1. Heather L. Brumberg MD, MPH
Comparison of Utilization of Interventional Therapies Between Moderately Preterm and Very Preterm Infants at 12 Months Corrected Age
Jessica L. Kalia DO
Paul Visintainer PhD
Heather L. Brumberg MD, MPH
Maria Pici MD
Jordan Kase MD

2. Background
In the last two decades, the prematurity rate has risen by more than 30%
A classification system of premature babies¹
Preterm <37 weeks gestation
Late preterm weeks gestation
Moderately preterm weeks gestation
Very preterm < 32 weeks gestation
In the last 2 decades, the rate of prematurity has risen by more than 30%. Premature birth has been classified into several gestational age categories. Preterm infants are those born at less than 37 weeks. Late preterms are weeks. Moderately preterms are born at weeks and very preterms have completed less than 32 weeks of gestation.
¹Mathews TJ et al. Natl Vital Stat Rep 2004

3. Moderately Preterm
Moderately preterm infants (32-36 weeks gestation) comprise over 80% of preterm births and are the fastest growing subgroup of preterm infants²
Their morbidity rates are higher than term infants
Brain weight at 34 weeks is only 65% of the brain weight of full term babies³
Few data are published addressing their developmental outcomes and follow up needs
With prematurity is on the rise, it has been shown that moderately preterm infants, those weeks gestation, comprise over 80% of all preterm births. They are the fastest growing subgroup of preterm infants. Their morbidity rates are higher than term infants. Interestingly, their brain weight at 34 weeks is only 65% of the brain weight of full term babies. Few data are published addressing their developmental outcomes and follow up needs. In our study, we looked at the use of Early intervention as one of the ways to assess the developmental needs of these babies.
²Davidoff MJ et al. Semin Perinatol 2006
³Guihard-Costa AM et al. Early Hum Dev 1990

4. Early Intervention
Early Intervention (EI) was created by Congress in 1986 under the Individuals with Disabilities Education Act (IDEA)
To be eligible for services a child must be < 3 years old with one of the following:
12 month delay in 1 functional area
33% delay in 1 functional area
25% delay in each of 2 areas (physical, cognitive, communication, social-emotional, adaptive)
In 1986 Congress created Early Intervention under the Individuals with Disabilities Education Act. A child is eligible for services if he or she is less than 3 yo and has either a 12 mo delay in 1 functional area, a 33% delay in 1 functional area, or a 25% delay in 2 major developmental areas- physical, cognitive, communication, social-emotional, or adaptive. There are several ways for a child to be referred to EI- a parent or any health care provider can make the referral. In addition, any baby born with a birth weight less than 1000 grams is automatically referred for evaluation.

5. Objective
Compare the enrollment in EI and the utilization of therapeutic services between moderately preterm (32-36 weeks gestation) and very preterm (<32 weeks gestation) infants at 12 months ± 2 months corrected age
The goal of our study was to compare at 12 mo ± 2mo corrected age, the enrollment in EI and the utilization of therapeutic services between moderately preterm and very preterm infants. We targeted enrollment in EI because in order for a child to qualify for this service, there must be at least a 33% developmental delay. This is an objective measurement that can be translated across examiners and developmental testing methods. It is important to understand that we looked at enrollment in EI not just babies who were referred for evaluation.

6. Methods
Preterm infants followed at the Regional Neonatal Follow-up Clinic in White Plains, NY from Jan 2005 through Oct 2006
Included all patients <37 weeks gestation who had an evaluation at 12 months ± 2 months corrected age (CA)
Stratified into moderately preterm (32-36 weeks gestation) and very preterm (<32 weeks gestation) groups
Antenatal, maternal, and neonatal variables obtained by NICU discharge summaries and parental report
In this retrospective study, our cohort of infants were preterm infants followed at the regional neonatal follow up clinic in White Plains, NY from Jan 2005 to Oct All preterms who had an evaluation at the follow up clinic at 12 mo ± 2mo corrected age were included and then stratified into moderately preterm and very preterm groups. We analyzed antenatal, maternal, and neonatal variables obtained by parental report and NICU discharge summaries.

7. Methods
Logistic regression used to compare moderately preterm to very preterm enrollment into early intervention (EI), physical therapy (PT), occupational therapy (OT), speech therapy (ST), and special education, controlling for antenatal, sociodemographic, and neonatal factors
Chi square and Fisher’s exact tests were used to compare characteristics of the very preterm (VP) and moderately preterm (MP) infants with significance of p<0.05
A logistic regression model was used to compare moderately preterm to very preterm enrollment into EI, PT, OT, speech therapy and special education. We controlled for antenatal, sociodemographic and neonatal factors in the analysis. Chi square and Fisher’s exact tests were used to compare characteristics of the very preterm and moderately preterm infants.

8. Results
Our dataset contained 497 preterm infants, of which 169 met our inclusion criteria. Of those, 77 were very preterm and 92 were moderately preterm babies were not yet 12 mo +/- 2 mo corrected age at the time of the study. 20% of the preterm babies were lost to follow up. 19 did not have an examination at the clinic during the time window we were studying. Over 65% of the patients we studied were born at Westchester Medical Center. The remainder were born in hospitals throughout the lower Hudson Valley region.

9. Patient Characteristics
Moderately
Preterm
Very Preterm
p value
Gestational age (weeks) #
34 ± 1
28 ± 2
<0.001
Birth wt (grams) #
2124 ± 493
1114 ± 374
Length of stay (weeks) #
2.3 ± 2.0
8.9 ± 5.4
5 min Apgar ^
9 (6,9)
7 (1,9)
Sex, n (%) NS
Male
55 (60)
37 (48)
Female
37 (40)
40 (52)
Delivery type, n (%)
NSVD
27 (32)
20 (26)
C/S
40 (48)
39 (51)
Stat C/S
17 (20)
18 (23)
We looked at various antenatal and neonatal characteristics of the babies included in our study. The very preterm and moderately preterm babies were significantly different from each other in obvious ways such as mean GA , birthweight, length of stay, and 5 minute Apgar score.
# mean ± SD , ^median (min,max), NS = not significant

10. Patient Demographics Moderately Preterm Very Preterm p value
Multiple gestation, n (%)
0.02
Singleton
62 (67)
60 (78)
Twins
21 (22)
17 (22)
Triplets
9 (10)
0 (0)
Medicaid, n (%)
80 (87)
71(92) NS
Maternal age (years) #
31 ± 7
29 ± 7
Maternal race, n (%)
0.01
Caucasian
34 (38)
14 (18)
African American
20 (22)
21 (28)
Hispanic
30 (33)
26 (34)
Other
6 (7)
15 (20)
Maternal substance abuse, n (%)
8 (9)
7 (9)
Multiple gestation differs between the moderately preterm and very preterm groups due to the 9 triplets in the moderately preterm group. There are also racial differences between the two groups.
# mean ± SD , NS = not significant

11. Patient Co-Morbidities
Moderately
Preterm
Very
p value
BPD, n (%)
0 (0)
18 (23)
<0.001
Caffeine, n (%)
10 ( 11)
60 (79)
Genetic disorder, n(%)
2 (2)
1 (1) NS
Hydrocephalus, n (%)
3 (3)
4 (5)
NEC, n (%)
5 (6)
0.020
RDS, n (%)
33 (36)
70 (91)
Congenital heart disease, n (%)
2 (3)
Neurologic disorder, n (%)
7 (8)
6 (8)
PVL, n (%)
ROP, n (%)
7 (9)
0.003
IVH Grade ≥ III, n (%)
4 (6)
We also looked at the morbidities in these infants. BPD, caffeine for apnea of prematurity, NEC, RDS, and ROP reached statistical significance between the two groups. This may be due to very preterm infants being more likely to have these morbidities than moderately preterm babies.
NS = not significant

