1. Outpatient Follow Up Of
Premature Infants
Dr. Khaled El-Atawi
A/Consultant, Neonatology
Clinical Quality Specialist
Latifa Hospital, DHA

2. Once a Premie
Always a Premie

3. Objectives
1.
2.
3.
4.
Discuss benefits of follow up.
Define who should be followed.
Define optimal age and methods of follow
up.
Recommendations.

4. References:
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Care of the Very Low-birthweight Infant Pediatrics in Review 2009;30;32.
Sauve R, Lee SK. Neonatal follow-up programs and follow-up studies: Historical
and current perspectives. Paediatr Child Health. May 2006; 11(5):267-70.
Romeo et al, Eur J Peadiatr Neurol 2008
Guideline Hospital discharge of the high-risk neonate. Pediatrics. Nov 2008;
122(5):1119-26.
O'Shea
M. Changing
characteristics
of
neonatal
follow-up
studies. NeoReviews. 2001; 2:e249-56.
Continuing Care of NICU graduates, Clinical Pediatrics 2003.
Vohr BR. Neonatal follow-up programs in the new millennium. NeoReviews.
2001; 2:e241-8.
http://www.cdc.gov
Hospital Discharge of the High-Risk Neonate
Proposed Guidelines AMERICAN
ACADEMY OF PEDIATRICS Committee
on Fetus and Newborn.
Pediatrics Vol. 122 No. 5 November 1, 2008
pp. 1119 -1126

5. Terms Related To Prematurity







Premature infants: infant < 37 weeks
gestation
LBW: birth weight < 2500 g
VLBW: birth weight < 1500 g
ELBW: birth weight < 1000 g
Chronologic age: time since birth.
Post-conceptional age: time since conception.
Corrected age: age corrected for prematurity.

6. High Risk Newborn and Developmental
Follow-Up: Who Needs It?


Birth weight less than 1500 grams.
Medical history or conditions consisting of
one of the following:





Bronchopulmonary dysplasia (O2 requirement at
36 weeks PCA).
NEC requiring surgical intervention.
IVH Grades III, IV or PVL.
Abnormal neurologic exam at time of discharge.
Seizures related to IVH or asphyxia.

7. High Risk Newborn and Developmental
Follow-Up: Who Needs It?



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Meningitis.
Any patient with HIE requiring cooling therapy.
Hearing or vision deficits.
Persistent pulmonary hypertension of the
newborn requiring high frequency ventilation or
inhaled nitric oxide.
Pathologic
jaundice
requiring
exchange
transfusion.

8. Risks Of Disability:

The following is an estimate of the risks of
disability in infants with birth weights less
than 1500 g:

Incidence of a disability




None (35-80%)
Mild-to-moderate (8-57%)
Severe (6-20%)
Type of disability




Mental retardation (10-20%)
Cerebral palsy (5-8%)
Blindness (2-11%)
Deafness (1-2%)

9. Risks Of Disability:

Psychomotor testing using screening tools
such as the Denver II Developmental
Screening Test or the Bayley Scale of Infant
Development are helpful to identify infants at
risk.

10. DISCHARGE PLANNING
Pediatrics Vol. 122 No. 5 November 1, 2008
pp. 1119 -1126

11. Discharge Planning:


The care of each high risk neonate after
discharge must be carefully coordinated to
provide ongoing multidisciplinary support
of the family.
The discharge planning team should include:
Parents
Neonatologist
Primary
Care
Physician
Social
Worker
Neonatal
Nurses

12. Discharge Planning:

Other professionals such as:






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Surgical specialists.
Pediatric subspecialists.
Pediatric occupational.
Physical, speech and respiratory therapists.
Infant educators.
Nutritionists.
Home health care liaisons.
Case manager selected by the team and family
may be included as needed.

13. Discharge Planning:



Discharge criteria differ depending on the infant’s
history and diagnosis.
The goal of the discharge plan is to assure successful
transition to home care.
The initiation of discharge planning should begin
when it is evident that recovery is certain, although
the exact date of discharge may not be
predictable.

14. Discharge Planning:

Essential elements includes:


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Physiologically stable infant.
Administration of age-appropriate immunizations
and the parents should receive a record of such
immunizations.
If appropriate, administration of palivizumab
should occur prior to discharge and follow-up
dosing arranged.
Vision and Hearing Screening.
Neonatal Screening.

