outpatient follow up of premature infants, by dr. khaled el-atawi a/consultant, neonatology clinical...

Outpatient Follow Up Of Premature Infants

Dr. Khaled El-Atawi

A/Consultant, Neonatology

Clinical Quality Specialist

Latifa Hospital, DHA

Once a Premie

Always a Premie

Objectives1. Discuss benefits of follow up.

2. Define who should be followed.

3. Define optimal age and methods of follow up.

4. Recommendations.

References: 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

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.

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.

High Risk Newborn and Developmental Follow-Up: Who Needs It?

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.

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%)

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.

Risks Of Disability:

DISCHARGE PLANNING

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

Social Worker

Neonatal Nurses

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:

NeonatologistParents

Primary Care

Physician

Discharge Planning: Other professionals such as:

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.

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.

Discharge Planning:

Essential elements includes: 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.

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.

Discharge Planning:

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.

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.

1. Parental Education.

2. Implementation of Primary Care.

3. Evaluation of Unresolved Medical Problems.

4. Development of the Home Care Plan.

5. Identification and Mobilization of Surveillance and Support Services.

6. Determination and Designation of Follow-up Care.

Discharge Planning:

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.

1. Parental Education:

The participation of the parents in giving care as early as feasible in the neonatal course has been shown to

have a positive effect on their confidence in handling the infant and readiness to assume full responsibility

for the infant’s care at home.

Parent rooming-in and telephone follow-up have all been reported to

facilitate parental education and adaptation to their infant’s care.

The parents will exhibit minimal stress in caring for their infant and have

adequately performed all tasks.

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.

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.

2. Implementation of Primary Care:

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.

Healthy LBW, AGA infants experience catch-up 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.

Growth Assessment

Correction For Prematurity Example:

Baby was born at 26 weeks gestation. i.e. 14 weeks premature

Now seen at “1 year of age”

Need to plot weight and development for 8.5 month

(Chronologic age)

(Corrected age)

(3.5 months)

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.

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.

Growth Assessment Certain conditions place infants at risk for growth

failure includes: 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.

GROWTH CHARTS

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.

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.

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.

Nutritional Requirements

Needs can be met by: Fortification of breast milk

Very expensive. Not available in the stores.

Use of specific formulas. Vitamin D supplement: 200 -400 IU/L

Nutritional Requirements

Nutrient-enriched formula versus standard term formula for preterm infants following hospital dischargeGinny 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.

Infant formulas for preterm infants: In-hospital and post-dischargeDavid 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 multi-component fortifier, is the preferred feed for very preterm infants as it has beneficial effects for both short and long term outcomes compared with formula.

Infant formulas for preterm infants: In-hospital and post-dischargeDavid 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.

Infant formulas for preterm infants: In-hospital and post-dischargeDavid 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.

Infant formulas for preterm infants: In-hospital and post-dischargeDavid 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.

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.

Full Term Preterm At Term

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

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

Neuro-Developmental Evaluation

Bayley Scales of Infant Development (BSID-III)

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

Griffiths Scales 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

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

Immunizations Preterm infants should be immunized at the usual

chronologic age 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

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

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.

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.

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.

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.

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.

FINAL THOUGHTS

Final ThoughtsParents 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.

Hence, the parents may be left with less-obvious 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.

Final Thoughts

Final Thoughts Correct growth and development for

prematurity. Give shots on time. Nutrition, nutrition, nutrition. Early recognition and intervention.

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

Thank You