This document summarizes a presentation on follow-up care for high-risk newborns. It discusses the medical home framework and components of health and developmental follow-up. Key points include:
- High-risk infants requiring ongoing care include preterms and those with special health care needs or technology dependence.
- Follow-up includes primary care, specialty care, developmental surveillance, and addressing family concerns from infancy through adulthood.
- Transition points for parents include concerns in the first 3 months after discharge and needs changing from ages 3 months to 1 year, 1-3 years, preschool, and beyond.
- Barriers to care include limited provider familiarity with complex conditions, insufficient reimbursement, and
This presentation is all about how to run a high risk follow up clinic for newborns discharged from a level II/III newborn care unit. It has been prepared mainly based on NNF protocol & AIIMS protocol.
This presentation is all about how to run a high risk follow up clinic for newborns discharged from a level II/III newborn care unit. It has been prepared mainly based on NNF protocol & AIIMS protocol.
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Presented by Dr Sujit, in Sir Ganga Ram Hospital
Trophic feeding, by dr Amal Ahmed Khalil ,Port Said University, mohamed osama hussein
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Growth charts in Neonates- Preterm and termSujit Shrestha
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Over 50 percent of all maternal complications and 60 percent of all primary caesarean sections arise from the high risk group of cases.
Ethical issues of extremely preterm babies’ care: the “grey zone” experiencesMCH-org-ua
International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)
Definition of High-risk Neonate: Any baby exposed to any condition that make the survival rate of the neonate at danger.
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A) High-risk pregnancies: e.g.: Toxemias
B) Medical illness of the mother: e.g.: Diabetes Mellitus
C) Complications of labor: e.g.: Premature Rupture Of Membrane (PROM), Obstructed labor, or Caesarian Section (C.S).D) Neonatal factors: e.g.: Neonatal asphyxia
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This webinar will explore the prevalence of premature births in Virginia as well as trends and issues related to premature birth. Information will include Part C eligibility determination for premature babies including one local system’s experience with eligibility determination and child count. Current research on the impact of prematurity on child development will also be explored.
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early intervention in high risk infants.pptxibtesaam huma
Early Intervention in High Risk Infants
-Dr. Quazi Ibtesaam Huma (MPT)
Dr. Suvarna Ganvir (Phd, Prof & HOD)
Dept. of Neurophysiotherapy
DVVPF’s College of Physiotherapy
Objectives
By the end of the seminar one would know
What is high risk infants?
Determinants of high risk infants
Monthwise neurodevelopment of infants in gestational age
Early intervention
General NICU guidelines for high risk infants
Recent advances
What is High Risk Infant?
A High risk infant is broadly defined as one who requires more than the standard monitoring and care offered to a healthy term newborn infant.
According to American Academy of Pediatrics, High risk infant may be defined as
Preterm Infant
Infant with special healthcare needs or dependence on technology
Infant at risk because of family issues.
Infant with anticipated early death.
High-Risk Clinical Signs
At 4 months of age, hypertonicity of the trunk or extremities is recognized as a high-risk clinical sign.
Less alternate kicking movement compared with typically developing LBW infant.
Abnormalities of kicking described by Prechtl as “cramped-synchronized,” that is, limited in variety and characterized by “rigid movement with all limbs and the trunk contracting and relaxing almost simultaneously,”
Preterm Infant
Preterm infant is the infant which is born before 36 weeks of gestation
Usually preterm infant have low birth weight i.e. less than 2.5 kgs
Determinants of High Risk Infant
Biological Risk
Attributed to medical/physical condition presence of
Asphyxia
Neonatal seizures
Prenatal exposure to drugs or alcohol
Brain-lesions
Low birth weight
Established Risk
Associated with diagnosis that is clearly established like,
Congenital malformation
Chromosomal abnormalities
CNS disorders
Metabolic disease.
Environmental & social risk
Refers to competency in parenting roles and factors in family dynamics
Suboptimal levels of stimulation and interaction in NICU
Inadequate parent-infant attachment
Insufficient educational preparation for caregiver roles
Meager financial resources of parents
Limited or absent family support to assist in taking care of and nurturing the infants in home environment.
The systems of infants develop in their stipulated time during gestational period prenatal or preterm results in specific injury
Commonest condition which requires early intervention
Newborn Maturity Rating—Ballard Score
Widely adopted because of the time efficiency
Ballard instrument involves only six physical and six neurological criteria, with a 0 to 5 scale and a maturity rating
designed to be used for neonates (20 to 44 weeks gestation) from birth through 3 days of age and has demonstrated concurrent validity with the Dubowitz gestational age calculation tool.
Neonatal Behavioral Assessment Scale
30- to 45-minute examination consists of observing, eliciting, and scoring 28 behavioral items on a 9-point scale and 18 reflex items on a 4-point scale
Six behavioral state categories are outlined in the NBAS: deep sleep,
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This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
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Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
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Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
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Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
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8 follow up care of high risk new born
1. Science at the heart of medicine
Follow-up Care of the High Risk Newborn
6th
Neonatal Conference
Hot Topics in Neonatal Medicine
February 21, 2011
Deborah Campbell, MD, FAAP
2. Faculty Disclosure
In the past 12 months, we have not had any significant
financial interest or relationship with the manufacturers of
the products or providers of the services that will be
discussed in my presentation.
This presentation will not include discussion of
pharmaceuticals or devices that have not been approved by
the FDA.
3. Objectives
1. Review management approaches to airway and respiratory
problems
2. Discuss the post-discharge nutritional needs for the VLBW or
medically complex infant and strategies to promote growth and
feeding problems
3. Identify normal and abnormal patterns of growth and
development
4. Describe necessary health maintenance strategies for the high
risk newborn– immunizations, vision and hearing screening
5. Describe the later childhood, adolescent and adult health and
functional outcomes for selected groups of high risk NICU
graduates
4. Medical Home Framework
Care that is:
Accessible
Family-centered
Comprehensive
Continuous
Coordinated
Compassionate
Culturally-sensitive
PCP shares
responsibility
Benefits
Efficiency
Care coordination
Limited resources, cost
Timeliness
Effectiveness
Problem-solving
Satisfaction
Family & health professional
Improved health/functional
status
5. Infants who require a medical home
AAP Policy statement:
Hospital Discharge of the
High Risk Infant (Pediatrics
2008; 122(5):1119)
Preterm infant
Infant with SHCN or
dependence on technology
Infant at risk because of
family issues
Infant with early anticipated
death
Ontario neighborhood
study (Wang et al. Arch Pediatr
Adolesc Med. 2009;163(7):608-615)
2.3% newborn had > 1
chronic care condition
at nursery discharge
CV
Respiratory
Congenital/genetic
Renal
Neuromuscular
GI
6. What are the important timeframes of
continuing care for the preterm, LBW child?
