Analysis of the efficacy of urine culture as part of sepsis evaluation in the premature infant

BACKGROUND: Premature infants have a higher incidence of urinary tract infection (UTI) than full term infants. UTI in premature infants can present with signs of sepsis: poor weight gain; temperature instability; metabolic acidosis; poor feeding; and abdominal distention. OBJECTIVE: The purpose of this study was to determine the usefulness of routine urine culture as part of a sepsis evaluation in the preterm infants. METHODS: We conducted a retrospective review of all infants with birth weight <1500 g (very low birth weight) who underwent sepsis evaluation at MetroHealth Medical Center between January 1991 and February 1998. All infants from whom urine and blood specimens were collected concomitantly for culture as part of a sepsis evaluation were included. RESULTS: Included were 538 infants. Their mean gestational age was 28.5 +/- 2.7 weeks, and mean birth weight was 1072 +/- 276 g. Blood and urine specimens for culture were taken from 349 infants on admission or in the first 24 h of life (Group A), their mean birth weight was 1147 +/- 244 g, and mean gestational age was 28.9 +/- 2.6 weeks. None of these infants had positive urine cultures; 8 infants (2%) had positive blood cultures. Blood and urine specimens were obtained from 189 infants later between Days 6 and 150 of life (Group B); their mean birth weight was 933 +/- 278 g, and mean gestational age was 27.5 +/- 2.5 weeks. Forty-eight infants (25.3%) in Group B had positive urine cultures, and 79 infants (41.7%) had positive blood cultures. Eighteen infants (38%) with positive urine cultures had positive blood cultures, and 30 infants (62%) had negative blood cultures. CONCLUSIONS: There is minimal benefit in obtaining urine cultures from very low birth weight infants as part of a sepsis evaluation in the first 24 h of life. It is important to obtain urine cultures from older infants with signs of sepsis to identify patients with UTI with or without bacteremia.     

Quantitative ultrasound measurements of bone speed of sound in premature infants

We measured bone speed of sound in premature infants by quantitative ultrasound. A total of 44 neonates participated in the study including 29 premature infants (median birth weight 1264 g, range 578-2420 g; median gestational age 31 weeks, range 24-36 weeks) and 15 full-term infants (median birth weight 3360 g, range 2700-3730 g; median gestational age 40 weeks, range 37-41 weeks). The left tibial speed of sound (SOS) was measured by quantitative ultrasound. Bone SOS was successfully measured in all infants. We found a significant correlation between tibial SOS and gestational age (r = 0.78, P < 0.0005), but a significant inverse correlation between tibial SOS and post-natal age (r = -0.78, P < 0.0005). Bone SOS was significantly (P < 0.05) higher in full-term infants (3101 m/s, range 2899-3314 m/s) compared to premature infants (2821 m/s, range 2516-3139 m/s), and compared to a subgroup of the premature infants who reached corrected age of full-term infants (2706 m/s, range 2516-2892 m/s, n = 13). Bone SOS was lower (2745 m/s, range 2533-3036 m/s, n = 16) in very low birth weight premature infants (birth weight < 1500 g). CONCLUSION: The results indicate that tibial speed of sound was reduced in premature infants (in particular very low birth weight) compared to full-term infants even when premature infants reached the corrected age of their full-term peers. The potential role of this technique in assessing osteopenia in premature infants warrants further exploration.     

Very preterm infant (< 32 weeks) vs very low birth weight newborns (1500 grammes): comparison of two cohorts]

Studies concerning very preterm newborns are either defined by birth weight (<1500 g) or gestational age (<32 weeks). The aim of our study was to underline limits of cohort definitions by birth weight. METHODS: Data come from the Nord Pas de Calais EPIPAGE cohort. Every birth occurring in 1997 before 32 weeks or with a birth weight less than 1500 g and transferred in a neonatal unit was included. Two cohorts were defined, one by gestational age (<32 weeks), the other by birth weight (<1500 g). Two subgroups could be defined from these to cohorts: group A (<32 weeks and > or =1500 g), from cohort (<32 weeks), group B (> or =32 weeks and <1500 g) from cohort (<1500 g). RESULTS: Five hundred nine newborns were included. Perinatal characteristics of both cohorts seemed comparable. The analysis by subgroups A and B revealed an excess of pulmonary and neurological morbidity in very preterm infant compared to very low birth weight newborn. This was linked to an excess of growth restricted newborns in this cohort with more advanced gestational ages. CONCLUSION: Cohorts of very preterm newborns should rather be defined by gestational age. If not possible, results in very low birth weight cohorts should also be given by gestational age and rate of growth restriction should be described.     

