ROP

Care of babies after discharge from NICU

Some of the surviving preterm babies may have neurodevelopment disability (NDD) in the form of cerebral palsy, cognition problems, visual, hearing and behaviour related problems. Intact outcomes, i.e. survival without disability requires screening these at-risk preterm babies to detect early deviations from normal development and employ timely interventions.

We as paediatricians have the responsibility to continue care of babies who are born preterm and discharged after special care in NICU. In this webinar we will learn all about the care of preterm babies after discharge from NICU. Discharge planning – what to include in the discharge summary and a checklist to be used before discharge, Medical care, Monitoring of growth, Nutrition advice , Immunizations of preterm baby, Neurodevelopment assessment, Recommendations on screening of babies (for prevention of NDD), Suggested schedule for multi-domain development screening tests

Continuity of care from NICU to home requires discharge planning, Each unit should have place dedicated to follow up services that include all/most of the services under one roof. Dedicated personnel must coordinate the screening of at-risk babies. The unit may plan one or more days of the week dedicated to follow up.

The preterm baby’s family must be given a discharge summary that includes all risk factors from antenatal period and after birth that may risk development of a preterm baby e.g. antenatal steroids, need for resuscitation at birth, need for oxygen and ventilation. This will ensure continuity of care after discharge from NICU

Having a check list will ensure patient safety and improve quality of discharge process. A model check list from our hospital is displayed. The objectives of care can be clubbed under the heads medical care and neurodevelopment assessment

As paediatricians we often are familiar with medical care of neonates. There are some issues specific to preterm babies

Preterm babies take little longer (about 2 weeks) than term babies to regain birth weight. After that they must gain about 15-20 grams / day. Head growth may be faster (0.5-1.0 cm / week) that term babies, in the first weeks.

Baby’s weight, length and OFC must be plotted on growth charts for preterm babies, weekly in the first few weeks of life. Fenton’s growth chart is a favored preterm growth chart. Tracking of weight and OFC on growth charts is more informative than the numbers

Fenton’s growth chart allows plotting till 50 weeks PMA. One can change to WHO growth charts thereafter.

Preterm babies must be fed breast milk alone till 6 months age, and complementary feeding started after that, like in term born babies.

BCG and OPV can be given at or after 34 weeks gestation, once the baby is medically stable and ready to go home. Hepatitis B may be given after 30 days or at discharge (if the mother is protected / or negative for Hep B).

Besides medical care, preterm babies must be screened at the right time by the right methods for neurodevelopment assessment

The success of a follow up program depends on the parents knowledge of need for screening and benefits of timely intervention. They must be educated at regular intervals, while the baby is in NICU and later, on the need for such testing, schedules and anticipated interventions e.g. laser photocoagulation, hearing aid etc

ROP screening must be completed as discussed and vision assessed at 9-12 months for refraction and squint. Hearing screen and diagnostic testing must be completed before the baby is 6 months old. Development assessment must be done periodically (suggest 4, 8 and 12 months). A neurosonogram should be done at 1-2 weeks and repeated at 36- 40 weeks of life. Baby may be referred to a specialist (neurologist, orthopedician, physical medicine etc) and need intervention, if deviation in development is found.

Often the preterm babies are discharged before the ROP screening I complete. The families must be educated on the need to follow up till ophthalmologist informs that screening is complete/treatment of ROP is required.

In addition to the ROP checks, preterm babies must be examined by eye specialists at 9 – 12 months age for refraction, squint and other visual problems. They are at high risk of myopia, strabismus, late retinal detachment and many other eye problems. Preterm/sick babies are at increased risk of sensorineural hearing loss. The universal screening for hearing impairment using OAE will miss sensorineural hearing loss. Hence, preterm babies must have an AABR screen before discharge from hospital. An abnormal hearing screening must be followed by diagnostic evaluation and decision to intervene made before the baby is 6 months old. Delay in treatment can adversely affect language development.

Neurodevelopment assessment includes assessment of tone and motor mile stones to detect cerebral palsy early. Multi – domain development tests must evaluate cognition, vision, hearing and language as well. Some of these tools are CDC grade, Denver II, Bayley scale etc. Periodic checks at 4, 8 and 12 months of age corrected for prematurity are suggested. At each visit, baby may be initiated on interventions, if deviation in development is noted.

Appropriate follow up is an opportunity to detect early and correct deviations in development. This will minimize disability in preterm survivors. The neonatologist must remain the nodal person to explain to the family the findings of the screening tests and treatments planned for NDD. Coordination of the specialists visits may be facilitate by dedicated staff. They are involved in parent education, managing appointments and guiding parents to intervention programs.

The goal of saving preterm babies, intact, i.e. with neurodisability can be achieved by timely screening as discussed and appropriate interventions.

Introduction...
1. Care of preterm...
2. Learning object...
3. Discharge plann...
4. Discharge summa...
5. Discharge plann...
6. Growth targets...
7. Preterm growth ...
8. Fetal-infant Gr...
11. Complementary ...
12. Immunization -...
13. Birth doses of...
14. Education of p...
15. Screening of p...
16. ROP screening...
17. Eye checkup at...
18. Hearing screen...
19. Neurodevelopme...
20. Opportunity to...
21. Intact outcome...
22. Table 01...
23. Table 02...
10. WHO growth cha...
9. Fetal-infant Gr...

