Follow up of high risk neonates

By Dr. Abhishek Sarkar & DR HASEN ALI

MIA M.D. PGT 1ST YEAR Dept. of Paediatric medicine

NBMC&H.

Contents• Introduction

• Why Follow Up?

• Who needs Follow Up

• Place of Follow Up?

• Pre discharge Preparation & Follow Up Protocol

• Intervention therapy including early stimulation

Introduction• Steady improvement in the quality of perinatal care in

India more VLBW and ELBW babies are surviving.

• Concerns of paediatricians have led to increased survival of high risk neonates.

• But the incidence of chronic morbidities like cerebral palsy(incidence 4.5-10%)etc. has increased.

• Timely and appropriate intervention.

Need For Follow UpPotential disconnect between perinatal

outcomes and longterm outcomes

To assess efficacy and safety of therapies- Short term outcomes , not sufficient.

Understanding of association between risk factors, therapies and survival.

No database of outcomes of at risk neonates available in India.

Candidates requiring Follow Up

Mild Risk:1. preterm, Weight 1500 g - 2500g2. HIE grade I3. Transient hypoglycemia4. Suspect sepsis5. Neonatal jaundice needing PT6. IVH grade 1

Moderate Risk:1. Babies with weight – 1000 g- 1500 g or

gestation < 33 weeks2. Twins/triplets3. Moderate Neonatal HIE4. Hypoglycemia, Blood sugar<25 mg/dl5. Neonatal sepsis6. Hyperbilirubinemia > 20mg/dL or

requirement of exchange transfusion7. IVH grade 28. Suboptimal home environment

High Risk:1. Babies with <1000g birth weight and/or

gestation <28 weeks2. Major morbidities such as chronic lung

disease, intraventricular hemorrhage, and periventricular leucomalacia

3. Perinatal asphyxia - Apgar score 3 or less at 5 min and/or hypoxic ischemic encephalopathy

4. Surgical conditions like Diaphragmatic hernia, Tracheo-oesophageal fistula

5. Small for date (<3rd centile) and large for date (>97th centile)

6. Mechanical ventilation for more than 24 hours

7. Persistent prolonged hypoglycemia and hypocalcemia

8. Seizures

9. Meningitis10. Shock requiring

inotropic/vasopressor support11. Infants born to HIV-positive mothers12. Twin to twin transfusion13. Neonatal bilirubin encephalopathy14. Major malformations15. Inborn errors of metabolism / other

genetic disorders16. Abnormal neurological examination at

discharge

Place and Personnel for Follow UpPlace of Follow Up should be-1.easily accessible2.directions should be made known.

LOW RISK BABIES:- PLACE-at a well baby clinic.Follow up with paediatrician/primary care

providerOBJECTIVE-to screen for deviation in

growth and development.

MODERATE RISK:- PLACE-in or near to a facility providing level 2 or level 3 NICU care.

Follow up with neonatologist and developmental paediatrician.

OBJECTIVE-to screen for developmental delay, manage intercurrent illnesses.

FOLLOW UP TEAM SHOULD CONSIST OF:-Developmental paediatricianDevelopmental TherapistRadiologistOphthalmologistAudiologistPhysiotherapistSocial worker & Dietician

• HIGH RISK BABIES:- PLACE- same as for Moderate risk

Follow up with Neonatologist.OBJECTIVE- to supervise and screen for

developmental delayFOLLOW UP TEAM SHOULD CONSIST OF:-Team as for moderate risk PLUSPaediatric neurologistGeneticistOccupational TherapistSpeech therapistEndocrinologistPaediatric surgeonOrthopaedician

Predischarge PreparationActive surveillance required before

discharge plus in follow upTo be done/planned before discharge:-1.Medical examination.2.Neurobehavioural and Neurological

examination3.Neuroimaging.4.ROP screening5.Hearing screening6.Screening for congenital Hypothyroidism.7.Screening for metabolic disorders.8.Assessment of parent coping and

developmental environment

Discharge Summary has to be provided.

