Exit of The Neonatal Unit and Ambulatory Follow Up of High Risk

KANGAROO MOTHER CARE METHOD
TRAINING MANUAL
SCIENCE AND TENDERNESS
OUTPATIENT KANGAROO MOTHER CARE

WITH KANGAROO FOLLOW UP
(up to term)
AND HIGH RISK FOLLOW UP

(Up to one year of corrected age)
KANGAROO MOTHER CARE LEARNING PORTAL
For the implementation, strengthening and updating of KMC programs
The Ministry of Health and Social Protection of Colombia, the World Food Program of the United Nations with the
technical support of the Kangaroo Foundation, prepared this training kit for all health professionals in charge of
preterm or /and low birth weight infants .
This tool summarizes the knowledge and experience gained by pediatricians, nurses, psychologists, social work-
ers, physiotherapists, ophthalmologists, optometrists in the management of these children.
The goals of this tool are to support the dissemination of the Kangaroo Mother Care Method, to decrease infant
morbidity and mortality worldwide and to improve the quality of survival of preterm and Low Birth Weight in-
fants. The original version was released in Spanish and can be found on this website.
Maternal and Child Health Integrated Program (MCHIP), and JSI Research & Training Inst. supported the
finalization of the English version. The coordination of this English version was assured by:
Dr. Nathalie Charpak,

Pediatrician, Kangaroo Foundation ‘ Scientific Director
Dr. Hélène Lefèvre-Cholay,

Neonatologist, senior advisor for KMC, JSI Research & Training Inst.
This Learning Portal is developed for professionals who have received a theoretical and a practical training in a
KMC implementing site.This training kit is prepared only for educational purposes, and should not be used for
profit activities.
All rights reserved. No part of this publication including videos may be reproduced, stored in a retrieval system,
or transmitted, in any form an by any means, electronic, mechanical, photocopying , recording or otherwise,
without the prior written permission of the Kangaroo Foundation, or the authors.
The videos and photographic material used in this Learning Portal received the appropriate authorization from
the parents and / or guardians of the preterm infants.
Contents
OUTPATIENT FOLLOW UP 6
I. INTRODUCTION 6
2. EARLY DISCHARGE FROM THE NEONATAL UNIT AND ADMISSION TO OUTPATIENT FOLLOW
UP OR TO A KANGAROO WARD 8
2.1 CHILD’S ELIGIBILITY CRITERIA FOR DISCHARGE 8
2.2 MOTHER’S ELIGIBILITY CRITERIA FOR DISCHARGE 9
2.3 FAMILY’S DISCHARGE ELIGIBILITY CRITERIA 9
3. PHYSICAL STRUCTURE OF A KMC OUTPATIENT CONSULTATION 11
4. COMPLETE ASSESSMENT OF THE NEWBORN WHEN ADMITTED TO AN OUTPATIENT KMC
OR TO A KMC ROOMING-IN PROGRAM 12
4.1. DETERMINING GESTATIONAL AGE (GA) AT BIRTH AND CLASSIFICATION ACCORDING TO THE LUBCHENCO’S TABLE. 14
a) Gestational Age (GA) based on the date of last menstrual period 14
b) GA based on the New Ballard test 14
c) GA based on ultrasonography 14
4.2 ANTHROPOMETRIC MEASUREMENTS 15
4.2.1 Taking anthropometric measurements 15
4.2.2 Reporting anthropometric measurements in growth charts 18
4.3. FENTON CURVES UP TO 40 WEEKS (STANDARD DEVIATION) 22
Weight for boys 1 23
Weight for girls 24
4.4. INITIAL PHYSICAL EXAM OF A PRETERM AND/OR LBW INFANT 25
4.5 OUTPATIENT KANGAROO ADAPTATION 29
4.5.1. Kangaroo adaptation activities 31
4.5.2. Assessing the kangaroo position 32
4.5.3. Assessment of breastfeeding 33
5. SPECIFIC TESTS 36
5.1 BRAIN SONOGRAPHY 36
5.2. OPHTHALMOLOGIC SCREENING 37
6. DRUGS PRESCRIBED TO CHILDREN IN THE KMC IN COLOMBIA 39
7. ASSESSING THE NEED FOR OXYGEN 41
8. EVALUATING THE FAMILY NEED FOR SUPPORT 45
9. ROUTINE KANGAROO FOLLOW UP, UP TO 40 WEEKS OF GESTATIONAL AGE AND A WEIGHT OF 2500G 49
9.1 DAILY KANGAROO FOLLOW UP 49
9.2 ACTIVITIES DURING FOLLOW UP VISIT UP TO 40 WEEKS 49
a) Careful and complete clinical assessment, similar to the one described during the first follow up visit. 49
b) Regular monitoring of the somatic growth 50
c) Strategies in case of insufficient weight gain 52
d) Advice on child care for “kangaroo infant” at home 53
e) Duration of the kangaroo position 55
f ) Neurological assessment (using axial tone) at 40 weeks of gestational age (Dr. Amiel Tison) 55
1. Clinical assessment of axial tone 56
2. Normal findings in full-term infants 56
3. Abnormal findings 59
4. Clustering of signs: description of three syndromes 61
10. HIGH RISK FOLLOW UP OF THE PRETERM AND / OR LB W INFANTS FROM 40 WEEKS UP TO ONE YEAR CORECTED AGE 68
10.1 INTRODUCTION 68
10.2. PHYSICAL EXAMINATION 68
10.3. MONITORING SOMATIC GROWTH 72
Fenton and WHO growth charts 74
10.4. COMPLEMENTARY FEEDING 77
10.4.1. Nutrition recommendations for ages up to 6 months(WHO -IMCI) 77
10.4.2. Nutrition recommendations for ages 6 months up to 12 months 78
10.4.3. Nutrition recommendations for ages 12 months up to 2 years 79
10.4.4. Nutrition recommendations for ages 2 years and older 79
10.5. PROPOSAL FOR DIFFERENT NEURO-MOTOR SCREENING FROM TERM (40 WEEKS OF GESTATIONAL AGE) UP TO ONE
YEAR OF CORRECTED AGE 81

10.5.1 The apparently normal survivors: neuromotor and cognitive function as they grow older 81
10.5.2. Tracing the effects of perinatal damage through childhood: 87
10.5.3 The INFANIB screening or Infant neurological battery test 88
11. PSYCHOMOTOR DEVELOPMENT 95
12. IMMUNIZATION 96
13. SUMMARY: PERIODICITY AND CONTENT OF FOLLOW UP CONSULTATIONS UP TO ONE YEAR OF
CORRECTED AGE. 98
BIBLIOGRAPHY 101
APPENDIX 1. LUBCHENCO CLASSIFICATION 104
APPENDIX 2. PHYSIOTHERAPY FOR PRETERM AND / OR LOW BIRTH WEIGHT INFANT 106
BIBLIOGRAPHY 120
APPENDIX 3. OPHTHALMOLOGICAL ASSESSMENT 122
BIBLIOGRAPHY 130
APPENDIX 4 .OPTOMETRIC ASSESSMENT 131
BIBLIOGRAPHY 137
APPENDIX 5. DIFFERENT TYPES OF AUDITORY SCREENING 138
BIBLIOGRAPHY 141
APPENDIX 6.CLINICAL RECORDS AND FOLLOW UP CARD FOR THE PRETERM AND/OR LB W INFANTS IN
THE KMC PROGRAM 142

Annexes
Table 1. Average oxygen saturation values in hemoglobin, in different physiological states.
(Lozano & et al, 1992) 42
Table 2. Predictive model for supplementation used in the Kangaroo Mother Method 51
(Acta Paediatr. 2002;91(10):1130-4) 51
Table 4. INFANIB classification scores 91
Table 5. Neurological anomalies 91
Table 7. ROP Screening 127
Two chapters of the 1995 English edition of the book The Newborn Infant: One Brain for Life, by
doctors Claudine Amiel-Tison and Ann Stewart (Les Éditions INSERM), are included in this module by
permission of Dr. C. Amiel-Tison.
Likewise, Dr. Amiel Tison granted permission to add subtitles to the video “Neuromotor exam during
the first five years of life.”

1.
Outpatient Follow Up
Introduction
Since its creation, KMC includes a follow-up program to support mother/family to

implement the different components of KMC at home. It is important to teach them
how to care for their fragile newborns and to support them after the discharge from
the neonatal unit and from the hospital. Even if the kangaroo mother-infant dyad
stays for a few days or weeks in a kangaroo ward in or out the hospital structure, this
outpatient follow-up must be implemented.
In different health care systems, the outpatient Kangaroo mother care (KMC) Programs
have been pioneers in the follow-up and systematic management of high risk newborns
at least during their first year of life.
The Kangaroo Mother Care method, as described in this training kit, includes a follow
up program in 2 steps:
1) From discharge from the neonatal unit up to 40 weeks of gestational age.
2) From term up to one year of corrected age
Follow up programs includes the following aspects:
• Outpatient Kangaroo adaptation: re-enforcement of the training in kangaroo

position and the kangaroo nutrition for families trained in KMC in the hospital and
then discharged to home in kangaroo position and training for new parents joining
the KMC program after discharge from different units not implementing KMC.
6 • Regular monitoring of somatic growth, neurological and psychomotor development,

as compared to referral standards during the first year of life.
• Early identification, treatment, and rehabilitation of any disorders in preterm and/or

LBW infants, which may include the intervention of specialists.
• Support and counseling strategies for the family.
o The support initiated in the Neonatology Unit must continue after discharge to help
the family to accept child and to reinforce the affective bond between mother and
child.
• Quality monitoring of the kangaroo clinical practice

INTRODUCTION
o To identify out-patient morbidity and mortality rates and assess the performance of
the health care programs,
o To audit the quality of care for preterm and/or LBW infants in the NICUs and the KMC
itself.
• Active immunization.
This high risk follow up part of the KMC has an immense value; without it, it would
not be possible to appreciate the results of the Kangaroo Mother care Method nor the
quality of care in the Neonatal Unit.
It is clear that one year of follow-up is not enough. Kangaroo follow up to 40 weeks
guarantees the child’s survival; follow up from 40 weeks to one year of corrected age,
guarantees the quality of this survival.
The concept of high risk neonates for neurological problems was born in England
in 1960 and refers to the child whose pre, peri, and post natal history put him at a
greater risk for presenting developmental impairments in the first years of life. These
impairments could be cognitive, motor, sensory, or behavioral; transient or permanent.
According to WHO, 3-5% of all pregnancies correspond to high risk pregnancies;

approximately 12% to moderate risk pregnancies. High risk pregnancies increase the
risk for infants, as 10-12% of infants need Neonatal Intensive Care and 3-5% will have
psycho-neuro-sensory risk factors.
Children weighing less than 1500 g and/or with gestational ages below 32 weeks; with
Apgar Scores lower than or equal to 3 at one minute after birth and below 7 at five
minutes after birth; newborns requiring mechanical ventilation for over 24 hours; and
children with recurrent neonatal seizures, sepsis, meningitis or encephalitis are also
at higher risk for neurological problems and would require a more long term careful 7
monitoring.
Preterm infants (less of 37 weeks of gestational age) and LBW infants (less than 2500 g)
are considered at risk infants.

2.
Early Discharge From The Neonatal Unit And
Admission To Outpatient Follow Up Or To A
Kangaroo Ward
The neonatal unit’s pediatrician/neonatologist is responsible to discharge infants to

home or to a kangaroo ward (rooming–in accommodation).
2.1 Child’s eligibility criteria for discharge
A child is considered to be eligible for discharge from the Neonatal Unit, whether to
rooming-in accommodation or to home, regardless of his weight or gestational age,
once the conditions listed below are present.
- The child’s in-hospital kangaroo adaptation has been successful; he is regulating his
temperature in kangaroo position and has an adequate sucking–swallowing-breathing
coordination.

EARLY DISCHARGE FROM THE NEONATAL UNIT AND ADMISSION TO OUTPA-
TIENT FOLLOW UP OR TO A KANGAROO WARD
- The child demonstrated adequate weight gain in the Neonatal Unit in kangaroo
position and incubator, for at least 3 days, if older than 10 days. (The child may lose
weight during the first few days and eligibility criteria for a stable child during the first
week are different).
- The child completed his treatment, if any.
- If the child is receiving oxygen through a cannula, it must be below ½ l/min.
- The child is breastfed and/or fed with extracted milk.
- There is a Kangaroo Mother Program available able to offer adequate follow-up.
2.2 Mother’s eligibility criteria for discharge
The mother is elegible to have her infant discharged from the Neonatal Unit when the
following conditions are present.
- She has accepted to participate in the KMC Program and has received the necessary
training in the Kangaroo Mother Method.
- She feels able to care for her child using KMC (position and nutrition) at home.
- She succeeds in in-hospital kangaroo adaptation. In particular, she has adequate

breastfeeding and milk extraction techniques.
- She is physically and mentally able to care for her child. The mother received a positive
recommendation from the multidisciplinary team in the case of a difficult situation,
such as a teenage mother, single mother with a child under oxygen, in difficult socio 9
economic situation, or alcoholism or drug addiction.
- The mother should not be under anti-depressive drugs or using sleeping pills.
- She is supported by her family in the KMC ward or/and in the outpatient KMC program.
2.3 Mother’s eligibility criteria for discharge
- The family is committed to and able to attend follow-up visits in the kangaroo
outpatient clinic and to comply with its requirements.
- The family has the will to be trained in KMC.

EARLY DISCHARGE FROM THE NEONATAL UNIT AND ADMISSION TO OUTPA-
TIENT FOLLOW UP OR TO A KANGAROO WARD
- The family understands well the method and it is feasible for them to care for the
baby at home.
- The family is available and will cooperate to care for the baby and insure his safety.
- The family will comply with follow-up appointments, specialized medical exams,
breastfeeding schedules, and drugs prescriptions.
- The family will adapt to the temporary changes implied by the adoption of KMC.:
maintain the kangaroo position 24 hours a day (sleep in semi-sitting position) and
redefine the cooperation roles of all family members, to support the primary caregiver.
Family members involved in Kangaroo child care should be free of infectious or
contagious, skin disease, fever, or significant obesity, and must be physically and
mentally able to manage the child under the KMC.
If all criteria have been met, except the possibility of the mother and the family returning
the next day and complying with the outpatient kangaroo follow up protocols, it is
better for the mother-kangaroo child dyad to stay in a KMC ward. When the child’s
condition makes it possible to have a weekly follow up, the mother and her child
are sent home under an outpatient follow up in a Kangaroo Mother Program. KMC
Rooming-in is only a transition stage in the home discharge process of a fragile child
and is used in many countries.
(See Appendix 2 The kangaroo ward or Rooming –in, as an alternative for home
discharge Module 4)
10

3. Physical Structure Of A Kmc Out Patient
Consultation
O
utpatient kangaroo follow up activities are usually organized daily in premises
staffed with a multi-disciplinary team, including pediatricians, nurses, and
psychologists trained in KMC. Small children in kangaroo position as well as
older “ex kangaroo children” attend routine follow up visits, during which their growth
as well as their neurological and psychomotor development is assessed. Sick children
are not admitted in the KMC outpatient clinic to avoid possible contamination.
Ideally, this place is located in a hospital where there is a Neonatal Unit equipped with
human and technological resources in case of an emergency identified in patients
attending the follow up consultation.
It is ideal and advisable to have a large room used both for consultation and as a waiting
room. In addition two separate areas are necessary; one where outpatient kangaroo
adaptation takes place and the other for psychology consultations, a teaching room
for new parents, or psychomotor evaluation.
The follow up consultation team includes a pediatrician, a nurse, a psychologist, and

a social worker. When necessary, other health professionals join the team, such as
nutritionists, physiotherapists, ophthalmologists, optometrists, and orthophonists.
This outpatient care is named “Group consultation” because; it brings together different
patients who are seen individually in the same space and for the same length of time
by a group of pediatricians, sitting side by side in the same examination table. Each
child is assessed individually and each family receives personalized recommendations;
yet, at the same time, the entire group is taught about KMC procedures and benefits.
11
This organization of the outpatient Kangaroo Mother Program has a very positive
impact on families and on the visitors of the KMC program. It is a hallmark of the
outpatient KMC Program and it is recognized to be effective.
The open (group) consultation is facilitated by a team of health care personnel working
together and using multimodal communication techniques, resulting in better
adherence to the program by the parents.
Video Kit: Outpatient follow up

PHYSICAL STRUCTURE OF A KMC OUT PATIENT CONSULTATION
This methodology also facilitates the collective learning processes and reinforces
the mother’s knowledge when she repeatedly hears the same advice. Parents, while
waiting, can also listen to the problems of other parents and exchange experiences
and difficulties.
This “group consultation” also decreases the parents’ anxiety. When they see babies
smaller than theirs, they realize that their child is in the same, if not better condition
than some of attending children. They also see older children and they may begin to
have better expectations for the future development of their small child. The presence
and availability of a psychologist supports parents in cases of depression, insecurity,
or vulnerability.
The commitment to attend the daily consultations at the beginning of the outpatient
KMC Program is demanding on parents, and in a way is similar to the daily visits they
did when the child was hospitalized, creating a link between neonatal unit and home
care.
12

Complete Assessment Of The Newborn When
4. Admitted To An Outpatient Kmc Or To A Kmc
Rooming-In Program
During the first contact or first follow up visit in the KMC ward or in the outpatient
Program, several activities are conducted for every preterm or LBW infant:
1. The gestational age at birth is determined as exactly as possible and the child is
classified according to the Lubchenco’s classification tables.
2. The anthropometric parameters are assessed (weight, height, head perimeter).
3. A full clinical assessment is conducted (from head to toes).

13
4. Outpatient KMC adaptation is reinforced or initiated as necessary.
5. Brain sonography and ophthalmologic screenings are requested if possible and if

necessary
6. Routine and specific drugs are prescribed.
7. The need for oxygen is assessed.
8. The need for family support is assessed and provided
All of these elements are noted in the child’s medical record and used as a baseline for
the follow up.

COMPLETE ASSESSMENT OF THE NEWBORN WHEN ADMITTED TO AN
OUTPATIENT KMC OR TO A KMC ROOMING-IN PROGRAM
4.1. Determining gestational age (GA) at birth and classification according to the
Lubchenco’s table.
It is crucial to establish as exactly as possible the gestational age at time of birth, as

different components of the follow up program depend of the GA at birth. Thus, it is the
first task for the pediatrician, either in the outpatient consultation or in the KMC ward,
to establish the use of different methods and parameters. Then the child is classified,
according to the correlations between his age and his weight1 at the time of birth
(using the Lubchenco’s classification) and this classification is noted in his medical
record.
As describe in Module 1, preterm or LBW infants may present different problems,

which vary according to the degree of immaturity and the correlation between weight
and gestational age. Mothers suffering from placental insufficiency, chronic hypoxia,
intrauterine infection, or genetic problems could give birth to infants who are not only
preterm, but who also have some degree of intrauterine growth retardation, which
can negatively impact the weight, height, and the head perimeter.
a) Gestational Age (GA) based on the date of last menstrual period
The first day of the last menstrual period (LMP) has been used as a reference point, since
it is estimated that the due date will be 280 days after it. Many mothers have irregular
cycles, are uncertain about this date, or experienced bleeding at the beginning of
pregnancy, making necessary to find other assessment methods.
b) GA based on the New Ballard test
The New Ballard (modified Ballard) test is generally used in the first 48 hours of the
baby’s life. This allows the pediatrician/ neonatologist to assess the gestational age
of the infant in a precise manner (+or - one week). There are other tests which are not
14 described here.
c) GA based on ultrasonography
In the last few years, ultrasonography assessment has become an integral part of
obstetric practice in many countries, including developing countries. Ultrasound is
used to determine the gestational age using the anthropometric measurements of
the fetus. The sonography during the first quarter is the most precise because during
this period the variations in fetal size are minimal. Before 27 weeks, the margin of error
is ± one week; until 36 weeks ± two weeks and after 36 weeks ± three weeks.
1 e.g. a child of 34 weeks gestational age will be classified differently ifhe is weighed at birth 2200 g or 1500 g)

Before reaching a conclusion, it is recommended that health personnel analyze the

different information and balance the possible due dates using these three methods:
date of last menstrual period, first trimester ultrasound, and the New Ballard test done
within 2 days after birth. An ultrasound done correctly in the first 12 weeks offers
excellent precision. If it does not exist, a well-conducted new Ballard test, in the first 48
hours offers reliable data. The LMP, even in a woman with regular menstrual periods,
is the least reliable method to establish correctly the GA, but it is sometimes the only
information available.
Together with the parents, the multi-disciplinary team of outpatient KMC reaches
an agreement on the due date (40 weeks of gestational age) and then, based on
it will decide when the high risk follow up will stop (one year after the due date).
It is important to make parents aware that the initial period of care until the child
reaches 40 weeks will be difficult and extremely demanding; but that the benefits of
these efforts extend for the rest of the child’s life.
The second period of follow up requires timely and appropriate intervention and is
more focused on physical, neuro-psychomotor, and sensory monitoring to prevent the
development of deviancies.
4.2 Anthropometric measurements
4.2.1 Taking anthropometric measurements
15

The anthropometric measurements are one the best indicators of nutritional status in
both neonates and older children. These measurements must be done with precision
and then reported into reference tables. The weight, the height in supine position, and
the head circumferences, are measured among others. They are generally considered
to be the most important indicators of growth and nutritional status.
In preterm and /or LBW infants, anthropometric measurements change rapidly during
their first months of extra uterine life. The growth rate depends considerably on the
quality of growth in utero and on the characteristics of the infant’s family group as
well as the duration and severity of the initial phases of adaptation to extra uterine
life (Neonatal Intensive care unit, parenteral nutrition). The consequences are both
neurological and nutritional.
16
Progressive increase in head circumference, height, and weight in each stage of the
kangaroo adaptation help to identify whether growth is symmetrical or not, which
substantially modifies the management and the expectations of future somatic
evolution. Anthropometry must be a routine procedure in Neonatal Care Units, as it
helps to identify those neonates at a higher risk for morbidity and mortality as well as
those who may present nutritional problems.
The majority of anthropometric measurements must be compared to tables of a

reference population similar to the target population.
However, subsequent measurements are more valuable, since they allow individualizing
growth charts.

During the first visit and every subsequent visit, anthropometric measurements are
recorded in the charts specific to the child’s gender and age. There are charts to be
used before and after 40 weeks. The chart to be used before 40 weeks allows registering
the weight, the height, and the head perimeter of preterm children on a weekly basis.
Lubchenco’s charts are the most common and the oldest available.
Luchencho and collaborators developed charts of intrauterine growth in 1963, based

17
on North American children between 24 and 42 weeks of gestational age from Denver,
Colorado, located at 1650 meters above sea level. These charts are well known and
widespread and have been successfully used as a reference parameter both for the
North American population and for many others.
In 1967, Battaglia-Lubchenco classified newborns according to the relation between

their gestational age and birth weight as: large, adequate, or small for gestational age.
The same parameters are used today to identify those groups of children who are at
greater perinatal risk of morbidity and mortality. It is considered that normal values
are between 10th percentile and 90th percentile; if they are below 10th percentile
they are considered small and above 90th percentile they are classified as large for
gestational age.

Benda y Babson (1976) developed a new chart of intrauterine growth for preterm
infants based on a small sample, offering low confidence at both ends of the chart.
It begins at 26 weeks with 500g-increase intervals. This chart was based strictly on
a white population of healthy children without any kind of nutritional support. This
characteristic makes this chart inadequate for many developing countries.
Currently, several Neonatology Units prefer Fenton’s curves, since they come from a
very large population sample, integrating data from different types of populations up
to 40 weeks of gestational age.
In this module, two series of charts may be consulted and downloaded: Fenton’s charts
up to 40 weeks and Fenton’s curves followed by the WHO curves in the same charts, in
percentiles up to the second year. This allows for the evaluation of the preterm baby’s
growth, with just a quick look, from birth to term and then to two years of corrected
age.
The gestational age is used until 40 weeks, at which time the corrected age is used
when assessing the preterm infant’s physical, neurological, psychomotor growth and
nutrition.
Follow up continues until the child is one year of corrected age. Often, at one year of
corrected age, the child’s weight, height, and head circumference match those of a full
term child (compensatory growth or catch up), although many times it takes longer for
height to catch up. Many neonatal teams are use corrected age until two years of life.
It is crucial to use the corrected age to avoid any inappropriate interventions, such
as giving nutritional supplements to a child who is growing regularly according to
his growth pattern when he is assessed using his corrected age, but appears to be
undernourished for his chronological age. This would not only lead to endangering
breastfeeding, but also to generate guilt in parents who are caring for their baby
correctly. In addition, it is an increased risk of infection and altering the child’s future
18
health.
Follow up on LBW infants who are small for gestational age demonstrates that growing
too fast (to catch up will full term infants), could cause the development of metabolic
conditions, such as obesity or hypertension in adulthood.
4.2.2 Reporting anthropometric measurements in growth charts
In order to monitor the growth of a child, it is necessary to report data on reference

growth charts.
• Establish the gestational age, or corrected age, if more than 40 weeks

• Measure weight, height, and head circumference
• Record these measurements with a dot in the appropriate place on the growth charts
• Interpret the growth indicators according to percentiles or standard deviations
• Connecting the dots from consecutive visits shows the child’ growth trend, and any
abnormality can then help health personnel to recognize deviations in a timely manner.
If a boy or a girl has a normal and adequate growth pattern, the curve obtained by the
connected dots follows a channel, parallel to the line corresponding to the median of
the reference population
19
Preterm infants, evaluated by their corrected age, should ideally follow the normal
growth channel (around 50th percentile). Any flattening of the growth curve or
changes of growth channel in children who were progressing in an adequate range,
require a careful assessment.
The following charts offer the parameters used to classify the child’s nutritional status
once a curve is established by connecting several measurements.

Height for age (H/A)
Cut-off point
Denomination
(Standard deviation or Percentile)
<2 Below length for age or stunting.
_> - 2 a < - 1 At risk for below length
_> - 1 Adequatelength
Weight for age (W/A)
Cut-off point
Denomination
<-3 Very low weight for age or severe

chronic malnutrition.
<-2 Low weight for age or
chronic malnutrition.
>
_-2 a <-1 At risk for low weight for age.
_> - 1 a < - 1 Adequate weight for age.
Head circumference (HP/A)

20
Cut-off point
Denomination
<-2 Risk factor for neurodevelopment
_> - 2 to < 2 Normal
Eventually Risk factor for
>2
neurodevelopment

Table: Lubchenco’s, Babson & Benda and Fenton charts for extra uterine growth from
premature birth up to 40 weeks of gestational age.
Lubchenco Babson & Benda Fenton

(1963) (1976) (2003)
Sample size (n). 5.635 300 26,973–82 million 3 4
Data source Colorado Usher and McLean Kramer, Niklasson,

General Hospital Beeby, CDC
Weight: 24 – 42
Gestational age 26 – 40
range (weeks) Head, Length: 22 – 50
26 – 42
Years data 1948 – 1961 1959 – 1963 1963 – 1996
collected
Weight: Canada Head,
Caucasian with length: Sweden &
Caucasian with low varying socioeconomic Australia Weight,
Demographics socioeconomic status backgrounds from Head
from Colorado Montreal
Length: USA
Inclusion Uncomplicated Each data source used

criteria. Caucasian pregnancy in private different criteria.
setting
Gross pathological Major congenital

conditions, age < anomalies, marked
Exclusion fetal malnutrition, Each data source used
criteria 24 or > 42, maternal different criteria
diabetes, incomplete maternal diabetes, no
records last menstrual period
listed
Infants (26-35 weeks) Gestational age not 21
Outliers whose weights were compatible with Each data source used
removed far above the 90th clinical assessment of different criteria
percentile gestationalage.
4 Fenton’s simple size differs based on measurements and gestational age.
Ref New preterm Infant Growth Curves Influence of Gender and Race on Birth Size
A Thesis Submitted to the Faculty of Drexel University by Sue A. Grovemanin partial fulfillment of the requirements
for the degree of Masters of Science in Human Nutrition, July 2008.

Percentiles taken Published Published percentile

from midpoint of percentilesplotted and data combined and
Methodology week and smoothed joined to other data smoothedat disjunction
mathematically for older children. 40 weeks
Old data Small sample size
(Especially at <30 wk.)
All Caucasians Old data
Limitations All from Colorado All Caucasians All from Mixing of data sources
Montreal
All low socioeconomic
Biweekly grid lines
Status
For over 15 years, the Kangaroo Mother Program has used the Lubchenco’s curves of
intra uterine growth to monitor somatic growth and to recognize on time any deviation.
Since 2012, Fenton’s curves up to 40 weeks are used, in line with most Neonatal Units
in Colombia.
4.3 Fenton curves up to 40 weeks (standard deviation)
Head circumference for boys
22

Head circumference for girls
Weight for boys
23

Weight for girls
Length for boys
24

Length for girls
4.4 Initial physical exam of a preterm and/or LBW infant
Skin:
The child’s assessment must begin by observing the skin, which is dry and flaky. It is
important to check for pallor, cyanosis, jaundice, bruises or birth marks. The presence
of lanugo (noticeable, fine, scarce body hair) must also be checked.
Head:
The head is assessed for shape and symmetry by observation and palpation and to 25
recognize mainly the following points/conditions:
• Caput succedaneum. Contusion and edema of the scalp.
• Molding. Overlapping of fetal skullbones can produce a pointed or flattened shape

in the baby’s head.
• Fontanels size: Fontanels are wider areas of fibrous connecting tissue that are present
where two or more sutures meet. Anterior and posterior fontanels are found at each
end of the sagittal suture. Coronal sutures are connected to the anterior fontanel and
the posterior fontanel is connected to the lambdoid sutures; they must be open and
normotensive.

