Longitudinal multicenter follow-up of high-risk infants: why, who, when, and what to assess

"My baby is fine, no need for more clinic visits." Facilitators and barriers for utilisation of follow-up services for children born preterm in low-resource setting: Parents' perceptions

OBJECTIVES

We sought to understand the facilitators and barriers impacting utilisation of follow-up services for children born preterm as perceived by parents in a low-resource setting.

METHODS

We conducted a qualitative study at Mulago Hospital, Uganda, with parents of children born preterm and aged 22-38 months at the time of the study. We collected data using five in-depth interviews and four focus group discussions. Data were analysed using thematic analysis informed by the social-ecological model.

RESULTS

Ten subthemes emerged that could be grouped into three main themes: (1) Individual: parents' knowledge, parenting skills, perception of follow-up and infant's condition; (2) Relationship: support for the mother and information sharing; (3) Institution: facility setup, cost of care, available personnel and distance from the facility. Parents of preterm infants perceived receiving timely information, better understanding of prematurity and its complications, support from spouses, availability of free services and encouragement from health workers as facilitators for utilisation of follow-up services. Limited male involvement, parents' negative perception of follow-up, stable condition of infant, health facility challenges especially congestion at the hospital, distance and care costs were key barriers.

CONCLUSION

An interplay of facilitators and barriers at individual, interpersonal and health system levels encourage or deter parents from taking their preterm children for follow-up services. Improving utilisation of services will require educating parents on the importance of follow-up even when children are not sick, eliciting maternal support from spouses and peers and addressing health system gaps that make follow-up unattractive and costly.

Early neurodevelopmental follow-up in the NICHD neonatal research network: Advancing neonatal care and outcomes, opportunities for the future

At the inception of the Eunice Kennedy Shriver National Institute of Child Health and Development Neonatal Research Network (NRN), provision of care for extremely preterm (EPT) infants was considered experimental. The NRN Follow-up Study Group, initiated in 1993, developed infrastructure with certification processes and standards, allowing the NRN to assess 2-year outcomes for EPT and to provide important metrics for randomized clinical trials. This chapter will review the NRN Follow-up Study Group's contributions to understanding factors related to improved neurodevelopmental, behavioral, and social-emotional outcomes of EPT infants. We will also discuss follow up challenges, including reassessing which outcomes are most meaningful for parents and investigators. Finally, we will explore how outcome studies have informed clinical decisions and ethical considerations, given limitations of prediction of complex later childhood outcomes from early neurodevelopmental findings.

Impact of the Coronavirus Pandemic on High-Risk Infant Follow-Up (HRIF) Programs: A Survey of Academic Programs

Objective: The impact of the COVID-19 pandemic on the functioning and services of academic high-risk infant follow-up (HRIF) clinics throughout North America. Study Design: Prospective 25-question questionnaire survey through REDCAP links that was sent over 10 weeks, to 105 US and 10 Canadian programs. Finally, 59 of 105 US programs and 5 of 10 Canadian responses were analyzed using SAS version 9.4. Results: In the US, 67% of programs reported closures between 1–5 months, whereas in Canada 80% of programs closed for 1–3 months. In the US 86% of programs provided telemedicine visits and only 42.5% provided multidisciplinary HRIF telemedicine visits. We enumerated innovative approaches specifically for the conduct of Telemedicine visits, the need for the standardization of various tests and services in a telemedicine setting, and to emphasize the urgent need for more government funding to improve follow-up and developmental services to this fragile group of newborns.

Transitions from short to long-term outcomes in pediatric critical care: considerations for clinical practice

Most children are surviving critical illness in highly resourced pediatric intensive care units (PICUs). However, in research studies, many of these children survive with multi-domain health sequelae that has the potential to affect development over many years, termed post-intensive care syndrome-pediatrics (PICS-p). Clinically, there are no recommendations for the assessment and follow-up of children with critical illness as exists for the premature neonatal and congenital heart disease populations. In research studies, primary and secondary outcomes are largely assessed at or prior to hospital discharge, disregarding post-hospital outcomes important to PICU stakeholders. Incorporating longer term outcomes into clinical and research programs, however, can no longer be overlooked. Barriers to outcomes assessments are varied and generalized vs. individualized, but some PICU centers are discovering how to overcome them and are providing this service to families-sometimes specific populations-in need. Research programs and funders are increasingly recognizing the value and need to assess long-term outcomes post-PICU. Finally, we should seek the strong backing of the PICU community and families to insist that long-term outcomes become our new clinical standard of care. PICUs should consider development of a multicenter, multinational collaborative to assess clinical outcomes and optimize care delivery and patient and family outcomes. The aim of this review is to present the potential considerations of implementing long-term clinical follow-up following pediatric critical illness.

Home-based early stimulation program targeting visual and motor functions for preterm infants with delayed tracking: Feasibility of a Randomized Clinical Trial

AIMS

To verify the feasibility of a home-based early stimulation program targeting visual and motor functions in preterm infants with delayed visual tracking.

METHOD

We applied a randomized controlled trial. We included thirty low-risk preterm infants, from both genders, with delayed visual tracking, gestational between 28-37 weeks, and age at entrance between 1-2 months of corrected age, and absence of visual impairments. Infants were divided into two groups as follows: a) standard care group (SC) that received general orientation about sensory and motor development (16 infants); b) experimental group, that received a four-week home-based early stimulation program targeting visual and motor functions (ESPVM) applied by the caregivers (14 infants). The feasibility outcomes were retention and loss rates, adherence, adverse events, and stress signals. We obtained preliminary data by comparing visual tracking, motor development, and sensory behavior between groups at the end of the intervention.

