This week in Pediatrics, the AAP released its Clinical Report (10.1542/peds.2023-062511) with guidance for the clinician in rendering pediatric care titled, “Primary Care Framework to Monitor Preterm Infants for Neurodevelopmental Outcomes in Early Childhood.” Authored by Dr. Beth Ellen Davis and colleagues from the Council on Children with Disabilities and the Committee on Fetus and Newborn, this useful report gives welcome evidence-based primary guidance to “…support decision making in the primary care medical home…” with respect to screening and surveillance of former premature infants at risk for developmental disabilities. High risk infant follow-up clinics, generally associated with urban tertiary care hospital neonatal intensive care units (NICUs), do not usually serve moderate and late preterm infants (gestational ages 32-36 weeks) or premature infants living in rural or hard to reach communities, and hence the majority of premature infants are followed by primary care practitioners. This Clinical Report summarizes care for the spectrum of infant risk factors for neurodevelopmental disability with a focus on enhanced surveillance and clinical decision making.
Figure 1 provides “A Primary Care Framework to Monitor Infants Born Prematurely for Neurodevelopmental Outcomes in Early Childhood” with a pathway that includes diagnoses that increase risk (e.g., necrotizing enterocolitis or bronchopulmonary dysplasia) and gestational age groupings. For each of the 4 key surveillance domains of visual impairment, auditory impairment, intellectual disability, and cerebral palsy, risk levels are color-coded in comparison to the general pediatric population as “very high risk”, “high risk” and “moderate-low risk” by condition and gestational age. This “all in one” algorithm is useful and clear. Text sections on each of the disability domains provide specific screening and surveillance cues based on evidence and prevalence of the condition. Screening and individualized surveillance, medical care coordination, and community-based supports are the pillars of care of the premature infant and family.
The approach summarized in Figure 1 does not include high-frequency lower-severity conditions such as language and learning disabilities, developmental coordination disorder, and mental and behavioral health conditions. However, the Clinical Report notes that these conditions are both consequential in themselves and if clustered in an individual can have a disproportionate impact and create a meaningful burden. Continuing all routine Bright Futures recommendations, adding additional screening and surveillance points as needed and outlined, considering social determinants of health, and being in touch with a consulting neonatologist are all part of the picture of the medical home care of former premature infants and their families, who may need extra “TLC” and guidance in support of their infant’s care. This Clinical Report is a service to all of us who enjoy the pediatric care of former premature infants – there is always something to learn, and with practice and clinical guidance, the best outcomes are possible.