15. Discharge Planning:


Family who can provide the necessary care.
Primary care physician who is prepared to the
responsibility with appropriate back up from
specialist physicians and other professionals as
needed.

16. Discharge Planning for Infants Requiring
Special Care Needs:

Oxygen dependent infants with BPD
should have stable oxygen saturations
measured by pulse oximetry at or above
94% in a stable or reducing flow rate for
at least two weeks prior to discharge.

17. Discharge Planning for Infants Requiring
Special Care Needs:

Infants having had bowel resection resulting in short
gut syndrome requiring intravenous alimentation at
discharge should have follow-up with pediatric
gastroenterology and appropriate plans for
maintenance of outpatient parenteral nutrition.

Parents require instruction in the care of the central
venous line as well as signs & symptoms of infection
with an emergency plan for follow-up if needed.

19. Discharge Planning:
1.
2.
3.
4.
5.
6.
Parental Education.
Implementation of Primary Care.
Evaluation of Unresolved Medical Problems.
Development of the Home Care Plan.
Identification and Mobilization of Surveillance
and Support Services.
Determination and Designation of Follow-up
Care.

20. 1. Parental Education.
Parental contact and involvement in the
care of the infant should be encouraged
from the time of admission.
Ample time for teaching the parents and
caregivers the techniques and the rationale for
each item in the care plan is essential.

21. 1. Parental Education:
The parents will exhibit minimal stress
The participation of the parents in
giving carefor early as feasible in the
in caring as their infant and have
neonatal course has beenall tasks.
adequately performed shown to
have a positive effect on their
confidence in handling the infant and
Parent to assume full responsibility
rooming-in and telephone
readiness
follow-up infant’s care at home. to
for the have all been reported
facilitate parental education and
adaptation to their infant’s care.

22. 2. Implementation of Primary Care:



Ideally Follow-up with a primary care
physician (PCP) should be scheduled.
Direct
communication
between
the
discharging physician and PCP prior to
discharge.
A discharge summary should be sent to the
PCP on the day of discharge.

23. 2. Implementation of Primary Care:


To avoid potential fragmentation of care,
discharge on weekends, especially of
infants with special needs, should be
avoided.
All follow-up appointments with
specialists should be made prior to
discharge.

24. Follow-up care by the Primary Care
Physician (PCP)

The major goals of the pediatrician or
family physician providing care to an
NICU graduate are to:



Provide ongoing assessment of growth and
nutritional intake.
Deliver preventive care.
Periodically
perform
neuro-developmental
assessments.

25. Growth Assessment


Healthy LBW, AGA infants experience catchup growth during the first 2 years of life.
Growth parameters should be plotted on
standard curves according to the infant’s
adjusted age.



Adjust the age until infant is 2-3 years.
After that age difference is insignificant.
The growth pattern is a valuable indicator of
an infant’s well-being.

26. Correction For Prematurity

Example:



Baby was born at 26 weeks gestation. i.e.
14 weeks premature (3.5 months)
Now seen at “1 year of age”
(Chronologic age)
Need to plot weight and development for
8.5 month (Corrected age)

28. Patterns Of Growth



Important to evaluate weight gain in
comparison to gains in length.
Low weight for length (or declines in all
parameters) indicates inadequate nutrition.
PCP must be alert to signs of growth failure
with particular emphasis on head growth as it
is a predictor of future outcome.

29. Patterns Of Brain Growth



Head growth is usually the first parameter to
demonstrate catch-up growth.
Rapid head growth must be distinguished
from pathologic growth caused by
hydrocephalus.
Insufficient brain growth identifies an infant
at risk for developmental disability.

30. Growth Assessment

Certain conditions place infants at risk for growth
failure includes:
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Bronchopulmonary dysplasia.
Central nervous system injuries such as severe
intraventricular hemorrhage or birth asphyxia.
Congenital heart disease.
Short-gut syndrome.
Esophageal or intestinal anomalies.
Renal disease.
Inborn errors of metabolism.
Chromosomal and/or major malformation syndromes.

