Outpatient Management of Premature Infants

Hartono Gunardi Dept of Child Health, FKUI-RSCM

Objectives
Screening Monitoring Intervention Morbidities

premature infants

Premature infants
National ~ 9% Premature/LBW prevalence in RSCM, Jakarta : 1998 : 17.8% 2008 : 26.8% Advances in neonatal care allow premature infants prone to a range of long term complications.
United Nations Statistics Division. The State of the Worlds Children 2009. Perinatologi FKUI-RSCM. 2009.

Prevalence

Blencowe H, Lancet, 2012:9;379(9832):2162-72

Outcome premature infants

Depends : gestational age, birth weight, perinatal insults, etc Risk : growth failure developmental problem (e.g.cerebral palsy) vision and hearing losses needs growth & development monitoring

Growth

Development

Greater weight gain before reaching term appears to be associated with improved neurodevelopmental outcome. Study of 613 infants ( GA < 33 wks) that greater weight gain, BMI, before 40 wks PMA head growth (term) higher Bayley MDI and PDI scores at 18 months CA
Belfort MB,et al. Pediatrics 2011; 128:e899.

Eye & hearing screening

Eye,

Premature infants prone to retinopathy of prematurity (ROP), visual hearing impairment, starbismus, visual field screen impairment.
ROP ~ 25,4% of VLBW infants Critical period of hearing and speech development : 6 month - 2 year old Hearing impairment prevalence in highrisk infants >10-20 more than normal infants
Nair PM dkk. Indian journal of pediatrics. 2003;70:303-6. Rundjan L, dkk. Sari Pediatri. 2005;6:149-54. Taghdiri MM, dkk. Iran J Pediatr. 2008;18:330-4.

ROP screening recommendations

American Academy of Pediatrics recommended:

Infant BW <1500 g or GA <32 week Infant BW 1500-2000 g and GA >32 week with
clinically unstable

FMUI-RSCM Neonatology Division recommended: Infant BW <1500 g or GA <37 week clinically unstable.
American Academy of Pediatrics, American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus. Pediatrics. 2006;117:572-6. Perinatologi FKUI-RSCM. 2009.

Eye screening : when to perform

First at clinically stable 2 weeks CA or 3233 weeks GA (ROP screening) Other ophthalmologic abnormalities: reduced visual acuity, strabismus, myopia
Referral to ophthalmology at 6 12 months

Further eye exam : at 1-2 year, 3-4 year, 4-5

year, and 5-6 year old
Wang CJ, dkk. Pediatrics. 2006;117:2080-92.

Hearing screening
Newborn >24 hour, perform OAE before discharge Pass Refer 3 months age: otoscopy , timpa-nometri, distortion product OAE, AABR Risk factor (-) Risk factor (+) Pass Refer Evaluation : audiology and ABR clicks + toneburst 500 Hz and/or ASSR Habilitation before 6 months age
Suwento R. KONAS PERHATI XIV; 2007.

No further evaluation

Speech development n audiology monitoring every 6 months for 3 years

Growth monitoring
Parameters : weight, length, head circumference Schedule : a weekly to biweekly( first 4-6 weeks after discharge) grows normally : 1st year : monthly, then 1-5 year: every three months, > 5 year : every 6 months. poor growth : monitor biweekly to monthly and needs evaluation + intervention.

Growth chart for preterm

1. Fenton preterm infant growth chart (2003)
22 weeks to 50 weeks (PMA) 2. Then : a. WHO growth chart b. CDC growth chart
Fenton TR. BMC Pediatrics 2003, 3:13

Fenton Chart
Start : 22 wks, 300 g, 100 g increment: Follow up to 50 wks PMA
Data : Kramer 2001; 676,605 Nicklasson 1991; 376,000 Beeby 1996; HC : 29,090 , BL: 26,973
BMC Pediatrics 2003, 3:13

