Multidisciplinary guidelines for the care of late preterm infants

 [bib_ref] Clinical outcomes of near-term infants, Wang [/bib_ref] [bib_ref] and the Committee on Fetus and Newborn. Postnatal glucose homeostasis in late-preterm..., Adamkin [/bib_ref] 

## Healthcare team
FAMILY EDUCATION* glucose is still low or infant is unable to adequately feed, provide IV glucose and consult with next-level perinatal care provider about transferring infant to higher level of care.
Reducing Risks of Feeding Difficulties References: 7, 12, [bib_ref] Kangaroo care and breastfeeding of motherpreterm infant dyads 0-18 months: a randomized,..., Hake-Brooks [/bib_ref] [bib_ref] Breastfeeding the late preterm infant, Walker [/bib_ref] Identify maternal risk factors that may affect successful breastfeeding: * Multiple gestation. * Diabetes. * Pregnancy-induced hypertension. * Chorioamnionitis. * Cesarean delivery. Provide assistance as needed to ensure adequate feeding frequency, at least 10-12 breastfeedings or 8-10 formula feedings per day. Maintain nursing staff lactation competencies consistent with scope of practice and responsibilities. Provide a dedicated lactation consultant, ideally an International Board Certified Lactation Consultant (IBCLC), whenever possible. Provide (or refer to) a feeding specialist (occupational or physical therapist or speech/language pathologist) to evaluate infants with persistent feeding difficulties. Adopt the Baby Friendly Hospital Initiative's Ten Steps to Successful Breastfeeding whenever possible (www.babyfriendlyusa.org/eng/10steps.html).
Explain LPI's increased risk for inadequate feeding: * Immature suck/swallow/breathe coordination. * Inadequate breastmilk transfer due to low muscle tone, ineffective latch, and decreased stamina. * Low milk supply due to inadequate breast emptying. Stress the value to mother and baby of exclusive breastmilk feeding. * Explain the value of colostrum in providing immune protection and nutrition. * Reassure mothers that small amounts of colostrum are usually adequate in the first few days if baby is feeding frequently enough. Teach how to recognize early feeding cues: * Opening eyes. * Moving head back and forth. * Opening mouth, tongue thrusting, rooting, or sucking on hands/fingers. * Crying (a late hunger cue often leading to difficulty with latch due to infant frustration). Explain the probable need to awaken infant for feeds due to LPI's immature brain and increased sleepiness. * Infant will transition to full cue-based feeds when closer to term gestational age. Encourage mothers to ask for assistance as needed with breastfeeding or formula feeding.

## First
Breastfeeding References: 7, 12, 24
Assess mother's desire to breastfeed as well as her knowledge and level of experience. Facilitate immediate, uninterrupted, and extended skin-to-skin contact for stable infants until after the first breastfeeding (usually within first 1-2 h).
Remind mother that babies are born to breastfeed. * Review benefits of breastfeeding for baby: decreased risk of infection, diarrheal illness, Sudden Infant Death Syndrome (SIDS), and obesity. * Review benefits for mother: decreased risk of breast cancer, ovarian cancer, and osteoporosis. * Review risks of formula feeding, e.g., increased risk of infection due to increased gastric pH and change in gut flora, risk of cow protein allergy, increased risk of SIDS (www.health-elearning.com/articles/JustOneBottle.pdf). Explain reasons for formula use if formula is medically indicated. Explain the importance of early and prolonged skin-to-skin contact: * Promote optimal physiological stability. * Facilitate the first breastfeeding.

## Continued breastfeeding
References: [bib_ref] Nipple shields for preterm infants: effect on milk transfer and duration of..., Meier [/bib_ref] Monitor and document breastfeeding frequency. A healthcare professional with appropriate education and experience in lactation support, such as a RN, midwife and/ or certified lactation consultant, should assess breastfeeding at least twice per day by evaluating: * Coordination of suck, swallow, and breathing. * Mother's breastfeeding position and comfort. * Baby's latch and milk transfer. * Mother's questions regarding breastfeeding. Consider use of ultrathin silicone nipple shield if infant has ineffective latch or milk transfer. * Use of shield requires close follow-up by knowledgeable healthcare professional. Assess mother's level of fatigue and coping. Refer mother to a qualified lactation specialist if feeding difficulties persist.
Provide written and verbal information about breastfeeding and ensure mother's understanding. Stress the importance of frequent breastfeedings, at least 10-12 times every 24 h, waking baby if necessary, and encourage recognition of and response to early feeding cues. Educate about the size of a newborn's stomach and the adequacy of frequent, small-volume feedings of colostrum. * Use the phrase ''when your milk supply increases'' rather than ''when your milk comes in'' to avoid implying that no milk is present during the colostrum phase. Stress the value of exclusive breastfeeding. Encourage mother to ask for assistance if needed.

## Monitoring breastfeeding success
References: 25
Monitor weight daily, ideally when the baby is unclothed (taking care to maintain a neutral thermal environment). * Weight loss of more than 3% per day or 7% by day 3 merits further evaluation and close monitoring. Document voiding and stool patterns.
Explain importance of tracking voids and stools to determine adequate feeding intake: * 3 voids and 3 stools by day 3. * 4 voids and 4 stools by day 4. * 6 voids and 4 stools by day 6 and thereafter.

## Supplementation

## References: 12, 25
Supplement feeds only if medically indicated. Maternal antenatal IV fluids may lead to infant diuresis in the first 24 h, increasing infant's urine output and apparent weight loss and should be taken into consideration when evaluating the need for supplementation. If indicated, supplement with (in order of preference) expressed breastmilk, donor human milk, hydrolyzed formula, or formula. Supplement using one of the following: * Feeding tube at breast. * Cup feeding. * Finger feeding. * Bottle feeding.
Explain reasons for supplementing breastfeeding if indicated. Explain options for providing supplementation, methods of delivery, and volumes to be given. Stress value of exclusive breastmilk feeding if possible and risks of introducing formula. Explain feeding plan. * Explain that supplementation may be needed until the baby appears to be growing adequately but will likely be discontinued when baby matures and adequate growth is ensured.

## Healthcare team
FAMILY EDUCATION* Supplement no more than recommended volumes (if breastfeeding is inadequate): * 2-10 mL per feed (first 24 h). * 5-15 mL per feed . * 15-30 mL per feed . * 30-60 mL per feed . Evaluate continued need for supplementation with daily feeding plan. Evaluate mother's understanding of feeding plan.

## Breast pumping
References: 27
Provide hospital-grade electric breast pump if pumping is needed. Assist with milk expression as soon as possible (ideally no later than 6 h after birth) if mother and infant are separated. Evaluate milk transfer and help mother hand express or pump after each feeding if milk transfer during breastfeeding is inadequate. Refer mother to a qualified lactation specialist if she has difficulty expressing milk or using breast pump.
Explain the importance of early and frequent milk expression if one of the following is present: * Mother and infant are separated. * Breastfeeding is inadequate due to infant's prematurity or illness. Address the importance of reassuring/informing the mother that despite having to initially use a breast pump, she can go on to successfully breastfeed. Teach techniques of milk expression: * Hand expression. * Mechanical milk pump use. * Hands-on pumping. Explain the importance of complete breast emptying at least 10-12 times per day to: * Reduce Feedback Inhibitor of Lactation (FIL). * Ensure adequate milk supply. Teach proper handling and storage of expressed milk.
Reducing Risks of Hyperbilirubinemia References: [bib_ref] Late-preterm' infants: a population at risk, Engle [/bib_ref] [bib_ref] Clinical outcomes of near-term infants, Wang [/bib_ref] [bib_ref] Incidence, course, and prediction of hyperbilirubinemia in near-term and term newborns, Sarici [/bib_ref] [bib_ref] Predictive ability of a predischarge hourspecific serum bilirubin for subsequent significant hyperbilirubinemia..., Bhutani [/bib_ref] [bib_ref] Combining clinical risk factors with serum bilirubin levels to predict hyperbilirubinemia in..., Bhutani [/bib_ref] [bib_ref] Late preterm infants: severe hyperbilirubinemia and postnatal glucose homeostasis, Adamkin [/bib_ref] Identify known maternal/infant/family risk factors that add to increased risk of LPI. Assess adequacy of feeding (especially breastfeeding), voiding, and stooling. Evaluate for visible jaundice within first 24 h. * If present, obtain either transcutaneous (TcB) or serum (TSB) bilirubin level. Obtain TcB or TSB at 24 h after birth or at the time of metabolic screening for all infants regardless of presence or absence of visual jaundice (visual assessment alone is not reliable). Plot bilirubin levels on hour-specific Bhutani Nomogram to determine risk category and intervention threshold(s) for infants 435 weeks GA. For infants o35 weeks GA, consult next-level perinatal care provider. Obtain repeat bilirubin level prior to transition/discharge to determine rate of rise. If rate of rise is 40.5 mg /dL/h, consider initiating phototherapy. If bilirubin levels checked prior to transition/discharge are higher than threshold for age in hours, initiate phototherapy. * Provide phototherapy in mother's room, if possible. * Monitor repeat bilirubin levels per hospital protocol. * Transfer to higher level of care if infant does not respond to phototherapy in expected manner. Plan for repeat bilirubin testing within 24-48 h if indicated for infants transitioned/discharged prior to 72 h of age. Additional testing may be needed to coincide with peak bilirubin levels which may occur on days 5-7 in LPIs.
Explain LPI's increased risk for hyperbilirubinemia: * Delay in bilirubin metabolism and excretion. * Peak bilirubin levels at days 5-7 after birth. * Twice as likely to have significantly high bilirubin levels and more susceptible to bilirubin toxicity. Provide written and verbal information about jaundice, risks of kernicterus, and possible need for phototherapy to treat hyperbilirubinemia. Teach how to recognize signs and symptoms of hyperbilirubinemia and when to alert healthcare provider for immediate evaluation of infant. Stress importance of adequate feeding to minimize the risk of dehydration and hyperbilirubinemia. Stress importance of follow-up for all LPIs.

## Optimizing neurologic development
References: 34
Assess parents' understanding of LPI brain immaturity and implications for apnea risks, feeding and sleeping behaviors, tone, and development.
Explain immaturity of LPI's brain and central nervous system (CNS). * Fetal brain cortical volume increases by 50% between 34 and 40 weeks GA, with great increase in surface area. Review implications of immature brain for apnea risks, feeding and sleeping behaviors, tone, and development, including: * Apnea of prematurity and periodic breathing. * Poor coordination of suck/swallow/breathe and need for pacing if bottle feeding. * Increased sleep needs and need to wake for feeds. * Decreased muscle tone and need for positioning support for airway and feeding/swallowing. Explain reasons for hearing screening. Reinforce understanding of hearing screening procedure. Stress importance of any follow-up that is indicated: * Date, time, and location of follow-up appointment. Explain that screening does not always diagnose a hearing deficit and that the need for follow-up does not always mean that the infant is impaired.

## Screening

## Newborn

## Anomalies

## References: 93
Evaluate infant for congenital anomalies. Consider pulse oximetry screening for congenital heart defects per hospital protocol.
Explain any physical or internal anomalies found. Stress importance of any follow-up that is indicated. * Date, time, and location of follow-up appointment.

