Nutrition in Premature Infants

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Nutrition in Premature Infants3/17/10
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• Generally, the more premature the baby, the more
  serious and long lasting are the health problems.

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• Preterm Infant Infants born lt37 weeks of
  gestation
• Low Birth Weight (LBW) Birth weight lt 2500 grams
  (5½ lbs)
• Very Low Birth Weight (VLBW) Birth weight lt 1500
  grams (31/3 lbs)
• Extremely Low Birth Weight (ELBW) Birth weight
  lt1000 grams (2¼ lbs)
• Small for Gestational Age (SGA) Infants born
  with growth parameters below the 10th percentile.
  
• Intrauterine Growth Retardation (IUGR) Failure
  to sustain intrauterine growth at expected rates
  can be caused by placental insufficiency,
  infection, malnutrition, etc. may or may not be
  born prematurely.

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Infants at highest risk post discharge

• VLBW and ELBW
• Small for gestational age (SGA) and
  Intrauterine Growth Retardation (IUGR)
• Primarily breastfeeding with no fortification
• Infants on special formulas
• Infants who require tube feedings at home
• Infants on total parenteral nutrition (TPN) gt 4
  weeks during hospitalization or on parenteral
  nutrition after hospital discharge
• Infants with gastrostomies or tracheotomies
• Infants with slow weight gain prior to hospital
  discharge (gaining less than 15 gm/kg/day)
• Infants with any of the following complications
  of prematurity
• o Bronchopulmonary dysplasia/chronic lung
  disease
• o Chronic renal insufficiency
• o Congenital alimentary track anomalies
• o Short bowel syndrome
• o Cyanotic congenital heart disease
• o Osteopenia of prematurity
• o Anemia of prematurity
• o Severe neurological impairments
• o Drug and/or alcohol exposure in utero

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Problems for premature infants

• temperature instability
• respiratory problems
• cardiovascular
• PDA, hypo/hypertension, low HR
• blood and metabolic
• gastrointestinal - NEC
• neurologic
• infections decreased immunity

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Care of premature babies may include

• temperature-controlled beds
• monitoring - temperature, blood pressure, heart
  and breathing rates, and oxygen levels
• extra oxygen by a hood or by a ventilator
• mechanical ventilators
• intravenous (IV) fluids - IV placed in a hand,
  foot, or scalp
• umbilical catheter
• Peripherally inserted central catheter (PICC)
• x-rays
• medications
• Kangaroo care

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Oxygen Tent/Hood
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PICC line - Peripherally inserted central
catheter
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Nasogastric Feeding Tube
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Tracheostomy and Ventilator
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Kangaroo care
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Infant Mortality

• Infant mortality is defined as death that occurs
  within the first year
• Major cause is low birthweight
• (lt 2500 g)
• Other leading causes inlcude
• 1) congenital malformations
• 2) preterm births
• 3) SIDS- sudden infant death syndrome

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Combating Infant Mortality

• Factors associated with mortality
• Social and economic status
• Access to health care
• Medical interventions
• Teenage pregnancy
• Availability of abortion services
• Failure to prevent preterm LBW births

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Premies have higher nutritional needs

• Due to
• 1) inadequate nutrient stores
• 2) immature physiological systems
• 3)  rapid growth rate
• 4) medical complications/illnesses

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Table 8-3, p. 227
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Estimating Energy Needs in Pediatrics
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• RDAs for Energy and Protein Category
• Age Energy (Kcal/kg) Protein (gm/kg)
• Infant 0-6 mos 108 2.2
• Infant 6-12 mos 98 1.6
• Child 1-3 yrs 102 1.2
• Child 4-6 yrs 90 1.1

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Estimating Nutritional Needs in Premature Infants
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Energy Needs

• Ideally 40 CHO, 50 fat, 10-12 protein
• Healthy full term infants need 100 kcals/kg/d
• Preterm infants need 110-180 kcals/kg/d to
  sustain a normal growth rate
• Most premature infants experience a period of
  slow growth after birth, followed by a period of
  catch-up growth. Their catch-up growth can be
  achieved by providing calories in excess of the
  RDA. Potentially as much as 20-30 more energy
  may be required.

