dr.

Mei Neni Sitaresmi, PhD, SpA(K)

Devisi Tumbuh kembang-Pediatri Sosial, FK UGM- RS

DR. Sardjito, Yogyakarta
Anggota UKK Tumbuh kembang-Pediatri Sosial, IDAI
Anggota Satgas Imunisasi, IDAI
Ketua Komda KIPI DIY
Pendidikan:
Dokter umum, FK UGM, l1989
Sp.A, FK UGM, 2002
Konsultas , Kolegium IKA, 2008
PhD, VU Netherland, 2009
Follow up of preterm babies

Mei Neni Sitaresmi

Bagian IKA, FK UGM
 EB
preterm baby, 32 weeks, 1.400 gram
 introduction
Preterm: gestational age < 37 completed
weeks, contributes substantially to the
incidence of low birth weight and is the
leading underlying cause of infant mortality
among infants with nonlethal congenital
anomalies
Maternal Nutrition and Birth Outcomes (2010) 32 (1): 5-25
Improve NICU care long-term impairments among
the survivors
 Morbidity of preterm babies
Morbidity:
infection
intraventricular hemorrhage (IVH) and periventricular
leukomalacia (PVL)
Sensory problems: hearing loss, retinopathy of
prematurity (ROP)
chronic lung disease or bronchopulmonary dysplasia
(BPD)
the patent ductus arteriosus (PDA)
Anemia of prematurity
Doyle LW, NeoReviews 2009
higher rate of hospital readmission and death during
the first year after birth, especially due to respiratory
tract infection
 Long term outcome
Neurodevelopment problems:
Motor delayed Cerebral Palsy
Global developmental delay/ Mental retardation
Speech and language delayed
behavioral problem: ADHD
Neurosensory: hearing and vision impairment
Learning disability, subnormal academic achievement
The problems increase with decreasing gestational
age
Doyle LW, NeoReviews 2009
 NICU discharge criteria

Parental counseling
Discharge
planning
Follow up

Promotion and prevention care

Growth monitoring
Neuorodevelopment and behavioural monitoring
Early intervention
(AAP, Committee on Fetus and Newborn. 2008)
 Goal of premature follow up
Parental counseling
Early identification of developmental disability
Identification and treatment of medical
complications
Provision of feedback for neonatologists,
pediatricians, obstetricians, and other
providers
 Follow up of preterm babies
Promotion and prevention:
Parental counseling
Breastfeeding, stimulation, KMC, sleep hygiene, sudden
infant death syndrome (SIDS) prevention
Immunization
Growth monitoring
Neurologic assessment
Sensory, developmental and behavioural
assessment
(AAP, Committee on Fetus and Newborn. 2008)
 immunization
Preterm infants are at high risk for increased
morbidity from vaccine-preventable diseases,
but they are the group to most likely have
delayed immunizations
Except hepatitis B, vaccines should be given at
full dose and on schedule by chronological age
to the medically-stable preterm infant
Satgas IDAI 2014, CDC 2015, AAP 12
Hepatitis B vaccine in premature infant
Preterm infants born to mother with HBsAg
positive or unknown must receive hepatitis B
vaccine and hepatitis B immune globulin (HBIG)
within 12 hours of birth
Infant with BW < 2.000 gram whose mother with
HBsAg negative: hep B vaccine should be
postponed at chronologic age 1 month or at
discharge if they are medically stable and have
gained weight consistently
(pink book, CDC 2015, satgas IDAI 2014)
Saari TS. 2003. Immunization of preterm and low birth weight infants. Pediatrics. 2003;112:193-198.
 Parental counseling
Breastfeeding:
breat milk may be protective factor for visual development,
intellectual development, brain growth and cognition
increased epidermal and transforming growth factors (EGF and
TGF-alpha) in mother's milk during the first postpartum month -
-> l importance in healing effects on gastrointestinal mucosa.
Kanguru mother care
Massage therapy with moderate pressure gained
significantly more weight, increase bone density, shorter
hospital stay (Field T, et al, Infant Behav Dev. ; 2010)
Sleep hygiene
the SIDS risk-reduction
Stimulation: child- primary care givers interaction
 Prevention on SIDS
TASK FORCE ON SUDDEN INFANT DEATH SYNDROME,
AAP 2011
preterm infants are at increased risk of SIDS
The association between prone sleeping and SIDS
appears to be stronger in LBW infants than in normal
BW infants
Preterm infants should be placed supine for
sleeping: protective airway mechanisme, at least
during the first year
Supervised, awake tummy time is recommended to
facilitate development and to minimize development
of positional plagiocephaly
 Prevention on SIDS
TASK FORCE ON SIDS, AAP 2011

Infants should be placed for sleep in a supine position

until 1 year of life, side sleeping is not safe and is not
advised.
Use a firm sleep surface
Room-sharing without bed- sharing
Keep soft objects and loose bedding out of the crib
Avoid smoke exposure during pregnancy and lactation
Breastfeeding is recommended
Avoid overheating
Infants should be immunized in accordance with
recommendations
 Growth assessment
Early indentification of health and nutrition
problem early intervention
adequat growth in early life decrease the risk
of CP and neurodevelopment problems
(Richard. Pediatrics; 2006)
Head circumference (HC) growth correlate
with MRI and neuodevelopment outcome
(Cheong JL. Pediatrics; 2008)
 Summary of Neurodevelopmental Outcomes: appropriate-for-
gestational-age (AGA) and small-for-gestational-age (SGA)
infants who attained adequate v. delayed extrauterine growth*

