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AIIMS- NICU protocols 2008

Follow-up of High Risk Neonates


Pradeep Kumar, M.Jeeva Sankar, Savita Sapra, Ramesh Agarwal, Ashok
Deorari and Vinod Paul
Division of Neonatology, Department of Pediatrics
All India Institute of Medical Sciences
Ansari Nagar, New Delhi 11!"
Address for correspondence:
Dr Ramesh Agarwal
Assistant Professor
Department of Pediatris
All !ndia !nstitute of Medial Sienes
Ansari "agar, "ew Delhi ##$$%&
'mail( aranag)rediffmail.om
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AIIMS- NICU protocols 2008
Abstract
*he improvement in perinatal are has led to inrease in survival as well as mor+idit, in
sik new+orns. *hese +a+ies need to +e followed up regularl, to assess growth and
neurodevelopmental outome and for earl, stimulation and reha+ilitation. -e present a
protool desri+ing the various omponents of a follow up program inluding setting up
of follow up servies, proedures and timings of follow up.
#ey words$ %ollow up& neurodevelopmental outcome& early stimulation
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AIIMS- NICU protocols 2008
Introduction
!mproving perinatal and neonatal are has led to inreased survival of infants who are
at.risk for long.term mor+idities suh as developmental dela, and visual/hearing
pro+lems
#, %
Moreover, man, of these neonates 0e.g. e1tremel, low +irth weight infants2
tend to have higher inidene of growth failure and ongoing medial illnesses A proper
and appropriate follow.up program would help in earl, detetion
of these pro+lems thus paving wa, for earl, intervention.
Importance of follow-up care
"umerous studies have shown that despite

su+stantial improvements in the neonatal
mortalit,, the inidene of hroni mor+idities and adverse outomes among survivors
has not delined muh.
3
*his highlights the need for a follow.up are servie that would
ensure s,stemati monitoring of the general health and neurodevelopmental outomes
after disharge from the hospital. *he monitoring would help the infants and their
families 0earl, identifiation of pro+lems and hene earl, reha+ilitation servies2 as well
as the ph,siians involved in their are 0to improve the 4ualit, of are provided and for
researh purposes2. *here is a ommon pereption that high risk follow.up mainl,
onerns with detetion and management of neurosensor, disa+ilit,. !nfat growth
failure and ongoing illnesses are e4uall, , if not more important issues in high risk follow.
up. Ade4uate emphasis must +e plaed on these .
5owever, a rigorous follow.up of all the neonates disharged from a partiular health
failit, would neither +e pratial nor feasi+le. *herefore, it is important to selet a ohort
of neonates who are at a higher risk of developing these adverse outomes 6 'at(ris)*
infants. Surprisingl,, there are no standardi7ed guidelines for follow up of high risk
infants even in tertiar, are enters
8
. -e have devised a follow up protool whih
identifies the su+set of neonates to +e followed up and outlines the optimal time for
follow.up visits and the appropriate assessment measures to +e adopted .
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AIIMS- NICU protocols 2008
Setting up of follow up serices
5igh risk infants9 follow.up re4uires a multidisiplinar, approah involving a team of
pediatriians, hild ps,hologist, pediatri neurologist, ophthalmologist,
otorhinolar,ngologist, ph,siotherapist, oupational therapist, medial soial worker, and
a dietiian. *he respetive role of eah team mem+er is summari7ed in *a+le #.
Table 1: Personnel required for follow-up program and their individual roles
S! No "eam member Role#s$
#. Pediatriians /
neonatologists
Serves as the nodal person of the team
*o assess growth and sreen for developmental
dela,
*o manage interurrent illnesses
%. :hild ps,hologist0s2 ;or formal neurodevelopmental assessment
Sreening for +ehavioral pro+lems and their
management
3. Pediatri neurologist <ong.term management of neurologial illnesses
suh as sei7ures
8. =phthalmologist ;ollow.up of R=P sreening/treatment
Assessment of visual auit, and sreening for
pro+lems suh as stra+ismus, n,stagmus, refrator,
errors, et.