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Example of Energy Needs in Premie

• a growing enterally fed premature infant without
  any acute illness are listed as follows
• Resting expenditure 50 cal/kg/d
• Minimal activity 4-5 cal/kg/d
• Occasional cold stress 10 cal/kg/d
• Fecal loss (10-15 of intake) 15 cal/kg/d
• Growth (4.5 cal/g of growth) 45 cal/kg/d
• Total required to produce a 10 g/d weight gain
  125 cal/kg/d

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Energy Reserves

• Premies weighing 1000g have 1 body fat and 120
  kcals/kg in reserve.
• Term infant has 16 body fat and 1500 1800
  kcals/kg in reserve.
• Inadequate energy allotment will result in poor
  protein retention.

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Carbohydrates

• Should provide 40-50 of total calories
• Too much can cause osmotic diuresis (loose
  stools).
• Too little CHO can cause hypoglycemia.
• Human milk and standard infant formulas contain
  lactose as CHO source.
• Preterm formulas contain lactose, glucose
  polymers, sucrose
• Sucrose is well tolerated, sucrase activity is at
  70 in early 3rd trimester.

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• Premies born before 28-32 weeks often have low
  levels of lactase enzyme resulting in an impaired
  ability to digest lactose.
• However, lactose enhances calcium absorption,
  which is important for bone mineralization in
  premies.
• Glucose polymers, have low osmolarity and are
  easily digestible.

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Protein Needs

• Term infants 1.8-2.2 g/kg/d to sustain normal
  growth
• Preterm infants as much protein as tolerated
  3.5-4 g/kg/d in an infant weighing lt1800 gms to
  support normal growth rate
• Protein requirements depend on age and clinical
  status

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protein

• Premature infant formulas contain more protein
  than term formulas.
• Inadequate protein intake is growth limiting
• Excessive protein intake can cause elevated
  plasma amino acid levels, azotemia or acidosis.

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Preterm human milk

• Preterm HM contains 3g protein per 100 kcals for
  the first 4 weeks.
• Term human milk contains 1.5 g protein per 100
  kcals.
• Preterm infants have immature hepatic enzymatic
  pathways
• Human milk or whey predominant premie formulas
  should be the feeding of choice.
• Whey protein forms small curds and is higher in
  conditionally essential amino acids

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LIPIDS

• 50 of total kcals
• Linoleic acid (LA) should comprise
• 3-5 of total kcals
• Alpha Linolenic acid (ALA) should comprise 1 of
  total kcals
• Arachadonic and docosahexanoic acids are added to
  formulas.
• Human milk contains long chain fatty acids (LCFA)
  (including arachidonic acid AA and DHA) and
  two lipases to aid absorption.

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Lipids

• ARA and DHA can be synthesized from linoleic acid
  (LA) and alpha linolenic acid (ALA). ARA and DHA
  become conditionally essential if there are
  inadequate amounts of LA and ALA provided.
• Term formulas contain LCFAs.
• LCFAs delay gastric emptying time.
• Preterm infants have low levels of lipases and
  bile salts needed for fat digestion and
  absorption.
• Preterm formulas contain LCFAs and MCT oil.

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MCT Oil

• -Triacylglycerols with fatty acids of between 6
  and 12 carbons in length that are short enough to
  be water soluble and are absorbed directly into
  the portal vein.
• -These synthetic fats are hydrolyzed rapidly and
  can rely on the small amount of intestinal lipase
  and bile salts for solubilization.
• -They are transported as free fatty acids, bound
  to albumin through the portal system. 7.7
  cals/mL and 8.3 cals /gm

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MCT Oil

• improves fat absorption, enhances calcium
  absorption, improves nitrogen retention and
  weight gain
• Provides a vehicle for fat soluble vitamins and
  emulsifiers
• does not require micelle formation for absorption
  and utilization.
• bypasses the portal vein and is directly absorbed
  into the lymphatics system
• enters the mitochondria independent of carnitine.

