Although the rates of mortality among extremely preterm and/or low birth weight newborns have been declining for decades, addressing the ongoing health and developmental needs of NICU graduates continues to be of considerable importance, given their increased susceptibility to neurodevelopmental impairments, other health problems, and mortality over the life course.1 

In the current issue of Pediatrics, McKelvey et al2  report on a propensity-matched study of a home-visiting program designed to support parents in addressing their infants’ needs after NICU discharge. The program, known as Following Baby Back Home (FBBH), is delivered by nurse–social-worker teams who focus on helping parents meet their children’s medical and developmental needs, including supporting adherence to medical appointments, linking families with other health and human services, and promoting infants’ growth and development. The program continues through child age 3.

Using a carefully crafted propensity-matched design, the authors found that compared with those in the control group (n = 485), infants enrolled in FBBH (n = 485) had higher rates of health care use (including postdischarge hospitalizations, emergency department visits, and wellness visits) and immunizations and lower rates of infant mortality (0.21% vs 1.44%; P < .001) through the first year of life. The authors report additional analyses in the supplement of their article, finding essentially no intervention-control differences for other risk factors, which provides some assurance that the propensity-matched groups were equivalent on other common predictors of child health and development. Although there is some suggestion that the FBBH group was at greater risk for preterm delivery, it is important to note that the rate of missing data for the preterm-risk variable, along with other prenatal risks (gestational diabetes gestational hypertension, and sexually transmitted disease infections), was higher for the FBBH group than the control group. The lower rate of missingness for these variables in the control group raises the possibility that providers had heightened concerns about this group’s clinical risk, leading them to make clinical notations more frequently.

Moreover, note that FBBH services were initiated with 44.5% of those referred, 21.9% of those referred declined, and 17.0% were not traceable. Although declining such services may reflect an accurate belief on the part of parents that they have no need for this service, they well may be at greater risk because of them not fully recognizing their needs or apprehensions about having providers visit their homes. Note, also, that the difficulties encountered with locating some prospective participants likely reflect instabilities in parents’ lives. Despite the FBBH and control groups having similar measured risks, they, thus, may have differed on other risks associated with their declining participation and not being traceable that may have contributed to the FBBH-control group differences reported here.

These kinds of concerns, along with the highly important mortality result, emphasize the importance of testing FBBH in a randomized clinical trial (RCT). If the effects reported hold in an RCT, policymakers will be in a much stronger position to justify investing public dollars in this program.

The authors explain that they did not conduct an RCT because of pragmatic limitations. There is a long history of randomized trials being conducted on home-visiting programs with this population, with consistently beneficial intervention effects found on measures of parent-infant interaction.3  Effects on other aspects of child health and development have been mixed. In no previous intervention study for NICU graduates, so far as I can tell, have researchers reported beneficial effects on infant mortality. If the current estimate of intervention effect on mortality is valid, home visiting by nurse–social-work teams should become a regular addition to NICU discharge planning. Having confirmatory data from a well-designed and conducted multisite trial would accelerate investments in this service to reach those in need on a larger scale. Our collective ability to ensure that NICU graduates get the help they need will depend on rigorous intervention development, testing, and community replication. The stage is well set by this study.

Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.

FUNDING: No external funding.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2020-029397.

     
  • FBBH

    Following Baby Back Home

  •  
  • RCT

    randomized clinical trial

1
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Competing Interests

POTENTIAL CONFLICT OF INTEREST: Funds to support writing this commentary were provided by the Prevention Research Center for Family and Child Health, directed by Dr Olds at the University of Colorado School of Medicine. Dr Olds has a contract with the Nurse-Family Partnership (NFP) to conduct research to improve the NFP program and its implementation; this contract covers portions of Dr Olds’s salary.

FINANCIAL DISCLOSURE: Dr Olds is the founder of Nurse-Family Partnership (NFP) and, with the University of Colorado, owns the NFP intellectual property. The University of Colorado receives royalties from governments and organizations outside of the United States that implement NFP and has contracts with those entities to guide the implementation of NFP with quality; none of the royalties or fees go to Dr Olds personally; they are used to support the Prevention Research Center for Family and Child Health research and program implementation work.