- ⇒ Thermal Care
- ⇒ Best Practices in Breast Milk Feeding
- ⇒ Developmental Supportive Care
- ⇒ Screening Protocols for High-risk Newborns at Discharge
Rhishikesh Thakre
INTRODUCTION
The purpose of thermal care is a series of measures to be taken to ensure that the newborn:
- Maintains a normal body temperature (36.5–37.5°C)
- Does not become too cold (<36.5°C = hypothermia)
- Does not become too hot (>37.5°C = hyperthermia)
These measures must be initiated from the time of birth, during hospital stay and at home (Boxes 1.1.1 and 1.1.2). Neonatal temperature may start falling by 0.5–1°C every minute if not supported after birth.
All newborns must be assessed for thermal wellbeing at every opportunity. No single sign is pathognomonic of thermal instability (Table 1.1.1). The recommended method of screening for thermal wellbeing is measuring axillary temperature by thermometer.
CHOICE OF HEATING EQUIPMENT: WARMER OR INCUBATOR
The decision of using incubator or radiant warmer in hospital care is based upon:
- Familiarity and ease of use.
- Experience of the staff.
- Quality of infection control measures.
Each equipment has its advantages and disadvantages. Following babies may be candidates for incubator care:
- Care of extremely low-birth-weight (LBW) babies for humidification.
- For isolating an infected baby to achieve barrier nursing.
- For use at low ambient temperature or when there is a lot of convective current where a radiant warmer fails to work.
- For transporting babies.
MODE OF THERMAL CONTROL—SKIN OR AIR MODE
Skin Mode
The heater output is controlled by the baby's skin temperature which is set at a desired level. The heater cycles to keep the skin temperature at that constant.
Advantages
- Useful in rewarming of hypothermic babies in a graded manner.
- A set skin temperature of 36°C would suffice for all LBW babies.
- Reduced need for close monitoring of infant temperature.
Disadvantages
- Marked fluctuations in air temperature.
- If the skin probe gets partially dislodged or displaced, overheating occurs.
- Inappropriately low ambient temperature if the infant is febrile.
- Fever is likely to be missed unless infant temperature is checked frequently.
- Masking of hypo- or hyperthermia in baby.3
Air Mode
The air temperature is set to a desired level and a thermostat in the air flow maintains this temperature.
Advantages
- Proportionate heat control.
- Fluctuations in air temperature minimal.
Disadvantages
- If the air probe is placed away from the body, it will cause variable heating.
- If the air probe is covered, it will cause variable temperature changes.
SITE OF TEMPERATURE PROBE
- The thermal sensor in skin mode needs to be fixed over abdomen firmly if the baby is in supine position.
- In prone position, the flank may be used.
- Areas with high metabolic rate as the right hypochondrium (due to underlying liver) need to be avoided.
- Probe should not be applied over bruised or broken skin.
SETTING TEMPERATURE
During the first week after birth, LBW babies should be provided with a carefully regulated thermal environment that is near the thermoneutral point. This can be achieved by adjusting temperature to maintain an anterior abdominal skin temperature of at least 36.5°C, using either servo-control or frequent manual adjustment of air temperature.
MANAGING A COLD BABY HYPOTHERMIA (TABLE 1.1.2)
- Active intervention must be done if the axillary temperature is less than 36.5°C.
- The method, or combination of methods selected will depend on the severity of the hypothermia and the availability of staff and equipment.
- Measure the baby's temperature every hour for 3 hours. Once the baby's temperature is normal, measure the baby's temperature every 3 hours for 12 hours.
- If the baby's temperature is increasing at least 0.5°C per hour over the last 3 hours, rewarming is successful.
- Ensure feeding and euglycemia if baby is active or start IV fluids and check sugar.
- Every hypothermic newborn should be assessed for infection.
MANAGING HYPERTHERMIA (>37.5°C)
Hyperthermia, because of overheating or underlying infection, can be ruled out by following bedside clues (Table 1.1.3).
- Put off the heat source.
- Do not give antipyretic drugs to reduce the baby's temperature.
- If hyperthermia is due to overheating, reduce the temperature setting on the warming device:
- Undress the baby partially or fully for 10 minutes and then clothe the baby.
- Observe for signs of sepsis (e.g. poor feeding, vomiting, and breathing difficulty) and repeat when the baby's temperature is within the normal range.
- Measure the baby's temperature every hour until it is within the normal range.
- Review nursing care practices to ensure that the problem does not happen again.
- If the hyperthermia is due to exposure to a high ambient temperature or sun exposure:
- Place the baby in a normal temperature environment (25°–28°C).
- Undress the baby partially or fully for 10 minutes, then dress and cover the baby.
- If the baby's temperature is more than 39°C: Sponge the baby or give the baby a bath for 10–15 minutes in water that is about 4°C lower than the baby's current temperature; Do not use cold water or water that is more than 4 °C lower than the baby's temperature.
- Measure the baby's temperature every hour.
- If the baby's temperature is still abnormal after 2 hours, treat for sepsis.
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- Allow the baby to begin breastfeeding at the earliest. If the baby cannot be breastfed, give expressed breast milk using an alternative feeding method.
- If there are signs of dehydration (sunken eyes or fontanel, loss of skin elasticity, or dry tongue or mucous membranes):
- Establish an IV line and give IV fluid at maintenance volume according to the baby's age. Increase the volume of fluid by 10% of the baby's body weight on the first day that the dehydration is noted.
- Measure blood glucose. If the blood glucose is less than 45 mg/dL (2.6 mmol/L), treat for low blood glucose.
- Once the baby's temperature is within the normal range, measure the baby's temperature every 3 hours for 12 hours. If the baby's temperature remains within the normal range, discontinue measurements.
- If the baby is feeding well and there are no other problems requiring hospitalization, discharge the baby.
- Advice the mother how to keep the baby warm at home and protect from overheating.
PRACTICE POINTERS (BOX 1.1.3)
- No heating device can function efficiently in a cold room.
- The head has the greatest potential for heat loss due to its surface area, therefore, cover the head to minimize heat losses in smaller babies.
- All staff using the equipment must have received the appropriate on-the-job training in its use.
- An instruction manual must always be available for reference purposes.
- A specific procedure for cleaning and maintenance of equipment must be specified and adhered to.
PARENT INFORMATION
- Keep the baby and mother together.
- Cover the baby's head always with a cap.
- If the environment is cold, place socks and gloves with warm clothing. If the environment is warm, use loose cotton clothing and ensure air circulation by keeping the windows open, fan turned on with no direct draft of air over the baby.
- Breastfeed the baby exclusively and on demand.
- Report if: (a) Baby's trunk and soles appear warm or cold to touch, and (b) Baby does not feed over 6 hours.
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KEY POINTS
- The newborn cannot regulate its temperature as well as an adult and, therefore, needs to be protected from cold and heat.
- Thermal instability in a newborn is more due to lack of knowledge than to lack of equipment.
- In trying to keep babies warm, it is important to make sure they do not become overheated. Hyperthermia is as dangerous as hypothermia.
- There is no single environmental temperature that is appropriate for all sizes, gestational ages and conditions of newborn babies.
BIBLIOGRAPHY
- EM McCall EM, Alderdice FA, Halliday HL, et al. Interventions to prevent hypothermia at birth in preterm and/or low-birth-weight babies. Cochrane Database Syst Rev. 2008;(1):CD004210.
- Sinclair JC. Servo-control for maintaining abdominal skin temperature at 36°C in low-birth-weight infants. Cochrane Database Syst Rev. 2002;(1):CD001074.
- Thermal protection of the newborn: a practical guide. Geneva: Department of Reproductive Health and Research (RHR), World Health Organization; 1997.
1.2 Best Practices in Breast Milk Feeding
Rhishikesh Thakre
INTRODUCTION
Human milk is the preferred source of nutrition for all newborns. It is considered as safe and appropriate, because of its better digestion and absorption, improvement in host defense, and improved neurodevelopmental outcomes.
GOOD CLINICAL PRACTICES FOR SUCCESSFUL BREASTFEEDING
Good practices for initiating, maintaining lactation prior to birth, in delivery room, postnatal ward, NICU, home and in office practices are highlighted (Boxes 1.2.1 to 1.2.6).
OPTIMIZING USE OF HUMAN MILK IN TERM/PRETERM
Key issues that need to be addressed to optimize use of human milk in term and preterm newborns are described in Table 1.2.1.
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ROLE OF BREAST MILK SUBSTITUTES
- Donor human milk is available as an alternative feeding option if breast milk is unavailable or mother cannot breastfeed. The donor breast milk is similar to mother's milk, has better tolerance and may reduce the risk of necrotizing enterocolitis (NEC). Pooled donor and mature human milks are meant for short-term use and are inadequate to support growth and bone mineralization in the low-birth-weight infant. A Cochrane review has found that feeding with formula compared to donor breast milk increases the risk of serious gut problems in preterm or low-birth-weight infants. The human milk banks are, however, few and not accessible to majority.
- Formula is used when neonates are not receiving breast milk or donor milk. Formula feeding has shown to cause better short-term growth and earlier hospital discharge. However, formula feeds are difficult to tolerate compared to human milk, may cause vomiting, abdominal distention, increased risk of infection and NEC. Studies show use of preterm formula (<2,000 g) was significantly contributing to higher weight gain at hospital discharge but no significant differences in weight, height or head circumference at 18 months and at 7.5–8 years in infants who had been fed preterm or standard infant formula.
- Studies examining the impact of nutrient-enriched formula on growth outcomes had mixed results. Considering the weak evidence of benefits and substantially higher costs of nutrient-enriched formula, its routine use cannot be justified in developing country settings.
- Animal milk has been used in developing world based on personal beliefs and cultural practices. Adverse effects and hazards following animal milk use have been documented in several studies. No policy statements on the use of animal milk were located from international or national organizations.
- Others: The use of water for enteral feeding also has been shown not to affect intestinal motility as compared with milk. Using glucose solution as first feed is strongly discouraged as it is hyperosmolar.
ROLE OF NUTRITIONAL SUPPLEMENTATION IN EXCLUSIVE BREASTFED NEONATES
Vitamin D: Breast milk alone is not sufficient to maintain newborn vitamin D levels within a normal range. On a community level, the WHO recommendations suggest intake of vitamin D of 400 IU per day.7
Iron: Iron supplementation at 6–8 weeks of age and as early as 2 weeks in very-low-birth-weight (VLBW) infants leads to significant improvements in hemoglobin at 4 weeks and 8 weeks and associated with improved neurocognitive development.
Calcium-phosphorus: Preterm human milk provides insufficient calcium and phosphorus to meet their estimated needs. There are no data on the effect of phosphorus and calcium supplementation on key clinical outcomes in infants with a birth weight greater than 1,500 g. It is suggested to supplement till 40 weeks postmenstrual age (PMA).
Zinc: There are no data on the effect of zinc on key clinical outcomes in preterm infants. Data from two trials in developing countries suggest that term low-birth-weight infants in developing countries may have lower mortality and morbidity if they receive zinc supplementation. There seems to be no evidence that zinc supplementation in these infants improves neurodevelopment or affects growth.
Human milk fortification: A Cochrane review on “multicomponent fortified human milk for promoting growth in preterm infants” concluded that supplementation of human milk with multicomponent fortifiers is associated with short-term increases in weight gain, linear and head growth. There are insufficient data to evaluate long-term neurodevelopmental and growth outcomes, although there appears to be no effect on growth beyond 1 year of life. The issues of concern in developing countries are higher prevalence of infections, a greater risk of contamination and high fortifier costs.
LCPUFA/DHA supplementation: In a Cochrane review, most studies found no significant differences in any visual assessment between supplemented and control infants. There was also no evidence that supplementation of formula with n-3 and n-6 long-chain polyunsaturated fatty acid (LCPUFA) impaired the growth of preterm infants.
SPECIAL ISSUES IN HUMAN BREAST MILK FEEDING
Breast Milk Expression
Low-cost interventions including initiation of milk expression sooner after birth when not feeding at the breast, relaxation, massage, warming the breasts, hand expression and lower cost pumps may be as effective, or more effective, than large electric pumps.
Human Immunodeficiency Virus +ve Mother
- Individualized decision making and counseling.
- Screening for acceptable, feasible, affordable, sustainable and safe (AFASS) criteria.
- Promote and actively counsel on exclusive breastfeeding.
- Expressed breast milk feeding for 6 months if all AFASS criteria not met.
- Avoid mixed feeding, early weaning, and abrupt weaning.
- Prepare for stopping breastfeeding at 6 months if AFASS criteria are met.
- Continue maternal antiretroviral therapy.
SUMMARY
- Breast milk is the most optimal for feeding and is the preferred choice for all neonates— well or sick.
- When not available, pasteurized donor human milk followed by formula milk is acceptable alternatives.
- All efforts must be made to ensure lactation in NICU mothers.
- Exclusive breastfeeding is recommended for at least first 6 months of life.
- Routine use of the multicomponent fortification of the breast milk should be avoided and targeted to less than 32 weeks gestation or less than 1,500 g birth weight baby who fails to gain weight despite adequate breast milk feeding.
BIBLIOGRAPHY
- Davanzo R, Travan L, Brovedani P. Practical strategies for promoting breastfeeding in neonatal intensive care. Minerva Pediatr. 2010;62(3 Suppl 1):205–6.
- Edmond K, Bhal R. Optimal feeding of the low-birth-weight infants. Technical Review. Geneva: World Health Organization 2006. pp. 1–130.
- Henderson G, Fahey T, McGuire W. Multicomponent fortification of human breast milk for preterm infants following hospital discharge. Cochrane Database Syst Rev. 2007;(4):CD004866.
- Lechner BE, Vohr BR. Neurodevelopmental Outcomes of Preterm Infants-fed Human Milk: A Systematic Review. Clin Perinatol. 2017;44(1):69–83.
- McFadden A, Gavine A, Renfrew MJ, et al. Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database Syst Rev. 2017;2:CD001141.
- Meier PP, Johnson TJ, Patel AL, et al. Evidence-based Methods That Promote Human Milk Feeding of Preterm Infants: An Expert Review. Clin Perinatol. 2017;44(1):1–22.
- Quigley M, Henderson G, Anthony MY, et al. Formula milk versus donor breast milk for feeding preterm or low-birth-weight infants. Cochrane Database Syst Rev. 2014;(4):CD002971.
- Smith HA, Becker GE. Early additional food and fluids for healthy breastfed full-term infants. Cochrane Database Syst Rev. 2016;(8):CD006462.
1.3 Developmental Supportive Care
Naveen Jain
INTRODUCTION
Preterm babies spend many days/weeks in the NICU. Environment of the ICU, sensory inputs and experiences of the preterm baby are very different from what the fetus experiences in utero. These may have impact on “normal development”. Development supportive care refers to the practices that are expected to simulate the natural environment/experiences of the fetus and minimize deviation from normal development.
Some of the practices are provided in Table 1.3.1.
EARLY PARENT PARTICIPATION
Preterm babies spend many days to weeks in the NICU. Conventionally, Indian NICUs limit the access of parents to NICU. This leads to long separation of the baby from his/her parents. Parents must be allowed to visit their baby unrestricted or at least allowed long visiting hours. They must be encouraged to touch their baby, talk to the baby and get involved in care processes like feeding (even by orogastric tube), diaper changes, touch and massage. They may even be trained to give nutritional supplements like calcium phosphate, iron, human milk fortifier (HMF), etc. This decreases the parent separation anxiety, decreases risk of infections (as parents are not carriers of multidrug resistant bugs like NICU staff!).
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Baby Position
In utero, the fetus is floating in amniotic fluid, and does not face gravity. But in the NICU, long durations of unsupported positioning of limbs may result in lengthening of some muscle groups and tone abnormalities. Babies placed supine in a nest demonstrate better postures and movements (general movements assessment tool). Symmetrical, flexed, and midline position using special wrap (Dandle ROOTM) also showed improvement in subsequent development.
Massage
A meta-analysis of 17 studies showed an advantage as improved weight gain and early discharge from hospital. No direct benefit on neurobehavior was demonstrated. A study is underway to assess the effect of massage on MRI, EEG of very preterm infants (PREMM—preterm massage by mother). Preterm babies receiving tactile kinesthetic stimulation (massage protocol) demonstrated better behavior (self-regulated and adjusted behavior responses).
Lighting
An elaborate paper was published recently describing details of NICU lighting, role of natural light, protection of baby's eyes from constant bright light, use of color in NICU, day-night cycling, dimming of light, etc. Recommendations include focused light of 2,000 Lux for procedures. Day light 100–200 Lux that includes natural light at night less than 50 lux.
Sound and Noise Levels
It is rational to reduce the noise of alarms, banging of incubator doors and decreasing loud conversations near babyside. There are systematic studies to prove the same. Music played in the unit has been tried, but no demonstrable benefit is noted. Ear plugs were used in a small trial, no difference was noted in babies with ear plugs.
Clustering of Care
Clubbing of procedures is expected to reduce the handling time and give more rest time to babies. But, scientific studies comparing clustering with care with routine care showed no differences.9
Minimizing Pain in Neonatal Intensive Care Unit
Decreasing painful procedures, nonpharmacological pain alleviation (breast milk, sucrose, etc.), topical analgesia, opioid and nonopioid analgesia.
Oromotor Stimulation
A systematic review that included 11 trials and 855 participants, showed shorter time to oral feeding, improved efficiency of feeding, greater feed intake and better weight gain. Some studies used non-nutritive sucking in addition, by placing a pacifier in the baby's mouth. In an Indian study, oromotor stimulation significantly reduced the duration of gavage feeding. The baby's cheeks, lips, tongue, and jaw were stroked and gums rubbed before every feed.
Kangaroo Mother Care
Recently published systematic review that included 13 studies demonstrated clear benefits in growth of very low-birth-weight babies and breast milk feeding rates.
Kangaroo mother care (KMC) involves skin-to-skin contact between the baby (wearing just a diaper) and between the breasts of the mother or bare chest father. The baby is covered with a blanket. This improves thermoregulation. Continuous kangaroo care (as long as possible) is recommended. KMC may be started very early, even when baby is on continuous positive airway pressure (CPAP), high flow nasal cannula (HFNC) or IV fluids. It is best continued as long as the baby likes the KMC.
FACILITATE AND PROMOTE LANGUAGE, VISION AND HEARING DEVELOPMENT
- Placing black/white/red, or high-contrast pictures and objects in line of vision, 8–15 inches from face as long as infant remains relaxed and focused.
- Providing auditory stimulation such as tapes of mother's and father's voices, music boxes, and classical music when infant is quiet, alert, relaxed, and appears interested.
- Talking or singing to infant when providing care or holding and touching him/her, using different pitches or volume in voice.
- Allowing for face-to-face interaction with infant with or without talking, depending on infant's developmental level.
BIBLIOGRAPHY
- Casavant SG, Bernier K, Andrews S, et al. Noise in the Neonatal Intensive Care Unit: What Does the Evidence Tell Us? Adv Neonatal Care. 2017;7(4):265–73.
- Lai MM, D'Acunto G, Guzzetta A, et al. PREMM: preterm early massage by the mother: protocol of a randomised controlled trial of massage therapy in very preterm infants. BMC Pediatr. 2016;16(1):146. doi: 10.1186/s12887-016-0678-7.
- Rodríguez RG, Pattini AE. Neonatal intensive care unit lighting: update and recommendations. Arch Argent Pediatr. 2016;114(4):361–7.
- Thakur N, Batra P, Gupta P. Noise as a Health Hazard for Children, Time to make a noise about it. Indian Pediatr. 2016;53(2):111–4.
- Tian X, Yi LJ, Zhang L, et al. Oral motor intervention improved the oral feeding in preterm infants: Evidence Based on a Meta-analysis With Trial Sequential Analysis. Medicine (Baltimore). 2015;94(31):e1310.
- Westrup B. Family-centered developmentally supportive care. NeoReviews. 2014;15(8):e325–35.
- Zahed M, Berbis J, Brevaut-Malaty V, et al. Posture and movement in very preterm infants at term age in and outside the nest. Childs Nerv Syst. 2015;31(12):2333–40.
1.4 Screening Protocols for High-risk Newborns at Discharge
Naveen Jain
INTRODUCTION
Babies who are sick at birth and require intensive care support (e.g. very preterm, asphyxia), who have risk factors in pregnancy (e.g. mother on anti-epileptic drugs), potential of adverse outcomes (e.g. renal pelvis dilatation) require special care before discharge from hospital and follow-up thereafter.
PRETERM BABIES
- Warmth: Educate parents to continue kangaroo mother care, wrap the baby in double layer of cotton clothes and caps, socks, and mittens. Advice them to touch the baby's abdomen and hands/feet with dorsum of the hand to assess thermal stability.
- Nutrition: Encourage the mother to provide her own breast milk supplemented with protein (human milk fortifier), calcium/phosphorus, iron, and multivitamins. An electric breast pump should be used 3–4 hourly till the baby is able to suck effectively directly (after 34 weeks gestation).
- Prevention of infection: Avoid crowded areas and visitors for a few weeks. Wash hands with soap and water before handling the baby. If formula milk is used, pay attention to sterilization and hygiene of water used, in handling of container, spoons, bottles, and avoid milk that is prepared more than 3–4 hours earlier.
- Assessment of growth: Weight, length, and occipital frontal circumference (OFC) must be plotted on growth charts for preterm babies. Babies must be tracking all parameters along their birth centile or parallel to the growth curves for a week prior to discharge (e.g. Fenton's growth chart).
- Immunization: BCG, OPV and hepatitis B can be given to almost all babies prior to discharge. If baby is 6 weeks old, then DTP, HIB, PCV, IPV, HB and rotavirus vaccines also can be given. The immunization schedule is the same as for term born babies. No change/delay is necessary because of prematurity.
- Screening tests before discharge:
- Retinopathy of prematurity screening:
- Retinopathy of prematurity (ROP) screening is recommended for all babies less than 34 weeks and/or less than 1,750 g at birth.
- Screening must start at 3–4 weeks after birth.
- An ophthalmologist trained in ROP screening must identify severe RoP requiring laser photocoagulation.
- Also, advise parents to continue screening for risk of late retinal detachment and other visual problems such as refraction problems, squint, etc. necessitating eye examination at 3–6 months and 9–12 months. Thereafter, an annual check-up is recommended till 6 years of age.
- Hearing screen: Otoacoustic emission (OAE) and automated brainstem-evoked response (ABER) audiometry must be performed ideally before discharge. As sensorineural impairment is possible, ABER is mandatory. Hearing impairment must be confirmed and treatment initiated before the baby is 6 months old.
- Anemia of prematurity: Preterm babies do not respond to anemia by increase in RBC production. They may require RBC transfusions if hemoglobin levels are low (most units transfuse at < 7 g/dL, some at strict thresholds of 6 g/dL). Hemoglobin levels are checked at 1–2 weeks intervals, starting from 4 weeks of life, till they are stable.
- Osteopenia of prematurity: Serum phosphorus and alkaline phosphatase levels are measured at 4 weeks of life and 1–2 weekly thereafter, till alkaline phosphatase levels are normal (some units practice till 40–44 weeks’ gestation age). If phosphorus levels are low (<5) and alkaline phosphatase high (>900), intake of calcium phosphate (150–200 mg/kg of calcium and 75–100 mg/kg of phosphorus) and vitamin D (400–1,000 IU/day).
- Congenital hypothyroidism: Two screening tests are recommended—first at 3–7 days of life and second test at 2–4 weeks of age.
- Physical examination: Examine for cardiac murmur, inguinal hernia, oral thrush, hemangioma, and hepatosplenomegaly.
- Neurological examination: Serial head circumference, neurobehavior, and structured neurologic examination (e.g. Hammersmith neonatal neurologic examination).
- Neuroimaging: First ultrasound head for all preterm babies less than 32 weeks gestation at birth. Follow-up ultrasound at 36–40 weeks age (good predictive ability).
- Parent readiness: Parents must be prepared through early participation and care of the baby, while in NICU and by serial health education sessions. Preterm baby must be roomed in with the parents for a few days before discharge, so that they are better prepared to take care of the baby.
- Referral to primary care physician.
- Ensure active medical problems are resolved or care process planned:
- Hospital-associated infection (HAI): Any fever/significant change in health, within a month after discharge can be HAI. Babies may have to be reinvestigated and treated (Table 1.4.1).
- Chronic lung disease of prematurity (bronchopulmonary dysplasia) is more common in extreme preterm babies. They may require home oxygen therapy. The parents must be educated regarding higher risks of respiratory insufficiency with minor illness requiring admission to hospital as an emergency.
- Preterm brain injury [(intraventricular hemorrhage/periventricular leukomalacia (IVH/PVL)]—increased risk of seizures, swallowing problems and may require enrolment to early intervention programs.
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At-risk Neonates
Disease-specific predischarge screening and follow-up must be documented and educated to parents.
Examples:
- HIE/seizures/meningitis—neurological examination at discharge, 4–8–12 months age and periodically thereafter.
- Antenatal renal pelvis dilatation—first postnatal ultrasound after third day. One more ultrasound at 1 month of age (even if first one was normal).
BIBLIOGRAPHY
- Ehrenkranz RA, Younes N, Lemons JA, et al. Longitudinal growth of hospitalized very-low-birth weight infants. Pediatrics. 1999;104(2 pt 1):280–9.
- Joint Committee on Infant Hearing of the American Academy of Pediatrics, Muse C, Harrison J, et al. Supplement to the JCIH 2007 position statement: principles and guidelines for early intervention after confirmation that a child is deaf or hard of hearing. Pediatrics. 2013;131/(4):e1324–49.
- Nair MKC, George B, Jain N, et al. Perinatal Risk Stratification of Preterm Neonates and Developmental Outcomes - PRE (Preterm Risk Evaluation) Network. J Neonatol. 2014;28(3):3.
- Phatak P. Manual on Developmental Assessment Scales for Indian Infants (DASII) (revised Baroda norms, 1997). Pune: Anand Agencies; 1997.
- Sujatha R, Jain N. Prediction of neurodevelopmental outcome of preterm babies using risk stratification score. Indian J Pediatr. 2016;83(7):640–4.