Length-for-age BOYS
Birth to 6 months (z-scores)
3 2
70

1 0 -1 -2 -3

70

65

65

Length (cm)

60

60

55

55

50

50

45 Weeks 0 1 2 3 4 5 6 7 8 9 10 11 12 13

45

Months

Age (Completed weeks or months)

Corrected age
Corrected age = chronological age prematurity Through 24 months of age Eg. A baby, GA 32 week, chronological age 4 month. Corrected age = 4 months (40-32 weeks) = 2 months

Weight-for-length BOYS
Birth to 6 months (z-scores)
14 14

3
13 12 11 10 13

2 1 0 -1 -2 -3

12 11 10 9 8 7 6 5 4 3 2

Weight (kg)

9 8 7 6 5 4 3 2 45 50 55 60 65 70 75 80

Length (cm)

Catch up
30-80% since birth to adolescence Catch-up growth : reaching 5th 10th percentile on standard growth chart (WHO/CDC), mostly first 6 months Sequence : head circumference, then weight and length. Individual, and influenced by multifactor.
Paul B, dkk. Indian journal of public health. 2008;52:16-20. Roggero P, dkk. The journal of maternal-fetal & neonatal medicine. 2011;24 Suppl 1:144-6. Hill AS, dkk Pediatric nursing. 2009;35:181-8.

Head circumference
Slow head growth is ~ developmental delay. VLBW whose HC < normal at 8 mo CA had : poor cognitive function poor academic achievement at 8 year poor behavior compared to controls with normal head size. Rapid increase HC: may indicate post hemorrhagic hydrocephalus
Hack M, et al. N Engl J Med 1991; 325:231.

Head circumference
Consider cranial US for signs/symptoms hydrocephalus Widely spaced sutures Tense fontanel Irritability Alterations in behavior/activity level Frequent downward deviation of eyes sunsetting

Developmental monitoring
Corrected age until 2 year Surveillance : at every visit Kuesioner Pra Skrining Perkembangan Milestones Parents Evaluation of Developmental Status (PEDS) Screening : Denver II or Bailey Infant Neurodevelopmental Screener (BINS)

KUESIONER PRA SKRINING PERKEMBANGAN Source : Denver Prescreening Develop. Questionairre (PDQ) Age : 3 months 6 years, duration 10 15 minutes Content : 10 questions for each age groups. Answered by parents. Yes, if child can do. No, if can not do Interpretation : Yes < 7 probable delay yes 7 8 yes > 9 Spesificity : 83 % repeat next week generally no delay

Sensitivity : 43 75 %

Interventions
Breast milk Kangaroo mother care Fe supplementation Touch therapy Music therapy

Long-term Human Milk Benefits

Subject

300 of the VLBW preterm infants at 7.5 to 8 years of age

Outcomes

Higher IQ 8.3-point advantage in IQ (P<0.0001) Fewer MDI score of <85 (P=0.036)

Patel AL et al. NeoReviews 2007;8;e459-66.

Kangaroo mother care

Improved growth and breast feeding rate Reduced nosocomial infections Higher MDI and PDI scores on the Bayley Scales of Infant Development-II of 25-34 week preterms on 6 months corrected age Higher DQ scores on the Griffiths Mental Development Scales at 12 months corrected age
Charpak N et al. Pediatrics 2001;108:1072-9. Feldman R et al. Pediatrics 2002;110:16-26.
Tessier R et al. Infant Behav Dev 2003;26:384-97.

Massage/Touch therapy
Tactile and kinestetics stimulation

Ferber SG et al. Infant Behav Dev 2005;28:7481. Field TM et al. Pediatrics 1986;77:654-8. Sizub J, Westrup B. Arch Dis Child Fetal Neonatal 2004;89:F384-9.

