See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/5320593

Follow-up of high risk neonates

Article in The Indian Journal of Pediatrics · June 2008

DOI: 10.1007/s12098-008-0075-9 · Source: PubMed

CITATIONS READS
15 3,358

6 authors, including:

Jeeva Sankar Savita Sapra

All India Institute of Medical Sciences All India Institute of Medical Sciences
242 PUBLICATIONS 15,286 CITATIONS 64 PUBLICATIONS 1,314 CITATIONS

SEE PROFILE SEE PROFILE

Ramesh Agarwal Ashok Kumar Deorari

All India Institute of Medical Sciences All India Institute of Medical Sciences
228 PUBLICATIONS 4,542 CITATIONS 374 PUBLICATIONS 7,206 CITATIONS

SEE PROFILE SEE PROFILE

All content following this page was uploaded by Savita Sapra on 17 April 2015.

The user has requested enhancement of the downloaded file.

 AIIMS- NICU protocols 2008

Follow-up of High Risk Neonates

Pradeep Kumar, M.Jeeva Sankar, Savita Sapra, Ramesh Agarwal, Ashok

Deorari and Vinod Paul

Division of Neonatology, Department of Pediatrics

All India Institute of Medical Sciences
Ansari Nagar, New Delhi –110029

Address for correspondence:

Dr Ramesh Agarwal
Assistant Professor
Department of Pediatrics
All India Institute of Medical Sciences
Ansari Nagar, New Delhi 110029
Email: [email protected]

Downloaded from www.newbornwhocc.org 1

 AIIMS- NICU protocols 2008

Abstract

The improvement in perinatal care has led to increase in survival as well as morbidity in
sick newborns. These babies need to be followed up regularly to assess growth and
neurodevelopmental outcome and for early stimulation and rehabilitation. We present a
protocol describing the various components of a follow up program including setting up
of follow up services, procedures and timings of follow up.

Key words: Follow up; neurodevelopmental outcome; early stimulation

Downloaded from www.newbornwhocc.org 2

 AIIMS- NICU protocols 2008

Introduction

Improving perinatal and neonatal care has led to increased survival of infants who are
at-risk for long-term morbidities such as developmental delay and visual/hearing
1, 2
problems Moreover, many of these neonates (e.g. extremely low birth weight infants)
tend to have higher incidence of growth failure and ongoing medical illnesses A proper
and appropriate follow-up program would help in early detection
of these problems thus paving way for early intervention.

Importance of follow-up care

Numerous studies have shown that despite substantial improvements in the neonatal
mortality, the incidence of chronic morbidities and adverse outcomes among survivors
has not declined much.3 This highlights the need for a follow-up care service that would
ensure systematic monitoring of the general health and neurodevelopmental outcomes
after discharge from the hospital. The monitoring would help the infants and their
families (early identification of problems and hence early rehabilitation services) as well
as the physicians involved in their care (to improve the quality of care provided and for
research purposes). There is a common perception that high risk follow-up mainly
concerns with detection and management of neurosensory disability. Infact growth
failure and ongoing illnesses are equally , if not more important issues in high risk follow-
up. Adequate emphasis must be placed on these .

However, a rigorous follow-up of all the neonates discharged from a particular health
facility would neither be practical nor feasible. Therefore, it is important to select a cohort
of neonates who are at a higher risk of developing these adverse outcomes – ‘at-risk’
infants. Surprisingly, there are no standardized guidelines for follow up of high risk
infants even in tertiary care centers4. We have devised a follow up protocol which
identifies the subset of neonates to be followed up and outlines the optimal time for
follow-up visits and the appropriate assessment measures to be adopted .

Downloaded from www.newbornwhocc.org 3

 AIIMS- NICU protocols 2008

Setting up of follow up services

High risk infants’ follow-up requires a multidisciplinary approach involving a team of

pediatricians, child psychologist, pediatric neurologist, ophthalmologist,
otorhinolaryngologist, physiotherapist, occupational therapist, medical social worker, and
a dietician. The respective role of each team member is summarized in Table 1.

Table 1: Personnel required for follow-up program and their individual roles

S. No Team member Role(s)

1. Pediatricians / • Serves as the nodal person of the team

neonatologists
• To assess growth and screen for developmental
delay
• To manage intercurrent illnesses

2. Child psychologist(s) • For formal neurodevelopmental assessment

• Screening for behavioral problems and their
management

3. Pediatric neurologist • Long-term management of neurological illnesses

such as seizures

4. Ophthalmologist • Follow-up of ROP screening/treatment

• Assessment of visual acuity and screening for
problems such as strabismus, nystagmus, refractory
errors, etc.

5. Otorhinolaryngologist • Hearing assessment (BERA, OAE, etc.)

• Management of hearing impairment, if any

6. Dietician • Dietary advice regarding complementary feeding

• Management of infants with failure to thrive and
those with special needs (e.g. galactosemia)

7. Medical social worker • To take care of the social issues to help improve
follow up rates

8. Physiotherapist • Assessment and grading of muscle tone and power

• Plan an appropriate training program for each infant
with tone abnormalities
• To teach the parents for continuing the prescribed
exercises at home

9. Speech / occupational • Rehabilitation of infants with impairment/disability

Downloaded from www.newbornwhocc.org 4

 AIIMS- NICU protocols 2008

therapist

Ideally, all the required personnel should be available under one roof at a place
earmarked for follow-up care. If this is not feasible, at least the services of pediatrician,
clinical psychologist, dietician, medical social worker, and physiotherapist should be
ensured in the follow-up clinic. Medical social worker is an important member of the
team liasoning with the family and helps them to keep follow up visits. Infants who need
hearing/visual assessment or speech therapy can be referred to the concerned specialist
on fixed days.

Who needs follow-up care?

Selection of high-risk infants should be based on the gestational age, birth weight,
occurrence and severity of perinatal/neonatal illnesses, interventions received in the
neonatal intensive care unit (NICU), presence of malformations, etc. It can further be
modified for each unit based on their admission and outcome profiles.

Panel 1 lists the cohort of high risk infants whom we follow-up in our unit.

Panel 1: High risk neonates who need follow-up care (customize as per policy)

1. Babies with <1800g birth weight and/or gestation <35 weeks

2. Small for date (<3rd centile) and large for date (>97th centile)
3. Perinatal asphyxia - Apgar score 3 or less at 5 min and/or hypoxic ischemic
encephalopathy
4. Mechanical ventilation for more than 24 hours
5. Metabolic problems – Symptomatic hypoglycemia and hypocalcemia
6. Seizures
7. Infections – meningitis and/or culture positive sepsis
8. Shock requiring inotropic/vasopressor support
9. Major morbidities such as chronic lung disease, intraventricular hemorrhage, and
periventricular leucomalacia
10. Infants born to HIV-positive mothers
11. Twin with intrauterine death of co-twin
12. Twin to twin transfusion
13. Hyperbilirubinemia > 20mg/dL or requirement of exchange transfusion
14. Rh hemolytic disease of newborn
15. Major malformations
16. Inborn
Downloaded fromerrors of metabolism / other genetic disorders
www.newbornwhocc.org 5
17. Abnormal neurological examination at discharge
 AIIMS- NICU protocols 2008

The developing brain of premature babies is extremely vulnerable to injury; the risk for
neurodevelopmental deficit increases with decreasing gestational age and birth weight
resulting in relatively high risk of cerebral palsy, developmental delay, hearing and vision
impairment and subnormal academic achievement 5. Similarly, small for date infants
(birth weight < 3rd centile) are also at significant risk of poor long term outcomes. Those
who required mechanical ventilation for more than 24hours, babies with metabolic
problems – symptomatic hypoglycemia as half of them have abnormal
neurodevelopmental outcome, symptomatic hypocalcemia, birth asphyxia Apgar score 3
or less at 5 min, abnormal neurological examination at discharge, seizures,
hyperbilirubinemia > 20mg/dL or requirement of exchange transfusion, Rh hemolytic
disease of newborn as they have anemia presenting till three to six months age,
infections – culture positive sepsis or meningitis, babies born to HIV infected mothers,
twin with intrauterine death of co-twin due to increased incidence of cerebral venous
thromboembolic phenomenon, twin to twin transfusion or major malformation. All infants
cared for in the NICU should have periodic preventive assessment by their primary care
physicians which should include regular assessment of growth, sensory function,
behavior and neurodevelopment. Infants with suspect findings should be referred for
more comprehensive evaluation to a center with experience in follow up of high risk
neonates.

Downloaded from www.newbornwhocc.org 6

 AIIMS- NICU protocols 2008

Pre-requisites for follow-up

To ensure proper follow-up of the high risk infants, parents (especially mother) and other
family members should be counseled even before discharge from the hospital.
Discharge should be planned well in advance so that the mother can be counseled
adequately.

Discharge planning: Discharge planning should ideally begin as soon as the baby is
admitted in the nursery. This gives adequate time for the caretakers to ask questions
and practice skills. The following criteria should be fulfilled before discharging a high risk
infant:
• Hemodynamically stable; able to maintain body temperature in open crib
• On full enteral feeds (either breast feeding or by paladai/spoon)
• Parents confident enough to take care of the baby at home
• Has crossed birth weight and showing a stable weight gain for at least three
consecutive days; in case of very low birth weight infants, weight should be at
least 1400 grams before considering for discharge.
• Not on any medications (except for vitamins and iron supplementation). Ideally
preterm babies on theophylline therapy for apnea of prematurity should be off
therapy for at least five days to make sure that there is no recurrence.
• Received vaccination as per schedule (based on postnatal age).

These criteria can be individualized to meet the infant and family needs.

Counseling prior to discharge: Counseling plays an important role in the care of these
babies at home; regular counseling sessions should be done before discharge. Parents
should be given advice regarding:
• Temperature regulation – proper clothing, cap, socks, Kangaroo mother care
etc.
• Feeding – type and amount of milk, method of administration, and nutritional
supplementation, if any.
• Prevention of infections – hand washing, avoidance of visitors, etc.
• Follow-up visits – where and when (Table I)
• Danger signs – recognition and where to report if signs are present
• Vaccination – schedule, next visit, etc.

Downloaded from www.newbornwhocc.org 7

 AIIMS- NICU protocols 2008

• Special needs – e.g. next visits for ROP screening.

• If possible the family should be provided with the telephone number of the health
care provider e.g. on-duty doctor in case the family needs to consult for infant’s
illness.

Procedure for follow-up

Venue: A specified site should be earmarked for follow up services. The parents should
be properly communicated about the venue and it should also be mentioned in the
discharge summary. Registration procedure at the follow-up clinic should be simplified to
avoid any undue delay. Ongoing illness is common problem among these infants. If the
infant develops any illness requiring admission, priority should be given for the same.

Record maintenance: There should be a separate but uniform file for each high risk
infant . We have separate files for male and female babies. Male babies get blue and
female babies get pink files. Addresses and telephone numbers should be entered
clearly in the file. If possible, an alternate address and telephone number should also be
recorded. It may be good idea to enquire an important landmark for locating the house in
case one needs to make a home visit. The family should also be given a booklet
containing follow-up information.

Schedule: The follow up schedule should be explained to the parents (see below).
Timings should be fixed and adhoc visits should be discouraged.

Corrected age: Age of the child since the expected date of delivery. The correction for
gestational immaturity at birth should be done till 24 months age. All developmental
milestones are assessed according to corrected age to compensate for the prematurity.
The addition of complementary feeds is also according to corrected age.

Postnatal age: Age of the child since birth. Immunization is done according to postnatal
age.

When to follow up

For the purpose of follow-up visits, at-risk infants can be grouped under two major
categories: (1) preterm/LBW infants and (2) infants with other conditions. The follow-up

Downloaded from www.newbornwhocc.org 8

 AIIMS- NICU protocols 2008

schedule for both these categories has been summarized in Table II. This schedule
represents minimum number of visits of high risk neonates. If the baby has ongoing
issues or illness, more frequent visits are recommended. Please note that first contact of
the infant with the health providers after discharge is important and helps in identification
of adjustment problems at home. Ideally this contact should be achieved by the home
visit.

Table II: Follow-up schedule of at-risk infants

Cohort Schedule for follow-up

1. Infants with <1800g birth • After 3-7 days of discharge to check if the baby has been
weight and/or gestation adjusted well in the home environment. Every 2 weeks
<35 weeks until a weight of 3 kg (immunization schedule until 10-14
weeks to be covered in these visits)
• At 3, 6, 9, 12 and 18months of corrected age and then
every 6 months until age of 8years

2. All other conditions • 2 weeks after discharge

• At 6, 10, 14 weeks of postnatal age
• At 3, 6, 9, 12 and 18months of corrected age and then
every 6 months until age of 8years
Note: If a preterm infant (< 35 weeks) develop any other morbidity covered in ‘other conditions’, he
should be followed up as per the schedule outlined for the first group of cohort

The selection of age of assessment depends on developmental acquisitions available at

a given age, availability and applicability of appropriate test instruments at specific ages
and the cost and feasibility of long-term tracking in the population in question. The long
term follow up of complete cohorts is optimal for determining the outcome of high risk
neonates and the safety of antenatal and perinatal interventions. Very low birth weight
babies or those born at less than 33 weeks gestation should be followed up for eye
check up for retinopathy of prematurity till the postnatal age of 44 weeks.

