Section 1 – Overview of clinics

Babies discharged from the Neonatal Unit will be offered follow up in one of two clinics:

1.1 Neonatal Neurodevelopmental Clinic (High Risk Clinic) –

• VLBW (<1500g) and / or gestational age <32 weeks
• Term infants with brain injury or abnormal neurological status in the early neonatal period including neonatal encephalopathy, neonatal seizures, neonatal stroke, abnormal cranial ultrasound or MRI
• Term infants with risk factors for neurodevelopmental impairment including meningitis, hypoglycaemia with signs of acute neurological dysfunction, hyperbilirubinaemia (levels at exchange threshold), congenital infection, chromosomal abnormality, inborn errors of metabolism.
• Any other infant that was discussed with a Consultant and the follow up team at the time of discharge or at any point of the follow up.

1.2 Neonatal Outpatient Clinic

• Infants born at 32 - 33+6 weeks of gestation
• Term babies with a specific problem identified on newborn examination or during their stay in hospital (typically: antenatally diagnosed dilatation of renal pelvis, congenital malformations, complicated neonatal transition with further investigations pending)
• Severe IUGR (birthweight <3rd centile)
• Hydrops fetalis
• Proven sepsis
• Any infant with recommendation from the Neonatal Consultant

1.3 We would not routinely offer follow up appointment for babies admitted with:

• Suspected but unproven sepsis
• Late preterm 34 - 36+6 weeks
• Term infants admitted for observation of grunting and tachypnoea

Section 2 - Method of assessment

2.1 Neonatal Neurodevelopmental (high risk infants)

2.1.1 Personnel
This service is lead by highly trained specialists in infant neurodevelopmental assessment: a physiotherapist and associate specialist supported by a consultant neonatologist. Neonatal trainees and advanced neonatal nurse practitioners are welcome to join for supervised assessment with the permanent clinic staff.

2.1.2 Type and frequency of neurodevelopmental assessment
In the Neonatal Unit:
All high risk babies will be assessed using a structured neurological examination (the Neonatal Hammersmith Assessment) on at least one occasion as an in-patient.

• In the Neurodevelopmental Clinic:
  High risk infants will be assessed at term equivalent age (38-42 weeks gestational age), 6 weeks, and then around 3 months, 6 months, 9 months, 12-15 months, 18 months and 24 months corrected age, using an appropriate standardized assessment tool. Currently infants are being assessed with the Prechtl´s Method on the Qualitative Assessment of General Movements
• Any child with abnormal neurological signs or failure to meet expected milestones will be referred for physiotherapy. Information will be passed on to appropriate Community Child Health Consultant and Paediatric Neurology Consultant where appropriate.
• Children will be followed-up in this clinic until 24 months corrected age, when they will undergo a Bayley III assessment. Infants with ongoing needs will be referred to appropriate NHS services. Infants born at <26 weeks of gestation will be flagged up for increased developmental surveillance for HV and GP.

2.1.3 Additional assessments

Nutrition and growth

• Every infant / child attending clinic will have weight and OFC measured and plotted on the growth chart that was started at birth. At 18 months all children able to stand will have their height measured.
• Breastfeeding will be advocated in line with Scottish Government and WHO recommendations.
• Advice and support will be given to parents if growth is sub-optimal. IUGR infants that don’t show signs of catch up growth before age of 18 months will be discussed with Paediatric Endocrinologist.
• Occasionally prescription for specialized preterm or high energy formula will be issued in liaison with dietician in RHSC.

Vitamins and iron supplements will be discussed and dose adjusted as required.

• Vitamins should be prescribed by GP until on a full family mixed diet usually at 9 months of age, RCPCH advises Vitamin D supplementation thereafter until 5 years of age (unless on more than 500ml formula milk which is already fortified with vitamin D). The Scottish Government, provide free vitamin D to all infants and children up to 3 years old.
• Iron supplement - the dose will be adjusted to achieve 0.2 ml/kg up to total dose of 1ml once daily, with every review. Advice will be given to discontinue Iron supplement when infant is on full family mixed diet usually around 9 months of chronological age.

Health promotion – advice will be offered that is consistent with national guidance about immunisations, avoiding exposure to passive smoke, dental care, sudden infant death syndrome.

Home oxygen therapy – Infants discharged on Home Oxygen Supplement will be referred to OP Paediatric Respiratory Clinic in RHSC if not weaning off Oxygen within 3 months from discharge.

Home tube feeding- Any infant discharged from Neonatal Unit with NGT in place will be followed up by the Neonatal Community Team. At 6 weeks appointment those babies will be expected to wean NGT – otherwise referral will be made according to HETF (home enteral tube feeding) pathways to CCH and Speech and Language Therapy.

Detailed physical examination

• On the first visit post discharge from the NNU every baby will be thoroughly examined with specific consideration of:
• Existing heart murmurs – if not already discussed with cardiologist, referral will be made for further assessment in Outpatient Clinic.
• Hernias: umbilical hernias will be discussed with parents and instruction given. Inguinal hernias require referral to paediatric surgery; parents will be instructed in details about possibility and recognition of strangulation.
• Skin changes – capillary Haemangioma assessed and discussed with parents. Some will require further referral to Paediatric Dermatology (for example if a haemangioma blocks the airways, affects vision or becomes ulcerated).

2.2 Neonatal Out-patient Clinic

• Late Preterm Infants (32 – 33+6 weeks of gestation at birth)
• General methodology of early neurodevelopmental assessments (up to 6 months) as described for high risk infants.

2.2.1 Babies born at 32 – 33+6 will attend until fully independently mobile. Those babies will have regular review at least 6 monthly and discharged when ambulant with a good walking pattern.

2.2.2 Follow-up of other babies in this clinic will be determined individually by the attending Neonatal Consultant

Appendix 1 - suggested milestones to assess

3 months corrected
Good Quality General Movements
Fidgety movements present as described by Prechtl
More extended posture
Reaching to touch toys in purposeful manner
Supports head in prone
Weight supported at the chest in prone

6 months corrected
Flexed posture,
Catching feet,
Propping when placed in sitting,
Chin tuck and anticipation on pull-to-sit,
Head in line with body
Extended elbows in prone position
Weight supported at pelvic level, weight shift
Attempts for rolling over with a twisting movement

9 months corrected
Good independent sitting with straight back reaching out with base of support
Rolling over back to front, front to back
Crawling backwards

12 months corrected
Transitional movements: rolling to sit, crawling from sitting, lying to sitting and pulling to stand
Cruising along the furniture
Chatting words, pretended language

18 months corrected
Fully independently mobile.
Points to make wants known
Understands simple commands

24 months corrected
Full Bayley III assessment in Leith Community Treatment Centre.