Follow up care of high risk newborn

WHY» There is steady improvement in the quality of perinatal care in

India.

» The incidence of chronic morbidities and adverse outcome in

survivors is increased as more VLBW and ELBW babies are

surviving.

» Timely and appropriate intervention can prevent or modify

many of these disabilities.

» The mission is to provide a continuum of specialized care to

sick babies discharged from NICUs.

» The objective is to identify early deviation of growth,

development or behaviour from normal and provide support and

interventions as indicated.

» Lack of evidence based data on the sequelae of these at - risk

newborns and most therapies used in neonatal period

» We have no systematic database of outcomes of at-risk neonate

Multidisciplinary Action

» Neonatologist/Pediatrician (coordinator),

» developmental pediatrician / therapist,

» ophthalmologist,

» ENT specialist, audiologist,

» physiotherapist / occupational therapist,

» pediatric neurologist,

» Clinical psychologist,

» Orthopedician

» Social worker/public health nurse

Who needs Follow up

» Biological risk factors-Prematurity, Low birth weight,

Asphyxia, Shock, Need for ventilation, CLD, Sepsis,

Jaundice, PDA, NEC, Malformations

» Interventions – e.g. post natal steroids/ hypocarbia

» Socio – economic

» Antenatal risk factor

Neurodevlopmental Disabilities (NDD)

» Cerebral palsy» Mental retardation» Hearing impairment» ROP» Squint , refractory errors» Learning problem, speech and language problem » Autism» ADHD

High risk factors

» Babies with <1000g birth weight and/or gestation <28

weeks

» Major morbidities such as chronic lung disease,

intraventricular haemorrhage and periventricular

leucomalacia, Perinatal asphyxia - Apgar score 3 or less

at 5 min and/or hypoxic ischemic encephalopathy

» Surgical conditions like Diaphragmatic hernia,Tracheo-

oesophageal fistula

» Persistent prolonged hypoglycemia and

hypocalcemia

» Seizures and meningitis

» Shock requiring inotropic/vasopressor support

» Infants born to HIV-positive mothers

» Twin to twin transfusion

» Neonatal bilirubin encephalopathy

» Small for date (<3rd centile) and large for date

(>97th centile)

» Mechanical ventilation for more than 24 hours

» Major malformations

» Inborn errors of metabolism / other genetic disorders

» Abnormal neurological examination at discharge

Mild risk for NDDAntenatal risk factors

PROM, booked pregnancy, completed ANS,>37 wks,Prolonged labor, no need of rescitation

No shock, normal neurological examination

>2500 Gm, good home environment,

> 1 abortion, infertility Treatment

Perinatal asphyxia / mild NE

Transient hypoglycemia

Suspect sepsis (screen negative)

Neonatal jaundice needing phototherapy

IVH grade 1 or 2

NICU admission

Moderate risk for NDDFetal growth abnormalities

Sub-optimal perinatal care

Gestation 33-36 weeks

Birth weight 1500-2500 gm

Multiple births (twins / tiplets)

Moderate neonatal encephalopathy (NE) grade 2

Hypoglycemia, blood sugar< 25 mg/dL, >3 days

Sepsis (culture + ve/ clinical and screen + ve)

Neonatal jaundice leading to Exchange transfusion

IVH-3 and above

NEC, PDA,(requiring Surgery), complex medical course

Prolonged encephalopathy of any cause

High risk for NDDFetal distress

Sub-optimal neonatal transfer / care

< 33 week< 1500 gm, preterm with SFD, 10th centile.

Metabolic disorders, Intra uterine Infection, congenital anomaly (nervous system / multiple / teratogens exposure

Severe NE ** - Grade 3, Prolonged encephalopathy > 2 wks, multi organ injury.

Symptomatic hypoglycemia seizure, refractory shock, no ANS

Kernicterus, meningitis, CLD,

hydrocephalus, severe hypoxia, ventilation > 7 days, apnea requiring resuscitation, abnormal neurological finding at discharge.

Where to follow up» Easily accessible to the parents

» Low risk infants can be followed up at a well baby clinic.

» Moderate and High risk infants followed up in or near to

a facility providing Level II and Level III NICU care

» A discharge summary must be provided to primary care

provider and parents

Prerequisites Before discharge

» Medical examination

» Neurobehavioral and Neurological examination

» Neuroimaging

» ROP screening

» Hearing screening

» Screening for congenital hypothyroidism

» Screening for metabolic disorders

» Assessment of parent coping and developmental

environment

When to follow up» Initial weekly examination is done

» The neuromotor examination at discharge and at 1 and 3

months of age has been used to predict CP at 1 year

» Neuroassessment at 12 months used to predict cognitive

performance at 36 months

» At 3-4 years intelligence can be assessed and later IQ

scores predicted.

» School achievement can be assessed at 6 years and

» IQ ,neurophysiological functions and school performance at

8years.

What should be Done at visit

» Medical examination - nutrition and growth, Immunization

» Neurological examination» Development assessment» Ophthalmologic assessment – squint and

refraction» Hearing and Language and speech Function» Behavioral, cognitive and intelligence status

MATERIAL REQUIRED» Red Ball.

» Red cubes.

» Red Ring with string.

» Rattle.

» Measuring tape.

» Picture Book .

» Pellets.

» Bell.

» Mirror.

Medical examination» Head circumference (OFC) is the simple tool that can

predict abnormal brain growth.» OFC must be recorded and plotted serially every health

visit till two years age.» weight and length potted on growth chart and compare

centiles» complete physical examination must look for common

anticipated medical problems» Unresolved medical problems must be addressed and

medications reviewed» In preterm babies use special growth chart for preterm

babies

» preterm very low birth weight babies grow poorly in

postnatal period.

» The growth failure is more marked in SGA babies

» Weight and Length recorded at each visit

» Weight and length must be plotted at every health

visit till 6 years of age.

» Use a standard Intrauterine growth chart to plot

centiles for weight, length and HC

» Follow with an appropriate postnatal growth chart

Charts used for growth monitoring» Kelly-Wright chart» Lubchenco chart» Who chart 2006» NICHD growth chart» CDC growth charts» Fenton TR.» Babson and Brenda’s chart » BMC Central 2003» Ehrenkranz

Nutrition » Ensure adequate postnatal nutrition.» Ensure adequate vitamin, minerals and Iron

supplementation» Start supplementary feeding as per baby’s readiness

NUTRITION – Assessing Adequacy

» Signs of effective breast feeding

rhythmic sustained suckling

audible swallow

softening of the maternal breast

maternal signs of milk ejection

a minimum of 10-12 times in a 24 hour period.

Urine output 6-8 times/day

Nutrition

» goal: 137 – 165 kcal/kg/day for catch-up growth

» Then, average caloric needs: 105 – 130 kcal/kg/day

» Protein 3.4-4.2g/kg/d

» Fat 5.3-7.2 g/kg/d

» Carbohydrate 7-17 g/kg/d

» Avg daily weight gain: 10 – 20 g/kg/d day for

term ,For preterm 15-20 g/kg/d

Nutrition – Micronutrients

» Iron – 2-4 mg/kg of iron per day» Folate – 25-50 mcg/kg/day» Vitamin D – 150 – 400 IU / day » Calcium 100-220 mg/kg/d» VitA-700-1500iu/kg/d,» Vit E-6-12iu/kg/d,

» Vit k-8-10mcg/kg/d,

» Thiamine-180-240mcg/kg/d,

» Riboflavin 250-360mcg/kg/d,

» Vit b6-150-210mcg/kg/d,

» Vit b12-0.3mcg/kg/d,

» Niacin 3.6-4.8mg/kg/d,

» Vit c18-24mg/kg/d

Immunizations

» AAP: medically stable preterm infants should receive full immunizations based upon their chronological age

» Tools for neurobehaviour assessment» Levenes grading of encephalopathy» Simple KIMS score» Neurobehavioural assessment of PT infant» Assessment of PT infants behavior» Brazelton newborn behavior assessment scales

Levenes scoreGrade 1 Grade 2 Grade 3

No seizure seizure Prolonged seizure

Irritable Lethargy Comatose

Mild hypotonia Marked tone abnormility Sev hypotonia

Poor sucking Tube feeding Needs ventilation

Brazelton scores» The Neonatal Behavioural Assessment Scale (NBAS)» This test the autonomic system, motor system, state

organisational system, interaction system, self-regulatory system.

» was designed to assess full-term babies from 37-48 weeks’ gestation.

Neurological evaluation» In preterm babies - NAPI (neurobehavioral assessment

of preterm infants)- It can be used for babies between 32 weeks gestation and term.

» it includes assessment of» Motor development & vigor» Scarf sign» Popliteal angle» Alertness & orientation» Irritability» Vigor and crying» Percentage sleep ratings

examination during followup

» Consciousness – Alert / lethargic / irritable» HR» RR» Pallor / icterus / edema» Neurocutaneous markers» Anterior fontanelle.» Occipito-frontal circumference.» Weight.» Height.» Congenital anamolies» Systemic Examination(CNS,CVS,RS.)» Cranial nerve examination

» Several tools have been found effective—

Hammersmith neonatal neurological screener,

neurodevelopmental risk examination, Amiel-

Tison—all examine different domains eg. tone,

reflexes,sensory and behavioral response

» It has great predictive value and can guide further imaging,

intervention planning.

» Neurological Assessment by Amiel –Tison scale, Hammersmith

neonatal / infant neurological examination at discharge and

periodically as indicated

» Neuro-motor assessment should be performed by corrected age

at least once during the first 6 months, once during the second six

months, and once yearly upto 6yrs

» Assessment of severity of disability (function) by GMFCS at 2

years

Hammersmith neonatal neurological examination

» It is best used for evaluation of term born “normal”

neonates in maternity ward/ first follow-up.

» If two items are in “blocked/ shaded area, the neonate

should have a detailed assessment.

» An optimality score is generated in the full test. It is mostly

used as a research tool.

It evaluates a baby in following areas-

» Posture and tone

» Tone patterns

» Reflexes

» Movements

» Abnormal signs or patterns

» Orientation / behavior

Neuroimaging – USG/CT/MRI» Important complement to clinical assessment in

the management of preterm and term neonates

with encephalopathy.

» It diagnosed of brain pathology for appropriate

immediate management and detection of those

lesions which are associated with long term

neurodevelopmental disability

» available modalities are Ultrasound, CT Scan, MRI

» All preterm babies born before 32 weeks and <

1500 grams birth weight must undergo screening

neurosonograms at 1-2 weeks and 36 – 40 weeks

corrected age

Amiel Tison Scale» It is good screening test for neuromotor assessment,

» the predictive value at 3 months examination for normal

outcome at 12 months is 93%.

» The main draw back of using this solely is that this scale

does not take into account the mental development.

» 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, suckling , swallowing

4. Head growth

- Head circumference and also skull for sutures, size of anterior fontanel

Tone assessment» Following parameters are recorded

1. Spontaneous posture- evaluated by inspecting the child

while he or she lies quiet

2. Passive tone- evaluated by measuring the angles at

extremities

3. Active tone- assessed with the infant moving

spontaneously in response to a given stimulus

4. deep tendon reflexes, abnormal persistence of primitive

reflexes, like ATNR, fisting and cortical thumb are also recorded.

Normal range of Angles during infancy

AGE(MONTHS)

ADDUCTOR ANGLE

POPLITIAL ANGLE

DORSI -FLEXION ANGLE OF FOOT

SCARF SIGN

0-3 40-80 80-100 60-70 ELBOW DOES NOT CROSSES MIDLINE

4-6 70-110 90-120 60-70 ELBOW CROSSES MIDLINE.

7-9 100-140 110-160 60-70 ELBOW GOES BEYOUND MID- LINE

10-12 130-150 150-170 60-70 ----------

» Test schedule - 3, 6, 9, 12 months

» Tone abnormalities» Normal tone» Hypotonia (mild / severe)» Hypertonia (mild / severe)

a. Pattern of tone abnormalities» Diplegia» Hemiplegia» Differential extensor tone against flexor tone

Reflexes

» Primitive reflexes at 3 months

Palmar grasp

Automatic walking

Moro reflex

Asymmetric tonic neck reflex

» Postural reflexes at 9 months

Parachute

Lateral propping

Developmental assessment» Parental concerns regarding development must be recorded

and respected.

» Development is assessed by

1) Developmental history (assessment by report)

2) Direct observations and interaction with examiner

3) Administration of specific tests

Developmental Tests

1. 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)

Development observation card

It 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, hear and listen

» Further grading of each milestone helps in defining stage of

development accurately

Trivandrum development screening chart (TDSC)

» TDSC is a simple screening test.

» They taken 17 items taken from Bayley Scale of Infant

development.

» 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 ageline.

» Currently TDSC is being validated for children till 6 years of age.

Denver development screening test

» detection of children with serious developmental delays.

» The test is best used for apparently normal children

» The test compares the index child against children of similar

age.

» The test is not designed to derive a developmental or mental

age, nor a development or intelligence quotient;

» It is a developmental screening device to obtain an estimate

of the child’s level of development.

» Allows diagnosis of the probable differential diagnosis of

developmental disability.

» It alert to the possibility of developmental delays so that

appropriate diagnostic studies may be pursued.

» It has 4 sectors – gross motor, fine motor, language and

social. All 4 are to be treated as independent tests and

interpreted separately.

» performed at 0- 6 months age, preferably 4 months

corrected age between 6-12 months preferably 8 months

corrected age and yearly thereafter till at least 6 years

age.

» a formal test for development assessment must be

performed within 2 months if abnormal

Hearing assessment

Indications :Family H/o hearing impairmentWeight < 1500 gmsNeonatal jaundiceMeningitis IU infections Intra cranial hemorrhageAsphyxiaRequired ventilationCranio facial anamoliesUse of drugs (Amino glycoside, frusemide

Hearing screening» occurring in approximately 2-4 infantsper1000 live births

» More than 50 percent of hearing impairment in children is

thought to be genetic and not related to infectious,

anatomic or other non-inherited

» Universal screening for hearing loss is a preferred strategy

over selective screening of at-risk groups

» Identification and intervention before age 6 months can

have a significant impact on the development of

expressive and receptive language.

» Auditory brainstem response (ABR), otoacoustic

emissions (OAEs), and automated ABR (AABR) testing

» any infant in the NICU or in the hospital for more than 5 days should undergo an ABR screening along with OAE

» The re-screening should be performed prior to 1 month of age

» If an infant does not pass the re-screening, referred for diagnostic audiological evaluation which should involve diagnostic BERA.

» recommendation includes audiologic testing every six months until three years of age.

» Behavioral pure tone audiometry is standard hearing test

eyes evaluation

» Indications – Pre-term babies < 34 wks /

1750 gms.

» ROP Screen at 4 wks of life.

» Requires trained Opthalmologist

» Follow up schedule determined by stage

of disease, plus disease, zone

» advisable to screen the baby every 1-2 weeks at least until the infant is 38-40 weeks of postmenstrual age.

» retinal wide field digital imaging (WFDI)» Tele-ROP trial

Learning, behavioural Problem» all VLBW and ELBW babies should be followed up till

adolescence.

» they often have poor school achievement and behavioral

difficulties, even worse in ELBW babies especially in

mathematics

» For behavioral assessment, CBCL scale can be used.

» CBC (Achenbach Child behavior checklist) which is

based on parental perception of children’s behavior, can

be used from 1.5-5 years aged children.

» Behavioral assessment can be done after one year age

Cognition problem» Children born VLBW or ELBW have relative impairments

of executive functioning,visual-motor skills, and memory

especially verbal memory

» Score lower on tests of academic achievement,

perceptual-organizational skills, visual processing tasks

and adaptive functioning

» Formal cognitive development, IQ is tested by 3 years

» Children born below 28 weeks or 1000 grams birth

weight must be referred for a Psycho-educational testing

(pre-school assessment) to detect learning

Scales for cognition» Malin’s Intelligence Scale for Indian Children (MISIC), » Seguin Form Board (SFB) » Vineland Social Maturity Scale (VSMS) » Weschler’s intelligence scale –revised (WISC-R)» Bender- Gestalt Test (BG)-visiomotor perception» Wide range achievement test (WRAT)-reading,

writing, math» Human figure drawing-emotion( goodengough)» School performance

Developmental supportive care» Optimize lighting

» Reduce noise, gentle music

» Club painful procedures, allow suck sucrose / breast

milk , hold hand

» Tactile stimulation – touch, gentle massage

» Kangaroo Mother Care

» Non-nutritive sucking

» Passive exercises

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

motor, cognitive, Neuro-sensory, language» Developmentally appropriate - through the normal

developmental channel (stimulate to achieve the next “mile-stone” rather than age-based)

» Physical stimulation – passive exercises to prevent development of hypertonia

» Caution – avoid over-stimulation (has shown negative effects on development when many inputs of different nature are simultaneously started)

Specific interventions» Motor impairment / Hypertonia – medications and

physiotherapy» Physiotherapy and occupational therapy» Speech therapy» Seizures» DDH and other Orthopedic» Squint correction» Behavior therapy and pharmacotherapy for

behavioral disorders» Therapy for learning disabilities

References » NNF Clinical Practice Guidelines Downloaded from

www.nnfpublication.org

» Manual of neonatal care.john cloharty

» Brazelton, T.B., Nugent, J.K. The Neonatal

BehaviouralAssessment Scale. Third edition. Clinics

inDevelopmental Medicine 137. London: MacKeith

Press,CUP. 1995.

» Nelson textbook of pediatrics 19 edition

» Care of newborn .meharbansingh

» Bonnie E. Stephens, MDa,b,*, Betty R.Vohr, MD.

NeurodevelopmentalOutcome of the Premature Infant