Follow up of High Risk Neonates.. Dr.Padmesh

FOLLOW-UP OF HIGH RISK NEONATES

Follow-up of High Risk Neonates

WHY is follow-up of high risk newborn important?

OVERALLADVERSEOUTCOME

WHAT is meant by ‘high risk newborn’? 1. Babies <1800g birth weight or gestation <35 weeks

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

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

4. Mechanical ventilation for more than 24 hours

5. Metabolic problems – Symptomatic hypoglycemia and hypocalcemia

6. Seizures

7. Infections – meningitis and/or culture positive sepsis

8. Shock requiring inotropic/vasopressor support

WHAT is meant by ‘high risk newborn’? 9. Major morbidities such as chronic lung disease, IVH, PVL.

10. Infants born to HIV-positive mothers

11. Twin with intrauterine death of co-twin

12. Twin to twin transfusion

13. Hyperbilirubinemia > 20mg/dL or requirement of exchange transfusion

14. Rh hemolytic disease of newborn

15. Major malformations

16. Inborn errors of metabolism / other genetic disorders

17. Abnormal neurological examination at discharge

WHO should be involved in follow up?

Pediatricians / Neonatologists

Child psychologist

Pediatric neurologist

Ophthalmologist

Otorhinolaryngologist

Dietician

Medical social worker

Physiotherapist

Speech / occupational therapist

Nodal person of team

Assess growth & screen for developmental delay

To manage intercurrent illnesses

Child psychologist

For formal neurodevelopmental assessment

Screening for behavioral problems and management

Child psychologist

Long-term management of neurological illnesses, seizures.

Child psychologist

Ophthalmologist

Follow-up of ROP screening/treatment

Assessment of visual acuity and screening for problems such as strabismus, nystagmus, refractory errors, etc

Child psychologist

Ophthalmologist

Hearing assessment (BERA, OAE, etc.)

Management of hearing impairment etc.

Child psychologist

Ophthalmologist

Dietician

Dietary advice regarding complementary feeding.

Management of infants with failure to thrive.

Child psychologist

Ophthalmologist

Dietician

To take care of the social issues

Child psychologist

Ophthalmologist

Dietician

Physiotherapist Plan an appropriate training program for each infant with tone

abnormalities

Teach parents to continue prescribed exercises at home

Child psychologist

Ophthalmologist

Dietician

Physiotherapist

Speech / occupational therapist

Rehabilitation of infants with impairment/disability

WHEN should high risk follow-up start?

WHEN should the babies be followed up?

WHEN should high risk follow-up start?

Should start BEFORE discharge,

and NOT AFTER!

WHEN should this high risk follow-up start?

Counseling prior to discharge: Temperature regulation – proper clothing, cap, socks, Kangaroo

mother care etc.

Feeding – type and amount of milk, method of administration, and nutritional supplementation, if any.

Prevention of infections – hand washing, avoidance of visitors.

Follow-up visits.

Danger signs – recognition and where to report if signs are present. (Respiratory rate >60/min, difficulty in breathing, decreased feeding, decreased activity, fever, etc)

Vaccination – schedule, next visit, etc.

ROP screening, if any.

Documentation:

Discharge summary must have : 1. Gestation,

2. Birth weight,

3. Discharge weight

4. Discharge head circumference,

5. Feeding method and dietary details,

6. Diagnosis (medical problems list),

7. Medications

8. References to other departments,

Documentation:

Discharge summary must have : 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.

Birth wt below 1800g Other

or GA below 35 wk. Conditions

After 3-7 days of discharge 2 weeks after discharge

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

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

HOW to follow-up? What should be looked for?

Assessment of feeding and dietary counseling

Growth monitoring

Immunization

Neurological examination

Developmental assessment and DQ

Hearing (BERA) - between 30 wks and 3 months

Ophthalmic evaluation - ROP screening, 6 mths, 9 mths

USG/CT brain - as indicated

Monitor and plot in appropriate charts at EACH VISIT:

Weight,

Head circumference,

Mid-arm circumference and

Length

Intra-uterine growth charts: Fenton or Wright’s charts (till 40 weeks PMA) and

WHO growth charts (for preterm infants after 40 weeks PMA and for term infants)

HOW to follow-up? What should be looked for? Intra-uterine growth charts: (IP 2012)

FEMALE

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, hear 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)

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 to be used only to alert the professional to the possibility of developmental delays so that appropriate diagnostic studies may be pursued.

3. Denver Developmental Screening Test–II (DDST-II)

Test Sensitivity: 56-83%

Test Specificity: 43-80%

Age range : 2 weeks to 6 years.

The test is comprised of 125 items, divided into four categories:

• Gross Motor

• Fine Motor/Adaptive

• Personal Social

• Language

3. Denver Developmental Screening Test–II (DDST-II)

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 quotient

Mental age Mental devpt quotient

Neurological assessment:

Hypertonia or hypotonia should be looked for by measuring the following angles:

adductor angle,

popliteal angle,

ankle dorsiflexion, and

scarf sign;

Amiel-Tison method

Neurological assessment:

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

a) Brisk reflexes with hypertonia or

b) Brisk reflexes with hypotonia or

c) Definitely and consistently elicited asymmetrical signs

d) Persistent abnormal posturing or abnormal movements

The tone abnormalities should be taken care by regular physiotherapy.

“ I regard developmental examination as an

essential part of everyday practice with a

minimum of equipment, in an ordinary mixed

clinic, and not in a special room, or at a special

time, or with special complicated equipment or by

a special doctor ”

R.S. Illingworth

http://dnbpediatricstheory.blogspot.in/

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