Follow up of High Risk Neonates.. Dr.Padmesh

Follow-up of High Risk Neonates

1. Follow-up of High Risk Neonates Dr.Padmesh . V

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? Years MORTALITY MORBIDITY 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 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)

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 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).

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 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

39. HOW to follow-up? What should be looked for? 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”.

40. 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 DQ

41. 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;

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

43. 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.

44. “ 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

45. http://dnbpediatricstheory.blogspot.in/