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Kangaroo Mother Care Method

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Title: Kangaroo Mother Care Method


1
Kangaroo Mother Care Method
  • OUTPATIENT KANGAROO MOTHER CARE
  •  
  • WITH KANGAROO FOLLOW UP (up to term)
  •  
  • AND HIGH RISK FOLLOW UP (up to one year of
    corrected age)
  •  
  • MODULE 5

2
outpatient follow up
  • The Kangaroo Mother Care method, as described in
    this training kit, includes a follow up program
    in 2 steps
  • 1) From discharge from the neonatal unit up to 40
    weeks of gestational age.
  • 2) From term up to one year of corrected age

3
outpatient follow up
  • Follow up programs includes the following
    aspects
  • Outpatient Kangaroo adaptation re-enforcement of
    the training in kangaroo position and the
    kangaroo nutrition for families trained in KMC in
    the hospital and then discharge to home in
    kangaroo position and training for new parents
    joining the KMC program after discharge from
    different units not implementing KMC.
  • Regular monitoring of somatic growth,
    neurological and psychomotor development, as
    compared to referral standards during the first
    year of life.
  • Early identification, treatment, and
    rehabilitation of any disorders in preterm and/or
    LBW infants, which may include the intervention
    of specialists.
  • Support and counseling strategies for the family.
  • Quality monitoring of the kangaroo clinical
    practice
  • Active immunization.

4
EARLY DISCHARGE FROM THE NEONATAL UNIT
  • Childs eligibility criteria for discharge
  • The childs in-hospital kangaroo adaptation has
    been successful he is regulating his temperature
    in kangaroo position and has an adequate
    suckingswallowing-breathing coordination.
  • The child demonstrated adequate weight gain in
    the Neonatal Unit in kangaroo position and
    incubator, for at least 3 days, if older than 10
    days. (The child may lose weight during the first
    few days and eligibility criteria for a stable
    child during the first week are different).
  • The child completed his treatment, if any.
  • If the child is receiving oxygen through a
    cannula, it must be below ½ l/min.
  • The child is breastfed and/or fed with extracted
    milk.
  • There is a Kangaroo Mother Program available able
    to offer adequate follow-up.

5
EARLY DISCHARGE FROM THE NEONATAL UNIT
  • Mothers eligibility criteria for discharge
  • She has accepted to participate in the KMC
    Program and has received the necessary training
    in the Kangaroo Mother Method.
  • She feels able to care for her child using KMC
    (position and nutrition) at home.
  • She succeeds in in-hospital kangaroo adaptation.
    In particular, she has adequate breastfeeding and
    milk extraction techniques.
  • She is physically and mentally able to care for
    her child. The mother received a positive
    recommendation from the multidisciplinary team in
    the case of a difficult situation, such as a
    teenage mother, single mother with a child under
    oxygen, in difficult socio economic situation, or
    alcoholism or drug addiction.
  • The mother should not be under anti-depressive
    drugs or using sleeping pills.
  • She is supported by her family in the KMC ward
    or/and in the outpatient KMC program.

6
EARLY DISCHARGE FROM THE NEONATAL UNIT
  • Familys discharge eligibility criteria
  • The family is committed to and able to attend
    follow-up visits in the kangaroo outpatient
    clinic and to comply with its requirements.
  • The family has the will to be trained in KMC.
  • The family understands well the method and it is
    feasible for them to care for the baby at home.
  • The family is available and will cooperate to
    care for the baby and insure his safety.
  • The family will comply with follow-up
    appointments, specialized medical exams,
    breastfeeding schedules, and drugs prescriptions.
  • The family will adapt to the temporary changes
    implied by the adoption of KMC. maintain the
    kangaroo position 24 hours a day (sleep in
    semi-sitting position) and redefine the
    cooperation roles of all family members, to
    support the primary caregiver. Family members
    involved in Kangaroo child care should be free of
    infectious or contagious, skin disease, fever, or
    significant obesity, and must be physically and
    mentally able to manage the child under the KMC.

