Follow-up after high-risk birth and NICU discharge — viva

Stem

Examiner-led viva on the follow-up of the high-risk NICU graduate. [1]

Examiner: This former 26-week infant is now five months corrected age. How do you apply corrected age, and why does it matter? [11]

Strong answer: Corrected age is chronological age minus the weeks born before forty weeks. This infant was born fourteen weeks early, so at five months corrected age I plot growth on Fenton charts to a post-menstrual age of fifty weeks then WHO or INTERGROWTH-21st standards, and I interpret milestones as a five-month-old, not a six-month-and-a-bit chronological infant. I continue correcting milestones for at least two years. Without correction I would either falsely alarm or falsely reassure the family, and both harm. [11]

Examiner: The General Movements Assessment shows absent fidgety movements and the HINE scores 38. What do you conclude, and on what evidence? [3]

Strong answer: This triad — absent fidgety General Movements at nine to twenty weeks post-term, a Hammersmith Infant Neurological Examination score under the 40 to 60 range, and a known grade 3 intraventricular haemorrhage — meets the international criteria for an early, accurate diagnosis of cerebral palsy before six months corrected. Prechtl established that absent or abnormal fidgety movements carry a high positive predictive value for cerebral palsy, and the Novak 2017 and Morgan 2021 guidelines established that the combined GMA-plus-HINE-plus-MRI approach diagnoses cerebral palsy accurately far earlier than waiting for delayed walking. I would not wait and see. [3] [4] [5]

Examiner: The head circumference is static across two visits. How does that change your management? [4]

Strong answer: A static head circumference over two visits is a neurological red flag, not stalled catch-up growth. I would investigate urgently with cranial imaging, review the metabolic and genetic picture, and ensure the brain MRI is current. Decelerating head growth signals impaired brain growth and raises the probability of cognitive as well as motor impairment, so it intensifies the surveillance and the multi-disciplinary referral. [4]

Examiner: What is your immediate management plan? [5]

Strong answer: I refer urgently for goal-directed active motor-task-oriented early intervention per the Morgan 2021 guideline, because the window for motor plasticity is early — the Cochrane evidence supports a modest motor benefit of post-discharge early developmental intervention. I coordinate physiotherapy, occupational therapy, speech-language and dietetics through the medical home, arrange a brain MRI and a full audiology and ophthalmology review, and book the next corrected-age visit with a clear plan. [5] [13]

Examiner: How will you counsel the parents? [2]

Strong answer: I would explain in plain language that the early signs indicate a motor disorder consistent with cerebral palsy, that we will start therapy now to support movement and development, and that we will follow thinking, language and behaviour through to school age. I would avoid both false reassurance and a catastrophic framing — outcome is probabilistic and depends on the evolving trajectory — and I would commit to close, honest, longitudinal follow-up. [2]

Examiner: This child had laser for retinopathy of prematurity. What sensory follow-up is needed? [7]

Strong answer: Retinopathy of prematurity follow-up continues until retinal vascular maturity is confirmed, per the AAP and American Academy of Ophthalmology schedule for any infant with a birthweight under 1500 g or gestational age of 30 weeks or less, and I would confirm that follow-up is scheduled and not abandoned. Hearing surveillance continues beyond the newborn AABR screen because late-onset, progressive or auditory neuropathy loss can be missed; I would confirm a recent, normal audiology assessment. [7]

Examiner: Suppose instead that this infant had a normal Bayley at two years and the family wanted to stop coming. What would you say? [9]

Strong answer: I would explain that the largest population-level burden of extremely preterm birth is not cerebral palsy but school-age learning difficulty, attention-deficit and executive dysfunction, with roughly half of survivors needing educational support even when early scores are average. A single normal early Bayley does not close the file. I would schedule a review at three to four years and a formal cognitive and executive assessment at school age, and ensure the family and school know that support may be needed. [9]