Some neurological abnormalities that are identified in the first year of life are transient or
improve whereas findings in other children may worsen over time.7 By 12 months
corrected age the cognitive and language assessment can be done. By 18-24 months
corrected age there is improved prediction to early school age performance.8, 9, 10
The
importance of long term follow up lies in the fact that minor neurological disabilities may
not be detected early and become apparent only with increasing age. Standard follow-up
for many multicenter networks is currently at 18-24 months corrected age.

Downloaded from www.newbornwhocc.org 9

 AIIMS- NICU protocols 2008

What should be done at follow up?

Table III summarizes the plan for follow up.

Table III: Follow up plan for high risk infants

Assessment Age in months

Downloaded from www.newbornwhocc.org 10

 AIIMS- NICU protocols 2008

Assessment of feeding and dietary 1 2 3 6 9 12 15 18 24 ......8years

counseling
Growth monitoring All visits
Immunization As per schedule (based on postnatal age)
Neurological examination ‫٭‬ ‫٭‬ ‫٭‬ ‫٭‬ ‫٭‬ ‫٭‬ ‫٭‬
Developmental assessment and DQ ‫٭‬ ‫٭‬ ¶ ‫٭‬ ¶ ¶ ‫٭‬
Hearing (BERA) ‫٭‬ ¶ ¶ ¶ ¶ ¶ ¶
Ophthalmic evaluation ‫٭‬ ¶ ¶ ¶ ¶ ¶
USG/CT brain As indicated
¶ if previous test abnormal

1. Assessment of feeding and dietary counseling: Parents should be asked

about the infants’ diet and offered dietary counseling at each visit. Breast feeding
frequency and adequacy should be assessed. The amount, dilution and mode of
feeding should be noted if supplemental feeding is given. It is a good idea to
enquire about source of milk as milk supplied by local vendors is often diluted
(dilution has the same impact on the infant whether done by the family or the
vendor!). It is also important to record the duration of exclusive breast feeding. If
a baby is not gaining adequate weight on exclusive breast feeding take care of
any illness, maternal problems which may interfere with feeding and milk output.
If poor weight gain persists despite all measures to improve breast milk output,
supplementation can be considered.

Complementary feeding should be started at 6 months corrected age. Initially,

semisolids should be advised in accordance with the local cultural practices . Spend
adequate time on explaining what to give and how to give. The common practice of
giving too little or too dilute complementary food such as rice-water, dal-water, too
much of juice, etc should be discouraged. The recommended meal frequencies –
assuming a diet with energy density of 0.8 kcal per gram or above and low breast
milk intake are: 2−3 meals per day for infants aged 6−8 months; 3−4 meals per day
for infants aged 9−11 months and children 12−24 months; additional nutritious
snacks may be offered 1−2 times a day, as desired. Complementary foods should be
varied and include adequate quantities of meat, poultry, fish or eggs, as well as
vitamin A-rich fruits and vegetables every day. Where this is not possible, the use of
fortified complementary foods and vitamin mineral supplements may be necessary to
ensure adequacy of particular nutrient intakes. As infants grow, the consistency of
complementary foods should change from semisolid to solid foods and the variety of
foods offered should increase. By eight months, infants can eat ‘finger foods’ and by

Downloaded from www.newbornwhocc.org 11

 AIIMS- NICU protocols 2008

12 months, most children can eat the same types of food as the rest of the family.
The major problem with the family food is that it is not nutrient-rich11.