• Plagiocephaly. Asymmetry of the skull.
• Craneotabes: Small areas of the parietal bones close to the suture lines; they may feel
soft and produce a clicking sound under pressure.
• Cephalohematome: Blood collection under the periostium of one of the bones of the
skull.
• Presence of the scaly suture, when performing a bilateral palpation of the skull. This
sign is part of Amiel Tison’s neurological triad, which is described further down in this
chapter.
Ears
External auditory canals must be checked and the type of development and position
of the pinna must be carefully observed. Abnormalities of the pinna (preauricular
tags) aligned with the ear or the corners of the mouth, may be related to renal or
gastrointestinal malformations.
Face
Assess the appearance of the face; its symmetry, detect the presence of malformations,
lesions of the facial nerve, hemangiomas, among others.
Eyes
Check for epicanthic folds (skin fold in the inner corner of the palpebral fissure, which is a
common in small children usually disappearing as the child grows older). Hypertelorism
(the distance between the 2 eyes is too large), as well as sub-conjunctival hemorrhage.
Possible transitional strabismus as eye movement is not fully coordinated.
26 An ocular secretion may be observed due to a conjunctive irritation or a blockage
of the nasal-lacrymal ductus. In this case, it is recommended to gently massage in
the internal corner of the eye. If secretion persists, the child must be referred to an
ophthalmologist.
Mouth
Thickening of the upper lip caused by suckling is normal. It is necessary to check the
size and position of the tongue and the integrity of the palate. It is possible to observe
small white-grayish areas on the palate’s mucous membrane, close to the palate’s
midline, called Epstein pearls; these are a normal. It is also important to check for
mycosis, petechiae, and for any malformations.

Thorax
Assess first its shape, symmetry, and movement.
• Clavicles: their surface should be smooth and firm. In case of fracture the bone will
be felt bigger, painful with a discontinued surface and sometimes a click can be heard
when the clavicle is moved.
• Breast buds: they are not noticeable by palpation in immature boys and girls. Their
size is determined by gestational age and adequate nutrition.
• Lungs: breathing in the newborn is largely abdominal and generally irregular (periodic).
Lungs expand symmetrically and have an adequate murmur; if this is asymmetrical or
diminished, some illness must be suspected.
• A certain retraction of the lower ribs is normal (they are softer).Only severe chest
indrawing is abnormal. if the child has been diagnosed with broncho-pulmonary
dysplasia, this may be his normal breathing pattern.
• Respiratory rate is counted during one minute; it should be between 40 to 60 breaths

per minute.
• Heart: rate is from 120 to 160 beats per minute. The apex is found in the 3rd or 4th left
interspace. A systolic murmur is frequently heard due to a permeable oval foramen,
which will close on its own. All murmurs accompanied by other symptoms or persisting
must be assessed carefully.
Abdomen
The palpation of the abdomen on a newborn requires patience and a gentle hand
from the physician. The liver is normally found in the epigastrium and around the right
costal ridge the edge can be felt in the mid axillary line during inhalation. The spleen, 27
when enlarged, presents itself more lateral than in the older child and the tip points
more towards the left than the right-hand flank. Femoral pulse must be included in
the physical assessment along with the palpation of both arteries as compared to the
radial pulse in the wrist.
Umbilical stump:
• Detachment of the cord usually takes place between 5 and 10days after birth, but can
take longer when the cord has been kept moist or in case of infection.
• Umbilical hernias may be present at birth, but appear more frequently during the
first year. In preterm infants they are common and are not related to any disease.

Nevertheless umbilical hernias could also be associated with other malformations,

such as the Beckwith syndrome, trisomy, and hypothyroidism.
There is no evidence that home-made treatments such as bandages, buttons or

adhesive tape reduce umbilical hernias; they spontaneously resolve as the abdominal
muscles develop. If the hernia is still present at one year of corrected age, an appropriate
treatment should be proposed by a pediatric surgeon.
Genitalia
It is important to assess for boys and girls the opening and position of the ureteral
orifice. For boys, both testicles must be palpable and descended into the scrotum. The
absence of hydrocele must be checked. In girls the labia are very different depending
of the gestational age: in girls with in later stages of development; the clitoris and labia
majora are more prominent
Anus and rectum
It is necessary to examine the location and permeability of the anus and the absence
of an anal fissure.
Extremities
A careful assessment of limbs and extremities must be conducted, with particular

attention to relative lengths of superior and inferior segments and a comparison of
both sides. Fingers and toes andpalms and soles offer information regarding the shape
and morphology of the creases (simian crease). Major alterations include: absence
of bones, equinovarus, polydactyly, and syndactyly. Occasionally, fractures may be
palpable.
28 Hips
Symmetric abduction is required; congenital hip dysplasia must be suspected when

limitations in abduction occur or if a distinctive 'clunk' can be heard and felt as the
femoral head relocates anteriorly into the acetabulum (Ortolani sign). Presence of
cortical thumb must be assessed.
Back
After the child has been placed in prone position, a thorough inspection and palpation
of the back, spine, gluts, and the inter-gluteal cleft is necessary, verifying the absence
of fistulae.

4.5 Outpatient kangaroo adaptation
Outpatient kangaroo adaptation is the period of social, emotional, and physical

adjustment at home for the mother and the family of the preterm and/ orLBW infant
to the Kangaroo Mother Method. It begins in the hospital during daily and continues
visits to the outpatient follow up clinic or in the KMC ward. It is a period of stress for the
mother as it is the first time she will be totally responsible of her child at home without
the close support of the hospital team.
In practice, outpatient
kangaroo adaptation
is conducted through
a process of education,
training and social and
emotional support.
Go to video: Starting
in-hospital kangaroo
adaptation
The process of the outpatient adaptation is characterized by the following aspects:
• It begins upon first contact in the outpatient follow up or in the KMC ward. 29
• It is a sensitive period requiring careful attention since the child will be under the
mother’s supervision, whether in rooming-in or at home.
• It is important to increase the mother’s confidence and to trust her.
• The health team must be available to solve any problems, even by phone.
• It is important to keep in mind the risk of hypoglycemia if the mother is not ready and
expert in feeding her child.
• It is necessary to discuss the use of nutritional supplements, especially for children

hospitalized and separated for a long time from their mothers. Milk production

increases progressively, but not from one day to the next.
• All weak aspects of in-hospital adaptation, or those in the process of being attained,
must be reinforced.
• An explanation on ‘sun baths’ for management of jaundice must be included.
• It is necessary to reinforce the technique for massage.
Keeping in mind the important aspects outlined below, will contribute to the
achievement of adequate adaptation to the KMC Method, however, some issues must
still be solved.
30
• Kangaroo parents, who are just attending the Kangaroo Mother Program for the
first time, have the opportunity to receive psychological support and to attend group
discussions.
• Due to prolonged hospitalization some problems could emerge such as nipple

confusion, suction difficulties, and malnutrition. Some techniques should be explained
and reinforced:.
o The suitability of using hind milk (according to gestational age) every two meals
o The possibility of feeding the child with a spoon, syringe, or dropper in case of
immaturity or tiredness.

o The need to use liquid preterm formula as a supplement: given as 30% of the daily
requirement with syringe or dropper and distributed on a 24-hour period, or the use of
fortifiers, depending on availability and the family’s ability to administer them.
4.5.1. Kangaroo adaptation activities
Once the child is discharged from the

neonatal unit home or to rooming-in
Kangaroo wards, he must attend daily
control visits with the Kangaroo Mother
Program team, as long as he meet the
eligibility criteria. If the child doesn’t
meet the requirements, he must be
readmitted immediately.
On the first day 5, the nursing staff will conduct the activities listed below.
• Assess if the child and the family meet the eligibility criteria for admission to rooming-
in accommodation or outpatient follow up.
• Evaluate the knowledge of the mother/ family on the KMC Method.
• Assess the management of the child in kangaroo position and nutrition.
• Assess the quality of care provided by the mother/family at home and check to see if 31
they are able to identify alarm/danger signs in the child.
• Make sure the family knows how to use the equipment for oxygen if the child needs
it.
• Explain what the follow up program is and how it will be conducted, in rooming-in
accommodation or in the outpatient program.
• Enquire about the social situation and emotional situation of the family and inform
the social worker and psychologist in order to react timely.
5 All of these tasks will be fulfilled during the first week of follow up visits

4.5.2. Assessing the kangaroo position
• The nurse checks that the child is held

between the caretaker’s breasts, in upright
ventral position, with his body and cheek
against the caretaker’s skin (“frog position”).
If not, all necessary adjustments are made,
since a child placed in an inadequate position
could present obstructive apnea. The correct
use of the kangaroo girdle is also checked,
as it helps to keep the child in the correct
32 position, it makes handling the child easier, and gives the mother or caretaker the
necessary confidence to hold the child. If the mother does not have a girdle, instruction
to purchase one or to make one are provided.
Video Kit Kangaroo

position
• The nurse also assesses whether or not the clothes of the kangaroo child are
appropriate for the climate.

4.5.3 Assessment of breastfeeding
The nurse assesses the breastfeeding technique looking for the following:
33
• The correct position of the mother; with her back straight, against the chair.
• The position of the child in strict contact with the mother’s body, with support to the
infant’s body from neck to buttocks.
• The correct attachment to the breast. Ideally the chin touches the breast, a large part
of the areola is inside the child’s mouth, the mouth is wide open, and the lower lip is
everted. The mother holds her breast in a C shape.
• The suckling form: cheeks are not sunken, mandibular movements are visible,
swallowing is audible; the hyoid bone is moving and there is milk in the child’s mouth.

The necessary explanations are given in order to teach the different nursing positions:
‘football’, “facing forward”, ‘sitting’, and the variations for twins.
It is also important to evaluate the mother’s milk production through manual extraction
and to check if the mother knows how to express her own milk. 6
Go to videos:
-How to successfully breastfeed a

preterm infant.
-Other forms of feeding preterm

34 infants.
According to the results of the assessment, appropriate actions are taken.
• Make the necessary adjustments so that the correct position of both mother and
child facilitates the manipulation of the child and improves breastfeeding.
• Teach the mother manual milk extraction techniques, as well as how to manage
different possible sources of breast discomfort (engorged breasts, cracked nipples,
etc.).
• Teach the hind milk technique, as a technique to increase weight gain.
6 See Module 3. Kangaroo Nutrition

• Teach alternative feeding techniques that use a dropper, syringe, or spoon.
• Teach feeding technique for twins and triplets.
• Discourage the use of artificial nipples that hinder the breastfeeding process and
have negative long term effects on the child’s health.
• Teach re-lactation techniques when the milk production is low.
• Provide education to the family on factors associated with good milk production,
including appropriate nutrition for nursing mothers.
• Identify support in the family to foster breastfeeding, attempting to establish nutrition

based exclusively on breast milk.
35

5. Specific Tests
5.1 Brain sonography
It is advisable, but not mandatory, to request a brain sonography for all preterm
and/or LBW infants. Where this exam is not easily available, it should be prescribed
only to higher risk children according to the local protocols.
If during the first year of life a child has an abnormal neuro psychomotor development
with a normal or abnormal brain sonography, a cerebral magnetic resonance imaging
scan is recommended (if available).
It is not necessary to repeat brain sonography in children with normal muscle tone and
normal neuro psychomotor development.
Having a first brain image of all infants included in KMC program allows for strong
documentation.
This algorithm, used in the Kangaroo Mother Program, shows the decision-making
process according to the results of the first sonography performed before or after
admission to the KMC program.
It is important to determine the grade of intra-ventricular hemorrhage (IVH), if any.
Grade I: germinal matrix
36 Grade II: germinal matrix and intra-ventricular hemorrhage without dilatation
Grade III: hemorrhage without dilatation
Grade IV: intraparenchymatous hemorrhage
If the hemorrhage is grade I or II, there is no need for a second ultrasound, since these
hemorrhages usually will reabsorb and the risk of sequel such as cerebral palsy or
mental retardation is 1%-2%. Nevertheless, repeated clinical neurological assessments
during the1st year of high risk follow ups are very important to detect any abnormalities.
If the hemorrhage is grade III or IV, the risk of a sequel increases significantly: up to
50%-70% incidence of cerebral palsy and/or mental retardation.

SPECIFIC TESTS
During the following control visits, it is necessary to monitor closely the child’s
neurological development, tone, and head circumference. In the case of any anomalya,
cerebral magnetic resonance imaging scan must be performed if available
In case of seizures, hydrocephaly, or neurological symptoms, the child will be referred

to neurology or pediatric neuro surgery department for adequate care.
5.2. Ophthalmologic screening
Due to technological advances, preterm mortality has decreased, but problems such
as retinopathy of prematurity (ROP) are on the rise. ROP consists of an abnormal
development of blood vessels in the peripheral retina. Most of these cases resolve
spontaneously but some cases progress to a noticeable loss of vision and even total
blindness. ROP is currently the first cause of blindness in Latin America.
50 years ago, developed countries went through a period of high incidence of ROP
when oxygen was used extensively, then, the administration of oxygen was controlled
and incidence of ROP decreased.
Today, children weighing less than 1500g or weighing between 1500g-2000g, with a
complex clinical history and associated risks, such as broncho pulmonary dysplasia,
respiratory distress syndrome, patent ductus arteriosus, sepsis, intraventricular
hemorrhage, or blood transfusion are still at risk of ROP.
In countries such as Colombia, increased access to neonatal technology has decreased

preterm mortality and increased pulmonary sequel and rates of ROP and blindness in
children due to lack of timely intervention. This includes children weighing even more
than 1500g.
This complication can be prevented with a timely treatment (laser surgery or

cryotherapy). It is necessary to screen all at-risk preterm infants admitted in Neonatal 37
Care Units in order to timely diagnose ROP.
In the Kangaroo Mother Program, all preterm infants <37 weeks attending the Program
are screened at 31-32 weeks or 28 days of life and will continue until the vascularization
of the retina is completed.
Later, an optometric assessment is conducted at 3 months of corrected age, to diagnose

refractive problems common in preterm and/or LBW children. 7
7 See annexes 3 and 4 this module, there is ample information, related to the importance of early
ophthalmology and optometry assessment

SPECIFIC TESTS
In order to optimize the available resources, ophthalmologist consultations are well

organized:
• Select one day of outpatient KMC to organize the ophthalmologist consultation. All
patients needing this exam should be requested to come on this day.
• As soon as the patients arrive the nurse applies eye drops to dilate the pupil, therefore
all children are ready for the ophthalmologist’s assessment and the consultation is
quick and continuous. It is important to monitor the effect of these drops as some
side effects could be observed, such as redness of the face, irritability and rarely
hyperthermia and hypertension.
The nurse should be repetitively informed on the possible side effect of these drops to
be sure that she controls carefully the number of drops she applies. Mothers/parents
must receive clear and adequate information about what could happen as some side
effects could last up to 24 hours.
38

6. Drugs Prescribed To Children In The Kmc In
Colombia
Medication Dosage Comments

Following the recommendations of theGuides of
Weekly addition of scientific evidence of the benefits of the KMC,it
vitamin K up to 40 is especially suggested to administer vitamin K
Vitamin K weeks to children orally, avoiding a rare but possible complication
predominantly fed such as late bleeding.
with breast milk.
The weekly oral dose is 2mg up to 40 weeks.
Following the recommendations of the Guides of
scientific evidence of the benefits of the KMC, about
vitamins, the dose to be administered until 40 weeks
should be: vitamin A (2000 to 2500 UI/day); vitamin
From the first week up
E(25 UI/day) y vitamin D (400-600 UI/day).
to week 40, administer
Multivitamins supplementary doses Reserves of fat-soluble vitamins (A, D, E, and K) are
of vitamins A,D and E. built in the last trimester of pregnancy. Since breast
milk contains insufficient amounts of them, they
must be administered as supplements to preterm
newborns until they reach term.
Metoclopramide; its only adverse effect is
drowsiness, which makes feeding difficult. In this
case, a lower dose is administered. Domperidone
From admittance up (very low clinical efficacy) and Cisapride are
Anti-reflux to 40 weeks. Longer if not recommended, since both medications
necessary (GER) originate cardiac side effects especially in preterm
infants(elongation of the QT).Actually the use of 39
metoclopramide in GER is discussed (low efficacy)
If xanthineis administered, an anti-reflux
medication must also be administered from the
Below 34 weeks and up first follow up visit, to control heart rate and
to 40 weeks, in order to tolerance. If tachycardia appears in an oxygen-
prevent or treat apnea dependent infant independently of the oxygen
Xanthine of prematurity and / flow, the following dose is suspended and the
or oxygen users. If oral daily dose is given is 2 parts.
theophylline is used, give
4mg/kg/day in 3 doses. Recently the use of xanthine to prevent apneas
and in oxygen- dependent infant is discussed.

DRUGS PRESCRIBED TO CHILDREN IN THE KMC IN COLOMBIA
From the first month

up to one year of
Preventive iron
chronological age.
supplementation Ferrous sulphate1-2mg/
kg/day.
Taken from the Manual of Technical Guidelines for the implementation of Kangaroo
Mother Programs in Colombia. Technical and financial agreement No. 638, 2009,
between the Ministry of Social Protection, UNICEF and the United Nations, World Food
Program (WFP).
40

7. Assessing The Need For Oxygen
A
study was conducted in Bogotá on healthy children between 5 days and 24
months, to measure the average oxygen saturation in children in different
physiological states (evaluated with a Nellcor N10 oxymeter). Average oxygen
saturation values were obtained for the altitude of Bogotá (2600m). These values could
serve as reference for measuring oxygen saturation in oxygen-dependent preterm
children in the same physiological states, high altitude cities like Bogotá. The normal
saturation value is over 90%.
41

ASSESSING THE NEED FOR OXYGEN
Table 1. Average oxygen saturation values in hemoglobin, in different

physiological states.
State of consciousness #of children Mean %
Alert inactive 150 93-4%
Sleeping 8 91-1% *
Crying 1 93-3%
Suckling 16 93-5%
Total 189 93-3%
(Lozano & et al, 1992). *p< 0.05 variance analysis
When oxygen is administered at home to a newborn, it must always be carefully

controlled in order to be stopped when it is no longer needed. This withdrawal must be
progressive, and the effects of this reduction must be measured at rest, while suckling
and sleeping.
Besides improving survival rates and quality of life, using oxygen at home reduces the
duration of hospitalization and cost of medical care. However, careful follow up and
monitoring of the baby and of the family is required.
This procedure is expensive since transporting the oxygen cylinder is complicated and
42
costly (requires private transportation) and source of stress for the family.
Likewise, it is necessary to give some training about nasal irrigation, changing the
nasal cannula, alarm/danger signs, and home management of oxygen.
Oxygen-dependent preterm infants are at high risk to be rehospitalized for pulmonary

infection, especially viral. Therefore, on the first day parents must receive strict
recommendations on hand-washing, visitor restrictions, and avoidance of contact
with people with a cold or flu.

Dynamic oximetry is used to measure

the oxygen saturation in the blood
and is measured in different situations:
when the child is awake, sleeping, and
suckling. Oximetry helps to determine
the minimum quantity of oxygen that
is needed to maintain an adequate
saturation. The child must be monitored
for at least 10 continuous minutes awake,
sleeping and suckling. The reference
oxygen saturation used is more than
90% and less than 94%.
This measurement looks to guarantee: i)

appropriate saturation while at rest; ii)
good oxygen saturation while suckling;
iii) adequate weight gain and iv) absence
of hypoxemia during sleep.
To perform a dynamic oxymetry correctly,

some points should be respected:
• The patient must be calm and

comfortable,
• A good pulse must be found to confirm

that the heart rate registered by the
oxymeter is the real heart rate of the
patient 43
• Oxymetry must not be done in the case

of bad peripheral perfusion due to cold
• After reduction of the oxygen flow, a

20-minute pause should be respected
before doing a new measurement.
During a dynamic oxymetry, any signs of

hypoxia should be assessed:
• Central cyanosis or pallor

• Faster breathing with severe chest in-drawing or respiratory pauses
• Drowsiness
• Fatigue during nursing and suckling
The recommended level of oxygen saturation is up to 93% in patients with

bronchopulmonary dysplasia. This value should not bed surpassed until retinal
vascularization is complete.
For this reason, a dynamic oxymetry (awake, spleeping, and suckling) is taken with
every admitted patient, from the first day until adequate somatic growth is achieved.
Then, it is taken on a weekly basis, until oxygen is not needed. .
If the saturation is above 94%, the oxygen flow must be reduced, waiting 20 minutes
between two measurements until normal values (90-93% at rest and suction and 88-
90% while sleeping with normal heart rate) are obtained; reduce slowly at each control
and only if the weight gains is adequate.
44

8. Evaluating The Family Need For Support
F
rom the moment the child is admitted to the Neonatal unit, parents should be
invited to be close to their child and to be part of the caring team. This process
ensures that the parents are more confident to care for the child when he is
discharged to home.
In the outpatient KMC, it is important to develop a organized training/teaching plan

that includes individual and group sessions.
45
• The development of an individualized teaching plan with the parents helps them to
develop the knowledge and skills necessary to care for their child.
• A written checklist or a scheme of specific areas or tasks to be mastered increases the

probability that parents/caretakers will receive complete instructions and acquire the
necessary experiences.
• Parents and caretakers must understand that the degree of immaturity and clinical
state of their child demands greater care and vigilance at home, more so than with a
full term child. It is essential to take the time necessary to teach each aspect of the care
plan and address any questions or concerns. Nevertheless, the child’s fragility must
not be overstated. If this should happen, the parents may become overly protective,

Evaluating The Family Need For Support
which may restrict his social development and lead to behavioral disorders, such as
the vulnerable child syndrome.
• Parents must also be trained on the best way to explain the preterm baby’s state to
their older children, the care he needs and the changes which will occur in the family
routine.
It is also necessary to check and possibly reinforce the parents’ newly acquired
knowledge during the daily follow up visit.
Permanent telephone assistance
It is important to have a pediatrician available on call day and night to answer the
parents’ questions and concerns regarding care for their fragile infant.
This will reassure many parents and also help them to immediately seek medical care
in case of danger signs.
During working hours, parents may call the KMC Programs directly.
Training workshops
Training workshops conducted during group consultation help to reinforce the

parents’/caretakers’ knowledge and, at the same time, provide an opportunity to know,
interact with, and help other parents who are experiencing similar situations
46

For each child, every effort must be made to concentrate the greatest number of
assessments and exams during the same consultation to avoid unnecessary traveling
and reduce the cost for parents.
Addressing parental concerns
Below, please find some of the concerns most frequently expressed during outpatient
follow up and the appropriate answers that must be given in order to help the parents
understand the process they are experiencing with their child.
Examples of some questions about feeding:
“Is the milk I produce is enough? When I try to manually extract it I hardly get an ounce” 47
Explain to the mother that her baby is small, his stomach is also small, but he is eating
every 2 hours. In addition, stress that the quantity of milk the baby is suckling directly
from the breast is greater than the volume she extracts manually.
“My child is irritable and cries a lot.”
Children who have been hospitalized for a long time in Neonatal Units may have
periods of irritability and crying. This may improve as the mother gets to recognize
them and develops calming strategies. Gastro-esophageal reflux could be a cause of
crying and irritability. If it is impossible to calm the baby, it is necessary to call the
pediatrician.

“What can I do if I observe that my child is uncomfortable inside the girdle?”
The child must be monitored to make sure he is not too hot in kangaroo position. If
this happens, the child must be allowed to take his arms out of the girdle. If discomfort
persists, the weight and gestational age of the child must be assessed to see if he
could be out of kangaroo position periodically, and then permanently.
“My child eats more frequently during the night than in the daytime, is it because he
is more alert?”
Remind the mothers that the child’s sleep patterns are organized according to the
external stimulation of the place where he is kept. If long periods of sleep are allowed
during the day, he will be awake more at night. In Neonatal Units, stimuli are usually
quite disorganized during the day and night. Parents should promote more activity
and offer more stimulation during the day and less during the night, progressively
creating routines for the child.
Some important points to keep in mind while supporting parents in KMC:
• The core of the relationship is interpersonal interaction.
• It is crucial to actively listen to parents, to make eye contact, to clarify, to think with
them, and encourage them to find solutions to their problems
• Try to understand the parents’ situation and respect their dignity, regardless of social
class, religion, or culture
• Avoid judging or blaming.

48
• Avoid any attitude of superiority; don’t use medical jargon. Use common words that
are easy to understand.
• Offer emotional control to their vulnerability

9. Routine Kangaroo Follow Up, Up To 40 Weeks
Of Gestational Age And A Weight Of 2500G
Go to videos:
-Neurological evaluation up to 40 weeks,
-Neurological evaluation of children younger

than 5 years. Dr. Claudine Amiel-Tison
9.1 Daily kangaroo follow up
It is done until the child is 40 weeks of gestational age and reaches 2 500 g. These visits
can be conducted in outpatient care or while the child is in a KMC ward.
Mothers who have already returned home or who are staying at a temporary home
must travel to the Kangaroo Mother Program outpatient consultation.
Organized KMC wards decrease the risk of mother-infant dyads not taking part in the
daily outpatient follow up. For example, some KMC wards allow the mother and child
to return home only once follow up can be done on a weekly basis. In a KMC ward, the
baby is assessed by a pediatrician and a nurse once a day, reinforcing the educational
process during each visit.
It is not recommended to keep “mother-kangaroo baby” rooming-in until 40 weeks

without proposing outpatient follow up, where the father and the family get involved
in caring for the child. Moreover, keeping mother-infant dyads in hospital until 40
weeks induces the risk of rejection of KMC method since mothers may not want to 49
be away from home for long period of time, separated from their other children and
partner.
9.2 Activities during follow up visit up to 40 weeks
a) Careful and complete clinical assessment, similar to the one described during the
first follow up visit.

