Long term follow up of high risk children: who, why and how?

Newborn intensive care survivors: a review and a plan for collaboration in Texas

BACKGROUND

Neonatal intensive care is a remarkable success story with dramatic improvements in survival rates for preterm newborns. Significant efforts and resources are invested to improve mortality and morbidity but much remains to be learned about the short and long-term effects of neonatal intensive care unit (NICU) interventions. Published guidelines recommend that infants discharged from the NICU be in an organized follow-up program that tracks medical and neurodevelopmental outcomes. Yet, there are no standardized guidelines for provision of follow-up services for high-risk infants. The National Institute of Child Health and Human Development Neonatal Research Network and the Vermont Oxford Network have made strides toward standardizing practices and conducting outcomes research, but only include a subset of developmental follow-up programs with a focus on extremely preterm infants. Several studies have been conducted to gain a better understanding of current practices in developmental follow-up. Some of the major themes in these studies are the lack of personnel and funding to provide comprehensive follow-up care; feeding difficulties as a primary issue for NICU survivors, families, and programs; wide variability in referral and follow-up care practices; and calls for standardized, systematic developmental surveillance to improve outcomes.

FINDINGS

We convened a one-day summit to discuss developmental follow-up practices in Texas involving four academic and three nonacademic centers. All seven centers described variable age and weight criteria for follow-up of NICU patients and a unique set of developmental practices, including duration of follow-up, types and timing of developmental assessments administered, education and communication with families and other health care providers, and referrals for services. Needs identified by the centers focused on two main themes: resources and comprehensive care. Participants identified key challenges for developmental follow-up, generated recommendations to address these challenges, and outlined components of a quality program.

CONCLUSIONS

The long-term goal is to ensure that all children maximize their potential; a goal supported through quality, comprehensive developmental follow-up care and outcomes research to continuously improve evidence-based practices. We aim to contribute to this goal through a statewide working group collaborating on research to standardize practices and inform policies that truly benefit children and their families.

Preterm Cognitive Function Into Adulthood

BACKGROUND

Very preterm (VP; gestational age <32 weeks) and very low birth weight (VLBW; <1500 g) births are related to impaired cognitive function across the life span. It is not known how stable cognitive functions are from childhood to adulthood for VP/VLBW compared with term-born individuals and how early adult cognitive function can be predicted.

METHODS

The Bavarian Longitudinal Study is a prospective geographically defined cohort study that followed 260 VP/VLBW and 229 term-born individuals from birth to adulthood. Data on cognitive function were assessed with developmental and IQ tests at 5 and 20 months and at 4, 6, 8, and 26 years of age.

RESULTS

Across all assessments, VP/VLBW individuals had significantly lower IQ scores than term-born controls, even when individuals with severe cognitive impairment (n = 69) were excluded. IQ scores were found to be more stable over time for VP/VLBW than term-born individuals, yet differences in stability disappeared when individuals with cognitive impairment were excluded. Adult IQ could be predicted with fair certainty (r > 0.50) from age 20 months onward for the whole VP/VLBW sample (n = 260) and from 6 years onward for term-born individuals (n = 229).

CONCLUSIONS

VP/VLBW individuals more often suffer from cognitive problems across childhood into adulthood and these problems are relatively stable from early childhood onward. VP/VLBW children's risk for cognitive problems can be reliably diagnosed at the age of 20 months. These findings provide strong support for the timing of cognitive follow-up at age 2 years to plan special support services for children with cognitive problems.

Long-term neurodevelopmental outcome in high-risk newborns in resource-limited settings: a systematic review of the literature

BACKGROUND

Improving outcomes beyond survival for high-risk newborns in resource-limited settings is an emerging challenge. Global estimates demonstrate the scale of this challenge and significant gaps in morbidity outcome data in high mortality contexts. A systematic review was conducted to document the prevalence of neurodevelopmental impairment in high-risk newborns who were followed up into childhood in low- and middle-income countries.

METHODS

High-risk newborns were defined as low, very or extremely low birthweight, preterm infants or those surviving birth asphyxia or serious infections. Electronic databases were searched and articles screened for eligibility. Included articles were appraised according to STROBE criteria. Narrative review was performed and median prevalence of key neurodevelopmental outcomes was calculated where data quality allowed.

RESULTS

6959 articles were identified with sixty included in final review. At follow-up in early childhood, median estimated prevalence (inter-quartile range) of overall neurodevelopmental impairment, cognitive impairment and cerebral palsy were: for survivors of prematurity/very low birthweight 21.4% (11.6-30.8), 16.3% (6.3-29.6) and 11.2% (5.9-16.1), respectively, and for survivors of birth asphyxia 34.6% (25.4-51.5), 11.3% (7.7-11.8) and 22.8% (15.7-31.4), respectively. Only three studies reporting outcomes following newborn serious bacterial infections were identified. There was limited reporting of important outcomes such as vision and hearing impairment. Major challenges with standardised reporting of key exposure and developmental outcome variables and lack of control data were identified.

CONCLUSION

Understanding the limitations of the available data on neurodevelopmental outcome in newborns in resource-limited settings provides clear direction for research and efforts to improve long-term outcome in high-risk newborns in these settings.