High-Risk Infant Follow-Up After NICU Discharge: Current Care Models and Future Considerations.

Preterm infants are at heightened risk for chronic health problems and developmental delays compared with term-born peers. High-risk infant follow-up programs provide surveillance and support for problems that may emerge during infancy and early childhood. Although considered standard of care, program structure, content, and timing are highly variable. Families face challenges accessing recommended follow-up services. Here, the authors review common models of high-risk infant follow-up, describe novel approaches, and outline considerations for improving the quality, value, and equity of follow-up care.

Ethical considerations in the management of infants with severe intraventricular hemorrhage.

Intrinsic and extrinsic factors unique to neonatal care can complicate predictions of neurological outcomes for infants who suffer from severe intraventricular hemorrhage. While care decisions are driven by the same bioethical principles used in other domains, neurological prognostication can challenge concepts of futility, require careful examination of parental values, uncover biases and/or potentially compromise the best interests of the future child. In the following chapter we will review bioethical principles and relevant concepts, explore challenges to decision-making surrounding diagnoses of severe intraventricular hemorrhage and conclude with a brief review of practical approaches for counseling parents about neurodevelopmental impairment given the constraints of prognostic uncertainty and assumptions related to quality of life. We will argue that neurological findings alone, even in the setting of severe intraventricular hemorrhage, often do not constitute enough evidence for redirection of care but can be permissible when the entire neonatal condition is considered.

Amplitude-integrated EEG in preterm infants: maturation of background pattern and amplitude voltage with postmenstrual age and gestational age.

OBJECTIVE: Amplitude-integrated electroencephalogram (aEEG) is a single channel EEG recorded from two parietal electrodes. The objective of this study was to test the hypothesis that aEEG maturation follows postmenstrual age (PMA) irrespective of gestational age (GA). METHODS: We recruited inborn infants with a GA <33 weeks and without evidence of neurologic anomaly. Serial aEEG recordings were assessed for: presence of continuous activity and mature sleep-wake cycling (SWC); low base voltage (V), that is, the lowest amplitude margin; high base V, that is, the most common amplitude margin; upper high V, that is, upper margin during highest activity; and span, that is, the difference between upper high and simultaneous high base V. Statistical analysis included logistic regression and repeated measures analysis of variance. RESULTS: We obtained 119 aEEG recordings in 31 preterm infants (GA 25 to 32 weeks; birth weight 600 to 1704 g, PMA 25 to 35 weeks). The frequency of mature SWC increased with PMA independent of GA, while the frequency of continuity increased with PMA and was higher in extremely preterm infants after correcting for PMA. Low base and high base V increased with PMA, while span and upper high V significantly decreased with PMA. In addition, high base V was higher in extremely preterm infants after correcting for PMA. CONCLUSIONS: In preterm infants aEEG matures predominantly with PMA. Our data suggest that some aspects of aEEG maturation are enhanced, rather than inhibited by extremely preterm birth. These data suggest that aEEG in preterm infants may need to be analyzed by comparing results with standards of similar PMA and GA.

Lack of effect of L-carnitine supplementation on weight gain in very preterm infants.

OBJECTIVE: Carnitine transfer across the placenta occurs predominantly during the third trimester. Unless L-carnitine is provided, very preterm infants develop carnitine deficiency. Although breast milk and infant formulas contain L-carnitine, parenteral nutrition solutions do not routinely provide L-carnitine. We hypothesized that prolonged L-carnitine supplementation in very preterm infants would improve weight gain and shorten length of stay in the hospital. STUDY DESIGN: The study was a double-blind parallel placebo-controlled randomized clinical trial. Eligible patients were <29 weeks of gestation, <72 hours of age, and did not have a potentially life-threatening congenital malformation or hereditary metabolic disorder. Patients were stratified by gestational age (23 to 25(6/7) and 26 to 28(6/7) weeks), and randomized to receive, either L-carnitine at a dose of 50 mumol/kg/day, or placebo. Carnitine was provided intravenously until the infants tolerated 16 ml/day of feeds. The sample size was calculated to have 80% power to detect a 10% increase in weight gain from birth until 36 weeks of postmenstrual age or discharge from the hospital. Secondary outcome variables included food efficiency (defined as weight gain divided by caloric intake), weight gain at 4 weeks of age, time to regain birth weight and length of stay. RESULTS: Among the 63 infants enrolled in the trial, 32 were randomized to L-carnitine and 31 to placebo. L-Carnitine supplementation did not significantly affect average daily weight gain from birth until 36 weeks or hospital discharge, or any of the secondary outcome variables. CONCLUSION: Prolonged supplementation of L-carnitine did not improve long-term weight gain in very preterm infants.

Care at the edge of viability: medical and ethical issues.

Decision-making for extremely immature preterm infants at the margins of viability is ethically, professionally, and emotionally complicated. A standard for prenatal consultation should be developed incorporating assessment of parental decision-making preferences and styles, a communication process involving a reciprocal exchange of information, and effective strategies for decisional deliberation, guided by and consistent with parental moral framework. Professional caregivers providing perinatal consultations or end-of-life counseling for extremely preterm infants should be sensitive to these issues and be taught flexibility in counseling techniques adhering to consistent guidelines. Emphasis must shift away from physician beliefs and behaviors about the boundaries of viability.