Routine Kangaroo Follow Up, Up To 40 Weeks Of Gestational Age
And A Weight Of 2500G
b) Regular monitoring of the somatic growth
After discharge, the monitoring is done on a daily basis to assess the child’s nutrition,
and the parents’ adherence to the KMC.
The aim of the kangaroo follow up (up to 40 weeks) is to achieve adequate growth, as
similar as possible to what the child would have achieved in utero.
During this period, the goal is to achieve a weight gain around 15-20 g/kg/day, a
weekly average increase in height of 0.8 cm, and an increase of head circumference
of 0.5 to 0.8 cm. These measurements are in line with the growth that the child would
have had in his mother’s womb, if he were not born prematurely.
50

During the initial monitoring, children are weighed daily (same scale) until the nutritional
goal (15g/kg/day) is achieved. Then, monitoring can be done on a weekly basis, until the child
reaches 40 weeks of gestational age.
If the child is less than 10 days old, there may be a “normal” weight loss around 10% of his birth
weight. After this initial loss of weight, newborns must begin to gain weight. Nevertheless,
preterm and/or LBW infants older than 10 days can lose weight or maintain the same weight
on the 2nd and 3rd day after discharge, due to the transition between hospital and home.
A model was developed to predict the need to supplement breast milk for a preterm child
with adequate weight for gestational age and less than 10 days of chronological age study.
This model is used in the KMC Program and was recalibrated in 2009 (data not published yet).
This model proposes to initiate the supplementation with preterm milk formula based on an
evaluation of the child’s height when joining the KMC Program and their status as a singleton
infant or a twin. However, the use of this model is always preceded by intensive support of
breastfeeding. It is the duration of this intensive support that will vary according to the height
and number of children.
The idea of this model is to not wait too long to start supplementation, so as not to endanger the
child’s growth capital, while, at the same time, to avoid interfering with exclusive breastfeeding.
Table 2. Predictive model for supplementation used in the Kangaroo Mother
Method
(Acta Paediatr. 2002;91(10):1130-4)
Supplementing Preterm Behavor

Weight Upon Type Of (Ambulatory
Infants Adequate For
Admittance Birth Kangaroo
Gestational Age (Ptaeg)
To Kmc Adaptation)
Hospitalized = 0> 10 Days
High Probability <42 cms Single 3 days of support
51
Without adequate
Average Probability <46 cms Multiple weight gain = initiate
supplement
42-44 cms Single Up to 5 days of support
A v e r a g e without adequate
Probability > weight gain = initiate
- 46 cms Multiple
supplement
One week of intense
support without
Low Probability >44 cms Single adequate weight gain =
initiate supplement

c) Strategies in case of insufficient weight gain
In order to obtain an adequate weight gain, direct breastfeeding through suckling must
be promoted, and the breast milk production must be evaluated using the following
techniques:
- Reinforce adequate child’s position at the breast and check the frequency of feedings
(every1 ½ hours during the day and every 2 hours at night).
- Assess the type of nutrition received by the child during hospitalization, as well as his
weight gain during the days before discharge, in order to decide if there is a need to
supplement breast milk with a fortifier or preterm milk formula. The goal is to support
as much as possible breastfeeding but also to maintain the growth potential of the
child.
- Assess the compliance with the KMC

guidelines: During the consultation, ask
parents how they implement permanent
skin-to-skin contact and if the mother
has the support of the family when caring
for her child. It is important to repeat to
parents the importance of having the
child in kangaroo position 24 hours a day
to guarantee thermoregulation, avoiding
changes in temperature, which generates
weight loss. If the mother indicates
that there are difficulties in the family,
request support from the psychologist
and the social worker to identify and
52 solve problems that may interfere with
the adequate compliance with the KMC
Method at home.
Teach the Hind milk technique: If a child older than 10 days but less than 35 weeks GA
is not gaining adequate weight or if he is tired easily when eating, feedings should be
alternated with breast milk given with a dropper, syringe, or cup. If this measure is not
improving weight gain, the hind milk technique should be used every two feedings.
- Decide to use fortifiers or preterm formula: If no adverse condition, such as anemia,

oxygen desaturation, or infection is identified that could explain inadequate weight
gain, it is important to supplement breastfeeding with preterm formula or to fortify

breast milk. This decision should be made by the “interdisciplinary” team (pediatricians,
nurse, psychologist, and social worker).
Fortifiers are not diluted homogeneously in breast milk and some studies reported
that they inhibit fat absorption. It is also important to take into consideration that
fortification requires manipulation, making it difficult to be used in many houses due
to poor hygiene or scarce clean water.
If it is decided to supplement breast milk with preterm formula, the quantity will be
30% of the daily ration (180-200 ml/kg/day), divided by the number of meals. Preterm
formula must be given with a syringe, dropper, or cup before breastfeeding so as not
to interfere with it. If formula is used, it is important to check that the mother knows
the basic hygienic rules for its use, as well as the techniques of feeding with syringe,
dropper, or cup. In order to avoid manipulation, liquid milk is preferred to powder
milk. The family will receive the amount of milk needed until the next day or next
appointment, after which the result of supplementation will be monitored. If the child
is still not gaining adequate weight, he must be hospitalized without waiting until he
becomes malnourished.
When the weight gain is adequate and regular with preterm formula supplementation
or fortifiers, this amount will be decreased progressively to ideally reach 40 weeks of
gestational age with exclusive breastfeeding.
d) Advice on child care for “kangaroo infant” at home
Mothers, families, and often the health staff must be reminded that the kangaroo
position does not last long, only few weeks.
Infants in Kangaroo position can receive most of the care they need, including feeding.
Theoretically skin-to-skin contact needs to be interrupted only to change diapers,
to clean and care for the umbilical cord, and during clinical assessments in the KMC 53
program.
Go to video:
Care of the premature infant
Bathing: A daily bath is not necessary and not recommended before 40 weeks,
especially for those infants in kangaroo position. Even if the child is immediately taken
out of the water and well dried, some evaporation subsists, leading to hypothermia,
which is immediately reflected in a lower weight gain. However, the child must be
cleaned every day with a cloth or soft sponge and warm water with special attention
to the diaper area.

Mother’s activities: Mothers with the baby in Kangaroo position can have several
recreational and educational activities at home. As mothers must comply with some
basic hygiene and personal requirements, it is important that someone help her to
carry the baby in skin to skin contact. Emphasize the importance of daily bathing and
frequent hand washing. Mothers must insure a quiet surrounding for the baby and
offer food with the required frequency and regularity.
54
Sleep and rest of kangaroo mother/caretaker: The mother, the father, or another family
member will sleep better with her baby in kangaroo position in a semi-sitting position,
with a 15°- 30° degree-tilt. This position reduces the risk of apnea and reflux. This can
be done using a “reclining” bed, or by elevating the head of the bed using a wedge-
shaped pillow.
The support of the father or family members is important, allowing the mother to sleep
between breastfeeding. This effort will not be too long—only few weeks—until the
child reached 40 weeks of gestation. A reclining chair could also be useful for resting
during the day.

e) Duration of the kangaroo position
Daily duration: Skin-to-skin contact should begin in the neonatal Unit (alternating
with periods in an incubator, not in a crib), so that transition to continuous kangaroo
position is imperceptible. The daily duration of skin-to-skin contact will need to
increase gradually until it is as continuous as possible, day and night, interrupted only
for diaper change and feeding sessions.
If the mother has an imperative need to leave her baby for a short time, he must be
kept well wrapped in a warm crib, covered by a blanket to keep him warm; or he must
be placed in a temperature regulation device, if available. During such interruptions,
family members (father or partner, grandparent, etc. ) or even a trusted friend may
contribute to the care of the baby by keeping him in kangaroo position in skin-to-skin
contact.
55
Total duration: As long as the mother and her baby are comfortable, skin-to-skin
contact may continue, at first in the institution and later, at home. This can continue
until the child repetitively shows signs of not tolerating the kangaroo position, such
as pulling his limbs out of the girdle, crying, and complaining every time the mother
attempts to place him in contact with her skin, especially if the child is over 37 weeks,
regardless of his weight.
f ) Neurological assessment (using axial tone) at 40 weeks of gestational age
(Dr. Amiel Tison )
During the early critical phase, it is not possible to clinically assess neurological
function in very preterm infants, since they are very small; they may be unstable

and / or ventilated.
This neglect to collect clinical information is understandable in the acute phase of

neonatal adaptation, but seems unjustified when the child recovers, can breathe
on his own and is able to tolerate some manipulation. At this point, and especially
when the preterm baby reaches 40 weeks, the neurological evaluation can offer
objective data on the anomalies or confirm normality.
A normal neurological evaluation at 40 weeks corrected age is sign of a favorable

outcome, if the results from the cerebral ultrasound are normal.
1. Clinical assessment of axial tone
Definition of muscle tone
- Passive tone is observed one segment at the time, with maneuvers that evaluate
the amplitude of a slow stretching executed by the observer, the child is passive;
the result is systematically measured or graded and expressed as an angle or as the
amplitude of displacement.
-Active tone is the muscular activity of the infant, as he responds to the examiner’s
maneuvers; the results are expressed by the presence or existence or absence of
an active motor response.
2. Normal findings in full-term infants
Posture
At rest, in supine position, the neck muscles are relaxed and there is very little or
56
no space between the examination couch and the spine.
Repeated ventral flexion of the head
On repeated flexion of the head, there should be no increase in resistance at the

third or fourth trial.
Passive tone in the trunk
Ventral flexion: with the child in supine, the examiner grasps the lower limbs and
pushes legs and pelvis towards the head, looking for maximum curvature of the
spine. Some passive flexion of the trunk is normally present.

Dorsal flexion: while the infant is laying on his/her side, the examiner places the
palm of the hand on the infant’s lumbar region, while pulling both legs backwards
with the other. There is minimal or no extension.
Comparison between flexion and extension: there is great individual variability in

the amplitude of flexion and extension in all ages, but in the normal individual,
flexion always surpasses extension.
Active tone in the neck
“Pull-to-sitting” maneuvers and reverse “sitting-to-lying” are used to separately assess

the reactions of the flexor and extensor muscles. Neck extension and flexion and the 57
balance between the two are evaluated by eliciting alternate contraction of the neck
flexor and extensor muscles, by gently rocking the child’s trunk about the vertical. From
the first days of life of a normal full-term newborn, these movements are symmetrical
and are described as “symmetrical breaking”. Performing this maneuver requires
practice so that an appropriate speed to elicit these signs from the maneuver: if too
brisk, the passive movement of the head occurs; if too slow, the absence of a response
may be misinterpreted.

Active tone in the trunk and lower limbs
Upright position: a) it is normal when the child is held vertically, he or she leans slightly
forward, sustaining his or her own weight; b) when there is global hypertension of
trunk and lower limbs, the body is arched.
58
Maturation of axial tone
The maturation process of the tone of extensor muscles is more precocious than that
of the flexor muscles. A perfect balance is only obtained around full term (40 weeks
of corrected age), and a complete control of the head at six to eight weeks. Once this
control is achieved, we assume that control of cortical structures has supplanted that
of sub cortical ones.

3. Abnormal findings
Active and passive tone may be abnormal in several different ways. Specific types of
abnormalities can be identified and they point to underlying pathology.
Posture
Supine position
A: retrocolis: posture with hyperextension of the head only
B: opisthotonos: posture with backward arching of neck and trunk
Repeated ventral flexion of the neck
When repeated passive flexion of the neck elicits an increased resistance, it shows
hypertonicity of the extensor muscles of the neck.
Passive tone in the trunk
59

Ventral flexion and dorsal extension: a-d normal balance, more flexion than extension;
b-e or b-f: abnormal balance with moderate or excessive extension, and no flexion;
c-f: global hypotonia with unlimited flexion and extension; b-d: global stiffness, from
a tendency in the family or poor cooperation from the child.
Active tone of the neck, abnormal responses
60
Global hypotonia: a. the passage of the head both forward and backward is passive and
there is no active response whatsoever; b. hypotonia confined to the flexors: passive
passage forward, active passage backward; c. hypertonia in the extensors: passage
forward is difficult but active, passage backward is “too good” (NB: typical “chin forward
position” as child leans forward).

Active tone in the trunk and lower limbs
Weak or absent global straightening is evident by attempting to place the child in a standing
position: no straightening occurs and no contraction is observed in the spinal muscles.
Excessive tone is indicated by arching the back, many times associated with pointed feet
and crossed, scissor-like legs.
4. Clustering of signs: description of three syndromes
Global hypotonia
Active and passive tone of flexor and extensor muscles of the axis is almost absent. In the
newborn, these signs are frequently associated with hypotonia of the limb muscles. This
easily recognized condition is usually referred to as “rag doll”.
Severe, generalized hypotonia is a frequent finding during the acute period of any brain
lesion in the neonatal period; it is non-specific. For instance, it can be observed during
the first stage of a hypoxic-ischemic injury, following to ICH or hyper bilirubinemic
encephalopathy. In these cases, hypotonia is of a central origin and just a manifestation
of a severe CNS depression. Systemic infection and sedative medication administered to
the infant or the mother can produce a similar clinical picture, although the mechanism
causing the hypotonia is different. Axial hypotonia can also be the main sign of spinal
or muscular disorders in the neonatal period. Clinical diagnosis is made by revising the
gestational history (diminished fetal movement, polyhydramnios) and the clinical features
of the newborn: the quality of alertness, cry, eye movement, deep tendon reflex, muscular
bulk, tongue fasciculation and topography of motor deficit. However, in order to reach a
diagnosis, additional laboratory investigation is required.
Hypotonia confined to the axial flexor muscles
A combination of symptoms, presented in the table below, comes from the inability of weak 61
or deficient flexor muscles (cortical control) to balance the normal extensor tone (under
sub-cortical control). In severe cases, this condition is easily recognized as the opisthotonic
posture. In contrast, in less severe cases, there is nothing remarkable about the posture,
and the condition can be identified by the response to the “pull to sit” maneuver, showing
imbalance between an poor response from the ventral flexors and a good dorsal extension
with a normal resting position of the head on the chest, at the end of the maneuver. Often,
hypotonia of the shoulder girdle (scarf ) is associated.
Hypotonia of the axial flexors muscles is nearly a constant in moderate or mild grades of
hypoxic-ischemic encephalopathy in the full-term newborn, or in the recovery phase of
the severe grade. It is not an isolated finding but rather one of several that comprise a
clinical picture that defines the hypoxic-ischemic encephalopathy.

Clinical findings in hypotonia confined to axial extensor muscles
Posture Normal or mild to severe opisthotonos
Repeated flexion of the head No increase in resistance
Passive tone of trunk More extension than flexion
Active tone
-Neck flexor muscles - Passive passage forward (no visible

contraction)
- Normal resting posture on the chest at

- Neck extensor muscles the end of the raise to sit.
- Straightening reaction Normal, active
Normal or excessive with arching
Associated finding in upper limb girdle Decrease of passive and active tone
(scarf, recoil and response to traction). (large scarf, no recoil poor or no response
to traction.
Hypertonia of the axial extensor muscles
The combination of signs presented in the table below result from increased axial
extensor tone in the presence of normal flexor tone. During the “raise to sit” maneuver,
the head does not move forward; the maneuver ends with the “chin poking forward”
position due to excessive extensor tone. Hypertonia of the trapezius muscle, inserted
62 in the scapula, results in external rotation of the shoulder, “high” elbows a “tight” scarf
and a permanent “candlestick” posture. There may be a number of underlying causes
for these symptoms; therefore interpretation must be done within the clinical context
of each case.

The candlestick posture is the result of the permanent contraction (shortening) of

the trapezius muscle (NB: the deep fold on the posterior aspect of the arm is the
consequence of permanent external rotation).
Clinical findings in hypertonia of the axial extensor muscles
Posture Mild to severe opisthotonos
Repeated flexion of head Increase of resistance
Passive tone of trunk More extension than flexion
Active tone
-Difficult passage forward (with visible

contraction)
- Neck flexor muscles
-“Chin forward” position at the end of
raise to sit
- Neck extensor muscles “Too good passage backward
- Straightening reaction Excessive with arching
Associated findings in upper limb girdle Markedly abnormal passive tone

(“candlestick” posture)
Raised intracranial tension
A combination of neurological and cranial signs helps identify this condition. The
magnitude of cranial signs depends on the maturation status of the skull bones.
63
Permanent or intermittent “sunsetting” may occur in addition to the predominance
in the tone of the extensors. Other neurological signs, such as yawning, drowsiness,
lethargy, irregular breathing, apneic episodes, bradycardia and vomiting may be
associated.
Physiopathology of axial extensor hypertonia in the presence of intracranial

hypertensionis speculative. Observation of premature newborns with intracranial
hypertension, after excessive sodium and water intake, shows that the extensor
hypertonicity is mechanical and completely reversible after a lumbar puncture. It is
generally accepted that in adults, extension of the neck is a reflex mechanism triggered
by pain from meningeal irritation and traction of the spinal nerve. Instead, since flexion
of the head increases the CSF tension in the cisterna magna, reflex extension rigidity
may alleviate it. Compression or irritation of the spinal branch of the accessory nerve,

at foramen magnum level may explain the contraction of the trapezius muscle. While
purely mechanical, this mechanism could decrease pressure and alleviate pain.
Meningitis
In nearly all cases, diagnosis is made before the appearance of evident neurological
signs. The mechanism that produces hypertonia in axial extensor muscles in meningitis
is the same one responsible for raised intracranial tension, which is one of the first
symptoms of meningeal inflammation.
Bilirubinencephalopathy
In the past, opisthotonos has been described in the second phase of kernicterus. Since
brain lesions in this pathology are mostly found in the basal ganglia and brain stem
nucleus, there may not be cortical involvement. Today, this pathology is very rare and
is commonly associated with an anoxic cerebral lesion.
Gastro-esophageal reflux (GER)
Opisthotonos has been described as a sign of GER, appearing to mimic neurological or

psychiatric disorders. In GER, opisthotonos appears in episodes of 30 to 60 seconds, a
probable response aimed at avoiding painful esophagitis at the often resulting from
GER. Other signs, such sudden stare, changes in skin color and apnea. Esophageal
spasm episodes have been documented in infants, associated with an anxious stare
followed by agitation, hyper-extension of neck and back, apnea and bradycardia.
Avoidance behavior: a possibly psychogenetic etiology of opisthotonos
In 1962, Ajuriaguerra described the “le dialogue tonique mère-enfant”, suggesting that
modifications in muscle tone are used as mediators of the mother-child interaction.
When there are difficulties in that relationship, there may be changes in tone which
64 simulate a neurological pathology. This may appear after the neonatal period, usually
at three months or later.
Short trapezius muscle: a diagnostic hazard
The maneuvers described above for evaluating active tone of the neck muscles
assume that the muscle length is normal. Nevertheless, impairment of one muscle set
may appear as an abnormal response of central origin. Different pre and post natal
situations may cause individual or groups of muscles to shorten, hindering normal
responses and making the interpretation of the maneuvers difficult.
Prenatally
An asymmetrical posture of head and neck, in utero, with rotation and flexion to one

side, will cause the shortening of one of the sternocleidomastoid muscle, while the
counter lateral muscle will elongate.
A head in hyper-extension, following a breech presentation, also produces abnormal

posture of head and neck. The group of extensor muscles is shortened and the flexor
group is elongated. Because of this, the flexor response to the “pull to sit” maneuver is
poor and the head does not deop forward at the end of the maneuver.
Post-natally
A shortening of the trapezius muscle may be produced if the infant is nursed in the
prone position for long periods of time, with the head extended to facilitate mechanical
ventilation. This situation is frequent in premature infants. In mature infants, this
condition is caused by the use of some types of baby carriers, which do not maintain
the head in the axis.
The clinical features of the short trapezius muscle are summarized in the table below.
These are similar to those of hypertonia of the neck extensor muscles. For a differential
diagnosis, Grenier offers different clinical clues to help distinguish a short trapezium
from opisthotonos of central origin.
- The trapezius’ tendon remains very tense, even if the child is awake and quiet, and
this is not modified with attempts to relax the baby.
- The trapezius muscle is hypertrophic; its triangular aspect can be easily seen from
under the skin.
- There is no increase in resistance with repeated flexion of the neck.
Clinical finding in short trapezius
65
Posture Minor to severe opisthotonos
very tense muscle even after relaxation
Repeated head flexion often hypertrophic trapezoid muscle
No increase in resistance (short

muscle, but normal elongation reflex)
Passive trunk tone
More amplitude in extension than in flexion
- Difficult passage forward (with visible

Active tone

- Neck flexor muscles muscle contraction)
- “Chin forward” position at the end of

the raise to sit
- Neck extensor muscles
“Too good” passage backwards
- Straightening reaction
Excessive with arching
Associated findings in upper limb girdle Markedly abnormal passive tone

(candlestick posture)
Prenatal deformation
Protracted mechanical ventilation

Risk circumstances
Predominant prone posture
Inadequate baby carrier
Additionally, authors such as Grenier and Towen emphasize that short trapezius are
frequently an isolated anomaly, without involving other abnormal CNS signs. Physical
therapy rapidly has a beneficial effect on the shortening of the trapezius muscle
and helps differentiate findings with central and peripheral origin in difficult cases.
66 Not recognizing the origin of an abnormal posture may lead to an excessively bleak
prognosis. In order to facilitate the neurological evaluation, to prevent the shortening
of the muscle, and to avoid such an error, preventive physical therapy should be
introducedas soon as an abnormal posture is observed, regardless of its origin.
The literature generally agrees that changes of the axial tone are important. By paying
attention to these signs, using a standardized clinical method it is possible to follow
the evolution of a brain lesion from the neonatal period through childhood, and maybe
understand the relationship between early injury and later childhood disabilities. This
is a sure way to learn to recognize children who will benefit from an active intervention
at the earliest possible time.
To conclude, in spite great progress in the detection and diagnosis of brain damage

in the newborn, through morphological investigation and electrophysiological

techniques, the contribution of the clinical examination will always be indispensable.
Neurological signs, especially those observed on the axis, provide important clues to
the pathology of perinatal brain damage. They also facilitate following the evolution of
brain damage during infancy and childhood. In numerous cases of moderate damage
or dysfunction, the signs observed in the neonatal period are the only evidence to
establish a relationship between early events to late neurological or psychological
outcome. Ideally, these signs must be sought during the neonatal period, following any
abnormalities into infancy. Even if these signs are only found in school-age children
being examined for the first time, they offer valuable evidence of the child’s problem
early origin.
67

High Risk Follow Up Of The Preterm And / Or
10. Lb W Infants From 40 Weeks Up To One Year
Corected Age
Go to video:
Neurological evaluation up to 40 weeks
10.1 Introduction
Kangaroo follow up after 40 weeks of corrected age is considered a high risk program.
Preterm and/or LBW infants have a high risk of developing sensory and neurodevelopment
problems during childhood, and they have special needs, different from those considered
in programs for healthy children.
Every high risk child must be followed until the first year of corrected age (counting from
the moment he reaches 40 weeks) for adequate monitoring of somatic growth and early
detection of audition, ophthalmological, and neurological sequel. However, these children
should also ideally be followed during school age and their adolescence in order to detect
and intervene with learning disorders that may have a late onset.
10.2. Physical examination
Assessment
Assessment - observation
Observation
General Observe malformation, skin color
Examine the sutures and fontanels, by palpation. If fontanels are prematurely
Head
closed, consider the possibility of microcephaly, craniosynostosis or
hyperthyroidism; refer to the specialist and follow up.
If fontanels are more open than normal, it may be due to hydrocephaly,

hypothyroidism, and malnutrition.
If overlapping sutures are found, they require further observation and monitoring.
68 Hair Verify hairline, hair distribution and texture (brittle), color, check for infection in
the scalp, pediculosis and general hygiene
Observe the shape, symmetry of movement (ruling out facial paralysis), and
Face
edema or augmented parotid glands.
Check for the presence or absence of external anomalies in the auricle, low set
Ears
ears, secretion, and hygiene.
If possible assess the tympanic membrane: color, translucency, secretion.

Eyelids: check for swelling and changes in color
Eyes
Conjunctive membranes: color, pallor, secretion
Sclera: jaundice, changes in color
Pupils: accommodation and size
Ocular movements: completeness and symmetry
Eyeballs: protruding or small in size

High Risk Follow Up Of The Preterm And / Or Lb W Infants From 40
Weeks Up To One Year Corected Age
Strabismus: (diagnosis must be made at six months);

refer to ophthalmology
Nose Check nostrils for permeability; assess possible deformity or deviation of nasal
septum.
Observe if child breathes well though nose, with a closed mouth.
Check for nasal congestion and bloody secretion, monitoring is necessary.
Check symmetry, oral mucosa, gums, frenulum linguae, teeth.

Mouth
Malformations such as anterior or posterior palatal suture must be referred to
plastic surgeon.
Malocclusion, check hygiene (cavities)
Inspect lips, gums, tongue, tonsils, pharynx and general hygiene.
Rule out swelling, hemangiomas or paralysis.
Teething: eruption of first teeth.
Neck Explore symmetry, flexibility pain, lumps, and augmented size of lymph nodes..
Assess the thyroid gland, looking for congenital goiter, nodules or tumors.
Torticollis: contracture of one side of the neck; the neck is flexed towards the
affected side. If present in the newborn and a lump is observed in the neck area,
the baby must be referred to physiotherapy.
Check for asymmetry; observe respiratory movements and intercostal retraction.
Trunk Enlarged mammary gland or milky secretion (only normal in newborns).
Listen to detect abnormal cardiac and/or respiratory sounds and murmurs. Refer 69
to a specialist.
In case of cardiac murmur , cyanosis, tachycardia, difficult breastfeeding with

excessive sweating. Refer to cardiology.
Check for distension, observe collateral venous circulation, navel.
Assess by palpation for liver, spleen, kidneys.
Abdomen
Presence of umbilical or inguinal hernias.
Umbilical hernia: refer to pediatric surgeon after 3 years.
Inguinal hernia: protruding lump in the inguinal or inguinal-scrotal region; it

is present when the baby cries or pushes, decreasing at rest, refer to pediatric
surgeon at the time of diagnosis.

Observe for symmetry, deformations or shortenings.

Check for hip dysplasia; in newborns assess Barlow’s sign, in infants, Ortolani’s
sign.
Limbs
Other findings may limited abduction in the affected side and asymmetry in the
skin folds.
In 18 month-old children watch for arched legs and walking t difficulties.
Beyond two years, examine the plantar arch for flat feet
Check symmetry, oral mucosa, gums, frenulum linguae, teeth.

Mouth
Malformations such as anterior or posterior palatal suture must be referred to
plastic surgeon.
Malocclusion, check hygiene (cavities)
Inspect lips, gums, tongue, tonsils, pharynx and general hygiene.
Rule out swelling, hemangiomas or paralysis.
Teething: eruption of first teeth.
Spinal Observe the posture while standing and in supine position; check for asymmetry
column and rigidity verifying if there are deviations from the normal curvature: lordosis,
scoliosis and kyphosis.
Check for the presence of spina bifida. It can be just a lump, a dimple, a birthmark
or a hairy patch anywhere from the child’s neck to his sacrococcygeal region.
Refer to neurosurgeon.
Pilonidal dimple: is a depression or dent in the sacral region; it must be kept in

good hygienic condition to avoid infection.
Observe the size and shape of external genitalia, hygiene, swelling,

Genitourinary pain or secretion.
70
In girls, check labia majora, minora, clitoris and hymen. Check to
detect synechia (fused labia, hymen is not observed).
In boys, observe size and placement of testicles; rule out

cryptorchidism and hydrocele by palpating the testicles; observe
foreskin to rule out phimosis, hypospadias and epispadia.
Observe the penis to determine size and check for phimosis and/or
adhesions in the foreskin, swelling or pain.
Cryptorchidism, undescended or absent testicles. Just wait until

child is one year old.

Hydrocele, augmented size of scrotal area, of cystic consistency; do not refer until
child is one year old, but if it seems tense and very overgrown, refer immediately.
Phimosis, disorder of the penis due to constriction of the orifice of the prepuce
so as to prevent the foreskin from being drawn back to uncover the glans penis.
Refer when child is three years old.
Epispadias, (the urethral meatus opens on the dorsal penile surface).
Hypospadias, (the urethral meatus opens on the underside of the penis).Refer

immediately.
In every case, refer to pediatric surgery according to the established timeline.
Anus: in the newborn, verify characteristics and permeability.
Check for fissures, perianal fistulae, and malformations of anus and rectum.
In case of perianal fistulae or malformations of anus or rectum, refer immediately

to pediatric surgery.
Inquire about constipation, a hard, dry stool accompanied by strain.
Observe color (cyanosis, jaundice, pallor),hemangiomas, rash, edema,general

Skin and hygiene.
annexes
Greenish coloration around the sacrococcygeal region, the so-called Mongolian
spots, is considered normal and will disappear at two years of age.
Dermatitis, watch for macerated skin due to prolonged contact with wet diapers.
Source: http://www.minsa.gob.pe/portal/p2005/docconsulta.asp
Eruption and loss of first teeth 71
Eruption Teeth loss

Teething (Age in years)
(Age in months)
Lower Upper Lower Upper
Central incisors 6 7½ 6 7½
Lateral incisors 7 9 7 8
Canines 16 18 9½ 11 ½
First molar 12 14 10 10 ½
Second molar 20 24 11 10 ½
Incisors Range + - 2 months
Range + - 6 months
Molars Range + - 4 months
Ref.: Hassler y Shaun: Atlas of the Month. Chicago. American Dental Association

10.3. Monitoring somatic growth
In 1990, WHO established growth charts with the National Center of Health Statistics
(NCHS) in 2003. These growth charts were revised taking into consideration breastfed
children. A divergence was found between the growth of breastfed children and the
NCHS-WHO reference charts, exclusively breasted children have a faster growth during
the first two or three months of life and then their growth became slower than on
the NCHS reference. This difference could increase the risk of infant morbidity and
mortality due to early introduction of other foods, after a mistaken interpretation of
the curves.
72
11 In 1993, through an exhaustive study on the application and interpretation of anthropometric patterns, the
WHO concluded that the growth curves made by the National Center for Health Statistics, NCHS/WHO did not
adequately represent the growth of children. For this reason, between 1997 and 2003 the WHO undertook a
longitudinal multicentric study on the growth pattern, (Multicentre Growth Reference Study - MGRS), in order
to generate new charts for the assessment of growth and development of children around the world. This study
collected primary growth data and related information from children from widely different ethnic backgrounds
and cultural settings (Brazil, Ghana, India, Norway, Oman and the USA). The study included children in optimal
conditions for growth, with ideal nutrition (exclusive breast milk and adequate supplementary nutrition), ideal
environment (water, sanitation, housing, and non-smoking mother) and ideal health care (immunizations,
routine pediatric care, and prenatal care).

The study uses weight, height-for-age, weight-for-age, weight-for-height, and body

mass index-for-age. These are the curves proposed to be used to assess the growth of
kangaroo children from 40 weeks to at least one year of corrected age.
WHO growth charts (2006& 2007) for children and adolescents from 0 to 18 years of
age are adopted in Colombia.
The periods of children somatic growth are: i) rapid growth period during infancy, ii)
stable growth during childhood, and iii) rapid growth during adolescence.
Boys are known to grow faster than girls andto be taller and heavier than girls, due to
testosterone levels present at birth and for the first six months of life. After that, there
is no difference between boys and girls; which means that deceleration of post natal
growth is greater in boys than in girls.
Approximately 66% of children change the pattern or growth channel (percentile line)
during their first 12 to 18 months. Children generally increase their height by 50% at
the end of their first year; this is followed by a gradual deceleration that continues
until the end of the 2nd year. Birth weight doubles at 6 months and triples at 1 year.
Head circumference quickly increases until 9 months (10 cm) and then only 3 to 4 cm
until reaching12 months of age.
Between 18 and 24 months the child grows slowly but constantly, an average of 5 cm
to 7.5 cm per year. During this period, most children stay in the same percentile line,
and any deviation suggest a pathology which requires further study (Salas & Peñaloza).
Control visits are conducted every six weeks during the year, if possible together with
immunizations or screenings appointments to minimize the number of visits/travels.
Weight, height, and head circumference are measured at each visit using the same 73
protocol and scales to avoid possible error. These parameters must be recorded in the
child’s growth chart; if a deviation from the percentile channel is found, the situation
should be analyzed to identify a possible cause for a poor weight gain (acute diarrheal
disease or common cold or fever). Once conditions are treated, the child normally gains
weight again. If the height is not adequate (stunting) the issue is much more complex
and all efforts should be made to find a cause. The possibility of cardiac conditions,
neurological impairment, such as growth hormone deficit, congenital hypothyroidism,
and other conditions are also considered.

