Discharge

 planning  &  follow  up  

of  the  NICU  
Rosalina  D  Roeslani  
 Background  
•  Discharging  an  NICU  pa<ent  early  has  several  
advantages  :  
–   enhancement  of  family-­‐infant  bonding  
–  Provision  of  a  beDer  environment  for  infant  
development  
–  Cost  reduc<on  
•  Disadvantages:  
–  Readmission  
–  Unresolved  medical  problem  
 AAP  recommenda<on  2008  
Hospital  discharge  of  high  risk  neonate  
High  risk  infant  :  
1.  Preterm  
2.  Infant  with  special  needs  or  dependency  of  
technology  
3.  The  infant  at  risk  because  of  family  issues  
4.  The  infant  with  an<cipated  death  
 Treatment  Criteria  
The  infant  should  be  consider  ready  for  
discharge  with  the  following  parameter  :  
•  Demonstrated  establishment  of  physiologic  
stability  &  competencies  (oral  feeding,  
thermoregula<on  &  respiratory  control)  
regardless  of  weight  
•  Maintaining  appropriate  growth    
 …  treatment  criteria  
•  AAP  supports  24  hours  of  full  oral  feeding  as  
adequate  for  late  preterm  (>  34  weeks)  &  term.  
Up  to  48  hours  of  full  oral  feeding  for  GA  <  34  
weeks.  Some<me    gavage  feeding  is  common  
problems  among  NICU  graduate.  
•  Discharge  can  occur  24  h  aYer  discon<nua<on  of  
parental  fluid  (full  fill  all  criteria  for  discharge)  
•  24  hours  on    glucose  stability  on  home  feeding  
regimen.  
 …  treatment  criteria  
•  AAP  support  12-­‐24  h  of  stable  body  
temperature  in  open  crib  for  preterm  GA  <34  
w.  GA  <34  w  stable  for  48  h.  
•  Respiratory  stability  :  term  should  be  observe  
for  up  to  24  hours  &  preterm  for  up  to  48  
hours  aYer  discon<nua<on  of  O2  therapy  
 
 …  treatment  criteria  
•  Apnea  of  prematurity  :  free  for  5  days  but  if  
the  GA  <34  weeks  usually  free  from  apnea  for  
7  days.  
•  Do  not  need  any  regular  cardiorespiratory  
monitoring  
 Family  assessment  
Should  start  from  <me  of  admission,  included:  
•  Parental  skill  &  willingness  to  take  
responsibility  
•  Parents  experience  &  understanding  of  
rou<ne  infant  care  and  ability  to  cope  with  
specific  problem  
•  Family  structure  &  extended  family  support  
 …  family  
•  Parents  medical  &  physiologic  history  
•  Home  environment  
•  Financial  
•  Cultural  &  language    
 Pre  discharge  evalua6on  &  
examina6on  
Specific  evalua<on  &  screening  of  NICU  graduate  
•  Ophtalmonologic  examina<on  (ROP  or  congenital  
problems/infec<on)  ROP  for  baby  <32  weeks  or  
BW  <  1250  gr.  Control  if  corrected  age  reach  32  
weeks  or  chronological  age  is  4  weeks  
•  Hearing  screening  before  aYer  birth,  recheck  at  3  
month,  BERA  (preterm,  meningi<s,  family  history  
of  sensory  neural  hearing  loss,  severe  
hyperbilirubinemia,use  of  ototoxic  drugs  
congenital  anomaly  of  the  ear  etc.  
 …Pre  discharge  evalua<on  &  
examina<on  
•  Cranial  Ultrasound  (IVH  or  PVL  :  1,3,7  day,  2  
weeks,  1,2,3  months  
•  Osteopenia  of  prematurity,  chronological  age  
1  months  
•  Immuniza<on  based  on  chronological  age,  
Hepa<<s  B  2  kg  

Predischarge  examina<on  is  essen<al  to  ensure  

good  general  health  &  growth.  
 Follow  up  
NICU  graduate  are  at  high  risk  of  adverse  
neurodevelopmental  outcome.  
 
Importance  of  follow  up  
•  Early  iden<fica<on  of  major  problems  of  perinatal  
origin  (CP,  developmental  delay,  deafness)    
•  Screening  for  other  medical  problem  (speech  delay,  
growth  failure)  
•  Maintenance  op<mum  health:  growth  &  development    
 …follow  up  

•  Anthropometry  assessment  
•  Systemic  review  :  health  problem:  feeding  &  
bowel  habits  
•  Assessment  of  vision  &  hearing  
 …follow  up  
•  Neurologic/neurodevelopmental  assessment  
–  Assessment  of  posture,tone,reflexes  
–  Achievement  of  developmental  
milestones(neurodevelopmental  outcome  at  
18-­‐24  m:  cogni<ve  24  m  &  behavior  5-­‐6  yr.)  
 
•  Review  of  medica<on  
•  Immuniza<on  
Early  Discharge    &  follow  up  infant  
with  PMK  
 Discharge
•  Criteria for mother & infant:
–  Infant already stable & no acute pathology
(apnea, infection etc.)
–  Oral feeding already established & appropriate
weight gained for 3 consecutive days
–  No hypothermia for 3 consecutive days
–  Mother could take care their baby & routine
follow up
 Follow up
Time (WHO) :
•  Corrected age < 37 week : 2 time/week
•  Corrected age > 37 week : 1time per week

South Africa protocols:

–  BW <1500 gram : every day
–  BW 1500-1800 gram: 3 - 4 time per week
–  BW 1800 – 2500 gram : once per week
 Pertumbuhan  janin  intrauterin  
 

Kecepatan  penambahan  berat  pada  janin  ter6nggi    pada  minggu  

ke  26  sampai  ke  36  
 
Pertumbuhan   op<mal   bagi   bayi   prematur   harus   sesuai  
dengan  kurva  pertumbuhan  intrauterin,  oleh  karenanya  
perlu  dukungan  nutrisi  yang  tepat.  

6th World Congress Perinatal Medicine In Developing Countries, Jakarta, March 9th, 2010
PEMANTAUAN PERTUMBUHAN

Intra  uterin   Lubchenko  

Kurva  
Fenton  
Pertumbuhan  

Ekstra  uterin   IHDP  

WHO  
Pertumbuhan  intrauterin  
(Lubchenko)  

IUGR  
Kurva  Pertumbuhan  Bayi  Prematur  

FENTON CHART
Kurva  Pertumbuhan  Bayi  Prematur  

FENTON  CHART-­‐    

FENTON  CHART-­‐    
Infant Health and Development Program [IHDP]
Panduan pemberian minum pada
bayi prematur
When to use preterm formula
•  Breastmilk+ HMF not enough
•  Weight length and HC less than 25 IHDP Chart

When to use post discharge formula

•  Weight 1800/2000 gram. Weight, length and HC >
p.25 IHDP chart

When to use standard formula

•  Z- score -2 s/d + 2 weight for age WHO chart
•  Z- score -2 s/d + 2 weight for length WHO chart
Catch Up Growth
1.  Pola catch up growth belum
dipahami benar
2.  Kehilangan pertumbuhan
dipengaruhi oleh berat dan lama
gangguan pertumbuhan serta usia
sat timbul
3.  Sulit terkoreksi bila gagal tumbuh
berlangsung lebih dari 2 tahun
4.  Defisit BB terkoreksi lebih dahulu
kemudian PB
5.  Anak yang wasted tetapi tidak
stunted catch up lebih cepat
Kenaikan Berat Badan ,Panjang Badan &
Lingkar Kepala Bayi Baru Lahir
0-3 bulan usia koreksi : 20 g/hari
3-6 bulan usia koreksi : 15 g/hari
6-9 bulan usia koreksi : 10 g/hari
9-12 bulan usia koreksi : 6 g/hari

Panjang badan : 1 cm/bulan

Lingkar kepala : 0,5 cm/minggu

Koreksi parameter pertumbuhan

Usia koreksi Usia koreksi

LK: 18 bulan BB: 24 bulan

Usia koreksi
PB: 42 bulan
Thank  You…    
 Soal    
1.  Bayi  boleh  di  puangan  dari  NICU  bila  
a.  BB  lebih  dari  2  kg  
b.  Stabil  di  suhu  ruangan  selama  24  jam  untuk  
UG  >34  minggu  
c.  Setelah  dapat  minum  8  kali  perhari  
d.  BB  naik  5-­‐10  g/hari  
e.  Bersedia  kontrol  dalam  24  jam  
2.    Kapan  pemeriksaan  pendengaran  dilakukan  
pada  bayi  berisiko  <nggi?  
a.   usia  sekolah  
b.   Mulai  bicara  
c.  Sesegera  mungkin  sebaiknya  diulang  
sebelum  berusia  3  bulan      
d.  Usia  1  tahun  
e.  Usia  2  tahun