Today, I review, link to, and excerpt from The Cribsiders‘ “#168: The (NICU) Graduate: Outpatient Follow-Up for High Risk Infants”.*
*Marshall C, Erdei C, Berk J, Chiu C, Masur S. “#168 The (NICU) Graduate: Outpatient Follow Up for High Risk Infants”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ February 18, 2026.
All that follows is from the above resource.
Dr. Erdei is a triple board certified physician (neonatology, pediatrics, and developmental-behavioral pediatrics!) who talks us through high risk infant clinic! There is no one-size-fits-all approach to NICU follow-up, so Dr. Erdei draws on her years of experience to share the set-up of her own clinic. We talk about common challenges like evaluating adequate growth, preterm formulas/fortifiers, feeding intolerance, neurodevelopmental assessments and her expert advice for helping babies thrive in their family unit once they go home!
NICU Follow-Up Pearls
- NICU follow-up programs should be thought of as subspecialty clinics that support pediatricians by giving tailored growth, feeding, and developmental plans
- Developmental milestones should always use corrected gestational age (chronological age minus number of weeks premature), but immunizations should always use the chronological age – we know the preemies can handle them!
- In general, we should use the World Health Organization (WHO) growth chart from 0-2 to evaluate growth once babies reach full term (always correct for prematurity! For a 6 month old born at 24 weeks, they are only corrected to 2 months!)
- Once a baby can maintain adequate growth velocity with 20 kcal/oz formula or breastmilk, they are usually able to transition from preterm formulas to standard term formulas or unfortified breastmilk
- Families can self-refer to early intervention – just because a baby didn’t quality at first doesn’t mean they won’t qualify months later
- Families are like medicine for preterm infants – their quality interactions like reading, singing and talking during quiet awake time promote development in a way nothing else can
Bayley Scales of Infant And Toddler Development
Ages and Stages Questionnaires (ASQ)
Sense II: Supporting & Enhancing NICU Sensory Experiences
Modified Checklist for Autism Screening in Toddlers (M-CHAT)
Early Intervention From The CDC
Early Intervention Contact Information By State
CDC’s Developmental Milestones
Watch Me! Celebrating Milestones and Sharing Concerns: FREE, online training course
NICU Follow Up Show Notes
What is NICU Follow-Up?
NICU follow-up clinics are interdisciplinary specialist clinics that focus on growth and neurodevelopment in the first several years of life for high risk infants. In the early post-NICU phase, feeding and growth require the utmost attention, then the focus shifts to the child’s development and integration into the family. The appointment rhythm and personnel make-up varies from institution to institution but typically consists of a physician lead (usually a neonatologist or developmental behavioral pediatrician), feeding support (dieticians and speech language pathologists/occupational therapists), and other developmental experts like physical therapists and pediatric providers with experience with this unique population. Dr. Erdei’s clinic has a virtual transition to home program that follows babies’ growth weekly for the infants at highest risk but otherwise sees babies at 4 months corrected gestational age, 8 months, and 12 months at least.
When we discuss developmental milestones, we ALWAYS use corrected gestational age! A baby born at 24 weeks wouldn’t be expected to meet one-month milestones until they have been alive for 5 months, since those first 4 months were supposed to be in the womb!
However, in regards to immunizations, we always use chronological age since, since we know the standard immunization schedule is safe for even the smallest infants!
Growth
Growth Goals
Dr. Erdei notes that there is no one-size-fits-all approach for optimizing growth in the preterm infant and there is some debate in the research space regarding best growth curves. However, in her practice, she uses the Olsen growth chart for preterm babies until 40 weeks postmenstrual age (PMA), although some centers use Fenton. For term infants, or infants who reach 40 weeks PMA, she switches to the WHO 0-2 growth chart (always corrected for prematurity! For example, in a 5 month old baby born 3 months early, we would plot at the 2 month vertical line on a growth chart).
In general, neonatologists and dieticians target a growth trajectory close to the baby’s percentile at birth. We know babies can lose up to 10% (or more, especially in the case of preemies) of birth weight, but then should gradually return to their birth percentile and stay on that growth trajectory. In the NICU, each baby’s total caloric intake (typically measured in kilocalories per kilogram per day, or kcal/kg/day) is adjusted for their own growth percentile and the catch-up growth that should happen over the course of months to even years! A general rule of thumb for a term-corrected baby is around 25-35 grams per day until 4 months corrected gestational age, then that goal decreases to closer to 20 grams per day.
Fortification and Formula
When promoting growth, we need to consider not only the formula or fortifier type, but also the caloric density. Standard formula is 20 kilocalories per ounce (kcal/oz) and we assume breastmilk is the same, but we don’t truly know as this varies by mother and by duration of lactation! Decisions about fortification rely primarily upon growth velocity. Typically, once a baby demonstrates a couple weeks of appropriate growth, for example gaining 28-30 grams per day, then they can transition to a lower caloric density (e.g. from 24 kcal/oz to 22 kcal/oz). The goal is always exclusive breastfeeding, thus in a breastfeeding mother, a transition to lower caloric density could look like going from four direct breastfeeds + four bottles of fortified expressed breastmilk per day to six breastfeeds + two fortified bottles. Dr. Erdei notes that while we tend to focus on weight, we must also consider a baby’s linear growth and head circumference (head growth is brain growth!).
Many preterm infants go home on preterm formulas or fortifiers to add to expressed breastmilk. These account for the different metabolic needs of preterm infants including not only the additional calories, but also added minerals like calcium, phosphorous, iron and vitamin D that are critical for catch-up growth. Generally, once a baby has achieved sufficient growth to no longer require additional caloric density (greater than the standard formula density of 20 kcal/oz), they can safely transition from a preterm formula to a standard formula. However, some populations like particularly growth restricted or small for gestational age infants or those with metabolic bone disease may benefit from a longer duration of preterm formula – this is when we rely on our dieticians to help us identify these cases! Overall, once a baby no longer needs preterm formula/fortification, it behooves us to transition to standard formula as special formulas pose significant cost and accessibility barriers and there is no added benefit to the micro and macro nutrient density once no longer needed.
Feeding Intolerance
NICU graduates encounter feeding intolerance often. Prematurity affects every organ system, including the gut, thus some feeding intolerance is to be expected in the NICU and afterwards. Furthermore, some NICUs use human milk fortifiers which are typically more extensively hydrolyzed and better tolerated than the more intact proteins in powdered formula. The transition from human milk to powdered bovine fortifiers occurs before going home, thus Dr. Erdei shares that in the weeks following discharge, her babies often require adjustments to more hydrolyzed or even elemental formulas to take alone or add to breastmilk. Generally, once babies reach their due date, there is no additional gestational age cut-off for these hydrolyzed formulas.
Babies are prone to reflux, given they are often lying down, taking an all-liquid diet, and their immature lower esophageal sphincter. Some are “happy spitters” requiring only reassurance (Cribsiders episode 75 on reflux has some great pearls!). Dr. Erdei’s threshold for formula re-evaluation is feeding intolerance interfering with feeding (e.g. no longer finishing bottles) or growth. Some NICU babies develop dysphagia – not wanting to take their bottles – while others may cough/sputter with feeds, thus speech language pathologists (SLP) are critical in evaluating for things like oral aversion and aspiration risk.
Vitamins and Minerals
Preterm infants often go home on multivitamin supplementation and should continue these until they consume a “completely mixed diet…and their growth has normalized” per the American Academy of Pediatrics (AAP). Preterm infants need up to 4 mg/kg/day of iron via formula and supplementation. Breastmilk is notably poor in iron, thus all breastfed babies should take iron supplements until consuming enough iron from solid foods. Preterm infants begin vitamin D supplementation early in their enteral feeding journey and should continue until they take 28-30 ounces of formula (infant formula is fortified with adequate Vitamin D at this volume) while breastfed infants should continue through 12 months. Some infants may go home on a separate multivitamin and iron supplement to account for different iron needs by gestational age and weight, again emphasizing the importance of an interdisciplinary approach tailored for each unique baby! Your friendly neighborhood NICU follow-up clinics will help with when to stop or change these supplements like multivitamins, iron and vitamin D!
Neurodevelopment
Assessment Tools
Different institutions use different developmental assessment tools, but regardless of location, each visit must include an informal assessment of how the infant is working within the family unit. Dr. Erdei’s clinic employs the Test of Infant Motor Performance (TIMP) at 4 months corrected. The Bayley assessment tool is a pretty ubiquitous instrument, assessing cognitive, motor, and language function and Dr. Erdei uses a Bayley screener at 8 months then the extended Bayley at 12, 18, 24 and 30-36 months at which point her infants typically transition to other neurodevelopmental centers if ongoing developmental care is needed. She also uses other common screening tools like the Ages and Stages Questionnaires (ASQ’s) and the Modified Checklist for Autism Screening in Toddlers (M-CHAT) (18 months, 24 months, and 36 months if needed) in addition to feeding screening questions.
Prematurity is a lifelong condition that results from a sudden interruption in pregnancy followed by separation from the family unit. Babies spend months with hospital stimuli instead of the normal biologic stimuli and they are at lifelong risk of neurodevelopmental challenges. We don’t yet have great assessment tools (although researchers are trying!) to accurately predict which developmental challenges these infants will face when, for example, they start school. What we can do is follow these babies closely and have a low threshold to initiate (or re-initiate) support services.
