Follow up of High Risk Neonate

Mohamed Khashaba
Professor of Pediatrics,
Neonatology
Head of NCU,MUCH
Mansoura University
Mohamed Khashaba, MD, Mansoura University
 ٍSurvival of high risk neonates has
been improving over the past few
years.
 What lies beyond survival of NICU
graduates?.

Mohamed Khashaba, MD, Mansoura University

 Quality of life is more important than
the mere survival.

Mohamed Khashaba, MD, Mansoura University

 LBW infants with normal range IQ make
greater use of special education tools
compared to full terms.

Mohamed Khashaba, MD, Mansoura University

 The high rate of MNDs and their
association with an increased risk for
learning difficulties justify their screening in
case of (even moderate) prematurity.

Arnaud C et al. Arch Pediatr Adolesc Med. 2007

Nov;161(11):1053-61

Mohamed Khashaba, MD, Mansoura University

 Challenges
 Once the High risk neonate is discharged,
he is taken back to a remote village or city
where facilities for sophisticated
psychomotor assessment are not
available.
 Orientation of many pediatricians and
families about the F-up needs is still
lacking.
Mohamed Khashaba, MD, Mansoura University
 Identification of differences and variations in
development should be interpreted cautiously,
taking account natural variations in early
development.
 It may be more accurate to observe children
over time rather than to make decision on the
basis of a single assessment.
Rosenbaum. Early Human Development,82:167-71.2006

Mohamed Khashaba, MD, Mansoura University

 Challenges
 Detailed neurodevelopmental assessment
is not feasible in a busy pediatric practice.
 Lack of the concept of multidisciplinary
approach to management.

Mohamed Khashaba, MD, Mansoura University

Objectives
1. Discuss benefits of follow up.
2. Define who should be followed.
3. Define optimal age and methods of
follow up.
4. Recommendations.

Mohamed Khashaba, MD, Mansoura University

Benefits of Follow up program
1. Early detection and management of
NDD.
2. Surveillance
3. Research

Mohamed Khashaba, MD, Mansoura University

Early detection of NDD
 No much can be done for a baby who
has already developed contractures or
blindness.

Mohamed Khashaba, MD, Mansoura University

Surveillance
1. Audit NICU interventions.
2. Influence the health care policy to
improve outcome.
3. Data about NICU outcome of specific
conditions.

Mohamed Khashaba, MD, Mansoura University

Postnatal steroids
 Prolonged steroids is associated with
reduction in cerebral blood flow,
delayed myelination of optic axons,
alteration of dopamine receptor
responses in animal studies.

Sapolsky et al. J neurosci.1990

Mohamed Khashaba, MD, Mansoura University

 Preterm twins weighing< 1000 g
did not have an increased
prevalence of major handicaps at 1
year of age compared with preterm
singletons
Gardner et al Obstet Gynecol. 1995 Apr;85(4):553-7.

Mohamed Khashaba, MD, Mansoura University

Research
 To evaluate long term impact of
interventions designed to improve
outcome

Mohamed Khashaba, MD, Mansoura University

 Providing basic developmental care in
the NICU had no effect on physical and
neurologic outcomes in preterm infants
born<32 weeks.

Celeste etal., PEDIATRICS Vol. 121 No. 2 : 239-245,2008

Mohamed Khashaba, MD, Mansoura University

Who needs to be followed up

 Biologic risk factors

 VLBW and ELBW.
 Cranial US abnormalities.
 Other neurological abnormalities.
 Encephalopathy persisting at discharge.
 Hyperbilirubinemia needing exchange.
 Recurrent apneas and bradycardia.
Mohamed Khashaba, MD, Mansoura University
Who needs to be followed up

 Biologic risk factors

 Complex congenital anomalies.
 Nosocomial infections, sepsis and
meningitis.
 Chronic lung disease.
 NEC.
 Failure to grow in NICU.
 Metabolic disorders
Mohamed Khashaba, MD, Mansoura University
Who needs to be followed up

 Intervention risk factors

 HFV or prolonged ventilation>1 week.
 Total parenteral nutrition.
 Prolonged 02 requirement.
 Surgical interventions.
 Postnatal steroids.