Fenton and WHO growth charts
MALE WEIGHT FROM BIRTH TO TWO YEARS

Fenton curve to 40 weeks and WHO to 2 years
Height in cm
Gestation weeks Months
MALE HEIGHT FROM BIRTH TO TWO YEARS

74
Height in cm

MALE HEAD CIRCUMFERENCE FROM BIRTH TO TWO YEARS

Head circumference in cm
FEMALE WEIGHT FROM BIRTH TO TWO YEARS

75
Height in cm

FEMALE HEIGHT FROM BIRTH TO TWO YEARS

Height in cm
FEMALE HEAD CIRCUMFERENCE FROM BIRTH TO TWO YEARS

76
Head circumference in cm

10.4. Complementary feeding
To receive adequate nutrition is a right for every child. Adequate foods provide the
necessary resources for optimal development (growth and psychomotor development).
Good nutrition during early infancy is fundamental to a child’s ability to fulfill his
human potential.
Preterm and LBW infants are exposed from a very young age to poor external conditions,
sometimes including during the pregnancy. The majority of preterm infants are not
able to receive the late part of trans-placental transfer of micronutrients; they are
fragile, suffering from great nutritional and immunological shortcomings.
It is crucial for preterm and LBW infants to receive exclusive breastfeeding for the first
six months of life as it is scientifically proven that it is the best nutrition for them before
receiving timely and adequate complementary feedings.
10.4.1 Nutrition recommendations for ages up to 6 months (WHO -IMCI)
The best way to feed a child from birth to at least 4 months of age is to breastfeed
exclusively, and ideally until 6 months. Exclusive breastfeeding means that the child
takes only breast milk and no additional food, water, or other fluids (with the exception
of medicines and vitamins, if needed).
Mothers should breastfeed children at this age as often as the child wants, day and
night. This will be at least 8 times in 24 hours in the case of preterm or LBW infant and
sometimes 12 times in 24 hours. Preterm or LBW infants do not request feedings; they
need to be woken up.
Mother’s milk, up to six months, contains adequate nutrients in terms of protein, fats,
carbohydrates, and iron.
77
Breast milk, except in exceptional circumstances, will not satisfy all the nutritional
requirements of infants beyond six months of age. This is clear when observing the
frequent decline in growth curves of children who are exclusively breastfed after six
months of chronological age.
Most babies do not need complementary foods before 6 months of age.
Breast milk remains the child's most important food, but at some time between the
ages of 4 and 6 months, some children begin to need foods in addition to breast
milk. These foods are often called complementary or weaning foods because they
complement breast milk.

The mother should only begin to offer complementary foods if the child shows interest
in semisolid foods, appears hungry after breastfeeding, or is not gaining weight
adequately. The child may show interest by reaching for the mother's food, or by
opening her mouth eagerly when food is offered.
By 6 months of age, all children should receive thick, nutritious, complementary

foods.
It is important to continue to breastfeed as often as the child wants, day and night.
The mother should give the complementary foods 1-2 times daily after breastfeeding
to avoid replacing the breast milk.
WHO recommends starting complementary food at 6 months if the child is

exclusively breastfed and at 4 months if the child receives mixed nutrition or
receives only formula.
Common sense, observation of the child’s growth, as well as family situation must
be used to introduce complementary foods. In some cases, it is logical to start
complementary foods at 5 months to keep the infant’s growth potential, such as in
the case of a 5-month-old child who, despite being exclusively breastfed by a stressed
working mother, is poorly nourished. More than half of the “kangaroo mothers” are
working mothers, and unfortunately too few efforts are made in the world to promote
exclusive breastfeeding six months.
On the other hand, it is not recommended to give complementary food before four
months as the child’s metabolism is not mature enough. His neuromuscular system and
coordination of chewing and swallowing movements are inadequate and his digestive
system is not able to fully absorb proteins, fats and carbohydrates. At 4 months, the
kidneys are not yet ready to regulate the elimination of different components, such as
78 big quantities of Nacl.
New foods will be introduced according to the chronological age of the patients,
since their digestive system was exposed to multiple substances since birth.
From six months to one year, the infant will go from exclusive breastfeeding to eating
the family diet. He will gradually get used to eating a variety of foods with different
texture, consistency, and taste.
10.4.2 Nutrition recommendations for ages 6 months up to 12 months
The mother should continue to breastfeed as often as the child wants.
However, after 6 months of age, breast milk cannot meet all of the child's energy needs.

From age 6 months up to 12 months, gradually increase the amount of complementary

foods given. Foods that are appropriate in your country are listed on the IMCI feeding
chart. By the age of 12 months, complementary foods are the main source of energy.
If the child is breastfed, give complementary foods 3 times daily.
If the child is not breastfed, give complementary foods 5 times daily. (If possible,
include feedings of milk by cup. However, cow's milk and other breast milk substitutes
are not as good for babies as breast milk.)
It is important to actively feed the child. Active feeding means encouraging the child to
eat. The child should not have to compete with older brothers and sisters for food from
a common plate. He should have his own serving. Until the child can feed himself, the
mother or another caretaker (such as an older sibling, father, or grandmother) should
sit with the child during meals and help get the spoon into his mouth.
An "adequate serving" means that the child does not want any more food after active
feeding.
A good daily diet should be adequate in quantity and include an energy-rich food
(for example, thick cereal with added oil); meat, fish, eggs, or pulses; and fruits and
vegetables.
10.4.3 Nutrition recommendations for ages 12 months up to 2 years
During this period, the mother should continue to breastfeed as often as the child
wants and also give nutritious complementary foods. The variety and quantity of food
should be increased. Family foods should become an important part of the child's diet.
Family foods should be chopped so that they are easy for the child to eat.
Give nutritious complementary foods or family foods 5 times a day. 79

Adequate servings and active feeding (encouraging the child to eat) continue to be
important.
10.4.4 Nutrition recommendations for ages 2 years and older
At this age, the child should be consuming a variety of family foods in 3 meals per day.
The child should also be given 2 extra feedings per day. These may be family foods
or other nutritious foods which are convenient to give between meals. Examples are
listed on the COUNSEL chart and below.

Good complementary foods are energy-rich, nutrient-rich, and locally affordable.
Examples in some areas are thick cereal with added oil or milk; fruits, vegetables, ,
meat, eggs, fish, and milk products. If the child receives cow's milk or any other breast
milk substitute, these and any other drinks should be given by cup, not by bottle.
The first foods to be offered to an infant are fruit, vegetables and natural cereals
in simple preparations, such as puree of soft consistency with no lumps that may
stimulate the vomiting reflex. When the child has teeth (at 8-9 months), the puree may
be thicker. Finally, the child eats the family diet, finely chopped.
The child’s tolerance to each new food must be tested by offering it for three to five
days. If well tolerated, a new food may be introduced. In patients with a history of
gastro esophageal reflux, acidic fruit should be introduced after the first year of age.
It is not recommended to add salt, sugar, or artificial sweetener to the baby’s diet.
Around eight months of age, the infant may eat finger foods, which require little
supervision from the caretaker. The process of socialization begins when the child
participates of the family meals.
Good feeding practices: adequate environment and utensils
• The spoon must be small, with smooth, rounded edges; offer a small amount of food
at a time.
• The child must be sitting and securely fastened to the chair.
• A nice, quiet environment must be provided and the utensils must be the child’s own.
• There should be no distractors at the time of the meals, especially television.

80
• Respect the child’s refusal to eat; observe to determine whether this is a total rejection,
if it happens repeatedly, or if it is associated with illnesses.
• Mixing dessert with the main meal in order to stimulate intake is not recommended.
• Establishing a flexible routine helps the child to organize his social interaction patterns
without undue anxiety.
From the moment the child begins receiving solid foods, he may also be offered water
to drink (boiled, in case there is no safe drinking water available and without added
sugar, honey, or any other sweetener or flavoring), , between meals or when he is
thirsty. Fresh fruit juices are a source of vitamins but also of calories.

Widening the scope of foods in the diet must not be interpreted as ‘permission’ for the
parents or caretakers to include foods in the baby’s diet which may foster bad eating
habits due to their energy density, glycemic index and content of salt. These habits may
have negative effects on the child’s health, such as malnutrition due to micronutrient
deficiency. The health professional who indicates the baby’s diet to the parents must
always bear in mind the economic situation of the family and the availability of certain
products according to the setting and the country. He must emphasize the correct
preparation of different products, supporting the family by offering guidance and
education, in order to have the best nutritional and hygienic conditions for the baby’s
meals.
These recommendations will vary according to culture and availability of certain

products.
Please insert here the feeding box of the IMCI chart booklet if existing
10.5. Proposal for different neuro-motor screening from term (40 weeks of
gestational age) up to one year of corrected age
10.5.1 The apparently normal survivors: neuromotor and cognitive function as they
grow older
Abnormal neuromotor signs in the first year of life

Go to video:
Neuromotor examination in children under

5 years, Dr Amiel Tison,
Transient signs
Neuromotor development takes place in a very precise and rapid manner during the
first year of life. Therefore, any deviation from the normal sequence can be readily 81
identified.

The development of passive tone and posture control may be monitored, during the
first year of life, by the use of four sets of norms, one for each trimester, starting from
term to three months of age. By the beginning of the second year, postural control
is mature enough to assure gross motor skills such as sitting, standing and walking.
All subsequent motor development will seem to be slower. Individual variations are
greater after the first year, so definition of normal development is less precise and
identification of anomalies is more difficult from the second year.
Consequently, various abnormal neuromotor signs observed at the end of the second
year and considered a manifestation of mild brain damage may not be identified
during the second year. There is a tendency to consider these signs as “transient”,
and to disregard them as if of no importance. These apparently transient signs may
be associated with a temporary functional impairment, such as delayed sitting or
walking. Since the effects on the function are also transient, adopting a sitting position
or walking are eventually achieved, these dysfunctions are called “delays” and, like the
signs, tend to be forgotten.
Experience has demonstrated that this is not a justified attitude; in fact, we have
learned to predict which of these children will return in eight or ten years with school
problems. Several prospective studies have confirmed that children who exhibit
abnormal even mild neurological signs at the end of the first year, are at excessive
risk for abnormalities in fine motor and cognitive function, and will frequently find
themselves with academic difficulties, often failing in school.
Subtle but permanent gross signs
Some signs which persist through infancy can provide hints needed to identify minor
neurological impairment. The imbalance of axial tone, the phasic reflex stretching
and the ridging of the squamous suture are three especially useful signs. They persist
82
throughout childhood, without appearing to fade away and they can be interpreted
based on our knowledge of brain maturation and the physiopathology of perinatal
brain damage. The presence or absence of these signs is unequivocal: they are either
present or they are not; interpretation is not dependent upon appreciation of a
normal range of passive tone, for example. Since they are such subtle signs, however,
a complete and systematic approach to neurological examination is needed in order
to detect them.
Imbalance of passive axial tone
Passive tone of the trunk is evaluated by the relative extents of the passive ventral
flexion and dorsal extension. In spite of great individual variability at all ages, in normal
individuals, flexion always exceeds extension. Therefore extension exceeding flexion
at any age is abnormal and we describe this finding as axial imbalance.

Normal or abnormal passive axial tone is easy to explore from the full term newborn’s
first days of life and at equivalent gestational age in preterm babies. When axial
imbalance is present, it persists unchanged through infancy and probably beyond that.
As mentioned earlier, imbalance of the passive axial tone indicates damage to the cortico
spinal tract, which should normally override the subcortical control. At first, posture is
83
under subcortical, which keep the contraction of the extensor muscles of the axis. With
progressive maturation of the motor cortex and the cortico spinal tracts, the unopposed
contraction of the axial extensor muscles is balanced by the action of the axis flexor muscles
of the axis and the balance of the axial tone is progressively accomplished. Although this
process begins at the end of fetal life, it continues throughout the first years of life, until
myelination of the cortico spinal tract is completed.
If mild damage is produced in the motor or premotor cortical areas, at cortical level, or
at any level of the cortico spinal descending pathways, an imbalance between flexor and
extensor muscles appear, because the tone of the extensors, under subcortical control,
is not counteracted by the tone of the flexors. When the damage is mild, this imbalance
is not clinically obvious and of no consequence for gross motor functions. However, it is
easy to demonstrate by comparing passive ventral flexion to passive dorsal extension by

performing the maneuvers described above. An imbalance in favor of extension represents

a mild and permanent degree of opisthotonos, as it is often seen after hypoxic-ischemic
encephalopathy. Only when the ischemic lesion is very extensive, a global hypotonia of
the axial tone indicates decerebration.
The serious, long term effects ofhypoxic-ischemic encephalopathy, as suggested by

opisthotonos or, when there is extensive damage, by global hypotonia of the whole axis,
are well known. This persisting imbalance of the axial tone also points to cortical level
damage, which affects higher motor control. Adverse long term neurodevelopment
outcomes are expected in children exhibiting axial imbalance. For instance, in a long term
follow up study of a cohort of very premature children, with gestational age of <33 weeks,
those children with persistent axial imbalance at one year of age, had an IQ of 75 ± 17 at
the age of four, as compared with 97 ± 18 in children who did not exhibit abnormal signs
of axial tone at one year.
Phasic stretch reflex in the gastrocnemius muscle
A slow dorsiflexion of the foot assesses the elastic quality of the gastrocnemius muscle.
However, in order to also measure all insertions, the leg must be extended at the knee.
Normally, the angle obtained is 70º or less. A fast dorsiflexion tests higher control of the
medullar monosynaptic stretch reflex. Commonly, higher control allows rapid modification
of the muscle length, without eliciting this reflex.
When higher control is hindered, fast dorsiflexion is suddenly arrested by this resistance to
passive movement. If the arrestis temporary and fast dorsiflexion can be completed, the
response is described as “phasic”. The arrest is sometimes accompanied by a short burst
ofclonic movements. This slightly abnormal response to dorsiflexion, is easily perceived by
the examiner and even quite visible to an observer. On the other hand, if the arresthappens
early in the maneuver and resistence persists so that dorsiflexion can only be completed
84 slowly, the response is described as “tonic” and is a well-recognized sign of lower limb
spasticity.

Phasic stretch reflex indicates a minor impairment of higher motor control which is probably
caused by damage in the corona radiate at the site of the descending motor pathways.
Postural muscles, especially the gastrocnemius, are especially rich in stretch receptors and
normally inhibited by higher motor control. An impairment of this higher control causes
exaggerated stretch reflexes, and consequently, spasticity. However, in a mild impairment
the stretch reflex will also be mildly exaggerated, and its effects will only be noticeable
when the child runs, when dorsiflexion is essential.
Although the phasic stretch reflex can be unilateral, it is usually bilateral with one side
being more compromised, as commonly seen in children with spastic diplegia (Little’s
disease).In fact, this sign probably represents a mild degree of spastic diplegia, implying
similar, but probably less extensive damage. This sign is rarely found in the first six months
of life, usually first noted between eight and ten months. The late onset of this sign is
probably because of a delayed descending wave of relaxation of passive tone, reaching
the lower limbs during normal maturation, around six to eight months. Once present, this
sign persists throughout childhood.
Squamous ridge
Throughout childhood, the head circumference grows in function of brain growth. Sutures
are not normally palpable; they are edge-to-edge, with no separation or overlapping.
There is a wide range of normal values for head circumference, so mild deviations from
the norm cannot be detected. A better parameter can be head growth velocity, but even
that may not be sensitive enough to show a slowing in head growth, which indicates mild
degrees of brain damage. When the brain grows slowly after a perinatal insult, an overlap
of the squamous suture is often the first sign. Overlapping presents as a sharp edge at this
stage. Later the ridge organizes becoming smoother and less obvious, but it is still easily
felt throughout childhood, remaining a marker of early brain growth deficit.
85

Functional consequences of mild neuromotor impairment
The functional consequences of perinatal brain damage may fluctuate throughout

childhood. Some may not be identified until later in life or even early adult life. The
acquisition of key skills gives indices to monitor these consequences and the pattern
permits tracing the relation with early damage. However, the influence of familial,
socioeconomic and biological factors such as gender and birth order, among others,
must also be considered. These factors are known to affect development and to
compound the effects of an existing injury.
The ordered sequence of motor development observed in a normal child depends

upon intact higher motor control. If this is impaired, motor development will also
likely be impaired. Failing to acquire a specific skill such as sitting or walking at the
appropriate time, may be the first sign of this. Although subject to the influences
mentioned above and to individual variation, sitting is expected to be achieved by
nine months and walking by 18 months, at the latest. If these expectations are not
met, it is conventionally referred to as a “delay”. However, as discussed earlier, it is an
indication of deviant development and deviance is likely to continue to be observed at
each new developmental phase. The way in which children fail may also be revealing.
By not achieving independent sitting by nine months, the child is considered to

have a functional delay; the way in which he fails indicates the type and extent of
the neurological deviance. For example, a child described as falling backwards
when sitting is becoming established, needs to sit with “high” and abducted knees
due to incomplete relaxation of the lower limbs. Furthermore, they have axial tone
imbalance. Their posture and tendency to fall backwards are characteristic of perinatal
brain damage. Even after they achieve walking, their gait may not be normal, which is
especially evident when they run, since rapid dorsiflexion at the ankle is essential.
86 In contrast to this delay in the acquisition of sitting, associated with a tendency to fall
backwards which is always neurologically abnormal, there are different implications
when a child flops forward. These children belong to a heterogeneous group which
includes familial hypotonia, muscular disease, genetic disorders and severe brain
damage. Thus, this is a finding which may be difficult to interpret.
The age of language and speech acquisition is another important landmark in the
preschool years, before cognitive assessment can be made. Cognitive assessment
becomes meaningful and reliable by four or five years, but it is only until the child is
eight years old that is really informative. Therefore, learning difficulties and school
failure may not be exposed until then, or even later, although damage in the perinatal
period there may be the underlying cause.

10.5.2 Tracing the effects of perinatal damage through childhood
Standardized neurological assessment and recording scheme
In time, the need for a method to assess the new forms of perinatal interventions and
managements which were newly introduced into obstetric and neonatal practice
became evident. Perinatal mortality alone was no longer an appropriate measure of
perinatal outcome. There was a need for an objective measure of infant morbidity,
especially those indicating CNS damage. According to the WHO definitions of
impairments, disabilities and handicaps, only impairment can fulfill the role of
morbidity outcome measure, since only they can represent “abnormality at the level
of the organ”. A method of assessment had to be designed to objectively detect
neurological abnormality, so infants could be classified as neurologically impaired
or intact. The procedure also had to be simple enough to apply to large numbers of
infants.
As modern prenatal care became more widely used and disciplines such as
epidemiology, among others, became involved in assessing feasibility and success, the
need for standardized, objective assessments and recording methods became more
evident. At the same time, the experience gathered from many groups confirmed that
neurological impairments identified with the basis of neurological signs persisting
through the first years of life, predicted long term outcome. It seemed probable that
these often subtle signs were permanent and could hint as to the link between early
injuries with later adverse outcomes.
An extension of the original neurological examination was then proposed with

additional standards for use up to the age of five. A grid for standardized recording
of findings along with results from other assessments of, for instance, cognitive and
higher motor functioning was also proposed.
87
The aim was to have a complete picture of a child, at a given moment in time, making it
possible to classify him as impaired or not. Impaired children can be further classified
according to the consequence of their impairment was a functional disability, without
making a subjective diagnosis. However, caution must be exercised when interpreting
this further subdivision. A disability is neither necessarily the measure of severity
or extent of impairment nor a true measure of the outcome; it may be particularly
misleading in early childhood, as effects or manifestations of impairment will vary
with the child’s age.
For instance, a neurological impairment that affects higher motor control may result
in a delay in the onset of independent walking; this would justify the description of
causing a disability at 15 months, once the child achieves independent walking, at

maybe 21 months. However, the underlying impairment remains unchanged.
On the basis of the great individual variability, the developmental sequence of gross
motor skills resulting in independent walking is not always present at the end of the
first year, even in ‘normal’ children. In fact, not achieving independent walking before
18 months is not considered a delay. For this reason, children participate of kangaroo
until they are one year old, corrected age or until 18 months of corrected age if they
are not walking by then.
Conclusions and implications
Deficits that persist throughout the first year of life indicate neurological damage, even
if they are subtle and without apparent functional neuromotor consequences. From
there on, some of these deficits seem to vanish, only to be replaced in later years by
other impairments, including those of cognitive functioning. These early neuromotor
deficits are sometimes described as transient. It is probable that they do not just
disappear; rather, they are too subtle to be elicited in the more robust 2 to 4 year old
child. However, with correct examination techniques, several persisting signs, such as
imbalance of axial tone, phasic response to dorsiflexion and squamous ridge can be
found in affected children. By following these signs from the early months of life, it
is possible to trace the early origin of those deficits which can only be identified as
children grow. Thus, the whole spectrum of neurological impairment, from the subtle
to those causing severe disability can be identified and labeled.
10.5.3 The INFANIB screening or Infant neurological battery test
Go to video:
Neurological assessment during outpatient

follow up after 40 weeks
88
The Infant neurological international battery, INFANIB, is a diagnostic/screening

method used to identify children with neuromotor anomalies during the first year of
life.
This method was developed by Dr. Patricia H. Ellison, a psychologist from the University
of Denver, Colorado, USA. It was validated in Colombia by a group of physical therapy
professors from the Universidad Nacional de Colombia during the 80s.
INFANIB is used in children older than 40 weeks and is useful for conducting a
“diagnostic screening” of the systematic monitoring of the preterm and LBW
population of the Kangaroo Mother Program. The screening is easy to do, it evaluates

global motor development, tone and archaic reflexes, allowing clinicians to detect
multiple neurological alterations such as hypotonia, hypertonia, dystonia, diplegie,
and hemiparesis, among others.
The instrument consists of 20 items that assess five factors; some signs can be evaluated
at term, others at 18 months of corrected age. The test is conducted according to the
corrected age.
The following table summarizes the five factors, the 20 ítems of the test, and the
aspects that it evaluates.
Table 3. Factors and Items INFANIB
Factors Items
Factor I Hands held Tonic labyrinthine Tonic labyrinthine Asymmetric tonic

Spasticity open or closed in supine in prone neck reflex
Factor II
Body derotative All fours Pulled to sitting Sitting
Head and trunk
Factor III Sideways For ward BAckwards

Body rotative
Vestibular parachute parachute parachute
Factor IV Positive support Dorsiflexion

Foot grasp Standing 89
Legs réflex of the foot
Factor V A b d u c t o r ’s Po p l i t e a l
Heel-to-ear Scarf sign
French angles angle angle
This test was chosen because it is easy to introduce in a systematic manner into the
clinical assessment done by the pediatrician during the follow up visit. It is quick and
pediatricians learned it easily. Although there are other neurodevelopmental tests
available, which can also be applied during systematic screening, we consider that
regular use of the same instrument for early detection of the most frequent neuromotor
disorders in children, allows adequate monitoring and early detection.

INFANIB for clinical evaluation and research
The instrument’s scoring sheets facilitate its clinical use.Standarized points lead to
identification of children with normal, transient, or abnormal neurological development.
The quantifying scoring system makes it possible to compare children according to
their age at testing. The different scorings and total scores make it possible to classify
children.
This test makes possible to integrate results in relation to the children’s neurological
evolution, from onset to later findings (for example, cerebral palsy, cognitive function,
and school performance).
Studies point out that the test’s characteristics are as follows.
i. It is highly specific and sensitive
ii. Facilitates early detection of neurological disorders
iii. Offers the possibility of taking timely and adequate therapeutic action to decrease
the emergence of inadequate patterns
The necessary elements to conduct the exam are listed below.
• A stretcher with a padded mat, the child must be naked
• The child’s corrected age at three, six, nine, and twelve months is used
• The exam must not be performed if the child exhibits irritability, fever, is ill, hungry,
sleepy or tired; this could interfere with the results
90 The test has been designed by a factorial analysis of five factors, each with four items.

Table 4. INFANIB classification scores
Age range Abnormal Transient Normal

Less than four
48 49 – 65 >66
months
Four to eight
<54 55- 71 >72
months.
Eight months
<56 59 – 82 83
or more.
The following table summarizes the possible findings obtained by applying INFANIB
Table 5. Neurological anomalies
Involves all four limbs

Is different from hypotonia
Spastic tetraparesis- Hypotonia of the arms and spasticity of the legs may
dyskineasia be found
There can be spasticity throughout, often with greater
involvement of the arms
Different combinations of abnormalities are possible
91
Is a one-sided involvement
Spastic hemiparesis
Generally greater abnormality of the arm than the leg
Bilateral involvement of the legs

Spastic diplegia
Mild involvement of the arms, often manifested as
delayed or clumsy fine motor control
Hypotonia: A floppiness frequently associated with delayed

acquisition of motor skills

Recommendations:
Tone anomalies (hypotonia, hypertonia, and dystonia) at 40 weeks, abnormal brain

ultrasound during the neonatal period: intensive physical therapy and careful
neurological follow up during the first year with a nuclear magnetic resonance imaging
(MRI).
CAT scan or MRI are only requested if hydrocephaly is suspected or to document

another lesion. Such exams help clarify the diagnosis or explain the evolution of a
clinical picture. It can also be requested when the diagnosis is based on an ultrasound
taken in the neonatal period, on the clinical and neurological exams (any degree of
IVH, for instance) and when an image of the patient’s brain before he is one year old
is required. However, such exams are not always available and they must not be a
substitute of the clinical evaluation.
When INFANIB results are abnormal, they dictate the physical therapy activities.
If neonatal ultrasound and INFANIB are not normal and the child’s history arouse
suspicion as to whether the anomaly is not due to a lack of adequate stimulation, an
MRI is requested to rule out an undetected lesion rom the neonatal period. INFANIB
is repeatedly administered throughout the year to assess the impact of physical and
other therapies, encouraging the participation of the parents. When INFANIB results
are normal, therapies are suspended.
92

93

Clearly, any other neurologic screening test may be used; the important thing
is to consistently use the same one and to standardize the management of the
child, following the results obtained.
During the first years of life, motor abilities are in a developmental stage. In order to
identify signs of deficiency and pathological signs in each stage, as deviation from
expected development, it is imperative to be familiar with the normal patterns of
development.
94

11. Psychomotor Development
A complete description of the evaluation of the psychomotor development is done in

module 6
95

12. Immunization
The extended Immunization Program (EPI) depends on each country and needs to be
adapted according to local political guidelines.
However, given the neurological high risk conditions of for the ‘kangaroo’ child (apnea,
hypothermia-induced seizures, and poor tolerance to vaccines) and based on scientific
evidence, it is recommended to use the inactivated poliovirus(IPV) and the acellular
pertussis vaccine.
Table 6. Vaccination Guidelines in the PMC in Colombia
Vaccines and
Age Comments
booster shots
If under 2000g at one month of life, delay
Newborn and children over
BCG until two months of chronological age and
2000g.
administer with the first dose of DPT-Polio.
Due to the theoretical risk of transmission to
other infants, the vaccine should not be given
to preterm infants until they are discharged
Two, four and six months of
from hospital. Inactivated polio vaccine
chronological age, with booster
Polio vaccine (IPV) may be used for long term hospitalized
shots at 18 months, five years
infants.
and then every 10 years.
It is also recommended if there is group
96
consultation in the KMC.
Newborn, two, four and six

Hepatitis B
months of age.
Diphtheria-tetanus-pertussis
Following scientific evidence, it is

Two, four and six months of
emphatically recommended to administer it
DPT age, with a tetanus booster
with acellular pertussis component (DPaT),
shot every ten years.
due to the high neurological risk of apnea,
hypothermia-induced seizures, and poor
tolerance to vaccines.

Immunization
Four to eight
Age Comments
months.
Haemophilus
Two, four and six months of Booster shot at 12 months or at 18 months
influenzae type b
age. with pentavalent vaccine.
(Hib)
Triple viral vaccine One year chronological age,
Mumps, measles and rubella
(MMR) a booster shot at five years.
One year of age, a booster

Yelllow fever
every ten years
Beginning at six months The seasonal vaccine is administered.

