Preterm Infant

1. 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
2. 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
3. Evaluation: Outpatient
   1. Assess Growth
      1. See Infant Feeding
      2. See Preterm Feeding Schedules
      3. See Premature Infant Fluid Requirements
      4. Use premature growth charts for infants <1500 grams (consider if <2500 grams)
      5. 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
         1. Denver Prescreening Developmental Questionnaire II (R-DPDQ)
         2. 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
4. Labs
   1. Hemoglobin At 6 months and 2 years
   2. Lead level at 9 to 12 months
5. Management
   1. 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
   2. Vaccination
      1. Administer via standard 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 if discharged from NICU and stable
      4. Influenza Vaccine (when over 6 months of age)
      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
         1. See RSV Vaccine for indications and dosing schedule
      7. References
         1. Bonhoeffer (2006) Arch Dis Child 91: 929-35
6. 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
7. Prognosis: Neurologic Outcome
   1. Age 24 weeks: 26% Normal Cognition
   2. Age 25 weeks: 52% Normal Cognition
   3. Age 26 weeks: 74% Normal Cognition
   4. Reference
      1. Kilpatrick (1997) Obstet Gynecol 90:803-8
8. Prevention
   1. See Preterm Labor
   2. See Preterm Labor Management
9. References
   1. Pediatrics (1998) 102:411-7
   2. LaHood (2007) Am Fam Physician 76:1159-66
   3. Verma (2003) Clin Pediatr 42: 299-315