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.
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,
 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 -
SGA Good neurodevelopmental Decreased motor functiondown
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

perempua
n
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
 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