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Human Milk

• Human milk is limited nutritionally for the small
  premature infant
• has unique nonnutritive qualities that make it a
  superior choice
• contains hormones, growth factors, antiviral and
  anti-inflammatory agents that help decrease the
  probability of sepsis and help to establish a
  healthy gastrointestinal flora.
• Contains 21 kcals/oz or 0.7 kcals/mL

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Benefits of Human Milk for the Preterm Infant

• Whey-predominant protein
• Improved nutrient absorption, especially of fat,
  zinc, and iron
• Low renal solute load
• Increased omega-3 fatty acids (DHA EPA)
• Presence of anti-infective factors
• Possible protection against necrotizing
  enterocolitis (NEC) and late-onset sepsis
• Promotion of maternal-infant attachment

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Human Milk Fortifier

• Milk based
• Increases levels of protein,
• energy, calcium, phosphorus,
• and many other vitamins and minerals
• Used to boost nutrients in breast milk
• Essential in feeding the preterm or sick infant
  consuming breast milk

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Benefits of Fortification of Human Milk for
Preterm Infants

• Improved weight gain
• Increased linear growth
• Normalization of serum calcium, phosphorus, and
  alkaline phosphatase
• Improved protein status
• Increased bone mineralization

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Human Milk Fortifier

• 3.5 kcals/packet
• To increase 2 calories per ounce add 1 packet to
  50 mL of breast milk
• To increase 4 calories per ounce add 1 packet to
  25 mL of breast milk

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Polycose

• glucose polymers from hydrolysis of cornstarch.
• To be used as a caloric supplement.
• mixes easily, has minimal flavor, and a low renal
  solute load.
• Comes in powder (23 kcals/6g Tbsp) or liquid (2
  kcals/mL).

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Vegetable oil

• 1 mL of canola oil has 8.3 kcals per mL and 9
  kcals per g of weight.
• Add 1 mL of oil to 3 ounces of milk and increase
  calories from 20 kcals/oz to 22.75 kcals/oz

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Preterm Infant Formulas

• RTF at 24 kcals/oz and 27 kcals/oz for hospital
  use only.
• At discharge, formula prescribed is 22 kcals/oz
• Preterm formulas are all hypo-osmolar (260
  mOsm/L) to prevent osmotic diarrhea

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Osmolality

• measurement of osmotic concentration/dissociation
  of particles in a solution.
• Serum osmolarity is 300 mOsm/kg water
• Amniotic fluid is 275 mOsm/L and infant begins
  swallowing this at 16 weeks gestation.
• Preterm breast milk is 290 mOsm/L.
• Preterm Infant formulas are 260 Mosm/L.

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• Soy-based formulas are not recommended for
  preterm infants.
• Preterm infants receiving soy formula have
  suboptimal carbohydrate and mineral absorption
  and utilization than cows milk-based formula.
• The American Academy of Pediatrics (AAP) doesnt
  recommend soy formula for infants born lt 1800 g
  since preterm infants showed significantly less
  weight gain, less linear growth, and lower serum
  albumin levels than those infants receiving cows
  milk-based formula.
• Studies also have shown lower levels of bone
  marker formation in the premature population
  which can lead to osteopenia.

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• Goats milk is not recommended for preterm
  infants.
• Goats milk is deficient in folic acid and
  vitamin B6.
• It is also higher in protein than human milk and
  infant formula which puts the premature infant at
  risk for dehydration due to the higher renal
  solute load.

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Breastfeeding preterm babies

• Feeding human milk to preterm infants provides
  nutritional, gastrointestinal, immunological,
  developmental, and psychological benefits that
  may impact their long term health and
  development. Human milk is advocated as the
  nutrition for preterm infants because it provides
  substances not supplied in formula.
• From the AAP American Academy of Pediatrics

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• Trophic feeding within the first 24 hours
• small, sustained amounts of enteral feedings soon
  after birth to sick or stabilizing premature
  infants, has become a standard of medical, as
  well as nutritional care in many neonatal
  nurseries
• This practice is best considered as an induction
  of gut maturation and function rather than as a
  source of nutrition for the purpose of sustaining
  growth.