NICU discharge criteria
Transition to home and community
Infancy
Early childhood
Late childhood
Adolescence and transition to adulthood
Parent and family support along the continuum of care
7. NICU Discharge Criteria
Able to maintain body temp in
open crib
Nippling all feeds well by
breast or bottle
Gaining adequate weight
34 weeks’ gestation, ~ 1800
grams
Average PT meets these criteria
between 34-38 weeks PMA
PT infants who remain beyond
this time may have
More significant CLD
Apnea
Feeding difficulties
Malformations
Other complications of
prematurity – surgery
Stable cardiorespiratory status
No apneas or bradycardias for
4-8 days PTD
Home monitoring
Caffeine
Home O2 for infants with
CLD
Severe GERD
Apneas + bradycardias
Car seat safety
~20% will have desaturations
in car seat
Parent rooming-in pre-
discharge
8. Health Care for the Preterm Infant
Primary care visits
Within 1 week after
discharge
Schedule of visits
depends on health
issues and parent
concerns
Periodic
developmental
surveillance
Specialty follow up
Cranial sonography at 40 w
PMA – PVL (if MRI not done
or residual IVH)
Ophthalmology
ROP checks until vasc
mature, ROP resolved
Q 6-12 mos. assess visual
function/acuity
Hearing
Behavioral audiometry at 8-
10 mos. CA
Periodic developmental
screening → Early
Intervention Program
9. Transition Points
Informational, support and resource needs change
along the health and developmental trajectory
Importance of eliciting from parents/families what they
perceive/assess their needs to be for information and
support
Parents may be at a different transition point than the
professionals
May have needs different than what professional perceives as
necessary or important
10. Transition Points for Parents:
Post-discharge concerns in the first 3 months
Feeding, weight gain, general health/illness and infections
Infant with more significant/complex health conditions
Home oxygen, cardiorespiratory monitoring
Repeated hospitalizations
Negotiating complex health care system
Multiple appointments w/ multiple specialists
At-risk (child find) registry-Early intervention
Communication (partnership building) w/ PCP, specialists,
between specialists and PCP, w/ family, friends, others
Parents feeling “abandoned” by NICU staff: child can’t be
readmitted; loss NICU support system
Slide series courtesy of D. Campbell
11. Transition Points: 3 months to 1 year
Continued concerns about feeding, weight gain and general
health
Social interaction and emerging milestones
For a subset of families
Concern about neurological problems: risk of CP
Loss of informal support network
Insecurity regarding what is “normal” for their infant
12. Transition Points: 1-3 years
Motor milestones are progressing
Even among infants with impairments
Generally, infants w/ motor problems continue to improve and
make steady progress
Language acquisition a concern for many families w/
preemies
May need EI referral for speech-language/communication
problems
13. Transition Points: Preschoolers
Some children socially immature for their age
Attentional problems and hyperactivity may be a problem
for 10-20%
Parents should be advised to watch for learning difficulties
and seek early remedial assistance
Preschool, nursery or specialized day care programs
14. Transition Points: Middle and Late Childhood
Formal psychometric testing, as a group:
Preterm children perform less well in terms of IQ, reading,
spelling, and math
50% perform in normal range
20-30% may present w/ LD
< 26 weeks’ gestation
> 30 weeks’ gestation- fewer problems
Remedial educational assistance required by 30-40%
Behavioral difficulties
Hyperactivity and attentional problems may persist and
interfere w/ learning process (parent and teacher reports)
15. Adolescence-Adulthood
Most motor difficulties, if present, less problematic
Learning problems persist in 30-40%
Math most challenging
Nearly 50% ELBW teens require PT/FT special educational
assistance
Grade repetition – 20-30%
Attention problems less taxing as grow older
Delinquency and risk-seeking behaviors less common than among
NBW FT counterparts
Less drug and alcohol use*
Less satisfied with appearance*
More regular use prescription medication*
* Cooke, Arch Dis Child 2004; 89: 210-206Hack et al., NEJM 2002; 346:149-57
16. Components of Follow-up Care
Primary care health
Medical home
Subspecialty care
Ophthalmology
Pulmonary
GI and nutrition
Endocrinology
Nephrology
Audiology
Speech-feeding
Pediatric surgery
ENT
Dental
Physiatry – orthopedics
Neurology – neurosurgery
High risk follow up
program
Monitor development of
children at risk for emerging
delays
Focus on identifying
problems as they emerge
Routine screening tests may
not identify DD in these
children
Periodic screening for
sensory, impairment, DD
Evaluation medical,
psychological, social factors
17. Components of Health and Developmental Follow
up for the Preterm and High Risk Infant
Science at the heart of medicine
18. Components of Health and Developmental Follow
up for the Preterm and High Risk Infant
Science at the heart of medicine
19. Timeline of Neurodevelopmental Child
Outcomes
1-3 yrs 4-7 yrs 8+ yrs
Cognitive
Executive function
Motor function
Temperament, self-regulation
Relationship to parent
Behavioral problems
Relationship to peers
Psychopathology
Antisocial behavior
School failure
NICHD Workshop. Pediatrics 2004; 114(5):1377-1397
20. Role of the pediatrician caring for a
preterm or other high risk infant
Managing /coordinating care for discharge diagnoses
Meet families prior to discharge from NICU
Attend discharge planning meeting
Obtain and review discharge summaries prior to 1st
office
visit
Anticipating new medical problems
Regular primary care issues
Addressing Family Concerns
21. Great Expectations
What’s expected of parents
Administration multiple
medications
Maintaining difficult feeding
strategies and schedules
Appropriate response to an
infant w/ poor state regulation
Irritable
Day/night confusion
Sensitive to sensory
stimulation
Manage multiple
appointments
Manage equipment and other
needs
Conduct the rest of their life
What’s expected of the PCP
Up to date on current
treatments and
technology
Know all drug doses and
indications for special
formulas
Comfortable w/
equipment
Coordinate the
“medical” home and
early intervention needs
22. Barriers Facing the PCP Providing
Primary Care for the HR Infant
Difficult for PCPs alone to provide medical homes for medically
complex, fragile infants
Limited familiarity with unusual disorders and
their therapies
Incomplete knowledge of available community
resources
Distance from tertiary care centers
Poor reimbursement for care coordination
Insufficient time
Arch Pediatr Adolesc Med. 2007;161(10):937-944
23. HRI/Preterm Follow-up Clinic
Tertiary center-based
or community-based
Comprehensive care v.
neurodevelopmental
surveillance only
Fragmentation in care
Not a true medical home
Time-limited (24-36
months corrected age)
Developmental
surveillance
Is not paid for by most
insurances
Covered under EPSDT
requirements for Medicaid
recipients
Many states do not include
these infants under
automatic eligibility for
early intervention
Screening and surveillance
by the PCP required, but
not paid for
24. Barriers Noted by Neonatal Programs that Limit
Offering Structured HRI Follow up Care
Funding
Cost and insufficient
reimbursement
Hospital/department/
division support
sustains many programs
(Kuppala, et al. personal communication;
C. Harrison, VA Neonatal Work Group,
2006)
Qualified personnel
Family compliance
with recommended
care
Lack of understanding
of the need for follow
up services
Multiple (competing)
health care needs
25. RN-specialist maintained contact w/ family/care givers and
community-based HCPs
Comparable health (growth, hospitalizations) and
developmental outcomes (median MDI, PDI)
Pediatrics 2007; 119:e947-e957
26. Tertiary Care-Primary Care Partnership Model
Gordon, et al. Arch Pediatr Adolesc Med. 2007;161(10):937-
944
27. Hospital-based CSHN Comprehensive
Primary Care Clinic Costs and Utilization
Berman et al. Pediatrics 2005; 115;e637-e642
Outpatient services had a per child loss; off-set
by increased income from ICU stays; fewer
non-ICU hospitalizations
28. Elements needed to maintain good follow up rates
Enrollment of patients prior
to hospital discharge
Identification of specific
contact person
Multiple back-up contact
addresses and phone
numbers
Post-discharge and interim
visits during the first year of
life
Clinical health and
developmental surveillance
Maintenance family
involvement with program
Close communication
with child’s PCP
Dedicated program
coordinator to track
families
Reimbursement for
transportation, parking
Funding to pay for all
of the above
NICHD Workshop. Pediatrics 2004; 114(5):1377-1397
29. Recommendations
Resident and fellow education on care of the high risk infant care
Continuing medical education for primary care providers (PCPs)
Tools to support the PCPs in caring for HRI
National resource and needs assessment to better define the
landscape of primary and HR FU care across the US
Consensus guidance for PCPs, states and insurers around the
components FU care for high risk infants
Registry that would allow for tracking of this specific population
of infants
Provincial/state and national population-based registries
31. What are the continuing health issues for
preterm and low birth weight children?