RESULTS

Retention rate was high, 90 % of the caregivers provided ESPVM at least 22 days, and 70 % provided SC at least 17 days. No adverse events were reported. At the end of intervention, the ESPVM group presented higher frequencies of complete visual tracking for cards 7 (ESPVM = 57.3 %, SC = 6.3 %, p = 0.006) and 8 (ESPVM = 64.3 %, SC = 12.2 %, p = 0.013), and lower scores for total sensory profile (ESPVM: median = 58, range = 46-69; SC: median = 71, range = 54-90; p = 0.016). The groups were similar for motor development.

CONCLUSIONS

The protocol was feasible, and the results encourage a larger randomized controlled trial.

Follow-through care for high-risk infants during the COVID-19 pandemic: lessons learned from the Vermont Oxford Network

OBJECTIVE

The COVID-19 pandemic has altered the delivery of follow-up care for high-risk infants. We performed an audit to characterize programmatic responses in a quality improvement network.

STUDY DESIGN

We audited 43 North American-based follow-up programs of the Vermont Oxford Network Extremely Low Birth Weight Follow-up Study Group in October, 2020. Our electronic survey included yes/no, agree/disagree, and free text response items.

RESULT

The response rate was 67.4%. Most programs altered capacity and the timing, frequency, or content of clinical assessments. Most perceived practice changes compromised their ability to ascertain infants' medical and developmental needs. There was a rapid uptake of telemedicine services. Despite challenges with implementation, many endorsed improved connectedness with families.

CONCLUSION

Programs adapted rapidly to meet the needs of high-risk infants during the pandemic. Clinical operations, assessment procedures, and quality metrics will also need to evolve. Quality improvement study group collaboratives are well-positioned to coordinate such work.

Improving Neonatal Follow-up: A Quality Improvement Study Analyzing In-hospital Interventions and Long-term Show Rates

Supplemental Digital Content is available in the text.

Neonatal follow-up (NFU) clinics play an essential role in the multidisciplinary care of preterm patients. Despite the inherent value of NFU clinics, many clinical programs report poor compliance with follow-up visits. Preterm infants followed with difficulty in the long-term have higher rates of disability and lower IQ scores, even after adjustment of significant perinatal and sociodemographic variables. This quality improvement study aimed to improve the show rate for preterm infants from 60% to 80% at the initial 6-month adjusted age visit by implementing a multilevel education bundle.

Developmental Support for Infants With Genetic Disorders

As the technical ability for genetic diagnosis continues to improve, an increasing number of diagnoses are made in infancy or as early as the neonatal period. Many of these diagnoses are known to be associated with developmental delay and intellectual disability, features that would not be clinically detectable at the time of diagnosis. Others may be associated with cognitive impairment, but the incidence and severity are yet to be fully described. These neonates and infants with genetic diagnoses therefore represent an emerging group of patients who are at high risk for neurodevelopmental disabilities. Although there are well-established developmental supports for high-risk infants, particularly preterm infants, after discharge from the NICU, programs specifically for infants with genetic diagnoses are rare. And although previous research has demonstrated the positive effect of early developmental interventions on outcomes among preterm infants, the impact of such supports for infants with genetic disorders who may be born term, remains to be understood. We therefore review the literature regarding existing developmental assessment and intervention approaches for children with genetic disorders, evaluating these in the context of current developmental supports postdischarge for preterm infants. Further research into the role of developmental support programs for early assessment and intervention in high-risk neonates diagnosed with rare genetic disorders is needed.

Turkish Neonatal Society guideline for the follow-up of high-risk newborn infants

Developments in perinatal and neonatal care have increased the survival rate of high-risk newborns but led to a rise in chronic diseases seen in these infants. A significant number of them attend primary and secondary health care centers after discharge; however, there are very few standard protocols for the long-term follow-up of these babies. Therefore, we aimed to establish a follow-up guideline that emphasizes on universal screening schemes and takes into consideration national data. The guide presented here provides brief recommendations for physicians in light of evidence-based data for the follow-up of high-risk newborn infants. The steps taken to monitor and solve the problems of all high-risk infants may vary. We hope the use of such a standard approach in evaluating each infant in daily routine will improve the life quality of these high-risk infants.

Spanish survey on follow-up programmes for children born very preterm

AIM

To describe variations in practice between follow-up programmes for very preterm children born at less than 32 weeks' gestation or with very low birth weight of less than 1,500 g.

METHODS

A survey on follow-up practices was electronically distributed to level II and III units among hospitals of the Spanish National Health Service in 2016. The survey included 70 questions covering issues such as follow-up organisation and resources, routine assessments, relationships with other services and families, information management and training.

RESULTS

The response rate was 91.5% (141/154). Among respondents, 70.9% (100/141) reported that they do provide follow-up and 42% do so up to six years of age. Routine neurological and ophthalmological follow-up is not performed in 60% and 37% of hospitals, respectively, and a second hearing assessment is not given in 62%. Just 38% of units have psychologist. In 41% of hospitals, training in follow-up skills is not included in Paediatric Residency training programme.

CONCLUSION

Although Spain has a nationwide health system that provides universal health coverage, we found that follow-up care for children born very preterm/very low birth weight is not equitable. Nearly half of paediatric residents receive no training in follow-up for this high-risk population.

Routine follow-up of preterm infants in New Zealand

AIM

To describe the routine follow-up of preterm infants by different District Health Boards (DHBs) in New Zealand (NZ), and to compare current practice with international guidelines.

METHODS

A descriptive survey of the existing routine follow-up management of preterm infants in NZ. From November 2015 until January 2016, a questionnaire was sent out across NZ to one paediatrician (n = 24) and one Child Development Service (CDS) (n = 20) from each DHB. All paediatricians responded and 85% of the CDSs responded. Responses were collated and compared to recommendations from paediatric literature.

RESULTS

There is tremendous variation across NZ of the eligibility criteria for routine preterm follow-up. Overall, a gestational age of <32 weeks and/or birthweight <1500 g was the most commonly used indication for routine preterm follow-up. The timing of visits and the assessments that were performed varied enormously. Respondents commonly reported that limited funding and resources prevented optimal follow-up management.