7
PHYSICAL STRUCTURE OF A KMC OUTPATIENT
CONSULTATION
  • Outpatient kangaroo follow up activities are
    usually organized daily in premises staffed with
    a multi-disciplinary team, including
    pediatricians, nurses, and psychologists trained
    in KMC. Sick children are not admitted in the KMC
    outpatient clinic to avoid possible
    contamination.
  • Ideally, this place is located in a hospital
    where there is a Neonatal Unit equipped with
    human and technological resources in case of an
    emergency.
  • The follow up consultation team includes a
    pediatrician, a nurse, a psychologist, and a
    social worker. When necessary, other health
    professionals join the team, such as
    nutritionists, physiotherapists,
    ophthalmologists, optometrists, and
    orthophonists.
  • Each child is assessed individually and each
    family receives personalized recommendations
    yet, at the same time, the entire group is taught
    about KMC procedures and benefits.
  •  

8
PHYSICAL STRUCTURE OF A KMC OUTPATIENT
CONSULTATION (2)
  •  
  • The open (group) consultation is facilitated by a
    team of health care personnel working together
    and using multimodal communication techniques,
    resulting in better adherence to the program by
    the parents.
  •  
  • This methodology also facilitates the collective
    learning processes and reinforces the mothers
    knowledge when she repeatedly hears the same
    advice. Parents, while waiting, can also listen
    to the problems of other parents and exchange
    experiences and difficulties.
  •  
  • This group consultation also decreases the
    parents anxiety. The presence and availability
    of a psychologist supports parents in cases of
    depression, insecurity, or vulnerability.
  • The commitment to attend the daily consultations
    at the beginning of the outpatient KMC Program is
    demanding on parents, and in a way is similar to
    the daily visits they did when the child was
    hospitalized, creating a link between neonatal
    unit and home care.

9
ASSESSMENT OF THE NEWBORN WHEN ADMITTED TO AN
OUTPATIENT KMC
  • The gestational age at birth is determined
    according to the Lubchencos classification
    tables.
  • The anthropometric parameters are assessed
    (weight, height, head perimeter)
  • A full clinical assessment is conducted (from
    head to toes)
  • Outpatient KMC adaptation is reinforced or
    initiated as necessary.
  • Brain sonography and ophthalmologic screenings
    are requested if possible and if necessary.
  • Routine and specific drugs are prescribed.
  • The need for oxygen is assessed.
  • The need for family support is assessed and
    provided

10
ASSESSMENT OF THE NEWBORN WHEN ADMITTED TO AN
OUTPATIENT KMC (2)
  • Gestational age at birth
  • The child is classified according to the
    correlations between his age and his weight at
    the time of birth (using the Lubchencos
    classification) and this classification is noted
    in his medical record.
  • It is important to make parents aware that the
    initial period of care until the child reaches 40
    weeks will be difficult and extremely demanding
    but that the benefits of these efforts extend for
    the rest of the childs life.
  • Anthropometric parameters (weight, height,
    head perimeter)
  • The weight, the height in supine position, and
    the head circumferences, are generally considered
    to be the most important indicators of growth and
    nutritional status.
  • Anthropometry must be a routine procedure in NCIU
    as it helps to identify those neonates at a
    higher risk for morbidity and mortality as well
    as those who may present nutritional problems.
  • During the first visit and every subsequent
    visit, anthropometric measurements are recorded
    in the charts specific to the childs gender and
    age.

11
ASSESSMENT OF THE NEWBORN WHEN ADMITTED TO AN
OUTPATIENT KMC (3)
  • The majority of anthropometric measurements must
    be compared to tables of a reference population
    similar to the target population.
  • Establish the gestational age
  • Measure weight, height, and head circumference
  • Record these measurements with a dot in the
    appropriate place on the growth charts
  • Interpret the growth indicators according to
    percentiles or standard deviations
  • Connecting the dots from consecutive visits shows
    the child growth trend, and any abnormality can
    then help health personnel to recognize
    deviations in a timely manner