Respiratory
Chronic lung disease,
respiratory infections
Apnea of prematurity
SIDS
Physical growth
Feeding difficulties
Oral health
Incomplete catch up growth
in short and long term
Cholestasis
Anemia
Hypothyroidism
Ophthalmology
Vision loss and impairment
Reduced visual acuity, color
vision, contrast sensitivity
Field defects, eye motility
disorders
Long term affects on pain
perception
Scars, deformations,
hernias
Bone mineralization
32. Complex Medical Outcomes
58% hospitalized > 1
time(s); 49% > 2 times
Respiratory (+ apnea) >
surgery (+ laser) >
FTGW
During a
hospitalization more
likely to be admitted to
a PICU, use chronic
technologies
(ventilator, GT-tube,
tracheostomy, PN)
Post-anesthesia
complications
Apnea
Hypertension
Increased incidence
related to thrombi,
renovascular, CLD
Late adolescence
Higher BPs awake and
during sleep
Unrelated IUGR/SGA
33. Complex Medical Outcomes
At 18 Months
Gastrostomy 8%
Tracheostomy 3%
Oxygen 6%
Ventilation at home 2%
50-60% hospitalized at least once
35. Incomplete Catch-up Growth
IU rates of weight gain not
typically achievable
At hospital discharge for
2000 gram infant
About 30 g/d
Patterns growth
AGA – growing along IU
growth curve
AGA – falling below curve
SGA – catch up growth
SGA –remains below curve
Babson-Benda Growth Charts
37. Correcting for Prematurity
Who? Babies < 37 (or < 35) weeks’ gestation
How long?
Adjust at least through 24 months if < 1500 grams;
correct through 12 months for 1501-2500 grams
How?
Assume a 30 day month (GA 29 weeks)
Date of testing Yr ‘06 Month 09 Day 9
Date of birth Yr ‘06 Month 03 Day 25
Chronologic age 5 14
Adjustment for PT 2 21
Corrected age 2 23
Round to the nearest week: CA = 2 mo. 3 w.
Alternatively: count exact time from birth
38. Monitoring Growth: Growth Charts
Larger, stable infants may show
catch up growth in the first 1-2
years
VLBW and ELBW infants may
not catch up in the first three
years
As a group tend to remain
permanently lighter and shorter
than infants born at term
Emerging data that too rapid
early growth in PT children has
adverse long term CV effects
(Singhal et al., 2004)
2000 Revised CDC Growth
Charts
Includes data on babies
>1500 g (adjust for CA)
Excludes < 1500 g
IHDP growth charts
Best available reference,
though reflects only 985
VLBWI from 1980s
(changes care, growth
patterns, outcomes)
< 1500 G use IHDP or
CDC based on adjusted age
until 24 mos. CA
39. Comparison of CDC growth chart and
IHDP VLBW - Girls
Solid line = CDC
Dotted line = IHDP
Sherry B, Mei Z, Grummer-Strawn L, Dietz WH. Evaluation of and recommendations for growth references for very low birth weight (< or =1500 grams)
infants in the United States.Pediatrics. 2003 Apr;111(4 Pt 1):750-8.
41. For VLBWI: No single reference growth curve better. (Sherry et al: Pediatrics
2003; 111: 750)
42. Patterns of Growth of VLBW infants
All growth parameters less than full term infants
Most LBW and PT infants catch up by 2-3 years of age
Smaller, less mature and sicker infants may take up to 7-8
years to catch up
Individual infants should follow their own curve
Weight gain:
20-25g/d up to 3 mo adjusted
15-20g/d 3-6 mo adjusted
HC is 1st
to catch up > weight > length
HC < 10th
centile at 8th
mo adjusted age associated with poor
cognitive function
Wt and length < 10th
centile at 2 yrs will remain < 10% at 5-
8yrs
43. Growth in NICU Influences
Neurodevelopment and Growth of ELBW
Infants (NICHD 2006)
Growth as variable in logistic regression model
includes: Gender, Race, GA, SGA, Mat.
Edu.,Severe IVH, PVL, RTBW, NEC, Late onset
sepsis, BPD, Postnatal steroids and center
44. Poor Weight Gain Increases Odds for Poor Outcomes
Ehrenkranz RA, et al. Pediatrics 2006;117:1253-61.
1.00.2 10.0 50.0
Odds Ratio (95% Confidence Interval)
2.53 (1.27–5.03)
2.25 (1.03–4.93)
8.00 (2.07–30.78)
ELBW infants, in-hospital growth: 12.0 v. 21.2 g/kg/day
Cerebral palsy
Bayley MDI <70
MDI=Mental Development Index
Neurodevelopmental
Impairment
45. Poor HC Growth Increases Odds for Poor Outcome
Ehrenkranz RA, et al. Pediatrics 2006;117:1253-61.
1.00.2 10.0 50.0
Odds Ratio (95% Confidence Interval)
3.64 (1.85–7.18)
2.33 (1.10–4.95)
4.10 (1.24–13.59)
ELBW infants, in-hospital HC growth: 0.67 v. 1.17 cm/wk
Cerebral palsy
Bayley MDI <70
HC=Head circumference
MDI=Mental Development Index
Neurodevelopmental
Impairment
46. Neuro/Intellectual Function at School Age with
Subnormal Head Circumference at 8 Months
Total Population Neurologically Intact
Condition
(criteria) (8 years)
HC
(nl)
(216)
HC (subnl)
(33) 13%
RR HC (nl)
(199)
HC (subnl)
(26)
RR
Neurological Impairment
(major neurological
abnormality)
~8% 21% 2.69* – – –
Low IQ
IQ <70
IQ <85
3%
27%
24%
52%
7.48†
1.91†
2%
26%
12%
46%
5.74
1.80
Limited Academic Skills
(read/math/spell std score
<80)
31% 56% 1.81† 28% 54% 1.88
* P<.05 by chi square test
† P<.01
HC subnormal; 1.1 versus 1.2 kg,
higher neonatal risk scores (1977-1979)
Hack. N Eng J Med. 1991.
Brain Growth and Neurodevelopment
47. Summary of Neurodevelopmental Outcomes: appropriate-for-
gestational-age (AGA) and small-for-gestational-age (SGA)
infants who attained adequate v. delayed extrauterine growth*
Neurodevelopmental Adequate Delayed extrauterine
outcomes in subgroups catch-up growth growth (EUGR)
of VLBW premature infants
AGA Good neurodevelopmental Decreased mental and
outcome motor function
SGA Good neurodevelopmental Decreased motor function
outcome (similar to AGA with
adequate catch-up growth
VLBW, very low birthweight.
*9 and 24 months
Catch - down
Catch - up
Latal-Hajnal et al J Pediatr 2003;143(2):163-70
48. Nutritional Support:
Nutritional intake ≠ Growth requirements
When to transition to standard formula?