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Early enteral feedings (trophic)

• defined as 5-25 mL/kg/d in the early days of life
  
• stimulates GI enzymatic development and activity
• promotes bile flow
• increases villous growth in the small intestine
• decreases the incidence of cholestatic jaundice
  (occurs with TPN use and no use of the GI tract)
• can improve overall tolerance of feeds
• gradual advancement of feeds will minimize the
  risk of feeding related complications such as
  Necrotizing Enterocolitis (NEC).

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• Begin feeds at 2cc/kg per feeding with an
  absolute minimal volume of 2 cc.
• Advance feeds every 7 days by 10-20 cc/kg/d

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Early Exposure to Enteral Feedings

• a decrease in the amount of time to reach full
  feedings
• a decrease in the number of days that feedings
  were held due to clinical signs of feeding
  intolerance
• a reduction in total hospital length of stay
• a minimized incidence of metabolic bone disease
• faster growth due to better total caloric intake
  compared with those who received TPN without
  enteral feedings

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Fewer Total Days of TPN

• resulted in lower bilirubin levels
• a decreased incidence of cholestasis
• improved calcium and phosphorus retention
• maintenance of lower alkaline phosphatase levels
  Alk Phos
• All have been found in premature infants fed
  small amounts of enteral nutrition compared with
  similar babies who remained NPO on TPN alone.

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Route of enteral feedings

• The route for enteral feeding is determined by
  the infant's ability to coordinate sucking,
  swallowing, and breathing, which appear at
  approximately 32 to 34 weeks' gestation.
• Infants who are alert and vigorous may be fed by
  nipple.
• Infants who are less mature, weak, or critically
  ill require feeding by tube to avoid the risk of
  aspiration and to conserve energy

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Feeding route

• Nasogastric and orogastric feedings are the most
  commonly used tube feedings in the neonatal
  intensive care unit.
• may be accomplished with intermittent bolus or
  continuous infusions of fortified human milk.
• Intermittent feedings every 2 to 3 hours simulate
  the pattern of feeding the infant will have when
  advanced to bottle feeding or breast feeding.

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When premies are ready to feed orally

• eyes may be open or closed
• responds to light touch
• looks at your face
• hands are near the mouth
• rooting (searching for the nipple) or sucking
• body movements are smooth, calm, and quiet

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Contraindications to feeding the premie

• Metabolic acidosis
• Respiratory instability
• Abdominal distension
• Severe asphyxia in the past 72 hours
• Sepsis
• Hypotension
• Hemodynamically significant PDA (Patent Ductus
  Arteriosis)
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When NOT to oral feed

• stares or avoids looking at you
• panic or worried look
• cannot wake up, excessive yawning
• shaking, startles easily
• gagging, gasping
• frantic activity back arched, arms extended,
  hands open, fingers separated
• color changes in skin

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STOP FEEDING!!

• gagging
• grimacing, pushing away
• milk drools out of the mouth
• stops sucking often or for a long time
• poor muscle tone, body and extremities are limp,
  jaw is open
• behavior change such as asleep, fussing, crying,
  shut down
• breathing faster than 60 times per minute
• stops breathing, heart rate slows, hypoxia
• seizures
• nostrils open wide (nasal flaring)
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Necrotizing Enterocolitis

• Necrotizing enterocolitis (NEC) is a serious
  intestinal illness in infants.
• "necrotizing" means damage and death of cells
• "entero" refers to the intestine
• "colitis" means inflammation of the colon
• Although NEC may develop in low-risk newborns,
  most cases occur in premature babies. NEC is more
  common in babies weighing less than 1,500 grams.

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necrotizing enterocolitis

• Premature infants with difficult blood and oxygen
  circulation, digestion, and fighting infection
• High-risk infants with enteral feeds
• difficult delivery or lowered oxygen levels, the
  body oxygenates and purfuses the most essential
  organs first, results in lowered oxygen in the
  gastrointestinal circulation.
• Too many red blood cells in the blood can slow
  down the oxygen delivery rate.

