Follow up a NICU graduate

Introduction And Rationale

Improving perinatal-neonatal care has led to the increased survival of high-risk newborns.
These survivors are at high risk of post-discharge morbidities.
Morbidities include growth failure, ongoing medical illnesses, neurosensory impairment, and developmental deficits.
A comprehensive follow-up program ensures intact survival and optimal quality of life.

Rigorous follow-up of all discharged neonates is neither practical nor feasible.
A cohort of high-risk neonates must be selected based on specific criteria.

Primary Criteria	Specific Clinical Conditions Requiring Follow-Up
Extreme Prematurity & Low Birth Weight	Birth weight < 1500 grams. Gestation < 32 weeks.
Severe Neurologic Injury	Hypoxic ischemic encephalopathy (HIE) stage 2 or higher. Meningitis. Abnormal neurological examination or seizures at discharge. Intraventricular hemorrhage (IVH) grade III or periventricular leukomalacia (PVL).
Respiratory Morbidity	Received mechanical ventilation for 48 hours or more. Chronic lung disease or bronchopulmonary dysplasia (BPD).
Severe Metabolic & Systemic Issues	Intrauterine growth < 3rd centile. Major malformations or inborn errors of metabolism. Symptomatic hypoglycemia or polycythemia. Hyperbilirubinemia requiring exchange transfusion.

Discharge planning should ideally begin many days before discharge.
The neonate must be hemodynamically stable and maintain body temperature in an open crib.
The infant must be on full enteral feeds, either through direct breastfeeding or paladai/spoon.
There must be a stable weight gain for at least three consecutive days.
Very low birth weight (VLBW) infants should reach a weight of at least 1600 grams before discharge.
The infant must be off all medications, except for vitamins and iron.
Preterm infants on caffeine therapy should be off treatment for at least 5 days prior to discharge.
Parents must be confident to care for the infant at home.

The follow-up schedule should be clearly explained and documented in the discharge summary.

Infant Category	Initial Visits	Subsequent Visits
Very Preterm Infants	3 to 7 days after discharge. Every 2 weeks until body weight reaches 3 kg.	1, 2, 3, 6, 9, 12, 15, 18, and 24 months. Yearly visits until 8 years of age.

Corrected age is the age of the child since the expected date of delivery.
Correction for gestational immaturity must be used until 24 months of age.
Anthropometric parameters, developmental milestones, and initiation of complementary feeds are assessed according to corrected age.
Postnatal age is the age since birth and is strictly used for scheduling immunizations.

Assessment involves accurate weight, length, and head circumference measurements.
Serial plotting on growth curves provides valuable information regarding nutritional status.
Fenton or Intergrowth-21 charts are used for preterm infants.
WHO Child Growth Standards can be used for monitoring growth after reaching term age.
Dietary counseling and breastfeeding assessment must be offered at each visit.

Early identification of developmental disability allows for appropriate planning and parental counseling.
Screening should be performed at 3, 6, 9, 18, and 24 months of corrected age.
Amiel-Tison neurological assessment is widely used for evaluating muscle tone.
Hammersmith Infant Neurological Examination (HINE) is a standardized clinical examination for infants between 2 and 24 months.
A HINE score of less than 40 is always associated with cerebral palsy (CP).
A HINE score less than 56 at three months strongly predicts CP at two years of corrected age.

Common Screening Tools	Description
Trivandrum Development Screening Chart (TDSC)	Assesses gross motor, fine motor, vision, hearing, and language.
Denver Developmental Screening Test-II (DDST-II)	Assesses gross motor, language, fine motor-adaptive, and personal-social domains.
Development Assessment Scale for Indian Infants (DASII)	An Indian adaptation of Bayley-II. Gives developmental age expressed as a percentile.

Retinopathy of prematurity (ROP) screening must continue until 40 to 44 weeks postconceptional age or until retinal vessels mature.
Visual acuity should be formally assessed at nine months of age.
Children failing a two-stage hearing screening should undergo a diagnostic Brainstem Evoked Response Audiometry (BERA) evaluation by 3 months of age.

High-risk infant follow-up requires a multidisciplinary approach.
The neonatologist or pediatrician acts as the nodal coordinator.
The team includes a clinical psychologist, early interventionist, physiotherapist, occupational therapist, and speech therapist.
A nutritionist and medical social worker are essential for diet and family support.
Specialists like an ophthalmologist and pediatric neurologist should be available for ready referral.

A structured checklist model, known as the "BLUE BOOK," guides the follow-up of a very preterm baby from birth to 6 years.
It documents perinatal risk factors, risk stratification, growth, and developmental screening.
This tool facilitates a systematic, organized, and complete transition of care from the NICU to the community.