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About 12 percent of all babies are premature, the majority of whom are late preterm births (between 34 weeks and 36 6/7 weeks). Here, Children’s Hospital Boston neonatologist Dara Brodsky, MD, talks about management of problems associated with the premature infant. Dr. Brodsky is the co-editor of a new book, Primary Care of the Premature Infant.
- neurodevelopmental problems
- nutritional problems
- hearing loss
- eye disease
- infections (e.g. RSV)
- anemia
First, they need to manage complications that have already occurred in the NICU. For example, a baby with chronic lung disease may go home on oxygen, so pediatricians should be involved in monitoring the baby’s respiratory status and growth. They should also monitor for new problems that might arise that haven’t been noted in the NICU. For example, premature infants are at increased risk for neurodevelopmental disabilities, including motor, cognitive, developmental and speech delays. Providing support to the family is also important, including helping them access resources and coordinating medical and social services.
Early Intervention (EI) has been helpful for premature infants in terms of their long-term outcomes. This is something that we try to arrange before the family goes home, but the pediatrician should make sure that it’s happening. There’s also an Infant Follow-up Program at Children’s designed for babies who are born less than or equal to 28 weeks. Babies who are less than or equal to 32 weeks and have some other risk factors (intracranial bleeding, periventricular leukomalacia, feeding and growth concerns, retinopathy of prematurity (ROP) and hearing loss) are also eligible. The program tries to assess a child every six months until age 3. Services include evaluation by a neonatologist, physical therapist, occupational therapist, neurologist, child psychologist and/or social worker. The staff coordinates with the pediatrician and the child’s EI program about any concerns.
In the short-term, it’s important to look for ROP. There are a few babies whose blood vessels are still growing and need to be followed within the first two to three weeks of going home, sometimes requiring an eye exam every other day. It’s absolutely critical that they have that close follow-up to make sure they don’t have any severe disease that might require laser therapy. For long-term follow-up, premature infants are at risk for myopia, amblyopia and strabismus. We recommend a repeat ophthalmologic exam at 9 to 12 months old for babies born at less than 32 weeks gestation. That’s not something that is done in the general population.
All babies are required to have a hearing screen before they’re discharged from the hospital. But premature infants born at less than 32 weeks gestation require another test at 12 months of age because of increased risk of hearing loss.
A dental exam should be performed by 12 months of age in premature infants born at less than 32 weeks gestation. The more premature an infant is, the more likely that he has required an endotracheal tube that can affect the growth of his teeth and development of some of the structures in his mouth.
Immunizations are based on chronological age and should never be delayed because of prematurity issues.
Many premature infants go home on a diet designed to have extra calories. Pediatricians need to monitor the baby’s growth to determine when adjustments should be made. Reasons to supplement calories include a flat or decelerating growth curve or a growth curve that is not approaching the lower percentile. If there’s no improvement in growth, further evaluation by a gastroenterologist, endocrinologist or dietician is necessary. Calories may be decreased gradually but the child’s weight should be monitored one to two weeks later.
Premature babies are at greater risk for anemia and may require iron supplementation. If the mother is breastfeeding, 2mg/kg of iron a day until the child is 12 months is recommended. Infants with severe anemia may require 4mg/kg/day. If the baby is formula-fed, only iron-fortified formulas are recommended. Vitamin D supplementation for preterm infants is the same as full-term infants.
More information: 617-355-8076 or childrenshospital.org/newborn
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