Annular pancreas in China: 9 years’ experience from a single center

To summarize the clinical characteristics, diagnosis, treatment and prognosis among 152 children with annular pancreas (AP). A retrospective review of 152 patients with AP who were treated with surgical repair between January 2009 and August 2017 was performed at our pediatric surgical units. Presenting symptoms, birth weight, radiological findings, associated anomalies, the type of surgery performed were analyzed. (1) 152 patients were identified, out of which 82 were males, and 70 were females; (2) the average birth weight of children with AP was less than that of healthy newborns. The birth weights of 5.4% premature infants were less than 1500 g; the birth weight of 17% full-term infants, 69% premature infants and 50% post-term infants were less than 2500 g. (3) 100 (66%) patients presented symptoms during neonatal period and 43 (28%) patients had duodenal obstruction diagnosed by prenatal ultrasound scan. (4) All cases were managed surgically by open laparotomy, and all patients were duly discharged. AP most commonly presents symptoms in early neonatal period. Infants with AP are associated with a higher rate of low birth weight, and it was because swallowed amniotic fluid could not be absorbed and impaired insulin secretion caused by abnormal pancreas. Ultrasonography, abdominal plain film and upper gastrointestinal series (UGI) are helpful, but cannot make the diagnosis, and surgery is the only effective way to diagnose and treat AP.     

Prevalence of birth defects among low-birth-weight infants. A population study

Major birth defects are diagnosed in about 3% to 4% of infants during their first year of life. Because many infants with birth defects have intrauterine growth retardation, are born prematurely, or both, the rate of birth defects undoubtedly varies according to the infant's birth weight. Nevertheless, the magnitude of such variation has not, to our knowledge, been adequately studied in well-defined populations. We analyzed data from the population-based Metropolitan Atlanta (Ga) Congenital Defects Program for 1978 through 1988. These data included information on 11,398 infants who were diagnosed with serious birth defects among 317,499 singleton live-born infants. Although the overall rate of birth defects was 3.6%, we observed a striking inverse relationship between the birth defects rate and the infants' birth weights. The birth defect rates were 16.2% for newborns weighing less than 1500 g at birth, 13.2% for newborns weighing from 1500 g to 1999 g, 6.2% for newborns weighing from 2000 g to 2499 g, 3.2% for newborns weighing from 2500 g to 3999 g, and 2.8% for newborns weighing 4000 g or more. Analyses by type of defect indicated that most birth defects were significantly associated with low birth weight. The higher risk of birth defects among low-birth-weight infants demonstrates that birth defects contribute to excess morbidity among low-birth-weight infants. Because of the overlap between birth defects and low birth weight, the prevention of low birth weight in the population depends greatly on a better recognition of the complex etiology of low birth weight and, in part, on the delineation of risk factors that influence the occurrence of birth defects.     

Perinatal risk factors and intraventricular hemorrhage in newborn infants of birth weight less than or equal to 1,500 g

In a retrospective study in 113 preterm newborns (birth weight less than or equal to 1500 g, gestational age less than 35 weeks) intraventricular hemorrhage (IVH I-IV) determined by serial sonographic examinations was correlated to a number of maternal and neonatal risk factors. While there was no significant correlation to bleeding during the gestation, premature rupture of the membranes, mode of delivery, and age of the mother, incidence of IVH was significantly lower in newborns born to mothers with EPH-gestoses (p less than 0.05). A significant high incidence of IVH was found in very premature newborns (p less than 0.025) and in newborns with hyaline membrane disease (p less than 0.005). No single risk factor for a high incidence of IVH was found. IVH in very low birth weight infants probably is caused by summation of several different perinatal risk factors.     

