Long-term neurodevelopmental outcome of preterm infants: Management

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All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jul 2016. | This topic last updated: Jul 06, 2016.

INTRODUCTION — Neurodevelopmental impairment is a major long-term complication for many former preterm infants. However, comprehensive ongoing assessment to detect neurodevelopmental sequelae and early interventions services are costly and labor intensive and may not be warranted in all preterm survivors. As a result, a key management issue confronting clinicians who care for preterm survivors and their families is identifying infants who are at risk for subsequent significant neurodevelopmental disability and who may benefit from early intervention. This is particularly challenging as available screening tools are not precise enough for accurate prediction of neurodevelopmental outcome for individual patients.

This topic will discuss follow-up neurodevelopmental care of former preterm infants recognizing the challenge of accurate clinical prediction. The epidemiology and risk factors of neurodevelopmental impairment for preterm infants are discussed separately. (See "Long-term neurodevelopmental outcome of preterm infants: Epidemiology and risk factors".)

DEFINITIONS

Prematurity — Degrees of preterm birth are typically defined by gestational age (GA) or birth weight (BW). The following definitions are used throughout this review.

The classification based upon GA is as follows:

●Late preterm birth – GA between 34 weeks and 36 6/7 weeks

●Moderate preterm birth – GA between 32 weeks and 33 6/7 weeks

●Very preterm birth – GA between 28 weeks and 31 6/7 weeks

●Extremely preterm birth – GA less than 28 weeks

 

The classification based upon BW is as follows:

●Low birth weight (LBW) – BW less than 2000 g

●Very low birth weight (VLBW) – BW less than 1500 g

●Extremely low birth weight (ELBW) – BW less than 1000 g

 

Percentiles of birth weights for the appropriate GA have been established (table 1A-B).

Neurodevelopmental outcome — The term neurodevelopmental outcome is a composite term and typically refers to cognitive, neurologic, and/or sensory outcomes.

Traditionally in outcome studies, neurodevelopmental impairment has been defined as the presence of one or more of the following:

●Cognitive delay based on scores on standardized cognitive tests that are 2 standard deviations below the mean. As an example, this would correspond to score of 70 or below on the Mental Developmental Index of the Bayley Scales of Infant Development.

 

●Moderate to severe cerebral palsy (CP) defined as a score of ≥2 on the Gross Motor Function Classification System (GMFCS).

 

●Hearing deficit/loss requiring amplification.

 

●Severe visual impairment with visual acuity of 20/200 or less in the better-seeing eye with best conventional correction (definition of legal blindness).

 

In addition, behavioral, psychological, and functional outcomes are increasingly being recognized as important long-term neurodevelopmental outcomes and will be discussed within this review.

CHALLENGES IN PREDICTING OUTCOME

Overview — The prediction of complex academic, behavioral, and functional outcomes for preterm infants is imprecise because of the limitations of available clinical tools to accurately prognosticate long-term neurodevelopmental outcome for individuals at school age, at adolescence, and as adults. The available clinical tools to predict outcome include:

●Neuroimaging (cranial ultrasonography and magnetic resonance imaging)

●Early childhood clinical assessment during the first two years of life consisting of neurologic examination and evaluation of cognitive and motor function, language and social development and behavior

 

Although these tools are useful in assessing population-based or large birth cohorts, they may not be specific enough to be helpful in accurately predicting outcome for all individual survivors. Nevertheless, based on available evidence, our approach for monitoring neurodevelopmental status is based on a risk assessment for the individual patient using these tools. Risk factors for neurodevelopmental impairment based on observational data from large cohort and population studies include extreme prematurity (gestational age [GA] less than 28 weeks), multisystem congenital malformations, and a neonatal course that includes one or more of the following conditions: severe asphyxia, intrauterine growth retardation, severe intraventricular hemorrhage (IVH), periventricular leukomalacia or infarction, meningitis, seizures, and respiratory failure requiring mechanical ventilation. (See "Long-term neurodevelopmental outcome of preterm infants: Epidemiology and risk factors", section on 'Neurodevelopmental disability and academic achievement' and "Long-term neurodevelopmental outcome of preterm infants: Epidemiology and risk factors", section on 'Associated conditions' and 'Follow-up neurodevelopmental care based on risk assessment' below.)