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Risk Factors That May Predispose Premature
Infants to Increased Incidence of Necrotizing
Enterocolitis by Drenkpohl et al in ICAN, vol 2
number 1, Feb 2010

• 384 charts reviewed.
• 78 infants dxd w/ NEC compared 246 w/o NEC
• Mtrs of NEC infants had higher incidence of PROM
  premature rupture of membranes
• More males developed NEC than females
• African Americans had a higher incidence of
  developing NEC
• NEC infants had a higher prior dx of sepsis, were
  prescribed H2 blockers more frequently.
• Gut priming and early enteral feeds less
  incidence of NEC
• True etiology remains unclear

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Symptoms usually develop in first 2 wks

• Abdominal distention
• Increased gastric residuals
• bile-colored (green) fluid in stomach
• bloody bowel movements
• signs of infection such as apnea, low heart rate,
  lethargy

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Signs/Symptoms

• An x-ray of the abdomen may show a bubbly
  appearance in the intestine and signs of air or
  gas in the large veins of the liver.
• Air may also be outside the intestines in the
  abdomen. A needle may be inserted into the
  abdominal cavity. Withdrawing intestinal fluid
  from the abdomen is often a sign of a perforation
  in the intestines.

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Problems from NEC may include

• perforation in the intestine, bacterial infection
• scarring or strictures of the intestine
• malabsorption if surgical resection is indicated
  and a large amount of intestine is removed.
• severe, overwhelming infection

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Treatment

• stop feedings, bowel rest
• NG tube to suction stomach
• IV fluids for nutrition and fluid replacement
• antibiotics for infection
• frequent x-rays to monitor the progress of the
  disease
• oxygen or ventilator if the abdomen is so
  distended that it interferes with breathing
• isolation procedures to prevent spread of infx
• Severe cases of NEC may require Bowel resection
  of the intestine or bowel to an ostomy (opening
  on the abdomen).

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Prevention

• Because the exact causes of NEC are unclear,
  prevention is often difficult.
• Studies have found that breast milk (rather than
  formula) may reduce the incidence of NEC.
• Starting feedings after an infant is stable and
  slowly increasing feeding amounts have been
  recommended.

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Chronic Lung Disease/Bronchopulmonary dysplasia
(BPD)

• long-term respiratory problem
• caused by injury to the lung tissue, such as
  mechanical ventilation and oxygen therapy.
• Oxygen can be toxic to the lungs especially when
  delivered into the lungs from a ventilator.
• The lung tissue can repair over time with
  adequate nutrition and subsequent growth.

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hyaline membrane disease/respiratory distress
syndrome

• a condition in which the air sacs cannot stay
  open due to lack of surfactant production in the
  lungs.
• Signs and symptoms include breathing difficulties
  at birth, cyanosis, flaring nostrils, grunting
  sounds with breathing, chest retractions.
• Treatment is with surfactant replacement.

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PDA is a normal fetal structure that is expected
to close within the first 24 hours. To prevent
damage to the heart, it must be closed with
either medications, a plug or with surgery.
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Patent Ductus Arteriosus (PDA)

• is a normal fetal structure, allowing blood to
  bypass circulation to the lungs since the fetus
  does not use her lungs (oxygen is provided
  through the mothers placenta).
• Flow from the right ventricle needs an outlet and
  the ductus provides this, shunting flow from the
  left pulmonary artery to the aorta.
• The high levels of oxygen which the PDA is
  exposed to after birth causes it to close in most
  cases within 24 hours.
• When it doesnt close, it is termed a Patent
  Ductus Arteriosus.

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diaphragmatic hernia

• Diaphragmatic hernia is a life threatening,
  multifactorial condition, "many factors," both
  genetic and environmental, are involved. It is
  thought that multiple genes from both parents are
  involved
• In utero, the diaphragm forms between the 7th and
  10th week of pregnancy.
• With the heart, lungs, and abdominal organs all
  taking up space in the chest cavity, the lungs do
  not have space to develop properly, called
  pulmonary hypoplasia.

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Signs and Symptoms at birth

• difficulty breathing
• fast breathing
• fast heart rate cyanosis (blue color of the skin)
  
• abnormal chest development, with one side being
  larger than the other
• abdomen that appears caved in (concave)
• GI problems, reflux may develop
• Developmental delays may occur