(two doses on the first
Influenza It is advised that every family member to be
immunization), booster shots
every year. in contact with the child is immunized.
Two, four and six months

Pneumococcal (booster between one year and
18 months)
Any additional immunization will depend

Two, four and six months
Other optional on the physician’s judgment
(booster between one year and
vaccines
18 months)
(rotavirus, measles, hepatitis A).
Taken from the technical guidelines for implementation of Kangaroo Mother Programs
in Colombia 97
Technical and Financial Cooperation Agreement No 638 de 2009, between the Ministry
of Social Protection, Social Welfare, UNICEF and WFP

Summary: Periodicity And Content Of
13. Follow Up Consultations Up To One Year
Of Corrected Age.
Periodicity according to
Aims of consultation
corrected age
If oxygen-dependent upon
Weekly oxymetry and pediatrics control twice a month
admittance to outpatient
until complete oxygen weaning.
KMP
Anthropometry (growth assessment: weight, length, head
circumference)
Physical exam
Exclusive breast feeding (EBF), if possible
Nutrition recommendations, at-home stimulation
1.5 months Check immunization card
Deliver infant stimulation and information leaflet
Ferrous sulfate and metoclopramide, if gastro esophageal reflux

is present
Special medication (Palivizumab if there is an outbreak of

syncytial respiratory virus –SRV- along with administration
criteria)
Anthropometry
Physical exam
EBF, if possible
98
Standardized neurological exam (for instance, INFANIB 3m)
Ferrous sulphate and metoclopramide, if gastro esophageal

reflux is present
3 months
Clinical exam; hip dysplasia and optometry screening
Information leaflet with exercises
Exercises
Refer to physical, occupational or speech therapy as needed
Check immunization card

Summary: Periodicity And Content Of Follow Up Consultations Up To
One Year Of Corrected Age.
Anthropometry
EBF, if possible; if adequate growth is not achieved and socio-

economic condition are depressed, advise on supplementary
nutrition.
Physical examination
Review hip dysplasia screening
Optometry consultation
Hearing screening: between three and six months of corrected

4.5 months age, with referral to speech therapy if needed. If screening was
performed in the NICU or at 40 weeks, only those children with
poor results will be screened again.
Recommendations for stimulation.
Special recommendations
Ferrous sulphate, if reflux symptoms persist, continue

administering metoclopramide

Anthropometry
Physical exam
Test of psychomotor development test, preferably adapted to

the country (in Colombia, the Griffiths and part of the Bayley are
used)
6 months Recommendations for supplementary nutrition
Recommendations for exercises
Refer to physical, occupational or speech therapy as needed
Following the results of INFANIB, refer for a nuclear magnetic

resonance, as needed
99
Anthropometry
Physical exam
Revise diet
Check for improvement in abnormal or transient findings

7.5 months in neurological examby the pediatrician or in psychomotor
development by the psychologist
Refer to therapy as needed or continue with home exercise plan

Ferrous sulphate

Summary: Periodicity And Content Of Follow Up Consultations Up To
One Year Of Corrected Age.
Anthropometry
Physical exam
Recommendations for supplementary nutrition

Nine months
Recommendations for exercises
Therapy or exercises as needed
Ferrous sulphate
Anthropometry
Physical exam
Ten months Recommendations for supplementary nutrition
Ferrous sulphate

Anthropometry
Diet
Physical exam
Twelve months Recommendations for diet
Test of psychomotor development test, preferably adapted to

the country (in Colombia, the Griffiths and part of the Bayley are
used)
100 Control at twelve months if independent walking is not developed
Anthropometry
Diet
Eighteen months Physical exam
Walking and language assessment

Bibliography
i. Cárdenas–López, C., & et al, D. K.–N.–F.–P. (Mayo/junio de 2005). Mediciones
antropométricas en el neonato.(Antropometric measurements in the neonate)
Recuperado el 9 de Diciembre de 2011, de Scielo: http://www.scielo.org
ii. WHO 1995. Physical Status: The use and interpretation of anthropometry.: Report
of a WHO Expert Committee; 1995. p. 1–452. [ Links. Geneva: WHO Expert Committee;
1995. p. 1–452.
iii. (Battaglia & Lubchenco, 1967)). A Practical Clasification of Newborn Infants by

weight and gestational age. Journal Pediatrics 71, pp 129-33.
iv. (Fenton, 2007) Evaluation of the Feasibility of International Growth Standards for
school-aged children and adolescents . Journal of Nutrition 137, pp 153-7.; Lubchenco,
L., Hansman, C., Dressler, M., & Boyd, E. ( 1963). Intrauterine growth as estimated from
live born birth-weight data at 24 to 42 weeks of gestation. Pediatrics 32, pp 793-800.
v. (AAP, 2006).
vi. (UNICEF, 2003). Recomendaciones para el control de la saturación de Oxígeno

óptima en prematuros.(Recommendations for control of of optimal oxygen saturation
in prematures) Argentina: Ministerio de Salud de la Nación, Grupo ROP.
vii. (Pearson & Boyce, 2004). The vulnerable child syndrome. Pediatr. Pediatric Rev.25(10),
pp 345–348.
viii. (Ruiz, Charpak, & Figueroa, 2002). Predictional need for supplementing
breastfeeding in preterm infants under Kangaroo Mother Care. Acta Pñ diatr 91:. , pp
1130-34.
ix. (Shanler RJ, 2005) Randomized trial of donor human milk vs preterm formula
101
and substitute for mothers' own milk in the feeding of extremely premature infants.
Pediatrics 116 , pp 400-406.
x. C.Amiel-Tison, C., & Steward, A. (1995). “ L´enfant nouveau né, un cerveau pour la
vie”.París: Les editions INSER
xi. (Salas & Peñaloza)
xii. (Simard, Lambert, Lachance, Audibert, & Gosselin, 2011).. Prediction of developmental
performance in preterm infants at two years of. Early Human Development.

Bibliography
Others important documents for consultation:
Babson, S., & Benda, G. (1976). Growth graphs for the clinical assessment of infants of
varying gestational age. Journal Pediatics 89, pp 814-20.
Campistol, J. ( 2003.). Fármacos empleados por vía oral para el tratamiento de la

espasticidad. (Oral medication for the treatment of spasticity) Rev Neurol .
Committee, J. (2007). Position Statement. ASHA, 36(12):38-41.
Conde-Agudelo, A., Belizan, J., & Diaz-Rosello, J. (2011). Kangaroo Mother care to
reduce Morbidity and Mortality in Low Birth Weight infants (Review) The Cochrane
Library 2011 , Issue 3..
CONPES. (2005). “Metas y estrategias de Colombia para el logro de los Objetivos de

Desarrollo del Milenio 2015. Asi vamos Colombia, (Aims and Strategies for Reaching
the Millennium Developmental Goals) 2015. 15.
CONPES. (2005). Modificación a Conpes social 91 del 14 de Junio de 2005. “Metas y

estrategias de Colombia para el logro de los objetivos.(Modifications to Copes Social91
of June 14, 2005. Aims and Strategies for Reaching the Millennium Developmental
Goals)
Dewey, K., & Brown, K. (2003). Update on technical issues concerning complementary
feeding of young children in developing countries and implications for intervention
programs. Food Nutr Bull Mar 24 (1), pp 5 - 28.
Habicht, J. (1974). Estandarización de métodos epidemiológicos cuantitativos sobre el

terreno.(Field standardization of quantitative epidemiological methods) Bol Oficina
102 Sanit Panam. 1974; 76. Bol Oficina Sanit Panam, pp 375–84.
L.R, M., Bada, H., & Barnes, P. (s.f.). Practice parameter: Neuroimaging of the neonate.
American Academy of Neurology and the Practice Committee of the Child Neurology
Society.
Lozano, J., & et al, O. R. (1992). Pulse oximetry reference values at high altitude. Archives
ofDisease in Childhood ; 67:, pp 299-301.
Olmos, C. E. (2008). Dieta Complementaria y Desarrollo de Alergias. (Supplementary

diet and allergy development) Precop (Revista Programa de Educación Continuada en
Pediatría)SCP Volumen 7 Número 4 ■ , pp 20 -28.

Bibliography
OPS, &WHO. (2003). Principios de orientación para la alimentación complementaria

del niño amamantado.(Guiding principles for supplementing the diet of the breastfed
child) Washington.
Osinaga-Itano, C. ( 1995). Early Identification and Early Intervention. The National

Symposium on Hearing in Infants, Vail, CO.
Pediatrics. (2004). Age Terminology During the Perinatal Period. PEDIATRICS Vol. 114
No. 5 November, pp 1360 - 64.
Russel, R., Green, N., & Steiner, C. e. (2007). Cost of Hospitalization for Preterm and Low
Birth Weight Infants in the United States. Pediatrics Vol. 120 No. 1 July 1, pp 2006 -2386.
SOCIAL, M. D., OPS, & NUTRIR. (2004). Guías alimentarias para los niños colombianos
menores de dos años.(Nutritional Guides for Colombian children under the age of two)
Bogoáa: Juanita Isaza Merchán.
Torres, M. E. (2008). Programas de seguimiento para neonatos. Protocolos Diagnóstico

Terapeúticos de la AEP: Neonatología,(Follow up programs for neonates.SAP
Therapeutic diagnostic protocols: Neonatology) pp 278- 84.
WHO. (2009). World Health Organization. [Online].; 2009.Recuperado el 06 de Diciembre

de 2011, de www.asivamosensalud.org: http://www.who.int/mediacentre/factsheets/
fs330/en/.
WHO. (2009). World Health Organization. [Online].; 2009.Recuperado el 06 de Diciembre

de 2011, de http://www.asivamosensalud.org/index.php?option=com_content&vi
ew=article&id=292:prevalencia-de-bajo-peso-al-nacer&catid=55:Indicadores&Item
id=74: http://www.who.int/mediacentre/factsheets/fs330/en/.
103
Yelin, B. (1997.). Diagnóstico temprano de la parálisis cerebral.(Early diagnosis of
cerebral palsy) Rev Neurol .

APPENDIX 1
LUBCHENCO CLASSIFICATION
Newborns are classified according to their weight and gestational age using the
Lubchenco’s international classification.
Preterm infant, adequate for gestational age (PT AGA). Preterm infant with a birth
weight between 10thpercentile and 90thpercentile for his gestational age.
Preterm infant, small for gestational age (PTSGA). Preterm infant with a birth weight
below 10th percentile for his gestational age.
Preterm infant, large for gestational age (PT LGA). Preterm infant with a birth weight
above percentile 90th for his gestational age.
At term infant, adequate for gestational age (AT AGA). Full term infant with a birth
weight between 10th percentile and 90th percentile for his gestational age.
At term infant, small for gestational age (AT SGA). Full term infant with a birth weight
below 10th percentile for his gestational age.
At term infant, large for gestational age (AT LGA). Full term infant with a birth weight
above 90thpercentile for his gestational age.
Post term infant, adequate for gestational age (Post T AGA). Post term infant with a
birth weight between 10thpercentile and 90thpercentile for his gestational age.
Post term infant, small for gestational age (Post T SGA). Post term infant with a birth
weight below 10thpercentile for his gestational age.
104 Post term infant, large for gestational age (Post T LGA). Post term infant with a birth
weight above 10thpercentile for his gestational age.
After determining the gestational age at birth and Lubchenco’s classification, the
hospitalization clinical records is revised, along with the discharge diagnosis.

Appendix 1
105

APPENDIX 2
PHYSIOTHERAPY FOR PRETERM AND / OR LOW BIRTH WEIGHT INFANT
Go to video:
: -Physical therapy in the intermediate care

unit and in outpatient care
Physiotherapy is a recognized health care profession. In this context, physiotherapy

supports the development of preterm or LBW infants in their continuous process of
maturation and organization. In spite of initial difficulties, physiotherapy has been
part of the KMC program for 20 years. Scientific studies prove that physiotherapy
improves the quality of life and leads to better prognosis for preterm or LBW infants.
Physiotherapists are important members of the KMC team.
Physiotherapy should begin in the Intensive Care Unit when the child is clinically stable
and continue later in the outpatient KMC program. Initially, physiotherapy support
ended when the child was able to crawl; however, then it became evident that it should
continue until children are able to walk.
The different processes of development appear and mature independently. They can
be modified or altered by internal and external conditions, therefore patients must be
observed to register anomalies, asymmetry, quality of movement and abnormal signs
The physiotherapist, together with the KMC follow up team, develop physical and
mechanical techniques and procedures for hospitalized and outpatient preterm
patients. Through direct and individual sessions, he/she provides adequate and
adapted care to improve the recovery of the locomotor system, to prevent learning
106 difficulties, to improve the psychomotor development and breathing capacity, and
strengthen the bond between parents/caretakers and the preterm infant.
A synactive theory of infant development provides a framework to understand the

behavior of preterm infants. Infant behaviors are grouped in 5 "subsystems of function”:
1. Motor subsystem - motor tone, movement, activity and posture.
2. Autonomic subsystem - basic physiological survival functions (skin color, tremors/

startles, heart and respiratory rate).
3. States subsystem - levels of central nervous system arousal - sleepy/drowsy, awake/

alert and fussing/crying

Appendix 2
4. Attention/interaction subsystem–availability for interactions, alertness and

robustness of the interaction.
5. Self-regulatory subsystem- presence and success of achieving and maintaining a

balance of the other 4 subsystems.
When a child is born prematurely, his subsystems are not properly developed and not
ready to adapt to a new environment, leading to frequent complications and neuro
psychomotor developmental delays.
The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) is

based on the observation of the child before, during, and after care giving experiences.
The observer assesses the infant’s ability to organize and modulate his subsystems. His
behavior is interpreted as steady/ relaxed or as stressed/discomfort. The goals are to
increase steady breathing, improve color, promote adequate rest, visceral function, a
calm facial expression, and an adequate tone (trunk and limbs) through a quiet and
soothing environment, comfortable positioning and individualization, and consistency
of care giving, according to each child’s needs and rest patterns.
Theoretical framework for physiotherapy in preterm infants
Every preterm child (born before 37 weeks of gestation) must be evaluated and
admitted in a program of early preventive stimulation to decrease the risk of
neurological deterioration and possible cerebral palsy, which would have considerable
impacts (emotional and financial) on their families. Obviously children with significant
disabilities are heavily demanding on their families in terms of economic resources,
health care, hospitalizations, frequent visits to health centers, use of special equipment
and services, difficulties and loss of time for traveling to and from work, and diminished
social and recreational life.
Some children show signs and symptoms of deterioration, such as irritability, altered
suction and swallowing, altered sleep-wake patterns, among others, suggesting 107
neurological lesion, alteration or malformation, which will impact their normal
development. It is imperative that health personnel detect these difficulties as early as
possible during the 1st trimester of life (when the brain plasticity is still significant) in
order to take timely preventive actions to avoid or decrease the significance of sequels.
Development of the child
Development involves all the changes in an organism from conception and depends
on the interactions between heredity and environment. These changes manifest
themselves through growth (increase in weight and height), ability and behavior
(perception, language, memory, learning, and knowledge), along with maturation.

Appendix 2
The newborn’s behavior reflects the functioning of his central nervous system. All
children follow the same progression in motor development, regardless of the age in
which they achieve each of the milestones.
Motor development has been considered intimately related to maturation; it is the

control of each of the elements of body movement. Development follows cephalo
caudal and proximodistal patterns, from gross to fine movement.
The mielinization is a dynamic process used to initiate maturational reflexes as the

physiological expression of mielinization in certain cerebral structures such as
medulla, stem, mid-brain and cortex. Mielinization of medullar reflexes begins in-
utero at 32 weeks of gestation and makes possible the most primitive reflexes: flexion
and extension of the limbs (walking/stepping reflex, straightening, palmar and plantar
grasp, crossed reflexes). The presence of these reflexes indicates an adequate spinal
mielinization. These reflexes will be initially assessed as normal or abnormal.
Motor development requires the gradual maturation of the nervous system and its
physiological state, including the child’s aptitudes, morphological aspect, and social
and adaptive behavior, and language.
During the child’s first three years, motor development is described as his eagerness to
have a progressive control of his muscular system, with the disappearance of primary
motor function, the progression of the wake-sleep patterns, and the repetition of
motor experiences. The first motor acquisitions of every child have been described as
the drive to go from simple to more complex movements.
Psychomotor development
A complete description of the evaluation of the psychomotor development is done in

module 6.
108
The level of psychomotor development is evaluated according to the child’s corrected
age. This is complemented by observation of the manifestations of functional motor
ability, reflex integration, adaptability and sensory modulation, as well as the possible
presence of neurological risk signs.
The typical course of development is an indicator of the structural and functional

integrity of the central nervous system and its effectors and follows patterns which are
more or less stable within the natural origin of the human species. There is a strong
interaction between the genetic basis and the environment, which is critical in the first
years. In today’s conceptions non- stimulating environments that impose a sustained
deprivation on the child, adversely affect overall development, which is a risk factor
for his later development.

Appendix 2
A child with neurological limitations shows poor strategies, monotony, and little
initiative to move; he may have difficulties with in one or both legs, one or both arms,
the trunk or the head, which will have negative impacts on general control.
Acquiring motor abilities during the first year of life is very important for the future
overall development, as this period is characterized by constant and rapid changes
in the motor growth rate and pattern. The first year of life may also be influenced by
diverse risk factors, such as premature birth or low birth weight. Preterm newborns
show evident deficiencies in overall motor performance during their first year of life,
possibly due to a transient hypotonia associated with prematurity. Several studies have
indicated that premature birth entails a significant risk of motor development delays.
Motor normal development sequence
3 months -Head control; 4 months – Rolling; 6 months-Sitting; 7 months- Creeping 9

months – crawling; 10 months –Standing and 12 months – Walking (±3-6 months).
Motor impairments: “The incidence/prevalence of disabilities is greater than any other

pediatric process of permanent character and severity. It is of the utmost importance
to establish adequate prevention, care and treatment programs” (Dr. J. Arizcun Pineda).
The assessment of the development of a child with neurological impairment is based

on important signs of disorganization or imbalance in relation to brain damage.
Thus, development must be assessed in terms of the behavioral and the neurological
development in an articulated manner while also representing both qualitative and
quantitative aspects.
The signification of alterations of muscle tone (hyper or hypotonia) must be considered

when making a diagnosis. The presence of neurological signs and their influence
on early child development must be rapidly recognized in order initiate an early
intervention program as soon as possible to avoid or diminish the severity of possible 109
sequels.
Early intervention programs use early indicators to detect brain damage. The aim is to
modify the structuring process of sequel(s?) through opportune intervention during
the first six months of life.
The early detection of motor anomalies is done by anamnesis and physical assessment.
Anamnesis allows health professionals to gather data that will guide the diagnostic on
a continuous basis.
From a clinical point of view, it is important to stress that rehabilitation program must
be centered not just on diagnosis but also on teaching parents/caretakers about the
characteristics of the developmental deviance, minimizing the risk of clinical severity.

Appendix 2
Muscle tone: Muscle tone refers to the tension (partial contraction) of muscles when
at rest, due to the action of the respective motor units and the proper functioning of
the corresponding reflex in order to keep the muscle in a relative state of straightening
and tension.
Muscle tone depends on the activity of motor units; it is determined by the algebraic
sum of the different excitation and inhibition inputs (simultaneously from the
peripheral and central nervous system), on the motor neuron.
A slight opposing resistance to passive mobilization indicates normal muscle tone

at rest. If resistance is too weak or nonexistent, tone is rated as hypotonic, given
that postural hypotonia is the inability to move or maintain posture against gravity.
However, if there is a marked resistance, it will indicate hypertonia.
Postural tone: For a clinical exploration of muscle tone, it is necessary to understand the
mechanics of postural control, the at-rest muscle length, conservation of posture and
execution of movement. Hypertonia, spasticity, rigidity and hypotonia are anomalies
of muscle tone.
Insufficiency of postural tone is selectively located in antigravity muscles (spinal, facial,

quadriceps and triceps). This produces instability and postural vices.
The development of rachis tonicity follows a cephalo-caudal direction:3 months

:Cervical stage; 6 months- Dorsal stage; 8 months- Lumbar stage and 9 months- Pelvic
stage.
During the first years of life, motor abilities are in development. To identify signs of
deficiency and pathological signs in each stage it is imperative to know the normal
patterns of development.
110 Based on observations founded on the wide range of possible neurological anomalies,
it seems that brain cell lesions do not always have a specific presentation during the
neonatal period and may sometimes be silent.
Posture control: Postural reactions and postural control may generate common
synergies in order to maintain a vertical position. Muscular synergies develop
appropriate temporal organization through experience.
Postural alterations imposed by movement may also be counteracted by sensory

feedback mechanisms (visual, vestibular, proprioceptive). These sensory impulses
contribute to postural control, which triggers unexpected defensive postural
adjustments to react to external disturbances.
Posture control is poorly developed when the central nervous system has been injured.

Appendix 2
Under these circumstances, this control may be absent, inappropriate ordelayed.
In-hospital management of physiotherapy
The physiotherapist must be integrated in the professional team in charge of preterm

patients in Intensive Care and Minimal Care Units, especially with those patients with
a history of neurological risks or injuries of the central nervous system.
1. Assessment conducted if possible in the presence of the mother
It is important to assess the neurological and biological development of the preterm

infant to reach an early diagnosis in order:
- To facilitate feeding and nutrition
- To achieve and/or improve cervical control
- To normalize muscle tone
- To conduct balance and equilibrium exercises to foster the acquisition of postural

goals ( to acquire specific movements)
- To promote global and fine motor development
- To stimulate cognitive function and to foster sensory development (Stimulating

vision and audition)
- To achieve the patient’s adaptation to the surroundings
- To teach parents to care for their hospitalized preterm infant.
During this assessment the child must be awake, fed one or two hours before, especially
in case of reflux; the surroundings must be quiet and well lit. All mobilizations must 111
be done gently.
The neurological maturation should be supported by the interpretation of:
• The gestational age at birth and detailed medical history of perinatal events.
• The assessment of passive and active tone and of archaic and other reflexes and
the assessment of postural reactions, balance and psychomotor development
(psychomotor developmental scales, INFANIB)
The physiotherapist will assess in a personalized manner thephysiological and

pathological reactions to identify any alteration of the central nervous system that can
interfere or interrupt the physiological processes or development, and will propose

Appendix 2
treatment priorities.
The physiotherapist will look for:
- Functional limitations , incorrect postures, limb position and alignment to avoid

retractions or distension of muscles, tendons and ligaments
- Bone and soft tissue problems
- Deviance in development
- Abnormal movement patterns
During the assessment, the child’s stability should be monitored to detect any reaction
to sensory input.
2. Gentle and correct positioning
It is fundamental to prepare the child when changing his position, to move him gently,
to contain his limbs (using the therapist’s hands and/or a blanket) during mobilization
to prevent his limbs to lag behind, to be certain that the head is supported and in line
with his body in supine position, and to verify that his head is supported and aligned
with his body in supine position.
The child must always feel contained during changing position, towards lateral
decubitus. The child must be held while in that position, in the incubator or crib, or
when supported by the caretaker’s forearm, keeping his head aligned.
Holding him in the caretaker’s arms or placing him on his side may help reduce stress
responses. This also avoids a complete change of position from prone to supine or vice
versa.
112
A good posture within the nest, favors ventilation and postural prophylaxis.
Postural support and comfortable positioning is essential to avoid the development of

future pathologies; the use of functional positioning aids is frequently necessary.
Preterm newborns tend to remain in the position they are placed in, however
uncomfortable, which could lead to modifications in muscle extension and elasticity
as well as contractures. As the infant’s cartilage and bone tissue, muscles, and tendons
are in maturation,a non-adequate position may create deformation which causes
neuromotor development alterations such as delays in normal motor development
and the appearance of disorders such as lower limb hypertonia , shoulder retraction
and abduction, increased neck extension (usually to one side), increased extension

Appendix 2
of the trunk with arched neck back and hip problems when remaining in a “frog-like”
position for extended periods of time, without proper containment.
It is important to use rolls, nests and pillows to promote comfortable positioning

and postural prophylaxis and to prevent such complications. A balance of extension
and flexion is achieved through correct and individualized positioning and frequent
position changes. Positioning affects both the infant’s physiology and behavior.
3. Motor rehabilitation
It is important to rapidly begin the rehabilitation process in stable hospitalized children.

Prevention is important; the rehabilitation process should be dynamic, preventive, and
precise in order to avoid disturbances in muscle tone and function, elongation, and
muscular atrophy.
For optimal response, it must be remembered that the greatest percentage of

mielinization occurs after delivery. Obviously that which exists cannot be changed but
some actions can be taken with great probabilities to improve the child’s condition.
Physiotherapist should provide passive, assisted, or free mobilization of ankles,

hands and elbows mainly; as well as isometric contraction of big muscles such as the
quadriceps, if necessary.
4. Promoting motor learning, acquisition of abilities and skills.
When lulling the baby to sleep, gently rock him at varying speeds; forward, backwards,
moving him away and then bringing him closer.
Encourage the child to grow accustomed to soft and loud sounds and to toys of varying
weights.
113
Show him objects of contrasting colors for him to follow visually. Play music and let
him watch books with colorful images. The ideal toys are those with movement and
sound. For example, rattles, musical mobiles, and balls.
Massage the baby using different textures: towel, velvet, sponge, brush, and others
(soft, rough, warm, moist). Use superficial massage as source of sensory, thermal, and
proprioceptive input.
Oral stimulation, inside and around the mouth, is an important regulatory center not
only because the baby receives nutrition through the mouth but also because the oral
area is more developed than other areas as a source of tactile discrimination.

Appendix 2
Outpatient care management
Once the patient is discharged from the hospital, the physiotherapy will continue or
start during the follow up visits.
The physiotherapist will:
a) Revise comprehensively the child’ clinical history, family history, including parental
expectations and demands, risks and protective factors, and availability of a parental
or family support network.
b) Conduct a comprehensive clinical assessment: Observing muscle tone, reflexes

and straightening reactions, Posture and flexibility,Global motor development,
coordination and balance.
c) And finally issue a diagnosis, a prognosis regarding physiotherapy, and a treatment

plan to be presented to the team and the parents.
1. Massage
The treatment begins with massage and progressive exercises
Massage using canola oil and different textured gloves, towel, false fur, brushes and
sponges, among others.
Massage one side of the body first and then the other, in a symmetrical way, emphasizing
the sole of the feet, providing to the child information in a more organized manner.
Massage from the feet towards the head in the direction of venous return and outward
from the body midline, while keeping the infant in good posture.
2. Progressive exercises to develop movements

114
The techniques developed by Kabath, Bobath, Doman and Vojta may be used according
to the patient’s specific needs, developmental stage, and health condition. Balls, rolls,
hammocks, swings, tilted surfaces, jungle gyms, and others may be used to stimulate
the vestibular system, weight transfer and rotational movement of trunk and body.
Movements must be stimulated according to the infant’s psychomotor developmental

period; motor stimulus must be age appropriated.
If the child has a good sensory integration base, he may develop new and more
complex abilities such as fine motor skills and later, academic skills such as drawing,
reading, and writing.

Appendix 2
3. Reinforcement of reflex activity and muscle tone
a) Reflex activity
Primitive reflexes: walking/stepping reflex, straightening, palmar and plantar grasp,

will be initially assessed as normal or abnormal, their presence indicate adequate
spinal mielinization.
Brain stem reflexes, static and postural reflexes, originated on neck-level nociception
movements are also analyzed.
-Tonic neck reflex in flexion: patient in supine position, when the baby flexes its neck,
its hips and knees will extend.
-Tonic neck reflex in extension: patient in prone position, as the child extends its neck
it will also extend its arms, and flex its hips and knees.
- Asymmetrical Tonic Neck Reflex (ATNR); patient lying on his back when the , head is
turned on one side the arm and leg on the side that he is looking toward will extend
or straighten, while his other arm and leg will flex.
- Positive support reaction: when the child is held under his arms or around his waist,
he will extend his hips, knees and ankle.
Both medullar and brain stem reflexes are integrated between 4 to 6 months of
corrected age.
All of these reflexes are inhibited or integrated in order to give way to mid-brain and
cortical reflexes, which in turn initiate (?) basic motor activity from head control to
changes in decubitus, to trunk control to walking.
This evolution is a product of mid-brain and cortex mielinization and produces the 115
labyrinthine and optical righting reflexes and all activities in supine, prone and sitting
positions. Likewise, these reflexes give the child adequate space awareness, positioning
his head and body in space, allowing him to ‘master’ his external surroundings, placing
his head and trunk in line.
As ‘automatic’ reflexes, such as Moro (startled), Landau (neck extension causing lower
limb extension), and parachute (protective response) are being used in an integrated
manner, a pre-walking or walking presumptive diagnosis can be established.
When these reflexes are not inhibited or integrated, there could be problems leading to
osteo-articular injuries. The presence of these reflexes indicates whether a central lesion
exists and is affecting the coordination of muscle groups and causing disturbances in

Appendix 2
movement, inadequate positions of all joints, and muscle tone disorders, which is a
determining factor in neurological disorders.
Muscle Tone
Muscle quality depends on the quality of muscle tone, elasticity, plasticity, resistance
to stretching and contraction. In cases of brain lesion, contraction behaves differently:
even histologically normal muscle may exhibit an abnormal response due to an
inadequate or irregular order from the damaged central nervous system. Therefore,
it is important to control muscular imbalances, which vary with position and / or
movement, may occur depending on muscle and bone growth and on posture. All
permanently inadequate postures may lead to pseudo-retractions, secondary to
posture and susceptible to control.
4. Multisensory stimulation program
Stimulation has been defined as “the set of actions aimed to provide the child with all
experiences he needs to develop his full potential. This is achieved by the presence of
people and objects in adequate quantity and opportunity and in a context of situations
of varying complexity, which generate a certain degree of interest and activity in the
child as a necessary condition to achieve a dynamic relationship with his surroundings
and an effective learning.”
An adaptive response implies an adequate, adjusted and harmonious response to the

demands or challenges of the environment.
Maturation is the effect of successive functional organization, which began in the uterus
and generates sensory energy of the utmost importance for the child’s harmonious
development.
116 Sensory inputs create a demand on the nervous system, organizing and processing
information to promote an adapted response. It is possible to influence the response
by controlling the input. This is one of the bases of the treatment of children with
sensory integrative disorders. This is also used to diagnose possible sensory disorders
in very LBW preterm infants.
It is important to stress that any lesion of the CNS generates developmental vulnerability
in patients, but it is also critical to remember that, due to neural plasticity, these
developmental risks are under the influence of protective factors (those of the infant
and of his environment).
The stimulation program must try to identify the child’s risk factors while facilitating the
protective factors, since it has been demonstrated that these factors can considerably

Appendix 2
reduce developmental damage to the child.
An important part of these sensory inputs is received by the brain through the ears.
They control balance, bodily movements, and coordination; they permit language
development, facilitate eloquent speaking and carrying a tune; control the eye
movements while reading as well as the arm, hand, and fingers when writing.
If a child is exposed to Mozart’s music before delivery and through the early years,
to the moment when he is learning to read and write, reproduce the developmental
stages of hearing by playing the music.
This stimulation program begins with a passive training phase of the ear, by placing
headphones or speakers with music near the mother’s abdomen during pregnancy,
or directly on the child. The second phase is an active one, with vocalization exercises
promoted by the mother.
During the passive phase, a combination of the recorded voice of the mother with
Mozart’s music is used as sound stimulation. The mother’s voice, reading aloud or
sending loving, positive messages to her baby generate favorable reactions and
behaviors.
The following step in the active phase consists in repeating words containing “hissing”
consonants such as s, f, ch and j (h/ in Spanish), which are high frequency sounds.
Mozart’s music must be used, adding rhymes, children’s songs, and readings of stories
with increasingly complex sounds each time.
Children are born with a drive to explore their surroundings and develop sensory
integration, if they receive sensory inputs. Some sensations (tact, proprioception and
movement, vestibular system) are more primitive than others allowing the specie to
survive.
117
The sensory input level refers to a point or intensity in which a particular individual
detects and responds to sensory information. The input level is not stable, but is
dynamic and directly influenced by intrinsic and extrinsic factors, such as the modality,
intensity, and location of the stimulus. Therefore, it is important to offer pleasant
sensory input to the child.
According to Gómez, Abrid and Jung (2004) a significant number of babies are born
with self-regulatory difficulties. Out of these, 7% exhibit persistent difficulties and are
referred to as “unadjusted.” These babies are irritable with impulsive behaviors, which
places them at risk for developmental disorders due to the vicious cycle established in
their environment.

Appendix 2
Vision
Tracking objects is one of the first visual response of an infant. To be able to visually tract
an object, several steps must be integrated: activation of neck muscles (proprioceptive
base) and movement and gravity reference from the inner ear. Good vestibular and
proprioceptive bases are necessary for the development of the four visual bases: to
locate, to fix, to track, and to alternate.
The vestibular system works in conjunction with the visual and proprioceptive systems
and their functions are intertwined. The baby attempts to respond to the effects of
gravity; if held upright and his head is supported, he will try to hold it and will be
intermittently successful. This is an important aspect to consider when performing any
type of intervention on neonates.
A full term infant moves a lot, receiving many proprioceptive messages which he
organizes to form what is known as “maturation patterns.”
Hospitalized newborns have limited opportunities for gentle and rhythmic vestibular
stimulation. Their fragile vestibular system is often overloaded. Sudden, uncontrolled
movements may have severe and prolonged disruptive effects on the child’s
autonomous nervous system.
Audition
The infant demonstrates his capacity to hear (audition), responding to various high-
pitched stimuli, such as his mother’s voice. Sensory integration and/or regulatory
disorders have been demonstrated to be precursors of later problems, more obvious
at a later age. These may affect interpersonal relationships and a certain basic inner
harmony needed to maintain the necessary interest and attention for learning and
achieving a good level of competence in the different tasks of daily life.
118 Abnormal motor development
Some components favor abnormal motor development in the preterm newborn, such
as head asymmetry (mainly towards the right side); increased extension of neck or
trunk; scapular retraction; extension of hips, knees and hallux (big toe); foot eversion
and thumb abduction.
Secondary components include pulmonary complications, genetic syndromes,

prolonged hospitalization, decrease or loss of the parent-infant bond.
These elements mostly determine inadequate weight and height gain; alterations in
the sleep-wake cycle; abnormal postures and behavioral patterns; poor movement
coordination; abnormal muscle tone development and difficulty performing functional

Appendix 2
tasks (roll, reach objects, and explore the environment).
If there is a delay in the motor development, the following aspects must be verified.
- An altered response to postural reactions may point towards ‘central incoordination’.
- Primitive reflexes are altered for the reasons given above.
- Persistent reflexes could indicate cerebral palsy, degenerative syndromes, or a state

of hyper excitability.
- Depressed or absent reflexes may be related to cerebral palsy, degenerative syndromes,

myopathies or Down’s syndrome.
- If there are permanent alterations in tone, it is important to keep in mind that; i)

hypertonia is present in cerebral palsy and degenerative syndromes and, ii) hypotonia
in the same entities and myopathies.
A motor delay with absence of the above conditions grants further investigation to see
whether there is a motor delay secondary to sensory or environmental deprivation or
a simple motor delay.
In case of retardation some considerations must not be overlooked: Existing disorders

of spontaneous movement and normal postural development., Complementary tests
such as karyotype, genetic studies, and electromyography could clarify the diagnosis,
though sometime no etiology is found.
Prematurity, LBW and prolonged hospitalization are intrinsic risk factors to jeopardize
harmonious development of preterm or LBW infants. Early integration of physiotherapy
into daily care (both in neonatal units and during follow up visits) is one of the major
ways to promote harmonious development by supporting motor development,
primary reflex stimulation, inhibition of abnormal movement, sensory integration and 119
multisensory stimulation, and linear and rotational vestibular stimulation.
If adequate intervention is done and if the parents can take an adequate and active
role in the care of their baby, they will positively identify with him and will be able to
adequately promote his development.
From the point of view of neuroscience, early, adequate, and opportune care must
begin by assuming that child development is the same in children with or without
disabilities.

Bibliography
Aguilar Rebolledo, Francisco. Plasticidad cerebral(BrainPlasticity). Rev Med IMSS 2003;
41(1):pp 55-64.
Alchouron, Carolina. Impacto de la prematurez en el crecimiento y desarrollo.(Impact of

prematurity on growth and development)Curso del InstitutoUniversitario del Hospital
Italiano de Buenos Aires(Course from the University Institute at the Italian Hospital in
Buenos Aires). 2 de abril al 13 de agosto de 2009.
http://campus.hospitalitaliano.org.ar/file.php/1/imprimibles/2009/822.pdf Revisado el 30 de
mayo de 2011(RevisedonMay 30, 2011)
Aviles, Clara. Occupational Therapy In Neonatal Care Unit: An Experience From The South.
Revista Chilena de Terapia Ocupacional Volumen 10, diciembre 2010 pp 9 – 20.
Bernal, Luis. Fisioterapia en pacientes críticos (Physiotherapy in patients in criticalcondition).

http://www.
Bly, Lois. Motor skills acquisition in the first year. USA: TherapySkillBuilders. 1994.
Bradic,Sonia.Desarrollo Psicomotor en niños chilenos de nivel socioeconómico bajo

provenientes de distintos sectores geográficos y étnicos. (Psychomotor development in
chilean children from low socio-economic status withdifferent geographic and ethnic
origins).1981.
Conforto AB, Cohen et al,LG, Dos Santos RL, Scaff M, Marie SK. Effects of somatosensory
stimulation on motor function in chronic cortico-subcortical strokes. Hassler y Shaun:
Atlas of theMonth Enfoque de sistemas dinámicos en el desarrollo motriz y adquisición
de la habilidad. Actualización de conocimientos en la ciencia del movimiento (Dynamic
system approach to motor development and skill acquisition. Updating knowledge in
movement science.)
120
Doménech, J. Rehabilitación Motora. (Motor rehabilitation) Rev. Neurol2002: pp 34-148.
Espinosa García, Eugenia. Neuropediatria (Neuropediatrics). Hospital Militar Central.

Bogotá: Colombia, 1999.
Griffin, T. Family-centered Care in the NICU. Journal of Perinatal & Neonatal Nursing
20(1):98-102, 2006.
Marques, Dos Santos; Videira, Lídia Maria. Medidas de Seguridad, Protección y Confort.
(Safety, protection and comfortmeasures). http://www.eccpn.aibarra.org/temario/seccion1/
capitulo12/capitulo12.htm. Revisado el 1 de junio de 2011. (Revised june 1, 2011)

Bibliography
Ramos Sánchez, Inmaculada. Detección y diagnóstico precoz de los trastornos del

desarrollo psicomotor. Ponencia presentada a la Mesa Redonda Seguimiento del
Recién Nacido de Riesgo en Atención Primaria, en la XCIV Reunión Científica de la
SPAOE, Córdoba, enero de 2008. (Early detection and diagnosis of psychomotor
developmental disorders. Paper presented at the Round Table on Folllow up of the
Newborn at Risk in Primary Care, during the XCIV SPAOE Scientific Meeting Cordoba,
January 2008).
Raniero, Elaine P. Et al. Patrón y tasa de adquisición de habilidades motoras de los

bebés prematuros durante los primeros cuatro meses de edad corregida. (Motor skill
patterns and rates of acquisition in premature babies during the first four months of
corrected age.) RevBrasFisioter, São Carlos, v. 14, n. 5, pp 396-403, septiembre octubre
2010
Sánchez-Rdriguez,G; Quintero-Villegas,LJ; Rodriguez-Camelo,G; Nieto-Sanjuanero,A;

Rodríguez-Balderrama,IDisminución del estrés del prematuro para promover su
neurodesarrollo: nuevo enfoque terapéutico.(Diminishing stress in the premature
to promote his neurological development: a new therapeutic approach.)
MedicinaUniversitaria 2010; 12(48): pp 176-180
Tamis W, Pin. Effectiveness of weight bearing exercises in children with cerebral palsy.
Murdoch Childrens Research Institute, Victoria, Australia. http://www.ausacpdm.org.
au/__data/assets/pdf_file/0018/14580/tamis_pin_2_06.pdf. Revisado el 03 de junio de
2011.
Tison, Amiel. Enfermedad Motora Cerebral Espástica (Spastic Cerebral Palsy)
Zanabria Salcedo, Martha. Predicción de secuela neurológica al año de edad en

niños prematuros evaluados con el examen evolutivo de la conducta.(Prediction
of neurological sequelae.at oneyear of age in premature infants assesssed with the 121
developmental behavioral scale)Vol. 4, Números: 1-2 enero-junio, julio-diciembre
2005.(Vol. 4, Numbers 1-2 January-June, 2005)

APPENDIX 3
OPHTHALMOLOGICAL ASSESSMENT
Retinopathy of prematurity (ROP) is the main cause of visual impairment in preterm

infants. The increased survival of extremely low birth weight (ELBW) infants in recent
years, due to advances in neonatal care, has produced a population of infants at very
high risk of developing ROP. It has been believed for many years that oxygen therapy
increases the risk of ROP in preterm infants; however, ROP can occur even with careful
control of oxygen therapy. Several factors increase the risk of ROP, especially those
associated with short gestation and low birth weight. Other identified risk factors
include sepsis, intra-ventricular hemorrhage, exposure to light and blood transfusions,
and mechanical ventilation
ROT is a vascular-proliferative process (abnormal growth of peripheral retinal vessels)

that affects preterm infants and may progress to retinal detachment and blindness.
122

Appendix 3
Preventive ophthalmological assessment, such as those routinely done in the KMC

program, has made diagnostic and treatment more timely, preventing serious visual
sequel.
Timely treatment (laser surgery or cryotherapy) has a 50% chance of positive outcome.
For a timely diagnosis of ROP, it is necessary to screen all preterm infants hospitalized
in Neonatal Intensive Care Units. In industrialized countries, the most severe forms
of ROP affect almost exclusively extremely preterm infants born with a weight of ≤
1000g. In these countries only babies with a BW of < 1.500 g. are assessed for ROP.
Larger infants are assessed only at the request of neonatologist if risks factors for the
development ROP are identified.
However, data coming from mid-to-low income countries, such as Colombia, suggest
that during the first step, larger, more mature babies need to be included in screening
programs to ensure that no child in need of treatment is left out.
The estimated incidence of ROP in a population of preterm infants (birth weight below
1500g and less 30 weeks GA) in industrialized countries is 16% to 56%, depending on
neonatal therapy.
Reported frequency of ROP in mid-to-low income countries is between 21.7% to 71.2%

t but few studies evaluated frequency of ROP in the < 1500g group.
Screening criteria in developed countries differs from those used in developing

countries, but all children with risk factors must be assessed. Such factors are not
always recorded in clinical histories, therefore the KMC program routinely screens all
infants born before 37 weeks of GA and those with identified risks factors.
The most important risk factors are listed below.

123
1. Mechanically assisted ventilation
2. Transfusion using adult hemoglobin
3. Hypoxia and hyperoxia
4. Shock, hypoperfusion
5. Apnea
6. Resuscitation maneuvers

Appendix 3
7. Acidosis
8. Sepsis
9. Prenatal steroids
10. Sepsis from Candida
11. Patent ductus arteriosus
12. Low gestational age and low birth weight
13. O2 supplementation Vitamin E deficiency
14. Ethnic origin
15. Indomethacin
16. Surfactant
17. High levels of light
Normal retinal development
The human retina begin developing from the 4th month of gestation. Vessels grow in
centrifugal direction from the optical disc. Due to the nature of the optical nerve, this
maturation initially ends on the nasal side of the retina, approximately at 8 months of
gestation. Temporal retina completes its growth near 40 weeks GA. Preterm infants
have an immature and incomplete vascularization of retina with an opaque, grayish
color of the retinal fundus, in contrast with a mature, vascularized and pink full term
retina. The transition between immature non vascularized and mature vascularized
124 retina is gradual, with clear limits between them.
The International Classification of Retinopathy of Prematurity (ICROP) is used to classify

ROP. To reach this classification, ICROP uses a number of parameters: the zones (1,2,3 )
to locate the disease; the circumference of the affected area using clock hours (1-12),
the severity of the disease (stage 1-5), and the presence or absence of "Plus Disease."
Each aspect of the classification has a technical definition.
Zones are centered on the optic nerve. The circumferential area affected is described
in segments, using the top of the eye as the number 12 of a clock.
The Stages of ROP are the aspect of retina at the junction between the vascularized
and avascular part.

Appendix 3
Three factors are assessed:
1. Zone of the disease, the retina is divided into three zones centered on the optic
nerve:
a. Zone I is the inner area; its radius is twice the distance from the optic nerve to the
center of the macula.
b. Zone II is concentric to the anterior and external; it has a radius between the center
of the optic nerve and the nasal horizontal ora serrata.
c. Zone III: the remaining retina
2. The extent of disease is recorded as 12 clock-hours, with each clock-hour representing

a 30° sector of affected retina.
3. The developmental moment of the lesion, according to a series of active degrees

(Fonseca, Gomez, Rodríguez, & Peralta, 2000)
It is important to underline that not all children who suffer ROP will progress to stage
five; some babies with ROP may suddenly recover from stages 1 or 2.
The zone numbers refer to the International Classification of Retinopathy of Prematurity

which designates three zones in the retina described below.
Posterior pole: centered on the optic nerve head; it is a circle whose radius is twice the
distance between the optic papilla and the macula. With a two-diopter magnifying
glass placed on the nasal edge of the optic nerve head, the field observed with the
glass corresponds to this zone.
Peripheral retina: centered on the optic papilla; it covers a circular area between the
125
inner circle of zone I and an outer circumference of the nasal ora serrate.
Extreme periphery: residual, crescent-shaped area between the exterior circle of zone
II and the oral serrata of the temporal side.
The extension is given by the number of clock hours circumferentially compromised

by retinopathy.
Stages of ROP according to ICROP
Stage 1: a thin white line lies within the plane of the retina at the junction of the
vascular and avascular retina.

Appendix 3
Stage 2: the demarcation line has greater width and height and extends above the
plane of the retina. Early on, the ridge may be white, evolving to pink or red as ROP
progresses
Stage 3: neovascular proliferation extends into the vitreous cavity.
Stage 4: partial retinal detachment.
A. Retinal detachment in which the fovea is still attached.
B. Retinal detachment in which the fovea is detached.
Stage 5: complete retinal detachment, typically funnel-shaped, further defined by the

configuration of the funnel
In addition, “Plus disease” may be present at any stage. This term refers to other ocular
findings indicative of vascular activity. The most widely recognized “plus disease” is the
posterior pole retinal venous dilation and arteriolar tortuosity. It signals a significant
level of vascular dilation and tortuosity observed at the posterior retinal vessels. This
condition may worsen the prognosis and reflects the increase of blood flow through
the retina.
Other” plus disease”
Venous dilatation
Mild twisting
Moderate to severe twisting
Severe twisting with arterial and venous dilation
Thickening of iridian vessels

126
Pupillary rigidity
Intra-retinal hemorrhages
Threshold disease
Stage 5 is a condition corresponding to a III “plus” Stage, in areas one or two, in more
than eight consecutive meridians or eight separate meridians. There is a high incidence
of complications with a high rate of retinal detachment.
During the evaluation of the premature infant, it is important to consider the child’s
clinical status, to conduct a comprehensive assessment, and report findings from the
physical examination, with emphasis on risk factors and criteria for suspected ROP.

Appendix 3
In the KMC program all newborns attending the outpatient clinic are screened. This is
carried out from week 31-32 or after the first 28 days of life.
Table 7. ROP Screening
Age at first evaluation
( weeks)
Gestational age
Chronological age Corrected age
(weeks)
32 4 36
31 4 35
30 4 34
29 4 33
22 9 31
127
Taken from: Technical guidelines for the implementation of Kangaroo Mother Programs
in Colombia. Ministry of Social Protection, United Nations, WFP, pp. 89 -92.

Appendix 3
Early detection of retinopathy of prematurity
This is the basis of useful treatment during the active phase of the disease. The first
assessment must be done through indirect ophthalmoscopy betweenr the 4th week
and the 6thweek of chronological age, and before completed 32 weeks GA.
Follow up schedule
Every 2 or 3 days:
Retinopathy type 2
Type 1, aggressive, posterior ROP.
Emergency. Laser or cryotherapy treatment; if not available, aggressive, posterior

type I ROP .
Every week:
Immature retina in Zone I with no ROP,
Stage 2 in Zone II
Regression of retinopathy in Zone I.
Every 2 weeks:
Stage 1 in Zone II.
Regression of retinopathy in Zone II.
Every 3 weeks:
128
Immature retina in zone II,
Stage 2 or 3 in zone III ,
Regression of retinopathy in zone III
Monitor until complete vascularization in Zone III is observed and there are clear signs
of regression without abnormal vascular tissue, which could be reactivated, or until
the child is 45 weeks of corrected gestational age and shows no signs of type 2 ROP or
worse.
Besides the possibility of developing ROP, preterm children also have a higher incidence
of other visual disorders. Strabismus and visual cortex deterioration are more frequent

Appendix 3
in preterm infants when compared with full-term infants. Severe myopia in relation
the severity of ROP is also frequent in preterm children.
Cryotherapy treatment is progressive and rapidly reaches amblyopia.
Anisometropia also carries a higher risk for secondary visual disorders, including
strabismus and amblyopia. Strabismus is more prevalent. Cerebral hemorrhages
are associated with visual acuity disorders, strabismus and nistagmus. Visual cortex
damage is generally accompanied by other visual disorders, such as ocular motility
disorders and optical nerve hypoplasia.
Ocular vigilance in preterm infants will depend on whether they were diagnosed with
no ROP, untreated ROP (mild stages of ROP) and moderate ROP, with spontaneous
regression or treated ROP.
For the group of children with treated ROP, and a more compromised visual future, it
is important to group patients according to the frequency of presentation of ocular
pathologies.
PT,without ROP PT,with treated ROP
Strabismus 4% 20%
Myopia 3-5% 25-30%
Hypeopia 4% 3% 129
The first group will be discharged from ophthalmology services when retinal
vascularization is completed. The frequency of follow up visits will be decided based
on the corrected age, with the aim of detecting the referred ophthalmological
pathologies. Optometric screening for refraction problems is conducted for all
children in the KMC Program at 3 months of corrected age, including those who
did not have ROP during the neonatal period.

Bibliography
Fonseca, A; Gomez, J; Rodríguez, JM; Peralta, J. Actualización en cirugía oftálmica

Pediátrica (UpdateonPediatricOphthalmicSurgery)2000 Editorial Tecnimedia
Terry, T. (1945). Ocular maldevelopment in extremely premature in fants: Retrolental

fibroplasia. General considerations. Ocular maldevelopment in extremely premature
in fants: Retrolental fibroplasia. General considerations. JAMA 1945; 128: pp. 582-585.
JAMA 128 , pp. 582-585.
Yebra, E., González, J., García, C., & Giráldez, M. (2008). The relationships between ocular
optical components and implications in the process of emmetropization. Arch Soc Esp
Oftalmol vol.83 no.5.
130

APPENDIX 4
OPTOMETRIC ASSESSMENT
At birth, the newborn´s eyes are already formed. However, vision has not completely
matured. Whatever maturation is achieved is due to factors such as: i) variations in the
structure of the eyeball (emmetropization): ii) a balanced muscular system that allows
the integration of information from both eyes at the cortical level for the development
of binocular vision, and iii) adequate development of the occipital cortex, in charge of
processing visual information.
131
Emmetropization is the process by which the refraction of the anterior ocular segment
and the axial length of the eye tend to balance each other to produce emmetropia.
Emmetropia is a refractive condition of the eye defined by the process in which the
rays of light are all brought accurately and without undue effort to a focus upon the
retina; as opposed to hypermetropia, myopia, an astigmatism.
The process of emmetropization must be understood, as this is a decisive factor when

deciding optical correction needs for a child.

Appendix 4
Straub defines the process of emmetropization as a tendency of the optic-ocular

system towards emmetropia due to a correlation of individual optical elements. The
starting point of the stimuli that trigger this process is the retina (Grovesnor, 2004).
Other studies define emmetropization as the regulatory process that tends to

reproduce a theoretically perfect eye, where any excess in an ocular component is
balanced through moderation in other areas (?).
The newborn eye measures approximately 18 mm in axial length and grows 6 mm until
adulthood, when it reaches a final length of 24 mm. At 3 years the eye has achieved
almost all its axial length and between the ages of 3 and 13 its length growths by 1
mm. If axial growth in length was not accompanied by offsetting changes in the other
elements in the system, a 15 diopters would be created. The greatest increase in the
eye’s axial length occurs in the vitreous chamber, from a 62.5% ratio at birth and 67%
between the ages of 4 and 5. And 69.5% at 13 to 14 years(Merchan, 2007).
Merchán (2007) explains that visual development of the first five years is another
aspect to consider. Most visual characteristics begin forming before birth when the
adequate synaptic connections are created, establishing and differentiating the retinal
and visual path neurons.
132

Appendix 4
The development of the visual system may be influenced by experience during the
first five years of life, with a critical period in the first six months, particularly for the
development of binocular vision. This makes early detection of any factor that may
alter or delay the maturation of the system very important. The above indicates that all
children must have their vision checked every six months from the time of birth , until
the age of 3, in order to ensure the optimal development of the visual system.
In the KMC Program, an ophthalmologist assesses the integrity of the child’s ocular
structure during the neonatal period, especially to care for the development of retinal
tissue, which may be altered (ROP) due several risk factors connected with their
prematurity, such as use of oxygen..
Once these children are discharged from ophthalmology, at the age of 3 or 4 months
of corrected age, they are referred to an optometrist (?)to assess the maturation of
their visual system. It is fundamental to do this at this age, since children are still in that
critical period of visual plasticity and optometry intervention is crucial to promote this
maturation.
An optometric exam assesses the degree of maturity of the visual system, by studying
3 fundamental aspects: the refractive, motor, and ocular status.
The assessment of the refractive status checks that the optical components of the ocular
globe correlate in such a way that the emmetropization process can be completed.
The refractive status is determined by retinoscopy under pupil dilatation. A drop of

Tropicamide 1% must be applied to each eye and after 20 minutes, the refraction may
be performed. It is also important to observe the shadows of both meridians of each
eye before applying Tropicamide to have an idea of the patient’s refraction before the
drops are applied.
133
The assessment of motor status determines if the movements of the ocular globe show
evidence of balance in the extra ocular muscles, which are the basis of the development
of binocular vision. It is performed through FTSD, Hirschberg and PPC tests.
FTSS (focus, track, sustain attention, shift). An attractive, soundless object is placed
20 cm from the child’s face. The object is slowly moved from the midline to the sides,
observing if the child focuses his gaze on the object and then if he tracks its trajectory.
The child will generally track the object with bursts of head movements, maintaining
attention on the object. If the child’s attention cannot be engaged using an object, the
examiner’s face may be used to observe tracking.
Then, another object, of similar characteristics is introduced in the child’s visual field,
to have him shift attention from one object to the other, and finally, a third object

Appendix 4
is introduced in parallel, for the child to observe. It is noted whether the child can
disengage his attention from one object and shift attention to a new one.
Most 3 to 4-month infants are able to focus, track, and sustain their attention on the
object and then abandon it and shift to another one.
On the observation sheet, F is noted, if the child just focuses but does not sustain, FT
if the child follows and tracks but doesn’t sustain, FTS, if the child focuses, tracks, and
sustains and FTSS if he focuses, tracks, sustains, and shifts. If the child only tracks the
examiner’s face, FR is recorded.
HIRSCHBERG test to assess the ocular globe alignment: a flashlight is held 40 cm from
the patient’s face at eye level to observe the location of luminous reflection on the
cornea. If the reflection is in the same relative position in both eyes the subject does
not suffer from strabismus. On the other hand, if the position is different in each eye,
the patient has strabismus, which is then classified according to its location: nasal
(exotropia), temporal (endotropia), superior (hypotropia) or inferior (hypertropia).
PCP test (Proximal Convergence Point): an object is placed 30 cm at eye level from
the child’s face and is slowly moved towards it until one of the eyes loses alignment,
recording the distance at which this happens.
134
The assessment of ocular status examines the

integrity of ocular structures: it is performed
through direct exam, direct ophthalmoscopy
under pupil dilation and evaluation of pupillary
pathway.

Appendix 4
External exam: this test assesses the external segment of the ocular globe. The following
structures are assessed:
Orbit
Relative size, shape, and position of the external orbital margins
Appropriate fit of the ocular globe inside the orbit
Physical appearance and relative comfort of eyelids and anterior segment of the globe
Size and shape of palpebral opening
Mobility patterns
Physical appearance of palpebral tissue
Lacrimal system
Appearance and volume of accumulated tears inside the palpebral opening
Appearance and relative firmness of the tissues in the lacrimal gland area
Appearance and relative firmness of the tissues in the nasolacrimal duct area
Conjunctiva Color and transparency; degree of vascular dilation of blood vessels.
Cornea: Size and shape; appearance of the cornea (transparency) and surrounding
areas
Sclera: Color; degree of vascular dilation.
Anterior chamber: Depth; transparency.