Massage/Touch therapy
As a pacifying or stressreducing effect promoted behavioral organization Optimized motherinfant interactions (at 3 months of age) Increased daily weight gain, and shortened hospital stay
Ferber SG et al. Infant Behav Dev 2005;28:7481. Field TM et al. Pediatrics 1986;77:654-8. Sizub J, Westrup B. Arch Dis Child Fetal Neonatal 2004;89:F384-9

Massage/Touch therapy

Immunization of premature infants

Preterm/LBW infants) less likely to receive immunizations in a timely fashion (high rates of medical complication)

For immunization = chronological age

Immunization of high-risk infants

Same schedule,
except hepatitis B Same dose Immunogenicity, eficacy, tolerability

LBW <2000 g with HBsAg (-) mother : Hep B vaccine at 1-2 month or BW >2000 g

Siregar SP. Pedoman Imunisasi di Indonesia. 2008. D'Angio CT. Paediatric drugs. 2007;9:17-32. Hendrarto TW. Pedoman Imunisasi di Indonesia. 2008.

Hepatitis B immunization in preterm infants

Preterm/LBW infants HBsAg (+) mother

Hepatitis B vaccine + HBIg in 12 hr, at 2 different site

LBW <2000 g : 4 dosis hepatitis B vacc at 0, 1, 23, and 6 months CA

BBLR > 2 000 g : 3 doses hepatitis B vaccine at 0, 1, and 6 months

HBsAg and anti-HBs are checked 1-2 months after last dose or at 9-18 month; If anti-HBs negative, give 3 additional doses, 2 month interval
Saari TN. Pediatrics. 2003;112:193-8.

Immunization of Preterm infants

LBW infants still hospitalized at 2 mo CA: give BCG,
DPT, IPV (inactivated polio vaccine) and Hib, PCV immunization, if clinically stable and no contra indication.

No increase of adverse events in preterm infants Apnoe might occur in 72 hours (most often in 12-24
hours) after DTPw in ELBW infants with <31 weeks gestational age.
D'Angio CT, dkk. Pediatrics. 1995;96:18-22. Khalak R, dkk. Pediatrics. 1998;101:597-603. Botham SJ, dkk. Journal of paediatrics and child health. 1997;33:418-21.

Morbidities
Cardiovacular : PDA, VSD Hypertension : BPD, umbilikal artery cath Respiratory : BPD, recurrent wheeze GI : GER, colic, constipation

ANEMIA of PREMATURITY
AOP is a normocytic, normochromic, hyporegenerative anemia characterized by a low serum EPO level.
AOP typically occurs at 3 to 12 weeks after birth in infants less than 32 weeks gestation Nadir for preterm : Hb 7 10 g/dL at 4 8 wks; for term infants : Hb 11 g/dL at 8 12 wks

Recommendation of Fe suplementation (IDAI)

0-2 year 2-12 th Lab

Preterm/LBW: 3 mg/kgBB/day since 1 mo - 2 year

Term infants: 2 mg/kgBB/day since 4 mo - 2 year Infant max dose = 15 mg/day, OD

1 mg/kgBB/day, 2x/week for 3 months every year

Hb check annually from 2 year until teenager. If anemia, look for etioloogy

Ikatan Dokter Anak Indonesia. http://www.idai.or.id/rekomendasi.asp.

Neurological abnormalities
Major : Spastic diplegia, hypotonia, hydrosefalus, microsephaly, mental retardation

Minor : Ataxia, coordination problem, specific learning disorders, ADHD, cognitive disturbance

 Surgical problems
Ingunal or umbilical hernia, chryptorchidism, hydrocel

Psycho-social problems
Child abuse and neglect, behaviour-emotional problems.

Growth Development Monitoring : until ?

American Academy of Pediatrics 1996: Growth and development of preterm or highrisk infants should be monitored until 7-10 years.

Conclusion
Premature infants are prone to have growth neurodevelopmental problem. Families of premature infants should be guided to comprehensive follow-up and early intervention. Close monitoring is needed to identify, stimulate/intervene to have better neurodevelopmental outcome.

Thank you