>. =torhinolar,ngologist 5earing assessment 0?'RA, =A', et.2
Management of hearing impairment, if an,
@. Dietiian Dietar, advie regarding omplementar, feeding
Management of infants with failure to thrive and
those with speial needs 0e.g. galatosemia2
A. Medial soial worker
*o take are of the soial issues to help improve
follow up rates
B. Ph,siotherapist Assessment and grading of musle tone and power
Plan an appropriate training program for eah infant
with tone a+normalities
*o teah the parents for ontinuing the presri+ed
e1erises at home
&. Speeh / oupational Reha+ilitation of infants with impairment/disa+ilit,
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AIIMS- NICU protocols 2008
therapist

!deall,, all the re4uired personnel should +e availa+le under one roof at a plae
earmarked for follow.up are. !f this is not feasi+le, at least the servies of pediatriian,
linial ps,hologist, dietiian, medial soial worker, and ph,siotherapist should +e
ensured in the follow.up lini. Medial soial worker is an important mem+er of the
team liasoning with the famil, and helps them to keep follow up visits. !nfants who need
hearing/visual assessment or speeh therap, an +e referred to the onerned speialist
on fi1ed da,s.
%ho needs follow-up care&
Seletion of high.risk infants should +e +ased on the gestational age, +irth weight,
ourrene and severit, of perinatal/neonatal illnesses, interventions reeived in the
neonatal intensive are unit 0"!:C2, presene of malformations, et. !t an further +e
modified for eah unit +ased on their admission and outome profiles.
Panel # lists the ohort of high risk infants whom we follow.up in our unit.
Panel 1: High risk neonates who need follow-up care (customize as per polic!
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#. ?a+ies with D#B$$g +irth weight and/or gestation D3> weeks
2. Small for date 0D3
rd
entile2 and large for date 0E&A
th
entile2
3. Perinatal asph,1ia . Apgar sore 3 or less at > min and/or h,po1i ishemi
enephalopath,
8. Mehanial ventilation for more than %8 hours
>. Meta+oli pro+lems 6 S,mptomati h,pogl,emia and h,poalemia
@. Sei7ures
A. !nfetions 6 meningitis and/or ulture positive sepsis
B. Shok re4uiring inotropi/vasopressor support
$. MaFor mor+idities suh as hroni lung disease, intraventriular hemorrhage, and
periventriular leuomalaia
#$. !nfants +orn to 5!V.positive mothers
##. *win with intrauterine death of o.twin
#%. *win to twin transfusion
!. 5,per+iliru+inemia E %$mg/d< or re4uirement of e1hange transfusion
#8. Rh hemol,ti disease of new+orn
#>. MaFor malformations
#@. !n+orn errors of meta+olism / other geneti disorders
#A. A+normal neurologial e1amination at disharge
AIIMS- NICU protocols 2008
*he developing +rain of premature +a+ies is e1tremel, vulnera+le to inFur,G the risk for
neurodevelopmental defiit inreases with dereasing gestational age and +irth weight
resulting in relativel, high risk of ere+ral pals,, developmental dela,, hearing and vision
impairment and su+normal aademi ahievement
>
. Similarl,, small for date infants
0+irth weight D 3
rd
entile2 are also at signifiant risk of poor long term outomes. *hose
who re4uired mehanial ventilation for more than %8hours, +a+ies with meta+oli
pro+lems 6 s,mptomati h,pogl,emia as half of them have a+normal
neurodevelopmental outome, s,mptomati h,poalemia, +irth asph,1ia Apgar sore 3
or less at > min, a+normal neurologial e1amination at disharge, sei7ures,
h,per+iliru+inemia E %$mg/d< or re4uirement of e1hange transfusion, Rh hemol,ti
disease of new+orn as the, have anemia presenting till three to si1 months age,
infetions 6 ulture positive sepsis or meningitis, +a+ies +orn to 5!V infeted mothers,
twin with intrauterine death of o.twin due to inreased inidene of ere+ral venous
throm+oem+oli phenomenon, twin to twin transfusion or maFor malformation. All infants
ared for in the "!:C should have periodi preventive assessment +, their primar, are
ph,siians whih should inlude regular assessment of growth, sensor, funtion,
+ehavior and neurodevelopment. !nfants with suspet findings should +e referred for
more omprehensive evaluation to a enter with e1periene in follow up of high risk
neonates.
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AIIMS- NICU protocols 2008
're-re(uisites for follow-up
*o ensure proper follow.up of the high risk infants, parents 0espeiall, mother2 and other
famil, mem+ers should +e ounseled even +efore disharge from the hospital.
Disharge should +e planned well in advane so that the mother an +e ounseled
ade4uatel,.
"ischarge planning: Disharge planning should ideall, +egin as soon as the +a+, is
admitted in the nurser,. *his gives ade4uate time for the aretakers to ask 4uestions
and pratie skills. *he following riteria should +e fulfilled +efore disharging a high risk
infant(
5emod,namiall, sta+leG a+le to maintain +od, temperature in open ri+
=n full enteral feeds 0either +reast feeding or +, paladai/spoon2
Parents onfident enough to take are of the +a+, at home
5as rossed +irth weight and showing a sta+le weight gain for at least three
onseutive da,sG in ase of ver, low +irth weight infants, weight should +e at
least #8$$ grams +efore onsidering for disharge.
