Follow-Up Care of the Premature Infant

Chapter 71 Follow-Up Care of the Premature Infant



Jane S. Lee, MD, MPH




Medical Knowledge and Patient Care


Technologic advances in perinatal care have led to an improvement in survival of infants born prematurely. Currently, an estimated 13% of all newly born infants in the United States are born preterm (defined as birth before 37 weeks gestation). Although the total number of survivors has increased, these infants continue to remain vulnerable to a variety of medical and developmental morbidities associated with their underlying immaturity. The importance of the role of the family as partners in providing care for their infant before and after discharge from a neonatal intensive care unit (NICU) cannot be underestimated.


Preparation for Discharge from the NICU: In 1998 the American Academy of Pediatrics (AAP) proposed guidelines on hospital discharge of high-risk neonates. The essential physiologic competencies that must be achieved before discharge include temperature regulation, maintenance of stable cardiorespiratory function, and the ability to nipple an adequate volume of feeding to sustain an acceptable pattern of growth. Although interrelated, each of these competencies may not be necessarily accomplished by the same postnatal age because the maturation of these processes is influenced by the infant’s birth weight (BW), gestational age (GA), and severity of associated medical illnesses. The majority of preterm infants typically attain these competencies between 34 and 36 weeks postmenstrual age (PMA).


Concurrently, the parents must also demonstrate an ability to care for their infant. As early as possible, at least two family members should participate in the infant’s care to ensure ample time for education in acquiring the skills and judgment required to provide appropriate care.



Common Medical Issues


Immunization is a critical component of preventive care. The timing and dosing of routine primary immunization for diphtheria, tetanus, pertussis, Haemophilus influenzae type b, poliomyelitis, pneumococcal disease, and influenza should be based on chronologic age and not on adjusted age. Because of increased risk for hospitalization from viral gastroenteritis, the AAP supports rotavirus immunization in medically stable preterm infants between 6 and 12 weeks of age at the time of discharge or after the infant has been discharged home.


Infants less than 2 kg born to mothers who are hepatitis B surface antigen (HBsAg) negative should receive the initial dose of hepatitis B vaccine (HBV) at 30 days (chronologic) or at hospital discharge, whichever occurs earliest. If maternal HBsAg status is unknown, HBV and hepatitis B immune globulin should be administered within the first 12 hours of age, because preterm and low-birth-weight infants may have a less predictable response to HBV. Infants born to HBsAg-positive mothers should receive HBV and hepatitis B immune globulin (HBIG) within 12 hours after birth as well as a series of three additional doses starting at 1 month of age.


Immunoprophylaxis with palivizumab has been shown to decrease the rate of hospital-associated respiratory syncytial virus (RSV). Prophylaxis is recommended for preterm infants and children younger than 2 years of age with chronic lung disease who require medical therapy (i.e., supplemental oxygen, bronchodilator, diuretic, or corticosteroid therapy) within 6 months before the anticipated start of the RSV season. Other groups for whom RSV prophylaxis is recommended include infants born ≤28 weeks’ gestation during the first 12 months, infants born between 29 and 31 weeks’ gestation during the first 6 months, and infants born between 32 and 35 weeks gestation who are less than 6 months, chronologic age, with at least two risk factors (i.e., child care attendance, school-age siblings, congenital abnormalities of the airway, or severe neuromuscular disease). Once prophylaxis is initiated, a total of up to five consecutive monthly doses should be administered to provide sufficient protection for the entire RSV season, except for those with neuromuscular disease, who need prophylaxis until 90 days of age. Even after a documented RSV infection, prophylaxis should continue because various strains of RSV may cocirculate.


Apnea of prematurity (AOP) is defined as a cessation of breathing of at least 20 seconds duration or a cessation of breathing associated with bradycardia or oxygen desaturation. In hospitalized infants, episodes may be treated with methylxanthine therapy and/or continuous positive airway pressure. Although AOP typically resolves by 37 weeks PMA, episodes may persist until approximately 43 weeks PMA. Before discharge, infants are typically observed for a preset observation period during which the infant should remain event-free. For infants with an unusually prolonged course of recurrent severe AOP, home cardiorespiratory monitoring may be prescribed until approximately 43 weeks PMA or after the cessation of extreme episodes, whichever comes last. Evidence-based review of the literature suggests there is no evidence that home monitoring will reduce apparent life-threatening events or deaths from sudden infant death syndrome.


Bronchopulmonary disease (BPD) represents an evolving process of lung injury of multifactorial origin related to underlying lung immaturity, abnormal lung development, inflammatory mediated injury, and inadequate repair response. The incidence of BPD is inversely proportional to birth weight, and the overwhelming majority of affected infants weigh less than 1250 grams at birth. Diagnosis of BPD is based on the requirement for supplemental oxygen or continuous positive airway pressure support after 28 days of age and/or after 36 weeks PMA. Following NICU discharge, BPD remains a significant cause of long-term morbidity. In those infants with a history of prolonged or multiple intubations, airway problems include subglottic stenosis, tracheal or bronchial granulomas, and acquired tracheobronchomalacia. Infants with BPD are more susceptible to pulmonary infections and reactive airway disease. Serious long-term sequelae include cor pulmonale and pulmonary hypertension. Affected infants often continue to require high caloric intake secondary to the increased energy expenditure associated with increased work of breathing. Ongoing treatment of BPD may include bronchodilators, fluid restriction, diuretics, electrolyte supplementation, and antibiotics.