31. GROWTH CHARTS

32. Nutritional Requirements



Nutritional requirements of the preterm infant
exceed the needs of the term infant at the
same adjusted gestational age.
Increased needs may persist for the first year
of life.
Chronic disease greatly increases calorie and
protein requirements.

33. Nutritional Requirements




Healthy preterm infants need 110 to 130
cal/kg/day
Infants with chronic disease may need 200
cal/kg/day
More then 24 cal formula can cause
hyperosmolar dehydration.
Solid food should be introduced at 6 months
corrected aged.

34. Nutritional Requirements

Preterm infant has increased nutritional needs
for:




Protein.
Minerals.
Calories.
Needs to be supplemented until baby is at
least 46 weeks post-conceptional age.

35. Nutritional Requirements

Needs can be met by:

Fortification of breast milk
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Very expensive.
Not available in the stores.
Use of specific formulas.
Vitamin D supplement: 200 -400 IU/L

36. Nutrient-enriched formula versus standard term formula for preterm infants
following hospital discharge
Ginny Henderson2, Tom Fahey3, William McGuire1,*Editorial Group:
Cochrane Neonatal Group Published Online: 21 JAN 2009




This review attempted to identify evidence that feeding these
infants with formula milk enriched with nutrients rather than
ordinary formula designed for term infants, would increase
growth rates and benefit development.
Seven good quality trials were identified. These trials
provided little evidence that unrestricted feeding with
nutrient-enriched formula milk affects growth and
development up to about 18 months of age.
Long-term growth and development has not yet been
assessed.
Further randomised controlled trials are needed to address
this question.

37. Infant formulas for preterm infants: In-hospital and post-discharge
David I Tudehope1,2,*, Denise Page3, Melissa Gilroy3
Journal of Paediatrics and Child Health Volume 48, Issue 9, pages 768–776,
September 2012

Human milk, supplemented with multicomponent fortifier, is the preferred feed for
very preterm infants as it has beneficial
effects for both short and long term outcomes
compared with formula.

38. Infant formulas for preterm infants: In-hospital and post-discharge
David I Tudehope1,2,*, Denise Page3, Melissa Gilroy3
Journal of Paediatrics and Child Health Volume 48, Issue 9, pages 768–776,
September 2012

Preterm formula is intended to provide
nutrient intakes to match intrauterine growth
and nutrient accretion rates and is enriched
with energy, macronutrients, minerals,
vitamins, and trace elements compared with
term infant formulas.

39. Infant formulas for preterm infants: In-hospital and post-discharge
David I Tudehope1,2,*, Denise Page3, Melissa Gilroy3
Journal of Paediatrics and Child Health Volume 48, Issue 9, pages 768–776,
September 2012


Since 2009, a nutritionally enriched PDF specifically
designed for preterm infants post hospital discharge
with faltering growth has been available in Australia
and New Zealand.
This formula is an intermediary between preterm and
term formulas and contains more energy (73
kcal/100 mL), protein (1.9 g/100 mL), minerals,
vitamins, and trace elements than term formulas.

40. Infant formulas for preterm infants: In-hospital and post-discharge
David I Tudehope1,2,*, Denise Page3, Melissa Gilroy3
Journal of Paediatrics and Child Health Volume 48, Issue 9, pages 768–776,
September 2012


Although the use of a PDF is based on sound
nutritional knowledge, the 2012 Cochrane
Systematic Review of 10 trials comparing
feeding preterm infants with PDF and term
formula did not demonstrate any short or long
term benefits.
Health professionals need to make individual
decisions on whether and how to use PDF.

41. Neuro-Developmental Evaluation

Should be part of all examinations.

Assessment of muscle tone and presence of
primitive reflexes.

Referral for therapies as appropriate.

Review attainment of milestones corrected for
gestational age.

42. Full Term
Preterm At Term

43. Neuro-Developmental Evaluation

Most premature infants will experience
temporary delays in development, this is due
to:



Prolonged hospitalization.
Impact of medical condition.
The impact of prematurity in preterm infants
without neurologic insult lessens over time

44. Neuro-Developmental Evaluation


Development proceeds from cephalic to caudal and
proximal to distal.
Developmental milestones:
 Motor skills (gross and fine)
 Language skills (expressive and receptive)
 Social skills
 Cognitive skills
 Adaptive skills

45. Bayley Scales of Infant Development
(BSID-III)

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Developed in US
Validated in UK with slight differences in
norms
Ages 0 - 42 months
Cognitive skill
Motor skill both fine & gross
Language both expressive & receptive

46. Griffiths Scales
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Developed in UK
Validated in UK and South Africa
Ages 0-8
Locomotor
Personal-Social
Hearing & Language
Hand-Eye
Performance
Practical Reasoning
www.aricd.org.uk

47. Denver Developmental Screening
Test

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Screening Test Only
Cross-cultural differences
Ages 0-6 years
Social /Personal
Motor both fine and gross
Language

48. Immunizations

Preterm infants should be immunized at the usual
chronologic age



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28 weeks now 60 days old (2 month-old)
PCA = 36 weeks
Due for DTaP, Hib, hep B, IPV, Prevnar
Vaccine dosages should not be reduced for
preterm infants
Follow immunization schedule as recommended
by AAP or as per country specific

49. Immunizations-RSV




RSV is the leading cause of Re-hospitalization in
infants under one year of age.
Risk factors are: Day care attendance, school age
sibling, lack of breast feeding, multiple births,
passive smoke exposure, birth within 6 months of
RSV season.
Synagis (monoclonal RSV antibody) is administered
at 15 mg/kg IM monthly during RSV season, usually
September/ October to April/ May. There is regional
and seasonal variations.
Hand washing helps control the spread of RSV

50. AAP Guideline for RSV prophylaxis




Infants < 2 yrs of age and with CLD who
required medical therapy within 6 months of
RSV season.
Infants < 28 weeks and < 12 months at the
start of RSV season.
Infant 29 to 32 weeks and < 6 months of age
at the start of RSV season.
32 to 35 weeks and < 6 months at start of
RSV season and with risk factors.

51. 3. Evaluation of Unresolved Medical
Problems.



Review of the hospital course and the active problem
list of each infant.
Careful physical assessment will reveal areas of
physiologic function that have not reached full
maturation for the infant.
The diagnostic studies can be identified and
alterations in management instituted. The intent
should be to assure implementation of appropriate
home care and follow-up plans.

52. 4. Development of the Home Care
Plan.

Although the content of the home care plan
may vary among infants, the common
elements include the following:





Identification and preparation of the in-home caregivers.
Development of a comprehensive listing of required
equipment and supplies and accessible sources.
Assessment of the adequacy of the physical facilities
within the home.
Development of an emergency care and transport plan as
indicated.
Assessment of available financial resources to assure the
capability to finance home care costs.

53. 5. Identification and Mobilization of
Surveillance and Support Services.



The availability of social support is essential to the success of
every parent's adaptation to the home care of a high-risk
infant.
Before discharge and periodically thereafter, a review of the
family's needs, coping skills, use of available resources,
financial problems, and progress toward goals in the home
care of their infant should be evaluated.
After the social support needs of the family have been
identified, an appropriate, individualized intervention plan
using available community programs, surveillance, or
alternative care placement may be implemented.

54. 6. Determination and Designation of
Follow-up Care.



The attending neonatologist has the responsibility
for coordination of follow-up care, although in an
individual institution, the tasks may be delegated to
other professionals.
A primary care physician should be identified as
early as possible to facilitate the coordination of
follow-up care planning between the primary care
setting and the subspecialty centre-based discharge
planning staff.
Primary care physician to meet the parents before the
discharge and, if possible, examine the infant in the
hospital.

55. FINAL
THOUGHTS

56. Final Thoughts
 Parents

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


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
experience, among others:
Guilt.
Fatigue.
Anxiety and emotional disturbances.
Financial difficulties (time away from work, medical
expenses)
Marital stress.
Family stress (what do you tell relatives and older siblings?)
These feelings don’t go away immediately on discharge.

57. Final Thoughts



Hence, the parents may be left with lessobvious emotional difficulties due to having
an NICU graduate.
As the PCP, it is important to understand
these feelings and to support not only the
patient, but the family as well.
It is important to know where to refer these
families if they need more support.

58. Final Thoughts




Correct growth and development
prematurity.
Give shots on time.
Nutrition, nutrition, nutrition.
Early recognition and intervention.
for

59. My best years of life that when
i was between the laps of a
women who is not my wife

60. Thank You