Despite increasing the survival of premature neonates over the past few decades, the complications of prematurity still account for the main problems of the health system (12). Long-term morbidity of preterm infants requires multidisciplinary follow-ups for the prevention of delayed complications of prematurity or following the present involvements of them for better outcomes of these high-risk infants (8, 9). The establishment of special multidisciplinary clinics for preterm babies needs a team consisting of neonatologists, ophthalmologists, pediatric neurologists, physical therapists, audiologists, and nutritionists for following the main problems of them in each area for the prevention or treatment of long-term morbidities (7, 13, 14).
The purpose of this study was to evaluate the post-discharge follow-up of preterm babies admitted to our NICU. A total of 140 premature infants were followed up for two years after discharge. According to the findings of this study, 25% of the newborns had more than eight visits, which shows desirable conditions. Unfortunately, 10% had just one visit to our clinic, which can be an alarm for the healthcare system to assess the causes of parents’ reluctance to bring their babies to clinics with the probability of missing their problems. Regarding the absence of a regionalization system for care at Iranian maternity hospitals, the place of residence of some patients in our NICU was far from our hospital and regular outpatient visiting of infants was not possible for parents.
The longest time interval of follow-up was 36 months observed just in one case. As mentioned in Table 1, 60 (42.8%) patients had visited at their three months of life, 55 (39.2%) at six months of life, and 14 (10%) at one-year-old; therefore, it seems that the number of visits to our clinic decreased with increasing the age of patients. It is possible that due to the reduction of their specific problems over time, the continuing of their outpatient care was done at other general centers near to their residence locations.
Based on the growth indices at birth in our population, the most values of birth weight, height, and head circumference were at the 50th percentile of growth charts; that is, 42.1% of neonate birth weights, 36% of neonate heights, and 37.4% of neonate head circumferences were at the 50th percentile of growth charts. This issue indicates that due to good prenatal care of mothers, the number of premature infants appropriate for gestational age (AGA) was higher than growth retardation. In a study in Taiwan that was done in 2007 - 2011, Tsai et al. reported that AGA preterm infant delivery at birth was more than SGA (65 % vs. 33.2%) (15).
Although the number of our neonates with AGA at birth was remarkable, the rate of growth impairments was significant after discharge from the hospital, particularly in extremely low birth weight infants (ELBW) with birth weight of less than 1000 g (n = 23 infants) so that at the age of one month, 50% of the infants were at the 50th percentile of weight while at the age of three months, 53% of the infants’ weight and 40% of the infants’ height were at the third percentile. Thus, this result indicates some degrees of growth impairment in these high-risk patients at a few months post-discharge. The justifying reasons for this issue can be the nutritional-related problems of these patients, such as the selection of milk, lack of proper lactation technique, use of unfortified breast milk, feeding with regular formula instead of a specific post-discharge formula for preterm infants, and gastrointestinal problems. However, at the age of six months, the number of patients at the third weight percentile decreased and 20% of the patients were at the 90th percentile of weight.
Based on our results, a better condition was observed in neonates with a birth weight of 1,000 to 1,500 g. Moreover, 54.5% by the age of three months and 50% at the age of six months were at the 50th weight percentile of the growth curve. In infants with a birth weight of more than 1,500 g, the rate of increasing birth weight was more appropriate than in the neonates with lower-birth weight. Thus, ELBW infants needed more attention to the nutritional state. Our results are consistent with the results of a study by Modi et al. that showed weight, height, and head circumferences of newborns at 12 months of age increased compared to their birth time, but they had lower mean scores than term neonates (16).
The findings of our study indicated that 17.1% of the infants at the time of discharge were exclusively breastfeeding; 53.6% were fed with breast milk and formula simultaneously and 29.3% were fed exclusively by the formula. Despite the emphasis on the exclusive breastfeeding for all infants, especially preterm babies, nearly 83% of our infants did not feed exclusively by their breasts of mothers. Similar to our result, in a study by Rodrigues et al., 91% of newborns were non-exclusively breastfed (17). In a study by Lee and Jang (18) in 2016, exclusive breastfeeding in premature newborns from the first week to 12th week of life and breastfeeding concurrent with formula increased from 5.7% to 19.8% and from 27.3% to 67.9%, respectively. Breastfeeding with formula at the same time decreased from 67% to 12.3%. However, the increase in nutrition with formula was much higher than the increase in breastfeeding (18).
