Care of the neonatal intensive care unit graduate
- Jane Stewart, MD
Jane Stewart, MD
- Assistant Professor of Pediatrics
- Harvard Medical School
Advances in neonatal intensive care have improved the survival of high-risk preterm and critically ill term infants (see "Incidence and mortality of the preterm infant", section on 'Trends over time'). Infants who are discharged from the neonatal intensive care unit (NICU) require continued comprehensive clinical care, which is provided by the primary care provider clinician.
This topic will review the care of the infant provided by primary care clinician who is discharged from the NICU. The discussion focuses on preterm infants who represent the majority of NICU graduates. Criteria for discharge and planning for discharge are presented separately. (See "Discharge planning for high-risk newborns".)
ROLE OF THE PRIMARY CARE PROVIDER
The primary care provider plays a key role in providing optimal continuity of treatment for NICU graduates by coordinating transition of care from the neonatologist, delivering direct medical care, and facilitating ongoing care for specific medical conditions of the infant by subspecialists and other health professionals [1-3].
To help facilitate and optimize the quality of care for these infants, the American Academy of Pediatrics (AAP) has developed guidelines for the primary care provider in the management of these high-risk infants . We concur with these guidelines that highlight the shared responsibility of the care of the infant between the primary care provider and the neonatologist, the need for effective communication with the family and other professionals involved in the care of the infant, the importance of continuity of care at the time of discharge from the NICU, and the role of the primary care clinician to provide direct care for these infants. The primary care clinician:
●Communicates with the neonatologist and family during the NICU course of the infant; especially important when the infant is getting close to being ready for discharge to home or transfer to a Level 2 facility. Ongoing communication facilitates the transfer of medical information (patient's medical history, medications, and technologic needs); allows collaborative arrangements for follow-up with primary, subspecialty, and neurodevelopmental care; and determines the appropriate timing of transfer. For the family, contact with both the neonatologist and primary care provider decreases confusion, anxiety and uncertainty regarding transfer of care. (See "Discharge planning for high-risk newborns".)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Verma RP, Sridhar S, Spitzer AR. Continuing care of NICU graduates. Clin Pediatr (Phila) 2003; 42:299.
- American Academy of Pediatrics Committee on Fetus and Newborn. Hospital discharge of the high-risk neonate. Pediatrics 2008; 122:1119.
- Kuo DZ, Lyle RE, Casey PH, Stille CJ. Care System Redesign for Preterm Children After Discharge From the NICU. Pediatrics 2017.
- The role of the primary care pediatrician in the management of high-risk newborn infants. American Academy of Pediatrics. Committee on Practice and Ambulatory Medicine and Committee on Fetus and Newborn. Pediatrics 1996; 98:786.
- Berger SP, Holt-Turner I, Cupoli JM, et al. Caring for the graduate from the neonatal intensive care unit. At home, in the office, and in the community. Pediatr Clin North Am 1998; 45:701.
- McCourt MF, Griffin CM. Comprehensive primary care follow-up for premature infants. J Pediatr Health Care 2000; 14:270.
- Belfort MB, Rifas-Shiman SL, Sullivan T, et al. Infant growth before and after term: effects on neurodevelopment in preterm infants. Pediatrics 2011; 128:e899.
- Samara M, Johnson S, Lamberts K, et al. Eating problems at age 6 years in a whole population sample of extremely preterm children. Dev Med Child Neurol 2010; 52:e16.
- Slack MH, Cade S, Schapira D, et al. DT5aP-Hib-IPV and MCC vaccines: preterm infants' response to accelerated immunisation. Arch Dis Child 2005; 90:338.
- Kirmani KI, Lofthus G, Pichichero ME, et al. Seven-year follow-up of vaccine response in extremely premature infants. Pediatrics 2002; 109:498.
- D'Angio CT, Maniscalco WM, Pichichero ME. Immunologic response of extremely premature infants to tetanus, Haemophilus influenzae, and polio immunizations. Pediatrics 1995; 96:18.
- Black S, Shinefield H, Fireman B, et al. Efficacy, safety and immunogenicity of heptavalent pneumococcal conjugate vaccine in children. Northern California Kaiser Permanente Vaccine Study Center Group. Pediatr Infect Dis J 2000; 19:187.
- Omeñaca F, Garcia-Sicilia J, Boceta R, et al. Antibody persistence and booster vaccination during the second and fifth years of life in a cohort of children who were born prematurely. Pediatr Infect Dis J 2007; 26:824.
- Rückinger S, van der Linden M, von Kries R. Effect of heptavalent pneumococcal conjugate vaccination on invasive pneumococcal disease in preterm born infants. BMC Infect Dis 2010; 10:12.
- D'Angio CT, Heyne RJ, O'Shea TM, et al. Heptavalent pneumococcal conjugate vaccine immunogenicity in very-low-birth-weight, premature infants. Pediatr Infect Dis J 2010; 29:600.
- Bonhoeffer J, Siegrist CA, Heath PT. Immunisation of premature infants. Arch Dis Child 2006; 91:929.
- Saari TN, American Academy of Pediatrics Committee on Infectious Diseases. Immunization of preterm and low birth weight infants. American Academy of Pediatrics Committee on Infectious Diseases. Pediatrics 2003; 112:193.
- Drotar D, Hack M, Taylor G, et al. The impact of extremely low birth weight on the families of school-aged children. Pediatrics 2006; 117:2006.
- Silverstein M, Feinberg E, Young R, Sauder S. Maternal depression, perceptions of children's social aptitude and reported activity restriction among former very low birthweight infants. Arch Dis Child 2010; 95:521.
- McCormick MC, Shapiro S, Starfield B. Factors associated with maternal opinion of infant development--clues to the vulnerable child? Pediatrics 1982; 69:537.
- McGrath-Morrow SA, Lee G, Stewart BH, et al. Day care increases the risk of respiratory morbidity in chronic lung disease of prematurity. Pediatrics 2010; 126:632.
- McCormick J, Tubman R. Readmission with respiratory syncytial virus (RSV) infection among graduates from a neonatal intensive care unit. Pediatr Pulmonol 2002; 34:262.
- Nachman SA, Navaie-Waliser M, Qureshi MZ. Rehospitalization with respiratory syncytial virus after neonatal intensive care unit discharge: A 3-year follow-up. Pediatrics 1997; 100:E8.
- Holmström G, el Azazi M, Kugelberg U. Ophthalmological follow up of preterm infants: a population based, prospective study of visual acuity and strabismus. Br J Ophthalmol 1999; 83:143.
- Hebbandi SB, Bowen JR, Hipwell GC, et al. Ocular sequelae in extremely premature infants at 5 years of age. J Paediatr Child Health 1997; 33:339.
- Quinn GE, Dobson V, Kivlin J, et al. Prevalence of myopia between 3 months and 5 1/2 years in preterm infants with and without retinopathy of prematurity. Cryotherapy for Retinopathy of Prematurity Cooperative Group. Ophthalmology 1998; 105:1292.
- Knight-Nanan DM, O'Keefe M. Refractive outcome in eyes with retinopathy of prematurity treated with cryotherapy or diode laser: 3 year follow up. Br J Ophthalmol 1996; 80:998.
- Repka MX, Summers CG, Palmer EA, et al. The incidence of ophthalmologic interventions in children with birth weights less than 1251 grams. Results through 5 1/2 years. Cryotherapy for Retinopathy of Prematurity Cooperative Group. Ophthalmology 1998; 105:1621.
- Bhutani VK, Abbasi S. Long-term pulmonary consequences in survivors with bronchopulmonary dysplasia. Clin Perinatol 1992; 19:649.
- Harper RG, Garcia A, Sia C. Inguinal hernia: a common problem of premature infants weighing 1,000 grams or less at birth. Pediatrics 1975; 56:112.
- Peevy KJ, Speed FA, Hoff CJ. Epidemiology of inguinal hernia in preterm neonates. Pediatrics 1986; 77:246.
- Powell TG, Hallows JA, Cooke RW, Pharoah PO. Why do so many small infants develop an inguinal hernia? Arch Dis Child 1986; 61:991.
- Rajput A, Gauderer MW, Hack M. Inguinal hernias in very low birth weight infants: incidence and timing of repair. J Pediatr Surg 1992; 27:1322.
- Creighton PR. Common pediatric dental problems. Pediatr Clin North Am 1998; 45:1579.
- Eastman DL. Dental outcomes of preterm infants. Newborn and Infant Nursing Reviews 2003; 3:93.
- Gray JE, McCormick MC, Richardson DK, Ringer S. Normal birth weight intensive care unit survivors: outcome assessment. Pediatrics 1996; 97:832.
- Hack M, Taylor HG, Drotar D, et al. Chronic conditions, functional limitations, and special health care needs of school-aged children born with extremely low-birth-weight in the 1990s. JAMA 2005; 294:318.
- Escobar GJ, McCormick MC, Zupancic JA, et al. Unstudied infants: outcomes of moderately premature infants in the neonatal intensive care unit. Arch Dis Child Fetal Neonatal Ed 2006; 91:F238.
- Underwood MA, Danielsen B, Gilbert WM. Cost, causes and rates of rehospitalization of preterm infants. J Perinatol 2007; 27:614.
- Houweling LM, Bezemer ID, Penning-van Beest FJ, et al. First year of life medication use and hospital admission rates: premature compared with term infants. J Pediatr 2013; 163:61.
- Kato T, Yorifuji T, Inoue S, et al. Associations of preterm births with child health and development: Japanese population-based study. J Pediatr 2013; 163:1578.
- Paranjothy S, Dunstan F, Watkins WJ, et al. Gestational age, birth weight, and risk of respiratory hospital admission in childhood. Pediatrics 2013; 132:e1562.
- Koivisto M, Marttila R, Saarela T, et al. Wheezing illness and re-hospitalization in the first two years of life after neonatal respiratory distress syndrome. J Pediatr 2005; 147:486.
- Ambalavanan N, Carlo WA, McDonald SA, et al. Identification of extremely premature infants at high risk of rehospitalization. Pediatrics 2011; 128:e1216.
- Korvenranta E, Lehtonen L, Peltola M, et al. Morbidities and hospital resource use during the first 3 years of life among very preterm infants. Pediatrics 2009; 124:128.
- Mourani PM, Kinsella JP, Clermont G, et al. Intensive care unit readmission during childhood after preterm birth with respiratory failure. J Pediatr 2014; 164:749.
- ROLE OF THE PRIMARY CARE PROVIDER
- INITIAL VISIT
- SUBSEQUENT VISITS
- - Administration
- - Hearing
- - Vision
- - Neurodevelopment
- Psychosocial issues and family support
- - Vulnerable child syndrome
- MEDICAL CARE OF SPECIFIC CONDITIONS
- - Bronchopulmonary dysplasia (BPD)
- Apnea of prematurity
- Sudden infant death syndrome (SIDS)
- Gastroesophageal reflux (GER)
- Ophthalmologic conditions
- - Retinopathy of prematurity
- - Other ophthalmologic conditions
- Neurodevelopmental problems
- - Post-discharge care
- - Hernias
- HOSPITAL READMISSIONS
- Other risk factors
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS