Follow-up of High Risk Neonates

1. FOLLOW-UP OF HIGH RISK NEONATES

2. WHY
WHAT
WHO
WHEN
HOW
Follow-up of High Risk Neonates

3. WHY
WHAT
WHO
WHEN
HOW
Follow-up of High Risk Neonates

4.  WHY is follow-up of high risk newborn
important?
OVERALL
ADVERSE
OUTCOME

5. WHY
WHAT
WHO
WHEN
HOW
Follow-up of High Risk Neonates

6.  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

7.  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

8. WHY
WHAT
WHO
WHEN
HOW
Follow-up of High Risk Neonates

9.  WHO should be involved in follow up?
 Pediatricians / Neonatologists
 Child psychologist
 Pediatric neurologist
 Ophthalmologist
 Otorhinolaryngologist
 Dietician
 Medical social worker
 Physiotherapist
 Speech / occupational therapist

10.  WHO should be involved in follow up?
 Pediatricians / Neonatologists
 Nodal person of team
 Assess growth & screen for developmental delay
 To manage intercurrent illnesses

11.  WHO should be involved in follow up?
 Pediatricians / Neonatologists
 Child psychologist
 For formal neurodevelopmental assessment
 Screening for behavioral problems and management

12.  WHO should be involved in follow up?
 Pediatricians / Neonatologists
 Child psychologist
 Pediatric neurologist
 Long-term management of neurological illnesses,
seizures.

13.  WHO should be involved in follow up?
 Pediatricians / Neonatologists
 Child psychologist
 Pediatric neurologist
 Ophthalmologist
 Follow-up of ROP screening/treatment
 Assessment of visual acuity and screening for problems
such as strabismus, nystagmus, refractory errors, etc

14.  WHO should be involved in follow up?
 Pediatricians / Neonatologists
 Child psychologist
 Pediatric neurologist
 Ophthalmologist
 Otorhinolaryngologist
 Hearing assessment (BERA,OAE, etc.)
 Management of hearing impairment etc.

15.  WHO should be involved in follow up?
 Pediatricians / Neonatologists
 Child psychologist
 Pediatric neurologist
 Ophthalmologist
 Otorhinolaryngologist
 Dietician
 Dietary advice regarding complementary feeding.
 Management of infants with failure to thrive.

16.  WHO should be involved in follow up?
 Pediatricians / Neonatologists
 Child psychologist
 Pediatric neurologist
 Ophthalmologist
 Otorhinolaryngologist
 Dietician
 Medical social worker
 To take care of the social issues

17.  WHO should be involved in follow up?
 Pediatricians / Neonatologists
 Child psychologist
 Pediatric neurologist
 Ophthalmologist
 Otorhinolaryngologist
 Dietician
 Medical social worker
 Physiotherapist
 Plan an appropriate training program for each infant with tone
abnormalities
 Teach parents to continue prescribed exercises at home

18.  WHO should be involved in follow up?
 Pediatricians / Neonatologists
 Child psychologist
 Pediatric neurologist
 Ophthalmologist
 Otorhinolaryngologist
 Dietician
 Medical social worker
 Physiotherapist
 Speech / occupational therapist
 Rehabilitation of infants with impairment/disability

19. WHY
WHAT
WHO
WHEN
HOW
Follow-up of High Risk Neonates

20.  WHEN should high risk follow-up start?
 WHEN should the babies be followed up?

21.  WHEN should high risk follow-up start?
Should start BEFORE discharge,
and NOT AFTER!

22.  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.

23.  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,

24.  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.

25.  WHEN should the babies be followed up?
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
age
At 3, 6, 9, 12 and 18months of corrected age and then
every 6 months until age of 8years

26.  WHEN should the babies be followed up?
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
age
At 3, 6, 9, 12 and 18months of corrected age and then
every 6 months until age of 8years

27.  WHEN should the babies be followed up?
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
age
At 3, 6, 9, 12 and 18months of corrected age and then
every 6 months until age of 8years

28.  WHEN should the babies be followed up?
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
age
At 3, 6, 9, 12 and 18months of corrected age and then
every 6 months until age of 8years

29. WHY
WHAT
WHO
WHEN
HOW
Follow-up of High Risk Neonates

30.  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

31.  HOW to follow-up? What should be looked for?
 Monitor and plot in appropriate charts at EACHVISIT:
 Weight,
 Head circumference,
 Mid-arm circumference and
 Length
 Intra-uterine growth charts: Fenton orWright’s charts (till 40
weeks PMA) and
 WHO growth charts (for preterm infants after 40 weeks PMA
and for term infants)

32.  HOW to follow-up? What should be looked for?
 Intra-uterine growth charts: (IP 2012)
MALE
FEMALE

33.  HOW to follow-up? What should be looked for?
 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 ScreeningTest (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).

34.  HOW to follow-up? What should be looked for?
 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

35.  HOW to follow-up? What should be looked for?
 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.

36.  HOW to follow-up? What should be looked for?
 2.Trivandrum development screening chart (TDSC) :

37.  HOW to follow-up? What should be looked for?
 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.

38.  HOW to follow-up? What should be looked for?
 3. Denver Developmental ScreeningTest–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

39.  HOW to follow-up? What should be looked for?
 3. Denver Developmental ScreeningTest–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”.

41.  HOW to follow-up? What should be looked for?
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

42.  HOW to follow-up? What should be looked for?
 Neurological assessment:
 Hypertonia or hypotonia should be looked for by
measuring the following angles:
 adductor angle,
 popliteal angle,
 ankle dorsiflexion, and
 scarf sign;

43.  HOW to follow-up? What should be looked for?
Amiel-Tison method

44.  HOW to follow-up? What should be looked for?
 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
or
 d) Persistent abnormal posturing or abnormal movements
 The tone abnormalities should be taken care by regular
physiotherapy.

46. “ 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

47. http://dnbpediatricstheory.blogspot.in/