Mohamed Khashaba, MD, Mansoura University

Who needs to be followed up
 Social and environmental factors.
 Low socioeconomic status.
 Low maternal education
 Environmental stress.

Mohamed Khashaba, MD, Mansoura University

 1st ophthalmologic exam. scheduled at 31

ws postconceptional age (or at 4-6 ws

postnatal in larger babies).

Mohamed Khashaba, MD, Mansoura University

 Hearing screening of candidate infants

scheduled before discharge (or at 3

months corrected age).

Mohamed Khashaba, MD, Mansoura University

Timing of Follow Up Visits
1. Initial visit 7-10 days after discharge
2. 4 ms corrected age
3. 8-12 ms corrected age
4. 18-24 ms
5. 4 years

Mohamed Khashaba, MD, Mansoura University

 Early visit

 To evaluate home environment and

ability of the parents to care for the
baby.

Mohamed Khashaba, MD, Mansoura University

Follow up at 3-4 months C age

 Growth and nutrition.

 Neurologic assessment.
 Gross motor development.
 Neuroimaging as needed.

Mohamed Khashaba, MD, Mansoura University

Bayley Infant
Neurodevelopmental Screener
((BINS

Used to screen development in children 3 to 

42 months
It uses 10 to 13 directly elicited items per three-
to six-month age range to assess neurologic
processes (reflexes and tone),
neurodevelopmental skills (fine motor,
.language ) , and cognitive processes
It categorizes performance into low, 
moderate, or high risk via cut scores and
.provides subtest cut scores for each domain

 The BINS detects 75 to 86 percent of children

with neurodevelopmental problems and
correctly identifies 75 to 86 percent of
children without such conditions
Bayley II Edition, 1993
Suggested early tests at 3 months

1. Axillary suspension
2. Head support
3. social smile
4. Disappearance of primitive reflexes.
5. Neurobehaviour.

Mohamed Khashaba, MD, Mansoura University

 Suggested early tests at 6 months
Failure to achieve 6 milestones may be 1st clue to NDD
later on
3. Absent roll to sit
4. Absent transfer of subjects
5. Absent reaching for objects
6. Abnormal adductor angle, scarf sign.
7. Absent rolling over
8. Absent sitting with support
Godbole et al., 1997

Mohamed Khashaba, MD, Mansoura University

 Inability to achieve social smile ,and
abnormal neurobehavior at 3 months
and
 Absent transfer of objects and voluntary
reach and pull to sit at 6 months
predicted delayed development at 1
year as tested by BSIB.
 Godbole et al., 1997
Mohamed Khashaba, MD, Mansoura University
 Some of the ND abnormalities are transient
and may disappear in the 2nd year.
 Closed monitoring and early intervention is
required.

Mohamed Khashaba, MD, Mansoura University

 Follow up of suspected minor variations
is needed before addressing NDD.

Mohamed Khashaba, MD, Mansoura University

 .Gross motor function exam. At 24 ms

No Level 0
Walk 10 steps Gait
Abnormalities? Yes Level 1

No
•Sits without hand support
Sits? Yes •Crawls on hands/knees with Yes Level II
(May use hands reciprocal leg movements
for support) •Pulls to standing
•cruises Level III
No No
Yes
Head control Level IV
In supported sitting?
No
Rolls Level V

Mohamed Khashaba, MD, Mansoura University

 Recommendations
 A multidisciplinary Follow up clinic should
be an integral component of any NICU.
 A simple approach for early neuro
developmental assessment is required to
suite most practioners.
 Early detection of mild disabilities is
important when prevention and not
rehabilitation is the choice.
Mohamed Khashaba, MD, Mansoura University