Given that 11 (7.9%) hydrocephalus, 4 (2.9%) PVL, and 3 (2.1%) GMH patients were reported in our study, it seems that the investigation of neurological and developmental prematurity-induced complications is highly important and has a significant role in the healing of these patients. In Tsai et al. study in Taiwan, the rate of PVL was 0.33% at GA 30 - 32 weeks, 1.19 % at GA 27 - 29 weeks, and 0.77 at GA 24 - 26 weeks (15).
One of the most important problems of prematurity is anemia. Prolonged hospitalization, lots of blood sampling, and the low levels of erythropoietin and iron storage of preterm infants are the leading causes of this problem before and after discharge from the hospital. The lack of attention to anemia can adversely affect the weight gain of infants or their neurological developments (19). In the present study, 47.1% of the neonates had post-discharge anemia and 20% of them required blood transfusions. Based on these results, it seems that the prevalence of post-discharge anemia is significantly high in premature infants. Therefore, paying more attention to the proper nutrition of premature infants and the use of food supplements, such as appropriate doses of iron drops, may prevent severe anemia and its consequences. These results are in line with the results of Domellof and Sjostrom’s study in 2015, in which 40% of preterm infants needed oral iron supplements after discharge from the hospital (20).
In the present study, 37 (26.4%) infants had a history of re-admission to the hospital because of intensified jaundice (requiring phototherapy), respiratory distress, and the need for hernia repair surgery. Considering that all neonates in this study were premature with low birth weight, it seems that this number is acceptable.
According to Underwood et al. (21) study, approximately 15% of premature infants needed at least one hospitalization during their first year of life, with the highest prevalence being in neonates with the gestational age of fewer than 25 weeks. The most common cause of re-admission was acute respiratory diseases (21).
One of the complications of prematurity is delayed hypothyroidism that can be detected in repeated screening tests. In the present study, delayed hypothyroidism requiring treatment with levothyroxine was detected in 2.9% of the neonates. In the study by Armanian et al., transient hypothyroidism was the most common endocrine problem in neonates with a prevalence of 33.33% (22).
One of the common problems of premature infants after discharge from the hospital is developmental delay and motor skill problems. In this study, 16.4% of newborns needed treatment with physical therapy. However, we did not use a standard assessment tool for the developmental evaluation of our patients, but based on routine physical examinations of the patients at the HRNFC or the reports of their parents, referring to a pediatric neurologist was suggested in cases with diagnosed or suspected developmental delay. Glass et al. (6) in 2015 reported high rates of neurodevelopmental abnormalities in preterm infants despite significant changes in the care of them. They also mentioned no improvement in the neurodevelopmental outcomes of preterm infants even though the incidence of some neurosensory impairments had been decreased (6).
A limitation of our study was the discordance of the time of visits of patients to the HRNFC. This irregularity in the interval of visiting our patients made the statistical analysis difficult and probably has caused inaccurate results of growth chart indices. Another limitation was the lack of planned neurodevelopmental assessments in our patients.
5.1. Conclusions
According to the results of this study, the follow-up of premature infants after discharge from the hospital is necessary by an expert multidisciplinary team. Growth and developmental problems, especially in neonates with birth weights of less than 1000 g, seem to be more important than in those with higher birth weights and as a result, more nutritional care is needed in this specific birth weight group. Considering the low percentage of exclusive breastfeeding in premature infants, comprehensive planning to increase the rate of breastfeeding by mothers of preterm neonates is very crucial. Due to the high prevalence of anemia and the need for blood transfusion after discharge from the hospital, proper nutrition with milk and dietary supplements is necessary to prevent anemia and blood transfusion. Developmental assessment of discharged premature infants should be taken into account in the outpatient care program after discharge from the hospital.
LEAVE A COMMENT HERE: