Clinical Focus

  • Neonatal-Perinatal Medicine

Academic Appointments

Professional Education

  • Board Certification: American Board of Pediatrics, Neonatal-Perinatal Medicine (2016)
  • ScD, Harvard TH Chan School of Public Health, Social and Behavioral Sciences (2014)
  • MPH, Harvard TH Chan School of Public Health, Clinical Effectiveness (2011)
  • Fellowship, Boston Children's Hospital, Neonatal-Perinatal Medicine (2011)
  • Board Certification: American Board of Pediatrics, Pediatrics (2009)
  • Residency, UCSF, Pediatrics (2008)
  • MD, Case Western Reserve University School of Medicine, Medicine (2005)

Current Research and Scholarly Interests

My research program has two distinct though closely related areas of focus. The first concerns understanding pathways through which chronic health problems impact behavioral development and functional outcomes among preterm infants. I am particularly interested in how neonatal multimorbidity and associated markers of epigenetic aging can help improve risk-prediction for long-term functional outcomes. My second area of academic focus is bringing health services research and improvement science approaches to studying the delivery of high-risk infant follow-up and developing innovative models of post-discharge care. This work includes a focus on population health management, value-based care, and equity-focused quality improvement.

All Publications

  • Community Considerations for Aggressive Intensive Care Therapy for Infants <24+0 Weeks of Gestation JOURNAL OF PEDIATRICS Guillen, U., Zupancic, J. F., Litt, J. S., Kaempf, J., Fanaroff, A., Polin, R. A., Martin, R., Eichenwald, E., Wilson-Costello, D., Edwards, A., Hallman, M., Buehrer, C., Fanaroff, J., Albersheim, S., Embleton, N. D., Shah, P. S., Dennery, P. A., Discenza, D., Jobe, A. H., Kirpalani, H. 2024; 268: 113948

    View details for DOI 10.1016/j.jpeds.2024.113948

    View details for Web of Science ID 001194171700001

    View details for PubMedID 38336203

  • NICU Language, Everyday Ethics, and Giving Better News: Optimizing Discussions about Disability with Families CHILDREN-BASEL Church, P., Dahan, M., Rule, A., Janvier, A., Stewart, J. E., Maypole, J. S., Fehlings, D., Litt, J. S., Banihani, R. 2024; 11 (2)


    The Neonatal Intensive Care Unit (NICU) has a language and culture that is its own. For professionals, it is a place of intense and constant attention to microdetails and cautious optimism. For parents, it is a foreign place with a new and unique language and culture. It is also the setting in which they are introduced to their child and parenthood for this child. This combination has been referred to as an emotional cauldron. The neonatal ethics literature mainly examines complex ethical dilemmas about withholding/drawing life sustaining interventions for fragile children. Rarely are everyday ethics or mundane ethics discussed. Microethics describe the mundane, discrete moments that occur between patients/families and clinicians. A key piece of these microethics is the language used to discuss patient care. Perception of prognoses, particularly around long-term neurodevelopmental outcome, is shaped with the language used. Despite this, clinicians in the NICU often have no specific training in the long-term neurodevelopment outcomes that they discuss. This paper focuses on the microethics of language used to discuss long-term neurodevelopmental outcomes, the developmental neuroscience behind language processing, and offers recommendations for more accurate and improved communication around long-term outcomes with families with critically ill neonates.

    View details for DOI 10.3390/children11020242

    View details for Web of Science ID 001174794000001

    View details for PubMedID 38397354

    View details for PubMedCentralID PMC10887718

  • Ensuring Optimal Outcomes for Preterm Infants after NICU Discharge: A Life Course Health Development Approach to High-Risk Infant Follow-Up. Children (Basel, Switzerland) Litt, J. S., Halfon, N., Msall, M. E., Russ, S. A., Hintz, S. R. 2024; 11 (2)


    Children born prematurely (<37 weeks' gestation) have an increased risk for chronic health problems and developmental challenges compared to their term-born peers. The threats to health and development posed by prematurity, the unintended effects of life-sustaining neonatal intensive care, the associated neonatal morbidities, and the profound stressors to families affect well-being during infancy, childhood, adolescence, and beyond. Specialized clinical programs provide medical and developmental follow-up care for preterm infants after hospital discharge. High-risk infant follow-up, like most post-discharge health services, has many shortcomings, including unclear goals, inadequate support for infants, parents, and families, fragmented service provisions, poor coordination among providers, and an artificially foreshortened time horizon. There are well-documented inequities in care access and delivery. We propose applying a life course health development framework to clinical follow-up for children born prematurely that is contextually appropriate, developmentally responsive, and equitably deployed. The concepts of health development, unfolding, complexity, timing, plasticity, thriving, and harmony can be mapped to key components of follow-up care delivery to address pressing health challenges. This new approach envisions a more effective version of clinical follow-up to support the best possible functional outcomes and the opportunity for every premature infant to thrive within their family and community environments over their life course.

    View details for DOI 10.3390/children11020146

    View details for PubMedID 38397258

    View details for PubMedCentralID PMC10886801

  • To Achieve Equitable, Integrated Care for Children, Family-Centered Work Must Focus on Systems FAMILIES SYSTEMS & HEALTH Rosenfeld, L., Litt, J. S. 2023; 41 (4): 547-549


    Child health inequities are largely the result of entrenched, structural barriers created by racism, sexism, xenophobia, classism, and ableism that generally persist across the life course (Braveman & Gottlieb, 2014). The impact of such inequities may be magnified for those with complex needs who face considerable challenges in adulthood (Bethell et al., 2014), such as preterm infants, who experience threats to both short- and longterm health and development. Challenges in integrated care remain for all children, especially this population, despite extensive work across many decades to address such issues. The family-centered medical home has been the dominant pediatric care model in the United States for the last four decades (Stille et al., 2010). Despite emphasizing cultural humility and placing family at the care team core, the medical home model has not been able to deliver on securing equitable, integrated care for all (Bennett et al., 2012). (PsycInfo Database Record (c) 2024 APA, all rights reserved).

    View details for DOI 10.1037/fsh0000809

    View details for Web of Science ID 001162349200004

    View details for PubMedID 38284974

    View details for PubMedCentralID PMC10827344

  • Does faster weight trajectory lead to improved neurodevelopmental outcomes in ELBW infants with bronchopulmonary dysplasia? JOURNAL OF PERINATOLOGY Munoz, F. A., Carter, E., Edwards, E. M., Jerome, M., Litt, J. S. 2024; 44 (2): 301-306


    Examine the relationship between weight trajectory and 2-year neurodevelopmental outcomes for extremely low birthweight (ELBW) infants with BPD.Secondary analysis of infants born from 2010 to 2019. The predictor was BPD severity and the outcome was neurodevelopmental impairment, defined as any Bayley Scales of Infant Development (BSID) III score <70 at 24 months' corrected age. Repeated measures logistic regression was performed.In total, 5042 infants were included. Faster weight trajectory was significantly associated with a decreased probability of having at least one BSID III score <70 for infants with grade 1-2 BPD (p < 0.0001) and an increased probability of at least one BSID III score <70 for infants with grade 3 BPD (p < 0.009). There was no significant association between weight trajectory and BSID III score <70 for infants with grade 0 BPD.The association between postnatal weight trajectory and neurodevelopmental outcome in this study differs by BPD severity.

    View details for DOI 10.1038/s41372-023-01808-z

    View details for Web of Science ID 001099085800001

    View details for PubMedID 37898685

    View details for PubMedCentralID 4787615

  • Organizational Health Literacy as a Tool for Health Equity: Application in a High-Risk Infant Follow-Up Program CHILDREN-BASEL Rosenfeld, L. E., Mccullagh, K., King, C. J., Torres, M., Litt, J. S. 2023; 10 (10)


    Healthy People 2030 emphasizes personal health literacy (individual skills) and organizational health literacy-the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others. However, research on the latter is in the early stages.This study describes an organizational health literacy assessment in a U.S. urban academic children's hospital. A variety of evidence-based health literacy assessments were used to assess patient information materials and the environment, including institutional practices, navigation, culture and language, and communication. Trained interviewers and analysts reached consensus for all assessments.Information Items: SMOG scores (n = 9) ranged from 7th- to 14th-grade reading level (average = 11.3). PEMAT-P scores (n = 9) ranged from 43.8% to 93.8% understandability and 0% to 80% actionability. CDC CCI scores (literacy demand) (n = 6) ranged from 18.2% to 58.8% (≥90% = excellent). SAM scores (suitability) (n = 6) fell in the "adequate" range (43.2-58.3%). The PMOSE/IKIRSCH scores (complexity) (n = 3) noted low-moderate difficulty. Apter's Hierarchy (n = 4) revealed three numeracy domains (50% = descriptive purposes and decision-making, 100% = interpreting information). Organization-level: Walking interviews highlighted organizational facilitators and barriers related to the pre-visit and visit environments. HLE2 domain scores ranged from 52% to 68%.Organizational health literacy demands far outweigh the average literacy skills of adults in the U.S. (patients and staff). Findings can be used to hone quality improvement and other processes to focus on structural solutions to increase health equity.

