Primary Care for PretermInfants & ChildrenA CPQCC Provider Toolkit May 2020

Primary Care for Preterm Infants& ChildrenA CPQCC Provider ToolkitJanice Lowe, MDJadene Wong, MDSuggested citation:Lowe J, Wong J. 2020. Primary Care for Preterm Infants & Children: A CPQCC Provider Toolkit.Stanford, CA: California Perinatal Quality Care Collaborative.Copyright information: 2020 California Perinatal Quality Care Collaborative.The material in this toolkit may be freely reproduced and disseminated for informational,educational, and non-commercial purposes only.For correspondence:Jadene Wong, MDStanford University School of Medicine1265 Welch Road, MS #5415Stanford, CA 94305Phone: (650) 725-6108Fax: (650) 721-5751Email: [email protected]:


AcknowledgementsAuthorsJanice A. Lowe, MD, is Clinical Professor of Pediatrics at the Stanford University School of Medicine. She trained in developmentaland behavioral pediatrics and practiced in primary care community settings for more than 20 years. Dr. Lowe is on the faculty ofthe High Risk Infant Follow-Up Program in the Division of Developmental-Behavioral Pediatrics, Department of Pediatrics at LucilePackard Children’s Hospital Stanford.Jadene Wong, MD, is Clinical Assistant Professor of Pediatrics at the Stanford University School of Medicine. She has practicedin primary care community settings for more than 20 years. Dr. Wong has practiced as a neonatal hospitalist on the faculty of theDivision of Neonatal and Developmental Medicine, Department of Pediatrics at Lucile Packard Children’s Hospital Stanford for morethan 10 years.Advisory GroupThe authors would like to acknowledge the following individuals for their expertise, guidance, and support.Henry Lee, MD, MSAssociate Professor of Pediatrics(Neonatal and Developmental Medicine)Stanford University School of MedicineJochen Profit, MD, MPHAssociate Professor of Pediatrics(Neonatal and Developmental Medicine)Stanford University School of MedicineChief Medical Officer of CPQCCStanford, CaliforniaChief Quality Officer of CPQCCStanford, CaliforniaHeidi M. Feldman, MD, PhDProfessor of Pediatrics(Developmental-Behavioral Pediatrics)Stanford University School of MedicineStanford, CaliforniaExternal ReviewersThe authors would like to acknowledge the following individuals who provided input during the toolkit development.Rachel Borovina, MDPediatricianSan Mateo Medical CenterSan Mateo, CaliforniaRonald Cohen, MDClinical Professor of Pediatrics (Neonataland Developmental Medicine)Stanford University School of MedicineStanford, CaliforniaLauraLe Dyner, MDPediatricianPalo Alto Medical FoundationLos Altos, California4Primary Care for PretermInfants & ChildrenA CPQCC Provider ToolkitOlivia Mayer, RD, CSPClinical Neonatal and Pediatric DietitianLucile Packard Children's HospitalStanfordStanford, CaliforniaHali Weiss, MDClinical Assistant Professor of Pediatrics(Developmental-Behavioral Pediatrics)Stanford University School of MedicineStanford, CaliforniaYousef Turshani, MDPediatrics Medical DirectorCounty of San MateoRedwood City, CaliforniaPaul H. Wise, MD, MPHProfessor of Pediatrics (Neonatal andDevelopmental Medicine)Stanford University School of MedicineStanford, CaliforniaAssociate Clinical Professor of PediatricsUniversity of California, San FranciscoSan Francisco, California

Executive SummaryApproximately 10% of births are preterm, and while there are regional and demographic variations, the high rate assures thatpediatric providers will see significant numbers of preterm infants and children in their practices. Primary care pediatricproviders are facing increasing time pressures as they balance providing quality clinical care, connecting with families,documenting in the electronic health record, and managing a practice. These providers need updated information readilyavailable to them as they manage primary care issues for preterm infants and children.Recommendations and guidelines for providing care for preterm infants and children come from a variety of nationalorganizations including the American Academy of Pediatrics (AAP), the Centers for Disease Control (CDC), and the AdvisoryCommittee on Immunization Practices (ACIP). The Primary Care for Preterm Infants & Children Toolkit combines many ofthe key recommendations in one easily accessible reference and helps inform pediatric providers when there are a variety ofapproaches to clinical presentations. The goal of the Toolkit is to support primary care pediatric providers as they care forpreterm infants and children.How To Use This ToolkitThe Primary Care for Preterm Infants & Children Tookit serves as an easily accessible reference for primary care providersin a clinic setting. It can be viewed online or downloaded and printed. The Tip Sheet and Periodicity Chart summarize keyinformation from the toolkit in two different two-page formats. A provider may choose to utilize either or both formats basedon personal preference and practice needs.We encourage NICUs to include guidance in their discharge summaries for primary care providers. The downloadable Tip Sheetcan be used by NICUs as a starting point for developing their own customized Tip Sheet. The document can be used to develop acustomized dot phrase or addendum to their usual discharge summary.DisclaimerThe recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medicalcare.Primary Care for PretermInfants & ChildrenA CPQCC Provider Toolkit5

IntroductionThis toolkit prepares the primary care provider with the skills andknowledge to care for preterm infants and children who are atincreased risk for morbidity, serious illness, and hospitalization.Prevalence of Preterm BirthAn estimated 15 million children are born preterm ( 37 weeks gestational age) each year worldwide, with greater than 500,000 bornannually in the United States.1 In 2018, the United States preterm birth rate was 10.02%. While this rate varies by geographic locationand ethnic groups, overall it assures that preterm children make up a significant portion of virtually every primary care practice thatprovides care for children.2In 2018, the state with the lowest preterm birth rate was Oregon at 7.8%, and the highest was Mississippi at 14.2%. Other states withhigh rates included Louisiana 13%, Alabama 12.5%, and West Virginia 11.8%. Aggregate data from 2015-2017 looking at racial/ethnicgroups showed the lowest rate of prematurity in the Asian/Pacific Islander population at 8.7%, followed by White 9%, Hispanic 9.4%,American Indian/Alaska Native 11.3%, and Black 13.6%.2Definition and RisksPreterm infants and children are often medically complex and have been shown to require increased outpatient visits andhospitalizations. The World Health Organization (WHO) defines preterm as babies born before 37 weeks gestation. Using theirterminology, an extremely preterm infant is born less than 28 weeks gestation, very preterm 28 to 32 weeks, and moderate to latepreterm 32 to 37 weeks.1Common issues for these at-risk infants are poor weight gain, infections, respiratory issues, and neurologic abnormalities. Preterminfants who are small for gestational age (SGA), less than 28 weeks gestational age, or have bronchopulmonary dysplasia (BPD),intraventricular hemorrhage (IVH) grade 3 to 4, or necrotizing enterocolitis (NEC) have been shown to have higher rates of health carevisits.3 One study found that infants born at 23 to 32 weeks gestational age had a mean of 20 outpatient visits in the first year of lifecompared to 12 outpatient visits for term infants without morbidities, with most visits occurring in the primary care setting.3 Preterminfants also have increased rates of rehospitalization during the first year of life with a 22% rehospitalization rate of infants 32 weeksGA in one study.4 In addition, increased rehospitalization rates persist through childhood and adolescence.5Primary care providers are responsible for health supervision and coordination of care for this high-risk population of preterm infantsand children. This toolkit aims to assist primary care providers in the care of these infants and children by summarizing the currentrecommendations for many of the issues that are relevant in the primary care setting.6Primary Care for PretermInfants & ChildrenA CPQCC Provider Toolkit

Primary Care for PretermInfants & ChildrenA CPQCC Provider Toolkit7

NutritionIn This SectionMonitoring Growth 8Post-Discharge Formulas 9Follow-Up After Discharge 10Reflux10Vitamin Supplementation10Monitor growth carefully, using thecorrect growth chart and adjustingfor gestational age. Always supportbreastfeeding. If needed, supplementwith post-discharge formulasspecially formulated to meet thenutritional needs of preterm infants.Do not overfeed infants who gainweight rapidly after discharge.It is crucial to monitor growth parameters in preterm infants and children,particularly in the immediate post-discharge period but also longer termthroughout childhood. Preterm infants are at high risk for growth failureand nutritional deficiencies because of multiple factors including difficultywith feeding, food tolerance, and food absorption. In addition, someinfants have increased metabolic demands due to comorbidities includingbronchopulmonary dysplasia (BPD), cardiac issues, and neurological issues.6Many infants have inadequate nutrition during their hospitalization due toillness and medical issues.7 However, there is evidence that weight gain in thepost-discharge period is associated with obesity trends and may affect longterm neurodevelopmental outcomes.8 9 Therefore, it is important to monitor foradequate growth and also to monitor for weight gain that is too rapid because ofassociation with long term morbidities.10Monitoring GrowthUse the Fenton growth chart forpreterm infants to maximum 50 weekspostmenstrual age (gestational age chronological age). Use the WHO growth8Primary Care for PretermInfants & ChildrenA CPQCC Provider Toolkit