12
ASSESSMENT OF THE NEWBORN WHEN ADMITTED TO AN
OUTPATIENT KMC (4)
  • Height for age (H/A)
  • Weight for age (W/A)

Cut-off point (Standard deviation or Percentile) Denomination
lt 2 Below length for age or stunting.
gt - 2 a lt - 1 At risk for below length
gt - 1 Adequatelength
Cut-off point (Standard deviation or percentile) Denomination
lt - 3 Very low weight for age or severe chronic malnutrition.
lt - 2 Low weight for age or chronic malnutrition.
gt - 2 a lt - 1 At risk for low weight for age.
gt - 1 a lt - 1 Adequate weight for age.
Head circumference (HP/A)
Cut-off point (Standard deviation or percentile) Denomination
lt - 2 Risk factor for neurodevelopment
gt - 2 a lt 2 Normal
gt 2 Eventually Risk factor for neurodevelopment
13
 ASSESSMENT OF THE NEWBORN WHEN ADMITTED TO AN
OUTPATIENT KMC (5)
  • Full clinical assessment (from head to
    toes)
  • Skin It is important to check for pallor,
    cyanosis, jaundice, bruises or birth marks.
  • Head The head is assessed for shape and symmetry
    by observation and palpation and to recognize
    mainly the following points/conditions
  • Caput succedaneum. Contusion and edema of the
    scalp.
  • Molding. Overlapping of fetal skullbones can
    produce a pointed or flattened shape in the
    babys head.
  • Fontanels size. Anterior and posterior fontanels
    are found at each end of the sagittal suture.
    They must be open and normotensive.
  • Plagiocephaly. Asymmetry of the skull.
  • Craneotabes Small areas of the parietal bones
    close to the suture lines they may feel soft and
    produce a clicking sound under pressure.
  • Cephalohematome Blood collection under the
    periostium of one of the bones of the skull.
  • Presence of the scaly suture, when performing a
    bilateral palpation of the skull. This sign is
    part of Amiel Tisons neurological triad, which
    is described further down in this chapter.

14
 ASSESSMENT OF THE NEWBORN WHEN ADMITTED TO AN
OUTPATIENT KMC (6)
  • Full clinical assessment (from head to toes)
  • Ears Abnormalities of the pinna aligned with the
    ear or the corners of the mouth, may be related
    to renal or gastrointestinal malformations.
  • Face Assess the appearance of the face its
    symmetry, detect the presence of malformations,
    lesions of the facial nerve, hemangiomas, etc.
  •  Eyes
  • Epicanthic folds (skin fold in the inner corner
    of the palpebral fissure
  • Hypertelorism (the distance between the 2 eyes is
    too large)
  • Sub-conjunctival hemorrhage
  • An ocular secretion may be observed due to a
    conjunctive irritation or a blockage of the
    nasal-lacrymal ductus. 
  • Mouth Check the size and position of the tongue
    and the integrity of the palate. It is also
    important to check for mycosis, petechiae, and
    for any malformations.

15
 ASSESSMENT OF THE NEWBORN WHEN ADMITTED TO AN
OUTPATIENT KMC (7)
  • Thorax Assess shape, symmetry, and movement.
  • Clavicles In case of fracture the bone will be
    felt bigger, painful with a discontinued surface
    and sometimes a click can be heard when the
    clavicle is moved.
  •  Breast buds they are not noticeable by
    palpation in immature boys and girls. Their size
    is determined by gestational age and adequate
    nutrition.
  • Lungs
  • Abdominal breathing in the newborn. Lungs expand
    symmetrically.  
  • Respiratory rate is counted during one minute it
    should be between 40 to 60 breaths per minute.
  • Heart
  • Rate is from 120 to 160 beats per minute.
  • A systolic murmur is frequently heard due to a
    permeable oval foramen, which will close on its
    own. All murmurs accompanied by other symptoms or
    persisting must be assessed carefully.