## Maternal screening
References: [bib_ref] Hed National Center for Chronic Disease Prevention and Health Promotion Coordinating Center..., Services [/bib_ref] [bib_ref] Smoking cessation in pregnancy: a review of postpartum relapse prevention strategies, Fang [/bib_ref] [bib_ref] Prevalence and risk factors for postpartum depression among women with preterm and..., Vigod [/bib_ref] [bib_ref] Emotional responses of mothers of late-preterm and term infants, Brandon [/bib_ref] [bib_ref] The Family Life Project Investigators. Late-preterm birth, maternal symptomatology, and infant negativity, Voegtline [/bib_ref] [bib_ref] Psychological distress and early lactation performance in mothers of late preterm infants, Zanardo [/bib_ref] Review maternal blood type. Review prenatal lab results and risk factors. * Be aware of Centers for Disease Control and Prevention (CDC) recommendations for HIV screening and treatment. Review ingestion of illicit and prescription drugs or other substances during pregnancy and refer mother to drug or alcohol rehabilitation program, if indicated. Review use of prescription or herbal medications or supplements of concern, if identified. Review smoking history (present or past use). * Refer family members who smoke to smoking cessation program. * Encourage mothers who quit smoking during or just prior to pregnancy to avoid relapse (high risk during the postpartum period). Screen for psychiatric illness or perinatal mood disorders (including postpartum depression and post-traumatic stress disorder). * Parents separated from the infant at birth (e.g., due to cesarean delivery or NICU admission) are at higher risk for perinatal mood disorders. * Mothers of infants born prematurely are at increased risk for mood disorders in the first 6 months postpartum (three times higher than mothers of term infants). * Make referrals for treatment if indicated. Evaluate mother's understanding of any referrals made.
Provide referrals to smoking cessation, drug or alcohol treatment, psychiatric, or support services, if indicated. Explain risks of secondhand smoke exposure. * Stress importance of providing a smoke-free environment for all infants and children, especially those born prematurely. Model proper hand hygiene when handling baby or feeding equipment. Model proper equipment, positioning, and monitoring of the newborn for bathing, diapering, and routine care. Model safe sleeping practices when placing baby in bed.
Teach importance of handwashing before handling baby or feeding equipment. Teach proper use of: * Bulb syringe to suction nares, if needed. * Thermometer to take auxiliary temperature. Teach about safe bathing procedures, bath temperature, and maintaining a neutral thermal environment during bathing and care. Stress importance of placing babies on their backs to sleep in hospital and at home.

## Support

## Staff support
Assess adequacy of staff support for physicians, midwives, nurses, lactation and feeding specialists, social workers, occupational therapists, physical therapists, case managers, transition/discharge planners, and home health services, including: * Availability of staff to support level of services offered. * Staffing ratios. * Competencies and skills. * Availability of referral services.
Explain roles of multidisciplinary staff. Provide case manager evaluation to initiate transition/ discharge planning process.

## Family support
Assess adequacy of family support including: * Partner's presence, involvement, and coping. * Grandparents and/or friends. Provide social worker evaluation of special needs as indicated.
Provide contact information for support resources as indicated.
Reinforce potential challenges of caring for LPI at home and encourage use of any needed resources.
*When communicating with families and providing education as listed in the Family Education column, concepts should be shared in a manner appropriate for the needs of the family including those whose first language is not English.

## Transition to outpatient care
Transition of care involves a set of actions designed to ensure continuity of care from inpatient to outpatient healthcare providers. Planning for transition of care should begin at the time of admission and requires a coordinated, multidisciplinary approach. The term ''transition of care'' is preferred to the term ''discharge planning'' in order to emphasize the active and dynamic nature of this process.
Optimal transition of care relies on accountable providers who ensure that accurate and complete information is successfully communicated and documented. The accountable sending provider sends the appropriate documents to the receiving provider in a timely manner, verifies the receipt of the information by the intended receiving provider, clarifies the receiving provider's understanding of the information sent, documents the transaction, and resends information if not received by the intended recipient. The accountable receiving provider acknowledges having received the documents and asks any questions for clarification of the information contained therein, uses the information, and takes actions as indicated, ensuring continuity of the plan of care or services.