Duration up to 12 months age, or
Achieve at least 25-50% (v. 90%) on standard growth
curve for CA
Minimum recommended weight gain
20g/d term-3 mo CA
15g/d 3-6 mo CA
10g/d 6-9 mo CA
6g/d 9-12 mo CA
1kg/6 mo 1-2 yrs
.7kg/6 mo 2-5 yrs
Minimum acceptable growth
Length < 0.5 cm/wk Head < 0.5 cm/wk
Caloric intake 105-130 kcal/kg/d
49. Nutrition: Breastmilk or Formula
Recommended* Breast Milk Similac Neosure ®
(22cal/oz)
Enfacare®
(22cal/oz)
Calories/kg/day 110-130 100 110 110
Protein g/kg 3-3.6 1.5 2.9 3.0
Fat g/kg 5-6 5.8 6.3 5.8
Carbohydrate
g/kg
10-13 10.8 11.3 11.8
Calcium mg/kg 175 42 115 132
Phosphorus
mg/kg
91 21 68 72
Iron mg/kg 1.7-2.5 0.04 2 2
Vitamin D IU/kg 150-400 3 78 88
Use of Preterm discharge formulas till 9 months adjusted age results in greater linear growth , weight gain, and bone mineral content than
term formulas; *Calculated at 150ml/kg/d
50. Breastmilk Feeding after Discharge
Adequate caloric and nutrient intake if feeding
breastmilk ad libitum and ingesting > 180
cc/kg/day
IQ advantage: + 8 points (~1 SD)
In comparison with PT infants fed post-discharge
formula (PDF) or term formula, infants receiving
BM had similar weight gain at 9 mos. to term
formula-fed PT infants (Lucas, Pediatrics 2001; O’Connor, JPGN 2003)
Weight gain greater from 1.5 to 9 months w/ PDF and
term formula
51. Special Formulas
24kcal formula - Similac ®
Special Care ®
with iron
For short term use after discharge for babies with osteopenia
CLD or SGA
Soy formula (Isomil, Prosobee) not recommended <40wks CA (low PO4)
Cow Milk Protein allergy:
Nutramigen, Alimentum (hydrolyzed protein)
Neocate, Elecare (amino acid base) : for severe allergy, heme + stools on above
formula
Malabsorption:
Alimentum, Pregestimil (available as 24kcal)
Neocate, Elecare : for heme + stools on above formula or fails to tolerate them
Supplementation - if intake is inadequate and calories required
Vegetable oil 9 cal/ml
MCT oil 7.6 cal/ml
Microlipid 4.5 cal/ml
Dry baby cereal 10cal/tsp
Polycose 2 cal/ml
52. Transitional Formulas – Nutritional Supplements
Continue post-discharge preterm formula for 9-12 months (at
least 40 wks CA) based on growth (ESPGHAN commentary in
JPGN 2006)
Benefits:
Enhanced growth if continued beyond 12 weeks
Increased mineral intake (Ca, P)
Transition to 30kcal/oz toddler formula (Pediasure) after 12
mo chronologic age if weight still < 5%
Mix half and half w/ whole milk (25 kcal/oz)
Nutren Jr. if sensitive to cow milk protein
Whole milk w/ Carnation Instant Breakfast added (one pack/8
oz = 30 kcal/oz)
53. Supplementing Human Milk
EnfaCare or Neosure to fortify Human Milk
Decide desired caloric concentration, Kcal/oz
Measurement of powdered formula (packed, level teaspoon)
Total amount of breast milk in ml (measure breast milk
first, then add powder)
Caloric density Added Formula HM volume
22 Kcal/oz 1 teaspoon 180 ml (6 oz)
24 Kcal/oz 1 teaspoon 90 ml (3 oz)
27 Kcal/oz 2 teaspoons 90 ml (3 oz)
54. Vitamins and Minerals
Infants fed breastmilk or
standard formula:
Multivitamin 0.5-1 ml/d
Until intake > 450 ml/d or
2.5 kg body weight
Vitamin D 400-800 IU/d
(continue for exclusively
breastfed)
Iron supplement 2 - 4 mg/kg/d
(exclusively breastfed for 1-2
mo)
Additional iron 4 – 6 mg/kg/d
if anemia - screen CBC and
retic. as clinically indicated
Fluoride supplements at
6 months if exclusively
breastfed, ready to feed
formula or formula not
prepared with fluoridated
water
Infants receiving
transitional formula do
not require vitamin
supplementation
55. Feeding Issues
Complicating health
conditions
GERD
BPD
Apnea
Inappropriate feeding
regimens
Poor or slowing growth
velocity – increased energy
expenditure
CLD/RAD
Abnormal tone (high/low)
Poor feeding due to:
Poor oromotor
coordination
Difficulty coordinating
suck, swallow,
breathing
Palatal grooves
Feeding fatigue
Feeding aversion
Difficulty w/ new
textures, chewing
56. Oral Feeding Aversion: Tactile Defensiveness
Caused by multiple noxious stimuli around the face
during neonatal period
Intubation, feeding tube, suctioning, tracheostomy changes
Coupled with lack of pleasant oral experience and/or
GERD
Clinical Picture:
Clamp down mouth, turn head away, push bottle or spoon,
arches and cries during feeding. May lead to inadequate
nutrition
Therapy: Will need speech therapy
May take months to years to properly feed orally
57. Gastric Tubes
Placed endoscopically or surgically
Standard tube placed initially 8-12 wks (percutaneous)
or 6-8wks (surgical) then replaced with button
Button has antireflux valve requiring special apparatus
to vent air out of stomach if fundoplication
Problems: leakage, irritation , migration, accidental
removal
Accidental removal:
If < 4 wks : place 10F red rubber catheter immediately by parent
and contact surgeon
If > 4 wks : parents can replace balloon gastrostomy. Button
needs ED visit within 1st
24hrs.
58. GERD
Signs and symptoms:
Vomiting
Gagging/Retching
Feeding aversion
Irritability after feeding
Failure to thrive
Reactive airway disease
Recurrent Pneumonia
Apnea/Bradycardia
Sandifer syndrome: truncal
arching, extension of head
and neck into opisthotonic
posture, with possible side-to
side twisting of head.
Diagnosis:
Extended timed pH-probe
Radio-labeled milk scan
Barium swallow will only
r/o anatomic cause
59. Management of GERD
Medical
Non pharmacological
Semi upright position ½ - 1hr
after feeds in 30-45° angle
prone - not car seat
Thicken feed - Rice cereal
Small frequent feeds
Minimize stimulation during
and after feeds
Decrease air swallowing
Pharmacological
Reglan
H2 receptor antagonists:
Cimetidine and ranitidine
Antacids: Maalox and
Mylanta
Surgical
Nissen Fundoplication
Indication:
Aspiration or
esophagitis
Associated pathology
eg. CP, MR
Complication: 10-30%
Bloating
Loosening of wrap
Esophageal dysmotility
Perforation
60. “Red Flags” indicate need for further workup
Wt <5th
centile on CDC chart
Wt loss or no wt gain from one month to next
Significant decline in percentiles (>2)
Deviation from normal weight gain
< 20g/d up to 3 mo
<15g/d 3-6mo
Wt for length < 5th
or > 95th
Deviation from normal HC growth
0.5 cm/wk up to 3 mo
0.25 cm/wk 3-6mo
Disproportionate head growth
61. Introduction of Solids
Factors associated with weaning (Fewtrell et al., 2003)
Formula fed infants tend to receive solids earlier
PT infants more likely to receive solids at both 6 and 12 wks post term
compared w/ AGA FT
Formula feeding and maternal smoking associated w/ earlier introduction
solids
Introduction solids between 4-6 months CA + readiness skills
Postural control (head, trunk), able to eat from spoon
Introduction > 4 solids before 17 wk CA increased risk for
eczema/atopy in PT (OR 3.49) (Morgan et al., 2003 [controversial; case
series])
If one/both parents atopic, onset in infant by 10 wks CA (OR 2.94)
62. Growth in Later Childhood-Adolescence
Doyle et al.: Mean wt. 1 SD below mean at 2 yrs, 5 yrs, 8 yrs;
catch up by 14 yrs
Girls aver. 7.3 kg less; boys weigh 8.3 kg less
Height: 4.5 cm (girls) -5.8 cm (boys) less at 14 yrs
Saigal et al. (2001): at 12-16 yrs
11% girls < 3%
8% boys < 3% (NBW FT 1%)
Hack et al. (2003): VLBW females catch-up by 20 yrs v.
VLBW males remain shorter and lighter
64. Immunizations
AAP recommends regular doses of immunizations be
given at the infant’s chronological age regardless of
weight or prematurity.
DTaP, Hib, IPV, MMR, Varicella, Prevnar
Hepatitis
Rotavirus
Influenza
Palivizumab
65. Hepatitis B
HBsAg neg mother:
Preterm
< 2kg : delay immunization until prior to discharge.
If <2 kg at discharge delay until 2 months.
4 doses
HBsAg pos mother:
HBIG + Hep B vaccine at birth
Post-vaccination testing
If <2kg should not count initially vaccine in 3 dose
schedule
HBsAg unknown:
Give 1st
dose Hep B vaccine at birthHBIG with first 12h
66. Influenza
After 6 mo age
High risk of respiratory illness e.g. BPD, mechanical vent,
heart disease
2 doses:
0.25ml IM
One month apart
Between October and mid-Nov
Household contacts should be given vaccine
67. RSV Prevention
Significant morbidity and re-hospitalization for preemies with BPD, on
ventilator
Palivizumab (Synagis):
IgG monoclonal antibody
55% reduction in RSV hospitalization in preemies
Indication:
Preemies <32 wks GA (<28wk GA for 1 yr, 29-32 wk GA for 6mo)
BPD within 1st
2 yrs of life who require diuretics, bronchodilators, home oxygen,
ventilation
Asymptomatic, acyanotic congenital heart disease
32-35 wk GA with risk factors eg. neurologic, resp disease, young siblings,
attendance of day care, smoke exposure
Given monthly IM
October- April in this region
RSV IVIG (Respigam) : given IV , provides higher titer but given in large
volume, used in immunodeficient patients or severe CLD likely to develop
serious sequelae from any viral resp illness.
70. ROP Screening
Who gets screened?
Bwt , 1500g or GA , <30 wks
Select infants 1500-2000g
w/ unstable course
ROP typically begins to
regress by 41-43 weeks
PMA
Frequency exams
Weekly: ROP that may
soon progress to threshold
ROP
ROP less than threshold
zone I
ROP in zone II
Q 2wks
Less severe ROP in zone
II
Q2-3 wks
Incomplete retinal
vascularization, but no
ROP
71. 10 Year Follow-up CRYO-ROP Study
Treated eyes
Better distance and near visual
acuity
Better anatomic status of
fundus- normal appearing
Less blindness
Late retinal detachment ~
14yrs of age more common in
untreated eye
ETROP Trial (2003, 2004)
Early Rx
↓ Risk poor vision
↓ Structural damage eye
Effect ablative therapy for
threshold ROP
Preserves peripheral vision
Reduction ~5-7% in visual
field area in treated eyes
27-35% deficit in visual
field area in untreated eyes
with severe ROP
Contrast sensitivity
33% reduction in
unfavorable CS results with
cryosurgery
72. Visual Sequelae of Preterm Birth:
Assess EOM, corneal light reflex, ability to fix;
Ophthalmologist evaluation by 1 year of age
Poor vision detected in
~2.5% VLBW children
Visual function
Reduced visual acuity,
color vision, contrast
sensitivity
Field defects, eye motility
disorders
Reduced visual acuity
47% all VLBW children
34% VLBW children
without ROP or
neurological complications
Strabismus
6-fold increase by 10-12 yrs
of age
Overall incidence 13.5 % at
3.5y for VLBW v. 2% born
at term
5.9% VLBW children
without ROP/neurological
complications
Esotropia dominating type
Secondary functional
amblyopia associated in
many
73. Hearing Loss in High Risk Infants
Prevalence permanent HL among
NICU infants 1-3%
10-20 X general population (v. 0.1-
0.3% all LB)
Auditory neuropathy/auditory
dyssynchrony common (Berg et al.,
Peds 2006)
Abnormal ABR, normal OAE
Normal outer hair cell function
Abnormal neural function
No acoustic reflexes
Poor speech perception
Fluctuating HL
If maturational, normalizes bet 12-
18 months
Known risk factors
Damage to inner hair cells
LBW
Low Apgar score, asphyxia
ECMO (25% affected; 50%
have progressive loss)
Ototoxic medications
GJB2-connexin 26 mutations
IVH
Hyperbilirubinemia
Acoustic (noise) trauma
Ventilation
Congenital infection -CMV
Sepsis, meningitis
Anatomical malformations
Family history
78. Respiratory Health: Chronic Lung Disease
Incidence 15-50% (varies by GA, NICU)
Oxygen Dependence at 36 wks PMA
Best predictor LT pulmonary outcome
57-70% at 23 wks Gestation
33-89% at 24 wks
39-61% at 500-800g BWT
O2 dependence at 1 year of age
GA (w) % Requiring
<23 24
24 13
25 7
79. Chronic Lung Disease: Associated
Pulmonary Problems
Early motor development
and feeding
Motor development
Low muscle tone
Decreased tummy time
when on O2
Poor prone skills
Feeding
Increased caloric
requirements
Tachypnea/fatigue w/
feeding
GER
Stridor
Tracheomalacia
Airway collapse
Laryngomalacia
Hypotonia
Upper airway
obstruction/abnormality
Subglottic stenosis
Vocal cord
paralysis/dysfunction
Persistent central apnea
80. CLD: Home Oxygen Therapy
Reduces
Mortality from SIDS
Desaturations, pulmonary
hypertension, reversible obstructive
lung disease
Risk nosocomial infection
Improves growth,
neurodevelopment
Need based on monitoring
during all ADL
During sleep, wakefulness and
feeding/activity
Infants w/ SaO2 < 90% (<93%
during sleep) need LT O2 therapy
Keep SaO2 between 92-
94%
95-98% if pulmonary
hypertension
Avoid SaO2 < 90% more
than 5% time
Wean based on 2 hour
challenge
Able to keep SaO2 > 92%
O2 flow < 0.02 l/kg/min
Wean daytime O2 first
81. Sample O2
weaning protocol
Science at the heart of medicine
Alternate daytime and nighttime
weaning
½ L/min → ¼ L/min → 1
/8 L/min
→ 1
/16 L/min → room air (21% O2)
Infant meets weaning criteria:
1.Maintain SpO2 > 95% during
sleep, while awake and when
feeding
2.Good weight gain
3.No increase in respiratory
symptoms
82. Bronchopulmonary Dysplasia/CLD:
Care at Home
Oxygen
No smoking
Diuretics
Bronchodilators
Airway issues
Nutrition
Feeding tolerance
Higher feedings
Fluid restriction
GERD
Cardiorespiratory
monitors
ALTE, SIDS
Home oxygen (long term
O2 therapy)
Infection
RSV prophylaxis
Pneumonia
Otitis media
83. Post-Discharge Management CLD
Monthly or bi-monthly visits
with pulmonary
Adjust for weight gain for at
least 1-2 months post D/C
Check chemistries q 2-4 wks
Wean/let outgrow meds when
off O2
Wean daytime O2 before
nighttime O2
Remember palivizumab
therapy!
