Follow-up Care of Very Preterm and Very Low Birth Weight Infants
Jane E. Stewart
Marsha R. Joselow
I. INTRODUCTION.
Of the just over four million births per year in this country, 2% or 88,000 are born very preterm, defined as less than 32 weeks’ gestational age (GA). Fortunately, the rate of very preterm births appears to have stabilized after a persistent increase over the period from 1990 to 2005; associated with the rising twin and triplet rate presumed to be related to increased use of fertility therapies. With advances in neonatal care, the number of critically ill very preterm infants who survive the neonatal period and are discharged from the NICU has increased; these infants, with their high rate of medical and developmental sequela, have unique follow-up needs that include the utilization of specialized medical and educational resources.
II. MEDICAL CARE ISSUES
Respiratory issues (see Chap. 34). Approximately 23% of very low birth weight (VLBW; birth weight <1,500 g) infants and 35% to 45% of extremely low birth weight (ELBW; birth weight <1,000 g) infants develop bronchopulmonary dysplasia (BPD; defined as O2 dependent at 36 weeks’ postmenstrual age). Infants with BPD should be monitored for related morbidities, including acute respiratory exacerbations, upper and lower respiratory infections, reactive airway disease, cardiac problems (e.g., pulmonary hypertension and cor pulmonale), growth failure, and developmental delay. Infants with severe BPD may require treatment with tracheostomy and long-term ventilator support. More commonly, infants with significant BPD require some combination of supplemental oxygen, bronchodilator, steroid, and diuretic therapy.
VLBW infants are four times more likely to be rehospitalized during the first year than are higher birth weight infants; up to 60% are rehospitalized at least once by the time they reach school age. Admissions during the first year of life are most commonly for complications of respiratory infections. In a recent study of extremely premature infants, 57% of infants born between 23 to 25 weeks’ gestation and 49% of those born between 26 to 28 weeks required rehospitalization in the first 18 months of life. The increased risk of hospitalization persists into early school age; 7% of VLBW children are hospitalized in a given year, compared with 2% of higher birth weight children.
Respiratory syncytial virus (RSV) is the most important cause of respiratory infection in premature infants, particularly in those with chronic lung disease. To prevent illness caused by RSV, VLBW infants should receive prophylactic
treatment with palivizumab (Synagis) monoclonal antibody. The American Academy of Pediatrics (AAP) recommends treatment during RSV season for at least the first year of life for infants born ≤28 weeks’ gestation and for at least the first 6 months of life for those born between 28 and 32 weeks’ gestation. Likewise, good hand hygiene by all those in close contact with infants, avoidance of exposure to others with respiratory infections (especially young children during the winter season), and avoidance of passive cigarette smoke exposure to prevent illness caused by respiratory viruses should be recommended to families. The influenza vaccine is also recommended for VLBW infants when they are older than 6 months; until then, care providers in close contact with the infant should strongly consider receiving the influenza vaccine.
Air travel. In general, air travel is not recommended for infants with BPD because of the increased risk of exposure to infection and because of the lowered cabin pressure resulting in lower oxygen content in the cabin air. If an infant’s PaO2 is ≤80 mm Hg, supplemental oxygen will be needed while flying.
Immunizations. VLBW infants should receive their routine pediatric immunizations according to the same schedule as term infants, with the exception of Hepatitis B vaccine. Medically stable, thriving infants should receive the Hepatitis B vaccine as early as 30 days of age regardless of gestational age or birth weight. If the baby is ready for discharge to home before 30 days of age, it can be given at the time of discharge to home. Although studies evaluating the long-term immune response to routine immunizations have shown antibody titers to be lower in preterm infants, most achieve titers in the therapeutic range.
Growth. VLBW infants have a high incidence of feeding and growth problems for multiple reasons. Infants with severe BPD have increased caloric needs for appropriate weight gain. Many of these infants also have abnormal or delayed oral motor development and have oral aversion because of negative oral stimulation during their early life. Growth should be followed carefully on standardized growth curves using the child’s age corrected for prematurity for at least the first 2 years of life. Supplemental caloric density is commonly required to optimize growth. Specialized premature infant formulas with increased protein, calcium, and phosphate (either added to human milk or used alone) should be considered in the first 6 to 12 months of life in infants who have borderline growth. ELBW infants commonly demonstrate growth that is close to or below the fifth percentile. However, if their growth runs parallel to the normal curve, they are usually demonstrating a healthy growth pattern. Infants whose growth curve plateaus, or whose growth trajectory falls off, warrant further evaluation to assess caloric intake. If growth failure persists, consultation with a gastroenterologist or endocrinologist to rule out gastrointestinal pathology, such as severe gastroesophageal reflux disease, or endocrinologic problems, such as growth hormone deficiency, should be considered.
Gastrostomy tube placement may be necessary in a small subset of patients with severe feeding problems. Long-term feeding problems are frequent in this population of children and they usually require specialized feeding and oral motor therapy to ultimately wean from gastrostomy tube feedings.
Anemia. VLBW infants are at risk for iron deficiency anemia and should receive supplemental iron for the first 12 to 15 months of life.
Rickets. VLBW infants who have had nutritional deficits in calcium, phosphorous, or vitamin D intake are at increased risk for rickets. Infants who are
at highest risk are those treated with long-term parenteral nutrition, furosemide, and those with decreased vitamin D absorption due to fat malabsorption. Infants with rickets diagnosed in the neonatal intensive care unit (NICU) may need continued supplementation of calcium, phosphorous, and vitamin D during the first year of life. All breast fed infants, and those consuming less than 1 Liter per day of formula, should receive 400 IU Vit D supplementation per day for the first year of life.
Sensory issues that need follow-up include vision and hearing.
Ophthalmologic follow-up
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