"ot on an, mediations 0e1ept for vitamins and iron supplementation2. !deall,
preterm +a+ies on theoph,lline therap, for apnea of prematurit, should +e off
therap, for at least five da,s to make sure that there is no reurrene.
Reeived vaination as per shedule 0+ased on postnatal age2.
*hese riteria an +e individuali7ed to meet the infant and famil, needs.
#ounseling prior to discharge: :ounseling pla,s an important role in the are of these
+a+ies at homeG regular ounseling sessions should +e done +efore disharge. Parents
should +e given advie regarding(
*emperature regulation 6 proper lothing, ap, soks, Kangaroo mother are
et.
;eeding 6 t,pe and amount of milk, method of administration, and nutritional
supplementation, if an,.
Prevention of infetions 6 hand washing, avoidane of visitors, et.
;ollow.up visits 6 where and when 0*a+le !2
Danger signs 6 reognition and where to report if signs are present
Vaination 6 shedule, ne1t visit, et.
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AIIMS- NICU protocols 2008
Speial needs 6 e.g. ne1t visits for R=P sreening.
!f possi+le the famil, should +e provided with the telephone num+er of the health
are provider e.g. on.dut, dotor in ase the famil, needs to onsult for infant9s
illness.
'rocedure for follow-up
$enue: A speified site should +e earmarked for follow up servies. *he parents should
+e properl, ommuniated a+out the venue and it should also +e mentioned in the
disharge summar,. Registration proedure at the follow.up lini should +e simplified to
avoid an, undue dela,. =ngoing illness is ommon pro+lem among these infants. !f the
infant develops an, illness re4uiring admission, priorit, should +e given for the same.
%ecord maintenance: *here should +e a separate +ut uniform file for eah high risk
infant . -e have separate files for male and female +a+ies. Male +a+ies get +lue and
female +a+ies get pink files. Addresses and telephone num+ers should +e entered
learl, in the file. !f possi+le, an alternate address and telephone num+er should also +e
reorded. !t ma, +e good idea to en4uire an important landmark for loating the house in
ase one needs to make a home visit. *he famil, should also +e given a +ooklet
ontaining follow.up information.
&chedule: *he follow up shedule should +e e1plained to the parents 0see +elow2.
*imings should +e fi1ed and adho visits should +e disouraged.
#orrected age: Age of the hild sine the e1peted date of deliver,. *he orretion for
gestational immaturit, at +irth should +e done till %8 months age. All developmental
milestones are assessed aording to orreted age to ompensate for the prematurit,.
*he addition of omplementar, feeds is also aording to orreted age.
Postnatal age( Age of the hild sine +irth. !mmuni7ation is done aording to postnatal
age.
%hen to follow up
;or the purpose of follow.up visits, at.risk infants an +e grouped under two maFor
ategories( 0#2 preterm/<?- infants and 0%2 infants with other onditions. *he follow.up
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AIIMS- NICU protocols 2008
shedule for +oth these ategories has +een summari7ed in *a+le !!. *his shedule
represents minimum num+er of visits of high risk neonates. !f the +a+, has ongoing
issues or illness, more fre4uent visits are reommended. Please note that first ontat of
the infant with the health providers after disharge is important and helps in identifiation
of adFustment pro+lems at home. !deall, this ontat should +e ahieved +, the home
visit.
Table '': (ollow-up schedule of at-risk infants
#ohort &chedule for follow-up
#. !nfants with D#B$$g +irth
weight and/or gestation
D3> weeks
After 3.A da,s of disharge to hek if the +a+, has +een
adFusted well in the home environment. 'ver, % weeks
until a weight of 3 kg 0immuni7ation shedule until #$.#8
weeks to +e overed in these visits2
At 3, @, &, #% and #Bmonths of corrected age and then
ever, @ months until age of B,ears
%. All other onditions % weeks after disharge
At @, #$, #8 weeks of postnatal age
At 3, @, &, #% and #Bmonths of corrected age and then
ever, @ months until age of B,ears
)ote: 'f a preterm infant (* +, weeks! develop an other morbidit covered in -other conditions./ he
should be followed up as per the schedule outlined for the first group of cohort
*he seletion of age of assessment depends on developmental a4uisitions availa+le at
a given age, availa+ilit, and applia+ilit, of appropriate test instruments at speifi ages
and the ost and feasi+ilit, of long.term traking in the population in 4uestion. *he long
term follow up of omplete ohorts is optimal for determining the outome of high risk
neonates and the safet, of antenatal and perinatal interventions. Ver, low +irth weight
+a+ies or those +orn at less than 33 weeks gestation should +e followed up for e,e
hek up for retinopath, of prematurit, till the postnatal age of 88 weeks.