CONCLUSION

There is regional disparity in the routine follow-up that preterm infants receive in NZ. A standardised approach to follow-up of preterm infants across NZ, as recommended in the literature, is difficult due to the lack of funding and resources.

[Follow-up protocol for newborns of birthweight less than 1500 g or less than 32 weeks gestation]

The mortality of children with a birthweight of less than 1500g or with a gestational age of less than 32 weeks (<1500<32) has decreased significantly in the last 20 years or so. Given the higher risk of disability in these children, follow-up after hospital discharge is considered essential. In this document, the Follow-Up Group of the Spanish Society of Neonatology, in collaboration with the Spanish Society of Paediatric Primary Care, propose a follow-up protocol specific for the<1500<32, which has as its aim to standardise the activities and evaluations according to good practice criteria.

Rates of early intervention services in children born extremely preterm/extremely low birthweight

AIM

To determine the rates of early intervention (EI) service use in extremely preterm (EP, <28 weeks' gestation) or extremely low birthweight (ELBW, <1000 g) infants between 1991 and 2013, and identify biological or socio-economic factors associated with receiving EI.

METHODS

Participants comprised consecutive EP or ELBW survivors born in 1991-1992, 1997 or 2005 in Victoria, Australia, and randomly selected, matched term-born controls. The main outcome measure was parent-reported EI participation up to 8 years of age. Neurodevelopmental outcomes and socio-economic risk factors were compared with EI participation to identify associations among the preterm groups.

RESULTS

The rates of EI were higher in the preterm groups than the control groups overall (odds ratio 4.29, 95% confidence interval 3.28, 5.59, P < 0.001), and the rates of EI rose significantly over time - from 42% in the 1991-1992 preterm cohort to 64% in the 2005 preterm cohort. Among the preterm groups, post-natal corticosteroid therapy, cystic periventricular leukomalacia and surgery in the newborn period were all independently associated with increased odds of receiving EI. Increased severity of disability was associated with higher rates of EI. The majority (95%) of preterm children with a physical impairment received EI, compared with only 73% of children with a cognitive impairment alone. EI participation rates were independent of social risk.

CONCLUSION

EI participation is high in the EP population, and rates of EI use have increased over time. Contrary to previous reports, social risk factors were not found to be associated with EI use.

Follow-up at two years of age and early predictors of non-compliance in a cohort of very preterm infants

AIM

To examine the rates of follow-up at two years of age and perinatal factors associated with non-compliance in an observational population-based cohort of very preterm children enrolled in a routine follow-up program.

METHOD

Data review of infants born between 2008 and 2012 in the Observatoire de La Grande Prématurité, Reunion Island cohort. All singletons born alive before 33weeks of gestational age and resident on the island at two years of age were included. Patients were considered compliant if they were timely evaluated between 20-28months of age, or non-compliant if they were not evaluated or evaluated after 28months of age.

RESULTS

Of the 802 survivors (mean gestational age of 30.3±2.0months, mean birthweight of 1364±396g), 468 (58.4%) were examined between 20-28months, 119 (14.8%) after 28months of age, and 215 (26.8%) were never evaluated, respectively. In multivariate analysis, factors associated with non-compliance were higher parity (>2), past history of preterm delivery, maternal diabetes (preexisting or gestational), appropriate for gestational status, and centre of birth.

CONCLUSION

Sustainable follow-up of vulnerable neonates remains a challenge in clinical practice. Early predictors of non-compliance can be used to define individualized and local follow-up strategies in these infants at high risk for developmental disabilities.

Prognostic neurodevelopmental testing of preterm infants: do we need to change the paradigm?

Longitudinal follow-up with assessment of developmental status at about 2 years of age is routine for high-risk newborns. The results of these assessments can be used for many purposes, including helping physicians, parents, and teachers plan educational or developmental interventions. These assessments also provide outcome measures for clinical research studies. Outcome results may also serve as a source of information for clinicians when counseling parents regarding provision of care for extreme preterm infants. Consideration should be given to use of different outcome metrics based on the purpose for testing. Categorization of composite cognitive, motor and neurosensory findings to define levels of impairment should be limited to research. Planning for individual interventions is better guided by descriptive findings. Current tools for assessing neurodevelopmental status at 2 years of age have important limitations. First, outcomes at early ages do not always predict function later in life. They are, at best, an estimate of longer-term outcomes, with important individual variation. For infants without severe neurologic injury, postnatal environmental factors play a predominant role in determining long-term cognitive and academic outcomes. Further investigations should assess quality of life and other considerations that are important for parents when making decisions about neonatal intensive care unit care for their infant.

Professional Nurses' Perceptions of Skills Required for Performing Preterm Infants' Follow-up Assessments

Improved perinatal and neonatal care enhances preterm infant survival rates, but the adverse outcomes remain high. Nurses play vitally important roles regarding the follow-up assessments, treatment, and care of preterm infants. This explorative, descriptive study aimed to describe nurses' perceptions of skills required to perform effective preterm infant assessments. Thirteen semistructured interviews were conducted. Identified themes included the role of the professional nurse, the importance of preterm infant assessments, lack of skills and knowledge to conduct quality assessments, formal and continuous development training needs, the absence of assessment tools and physical resources to perform standardized assessments of preterm infants, and the required support and referral systems.

Early neurodevelopmental outcomes of extremely preterm infants

Infants born at extreme preterm gestation are at risk for both death and disability. Although rates of survival have improved for this population, and some evidence suggests a trend toward decreased neuromotor impairment over the past decades, a significant improvement in overall early neurodevelopmental outcome has not yet been realized. This review will examine the rates and types of neurodevelopmental impairment seen after extremely preterm birth, including neurosensory, motor, cognitive, and behavioral outcomes. We focus on early outcomes in the first 18-36 months of life, as the majority of large neonatal studies examining neurodevelopmental outcomes stop at this age. However, this early age is clearly just a first glimpse into lifetime outcomes; the neurodevelopmental effects of extreme prematurity may last through school age, adolescence, and beyond. Importantly, prematurity appears to be an independent risk factor for adverse development, but this population demonstrates considerable variability in the types and severity of impairments. Understanding both the nature and prevalence of neurodevelopmental impairment among extremely preterm infants is important because it can lead to targeted interventions that in turn may lead to improved outcomes.

Development of Children in Iran: A Systematic Review and Meta-Analysis

Background:

In order to gain a better perspective of the developmental status of children in different regions of Iran, this study was carried out to determine the prevalence and the factors impacting child development in Iranian studies.

Materials and Methods:

Articles published in Iranian and international journals indexed in the SID, PubMed, Scopus and Magiran databases from 2001-2015 were systematically reviewed using standard and sensitive keywords. After evaluating the quality of 155 articles in the initial search, 26 articles were analyzed according to the inclusion criteria. After investigations, meta-analysis was done for six studies and the results were combined using Random Effects model, and the heterogeneity of studies was evaluated using the I² index. Data analysis was performed using STATA version 11.2.

Results:

Eagger & Beggs tests, respectively with 0/273 & 0/260 did not confirm the probability of publication bias in the data, but heterogeneity in studies was confirmed (p<0/001). On such basis, the pooled prevalence of developmental disorder based on Random Effect model was calculated to be 0.146, CI (0/107-0/184). The prevalence of developmental disorders in children in the studies reviewed was reported between 7 to 22.4%. The most important risk factors were in SES (Socio Economic Status) and Prenatal, Perinatal, Neonatal &Child groups.

Conclusion:

More extensive studies and early intervention with respect to causes of developmental delay in children seems necessary.

Neurodevelopmental Outcomes After Neonatal Surgery for Major Noncardiac Anomalies

CONTEXT

Increasing concerns have been raised about the incidence of neurodevelopmental delay in children with noncardiac congenital anomalies (NCCA) requiring neonatal surgery.

OBJECTIVE

This study aimed to determine the incidence and potential risk factors for developmental delay after neonatal surgery for major NCCA.

DATA SOURCES

A systematic search in PubMed, Embase and the Cochrane Library was performed through March 2015.

STUDY SELECTION

Original research articles on standardized cognitive or motor skills tests.

DATA EXTRACTION

Data on neurodevelopmental outcome, the Bayley Scales of Infant Development, and risk factors for delay were extracted.

RESULTS

In total, 23 eligible studies were included, reporting on 895 children. Meta-analysis was performed with data of 511 children, assessed by the Bayley Scales of Infant Development at 12 and 24 months of age. Delay in cognitive development was reported in a median of 23% (3%-56%). Meta-analysis showed a cognitive score of 0.5 SD below the population average (Mental Development Index 92 ± 13, mean ± SD; P < .001). Motor development was delayed in 25% (0%-77%). Meta-analysis showed a motor score of 0.6 SD below average (Psychomotor Development Index 91 ± 14; P < .001). Several of these studies report risk factors for psychomotor delay, including low birth weight, a higher number of congenital anomalies, duration of hospital admission, and repeated surgery.

LIMITATIONS

All data were retrieved from studies with small sample sizes and various congenital anomalies using different neurodevelopmental assessment tools.

CONCLUSIONS

Cognitive and motor developmental delay was found in 23% of patients with NCCA. Meta-analysis showed that the mean neurodevelopmental outcome scores were 0.5 SD below the normative score of the healthy population.

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.

Neurodevelopmental outcomes of extremely preterm infants

Survival of extremely preterm infants has improved since 2000. Neurodevelopmental impairment rates remain high at the limits of viability. Although improved survival and neurodevelopmental impairment rates are associated with higher gestational age and more recent year of birth, significant variability in findings among geographic areas and networks is evident, and seems related to differences in population, management style, regional protocols, definitions, and outcome assessments. Outcome studies during adolescence and young adult age are needed to determine the long-term impact of extremely preterm birth.

Premature infants with birth weights of 1500-1999 g exhibit considerable delays in several developmental areas

AIM

To establish the prevalence and factors associated with developmental scores and delays in premature infants.

METHODS

A cross-sectional study was conducted on 100 premature infants with corrected ages of 18-24 months (actual ages 19.9 ± 2.0 months) and birth weights of 1500-1999 g. Bayley III scales were used to assess developmental scores, percentage of children with developmental scores <85, factors associated with developmental scores and delays in at least one developmental domain.

RESULTS

The percentages and 95% confidence intervals of those children with developmental delays were as follows: cognitive (2.0%; 0.6-7.0%), language (5.0%; 2.2-11.2%), motor (3.0%; 1.0-8.5%), socio-emotional (13.0%; 7.8-20.1%), general adaptive (26.0%; 18.4-35.4%), conceptual (17.0%; 10.9-25.6%), social (46.0%; 36.6-55.7%) and practical (21.0%; 14.2-30.0%). Factors associated with delay in at least one developmental domain were as follows: caesarean delivery, low per capita income and peri-intraventricular haemorrhage. Factors associated with a reduction in developmental scores were as follows: non-white ethnicity, lower social class, caesarean delivery, male gender, peri-intraventricular haemorrhage, mechanical ventilation and length of hospitalisation.

CONCLUSION

Premature infants with birth weights of 1500-1999 g exhibited considerable delays in several developmental areas. In addition to biological factors, environmental factors contributed to the reduced scores and/or developmental delays.

Trends and challenges in United States neonatal intensive care units follow-up clinics

OBJECTIVE

A mandate exists that all level III neonatal intensive care units (NICUs) provide a means to assess and follow their high-risk neonates after discharge. However, no standardized guidelines exist for the follow-up services provided. To determine trends of structure and care provided in NICU follow-up clinics in both the academic and private clinical setting.

STUDY DESIGN

We sent an Internet survey to NICU follow-up clinic directors at both academically affiliated and private centers. This study received institutional review board exemption.

RESULT

We received 89 surveys from academic institutions and 94 from private level III follow-up programs. These responses represent 55% of academic programs and 40% of private programs in the United States. Similar to academic institutions, 18% of private NICU follow-up clinics provide primary care services to patients. In both settings, the hospital supports 60% of the funding required for clinic activities. Forty-five percent of NICU graduates seen in both private and academic follow-up clinics have public aid as their primary insurance. Eighty-five percent of NICUs in both settings have guidelines outlining requirements for referrals to the follow-up clinic. Academic programs find feeding difficulties the most difficult, whereas private programs find bronchopulmonary dysplasia and feeding difficulties equally as difficult.

CONCLUSION

The care and struggles of NICU follow-up clinics are similar in both the academic affiliated and private settings. Similar referrals, clinical evaluation and medical care occur with varying struggles.

Social-emotional delays at 2 years in extremely low gestational age survivors: correlates of impaired orientation/engagement and emotional regulation

BACKGROUND

Premature infants are less socially and emotionally competent at school age than infants born at term.

AIMS

To evaluate the correlates of social and emotional delays at 2 years of age among prematurely born children.

STUDY DESIGN

This is a prospective cohort study.

SUBJECTS

904 children born at <28 weeks gestation during 2002-2004 and enrolled in the ELGAN study who survived until age 2 years and returned for a developmental assessment.

OUTCOME MEASURES

The Bayley Behavior Rating Scale (BRS), a neurological examination, and the Bayley Scales of Infant Development II (BSID-II).

RESULTS

Fully 31% of children had a non-optimal (14%) or questionable (17%) (NO/Q) BRS score for Emotional Regulation (ER), and 27% had a non-optimal (13%) or questionable (14%) score for Orientation/Engagement (O/E). Children with NO/Q scores on ER and O/E were more likely than others to have MDI and PDI scores <70 and be unable to walk. Antecedents of NO/Q OE scores included multi-fetal pregnancy, while antecedents of NO/Q scores for both ER and O/E included indicators of socioeconomic disadvantage, and male sex.

CONCLUSIONS

Over 25% of children born extremely premature exhibit socio-emotional delays during developmental assessment at age 2 years. Antecedents of these delays include sociodemographic characteristics, as well as those common antecedents of other impairments commonly observed among extremely preterm infants.

Current state of high-risk infant follow-up care in the United States: results of a national survey of academic follow-up programs

OBJECTIVE

High-risk infant follow-up programs have the potential to act as multipurpose clinics by providing continuity of clinical care, education of health care trainees and facilitating outcome data research. Currently there are no nationally representative data on high-risk infant follow-up practices in the United States. The objective of this study is to collect information about the composition of high-risk infant follow-up programs associated with academic centers in the United States, with respect to their structure, function, funding resources and developmental assessment practices, and to identify the barriers to establishment of such programs.

STUDY DESIGN

Staff neonatologists, follow-up program directors and division directors of 170 Neonatal Intensive Care Units (NICU) associated with pediatric residency programs were invited to participate in an anonymous online survey from October 2009 to January 2010.

RESULT

The overall response rate was 84%. Ninety three percent of the respondents have a follow-up program associated with their NICU. Birth weight, gestational age and critical illness in the NICU were the major criteria for follow-up care. Management of nutrition and neurodevelopmental assessments was the most common service provided. Over 70% have health care trainees in the clinic. About 75% of the respondents have the neurodevelopmental outcome data available. Most of the respondents reported multiple funding sources. Lack of personnel and funding were the most common causes for not having a follow-up program.

CONCLUSION

High-risk infant follow-up programs associated with academic centers in the United States are functioning as multidisciplinary programs providing clinical care, trainee education and facilitating outcomes research.

Follow-up studies of very low birthweight children in Sweden

Follow-up studies are essential to our knowledge of outcome in very low birthweight (VLBW) or extremely preterm (EPT) infants because those children have a greater risk for developing neurosensory disabilities and behavioural and educational problems and have decreased probability for an optimal transition into adulthood compared to term controls. Outcome data are of interest not only to healthcare professionals but also to parents, schoolteachers and society. The aim of this review is to describe the follow-up studies of seven populations of VLBW or EPT infants performed in Sweden and published between 1995 and 2009.

CONCLUSION

 The time has come to implement evident data from these Swedish follow-up studies into clinical practice and to perform regular and specific follow-up examinations during childhood for all VLBW and EPT children. These assessments, specially designed for high-risk infants, should consider the potential outcomes for neurological, visual, auditory function and cognitive function as well as behaviour and growth, from birth to school-start.

Improvement of developmental outcome between 24 and 36 months corrected age in very preterm infants

AIM

 To study early developmental course in preschool-aged very preterm infants and its association with perinatal risk factors and test-taking behaviour.

METHODS

  Children born <30 weeks gestation and/or <1000g in the Academic Medical Center of Amsterdam were assessed at 24 and 36 months corrected age with the Dutch Bayley Scales of Infant Development-II (BSID-II-NL) and neurological examination. Linear regression analyses for developmental change were performed with perinatal risk factors.

RESULTS

  One hundred and forty-six children, mean GA 28 weeks and mean birth weight 1043 g, participated. Mental and psychomotor scores improved significantly with 6 and 7 points, respectively, from 24 to 36 months (p < 0.01). Mild to severe problems on at least one domain occurred less often at 36 (32%) compared to 24 months (63%) (p < 0.01), using corrected scores. Mental improvement was associated with being born very small for gestational age or <28 weeks; psychomotor improvement was associated with not being treated with indomethacin. Difficult test behaviour occurred mostly at 24 months and was associated with non-optimal development at 36 months.

CONCLUSION

  Improved developmental outcome and test behaviour were found at 36 compared to 24 months in a cohort of very preterm children. Long-term outcome studies and retesting of behaviourally difficult children are recommended.

