• Discharge of high-risk infants
  
• Immunization
  
• Specialized follow-up clinics
  
• Follow-up of preterm infants

Introduction

Babies who have required neonatal intensive care are at high risk of long-term neurodevelopmental problems. Parents are often anxious around the time of discharge from hospital, particularly after a prolonged stay. Careful follow-up of these high-risk infants is essential to enable early identification of problems and the initiation of appropriate treatments. Specialized follow-up clinics play an important role in the long-term surveillance of these high-risk infants.

Discharge of High-Risk Infants

Before discharge the parents will need advice on feeding, sleeping, nutritional supplementation, introduction of complementary food and immunizations. They will need education about the preventable risk factors for sudden infant death syndrome (SIDS; see Chapter 14). An information booklet on these subjects may be issued to the parents. Some parents will also require training in basic resuscitation techniques, depending on the condition of the baby. In certain circumstances parents will require additional training before discharge (e.g. nasogastric feeding, gastrostomy care, tracheostomy care, etc.).

A full discharge summary should be sent to the infant’s general practitioner and referring paediatrician/obstetrician at time of discharge. Parents should have a copy of the discharge sum­mary. The summary should highlight ongoing care at discharge and need for follow-up. Parents should be advised about the role of the general practitioner in follow-up and the availability of other services such as a child health nurse or community clinics. Parents may also be provided with information on local support groups and other resources.

Rooming in

Ideally, the mother and father should ‘room in’ with their baby, or at least sleep in the hospital in close proximity to the baby for some days and nights before discharge, so that they can gain confidence and learn to care for their previously sick or preterm infant.

Feeding Advice

Feeding of the low birthweight (LBW) infant is discussed in Chapter 9. The frequency of feeds depends on the maturity and neurological integrity of the infant, but 3–4 hourly feeds are usually necessary on discharge from the neonatal unit. The mother should be encouraged to demand-feed her baby, but feeds should not be more than 5 h apart during the day. Artificially fed infants are usually transferred from a preterm formula to a term formula before discharge although transitional formulas are now available and can be used in the interim. The maternal and child health clinic or the general practitioner should follow the growth of preterm and high-risk infants during the first year of life and plot length, weight and head circumference on appropriate percentile graphs.

Nutritional Supplementation

Iron

Term infants receive sufficient iron from breast milk until about 6–9 months of age. Although the iron content in breast milk is low (0.5 mg/L), the absorption is excellent. The term infant being fed on iron-fortified formula receives sufficient iron until 6 months, at which time iron-containing foods such as cereals, vegetables, eggs and meat should be started. The preterm infant needs supplemental iron from 3 months of age, whether breastfed or not. In some units iron therapy is commenced in hospital between days 14 and 28 with ferrous sulphate paediatric mixture, and is continued until solids are commenced.

Vitamins

Term infants probably receive adequate vitamins in their breast milk or vitamin-fortified breast-milk substitutes. However, preterm infants and other ill infants will require extra vitamins, especially D and C. Human milk fortifiers contain vitamins. Preterm infants with inadequate vitamin C intake often have an immaturity of the enzyme phenylalanine hydroxylase and may develop transient tyrosinaemia. In some units, a multivitamin preparation such as Dalivit, Pentavite or ABIDEC will be commenced in weeks 3–4 of life and continued until 6–12 months.

Fluoride

Fluoride drops are recommended in areas where the water supply is not fluoridated. It is important to adhere to recommended dosage schedules as excessive fluoride may cause tooth staining as a result of fluorosis. Fluoride drops should preferably be given in water rather than milk to permit better absorption.

Immunization

Details of the immunization schedules in the UK and Australia are shown in Tables 26.1 and 26.2. The current recommendations advise starting the immunization programme when the infant is 2 months of actual age, rather than age corrected for prematurity.

Table 26.1 Immunization schedule in the UK

Table 26.2 Immunization schedule in Australia

Age	Immunization (vaccine given)
Birth	Hepatitis B, tuberculosis only if high risk
2 months	DTaP/IPV(polio)/Hib (diphtheria, tetanus, pertussis, and polio, and Haemophilus influenzae type b) – all-in-one injection, plus: PCV (pneumococcal conjugate vaccine) – in a separate injection Oral rotavirus
4 months	DTaP/IPV(polio)/Hib (2nd dose) PCV (2nd dose) Oral rotavirus (2nd dose)
6 months	DTaP/IPV(polio)/Hib (3rd dose) PCV (3rd dose) Oral rotavirus (3rd dose)
12 months	Hib/MenC (combined as one injection – 4th dose of Hib and 3rd dose of MenC) plus: MMR (measles, mumps and rubella – combined as one injection), plus: Infant Pneumococcal if high risk
18 months	Varicella Hepatitis A if high risk
24 months	Hepatitis A (2nd dose) if high risk Pneumococcal if high risk
4 years	DTaP/IPV(polio) (diphtheria, tetanus, pertussis, and polio), plus: MMR (second dose) – in a separate injection
8 years	Varicella (2nd dose) Hepatitis B (2 doses) Girls only – HPV (human papillomavirus) – three injections The second injection is given 1–2 months after the first one. The third is given about 6 months after the first one
10 years	DTaP (diphtheria, tetanus, pertussis)
Adults	Influenza Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Related Related posts: 23 Neurodevelopmental follow-up and assessment of hearing and vision 5 Resuscitation at birth 17 Gastrointestinal and abdominal disorders 22 Neurological disorders Stay updated, free articles. Join our Telegram channel Join Tags: Essential Neonatal Medicine Jun 18, 2016 | Posted by admin in PEDIATRICS | Comments Off on 26 Discharge and follow-up of high-risk infants Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access