Some neurologial a+normalities that are identified in the first ,ear of life are transient or
improve whereas findings in other hildren ma, worsen over time.
A
?, #% months
orreted age the ognitive and language assessment an +e done. ?, #B.%8 months
orreted age there is improved predition to earl, shool age performane.
B, &, #$
*he
importane of long term follow up lies in the fat that minor neurologial disa+ilities ma,
not +e deteted earl, and +eome apparent onl, with inreasing age. Standard follow.up
for man, multienter networks is urrentl, at #B.%8 months orreted age.
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AIIMS- NICU protocols 2008
%hat should be done at follow up&
*a+le !!! summari7es the plan for follow up.
"able III: Follow up plan for high risk infants
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0ssessment Age in months
0
AIIMS- NICU protocols 2008
. 0ssessment of feeding and dietar counseling: Parents should +e asked
a+out the infants9 diet and offered dietar, ounseling at eah visit. ?reast feeding
fre4uen, and ade4ua, should +e assessed. *he amount, dilution and mode of
feeding should +e noted if supplemental feeding is given. !t is a good idea to
en4uire a+out soure of milk as milk supplied +, loal vendors is often diluted
0dilution has the same impat on the infant whether done +, the famil, or the
vendorH2. !t is also important to reord the duration of e1lusive +reast feeding. !f
a +a+, is not gaining ade4uate weight on e1lusive +reast feeding take are of
an, illness, maternal pro+lems whih ma, interfere with feeding and milk output.
!f poor weight gain persists despite all measures to improve +reast milk output,
supplementation an +e onsidered.
:omplementar, feeding should +e started at @ months orreted age. !nitiall,,
semisolids should +e advised in aordane with the loal ultural praties , Spend
ade4uate time on e1plaining what to give and how to give. *he ommon pratie of
giving too little or too dilute omplementar, food suh as rie.water, dal.water, too
muh of Fuie, et should +e disouraged. *he reommended meal fre4uenies 6
assuming a diet with energ, densit, of $.B kal per gram or a+ove and low +reast
milk intake are( %I3 meals per da, for infants aged @IB monthsG 3I8 meals per da,
for infants aged &I## months and hildren #%I%8 monthsG additional nutritious
snaks ma, +e offered #I% times a da,, as desired. :omplementar, foods should +e
varied and inlude ade4uate 4uantities of meat, poultr,, fish or eggs, as well as
vitamin A.rih fruits and vegeta+les ever, da,. -here this is not possi+le, the use of
fortified omplementar, foods and vitamin mineral supplements ma, +e neessar, to
ensure ade4ua, of partiular nutrient intakes. As infants grow, the onsisten, of
omplementar, foods should hange from semisolid to solid foods and the variet, of
foods offered should inrease. ?, eight months, infants an eat Jfinger foods9 and +,
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Assessment of feeding and dietary
counseling
# % 3 @ & #% #> #B %8 ......B,ears
-rowth monitoring All visits
Immuni.ation As per shedule 0+ased on postnatal age2
Neurological e/amination KKKKKKK
Developmental assessment and D0 KKMKMMK
1earing 2345A6 K N N N N N N
7phthalmic evaluation K N N N N N
8S-9:; +rain As indiated
N if previous test a+normal

AIIMS- NICU protocols 2008


#% months, most hildren an eat the same t,pes of food as the rest of the famil,.
*he maFor pro+lem with the famil, food is that it is not nutrient.rih
##
.
2. 1rowth monitoring: Orowth 0inluding weight, head irumferene, mid.arm
irumferene and length2 should +e monitored and plotted on an appropriate
growth hart at eah visit. -e use -right9s harts 0till 8$ weeks PMA2 and -5=
growth harts 0for preterm infants after 8$ weeks PMA and for term infants2 for
growth monitoring , *he infant9s growth pattern 0slope of the urve2 is ompared
with the standard urveG an, deviation should +e noted and appropriate remedial
ation taken. -eight should +e taken on an eletroni weighing sale. <ength
should +e measured with an infantometer. *he infant should +e held supine and
legs full, e1tended. *he feet should +e pressed against the mova+le foot piee
with the ankles fi1ed to &$P. 5ead irumferene should +e measured with
nonstretha+le fi+erglass tape.
