Developmental Care for the Preterm Infant: The Role of NICU Follow-up Clinics

Educational Objectives

The goal of this program is to improve developmental care for preterm infants. After hearing and assimilating this program, the clinician will be better able to:

1. Reduce the risk for long-term sequelae of premature birth through early recognition and intervention.

2. Recognize the children who warrant neonatal intensive care unit (NICU) follow-up.

3. Advise parents on what to expect at a NICU follow-up clinic.

Summary

Terminology: preterm infant — <37 wk of gestation; late preterm infant — 34 to 36 wk of gestation; chronologic or adjusted age — infant’s age if child had been born on due date

Premature births in United States: account for ≈12% of all births (based on 2011 data), but majority late preterm infants; rate of survival continues to improve in all age groups; ≈20% of 23-wk infants surviving, with overall survival of 95% for preterm infants; in neonatal ICU (NICU), goal is to survive and do well during NICU course; in NICU follow-up, goal to help families with possible long-term sequelae of premature birth (eg, effects on quality of life, academic success, family stress); rate of divorce and marital distress higher in families with children at risk for disabilities; more medical appointments; tendency for lower socioeconomic status

Outcomes: preterm infants <27 wk at 30 mo — ≈60% have no intellectual disability (similar for language disability); ≈45% have some range of motor disability (mild to severe); only ≈40% have no diagnosed disability; for each preterm week, risk increases (reduction of cognition scores by 2.5 points, language scores by almost 4 points, and motor scores by 2.5 points); more delays seen in boys, particularly in language, compared to girls; ≈7% develop cerebral palsy (CP); visual and hearing impairments more common than in full-term population; cognitive outcomes — based on meta-analyses, infants <33 wk of gestation have cognitive scores 10 points lower, compared to typically developing full-term infant; at greater risk for problems with academic achievement (grade progression or progression within classroom; often in lower reading group), inattention (eventual diagnosis of attention-deficit/hyperactivity disorder common), behavior problems, and poor executive function; motor outcomes — rate of CP increases with each additional week of prematurity; CP seen in 4% to 12% of infants weighing <1000 g; CP 6 times more likely even in late preterm infants (generally not eligible for follow-up or early intervention services until delays seen [often not until child ≈2 yr of age]); developmental coordination disorder (minor neurologic dysfunction) seen in 9% of preterm infants (interventions include motor learning strategies); lower-level disability often not diagnosed until child approaches school age

Current methods of early detection: standardized tests — if child falls inside average, not qualified for services; imaging studies — not routinely performed in NICU; impairment-based measures — early essential movement patterns (eEMP) looks at tone and reflexes to predict CP, but does not show reliable results until infant close to 12 mo of age

Developmental red flags: related to developmental milestones at specific ages; if infant at 1 mo of age (adjusted age) still losing food while feeding, sign of developmental risk and evaluation warranted; early feeding difficulty possible predictor for motor disability; determine whether infant by 3 mo of age able to lift legs off support surface and kick, and keep head in middle (vs keeping head rotated to side)

Other issues warranting treatment: infants in NICU more likely to have head preferences that may progress to torticollis and plagiocephaly (easier for staff in NICU if infant’s head on left and feet on right); torticollis and plagiocephaly more common in preterm infants and require early treatment; breath-holding during feeding requires visit to pediatrician; be alert for social issues within family; if infant arches back or pushes away, work with family to intervene; if behavior continues, warrants evaluation (possibly related to hypertonicity and spasticity)

Developmental education in NICU: brochures from American Academy of Pediatrics (AAP), March of Dimes, and Neonatal Nursing Association guide parents in supporting development of preterm infant, red flags to look for, and expectations for child’s development

Options for early detection: no standard system for assessing high-risk children; no mandate for follow-up of infants born at less than certain age of gestation; pediatricians should screen infants in consistent manner and order neurologic consultation when indicated; early intervention programs mandated by Individuals with Disabilities Education Improvement Act; papers from AAP — in 1996, highlighted role of primary care pediatrician in management of high-risk infants; in 2000s, emphasis on designing and mandating interdisciplinary follow-up programs to support high-risk infants

