Early Intervention Referral Among Very Low Birth Weight Infants
Early Intervention Referral Among Very Low Birth Weight Infants
Objectives: Access to Early Intervention (EI) services may improve cognitive and behavioral outcomes in very low birth weight infants, but few states have population-based data to evaluate EI outreach efforts. We analyzed Massachusetts (MA) infants born weighing <1,200 g to identify maternal and birth characteristics that predicted EI referral and timing of referral.
Methods: MA birth and hospital discharge records (Jan. 1998-Sept. 2000) were linked to EI referral records (Jan. 1998-Sept. 2003) via probabilistic and deterministic methods (88% linkage). Timing of EI referral among infants weighing <1,200 g was examined by infant and maternal characteristics using categorical (0-12 months, 12-36 months, or no referral) time comparisons in the crude analysis. Survival functions calculating median time to referral, and adjusted hazard ratios (HR) with 95% confidence intervals (CI) were calculated for continuous time comparisons of EI referral from birth to 36 months.
Results: Of 1,233 infants weighing <1,200 g, 93.2% were referred to EI. After risk adjustment, referral was more likely among multiple-birth infants (HR = 1.17, 95%CI 1.06-1.30) and less likely among infants <28 weeks (HR = 0.70; 95%CI 0.64-0.77) or with low Apgar scores (<5 at 5 min; HR = 0.75; 95%CI 0.62-0.92). EI referrals were lower for infants of black non-Hispanic mothers, and mothers without private insurance (HR = 0.85; 95%CI 0.74-0.98 and HR = 0.77; 95%CI 0.68-0.86, respectively).
Conclusions: In MA, most infants born <1,200 g are referred to EI, but disparities exist. Analysis of linked population-based health and developmental services can inform programs in order to reduce disparities and improve access for all high-risk infants.
Advances in perinatal technologies have improved the survival of very low birth weight (VLBW) infants, yet these infants continue to face the risk of significant morbidity, including neurodevelopmental disability. Evidence suggests that VLBW infants, even in the absence of significant radiographic findings or severe neuromotor conditions, may manifest complex neurodevelopmental deficits throughout infancy, childhood, adolescence and adulthood. In addition to the risk of physical injury to the developing brain, VLBW infants face a stressful early environment due to prolonged hospitalization and may be more vulnerable than their older, heavier peers to social and environmental factors post-discharge. Because of their increased risk of poor developmental and behavioral outcomes, VLBW infants are particularly in need of programs such as Early Intervention (EI). Studies have shown that beginning developmental/behavioral interventions as early as possible can help to improve cognitive, behavioral, and social outcomes for low birth weight infants, particularly in low-income families.
Early childhood developmental interventions are federally mandated by Part C of the Individuals with Disabilities Education Act (IDEA) to provide developmental services for families of children aged 0-3 years with developmental risks due to identified disabilities, birth risks, social or environmental circumstances. IDEA includes services that enhance physical, cognitive, communication, social/emotional and or adaptive development and by federal statute these services must include, but are not limited to, physical therapy, occupational therapy, assisted technology, audiology, vision, speech and language therapy, nutrition, social and psychological services, family training, counseling, medical evaluation and nursing services, and home visits. The type and extent of these services are determined by an Individualized Family Service Plan (IFSP). States coordinate EI services and must offer these services to children with developmental delay or those with an established disability. Some states also choose to serve those "at risk" for poor developmental outcome.
Many of the risk factors for EI eligibility, particularly early in life, may be identifiable on the infant"s birth certificate, or maternal or infant hospital record. High-risk infants, including preterm and very low birth weight infants, are of particular interest to state EI programs, especially given recent national increases in preterm births. However, EI eligibility due to risk factors alone varies by state, based on each individual state"s eligibility criteria. Although characteristics of children receiving EI services have been described, most states have no information on population-based patterns of EI referrals, particularly among very low birth weight infants.
At present, Massachusetts EI is one of the most inclusive programs in the country, serving approximately 7% of children aged 0-3 years, compared to 1-2% among other states with service provision for children with developmental delay, established disability or those at-risk for delay, including infants born weighing less than 1,200 g. The aim of this analysis was to use a population-based perinatal data system in Massachusetts to examine the extent and timing of EI referral, by maternal and infant characteristics, among infants born weighing <1,200 g, a group of infants that are especially vulnerable for developmental delay.
Abstract and Background
Abstract
Objectives: Access to Early Intervention (EI) services may improve cognitive and behavioral outcomes in very low birth weight infants, but few states have population-based data to evaluate EI outreach efforts. We analyzed Massachusetts (MA) infants born weighing <1,200 g to identify maternal and birth characteristics that predicted EI referral and timing of referral.
Methods: MA birth and hospital discharge records (Jan. 1998-Sept. 2000) were linked to EI referral records (Jan. 1998-Sept. 2003) via probabilistic and deterministic methods (88% linkage). Timing of EI referral among infants weighing <1,200 g was examined by infant and maternal characteristics using categorical (0-12 months, 12-36 months, or no referral) time comparisons in the crude analysis. Survival functions calculating median time to referral, and adjusted hazard ratios (HR) with 95% confidence intervals (CI) were calculated for continuous time comparisons of EI referral from birth to 36 months.
Results: Of 1,233 infants weighing <1,200 g, 93.2% were referred to EI. After risk adjustment, referral was more likely among multiple-birth infants (HR = 1.17, 95%CI 1.06-1.30) and less likely among infants <28 weeks (HR = 0.70; 95%CI 0.64-0.77) or with low Apgar scores (<5 at 5 min; HR = 0.75; 95%CI 0.62-0.92). EI referrals were lower for infants of black non-Hispanic mothers, and mothers without private insurance (HR = 0.85; 95%CI 0.74-0.98 and HR = 0.77; 95%CI 0.68-0.86, respectively).
Conclusions: In MA, most infants born <1,200 g are referred to EI, but disparities exist. Analysis of linked population-based health and developmental services can inform programs in order to reduce disparities and improve access for all high-risk infants.
Background
Advances in perinatal technologies have improved the survival of very low birth weight (VLBW) infants, yet these infants continue to face the risk of significant morbidity, including neurodevelopmental disability. Evidence suggests that VLBW infants, even in the absence of significant radiographic findings or severe neuromotor conditions, may manifest complex neurodevelopmental deficits throughout infancy, childhood, adolescence and adulthood. In addition to the risk of physical injury to the developing brain, VLBW infants face a stressful early environment due to prolonged hospitalization and may be more vulnerable than their older, heavier peers to social and environmental factors post-discharge. Because of their increased risk of poor developmental and behavioral outcomes, VLBW infants are particularly in need of programs such as Early Intervention (EI). Studies have shown that beginning developmental/behavioral interventions as early as possible can help to improve cognitive, behavioral, and social outcomes for low birth weight infants, particularly in low-income families.
Early childhood developmental interventions are federally mandated by Part C of the Individuals with Disabilities Education Act (IDEA) to provide developmental services for families of children aged 0-3 years with developmental risks due to identified disabilities, birth risks, social or environmental circumstances. IDEA includes services that enhance physical, cognitive, communication, social/emotional and or adaptive development and by federal statute these services must include, but are not limited to, physical therapy, occupational therapy, assisted technology, audiology, vision, speech and language therapy, nutrition, social and psychological services, family training, counseling, medical evaluation and nursing services, and home visits. The type and extent of these services are determined by an Individualized Family Service Plan (IFSP). States coordinate EI services and must offer these services to children with developmental delay or those with an established disability. Some states also choose to serve those "at risk" for poor developmental outcome.
Many of the risk factors for EI eligibility, particularly early in life, may be identifiable on the infant"s birth certificate, or maternal or infant hospital record. High-risk infants, including preterm and very low birth weight infants, are of particular interest to state EI programs, especially given recent national increases in preterm births. However, EI eligibility due to risk factors alone varies by state, based on each individual state"s eligibility criteria. Although characteristics of children receiving EI services have been described, most states have no information on population-based patterns of EI referrals, particularly among very low birth weight infants.
At present, Massachusetts EI is one of the most inclusive programs in the country, serving approximately 7% of children aged 0-3 years, compared to 1-2% among other states with service provision for children with developmental delay, established disability or those at-risk for delay, including infants born weighing less than 1,200 g. The aim of this analysis was to use a population-based perinatal data system in Massachusetts to examine the extent and timing of EI referral, by maternal and infant characteristics, among infants born weighing <1,200 g, a group of infants that are especially vulnerable for developmental delay.