Introduction

DR. NAVEEN JAIN
MD, DM (Neonatology)

Senior Consultant
Department of Pediatrics
Kerala Institute of Medical Sciences
Trivandrum

1. Care of preterm infants after hospital discharge

► Some of the preterm babies are at risk of neurodisability

► Screening of these at - risk babies, timely referral &
intervention will decrease disabilities

2. Learning objectives

Comprehensive care of preterm babies after discharge from the hospital

► Discharge planning
► Medical care
      ♦ Growth monitoring
      ♦ Recommendations on nutrition after discharge
      ♦ Recommendations on vaccination

► Neurodevelopment assessment
      ♦ Recommendations on screening (for prevention of
         neurodevelopment disability, NDD)
      ♦ Suggested follow up schedule for assessment
         with development

3. Discharge planning

► Each unit should have place dedicated to follow up services
that include all/ most of the services under one roof

► Dedicated personnel must coordinate the screening of at-risk
babies

► The unit may plan one or more days of the week dedicated
to follow up

4. Discharge summary

► The discharge summary must include baby’s gestation,
birth weight and risk factors for neurodevelopment – e.g.

      ♦ Antenatal steroids given/ evidence of fetal growth
         restriction/ fetal distress/ chorioamnionitis
      ♦ Need for resuscitation at birth
      ♦ Need for oxygen/ ventilation
      ♦ Shock/ need for blood transfusion
      ♦ Sepsis/ meningitis
      ♦ Adequacy of growth
      ♦ Hypoglycemia/ jaundice

5. Discharge planning – checklist

► Medical care
      ♦ Weight tracking on preterm growth chart
      ♦ Head circumference tracking
      ♦ Nutrition advice
      ♦ Immunization advice

► Neurodevelopment assessment
      ♦ ROP screening done/ scheduled
      ♦ Vision evaluation educated
      ♦ Hearing screen done/ scheduled
      ♦ Neuro sonogram done/ scheduled
      ♦ KMC
      ♦ Parent readiness for discharge

6. Growth targets

► Once preterm babies regain their birth weight (BW),
expected growth targets are:

      ♦ Weight – 15 to 20 gm/ kg per day
      ♦ Head circumference – 0.5 to 1 cm /week
      ♦ Length – 1 cm/week till 40 weeks

7. Preterm growth charts

► Weight, length and head circumference should be measured
    even when baby is in NICU and continued after discharge
► 1-2 weekly (after discharge from hospital) for a few weeks,
    then at each health care visit for vaccination
► The growth parameters must be plotted and growth
    tracked on growth charts for preterm babies (example:
    Fentons growth chart)

8. Fetal-infant Growth Chart for preterm infants - GIRLS

11. Complementary feeding

► Exclusive breast milk must be continued till 6 months
of age corrected for prematurity

► Complementary feeding with semisolid foods should be
started at 6 months of age

► There is no change in age of starting complementary
feeding for preterm babies

12. Immunization - no change for preterm babies

► The immunization schedule remains unchanged for preterm
babies (chronological age: counted from the date the baby
was born)

► Medically stable PT and low birth weight (LBW) infants
    should receive full doses of diphtheria, tetanus, acellular
    pertussis, Haemophilus influenzae type b, hepatitis B,
    poliovirus, and pneumococcal conjugate vaccines at a
    chronologic age consistent with the schedule recommended
    for full-term infants

13. Birth doses of BCG/ Hep B and OPV at discharge

► The birth doses of BCG, OPV may be given once the preterm
baby is medically stable and ready for discharge (at or after
34 weeks gestation)

► If preterm baby is < 2 kg, one may give Hep B once the baby is
30 days old/ ready for discharge (mother is Hep B negative
or immunized)

14. Education of parents on follow up

Neurodevelopment assessment

► Parents should be educated regarding

      ♦ The need to test
      ♦ Follow up schedules
      ♦ Possible interventions if a deviation from normal
        is detected

15. Screening of preterm babies – to prevent NDD

► ROP screening

► Vision assessment at 9-12 months

► Hearing screening and diagnostic tests before 6 months
of age

► Multi - domain development tests at 4, 8 & 12 months

► Neurosonogram at 1-2 weeks and 36- 40 weeks

16. ROP screening

► Often the preterm babies are discharged before the ROP
screening is complete

► The families must be educated on the need to follow up till
ophthalmologist informs that screening is complete/
treatment of ROP is required

17. Eye checkup at 9-12 months

► Preterm babies are at increased risk of strabismus, myopia
and late retinal detachment

► They should undergo examination by an ophthalmologist at
9 to 12 months of age

18. Hearing screen

► Preterm sick babies are at increased risk for sensorineural
hearing loss, so automated auditory brainstem response
(AABR) should be done

► It is best to complete AABR before discharge from hospital
  at birth admission
      ♦ Otoacoustic emissions (OAE) will fail to detect
        sensorineural hearing loss

► In baby fails screening tests, confirmation of hearing loss
and intervention must be initiated before 6 months age

19. Neurodevelopment assessment

► Assess neurologic abnormalities (tone)

► Multi-domain development screening
(e.g. CDC grade, Denver II, Bayley screener)

► Time: 4 , 8 and 12 months age corrected for prematurity

► Recognize, refer for early intervention

20. Opportunity to reduce disability

► Appropriate follow up is an opportunity to detect early and
correct deviations in development

► Neonatologist must explain to parents the tests and the
treatments

► Visits to the specialists may be facilitate by dedicated staff
      ♦ They are involved in parent education, managing
         appointments and guiding parents to intervention
         programs

21. Intact outcomes

► The goal to save preterm babies without disability can be
achieved by timely screening and appropriate interventions