Growing Preterm and Low Birth Weight Infant - Bedside Clinical Proforma

1. Patient Demographics & Chronological Staging

• Mother's Name: Mother's Name | Baby's Name / Tag: Baby of ...
• Sex: Male / Female | Age (Chronological): Days / Weeks
• Gestational Age at Birth: Completed Weeks (by LMP / 1st Trimester USG / New Ballard Score)
• Birth Weight: Grams (LBW / VLBW / ELBW)
• Birth Intrauterine Classification: AGA / SGA (<10th centile) / LGA (>90th centile) (Fenton 2013 / INTERGROWTH-21st)
• Current Post-Menstrual Age (PMA): Gestational Age + Chronological Weeks
• Current Corrected Age (Post-Term): PMA minus 40 weeks
• Current Weight: Grams | Current Length: cm | Current Head Circumference: cm
• Address / Residence: City / District | Informant & Reliability: Mother / Father (Reliable)

2. Chief Complaints & Current Status

• Prematurity and Low Birth Weight at birth
• Duration in NICU / SCNU: ... days
• Transferred to KMC ward / step-down on: ...
• Current feeding method: Direct breastfeeding / EBM by paladai / spoon / OGT
• Presenting for: Growth monitoring / KMC evaluation / ROP follow-up / Hearing screen / Immunization

3. History of Present Illness (Organ-System NICU Course)

• Respiratory Course:
  • Respiratory distress at birth: Yes / No | Silverman-Anderson score: ... / 10
  • Surfactant therapy: Poractant alfa / Beractant | Dose: ... mg/kg | Method: LISA / INSURE / ETT
  • Respiratory support: Bubble CPAP / HFNC / Mechanical Ventilation | Duration: ... days
  • Apnea of Prematurity (AOP): Yes / No | Frequency: ... episodes/day | Caffeine citrate: Yes / No (Duration: ...)
  • Current respiratory status: Room air / Supplemental oxygen | SpO2: ... %
• Cardiovascular Course:
  • Hemodynamically significant PDA: Yes / No | Clinical signs: Hyperdynamic precordium / Bounding pulses / Murmur
  • Echocardiography: PDA size: ... mm | LA:Ao ratio: ... | Direction of shunt: Left to right
  • Medical closure: Oral Paracetamol (15 mg/kg Q6H x 3d) / Ibuprofen | Response: Closed / Reopened / Surgical
• Gastrointestinal, Feeding & Nutrition:
  • Minimal Enteral Nutrition (MEN) initiated on: Day ... of life | Feed type: Colostrum / EBM
  • Parenteral Nutrition (TPN): Yes / No | Amino acids: ... g/kg/d | Lipids: ... g/kg/d | Duration: ... days
  • Feed advancement rate: ... mL/kg/day | Reached full enteral feeds (150 mL/kg/day) on: Day ...
  • Feeding intolerance / Necrotizing Enterocolitis (NEC): Abdominal distension / Bile aspirates / Bell's Stage
  • Human Milk Fortification (HMF): Initiated on Day ... (at feed volume ≥100 mL/kg/day) | Sachets per 50 mL: ...
• Infection & Hematology:
  • Early-onset sepsis (<72h) / Late-onset sepsis (>72h): Workup | Blood culture: Sterile / Organism: ...
  • Antibiotics received: First-line (Ampicillin + Gentamicin) / Second-line | Duration: ... days
  • Neonatal Hyperbilirubinemia: Peak TSB: ... mg/dL (Phototherapy duration: ... hours / Exchange transfusion: Yes/No)
  • Anemia of Prematurity: Nadir Hemoglobin: ... g/dL | PRBC transfusions received: ... times
• Neurological & Sensory Screening:
  • Serial Neurosonograms: Day 3 / Day 7 / Day 28 | Findings: Normal / IVH (Grade I-IV) / PVL
  • ROP Screening (Rule of 30 days): Screened on Day ... | Zone: I / II / III | Stage: 1 / 2 / 3 | Plus disease: Yes/No
  • Hearing Screen: OAE / AABR | Pass / Refer bilaterally

