II. Definitions: Preterm

  1. Early term
    1. Gestational age 37 to <39 weeks
  2. Late preterm
    1. Gestational age 34 to <37 weeks
  3. Very premature
    1. Gestational age 25 to 32 weeks
  4. Extremely premature
    1. Gestational age 25 weeks or less
  5. Border of viability
    1. Gestational age 22 to <25 weeks

III. Definitions: Weight

  1. Low birth weight
    1. Birth weight <2500 grams (5 pounds 8 ounces)
  2. Very low birth weight
    1. Birth weight <1500 grams (3 pounds 5 ounces)
  3. Extremely low birthweight
    1. Birth weight <1000 grams (2 pounds 3 ounces)

IV. Definitions: Age

  1. Gestational age (GA)
    1. Time duration from LMP to delivery date
  2. Chronological age (Postnatal age)
    1. Time duration from delivery date (birth date)
  3. Postmenstrual age
    1. Gestational age plus Chronological age
    2. Example: Preterm Infant born at 26 weeks (GA) and now 6 weeks after delivery (Chronological age)
      1. Postmenstrual age = 26 + 6 = 32 weeks
  4. Corrected age
    1. Chronological age minus weeks premature
    2. Example: For 26 week Premature Infant (14 weeks premature), now 6 months or 26 weeks after delivery
      1. Corrected age = 26 - 14 = 12 weeks or 3 months

V. Associated Conditions: Comorbidity in Preterm Infants

  1. Chronic lung disease (e.g. Bronchopulmonary Dysplasia)
  2. Apnea of Prematurity
  3. Pediatric Gastroesophageal Reflux (earlier onset and more severe than in term infants)
  4. Cryptorchidism
  5. Hernia
  6. Developmental Delay
  7. Growth Delay
  8. Sudden Infant Death Syndrome

VI. Evaluation: Prior to NICU discharge

  1. Care seat test
    1. Demonstrates that infant tolerates restraints without respiratory distress
    2. May require prone or supine care safety device as alternative
  2. Cranial Ultrasound (for infants born before 30 weeks gestation)
    1. Screens for intraventricular Hemorrhage and periventricular leukomalacia
    2. Performed at 7-10 days of life and at 36-40 weeks adjusted age

VII. Evaluation: Outpatient Schedule

  1. Post-hospital discharge at 24-48 hours
    1. Review hospital course, medications and medical equipment
    2. Review urine and stool output
    3. Measure weight, length and Head Circumference
      1. Visit weight below NICU discharge weight warrants a repeat visit within 72-96 hours
      2. Obtain weekly or biweekly weight for the first 4-6 weeks after hospital discharge
    4. Repeat Newborn Exam
    5. Review subspecialty follow-up (typically aranged by NICU, see indications below)
    6. Review SIDS prevention
  2. Post-hospital discharge at 2-4 weeks
    1. Review medications and subspecialty monitored issues
    2. Review feeding history
    3. Measure weight, length and Head Circumference
      1. Continue to obtain weekly or biweekly weight for the first 4-6 weeks after hospital discharge
      2. Plot Growth Parameters on premature growth chart for the first 24 months of life
      3. Expect catch-up to occur first with Head Circumference, then with length and then with weight
      4. Neurosurgery/Imaging evaluation for disproportionate head growth (may reflect Hydrocephalus or Craniosynostosis)
    4. Physical exam
    5. Iron Supplementation for Breastfed infants (low dose for formula fed infants)
  3. Chronological age 2 months, 4 months, 6 and 9-12 month visits
    1. Review medications and subspecialty monitored issues
    2. Review feeding history
      1. Feeding fortification may be stopped when weight for age >25th percentile
      2. Complimentary foods may be introduced at 4-6 months Corrected age
      3. Transition to whole milk at 12 months (same as term infants)
    3. Developmental Screening
    4. Measure weight, length and Head Circumference (see precautions above)
    5. Physical exam
    6. Hearing screening (if indicated for high risk infants at 3 months, and repeat again at 9-12 months)
    7. Ophthalmologic screening (6-9 months of age)
    8. Iron Deficiency screening (4 to 8 months of age and again at 9-12 months)
    9. Lead level screening at 12-24 months (as indicated, although AAP still recommends universal screening as of 2014)
    10. Immunizations (see below)

VIII. Indications: Subspecialty Follow-up

  1. Pulmonology
    1. Oxygen therapy
    2. Cardiorespiratory monitor
    3. Tracheostomy
    4. Bronchopulmonary Dysplasia
  2. Gastroenterology
    1. Enteral Tube Feedings
  3. Neurology
    1. Intraventricular Hemorrhage
    2. Intraventricular shunt
  4. Ophthalmology
    1. Retinopathy of Prematurity
  5. Urology
    1. Cryptorchidism
    2. Inguinal Hernia
  6. References
    1. (2004) Pediatrics 114(Suppl 5): 1377-97 [PubMed]