Nutrition: The overwhelming majority of very low-birth-weight infants exhibit poor postnatal growth. To sustain weight gain, these infants often require between 110 and 130 kcal/kg/day. Serial measurements of the infant’s weight, length, and head circumference are necessary to assess overall growth pattern. The infant’s adjusted age is typically used to plot these measurements until 18 months of age or catch-up growth has been achieved.


Human breast milk is the recommended source of nutrition for all infants. However, for many preterm infants, formulas are the major nutrition source upon discharge. Even preterm infants who are receiving breast milk may need to be supplemented with several feedings per day of preterm discharge formula, which typically provides 22 kcal/oz and is enriched with additional protein, minerals, vitamins, and trace elements. The AAP recommends continued use of postdischarge formula until 9 months postnatal age. Alternatively, the higher- calorie formula may be discontinued once catch-up growth is achieved. Introduction of solid foods is based on the infant’s oral-motor readiness, which typically occurs between an adjusted age of 4 and 6 months. Similarly, transitioning to cow’s milk should be avoided until 12 months adjusted age.


Additional vitamin and iron supplementation may be necessary. A vitamin D supplement of 400 International Units/day is recommended until 12 months of age in breastfed infants and formula-fed infants ingesting less than 500 mL/day of vitamin-D fortified formula. Iron supplementation is required through the first year of life. An oral supplement of 2 mg/kg/day should be given to all breastfed infants until 12 months of age. Formulas typically provide approximately 2 mg/kg/day of iron for the average premature infant consuming 150 mL/kg/day of formula. Depending on the degree of prematurity, an additional 1 mg/kg/day may be beneficial.


Gastroesophageal reflux disease (GERD) is a frequent problem in the preterm infant. The primary mechanism is believed to be related to a transient and inappropriate relaxation of the lower esophageal sphincter. GERD is often successfully managed with conservative measures such as flat prone/upright positioning, more-frequent smaller-volume feedings, formula thickening with cereal, and/or a trial of hypoallergenic formula. Medical therapy consisting of acid suppression with either an H2 antagonist or a proton pump inhibitor is reserved for those infants with persistent moderate-to-severe symptoms. A prokinetic agent may also be considered in difficult to manage cases. In severe disease, transpyloric feeding or Nissen fundoplication may be indicated.


Neurodevelopmental Disabilities: Premature infants continue to face significant challenges into childhood. They are at risk for a variety of neurodevelopmental disabilities secondary to injury to the developing brain. Disabilities range from major disabilities such as cerebral palsy and intellectual deficits to subtle impairments of sensory integration, learning differences, and problems with behavior and temperament. A fundamental aspect of routine care is developmental surveillance. Using a standardized screening tool such as the Denver Developmental Screening test, the pediatrician may identify infants who require a more comprehensive evaluation. For the first 2 years of life, developmental milestones should be adjusted to account for the infant’s prematurity. Once a delay is diagnosed, referral for early intervention services is recommended for infants and children less than 3 years of age with special developmental and educational needs. (See Chapter 25, The Special Needs Child.)


A subset of premature infants, typically the smallest and most premature, are also monitored through NICU-affiliated neonatal follow-up programs. These programs may not provide primary care but work in a consultative mode to monitor medical care by serial evaluation of health and neurodevelopmental outcomes. Detailed assessments typically include evaluation of alertness, posture, passive and active muscle tone, deep tendon reflexes, primitive reflexes, postural reactions, and formal testing of functional abilities using measures such as the Bayley Scales of Infant Development.


Retinopathy of prematurity (ROP) is a serious vasoproliferative disorder that may result in severe visual impairment or blindness in preterm infants. The AAP recommends ROP screening for preterm infants with BW ≤1500 grams or gestation age ≤30 weeks and for clinically unstable preterm infants with BW between 1500 and 2000 g or gestational age older than 30 weeks who are considered to be at high risk based on their medical course. Serial retinal examinations should be performed by an experienced ophthalmologist who has sufficient knowledge and experience to enable accurate identification of the location and sequential retinal changes of ROP. Treatment with laser therapy, when indicated, has been shown to decrease the incidence of retinal detachment and blindness. Upon discharge, it is imperative that ophthalmologic follow-up be documented and reviewed with the parents because infants with a history of ROP are at risk for subsequent ophthalmologic complications such as strabismus, significant refractive error, amblyopia, cataract formation, and impaired visual acuity. Careful monitoring and follow-up can minimize risk for long-term visual impairments.


Hearing Loss: Universal newborn hearing screening is recommended for all newborns. Acceptable methodologies for screening include auditory brainstem response and evoked otoacoustic emissions. Approximately 2% to 4% of preterm infants born at less than 32 weeks gestation will develop some degree of hearing loss. Additional evaluations are warranted if there are concerns about speech and hearing because hearing deficits may present after discharge. Early recognition of hearing impairment, appropriate hearing amplification, and early intervention services are critical for optimal language development. Prognosis depends largely on the degree of hearing impairment as well as the timing of diagnosis and treatment.

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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Follow-Up Care of the Premature Infant

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