Neonatology

Caring for our tiniest and most fragile babies.

Frequently Asked Questions

What is the High-Risk Infant (HRI) Clinic?

The High-Risk Infant Follow-Up Clinic at Rady Children’s is designed to assist families with follow-up care for infants and young children who are at high risk for developmental and neurological problems following discharge from the neonatal intensive care unit.

We provide ongoing evaluation of the growth and development of these high-risk infants and young children, coordinate care with your infant’s pediatrician, and recommend referrals to specialty services and clinics when needed.

Why does this clinic exist?

California Children’s Services (CCS) is a state medical program created to treat children with physically handicapping conditions. CCS mandates that all hospitals with level III NICUs provide a means to assess and follow their high-risk infants after discharge. We are here to work with your pediatrician to provide optimal screening and needed follow-up referrals.

Who are the staff involved in the Rady Children’s HRI Follow-up Clinic?

• Brian Lane, M.D., Medical Director
• Mary Louise Schreiber, Pediatric Nurse Practitioner
• Claudia Horita, Administrative Coordinator
• Kristin Gist, Administrative Director

Who may attend HRI Clinic?

Infants and young children from birth to 3 years of age who are at risk due to premature birth, low birth weight or other problems at birth. We see children who were cared for in the NICU at Rady Children’s, Sharp Mary Birch Hospital and other participating hospitals. We also welcome children who have not been cared for in the NICU if their primary care doctor has a concern for developmental delay.

What specific risk factors place an infant or child at risk for developmental and/or neurological problems?

CCS mandates follow-up for certain at-risk infants. These infants include those who:

• Gestational age at birth was less than 32 weeks
• Birth weight less than 1,500 grams
• Cardiorespiratory depression at birth
• Apgar score of less than or equal to 3 at five minutes
• Hypoxia, acidemia, hypoglycemia and/or hypotension
• Persistent apnea which required medication (e.g., caffeine) for the treatment of apnea at discharge
• Required oxygen for more than 28 days of hospital stay and diagnosed with chronic lung disease
• ECMO
• Received inhaled nitric oxide
• Had or have seizure activity
• Documented brain injury or intracranial pathology

A more inclusive list of identified risk factors for adverse neurodevelopmental outcomes in preterm and term infants can be grouped into three areas. Your infant or child may qualify for services based on one or more of these factors:

Biological risk factors:

• Infants born weighing less than 1,500 grams (3 lb.4oz.)
• Head ultrasound abnormalities
• Seizures/meningitis/hydrocephalus/other neurological problems
• Necrotizing enterocolitis (NEC)
• Chronic lung disease (CLD) also known as respiratory distress syndrome (RDS)
• Complex medical problems
• Small for age at birth
• Multiple births (twins, triplets)
• Twin-twin transfusion
• Complex congenital abnormalities
• Repetitive apnea and bradycardia
• High bilirubin levels requiring exchange transfusion
• Failure to grow in NICU
• Infection (e.g., meningitis, infections acquired in hospital)
• Mother with multiple birth history*
• Birth defects
• Metabolic disorders
• Abnormal neurological exam at time of discharge

Medical/surgical interventions during the early months that may place your infant at increased risk:

• Resuscitation
• Steroids given after birth
• High-frequency mechanical ventilation for longer than 48 hours
• Prolonged oxygen therapy
• Total parenteral nutrition (TPN)/nutritional therapies
• Other medications
• Medical complications in the NICU
• Congenital abnormalities requiring medical or surgical treatment
• Surgery for NEC, patent ductus arteriosus (PDA) or shunt
• ECMO

Social/environmental risk factors:

• Low maternal education
• Teen mother
• Low income
• Extreme poverty
• Single parent
• No health insurance/ on Medi-Cal
• Drugs/alcohol/smoking/ substance abuse in the family
• No prenatal care
• Environmental stress

Who is eligible?

Infants and young children from birth to 3 years at risk for developmental delay or neurological dysfunction.

How many visits can my child receive?

Your infant or child can be seen up to three times in our clinic before the age of 3 years. With any further follow-up needs, children can continue to be followed through the Developmental Evaluation Clinic (DEC).

At what age is my child seen?

Infants are usually seen at 6 months, 12 months and 18 months (use adjusted age if infant was born prematurely).

How can my child be referred to this clinic?

As parents of an infant graduating from an intensive care unit, after discharge from the nursery you can start the process by calling us at 858-966-8801. Your pediatrician may also refer your infant or young child to us.

What happens during a neurodevelopmental visit?

The clinic visit takes approximately one hour. The child and family are seen by a nurse practitioner. She will gather information about your child’s health history since discharge from nursery or last HRI visit. Next, she will evaluate your child using a developmental screening exam followed by a physical exam, specifically looking for neuromuscular findings. You will be asked to report your child’s early language milestones. At the end of the exam, your child’s weight, height and head circumference will be measured. Finally, testing results and recommendations will be discussed.

What tests are used?

The Bayley Neurodevelopmental Screening Test, 3rd Edition is used to identify risk for developmental delay and assess neurological function. If indicated, a more comprehensive exam may be used at the third visit.

The Amiel-Tison Neuromuscular Exam is used to evaluate muscle tone, range of motion and reflexes.
The REEL-3 uses parent/guardian report to evaluate your infant or child's language skills.

What happens after the visit?

Results are discussed with the medical director and a copy of the visit report is mailed to you and your pediatrician. Referrals to specialty clinics are either made or recommended.

If my infant or child shows some potential for delay or problem, to which specialty clinics do you usually refer?

California Early Start (CES) with any concerns or suspicion for delay. We recommend that CES do an evaluation for specific delays (e.g., gross motor, fine motor, cognitive or language). If they feel that specific services are needed, a therapist or teacher may come to your home, or you may be eligible for occupational, physical or speech therapy services through Rady Children’s or another provider. Your child’s pediatrician will be involved in this process.