Kangaroo Mother Care Method OUTPATIENT KANGAROO MOTHER CARE WITH KANGAROO FOLLOW UP (up to term) AND...

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

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

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.

EARLY DISCHARGE FROM THE NEONATAL UNIT

Child’s eligibility criteria for discharge

•The child’s in-hospital kangaroo adaptation has been successful; he is regulating his temperature in kangaroo position and has an adequate sucking–swallowing-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.

EARLY DISCHARGE FROM THE NEONATAL UNIT Mother’s 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.

EARLY DISCHARGE FROM THE NEONATAL UNIT Family’s 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.

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.

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 mother’s 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.

ASSESSMENT OF THE NEWBORN WHEN ADMITTED TO AN OUTPATIENT KMC

1. The gestational age at birth is determined according to the Lubchenco’s classification tables.

2. The anthropometric parameters are assessed (weight, height, head perimeter)

3. A full clinical assessment is conducted (from head to toes)4. Outpatient KMC adaptation is reinforced or initiated as necessary.5. Brain sonography and ophthalmologic screenings are requested if

possible and if necessary.6. Routine and specific drugs are prescribed. 7. The need for oxygen is assessed.8. The need for family support is assessed and provided

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 Lubchenco’s 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 child’s 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 child’s gender and age.


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


Height for age (H/A)Cut-off point(Standard deviation or Percentile)

Denomination

< 2 Below length for age or stunting.

> - 2 a < - 1 At risk for below length

> - 1 Adequatelength

Weight for age (W/A)Cut-off point(Standard deviation or percentile)

Denomination

< - 3Very low weight for age or severe chronic malnutrition.

< - 2Low weight for age or chronic malnutrition.

> - 2 a < - 1 At risk for low weight for age.

> - 1 a < - 1 Adequate weight for age.

Head circumference (HP/A)Cut-off point(Standard deviation or percentile)

Denomination

< - 2 Risk factor for neurodevelopment

> - 2 a < 2 Normal

> 2Eventually Risk factor for neurodevelopment


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

baby’s 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 Tison’s neurological triad, which is described further down in this chapter.


• 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.


• 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.


• 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.


• 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.


• 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

mother’s supervision, whether in rooming-in or at home.• It is important to increase the mother’s 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.


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.


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.


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 <37 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.


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%.

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

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.

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 child’s 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.


c) Strategies in case of insufficient weight gain

• Reinforce adequate child’s 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.


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.

• Mother’s 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.


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 .

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.

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.


• 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.


• 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.


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.



Factors Items

Factor ISpasticity

Hands held open or closed

Tonic labyrinthine in supine

Tonic labyrinthine in prone

Asymmetric tonic neck reflex

Factor IIHead and trunk

Body derotative

All foursPulled to sitting

Sitting

Factor IIIVestibular

Body rotative

Sideways parachute

Forward parachute

BAckwards parachute

Factor IVLegs

Positive support réflex

Dorsiflexion of the foot

Foot grasp Standing

Factor VFrench angles

Abductor’s angle

Popliteal angle

Heel-to-ear Scarf sign



• This test makes possible to integrate results in relation to the children’s 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 child’s 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.


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.

IMMUNIZATION

Vaccines and booster shotsAge Comments

BCGNewborn 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 BNewborn, 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-pertussisFollowing 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.

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

InfluenzaBeginning 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 physician’s judgment(rotavirus, measles, hepatitis A).

The extended Immunization Program (EPI) depends on each country and needs to be adapted according to local political guidelines.

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 examExclusive breast feeding (EBF), if possibleNutrition recommendations, at-home stimulationCheck immunization cardDeliver infant stimulation and information leafletFerrous sulfate and metoclopramide, if gastro esophageal reflux is presentSpecial medication (Palivizumab if there is an outbreak of syncytial respiratory virus –SRV- along with administration criteria)

3 months

Anthropometry Physical examEBF, if possibleStandardized neurological exam (for instance, INFANIB 3m)Ferrous sulphate and metoclopramide, if gastro esophageal reflux is presentClinical exam; hip dysplasia and optometry screeningInformation leaflet with exercisesExercisesRefer to physical, occupational or speech therapy as neededCheck immunization card

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 examinationReview hip dysplasia screeningOptometry consultationHearing 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 recommendationsFerrous sulphate, if reflux symptoms persist, continue administering metoclopramideCheck immunization card

6 months

Anthropometry Physical examStandardized 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 nutritionRecommendations for exercisesRefer to physical, occupational or speech therapy as neededFollowing the results of INFANIB, refer for a nuclear magnetic resonance, as neededCheck immunization card

7.5 months

Anthropometry Physical examRevise dietCheck for improvement in abnormal or transient findings in neurological examby the pediatrician or in psychomotor development by the psychologistRefer to therapy as needed or continue with home exercise planFerrous sulphateCheck immunization card

SUMMARY (3)

Nine months

Anthropometry Physical examStandardized neurological exam (for instance, INFANIB 9m)Recommendations for supplementary nutritionRecommendations for exercisesTherapy or exercises as neededFerrous sulphateCheck immunization card

Ten months

Anthropometry Physical examRecommendations for supplementary nutritionFerrous sulphateCheck immunization card

Twelve months

Anthropometry DietPhysical examStandardized neurological exam (for instance, INFANIB 9m)Recommendations for dietTest 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 developedCheck immunization card

Eighteen months

Anthropometry DietPhysical examWalking and language assessmentCheck immunization card

Kangaroo Mother Care Method OUTPATIENT KANGAROO MOTHER CARE WITH KANGAROO FOLLOW UP (up to term) AND...

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