nasal cannula oxygen at approximately 1/4 liter/min and was discharged with an apnea-bradycardia monitor. Whe was receiving Vidaylin [vitamins] plus Fer-in-Sol [iron]. She was scheduled to be seen by Dr. Cole for evaluation of her cardiac abnormality and by [eye doctors] for continued follow up of her retinopathy.

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