Yes, Materi 16 Januari 2013

7/28/2019 Yes, Materi 16 Januari 2013

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Outpatient Management of Premature Infants

Hartono Gunardi

Dept of Child Health, FKUI-RSCM



Objectives

• Screening

•Monitoring premature infants• Intervention

•Morbidities



• National ~ 9%

• Premature/LBW prevalence in RSCM, Jakarta :

1998 : 17.8%

2008 : 26.8%

• Advances in neonatal care allow prematureinfants prone to a range of long termcomplications.

Premature infants

United Nations Statistics Division. The State of the World’s Children 2009.Perinatologi FKUI-RSCM. 2009.



Prevalence

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



• Depends : gestational age, birth weight,

perinatal insults, etc

•

Risk : growth failuredevelopmental problem (e.g.cerebral palsy)

vision and hearing losses

needs growth & development monitoring

Outcome premature infants



Growth Development

• Greater weight gain before reaching term appears tobe 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,

hearingscreen

Premature infants prone to retinopathyof prematurity (ROP), visual

impairment, starbismus, visual fieldimpairment.

ROP ~ 25,4% of VLBW infants

Critical period of hearing and speechdevelopment : 6 month - 2 year old

Hearing impairment prevalence in high-risk infants >10-20 more than normalinfants

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, American Academy of Ophthalmology,

American Association for Pediatric Ophthalmology and Strabismus. Pediatrics. 2006;117:572-6.

Perinatologi FKUI-RSCM. 2009.

FMUI-RSCM Neonatology Division recommended:Infant BW <1500 g or GA <37 week clinically

unstable.

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



Eye screening : when to perform

• First at clinically stable 2 weeks CA or 32-

33 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, 4-5year, and 5-6 year old

Wang CJ, dkk. Pediatrics. 2006;117:2080-92.



Hearing screening

Suwento R. KONAS PERHATI XIV; 2007.

Newborn >24 hour, perform OAE before discharge

Pass Refer

3 months age: otoscopy , timpa-nometri,

distortion product OAE, AABR

Pass Refer

Risk

factor (-)

Risk

factor (+)

No further

evaluation

Speech development n

audiology monitoring every 6

months for 3 years

Evaluation : audiology and

ABR clicks + toneburst 500Hz and/or ASSR

Habilitation before 6

months age



• 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 monthlyand needs evaluation + intervention.

Growth monitoring



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



Start :

• 22 wks,

• 300 g,

• 100 g increment:

Follow up to 50 wksPMA

Data :

Kramer 2001; 676,605

Nicklasson 1991; 376,000

Beeby 1996; HC : 29,090 , BL:26,973

Fenton Chart

BMC Pediatrics 2003, 3:13



Age (Completed weeks or months)

L e n g t h ( c m )

Length-for-age BOYSBirth to 6 months (z-scores)

-3

-2

-1

0

1

2

3

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

3 4 5 6

Weeks

Months

45

50

55

60

65

70

45

50

55

60

65

70



Corrected age

Corrected age = chronological age−

prematurity

Through 24 months of age

• Eg. A baby, GA 32 week, chronological age 4month.

Corrected age = 4 months – (40-32 weeks)

= 2 months



W e i g h t

( k g )

Weight-for-length BOYSBirth to 6 months (z-scores)

Length (cm)

-3

-2

-1

0

12

3

45 50 55 60 65 70 75 80

2

3

4

5

6

7

8

9

10

11

12

13

14

2

3

4

5

6

7

8

9

10

11

12

13

14



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

poor behavior

compared to controls with normal head size.

• Rapid increase HC: may indicate post hemorrhagic

hydrocephalusHack M, et al. N Engl J Med 1991; 325:231.

at 8 year



Consider cranial US for signs/symptoms

hydrocephalus

– Widely spaced sutures

– Tense fontanel– Irritability

– Alterations in behavior/activity level

–Frequent downward deviation of eyes“sunsetting”

Head circumference



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)



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 repeat next weekyes > 9 generally no delay

Sensitivity : 43 – 75 %

Spesificity : 83 %

KUESIONER PRA SKRINING PERKEMBANGAN



Interventions

• Breast milk

• Kangaroo mother care

•

Fe supplementation• Touch therapy

• Music therapy



Long-term Human Milk Benefits

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

• 300 of the VLBW preterminfants at 7.5 to 8 years of age

Subject

•Higher IQ 8.3-point advantage in IQ (P<0.0001)

• Fewer MDI score of <85(P=0.036)

Outcomes



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;28:74–81.

Field TM et al. Pediatrics 1986;77:654-8.

Sizub J, Westrup B. Arch Dis Child Fetal Neonatal 2004;89:F384-9.




• As a pacifying or stress-

reducing effect promoted

behavioral organization

• Optimized mother–infant

interactions (at 3 months of

age)

• Increased daily weight gain,

and shortened hospital stayFerber SG et al. Infant Behav Dev 2005;28:74–81.

Field TM et al. Pediatrics 1986;77:654-8.

Sizub J, Westrup B. Arch Dis Child Fetal Neonatal 2004;89:F384-9.



Preterm/LBW infants) less likely

to receive immunizations in atimely fashion (high rates of medical complication)

For immunization =

chronological age

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

Immunization of high-risk infants

Siregar SP. Pedoman Imunisasi di Indonesia. 2008.

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



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.

b d



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: 3mg/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 for3 months every year

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

Recommendation of Fe suplementation (IDAI)

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 problemsIngunal 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 high-

risk 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 betterneurodevelopmental outcome.



Thank you

Yes, Materi 16 Januari 2013

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