Neuroimaging — Advances in the development and utilization of cranial ultrasound and magnetic resonance imaging (MRI) have enhanced detection of brain injury in preterm infants and improved the understanding of the links between brain injury and neurodevelopmental outcomes. In particular, neuroimaging is able to identify preterm infants with significant brain injury, who are at-risk for neurodevelopmental impairment. However, data correlating with clinical outcome remain inadequate to use these modalities as the sole accurate predictor of long-term neurodevelopmental outcome for individuals.

Ultrasonography — Cranial ultrasonography is the primary neuroimaging modality used to evaluate intracranial pathology in preterm infants and predict long-term outcome. It can reliably detect germinal matrix IVH, and periventricular leukomalacia. Abnormal ultrasound findings associated with an increased risk of cognitive delay and/or psychomotor delay include moderate/severe ventriculomegaly, echolucency and echodensity, severe IVH (≥grade III), and periventricular hemorrhage [1,2] (see "Periventricular leukomalacia", section on 'Prognosis' and "Management and complications of intraventricular hemorrhage in the newborn"). Although patients with neonatal cranial ultrasound abnormalities compared with those with normal studies are more likely to have long-term neurodevelopmental outcome impairment, a significant number of patients with a normal ultrasound may still have cognitive and psychomotor delay.

This was illustrated in a prospective study of 1017 extremely preterm infants with a GA <28 weeks that reported cognitive delay in 23 percent of those with normal neonatal ultrasounds and psychomotor delay in 26 percent with a normal study [1]. In this study, testing was performed at 24 months of corrected age using the 2nd edition of the Bayley Scales of Infant Development.

It also remains uncertain whether low-grade (grade I or II) periventricular hemorrhage detected by cranial ultrasonography has an impact on the outcomes of extremely low GA infants due to conflicting data. A National Institute of Child Health and Human Development (NICHD) multicenter longitudinal observation study of infants born less than 27 weeks failed to demonstrate any significant neurodevelopmental impact of low-grade periventricular hemorrhage [3]. In addition, two population-based studies found no significant differences in cognitive or educational outcomes for infants with low-grade hemorrhage compared with those with normal ultrasound scans [4,5]. However, both studies suggested an increased risk of cerebral palsy (CP) associated with grade II periventricular hemorrhage. In contrast, a single-center retrospective study reported individuals with isolated grade I and II IVH were at increased risk for neurodevelopmental impairment and cognitive/language impairment at 20 months corrected age [6].

Ultrasonography is not as sensitive as MRI in detecting diffuse white matter abnormalities or cerebellar abnormalities in the posterior fossa, particularly during the first month of life [7]. However, extremely preterm infants with normal ultrasounds at term equivalent are unlikely to have moderate or severe white matter or gray matter abnormalities on MRI performed at term age equivalent [8]. Ultrasound is considerably less expensive and more readily available for neuroimaging in preterm infants than MRI. As a result, it is the most commonly used neuroimaging modality for the detection of brain injury. But, as noted above, the lack of sensitivity in detecting all patients with ultrasound must be taken into account.

Magnetic resonance imaging (MRI)

MRI at term gestation — The lack of sufficient precise MRI data limits the clinical usefulness of MRI at term gestation to accurately predict long-term neurodevelopmental outcome for the individual survivor. In addition, neonatal MRI is a costly and challenging procedure. As a result, we do NOT perform routine MRI to predict neurodevelopmental outcome for all former preterm infants [9,10] (see 'Our approach' below). However, there are other centers that perform routine MRI at term for all preterm survivors.

Neonatal MRI studies have shown that the majority of very preterm infants have white matter abnormalities, which include increasing ventricular size, decreasing white matter volume, increasing intensity of white matter signal, and evidence of decreasing myelination [11-13]. In addition, there is evidence that these findings are useful in predicting long-term neurodevelopmental outcome based on studies that have shown correlation between neurodevelopmental outcome and either normal or seriously abnormal MRI scans at term equivalent [11-17]. However, only using MRI data is insufficient to predict neurodevelopmental outcome for individual patients.