Infantile urinary tract infection and timing of micturating cystourethrogram

ObjectiveThe investigation of infantile febrile urinary tract infection (UTI) is still a subject of debate and controversy. To evaluate for vesicoureteric reflux (VUR) most authorities recommend a micturating cystourethrogram (MCUG) to be performed at least 4 weeks after UTI to avoid false positive.Patients and methodsAt a tertiary centre for paediatric specialities, information on 427 infants who had undergone MCUG following a first febrile UTI was prospectively recorded and their case notes reviewed. The infants were divided into two groups: Group A (117) with MCUG performed less than 4 weeks from UTI diagnosis and Group B (310) with MCUG after at least 8 weeks from diagnosis.ResultsOf the 427 children, VUR was detected in 33% of those for whom MCUG was performed less than 4 weeks after UTI diagnosis and in 24% of those for whom it was performed at least 8 weeks after diagnosis.ConclusionNeither the prevalence nor the grade of VUR in infants with a first episode of UTI is influenced by the timing of the MCUG following diagnosis. We therefore suggest that it is better to perform an MCUG as soon as possible, provided inflammation has subsided.     

Mortality in 504 infants weighing less than 1501 g at birth and treated in four neonatal intensive care units of South-Belgium between 1976 and 1980

Mortality was studied in 504 infants weighing less than 1501 g at birth and treated in four neonatal intensive care units of South-Belgium between 1976 and 1980. Two hundred and twenty-one babies died during their stay at the hospital, a mortality rate of 438 per 1000 live births. The neonatal mortality rate (mortality during the first 28 days of life) was 373 per 1000 live-births. Thirty-three infants died after the neonatal period, which is 15% of the total number of deaths. Twothirds of these post-neonatal deaths were related to complications of diseases associated with pre-term delivery. Mortality rates were higher in infants of less than 1001 g than in those of 1001–1250 g or 1251–1500 birth weight. In each birth weight category, patients born in their own obstetrical departments and referred infants had similar mortality rates. Longitudinal analysis showed improving mortality rates between 1976 and 1977 in the total population of VLBW infants, between 1977 and 1978 in infants of <1001 g and in 1980 compared to 1976 in the 1251–1500 g group. There were higher incidences of need for ventilatory assistance, patent ductus arteriosus, necrotising enterocolitis and septicaemia in referred patients of <1001 g than in patients born in their own obstetrical departments with comparable birth weight. Artification ventilation was more often required in referred infants of 1251–1500 g. This study confirms the importance of considering at least the complete hospital stay when analysing mortality in VLBW infants. Infants of <1001 g had high mortality, particularly after the neonatal period. This phenomenon was asscciated with complications of morbid conditions related to extreme prematurity.Abbreviations VLBW very low birth weight - PDA patent ductus areeriosus - NEC necrotising enterocolitis     

Late rise of thyroid stimulating hormone in ill newborns

OBJECTIVES: To determine the frequency and characteristics of late rise of thyroid stimulating hormone (LRT) among ill newborns. INFANTS AND METHODS: Data were retrospectively analyzed from infants in intensive care settings with abnormal thyroid tests over 13 months. Thyroid tests were performed by filter paper if neonatal intensive care >4 weeks or serum if clinically indicated. LRT was defined as thyroid stimulating hormone (TSH) >10 microIU/ml after normal TSH on initial newborn screen. RESULTS: LRT was identified in 13 infants. Of 736 admissions to the neonatal intensive care unit (NICU), 10 (1.4%) had LRT. Excluding 3/10 with diagnosis at <1 week of age the frequency is 0.95%. Three additional cases occurred in other ICUs. TSH elevation resolved in 6/13 (group A, TSH 10.6-20.6 microIU/ml) and persisted in 7/13 necessitating treatment (group B, TSH 10.5-1326 microIU/ml). 7/13 had birth weights <1500 g. 11/13 had gestational ages <37 weeks. LRT was associated with surgery, sepsis workup, dopamine, and gastrointestinal disorders. CONCLUSIONS: LRT was not infrequent in ill newborns. Most were premature and half were not very low birth weight. We recommend monitoring of thyroid function by serum specimen in ill newborns with prolonged ICU care regardless of birth weight.     

高胆红素血症新生儿血清S-100蛋白及总胆红素与白蛋白比值的变化及意义

目的 研究高胆红素血症(高胆)新生儿血清S-100蛋白水平和总胆红素(TBC)与白蛋白(B/A)比值的变化,为早期预测胆红素脑损伤提供新的方法.方法 根据胎龄、体质量和是否符合黄疸干预标准将出生7 d内的84例新生儿分为足月高胆组、足月对照组、早产高胆组、早产对照组.检测4组血清S-100蛋白、TBC、白蛋白水平,计算B/A比值.结果 足月高胆组S-100蛋白含量[(0.36±0.14)μg/L]高于足月对照组[(0.25±0.07)μg/L],差异有显著性(P＜0.05),足月高胆组S-100蛋白含量与B/A比值呈正相关性(r=0.509,P＜0.05).早产高胆组S-100蛋白含量[(0.40±0.09)μg/L)高于早产对照组[(0.28±40.05)μg/L],差异有显著性(P＜0.05),S-100蛋白含量与B/A比值无相关性(r=0.356,P＞0.05).结论 血清S-100蛋白和B/A比值可作为早期预测胆红素神经毒性的敏感指标.     

Investigating febrile UTI in infants: Is a cystogram necessary?

ObjectiveCurrent imaging recommendations for investigating any infantile febrile urinary tract infection (UTI) are ultrasound scan (US), micturating cystourethrogram (MCUG) and dimercaptosuccinic acid (DMSA) scan. The aim of this retrospective cohort study was to determine the need and indications for MCUG in the investigation of a first febrile infantile UTI, as doubts have been raised over its benefit.Patients and methodsInformation on 427 infants who had undergone US, MCUG and DMSA following a first febrile UTI was prospectively recorded. The infants were divided into two groups: A (354) with normal renal US and B (73) with abnormal US. DMSA findings were correlated with findings on MCUG. Main outcome measures were incidence of recurrent UTIs, change in management or intervention as a result of MCUG, and outcome at discharge.ResultsOnly 21/354 (6%) infants in Group A had both scarring on DMSA and vesicoureteric reflux (VUR), predominantly low-grade on MCUG. In Group B (abnormal US), 23/73 (32%) had scarring on DMSA and vesicoureteric reflux, predominantly high grade on MCUG. Of the infants with non-scarred kidneys, 73% had dilating reflux. Successful conservative treatment was performed in 423 infants, and 4 infants in Group B required surgery.ConclusionWe recommend US and DMSA in all infantile febrile UTI cases. Where US is normal, MCUG should be reserved for those cases with abnormal DMSA. Where US is abnormal, MCUG should be performed irrespective of findings on DMSA scan. A randomized prospective study is necessary to evaluate this further.     

Developmental outcome in very low birth weight infants 6 to 36 months old

A cohort of 78 infants weighing less than 1500 g at birth was followed prospectively to determine the impact of birth weight, age of assessment, and skill area on their developmental performance. Five skill areas were tested using the Griffiths Mental Scales of Development at 6, 12, 24, and 36 months of age. Infants were divided into three birth weight groups: less than 750 g, 750-1000 g, and 1001-1500 g. A significant age and skill interaction was found, with the locomotor and eye-hand skills decreasing consistently over time, and the personal-social and hearing and speech skills initially decreasing and then rising from 12 to 36 months. Infants born at less than 1000 g consistently performed more poorly than those born at 1001-1500 g. Explanations for the variation in scores and the implications of these findings to the evaluation of low birth weight infants are discussed.     

通过临床评估早期诊断早产儿院内感染的初步探讨

目的　探讨用临床表现及实验室检查评分的方法判断早产低出生体重儿院内细菌感染的可能性。方法　将研究对象按现行新生儿感染的诊断标准分为感染组 (A组 )及对照组 (B组 ) ,按照临床表现的严重程度及临床常用实验室检查结果予以综合性评分 ,并以有效抗生素治疗后进行对照 ,分别对组间及组内的评分进行比较。结果　治疗前 2 4hA组评分大于B组 ,两组评分之间差异有显著性 (P <0 0 1) ,有效抗生素治疗后A组与B组评分之间差异无显著性 (P >0 0 5 )。在A组治疗前与治疗后评分差异有显著性 (P <0 0 1)。B组中≥ 11分者在抗生素治疗后评分下降 ,并与治疗前比较差异有显著性 (P <0 0 1) ;<11分者差异无显著性。提示现行诊断新生儿感染的标准 ,对早产儿及胎龄小的极低出生体重儿不敏感。结论　对早产儿及低出生体重儿进行临床综合评分 ,有利于判断患儿感染的可能性 ,并可监测抗感染治疗的有效性。     

Very low birth weight outcomes of the National Institute of Child Health and Human Development Neonatal Network

This report describes the neonatal outcomes of 1765 very low birth weight (less than 1500 g) infants delivered from November 1987 through October 1988 at the seven participating centers of the National Institute of Child Health and Human Development Neonatal Intensive Care Network. Survival was 34% at less than 751 g birth weight (range between centers 20% to 55%), 66% at 751 through 1000 g (range 42% to 75%), 87% at 1001 through 1250 g (range 84% to 91%), and 93% at 1251 through 1500 g (range 89% to 98%). By obstetric measures of gestation, survival was 23% at 23 weeks (range 0% to 33%), 34% at 24 weeks (range 10% to 57%), and 54% at 25 weeks (range 30% to 72%). Neonatal morbidity included respiratory distress (67%), symptomatic patent ductus arteriosus (25%), necrotizing enterocolitis (6%), septicemia (17%), meningitis (2%), urinary tract infection (4%), and intraventricular hemorrhage (45%, 18% grade III and IV). Morbidity increased with decreasing birth weight. Oxygen was administered for greater than or equal to 28 days to 79% of less than 751-g birth weight infants (range between centers 67% to 100%), 45% of 751- through 1000-g infants (range 20% to 68%), and 13% of 1001- through 1500-g infants (range 5% to 23%). Ventilator support for greater than or equal to 28 days was given to 68% of infants at less than 751 g, 29% at 751 through 1000 g, and 4% at greater than 1000 g. Hospital stay was 59 days for survivors vs 15 days for infants who died. Sixty-nine percent of survivors had subnormal (less than 10th percentile) weight at discharge. The data demonstrate important intercenter variation of current neonatal outcomes, as well as differences in philosophy of care and definition and prevalence of morbidity.     

Dopamine infusion and hypothyroxinaemia in very low birth weight preterm infants

The purpose of this study was to assess the relationship between transient hypothyroxinaemia of prematurity (THOP) in very low birth weight newborns and dopamine administration. A total of 172 newborns was enrolled in a prospective observational study and divided into three groups: group A included newborns who were never treated with dopamine; group B were infants in whom dopamine treatment was discontinued for at least 6 h before the congenital hypothyroidism screening and group C included infants who were given dopamine during the screening. Among those newborns given dopamine, the THOP incidence was higher (11.6% in group A; 53.8% in group B; 89.3% in group C), and the vales of TSH (1.67±2.32 µU/ml in group A; 1.29±1.74 µU/ml in group B; 0.89±1.34 µU/ml in group C) and thyroxine (6.1±2.2 µg/dl in group A; 3.9±1.9 µg/dl in group B; 2.4±1.4 µg/dl in group C) were significantly lower. These differences were further confirmed even after gestational age stratification and mathematical correction for differences in clinical conditions. The effects of dopamine appear to be dose-dependant. Conclusion:even if it cannot be excluded that reduced thyroid stimulating hormone and thyroxine concentrations are caused by non-thyroidal illness, the results suggest that the infusion of dopamine reduces the thyroid stimulating hormone and thyroxine levels in very low birth weight newborns.Abbreviations CHT congenital hypothyroidism - ESS euthyroid sick syndrome - GA gestational age - iRDS infantile respiratory distress syndrome - THOP transient hypothyroxinaemia of prematurity - VLBW very low birth weight     

THE HYALINE MEMBRANE DISEASE–INTRAVENTRICULAR HEMORRHAGE RELATIONSHIP IN THE VERY LOW BIRTH WEIGHT INFANT: PERINATAL ASPECTS

ABSTRACT. A large retrospective clinical study is reported confirming pathologic studies upon the effect of hyaline membrane disease on the occurrence of intraventricular hemorrhage in very low birth weight infants. Two hundred and twenty infants with birth weight 1500 g and gestational age 32 weeks were studied. Infants with hyaline membrane disease (112) had 56 % incidence of intraventricular hemorrhage whereas of those without hyaline membrane disease (108) only 31% developed intraventricular hemorrhage ( p < 0.001). When controlled for gestational age, the more immature infants ( 1000 g) exhibited no difference in the occurrence of intraventricular hemorrhage whether hyaline membrane disease coexisted or not. In the 1001–1500 g group, the occurrence of hyaline membrane disease with intraventricular hemorrhage was significant ( p < 0.001). The association of lower Apgar scores and the influence of intermittent positive pressure ventilation in infants with intraventricular hemorrhage is discussed. Extreme immaturity negates all perinatal clinical expertise in determining neonatal outcome. Therefore, carrying pregnancies beyond 28 weeks gestation is mandatory. Beyond 28 weeks, pulmonary maturity and the influence of therapeutic modalities and maternal transport become increasingly important.     