chart from 0 to 2 years. Usethe CDC growth chart from 2to 20 years. Use corrected ageto adjust for prematurity until atleast two years of age.The first step in monitoring growth requires using ageappropriate growth parameters and growth charts. The Fentongrowth chart is most frequently used for preterm infants. It isbased on 977 preterm infants in three North American citiesand was subsequently revised and validated using data from6 developed countries.11 The Fenton growth chart does notrequire age adjustment as the chart shows gestational age, forwhich the provider uses postmenstrual age (gestational age chronological age). The Fenton growth chart can be used until50 weeks postmenstrual age.12Both the American Academy of Pediatrics (AAP) and the Centersfor Disease Control (CDC) recommend using the WHO growthchart for children 0 to 2 years of age and the CDC growth chartfor children 2 to 20 years of age. Age should be corrected forprematurity until at least two years of age. The WHO growthstandards are based on data collected between 1997-2003 on8,440 children in 6 countries (Brazil, Ghana, India, Norway, Oman,and USA). These children were predominantly breastfed for thefirst 4 months of age and continued breastfeeding to one year.Selected children were healthy and living under conditions likelyto favor achievement of full genetic growth potential.13 The CDCgrowth charts are based on data from the National Health andNutrition Examination Survey (NHANES) data of children in theUnited States.14Post-Discharge FormulasConsider using post-dischargeformulas such as EnfaCare andNeoSure in infants 1800 gramsbirth weight and selected otherhigh-risk infants.Post-discharge formulas may be used for supplementationor feeding of preterm and very low birth weight (VLBW 1500grams) infants when there is inadequate growth with breast milkalone. The post-discharge formulas that are most frequentlyused in the United States are EnfaCare and NeoSure , both 22cal/oz. The contents of these formulas vary from the formulasfor term infants in several areas including increased calories,protein, calcium, and phosphorus, which are known to berequired in higher amounts for VLBW infants.The amount and length of usage of post-discharge formulasare controversial, and recommendations vary considerablyamong geographic regions and institutions. Some studies haveshown improved growth and brain growth with the usage ofpost-discharge formulas compared with standard formulas,but studies have not shown consistent results. In addition, thereis growing evidence that breast milk provides similar growthand development to post-discharge formulas, and many do notcurrently recommend their usage if there is adequate growthwith breast milk. 15While all providers and families should be aware that specificrecommendations vary and recommendations should beadjusted for each individual infant, some options for VLBWinfants at discharge include:1.Substitute post-discharge formula for breast milk 2 to 3feedings per day2.Fortification of mother’s milk with post-discharge formulapowder to 22 or 24 calories for 2 to 3 feedings per day3.Post-discharge formula to 22 or 24 calories withfrequency determined by growth trajectory 16In addition, the question arises as to how long to continuepost-discharge formulas. Again, each individual infant should befollowed, but here are some general guidelines: BW 1800 grams: May not be necessary BW 1501-1800 grams: Up to 3 months BW 1001-1500 grams: Up to 6 months BW 751-1000 grams: Up to 9 months BW 750 grams: Up to 12 months16Primary Care for PretermInfants & ChildrenA CPQCC Provider Toolkit9

Follow-up AfterDischargeSee all infants within 48-72 hoursof discharge from the NICU.Preterm infants are at risk for growth failure after discharge,and most sources recommend a follow-up appointment within72 hours of discharge from the NICU. The nutrition goals afterdischarge are to promote breastfeeding, provide appropriatenutrients, achieve a normal rate of growth for adjusted age, andavoid overfeeding.15Some general guidelines to monitor growth are:1.Provide follow-up within 72 hours after discharge from theNICU2.Recheck every two weeks initially until stable weight gainis established3.Continue to follow closely if taking post-discharge formulato monitor for too rapid weight gain4.Use clinical judgmentRefluxReflux occurs in almost allpreterm infants. Treatment withpositioning or pharmacologicagents is usually not indicatedand may cause harm.Gastroesophageal reflux (GER) is almost universal in preterminfants and usually occurs many times per day due to transientrelaxation of the lower esophageal sphincter. Signs previouslyattributed to GER including desaturation, apnea, bradycardia,irritability, arching, perceived postprandial discomfort, feedingintolerance, or aversion have not been shown to be temporallyrelated to the occurrence of GER. In addition, medications often10Primary Care for PretermInfants & ChildrenA CPQCC Provider Toolkitused to treat reflux such as Histamine-2 (H2) receptor blockers(e.g. ranitidine, famotidine) and proton pump inhibitors (PPIs)(e.g. lansoprazole, omeprazole) have not been shown to beefficacious in reducing GER. H2 blockers may be associatedwith adverse effects including increased incidence of necrotizingenterocolitis and late-onset infections. PPI use may beassociated with gastroenteritis, pneumonia, and increased riskfor childhood fractures. 17 18In most cases, treatment with positioning or pharmacologicalagents is not indicated and may cause harm. GER is considereda normal developmental occurrence that will resolve with time.17Infants with anatomic abnormalities, recurrent pneumonia, ordifficulty with feeding may be at higher risk for pathology thatrequires intervention.19Vitamin SupplementationVITAMIN D: Supplement infantswith 400 IU of Vitamin D per day.The AAP recommends 400 IU of Vitamin D per day in infantsunder 1 year of age to optimize bone health and prevent rickets.Due to low levels of Vitamin D in breast milk, all breastfeedinginfants should be supplemented with 400 IU per day. Allformulas in the United States contain at least 400 IU of VitaminD per liter. Infants who are partially breastfed or taking less than1 liter of formula per day should also be supplemented. 20VITAMIN A: Vitamin Asupplementation is not routinelyrecommended.There has been controversy in the past as to whetherpreterm and low birth weight infants benefit from VitaminA supplementation to prevent mortality and morbidity. ACochrane study in 2016 did not find sufficient evidence torecommend routine supplementation, and there are no currentrecommendations for routine supplementation.21

IRON: Supplement all preterm infants with iron unless they havereceived blood transfusions.Most preterm infants should be supplemented with iron 2-3 mg/kg per day for the first 6 to 12 months after birth until the infant takessufficient iron-fortified formula and complementary foods to provide sufficient iron.Preterm infants are at high risk for iron deficiency anemia for several reasons including decreased iron stores at birth, the high rate ofcatch-up growth and its associated increase in blood volume, and iatrogenic depletion through blood testing during hospitalizations.Some studies have suggested that early iron deficiency in preterm infants may result in neurological abnormalities and effects onneurodevelopment. 22 23All preterm infants should have an iron intake of at least 2 mg/kg per day through 12 months of age. Recommendations includetreating with iron supplements 2-3 mg/kg/day through 6 months of age or until the infant begins eating complementary foods ortakes sufficient iron-fortified formula that supplies 2 mg/kg of iron. An exception would be infants who have received an iron loadfrom multiple transfusions of red blood cells. There is no universal recommendation for performing laboratory tests for anemia inpreterm infants. Timing can be guided by inpatient laboratory values prior to discharge. Another approach would be to considerchecking for anemia in higher risk patients 4-6 weeks after discharge and as needed thereafter.24 Infants who are anemic should betreated with therapeutic doses of iron (4-6 mg/kg/day).25Primary Care for PretermInfants & ChildrenA CPQCC Provider Toolkit11

ImmunizationsIn This SectionHepatitis B Vaccine 12Rotavirus Vaccine 13Immunoprophylaxis 13Follow general recommendations bychronological age except for specialprotocols for Hepatitis B Vaccine andRotavirus Vaccine.Preterm infants and children should be immunized with the routine immunizationschedule without adjustment for gestational age or birth weight with theexception of Hepatitis B vaccine. Routine immunizations other than HepatitisB vaccine have been shown to have adequate safety and antibody response.26It is important to follow immunization status carefully in this population, asa recent study showed that preterm children had a lower rate of completedimmunizations than full term children with over half who were under-immunizedat 19 months and over one-third who were still under-immunized at 36 months.27Hepatitis B VaccineFollow special recommendationsfor infants 2000 grams because ofdiminished antibody response.Hepatitis B vaccine has been shown to produce a diminished antibody responsein low birth weight infants.28 29 30 Therefore the schedule and indications forinfants 2000 grams have special considerations listed below.MOTHER IS HBsAg-NEGATIVE: 1 dose within 24 hours of birth for all medically stable infants 2000grams. For infants 2000 grams, administer 1 dose at chronological age 1month or hospital discharge. A dose received by an infant 2000 grams AND 1 month of age doesnot count towards the primary series.MOTHER IS HBsAg-POSITIVE:12Primary Care for PretermInfants & ChildrenA CPQCC Provider Toolkit Administer Hepatitis B vaccine and 0.5 mL of Hepatitis B immuneglobulin (HBIG) (at separate anatomic sites) within 12 hours of birth,regardless of birth weight. For infants 2000 grams, administer 3 additional doses of vaccine (total

of 4 doses) beginning at age 1 month. Test for HBsAg and anti-HBs at age 9-12 months. IfHepatitis B vaccine series is delayed, test 1-2 monthsafter final dose.MOTHER’S HBsAg STATUS IS UNKNOWN: Administer Hepatitis B vaccine within 12 hours of birth,regardless of birth weight. For infants 2000 grams, administer 0.5 mL of HBIG inaddition to Hepatitis B vaccine within 12 hours of birth.Administer 3 additional doses of vaccine (total of 4doses) beginning at age 1 month. Determine mother’s HBsAg status as soon as possible.If mother is HBsAg-positive, administer 0.5 mL of HBIGto infants 2000 grams as soon as possible but no laterthan 7 days of age.31Rotavirus VaccineFollow the routine schedule, butdo not miss opportunities toadminister the vaccine becauseit is usually not given duringhospitalization. The first dosemust be given between 6 weeksand 14 weeks 6 days of age, andall doses must be completedbefore 8 months of age.Rotavirus vaccine is the other immunization that requiresspecial consideration for preterm infants and other infantshospitalized in the neonatal period. The recommendationsfor rotavirus vaccine for preterm infants follow the standardrecommendations. However, because it is a live vaccine that canbe shed by the recipient in the stool after administration, it is notroutinely administered during NICU hospitalizations in the UnitedStates because of concerns regarding nosocomial infections.Some NICUs administer the vaccine at hospital discharge.In addition, rotavirus vaccine is unique among the routinevaccines in that it must be administered by a minimum age.The first dose of rotavirus vaccine must be administered before15 weeks chronological age. Some premature infants are stillhospitalized at this age and therefore miss the opportunity tohave this vaccine. Others are discharged close to the maximumage for the first dose of 14 weeks 6 days and have a smallwindow of opportunity to receive the vaccine.32 Administrationof rotavirus vaccine should always be considered at the firstoutpatient visit after discharge. An infant can be given the firstdose of rotavirus vaccine between the ages of 6 weeks and 14weeks 6 days. All doses must be completed before the age of 8months. 31ImmunoprophylaxisDo not miss the opportunityto protect vulnerable childrenfrom Respiratory Syncytial Virusinfections.Palivizumab (Synagis ) prophylaxis is recommended forchildren who are at high risk of serious lower respiratory tractdisease from Respiratory Syncytial Virus.PALIVIZUMAB RECOMMENDATIONS IN THE FIRST YEAR OFLIFE:The most common indication for palivizumab prophylaxis in thefirst year of life for children is for preterm infants born 29 weeksgestational age. It is also recommended for children born 32weeks gestational age who required oxygen 21% for at least 28days after birth. Other indications in the first year of life includehemodynamically significant heart disease and consideration forchildren with pulmonary abnormality or neuromuscular diseasethat impairs the ability to clear secretions.PALIVIZUMAB RECOMMENDATIONS IN THE SECOND YEAROF LIFE:For children younger than 24 months, palivizumab prophylaxisis recommended for children who required at least 28 days ofsupplemental oxygen after birth and who continue to requiremedical intervention within 6 months of the start of the secondPrimary Care for PretermInfants & ChildrenA CPQCC Provider Toolkit13

RSV season (supplemental oxygen, chronic corticosteroid, or diuretic therapy). It is also recommended for children who will beprofoundly immunocompromised during the RSV season.GENERAL RECOMMENDATIONS FOR PALIVIZUMAB:Palivizumab may be administered up to 5 monthly doses during the RSV season. Infants born during the RSV season may requirefewer doses. In addition, there may be special considerations for Alaska Native infants and American Indian populations. 33 Acomplete list of recommendations is available at iatrics/134/2/415.full.pdfAll primary care practices should develop a system by which they keep a record of children who might qualify for palivizumabthroughout the year. Designating an office champion may facilitate appropriate systems in an individual practice.14Primary Care for PretermInfants & ChildrenA CPQCC Provider Toolkit

ScreeningPreterm infants and childrenneed more frequent hearingand ophthalmologic screeningsand careful monitoring forneurodevelopmental andpsychosocial issues.In This SectionNeurodevelopmental 15Hearing 16Opthalmologic17Psychosocial 18One of the most important roles of the primary care provider in the care ofpreterm children is their continual monitoring and screening. It is well knownthat preterm children have increased risks in many domains, and it is importantto establish and maintain an office structure that assures that routine andindicated screens are performed at appropriate intervals with timely referralswhen needed.Neurodevelopmental ScreeningFollow Bright Futures guidelines forsurveillance and screening. Provide earlyreferrals as indicated.Numerous studies have shown increased neurodevelopmental risks to pretermand low birth weight children. A meta-analysis of 30 studies that included10,293 very preterm and very low birth weight children showed decreasinggestational age and birth weight resulted in higher prevalence of cognitive delays(16.9%), motor delays (20.6%), and cerebral palsy (6.8%).34 Another meta-analysisof 6,163 very preterm and 5,471 term children who were evaluated at ages 4 to17 years showed that the preterm children scored lower in intelligence measures,executive functioning, and processing speed. 35A recent meta-analysis confirmed an increased prevalence of autism spectrumdisorder (7% in this study) in preterm children including late preterm childrenthat was well above the prevalence in the general population (0.76%).36 37 It hasalso been shown that preterm children have an increased risk of having attentiondeficit hyperactivity disorder (ADHD), with the risk of ADHD increased by eachdeclining week of gestational age, including affecting late preterm children.38The AAP recommends developmental surveillance at each preventive care visitin the areas of social language and self-help, verbal language, gross motor skills,and fine motor skills. Developmental screening with evidence-based tools isrecommended at 9, 18, and 30 months of age. Autism screening with an autism-Primary Care for PretermInfants & ChildrenA CPQCC Provider Toolkit15

specific tool is recommended at 18 months and 2 years.39 Itis important to follow developmental milestones carefully inall preterm children and examine for abnormalities of tone andmovement at each visit. Schedule interim visits as indicated andhave a low threshold for referrals for any concerns. It is alwaysimportant to involve parents and other family members in shareddecisions regarding appropriate referrals. Common referralsfor additional diagnostic evaluation for preterm children mayinclude orthopedics, neurology, developmental and behavioralpediatrics, and high risk infant follow-up programs (available insome states). Developmental intervention and support oftencome from physical therapy, occupational therapy, speech andlanguage therapy, and early intervention programs.Early intervention programs are federally mandated programsthat are available in all states and territories to provide servicesand supports for infants and toddlers with disabilities. Theseprograms were enacted in 1986 under the Individuals withDisabilities Education Act and funded through grants to stategovernments from the federal government and other statefunding sources. Services may be supported by private healthinsurance, are available free or at reduced cost for any eligiblechildren, and may include speech therapy, physical therapy, andother types of services based on needs. 40Hearing ScreeningProvide screening by 1 monthof age, diagnostic evaluation forfailed screens by 3 months ofage, and intervention for hearingloss by 6 months of age.All infants admitted to the NICUfor 5 days should have ABRscreening prior to discharge and,if normal, audiology assessment16Primary Care for PretermInfants & ChildrenA CPQCC Provider Toolkitby 30 months of age.Infants with high-risk conditionssuch as meningitis, culturepositive sepsis, CMV infection,ECMO requirement, andhyperbilirubinemia requiringexchange transfusion need morefrequent screens. Always screenif there are concerns regardinghearing.Children who were admitted to the NICU have a 2 to 4 percentrisk for hearing loss, primarily due to sensorineural hearingloss (SNHL) and auditory neuropathy (AN). This is ten timesthe rate in the general newborn population (1-2/1000).41 Someof the risk factors associated with hearing loss are low birthweight, hyperbilirubinemia, hypoxia, ototoxic drugs (especiallyaminoglycosides), and infection (especially meningitis and CMV).The AAP’s Early Hearing Detection and Intervention program(EHDI) 1-3-6 recommends hearing screening by 1 month,diagnosis of hearing loss by 3 months, and enrollment inintervention by 6 months. Early detection and intervention havebeen shown to be highly effective, and they increase vocabularyand help all children regardless of their level of hearing lossor other determining factors.42 Other studies have shownthat amplificatio

chronological age). The Fenton growth chart can be used until 50 weeks postmenstrual age.12 Both the American Academy of Pediatrics (AAP) and the Centers for Disease Control (CDC) recommend using the WHO growth chart for children 0 to 2 years of age and the CDC growth chart for children 2 to 20 years of age. Age should be corrected for