The limitation of MRI alone to accurately predict neurodevelopmental outcome was illustrated by the following:

●In one study of 167 preterm infants (GA ≤30 weeks) who had MRI performed at the equivalent of term gestation and underwent a comprehensive neurodevelopmental assessment at two years of corrected age, moderate to severe white matter abnormalities on MRI were predictive of severe motor delay and CP at two years of age [11]. However, 7 of 47 patients (15 percent) with no white matter abnormality had severe impairment and almost half of the 35 patients with moderate to severe abnormalities did not have any evidence of severe impairment.

 

In a subsequent report of 104 of the original cohort evaluated at four and six years of age, children with any white matter abnormality were more likely to have neurodevelopmental impairment, and those with moderate to severe abnormalities were at risk for the greatest degree of cognitive impairment [14]. However, similar to the findings at two years of age, there were a few children without white matter abnormalities who had poor neurocognitive outcome, and several children who had moderate to severe white matter abnormalities without impairment.

 

●In an NICHD study of 480 extremely preterm infants (GA <28 weeks), MRI obtained between 35 and 42 weeks postmenstrual age demonstrated increasing severity of white matter abnormalities and significant cerebellar lesions were independently associated with adverse outcome (death or neurodevelopmental impairment) at 18 to 22 months corrected age [12]. However, 4 of 98 infants (4 percent)without any white matter abnormality had neurodevelopmental impairment, while 3 of 18 infants with severe MRI abnormalities were unimpaired or mildly impaired.

 

These results demonstrate that abnormal MRI scans are predictive of poor neurodevelopmental outcome for a general cohort of patients. However, they also show MRI findings are inadequate to predict outcome for the individual infant because they are not precise enough for accurate prognostication in the clinical setting.

The cost and challenge of performing MRI in infants also limit the routine use of MRI. Infants need to be transported to the MRI suite and sedation is often required to minimize motion artifact, requiring personnel with expertise in neonatal transport and sedation. Accurate neonatal MRI readings require expertise by knowledgeable pediatric neuroradiologists. In particular, the ability to detect mild and moderate degrees of injury on MRI may need sophisticated scanning sequences as well as proficiency in the analysis of results. In the previously discussed NICHD study, MRI only marginally improved the information that was obtained by a combination of early (4 to 14 days of life) and late (term equivalent) cranial ultrasounds [12].

MRI during childhood, adolescence, and adulthood — Subsequent structural brain changes documented in former preterm infants at school age, adolescence and adulthood include the following [18-27].

●Thinning of the corpus callosum

●Increased ventricular volume

●Decreased relative volume of gray and white matter during brain growth throughout childhood and adolescence

●Decreased total brain volume

 

Our approach — We do NOT routinely obtain MRI for all preterm infants because it is inadequate to accurately predict long-term outcome for the individual patient and it is a costly procedure [10]. As noted above, there are other centers in which MRI is performed at term gestation in all preterm survivors.

In our practice, imaging is performed at term gestation equivalent ONLY for infants in the following clinical settings by an experienced and knowledgeable pediatric neuroradiology team:

●Follow-up of abnormal cranial ultrasound results (eg, severe periventricular hemorrhage, periventricular leukomalacia, and hydrocephalus) [28]

●Abnormal neurologic examination

●Suspected congenital or metabolic defect

 

However, the use of neuroimaging alone is insufficient to determine long-term outcome and follow-up intervention for individual patients [10]. Clinicians need to remember that MRI results should be integrated with clinical information (physical examination findings, presence of other risk factors [eg, associated conditions such as bronchopulmonary dysplasia], and neurocognitive testing) to assess the risk for developmental delay for each individual patient. At the present time, in our practice these data (although still suboptimal) are used to guide management regarding the intensity and duration of follow-up and the need for early intervention. (See 'Approach for follow-up care' below.)

Timing of clinical assessment — Neurodevelopmental outcome is assessed more accurately at school age than in early childhood because over time there is cognitive recovery as the brain continues to develop. Prediction of school age outcome improves as the age at the time of assessment increases. However, early assessment can identify preterm infants who have severe impairment that does not resolve by school age and who can benefit from early intervention.