Need at least 24 cal/oz formula
(120-140 kcal/kg/d)
Medications
Hydrochlorthiazide
20-40 mg/kg/d ÷ q 12h
Spironolactone
2-4 mg/kg/d ÷ q 12h
Furosemide
2-4 mg/kg/dose q 12-
24h
KCL
1-4 mEq/kg/d ÷ q 6-12h
84. Medications Used in the Management of CLD
Bronchodilators
Albuterol (Proventil,
Ventolin)
0.5 cc by nebulizer or
inhaler q 6-12h
Ipratropium (Atrovent)
0.5 cc by nebulizer or
inhaler q 12h
Levalbuterol (Xopenex)
0.62 mg respule by
nebulizer
Anti-inflammatory drugs
Cromolyn (Intal)
Inhaler or nebulizer
Takes 2-4 weeks for
adequate trial
Inhaled steroids
Budesonide (Pulmicort)
0.25-0.5 mg respule q 12-
24h
Fluticasone (Flovent)
0.125 mg (1 puff) q 12 h
Betamethasone
Oral prednisone for serious
exacerbations
85. Respiratory Health
50-80% develop RAD
10-15% mortality rate post surfactant – sudden death
common
Lung function improves between 8 and 14y
At 14 yrs:
Clinical respiratory health comparable to NBW children
Rate asthma not significantly different
Overall lung function essentially normal
Lower for all air flow variables, but no difference in lung volume or air
trapping
No differences between ELBW children with/without BPD
ELBW teens had lower aerobic capacity, strength,
endurance, flexibility and activity level
Less previous and current physical activity, sports participation,
poorer coordination (Rogers et al., 2006)
86. Home Monitoring Indications
Persistent apnea
On caffeine
Maintain on caffeine until 44 w PMA
Continue monitoring for 2-4 weeks after discontinuing
caffeine
Persistent bradycardias with feedings
Severe GERD
Infants requiring side or prone positioning
Have O2 on standby at home
87. SIDS Risk for Preterm Infants
Risk
FT: 1.0/1000
PT
2-2.5 kg 3.8/1000
1.5-2kg 6.4/1000
< 1.5 kg 7.5/1000
Full term infants
SIDS risk greatest at 52.3
weeks PMA
Preterm
SIDS risk highest at 50 + 2
w PMA
24-28 weeks GA
45.8 weeks PMA
Apnea appears to resolve
in most PT infants before
age of SIDS deaths
Apnea > 30 sec resolves by
43 wks
Monitoring warranted if
significant apnea persists
at time of d/c
Monitor not needed for
apnea if > 8 days apnea-
free in hospital
88. SIDS Prevention – PT Infant Sleep Position
Preterm infant sleep position
Less frequent use of non-prone (back or side sleeping)
by parents
64% supine at hospital D/C → 35 % at 2mos CA (Adams et al,
1998)
GER was common reason cited for change to prone
Risk SIDS greatest for infants in unstable side position
or within first 2 weeks of sleep position change for
premature infants (De-Kun et al, 2003)
Recommendation for healthy PT: supine, safe
sleep practices, smoke free, don’t overheat
Alternative sleep position- sidelying, arm extended no
longer recommended (OR 3.9 x ↑ risk SIDS)
89. Oral Health
Higher prevalence of
enamel defects: 40-70%
Enamel hypoplasia
96% v. 45%
Primary teeth
78% v. 20%
Secondary teeth
83% v. 36%
Osteopenia
Not prevented by mineral
supplementation or
vitamin D
First tooth eruption later in
PT girls than PT boys
60% > 10 mos. age (< 1kg,
< 31 wks)
Permanent dentition
Incisors, molars
Palatal grooves
High arched palate
Speech, bite
90. Other Health Issues
Scars and deformations
Nares
Notches, septal
damage/deviations
Skin sloughs, scars, contractures
Capillary hemangiomas
increase during first year then
fade
Hernias
Inguinal, umbilical
Increased incidence
cryptorchidism and undescended
testis, refer to urologist after 6mo
Anemia
Metabolic bone disease
(osteopenia)
Inadequate dietary phosphorus
Diuretics
RDA Vitamin D 400 IU/d
Malabsorption/ rapid transit
time
Short bowel syndrome
Cholestasis
Elemental formula containing
MCT oil
Supplemental fat-soluble
vitamins (A, D, E, K)
Ursodeoxycholic acid
91. Other Health Issues
Orthopedic:
Internal or ext rotation of LE corrects when baby walks
Ankle clonus, toe standing, truncal hypotonia, shoulder
girdle hypertonia usually resolve by 18 mo
Hand preference before 18 mo may indicate hemiparesis
Positional plagiocephaly
Position head on rounded side
Torticollis
Neck exercises w/ diaper changes, 3 repetitions, 10 count each
Cranial orthotic – bands, helmet if severe deformation or
no improvement
93. Behavior and Pain Perception:
Acute Consequences
Stress responses
Hormonal, behavioral,
and autonomic
Changes in HR, RR,
BP, blood vessel tone
Changes in CBF, brain
blood volume and
oxygen delivery
↑ risk IVH and PVL
Short-term sequelae of
prior noxious stimuli
Lower threshold to tactile
stimulation
Hypersensitive to pain
Chronic pain responses to
local injury
Link with cumulative
painful procedures and
subsequent pain and stress
behaviors
↓ behavioral response to
additional acute painful
events at 32 wks’ corrected
age
94. Longer-term Sequelae of Prior Noxious
Stimuli
Lack of normal pain
sensitivity as toddler
among ELBW children,
esp. < 800g (1lb 12 oz)
↓ pain sensitivity at 18
months corrected age
Child temperament and
reported pain sensitivity
appear independent
Muted pain response to the
normal pain consequences
of acute injury
Gross motor coordination and
motor planning less well
developed
At 4.5 yrs exhibit greater
somatization by parent report
At 8-10 yrs, overall NBW and
ELBW children had similar
perceptions of pain intensity
ELBW rated medical pain >
psycho-social pain
Higher pain intensity to
recreational pain
Buskila et al., Arch Pediatr Adolesc Med 2003; 157: 1079-1082
95. Neurological Outcomes
Early developmental
problems related to
brain immaturity
• Autonomic instability
• Abnormal state
regulation and
behavioral organization
• Motor problems – lack
of graded flexion
Late – abnormal brain
maturation
• Extreme immaturity or
brain injury
• Risk for longterm
cognitive, speech,
motor, vision, behavior
and attention problems
96. Functional Outcomes
Functional limitation
Restriction of ability to
perform an essential activity
Self-care
Mobility and locomotion
Communication
Socialization
Compensatory dependence
Need for services above
routine
Percentage children with a
health problem affecting >
1 activity of daily living
1001-1500g 34%
< 1000g 46%
School age outcomes
Standard Placement 50%
Resource 30%
Special Education 20%
Repeat a grade 16%
97. Minor Neurodevelopmental Difficulties
Cognitive
Mean IQ 8-10 points lower than FT
Borderline intelligence – IQ 70-84
750-1500g 20%
<750g 33%
Learning deficits
45% - 65% v. 11% FT
Reading, spelling, math skills
Memory tasks and processing speed
98. CNS Complications in Preterm Infants
Intraventricular Hemorrhage
Incidence ↑ with small GA
Screening Head Ultrasound or
CT/MRI
Complications : hemorrhagic
cerebral infarct, porencephalic
cyst, hydrocephalus,
ventriculomegaly, PVL
Assess muscle tone – usually
high tone in preemies up to
12-18 months.