Early developmental assessment of children with major non-cardiac congenital anomalies predicts development at the age of 5 years

AIM

the aim of this study was to evaluate cognitive and motor development in children with major congenital anomalies and the predictability of development at age 5 years.

METHOD

a prospective, longitudinal follow-up study was undertaken. The Dutch version of the Bayley Scales of Infant Development - Mental Developmental Index (MDI) and Psychomotor Developmental Index (PDI) - were administered at the ages of 6, 12, and 24 months. The Revised Amsterdam Children's Intelligence Test - IQ and the Movement Assessment Battery for Children - Total impairment score (TIS) were used at age 5 years. A total of 117 children participated in the study. After excluding 12 children who had a major chromosomal or syndromal abnormality, the analysis was limited to 105 children (50 females, 55 males). Seven groups of congenital anomalies were distinguished: (1) small intestinal anomalies; (2) abdominal wall defects, comprising gastroschisis and omphalocele; (3) oesophageal atresia; (4) congenital diaphragmatic hernia; (5) Hirschsprung disease; (6) anorectal malformations; and (7) miscellaneous diagnoses. Logistic regression analyses served to determine the ability of MDI and PDI to predict IQ and TIS at age 5 years.

RESULTS

at age five, 83.7% of 104 children had an IQ of 85 or above and 16.3% an IQ of less than 85. TIS was normal in 71.3% of 87 children, while 17.2% demonstrated a borderline score and 11.5% a definite motor problem. MDI and PDI scores showed equal sensitivity to predict IQ (p=0.004 at 6 and 12mo, p=0.001 at 24mo) and TIS (p<0.001 at 6 and 12mo, p=0.002 at 24mo). MDI and PDI were positively correlated with IQ and TIS; TIS was positively correlated with IQ.

INTERPRETATION

IQ scores at 5 years of age corresponded to Dutch population scores, but TIS scores differed significantly. Early development of children with major congenital anomalies is predictive of development at 5 years, which can guide individualized follow-up for this vulnerable group of children.

Indicators of compliance for developmental follow-up of infants discharged from a regional NICU

AIM

To identify factors associated with compliance of scheduled outpatient developmental follow-up appointments in an effort to better ensure future care.

METHODS

This retrospective observational cohort study looked at patients born between January 7(th) 2006 and June 30(th) 2007 and discharged from a regional neonatal intensive care unit (RNICU). Discharge summaries were reviewed to attain information regarding 16 patient descriptives and 12 patient morbidities. Data were recorded and analyzed utilizing the statistical software SPSS 11.5.

RESULTS

Children of older mothers were more likely to attend follow-up (compliant: 30 years vs. non-compliant: 27 years). Factors which significantly improved compliance with follow-up care were patient contact after discharge (compliant: 65% vs. non-compliant: 35%) and early intervention referral (compliant: 64% vs. non-compliant: 36%). Factors which significantly hindered compliance were maternal drug use during pregnancy (compliant: 11.8% vs. non-compliant: 88%), and patient transfer to outside NICUs [(transferred out: compliant: 3 (10.3%), non-compliant 25 (89.3%)].

CONCLUSIONS

Several factors associated with compliance have been identified. Direct patient contact after discharge positively correlated with improved follow-up attendance. The severity of patient disease in the NICU did not impact follow-up rates. As a result close attention needs to be paid to factors which influence compliance with outpatient follow-up for developmental screening.

Exposure to maternal voice in preterm infants: a review

The mother's voice, along with other developmentally appropriate sensory events (ie, touch, light, smells), stimulates maturation of the sensory systems and helps shape normal fetal development. While vast changes in the neonatal intensive care unit have occurred over the last 2 decades, little research has addressed the loss of exposure to maternal voice for the preterm infant. To address this gap, we compared studies that directly investigated effects of exposure to maternal voice on preterm infants. Studies reviewed were conducted between 1972 and 2007. All presented recordings of maternal voice at sound levels above current recommendations, and few of the findings reached statistical significance. Some potentially positive developmental effects were indicated. Future study of the effects of exposure to maternal voice on preterm infants using recommended sound levels is needed.

[Assessment of preterm children's early development]

Preterm birth is an event that affects the child's healthy development. Several studies have addressed the evaluation of children born preterm and the influence that multiple risk factors have on the course of their development. This study performed a systematic review of the literature from 2000 to 2005 about the evaluation of the development of children born preterm until the age of 24 months. The biological risk factors were present in every study, with highlights on intraventricular hemorrhage, necrotizing enterocolitis, chronic pulmonary disease, and retardation of intrauterine development as the most studied risks. The child's motor development was the most studied area. In terms of age, the first evaluations focused on the first six months of life. Neonatal risk, low birth weight, baby boys, cerebral injuries, and first-week abnormal spontaneous movements were predicting factors of preterm child development at the age of two years.

Interdisciplinary structural follow-up of surgical newborns: a prospective evaluation

BACKGROUND

Information on physical and developmental outcomes of children with anatomical congenital anomalies (CAs) may indicate the need for early intervention and reduce impact on the child's life and parental burden.

METHODS

From 1999 to 2003, 101 children with CA (76.5% of initial survivors) were seen 6-monthly in a tertiary children's hospital. Growth, neurologic outcome, mental and psychomotor development as determined with the Bayley Scales of Infant Development, and categorization of predictive sociodemographic and medical variables of the children were evaluated prospectively and longitudinally.

RESULTS

Congenital diaphragmatic hernia (CDH) and esophageal atresia patients showed impaired growth, that is, both height for age (-1.5 standard deviation score [SDS]) and weight for height (-1.0 SDS). Overall neurologic outcome was normal, however, suspect or abnormal for 40% of CDH patients. Overall mental development was normal, but psychomotor scores were significantly lower than the norm (95% confidence interval, 83.8-92.2 at 6 months and 87.9-98.5 at 24 months). Sex, maternal age, socioeconomic status, CA, severity-of-disease covariables, and need of medical appliances at home could predict negative outcome significantly (P < .05).

CONCLUSIONS

The CA survivors show impaired growth and psychomotor developmental delay up to age 2 years. This warrants specific follow-up programs and infrastructure for these patients.

Influence of behaviour and risk factors on motor performance in preterm infants at age 2 to 3 years

The aim of this cross-sectional study was to determine the influence of test-taking behaviour and risk factors for delayed motor performance in 437 preterm infants (244 males, 193 females; < or = 32 weeks of gestation) at the corrected age of 2 to 3 years (mean 29mo [SD 3.3]). Other mean (SD) sample demographics were: postmenstrual age 29(+5) weeks (1(+5)), range 25(+0)-32(+0); birthweight 1213.7g (331.7), range 468-2350; and days in the neonatal intensive care unit 21.1 (21.3), range 1-165. Children (n=23) with a severe disability were excluded. We assessed motor performance and behaviour during testing with the Motor Scale and the Behaviour Rating Scale (BRS) of the Bayley Scales of Infant Development, 2nd edition (BSID-II). Risk factors were tested against delayed motor performance as the dependent variable in binary logistic regression analysis. Median score on the Motor Scale in terms of the BSID-II Psychomotor Developmental Index (PDI) was 86. 'Delayed' motor performance was observed in 46.5% of the children tested, and behaviour was 'not-optimal' in 31.4%. The Motor Scale and BRS scores were significantly correlated (r(s)=0.62, p<0.01). Risk factors for delayed motor performance were: neonatal convulsions (odds ratio [OR] 4.5; 95% confidence interval [CI] 1.6-12.9), low maternal educational level (OR 3.3; 95% CI 1.7-6.5), male sex (OR 2.8; 95% CI 1.8-4.3), and chronic lung disease (OR 2.1; 95% CI 1.1- 4.1). We conclude that preterm infants are at high risk of delayed motor performance and non-optimal test-taking behaviour.

Impact of a child with congenital anomalies on parents (ICCAP) questionnaire; a psychometric analysis

Background

The objective of this study was to validate the Impact of a Child with Congenital Anomalies on Parents (ICCAP) questionnaire. ICCAP was newly designed to assess the impact of giving birth to a child with severe anatomical congenital anomalies (CA) on parental quality of life as a result of early stress.

Methods

At 6 weeks and 6 months after birth, mothers and fathers of 100 children with severe CA were asked to complete the ICCAP questionnaire and the SF36. The ICCAP questionnaire measures six domains: contact with caregivers, social network, partner relationship, state of mind, child acceptance, and fears and anxiety. Reliability (i.e. internal consistency and test-retest) and validity were tested and the ICCAP was compared to the SF-36.

Results

Confirmatory factor analysis resulted in 6 six a priori constructed subscales covering different psychological and social domains of parental quality of life as a result of early stress. Reliability estimates (congeneric approach) ranged from .49 to .92. Positive correlations with SF-36 scales ranging from .34 to .77 confirmed congruent validity. Correlations between ICCAP subscales and children's biographic characteristics, primary CA, and medical care as well as parental biographic and demographic variables ranged from -.23 to .58 and thus indicated known-group validity of the instrument. Over time both mothers and fathers showed changes on subscales (Cohen's d varied from .07 to .49), while the test-retest reliability estimates varied from .42 to .91.

Conclusion

The ICCAP is a reliable and valid instrument for clinical practice. It enables early signaling of parental quality of life as a result of early stress, and thus early intervention.

Hospital discharge of the high-risk neonate

This policy statement updates the guidelines on discharge of the high-risk neonate first published by the American Academy of Pediatrics in 1998. As with the earlier document, this statement is based, insofar as possible, on published, scientifically derived information. This updated statement incorporates new knowledge about risks and medical care of the high-risk neonate, the timing of discharge, and planning for care after discharge. It also refers to other American Academy of Pediatrics publications that are relevant to these issues. This statement draws on the previous classification of high-risk infants into 4 categories: (1) the preterm infant; (2) the infant with special health care needs or dependence on technology; (3) the infant at risk because of family issues; and (4) the infant with anticipated early death. The issues of deciding when discharge is appropriate, defining the specific needs for follow-up care, and the process of detailed discharge planning are addressed as they apply in general to all 4 categories; in addition, special attention is directed to the particular issues presented by the 4 individual categories. Recommendations are given to aid in deciding when discharge is appropriate and to ensure that all necessary care will be available and well coordinated after discharge. The need for individualized planning and physician judgment is emphasized.

Applying Dutch and US versions of the BSID-II in Dutch children born preterm leads to different outcomes

The aim of the present study was to evaluate whether the application of Dutch versus US test procedures and norms of the Bayley Scales of Infant Development - 2nd edition (BSID-II) leads to different developmental outcomes. The BSID-II was administered to 376 preterm infants (191 males, 185 females; mean gestational age 30wks [SD 2.7], mean birth-weight 1242g [SD 385]) at corrected ages of 6, 12, 24, and/or 36 months. Raw scores were calculated twice with US and Dutch test procedures. Raw scores as well as Mental Developmental Index (MDI) and Psychomotor Developmental Index (PDI) scores, calculated on the basis of Dutch versus US normative data, were compared. Small but statistically significant Dutch-US differences were found between raw scores. Large, clinically relevant Dutch-US differences were found for MDI and PDI scores, especially at 6 and 12 months. These differences were likely to have been caused by a bias in the Dutch normative data, although a slower developmental pace of Dutch children in general could also have a role. This study highlights the problems that can occur when using a test that was developed in another country, even when local standardization is available.