This was illustrated in a 10-year prospective study of 129 extremely low birth weight (ELBW, birth [BW] weight ≤1000 g) infants born between 1993 and 1998 who were evaluated at the equivalent of term gestation, and at 3, 6, 12, and 18 months corrected age, with follow-up evaluation between 5 and 10 years of age (mean 8.5 years) [29]. Assessment included neurologic examination, language and social development, behavior, and psychometric testing. The percentages of cases in which the neurodevelopmental status at school age was correctly predicted, were 49, 68, and 70 percent when the assessment was performed "at term," and at two and four years of age, respectively. In contrast, patients with CP were accurately identified by two years of age.

Similarly, a prospective study of 296 premature infants (BW between 600 and 1250 g), who were serially evaluated at 36, 54, 72, and 96 months corrected age, showed improvement in verbal and IQ test scores over time [30].

Despite these concerns, early assessment can identify former preterm infants who have severe impairment that does not resolve by school age and who can benefit from early intervention. For example, in the EPICure study from Great Britain and Ireland of 308 former extremely preterm infants born in 1995, individuals with severe disability at 30 months of age continued to have moderate to severe disability at six years of age [31]. In another study from Australia, adverse cognitive and academic outcomes persisted in adolescents born <28 weeks gestation, particularly those with neonatal IVH and postnatal corticosteroid therapy [32]. In this cohort, biological factors associated with poor neurodevelopmental outcome were equal to or exceeded those of social factors. (See "Long-term neurodevelopmental outcome of preterm infants: Epidemiology and risk factors", section on 'Prevalence and severity'.)

APPROACH FOR FOLLOW-UP CARE — At discharge, the overall goals of follow-up care for the neonatal intensive care unit (NICU) survivor and his/her family are to effectively manage long-term sequelae of preterm birth, facilitate optimal growth and development of the child, integrate the child into the family, school system, and targeted community services, and communicate effectively with the primary care provider. Because of the need to provide optimal care to the infants discharged from the NICU, which are primarily preterm infants, the American Academy of Pediatrics (AAP) has developed guidelines for the primary care provider in the management of these patients [33]. These guidelines include recommendations for screening, evaluation, and referral for hearing and vision loss, and neurodevelopmental disorders. (See "Discharge planning for high-risk newborns" and "Care of the neonatal intensive care unit graduate".)

Follow-up neurodevelopmental care based on risk assessment — As noted above, the ability to predict neurodevelopmental outcome for an individual patient is limited by the lack of precise clinical tools. As a result, ongoing evaluation through school age is often needed to detect neurodevelopmental deficits, particularly subtle behavioral and functional impairment that are not evident during the first years of life. Yet, the cost and effort to provide comprehensive follow-up care and the anxiety that this may provoke in parents may not be warranted in all preterm survivors.

Our approach for follow-up care is initially broad and focused on identifying all at-risk infants at discharge as they transition to the home environment. The need and degree of neurodevelopmental follow-up and intervention for individual patients are modified based on additional information gathered over the first few years of life.

Based on the available evidence, our approach centers on the probability of neurodevelopmental impairment that increases in the following clinical settings:

●Infants with a gestational age (GA) less than 30 weeks as the risk of neurodevelopmental delay increases with decreasing GA

 

●Presence of congenital anomalies

 

●Presence of perinatal complications including severe asphyxia, intrauterine growth retardation, meningitis, seizures, respiratory failure requiring intubation and mechanical ventilation, and neuroimaging findings of severe intracranial hemorrhage, periventricular leukomalacia/infarction, or other evidence of white matter abnormality (see 'Neuroimaging' above)

 

Results from one case series suggest that this multivariate approach (risk factor assessment and magnetic resonance imaging [MRI] evidence of white matter injury) may be helpful in identifying cognitive and behavioral problems in children born very preterm [34].

Initial outpatient visit — The initial follow-up visit with the primary care provider should occur within a few days to a week after neonatal discharge depending on the infant's GA and clinical status. (See "Care of the neonatal intensive care unit graduate", section on 'Initial visit'.)

This visit should evaluate the adaptation to the home environment and troubleshoot any medical concerns. There should be specific assessment of the infant's feeding behavior, frequency, and volume; safe sleep positioning; and medication dosing and administration practices. The parents understanding of the home feeding plan including the way to increasing the calories of the breast milk (if needed) and/or mixing the formula. In addition, the physical examination should include assessment of the infant's head control, muscle tone, level of alertness and activity, and presence of asymmetric neurologic findings. (See "Care of the neonatal intensive care unit graduate", section on 'Outpatient management' and "Neurologic examination of the newborn".)