12. Rate of Therapy Use * * * * * p= <0.05 *
From this data, we can see that 36% of MP used EI, 28% used PT, 17% OT, 16% ST and 8% special education. This is a substantial number of services needed by babies considered to be “near” term. We also may be underestimating their use of speech therapy and special education as these services are usually started after 12 months of age.
* p= <0.05

13. Very Preterm vs. Moderately Preterm Odds RatiosEI PT OT
Speech *
Special Ed
When we looked at the unadjusted odds ratios comparing the use of therapies in very preterms to moderately preterms, not surprisingly we found that very preterm infants were more likely to utilize EI, PT, OT, speech therapy and special education. 1 10

14. Very Preterm vs. Moderately Preterm Adjusted Odds RatiosEI
Adjusted for:
5 minute Apgar score
Caffeine
BPD
RDS
Length of stay PT OT
Speech
However, when we adjusted for the neonatal characteristics that were significantly different between the moderately preterm and very preterm infants- the 5 minute Apgar score, caffeine for apnea of prematurity, BPD, RDS, and length of stay there was no significant difference between the likelihood of very preterms and moderately preterms to use EI, PT, OT, speech tx and special education. Perhaps extrauterine brain growth is different than intrauterine, and any degree of prematurity, even moderate prematurity may put babies are at risk for developmental delays.
Special Ed 1 10

15. Summary
Over 1/3 of moderately preterm infants were enrolled in EI and 28% received physical therapy
When adjusting the odds ratios for neonatal factors, there was no difference in the odds of utilizing therapies between the two gestational age groups
We conclude that in our cohort of infants, over 1/3 of the moderately preterm infants were enrolled in EI and 28% received PT. When we adjusted for factors such as the 5 minute Apgar score, caffeine for apnea of prematurity, BPD, RDS and length of stay, there was no difference in the odds of utilizing therapies between moderately preterm and very preterm infants.

16. Conclusion
Moderately preterm babies are at risk and must be screened and referred for interventional therapies
They should not be considered “small” full term infants
Therefore we conclude that moderately preterm babies are at risk for developmental delay and must be screened and referred for interventional therapies. We should not treat them as small full term infants.

17. Implications
If our results could be extrapolated to the general population, there would be 150,000 moderately preterm and 75,000 very preterm infants enrolled in EI per year
We speculate that if our results could be extrapolated to the general population, being that there are almost 4.2 million births per year and a 12.5% prematurity rate, there would be 150,000 moderate preterms and 75,000 very preterm infants enrolled in early intervention each year. Quite a few moderately preterm infants! Future studies need to be done on this rapidly growing group of moderately preterm infants. Prospective and longitudinal studies could be done to show developmental, behavioral, cognitive, psychomotor and medical outcomes of these at risk infants. Thank you.

18. Acknowlegements Westchester Medical Center
Jordan Kase MD
Heather Brumberg MD, MPH
Sergio Golombek MD, MPH
Dept of Epidemiology, NY Medical College
Paul Visintainer PhD
Children’s Rehabilitation Center
Maria Pici MD

19. Back up slides

20. Moderately Preterm Services Utilized
Gestational Age
Early Intervention
n (%)
Physical
Therapy
32 weeks
7 (44)
4 (25)
33 weeks
6 (30)
3 (15)
34 weeks
6 (19)
35 weeks
6 (40)
36 weeks
8 (80)
7 (70)

21. Hospital of Birth Bon Secours 0.6% Phelps Memorial Horton Hospital
3.0%
Putnam Hospital
4.2%
Hudson Valley
1.8%
Sound Shore
12.4%
Lawrence Hospital
St. Anthony’s
Nyack Hospital
1.2%
St. John’s
Riverside
Our Lady of Mercy
2.4%
St. Luke’s
Westchester Medical Center
66.9%

22. Excluded patients 328 babies not evaluated
19 babies with no assessment at 12 months
± 2 months corrected age
208 babies were not yet 12 months ± 2 months corrected age at time of study
101 babies lost to follow-up (20%)

23. Characteristics of moderately preterm infants
Excluded
Moderate
Preterms
Included
p value
Gestational age (weeks) *
34 ± 1
0.71
Birth wt (grams)*
2152 ± 465
2124 ± 492
0.65
Length of stay (weeks)*
2.6 ± 4.3
2.3 ± 2.0
0.34
Sex, n (%)
0.44
male
104 (54)
55 (60)
female
88 (45)
37 (40)
Delivery type, n (%)
0.45
nsvd
73 (39)
27 (32)
c/s
84 (45)
40 (47)
stat c/s
29 (16)
17 (20)
* Mean ± SD

24. Characteristics of moderately preterm infants
Excluded moderately preterm
Included moderately preterm
p value
Multiple gestation, n (%)
0.002
singleton
147 (77)
62 (67)
twins
42 (22)
21 (22)
triplets
2 (1)
9 (10)
Medicaid, n (%)
123 (64)
80 (86)
<0.001
Maternal age (years)
30 ± 6
31 ± 7
0.808
Maternal race, n (%)
0.448
Caucasian
81 (44)
35 (39)
African American
28 (15)
21 (23)
Hispanic
59 (32)
30 (33)
Other
17 (9)
4 (4)
Maternal substance abuse, n (%)
11 (6)
8 (8)
0.446

25. Characteristics of moderately preterm infants
Excluded
Moderately
Preterm
Included
p value
BPD, n (%)
1 (53)
0 (0)
0.675
Caffeine, n (%)
19 (10)
10 (11)
0.833
Genetic disorder, n (%)
7 (4)
2 (2)
0.723
Hydrocephalus, n (%)
2 (1)
3 (3)
0.334
NEC, n (%)
1 (0.5)
0.680
RDS, n (%)
81 (43)
33 (36)
0.364
Congenital heart disease, n (%)
15 (8)
0.274
PVL, n (%)

26. Characteristics of very preterm infants
Excluded Very Preterms
Included Very Preterms
p value
Gestational age (weeks)*
28 ± 2
0.330
Birth wt (grams) *
1184 ± 409
1114 ± 374
0.204
Length of stay (weeks)*
8.8 ± 5.3
8.9 ± 5.4
0.920
Sex, n (%)
0.670
male
70 (51)
37 (48)
female
66 (48)
40 (52)
Delivery type, n (%)
0.454
nsvd
41 (31)
20 (26)
c/s
55 (41)
39 (51)
stat c/s
37 (28)
18 (23)
* mean, SD

27. Characteristics of very preterms
Excluded Very Preterms
Included Very Preterms
p value
Multiple gestation, n (%)
0.591
singleton
101 (74)
60 (78)
twins
32 (24)
17 (22)
triplets
3 (2)
0 (0)
Medicaid , n (%)
108 (79)
71 (92)
0.018
Maternal age (years)**
28 ± 6
29 ± 7
0.400
Maternal race, n (%)
0.131
Caucasian
40 (32)
16 (21)
African American
27 (21)
21 (28)
Hispanic
48 (38)
26 (34)
Other
11 (9)
13 (17)
Maternal substance abuse, n (%)
2 (1)
7 (9)
0.012
** mean, SD

28. Characteristics of very preterms
Excluded Very Preterms
Included Very Preterms
p value
BPD, n (%)
28 (21)
18 (23)
0.731
Caffeine, n (%)
100 (76)
60 (78)
0.863
Genetic disorder, n (%)
1 (1)
0.596
Hydrocephalus, n (%)
4 (3)
4 (5)
0.468
NEC, n (%)
14 (10)
5 (6)
0.655
RDS, n (%)
120 (90)
70 (90)
0.816
Congenital heart disease, n (%)
9 (7)
2 (3)
0.335
PVL, n (%)
0.556
ROP, n (%)
7 (9)
0.824