Outcome of paediatric intensive care survivors

The development of paediatric intensive care has contributed to the improved survival of critically ill children. Physical and psychological sequelae and consequences for quality of life (QoL) in survivors might be significant, as has been determined in adult intensive care unit (ICU) survivors. Awareness of sequelae due to the original illness and its treatment may result in changes in treatment and support during and after the acute phase. To determine the current knowledge on physical and psychological sequelae and the quality of life in survivors of paediatric intensive care, we undertook a computerised comprehensive search of online databases for studies reporting sequelae in survivors of paediatric intensive care. Studies reporting sequelae in paediatric survivors of cardiothoracic surgery and trauma were excluded, as were studies reporting only mortality. All other studies reporting aspects of physical and psychological sequelae were analysed. Twenty-seven studies consisting of 3,444 survivors met the selection criteria. Distinct physical and psychological sequelae in patients have been determined and seemed to interfere with quality of life. Psychological sequelae in parents seem to be common. Small numbers, methodological limitations and quantitative and qualitative heterogeneity hamper the interpretation of data. We conclude that paediatric intensive care survivors and their parents have physical and psychological sequelae affecting quality of life. Further well-designed prospective studies evaluating sequelae of the original illness and its treatment are warranted.

The role of neonatal networks

A neonatal network is a collaboration involving more than one clinical site where a common protocol is used for a randomized trial, observational study, or quality improvement project. Because the prevalence of important outcomes (e.g., death or neurodevelopmental impairment) is low among neonates, multi-site studies have been an essential contributor to the identification of interventions for improving the health of neonates. In this review we summarize key aspects of the conduct of multi-site studies and describe some of the prominent accomplishments and contributions of neonatal networks. Important contributions of randomized trials and observational studies include the identification, and assessment, of potential strategies for prevention of cerebral palsy, chronic lung disease, and blindness due to retinopathy of prematurity. In addition, quality improvement projects by neonatal networks have greatly facilitated the dissemination of information about, and implementation of, evidence-based interventions.

Laparotomy versus peritoneal drainage for necrotizing enterocolitis or isolated intestinal perforation in extremely low birth weight infants: outcomes through 18 months adjusted age

OBJECTIVE

Extremely low birth weight (ELBW; < or =1000 g) infants with necrotizing enterocolitis (NEC) or isolated intestinal perforation (IP) are treated surgically with either initial laparotomy or peritoneal drain placement. The only published data comparing these therapies are from small, retrospective, single-center studies that do not address outcomes beyond nursery discharge. The objective of this study was to conduct a prospective, multicenter, observational study to (1) develop a hypothesis about the relative effect of these 2 therapies on risk-adjusted outcomes through 18 to 22 months in ELBW infants and (2) to obtain data that would be useful in designing and conducting a successful trial of this hypothesis.

METHODS

A prospective, cohort study was conducted at 16 clinical centers within the National Institute of Child Health and Human Development Neonatal Research Network. To assist in risk adjustment, the attending pediatric surgeon recorded the preoperative diagnosis and intraoperative diagnosis and identified infants who were considered to be too ill for laparotomy. Predefined measures of short- and longer-term outcome included (1) either predischarge death or prolonged parenteral nutrition (>85 days) after enrollment and (2) either death or neurodevelopmental impairment on a standardized examination at 18 to 22 months' adjusted age.

RESULTS

Severe NEC or IP occurred in 156 (5.2%) of 2987 ELBW infants; 80 were treated with initial drainage, and 76 were treated with initial laparotomy. By 18 to 22 months, 78 (50%) had died; 112 (72%) had died or were shown to be impaired. Outcome was worse in the subgroup with NEC. Laparotomy was never performed in 76% (28 of 36) of drain-treated survivors.

CONCLUSIONS

Drainage was commonly used, and outcome was poor. Our findings, particularly the risk-adjusted odds ratio favoring laparotomy for death or impairment, indicate the need for a large, multicenter clinical trial to assess the effect of the initial surgical therapy on outcome at > or =18 months.

Neurodevelopmental outcome and growth at 18 to 22 months' corrected age in extremely low birth weight infants treated with early erythropoietin and iron

BACKGROUND

Clinical trials evaluating the use of erythropoietin (Epo) have demonstrated a limited reduction in transfusions; however, long-term developmental follow-up data are scarce.

OBJECTIVE

We compared anthropometric measurements, postdischarge events, need for transfusions, and developmental outcomes at 18 to 22 months' corrected age in extremely low birth weight (ELBW) infants treated with early Epo and supplemental iron therapy with that of placebo/control infants treated with supplemental iron alone.

METHODS

The National Institute of Child Health and Human Development Neonatal Research Network completed a randomized, controlled trial of early Epo and iron therapy in preterm infants < or =1250 g. A total of 172 ELBW (< or =1000-g birth weight) infants were enrolled (87 Epo and 85 placebo/control). Of the 72 Epo-treated and 70 placebo/control ELBW infants surviving to discharge, follow-up data (growth, development, rehospitalization, transfusions) at 18 to 22 months' corrected age were collected on 51 of 72 Epo-treated infants (71%) and 51 of 70 placebo/controls (73%) by certified examiners masked to the treatment group. Statistical significance was determined using chi2 analysis.

RESULTS

There were no significant differences between treatment groups in weight or length or in the percentage of infants weighing <10th percentile either at the time of discharge or at follow-up, and no difference was found in the mean head circumference between groups. A similar percentage of infants in each group was rehospitalized (38% Epo and 35% placebo/control) for similar reasons. There were no differences between groups with respect to the percentage of infants with Bayley-II Mental Developmental Index <70 (34% Epo and 36% placebo/control), blindness (0% Epo and 2% placebo/control), deafness or hearing loss requiring amplification (2% Epo and 2% placebo/control), moderate to severe cerebral palsy (16% Epo and 18% placebo/control) or the percentage of infants with any of the above-described neurodevelopmental impairments (42% Epo and 44% placebo/control).

CONCLUSIONS

Treatment of ELBW infants with early Epo and iron does not significantly influence anthropometric measurements, need for rehospitalization, transfusions after discharge, or developmental outcome at 18 to 22 months' corrected age.