Serial US, CT/MRI
Early intervention
Hydrocephalus
Assess Head
circumference and signs
of ↑ ICP once/month if
pt has Hx of IVH
DD: catch up growth –
Hydrocephalus HC
>1.25cm/wk, signs of
ICP, changing
neurological status
Serial US if S+S of ↑
ICP or ↑ HC
99. CNS Complications in Preterm Infants
Periventricular leukomalacia:
Ischemic infarction of white
matter adjacent to lateral
ventricle
Occurs in 25% infants <1500g
Diagnosed by US or MRI as
white matter cysts as early as 1st
wk if insult occurs in utero
Usually 2-8wks after insult
Closely associated with CP,
developmental delay, epilepsy,
visual impairment
Assess development and visual
assessment within first 6mo,
Early intervention
Microcephaly
HC < 3rd
centile, if HC less
than wt/length centiles, >2
standard deviations below
mean
Primary or acquired
Major risk factor for Mental
retardation
100. Preterm Birth Affects All areas of the Brain at
8 Years
Whole brain
Cerebral gray
Subcortical gray
Cerebral white
Most vulnerable areas
of PT brain
Sensorimotor cortex
Premotor cortex
Mid-temporal cortex
Cerebral volumes
related to
FS IQ, verbal IQ,
performance IQ, Peabody
picture vocabulary test
GA, VM, PVL, chorioamnionitis
significantly related to brain volume
NEJM
101. What about preterm infants with milder
or no evidence of injury?
Lower grades IVH I-II poorer ND outcome at 20
mos CA than infants with no IVH
Higher rates MDI << 70 (45%, OR 2), major neuro
abnormality (13%, OR 2.6), ND impairment (47%, OR
1.83) [Patra et al., 2006]
Among low risk preterm infants 28-33 weeks GA
with normal cranial US, MRI reveals:
At 42 weeks’ postmenstrual age, gray matter volumes
were not different between preterm and term infants
Myelinated white matter was decreased, as were
unmyelinated white matter volumes in the region
including the central gyri (Mewes et al., Pediatrics 2006)
102. Factors Associated with Neurodevelopmental Morbidity
in Infants with Normal Cranial Ultrasounds
Science at the heart of medicine
103. Developmental Disabilities
Developmental screening :
Medical history, parent
interview, standard tools,
clinical observation
Document progress
Detect delays
Refer for Early intervention
Always use adjusted age up to
2.5 yrs
Learning difficulty
At school age
IEP
Behavioral problems:
1st
year: Irritability,
irregularity in behavior, sleep
disorders
Toddlers : willfulness,
hyperactivity, fearfulness
School age: ADHD,
aggressive behavior,
withdrawal, limited social
skills
Autism spectrum disorders
104. Neuromuscular Assessment
Motor milestones
Evaluate quality of movement (variety, fluidity, range, asymmetry,
initiation, grading, endurance and strength)
Sequential assessment
Tone/posture
Hypertonia> hypotonia > dystonia
Signs of hypertonicity, hypotonia dystonia
Developmental and postural reflexes
Reflexes should disappear by 4-6 mo of age to allow normal development –
otherwise suspect CP
Balance and protective reactions
Reactions should appear by 4-9 mo of age when infants balance is
threatened
Behavior
Sensory integration issues
Social skills/Play
105. General Developmental Screening Tools
Battelle Developmental Inventory Screening Tool (BDI-
ST)
Child Development Inventory (CDI)
Bayley Infant Neurodevelopment Screen (BINS)
Denver II
Cognitive Adaptive Test/Clinical Linguistic Auditory
Milestones Scales (CAT/CLAMS)
Early Language Milestone Scale
Ages and Stages Questionnaires and ASQ-SE
Parent’s Evaluation of Developmental Status (PEDS)
M-CHAT (autism/ASD screen)
106. Frequent Neurodevelopment
Abnormalities
Autonomic
instability/behavioral
disorganization
Jittery
Mottles easily
Difficulty transitioning
between states
Poor self-calming
Stress signs
Apnea/bradycardia
Increased risk ASD
Sensory motor integration
problems
Abnormal muscle tone
Hypertonia/hypotonia
Lack of graded flexion
(imbalance between
flexion-extension)
Delayed milestones –
poor movement quality
Delayed cognition
Delayed speech
development
107. Sensory Motor Integration
Secondary to abnormal early stimulation
Light, noise, touch, pain, oral
Clinical symptoms in infants-toddlers
Feeding problems/aversion
Difficulty transitioning to solids (textures/tastes)
Excessive mouthing objects (sensory seeking behaviors)
Sensitivity to different stimuli (feet)
Grass, sand, carpet
Toe-walking without socks
Hyperactivity
Delayed language development
108. Common Motor Abnormalities
Low central (truncal)
tone
Poor head control
Poor prone skills
Shoulder retraction
Wide base of support in
sitting
Movement
forward/backward only
No reach to side or
rotation
Imbalance
flexion/extension
Arching, pushing into
standing when held or
positioned into sitting
Poor transitional skills
Rolling, sitting, standing
Static sitter
Tight muscle groups
Frog legged
Torticollis
110. Family Support
Ideally parents involved prior to discharge in
care of baby
At visit:
Schedule longer visit
Be aware of parents concerns
Give careful explanation and clarification
Be aware of families financial resources and support
system
Special attention to single parents
Assess for signs maternal postpartum depression
111. Impact of Preterm or Sick Infant
Birth
Parental stress and distress
Parental perception of infant
vulnerability
Technology dependence at
home
Parenting - bonding, infant
attachment
Perceived parenting
competence
Difficult to find appropriate
child care
Lack of respite
Costs of care
Multiple provider visits
Medical bills
Lost work
Impact on family
functioning
Divorce, single parenting
Sibling issues
Child
neglect/maltreatment
Vulnerable child
syndrome
Family and friends don’t
understand
Taylor et al., Arch Pediatr Adolesc Med 2001; 155: 155-161
112. Effect of Neglect on Outcome at
< 1000 gm Birth WeightCognitivezscore(SDI)Cognitivezscore(SDI)
0.00.0
-0.5-0.5
-1.0-1.0
-1.5-1.5
-2.0-2.0
-2.5-2.5
1 year1 year 2 years2 years 4 years4 years
0.50.5
No referral for neglectNo referral for neglect
Any referral forAny referral for
neglectneglect
Substantiated referralSubstantiated referral
for neglectfor neglect
Strathearn 2001Strathearn 2001
113. What do “long-term outcomes” mean to the
families?