#%

!. "evelopmental assessment: Assessment of developmental milestones should
+e done aording to the orreted age. *he milestones should +e assessed in
four domains. gross motor, fine motor, language, and personal.soial 2see page
1 with instructions for filling given in page " of 15: file6, *he date of
assessment and the infants9 orreted age should +e mentioned against eah
milestone. ?ased on the date of ahievement of milestones in a partiular
domain and the e1peted age of ahieving them, the developmental age an +e
alulated.
!nfants who lag +ehind in an, domain should undergo a formal developmental
evaluation +, a linial ps,hologist using tests suh as Developmental assessment
of !ndian !nfant !! 0DAS!! !!2
#3
. *his sale onsists of @A items for assessment of motor
development and #@3 items for assessment of mental development. Motor sale
assesses ontrol of gross and fine motor musle groups. Mental sale assesses
ognitive, personal and soial skills development. ?oth mental development inde1
and ps,homotor development inde1 an +e alulated +, DAS!!. *he age
plaement of the item at the total sore rank of the sale is noted as the hild
developmental age. *his onverts the hild total sores to his motor age 0MoA2 and
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AIIMS- NICU protocols 2008
mental age0MeA2. *he respetive ages are used to alulate his motor and mental
development 4uotients respetivel, +, omparing them with his hronologial age
and multipl,ing it +, #$$. 0DMoQ R MoA/:A 1 #$$ and DMeQ R MeA/:A 1 #$$2.
*he omposite DQ is derived as an average of DMoQ and DMeQ.
*he Vineland Soial Maturit, Sale measures soial ompetene, self.help skills,
and adaptive +ehavior from infan, to adulthood. *he Vineland sale onsists of a
##A.item interview with a parent or other primar, aregiver.
!t is emphasi7ed here that developmental stimulation of the hild should not +e
dela,ed if the a+ove mentioned tests are not availa+le. Age appropriate
stimulation should +e provided to these +a+ies. Mental development inde1 and
Ps,homotor development inde1 at 3, #%,#B and %8 months and ever, 3 months
if a+normal.
". 'mmunization: !mmuni7ation should +e ensured aording to hronologial age
, Parents should +e offered the option of using additional vaines suh as
5emophilus influen7ae ?, t,phoid and MMR.
#. 2ngoing problems: *he, should +e mentioned in the follow up notes . *he
management of ongoing illnesses is an integral part of an, high risk follow up
program. *he hospital admission of the hild should +e prioriti7ed, if re4uired.
%. )eurological assessment: 'valuation of musle tone is an integral part of the
neurologial e1amination. A wa1ing and waning pattern of neuromotor
development from %B weeks of gestation to the end of first ,ear of life was
reported +, Amiel.*ison. ;rom %B to 8$ weeks gestation, the a4uisition of
musle tone and motor funtion spreads from lower e1tremities towards the
head. After full term, the proess is reversed so that rela1ation and the motor
ontrol proeed downwards for the ne1t #% to #B months. So the upper lim+s
+egin to rela1 and a4uire skills +efore the lower lim+s. *he a1ial tone follows a
similar pattern. 5ead ontrol appears first followed +, the a+ilit, to sit, stand and
walk. 5,pertonia or h,potonia should +e looked for +, measuring the following
angles( addutor angle, popliteal angle, ankle dorsifle1ion, and sarf signG an,
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AIIMS- NICU protocols 2008
as,mmetr, +etween the e1tremities should also +e reorded. An, histor, of
sei7ures or involuntar, movements should also +e reorded.
5,pertonia in lower lim+s is defined as when either addutor angle is restrited to
less than the age speifi norms as per Amiel.*ison or if there is sissoring or tight
tendo.ahilles or restrition of ankle dorsifle1ion on e1tension of knee. 5,pertonia in
upper lim+s is defined as when sarf sign does not ross midline at one ,ear
orreted age. 5,pertonia of the nek e1tensors an +e inferred +, an inreased gap
+etween the nape of the nek and e1amination ta+le with the infant l,ing in supine
position.
*he following angles should +e measured to assess tone as shown in ;igure#,
*a+le !V(
"able I): *uscle "one Norms

*runal e1tensor h,pertonia( there is a tenden, of +od, to go into
h,pere1tension or opisthotonus.
:ere+ral pals,( Definitel, a+normal neurologial e1amination with upper motor
neuron signs with motor developmental dela,.
