Caring for the graduate from the neonatal intensive care unit. At home, in the office, and in the community

This article focuses on recent progress in the understanding of optimal care for the neonatal intensive care unit (NICU) graduate in three domains that have relevance to primary care pediatricians: the concept of developmentally supportive care for the immature central nervous system of fragile premature infants; an understanding of the function and systems of community-based early intervention available for medically complex, developmentally challenged and at-risk infants; and the management of technology-dependent children at home.

Changes in survival patterns of very low-birth-weight infants from 1980 to 1993

OBJECTIVE

To determine changes in survival patterns among very low-birth-weight ( < 1500 g) infants between 1980 and 1993.

METHODS

The records of 12,960 infants treated in nine perinatal intensive care centers in Florida were analyzed on the basis of survival (discharged alive from hospital) according to four independent variables: birth weight, race, sex, and transport status. Survival curves were generated using log linear regression techniques for each race by sex by transport status group.

RESULTS

Race, sex, and transport status correlated significantly with survival: survival percentages were higher among black infants, female infants, and infants transported to the perinatal intensive care centers than among white infants, male infants, and those admitted initially to the tertiary care centers. After 1985, 95% of neonates with birth weights between 1200 and 1500 g survived. In addition, survival of 500- to 500-g transported black male infants increased from zero to near 80% during the 13-year period; that of 500- to 550-g inborn white female infants rose from 35% to 70%.

CONCLUSIONS

These results illustrate the value of taking into account race, sex, and transport status in efforts to understand the contribution that neonatal intensive care of extremely low-birth-weight infants makes to the lowering of infant mortality, and of using multivariable statistical procedures to generate predicted survival probabilities for different subpopulations. These probabilities can be applied to (1) predicting survival for specific subgroups of extremely low-birth-weight infants, and (2) helping physicians develop clinical guidelines for extending care to infants at the threshold of viability.

Needs of handicapped infants, toddlers and families. Florida's response

The State of Florida and its physicians are moving into a wonderful time of opportunity to serve the special needs of infants and toddlers at risk for developmental delays. If we meet our challenge we will no longer judge our success by a viable pregnancy or "graduation" from the nursery. We will begin to expect a community-wide response that prepares a child for education so successful that he or she will graduate prepared to work as a full member of the community. Not all our interventions will succeed at that level, but we have learned that good ones can place almost all our special needs children into the community. Physicians will have a major role in the success of this system of care for handicapped infants, toddlers and their families.

Epilepsy and education: the pediatrician's expanding role

School systems, teachers, health systems, and physicians are striving to assist students to reach their full potential. Physicians have an understanding of seizures and medications that should be shared with teachers. In turn, teachers know what parts of students' learning seem to be affected by their epilepsy; they also work with students every day and this gives them a unique perspective of changes in the patient's status. Epilepsy can profoundly affect the student-patient, the school, and the home. Pediatricians are in the unique position to share medical information with teachers and parents. By sharing this information, physicians encourage collaboration. Increased collaboration, in turn, helps to reduce the myths and fears surrounding epilepsy. It provides teachers with the information they use to plan instructional programs, and it improves physicians' decisions regarding diagnosis and treatment. Physician/teacher collaboration is generally advocated for patients-students in the "devastated" and the "compromised" groups. Collaboration is not necessary in patients without problems and it is probably preferable not to risk stigmatizing otherwise intact children by attaching the label "epilepsy" to them. When collaboration is indicated, teachers will need some way of organizing information about students' seizure, educational, medical, and psychosocial background. The appendix contains a list of questions grouped according to these categories. If teachers can answer these questions they will be well on the way to resolving the problems confronting the student with epilepsy. It is hoped that physicians will be available and willing to assist teachers and that teachers will seek their assistance.

The families of children who fail to thrive: preliminary investigations of parental deprivation among organic and non-organic cases

A majority of cases of failure to thrive (FTT) do not have a known organic etiology. Social and psychological determinants are sought for these "non-organic failure to thrive" (N-O FTT) cases. Social and psychological differences between non-organic and organic cases are also explored here. With the introduction of the term, "maternal deprivation," medical practitioners have implicated mothers' deficiencies as instrumental in the etiology of N-O FTT. However, these mothers are themselves usually deprived. Lack of cooperation in childcare by both parents is noted when classic clinical cases are reviewed. We suggest that the concept, "parental deprivation," provides a more accurate model. Preliminary research findings support our hypothesis that mothers of FTT infants do not have good social support networks. Teen motherhood and socioeconomic status also appear to be important, but not necessary as determinants. An unexpected finding is that there are few differences in the social deficiencies of families of N-O FTT infants as compared to those failing for organic reasons. Two unanticipated findings appear noteworthy. First, infants failing for organic reasons are significantly smaller and thinner at birth, independent of pregnancy complications or prematurity. Second, infants failing for non-organic reasons are more likely to present during the period of infant-caretaker role development and less likely in the later toddler stage. Additional research into the feasibility of strengthening family supports as a basis of intervention is recommended.

Failure to thrive

Failure to thrive is one of the most common diagnostic problems in pediatrics. The term is applied to describe a still poorly defined entity. We will define failure to thrive, review the frequency of various etiologies, and present a logical approach to this problem.