Infants who should be referred to NICU follow-up clinics: infants with — very low birth weight (<1500 g); ≤28 wk gestation at birth; significant neurologic injury (eg, periventricular leukomalacia, grade 3 or 4 interventricular hemorrhages); chronic lung disease, even without neurologic changes or meeting other criteria; anoxic event at birth (eg, term infant with severe meconium aspiration, problem resulting in hypoxic-ischemic encephalopathy); infants who may benefit from follow-up care — ≤35 wk gestation; exposure to drugs; chromosomal abnormalities (eg, Down syndrome, trisomy 18); infants born to families with parenting challenges or problems with availability for social support in community

Rationale for NICU follow-up clinics: most multidisciplinary, with multiple services and specialists available in one place; adequate appointment time for testing and assessment

NICU follow-up schedule: most data suggest that infant should be seen in first 3 mo of life; first visit early screener for disabilities, and serves to connect families that require support; further follow-ups at 6 mo, 12 mo, 18 mo, and 24 mo; advisable to have additional visit close to school entry (school system provides no identification of children requiring extra services until children failing in classroom)

What parents should expect at NICU follow-up clinic: review of NICU medical course and current medical challenges; neurologic and developmental examination; assessment for social risks; review whether needs for community services or specialist’s attention being met; opportunity for educating families; suggestions of activities and discussion of future plans

Collaborating with NICU follow-up: help parents understand importance of NICU follow-up clinic; encourage parents to attend follow-up visits; send questions, concerns, and reports to clinic

 

Readings

Grant R, Isakson EA: Regional variations in early intervention utilization for children with developmental delay. Matern Child Health J, 2013 Sep;17(7):1252-9; Grissom M: Disorders of childhood growth and development: screening and evaluation of the child who misses developmental milestones. FP Essent, 2013 Jul;410:32-44; quiz 45-50; Harmon SL et al: Factors associated with neonatal intensive care follow-up appointment compliance. Clin Pediatr (Phila), 2013 May;52(5):389-96; Kuppala VS et al: Current state of high-risk infant follow-up care in the United States: results of a national survey of academic follow-up programs. J Perinatol, 2012 Apr;32(4):293-8; Mackrides PS, Ryherd SJ: Screening for developmental delay. Am Fam Physician, 2011 Sep 1;84(5):544-9; Maitre NL et al: Early prediction of cerebral palsy after neonatal intensive care using motor development trajectories in infancy. Early Hum Dev, 2013 Oct;89(10):781-6; McLaughlin MR: Speech and language delay in children. Am Fam Physician, 2011 May 15;83(10):1183-8; Milgrom J et al: Early communication in preterm infants following intervention in the NICU. Early Hum Dev, 2013 Sep;89(9):755-62; Nordhov SM et al: Early intervention improves cognitive outcomes for preterm infants: randomized controlled trial. Pediatrics, 2010 Nov;126(5):e1088-94; Oberklaid F, Drever K: Is my child normal? Milestones and red flags for referral. Aust Fam Physician, 2011 Sep;40(9):666-70; Spittle A et al: Early developmental intervention programmes post-hospital discharge to prevent motor and cognitive impairments in preterm infants. Cochrane Database Syst Rev, 2012 Dec 12;12:CD005495.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Dusing was recorded at the 35th Annual Pediatric Primary Care Conference, held July 19-21, 2013, in Virginia Beach, VA, and sponsored by the Department of Pediatrics, Virginia Commonwealth University School of Medicine, and VCU Office of Continuing Medical Education. For future CME activities from this sponsor, or to attend the 36th Annual Pediatric Primary Care Conference from July 18-20, 2014 in Virginia Beach, VA, please visit www.vcuhealth.org/cme/aboutus. The Audio-Digest Foundation thanks Dr. Dusing and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

PD602402

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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