Spastic h+pertonia s+ndromes:
5emiplegia. onl, one half of +od, involved
Diplegia. paresis of lower lim+s more than upper lim+s
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Age
#months$
Adductor
angle
'opliteal
angle
Dorsifle,ion
angle
Scarf sign
--. 8$P .B$P B$P .#$$P @$P .A$P 'l+ow does not ross
midline
/-0 A$P .##$P &$P .#%$P @$P .A$P 'l+ow rosses midline
1-2 ##$P .#8$P ##$P .#@$P @$P .A$P 'l+ow goes +e,ond
a1illar, line
3--34 #8$P .#@$P #>$P .#A$P @$P .A$P
"
AIIMS- NICU protocols 2008
Quadriplegia. Paresis of all four lim+s with upper lim+ involvement e4ual to or
more than lower lim+s.
A+normal neurologial e1amination should +e defined as definite a+normalities !n
the form of(
a2 ?risk refle1es with h,pertonia or
+2 ?risk refle1es with h,potonia or
2 Definitel, and onsistentl, eliited as,mmetrial signs or
d2 Persistent a+normal posturing or a+normal movements
*he tone a+normalities should +e taken are +, regular ph,siotherap,. *his
improves mo+ilit, of Foints and loomotion of the hild. *he hild should +e
provided with speial shoes if re4uired. =rthopedi evaluation should +e done
and orretive surger, for ontratures should +e done as re4uired. All possi+le
efforts should +e made to improve mo+ilit, of these hildren and make them
funtionall, less dependent and independent if possi+le.
3e evaluation: *he hek.up for retinopath, of prematurit, starts in the "!:C and
ontinues till 88 weeks postoneptional age or till the retinal vessels have matured.
Refer to protool on Retinopath, of prematurit,
#8
.
At & months orreted age the ophthalmologist should evaluate the +a+, for vision,
s4uint, atarat and opti atroph,. Su+Fetive visual assessment an +e made from
linial lues as ina+ilit, to fi1ate e,es, roving e,e movements and n,stagmus.
=+Fetive visual assessment should +e done with the *eller Auit, :ard. !t has
seventeen %>.> S ># m ards. ;ifteen of these ontain #%.> S #%.> m pathes of
s4uare.wave gratings0 vertial +lak and white strips2 ranging in spatial fre4uen,
from 3B.$ ,les/m to $.3% ,les/m. *he range is in half otave steps. A ,le
onsists of one +lak and one white stripe and an otave is a halving or dou+ling of
spatial fre4uen,. !n Snellens terms it is an halving or dou+ling of the denominator
e.g. @/@, @#%, @/%8. 5alf otave steps would +e @/@, @/&, @/#%, @/#B, @/%8 and so on.
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*here is a low vision ard ontaining %>.> S %3 m path of $.%3 m ,le/m0 %.%
m wide +lak or white stripes2. *he seventeenth ard is a +lank gre, ard with no
grating pattern. *he gratings have B% 6 B8T ontrast and are mathed to the
surrounding gre, ard to within #T in spae average luminane. *his minimi7es the
hane of a patient fi1ating +eause of +rightness differene. Detetion of pattern
alone determines the fi1ating preferene. Proper illumination without an, shadows
should +e ensured 0#$ andelas /s4m2. *esting distane from patient9s e,es to the
ards should +e maintained onstant as it determines the visual auit,. :hildren from
Am to 3, should +e tested at >> m and later at B8 m.
Reha+ilitation for visual impairment should +e earl, so that the hild gets appropriate
stimulation. !f dela,ed the restoration of the vision ma, not +e possi+le +eause of
ontinuous sensor, deprivation of the opti nerve. *he hild should +e provided with
glasses or orretive surger, as appropriate. !t should +e emphasi7ed that a good
high risk follow up program does not onl, pik up handiaps earl, +ut also ensures
earl, orretive measures and reha+ilitation. *his emphasi7es the multidisiplinar,
and well oordinated approah to suh +a+ies
&. Hearing evaluation: 5igh risk infants have higher inidene of moderate to
profound hearing loss 0%.>.>T vs. #T2. Sine linial sreening is often
unrelia+le, +rainstem auditor, evoked responses 0?A'R/?'RA2 should +e
performed +etween 8$ weeks PMA and 3 months postnatal age. A sreening
?'RA is usuall, done initiall,. !f this is a+normal, a diagnosti ?'RA should +e
done within % weeks of the initial test. !nfants with unilateral a+normal results
should have follow.up testing within three months. *he test should +e arried out
in a sound.proof room and the infant should +e sedated with oral trilofos
>$mg/kg 3$ min +efore the proedure. *o measure the eletrial pulses, small
monitoring eletrodes are plaed on the salp. 'arphones provide a liking
noise to the ear and the response from the +rainstem is measured time.loked to
the liks. *he liks ma, +eome louder or softer, faster or slower, to see how
the auditor, responds to these different stimulus parameters. *he other method
of assessment for hearing is oto.aousti emission 0=A'2. *his reords aousti
feed+ak from the ohlea through the ossiles to the t,mpani mem+rane and
ear anal following a lik stimulus. !t is 4uiker to perform than ?'RA +ut is
more likel, to +e affeted +, de+ris or fluid in the e1ternal and middle ear. !t is
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una+le to detet some form of sensorineural hearing loss inluding auditor,
d,ss,nhron,.