135
Iris and pupil: Pigmentation; anatomical structure vs. physiological status
Status of adjacent components (Rosner, 1990)
Assessment of the pupillary pathway: under a dim light, a flashlight is directed towards
the right pupil to verify the presence of a direct pupillary reaction (myosis) in that eye
and a consensual myosis reflex in the other pupil. Identify the presence of mydriasis
when the light is withdrawn from the right eye. (Herranz, Vecilla, & Antolinez, 2010).
Repeat the procedure on the left eye.
Ophthalmoscopy: this test assesses the internal segment of the eyeball, permitting the
clinician to note cornea or lens opacity, observe the papilla and the neuroretinal rim,

Appendix 4
the macular area and the artery-vein relation
The right eye is examined first, by placing the ophthalmoscope on the examiner’s right
eye, if possible, using a sound to get the patient’s attention so that the papilla can
be examined. If this step is skipped, the baby will fix his gaze directly on the light
of the ophthalmoscope, which will only allow for the examination of the fovea. The
procedure is repeated for the left eye and must be first conducted at a distance of 50
cm. to assess and compare the red retinal reflex in both eyes.
Finally, parents must know and understand the importance of having their children
evaluated every six months, during their first three years, in order to achieve an optimal
development of the visual system.
136

Bibliography
Grovesnor, T. (2004). Optometría de atención primaria,(Primary Care Optometry)
Primera edición,Barcelona, España: Editorial Masson S.A.
anz, M., Vecilla, R., & Antolinez, G. (2010). Manual de Optometría (Optometry Manual)
Madrid, España.: Editorial Panamericana.
Merchan, S. (2007). Corrección del astigmatismo hipermetrópico y la hipermetropía

simple en niños de 0-4 añospara la salud visual y ocular. (Correctinghypermetropic
astigmatism and simple hypermetropia in children 0-4 years old for visual and ocular
health)Ciencia y tecnología No 9 105-115 /julio-diciembre .
Rosner, J. (1990). Pediatric Optometry.Houston: Editorial Butterworth Publishers.
Sheridan y Sorby. (1960).
Yebra, E., González, J., García, C., & Giráldez, M. (2008). The relationships between ocular
optical components and implications in the process of emmetropization. Arch Soc Esp
Oftalmol vol.83 no.5.
http://www.programacanguro.org/ Fecha de consulta: mayo 21 de 2010
137

APPENDIX 5
DIFFERENT TYPES OF AUDITORY SCREENING
The strategy using only risk indicators misdiagnoses 50% of cases of hearing loss. This
fact alone justifies the implementation of a universal screening program for auditory
impairments in order to detect, in the newborn population, those with a possible
hearing loss, using auditory evoked potentials. This can be assessed with the use
of equipment able to detect possible hearing loss in children between birth and 6
months of age with 98% consistency.
It is necessary to standardize tests and introduce study protocols that help unify
138 criteria amongst the different professionals involved in the detection of auditory
impairments. Team work or interdisciplinary teams are linked to a process of quality
care and permanent support offered to parents.
Today, effective diagnostic tools are available for studying the auditory function at any
age.
In the United States, auditory screening programs of neonates with associated risk
factors have existed for nearly 20 years. The prevalence of hearing loss is estimated at
around 2.5% reaching 10% in high risk children(1). Several studies found that hearing
impairment should be diagnosed as soon as possible and that children fitted with
amplifying devices around six months have better language skills as compared to
children treated at a later age. It is clear that the age at which the process of special

Appendix 5
education begins (aural-oral re/habilitation) has a revealing effect on the development

of language and communicative abilities in schooled, deaf adolescents. This supports
the idea of starting universal auditory detection-screening programs (2007) in babies,
ideally in the first three months of life (Committee, 2007), or at least before six months
of age, in order to allow for earlier intervention.
Objectives of early auditory screening in the KMC Program
With the support of the family and through information collected in medical records,
an Auditory Loss Risk chart is established. This screening process is completed with
a behavioral evaluation protocol for children from zero to six months of age, which
contains tests and tympanograms (an analysis of the functionality of the middle ear).
For every child found positive for hearing loss, automated evoked potentials screening
is repeated in the month following his assessment and after a period of auditory
stimulation.
In case the child is found with hearing loss, refer the child and provide the parents with
adequate indications to help them to equip the child with auditory amplification and
likewise, to offer the required auditory stimulation.
The diagnosis must be immediately confirmed, within the first six months of age,
by electrophysiological tests, such as specific frequency auditory evoked potentials
or stable state auditory evoked potentials; electro acoustical tests such as distorted
product oto-acoustic emissions and immittance (tympanograms and stapedial reflex
determination) audiometry.
Inform and train parents on the benefits of an adequate auditory stimulation from
birth as well as on the importance of periodical auditory assessment.
Screening activities in the KMC Program, before 6 months

139
Automated auditory evoked potentials screening consists of a test with click-type
stimulation (with a frequency band of 1000 to 6000 Hz), with an intensity of 35 dB n
HL, and a rate of 33 pulses per second and rarefied polarity. This aims to identify the V
wave (lower brain stem register) in latencies aligned to the maturational level of the
auditory pathway for this age range (0 to 6 months of age).
Tympanograms screening (static complacency): state and mobility of the tympanic

membrane in relation to the mid ear structures.
Behavioral screening: test for free-field sound localization, minimum response to pure
tones, modulated frequency or noise, reaction to spoken language and startle levels.

Appendix 5
Audiological testing of children with abnormal screening results.
Distortion product oto-acustic emissions (PDOAE) are responses generated when the
cochlea is stimulated simultaneously by two pure tone frequencies. It is done through
frequency octaves and gathers information on the status of the outer hair cells and
translates the information into a distortion audiogram.
Short latency auditory evoked potentials (BAER, topodiagnosis or neurological)
It is conducted mono aurally, at 90 dB HL, with counter lateral masking of 60 dB SLP,

1000 to 2000 average sweeps, at a speed of conduction of 10 pulses per second and
polarity of refraction. There must be replicability criteria, two channels (ipsilateral
and contralateral), inter-aural wave V difference and Selters and Brackman correction
factor.
Short latency auditory evoked potentials (click threshold or specific frequency

BAER – intensity-latency function curve), with click stimulus or stimulus by specific
frequency (500, 1000, 2000, 4000 Hz) conducted from 90 dB, in monoaural descent,
with contralateral masking of 60 dB SPL.
Auditory steady-state response (ASSR) evoked potentials. Conducted starting at 80 dB

SPL (insert earphones), with stimulus, generating the electro physiological audiogram
by frequencies from 500 to 4000 Hz, simultaneously stimulating all eight frequencies
in both ears.
Threshold (auditory acuity – sensitivity) measurement, through tonal audiometry

conducted with frequencies of 250, 500, 1000, 3000, 4000, 6000 and 8000 Hz, assessing
bone and air conduction. In case of need, masking levels will be used to prevent the
non-tested ear from hearing the stimuli. The procedure will be performed separately
on each ear. In case of difficulty to perform the bone conduction procedure, Sensitivity
140
Acuity Level (SAL, based on frontal tonal stimulation) will be conducted.
For young children (less than two years of age or with some form of handicap), a
free field pure tone audiometry test will be performed, using speakers and the visual
response audiometry (VRA) to generate a conditioned responses and get minimum
levels of response. In subsequent consultation, it will be possible to achieve monoaural
responses. Likewise, monitoring of these response levels through play and analysis of
these behavioral responses may be possible.

Bibliography
1Abbot, S., Northern, J., & Yosinaga-Itano, C. (1999). Hearing screening in Newborns
under 24 hours of age. Seminars in hearing – volume 20, number, 4. USA.
Committee, J. (2007). Position Statement. ASHA, 36(12):pp38-41.
Levitt, H., McGarr, N., & Jennifer, D. (1989.). Development of language and communication
Skills in hearing-impaired children. ASHA Monogrphs, number 26, Rockville, MD:
American Speech-Language Hearing Association.
Markides, A. (1986). Age at fitting of hearing aids and speech intelligibility. Journal
Audiol, 20:pp165-168.
Osinaga-Itano, C. ( 1995). Early Identification and Early Intervention. The National

Symposium on Hearing in Infants, Vail, CO.
141

APPENDIX 6
CLINICAL RECORDS AND FOLLOW UP CARD FOR THE PRETERM AND/OR LB W INFANTS
IN THE KMC PROGRAM
The Kangaroo Mother Program clinical record is an easy tool to manage and a useful
one to monitor the premature and / or low birth weight infant. It has been undergone
several modifications through time. This tool is currently an instrument that holds
indispensible information for a good follow up of the baby and the main source of
date for monitoring both the children and the care service processes in each KMP.
The greatest responsibility for guaranteeing quality recording of all information

pertaining to each child and each medical recordlies on the health care professionals,
who accountable before society and the scientific research entities. Subsequent
analysis of the data bases structured from the information thus gathered will promote
the improvement of the KMM and its conceptual development; advances in the
development of new approaches to management and treatment and the opportunity
for our surviving present and future patients to have a better quality of life.
This clinical record must be completed from the time a child is identified as eligible
for the KMM, whether at the Neonatal Unit or rooming-in accommodation or at least
on the first day of attendance to the Kangaroo Mother Program as the case may be.
The ‘kangaroo’ nurse fills out the sections of the form corresponding to the family’s
socio economic background; the pregnancy and delivery history; the child’s neonatal
hospitalization and in-hospital kangaroo adaptation, in the Neonatal Unit or rooming-
in accommodation, where applicable. This professional assesses the process of
kangaroo adaptation and initiates the outpatient sessions by reporting the findings
from the first session to the pediatrician. The nurse also verifies the kangaroo parents’
information and expertise on their child’s management. The pediatrician verifies the
142 information in the child’s clinical record and fills out the health care card; examines
the child; records the results from the physical exam conducted upon admittance
to the outpatient phase and schedules outpatient follow up, in agreement with the
nurse, the psychologist and the social worker, if necessary. Kangaroo follow up is a
multidisciplinary intervention.
Kangaroo medical records and its sections
Given that Resolution number 1995, of July 1999 from the Colombian Ministry of Social
Protection provides the norms for the management of medical records, this aspect is a
fundamental part of this annex. Accordingly, it must be well known and of mandatory
compliance on the part of the any member of the personnel who takes part of the
management of clinical records.

Appendix 6
Administrative criteria
General norms for completing the forms
The clinical record forms must be totally completed, so that next to each question there
must be an answer whether it is a number, a text or a line drawn across to indicate the
fact that there has been an inquire or exam about the data in question. Records must
be made in chronological order and written in black ink, never in water-soluble ink,
which may jeopardize their readability.
Clinical records must be completed in legible handwriting so that any person who
accesses it can read it with ease. No erasures, overwritten words or other alterations
are admitted in them.
Blank spaces must not be left in the forms. If any are found, a line must be drawn
across to nullify the possibility of using the space, which may alter the continuity of
the record.
After each entry, the attending professional must sign it, stamp it with his seal and
write his professional registration number. If no seal is available, the professional’s full
name and professional registration number must be written.
Every date is written in numbers as follows: day (dd)/month (mm)/year (yy), separated
by a slash (/). Letters, Roman numerals or an inverted order (for example month/day/
year or year/month/day) must never be used.
Clinical records in the ProgramaCanguro Integral Ltda. (Comprehensive Kangaroo

Program) are color coded: blue clinical record forms are used for boys, pink ones are
used for girls. White clinical record forms are used for babies of undetermined gender.
User identification
143
Clinical record number: to open the clinical record, the following numbers will be
used: citizenship identity card for people over 18, identity card, for minors and civil
birth registration for children under 7. In case there are no identity documents for the
minor, the mother’s citizenship identification card if available and in its absence, the
father’s, followed by a consecutive digit to indicate the birth order of the child within
the family. For example, a record numbered 34215029-1, indicates the first baby of
a family to be admitted in the Program, if there is a twin or triplet, the digits 2 and 3
would be used to indicate it.
Name and last names of mother: the mother’s full name, as it appears in her identity
number must be recorded. If there is only one last name, aa line across must be drawn
to indicate it.

Appendix 6
Name and last names of father: the mother’s full name, as it appears in her identity
number must be recorded. If there is only one last name, aa line acrossmust be placed
to indicate it.
Name and last names of child: the mother’s full name, as it appears on her birth
certificate number must be recorded. If there is only one last name, aa line across must
be drawn to indicate it.
Date of birth: date of delivery. It must specify the day (with two digits), the month
(two digits) and the year (two digits), in that order. Letters or Roman numbers are not
admissible.
Code: a consecutive number indicating admittance to the Kangaroo Program that

carries out outpatient follow up and it consist of a four digit number, from 0001 to
9999.
ID (user identification): refers to the birth certificate (o legal identification number

in order to complete it, it is necessary to ask the parents. If these are unavailable, the
consecutive number of live birth certificate will be used. This document begins with
a letter and is a given to the mother in the hospital where she delivered her baby, The
number in it will be used in the birth certificate as well.
Date for 40 weeks of gestational age: it indicates the date when term pregnancy is
completed; the day (with two digits), the month (two digits) and the year (two digits),
in that order.
Insurance company: identifies the user’s health care provider institution or the type
of coverage by the General Social Security System in Health. The complete name of
the insurance company or the word NONE, in case there is no affiliation is written. The
stage of outpatient follow up authorized by the insurance company may be indicated.
144
Address and neighborhood: identifies the user’s place of residence in case there is a
need to establish contact. The streets, Carrera, block, building or apartment number
must be identified as well as the name of the municipality, in case the domicile is
outside the urban perimeter.
Home telephone numbers: the telephone number assigned to the user’s place of
residence. It must be completed with seven digits if it from is an urban area and include
the indicative, if it belongs to a rural area.
Work phone numbers: indicates the phone number of the work place. It must be
completed with seven digits and an extension number if there is one.
Phone numbers of a relative: it is the phone number of a family member that can

Appendix 6
be used to establish contact with the user; the name of the contact person must be
recorded in order to facilitate communication.
Cellular phone number: it refers to the number of the father’s or the mother’s cellular
number. The first three digits that identify the mobile telephone company and the
subsequent seven digits of the phone number must be recorded.
Clinical criteria
Date of consultation: the day (with two digits), the month (two digits) and the year
(two digits), in that order. Letters or Roman numbers are not admissible.
Time of admittance: time of admittance to the KMC outpatient clinic.
Chronological age: record it in days, counted from the date of birth to the day of the
consult.
Corrected age (weeks or months): it is the result of subtracting the number of weeks
needed to complete 40 weeks of gestation from the chronological age. The term must
only be used in children of up to three years of age, who were born prematurely.
Weight: indicates the baby’s weight at the time of the visit; it is recorded in grams,
following the parameters from the nursing procedure guidelines.
Height: indicates the baby’s measurements in centimeters, taken at the time of the
visit by following a cephalo-caudal direction and following the parameters from the
nursing procedure guidelines.
Head circumference (HC): defines the measurement of the cranial circumference in

centimeters taken by following the parameters from the nursing procedure guidelines.
Type of diet: in this box the type of food received by the baby up to the time of medical 145
evaluation is recorded by choosing the appropriate alternatives printed in the lower
part of the clinical record.
1: Exclusive breastfeeding
2: Breastfeeding plus artificial formula
3: Exclusive formula feedings
±.Introduction to supplementary nutrition (diversification)
This record must be done every time the child is evaluated in outpatient follow up.
Need for oxygen (O2):the number of liters per minute received by the user is recorded.

Appendix 6
The word ‘suspended’ must be written in the corresponding box, if the prescriptions
suspended. If there are any changes in the prescription during consult, the new
prescription must appear in the actions recorded in the medical chart.
Vitamin K: record with an (x) if, at the date of the visit the patient is receiving Vitamin
K, whether orally or IM; the dose must be recorded in the medication sheet.
Time of consult: record the time when the patient is seen
Clinical evolution
Consists of pre-established variables that must be completed each time an intervention

is conducted by the medical professionals from the Kangaroo Mother Program. Every
space must be completed in the corresponding boxes.
Anamnesis (obtained from the information given by the child’s companion). Any
relevant aspects that may lead to diagnosis are recorded.
Physical exam: record the positive aspects considered relevant when establishing
the care diagnosis. It may include comments referring to the evolution of weight and
height gain.
Results from measurements obtained during oximetry and glucometry consultation.
Medication: if any medication is being administered, or if there are any changes in

the medications, the generic name, dose and frequency of administration must be
recorded.
Breast feeding supplementation: if supplements to breastfeeding are being delivered,

specify dose and frequency.
Record of reports of diagnostic aids requested in previous visits or by other professionals,

146 such as brain ultrasound, CT scan or MRI, echocardiogram, hip X-rays and laboratory
tests among others.
Recods of any specialist consultation with ophthalmology, optometry, audiology,

neurology, orthopedics, and others.
Indicate the next scheduled visit.
Professional’s signature: record signature and/or name and seal of the professional.
The first evolution note, corresponding to admittance, must contain all medications
prescribed to the child upon discharge; diagnostic aid exams requested by the doctor
or any pending non-HMO procedures, as well as the actions of the pediatrician to that
respect.

Appendix 6
Admittance clinical records – history
Social and professional characteristics of the family
Origin: record the name of the city, department or region where the family comes
from.
Type of housing: indicate whether rural or urban.
Marital status: it refers to the child’s mother and records if she is single, married or in
common law marriage.
Age of mother and father: record their ages in years.
Schooling: record the mother’s and father’s schooling, writing the highest level as
follows: none, incomplete primary, complete primary, incomplete secondary, complete
secondary, incomplete university, complete university.
Occupation of mother and father: for the mother, record her occupation; if she is a
homemaker or works outside the home, in which case specify her job and functions in
the company where she works. For the father, record the same information; indicate
whether he in unemployed or working, in which case, specify his job and functions in
the company where he works.
Monthly income: describe the monthly income of the people in the family.
Number of people living with this income: refers to the number of people in the
household.
Age of children: record the children’s ages and gender (with symbols).
Distance of the home (from the hospital where the Kangaroo Mother Program is
located): record if the patient lives in the city, within one, two or more hours from the 147
Program.
Family nutrition: record the number of meals taken each day and their quality in the
following terms: good, basely sufficient, insufficient, severely insufficient and no data.
Availability of clean drinking water: record whether the family has drinking water at
home.
Separation during pregnancy: interruption of the couple’s cohabitation (if they were)
during the pregnancy period. Record yes or no to indicate an affirmative or a negative
answer.

Appendix 6
The answer to the last question must correlate with the mother’s recorded marital
status. If she declares she’s not living with her partner, her marital status will be ‘single’
and not ‘common law marriage’. Remember that common law marriage is considered
as such after the couple has been living together for two or more years.
Unwanted pregnancy: it refers to the planning of the pregnancy. Record yes or no to

indicate an affirmative or a negative answer.
Help with childcare during the first month: the presence of one or more people in the
home, keeping the mother company during the first month. This fact is very important
for those patients requiring oxygen support. Record yes for an affirmative answer, for
a negative answer, write the word no, or draw a line across to indicate that this aspect
was considered.
The mother worked during pregnancy (during gestation): it must be remembered that
some mothers work in their homes (different from homemaking) and do not mention
it; thus, the questioning must be appropriately directed. It is necessary to record yes or
no to indicate an affirmative or negative answer. Likewise, the duration of this work, in
months must be recorded.
Other comments: record any additional comments not included in the questions
above.
Pregnancy and prenatal care
Mother’s weight: measured in kilograms before pregnancy
Father’s weight: the father’s usual weight, in kilograms
Mother’s height: measured in centimeters
Father’s height: measured in centimeters

148
Relevant obstetric and gynecological history
G: number of gestations, including this one
B: number of births, including this one
C: number of cesarean births, including this one
A: number of abortions
Premature: number of premature children (including this one)
Live births: number of children born alive (including this one)

Appendix 6
Still births: number of stillborn children
Ectopic: number of extra uterine pregnancies
Date of last menstrual period (LMP): day, month and year of last period, recorded
according to the general norm.
Estimated due date (EDD): date calculated by adding 40 weeks to the date of the last
normal menstrual period (LMP)
Number of prenatal care visits: number of prenatal care visits during gestation. Specify
who carries out the prenatal care: obstetrician or professional midwife (in countries
where this profession exists), general practitioner or non-specialized nurse.
Number of pregnancies while using birth control: number of times the mother has
become pregnant while using some method of birth control.
Method: birth control method used when became pregnant.
Month of first prenatal visit: month of first prenatal visit in the current pregnancy.
Personal history: it refers to the pathologies present in the mother prior to the
pregnancy.
Family history: it refers to the pathologies present in the family in first and second
degree of consanguinity.
Record whether any of the following pathologies were present during pregnancy.
Bleeding: record yes or no. If the answer is affirmative, find in which trimester and
record it.
Urinary tract infection: record yes or no. If the answer is affirmative, find in which 149
trimester and record it.
Accidents: record yes or no. If the answer is affirmative, find in which trimester and
record it.
Surgery; record yes or no. If the answer is affirmative, find in which trimester and record
it.
Anemia: record yes or no. If the answer is affirmative, find in which trimester and record
it.
Respiratory disease: record yes or no. If the answer is affirmative, find in which trimester
and record it.

Appendix 6
Threatened premature labor: record yes or no. If the answer is affirmative, find in which
trimester and record it.
Other: record yes or no. If the answer is affirmative, find in which trimester and record
it, accompanied by a brief summary of the situation.
Hospitalizations during pregnancy: record yes if the answer is affirmative, no if the

answer is negative.
Number of days: number of days of hospital stay.
Reason: specify diagnosis.
Ante-natal hospitalization: record yes or no.
Number of days: number of days of hospital stay.
Reason: specify diagnosis at admittance.
To obtain the following information, collect data from the prenatal care card, mainly. If
it is unavailable, question the mother rigorously and record the information gathered.
Number of ultrasound exams during pregnancy: number of obstetric ultrasound exams

during this pregnancy.
Results: brief description of ultrasound findings.
Laboratory exams taken during pregnancy
Urine test
Number: number of exams taken during pregnancy

150
Results: record any relevant findings
Toxoplasmosis
Number: corresponds to the number of the exam taken (1°, 2°, etc.)
Results: Record whether positive or negative
Rubella
Results: Record type of exam (IgG or IgM positive or negative)

Appendix 6
Serology
Results: Record whether reactive or nonreactive.
HIV
Results: Record report
Hepatitis B:
Results: Record report
Other exams: record the exam and its results
Medication administered during pregnancy: any medication administered to the

mother during this pregnancy.
Hypertensive treatment: record no, if it has not been administered; if the answer is
affirmative, write the generic name of the medication.
Antibiotics: record yes or no.
Uterine inhibitors: record yes or no.
Anti-anemic medication: record yes or no (if iron supplements were administered).
Anticoagulants: record yes or no.

151
Other medications: record no if no other medication was administered. If the answer is
affirmative, it is necessary to write the generic name of the medication.
Mother’s blood type and Rh factor: record through verbal information, epicrisis or live
birth certificate.
Smoked: record yes or no and number of cigarettes smoked per day.
Alcohol consumption: indicate whether the mother consumed any alcohol during
pregnancy. Record yes or no and number of times per week.

Appendix 6
Hallucinogenic or other substances: indicate whether the mother consumed any type
of hallucinogenic substances, any type of stimulants; record yes or no.
Other comments: record any additional comments, different from the previous
questions.
Delivery
Date: record the date of delivery in order, the day (two digits), the month (two digits)
and the year (last two digits).
Type of delivery: indicate if it was a vaginal or cesarean delivery.
Instrumented: record if it was an instrumented delivery.
Programming: in case of cesarean delivery, record if it was an elective surgery or not.
Place: place and institution where delivery was attended.
Who attended: record if delivery was attended by trained health care personnel or by
a traditional midwife.
Duration of premature membrane rupture (PMR): record the duration of PMR in hours.
In case the situation did not present itself, write no or doesn’t know.
Duration of labor: record the number of hours. If it was a cesarean delivery, write the
word no.
Pre partum medication: indicate the medication administered to the mother during
this period.
152 Hypertensive treatment: record yes or no. If the answer is affirmative, write the generic
name of the medication.
Antibiotic: record yes or no.
Uterine inhibitor: record yes or no. Corticoids: record yes or no. Specify number of
doses of corticoids taken by the mother for lung maturation in pre partum or during
pregnancy.
Other: record yes or no and the generic names of the medication.
Fetal distress: record yes or no. Depending on each case, indicate if any of the following
conditions was present: diminished fetal movements, meconial amniotic fluid,
tachycardia, and bradycardia.

Appendix 6
Reactive fetal monitoring: non-reactive, dubious, or other (describe).
Complications of pregnancy: record as appropriate: placenta previa, placental

abruption, multiple pregnancy (describe), umbilical cord pathology, pre eclampsia,
amnionitis or other. If the answer is negative, the word no must be written or a line
drawn across to indicate the question was made.
Presentation of the child: cephalic, breech, transverse.
Placenta: characteristics of the placenta.
Duration of hospitalization: record the number of days of hospitalization for the mother
or write the Word no in case the mother was not hospitalized.
ICU (days): write the number of days that the mother was hospitalized in the Intensive
Care Unit or the word no if she was not hospitalized.
Mother’s status at discharge: describe the mother’s status at the time of hospital
discharge: alive, deceased, missing.
Other comments: record other aspects not previously included and that leads to
defining risk factors for the mother-infant pair.
Any other relevant, additional or supplementary comment must be registered in the

annex of the clinical records, under “other care”.
Birth of the baby
Weight: record the birth weight of the baby in grams. Source: epicrisis or live birth
certificate.
Length: record the measurement in centimeters, following a cephalocaudal direction. 153
Head circumference: record the head circumference in centimeters.
Gender: write if male or female. Write M (male), F (female) and U (undetermined).
Gestational age from last menstrual period (LMP): record the gestation weeks using
the tools in the protocol.
Ballard: record the results of this test in weeks of gestation. If Ballard is not used, write
the test used and the results obtained.
Gestational age through ultrasound (first trimester): GA through USS, first trimester;
record here the fetus’ gestational age reported by ultrasound, only if it was given in

Appendix 6
the first trimester.
Apgar: record the scores of this assessment, one minute, five minutes and ten minutes
after delivery, as indicated by the test protocol.
Lubchenco: record the scores resulting from the application of this test.
Neonatal reanimation: record yes in the box corresponding to each condition, as

follows: spontaneous (if Apgar score is 8 or more); conduced (if Apgar score was 5 to
8); or induced (if Apgar score is 4 or less). Record no or draw a line across to indicate
that the other alternatives are excluded.
Other comments: record other aspects not previously included that lead to defining
risk factors for the newborn and may guide their management.
Hospitalization in the NCU: record yes or no, accordingly.
Referred:recordyes or no to indicate if the baby was born in one institution and then
was referred to a different one.
Where: indicate the name of the institution that received the newborn.
Hospitalized with the mother: indicates if the newborn was hospitalized with his
mother. In case the answer is affirmative, write the number of days. In case is negative,
write the word no or draw a line across to indicate that this aspect was considered.
How many days: duration of hospital stay.
Other comments: record any additional comments not recorded in previous questions.
Hospitalization and diagnoses

154 Date of admittance: register the date of admittance to the institution, as follows: day
(two digits), month, (two digits) and year (last two digits).
Date of discharge: register the date of discharge from the institution, as follows: day
(two digits), month, (two digits) and year (last two digits).
Days of hospital stay: duration of hospital stay in days.
Total days with O2: duration and technique of oxygen administration, as follows: with
respirator, with CPAP, with hood, in incubator or with cannula. Record yes if the answer
is positivefor the selected option(s). In case of a negative answer, write the word no, or
draw a line across to indicate that this aspect was considered.

Appendix 6
Days in the NICU: duration of stay in the Neonatal Intensive Care Unit, in days.
Days in incubator: duration of stay in incubator, in days.
Days with parenteral nutrition: record the number of days of administration of

parenteral nutrition.
Phototherapy days: register the duration of administration of this type of therapy.
Head ultrasound: record the number of head ultrasound taken during hospitalization.
Results: record two reports, one from the last head ultrasound and the other from the
one which interpretation carries more weight in the clinical and medical management
of the patient.
Head CT scan or MRI: record yes or no to indicate whether a CT scan or an MRI was
taken during the newborn’s hospitalization.
Results: record two reports, one from the last head CT scan and the other from the one
which interpretation carries more weight in the clinical and medical management of
the patient.
Echocardiogram: record yes or no to indicate whether an echocardiogram was given

to the newborn during his hospitalization.
Results: record two reports, one from the last echocardiogram and the other from the
one which interpretation carries more weight in the clinical and medical management
of the patient.
Genetic exam: record yes or no to indicate whether a genetic exam and cariotype was
done during the hospitalization.
155
Other exams: describe any other exam not previously described, which may be relevant
to the clinical records of the newborn.
Surfactant: record the number of doses administered during hospitalization. In case

there were none, write the word no or draw a line across to indicate that this aspect
was considered.
Indomethacin: record the number of doses administered during hospitalization. In

case there were none, write the word no or draw a line across to indicate that this
aspect was considered.
Ibuprofen: record the number of doses administered during hospitalization. In case


Appendix 6
was considered.
Days of antibiotic administration: record the number of days of antibiotic therapy

administered during hospitalization. In case there were none, write the word no or
Other antibiotics: write the scheme of antibiotic administration during hospitalization.

In case there were none, write the word no or draw a line across to indicate that this
Number of blood transfusions: record the number of transfusions given to the newborn.
Report from the latest hemoglobin exam: record the figure shown in the report. In
case there were none, write the word no or draw a line across to indicate that this
Report from the latest hematocrit exam: record the figure shown in the report. In case
was considered.
Report from the latest bilirubin exam: record the figure shown in the report. In case
was considered.
Anti-reflux medication: inquire if the child receives anti-reflux treatment. In case of a

negative answer, write the word no or draw a line across to indicate that this aspect
was considered.
Anticonvulsant medication: inquire if the child receives anticonvulsant treatment. In

case of a negative answer, write the word no or draw a line across to indicate that this
156 Other medication: record any other medication administered, different from antibiotics
and not previously described, which may be relevant to the newborn’s clinical records.
Discharge diagnosis
Intraventricular hemorrhage: record yes or no
Grade: record the grade of intraventricular hemorrhage: I, II. III, IV
Method of diagnosis: record the diagnostic aid used to diagnose the intraventricular
hemorrhage.
Primary apnea: record yes or no

Appendix 6
Secondary apnea: record yes or no
Pathologic jaundice: record yes or no
Hypoglycemia: record yes or no
Respiratory distress syndrome: record yes or no
Diagnosis: record the respiratory diagnosis
Meningitis:
Bacterial: record yes or no
Viral: record yes or no
Unspecified: record yes or no
Omphalitis: record yes or no..
Arthritis:
Septic: record yes or no
Which articulation: describe
Necrotizing enterocolitis: record yes or no
Bronchopneumonia: record yes or no
Other infections: record yes or no
Indicate by writing an X, the moment of appearance, neonatal sepsis, late-onset sepsis

or nosocomial infection.
157
Neurological dysfunction: record yes or no
Abnormal tone: record yes or no
Seizures: record yes or no
Other diagnoses at discharge: record any other diagnosis not previously described
and relevant to the newborn clinical records; specify if the seizures were of early or
late onset, if hypoglycemia was or not symptomatic, among other possible diagnoses.
Oxygen administration: record yes or no
How many liters: record how many liters per minute the child is receiving.

Appendix 6
Bronchopulmonary dysplasia: record yes or no
Blood type and Rh: write the child’s blood type and Rh.
Weight at discharge: write the child’s weight in grams at the time of hospital discharge.
Type of diet at discharge: exclusive BF exclusive maternal breastfeeding, BF+AM

breastfeeding plus artificial milk or AM if only received exclusive artificial milk.
In-hospital kangaroo adaptation
It is a summary of the child in-hospital adaptation to the kangaroo position, in the

Neonatal Unit or in rooming-in kangaroo accommodation, according to the information
recorded by the nursing staff in the adaptation page.
The patient complies with all eligibility criteria. Write yes or no. Criteria must be
established by each Neonatal Unit or each hospital.
Total number of days in adaptation: write in numbers.
In the Neonatal Intensive Care Unit (NICU): write the number of days that mother and
child were in in-hospital adaptation while the child was in intensive care. In case of a
negative answer, write the word no, or draw a line across to indicate that this aspect
was considered.
Total number of days of adaptation while in Neonatal Unit and / or Intermediate and
Minimal Care Unit: write the number of days that the mother and her child were in in-
hospital adaptation.
Number of days in ICU: number of days in the UN. In case of a negative answer, write
the word no, or draw a line across to indicate that this aspect was considered.
Total number of days in rooming-in adaptation: write the number of days that the
158 mother and her child received care during rooming-in and after discharge from the
Neonatal Unit. In case of a negative answer, write the word no, or draw a line across to
indicate that this aspect was considered.
Hours in kangaroo position: record the maximum number of hours per day.
Weight gain in the Intensive Care Unit: record weight gain in grams per Kg/day.
Weight gain in the Neonatal Unit: record weight gain in grams per Kg/day.
Weight gain in the rooming-in: record weight gain in grams per Kg/day.
Training of another care provider in the Intensive Care Unit: record yes or no.

Appendix 6
Training of another care provider in the Neonatal Unit: record yes or no.
Training of another care provider in rooming-in: record yes or no.
Breastfeeding adaptation: the nurse who participates in the process of in-hospital

kangaroo adaptation marks the child’s adapting to breastfeeding, following the
kangaroo adaptation scale, as follows: good, average or poor. In case this activity is
not present, the word no must be written, or a line drawn across to indicate that there
was in inquire on this aspect.
Milk extraction technique: the nurse who participates in the process of in-hospital
kangaroo adaptation marks how well the mother learned the technique during
hospitalization, following the kangaroo adaptation scale, as follows: good, average or
poor. In case this activity is not present, the word no must be written, or a line drawn
across to indicate that there was in inquire on this aspect.
Eyedropper administration technique: the nurse who participates in the process of

in-hospital kangaroo adaptation marks how well the mother learned the technique
during hospitalization, following the kangaroo adaptation scale, as follows: good,
average or poor. In case this activity is not present, the word no must be written, or a
line drawn across to indicate that there was in inquire on this aspect.
Mother wishes to breastfeed: mark yes or no in the corresponding box.
Child tires while suckling: if the answer is yes, describe. In case of a negative answer,
write the word no or draw a line across to indicate that there was in inquire on this
aspect.
Discharge adaptation outcome: write the outcome according to the kangaroo

adaptation scale: acquired, in process of being acquired, not acquired.
Other comments on in-hospital adaptation: briefly describe those aspects not

previously considered, which are related to in-hospital kangaroo adaptation and 159
relevant to the child’s clinical records.
Signature and professional registration number. Record them appropriately, as

corresponding to the attending professional who carried out the health care activity.
Admittance physical exam
Date of admittance: it refers to the date in which the user was admitted to outpatient
KMP; it must specify the date as: day (with two digits), month (two digits) and year.
When completing the admittance physical exam, mark N= Normal - A= Altered. If

altered, describe in the clinical course page.

Appendix 6
General aspect
Eyes
Nose
Ears
Mouth
Neck
Thorax
Cardiovascular
Pulmonary
Abdomen
Navel
Skin and annexes
Genitalia
Anus
Musculoskeletal
Extremities
Neurological
160 Diagnostic impression (IDX): record the diagnostic impressions that may influence the
management of the child, organized according to clinical importance.
IDx1
IDx 2
IDx3IDx 4
IDx5
IDx 6

Appendix 6
Chronological age: time elapsed (days, weeks, months or years) from birth to the day
of the exam.
Corrected age (weeks or months): is the result of subtracting the weeks needed for the
child to complete 40 weeks gestation from his chronological age.
The term must only be used in children born prematurely up to three years of age.
Weight: register the baby’s weight in grams at the time of the admittance to KMP,
taken according to the parameters of the nursing procedural guide.
Length: record the baby’s cephalocaudal measurement at the time of the admittance
to KMP, taken according to the parameters of the nursing procedural guide.
Head circumference (HC): register the measurement of the head circumference in

centimeters, taken according to the parameters of the nursing procedural guide.
Medications: in the corresponding box, register doses and frequency of administration

of the following medications:
Metoclopramide
Theophylline
Multivitamins
Vitamin D
Iron
In case of a negative answer, write the word no, or draw a line across to indicate that
this aspect was considered.
Other medication:In case of a negative answer, write the word no, or draw a line across 161
to indicate that this aspect was considered. Write any other medications prescribed
during admittance, specifying the dosage.
Diet: record the type of diet received by the child at the time of admittance to the
Program.
Cannula-administered oxygen: register the dose in lt/min at the time of admittance.

In the corresponding box, indicate whether administration is permanent. In case of
a negative answer, specify the prescription. In the designated box, indicate whether
the child has been diagnosed with bronchopulmonary dysplasia and in case of a
negative answer, write the word no or draw a line across to indicate that this aspect
was considered.

Appendix 6
Thoracic x-rays: record any relevant findings for the clinical records from this diagnostic
tool.
Head ultrasound: record any relevant findings for the clinical records from this
diagnostic tool, along with the date of the exam.
CT scan or head MRI: record any relevant findings for the clinical records from this
diagnostic tool.
Malnutrition: record the presence of any degree of malnutrition in the child, at the
time of admittance, assessed according to the management protocol and the growth
charts used in consultation. In case of a negative answer, write the word no or draw a
line across to indicate that this aspect was considered.
Inguinal hernia: record the presence of inguinal hernia in the child at the time of
admittance to the Program. In case of a negative answer, write the word no or draw a
line across to indicate that this aspect was considered.
Signature and professional registration number. Record the signature and professional
registration number of the attending professional.
Physical exam at 40 weeks of corrected age, outpatient consultation.
40 weeks date: it refers to the date when the child is 40 weeks of corrected age. It must
specify, the day (with two digits), the month (two digits) and the year (four digits).
Total number of visits: record the total number of consultation visits accumulated
during the period between the child’s nine and 12 months of corrected age.
TSH: report of TSH exam.
Weight: register the baby’s weight in grams at the time of the check-up visit, taken
162
according to the parameters of the nursing procedural guide.
Length: record the baby’s cephalocaudal measurement at the time of the check-up
visit, taken according to the parameters of the nursing procedural guide.

Attendance to the KMP: write yes in case he has attended the program on a regular basis.
If he has missed one visit, it is considered “average”; missing two or more appointments
is considered “attendance with risk for the child”. In case of a negative answer, write the
word no, or draw a line across to indicate that this aspect was considered.

Appendix 6
Days of Outpatient Kangaroo Adaptation (AKA): write the number of days that the
family participated in this stage of the Program. In case of a negative answer, write the
word no, or draw a line across to indicate that this aspect was considered.
Age of birth weight recovery: write the chronological age.
Age of recovery of weight upon admittance to KMP (if the child lost weight after being
admitted to the KMP): write the chronological age.
KP discharge: record the child’s chronological age when taken out of the kangaroo
position, in days.
Weight at KP discharge: record the child’s weight when taken out of the kangaroo
position, in grams.
Length at KP discharge: record the child’s length when taken out of the kangaroo
position, in centimeters.
Head circumference at KP discharge: record the child’s head circumference when taken
out of the kangaroo position, in centimeters.
Diet: record the type of diet received by the child up to the age of three months, as
follows: BF exclusive maternal breastfeeding, BF+AM breastfeeding plus artificial milk
or AM if only received exclusive artificial milk. Record in the corresponding boxes, the
number of bottles and the number of ounces administered to the baby and if there is
an adequate supplementary feeding In case of a negative answer, write the word no,
or draw a line across to indicate that this aspect was considered.
Age of O2weaning: write the chronological age in days when supplementary oxygen
is definitely suspended (for children who are discharged from the hospital with
supplementary oxygen).
163
Medication: in the corresponding box, record the dosage and frequency of
administration of the following medications: metoclopramide, multivitamins, iron,
antibiotics (of this last one, specify which and how long in number of days). In case of
was considered.
Other medication: write any other medications prescribed during admittance,

specifying the dosage. Specify if palivizumab.
Ophthalmology: record the report from ophthalmology screening. In case not having
an evaluation, write the word no
Neurological exam: record whether it is normal or if it is altered, according to the triad

Appendix 6
evaluation of Amiel Tison (squamous suture, dorsiflexion of the foot and axis tone), if
positive, provide further information on the corresponding evolution page.
Head ultrasound: record the results of this diagnostic tool if taken during follow up. In
case it hasn’t been done, write the word no or draw a line across to indicate this aspect
was considered.
Other exams: write the results of any other exams given to the child during outpatient
follow up.
Immunization: write the number of doses applied, BCG, DTaB+IPV+Hib and Hep B
during this period. Write in the appropriate boxes any other vaccines given to the child
and their corresponding doses.
Number of re admittance for hospitalization: describe the number of hospitalizations

accumulated until the child is nine months of corrected age, and the total number of
hospital stay days each time. In case of a negative answer, write the word no, or draw
a line across to indicate that the question was made to parents.
As additionalinstructions: ages 1, 2 and 3, correspond to the age of the child when

he was hospitalized for the first, second and third time. Likewise, diagnosis 1, 2 and 3
correspond to the main diagnosis made at the time of the respective hospitalization.
Diagnosis at 40 weeks of corrected age: record the child’s main diagnosis,made at 40

weeks of corrected age.
Physical exam at three months of corrected age, outpatient consultation.
Three months date: it refers to the date when the child is three months of corrected
164
age. It must specify, the day (with two digits), the month (two digits) and the year (four
digits).
during the period between the child was assessed in KMP or emergency room, and
the time he is three months of corrected age, according to the records in his card or
the caretaker`s report.

Appendix 6

follows: 1. BF exclusive maternal breastfeeding, 2. BF+AM breastfeeding plus artificial
milk, 3. AM if only received exclusive artificial milk. Record in the corresponding boxes,
the number of bottles and the number of ounces administered to the baby and 4. +
supplementary feeding . In case of a negative answer, write the word no, or draw a line
across to indicate that this aspect was considered.

was considered.

specifying the dosage.
INFANIB: record the results of the neurological assessment during this period in terms
of normality, abnormality or transitory state.
Therapies: record the type and number of therapies received by the child.
X-rays: record those findings which are relevant for the child’s medical history.
Audiology: record the report from audiology screening. In case not having an
evaluation, write the word no or trace a line 165
Ophthalmology: record the report from ophthalmology screening. In case not having
an evaluation, write the word no or trace a line
Optometry: record the report from optometry screening. In case not having an
evaluation, write the word no or trace a line

Other instructions refer to: ages 1, 2 and 3, correspond to the age of the child when

Appendix 6
Diagnosis at three months: record the child’s main diagnosis, made at three months of
corrected age.
Physical exam at six months of corrected age, outpatient consultation.
Six months date: it refers to the date when the child is six months of corrected age. It
must specify, the day (with two digits), the month (two digits) and the year (four digits).
during the period between the children’s three and six months of corrected age.

an adequate supplementary feeding. In case of a negative answer, write the word no,
166 or draw a line across to indicate that this aspect was considered.

was considered.


Appendix 6
Surgically corrected hernia: record yes or no.
Psychomotor development test (Griffith Mental Development Scales plus Bayley

Behavior Rating Scale in our case):record the results of this evaluation, which can be
found in the psychology evolution chart. Also record the child’s chronological age at
the time of testing.
Physical exam at nine months of corrected age, outpatient consultation.
Nine months date: it refers to the date when the child is nine months of corrected age.
It must specify, the day (with two digits), the month (two digits) and the year (four
digits).
during the period between the children’ssix and nine months of corrected age.

167
an adequate upplementary feeding. In case of a negative answer, write the word no, or

was considered.

Appendix 6

CT scan or brain magnetic resonance imaging scan (MRI): record the results of this
diagnostic aide. In case of a negative answer, write the word no, or draw a line across
to indicate that the question was made to parents.
Age of O2weaning: write the chronological age in days whenO2weaningwas decided.

168
Diagnosis at nine months: record the child’s main diagnosis, made at nine months of
corrected age.
Physical exam at twelve months of corrected age, outpatient consultation.
12months date: it refers to the date when the child is 12 months of corrected age. It

Appendix 6
must specify, the day (with two digits), the month (two digits) and the year (four digits).
during the period between the child’s nine and 12 months of corrected age.

an adequate supplementary feeding In case of a negative answer, write the word no,
or draw a line across to indicate that this aspect was considered.

was considered.

during this period. Write in the appropriate boxes any other vaccines given to the child 169
CT scan or brain magnetic resonance imaging scan (MRI): record the results of this
diagnostic aide. In case of a negative answer, write the word no, or draw a line across
to indicate that the question was made to parents.

Appendix 6
Psychomotor development test (Griffith Mental Development Scales plus Bayley

Behavior Rating Scale in our case):record the results of this evaluation, which can be
found in the psychology evolution chart. Also record the child’s chronological age at
the time of testing.
Age of O2weaning: write the chronological age in days when =2 weaning was
determined.

Diagnosis at 12 months: record the child’s main diagnosis,made at 12 months of

corrected age.
Cerebral palsy: record if these is a cerebral palsy diagnosis.
Malnutrition: record if there is a malnutrition diagnosisand its degree on the growth

170 curves used in consultation.
Weight and height gaingrowth curves
They are on the back of the evolution summary sheets and must be completed every
visit, marking the graph with a black ink pen and joining the dots to form a curve.
Any relevant findings must be recorded on the evolution page. It is documented in the
clinical records and the health card, with an explanation to parents about their child’s
nutritional status.

Appendix 6
To obtain the nutritional status of boys and girls, their weight and length mist be
recorded on the graph, on the date corresponding to the check-up visit; locating the
child’s age on the horizontal axis and the weight or length on the vertical axis. After
marking both measurements, the dots are connected with prior measurements. The
positive or negative standard deviations determine if the child is at nutritional risk or
growing normally, according to the tables, taken from the manual: Instructivo para la
Implementación de los Patrones de Crecimiento de la OMS en Colombia(Instructions
for the Implementation of WHO Growth Patterns in Colombia) 2011 Page. 20 -26
The Griffith Mental Development Scales
For our KMP children, an assessment is conducted at 6 and 12 months of corrected

age. The boxes corresponding to the date of the test, the child’s chronological age
and corrected age must be filled out. According to the protocol, the results of the
assessment must also be recorded, in the corresponding bubbles: locomotor, personal-
social, hearing and language, eye and hand co-ordination, performance and practical
reasoning.Assessment is accompanied by a set of exercises aimed at the improvement
of the child’s weak areas, if there are any. In this case, the assessment is repeated at seven
and a half months and results are reported in the same psychomotor development
follow up table. In case of a significant delay, the child is referred to the corresponding
specialist.
Bayley Behavior Rating Scale
It is given to children simultaneously with the Griffiths Mental Development Scales,

at six and 12 months of corrected age. In the corresponding box, indicate the date
given and the child’s chronological and corrected ages. Following protocol, indicate
the results of the assessment in the corresponding bubble, as follows: locomotor,
personal-social, hearing and language, eye and hand co-ordination, performance and
practical reasoning
171
Ophthalmological screening
An evaluation is conducted to determine the presence of retinopathy of prematurity.
Date: it refers to the date of attention and must specify in its order, the day (with two
digits), the month (two digits) and the year (two digits). All children admitted to the
KMP when they are 32 or 33 weeks of gestational age, or as soon as they are 28 days
old, are screened.
Diagnosis: indicate the degree of vascularization (complete, incomplete, avascular) in

each eye, separately, specifying the area (1, 2 or 3). Indicate the presence and degree
of retinopathy (ROP I, ROP II, ROP II plus, ROP III, ROP III plus, ROP IV, ROP V) in each
separate eye, specifying the affected area (1, 2 or 3).

Appendix 6
Course of action: define the course of action required for the diagnosis and make any
pertinent additional comments. If additional space for brief comments is needed, the
page entitled “Other care.” , recording the date (day, month, year), the comment and
the signature of the attending professional, along with their professional registration
number.
Optometry screening
A screening is carried out in order to detect and treat the most frequent refraction
efects in premature children, following the protocol.
Date: it refers to the date of attention and must specify in its order, the day (with two
digits), the month (two digits) and the year (two digits). It usually is around three
months of corrected age.
Diagnosis: indicate the diagnosis in the corresponding box, as follows: astigmatism,

astigmatism-myopia, hyperopia, astigmatism-hyperopia, myopia, nistagmus,
dacryostenosis, blepharitis, conjunctivitis or any other diagnosis along with its
description.
Course of action: indicate the corresponding course of action, such as gentle massage
with the finger, occlusion, x-rays, tracking exercises, eye cleansing.
Follow up visit: mark the corresponding box to indicate if the next optometry
appointment will be in 15 days, one, three or six months or a year. If additional space
for brief comments is needed, the page entitled “Other care”, recording the date (day,
month, year), the comment and the signature of the attending professional, along with
their professional registration number.
Checking for hip dysplasia: following the norm and as soon as they are three months
old, all children who are three months old must be assessed byx-ray or clinically.
172
Other care
A space designated for recording the notes from the specialists’ or the members of
the team on the evolution of the patient which are pertinent to the continuity and
coherence of the clinical records.
Para clinical exams: a space designated for recording any diagnostic aides used with
the patient, ordered by the Kangaroo Program professionals or those done in other
institutions that can guide the child’s management.
Nurse’s notes: record all activities carried out by the nursing staff, such as oxymetry,
administration of medications within the facility, specifying doses and route of
administration, (including palivizumab). Record any adverse post-vaccination reactions

Appendix 6
and any other issue considered pertinent to the continuity and completeness of the
child’s medical history.
Reporting developments of the patient: a space designated for recording the comments
of social work, no-shows and hospitalizations.
Administrative criteria: corresponds to filling out the heading with the information
regarding the names of mother and child, their IDs, the KMP code, HMO identification
number and contact telephone numbers.
Date and time: refers to the date of assistance to the user and must specify in the
following order, the day (with two digits), the month (two digits) and the year (two
digits). The date of contact must correspond to the day following the recorded non-
attendance to any of the activities scheduled by the health care professionals. An
effective contact must be recorded four days after the non-assistance. Otherwise,
the situation will be discussed with the Program scientific coordinator in order to
determine the course of action.
Informer: record the name and kinship of the person taking the call.
No-show: indicate if the absence is motivated by any of a variety of reasons for non-
complying (the reasons must be documented in the space designated for observations).
Hospitalized: indicate if the reason for the absence is the child’s hospitalization and
allow a health care professional to document and record the reason for it in the same
space for observations.
Observations: indicate if communication is being effective (if an answer is received).

Briefly and concisely describe the reason for not attending the scheduled activity and
the rescheduled date, if possible. Record all issues that may guide the future actions to
be undertaken during follow up of the user.
173
Record of medications
The nurse records the administration of medications and must keep the following
aspects in mind.
Name of medication: (generic presentation)
Dosage: record the prescribed dosage and the one to be administered to the patient
Route: record the route of administration. ORL (Oral), IM (Intra Muscular); IV (Intra
venous), SC (Subcutaneous).
Time: record the correct time for the administration of the medication. 12 noon not to
be confused with 12 (midnight); use military time to avoid this: 0-24.

Appendix 6
Signature of nursing professional.Record signature and seal of the professional who

carried out nursing activities.
The follow up card
Why having such a card?
The KMP follow up card has the aim of providing parents with a summary of their
child’s clinical records and evolution, to facilitate the access to and recording of the
information to any health care professional who performs an intervention on the child.
It is also a source of information to the parents, on the child’s evolution, physician’s
orders, medication, nutrition, neurological exams, and dates of consultation with other
medical specialties. The aim is to have a complete record file on the child, which allows
his evaluation at any specific time.
Card sections
Section 1. It is comprised of information about the care sites, with addresses and
telephone numbers.
Section 2. It contains a clear message to parents indicating the protection activities for
the most fragile children who are younger than 40 weeks.
It warns the parents about the prohibition of bringing children to check up visits when
they are sick, with contagious diseases and when they older than 40 weeks.
It explains, in a clear and simple manner, the benefits brought about to the child by
breastfeeding.
It must contain the phone number of a hotline, where parents can easily access advice
on their concerns and answers to their questions, outside of office hours, avoiding the
174 need for taking patients to the emergency room, if it is not necessary.
Section 3. It presents the patients’ rights and duties.
Section 4. Corresponds to the identification of the child and his parents: names and
surnames are recorded; the number of clinical records; health maintenance organization;
birth certificate or identity document number; date and place of birth, specifying the
health care institution; address, neighborhood and current phone numbers; leaving
enough blank spaces in case of any changes of address. The identification spaces will
be filled out by the nursing staff, from the time of admittance.
Section 5. Detailed information on the mother: age; blood type; number of births;
height and birth; any illnesses present during pregnancy and their treatment; prior

Appendix 6
premature deliveries, including this one; amenorrhea; any relevant family medical
history; a space to register other issues not included above and comments, where the
date when the child will be 40 weeks of post conceptual age will be recorded.
Section 6. In this section there is the patient’s birth information. A first part with the
date and place of birth; type of delivery; APGAR scores; weight, length and head
circumference at birth; blood type; gestational age and Lubchenco classification. A
second part includes weight, length and head circumference at discharge; date of
discharge; oxygen needed, specifying if ventilation (mechanical, hood, CPAP or cannula)
was needed and for how long; blood transfusions (how many and date of last one in
order to determine if child is eligible for management with erythropoietin; record of
exchange transfusions if there were any); any treatmentsreceived, such as antibiotics,
surfactant, and parenteral nutrition, among others. The discharge diagnosis must also
be included.
Sections 7, 9 and 9. In these pages there are prenatal and postnatal weight, length and
head circumference charts.
Section 10. Spaces to record assessment in ophthalmology, optometry and audiology

are provided. The diagnosis, date of assessment and course of action are recorded.
Additional sections. In the following pages all observations of the daily medical
checkups must be recorded, with spaces for the date, chronological age, corrected age,
weight, head circumference, type of food received, oxygen, diagnosis, management,
nutritional assessment and course of action.
The daily weight gain must be registered in grams/kg/day, marking it in the growth
charts; any relevant aspects of the control appointment must be recorded; interpretation
of exams or a record of any results not yet picket up.
It must provide room to register the results of the developmental scales given by 175
psychology and also the results of any assessments conducted by physical and
occupational therapy, with the dates of these assessments. This way the patient can
always carry the assessments conducted and their results with him.
Two pages with spaces to write the date, diagnosis and management of hospitalizations
after discharge; a page to write the results of diagnostic aides with a space for the
date; a medication page, where all medications prescribed are recorded with the date
of prescription, dose, frequency and route of administration, starting and finishing
dates, space for the doctor’s signature and seal; a double page to register the current
immunization scheme with the name of the vaccine, first and second doses, the date
of the next immunization and among other aspects, the lot number (required by the
respective health authority)

Appendix 6
All identification spaces will be filled out by the nursing staff and immunizations
recorded by the vaccination aide. The sheets where a control of appointments is
recorded must include date, time, type of assistance and a signature of the person
assigning the appointment.
In the last pages there is information about what is considered normal conditions in
a baby, such as sneezing, pushing, hiccups and bowel habits. There are also general
recommendations such as birth registration of the minor, the need for checking all
assigned control appointments and all legal procedures and formalities required by
the health maintenance organizations.
Alarm signs must be written in red, since all the family must know what they are and
how to react to them. Alarm signs for oxygen users must also be included. It also
contains phrases referring to breastfeeding and its benefits.
Register vaccines in each immunization session.
i According to Cárdenas–López et al.from the Clinical Nutrition Section, Office of Research, National Institute of Perinatology
(INPER, from its acronym in English), Mexico, D.F., (Cárdenas–López & et al, 2005)
ii (WHO, 1995).
iii (Battaglia & Lubchenco, 1967).
iv (Fenton, 2007) (Lubchenco, Hansman, Dressler, & Boyd, 1963)
v (AAP, 2006).
176 vi (UNICEF, 2003).
• vii (Pearson & Boyce, 2004)
vii (Ruiz, Charpak, & Figueroa, 2002).
ix (Shanler RJ, 2005)
xi(Salas & Peñaloza)
xi (Simard, Lambert, Lachance, Audibert, & Gosselin, 2011).
xiii Dr. Als
xiv Brazelton .
xvi (Balakrishnan, Stephens, Burke, & al, 2011).
xvii (Sonia Bralic and others).

Exit of The Neonatal Unit and Ambulatory Follow Up of High Risk

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Exit of The Neonatal Unit and Ambulatory Follow Up of High Risk

Uploaded by

Copyright:

Available Formats

KANGAROO MOTHER CARE METHOD

OUTPATIENT KANGAROO MOTHER CARE

AND HIGH RISK FOLLOW UP

Dr. Nathalie Charpak,

Dr. Hélène Lefèvre-Cholay,

YEAR OF CORRECTED AGE 81

SCIENCE AND TENDERNESS

(Acta Paediatr. 2002;91(10):1130-4) 51

Table 4. INFANIB classification scores 91

Table 5. Neurological anomalies 91

Table 7. ROP Screening 127

SCIENCE AND TENDERNESS

Since its creation, KMC includes a follow-up program to support mother/family to

1) From discharge from the neonatal unit up to 40 weeks of gestational age.

2) From term up to one year of corrected age

Follow up programs includes the following aspects:

• Outpatient Kangaroo adaptation: re-enforcement of the training in kangaroo

6 • Regular monitoring of somatic growth, neurological and psychomotor development,

• Early identification, treatment, and rehabilitation of any disorders in preterm and/or

• Support and counseling strategies for the family.

• Quality monitoring of the kangaroo clinical practice

SCIENCE AND TENDERNESS

According to WHO, 3-5% of all pregnancies correspond to high risk pregnancies;

SCIENCE AND TENDERNESS

The neonatal unit’s pediatrician/neonatologist is responsible to discharge infants to

2.1 Child’s eligibility criteria for discharge

SCIENCE AND TENDERNESS

- The child completed his treatment, if any.

- If the child is receiving oxygen through a cannula, it must be below ½ l/min.

- The child is breastfed and/or fed with extracted milk.

- There is a Kangaroo Mother Program available able to offer adequate follow-up.

2.2 Mother’s eligibility criteria for discharge

- She succeeds in in-hospital kangaroo adaptation. In particular, she has adequate

2.3 Mother’s eligibility criteria for discharge

- The family has the will to be trained in KMC.

SCIENCE AND TENDERNESS

SCIENCE AND TENDERNESS

The follow up consultation team includes a pediatrician, a nurse, a psychologist, and

Video Kit: Outpatient follow up

SCIENCE AND TENDERNESS

SCIENCE AND TENDERNESS

2. The anthropometric parameters are assessed (weight, height, head perimeter).

3. A full clinical assessment is conducted (from head to toes).

5. Brain sonography and ophthalmologic screenings are requested if possible and if

6. Routine and specific drugs are prescribed.

7. The need for oxygen is assessed.

8. The need for family support is assessed and provided

SCIENCE AND TENDERNESS

It is crucial to establish as exactly as possible the gestational age at time of birth, as

As describe in Module 1, preterm or LBW infants may present different problems,

a) Gestational Age (GA) based on the date of last menstrual period

b) GA based on the New Ballard test

SCIENCE AND TENDERNESS

Before reaching a conclusion, it is recommended that health personnel analyze the

4.2 Anthropometric measurements

4.2.1 Taking anthropometric measurements

SCIENCE AND TENDERNESS

The majority of anthropometric measurements must be compared to tables of a

SCIENCE AND TENDERNESS

Luchencho and collaborators developed charts of intrauterine growth in 1963, based

In 1967, Battaglia-Lubchenco classified newborns according to the relation between

SCIENCE AND TENDERNESS

4.2.2 Reporting anthropometric measurements in growth charts