    View details for DOI 10.3390/children10101658

    View details for Web of Science ID 001092468500001

    View details for PubMedID 37892321

    View details for PubMedCentralID PMC10605611

  • Outcomes assessments should reflect the dynamic and contextual nature of early childhood development PEDIATRIC RESEARCH Litt, J. S., Church, P. 2024; 95 (3): 613-614

    View details for DOI 10.1038/s41390-023-02816-7

    View details for Web of Science ID 001081725800001

    View details for PubMedID 37704709

    View details for PubMedCentralID 9677545

  • High-Risk Infant Follow-Up After NICU Discharge Current Care Models and Future Considerations CLINICS IN PERINATOLOGY Litt, J. S., Campbell, D. E. 2023; 50 (1): 225-238


    Preterm infants are at heightened risk for chronic health problems and developmental delays compared with term-born peers. High-risk infant follow-up programs provide surveillance and support for problems that may emerge during infancy and early childhood. Although considered standard of care, program structure, content, and timing are highly variable. Families face challenges accessing recommended follow-up services. Here, the authors review common models of high-risk infant follow-up, describe novel approaches, and outline considerations for improving the quality, value, and equity of follow-up care.

    View details for DOI 10.1016/j.clp.2022.11.004

    View details for Web of Science ID 000995687100001

    View details for PubMedID 36868707

  • Racial Inequity in High-Risk Infant Follow-Up Among Extremely Low Birth Weight Infants PEDIATRICS Fraiman, Y. S., Edwards, E. M., Horbar, J. D., Mercier, C. E., Soll, R. F., Litt, J. S. 2023; 151 (2)


    High-risk infant follow-up programs (HRIFs) are a recommended standard of care for all extremely low birth weight (ELBW) infants to help mitigate known risks to long-term health and development. However, participation is variable, with known racial and ethnic inequities, though hospital-level drivers of inequity remain unknown. We conducted a study using a large, multicenter cohort of ELBW infants to explore within- and between-hospital inequities in HRIF participation.Vermont Oxford Network collected data on 19 503 ELBW infants born between 2006 and 2017 at 58 US hospitals participating in the ELBW Follow-up Project. Primary outcome was evaluation in HRIF at 18 to 24 months' corrected age. The primary predictor was infant race and ethnicity, defined as maternal race (non-Hispanic white, non-Hispanic Black, Hispanic, Asian American, Native American, other). We used generalized linear mixed models to test within- and between-hospital variation and inequities in HRIF participation.Among the 19 503 infants, 44.7% (interquartile range 31.1-63.3) were seen in HRIF. Twenty six percent of the total variation in HRIF participation rates was due to between-hospital variation. In adjusted models, Black infants had significantly lower odds of HRIF participation compared with white infants (adjusted odds ratio, 0.73; 95% confidence interval, 0.64-0.83). The within-hospital effect of race varied significantly between hospitals.There are significant racial inequities in HRIF participation, with notable variation within and between hospitals. Further study is needed to identify potential hospital-level targets for interventions to reduce this inequity.

    View details for DOI 10.1542/peds.2022-057865

    View details for Web of Science ID 001050089800022

    View details for PubMedID 36594226

    View details for PubMedCentralID PMC10696436

  • Impaired pulmonary function mediates inattention in young adults born extremely preterm ACTA PAEDIATRICA Litt, J. S., Johnson, S., Marlow, N., Tiemeier, H. 2023; 112 (2): 254-260


    To test whether poor childhood pulmonary function explains the relationship between extremely preterm (EP) birth and attention-deficit/hyperactivity disorder (ADHD) symptoms in young adulthood.EPICure birth cohort participants include children born <26 weeks' gestation in the United Kingdom and Ireland in 1995 and their term-born classmates. Predictor was EP birth. Outcomes were inattention/hyperactivity subscale z-scores at 19 years. Forced expiratory volume (FEV1) z-scores in childhood and young adulthood were mediators. We used recursive path analysis to determine the direct effect of EP birth on inattention/hyperactivity and its indirect effect through pulmonary function.Ninety EP and 47 term-born participants had pulmonary function testing at 11 and 19 years. Inattention z-scores were higher in the EP group (mean difference 0.55 [95% CI 0.11, 0.99]) but not hyperactivity. Compared to term-born peers, EP participants had lower FEV1 z-scores at 11 (mean difference-1.35 [95% CI -1.72, -0.98]) and 19 (mean difference-1.29 [95% CI -1.65, -0.92]). Path models revealed that childhood pulmonary function explained the relationship between EP birth and inattention.Extremely preterm young adults have increased risk for inattention compared to term-born peers. Poor pulmonary function appears to underlie this risk. The mechanisms responsible remain unclear and warrant further study.

    View details for DOI 10.1111/apa.16586

    View details for Web of Science ID 000882355100001

    View details for PubMedID 36330674

  • Implications of racial/ethnic perinatal health inequities on long-term neurodevelopmental outcomes and health services utilization SEMINARS IN PERINATOLOGY Fraiman, Y. S., Barrero-Castillero, A., Litt, J. S. 2022; 46 (8): 151660


    Infants born preterm and with low birth weight have increased risk for neurodevelopmental challenges later in life compared to term-born peers. These include functional motor impairment, cognitive and speech delays, neurobehavioral disorders, and atypical social development. There are well-documented inequities in the population distributions of preterm birth and associated short-term morbidities by race, ethnicity, language, and nativity. Far less is known about how these inequities affect long-term outcomes, though the impact of unequal access to post-discharge support services for preterm infants raises concerns about widening gaps in health, development, and functioning. In this review, we describe what is currently known about the impact of race, ethnicity, nativity, and language on long-term outcomes. We provide a framework for understanding inequities in social, political, and historical context. And we offer guidance for next steps to delineate mechanistic pathways and to identify interventions to eliminate inequities in long-term neurodevelopmental outcomes through research, intervention, and advocacy.

    View details for DOI 10.1016/j.semperi.2022.151660

    View details for Web of Science ID 000892225200009

    View details for PubMedID 36175260

  • Change in neurodevelopmental outcomes for extremely premature infants over time: a systematic review and meta-analysis ARCHIVES OF DISEASE IN CHILDHOOD-FETAL AND NEONATAL EDITION Kaempf, J. W., Guillen, U., Litt, J. S., Zupancic, J. F., Kirpalani, H. 2023; 108 (5): F458-F463


    Survival rates of extremely premature infants are rising, but changes in neurodevelopmental impairment (NDI) rates are unclear. Our objective was to perform a systematic review of intrainstitutional variability of NDI over time.Systematic review and meta-analysis.Ovid MEDLINE, Embase, PubMed, Cochrane Library and Google Scholar.Study eligibility: (1) at least two discrete cohorts of infants born <27 weeks' gestation or <1000 g birth weight, (2) one cohort born after 1990 and at least one subsequent cohort of similar gestational age, (3) all cohorts cared for within the same Neonatal Intensive Care Unit(s) (NICU) and (4) neurodevelopmental outcomes at 18-36 months corrected age.Change in NDI rates. Quality, validity and bias were assessed using Grading of Recommendations, Assessment, Development, and Evaluation and Quality in Prognosis Studies guidelines.Of 203 publications, 15 were eligible, including 13 229 infants. At the first time point, average NDI rate across study groups weighted by sample size was 41.0% (95% CI 34.0% to 48.0%). The average change in NDI between time points was -3.3% (95% CI -8·8% to 2.2%). For each added week of gestation at birth, the rate of NDI declined by 9.7% (95% CI 6.2% to 13.3%). Most studies exhibited moderate-severe bias in at least one domain, especially attrition rates.When comparing discrete same-centre cohorts over time, there was no significant change in NDI rates in infants born <27 weeks' gestation or <1000 g. Higher survival rates unaccompanied by improvement in neurodevelopment highlight urgency for renewed focus on the causes of NDI and evidence-based strategies to reduce brain injury.

    View details for DOI 10.1136/archdischild-2022-324457

    View details for Web of Science ID 000872154700001

    View details for PubMedID 36270779

  • Increased Breastfeeding Proportion Is Associated with Improved Gross Motor Skills at 3-5 Years of Age: A Pilot Study NUTRIENTS D'Souza, E. E., Vyas, R., Sisitsky, M., Feldman, H. A., Gagoski, B., Litt, J., Larsen, R. J., Kuchan, M. J., Lasekan, J. B., Sutton, B. P., Grant, P., Ou, Y., Morton, S. U. 2022; 14 (11)


    Breastmilk provides key nutrients and bio-active factors that contribute to infant neurodevelopment. Optimizing maternal nutrition could provide further benefit to psychomotor outcomes. Our observational cohort pilot study aims to determine if breastfeeding extent and breastmilk nutrients correlate with psychomotor outcomes at school age. The breastfeeding proportion at 3 months of age and neurodevelopmental outcomes at 3-5 years of age were recorded for 33 typically developing newborns born after uncomplicated pregnancies. The association between categorical breastfeeding proportion and neurodevelopmental outcome scores was determined for the cohort using a Spearman correlation with and without the inclusion of parental factors. Vitamin E and carotenoid levels were determined in breastmilk samples from 14 of the mothers. After the inclusion of parental education and income as covariates, motor skill scores positively correlated with breastmilk contents of α-tocopherol (Spearman coefficient 0.88, p-value = 0.02), translutein (0.98, p-value = 0.0007), total lutein (0.92, p-value = 0.01), and zeaxanthin (0.93, p-value = 0.0068). Problem solving skills negatively correlated with the levels of the RSR enantiomer of α-tocopherol (-0.86, p-value = 0.03). Overall, higher exposure to breastfeeding was associated with improved gross motor and problem-solving skills at 3-5 years of age. The potential of α-tocopherol, lutein, and zeaxanthin intake to provide neurodevelopmental benefit is worthy of further investigation.

    View details for DOI 10.3390/nu14112215

    View details for Web of Science ID 000808803600001

    View details for PubMedID 35684014

    View details for PubMedCentralID PMC9182886

  • Assessment of Maternal Macular Pigment Optical Density (MPOD) as a Potential Marker for Dietary Carotenoid Intake during Lactation in Humans NUTRIENTS Al-Hassan, A., Vyas, R., Zhang, Y., Sisitsky, M., Gagoski, B., Litt, J. S., Larsen, R. J., Kuchan, M. J., Lasekan, J. B., Sutton, B. P., Grant, P., Ou, Y., Morton, S. U. 2022; 14 (1)


    Pregnancy and lactation can change the maternal nutrient reserve. Non-invasive, quantitative markers of maternal nutrient intake could enable personalized dietary recommendations that improve health outcomes in mothers and infants. Macular pigment optical density (MPOD) is a candidate marker, as MPOD values generally reflect carotenoid intake. We evaluated the association of MPOD with dietary and breastmilk carotenoids in postpartum women. MPOD measurements and dietary intake of five carotenoids were obtained from 80 mothers in the first three months postpartum. Breastmilk samples from a subset of mothers were analyzed to determine their nutrient composition. The association between MPOD and dietary or breastmilk carotenoids was quantitatively assessed to better understand the availability and mobilization of carotenoids. Our results showed that dietary α-carotene was positively correlated with MPOD. Of the breastmilk carotenoids, 13-cis-lutein and trans-lutein were correlated with MPOD when controlled for the total lutein in breastmilk. Other carotenoids in breastmilk were not associated with MPOD. Maternal MPOD is positively correlated with dietary intake of α-carotene in the early postpartum period, as well as with the breastmilk content of lutein. MPOD may serve as a potential marker for the intake of carotenoids, especially α-carotene, in mothers in the early postpartum period.

    View details for DOI 10.3390/nu14010182

    View details for Web of Science ID 000741701100001

    View details for PubMedID 35011057

    View details for PubMedCentralID PMC8746783

  • Race, language, and neighborhood predict high-risk preterm Infant Follow Up Program participation JOURNAL OF PERINATOLOGY Fraiman, Y. S., Stewart, J. E., Litt, J. S. 2022; 42 (2): 217-222


    Infant Follow Up Programs (IFUPs) provide developmental surveillance for preterm infants after hospital discharge but participation is variable. We hypothesized that infants born to Black mothers, non-English speaking mothers, and mothers who live in "Very Low" Child Opportunity Index (COI) neighborhoods would have decreased odds of IFUP participation.There were 477 infants eligible for IFUP between 1/1/2015 and 6/6/2017 from a single large academic Level III NICU. Primary outcome was at least one visit to IFUP. We used multivariable logistic regression to identify factors associated with IFUP participation.Two hundred infants (41.9%) participated in IFUP. Odds of participation was lower for Black compared to white race (aOR 0.43, p = 0.03), "Very Low" COI compared to "Very High" (aOR 0.39, p = 0.02) and primary non-English speaking (aOR 0.29, p = 0.01).We identified disparities in IFUP participation. Further study is needed to understand underlying mechanisms to develop targeted interventions for reducing inequities.

    View details for DOI 10.1038/s41372-021-01188-2

    View details for Web of Science ID 000685596200001

    View details for PubMedID 34404926

    View details for PubMedCentralID PMC8859815

  • Follow-through care for high-risk infants during the COVID-19 pandemic: lessons learned from the Vermont Oxford Network JOURNAL OF PERINATOLOGY Litt, J. S., Mercier, C. E., Edwards, E. M., Morrow, K., Soll, R. 2021; 41 (11): 2625-2630


    The COVID-19 pandemic has altered the delivery of follow-up care for high-risk infants. We performed an audit to characterize programmatic responses in a quality improvement network.We audited 43 North American-based follow-up programs of the Vermont Oxford Network Extremely Low Birth Weight Follow-up Study Group in October, 2020. Our electronic survey included yes/no, agree/disagree, and free text response items.The response rate was 67.4%. Most programs altered capacity and the timing, frequency, or content of clinical assessments. Most perceived practice changes compromised their ability to ascertain infants' medical and developmental needs. There was a rapid uptake of telemedicine services. Despite challenges with implementation, many endorsed improved connectedness with families.Programs adapted rapidly to meet the needs of high-risk infants during the pandemic. Clinical operations, assessment procedures, and quality metrics will also need to evolve. Quality improvement study group collaboratives are well-positioned to coordinate such work.

    View details for DOI 10.1038/s41372-021-01158-8

    View details for Web of Science ID 000678019800001

    View details for PubMedID 34315972

    View details for PubMedCentralID PMC8314022

  • Long-term respiratory and developmental outcomes in children with bronchopulmonary dysplasia and history of tracheostomy JOURNAL OF PERINATOLOGY Annesi, C. A., Levin, J. C., Litt, J. S., Sheils, C. A., Hayden, L. P. 2021; 41 (11): 2645-2650


    The long-term morbidity among children with severe bronchopulmonary dysplasia who require tracheostomy (tBPD) relative to those without tracheostomy (sBPD) is not well characterized. We compared childhood lung function and neurodevelopmental outcomes in tBPD and sBPD.Retrospective case-control study of N = 49 tBPD and N = 280 sBPD subjects in Boston Children's Hospital Preterm Lung Patient Registry and medical record. We compared NICU course, childhood spirometry, and neurodevelopmental testing.tBPD subjects were more likely than sBPD to be Black, have pulmonary hypertension, and have subglottic stenosis. tBPD subjects had lower maximal childhood FEV1 % predicted (β = -0.14) and FEV1/FVC (β = -0.08); spirometry curves were more likely to suggest fixed extrathoracic obstruction. tBPD subjects had greater cognitive and motor delays <24 months, and greater cognitive delays >24 months.Compared to subjects with sBPD who did not require tracheostomy, tBPD subjects suffer from increased long-term impairment in respiratory function and neurodevelopment.

    View details for DOI 10.1038/s41372-021-01144-0

    View details for Web of Science ID 000675344000001

    View details for PubMedID 34290373

    View details for PubMedCentralID PMC8294252

  • Quantification of magnetic resonance spectroscopy data using a combined reference: Application in typically developing infants NMR IN BIOMEDICINE Larsen, R. J., Gagoski, B., Morton, S. U., Ou, Y., Vyas, R., Litt, J., Grant, P., Sutton, B. P. 2021; 34 (7): e4520


    Quantification of proton magnetic resonance spectroscopy (1 H-MRS) data is commonly performed by referencing the ratio of the signal from one metabolite, or metabolite group, to that of another, or to the water signal. Both approaches have drawbacks: ratios of two metabolites can be difficult to interpret because study effects may be driven by either metabolite, and water-referenced data must be corrected for partial volume and relaxation effects in the water signal. Here, we introduce combined reference (CRef) analysis, which compensates for both limitations. In this approach, metabolites are referenced to the combined signal of several reference metabolites or metabolite groups. The approach does not require the corrections necessary for water scaling and produces results that are less sensitive to the variation of any single reference signal, thereby aiding the interpretation of results. We demonstrate CRef analysis using 202 1 H-MRS acquisitions from the brains of 140 infants, scanned at approximately 1 and 3 months of age. We show that the combined signal of seven reference metabolites or metabolite groups is highly correlated with the water signal, corrected for partial volume and relaxation effects associated with cerebral spinal fluid. We also show that the combined reference signal is equally or more uniform across subjects than the reference signals from single metabolites or metabolite groups. We use CRef analysis to quantify metabolite concentration changes during the first several months of life in typically developing infants.

    View details for DOI 10.1002/nbm.4520

    View details for Web of Science ID 000645057200001

    View details for PubMedID 33913194

  • Prevalence of problematic feeding in young children born prematurely: a meta-analysis BMC PEDIATRICS Pados, B., Hill, R. R., Yamasaki, J. T., Litt, J. S., Lee, C. S. 2021; 21 (1): 110


    Difficulties related to eating are often reported in children born preterm. The objective of this study was to quantitatively synthesize available data on the prevalence of problematic feeding in children under 4 years of age who were born preterm.Literature was identified from PubMed, CINAHL, and PsycInfo. The search was limited to English language and publication years 2000-2020. To be included in the meta-analysis, the article had to report the prevalence of problematic oral feeding within a population of children born prematurely (< 37 weeks' gestation), and the child age at the time of study had to be between full-term corrected age and 48 months. For studies meeting inclusion criteria, the following data were extracted: sample size and subsamples by gestational age and/or child age at time of study; definition of problematic feeding; measures used for assessment of feeding; gestational age at time of birth of sample; child age at time of study; exclusion criteria for the study; and prevalence of problematic feeding. Random-effects meta-analyses were performed to estimate the prevalence of problematic feeding across all studies, by gestational age at birth, and by child age at time of study.There were 22 studies that met inclusion criteria. Overall prevalence of problematic feeding (N = 4381) was 42% (95% CI 33-51%). Prevalence was neither significantly different across categories of gestational age nor by child age at the time of study. Few studies used psychometrically-sound assessments of feeding.Problematic feeding is highly prevalent in prematurely-born children in the first 4 years of life regardless of degree of prematurity. Healthcare providers of children born preterm should consider screening for problematic feeding throughout early childhood as a potential complication of preterm birth.Not applicable.

    View details for DOI 10.1186/s12887-021-02574-7

    View details for Web of Science ID 000626583800001

    View details for PubMedID 33676453

    View details for PubMedCentralID PMC7936467

  • Racial and ethnic disparities in adult COVID-19 and the future impact on child health PEDIATRIC RESEARCH Fraiman, Y. S., Litt, J. S., Davis, J. M., Pursley, D. M., Pediat Policy Council 2021; 89 (5): 1052-1054

    View details for DOI 10.1038/s41390-021-01377-x

    View details for Web of Science ID 000616434700005

    View details for PubMedID 33564130

    View details for PubMedCentralID PMC7871017

  • Quality improvement for NICU graduates: Feasible, relevant, impactful. Seminars in fetal & neonatal medicine Litt, J. S., Hintz, S. R. 2021: 101205


    Continuous quality improvement (CQI) has become a vital component of newborn medicine. Applying core principles - robust measurement, repeated small tests of change, collaborative learning through data sharing - have led to improvements in care quality, safety, and outcomes in the Neonatal Intensive Care Unit (NICU). High-risk infant follow-up programs (HRIF) have historically aided such quality improvement efforts by providing outcomes data about NICU interventions. Though as a discipline, HRIF has not universally embraced CQI for its own practice. In this review, we summarize the history of CQI in neonatology and applications of improvement science in healthcare and describe examples of CQI in HRIF. We identify the need for consensus on what defines 'high-risk' and constitutes meaningful outcomes. Last, we outline four areas for future investment: establishing evidence-based care delivery systems, standardizing outcomes and their measures, embracing a family-centered approach prioritizing parent goals, and developing professional standards of care for HRIF.

    View details for DOI 10.1016/j.siny.2021.101205

    View details for PubMedID 33589361

  • Telomere length shortening in hospitalized preterm infants: A pilot study PLOS ONE Belfort, M., Qureshi, F., Litt, J., Enlow, M., De Vivo, I., Gregory, K., Tiemeier, H. 2021; 16 (1): e0243468


    Leukocyte telomere length is a biomarker of aging-related health risks. Hospitalized preterm infants frequently experience elevated oxidative stress and inflammation, both of which contribute to telomere shortening. Our aim was to examine changes in telomere length during neonatal intensive care unit (NICU) hospitalization in a cohort of preterm infants <32 weeks' gestation. We conducted a longitudinal study of 10 infants (mean gestational age 27 weeks, range 23.5 to 29, at birth). We isolated DNA from dried blood spots and used Real Time Quantitative PCR to measure relative leukocyte telomere length in triplicate at three time points for each participant. From birth to discharge, infants experienced an average decline in relative telomere length of 0.021 units per week (95% CI -0.040, -0.0020; p = 0.03), after adjustment for gestational age at birth. Our results suggest a measurable decline in telomere length during NICU hospitalization. We speculate that telomere length change may convey information about NICU exposures that carry short- and long-term health risks.

    View details for DOI 10.1371/journal.pone.0243468

    View details for Web of Science ID 000639428800004

    View details for PubMedID 33471805

    View details for PubMedCentralID PMC7817026

  • The Inter-Relationships of Extremely Low Birth Weight, Asthma, and Behavior: A Study of Common Cause, Mediation, and Moderation ACADEMIC PEDIATRICS Litt, J. S., Minich, N., Taylor, H., Tiemeier, H. 2020; 20 (7): 975-982


    Extremely low birth weight (ELBW; <1000 g) infants are at risk for both asthma and problems like inattention, hyperactivity, anxiety, and depression. Asthma predicts behavioral and emotional problems in term-born children. The nature of these associations is poorly understood. We tested 3 models of association: independent risk, mediation, and effect modification to explore interplay among birth weight, asthma, and behavioral and emotional problems.We used data from a prospective cohort of ELBW infants born 1992 to 1995. Exposure was ELBW; primary outcomes were parent-reported diagnosis of asthma and symptoms of inattention, hyperactivity, anxiety, and depression at age 8 years. Covariates included child sex and maternal socioeconomic status.There were 139 ELBW and 101 normal BW (>2500 g) children followed to 8 years. ELBW children were more likely to have asthma (35.7% vs 14.4%, P < .05). Inattention, hyperactivity, depression, and anxiety scores were higher among ELBW children and children with asthma. ELBW was a common cause of asthma and anxiety. There was no evidence of mediation or effect modification by asthma on the effect of ELBW on behavior and emotion symptoms.Asthma does not underlie or amplify the effect of ELBW on behavioral and emotional problems at school age, suggesting that increased risk for respiratory morbidity and neurodevelopment represent largely independent consequences of developmental vulnerability related to ELBW. Noting the impact of chronic illnesses on neurodevelopment in other populations, data focused on symptom trajectories over time in a larger cohort may be necessary to shed further light onto this question.

    View details for Web of Science ID 000571991900017

    View details for PubMedID 32445826

    View details for PubMedCentralID PMC7483415

  • EPICE cohort: 2-year neurodevelopmental outcomes after very preterm birth. Archives of disease in childhood. Fetal and neonatal edition Litt, J. 2020; 105 (4): 344-345

    View details for DOI 10.1136/archdischild-2019-318444

    View details for PubMedID 32041722

  • Community-Based Early Intervention Services for High-Risk Infants: Unanswered Questions Leave Room for Improvement ACADEMIC PEDIATRICS Litt, J. S. 2020; 20 (5): 575-576

    View details for Web of Science ID 000546764500003

    View details for PubMedID 32114089

  • Health Equity and the Social Determinants: Putting Newborn Health in Context PEDIATRICS Litt, J. S., Fraiman, Y. S., Pursley, D. M. 2020; 145 (6)

    View details for DOI 10.1542/peds.2020-0817

    View details for Web of Science ID 000562973000044

    View details for PubMedID 32381624

    View details for PubMedCentralID PMC7426997

  • Predicting the outcomes of preterm neonates beyond the neonatal intensive care unit: What are we missing? PEDIATRIC RESEARCH Crilly, C. J., Haneuse, S., Litt, J. S. 2021; 89 (3): 426-445


    Preterm infants are a population at high risk for mortality and adverse health outcomes. With recent improvements in survival to childhood, increasing attention is being paid to risk of long-term morbidity, specifically during childhood and young-adulthood. Although numerous tools for predicting the functional outcomes of preterm neonates have been developed in the past three decades, no studies have provided a comprehensive overview of these tools, along with their strengths and weaknesses. The purpose of this article is to provide an in-depth, narrative review of the current risk models available for predicting the functional outcomes of preterm neonates. A total of 32 studies describing 43 separate models were considered. We found that most studies used similar physiologic variables and standard regression techniques to develop models that primarily predict the risk of poor neurodevelopmental outcomes. With a recently expanded knowledge regarding the many factors that affect neurodevelopment and other important outcomes, as well as a better understanding of the limitations of traditional analytic methods, we argue that there is great room for improvement in creating risk prediction tools for preterm neonates. We also consider the ethical implications of utilizing these tools for clinical decision-making. IMPACT: Based on a literature review of risk prediction models for preterm neonates predicting functional outcomes, future models should aim for more consistent outcomes definitions, standardized assessment schedules and measurement tools, and consideration of risk beyond physiologic antecedents. Our review provides a comprehensive analysis and critique of risk prediction models developed for preterm neonates, specifically predicting functional outcomes instead of mortality, to reveal areas of improvement for future studies aiming to develop risk prediction tools for this population. To our knowledge, this is the first literature review and narrative analysis of risk prediction models for preterm neonates regarding their functional outcomes.

    View details for DOI 10.1038/s41390-020-0968-5

    View details for Web of Science ID 000539278400001

    View details for PubMedID 32428926

    View details for PubMedCentralID PMC7276948

  • Developmental Support for Infants With Genetic Disorders PEDIATRICS Wojcik, M. H., Stewart, J. E., Waisbren, S. E., Litt, J. S. 2020; 145 (5)


    As the technical ability for genetic diagnosis continues to improve, an increasing number of diagnoses are made in infancy or as early as the neonatal period. Many of these diagnoses are known to be associated with developmental delay and intellectual disability, features that would not be clinically detectable at the time of diagnosis. Others may be associated with cognitive impairment, but the incidence and severity are yet to be fully described. These neonates and infants with genetic diagnoses therefore represent an emerging group of patients who are at high risk for neurodevelopmental disabilities. Although there are well-established developmental supports for high-risk infants, particularly preterm infants, after discharge from the NICU, programs specifically for infants with genetic diagnoses are rare. And although previous research has demonstrated the positive effect of early developmental interventions on outcomes among preterm infants, the impact of such supports for infants with genetic disorders who may be born term, remains to be understood. We therefore review the literature regarding existing developmental assessment and intervention approaches for children with genetic disorders, evaluating these in the context of current developmental supports postdischarge for preterm infants. Further research into the role of developmental support programs for early assessment and intervention in high-risk neonates diagnosed with rare genetic disorders is needed.

    View details for DOI 10.1542/peds.2019-0629

    View details for Web of Science ID 000531417100031

    View details for PubMedID 32327449

    View details for PubMedCentralID PMC7193975

  • Optimizing High-risk Infant Follow-up in Nonresearch-based Paradigms: The New England Follow-up Network PEDIATRIC QUALITY & SAFETY Litt, J. S., Edwards, E. M., Lainwala, S., Mercier, C., Montgomery, A., O'Reilly, D., Rhein, L., Woythaler, M., Hartman, T. 2020; 5 (3): e287


    To establish the first regional quality improvement collaborative solely dedicated to follow-through care of high-risk infants after Neonatal intensive care unit (NICU) discharge and to characterize extremely low birth weight (ELBW) follow-up in New England.Eleven of 14 follow-up programs in New England partnered with the Vermont Oxford Network (VON) ELBW project for an initial data collection project. We collected information about the health status and developmental outcomes of infants born ≤1,000 g or younger than 28 weeks 2014-2016 at the 18-24 months corrected for gestational age (CGA) follow-up visit. VON collected and compiled the data.Of 993 eligible infants, 516 (52.0%) had follow-up visits. The rehospitalization rate was 33.9%, mostly respiratory illness. Ninety-six children (19.3%) had weight less than 10th percentile and 44 (8.9%) had weight less than third percentile at 18-24 months. Only 170 (61.4%) children had recommended hearing screening after NICU discharge. Forty-six (9.1%) had cerebral palsy; 81 of the 441 infants that completed all 3 sections of the Bayley Scales of Infant Development, third edition (18.4%) had any composite score less than 70. Over half of the social and demographic data were missing.Most quality initiatives in neonatology stop at NICU discharge. This first project by the New England Follow-up Network showed a low rate for clinical follow-up. It demonstrated many opportunities to improve postdischarge follow-through specific to NICU-based care. Future projects will aim to improve the quality of follow-through services through collaborative learning, data sharing, and comparative outcomes.

    View details for DOI 10.1097/pq9.0000000000000287

    View details for Web of Science ID 000714176000019

    View details for PubMedID 32656462

    View details for PubMedCentralID PMC7297406

  • Maternal Dietary Intake of Omega-3 Fatty Acids Correlates Positively with Regional Brain Volumes in 1-Month-Old Term Infants CEREBRAL CORTEX Morton, S. U., Vyas, R., Gagoski, B., Vu, C., Litt, J., Larsen, R. J., Kuchan, M. J., Lasekan, J. B., Sutton, B. P., Grant, P., Ou, Y. 2020; 30 (4): 2057-2069


    Maternal nutrition is an important factor for infant neurodevelopment. However, prior magnetic resonance imaging (MRI) studies on maternal nutrients and infant brain have focused mostly on preterm infants or on few specific nutrients and few specific brain regions. We present a first study in term-born infants, comprehensively correlating 73 maternal nutrients with infant brain morphometry at the regional (61 regions) and voxel (over 300 000 voxel) levels. Both maternal nutrition intake diaries and infant MRI were collected at 1 month of life (0.9 ± 0.5 months) for 92 term-born infants (among them, 54 infants were purely breastfed and 19 were breastfed most of the time). Intake of nutrients was assessed via standardized food frequency questionnaire. No nutrient was significantly correlated with any of the volumes of the 61 autosegmented brain regions. However, increased volumes within subregions of the frontal cortex and corpus callosum at the voxel level were positively correlated with maternal intake of omega-3 fatty acids, retinol (vitamin A) and vitamin B12, both with and without correction for postmenstrual age and sex (P < 0.05, q < 0.05 after false discovery rate correction). Omega-3 fatty acids remained significantly correlated with infant brain volumes after subsetting to the 54 infants who were exclusively breastfed, but retinol and vitamin B12 did not. This provides an impetus for future larger studies to better characterize the effect size of dietary variation and correlation with neurodevelopmental outcomes, which can lead to improved nutritional guidance during pregnancy and lactation.

    View details for DOI 10.1093/cercor/bhz222

    View details for Web of Science ID 000535900800006

    View details for PubMedID 31711132

    View details for PubMedCentralID PMC8355466

  • Positive health: rebranding an old package with a new name? PEDIATRIC RESEARCH Litt, J. S., Tiemeier, H. 2019; 86 (6): 688-689

    View details for DOI 10.1038/s41390-019-0454-0

    View details for Web of Science ID 000500568000005

    View details for PubMedID 31200388

  • Health related quality of life (HRQoL) in mothers of premature infants at NICU discharge JOURNAL OF PERINATOLOGY Obregon, E., Litt, J. S., Patel, P., Ziyeh, T., McCormick, M. C. 2019; 39 (10): 1356-1361


    Premature delivery and a potential Neonatal Intensive Care Unit admission may be associated with the risk of poor maternal health. We aimed to examine the mothers' health-related quality of life (HRQoL) at the time of infant discharge.Fifty mothers completed the Medical Outcomes Study-Short Form 12. It has a Physical Component Score (PCS) and Mental Component Score (MCS), both with a mean of 50 and standard deviation of 10. Analysis included infant, maternal, and pregnancy-related characteristics.In multivariable analyses, a household income of <150K lowered the PCS by 10 points (p = 0.003) compared to those with higher incomes. Marginal significance was noted in GA, for every week gained the PCS score was lower by 1.5 points.Several risk factors are associated with lower physical health ratings in mothers of preterm infants at discharge. This information can be used to inform providers in their anticipatory guidance to the family and follow-up plans.

    View details for DOI 10.1038/s41372-019-0463-1

    View details for Web of Science ID 000493316700008

    View details for PubMedID 31417142

  • Characterizing Early State Regulation in Preterm Infants JOURNAL OF DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS Litt, J. S., Ho, T., Obregon, E., Patel, P., Ziyeh, T., McCormick, M. C. 2019; 40 (4): 293-300


    To characterize state regulation and behavior of preterm infants after discharge from the neonatal intensive care unit (NICU).We recruited singleton infants born at ≤35 weeks of gestational age (GA) before NICU discharge. Parents completed surveys at discharge and 1, 3, and 6 months after discharge. Infant medical history was gleaned from the medical record. Surveys captured sociodemographic information and measures of infant state regulation (Baby Pediatric Symptom Checklist [BPSC]) and feeding behaviors. We calculated the median BPSC subscale scores at each time point and the proportion of infants with scores in the problem range (≥3/5). We explored longitudinal and cross-sectional correlates of BPSC scores.Fifty families completed the discharge questionnaire, and 42 (84%) completed the 6-month questionnaire. The median GA at birth was 34 weeks (IQR 30.1, 34.4 weeks); the median birth weight was 1930 g (IQR 1460, 2255 g). The median scores were above population norms for irritability and difficulty with routines. Twenty-one infants (40%) had irritability subscale scores in the problem range at 1 month, and 20 (38%) had problem scores on difficulties with routines. Only 9 infants (17%) had problem scores on the inflexibility subscale. Scores in all 3 domains showed different patterns from population norms from 1 to 6 months. BPSC scores were correlated with infant feeding behaviors at 1, 3, and 6 months.Scores for irritability and difficulty with routines among preterm infants were high compared with population norms and differed from normative values through 6 months after discharge. Preterm infants demonstrate problems with state regulation after NICU discharge that may require directed intervention.

    View details for DOI 10.1097/DBP.0000000000000659

    View details for Web of Science ID 000467816100008

    View details for PubMedID 30908422

  • System-Specific Patterns of Thalamocortical Connectivity in Early Brain Development as Revealed by Structural and Functional MRI CEREBRAL CORTEX Ferradal, S. L., Gagoski, B., Jaimes, C., Yi, F., Carruthers, C., Vu, C., Litt, J. S., Larsen, R., Sutton, B., Grant, P., Zollei, L. 2019; 29 (3): 1218-1229


    The normal development of thalamocortical connections plays a critical role in shaping brain connectivity in the prenatal and postnatal periods. Recent studies using advanced magnetic resonance imaging (MRI) techniques in neonates and infants have shown that abnormal thalamocortical connectivity is associated with adverse neurodevelopmental outcomes. However, all these studies have focused on a single neuroimaging modality, overlooking the dynamic relationship between structure and function at this early stage. Here, we study the relationship between structural and functional thalamocortical connectivity patterns derived from healthy full-term infants scanned with diffusion-weighted MRI and resting-state functional MRI within the first weeks of life (mean gestational age = 39.3 ± 1.2 weeks; age at scan = 24.2 ± 7.9 days). Our results show that while there is, in general, good spatial agreement between both MRI modalities, there are regional variations that are system-specific: regions involving primary-sensory cortices exhibit greater structural/functional overlap, whereas higher-order association areas such as temporal and posterior parietal cortices show divergence in spatial patterns of each modality. This variability illustrates the complementarity of both modalities and highlights the importance of multimodal approaches.

    View details for DOI 10.1093/cercor/bhy028

    View details for Web of Science ID 000462494100023

    View details for PubMedID 29425270

    View details for PubMedCentralID PMC6499009

  • Racial and Ethnic Disparities in the Use of Mother's Milk Feeding for Very Low Birth Weight Infants in Massachusetts JOURNAL OF PEDIATRICS Parker, M. G., Gupta, M., Melvin, P., Burnham, L. A., Lopera, A. M., Moses, J. M., Litt, J. S., Belfort, M. B. 2019; 204: 134-+


    To examine the extent to which maternal race/ethnicity is associated with mother's milk use among hospitalized very low birth weight (VLBW) infants and maternal receipt of hospital breastfeeding support practices (human milk prenatal education, first milk expression <6 hours after delivery, lactation consultation <24 hours, any skin-to-skin care <1 month).We studied 1318 mother-VLBW infant pairs in 9 Massachusetts level 3 neonatal intensive care units (NICUs) between January 2015 and November 2017. We estimated associations of maternal race/ethnicity with any and exclusive mother's milk on day 7, on day 28, and at discharge/transfer and hospital practices. We estimated HRs comparing the probability of continued milk use over the hospitalization by race/ethnicity and tested mediation by hospital practices, adjusting for birth weight and gestational age and including hospital and plurality as random effects.Mothers were 48% non-Hispanic white, 21% non-Hispanic black, and 20% Hispanic. Initiation of mother's milk was similar across groups, but infants of Hispanic mothers (hazard ratio [HR], 2.71; 95% CI, 2.05-3.59) and non-Hispanic black mothers (HR, 1.55; 95% CI, 1.17-2.07) stopped receiving milk earlier in the hospitalization compared with infants of non-Hispanic white mothers. Hispanic mothers had lower odds of providing skin-to-skin care at <1 month (OR, 0.61; 95% CI, 0.43-0.87) compared with non-Hispanic whites.Hispanic and non-Hispanic black mothers were less likely than non-Hispanic white mothers to continue providing milk for their VLBW infants throughout the NICU stay.

    View details for DOI 10.1016/j.jpeds.2018.08.036

    View details for Web of Science ID 000453785200026

    View details for PubMedID 30274926

  • Preterm infants are less likely to have a family-centered medical home than term-born peers JOURNAL OF PERINATOLOGY Litt, J. S., McCormick, M. C. 2018; 38 (10): 1391-1397


    The family-centered medical home (FCMH) is the recommended healthcare delivery model for children. It is unknown how frequently preterm (PT) children receive care in a FCMH and how this affects health services use.We studied 18,397 children aged 0-3 years in the 2010/2011 National Survey of Children's Health. We compared PT (<37 weeks) and full-term (FT) children on rates of FCMH and receiving prescribed health services. Regression models included sex, race, income, insurance status, and having a special health care need (SHCN).PT children were significantly less likely to have a FCMH (57% vs. 66%) compared to FT peers despite higher rates of SHCN (16% vs. 5%). PT children were less likely to receive prescribed services (aOR 0.34, 95% CI 0.34, 0.34); lacking a FCMH explained 69% of this effect.Ensuring PT children have access to medical homes may decrease unmet service needs post-hospital discharge.

    View details for DOI 10.1038/s41372-018-0180-1

    View details for Web of Science ID 000446499400017

    View details for PubMedID 30046181

  • Early Intervention Services Improve School-age Functional Outcome Among Neonatal Intensive Care Unit Graduates ACADEMIC PEDIATRICS Litt, J. S., Glymour, M., Hauser-Cram, P., Hehir, T., McCormick, M. C. 2018; 18 (4): 468-474


    To evaluate the effect of community-based early intervention (EI) services the on functional outcomes of high-risk infants at school age.This was a retrospective cohort study using data from the US Department of Education's National Early Intervention Longitudinal Study. Participants were enrolled in 1997 to 1998 with follow-up through 5 years and had a neonatal intensive care unit (NICU) admission, birth weight >400 g, and gestational age >23 weeks. Kindergarten outcomes were teacher assessments of academic and physical skills compared with classmates. Because treatment assignment is determined according to level of clinical need, we used repeated measures, marginal structural models with inverse probability of treatment weighting to account for confounding by indication.Of 405 participants, 47% had academic ratings average/above average and 71% had physical skills ratings average/above average. Odds of average/above average academic skills were lower for those with delayed EI enrollment (adjusted odds ratio [aOR], 0.65; 95% confidence interval [CI], 0.43-0.99) and trending, although not significantly, higher for those with greater service duration (aOR, 1.47; 95% CI, 0.98-2.22) and breadth (odds ratio, 1.74; 95% CI, 0.95-3.20). Odds of average/above average physical skills were lower for those with delayed EI enrollment (aOR, 0.61; 95% CI, 0.40-0.93) and higher for those with greater intensity (aOR, 1.06; 95% CI, 1.00-1.13) and breadth (aOR, 1.86; 95% CI, 1.03-3.35), approaching significance for those with greater service duration (aOR, 1.41; 95% CI, 0.96-2.09).Longer, more intense services were associated with higher kindergarten skills ratings in children at risk for disabilities. Our novel findings support the effectiveness of large-scale EI programs and reinforce the importance of referral after NICU discharge.

    View details for DOI 10.1016/j.acap.2017.07.011

    View details for Web of Science ID 000431387700018

    View details for PubMedID 28780329

  • The acceptability and feasibility of emailed parent questionnaires for medical and developmental surveillance after NICU discharge JOURNAL OF PERINATOLOGY Litt, J. S., Agni, M., Jacobi-Polishook, T., Melvin, P., McCormick, M. C., Stewart, J. E., Belfort, M. B. 2018; 38 (4): 392-401


    The following are the objectives of this study: (1) Assess the feasibility and acceptability of emailing parent-reported measures of infant health and development after NICU discharge. (2) Examine whether post-discharge questionnaire data helps identify infants most likely to benefit from specialized follow-up care.Parents of 51 infants <32 weeks' gestation received email questionnaires at 44 weeks postmenstrual age (PMA) and 6 months corrected age (CA). Adverse infant outcomes were assessed in-person at 6 months: (1) Bayley-III cognitive or motor score <85; (2) weight, length, or head circumference <10th percentile; (3) new referral for medical or developmental services.Questionnaire response was 48 (94%) at 44 weeks PMA and 46 (90%) at 6 months CA. 36 (70%) infants were assessed at 6 months; 72% had at least 1 adverse outcome. Poorer transition home, feeding problems, and special health care needs at 44 weeks PMA predicted adverse outcomes. Feeding problems, maternal depression, and lower infant health-related quality of life at 6 months CA correlated with adverse outcomes.Emailed questionnaires after NICU discharge were feasible to implement and acceptable to families. Repeated post-discharge assessments may help identify infants at heightened health and developmental risk.

    View details for DOI 10.1038/s41372-017-0022-6

    View details for Web of Science ID 000432281900015

    View details for PubMedID 29269893

  • Special health care needs explains the effect of extremely low birth weight on math but not language achievement EARLY HUMAN DEVELOPMENT Litt, J. S., Minich, N., Taylor, H., Hack, M. 2017; 115: 82-87


    Extremely low birth weight (ELBW; <1kg) adolescents are at risk for special health care needs (SHCN) and poor math achievement compared to normal birth weight (NBW) peers. SHCN are associated with poor academic achievement among NBW children. We hypothesize that SHCN explain the effect of ELBW on math achievement.We compared age 14 Woodcock-Johnson Calculation standard scores between 181 ELBW infants and 115 NBW controls. Persistent SHCN included: 1) prescription medication or equipment use, 2) subspecialty or therapeutic service use, or 3) hospitalization. We used nonlinear marginal effects models to decompose the total effect of ELBW on math into the following 4 components: the effect of ELBW controlling for SHCN, the effect of SHCN controlling for ELBW, effect modification by SHCN, and mediated interaction where SHCN is both causal mediator and effect modifier. Models were adjusted for sociodemographic factors.ELBW adolescents had lower mean math scores than NBW peers (81.3 vs. 96.4). SHCN were more common among ELBW adolescents (54.1% vs. 27%). The total effect of ELBW on math scores was -15.7 points (95% CI -21.0, -10.5). The effect of birth weight alone was -7.6 points (95% CI -13.7, -1.4); the effect of SHCN alone was negligible. SHCN interaction and mediated interaction effects each accounted for 25% of the total effect.Birth weight alone explains only half of the effect of ELBW on math achievement. We found evidence of effect modification and mediation by SHCN. Understanding these explanatory pathways may lead to targeted interventions for improved outcomes.

    View details for DOI 10.1016/j.earlhumdev.2017.09.019

    View details for Web of Science ID 000416498900015

    View details for PubMedID 28987710

  • Reason for Referral Predicts Utilization and Perceived Impact of Early Intervention Services JOURNAL OF DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS Javalkar, K., Litt, J. S. 2017; 38 (9): 706-713


    Children participating in early intervention (EI) vary in their medical needs and degree of delay, and previous studies have shown significant differences in EI enrollment based on the reason for referral. The effect of reason for referral on service provision and family satisfaction is largely unknown.We used data from the National Early Intervention Longitudinal Study for our secondary data analysis. The main predictor was the reason for referral: a diagnosed condition, documented developmental delay, or other risk factors. Outcomes included unmet service needs, program dropout, and family satisfaction with services.The 2966 participants were mostly white (51.9%), male (60.3%), and had an annual household income at or below $50,000 (77.0%). There were 1924 referred due to diagnosis, 691 due to delay, and 351 due to other risks. Compared with the diagnosis group, children with delays were more likely (adjusted odds ratio [aOR] 1.38, 95% confidence interval [CI], 1.02-1.87) to have unmet service needs and to drop out of EI programs (aOR 1.44, 95% CI, 1.07-1.96); their families were less likely to report that services were highly individualized (aOR 0.80, 95% CI, 0.65-0.98) or had an impact on their children's development (aOR 0.77, 95% CI, 0.62-0.96).Children participating in EI because of developmental delays are more likely to have unmet service needs, drop out of services because of a reason other than ineligibility (family or child-related reason), and have lower caregiver satisfaction than those participating because of diagnosed conditions. It is important to determine reasons for these differences and their impact on developmental outcomes.

    View details for DOI 10.1097/DBP.0000000000000494

    View details for Web of Science ID 000419806500004

    View details for PubMedID 28914728

  • The Outcomes of Very Preterm Infants: Is It Time to Ask Different Questions? PEDIATRICS McCormick, M. C., Litt, J. S. 2017; 139 (1)

    View details for DOI 10.1542/peds.2016-1694

    View details for Web of Science ID 000392122000023

    View details for PubMedID 27940511

  • Strengthening Early Intervention for Very Preterm Infants. Pediatrics McCormick, M. C., Litt, J. S. 2016; 138 (6)

    View details for PubMedID 27940712

  • The Impact of Special Health Care Needs on Academic Achievement in Children Born Prematurely ACADEMIC PEDIATRICS Litt, J. S., McCormick, M. C. 2016; 16 (4): 350-357


    Preterm, low-birth-weight (LBW) children are at increased risk for poor academic achievement and special health care needs (SHCN) compared to term-born peers. It is not known how having SHCN during childhood modifies the relationship between LBW and achievement over time.We used data from the Infant Health and Development Program, a multisite randomized trial of an intervention for preterm, LBW infants with longitudinal follow-up. Primary outcome measures were Woodcock-Johnson Tests of Academic Achievement math and reading scores at age 8 and 18 years. Primary predictor was having a SHCN, defined by prescription medication and medical services use, receipt of special therapies, or any functional limitation. We used repeated measures multivariate analysis of covariance to test the effect of SHCN on achievement at 8 and 18 years and effect modification by IQ.The 576 participants had a mean body weight of 1798.1 ± 455.0 g and a median gestational age of 33 weeks (range, 26-37 weeks). Mean achievement scores were as follows: math (age 8) 97.5 ± 21.6, math (age 18) 90.1 ± 18.3, reading (age 8) 99.0 ± 20.1, and reading (age 18) 96.8 ± 23.5. Mean full scale IQ at age 8 was 92.3 ± 18.2. Eighty percent had a SHCN. Mean achievement scores were significantly different between those with and without SHCN in both math and reading. There was no evidence of effect modification by IQ.SHCNs are associated with poor academic achievement. Targeted interventions for improving performance outcomes by reducing the burden of chronic health problems may be accomplished through prevention strategies or efforts to limit the frequency and severity of symptoms.

    View details for Web of Science ID 000375372800006

    View details for PubMedID 26724181

  • Predictors of caregiver satisfaction with visiting nurse home visits after NICU discharge JOURNAL OF PERINATOLOGY Awindaogo, F., Smith, V. C., Litt, J. S. 2016; 36 (4): 325-328


    High-risk infants are commonly referred to Visiting Nurse Association (VNA) agencies for post-hospitalization services after discharge from the neonatal intensive care unit (NICU). Little is known about the effectiveness and perceived benefits of routine VNA services for these infants. The objective of this study was to identify factors predictive of family satisfaction with VNA services after NICU discharge.This is an observational study using data collected from routine quality assurance phone calls to families after NICU discharge. The setting is a single NICU at a large, urban academic medical center in Boston, MA, USA. We included all hospitalized infants discharged from the NICU from 1 January 2008 to 31 July 2014. Predictors included markers of infant biological and social risk and a survey measure of parent and nurse perceptions of parents' preparedness at discharge. The outcome was parent response to the question, 'Did you find the VNA visit helpful?' at 2 weeks post discharge.Bivariate analyses showed perceived helpfulness of VNA visits associated with low maternal parity, lower 1-min Apgar score, lower birth weight and gestational age, diagnosis of respiratory distress syndrome and intraventricular hemorrhage and low discharge readiness scores. Only low maternal parity (odds ratio (OR) 1.82, 95% confidence interval (CI) 1.35, 2.46) and birth <35 weeks' gestation (OR 1.45, 95% CI 1.15, 1.83) were significant predictors in multivariable analysis.Low maternal parity and gestational age <35 weeks predicted parent satisfaction with VNA services. Referral for VNA services is common after NICU discharge. There are currently no guidelines indicating which infants and families stand to benefit most from such services. Our findings may help in developing and streamlining processes for post-hospitalization VNA service referrals for high-risk infants.

    View details for DOI 10.1038/jp.2015.195

    View details for Web of Science ID 000372857400015

    View details for PubMedID 26675001

  • Care Coordination, the Family-Centered Medical Home, and Functional Disability Among Children With Special Health Care Needs ACADEMIC PEDIATRICS Litt, J. S., McCormick, M. C. 2015; 15 (2): 185-190


    Children with special health care needs (CSHCN) are at increased risk for functional disabilities. Care coordination has been shown to decrease unmet health service use but has yet been shown to improve functional status. We hypothesize that care coordination services lower the odds of functional disability for CSHCN and that this effect is greater within the context of a family-centered medical home. A secondary objective was to test the mediating effect of unmet care needs on functional disability.Our sample included children ages 0 to 17 years participating the 2009-2010 National Survey of Children with Special Health Care Needs. Care coordination, unmet needs, and disability were measured by parent report. We used logistic regression models with covariate adjustment for confounding and a mediation analysis approach for binary outcomes to assess the effect of unmet needs.There were 34,459 children in our sample. Care coordination was associated with lower odds of having a functional disability (adjusted odds ratio 0.82, 95% confidence interval 0.77, 0.88). This effect was greater for care coordination in the context of a medical home (adjusted odds ratio 0.71, 95% confidence interval 0.66, 0.76). The relationship between care coordination and functional disability was mediated by reducing unmet services.Care coordination is associated with lower odds of functional disability among CSHCN, especially when delivered in the setting of a family-centered medical home. Reducing unmet service needs mediates this effect. Our findings support a central role for coordination services in improving outcomes for vulnerable children.

    View details for DOI 10.1016/j.acap.2014.08.006

    View details for Web of Science ID 000350784900010

    View details for PubMedID 25311760

  • The Effect of the Infant Health and Development Program on Special Education Use at School Age JOURNAL OF PEDIATRICS Litt, J. S., Glymour, M., Hauser-Cram, P., Hehir, T., McCormick, M. C. 2015; 166 (2): 457-+


    To evaluate the effect of an intensive early intervention on special service use at school-age.The Infant Health and Development Program was a randomized controlled trial of an intervention for low birth weight (<2500 g) infants ages 0-3 years. We used multivariate logistic regression to test the association between intervention and risk of special education, remedial reading and math, and speech therapy at age 8 years. We also compared rates of service use between study arms among those with learning disabilities (LDs).There were 875 complete cases at 8-year follow-up. There were no statistically significant differences between groups in risk of special education (risk ratio [RR] 0.86, 95% CI 0.64-1.15), remedial reading (RR 0.88, 95% CI 0.68-1.14), remedial math (RR 0.92, 95% CI 0.63-1.34), or speech therapy (RR 0.87, 95% CI 0.62-1.23). The treatment arms did not differ in rates of LDs, and service use for those with LDs was low and unaffected by study group.Early gains in IQ from infant interventions may not protect children as they face the educational demands of grade school. Only a fraction of those having a LD were receiving school-based support services, indicating a high level of unmet need among low birth weight children with disabilities.

    View details for DOI 10.1016/j.jpeds.2014.09.066

    View details for Web of Science ID 000348496200050

    View details for PubMedID 25449222

  • Placental pathology and neonatal thrombocytopenia: lesion type is associated with increased risk JOURNAL OF PERINATOLOGY Litt, J. S., Hecht, J. L. 2014; 34 (12): 914-916


    To investigate the association between thrombocytopenia and placental lesions.Cases included singleton infants admitted to the intensive care unit (2005 to 2010) with platelet counts <100 000 μl(-1). We selected a contemporaneous control group matched for gestational age: 49 cases and 63 controls. The frequency of thrombosis in fetal vessels, fetal thrombotic vasculopathy, acute chorioamnionitis, chronic villitis, infarcts, hematomas, cord insertion and increased circulating nucleated red blood cells were identified on retrospective review of placental histology. Logistic regression models were used to test for associations.Placental lesions associated with poor maternal perfusion (odds ratio (OR) 3.36, 95% confidence interval (CI) 1.38, 8.15) or affecting fetal vasculature (OR 2.75, 95% CI 1.05, 7.23), but not inflammation, were associated with thrombocytopenia. A Pearson Chi-Square Test for Independence for fetal and maternal lesions indicated that the two are independent factors.Poor maternal perfusion and fetal vascular lesions are independently associated with thrombocytopenia in the newborn.

    View details for DOI 10.1038/jp.2014.117

    View details for Web of Science ID 000345486000008

    View details for PubMedID 24945163

  • Influence of Clinical and Sociodemographic Characteristics on Early Intervention Enrollment After NICU Discharge JOURNAL OF EARLY INTERVENTION Litt, J. S., Perrin, J. M. 2014; 36 (1): 37-48
  • Academic achievement of adolescents born with extremely low birth weight ACTA PAEDIATRICA Litt, J. S., Taylor, H., Margevicius, S., Schluchter, M., Andreias, L., Hack, M. 2012; 101 (12): 1240-1245


    To assess academic achievement, rates of learning disabilities (LD) and special education in extremely low birth weight (ELBW <1 kg) adolescents relative to normal birth weight (NBW) controls and to identify cognitive weaknesses.Compared 181 ELBW adolescents born from 1992 to 1995 (mean age 14.8 years, mean BW 809 g, mean GA 26.4 weeks) and 115 NBW term controls. Measures included tests of IQ, reading and math achievement and executive function. Analyses included ANCOVA and logistic and linear regression. Covariates were sex, race and socioeconomic status.Extremely low birth weight adolescents had significantly lower scores on tests of IQ (87.1 vs. 96.4), achievement (88.6 vs. 95.5 reading; 81.3 vs. 93.2 math) and executive function than the NBW group (all p-values <0.001). ELBW also had higher rates of math LD, 51(50%) vs. 26 (28%), OR (95% CI) = 3.10 (1.65, 5.84), p < 0.001, and need for special education, 88 (49%) vs. 11(10%), OR (95% CI) = 11.78 (5.67, 24.47), p < 0.001. Measures of executive function were related to math independent of IQ.Extremely low birth weight adolescents born in the 1990s have poorer achievement and higher rates of math LD than NBW peers. The findings suggest a need for more intensive interventions addressing the specific cognitive vulnerabilities in this population.

    View details for DOI 10.1111/j.1651-2227.2012.02790.x

    View details for Web of Science ID 000310868300028

    View details for PubMedID 22812699

  • Prematurity: An Overview and Public Health Implications ANNUAL REVIEW OF PUBLIC HEALTH, VOL 32 McCormick, M. C., Litt, J. S., Smith, V. C., Zupancic, J. F., Fielding, J. E., Brownson, R. C., Green, L. W. 2011; 32: 367-379


    The high rate of premature births in the United States remains a public health concern. These infants experience substantial morbidity and mortality in the newborn period, which translate into significant medical costs. In early childhood, survivors are characterized by a variety of health problems, including motor delay and/or cerebral palsy, lower IQs, behavior problems, and respiratory illness, especially asthma. Many experience difficulty with school work, lower health-related quality of life, and family stress. Emerging information in adolescence and young adulthood paints a more optimistic picture, with persistence of many problems but with better adaptation and more positive expectations by the young adults. Few opportunities for prevention have been identified; therefore, public health approaches to prematurity include assurance of delivery in a facility capable of managing neonatal complications, quality improvement to minimize interinstitutional variations, early developmental support for such infants, and attention to related family health issues.

    View details for DOI 10.1146/annurev-publhealth-090810-182459

    View details for Web of Science ID 000290776200020

    View details for PubMedID 21219170

  • Learning disabilities in children with very low birthweight: Prevalence, neuropsychological correlates, and educational interventions JOURNAL OF LEARNING DISABILITIES Litt, J., Taylor, H. G., Klein, N., