"NEONATOLOGY PRESENTATIONS

1. Follow up of a NICU Graduate
Dr.Ashish Jain DM (Neonatology)
Assistant Professor (Neonatology)
Department of Neonatology
Maulana Azad Medical College
New Delhi
26th July 2017 1Dr Ashish Jain DM (Neonatology)

2. Chapter Layout
• Why is FU Needed?
• Follow-up Team
• IN NICU team and DSC
• Who needs Follow-up / Some evidence and degree of NDD
Categorical ( At risk Follow-up)
• Discharge planning / Hammersmith abridged scale
• Follow-up Schedule
3rd December 2011 Dr Ashish Jain DM (Neonatology) 2

3. Cont.
• Schedule Layout ( 1 -2 Para each with template paper as annexure
in the end )
• A= Anthropometry
• B= Breastfeeding
• C= Maternal Concerns
• D= Development
• E = Eye
• F= Follow-up Investigations
• G= Growth Monitoring ( Charts )
• H= Hearing
• I = Immunization with special ref to Preterm
• J = Just Keep in Mind ( Danger signs )
• Representative discharge summary and follow-up book
• Establishment of a follow-up clinic / Experiences and references
• Key Messages
3rd December 2011 Dr Ashish Jain DM (Neonatology) 3

4. Volume
• 5 Pages
• Word count of 4000
• Annexures ( Both sides : 5)
• Few Photographs for difficult signs
• CR issues , as many charts will be enclosed
3rd December 2011 Dr Ashish Jain DM (Neonatology) 4

5. Introduction, Why ?
• Neonatal Intensive care in a NICU has long lasting
effects
• As more and more high-risk neonates are surviving,
there is higher rates of major and minor disabilities
• Growth failure and ongoing medical illnesses are
more frequent in these NICU graduates
• Early detection & early intervention has shown to
help these babies
3rd December 2011 5Dr Ashish Jain DM (Neonatology)

6. Intensive care
Follow up care
Magnitude of Follow-up care needed after NICU care
Intensive care is incomplete and un-committed without a follow-up3rd December 2011 6Dr Ashish Jain DM (Neonatology)

7. Follow-Up Team
• Pediatrician/Neonatologist – Primary care
• Nurse
• Developmental therapist
• Nutrition specialist
• Clinical psychologist
• Ophthalmologist
• Audiologist
• Social worker
3rd December 2011 7Dr Ashish Jain DM (Neonatology)

8. Pediatrician Or
Neonatologist +
Nurse
Ophthalmologist +
Audiologist +
Ultrasonologist +
Metabolic Lab
Once a week
Developmental
Therapist + Clinical
Psychologist +
Nutrition
Specialist
SOCIAL WORKER/ TELEPHONE CALLS
3rd December 2011 8Dr Ashish Jain DM (Neonatology)

9. At risk Neonate identification
• <1800 grams/ <34 weeks
• Small for date < 3 percentile
• Large for date > 97 percentile
• Major malformation
• Culture proven sepsis/ meningitis
• Hyperbilirubinemia (>20 mg/dl)
• Symptomatic hypoglycemia/ polycythemia
• Seizures
• APGAR<4 at 5 minutes ( Birth asphyxia)
• Aminoglycosides/prolonged diuretics
Balance and prioritize based on your resources
3rd December 2011 9Dr Ashish Jain DM (Neonatology)

10. Good discharge planning=Good Follow-up
• Readiness of Discharge :
1. Crossed birth weight
2. At least 1.4-1.6kg
3. Steady weight gain
4. Able to maintain temp in open crib
5. Accepting all feeds orally
6. Medically stable – no apnea/bradycardia
7. No major medical or nursing care needs that cannot be managed at
home
8. Mother Confident to take care of the baby / Danger Signs / Medication
Parents Confident
3rd December 2011 10Dr Ashish Jain DM (Neonatology)

11. Discharge Summary (Components)
Correct Address and
telephone No
Discharge summary
(History/ Course/
Plan)
Referrals with logistics
and date
Parental Education
• Condition and disorder of
the infant
• Need for follow up (why,
when, where)
• Brain plasticity and
importance of early
intervention
Notify emergency care
providers
• Give the numbers , person to
contact, place to rush
3rd December 2011 11Dr Ashish Jain DM (Neonatology)

12. Schedule of Follow-up
Every Wk till 1
month
Monthly till 3
months
3 monthly till 1 yr
6 monthly till 5
yrs
Yearly till 16
yrs
Customize
to your
resources
A
B
C
D
E
F
G
H
I
3rd December 2011 12Dr Ashish Jain DM (Neonatology)

13. EARLY
INTERVENTION
Anthropometry
Breastfeeding
Counseling
Parental Edu
Development
EyeFollow-Up
investigations
Growth
charts
Hearing
Immunization
3rd December 2011 13Dr Ashish Jain DM (Neonatology)

14. Anthropometry (Page 01) A
Date CGA
(EDD=40
wks)
Wt Wt
Gain
HC HC Gain Length L Gain Remarks
3/12/11 36 + 2days 2200 16/k/d 32 0.5/wk 44.5 cm 0.6/wk Progress
Rate of Head Growth very Important
Preterm 0.5-0.75cm/wk till term after 1st week
1st 3 months 2cm/month
4-6 months 1cm/month
7-12 months 0.5cm/ month
12-24 months 2 cms
24months to 5 years 0.5 cm/yr
3rd December 2011 14Dr Ashish Jain DM (Neonatology)

15. Breastfeeding / Feeding (Page 02) B
Date CGA
(EDD=40
wks)
B Feeding Other feeds Complim
entary
Supplements Remarks
3/12/11 36 +
2days
Ex : YES
Po : Good
At : Bad
HZ: 8-10
Pr : Nil
Ng : YES
H20: NO
TOP: yes
Type: FF
Bottle : NO
Dilun : Appr
Quantity
:
Content :
Hz :
Snacks :
HMF :
Vitamin D :
Vitamin E :
Iron :
Calcium :
Phosphorous
Calories :
Protein :
3rd December 2011 15Dr Ashish Jain DM (Neonatology)

16. Counseling (Page 03) c
Date CGA
(EDD=40
wks)
Hygiene/
Mother diet
KMC Concerns Monitor
medication
administration
Remarks
3/12/11 36 +
2days
Bath
Diet
Sleep
Breast Care
Demo Bath
Powder
Oil
Nipple
Diaper
S dermatitis
Hiccups
Posse ting
Growth
•Demonstrate
the dilution
• administration
of medications
• danger signs
recognition,
•Drill in case of
ALTE
•Expression
•Understanding
of discharge Plan
3rd December 2011 16Dr Ashish Jain DM (Neonatology)

17. Development (Page 04) D
Date 40 wks 2
months
4
months
6
months
9
months
12
months
3/12/11
DDST
Gross Motor
Fine Motor
Socio-Adaptive
Language
CDC
Head Holding (4 months)
Sitting (8 Months)
Standing (12 Months)
Amiel Tison
Other Observation
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18. DENVER DEVELOPMENTAL SCREENING TEST
3rd December 2011 18Dr Ashish Jain DM (Neonatology)

19. NORMAL – pass all (2) items to left and any one
cut by age line
3rd
July17
P
P
P
NORMAL
3rd December 2011 19Dr Ashish Jain DM (Neonatology)

20. Abnormal – fail all (2) items to left
3rdJuly17
F
F
ABNORMAL
3rd December 2011 20Dr Ashish Jain DM (Neonatology)

21. Questionable – Pass all (2) items to left but none cut
by age line
July3rd2017
P
P
F
F
F
QUESTIONABLE
3rd December 2011 21Dr Ashish Jain DM (Neonatology)

22. Questionable – fail 1 items to left but none cut
by age line
3rdJuly
2017
P
F
F
F
F
QUESTIONABLE
3rd December 2011 22Dr Ashish Jain DM (Neonatology)

23. Assessment of tone :Normal range of angles in
infancy
Age
(mon)
Adductor
angle
Popliteal
angle
Dorsi-
flexion of
ankle
Scarf sign
(position of elbow)
0-3 40-80 80-100 60-70 Does not cross
midline
4-6 70-110 90-120 60-70 Just crosses
7- 9 110-140 110-160 60-70 Beyond axillary
line
10-12 140-160 150-170 60-70 ”
3rd December 2011 23Dr Ashish Jain DM (Neonatology)

24. CDC Grading : Interpretation
CDC Grading of major milestones
developed at Child Development Center,
Trivandrum
Interpretation of CDC grading
Grade 0, 1, and 2 – abnormal for that age
Grade 3, 4, and 5 – normal for age
3rd December 2011 24Dr Ashish Jain DM (Neonatology)

25. Grading of Head holding (4 months)
Head holding – completed 4 months
Grade 0: No head holding at all
Grade 1: head erect and steady momentarily
Grade 2: dorsal suspension – head lifts along with body
Grade 3: prone position, elevates on arms, lifting chest
If child lifts head without rising on arms, with head lag or without grade 2,
this is abnormal
Grade 4: head hold steady while mother moves around
Grade 5: head balanced at all times
3rd December 2011 25Dr Ashish Jain DM (Neonatology)

26. Eye : ROP (Page 05) E
• <1750 or <34 or up to 1.8kg /34 with risk factors (oxygen
therapy > 4 hours, MV,ET)
• Post natal 4 weeks or 31 weeks which ever is later
• Follow-up 1-2 weeks depending upon the stage
• Treatment (based on ET ROP)
– Zone 1: any stage with plus disease
– Zone 1: stage 3 – no plus disease
– Zone II stage 2 or 3 with Plus disease
• At 6-9 months: squint, nystagmus and refractive
errors
3rd December 2011 26Dr Ashish Jain DM (Neonatology)

27. Eye : ROP (Page 05) E
Date CGA Right Eye Left Eye Next
Exam
Zone Stage Clock Plus Zone Stage Clock Plus
Date Examination Finding
9 months
12 months
5 years
3rd December 2011 27Dr Ashish Jain DM (Neonatology)

28. Follow-Up Investigations/ Referrals
Date CGA USG Ca/P/AP CT MRI Hb/PCV Others
T4/TSH
1st week
40 Wks
3 mths
F
Date Department Advice Next Visit
Genetics
Hematology
Pediatric Surgery
Orthopedics
3rd December 2011 28Dr Ashish Jain DM (Neonatology)

29. Screening for congenital hypothyroidism
When to screen
Logistics Details
Who to screen Desirable All neonates, Mandatory All babies at risk
of NDD
When to screen •Beyond day 3 and before 1 week of life
•Before discharge from hospital (if early discharge)
How to screen Desirable TSH and Free T4, recommended TSH for all
and FT4 if necessary
What to look for TSH > 20 in 1st 2 weeks of life, TSH > 10 after 1st 2
weeks of life
(Start treatment by 2 weeks)
3rd December 2011 29Dr Ashish Jain DM (Neonatology)

30. • Indications
– Preterm < 32 weeks gestation, < 1500 grams weight at
birth
– Preterm with abnormal Neuro – symptoms /
examination – seizures, lethargy, apnea, with sudden
onset pallor, bulging anterior fontanel, tight popliteal
angles
• Protocol – 1st at 1-2 weeks and , 2nd at 36 - 40
weeks gestation*
* Look for evidence of brain atrophy as in ventriculomegaly / cystic Peri-
Ventricular Leukomalacia
Neuro-sonogram
3rd December 2011 30Dr Ashish Jain DM (Neonatology)

31. Growth Characteristics : Charts G
Time Chart that can be used Annexure Needed
Till 40
weeks
Correct
ed Age
Intergrowth –Fetal –Preterm growth charts 2 (1 page)
After
40
Weeks
WHO GROWTH CHARTS
WT for AGE
HT for Age
HC for Age
Wt for Height
(Separate for Boys and Girls)
4 (Boys)
4 (Girls)
4 Pages
Total 10 Charts and 5 pages
3rd December 2011 31Dr Ashish Jain DM (Neonatology)

32. FETAL GROWTH
STANDARD
CHARTS

33. POSTNATAL GROWTH OF PRETERM CHARTS

34. POSTNATAL GROWTH OF PRETERM CHARTS

35. VERY PRETERM CHARTS

36. WHO Growth Charts
3rd December 2011 36Dr Ashish Jain DM (Neonatology)

37. Need for Early Screening
Who to screen ? Desirable – all neonates, Mandatory – all babies
admitted to NICU
When to screen ? • Desirable – before discharge from NICU, Mandatory
– within 3 months of life
• Babies who risk factors for hearing loss should have a
diagnostic hearing test at 1 yr (even if passed the
screening test)
How to screen ? •OAE – for all babies
•BERA – babies who fail repeat OAE / babies at high
risk of NDD
When to intervene ? •ASAP at least by 6 months of age
3rd December 2011 Dr Ashish Jain DM (Neonatology) 37
Hearing Screening H

38. Need for Early Screening
HIV Positive Mothers
• Asymptomatic : Similar to
other babies
• Symptomatic : Avoid Live
vaccines, e.g., BCG, OPV
HIB Vaccine
• Offer vaccine in the high risk
population of VLBW babies
as greater risk of fatal
pneumonia
3rd December 2011 Dr Ashish Jain DM (Neonatology) 38
Immunization
(Only place where chronological age is used and not CGA) I
Influenza vaccine
• Preferred and offered in the
VLBW babies and babies
with CLD
• Evidence poor
• Biology/ rationale to use in
the Birth asphyxia babies
and the babies with seizures
• No evidence ?
A cellular Vaccines

39. Immunization and HbsAg of Mother
Status Recommended
HBS Ag + Mother HBIG (24), HBV (24), 6wks, 14 wks or 6 wks,
6 months
HBIG (12), HBV (12) , 1,2,6 months (PT), 1
and 6 months(Term),
check for seroconversion 9-15 months
HBSAg Unknown 0, 6wks,14wks or O, 6wks , 6 months
0,1,6 (HBIG upto 7 days-term or <12 hrs if
PT)
HBSAg Negative 0,6wks,14wks or0, 6wks,6months or 6, 10 &
14 weeks.
PT 30 days/2kg/discharge, 1 , 6 months
Term: 0,1,6
3rd December 2011 39Dr Ashish Jain DM (Neonatology)

40. Need for Early Screening
1. Lack of alertness
2. Episodes of inconsolable cry
3. Excessive sensitivity to light or noise
4. Poor sleep
5. Constant fisting after 2 mo
6. Decreased spontaneous motility
7. Lip smacking/ chewing
8. Asymmetric movements/posture
9. Poor suck/swallow coordination
10. Feeding difficulty / Tongue thrusting
11. Hand dominance before 18 mo.
12. Poor head growth
13. Tone abnormalities
14. Persistence of primitive reflexes
15. Delayed appearance of postural/ protective reflexes
16. Lack of ocular/ visual/verbal/auditory responses
17. Seizures
3rd December 2011 Dr Ashish Jain DM (Neonatology) 40
Just Watch for J

41. High risk file
Paper Information
O Identification, emergency numbers, primary care giver,(JR,SR,COC)
Team leaders, Map, Days-Time-Clinic
1 Discharge with 5 components
2F Anthropometry
2B Breastfeeding/ Feeding
3F Counseling / Nutrition
3B Developmental status
6 (Annexure) DDST / AT / CDC on the back
7A ROP
7B Follow-up investigations / special consults
8-12 Annexure for the Charts
13 Immunization / hearting
14 & 15 Information to parents
3rd December 2011 41Dr Ashish Jain DM (Neonatology)

42. Conclusions
• Follow up of high risk neonate is an important aspect
of neonatal care
• This is mandatory for a NICU
• Importance needs to be understood and explained to
the parents
• Multidisciplinary approach but doable by a
pediatrician
• Record keeping is vital and recall important for
sustenance
3rd December 2011 42Dr Ashish Jain DM (Neonatology)