One in 10 U.S. infants is born preterm (<37 weeks’ gestation), and most are cared for by their primary care pediatrician.
While advances in neonatal intensive care units have improved neonatal mortality dramatically, especially for extremely preterm infants (<28 weeks’ gestation), prematurity and other perinatal conditions place infants at high risk for many developmental disabilities.
A new AAP clinical report consolidates contemporary data to provide a primary care framework that informs pediatricians about developmental risks for infants with a history of prematurity.
The report Primary Care Framework to Monitor Preterm Infants for Neurodevelopmental Outcomes in Early Childhood, from the AAP Council on Children with Disabilities and Committee on Fetus and Newborn, is available at https://doi.org/10.1542/peds.2023-062511 and will be published in the July issue of Pediatrics.
Challenging evaluations
Pediatricians are trained to recognize early developmental differences by providing targeted screening and enhanced surveillance throughout infancy, toddler and preschool years. Despite extensive research on neonatal outcomes, clinical decision-making about the degree of developmental risk associated with a child’s perinatal history can be challenging.
The report provides suggestions for enhanced monitoring by pediatricians throughout early childhood when increased developmental risks are identified.
The framework, for example, helps providers quickly appreciate the risk of a motor disability such as cerebral palsy (CP) in a child born at less than 28 weeks’ gestation, which is 23-45 times greater than for children in the general pediatric population. Even a child born at 32-36 weeks’ gestation has a risk of CP that is two times greater than the general pediatric population.
There is a brief update on developmental disabilities associated with prematurity and neonatal complications such as gestational age, intraventricular hemorrhage, hypoxic ischemic encephalopathy, bronchopulmonary dysplasia, retinopathy of prematurity and necrotizing enterocolitis.
Discussing findings
To help pediatricians discuss their findings with families, brief overviews address developmental disabilities associated with prematurity, including neurodevelopmental impairment, intellectual disability, visual impairment, hearing loss and autism spectrum disorder, and risk for later-presenting, lower-severity disabilities, such as learning disorders.
Pediatricians also can use the report to help them confidently reassure a family when their child is developing typically in various developmental domains, despite a high-risk history.
Recommendations
In addition to maintaining a collaborative relationship with local neonatology and high-risk infant follow-up programs, pediatricians can implement appropriate next steps for all children born prematurely, which may include:
- referral to early intervention services (Individuals with Disabilities Education Act Part C);
- enhanced screening and surveillance as outlined in Figure 2 in the report; and
- discussions with families about when and how developmental monitoring is occurring, and provision of additional supports if social determinants of health needs are unmet.
For children with increased degrees of risk for developmental disabilities, additional actions may include:
- referral to high-risk infant follow-up program and supports;
- timely referral or follow-up to ophthalmology and audiology, if indicated;
- caregiver education about episodes that may be a sign of a seizure disorder; and/or
- referral to physical therapy, occupational therapy and/or speech-language pathology to clarify the nature of developmental concerns.
The benefits of risk awareness based on a child’s perinatal course can help inform the need for enhanced developmental surveillance between regularly scheduled health supervision visits and developmental screening. This can facilitate early identification, timely intervention and healthy development for all children.
Dr. Davis is a lead author of the clinical report. She is a former member of the AAP Council on Children with Disabilities Executive Committee.
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