What we expect for child and
family v. what family expects for
the child and themselves
Impact of high risk birth, sick
infant, and/or multiple gestation
on family dynamic and family
functioning
Strategies
Listening to and empowering
parents
Reassurance
Respite
Effects on parents and their
perception of themselves as
parents
Trajectory of motherhood and
“motherhood interrupted”
Supporting parents of a
chronically ill or disabled child
Adaptation to the crisis
Normalization
Chronic sorrow
Fluctuation between states
114. Information and Resources Needed by Families
Support for their role as
parents
Understanding preemie
development
Physiologic, motor, states of
consciousness, attention,
self-regulation
Avoiding hypervigilance -
vulnerable child
Negotiating transitions and
school challenges
Social support network
Family, friends, co-
workers
Community resources
Parent support
programs/networks
Health insurance,
programs for children
w/ special health care
needs
Respite Care
116. Adolescence to Young Adulthood
Most motor difficulties, if persistent are less
problematic as child adapts
Increasing complexity of tasks
LD persist in 30-40%
Math most challenging
Nearly 50% ELBW children require PT or FT special
educational assistance
Grade repetition in 20-30%
Attentional problems less taxing as children grow
older
Delinquency and risk-seeking behaviors less common
among PT compared w/ FT children
118. Transition to Adulthood
Intellectual and academic achievement
Mean IQ 81-98
IQ < 85 19-47%
Completed HS/GED 56-85%
Post high school (secondary) 37-38%
Work status
Fully employed 48%
Unemployed 14-26%
Chronic illness 47%
Neurosensory impairment 12-28%
Vision 37%
Retinal detachment 4-7%
Science at the heart of medicine
119. Behavioral Outcomes and Evidence
Psychopathology at 20 Years of Age
VLBW men
Fewer delinquent behaviors
No differences in
Internalizing
Externalizing
Total problem behaviors
Parents report
More thought problems
More attention difficulties but
not more ADHD
VLBW women
More withdrawn behaviors
Fewer delinquent behaviors
Internalizing behaviors
(anxious/depressed,
withdrawn) borderline clinical
cut-off (30% v. 16%, OR 2.2)
Parents report more
anxious/depressed (OR 4.4),
withdrawn (OR 3.7) and
attention problems (OR 2.4)
Hack et al., Pediatrics 2004; 114: 932-940
120. References
Bernbaum J. Preterm infants in Primary Care: A guide to office management.
Ritchie S. Primary care of the premature infant discharged from the neonatal
intensive care unit. MCN Am J Matern Child Nurs. 2002 Mar-Apr;27(2):76-85
Sherry B, Mei Z, Grummer-Strawn L, Dietz WH. Evaluation of and
recommendations for growth references for very low birth weight (< 1500 grams)
infants in the United States. Pediatrics 2003 Apr;111(4 Pt 1):750-8.
Brodsky D, Ouellette MA. Primary Care of the Premature Infant. Saunders Elsevier
Publisher, Philadelphia, 2008.
Campbell DE, Imaizumi SO, Bernbaum JC. Health and Developmental Outcomes
for Infants Requiring Intensive Care, in McInerny TK, Adam HM, Campbell DE,
Kamat DM, Kelleher KJ, eds. American Academy of Pediatrics Textbook of
Pediatric Care, Elk Grove Village, IL: American Academy of Pediatrics, 2009, pp
852-867
Bernbaum JC, Campbell DE, Imaizumi SO. Follow up Care for the Graduate From
the Neonatal Intensive Care Unit, in McInerny TK, Adam HM, Campbell DE,
Kamat DM, Kelleher KJ, eds. American Academy of Pediatrics Textbook of
Pediatric Care, Elk Grove Village, IL: American Academy of Pediatrics, 2009, pp
867-882
121. Science at the heart of medicine
Care of the Moderate and Late
Preterm Infant
122. What about the larger low birth weight
infant?
LBW (1500-2499g) associated with 1.38 greater
risk of special health care needs (SHCN)*
Significantly greater
Use/need for medication
High usage HC services
Any chronic condition
LD
Emotional/behavioral problem
Higher rates of rehospitalization among infants 33-36
weeks’ GA (Escobar et al. Pediatrics 1999)
Most for non-life threatening illnesses
*Stein RK, Siegel MJ, Bauman LJ. Pediatrics 2006; data derived from 2002 National Health Interview Survey
123. Moderately Preterm Infants: 30-34 weeks
(Escobar et al., Arch Dis Child 2006, Seminars in Perinatology 2006)
Accounts for 3.9% LB in US and 32% all premature infants
Experience substantial morbidity
45.7% req. assisted ventilation
3.2% req supplemental O2 at 36 wks PMA
11.2% req hospital readmission within 3 mos.
Higher in males and with CLD
124. Late preterm infants:
34-36 6
/7 weeks’ gestation
Study groups full term and near term infants with
comparable Apgar scores
Larger preterm infants had more:
Temperature instability
Hypoglycemia
Respiratory distress + need for O2/ asst. ventilation
Jaundice
Frequent sepsis evaluations
More IV fluids
Wang et al. Pediatrics 2004: 114:372-376; Escobar et al., Seminars in Perinatology 2006
125. Higher rates of c-sections and inductions
among singleton live births: US 1992 - 2002
March of Dimes Perinatal Data Center, 2005
C-sections
Inductions
34-36.6 weeks
in 2002:
C/S: ~ 28%
Induction: ~ 18%
126. What is the impact to infant health from rising
late PTB? Need to separate causes and effects
Increased morbidities - Higher Neonatal and Infant
mortality:
U.S. neonatal deaths/1000 live births (2002)
34-36 weeks = 4.1
37-41 weeks =0.9
U.S. infant deaths/1000 live births (2002)
34-36 weeks = 7.7
37-41 weeks = 2.5
127. What morbidities associated with
Late PTB?
Increased immediate morbidities:
Respiratory distress
Jaundice
Feeding difficulties
Hypoglycemia
Temperature instability
Sepsis
Increased NICU use (and re-admissions)
Increased cost
Long term outcome – emerging DATA!
128. Frequency of RDS, sepsis and apnea:
34 to 36 weeks of gestation
Arnon, et al. Paediatr Perinat Epidemiol, 2001
130. Late Preterm Births: Excess Hospital
Costs
Gilbert, et al. Obstetrics Gynecology, 2003
131. Multivariant Model for Rehospitalizations
Adapted from: Escobar, et al. Arch Dis Child, 2005 (Kaiser)
132. 75-7875-78 79-8279-82 83-8683-86 87-8987-89 91-9491-94
32-36 Weeks Gestation32-36 Weeks Gestation
Prenatal
Unclassifiable
Hagberg, Acta Paedtr 2000
Birth yearsBirth years
Per1000livebirthsPer1000livebirths
1212
1010
88
66
44
22
00
Prevalence of Cerebral Palsy Over TimePrevalence of Cerebral Palsy Over Time
Peri/neonatal
133. Educational Outcomes for Children Born
@ 32-35 weeks’ Gestation
At age 7 yrs (GA 34.3 w)
25% non-teaching assistant (resource room)
4% special education, 3% special school or class
Problems with 32-35w 32w 35w
Writing 32% 50% 33%
Fine motor 31% 50% 33%
Math 29% 42% 31%
Speaking/listening 19% 33% 18%
Reading 21% 25% 22%
Physical education 12% 33% 9%
134. Behavioral Outcomes for Children Born
@ 32-35 Weeks Gestation
Huddy et al (UK)-age 7 (mean GA 34.3w)
19% abnormal hyperactivity score v. population norm
10%
IHDP at age 8*
8-12% with serious behavioral problems on CBC v.
expected 2% for general population
135. Primary Care of the HR Infant: An Analogy
Eric Larson and Robert Reid: (JAMA 2010; 303:1644-1645)
“Group Health’s early medical home experience
suggests that patient-centered medical homes can be an
effective model of primary care, but only if health
organizations and systems invest resources, rethink
reimbursement and redesign teams to address the
comprehensive and increasingly complex needs of an
aging population.”
Editor's Notes
·
N = 600; Birth Wt: 501-1000 g. Growth as a variable in the logistic regression model included: Gender, Race, GA, SGA, Maternal education, Severe IVH, PVL, Days to Return to Birth Weight, NEC, Late onset sepsis, BPD, Postnatal steroids and study center.
N = 600; Birth Wt: 501-1000 g. Growth as a variable in the logistic regression model included: Gender, Race, GA, SGA, Maternal education, Severe IVH, PVL, Days to Return to Birth Weight, NEC, Late onset sepsis, BPD, Postnatal steroids and study center.