Neurodevelopmental Adequate Delayed extrauterine

outcomes in subgroups catch-up growth growth (EUGR)
of VLBW premature infants

AGA Good neurodevelopmental Decreased mental and

outcome motor function
Catch - down
SGA Good neurodevelopmental Decreased motor function
outcome (similar to AGA with
adequate catch-up growth Catch - up

VLBW, very low birthweight. Latal-Hajnal et al J Pediatr 2003;143(2):163-70

*9 and 24 months
Poor HC Growth Increases Odds for Poor Outcome
ELBW infants, in-hospital HC growth: 0.67 v. 1.17 cm/wk

Cerebral palsy
4.10 (1.2413.59)

Bayley MDI <70

2.33 (1.104.95)

Neurodevelopmental
Impairment 3.64 (1.857.18)

0.2 1.0 10.0 50.0

Odds Ratio (95% Confidence Interval)
HC=Head circumference
MDI=Mental Development Index
Ehrenkranz RA, et al. Pediatrics 2006;117:1253-61.
 Growth assessment
Weight, length, and head circumferences should be
collected routinely and serially in all programs by
examiners trained to reliability using standard
techniques.
plot precisely, interpreting the growth
< 2 years:
weight should be obtained with the child completely
undressed.
length is obtained by using a pediatric length board,
maximal occipital frontal head circumference is
recorded to the nearest millimeter by using a non
stretch measuring tape
British Columbia, WHO growth standard training module, 201
 Corrected age for prematurity (<37
weeks):
Corrected postnatal age:
Is based on 40 weeks gestation
Is used until 24 months postnatal age
Calculate corrected age as follows:
Current postnatal age in weeks subtract (40 weeks
gestation age in weeks at birth) equal corrected
age in weeks:
Eg at 14 weeks postnatal age, an infant born at 30
weeks gestational age would be 4 weeks corrected
postnatal age: (14- (40-30))= 4 weeks corrected age
British Columbia, WHO growth standard training module, 2014
 Growth chart for preterm babies
Large preterm birth sample size of 4 million infants;
1991 -2007
Girl and boy specific charts
Equivalent to the WHO growth charts at 50 weeks
gestational age (10 weeks post term age)
> 10 weeks old: use WHO growth standard 2006
should be plotted as exact ages: eg a baby at 25 3/7
weeks should be plotted along the x axis between 25
and 26 weeks.

(Fenton TR; BMC Pediatrics 2013

perempuan
laki
 Poor growth
Poor feeding skill:
Sucking, swollen reflex
Sensory problems/ feeding aversion
In-adequate intake:
Breast milk Fortification with human milk fortifier
Formula milk: preterm formula, post discharge
formula, standard formula
Increase metabolism:
Cardiac problems, respiratory
 Head circumference growth
VLBW/ ELBW babies have higher risk for
developing hydrocephalus
Head growth out of proportion to any catch-
up growth in weight or length or genetic
potential is an indication for further
evaluation
 hearing
Premature baby should undergo hearing
examinations prior to discharge or 1 month
corrected age (if not by discharge)
Repeat at 6 months old
Other risk factors: meningitis, asphyxia,
exchange transfusions, and administration of
ototoxic drugs, such as gentamicin
 vision
Screening of ROP:
At chronologic age 4 weeks (or at 31 weeks' post
conceptual age if the infant was born before 27
weeks' gestation) and, depending on the results, at
least every 2 weeks thereafter until the retina is fully
vascularized or ROP regresses
Screening for myopia, strabismus, and amblyopia,
nystagmus
AAP section on Ophthalmology/ American Academy of
Ophthalmology (AAO)/ American Association of Pediatric
Ophthalmology and Strabismus (AAPOS), 2013
 Vision screening
Regular, long-term ophthalmologic follow-up,
including eye examination at one and five
years of age is recommended for all ELBW
infants regardless of presence or absence of
ROP
 Neurologic examination
observation of posture, movement, and
quality of movement before the onset of the
formal examination
Primitive reflex
postural tone: ventral suspension, trunchal
positioning
symmetrical posture
Neuromotor screening expert panel, AAP, Pediatrics 2013
 Development and behavioral
monitoring
Developmental surveillance at every visit
Developmental screening if developmental
surveillance concerned, 9 month, 18 months,
24/30 months and 48 months of ages
AAP, 2006;
Developmental Surveillance
Developmental Screening

18 months 24/30
9 months months
 Screening- development :

Pre-screening development questionnaires

KPSP
Parents evaluation on development status
(PEDS)
Denver II
BINS ( Bayley Infant Neurodevelopment Screener)
Capute Scale
Pediatric symptom checklist (PSC)
Checklist for Autism in Toddlers ( CHAT)/ M-CHAT
Abbreviated Conners rating scale
Strength & difficulty questionnaire (SDQ)
 Take home messages
Discharge planning of preterm babies including
parental counseling of essential cares: breastfeeding,
early stimulation, KMC, sleep hygiene, and
prevention of SIDS
every preterm infant needs extra-vigilant monitoring
and early referral for concerns:
Health, growth, neurodevelopment, cognitive and
behavioral problem