2. Growth monitoring: Growth (including weight, head circumference, mid-arm

circumference and length) should be monitored and plotted on an appropriate
growth chart at each visit. We use Wright’s charts (till 40 weeks PMA) and WHO
growth charts (for preterm infants after 40 weeks PMA and for term infants) for
growth monitoring . The infant’s growth pattern (slope of the curve) is compared
with the standard curve; any deviation should be noted and appropriate remedial
action taken. Weight should be taken on an electronic weighing scale. Length
should be measured with an infantometer. The infant should be held supine and
legs fully extended. The feet should be pressed against the movable foot piece
with the ankles fixed to 90˚. Head circumference should be measured with
nonstretchable fiberglass tape.12

3. Developmental assessment: Assessment of developmental milestones should

be done according to the corrected age. The milestones should be assessed in
four domains- gross motor, fine motor, language, and personal-social (see page
10 with instructions for filling given in page 9 of HRC file). The date of
assessment and the infants’ corrected age should be mentioned against each
milestone. Based on the date of achievement of milestones in a particular
domain and the expected age of achieving them, the developmental age can be
calculated.

Infants who lag behind in any domain should undergo a formal developmental
evaluation by a clinical psychologist using tests such as Developmental assessment
of Indian Infant II (DASII II)13. This scale consists of 67 items for assessment of motor
development and 163 items for assessment of mental development. Motor scale
assesses control of gross and fine motor muscle groups. Mental scale assesses
cognitive, personal and social skills development. Both mental development index
and psychomotor development index can be calculated by DASII. The age
placement of the item at the total score rank of the scale is noted as the child
developmental age. This converts the child total scores to his motor age (MoA) and

Downloaded from www.newbornwhocc.org 12

 AIIMS- NICU protocols 2008

mental age(MeA). The respective ages are used to calculate his motor and mental
development quotients respectively by comparing them with his chronological age
and multiplying it by 100. (DMoQ = MoA/CA x 100 and DMeQ = MeA/CA x 100).
The composite DQ is derived as an average of DMoQ and DMeQ.

The Vineland Social Maturity Scale measures social competence, self-help skills,
and adaptive behavior from infancy to adulthood. The Vineland scale consists of a
117-item interview with a parent or other primary caregiver.

It is emphasized here that developmental stimulation of the child should not be

delayed if the above mentioned tests are not available. Age appropriate
stimulation should be provided to these babies. Mental development index and
Psychomotor development index at 3, 12,18 and 24 months and every 3 months
if abnormal.

4. Immunization: Immunization should be ensured according to chronological age

. Parents should be offered the option of using additional vaccines such as
Hemophilus influenzae B, typhoid and MMR.

5. Ongoing problems: They should be mentioned in the follow up notes . The

management of ongoing illnesses is an integral part of any high risk follow up
program. The hospital admission of the child should be prioritized, if required.

6. Neurological assessment: Evaluation of muscle tone is an integral part of the

neurological examination. A waxing and waning pattern of neuromotor
development from 28 weeks of gestation to the end of first year of life was
reported by Amiel-Tison. From 28 to 40 weeks gestation, the acquisition of
muscle tone and motor function spreads from lower extremities towards the
head. After full term, the process is reversed so that relaxation and the motor
control proceed downwards for the next 12 to 18 months. So the upper limbs
begin to relax and acquire skills before the lower limbs. The axial tone follows a
similar pattern. Head control appears first followed by the ability to sit, stand and
walk. Hypertonia or hypotonia should be looked for by measuring the following
angles: adductor angle, popliteal angle, ankle dorsiflexion, and scarf sign; any

Downloaded from www.newbornwhocc.org 13

 AIIMS- NICU protocols 2008

asymmetry between the extremities should also be recorded. Any history of

seizures or involuntary movements should also be recorded.

Hypertonia in lower limbs is defined as when either adductor angle is restricted to

less than the age specific norms as per Amiel-Tison or if there is scissoring or tight
tendo-achilles or restriction of ankle dorsiflexion on extension of knee. Hypertonia in
upper limbs is defined as when scarf sign does not cross midline at one year
corrected age. Hypertonia of the neck extensors can be inferred by an increased gap
between the nape of the neck and examination table with the infant lying in supine
position.

The following angles should be measured to assess tone as shown in Figure1,

Table IV:

Table IV: Muscle Tone Norms

Age Adductor Popliteal Dorsiflexion Scarf sign

(months) angle angle angle

0-3 40˚ -80˚ 80˚ -100˚ 60˚ -70˚ Elbow does not cross

midline
4-6 70˚ -110˚ 90˚ -120˚ 60˚ -70˚ Elbow crosses midline
7-9 110˚ -140˚ 110˚ -160˚ 60˚ -70˚ Elbow goes beyond

axillary line
10-12 140˚ -160˚ 150˚ -170˚ 60˚ -70˚
Truncal extensor hypertonia: there is a tendency of body to go into
hyperextension or opisthotonus.

