You should see your baby's doctor within 2 weeks after you take your baby home unless your doctor has stated otherwise.

Your baby's doctor will want you to call if you have any questions.

You can also contact the NICU where your baby was the past weeks or months.

A low to mid-70's temperature is warm enough as long as the baby is dressed appropriately.

One rule of thumb is to dress your baby like you are dressed for that kind of day and a similar amount of activity (usually sleeping or quiet). The best way to tell if your baby is dressed warm enough is to look and touch his skin.

• If your baby's hands are cold, blue or blotchy, add socks, hat, sweater or another blanket.
• If your baby seems restless or fussy and his skin is flushed or reddened, remove a piece of clothing or blanket.
• When your baby is sleeping, add one blanket.

If these things do not make a difference and your baby continues to be uncomfortable, take your baby's temperature; your baby could be sick.

Parents are the best at knowing when their baby just doesn't seem to be acting the same. Some premature infants are more susceptible to colds or respiratory infections. Babies can become dehydrated (lose of fluid and nutrients) quickly. A change in your baby's response or behavior could be a sign that your baby is sick. These include:

• Change in your baby's breathing pattern
• Excessive crying or irritability
• Change in eating pattern
• Difficult to wake up or not as active as usual
• Coughing, not associated with feeding
• Vomiting all or most of his/her feedings
• Frequent liquid stools within a short period of time (6-8 hours)
• Not as many wet diapers as usual and urine is a darker color
• Blue or pale colored skin
• Fever

Don't hesitate to call your pediatrician. No question is foolish or unimportant. Your doctor is there to answer all your questions.

• If you are using a glass thermometer, shake the mercury down by snapping the wrist sharply while holding the thermometer. Check to make sure the mercury is below 96 degrees F.
• Place the tip of the thermometer under the arm pit making sure that it is in contact with both the skin on the arm and the skin of the chest.
• Hold the arm down next to the side of the chest keeping the thermometer under the arm.
• Keep in place for at least 3-4 minutes.
• Axillary temperatures are slightly lower than rectal temperatures.

It is a good practice to have already taken the temperature when you call your doctor or go to an appointment for an illness.

It is always best to take the temperature rather than feel your baby's skin.

Your doctor should be called if :

• Your preemie is under 2 months of age and the temperature is over 99 degrees F axillary or 100.5 degrees F rectally.
• Your preemie has a temperature over 99 degrees F axillary or 100.5 degrees F rectally and other signs of illness.
• Fever is present more than 3 days.
• The temperature is less than 97 degrees F.

Spitting with a feeding is a common occurrence in prematures. It can also occur with a burp or soon after a feeding and may be called a "wet burp". It is usually only a small amount.

Vomiting is a continuous throwing up of large quantities of food or liquid, and occurs other than at feedings.

By the time your baby is ready to go home, his/her bowel movement will probably be yellow or light brown in color. Normal consistency is soft with some form or mushy. Some babies may have a bowel movement with every feeding and others may have one once every day or two.

If your baby has not had a bowel movement for 2-3 days and seems uncomfortable, or after that time has one in the form of hard pebbles, s/he may be constipated. Call your doctor. There may be well meaning friends who have home remedies to use for constipation but it is always best to check with your doctor instead.

If your baby does not seem uncomfortable and is eating well your baby may just be a baby who has infrequent bowel movements. Breast fed babies may not have bowel movements every day.

If your baby has frequent watery liquid stools in 6-8 hours time or seems to have looser stools more often than regular, your doctor should be called.

At one time or another all babies will have a rash in their diaper area. Some things to remember when this happens to your baby are:

• Keep the area clean. Use a wash cloth with soap and warm water after each diaper change, making sure to rinse off the soap. Allow the area to air dry before replacing the diaper. Diaper wipes may irritate the baby's skin.
• Leave the diaper off and let the rash be open to the air as much as possible. This can be done when the baby is sleeping.
• Change the diaper often .
• Use a diaper ointment containing zinc oxide, which can be found at any pharmacy. After washing off your baby's diaper area rub a thin layer of this ointment on your baby's reddened skin. If there is no improvement after 3 days, call your doctor.

Premature babies may seem to sleep a great deal initially. They should be waking on a regular basis for feeding. By the time of discharge your baby has developed a routine of sleeping.

If your baby has its days and nights mixed up, it is best to minimize the stimulation during the night feeding time. Some ways you can do this are:

• Use only a night light when getting up to feed the baby.
• Change the baby before the feeding.
• Talk very minimally and softly during the time you are up with him/her.
• If you normally rock the baby after the feeding, do so for only a very short time. The baby will begin to learn to settle him/her self.

The adjustment to the home environment from the noisy nursery is difficult for some babies. Some suggestions to help your baby make this transition are:

• Keep the lights dimmed.
• If your baby is fussy, swaddle your baby by wrapping his/her arms and legs snugly in a blanket. Play soft low music, or keep the television on during the day.

You do not have to bathe your baby every day if you are keeping the diaper area clean with each diaper change. Baby's skin can dryout very quickly if bathed too often. A complete bath 1 or 2 times a week is sufficient.

Your babies face should be washed every day with a wash cloth and warm water. Pay attention to the folds under his chin where milk may collect. Most babies do not like to have their face washed and will wiggle and squirm. It helps to do one side of his face at a time, trying not to completely cover the face all at once.

Wiping your baby's nose with a soft tissue will usually help remove extra secretions. If you have a bulb syringe be sure to push the air out of the bulb before gently inserting the very tip of the syringe into the nose. You do not want to use any force or squeeze the air into your baby's nose.

By adding humidity to the house, (turning on the shower, washing clothes or having a humidifier) it may help your baby to breath easier. If the stuffiness continues and your baby doesn't seem to be getting any better, it is wise to call the doctor to have it checked out. It could be a cold.

Yes, hiccups and sneezes are normal. Normally the hiccups will just go away by letting them run their course. You can offer a little water and if you are breast feeding let him/her suckle at the breast for a minute or two.

Hiccups may also be a sign that your baby is feeling a little stressed and needs to have some quiet time.

Sneezes will help to clear the passages of your baby's nose. It is nature's way of helping the infant get rid of dust or other irritants. Persistent sneezing may be a signal that the nose needs to be cleared with the bulb syringe. Sneezing also occurs when your baby has a cold.

Try to discuss any concerns you may have with your doctor. Your doctor can tell you if there is reason to suspect that there is concern about your baby's health in the future.

It is impossible to tell how your child will grow in the future. Your baby's doctor will be following your baby's height, weight, and head measurement at each visit. Most children who were born prematurely attain their "genetic potential" for growth; that is, their adult height and weight are similar to their brothers and sisters. However, some preemies continue to grow slowly and are small adults. Preemies whose chances are greatest for remaining small are:

• those who were <2 1/2 pounds at birth
• those who, at birth, were small for their number of weeks' of gestation
• those who were very sick for a long period of time
• those with consistently poor weight gain while in the nursery

Your baby's doctor will assess if your baby is developing appropriately.

It is important that you follow the schedule for all follow up appointments. Some nurseries have developmental follow up clinics to assess development.

Keep in mind that if your baby was born early that it is normal to see slower growth and development. Remember do not compare your 3-month old with your neighbor's 3-month old who was full-term at birth. For more information, see Fostering Development After Discharge and the section on Later Problems of Former Preemies.

Feeding patterns differ between babies and vary from day to day. Before discharge from your NICU (Neonatal Intensive Care Unit), the nurses can give you an idea of your baby's feeding pattern. Most preemies feed every 2 1/2 - 4 hours.

Look for cues that your baby is hungry. Premature babies do not always cry, but may move around and become restless if it has been 2-3 hours since they last ate.

Often the doctor will want you to awaken your baby if it has been longer than 4 or 5 hours since the last feed. Discuss this with your doctor.

A baby who weighs about 4 1/2 lbs. usually needs 12-15 ounces of formula or milk per day. A good way to see if your baby is getting enough to eat is to observe how many wet diapers he/she has in a 24 hour period. Your baby should have 6-8 wet diapers every day.

Most formula fed baby's will be taking 2-3 ounces every 3-4 hours when discharged from the hospital. If your baby is finishing the feeding in a shorter time and still acting hungry offer an extra ounce or two.

A breast feeding baby will usually increase its feeding time by sucking longer or wanting to eat more often. This builds up the mothers milk supply. Sometimes this means that your baby will want to eat every 2 hours until your supply will meet his/her demands.

Your doctor will check your baby's weight at each visit and let you know if the weight gain is appropriate.

Most nurseries encourage the mothers to pump their breasts while their baby is in the hospital. The nurses will work with you and your baby once your baby is able to begin the process of sucking, swallowing and breathing.

Premature babies may take days or weeks to learn how to nurse. It is important to remember to be patient and try not to become discouraged if you have chosen to breast feed. There are times when this transition is not entirely successful; it is important to not feel guilty.

There are three forms of formula: powdered, concentrate, and ready to feed.

The nutritional content of the three preparations of formula are the same.

Most formula found in stores has 20 calories per ounce. Your doctor will want you to use 20 calorie, unless she/he has specifically told you to use a higher calorie. It is very important to use only what the doctor has ordered.

Higher calorie formulas containing 24 or 27 calories per ounce, need to be ordered and can be very expensive. Here are recipes for mixing formula from powder or concentrate.

• least expensive to buy.
• try using warm water and mixing it in a blender to help dissolve formula.
• with measuring scoop in the can:

• once the can is opened the powder must be used within 1 month.

• most convenient to use.

• should be sealed and kept in the refrigerator, once the can is opened.
• should be used within 48 hours.

Bottles, nipples, measuring cups, containers, brushes and any other equipment used for feeding should be washed in hot, soapy water and then rinsed in hot, running water. Glass or metal pieces can be washed in the dishwasher.

Crying is a form of communication. Your baby has different cries for different needs.

Frequent causes of crying are:

• Hunger, especially if it has been over 2 hours since the last feed
• Discomfort, such as wet or dirty diapers, too tight clothing, too hot or too cold
• Need for position change
• Stuffy nose preventing easy breathing
• A form of tension release
• Over stimulation. Some premature babies are highly irritable. They may have a low tolerance for activity around them or frequent contact with the caregiver.
• Illness. If your baby's cry suddenly changes in intensity or seems abnormal for him/her, talk to your doctor.

Your baby will develop a trust that you will be there when he cries if you respond to all crying. This sense of trust will be a necessary foundation in his development.

Many premature babies will have days of frequent crying. They can be more sensitive to stimulation and they can be more sensitive to gas pains.

• Be sure your baby is not wet, hungry or uncomfortable.
• Burp your baby every five minutes while feeding.
• Be sure your infant is not ill (fever, diarrhea, poor color).
• Swaddle your baby by wrapping his arms and legs snugly in a blanket.
• Rock your baby or place baby securely in an infant swing.
• Hold your baby skin to skin on your chest.
• Walk with your baby or take your baby for a ride in the car securely fastened in a car seat.
• Keep your baby's head higher than the rest of the body while feeding.
• Place a warmed rolled towel under your baby's stomach when lying down or give your baby a warm bath.

Many parents find that it is very difficult to keep in control during a frantic crying episode. Try to remain calm. Call for help especially if you feel so stressed that you fear that you might hurt the baby. It is always okay to check with your doctor, with any concern you may have.

It is a common occurrence for a premature baby to have some breathing difficulty when they are eating. The baby is so busy sucking that he/she may forget to take a breath or to swallow. You might notice your baby becoming a little pale or "bluish" around their mouth, and not sucking. If this happens:

• STOP THE FEEDING
• Sit your baby up on your lap. Often times by patting him/her on their back it will be enough to remind them to take a breath. You may have to take "breaks" during the feedings, allowing time to burp more often.
• If your baby sometimes has this problem, it is a good idea to always feed with a light on.
• Call your baby's doctor about any change or problem your baby may have.

Learning CPR is appropriate for all parents whether or not their baby was born prematurely.

If your nursery offers CPR for children, it is a good idea to take the course. The Red Cross offers classes in adult and infant CPR also.

CPR prepares parents for an emergency if one should occur.

It is best not to take your baby out in public for the first three months after bringing your baby home from the hospital.

When you do take him/her out, try to avoid crowds of people who might have colds and other illnesses. Some of these places may be:

• Church.
• Older children's school.
• Malls or grocery stores.
• Your baby's doctors office. When arriving for your appointment, you could ask if you could be put in an examining room to wait.

When your baby gets home there will be many well meaning people who want to come and visit. Some things to keep in mind are:

• People with colds or the flu will have to visit at a later date.
• Your premature will be more sensitive to stimulation and may do better if not held or only held for a limited time by one person.
• You can limit the number of people who visit at one time and limit the amount of time they visit.
• Don't let people drink hot liquids or smoke and hold the baby at the same time.
• Remember you are your baby's best advocate. It is okay to say that your doctor said it is not good to have visitors until your baby is a little older.

People may respond with surprise or concern about your premature baby's size.

They may be afraid to hold for fear of "breaking" your little one. This is a common response and they will need your reassurance that they will not harm your baby.

Grandparents can help with the care of siblings once you are home. Maybe an outing or an overnight at their house will help you and give the siblings a special time with their grandparents. Often there is very little energy left to handle regular day time living with other children. If possible having a grandparent come to stay for a short time can be a big help.

If there is a special relative whom you trust to stay with your little one, begin to take time with your spouse. Going for a walk or for a cup of coffee can help you keep in touch with each other.

Meals for the freezer or grocery shopping is another way for others to help.

While most relatives are well-meaning, there are those who give advice you do not want to hear or advice that is incorrect for your baby. Parents need to decide what is best for their family and whether visits or phone calls from others will help or hinder. You have come home equipped with the best knowledge to care for your baby and, as the parent, know what is best for your little one.

It is a stressful time for everyone. If you find just one person who will be there to listen and be your advocate, they can help you explain your needs to the others in your family.

The birth of a premature baby is an emotional time for everyone. As a grandparent you probably joyfully anticipated the birth of a healthy baby. It is natural to want to take your child's fears, pain and anxiety away, but that is not what s/he needs right now. The parent(s) of the new baby need to be supported. They are going through a life crisis.

By visiting your baby in the hospital you have been getting to know your baby and your baby has been getting to know you.

Things that parents can do once you are home:

• Talk, read a book, or sing to your baby in a soft voice.
• Draw a picture with a black marker on a white piece of paper. Place it near your baby's crib or infant seat while your baby is awake. Babies like to look at the contrasting colors.
• Touch and hold your baby closely to you.
• Carry your baby in a sling or pack in the front of you.
• Lay on your side on the bed and place your baby down next to you so he/she can see your face. Babies love to look at faces and eyes.

Premature babies are much more sensitive to stimulation. Some signals to watch for that would show that your baby might be getting tired are:

• Turning away from you, or squirming
• Grimaces, yawning, sneezing or sticking tongue out
• Faster breathing
• Crying or becoming irritable, maybe spitting up
• Skin color changes
• Straining as if to have a bowel movement
• Arching of the neck and back

Remember to keep in mind that your baby needs to have short times of stimulation because he/she tires quickly.

Premature babies may not always cry when they need something.

Ways to tell if your baby may need something are:

• Squirming or moving their arms or legs, becoming more active in their crib
• Facial grimaces
• Crying

Immunizations may begin at the hospital before you leave to go home. Premature babies are usually immunized at the same age after birth as term babies.

• If there is any question whether to immunize your baby at the hospital, your baby's doctor will make that decision.
• It is very important to follow your baby's schedule for immunizations. They will be given when you see your baby's doctor.

Exposing infants and children to any smoke is not good. No one should be allowed to smoke cigarettes in your house.

• If people have a need to smoke, have them smoke outside.
• If a parent smokes, remember to not smoke in a closed car with the windows up.
• Never smoke while holding your baby.

Even though preemies may be positioned for sleep on their stomachs in the nursery while they are on monitors, your baby should not be positioned on his/her stomach or side for sleeping at home unless specifically requested by your baby's doctor. You should put your baby lying down on his/her back for sleep.

While awake your baby can be either on his/her stomach or side lying. Tummy time is important for infants because it helps babies develop strength in their neck, legs and upper body. To help a baby with side lying, place your baby on either side with his bottom arm pulled slightly in front of him. This will prevent him from turning over to his stomach. It is also helpful to put a small blanket roll behind and next to his back to help support the side position. As babies get older they will roll to their back.

The following are age-specific activities that you and your baby can try. In all examples, age is determined by correcting for the weeks of prematurity; for example if your baby was two months early, activities listed at two months would be expected at four months. Another way is to use your baby's due date, not the actual date of birth.

Mental development is fostered by:

• Providing an interesting environment and toys. Let your baby explore them safely.
• Talking to your baby often. Use a lot of facial expressions.
• Singing to your child.
• Reading to your child. Start this habit at a few months of age and continue it daily until your child reads well.

The following guidelines are from "Helping Baby Grow", WI Department of Health and Social Services, Division of Health, with permission (POH 4022, 9/97). A premature baby's age should be corrected for the weeks of prematurity; therefore, consider your baby's age from his/her due date, not from the actual date of birth.

Baby is able to:

• respond to sounds by blinking, crying, or startling
• lift head momentarily when on stomach
• be comforted most of the time by being held or spoken to
• follow with eyes and sees best at a distance of 8-12 inches
• move all extremities
• cry a lot; it's his or her only way of telling you what s/he wants

Offer your baby:

• bright colors, contrast patterns and shint objects
• lots of cuddling and holding
• a change of position so s/he can look at different things
• talking and singing in a soft voice
• gentle motion, like rocking and swaying

Baby is able to:

• coo and vocalize
• hold on to other's fingers
• smile when spoken to
• show some head control in an upright position
• open hands most of the time now
• may begin to sleep 5-6 hours during the night and take 3 naps during the day
• show interest in seeing different things and hearing different sounds

Offer your baby:

• a pacifier to help meet the need to suck
• a massage after bath, s/he likes your touch
• the feel of soft fabric and textures on his/her skin
• repetition of sounds that he makes
• stimulation by opening and closing your mouth or eyes
• musical toys
• time to
• play on his/her tummy

Baby is able to:

• smile, laugh and squeal
• roll over from stomach to back
• reach for and bat at objects
• pass toy from hand to hand
• show signs of stranger anxiety
• recognize his/her own name
• stand up if held under arms
• bring toy to mouth
• make single sounds
• hold head erect, raise body on hands, arch back and rock when on tummy

Offer your baby:

• your response when s/he "talks" to you; s/he will answer back and smile
• safe squeaky toys and rattles to grab or kick
• a game of pat-a-cake
• a mirror to look at self
• time to play on her tummy when awake strengthen leg, back, and arm muscles
• different places to play during the day; s/he likes to see new things
• toys to teethe on

Baby is able to:

• sit up alone
• "babble" a lot
• roll around
• scoot around on his tummy or crawl
• put toes in his/her mouthlearning to use fingers
• solve simple problems, such as making a bell ring
• look at and study things for a long time

Offer your baby:

• the sounds of toys when they are dropped
• a container to put things into
• the opportunity to explore; s/he is very curious
• reading books and point out pictures that s/he sees everyday
• hide a toy under a cup or cloth for him/her to find

Baby is able to:

• crawl
• sit alone and turn body in a complete circle
• pull self up on furniture and walk holding on
• walk if hands are held
• it down from a standing position

Offer your baby:

• animal sounds
• play hide and seek
• roll a ball back and forth
• teach him/her to pick up toys by doing it with him/her

Child is able to:

• climb onto a low ledge or step
• stand alone and walk
• stoop and stand up again
• speak two or three word sentences
• wave "bye-bye"
• take off clothes, but can't put them back on
• open and close doors
• look in the correct direction when asked where something is

Offer your toddler:

• play "copy what I do"
• play music and dance with him/her
• practice naming body parts
• a large safe area to explore and strengthen muscles needed for walking and running

Child is able to:

• climb on things and up stairs on hands and knees
• carry things in each hand
• follow simple requests such as "give me the ball"
• point to pictures you name, if the things are familar
• say "no" a lot!
• recognize self in a mirror or photo

Offer your toddler:

• help to discover how things move
• gentle bouncing on your knee or lap
• clap with her in time to music
• the feel of different kinds of textures
• things to throw, push and pound on

Child is able to:

• explore
• run without falling too often
• stand on either foot, holding on
• kick a ball
• climb on everything!
• be very independent
• ask a lot of questions, mostly "why?" or What's that?"

Offer your child:

• music and teach him/her to dance and clap hands to the beat
• wooden spoons to beat on something to make noise
• blocks of varying shapes and sizes
• show how to stack things and what happens when they fall down
• encourage and priase each tiny accomplishment
• be calm and patient
• read to your child often
• point to objects that are familiar and ask him/her to name them

Child is able to:

• express feelings of love and anger
• show right or left handedness
• use gestures when communicating
• understand "mine" and "yours"
• walk backwards
• pedal a small tricycle
• balance on one foot for about a second
• understand why some things happen (a switch turns on a light)
• walk up stairs with both feet on each step, holding a railing
• recognize and name people s/he knows from a photograph

Offer your child:

• encouragement to wash and dry his/her own hands
• help tp pick up and put away toys
• a puzzle with three to six pieces
• help to match colors and to learn their names
• talk to child about what you're doing, without using baby talk
• communicate to child by talking and listening
• help child develop an imagination by encouraging and joining in with his/her pretend play

Child is able to:

• walk on tiptoes and hop
• walk up stairs taking turns with each foot
• tell you where things are
• sort and put things away
• throw a ball overhead and catch a large ball
• repeat simple rhymes
• dress and undress self
• match objects that have the same function (cup and plate)
• brgin to control bladder and bowel movements during the day
• walk down stairs, usually with both feet on each step

Offer your toddler:

• routines that make him/her comfortable
• teach him to understand alike and different
• a form boerd to match shapes on
• draw an "X" on paper and have child copy you
• establish simple rules, explain them to child, and stack to them
• simple instructions (please throw the napkin in the trash)
• give him reasonable, limited choices (do you want peanut butter and jelly or grilled cheese for lunch?)

The following guidelines are from "Helping Baby Grow", WI Department of Health and Social Services, Division of Health, with permission (POH 4022, 9/97).

Sometimes parents continue to think of their former preemie as fragile and susceptible to problems even though the child is physically and developmentally healthy. They become overly protective, worry excessively, and unknowingly slow or change their child's development. The former preemie may fail to develop self confidence and/or a sense of independence.

First, try to interact with this child like you would if s/he had been born at term. Encourage socialization and age-appropriate activities. When considering expectations and when to introduce activities in the first two years of life, use the child's "corrected age", his/her age corrected for the number of weeks of prematurity. For example, if your baby is ten months old and was three months premature, your expectations should be that for a seven month old. After age two, you do not need to correct for prematurity.

Learning deficits or learning disabilities at school age occur in about 10% of children born at term. They are more common in former preemies; the smaller and sicker the preemie, the greater the risk. Up to 45% of infants weighing <3 1/4 lbs. at birth have one or more abnormalities on testing at school age. It is usually not possible to predict at the time of discharge or during early development who might develop these problems. Sequential evaluation over time is the best predictor. Knowing what problems might develop can make you alert to signs of difficulty. Early diagnosis enables early evaluation and intervention. On the other hand, being overly concerned and always questioning your child's development may be detrimental in itself. Problems which are normal at a younger age may be abnormal at a later time. If you have a question about your child's development or performance, talk to your child's doctor or teacher or have your child tested.

Behavior is a complex interaction of a child's biologic vulnerabilities, innate strengths, a nurturing environment and parenting styles. A problem in any single area may lead to undesirable behaviors. A mismatch between these areas (for example a very strong-will child with a parent who is unable to set limits) can also emerge as behavior problems. Behavioral problems are not limited to infants who were born prematurely, but they are more common in former preemies. Children with other learning problems are at greater risk for behavioral problems, and behavioral problems can interfere with learning.

Behavior problems usually start before school age. They often are exaggerations of normal responses or behaviors, or persistence of behaviors beyond the usual age where they are common. Some of these include:

• Too aggressive at play, other children won't play with him/her
• Temper tantrums- severe, long, or age-inappropriate
• Won't comply with requests
• Can't tolerate any change in routine
• Excessive fears
• Can't play quietly
• Can't stay seated for meals or short activities
• Always moving

Almost all children have periods of time when they misbehave or go through difficult stages. Your child's teacher or school will probably alert you if your child's behavior is out of the usual range. However, if you have concerns, discuss them with your child's teacher or pediatrician. Common signs of behavioral problems include:

• Doing poorly in school
• Difficulty paying attention
• Not completing projects or tasks
• Not following directions
• Difficulty sitting still for even short periods of time; always moving
• Impulsive behavior; acting before thinking about it
• Fighting, bullying or stealing

The above listed behaviors usually catch a teacher's attention quickly. Another behavior pattern is one characterized by anxiety and withdrawal. Signs include the following:

• Extreme shyness
• Not wanting to play or be with others
• Extreme fears or worry about the unknown, such as new activities or places
• Being over-sensitive to touch or sound

Children who have these problems are often in need of greater structure in their environment and more defined limits. Sometimes parents of preemies are reluctant to set limits, enforce rules or deny their child's requests because the child had to go through so much in the early months or because they don't want to dampen their child's strong will that made him/her a survivor. But, consistency in rules and limits and more structure often lead to a more secure environment in which to develop. If behavior problems persist or get worse, discuss them with your child's doctor or pre-school teacher.

The most common eye problems to appear after discharge are:

• Poor vision (either near sighted or far sighted)
• Strabismus (inward or outward turning of one or both eyes)
• Amblyopia (lazy eye due to unequal vision)
• Nystagmus (constant or frequent jerking movements of the eye)
• Decreased color vision (some colors look alike, for example purple,blue,green)
• Smaller field of vision

• Hemangiomas are small networks of tiny blood vessels. They can appear anywhere on the skin and grow rapidly for several months. If they are on the eyelid or skin surrounding the eye, they may interfere with vision. Hemangiomas are more common in premature infants.
• Former preemies can have eye problems common in all children, these include:
• Conjunctivitis - inflamation or infection of the surface of the eye
• Blocked tear duct

If your child develops any of the following, your infant needs to see an ophthalmologist (eye doctor) very soon; s/he may have a serious vision problem.

• Infant frequently pokes at his/her eye
• Infant often waves hand in front of his/her face
• Lazy eye, slow to move
• Constant movement of eyes, even when trying to look at something
• Frequent crossing of eyes, beyond three months of age correcting for prematurity
• One eye that stays out or in most of the time
• Frequent or constant jerking of eyes especially when looking straight ahead. A few jerks when looking to the far left or far right is normal.
• The infant fails to blink to a camera flash just in front of the face
• The surface of the eye or the pupil (black circle in the center of the eye) appears cloudy or white
• In a photo, the center of one eye appears red while the other eye does not
• Abnormal head turn or head tilt
• The infant (beyond 6 weeks of age correcting for the weeks of prematurity) cannot fix his/her eyes on an object or a face, or follow it as it moves
• The infant's eyelid droops so much that it completely covers the pupil (black center) of the eye when he/she is awake
• Normal lighting seems to hurt the baby's eyes and make him/her cry or turn away

Common problems can often be handled by your baby's regular doctor. These include:

• Frequent tearing (blocked tear duct)
• Redness to the eyes with cloudy or yellow drainage (may indicate a conjunctivitis or infection on the surface of the eye)

If you have a question about your baby's sight or think your child may not see well, call your baby's physician or an eye doctor.

It is important to keep any eye appointment that was arranged at your baby's discharge, even if you do not think there is an eye problem.

Infants who have poor vision can be fitted with glasses. If the correction of vision would require very heavy or thick lens, soft contact lens may be prescribed. Other conditions, such as wondering eye and crossed eye, are treated with patching of one eye to encourage the use of the other eye. Early treatment is important for best visual outcome later on.

When infants see much better out of one eye, or if using both eyes causes double vision, they will gradually stop using (seeing out of) the weaker eye. Visual pathways are still being established in the first few months and years of life. Making and keeping these connections requires regular use of the eye. If a child "blocks out" vision in one eye during this critical period in eye development, these connections are not established and cannot be made at a later age. Sight from two eyes is necessary for determining what is close and far away (depth perception). Poor vision may slow mental development and physical progress in many areas such as recognition of objects, learning symbols such as letters or pictures, and motor activities such as walking or climbing.

Children can also develop hearing loss after birth during childhood.

Many nurseries screen babies for hearing. Commonly used hearing tests are:

• Auditory Brainstem Response (example, ALGO). Three electrodes are placed on the baby's head and a click sound is delivered to the baby's ear by a small headphone. The baby's brainwave response to the sound is recorded and compared to a normal baby pattern.
• Otoacustic Emissions. A small rubber probe is placed in the ear canal. It delivers a sound which travels to the inner ear. The inner ear sends back an echo which is picked up by a microphone in the probe.
• The Crib-o-gram. A loud sound is presented to the infant during light sleep. If the baby responds by arousing from sleep or startling, s/he passes. This test only detects severe hearing loss.

Hearing tests are designed to not miss a possible hearing problem. There are many "false positives" or abnormal tests in babies who eventually turn out to have normal hearing. Things that cause false positive tests include:

• Ear wax or other substance blocking the canal
• Narrow ear canal
• Testing in a noisy setting
• Ear infection
• Restless, fussy baby
• Certain medications

Some medical problems of preemies cause changes in hearing which go away when the problem resolves. For that reason, babies are usually tested near the time of discharge, not when they are the sickest.

Any abnormal screening test must be verified by another test at later point in time.

The following is a check list for hearing.

Hearing is often decreased during a cold or ear infection. When children are young, their speech and communication may be noticeably poorer during a cold or ear infection, but should return to the previous level after the illness.

Notify your child's doctor of your concern and make arrangements to have his/her hearing tested. This testing should be done at your earliest convenience and when your child does not have a cold or ear infection. Do not delay several months; early detection of hearing loss is very important!

Hearing is essential for speech and language development. The sooner a hearing loss is detected, the sooner the child can be treated and the better language and speech s/he will develop.

If there is some hearing, sounds can be amplified (increased) by a hearing aids. If the loss is severe, children may also be taught other forms of communication such as sign language or lip reading. Speech and hearing therapists can teach you how to best communicate with your child. Specialists must determine the location of the hearing problem (outer, middle or inner ear) before deciding on the best treatment.

The most common dental problems are:

• Abnormal formation of enamel (white outer covering of the tooth)
• Slow teething, especially of the first baby teeth. As the child gets older, there is catch up to the normal teething pattern.
• High arch or groove to the palate (roof of the mouth)
• Abnormal bite called cross-bite

We do not know all of the reasons for these problems, but some common factors are:

• Stress and severe illness delay and alter normal tooth formation.
• Normally during the second half of pregnancy the teeth are forming enamel from calcium and phosphorus. It is not possible to deliver as much calcium and phosphorus to the preemie as s/he would get if s/he were in the womb. This is true even though formulas, breast milk and nutritional fluids by vein are fortified with added calcium and phosphorus.
• If a baby needs to be on the breathing machine, the breathing tube that is in the mouth rubs or presses against the roof of the mouth and the gums. Over time this may make the palate high and more arched than normal. The pressure of the tube or an instrument on the gums may also change the development of the teeth under the gum.

Often small abnormalities in enamel formation are not visible. More severe abnormalities are:

• The teeth may not appear as white as other children's. They may have a gray or brownish color.
• The teeth may have an uneven surface.
• The teeth may have an abnormal shape.

When the emamel of the tooth is poorly formed, it is much easier for the tooth to develop cavities.

It is very important to do the following:

• Develop good toothbrushing habits as soon as the teeth break through the gums. The teeth should be cleaned two times a day, morning and before bedtime.
• Avoid the habit of letting your child sleep at night or nap with a bottle. It can cause decay so severe that it destroys the teeth. Dentists refer to this as Nursing Bottle Tooth Decay.

The baby teeth are most often affected with enamel problems. Sometimes the first permanent teeth to come in are affected also, but usually to a lesser degree. These include the front teeth (incisors) and the first permanent molars (six-year molars).

Often problems look worse than they actually are. Good dental care and regular teethbrushing may be all that is needed. Cavities can be filled just as for any child with a dental cavity.

The shape of the palate can effect many things, including speech and bite. As your child gets older, the shape of the palate, along with other factors, determine if your child needs braces or other orthodontics. Most children seem to adapt to the shape of their palate and will compensate if their palate is higher than normal.

The need for braces is determined by many factors including the shape of the palate and the presence of a cross-bite. The chances that your preemie will need braces are probably a little higher than average.

Pediatric dentists prefer to see children at a very young age. The current recommendation of the American Academy of Pediatric Dentistry is for any child to see the dentist by his/ her first birthday. Since preemies are known to have more dental problems, this early exam is often beneficial. At this visit your dentist may:

• Show you how to care for your child's teeth; give tips on brushing
• Address diet concerns that relate to teeth
• Find any problems that need attention

No matter what the age, if you notice any questionable areas in your child's teeth, make a dental appointment.

Many procedures and conditions experienced in the NICU involve some pain for the baby. Yet, there are many different opinions on how much the newborn experiences pain, how to tell whether a baby is experiencing pain, and what should be done to relieve pain.

For adults and older children, we know that there are two parts to a painful experience.

• The sensory experience. This happens when the pain nerves are stimulated by some harmful event, such as a finger prick or cut.
• The emotional experience. This is what the sensory event seems or feels like to the individual person. Many things affect this. They include what we remember from past experiences and have learned from our family and friends, how well we are feeling otherwise at the time, and whether it is a brief, one-time event or will last for an unknown amount of time.

For babies, we know that:

• The sensory experience is well developed as early as 24 weeks of gestation. Babies do feel pain.
• The emotional experience is not well understood. There are questions about what the sensory event means to the newborn, whether the baby remembers it, and whether it has any effect on the baby after the pain has gone.

Unfortunately, there is no one behavior or set of behaviors or physiological signs (heart rate, breathing rate, blood pressure, oxygen levels), that we know for sure mean that a baby is in pain.

• If there is some obvious painful event, and the baby responds with a change in either behavioral or physiological signs, it seems fairly safe to assume the baby is in pain.
• However, if there is no obvious event, it is not always easy to tell if a baby is experiencing pain.

A baby may show the following signs that we interpret as indicating pain:

• crying, grimacing
• trouble sleeping
• an increase in motor activity, jerky movements, or stiffness
• flushing -- turning red
• high breathing and heart rates, or drops in oxygen levels.

Or, a baby may instead show:

• falling asleep or becoming drowsy
• a decrease in motor activity, or floppiness
• turning pale, or no color change
• decreased breathing rate or slowing of the heart rate.

There are now several tools designed to help determine when a baby is in pain. They usually rate how irritable the baby appears (crying, whimpering, grimacing), change in activity level, change in sleep patterns, change from usual ways of responding, and stability of physiological signs (heart rate, breathing, oxygen levels). If a tool like this is used by the nurses in your nursery, becoming familiar with it may help you as a parent to understand your baby's responses when there is reason to suspect pain. These tools are only rough guides; there is as yet no sure way to know when your baby actually is experiencing pain.

There are a number of drugs that can be used for relieving the sensory experience of pain in babies. However, all drugs have disadvantages as well as benefits. Different nurseries prefer different drugs. To find out which drugs might be used for your baby, consult the nurses and physicians in your nursery.

Sometimes, the physician or nurse may decide that using a drug to reduce pain is more harmful to the baby than the experience of pain. For example, drugs used for pain may cause the blood pressure to fall, impair the baby's ability to breathe, or hide a fever.

There are a number of other ways to help relieve the sensory experience of pain and help the baby cope with the experience of pain or discomfort.

• Giving rhythmical, repetitive stimulation may block out painful sensations. For example, rocking and music often are soothing.
• Firm touch may block painful sensations. (Light finger-tip touching usually is arousing, not soothing.) Gentle but firm pressure with the hand, or swaddling the baby tightly, provide a constant touch sensation that may block pain.
• Distraction can reduce the baby's attention to painful sensations. Sucking on a pacifier can provide distraction.

Responding quickly to signs of pain or discomfort gives the baby some control. A pacifier also gives some control -- the baby can stop and start sucking or adjust the strength of sucking.

No, babies will react in different ways to these attempts to soothe them. For example, for some babies being touched or rocked is not soothing, and for others, sounds or music also may not be calming. It always is important to carefully watch how the baby responds when trying any of the suggested ways to relieve pain or discomfort. Try something else if what you are doing seems to be more stressful than helpful.

When we experience pain or discomfort, each of us tries to deal with it or adapt to it in ways that work for us. Therefore, rather than trying to identify a set of specific behaviors or signs that mean your baby is in pain, it is more helpful to learn how each individual baby tries to cope with being upset or uncomfortable, and what works best to help him or her feel more comfortable.