Postnatal Weight Gain of Exclusively Breast Fed Preterm African Infants

The weight of 64 preterm appropriate for gestational age infants were followed closely during the period of stay in the newborn unit. They were subdivided into three groups: A (1001-1250 g), B (1250-1500 g), and C (1501-1750 g). The mean gestation for these groups were 28.7, 30.5, and 31 weeks, respectively, while mean birth weights were 1132 +/- 81.7 g, 1377 +/- 85.6 g, and 1641 +/- 88.6 g. All were fed their own mothers breast milk during the period of study with no supplements. During the first week, there was significant weight loss in all groups as follows: A (12.0 per cent), B (7.7 per cent), and C (4.4 per cent). Thereafter, only group A lost weight in the second week, but the loss was not significant. Birth weights were regained at 23, 16, and 15 days, respectively. The weight gain after the initial loss was A (20.0 g), B (20.4 g), and C (20.2 g) per day. Group A had the fastest growth rate.     

Predictive value of Apgar score in infants with very low birth weight

BACKGROUND: Accurate prediction of the prognosis of infants with very low birth weight is beneficial both for their parents and for healthcare professionals. METHODS: This was a population-based study of all low-birth-weight infants admitted to neonatal units in one region in Japan. The Apgar score at 1 and 5 min and neonatal mortality were retrospectively analyzed to obtain the predictive values of the scores. The results were stratified into two categories by birth weight and three time periods (1980-1986, 1987-1993 and 1994-2000). RESULTS: The predictive values improved in the later years, and therefore only the data obtained in the period 1994-2000 were used. A score of less than 5 at 5 min appears to be a good predictor of neonatal mortality in infants with a birth weight between 1500 g and 2499 g (positive likelihood ratio, 17.59 [95% confidence interval (CI) 12.68-24.40]); however, there is no evidence that the score is a good predictor of neonatal mortality in infants with very low birth weight. CONCLUSION: In infants with a low birth weight between 1500 g and 2499 g, an Apgar score at 5 min of less than 5 is a good predictor of neonatal mortality. The score is not useful in predicting the short-term prognosis of very low-birth-weight infants.     

Early neurodevelopmental outcome of very low birthweight infants

ABSTRACT. In the 18 months, January 1979 to July 1980, 149 infants who weighed ≤1500g at birth were cared for in the neonatal intensive care unit at Queen Victoria Medical Centre, Melbourne. During this period the neonatal survival rate for infants weighing 501–1000g was 57% and for those weighing 1001–1500g was 91%. Of the 123 neonatal survivors, four died within the first year after birth. One hundred and seventeen (98%) of 119 surviving infants have been assessed at follow-up. At a mean age of 12.3 months (corrected for prematurity), 11 (9%) survivors had physical handicaps only and four (3%) had developmental delay, including one child who was also physically handicapped. Nine of the 14 children with a defined handicap were considered to have significant functional handicap. Therefore 108 (92%) survivors are able to function within the normal range. These results suggest that the chance of survival for infants of very low birthweight has continued to increase whereas their handicap-rate has remained stable and relatively low.     

Low birth weight and home intervention strategies: preterm infants

We investigated the effects of a 1-year home intervention on premature infants with low (less than 1500 g) and higher (1500-2000 g) birth weights. Infants from each weight condition were block randomly assigned to a control or to one of two treatment groups. One treatment group focused on the development of the infant; the other treatment group focused on the parent-infant interaction. The low birth weight infants obtained significantly lower Bayley mental and motor scores, and were more passive and less intense than the higher birth weight infants. However, the low birth weight infants and their parents were more responsive to the home intervention than were the higher birth weight infants, as demonstrated by changes in the Bayley mental scores and the Home Observation for Measurement of the Environment (HOME) inventory. These findings exemplify the reciprocal relationship between the child's characteristics and parental responding. The importance of selecting the most high-risk premature infants for early home intervention is outlined.