Cerebral palsy: Definitely abnormal neurological examination with upper motor

neuron signs with motor developmental delay.

Spastic hypertonia syndromes:

Hemiplegia- only one half of body involved

Diplegia- paresis of lower limbs more than upper limbs

Downloaded from www.newbornwhocc.org 14

 AIIMS- NICU protocols 2008

Quadriplegia- Paresis of all four limbs with upper limb involvement equal to or
more than lower limbs.

Abnormal neurological examination should be defined as definite abnormalities In

the form of:

a) Brisk reflexes with hypertonia or

b) Brisk reflexes with hypotonia or

c) Definitely and consistently elicited asymmetrical signs or

d) Persistent abnormal posturing or abnormal movements

The tone abnormalities should be taken care by regular physiotherapy. This

improves mobility of joints and locomotion of the child. The child should be
provided with special shoes if required. Orthopedic evaluation should be done
and corrective surgery for contractures should be done as required. All possible
efforts should be made to improve mobility of these children and make them
functionally less dependent and independent if possible.

Eye evaluation: The check-up for retinopathy of prematurity starts in the NICU and
continues till 44 weeks postconceptional age or till the retinal vessels have matured.
Refer to protocol on Retinopathy of prematurity14 .

At 9 months corrected age the ophthalmologist should evaluate the baby for vision,
squint, cataract and optic atrophy. Subjective visual assessment can be made from
clinical clues as inability to fixate eyes, roving eye movements and nystagmus.
Objective visual assessment should be done with the Teller Acuity Card. It has
seventeen 25.5 × 51 cm cards. Fifteen of these contain 12.5 × 12.5 cm patches of
square-wave gratings( vertical black and white strips) ranging in spatial frequency
from 38.0 cycles/cm to 0.32 cycles/cm. The range is in half octave steps. A cycle
consists of one black and one white stripe and an octave is a halving or doubling of
spatial frequency. In Snellens terms it is an halving or doubling of the denominator
e.g. 6/6, 612, 6/24. Half octave steps would be 6/6, 6/9, 6/12, 6/18, 6/24 and so on.

Downloaded from www.newbornwhocc.org 15

 AIIMS- NICU protocols 2008

There is a low vision card containing 25.5 × 23 cm patch of 0.23 cm cycle/cm( 2.2
cm wide black or white stripes). The seventeenth card is a blank grey card with no
grating pattern. The gratings have 82 – 84% contrast and are matched to the
surrounding grey card to within 1% in space average luminance. This minimizes the
chance of a patient fixating because of brightness difference. Detection of pattern
alone determines the fixating preference. Proper illumination without any shadows
should be ensured (10 candelas /sqm). Testing distance from patient’s eyes to the
cards should be maintained constant as it determines the visual acuity. Children from
7m to 3y should be tested at 55 cm and later at 84 cm.

Rehabilitation for visual impairment should be early so that the child gets appropriate
stimulation. If delayed the restoration of the vision may not be possible because of
continuous sensory deprivation of the optic nerve. The child should be provided with
glasses or corrective surgery as appropriate. It should be emphasized that a good
high risk follow up program does not only pick up handicaps early but also ensures
early corrective measures and rehabilitation. This emphasizes the multidisciplinary
and well coordinated approach to such babies

7. Hearing evaluation: High risk infants have higher incidence of moderate to

profound hearing loss (2.5-5% vs. 1%). Since clinical screening is often
unreliable, brainstem auditory evoked responses (BAER/BERA) should be
performed between 40 weeks PMA and 3 months postnatal age. A screening
BERA is usually done initially. If this is abnormal, a diagnostic BERA should be
done within 2 weeks of the initial test. Infants with unilateral abnormal results
should have follow-up testing within three months. The test should be carried out
in a sound-proof room and the infant should be sedated with oral triclofos
50mg/kg 30 min before the procedure. To measure the electrical pulses, small
monitoring electrodes are placed on the scalp. Earphones provide a clicking
noise to the ear and the response from the brainstem is measured time-locked to
the clicks. The clicks may become louder or softer, faster or slower, to see how
the auditory responds to these different stimulus parameters. The other method
of assessment for hearing is oto-acoustic emission (OAE). This records acoustic
feedback from the cochlea through the ossicles to the tympanic membrane and
ear canal following a click stimulus. It is quicker to perform than BERA but is
more likely to be affected by debris or fluid in the external and middle ear. It is

Downloaded from www.newbornwhocc.org 16

 AIIMS- NICU protocols 2008

unable to detect some form of sensorineural hearing loss including auditory

dyssynchrony.

