Guidelines for the follow-up of at-risk neonates according paho

Neonate at-risk using diaper on a stretcher cared for by a nurse

Pan American Health Organization (PAHO) identified the need to develop Guidelines for following up neonates in Latin America and the Caribbean who present risk factors, in order to identify and address these factors early on and to improve the infant’s health and quality of life, for this, they produced a guide titled "Evidence-based clinical practice guidelines for the follow-up of newborns at risk" [1].

Congenital defects of the immune system of an at-risk newborn affect its ability to fight an infection even healthy neonates already have immature immune systems [2].

Advances in neonatal care worldwide have helped to reduce the neonatal mortality rate considerably, particularly in Latin America and the Caribbean. This, in turn, has increased survival rates for infants born premature or presenting risk factors that can affect their growth, development, and quality of life. Improved survival rates and the reduced impact of specific risk factors are associated with neonatal care, special care units, and the follow-up of neonates in accordance with these factors.

The term “at-risk neonate” refers to all neonates who present risk factors and require multidisciplinary care after being discharged from the health care provider. This includes premature neonates, neonates with acquired or congenital diseases, and neonates who appear to be healthy but for whom abnormal health outcomes may be detected through timely follow-up [1]. Neonates whose situation may imply a risk to their health, growth and development, must be identified before hospital discharge.

Information collected from the guide “Evidence-based Clinical Practice Guidelines for the Follow-Up of At-Risk Neonates. Abriged version. Washington, D.C.: Pan American Health Organization; 2021. License: CC BY-NC-SA 3.0 IGO.” [1].

How to use the PAHO at-risk neonates Guide?

For each clinical question, a set of recommendations and good practices provides guidance for the follow-up of at-risk neonates. Each recommendation shows the quality of the evidence based on the GRADE system

Quality of the evidence	Meaning
High ⊕⊕⊕⊕	Further research is very unlikely to change confidence in the estimate of effect.
Moderate ⊕⊕⊕	Further research is likely to have a significant impact on confidence in the estimate of effect and may change the estimate.
Low ⊕⊕	Further research is very likely to have a significant impact on confidence in the estimate of effect and is likely to change the estimate.
Very low ⊕	Any estimate of effect is very uncertain.

The recommendations also include the strength of the recommendation based on the GRADE system.

Strength of the recommendation	Meaning
Strong fo	The desirable effects clearly outweigh the undesirable effects. RECOMMENDED
Conditional for	The desirable effects probably outweigh the undesirable effects. SUGGESTED
Conditional against	The undesirable effects probably outweigh the desirable effects. Further research is likely to change the recommendation not to carry out the recommendation. NOT SUGGESTED
Strong against	The undesirable effects clearly outweigh the undesirable effects. NOT RECOMMENDED SE RECOMIENDA NO HACERLO.

Summary of the PAHO recommendations

We will show you some of the most relevant recommendations, this is an extract identical to the guide without any modification, to see all the complete Summary recommendations go to reference [1].

Recommendation 1.

It is recommended that parents, mothers, or caregivers of neonates who weigh less than 2.5 kg are enrolled into an intermittent or continuous kangaroo mother care program. Alternatively, training in the “skin-to-skin” contact technique is recommended (six hours before the birth if there are no comorbidities contraindicating it) when an infant is discharged from a neonatal intensive care unit in hospitals or countries where it is available. This is in order to increase the neonate’s body weight and encourage breastfeeding, and to reduce the risk of death, severe infection or sepsis.

Quality of the evidence: moderate ⊕⊕⊕

Strength: Strong for.

Good practice point: The kangaroo mother care program or skin-to-skin technique should be developed by trained teams with the use of protocols and continuous monitoring to ensure that the results of premature neonates can be assessed. In addition, parents should be properly trained on how to care for a newborn at home.

Recommendation 3.

We suggest ensuring that infants can carry out full oral and enteral feeding (preferably sucking and occasionally with a tube) before being discharged, either through exclusive breastfeeding, mixed feeding, feeding with milk formula or breast milk substitutes, and ensuring that hypoglycemia has been resolved in cases where it has been present.

Quality of the evidence: low ⊕⊕

Strength: Strong for.

Good practice point: Ensure that the indicated volumes of formula are available or that enough breast milk is present, as malnutrition can occur associated with their high level of risk, which would worsen their vital and neurosensory prognosis.

Recommendation 4.

It is recommended to check the following criteria for discharging high-risk neonates on the neonatal care unit, along with the basic criteria for all neonates:

Recommendations for premature neonates

a. Ensure that pre-term neonates with gestational ages of 35 weeks or more are clinically stable (temperature of 36.5ºC to 37.5ºC) for 24 hours.

b. Adequate oral feeding for at-risk neonates. In premature neonates with a gestational age of less than 34 weeks, observing 48 hours of oral feeding is sufficient. Premature babies should have a good latch on the mother’s breast and should have established the sucking reflex, swallowing, and breathing. The mother should also be giving enough encouragement to help the baby to suck adequately during feeding.

c. For premature neonates, we recommend confirming that they can regulate their body temperature during skin-to-skin contact.

d. Adequate weight gain, either an established goal of 18 g/kg/d of weight and 0.9 cm/week in head circumference. Alternatively, tolerating the “kangaroo” position for a prolonged period of time, combined with a weight gain of 15 g/kg/day until 37 weeks and 8-11 g/kg/day starting in week 38.

e. In premature neonates, oxygen saturation targets should be between 92% and 94%.

Recommendations for all at-risk neonates

a. Before being discharged, neonates should be able to maintain a supine position.

b. Check that the neonate does not present with apnea. This should be evaluated in at-risk neonates who tolerate a supine position or premature neonates in the kangaroo care program for 48 hours after oxygen is discontinued. Oxygen saturation targets for neonates with bronchopulmonary dysplasia are 92% to 95%.

c. Vaccination record and the Expanded Program on Immunization for neonates in NICUs in accordance with local schedule and actual age.

d. Social and family risk assessment carried out by the social worker.

Quality of the evidence: low ⊕⊕

Strength: Strong for.

Recommendation 8.

It is recommended that parents be given information on proper management of the at-risk neonate at home when they are discharged from the neonatal care unit. This includes information on: techniques for drying a newborn after a bath, skin-to-skin contact, eye care, vaccination schedule, thermal protection, exclusive breastfeeding, nutrition requirements, CPR technique, massages, adequate parent-infant interaction, a follow-up plan, proper holding positions, administering medicine, or multivitamins if necessary, warning signs, and where to go in the event of an emergency.

Quality of the evidence: low ⊕⊕

Strength: Strong for.

Good practice point: As well as providing information on discharge, we suggest holding workshops during their stay in hospital. This is to ensure that parents understand all the information and that there are no complications caused by improper management of neonates. Both printed and audiovisual information should be provided so that parents can consult it at home. This information can be conveyed in person, by email, or by text message.

Recommendation 14.

Testing with brain MRI or ultrasound is not suggested for screening for neurological disorders in high-risk infants. These tests should only be performed in cases where it is justified.

Quality of the evidence: very low ⊕

Strength: Conditional against.

Recommendation 15.

Neurological evaluations should be carried out using the Dubowitz examination at the term-equivalent age and the Amiel-Tison examination, Bayley III (or higher) scale, or the test that is approved in each country, with a view to screening for neurological disorders in high-risk infants.

Quality of the evidence: moderate ⊕⊕⊕

Strength: Strong for.