Follow up of High Risk Neonate

Mohamed KhashabaProfessor of Pediatrics,

NeonatologyHead of NCU,MUCH

Mansoura University

Mohamed Khashaba, MD, Mansoura University

�Survival of high risk neonates has been improving over the past few years.

What lies beyond survival of NICU graduates?.

Mohamed Khashaba, MD, Mansoura University

Quality of life is more important than

the mere survival.

Mohamed Khashaba, MD, Mansoura University

LBW infants with normal range IQ make greater use of special education tools compared to full terms.

Mohamed Khashaba, MD, Mansoura University

The high rate of MNDs and their association with an increased risk for learning difficulties justify their screening in case of (even moderate) prematurity.

Arnaud C et al. Arch Pediatr Adolesc Med. 2007

Nov;161(11):1053-61

Mohamed Khashaba, MD, Mansoura University

Challenges

Once the High risk neonate is discharged, he is taken back to a remote village or city where facilities for sophisticated psychomotor assessment are not available.

Orientation of many pediatricians and families about the F-up needs is still lacking.

Mohamed Khashaba, MD, Mansoura University

Identification of differences and variations in development should be interpreted cautiously, taking account natural variations in early development.

It may be more accurate to observe children over time rather than to make decision on the basis of a single assessment.

Rosenbaum. Early Human Development,82:167-71.2006

Mohamed Khashaba, MD, Mansoura University

Challenges

Detailed neurodevelopmental assessment is not feasible in a busy pediatric practice.

Lack of the concept of multidisciplinary approach to management.

Mohamed Khashaba, MD, Mansoura University

Objectives

1. Discuss benefits of follow up.

2. Define who should be followed.

3. Define optimal age and methods of follow up.

4. Recommendations.

Mohamed Khashaba, MD, Mansoura University

Benefits of Follow up program

1. Early detection and management of NDD.

2. Surveillance

3. Research

Mohamed Khashaba, MD, Mansoura University

Early detection of NDD

No much can be done for a baby who has already developed contractures or blindness.

Mohamed Khashaba, MD, Mansoura University

Surveillance

1. Audit NICU interventions.

2. Influence the health care policy to improve outcome.

3. Data about NICU outcome of specific conditions.

Mohamed Khashaba, MD, Mansoura University

Postnatal steroids

Prolonged steroids is associated with reduction in cerebral blood flow, delayed myelination of optic axons, alteration of dopamine receptor responses in animal studies.

Sapolsky et al. J neurosci.1990

Mohamed Khashaba, MD, Mansoura University

Preterm twins weighing< 1000 g did not have an increased prevalence of major handicaps at 1 year of age compared with preterm singletons

Gardner et al Obstet Gynecol. 1995 Apr;85(4):553-7.

Mohamed Khashaba, MD, Mansoura University

Research

To evaluate long term impact of interventions designed to improve outcome

Mohamed Khashaba, MD, Mansoura University

Providing basic developmental care in the NICU had no effect on physical and neurologic outcomes in preterm infants born<32 weeks.

Celeste etal., PEDIATRICS Vol. 121 No. 2 : 239-245,2008

Mohamed Khashaba, MD, Mansoura University

Who needs to be followed up

Biologic risk factors VLBW and ELBW. Cranial US abnormalities. Other neurological abnormalities. Encephalopathy persisting at discharge. Hyperbilirubinemia needing exchange. Recurrent apneas and bradycardia.

Mohamed Khashaba, MD, Mansoura University

Who needs to be followed up

Biologic risk factors Complex congenital anomalies. Nosocomial infections, sepsis and

meningitis. Chronic lung disease. NEC. Failure to grow in NICU. Metabolic disorders

Mohamed Khashaba, MD, Mansoura University

Who needs to be followed up

Intervention risk factors HFV or prolonged ventilation>1 week. Total parenteral nutrition. Prolonged 02 requirement. Surgical interventions. Postnatal steroids.

Mohamed Khashaba, MD, Mansoura University

Who needs to be followed up

Social and environmental factors. Low socioeconomic status. Low maternal education Environmental stress.

Mohamed Khashaba, MD, Mansoura University

1st ophthalmologic exam. scheduled at 31

ws postconceptional age (or at 4-6 ws

postnatal in larger babies).

Mohamed Khashaba, MD, Mansoura University

Hearing screening of candidate infants

scheduled before discharge (or at 3

months corrected age).

Mohamed Khashaba, MD, Mansoura University

Timing of Follow Up Visits

1. Initial visit 7-10 days after discharge

2. 4 ms corrected age

3. 8-12 ms corrected age

4. 18-24 ms

5. 4 years

Mohamed Khashaba, MD, Mansoura University

Early visit

To evaluate home environment and ability of the parents to care for the baby.

Mohamed Khashaba, MD, Mansoura University

Follow up at 3-4 months C age

Growth and nutrition. Neurologic assessment. Gross motor development. Neuroimaging as needed.

Mohamed Khashaba, MD, Mansoura University

Bayley Infant Neurodevelopmental Screener (BINS)

Used to screen development in children 3 to 42 monthsIt uses 10 to 13 directly elicited items per three- to six-month age range to assess neurologic processes (reflexes and tone), neurodevelopmental skills (fine motor, language ) , and cognitive processes.

It categorizes performance into low, moderate, or high risk via cut scores and

provides subtest cut scores for each domain .

The BINS detects 75 to 86 percent of children with neurodevelopmental problems and correctly identifies 75 to 86 percent of children without such conditions

Bayley II Edition, 1993

Suggested early tests at 3 months

1. Axillary suspension

2. Head support

3. social smile

4. Disappearance of primitive reflexes.

5. Neurobehaviour.

Mohamed Khashaba, MD, Mansoura University

Suggested early tests at 6 months

Failure to achieve 6 milestones may be 1st clue to NDD later on

1. Absent roll to sit2. Absent transfer of subjects3. Absent reaching for objects4. Abnormal adductor angle, scarf sign.5. Absent rolling over6. Absent sitting with support

Godbole et al., 1997

Mohamed Khashaba, MD, Mansoura University

Inability to achieve social smile ,and abnormal neurobehavior at 3 months and

Absent transfer of objects and voluntary reach and pull to sit at 6 months predicted delayed development at 1 year as tested by BSIB.

Godbole et al., 1997

Mohamed Khashaba, MD, Mansoura University

Some of the ND abnormalities are transient and may disappear in the 2nd year.

Closed monitoring and early intervention is required.

Mohamed Khashaba, MD, Mansoura University

Follow up of suspected minor variations is needed before addressing NDD.

Mohamed Khashaba, MD, Mansoura University

Gross motor function exam. At 24 ms.

Walk 10 steps Gait Abnormalities?

Level 0

Level 1

No

Yes

No

YesSits? (May use hands

for support)

•Sits without hand support•Crawls on hands/knees with reciprocal leg movements•Pulls to standing•cruises

Yes

No

Level II

Level IIINo

Head controlIn supported sitting?Rolls

Yes

No

Level IV

Level V

Mohamed Khashaba, MD, Mansoura University

Recommendations A multidisciplinary Follow up clinic should

be an integral component of any NICU. A simple approach for early neuro

developmental assessment is required to suite most practioners.

Early detection of mild disabilities is important when prevention and not rehabilitation is the choice.

Mohamed Khashaba, MD, Mansoura University