*he severit, of hearing loss is profound 0A$ d? or more of hearing loss2, severe 0>$
d? . A$ d?2, moderate 03$ d? . >$ d?2 and mild 0#> d? . 3$ d?2.
*he audiologial testing should +e done at 3 months of age. !nfants with true hearing
loss should +e referred for earl, intervention to enhane the hild9s a4uisition of
developmentall, appropriate language skills. *he hild should +e provided with
hearing aids and if severe to profound hearing loss ohlear implants should +e
onsidered +, #% months age. ;itting of hearing aids +, the age of @ months has
+een assoiated with improved speeh outome. !nitiation of earl, intervention
servies +efore three months age has +een assoiated with improved ognitive
development at 3,ears age
#>
5arl+ stimulation
*he high risk +a+, re4uires more attention of the famil, mem+ers. Parents and
famil, mem+ers need to aid the development proess in an age appropriate wa,
spending 4ualit, time with hildren. Suh interations improve parent hild
relationship and +ring a+out positive parental attitudinal hange. 'ffetive
parents supervise their hildren in an age appropriate wa,, use onsistent
positive disipline, ommuniate learl, and supportivel,, and show warmth,
affetion, enouragement, and approval. *he ations of the hild should +e
appreiated. *his makes him happ, and enourages doing more ativities.
--4 months(
Activities
Maintain e,e to e,e ontat
*alk and sing to the +a+, while +athing, dressing and feeding
5elp the +a+, to turn his head to sound and light
Auditory
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Provide different sounds to the hild like rattle, +ell, s4uee7ing a to,.
Make the hild listen to musi, high pithed and low pithed human
sounds
5umming in a soft low voie
<isual
Keep the +a+, in a well lighted room
Shine mo+ile, olor +alls and hang +right lothes
;actile
Put the +a+, on different surfaes like soft lothes, mattresses, ru++er mat
and mother9s lap
:hange the hild9s position fre4uentl, like putting on his +ak, sides and
tumm,
#inesthetic
Support the head and gentl, rok the hild avoiding sudden Ferk,
movements
4-/ months
-eneral stimulation
5old the +a+, at the shoulder
Plae things Fust out of the reah of the +a+,. Stimulate him to reah out
and grasp the o+Fet
Auditory
Oive sound produing to,s
*alk to the hild more fre4uentl,
Point out the names of o+Fets shown to the hild
<isual
5ang +right o+Fets a+out 3$m a+ove the ri+
Maintain e,e ontat while talking to the hild
;actile
Oive the hild paper to rum+le and things to +ite and suk
Plae the hild on a ru++er mat on the ground allowing him to move freel,
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AIIMS- NICU protocols 2008
/-0 months:
-eneral activities$
Sit the +a+, in the mother9s lap and ask her to gentl, +oune her knees
singing songs.
Plae the hild flat on the +ak on the ground over a soft surfae. Show
him a olorful to,. Slowl, turn him +, fle1ing the far awa, leg. Assist him to
turn over the tumm,.
Show an attrative to, and enourage the hild to reah out to it.
Put ,our hands under the hild9s feet and move his legs up and down like
pedaling a ,le.
Auditory
Shake a +ell or a s4ueak, to, over the head of the +a+,. 'nourage him
to turn his head and loate the sound
0-6 months:
:all the hild +, his name
Make the hild sit as long as possi+le. Oive support to his pelvis.
Oive him piees of paper to tear
'nourage him to roll over his tumm, +, showing him olorful to,s on one
side.
6-3- months:
Make the hild stand +, holding onto the furniture
'nourage the hild to lap hands
Oive him a small ontainer and ask to drop small thing into it.
'nourage him to produe monos,lla+les.
Show him piture +ooks and assist to turn the pages.
3--34 months:
<et the hild pla, with other hildren
"ame the +od, parts while +athing him
*ake the hild on a walk and show him different animals and +irds
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Do simple ations like lapping, +,e.+,e and enourage op,ing these
ations.
'nourage him to pull to stand +, holding the furniture
Make the hild sit in front of a mirror so that he an see himself
34-37 months:
Oive piture +ooks to the hild. *alk a+out what ,ou see and let him turn
the pages
Ask him to put u+es one over the other
Ask him to put things into the ontainer and then take out things out of the
ontainer.