It must contain:-1. Gestation, 2. Birth weight, 3. Discharge weight4. Discharge head circumference, 5. Feeding method and dietary details, 6. Diagnosis (medical problems list),7. Medications8. References to other departments

9. Days on oxygen and gestation when baby went off oxygen,

10. Findings of last hematological assessment,

11. Metabolic screen, 12. ROP screen, 13. Hearing screen, 14. Thyroid screen, 15. Ultrasound cranium, 16. Immunization status,17. Assessment of family

Follow up protocolFollowing are to be done at follow up:-

1.Medical Examination- Nutrition and growth, Immunization

2.Neurological examination3.Development assessment4.Ophthalmologic assessment- squint and

refraction5.Hearing and Language and speech6.Gross Motor Function7.Behavioural,Cognitive and intelligence status.

Schedule for Follow UpFrequency and type of tests used depends on

“intensity or level of follow up” assigned.

Initial weekly follow up to ascertain adjustment to home environment and weight gain.

Neuromotor exam at discharge and at 1,3 ,6,9 and 12 months of age.

Squint and Refraction-at 9 months to 1 year of age.

Other visual problems at 1 year and yearly till school age.

Language and speech assessment – newborn hearing test repeat hearing test at 1 year.

Development Assessment –At least once in:-1. first 6 months, 2.next 6 months, 3.every year

till 5 years.

Formal Developmental assessment -within 2 months of parental concern/abnormal screening test.

AT:- 2 years -severity of disability by GMFCS3-4 years –intelligence and later prediction of IQ

scores6 years – School achievement 8 years - IQ, neurophysiological functions and

school performance

HOW LONG TO FOLLOW UP?- Till late adolescence, or at least till school.

Follow Up Schedule (AIIMS)

Birth wt below 1500g Other or GA below 32 wk.

Conditions After 3-7 days of discharge 2 weeks after

discharge

Every 2 wks until 3 kg 6, 10, 14 wks of postnatal

age

At 3, 6, 9, 12,15 and 18months of corrected age and then every 6 months until age of 8years

Medical Follow Up- Growth & NutritionGROWTH- Standard anthropometric measurements :- a) Weight,

b)Length, c)Head circumference.Growth chart :- Intrauterine OR Postnatal?Both have advantages as well as disadvantages.

Recommendations(As per NNF):- 1)standard intrauterine growth chart to plot centiles for weight , length and HC

Follow up with an appropriate postnatal growth chart Kelly-Wright chart or Ehrenkranz growth

chartNew growth chart Fenton TR- updated version

of Bebson and Brenda’s chart.

After 40 weeks – WHO /CDC growth chart can be used.

A new reference to compare growth of VLBW babies is needed specially in our country.

2)OFC – Plotted at every health visit till 2 years in

context of length.

3)Weight and length –Plotted at every health visit till 6 years of

age.

Growth chart for VLBW (Ehrenkranz)

A new fetal-infant growth chart for preterm infants -Fenton TR

WHO Growth Charts(For Boys)

WHO Growth Charts(For Girls)

NUTRITIONPost discharge nutrition

HMF- Fortification remains debatable after discharge.

Enriched formulas - available for formula fed babies, but no data is available for breast fed babies

Fortification - a difficult proposition for them

Studies reported slower accretion in radius and whole body bone mass with unsupplemented human milk vs formula.

Risk of continued fortification Excess concentration of nutrients at corrected age term and beyond.

Close observation is required for at risk babies on full breast feeds with poor growth or biochemical abnormalities.

Adequate postnatal nutrition.

Adequate vitamin(A,E,D) , minerals and Iron supplementation - Helps to prevent osteopenia of prematurity, late hyponatremia(requiring Na supplementation)

Supplementary feeding of preterm neonates-

No standard guideline available regarding age of starting.

In general decided by readiness of eating semisolids.

IMMUNIZATIONPreterm/VLBW babies are to be

immunized according to their chronological age and as per guidelines for full term newborns.

Medical Examination

Complete physical examination to be done look for common anticipated medical problems with impact on development-e.g hip exam, dysmorphism, neuro-cutaneous markers etc.

Unresolved medical problems has to be addressed and medications has to be reviewed-

1)CLD 2)GERD 3) Reactive airway disease , etc.

Neurological assessmentThe neurological examination of infant, toddler and

child is an integral part of follow up careAmiel Tison Scale Evaluation of the tone-a fundamental part of this assessment. Pattern of development of tone - gestation

dependent From 28 to 40 weeks- caudo-cephalic

direction. After 40 weeks- cephalo-caudal

The assessment is done under the following headings: 1. Neuromotor - Tone in upper limb , lower limb and axial 2. Neurosensory - Hearing and vision 3. Neurobehavioural - Arousal pattern, quality of cry, sucking ,swallowing 4. Head growth - HC and also skull for sutures, size of AF

Tone may be assessed in the form of -1. Spontaneous posture 2. Active tone 3. Passive tone

Spontaneous posture - evaluated by inspecting the child while he or she lies quietActive tone- assessed with the infant moving spontaneously in response to a given stimulusPassive tone - evaluated by measuring the angles at extremities. The resistance of the extremity to these maneuvers is measured as angle as given below

Amiel-Tison method

Abnormal neurological examination should be defined as definite abnormalities in the form of:

a) Hypertonia or b) Hypotonia or c) Definitely and consistently elicited asymmetrical signs or d) Persistent abnormal posturing or abnormal movements The tone abnormalities should be taken care by regular physiotherapy

Developmental assessment Various development scales which

are used commonly are- 1. Devpt Observation Card (DOC) with CDC

grading 2. Trivandrum Developmental Screening Chart

(TDSC) 3. Denver Development Screening Test (DDST) /

Denver II 4. Development Assessment scale for Indian

Infants (DASII)

In Indian context, DASII is the best formal test for development assessment (below 30 months).

1.Devpt Observation Card (DOC) with CDC grading:

DOC is a self-explanatory card that can be used by parents.

Four screening milestones Social Smile by 2 months Head holding by 4 months Sit alone by 8 months Stand alone by 12 months

Make sure the baby can see and listen

2. Trivandrum development screening chart (TDSC) :

TDSC is a simple screening test. There are 17 items taken from Bayley Scale of Infant

development. The test can be used for children 0-2 years age. No kit is required. Anybody, including an Anganwadi worker can

administer the test. Place a scale against age line; the child should pass

the item on the left of the age- line

2. Trivandrum development screening chart (TDSC) :

3. Denver development screening test (DDST)

• Compares the index child against child of similar age. • Four sectors- Gross motor, Fine motor, Language & social• The test items are represented on the form by a bar that spans the

age at which 25%, 50%, 75%, and 90% of the standardization sample passed that item.

• The child’s age is drawn as a vertical line on the chart and the examiner administers the items bisected by the line.

• The child’s performance is rated “Pass”, “Caution”, or “Delay” depending on where the age line is drawn across the bar.

• The number of delays or cautions determine the rating of “normal” or “suspect”.

4. Development Assessment scale for Indian Infants (DASII)

67 items for assessment of motor development, and 163 items for assessment of mental development.

Motor age Motor devpt quotientMental age Mental devpt quotientDQ

Squint and refraction assessment By 9-12 months age, irrespective of ROP status.

Language and speech assessment

Babies with risk factors for hearing loss- repeat diagnostic hearing test at 12 months age- retesting of hearing by behavioral audiometry at 1 year.

Comprehensive assessment of speech and

language must be done between 1-2 years age using Language Evaluation Scale Trivandrum (0-3).

Gross Motor FunctioningAn important adjunct to the neurologic

assessment. A gross motor functional classification scale

(GMFCS) is used in many western centresUsed between 18 months to 12 years Contains a scoring system for gross motor skill

levels by direct observation. 5 levels from normal category to severe

disability

Learning ProblemsAll VLBW and ELBW babies should be followed

up till adolescence for school difficulties and development of intervention strategies to improve the outcome

Behavioural,Cognitive and Intelligence status

Many cognitive,learning and behavioral problems that are commoner in at-risk neonates are apparent only on longer follow up.

Behavioral assessment can be done after 1 yr of age

Formal cognitive development, IQ is tested by 3 years

Intervention including Early stimulation therapy

• Interventions aiming at enhancing parent – infant relationship

focuses on sensitizing the parents to infant cues and teach appropriate and timely response to the infant’s needs

• A recent Meta analysis showed that early intervention improved cognitive outcome at infant age (0-2 years)

• It is recommended to start early intervention while the baby is still in NICU/SNCU

Early intervention after discharge from NICU/SNCU

Who should be initiated on an early stimulation programme?