For any patient with any suspected developmental delay, a prompt referral for comprehensive evaluation to a pediatric neurologist and/or developmentalist and early intervention is warranted.

Infants ≥30 weeks gestation without additional risk factors — For infants with a GA ≥30 weeks and who have no other risk factors for poor neurodevelopmental outcome, we suggest routine follow-up with their primary care provider as this group of infants are at low risk for developing significant neurodevelopmental delay requiring early intervention. For these patients, the Ages and Stages Screening Tool is an appropriate tool to screen for developmental delay. However, primary care providers should be aware these former preterm infants including late preterm infants still are at greater risk for long-term neurodevelopment impairment than those born at term and be alert to any sign or symptom of delay or neurologic abnormality. (See "Long-term neurodevelopmental outcome of preterm infants: Epidemiology and risk factors", section on 'Very preterm infant' and "Long-term neurodevelopmental outcome of preterm infants: Epidemiology and risk factors", section on 'Moderate to late preterm infants' and "Developmental and behavioral screening tests in primary care", section on 'Developmental screening tests'.)

Children who fail a screening test or in whom there is a concern of delay or neurologic abnormality should be promptly referred for additional developmental assessment and evaluation. (See "Developmental-behavioral surveillance and screening in primary care", section on 'Failed screening test'.)

Infants <30 weeks gestation and/or with risk factors — Ideally, care for at-risk infants (based on a GA <30 weeks, prolonged complicated NICU course, and/or risk factors) should be shared by the primary care provider and a high-risk neonatal follow-up program consisting of a multidisciplinary team with expertise in the care of ongoing medical problems (administration of multiple medications, severe chronic lung disease, and poor growth) and neurodevelopmental and nutritional/feeding follow-up assessment. These newborn follow-up programs are also a readily available resource when concerns are identified during primary care visits. (See "Care of the neonatal intensive care unit graduate", section on 'Outpatient management' and "Long-term neurodevelopmental outcome of preterm infants: Epidemiology and risk factors", section on 'Neurodevelopmental disability and academic achievement' and "Long-term neurodevelopmental outcome of preterm infants: Epidemiology and risk factors", section on 'Associated conditions'.)

We suggest the following components be added to complement the ongoing routine care provided by the primary provider:

●Neurologic assessment for motor deficits including cerebral palsy (CP)

●Vision assessment

●Hearing assessment

●Cognitive and motor assessment

●Early intervention program based on needs of the individual patient

 

In our center, follow-up visits to a neonatal follow-up clinical program are scheduled as follows:

●Four months of corrected age – Assess growth and nutritional needs and detect severe neurologic abnormalities that may require intervention (occupational or physical therapy)

 

●Eight to 12 months of corrected age – Evaluate for early signs suggestive of CP or other neurologic abnormalities including hearing and vision problems and initial cognitive and developmental assessment

 

●Eighteen to 24 months of corrected age – Ongoing assessment of cognitive and language assessment, and confirmation of persistent neurologic deficits including CP with a complete neurologic examination

 

●Additional follow-up is dependent on the needs of the child based on previous assessment and include further cognitive testing, and academic achievement standardized testing in mathematics, reading, and spelling starting at school age, and neurophysiologic evaluation (attention, executive function, memory, and fine and gross motor function)

 

Neurologic assessment — Neurologic assessment during the first year of life focuses on changes in muscle tone [35]. Normally, there is a progressive increase in active muscle tone (eg, head control and back support) and a concomitant decrease in passive tone. However, early transient muscle tone abnormalities are common, ranging from 40 to 80 percent of preterm infants. These include hypotonia with poor back support or hypertonia with slightly increased tone in the upper extremities. Nevertheless, abnormal tone at four months corrected age, especially hypertonia, is an indicator of poor prognosis. By eight months corrected age, head growth, which is strongly related to neurodevelopmental outcome, should have been achieved. In addition, evaluation of infants in the sitting position may identify children with lower extremity hypertonia at risk for later CP as they often will fall backward when placed to sitting. (See "Clinical features and classification of cerebral palsy", section on 'Early signs of CP'.)

Cerebral palsy — CP is a heterogeneous group of clinical syndromes that are characterized by abnormal muscle tone, posture, and movement. The prevalence of CP is greatest in very preterm infants with a GA <32 weeks with reported CP risk 40 to 80 times greater in very preterm infants compared with individuals who were born at term. (See "Epidemiology, etiology, and prevention of cerebral palsy", section on 'Prevalence' and "Epidemiology, etiology, and prevention of cerebral palsy", section on 'Prematurity'.)

Clinicians should monitor very preterm infants during office visits for early neurologic signs of CP such as initial hypotonia, spasticity, abnormal postural reflexes, increased tone, and deep tendon reflexes. Patients demonstrating any of these findings should be referred for evaluation by a pediatric neurologist. Patients who have CP will require further evaluation and care from a multidisciplinary team including neurologists and physical and occupational therapists. Children with the diagnosis of CP should also undergo functional assessments to determine the degree of impairment. (See "Clinical features and classification of cerebral palsy" and "Epidemiology, etiology, and prevention of cerebral palsy" and "Management and prognosis of cerebral palsy".)

Hearing — NICU graduates should be screened for hearing loss prior to discharge. Hearing screen should be repeated at five to six months corrected age or sooner if there are concerns about hearing impairment. If an abnormal hearing screen is present, formal audiologic assessment should be performed. If the patient has sensorineural hearing loss, referral to a multidisciplinary team (audiologists, otolaryngologists, and speech pathologists) for management of the patient is recommended. (See "Screening tests in children and adolescents", section on 'Hearing screen' and "Hearing impairment in children: Treatment".)

Vision — Very preterm infants are at increased risk for retinopathy of prematurity (ROP). Retinal screening by an ophthalmologist should be performed in all very preterm with a GA less than 30 weeks, and in more mature premature infants whose clinical course places them at increased risk (eg, treatment with supplemental oxygen). The initial screen is performed at four to six weeks after birth with additional examinations at intervals of one to three weeks until the retinal vessels have fully matured. (See "Retinopathy of prematurity", section on 'Screening'.)

Former preterm infants are at risk for other ophthalmologic abnormalities including reduced visual acuity, strabismus, myopia, and astigmatism, and should be screened by an ophthalmologist at 9 to 12 months of corrected age. A later assessment of visual acuity prior to the start of school is also indicated as the emergence of myopia may occur at this time. (See "Care of the neonatal intensive care unit graduate", section on 'Vision' and "Care of the neonatal intensive care unit graduate", section on 'Ophthalmologic conditions'.)

Cognitive and motor assessment — Screening for cognitive and motor impairment is imperative to identify infants who would benefit from early intervention programs (EIPs) and special educational school programs. This should include screening for neurodevelopment problems that occur more frequently in infants of extreme prematurity (GA <28 weeks), such as CP and cognitive and learning delay. Preterm infants are also at risk for difficulties with complex language function [36]. (See "Long-term neurodevelopmental outcome of preterm infants: Epidemiology and risk factors", section on 'Extremely preterm infant'.)

In our practice, the first developmental assessment is typically performed at eight months corrected age using the Bayley Scales of Infant Development. The Bayley Scales were developed for children 1 to 42 months of age and include evaluations of cognition, language, motor, and social-emotional and adaptive behavior. These scales yield developmental indices with a mean of 100. In the first year of life, motor skills are heavily weighted; however, by the second year, cognition, language, and behavior may be better assessed. Formal developmental assessment using the Bayley Scales is repeated at 18 to 24 months corrected age along with a neurologic examination.

Early intervention programs — Early intervention programs (EIPs) appear to be effective at improving cognitive development in preterm infants. This was illustrated in a systematic review of identified randomized or quasi-randomized trials that found EIPs improved cognitive outcome of children born preterm when evaluated during infancy or at preschool age but not at school age [37]. There is also evidence that early enrichment programs may improve the outcome of high-risk preterm children, especially those from socioeconomically deprived groups [38].

United States — In the United States, the Individuals with Disabilities Education Act (IDEA), a federal law, mandates early intervention for eligible patients between birth and three years of age. The individual states are responsible for the delivery of EIPs and the primary care provider needs to be familiar with the state regulations of his/her community.

Each state is required to identify and evaluate patients at risk or who currently demonstrate developmental delays or disabilities. In most states, patients discharged from NICU meet the eligibility criteria for diagnostic evaluation, which consists of a multidisciplinary set of assessments (eg, medical, nutritional, speech/language, hearing, vision, development, and family). However, eligibility for EIPs differs from state to state and not all NICU graduates will qualify in some states. Unfortunately, many children undergo their initial assessment for early intervention and are found to have a normal neurologic exam and are thus discharged from EIPs. It is important to evaluate children at subsequent time points for the emergence of possible developmental delay.

SUMMARY AND RECOMMENDATIONS

●Preterm infants are at increased risk for impaired neurodevelopmental outcome compared with individuals born full term. These sequelae include cognitive abnormalities, motor deficits including mild fine or gross motor delay, cerebral palsy (CP), and vision and hearing losses. The risk of impairment increases with decreasing gestational age (GA). (See "Long-term neurodevelopmental outcome of preterm infants: Epidemiology and risk factors", section on 'Neurodevelopmental disability and academic achievement'.)

 

●The overall management goal is to identify all former preterm infants at risk for subsequent long-term neurodevelopmental disability and who would benefit from early intervention programs (EIPs). However, this is particularly challenging as available screening tools are not precise enough for accurate prediction of neurodevelopmental outcome for individual patients. In addition, the expense and skilled personnel needed to provide comprehensive follow-up care and the anxiety that this may provoke in parents may not be warranted in all preterm infants. (See 'Challenges in predicting outcome' above and'Approach for follow-up care' above.)

 

•Although neuroimaging (cranial ultrasonography and magnetic resonance imaging [MRI]) can identify infants with significant brain injury who are at risk for neurodevelopmental impairment, data correlating with clinical outcome remain inadequate to use these modalities as the sole accurate predictor of long-term neurodevelopmental outcome for individuals. If neuroimaging is performed to assist in long-term neurodevelopmental prediction, we suggest that MRI be performed at term gestation. In our center, MRI is performed to follow-up on patients with abnormal cranial ultrasound results and those with an abnormal neurologic examination, or with congenital or metabolic defect(s). (See 'Neuroimaging' above.)

 

•Neurodevelopmental outcome is assessed more accurately at school age than in early childhood. Although over time, there is cognitive recovery as the brain continues to develop, early assessment can identify preterm infants who have severe impairment that does not resolve by school age and who can benefit from early intervention. (See 'Timing of clinical assessment' above.)

 

●Because of the limitations of available reliable tools for prediction, our approach for follow-up care is initially broad and focused on identifying and following at-risk infants at discharge. The need and degree of neurodevelopmental follow-up and intervention for individual patients are modified based on additional information. (See 'Approach for follow-up care' above.)

 

•For preterm infants with a GA ≥30 weeks and who have no other risk factors for poor neurodevelopmental outcome, routine follow-up with their primary care provider is suggested. This group of infants is at low risk for developing significant neurodevelopmental delay requiring early intervention. At these visits, patients should be screened for developmental delay. Children who fail a screening test or in whom there is a concern of delay or neurologic abnormality should be promptly referred for additional developmental assessment and evaluation. (See 'Infants ≥30 weeks gestation without additional risk factors' above.)

 

•For preterm infants with a GA <30 weeks and/or have other risk factors for poor neurodevelopmental outcome (eg, congenital anomalies or complicated neonatal course), optimal follow-up care is shared by the primary care provider and a high-risk neonatal follow-up program. Follow-up visits in our neonatal program are scheduled through the first two years of life and complement the ongoing primary care visits by providing comprehensive neurologic, hearing, vision, and cognitive and motor assessment, and referral to EIPs, if needed. Further follow-up beyond two years of age is arranged on the individual needs of the child. (See 'Infants <30 weeks gestation and/or with risk factors' above.)

 

ACKNOWLEDGMENT — The editorial staff at UpToDate would like to acknowledge Yvette Johnson, MD, MPH, who contributed to an earlier version of this topic review.

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