5ide a small to, under a loth. 'nourage the +a+, to find the hidden to,.
Ask the hild to sri++le +, drawing a few lines. ;irst demonstrate what he
is supposed to do.
How to ensure a good follow up rate
*he importane of follow up should +e emphasi7ed fre4uentl, to the parents. *he
permanent and present addresses along with phone num+ers should +e kept to ensure
follow up. !f the parents do not turn up for follow up the, should +e telephoned and
letters should +e posted to ensure good follow up rates. *here should +e a dediated
person who an adFust the timing with the parents. !f possi+le home visits should +e
arranged for those who do not turn up. *here should +e a omprehensive assessment of
the hild under one roof to minimi7e the hassles of roaming from one orner of the
hospital to the other.
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References
. "ara,an S, Aggarwal R, Cpadh,a, A, Deorari AK, Singh M, Paul VK. Survival and mor+idit, in
'1tremel, <ow ?irth -eight 0'<?-2 infants. Indian Pediatr %$$3G 8$( #3$.#3>.
2. :ostello D, ;riedman 5, Minih ", Siner ?, *a,lor O, Shuhlter M, 5ak M. !mproved
neurodevelopmental outomes for e1tremel, low +irth weight infants in %$$$.%$$%. Pediatrics %$$AG
##&( 3A.8>.
!. 'so+ar O, <itten+erg ?, Petitti D? =utome among surviving ver, low +irthweight infants( a meta.
anal,sis. Arch Dis :hild ;e+#&&#G @@( %$8 . %##.
". -ang :J, MOl,nn 'A, ?rook R5, et al. Qualit,.of.are indiators for the neuro.developmental follow.
up of ver, low +irth weight hildren( results of an e1pert panel proess. Pediatrics, %$$@G ##A0@2(%$B$ 6
%$&%.
#. Vohr ?R, -right <, Anna M, Perritt R, Poole -K, *,son J', et al. :enter for the "eonatal Researh
"etwork :enter differenes and outomes of e1teremel, low +irth weight infants. Pediatrics
%$$8(##3(AB#.AB&.
%. :haudhari S, ?halerao M, :hitale A, Pandit A, "ene C. Pune <ow ?irth -eight Stud, . A Si1 Uear
;ollow Cp. Indian Pediatr#&&&G 3@(@@&.@A@.
&. Drillien :. A+normal neurologial signs in the first ,ear of life in low +irth weight infants( possi+le
prognosti signifiane. Dev Med :hild Neurol #&&AG #8(>A>.B8.
8. -eisglas.Kuperus ", ?aerts -, Smrkovsk, M, Sauer PJ. 'ffets of +iologial and soial fators on the
ognitive development of ver, low +irth weight hildren. Pediatrics,#&&3G &%(@>B 6@@>.
$. De7oete JA, MaArthur ?A, *uk ?. Predition of ?a,le, and Stanford.?inet sores with a group of ver,
low +irthweight hildren. :hild :are 1ealth Dev,%$$3G %&(3@A 63A%.
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AIIMS- NICU protocols 2008
0. <ee 5, ?arratt MS. :ognitive development of preterm low +irth weight hildren at > to B ,ears old. = Dev
3ehav Pediatr,#&&3G #8(%8% 6%8&.
. Report of the glo+al onsultation, and summar, of guiding priniples for omplementar, feeding of the
+reastfed hild Authors( -orld 5ealth =rgani7ation
2. !mplementation of the -5= Multienter Orowth Referene Stud, in !ndia V". ?handari, S. *aneFa, *.
Rongsen, J. :hetia, P. Sharma, R. ?ahl, D. K. Kash,ap, and M. K. ?han, for the -5= Multienter
Orowth Referene Stud, Oroup
!. Phatak ?. Mental and motor growth of !ndian +a+ies 0#.3$ months2. ;inal report. Department of :hild
Development, MSC?, ?aroda, #&A$.
". :hawla D, Agarwal R., Deorari AK, Paul VK. Retinopath, of Prematurit,. Indian =ournal of Pediatrics
%$$BGA>0#2(A3.A@
#. "!5 Joint :ommittee on !nfant 5earing. Uear %$$$ position statement( Priniples and guidelines for
earl, hearing detetion and intervention programmes. Pediatrics %$$$G #$@(A&B.B#A.

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AIIMS- NICU protocols 2008
;igure#(Amiel.*ison method of assessment of tone in infants
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Scarf s'gn
Add(ctor
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Dors'fle)'on
angle
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