IX. Evaluation: Outpatient focus areass

  1. Assess Growth
    1. See Preterm Infant Growth
    2. See Infant Nutrition
    3. See Preterm Feeding Schedules
    4. See Premature Infant Fluid Requirements
    5. Use premature growth charts for infants <1500 grams (consider if <2500 grams) for first 24 months of life
    6. Expect 20-30 grams of weight increase daily for adequate growth
  2. Developmental Examination at each routine Well Child Visit
    1. Refer on identifying Developmental Delay
      1. Programs available to children under age 3 are federally funded
    2. Tools - complete Developmental Screening at 9, 18, and 24-30 months
      1. See Developmental Evaluation
      2. Denver Prescreening Developmental Questionnaire II (R-DPDQ)
      3. Denver Developmental Screening Test II (DDST-2)
  3. Neurologic Examination red flags
    1. Asymmetric motor activity or weakness
    2. Hyperreflexia
    3. Altered muscle tone (hypertonia or hypotonia)
  4. Vision Evaluation (evaluating Retinopathy of Prematurity)
    1. Initial Retinal Examination: 31 weeks Postmenstrual age
    2. Subsequent Retinal Examination: Per ophthalmologist based on first exam
  5. Newborn Hearing Screening
    1. Initial examination: Prior to NICU discharge
    2. Subsequent examination: Consider routine repeat testing

X. Labs

  1. Hemoglobin At 6 months and 2 years
  2. Lead level at 9 to 12 months

XI. Management

  1. See Infant Nutrition
  2. Specific Condition Management
    1. Bronchopulmonary Dysplasia
      1. May require additional Caloric Intake, reactive airway management and home oxygen
    2. Apnea of Prematurity
      1. May require Methylxanthines and apnea monitor
  3. Immunization
    1. Administer via standard Primary Series schedule based on Chronological age (not adjusted for gestation)
    2. DTaP Vaccine, Hib Vaccine, IPV Vaccine and Prevnar are unaffected by prematurity
    3. Rotavirus Vaccine may be given after age 6 weeks (until 15 weeks) if discharged from NICU and stable
    4. Influenza Vaccine starting at 6 months Chronological age (2 doses, 4 weeks apart)
    5. Hepatitis B Vaccine is modified if birth weight < 2000 grams
      1. Based on maternal Hepatitis B Infection status
      2. See Hepatitis B Vaccine for schedule and modifications
    6. Respiratory Syncytial Virus Vaccine (Palivizumab or Synagis)
      1. See RSV Vaccine for indications and dosing schedule
    7. References
      1. Bonhoeffer (2006) Arch Dis Child 91: 929-35 [PubMed]

XII. Prognosis: Overall Outcome

  1. Formula to estimate survival and morbidity
    1. Percent Survival: (Age in weeks - 20) x 10
    2. Percent Handicap-free: Survival + 10
  2. Example
    1. 23 Weeks: 30% Survival, 40% Handicap-free
    2. 24 Weeks: 40% Survival, 50% Handicap-free
    3. 25 Weeks: 50% Survival, 60% Handicap-free
    4. 26 Weeks: 60% Survival, 70% Handicap-free
    5. 27 Weeks: 70% Survival, 80% Handicap-free
    6. 28 Weeks: 80% Survival, 90% Handicap-free
    7. 29 Weeks: 90% Survival, 95% Handicap-free
    8. 30 Weeks: >95% Survival, >95% Handicap-free

XIII. Prognosis: Neurologic Outcome

  1. Extreme prematurity (<25 weeks) is associated with significant risk of cognitive deficits
    1. Cognitive deficit risk: 45-50% (overall)
    2. Age 24 weeks: 74% Cognitive deficit risk
    3. Age 25 weeks: 48% Cognitive deficit risk
    4. Age 26 weeks: 26% Cognitive deficit risk
    5. Kilpatrick (1997) Obstet Gynecol 90:803-8 [PubMed]
  2. Very Premature Infants (27-32 weeks)
    1. Cognitive deficit risk: 28-40%
    2. Stephens (2009) Pediatr Clin North Am 56(3): 631-46 [PubMed]
    3. Vohr (2005) Pediatrics 116(3): 635-43 [PubMed]
  3. Late Preterm Infants (34-37 weeks)
    1. Fourfold increased risk of Cerebral Palsy than term infants
    2. Petrini (2009) J Pediatr 154(2): 169-76 [PubMed]

XIV. Prevention

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