8 follow up care of high risk new born

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

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.

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

Medical Home Framework

Care that is: Accessible Family-centered Comprehensive Continuous Coordinated Compassionate Culturally-sensitive

PCP shares responsibility

Benefits Efficiency

Care coordinationLimited resources, cost

Timeliness Effectiveness

Problem-solving Satisfaction

Family & health professional Improved health/functional

status

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 dischargeCVRespiratoryCongenital/geneticRenalNeuromuscularGI

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

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

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

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 professionalsMay have needs different than what professional perceives as

necessary or important

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 systemSlide series courtesy of D. Campbell

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

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

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

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)

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

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

Components of Health and Developmental Follow up for the Preterm and High Risk Infant


Timeline of Neurodevelopmental Child Outcomes

1-3 yrs 4-7 yrs 8+ yrsCognitiveExecutive functionMotor functionTemperament, self-regulationRelationship to parentBehavioral problemsRelationship to peersPsychopathologyAntisocial behaviorSchool failure

NICHD Workshop. Pediatrics 2004; 114(5):1377-1397

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

Great ExpectationsWhat’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

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

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

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

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

Tertiary Care-Primary Care Partnership Model

Gordon, et al. Arch Pediatr Adolesc Med. 2007;161(10):937-944

Hospital-based CSHN Comprehensive Primary Care Clinic Costs and Utilization

Berman et al. Pediatrics 2005; 115;e637-e642Outpatient services had a per child loss; off-set by increased income from ICU stays; fewer non-ICU hospitalizations

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

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

Complications of prematurity and high risk birth

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

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 adolescenceHigher BPs awake and

during sleepUnrelated IUGR/SGA

Complex Medical Outcomes

At 18 Months Gastrostomy 8% Tracheostomy 3% Oxygen 6% Ventilation at home 2% 50-60% hospitalized at least once

Growth and Nutrition

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

Physical Growth

Correcting for PrematurityWho? 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 9Date of birth Yr ‘06 Month 03 Day 25Chronologic age 5 14Adjustment for PT 2 21Corrected age 2 23Round to the nearest week: CA = 2 mo. 3 w.

Alternatively: count exact time from birth

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

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.

Assessment of individual growth trends is important for

each infant!!

For VLBWI: No single reference growth curve better. (Sherry et al: Pediatrics 2003; 111: 750)

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

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

Poor Weight Gain Increases Odds for Poor Outcomes

Ehrenkranz RA, et al. Pediatrics 2006;117:1253-61.

1.00.2 10.0 50.0Odds 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

Poor HC Growth Increases Odds for Poor Outcome

Ehrenkranz RA, et al. Pediatrics 2006;117:1253-61.

1.00.2 10.0 50.0Odds 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

Neuro/Intellectual Function at School Age with Subnormal Head Circumference at 8 Months

Total Population Neurologically IntactCondition(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 IQIQ <70IQ <85

3%27%

24%52%

7.48†

1.91†

2%26%

12%46%

5.741.80

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

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 extrauterineoutcomes 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 - downCatch - up

Latal-Hajnal et al J Pediatr 2003;143(2):163-70

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

Nutrition: Breastmilk or FormulaRecommended* 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

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

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

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)

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 volume22 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)

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

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

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

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.

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

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 esophagitisAssociated pathology eg.

CP, MR Complication: 10-30%

BloatingLoosening of wrapEsophageal dysmotilityPerforation

“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

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)

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 yrsGirls aver. 7.3 kg less; boys weigh 8.3 kg lessHeight: 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

Immunizations

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

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 birth\HBIG with first 12h

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

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.

May consider post-op booster dose

Vision and Hearing

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

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

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

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

pediatrics.org/cgi/doi/10.1542/peds.2007-2333

Chronic Lung Disease

Respiratory Health: Chronic Lung Disease

Incidence 15-50% (varies by GA, NICU) Oxygen Dependence at 36 wks PMA

Best predictor LT pulmonary outcome57-70% at 23 wks Gestation33-89% at 24 wks39-61% at 500-800g BWT

O2 dependence at 1 year of age GA (w) % Requiring <23 24 24 13 25 7

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/abnormalitySubglottic stenosisVocal cord

paralysis/dysfunction Persistent central apnea

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

Sample O2 weaning protocol


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 feeding2.Good weight gain3.No increase in respiratory symptoms

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

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

KCL1-4 mEq/kg/d ÷ q 6-12h

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

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)

Home Monitoring Indications

Persistent apnea On caffeine

Maintain on caffeine until 44 w PMAContinue 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

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

SIDS Prevention – PT Infant Sleep Position

Preterm infant sleep position Less frequent use of non-prone (back or side sleeping)

by parents64% 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)

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

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

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

Neurobehavior and Neurodevelopment


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

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

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

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 outcomesStandard Placement 50%Resource 30%Special Education 20%Repeat a grade 16%

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

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

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

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

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)

Factors Associated with Neurodevelopmental Morbidity in Infants with Normal Cranial Ultrasounds


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

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

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)

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

Sensory Motor Integration

Secondary to abnormal early stimulation Light, noise, touch, pain, oral Clinical symptoms in infants-toddlers

Feeding problems/aversionDifficulty transitioning to solids (textures/tastes)Excessive mouthing objects (sensory seeking behaviors)Sensitivity to different stimuli (feet)

Grass, sand, carpetToe-walking without socksHyperactivityDelayed language development

Common Motor Abnormalities

Low central (truncal) tone Poor head control Poor prone skills Shoulder retraction Wide base of support in

sittingMovement

forward/backward onlyNo reach to side or rotation

Imbalance flexion/extension Arching, pushing into

standing when held or positioned into sitting

Poor transitional skillsRolling, sitting, standingStatic sitterTight muscle groups

Frog legged Torticollis

Supporting the Family

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

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

Effect of Neglect on Outcome at < 1000 gm Birth Weight

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0.50.5No referral for neglectNo referral for neglect

Any referral for Any referral for neglectneglect

Substantiated referral Substantiated referral for neglectfor neglect

Strathearn 2001Strathearn 2001

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

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

Adolescent and Adult Issues of Premature Infant

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

Transition to Adulthood


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%


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

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


Care of the Moderate and Late Preterm Infant

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 medicationHigh usage HC servicesAny chronic conditionLDEmotional/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

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

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

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%

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 = 4.137-41 weeks =0.9

U.S. infant deaths/1000 live births (2002)34-36 weeks = 7.737-41 weeks = 2.5

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!

Frequency of RDS, sepsis and apnea: 34 to 36 weeks of gestation

Arnon, et al. Paediatr Perinat Epidemiol, 2001

Clinical Outcomes: Full term v. Late Preterm

Wang, et al. Pediatrics, 2004

Late Preterm Births: Excess Hospital Costs

Gilbert, et al. Obstetrics Gynecology, 2003

Multivariant Model for Rehospitalizations

Adapted from: Escobar, et al. Arch Dis Child, 2005 (Kaiser)

75-7875-78 79-8279-82 83-8683-86 87-8987-89 91-9491-94

32-36 Weeks Gestation32-36 Weeks Gestation

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Prevalence of Cerebral Palsy Over TimePrevalence of Cerebral Palsy Over Time

Peri/neonatal

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%

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

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.”

8 follow up care of high risk new born

Healthcare