The severity of hearing loss is profound (70 dB or more of hearing loss), severe (50
dB - 70 dB), moderate (30 dB - 50 dB) and mild (15 dB - 30 dB).

The audiological testing should be done at 3 months of age. Infants with true hearing
loss should be referred for early intervention to enhance the child’s acquisition of
developmentally appropriate language skills. The child should be provided with
hearing aids and if severe to profound hearing loss cochlear implants should be
considered by 12 months age. Fitting of hearing aids by the age of 6 months has
been associated with improved speech outcome. Initiation of early intervention
services before three months age has been associated with improved cognitive
development at 3years age15

Early stimulation
The high risk baby requires more attention of the family members. Parents and
family members need to aid the development process in an age appropriate way
spending quality time with children. Such interactions improve parent child
relationship and bring about positive parental attitudinal change. Effective
parents supervise their children in an age appropriate way, use consistent
positive discipline, communicate clearly and supportively, and show warmth,
affection, encouragement, and approval. The actions of the child should be
appreciated. This makes him happy and encourages doing more activities.

0-2 months:
Activities
• Maintain eye to eye contact
• Talk and sing to the baby while bathing, dressing and feeding
• Help the baby to turn his head to sound and light
Auditory

Downloaded from www.newbornwhocc.org 17

 AIIMS- NICU protocols 2008

• Provide different sounds to the child like rattle, bell, squeezing a toy.
Make the child listen to music, high pitched and low pitched human
sounds
• Humming in a soft low voice
Visual
• Keep the baby in a well lighted room
• Shine mobile, color balls and hang bright clothes
Tactile
• Put the baby on different surfaces like soft clothes, mattresses, rubber mat
and mother’s lap
• Change the child’s position frequently like putting on his back, sides and
tummy
Kinesthetic
• Support the head and gently rock the child avoiding sudden jerky
movements
2-4 months
General stimulation
• Hold the baby at the shoulder
• Place things just out of the reach of the baby. Stimulate him to reach out
and grasp the object
Auditory
• Give sound producing toys
• Talk to the child more frequently
• Point out the names of objects shown to the child
Visual
• Hang bright objects about 30cm above the crib
• Maintain eye contact while talking to the child
Tactile
• Give the child paper to crumble and things to bite and suck
• Place the child on a rubber mat on the ground allowing him to move freely

Downloaded from www.newbornwhocc.org 18

 AIIMS- NICU protocols 2008

4-6 months:
General activities:
• Sit the baby in the mother’s lap and ask her to gently bounce her knees
singing songs.
• Place the child flat on the back on the ground over a soft surface. Show
him a colorful toy. Slowly turn him by flexing the far away leg. Assist him to
turn over the tummy.
• Show an attractive toy and encourage the child to reach out to it.
• Put your hands under the child’s feet and move his legs up and down like
pedaling a cycle.
Auditory
• Shake a bell or a squeaky toy over the head of the baby. Encourage him
to turn his head and locate the sound
6-8 months:
• Call the child by his name
• Make the child sit as long as possible. Give support to his pelvis.
• Give him pieces of paper to tear
• Encourage him to roll over his tummy by showing him colorful toys on one
side.
8-10 months:
• Make the child stand by holding onto the furniture
• Encourage the child to clap hands
• Give him a small container and ask to drop small thing into it.
• Encourage him to produce monosyllables.
• Show him picture books and assist to turn the pages.
10-12 months:
• Let the child play with other children
• Name the body parts while bathing him
• Take the child on a walk and show him different animals and birds

Downloaded from www.newbornwhocc.org 19

 AIIMS- NICU protocols 2008

• Do simple actions like clapping, bye-bye and encourage copying these

actions.
• Encourage him to pull to stand by holding the furniture
• Make the child sit in front of a mirror so that he can see himself
12-15 months:
• Give picture books to the child. Talk about what you see and let him turn
the pages
• Ask him to put cubes one over the other
• Ask him to put things into the container and then take out things out of the
container.
• Hide a small toy under a cloth. Encourage the baby to find the hidden toy.
• Ask the child to scribble by drawing a few lines. First demonstrate what he
is supposed to do.

