World Incidence of Preterm Birth 2010

Countries with the Highest Number of

Premature Births (2010)
World Health Organization
India
China
Nigeria
Pakistan
Indonesia
USA
Bangladesh
Philippines
Dem. Republic of Congo
Brazil
Philippine Statistics
350,000 preterm birth every year
84% are late preterm infants
paradigm shift of care = increase in survival rate
complete prenatal care
antenatal steroids
Essential Intrapartum Newborn Care
Breastfeeding
Kangaroo Mother Care
UNICEF Philippines Report 2012
CASE
Maternal History
30 y/o G2P2, with gestational hypertension
Maternal fever, PROM 20 hours
previously admitted, received betamethasone
scheduled for emergency CS
Birth & NICU Course
34 weeks, 1.8 kg, female, Apgar Score 7,8,8
respiratory distress requiring oxygen support
CXR: pneumonia
given appropriate antibiotics
received early parenteral & enteral nutrition (breastmilk)
Case
Discharged at 2 weeks old
Discharge weight 1.9kg
given vaccines
screenings prior to discharge : NBS, ROP, cranial US
schedule for follow-up to the Pediatrician
What is the optimum follow-up care
for this NICU graduate???
Maria Conchitina T. Bandong, MD, MBAH
Follow-Up Care of a NICU Graduate
by a General Pediatrician
Learning Objectives
To provide a framework for the transition of care of a
Preterm Infant from NICU to Out-patient
To discuss the essentials of follow-up care of a NICU
graduate
growth & nutrition
immunization
development
screenings
Critical Components of
NICU Discharge
(American Academy of Pediatrics)
1. Parental Education
2. Implementation of Primary Care
3. Evaluation of Unresolved Medical Problems
4. Development of Home Care Plan
5. Identification & Mobilization of Surveillance & Support
Services
6. Determination & Designation of Follow-up Care
Growth and Nutrition
Benefits of Human Milk & Breastfeeding for
Preterm Infants
promotes more rapid gastric emptying
improves gut motility
increases fat absorption: lipase & other enzymes
contains hormones, peptides, AA, nucleotides, growth
factors
provides Bifidobacteria & Lactobacilli
Human Milk & the Nutritional Needs of Preterm Infants
Tudehope et al
Journal of Pediatrics 2013
Benefits of Human Milk & Breastfeeding for
Preterm Infants
lower rates of NEC, diarrhoea, & urinary tract infection
associated with significantly higher IQ scores compared
to LBW formula fed infants
protective against atopic disease for up to 4 years of
age
decreased incidence of ROP compared with formula fed
infants
Mothers: strong feelings of attachment, maternal
empowerment, self confidence & esteem
Human Milk & the Nutritional Needs of Preterm Infants
Tudehope et al
Journal of Pediatrics 2013
Nutritional Supplements
to Breastmilk
BREASTMILK
+
Nutritional Facts of
Human Milk Fortifier (HMF)
Per serving % Daily Value
Calories 14
Calories from Fat
3
Total Fat 0.4g 1%
Sodium 15mg 1%
Carbohydrate
1.8g
1%
Protein 1.0g
macronutrients + minerals: calcium, phosphorus,
sodium, vitamins ADEK, riboflavin, folic acid & zinc
Nutritional Supplements
to Breastmilk
Human milk fortifiers (HMF)
increase in weight gain: 2.3g/kg/d
increase in linear growth: 0.12 cm/wk
increase in head growth 0.12/wk
Human Milk & the Nutritional Needs of Preterm Infants
Tudehope et al
Journal of Pediatrics 2013

Fenton Preterm Growth
Chart for Boys
Monitoring of Growth Preterm Infants
Fenton Preterm Growth
Chart for Girls
Monitoring Growth of Preterm Infants
Guidelines for Breastfeeding
Premature Infants
