8 follow up care of high risk new born
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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
Science at the heart of medicine
Components of Health and Developmental Follow up for the Preterm and High Risk Infant
Science at the heart of medicine
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
Science at the heart of medicine
Science at the heart of medicine
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
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 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
Science at the heart of medicine
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
Science at the heart of medicine
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
Cog
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e (S
DI)
Cog
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0.00.0
-0.5-0.5
-1.0-1.0
-1.5-1.5
-2.0-2.0
-2.5-2.51 year1 year 2 years2 years 4 years4 years
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
Science at the heart of medicine
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
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
Science at the heart of medicine
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
Prenatal
Unclassifiable
Hagberg, Acta Paedtr 2000Birth yearsBirth years
Per
10 0
0 liv
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er 1
0 00
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1212
1010
88
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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.”
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