How to ensure a good follow up rate

The importance of follow up should be emphasized frequently to the parents. The

permanent and present addresses along with phone numbers should be kept to ensure
follow up. If the parents do not turn up for follow up they should be telephoned and
letters should be posted to ensure good follow up rates. There should be a dedicated
person who can adjust the timing with the parents. If possible home visits should be
arranged for those who do not turn up. There should be a comprehensive assessment of
the child under one roof to minimize the hassles of roaming from one corner of the
hospital to the other.

Downloaded from www.newbornwhocc.org 20

 AIIMS- NICU protocols 2008

References

1. Narayan S, Aggarwal R, Upadhyay A, Deorari AK, Singh M, Paul VK. Survival and morbidity in
Extremely Low Birth Weight (ELBW) infants. Indian Pediatr 2003; 40: 130-135.

2. Costello D, Friedman H, Minich N, Siner B, Taylor G, Schuchlter M, Hack M. Improved

neurodevelopmental outcomes for extremely low birth weight infants in 2000-2002. Pediatrics 2007;
119: 37-45.

3. Escobar G, Littenberg B, Petitti DB Outcome among surviving very low birthweight infants: a meta-
analysis. Arch Dis Child Feb1991; 66: 204 - 211.

4. Wang CJ, McGlynn EA, Brook RH, et al. Quality-of-care indicators for the neuro-developmental follow-
up of very low birth weight children: results of an expert panel process. Pediatrics. 2006; 117(6):2080 –
2092.

5. Vohr BR, Wright L, Anna M, Perritt R, Poole WK, Tyson JE, et al. Center for the Neonatal Research
Network Center differences and outcomes of exteremely low birth weight infants. Pediatrics
2004:113:781-789.

6. Chaudhari S, Bhalerao M, Chitale A, Pandit A, Nene U. Pune Low Birth Weight Study - A Six Year
Follow Up. Indian Pediatr1999; 36:669-676.

7. Drillien C. Abnormal neurological signs in the first year of life in low birth weight infants: possible
prognostic significance. Dev Med Child Neurol 1997; 14:575-84.

8. Weisglas-Kuperus N, Baerts W, Smrkovsky M, Sauer PJ. Effects of biological and social factors on the
cognitive development of very low birth weight children. Pediatrics.1993; 92:658 –665.

9. Dezoete JA, MacArthur BA, Tuck B. Prediction of Bayley and Stanford-Binet scores with a group of very
low birthweight children. Child Care Health Dev.2003; 29:367 –372.

Downloaded from www.newbornwhocc.org 21

 AIIMS- NICU protocols 2008

10. Lee H, Barratt MS. Cognitive development of preterm low birth weight children at 5 to 8 years old. J Dev
Behav Pediatr.1993; 14:242 –249.

11. Report of the global consultation, and summary of guiding principles for complementary feeding of the
breastfed child Authors: World Health Organization

12. Implementation of the WHO Multicenter Growth Reference Study in India —N. Bhandari, S. Taneja, T.
Rongsen, J. Chetia, P. Sharma, R. Bahl, D. K. Kashyap, and M. K. Bhan, for the WHO Multicenter
Growth Reference Study Group

13. Phatak B. Mental and motor growth of Indian babies (1-30 months). Final report. Department of Child

Development, MSUB, Baroda, 1970.

14. Chawla D, Agarwal R., Deorari AK, Paul VK. Retinopathy of Prematurity. Indian Journal of Pediatrics
2008;75(1):73-76

15. NIH Joint Committee on Infant Hearing. Year 2000 position statement: Principles and guidelines for
early hearing detection and intervention programmes. Pediatrics 2000; 106:798-817.

Downloaded from www.newbornwhocc.org 22

 AIIMS- NICU protocols 2008

Adductor
Scarf sign angle

Dorsiflexion Popliteal
angle angle

Figure1:Amiel-Tison method of assessment of tone in infants

Downloaded from www.newbornwhocc.org 23

View publication stats