Feed on demand - Baby led Feeding
Supplement some feedings with milk fortifier until catch-up
growth is achieved & daily weight gain is adequate (20 to 30
g/day) or until 2.5kg
Supplement feedings with 0.5 to 1.0 ml of standard
multivitamins per day until the infant reaches a weight of 5kg
Supplement feedings with 2 to 4 mg/kg of iron per day
Supplement feedings with 200 to 400 IU of Vit D per day
starting at 2 months of age
Outpatient Care Of the Premature Infant
A Lahood Md et al
Academy of Family Physicians 2007
Immunization of Preterm (PT) & Low
Birth Weight (LBW) Infants
Timing
Medically stable PT & LBW infants should receive ALL
routinely recommended vaccines at same chronologic
age recommended for FT infants
Dosing
Same dose as given to FT infants
Not reduced or divided
Immunization of Preterm & Low Birth Weight Infants
AAP Clinical Report
Pediatrics Vol 112 July 2003
Immunization of Preterm (PT) & Low
Birth Weight (LBW) Infants
Vaccine administration
site of choice: anterolateral thigh for IM vaccines
needle length: depends on muscle mass, less than
standard 7/8 inch to 1 inch length used for FT
Immunization of Preterm & Low Birth Weight Infants
AAP Clinical Report
Pediatrics Vol 112 July 2003
Hepatitis B Immunoprophylaxis
Scheme for PT & LBW Infants
Maternal Status Infant > 2000g Infant < 2000g
HBsAg positive
- Hep B vaccine + HBIG
within 12 h of birth
- Immunize with 3 doses
at 0, 1, 6 mo of
chronologic age
- Check anti-HBs &
HBsAg at 9-15 mo of
age
- If infant is HBsAg & anti-
HBs negative, re-
immunize with 3 doses
at 2 mo intervals & retest
- Hep B vaccine + HBIG
within 12 h of birth
- Immunize with 4 vaccine
doses at 0, 1, 2-3, & 6-7
mo of chronologic age
- Check anti-HBs &
HBsAg at 9-15 mo of
age
- If infant is HBsAg & anti-
HBs negative, immunize
with 3 doses at 2 mo
intervals & retest
Immunization of Preterm & Low Birth Weight Infants
AAP Clinical Report
Pediatrics Vol 112 July 2003
Hepatitis B Immunoprophylaxis
Scheme for PT & LBW Infants
Maternal Status Infant > 2000g Infant < 2000g
HBsAg status
unknown
- Hep B vaccine by 12 h
+ HBIG within 7 days
if mother tests HBs Ag
positive
- Test mother for
HBsAG immediately
- Hep B vaccine + HBIG
by 12h
- Test mother for
HBsAg immediately &
if results are
unavailable within 12h,
give infant HBIG
Hepatitis B Immunoprophylaxis
Scheme for PT & LBW Infants
Maternal Status Infant > 2000g Infant < 2000g
HBsAg negative
- Hep B vaccine at birth
preferred
- Immunize with 3 doses
at 0-2, 1-4, & 6-18 mo of
chronologic age
- May give hep B
containing combination
vaccine beginning 6-8
weeks of chronologic
age
- Follow up anti-HBs &
HBsAg testing not
needed
- Hep B vaccine dose 1 at
30 days of chronologic
age if medically stable,
or at hospital discharge if
before 30 days of
chronologic age
- Immunize with 3 doses
at 1-2, 2-4, & 6-18 mo of
chronologic age
- May give Hep B
containing combination
vaccine beginning at 6-8
week of chronologic age
- Follow-up anti-HBs &
HBsAg testing not
needed
Special Considerations for
Immunization of PT Infants
Immunize all children with Hepatitis B at birth
regardless of birth weight to confer a mild degree of
immunity. If <2kg, this dose should not be included in
the 3-dose vaccination series
Combination vaccines are safe & effective for preterm
infants & should be used as indicated, with exception of
combination Hep B vaccines, which should be delayed
until at least 6 weeks of age & weight greater than 2kg.
Special Immunization Considerations of the Preterm Infant
Ashraf Gad MD et al
Journal of Pediatric Health Care; Nov/Dec 2007
Special Considerations for
Immunization of PT Infants
Republic Act 10152
Mandatory Infants & Children Health Immunization
Act of 2011
ALL infants must be given birth dose of hepatitis B
vaccine within 24 hours of birth
Department of Health Philippines 2011
Special Considerations for
Immunization of PT Infants
Rotavirus vaccine
3 dose schedule is recommended at ages 2,4, & 6
months
1st dose administered between 6-12 weeks of age
subsequent doses: 4 to 10 week interval
can be administered together with DTaP, Hib, IPV,
hep B, & pneumococcal conjugate
Special Immunization Considerations of the Preterm Infant
Ashraf Gad MD et al
Journal of Pediatric Health Care; Nov/Dec 2007
Developmental Assessment
Developmental Assessment of Preterm
Infants
Inverse relationship between birthweight or gestational
age & risk for development of neuro-development
disabilities
cerebral palsy
global developmental delay
intellectual disability
language impairments
Early Childhood Development of Late
Preterm Infants: A Systematic Review
McGowan etal
Pediatrics Vol 127 June 2011
Developmental Assessment of Preterm
Infants
EMPHASIS on early identification of developmental
delay
Neurologic examination is VITAL
alertness
posture
muscle tone
reflexes
Outpatient Care Of the Premature Infant
A Lahood Md et al
Academy of Family Physicians 2007
Developmental Assessment of Preterm
Infants
Be ALERT for abnormalities
weakness
asymmetries
hyper-reflexia
generalized or focal hypertonia
hypotonia - more common
Outpatient Care Of the Premature Infant
A Lahood Md et al
Academy of Family Physicians 2007
Developmental Assessment of Preterm
Infants

Early intervention is the KEY!!!
REFER even before detection of delay
Cranial Ultrasound Examination for
Preterm Infants
Routine screening is recommended for ALL infants born
before 32 weeks of gestation
Timing: 2nd & 6th weeks of life
High sensitivity & specificity in predicting presence or
absence of later neurodevelopment delays
presence of cysts: 67% sensitivity & 96% specificity as predictor
of CP
presence of white matter injury: predictor of anxiety disorders,
TICS, ADHD
Routine Screening Cranial Ultrasound Examinations for
Prediction of Long Term Neurodevelopmental Outcomes
in Preterm Infants
Canadian Pediatric Society Statement January 2011
Infant Massage
Newborn Screening for
Preterm Infants
Retinopathy of Prematurity
Criteria for Screening
All premature infants <35 weeks GA or birth weight <2000g
MUST be screened for ROP
Infants with GA > 35 weeks or BW > 2000g assessed by the
Pediatrician or Neonatologist as having unstable clinical
course should be screened for ROP
Recommended Philippine Guidelines for Screening and Referral of ROP
ROP Working Group; Philippine Academy of Ophthalmology
November 17, 2013
Retinopathy of Prematurity
Risk Factors in PT Infants Associated with Development of
ROP
Perinatal Risk Factors
Maternal infection during 3rd trim, placenta previa, poor
nutrition, pre-eclampsia/eclampsia, PROM >18 hours, multiple
gestation
Neonatal Risk Factors
Oxygen supplementation, anemia, IVH, jaundice, RDS,
seizure, sepsis, any syndrome, blood transfusion
Recommended Philippine Guidelines for Screening and Referral of ROP
ROP Working Group; Philippine Academy of Ophthalmology
November 17, 2013
Retinopathy of Prematurity
Timing of Screening
1st examination must be performed at 2 weeks postnatal
age or at 32 weeks post conceptional age/corrected age,
whichever comes FIRST
If infant referred for ROP screening cannot be examined
due to critical systemic condition, the reasons for doing so
should be clearly stated in medical chart & examination
rescheduled within 1 week of intended examination
Follow-up examination recommended by the
Ophthalmologist
Recommended Philippine Guidelines for Screening and Referral of ROP
ROP Working Group; Philippine Academy of Ophthalmology
November 17, 2013
Hearing Screening in
Preterm Infants
Must be done before NICU
discharge
May need to be repeated on
follow-up depending on initial
results
Medical Problems of a
Preterm Infant
GERD
Anemia of Prematurity
Infection
Hypertension & Insulin resistance as adult
Outpatient Care Of the Premature Infant
A Lahood Md et al
Academy of Family Physicians 2007
KEY Points to REMEMBER
Good communication between the Neonatologist &
General Pediatrician
Follow specific recommendations
Early prevention & intervention is important
Developmental assessment is MANDATORY
Refer & Refer Back
Follow-up until adolescence