4. Antenatal, Natal & Postnatal History

• Maternal Age: ... years | Gravida: ... Para: ... Living: ... Abortion: ...
• Antenatal Complications: Pre-eclampsia / GDM / Chorioamnionitis / Oligohydramnios / Antepartum hemorrhage
• Umbilical Artery Doppler Scans: Normal / Increased resistance / Absent end-diastolic flow (AEDF) / Reversed flow (REDF)
• Antenatal Corticosteroids: Inj. Betamethasone 12 mg IM (2 doses 24h apart): Complete / Incomplete / None
• Intrapartum Magnesium Sulfate for Neuroprotection: Received / Not received
• Delivery: Normal vaginal / Emergency LSCS / Elective LSCS | Indication: ... | Rupture of membranes: ... hours
• Delayed Cord Clamping (30-60 seconds): Performed / Withheld due to resuscitation
• Resuscitation: Immediate cry / Delayed cry | T-piece resuscitator CPAP / PPV / Chest compressions | Apgar: 1m ... 5m ...

5. Family & Immunization History

• Consanguinity: Present / Absent | Pedigree: 3 generations
• Birth Vaccines: BCG (0.05 mL ID) / Hep B (0.5 mL IM) / OPV (zero dose) administered at ... kg
• Future Immunization Guidance: Given strictly as per CHRONOLOGICAL age, NOT corrected age!

6. Current Feeding & Nutritional Calculations

• Current Weight: ... kg | Daily feed volume: ... mL/kg/day (Target: 150-180 mL/kg/day)
• Caloric density: Unfortified EBM (67 kcal/dL) vs Fortified EBM with HMF (80 kcal/dL)
• Caloric intake: ... kcal/kg/day (Target: 110-130 kcal/kg/day) | Protein: ... g/kg/day (Target: 3.5-4.5 g/kg/day)
• Elemental Iron supplementation: ... mg/kg/day (Target: 2-3 mg/kg/day started at 2 weeks postnatal age)
• Vitamin D3 supplementation: ... IU/day (Target: 400-800 IU/day)
• Calcium & Phosphorus drops for Metabolic Bone Disease prevention: ... mg/kg/day

7. Kangaroo Mother Care (KMC) Assessment

• Duration of KMC per day: ... hours (Target: continuous ≥12-16 hours/day)
• Mother's positioning: Upright between breasts, frog-leg hip abduction, neck extended
• Thermal stability: Axillary temperature maintained at 36.5 - 37.5°C
• Weight gain velocity: ... g/kg/day (Target: ≥15-20 g/kg/day for 3 consecutive days)

8. Physical Examination & Anthropometry

• Vitals: HR: ... /min | RR: ... /min | Temp: ... °C | SpO2: ... % | CRT: ... s
• Weight: ... g | Length: ... cm | Head Circumference: ... cm | Plotted on Fenton 2013 curve: Centile ...
• General: Pink, active, no jaundice, no pallor, no edema, no skin lesions / peeling
• Neuromuscular Maturity (New Ballard / Amiel-Tison):
  • Posture: Semi-flexed / Fully flexed
  • Heel to ear / Popliteal angle: ... degrees
  • Scarf sign: Elbow crosses midline / meets midline / does not reach midline
• Primitive Reflexes: Sucking: Strong / Weak | Rooting: Present | Moro: Complete / Incomplete | Grasps: Symmetrical
• CVS: Normal S1, S2, no murmurs | Peripheral pulses equal, normal volume
• RS: Clear breath sounds, no retractions, Silverman-Anderson score: 0/10
• Abdomen: Soft, non-tender, liver ... cm, spleen not palpable, umbilicus clean
• Genitalia: Testes descended in scrotum / Labia majora covers minora | Stretched penile length: ... cm

9. Comprehensive Discharge Checklist

• Weight gaining ≥15-20 g/kg/day for 3 consecutive days
• Maintaining normothermia (36.5-37.5°C) in room air without KMC for 4-6 hours
• Successful exclusive breastfeeding / paladai feeding without aspiration or fatigue
• ROP screening scheduled / completed
• Hearing screen (AABR / OAE) passed
• Mother confident in KMC, danger signs recognition, and paladai feeding