16
 ASSESSMENT OF THE NEWBORN WHEN ADMITTED TO AN
OUTPATIENT KMC (8)
  • Abdomen
  • The palpation of the abdomen on a newborn
    requires patience and a gentle hand from the
    physician. Femoral pulse must be included in the
    physical assessment along with the palpation of
    both arteries as compared to the radial pulse in
    the wrist.
  • Umbilical stump Detachment of the cord usually
    takes place between 5 and 10days after birth, but
    can take longer when the cord has been kept moist
    or in case of infection.
  • Umbilical hernias
  • May be present at birth, but appear more
    frequently during the first year. In some cases
    could be associated with other malformations,
    such as the Beckwith syndrome, trisomy, and
    hypothyroidism.
  • They spontaneously resolve as the abdominal
    muscles develop. If the hernia is still present
    at one year of corrected age, an appropriate
    treatment should be proposed by a pediatric
    surgeon.
  • Genitalia Assess for boys and girls the opening
    and position of the ureteral orifice. For boys,
    both testicles must be palpable and descended
    into the scrotum. In girls with in later stages
    of development the clitoris and labia majora are
    more prominent.

17
 ASSESSMENT OF THE NEWBORN WHEN ADMITTED TO AN
OUTPATIENT KMC (9)
  • Anus and rectum Examine the location and
    permeability of the anus and the absence of an
    anal fissure.
  • Extremities assessment of lengths of superior
    and inferior limbs and a comparison of both
    sides. Major alterations include absence of
    bones, equinovarus, polydactyly, and syndactyly.
    Occasionally, fractures may be palpable.
  • Hips Symmetric abduction is required
    congenital hip dysplasia must be suspected when
    limitations in abduction occur or if a
    distinctive 'clunk' can be heard and felt as the
    femoral head relocates anteriorly into the
    acetabulum (Ortolani sign). Presence of cortical
    thumb must be assessed.
  • Back After the child has been placed in prone
    position, a thorough inspection and palpation of
    the back, spine, gluts, and the inter-gluteal
    cleft is necessary, verifying the absence of
    fistulae.

18
 ASSESSMENT OF THE NEWBORN WHEN ADMITTED TO AN
OUTPATIENT KMC (10)
  • Outpatient kangaroo adaptation
  • It begins upon first contact in the outpatient
    follow up or in the KMC ward.
  • It is a sensitive period requiring careful
    attention since the child will be under the
    mothers supervision, whether in rooming-in or at
    home.
  • It is important to increase the mothers
    confidence and to trust her.
  • The health team must be available to solve any
    problems, even by phone.
  • It is important to keep in mind the risk of
    hypoglycemia if the mother is not ready and
    expert in feeding her child.
  • It is necessary to discuss the use of nutritional
    supplements, especially for children hospitalized
    and separated for a long time from their mothers.
    Milk production increases progressively, but not
    from one day to the next.
  • All weak aspects of in-hospital adaptation, or
    those in the process of being attained, must be
    reinforced.
  • An explanation on sun baths for management of
    jaundice must be included.
  • It is necessary to reinforce the technique for
    massage.

19
 ASSESSMENT OF THE NEWBORN WHEN ADMITTED TO AN
OUTPATIENT KMC (11)
  • The Nurse
  • Assess if the child and the family meet the
    eligibility criteria for admission to rooming-in
    accommodation or outpatient follow up.
  • Evaluate the knowledge of the mother/ family on
    the KMC Method.
  • Assess the management of the child in kangaroo
    position.
  • Assess the breastfeeding technique.
  • Assess the quality of care provided by the
    mother/family at home and check to see if they
    are able to identify alarm/danger signs in the
    child.
  • Make sure the family knows how to use the
    equipment for oxygen if the child needs it.
  • Explain what the follow up program is and how it
    will be conducted, in rooming-in accommodation or
    in the outpatient program.
  • Enquire about the social situation and emotional
    situation of the family and inform the social
    worker and psychologist in order to react timely.

20
 ASSESSMENT OF THE NEWBORN WHEN ADMITTED TO AN
OUTPATIENT KMC (12)
  • Brain sonography
  • It is advisable, but not mandatory for all
    preterm and/or LBW infants. Where this exam is
    not easily available, it should be prescribed
    only to higher risk children according to the
    local protocols.
  • If during the first year of life a child has an
    abnormal neuro psychomotor development with a
    normal or abnormal brain sonography, a cerebral
    magnetic resonance imaging scan is recommended
    (if available).
  • It is not necessary to repeat brain sonography in
    children with normal muscle tone and normal neuro
    psychomotor development.

21
 ASSESSMENT OF THE NEWBORN WHEN ADMITTED TO AN
OUTPATIENT KMC (13)
  • Ophthalmologic screening
  • It is necessary to screen all at-risk preterm
    infants admitted in Neonatal Care Units in order
    to timely diagnose ROP.
  • In the KMCP all preterm infants lt37 weeks
    attending the Program are screened at 31-32 weeks
    or 28 days of life and will continue until the
    vascularization of the retina is completed.
  • An optometric assessment is conducted at 3 months
    of corrected age, to diagnose refractive problems
    common in preterm and/or LBW children.

22
ASSESSMENT OF THE NEWBORN WHEN ADMITTED TO AN
OUTPATIENT KMC (14)
  • DRUGS PRESCRIBED TO CHILDREN IN THE KMC IN
    COLOMBIA
  • Vitamin K
  • Multivitamins
  • Antireflux medication
  • Xanthine
  • Iron supplementation
  • ASSESSING THE NEED FOR OXYGEN
  • Besides improving survival rates and quality of
    life, using oxygen at home reduces the duration
    of hospitalization and cost of medical care.
  • Oximetry helps to determine the minimum quantity
    of oxygen that is needed to maintain an adequate
    saturation.
  • The child must be monitored for at least 10
    continuous minutes awake, sleeping and suckling.
    The reference oxygen saturation used is more than
    90 and less than 94.

23
EVALUATING THE FAMILY NEED FOR SUPPORT
  • In the outpatient KMC, it is important to develop
    a organized training/teaching plan that includes
    individual and group sessions.
  • It is important to have a pediatrician available
    on call day and night to answer the parents
    questions and concerns regarding care for their
    fragile infant.
  • Training workshops conducted during group
    consultation help to reinforce the
    parents/caretakers knowledge
  • Address parental concerns

24
ROUTINE KANGAROO FOLLOW UP, UP TO 40 WEEKS OF
GESTATIONAL AGE AND A WEIGHT OF 2500G
  • Daily kangaroo follow up is done until the child
    is 40 weeks of gestational age and reaches 2 500
    g.
  • These visits can be conducted in outpatient care
    or while the child is in a KMC ward.
  • Mothers who have already returned home or who are
    staying at a temporary home must travel to the
    Kangaroo Mother Program outpatient consultation.
  • Activities during follow up visit up to 40
    weeks
  • a) Careful and complete clinical assessment,
    similar to the one described during the first
    follow up visit.

25
ROUTINE KANGAROO FOLLOW UP, UP TO 40 WEEKS OF
GESTATIONAL AGE AND A WEIGHT OF 2500G (2)
  • b) Regular monitoring of the somatic growth
  • After discharge, the monitoring is done on a
    daily basis to assess the childs nutrition, and
    the parents adherence to the KMC.
  • The goal is to achieve a weight gain around 15-20
    g/kg/day, a weekly average increase in height of
    0.8 cm, and an increase of head circumference of
    0.5 to 0.8 cm.
  • There may be a normal weight loss around 10 of
    his birth weight in the first 10 days of birth.

26
ROUTINE KANGAROO FOLLOW UP, UP TO 40 WEEKS OF
GESTATIONAL AGE AND A WEIGHT OF 2500G (3)
  • c) Strategies in case of insufficient
    weight gain
  • Reinforce adequate childs position at the breast
    and check the frequency of feedings (every1 ½
    hours during the day and every 2 hours at night).
  • Assess the type of nutrition received by the
    child during hospitalization, as well as his
    weight gain during the days before discharge.
  • Assess the compliance with the KMC guidelines.
  • Teach the Hindmilk technique.
  • Decide to use fortifiers or preterm formula.

27
ROUTINE KANGAROO FOLLOW UP, UP TO 40 WEEKS OF
GESTATIONAL AGE AND A WEIGHT OF 2500G (4)
  • d) Advice on child care for kangaroo
    infant at home
  • Mothers, families, and often the health staff
    must be reminded that the kangaroo position does
    not last long, only few weeks.
  • Bathing A daily bath is not necessary and not
    recommended before 40 weeks, especially for those
    infants in kangaroo position.
  • Mothers activities Mothers with the baby in
    Kangaroo position can have several recreational
    and educational activities at home.
  • Sleep and rest of kangaroo mother/caretaker The
    mother, the father, or another family member will
    sleep better with her baby in kangaroo position
    in a semi-sitting position, with a 15- 30
    degree-tilt. This position reduces the risk of
    apnea and reflux.

28
ROUTINE KANGAROO FOLLOW UP, UP TO 40 WEEKS OF
GESTATIONAL AGE AND A WEIGHT OF 2500G (5)
  • e) Duration of the kangaroo position
  • Daily duration will need to increase gradually
    until it is as continuous as possible, day and
    night, interrupted only for diaper change and
    feeding sessions.
  • Total duration As long as the mother and her
    baby are comfortable, skin-to-skin contact may
    continue, at first in the institution and later,
    at home.
  • f) Neurological assessment at 40 weeks of
    gestational age using axial tone (Dr. Amiel
    Tison)
  • Clinical assessment of axial tone Passive tone
    and Active tone
  •  Global hypotonia Active and passive tone of
    flexor and extensor muscles of the axis is almost
    absent.
  • Hypotonia confined to the axial flexor muscles
  • Hypertonia of the axial extensor muscles
  • Raised intracranial tension association with
    yawning, drowsiness, lethargy, irregular
    breathing, apneic episodes, bradycardia and
    vomiting .

29
HIGH RISK FOLLOW UP OF THE PRETERM AND / OR LB W
INFANTS FROM 40 WEEKS UP TO ONE YEAR CORECTED AGE
  • Every high risk child must be followed until the
    first year of corrected age (counting from the
    moment he reaches 40 weeks) for adequate
    monitoring of somatic growth and early detection
    of audition, ophthalmological, and neurological
    sequel.
  • Physical examination
  • Monitoring somatic growth
  • Complementary feeding
  • The best way to feed a child from birth to at
    least 4 months of age is to breastfeed
    exclusively, and ideally until 6 months.
  • Mothers should breastfeed children at this age as
    often as the child wants, day and night. This
    will be at least 8 times in 24 hours in the case
    of preterm or LBW infant and sometimes 12 times
    in 24 hours. Preterm or LBW infants do not
    request feedings, they need to be woken up.

30
HIGH RISK FOLLOW UP OF THE PRETERM AND / OR LB W
INFANTS FROM 40 WEEKS UP TO ONE YEAR CORECTED AGE
(2)
  • Complementary feeding
  • At some time between the ages of 4 and 6 months,
    some children begin to need foods in addition to
    breast milk. These foods are often called
    complementary or weaning foods because they
    complement breast milk.
  • By 6 months of age, all children should receive
    thick, nutritious, complementary foods.
  • From age 6 months up to 12 months, gradually
    increase the amount of complementary foods given.
  • If the child is not breastfed, give complementary
    foods 5 times daily.

31
HIGH RISK FOLLOW UP OF THE PRETERM AND / OR LB W
INFANTS FROM 40 WEEKS UP TO ONE YEAR CORECTED AGE
(3)
  • Abnormal neuromotor signs in the first year of
    life
  • Various abnormal neuromotor signs observed at the
    end of the second year and considered a
    manifestation of mild brain damage
  • Signs
  • Imbalance of axial tone,
  • Phasic reflex stretching (up to 6 months of life)
  • Ridging of the squamous suture
  • Cortical thumb
  • The functional consequences of perinatal brain
    damage may fluctuate throughout childhood. Some
    may not be identified until later in life or even
    early adult life.

32
HIGH RISK FOLLOW UP OF THE PRETERM AND / OR LB W
INFANTS FROM 40 WEEKS UP TO ONE YEAR CORECTED AGE
(4)
  • Tracing the effects of perinatal damage through
    childhood
  • Deficits that persist throughout the first year
    of life indicate neurological damage, even if
    they are subtle and without apparent functional
    neuromotor consequences.
  • These early neuromotor deficits are sometimes
    described as transient. It is probable that they
    do not just disappear rather, they are too
    subtle to be elicited in the more robust 2 to 4
    year old child.
  • However, with correct examination techniques,
    several persisting signs, such as imbalance of
    axial tone, phasic response to dorsiflexion and
    squamous ridge can be found in affected children.

33
HIGH RISK FOLLOW UP OF THE PRETERM AND / OR LB W
INFANTS FROM 40 WEEKS UP TO ONE YEAR CORECTED AGE
(5)
  • The INFANIB screening or Infant neurological
    battery test
  • The Infant neurological international battery,
    INFANIB, is a diagnostic/screening method used to
    identify children with neuromotor anomalies
    during the first year of life.
  • INFANIB is used in children older than 40 weeks
    and is useful for conducting a diagnostic
    screening of the systematic monitoring of the
    preterm and LBW population of the Kangaroo Mother
    Program.
  • Evaluates global motor development, tone and
    archaic reflexes, allowing clinicians to detect
    multiple neurological alterations such as
    hypotonia, hypertonia, dystonia, diplegie, and
    hemiparesis, among others.

34
HIGH RISK FOLLOW UP OF THE PRETERM AND / OR LB W
INFANTS FROM 40 WEEKS UP TO ONE YEAR CORECTED AGE
(6)
  • The INFANIB screening or Infant neurological
    battery test

Factors Items Items Items Items
Factor I Spasticity Hands held open or closed Tonic labyrinthine in supine Tonic labyrinthine in prone Asymmetric tonic neck reflex
Factor II Head and trunk Body derotative All fours Pulled to sitting Sitting
Factor III Vestibular Body rotative Sideways parachute Forward parachute BAckwards parachute
Factor IV Legs Positive support réflex Dorsiflexion of the foot Foot grasp Standing
Factor V French angles Abductors angle Popliteal angle Heel-to-ear Scarf sign
35
HIGH RISK FOLLOW UP OF THE PRETERM AND / OR LB W
INFANTS FROM 40 WEEKS UP TO ONE YEAR CORECTED AGE
(7)
  • The INFANIB screening or Infant
    neurological battery test
  • This test makes possible to integrate results in
    relation to the childrens neurological
    evolution, from onset to later findings
  • It is highly specific and sensitive
  • Facilitates early detection of neurological
    disorders
  • Offers the possibility of taking timely and
    adequate therapeutic action to decrease the
    emergence of inadequate patterns
  •  The necessary elements to conduct the exam
    are  
  • A stretcher with a padded mat, the child must be
    naked
  • The childs corrected age at three, six, nine,
    and twelve months is used
  • The exam must not be performed if the child
    exhibits irritability, fever, is ill, hungry,
    sleepy or tired this could interfere with the
    results.

36
HIGH RISK FOLLOW UP OF THE PRETERM AND / OR LB W
INFANTS FROM 40 WEEKS UP TO ONE YEAR CORECTED AGE
(8)
  • The INFANIB screening or Infant
    neurological battery test
  • Recommendations
  • Tone anomalies (hypotonia, hypertonia, and
    dystonia) at 40 weeks, abnormal brain ultrasound
    during the neonatal period intensive physical
    therapy and careful neurological follow up during
    the first year with a nuclear magnetic resonance
    imaging (MRI).
  • CAT scan or MRI are only requested if
    hydrocephaly is suspected or to document another
    lesion.
  • INFANIB is repeatedly administered throughout the
    year to assess the impact of physical and other
    therapies, encouraging the participation of the
    parents.
  • When INFANIB results are normal, therapies are
    suspended.

37
IMMUNIZATION
Vaccines and booster shots Age Comments
BCG Newborn and children over 2000g. If under 2000g at one month of life, delay until two months of chronological age and administer with the first dose of DPT-Polio.
Polio vaccine Two, four and six months of chronological age, with booster shots at 18 months, five years and then every 10 years. Due to the theoretical risk of transmission to other infants, the vaccine should not be given to preterm infants until they are discharged from hospital. Inactivated polio vaccine (IPV) may be used for long term hospitalized infants. It is also recommended if there is group consultation in the KMC.
Hepatitis B Newborn, two, four and six months of age.  
DPT Two, four and six months of age, with a tetanus booster shot every ten years.   Diphtheria-tetanus-pertussis Following scientific evidence, it is emphatically recommended to administer it with acellular pertussis component (DPaT), due to the high neurological risk of apnea, hypothermia-induced seizures, and poor tolerance to vaccines.
Haemophilus influenzae type b (Hib) Two, four and six months of age. Booster shot at 12 months or at 18 months with pentavalent vaccine.
38
IMMUNIZATION (2)
Triple viral vaccine (MMR)   One year chronological age, a booster shot at five years. Mumps, measles and rubella
Yelllow fever   One year of age, a booster every ten years  
Influenza Beginning at six months (two doses on the first immunization), booster shots every year. The seasonal vaccine is administered. It is advised that every family member to be in contact with the child is immunized.
Pneumococcal vaccine Two, four and six months (booster between one year and 18 months)  
Other optional vaccines     Any additional immunization will depend on the physicians judgment (rotavirus, measles, hepatitis A).
The extended Immunization Program (EPI) depends
on each country and needs to be adapted according
to local political guidelines.
39
SUMMARY PERIODICITY AND CONTENT OF FOLLOW UP
CONSULTATIONS UP TO ONE YEAR OF CORRECTED AGE.
Periodicity according to corrected age Aims of consultation
If oxygen-dependent upon admittance to outpatient KMP Weekly oxymetry and pediatrics control twice a month until complete oxygen weaning.    
1.5 months Anthropometry (growth assessment weight, length, head circumference) Physical exam Exclusive breast feeding (EBF), if possible Nutrition recommendations, at-home stimulation Check immunization card Deliver infant stimulation and information leaflet Ferrous sulfate and metoclopramide, if gastro esophageal reflux is present Special medication (Palivizumab if there is an outbreak of syncytial respiratory virus SRV- along with administration criteria)
3 months Anthropometry Physical exam EBF, if possible Standardized neurological exam (for instance, INFANIB 3m) Ferrous sulphate and metoclopramide, if gastro esophageal reflux is present Clinical exam hip dysplasia and optometry screening Information leaflet with exercises Exercises Refer to physical, occupational or speech therapy as needed Check immunization card
40
SUMMARY (2)
4.5 months Anthropometry EBF, if possible if adequate growth is not achieved and socio-economic condition are depressed, advise on supplementary nutrition. Physical examination Review hip dysplasia screening Optometry consultation Hearing screening between three and six months of corrected age, with referral to speech therapy if needed. If screening was performed in the NICU or at 40 weeks, only those children with poor results will be screened again. Recommendations for stimulation. Special recommendations Ferrous sulphate, if reflux symptoms persist, continue administering metoclopramide Check immunization card
6 months Anthropometry Physical exam Standardized neurological exam (for instance, INFANIB 6m) Test of psychomotor development test, preferably adapted to the country (in Colombia, the Griffiths and part of the Bayley are used) Recommendations for supplementary nutrition Recommendations for exercises Refer to physical, occupational or speech therapy as needed Following the results of INFANIB, refer for a nuclear magnetic resonance, as needed Check immunization card
7.5 months Anthropometry Physical exam Revise diet Check for improvement in abnormal or transient findings in neurological examby the pediatrician or in psychomotor development by the psychologist Refer to therapy as needed or continue with home exercise plan Ferrous sulphate Check immunization card
41
SUMMARY (3)
Nine months Anthropometry Physical exam Standardized neurological exam (for instance, INFANIB 9m) Recommendations for supplementary nutrition Recommendations for exercises Therapy or exercises as needed Ferrous sulphate Check immunization card
Ten months Anthropometry Physical exam Recommendations for supplementary nutrition Ferrous sulphate Check immunization card
Twelve months Anthropometry Diet Physical exam Standardized neurological exam (for instance, INFANIB 9m) Recommendations for diet Test of psychomotor development test, preferably adapted to the country (in Colombia, the Griffiths and part of the Bayley are used) Control at twelve months if independent walking is not developed Check immunization card
Eighteen months Anthropometry Diet Physical exam Walking and language assessment Check immunization card
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