Profile of at-risk newborns attended by nurses in outpatient follow-up clinic: a retrospective cohort study

ABSTRACT Objective: to analyze the cohort profile of at-risk newborns attended by nurses in a multidisciplinary follow-up clinic, with emphasis on the type of feeding and weight gain, after hospital discharge. Method: retrospective cohort, whose population is composed of at-risk newborns attended in a 4-year period. Data came from medical records and attendance report, later exported to R Program. The outcome variables were number of the nursing consultation, type of feeding, daily weight gain and main guidelines. We used descriptive statistics, frequency distribution and applied Mann-Whitney, Chi-Square, Spearman correlation, Variance and Tukey analysis, with p <0.05 being significant. Results: a total of 882 consultations with 629 infants and families were analyzed. The frequencies of exclusive breastfeeding and weight gain increased as the consultations progressed. The infants who needed more consultations and with lower weight gain were those with lower gestational age (p = 0.001) and birth weight (p = 0.000), longer length of hospital stay (p <0.005), and diagnoses related to extreme prematurity (p <0.05), among others. Conclusion: nurses verified the importance of outpatient follow-up of at-risk newborns, especially in promoting breastfeeding and healthy growth.


Introduction
Many are the sequelae and complications arising from the neonatal period, but the postnatal care is a critical phase, with great psychophysiological, social, economic and family changes. Improper care at this time can lead to various illnesses and death. Even so, this moment is somewhat neglected for specialized health care, which is lower in the postnatal period than before and during birth (1) .
In this scenario, we highlight the at-risk newborns (ARNB), who have the highest rates of morbidity and mortality and the highest risks of developing disabling sequelae throughout life (2) . International studies, for the most part, report that the ARNBs who receive follow-up are and/or should, basically, those premature and with low birth weight (3)(4) . Other studies end up adding more risk criteria as in need for follow-up, such as small for gestational age (SGA), newborns (NB) with malformations, neonatal encephalopathy, surgical newborns, who had central nervous system infections or hyperbilirubinemia, who failed in hearing screening, who had neurobehavioral abnormalities in the neonatal period, and at-term infants who required more than 24 hours of mechanical ventilation (5) .
Regardless of the criteria used to classify the NB as at-risk or not, the surveys converge to a consensus that this population must be monitored in a differentiated, systematic and frequent way. Structured and specialized programs for the follow-up of ARNBs (especially the premature ones) are suggested and described as essential to ensure continuity of care, promote health, empower parents and families, prevent and identify early complications and illnesses, and reduce morbidity and mortality and motor, behavioral and neurodevelopmental sequelae (1)(2)(4)(5)(6)(7)(8)(9) .
However, for this monitoring of the ARNBs to be really effective, it should be carried out by a multiprofessional and specialized team, which should be composed mainly of neonatologists, nurses, physiotherapists, occupational therapists, speech therapists, ophthalmologists, neurologists, psychologists and cardiologists (4)(5) .
The role of each of these professionals in following the ARNB is evident when one observes the inherent characteristics of their professions and specialties.
However, this is not a reality regarding the role of nurses working in Brazilian follow-up clinics, nor is there is any clarity regarding the profile of ARNBs served by this professional category. The literature also states that there are few national scientific productions on the outpatient follow-up of these infants by the nurse, mainly and essentially addressing premature infants (10) .
Thus, to clarify the above issues, this study was carried out with the objective of analyzing the cohort profile of at-risk newborns who were attended by nurses in a multidisciplinary follow-up clinic, with emphasis on the type of feeding and the weight gain after discharge from hospital.