## Healthcare

## Short-term follow-up care
Late preterm infants (LPIs) should be seen by their community primary care provider within 1-2 days after transition/ discharge from the hospital; the provider should assess the infant's continued stability, review screening results, ensure ongoing safety, and evaluate the adequacy of support systems. LPIs can appear deceptively vigorous on the first day or two after birth prior to transition/discharge. It is not unusual for morbidities common to LPIs to first appear a few days after transition/ discharge. If not detected and managed early, these can quickly escalate and lead to re-hospitalization, increased family stress, and even permanent disability and death. [bib_ref] Late-preterm' infants: a population at risk, Engle [/bib_ref] It is especially important that breastfeeding LPIs be seen within a day after transition/discharge because of the feeding challenges so prevalent in this population. Immature feeding patterns, such as uncoordinated suck/swallow/breathe, ineffective milk transfer, and increased sleepiness because of immature brain/central nervous system (CNS) development, may not be apparent until the mother's milk supply increases on postpartum days 2-5. Feeding failure, in both breastfed and formula-fed newborns, can be caused by other morbidities more common in LPIs, such as respiratory distress, cold stress, sepsis, hyperbilirubinemia, low muscle tone, and decreased stamina. Congenital heart disease and patent ductus arteriosis, also more common in LPIs, should be considered for any infant with feeding failure.
The community follow-up care provider should have received a copy of the transition/discharge summary from the in-hospital care provider prior to the initial follow-up visit. To guide evaluation, the follow-up care provider should carefully review maternal and infant history, as well as the infant's hospital course, on the first follow-up visit. Because LPIs have many needs

## Support

## Staff support
Assess adequacy of staff support for physicians, midwives, nurses, lactation and feeding specialists, social workers, occupational therapists, physical therapists, case managers, transition/discharge planners, and home health services. * Availability of staff to support level of services offered. * Staffing ratios. * Competencies and skills. * Availability of referral services.
Explain roles of multidisciplinary staff.

## Family and social support
Evaluate support needs and address barriers to care: * Family/Social support network. * Communitybased services (e.g., WIC, lactation support, social services Complete transition/discharge summary: * Maternal history, prenatal lab results, labor and delivery course. * Birth events, Apgar scores, measurements. * Hospital course, lab results, procedures, medications. * Immunizations given. * Feeding history and detailed feeding plan. * Growth chart with birth and transition/discharge weights. * Follow-up appointments planned. Send copy of transition/discharge summary to community primary care provider. * Document acknowledgment that the intended recipient received and understood the information sent. * Resend information if not received. Give copy of transition/discharge summary to parents (in person) and evaluate parents' understanding of content. Evaluate and assist with transportation issue(s), as needed.
Explain content of transition/discharge summary. * Stress importance of bringing transition/discharge summary to all follow-up appointments. Explain infant's growth curve, immunization record, list of medications, feeding plan, and follow-up.
* Ensure parents understanding of information explained. * Ask parents if they have any questions or concerns that have not already been addressed. * Provide a call-back number for general questions that come up after the family is home.
*When communicating with families and providing education as listed in the Family Education column, concepts should be shared in a manner appropriate for the needs of the family including those whose first language is not English. and because it is critically important to assess carefully the issues of continued stability, screening, safety, and support, it may be necessary to schedule extra time for follow-up visits of LPIs. Short-term follow-up care should include weekly asse-ssments until the infant reaches 40 weeks of corrected gestational age (GA) (the infant's due date) or is clearly thriving.Determine family understanding of post-discharge feeding plan and assess adherence to plan (including iron and Vitamin D supplementation). Assess current feeding practices, including type of milk, length of time feeding, amount taken (if formula fed). Assess urine output, stool color, and frequency and symptoms of gastroesophageal reflux disease (GERD), colic, or oral aversion. Reinforce LPI's increased risk for failure to thrive and re-hospitalization: * Immature feeding skills. * Ineffective sucking/swallowing. * Uncoordinated suck/swallow/breathe; may not be noticed until after increase in breastmilk supply. * Longer sleep cycles, may need to wake for feedings. Review normal feeding frequencies: * 10-12 times/ day for breastfeeding infants. * 8-10 times/day for formula-fed infants. Review normal urine output and stool frequency and color as indicators of adequate feeding intake (and lack of normal urine/stool as signs of dehydration): * At least 6 wet diapers/24 h by day 5 after birth. * At least 1 yellow seedy stool daily by day 4 after birth. Review benefits of breastfeeding/breastmilk for all infants and their mothers. Provide contact information for lactation specialist and community breastfeeding support. Explain the differences between corrected gestational age (GA) and chronological age. Stress the importance of skin-to-skin holding for optimal brain development. Review maternal prenatal lab results and risk factors. Review ingestion of illicit and prescription drugs or other substances during pregnancy and referrals to drug or alcohol rehabilitation program. Review use of prescription or herbal medications or supplements of concern, if identified. Review smoking history (present or past use). * Refer family members who smoke to smoking cessation program. * Encourage mothers who quit smoking during or just prior to pregnancy to avoid relapse (high risk during the postpartum period). Screen for psychiatric illness or perinatal mood disorders (including postpartum depression and posttraumatic stress disorder). * Parents separated from the infant at birth (e.g., due to cesarean delivery or NICU admission) are at higher risk for perinatal mood disorders. * Mothers of infants born prematurely are at increased risk for mood disorders in the first 6 months postpartum (three times higher than mothers of term infants). * Make referrals for treatment if indicated. Evaluate mother's understanding of any referrals made.

## Screening

## Newborn screening

## Long-term follow-up care
There is no recognized endpoint to long-term follow-up care of late preterm infants (LPIs). Because research has documented increased morbidities for LPIs during infancy, childhood, adolescence, and through adulthood, follow-up care must begin at birth and continue, with varying degrees of surveillance and reflecting individual needs, throughout the lifespan. The importance of establishing a medical home for each LPI cannot be overemphasized. A medical home is necessary to ensure that appropriate screening and assessments are completed, referrals are made, continuity of care is coordinated and implemented by a multidisciplinary team, and duplication of services is avoided. At each follow-up visit the continued stability, screening, safety, and support of LPIs and their families should be assessed.
Ongoing follow-up care should continue to be culturally, developmentally, and age-appropriate, taking into account families' preferences and ensuring that parents are active participants in making informed decisions about follow-up testing and therapeutic interventions. Communication should occur and education should be provided in ways that are appropriate for families with limited or no English proficiency or health literacy and in ways that are developmentally appropriate for the target audience (e.g., teen parents).
If an LPI was transitioned to a higher level of care during the initial or subsequent hospitalizations, or if the mother and infant were separated at birth, both mother and father/partner should be monitored closely for signs of postpartum depression and posttraumatic stress disorder during the postpartum period and the first year of the infant's life. Because optimal infant development is so influenced by the mental health of the infant's primary caregivers, especially that of the mother, referrals should be made for professional help and community support whenever indicated. [bib_ref] Contributions from the decade of the brain to infant mental health: an..., Schore [/bib_ref] Teach about LPI's increased risk for developmental delays: * Psychomotor delay. * Cerebral palsy. * Cognitive delay. * Delay in school readiness. * Increased need for special educational services. * Increased disability (74% of total disability associated with preterm birth). Stress importance of developmental follow-up. * Review date, time, and location of follow-up appointments.

## Behavioral screening
References: 77, 86, 106
Ask parents about any signs of behavioral or emotional disturbances in toddler or child. Assess family's support system and coping abilities. Make referrals as indicated.
Educate about LPI's increased risk for behavioral and emotional disturbances: * Attention disorders. * Hyperactivity. * Internalizing behaviors. * Autism. * Schizophrenia. Stress importance of alerting primary care provider regarding abnormal behaviors.

## Maternal screening
References: [bib_ref] Hed National Center for Chronic Disease Prevention and Health Promotion Coordinating Center..., Services [/bib_ref] [bib_ref] Smoking cessation in pregnancy: a review of postpartum relapse prevention strategies, Fang [/bib_ref] [bib_ref] Prevalence and risk factors for postpartum depression among women with preterm and..., Vigod [/bib_ref] [bib_ref] Emotional responses of mothers of late-preterm and term infants, Brandon [/bib_ref] [bib_ref] The Family Life Project Investigators. Late-preterm birth, maternal symptomatology, and infant negativity, Voegtline [/bib_ref] [bib_ref] Psychological distress and early lactation performance in mothers of late preterm infants, Zanardo [/bib_ref] Review ingestion of illicit and prescription drugs or other substances during pregnancy and refer mother to drug or alcohol rehabilitation program, if indicated. Review use of prescription or herbal medications or supplements of concern, if identified. Review smoking history (present or past use). * Refer family members who smoke to smoking Provide referrals to smoking cessation, drug or alcohol treatment, psychiatric, or support services, if indicated. Explain risks of secondhand smoke exposure. * Stress importance of providing a smoke-free environment for all infants and children, especially those born prematurely. * Secondhand smoke exposure is associated with apnea, Sudden Infant HEALTHCARE TEAM FAMILY EDUCATION* cessation program. * Encourage mothers who quit smoking during or just prior to pregnancy to avoid relapse (high risk during the postpartum period). Screen for psychiatric illness or perinatal mood disorders (including postpartum depression and post-traumatic stress disorder). * Parents separated from the infant at birth (e.g., due to cesarean delivery or NICU admission) are at higher risk for perinatal mood disorders. * Mothers of infants born prematurely are at increased risk for mood disorders in the first 6 months postpartum (three times higher than mothers of term infants). * Make referrals for treatment if indicated. Evaluate mother's understanding of any referrals made. Provide verbal and written information about where to get professional and community support.

## Developmental risk factors
Assess for fine and gross motor development and behaviors that may lead to potential safety risks.
Review LPI's increased risk for fine and gross motor development and behaviors that may lead to potential safety risks: * Hyperactivity. * Seizure disorder.

## Support

## Infant support
Assess and address specialized support needs and make referrals, if indicated: * Physical, occupational, or speech therapy. * Subspecialty care. * Early childhood intervention (0-3 years). * School disability programs (ages 3 years and up). Use resources such as Child Find (free screenings, available in all states) to identify children who may need early intervention services (www.childfindidea.org). Use resources such as the National Dissemination Center for Children with Disabilities (www.nichcy.org).
Reinforce LPI's increased risk for need of specialized support and resources. Provide verbal and written information about how to find state and community resources.

## Family support
Assess adequacy of family's support system. Identify family's support needs: * Parent support groups for specific disabilities. * State parent-toparent groups or other parenting support groups. * State parent training and information Ask parents if they have any questions or concerns that have not already been addressed. Provide a call-back number for general questions that come up when family is home.
Reinforce increased risk of need for specialized family support due to special needs of infants born prematurely. Provide verbal and written information about how to find state and community resources for families of infants born prematurely.
*When communicating with families and providing education as listed in the Family Education column, concepts should be shared in a manner appropriate for the needs of the family including those whose first language is not English.
[fig] *: Secondhand smoke exposure is associated with apnea, SIDS, behavior disorders, hyperactivity, oppositional defiant disorder, sleep abnormalities, and upper respiratory infections. Explain risks and benefits of prescription and herbal medications and supplements, if indicated. Where medications are indicated, encourage use of medications compatible with breastfeeding, if possible. Reference LactMed at http://toxnet.nlm.nih.gov/cgi-bin/sis/ htmlgen?LACT. Provide information about the signs and symptoms of postpartum depression and post-traumatic stress disorder, and encourage parents to seek help if needed. SAFETY In-Hospital Safety References: 7 [/fig]