Babies at risk of Neurodevelopmental disabilities based on risk factors & Initial assessment

When can early stimulation be started? As soon as baby is medically stable and continued till at least 1 year age

In the NICU/SNCU- Optimize lighting Reduce noiseClub painful procedures, allow sucking sucrose /

breast milk , hold hand Tactile stimulation – touch, gentle massage Kangaroo Mother Care Non-nutritive sucking Passive exercises

What is done in early stimulation?

Assess parenting –skills and educate Stimulate the child in all sectors of development

– motor, cognitive, Neuro-sensory, languageStimulate to achieve the next mile-

stone(developmentally appropriate rather than age-based)

Physical stimulation – passive exercises to prevent development of hypertonia

Caution – Avoid over-stimulation (negative effects on development when many inputs of different nature started simultaneously)

At Home-Birth to 2 months- Place your baby's head and

neck on the crook of your elbow and forearm while lifting or carrying her

2 to 4 months- • Help your baby to roll by placing her on either side• Calling her name or making a sound with the rattle

from behind encouraging her to turn4 to 6 months –• Play different types of music for her to listen• Make her sit in front of the mirror and imitate the

sounds that she makes• Roll a medium size ball gently in front of her for her to

follow• Give her small light rattles to hold in each hand• Encourage her sit by herself leaning on her arms and

taking their support• Start an activity that she enjoys and then stop see if

she moves her body in the same manner to indicate her desire to continue the play

6 to 8 months-• Call the child by one name only and encourage her to

respond by smiling at her.• Make her sit independently for 5 to 10 mins by putting her

brightly colored and musical toys in front of her. If she loses balance, after some time help her to sit again by holding her from the hips lightly.

• Give her a spoon to bang on a steel plate, small drum to bang her hand on, rattle to shake,paper to crumble and tear (please be there when she is playing with paper).

• Encourage crawling when she is on her tummy by placing her favorite toy in front of her just a little out of her reach.

• Repeat the sounds of “da da, ma ma, ga ga, ba ba” that she makes. Pretend you understand them and answer back in your mother tongue with different intonations.

• Keep talking to her and naming all the family members as come to her, hold or play with her.

8 to 10 months-

• Put two blocks in each hand and encourage her to bang them together while looking at them. Encourage her to clap her hands.

• Hold her hand and help her to take out toys one by one from a tub filled with toys. Once she has learnt to take out the toys, hold her hand and encourage her to drop the toys back into the tub one by one.

• When a family member leaves, ask her to wave bye bye.

• Take her in your lap and show her picture books with single, large, colorful pictures of everyday objects and animals. You name and point at the pictures.

10 to 12 months-Show her the functions of objects used in daily life, like

glass for drinking mobile for talking, comb for the hair.

Encourage her to hold furniture and take some step around it.

12 to 15 months-Take her hand and help her to point to a toy or any food

item she wants. You say the name of the toy and encourage her to take out a sound resembling the name.

Hold her lightly from the back and give her the confidence to take few steps on her own.

Specific interventions

Motor impairment / Hypertonia – medications and physiotherapy and occupational therapy

Speech therapy

Squint correction

Behavior therapy and pharmacotherapy for behavioral disorders

Therapy for learning disabilities

Summary• All health facilities caring for sick neonates must

have a follow up program with establishment of a multidisciplinary team.

• The level of follow up can be based on anticipated severity of risk to neurodevelopment. The frequency of follow up and the type of tests depend on “intensity or level of follow up” assigned. The schedule for follow up must be planned before discharge from birth admission.

• Prior to discharge, a detailed medical and neurological assessment, neurosonogram, ROP screen and hearing screen should be initiated. A psychosocial assessment of the family should also be done.

• The follow up protocol should include assessment of growth, nutrition, development, vision, hearing and neurological status.

Summary(contd…)• Formal developmental assessment must be

performed at least once in the first year and repeated yearly thereafter till six years of life. In Indian context, DASII is the best formal test for developmental assessment (till 2 year 6 months).

• Ideally, the follow up should continue till late adolescence, at least till school as many cognitive problems, learning problems and behavioral problems that are more common in at-risk neonates are apparent only on longer follow up.

• Early intervention programme (early stimulation) must be started in the NICU/SNCU once the neonate is medically stable.

• Timely specific intervention must be ensured after detection of deviation of neurodevelopment from normal.

S U

M M A R Y

HAVE A NICE

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