Results
During the data collection period,     Of the 629 infants attended by nurses, two babies returned five times and were scheduled for yet another return visit (Table 1), which is equal to at least 10 consultations during this initial follow-up at the follow-up outpatient clinic.
Also according to the number of the consultation/ visit with the nurses, we found the most common medical diagnoses since the hospitalization of the infants, which are presented below in Figure 1.
All the diagnoses presented in Figure 1 had a frequency greater than 7.6% (n = 67) of the total of 882 visits. Other diagnoses that were not included in Figure   1 presented frequencies of 2 to 6%, some of them being According to the stratification by nursing consultation, additionally, the main guidelines/interventions performed were listed, which are found in Figure 2.
All of the guidelines cited in Figure 2 Table 2 shows the variables that demonstrate the difference in profile between the babies that obtained a weight gain lower than and greater than 20 g/day.  The application of the Chi-square test between the low weight gain and the variables shown in Table   2 related to the patient's outcome showed that there is a significant association between discharge from the outpatient clinic and whether the baby should return, that is, the fact that the baby has had a low weight gain influences whether he/she will be discharged from the outpatient clinic or if he/she will have a scheduled return visit.
When the Mann-Whitney test was applied, there was a significant difference between the variables current weight, number of days until the return visit and length of hospital stay with the fact that the baby was classified or not as with low weight gain ( Table 2) The analysis of variance (ANOVA) was used to verify whether there is a difference between the weight gain and the feeding groups (EBF, mixed breastfeeding, artificial feeding and solid diet), origin (FD-cities, cities of Goiás and Minas Gerais). By the p-value, a significant difference of weight gain was found according to the type of feeding (p = 0.012), but not for origin (p = 0.616) ( It should be added to these data that the guidelines/interventions that had a statistical difference and were more frequent in low weight gain babies were encouragement to breastfeeding (p = 0.025), correction of position and latch (p = 0.000); posterior milk (p = 0.000); translactation (p = 0.000); artificial milk preparation (p = 0.004); intake or increase of artificial milk (p = 0.000); referral to physiotherapy (p = 0.032) and speech therapy (p = 0.007).
Considering that described in Table 1, it was possible to notice that the sex of the NB attended was relatively balanced. Only in the last consultations, the male gender was predominant, but in relation to the weight gain, the female gender found statistical significance. Studies that indicate the profile of the attendees also vary in the predominance of males (17) or females (10,(20)(21) , and other studies related to growth also show that girls are the ones that gain less weight during outpatient follow-up (21)(22) .
The first visit to the follow-up clinic under study is around the 3rd to 9th day after discharge. A retrospective American study that evaluated 65,085 discharges demonstrated that less than seven days after discharge is the ideal time for this first consultation to occur (for reducing readmissions) (23) . The average of EBF in this Rev. Latino-Am. Enfermagem 2019;27:e3113.
first consultation was around 55% and of breastfeeding in general was above 85%. This frequency of EBF can be considered adequate if compared to that found in an Israeli study that showed that only 109 of 162 mothers (67%) were breastfeeding (exclusively or not) their preterm infants at the time of hospital discharge (24) .
However, if confronted with a prospective cohort of 137 preterm infants performed in the northeast region of Brazil, the frequency is below the 56.2%, found on discharge from the Kangaroo ward (20) , being necessary to consider that the Kangaroo Method was related to increased EBF in other researches (12,25) . It should be noted that, as in this study, in another publication from Paraná state, a descriptive and retrospective study of 25 premature infants, it was shown that the growth was not altered according to what the baby was ingesting (10) .
Some findings of this research allow us to infer that the follow-up clinic has promoted and stimulated EBF. Regarding the origin, about 40% of the babies attended in the Ambulatory are from neighboring states, such as Goiás and Minas Gerais. This fact may lead to greater dropout of this follow-up, as this is, sometimes, related to the greater distance between the residence and the follow-up clinic (12,26) .
Regarding the data on GA and birth weight present in Table 1, this study found that the lower the gestational age and the birth weight, the more frequent and the greater the follow-up visits are. Some researches show this need for more frequent follow-up when they affirm that low birth weight and prematurity are related to an increase in morbidity and mortality, chronic conditions and readmissions (2)(3)9,19,(27)(28)(29)(30)(31) , as well as to the greater risk of growth deficit (3,21) , developmental delays and cognitive and behavioral problems (3,7,(31)(32) . In addition, growth must be closely monitored in the first year of life of patients with this profile, thus ensuring optimal brain nutrition and reducing risks of neurodevelopmental delays (19,33) .
It was also observed that the longer the infant's length of hospital stay, the greater the need for return visits and the greater risk of lower weight gain. Since length of hospital stay directly correlates with GA (3) , this data also corroborates a study carried out in Sweden with 1,410 premature infants on an early discharge program, in which the ones that had more readmissions were those with longer hospital stay (11) , that is, greater length of hospital stay is related to higher risk of morbidities and growth deficit.
The ascending evolution of the current weight over the consultations, just like that of the weight gain until the third consultation, shows the effectiveness of the follow-up clinic in guaranteeing an adequate ARNB growth, which was also evidenced in another research (10) .
It is even known that weight gain is an important diagnoser of baby's health (11) , and a statistically significant difference could be verified from the first to the second consultation regarding weight gain in this study. This may indicate that the assistance provided to the ARNBs was effective and that the guidance provided at the initial consultations had a positive impact on growth.
Regarding the most common medical diagnoses of hospitalization present in the served population, these were equivalent to others found in follow-ups performed by nurses (10) . Especially with regard to the last consultations, it is believed that the presence of these diagnoses may even be considered as a risk factor for postnatal complications, and thus they should be closely monitored.
Most of these diagnoses are found in premature infants born with less than 1,500g, neuropathic and those with longer length of stay (2)(3)19) , and in some studies, they are also present in chronic infants coming from the NICU (27) and in those who most needed readmissions (9,11,29) . Neonatal conditions, such as prematurity, asphyxia, infections and hyperbilirubinemia, were associated with sequelae and compromised survival in a retrospective Italian cohort performed with 123 subjects (7) . Anemia must be monitored and treated frequently because it can lead to low weight gain and changes in development (19,33) . Incompatibility, jaundice, malnutrition and enterorrhagia had a greater need for return visits in order to verify and guarantee the reversibility of these problems.
Some medical diagnoses were also found to be statistically significant for weight gain, in addition to prematurity and low birth weight, namely BPD, Premature infants with chronic lung disease may have a delay in oral feeding proficiency (14,19) . In a descriptive study with preterm infants in follow-up, birth diagnoses referring to extreme prematurity (such as the first seven diagnoses mentioned above) were associated with weight loss (10) . An international protocol for the care of late preterm infants revealed that patients with respiratory and cardiac disorders are more susceptible to feeding problems and consequently to failure of growth (28) . A prospective cohort conducted in Paraná with 237 ARNBs confirmed that low birth weight associated with prematurity, mother under 17 years old and congenital anomalies were risk factors added to readmissions (which are even longer than infants without these aspects) until the third month of life (9) . A disease can obviously alter growth, since the weight gain is lower during a illness (10) .  (4) and to ensuring appropriate care for ARNBs, especially premature infants (19) .
Since the first consultation with the nurse, the bond of the parents and other family members with the baby is confirmed or refuted, and the bonds of these with the professional are strengthened. This fact and joint accountability are essential for successful follow-up (12,18) . And as the doctor and the nurses who work in the outpatient clinic work in other neonatal units of the hospital, this strengthening is facilitated.
Parents are more comfortable if the professional who attends them after discharge works in another sector of the hospital (15) and tend to rely more on NICU nurses to provide guidance at this level of care (18) .
The results of this study confirm that the major risk factors related to the morbidity and mortality of ARNBs could be minimized through actions of health promotion and disease prevention (2) . Some papers advocate the Rev. Latino-Am. Enfermagem 2019;27:e3113.
provided by this study also allows that nurses explore