Introduction And Rationale
- Improving perinatal-neonatal care has led to the increased survival of high-risk newborns.
- These survivors are at high risk of post-discharge morbidities.
- Morbidities include growth failure, ongoing medical illnesses, neurosensory impairment, and developmental deficits.
- A comprehensive follow-up program ensures intact survival and optimal quality of life.
Indications For High-Risk Follow-Up
- Rigorous follow-up of all discharged neonates is neither practical nor feasible.
- A cohort of high-risk neonates must be selected based on specific criteria.
| Primary Criteria | Specific Clinical Conditions Requiring Follow-Up |
|---|---|
| Extreme Prematurity & Low Birth Weight | Birth weight < 1500 grams. Gestation < 32 weeks. |
| Severe Neurologic Injury | Hypoxic ischemic encephalopathy (HIE) stage 2 or higher. Meningitis. Abnormal neurological examination or seizures at discharge. Intraventricular hemorrhage (IVH) grade III or periventricular leukomalacia (PVL). |
| Respiratory Morbidity | Received mechanical ventilation for 48 hours or more. Chronic lung disease or bronchopulmonary dysplasia (BPD). |
| Severe Metabolic & Systemic Issues | Intrauterine growth < 3rd centile. Major malformations or inborn errors of metabolism. Symptomatic hypoglycemia or polycythemia. Hyperbilirubinemia requiring exchange transfusion. |
Prerequisites For Discharge And Follow-Up
- Discharge planning should ideally begin many days before discharge.
- The neonate must be hemodynamically stable and maintain body temperature in an open crib.
- The infant must be on full enteral feeds, either through direct breastfeeding or paladai/spoon.
- There must be a stable weight gain for at least three consecutive days.
- Very low birth weight (VLBW) infants should reach a weight of at least 1600 grams before discharge.
- The infant must be off all medications, except for vitamins and iron.
- Preterm infants on caffeine therapy should be off treatment for at least 5 days prior to discharge.
- Parents must be confident to care for the infant at home.
Schedule Of Follow-Up
- The follow-up schedule should be clearly explained and documented in the discharge summary.
| Infant Category | Initial Visits | Subsequent Visits |
|---|---|---|
| Very Preterm Infants | 3 to 7 days after discharge. Every 2 weeks until body weight reaches 3 kg. | 1, 2, 3, 6, 9, 12, 15, 18, and 24 months. Yearly visits until 8 years of age. |
Corrected Age Versus Postnatal Age
- Corrected age is the age of the child since the expected date of delivery.
- Correction for gestational immaturity must be used until 24 months of age.
- Anthropometric parameters, developmental milestones, and initiation of complementary feeds are assessed according to corrected age.
- Postnatal age is the age since birth and is strictly used for scheduling immunizations.
Domains Of Assessment
Growth And Nutrition
- Assessment involves accurate weight, length, and head circumference measurements.
- Serial plotting on growth curves provides valuable information regarding nutritional status.
- Fenton or Intergrowth-21 charts are used for preterm infants.
- WHO Child Growth Standards can be used for monitoring growth after reaching term age.
- Dietary counseling and breastfeeding assessment must be offered at each visit.
Neuromotor And Developmental Screening
- Early identification of developmental disability allows for appropriate planning and parental counseling.
- Screening should be performed at 3, 6, 9, 18, and 24 months of corrected age.
- Amiel-Tison neurological assessment is widely used for evaluating muscle tone.
- Hammersmith Infant Neurological Examination (HINE) is a standardized clinical examination for infants between 2 and 24 months.
- A HINE score of less than 40 is always associated with cerebral palsy (CP).
- A HINE score less than 56 at three months strongly predicts CP at two years of corrected age.
| Common Screening Tools | Description |
|---|---|
| Trivandrum Development Screening Chart (TDSC) | Assesses gross motor, fine motor, vision, hearing, and language. |
| Denver Developmental Screening Test-II (DDST-II) | Assesses gross motor, language, fine motor-adaptive, and personal-social domains. |
| Development Assessment Scale for Indian Infants (DASII) | An Indian adaptation of Bayley-II. Gives developmental age expressed as a percentile. |
Hearing And Vision
- Retinopathy of prematurity (ROP) screening must continue until 40 to 44 weeks postconceptional age or until retinal vessels mature.
- Visual acuity should be formally assessed at nine months of age.
- Children failing a two-stage hearing screening should undergo a diagnostic Brainstem Evoked Response Audiometry (BERA) evaluation by 3 months of age.
Multidisciplinary Follow-Up Team
- High-risk infant follow-up requires a multidisciplinary approach.
- The neonatologist or pediatrician acts as the nodal coordinator.
- The team includes a clinical psychologist, early interventionist, physiotherapist, occupational therapist, and speech therapist.
- A nutritionist and medical social worker are essential for diet and family support.
- Specialists like an ophthalmologist and pediatric neurologist should be available for ready referral.
The BLUE BOOK Checklist Model
- A structured checklist model, known as the "BLUE BOOK," guides the follow-up of a very preterm baby from birth to 6 years.
- It documents perinatal risk factors, risk stratification, growth, and developmental screening.
- This tool facilitates a systematic, organized, and complete transition of care from the NICU to the community.