Prematurity: Follow-Up
James A. Blackman
Robert J. Boyle
I. Description of the problem. Infants born before the 37th week of gestation are at risk for chronic medical, neurodevelopmental, and behavioral problems. The shorter the gestation and greater the number of associated medical and psychosocial complications, the higher the risk and need for close primary care surveillance.
A. Epidemiology.
Approximately 13% of all births are less than 37 weeks’ gestation; 2% less than 32 weeks.
Survival rate for infants born at 23-25 weeks gestation has improved.
The incidence of prematurity has increased over the last decade but mortality and morbidity risk for this group has declined dramatically (Table 65-1).
The births, often premature, of multiples due to popularity of in vitro fertilization have increased.
B. Risk factors for developmental and behavioral problems. Risk factors mandating especially close developmental surveillance include the following:
Very low birth weight (<1500 g)
Gestational age <28 weeks
Intrauterine growth restriction
Neonatal seizures
Persistent head ultrasound/computed tomography/magnetic resonance imaging (MRI) abnormalities, including ventricular dilatation or asymmetry, periventricular leukomalacia, diffuse white matter injury, or porencephalic cysts
Chronic lung disease
Persistent feeding problems (e.g., need to gavage feed beyond 34 weeks postconceptual age)
Biological risk alone does not determine outcome. Rather, it is the interaction of those risks with social and environmental factors that best predicts long-term functioning. In the first 2 years, biological factors are strong predictors of developmental function, especially in the motor domain. However, after 2 years of age, socioenvironmental factors assume a far more prominent role in determining cognitive outcome and school success. The primary care clinician is not able to change the preexisting organic insults but can alter and improve a child’s developmental and behavioral functioning by supporting the social environment.
II. Evaluation.
A. Common health problems of the premature infant. Since chronic medical problems and developmental and behavioral difficulties are inextricably linked, meticulous management of these problems will enhance the likelihood of good outcomes.
1. Neurologic. Maintain good seizure control through judicious use of anticonvulsant medications. Anticonvulsants for neonatal seizures often are weaned during the first year of life.
2. Ophthalmologic. Many premature infants leave the neonatal intensive care unit (NICU) with retinopathy of prematurity that is not fully resolved. Strabismus and myopia are more common among premature infants. Ensure follow-up by a pediatric ophthalmologist.
3. Audiologic. Newborn hearing screening is mandatory in most states. Be certain that hearing has been tested or that screening failures are followed-up. Infants with a history of prematurity or neonatal intensive care, or other risk factors should be retested at least once in the first 3 years of life. Infants with syndromes associated with hearing loss, hyperbilirubinemia requiring exchange transfusion, or congenital infection should be screened more frequently (see Chapter 50).
4. Respiratory. Pulmonary symptoms can impede developmental progress. In concert with specialists in chronic lung disease, optimize pulmonary function. Annual
influenza vaccine and respiratory syncytial virus prophylaxis for eligible infants will decrease respiratory morbidity.
Table 65-1. Risk by birth weight
Birth weight (g)
Mortality (%)
Major morbidity of survivorsa (%)
Minor morbidity of survivorsb (%)
<800
20-50
20-30
20-30
800-1000
10-20
15-20
15-20
>1000-1500
5-10
10-15
10-15
a Includes developmental quotient below 70, severe cerebral palsy, deafness, and blindness.
b Includes learning disabilities, borderline cognitive function, attention deficits, and poor school achievement (5%-10% in the general population) among children without major morbidity.
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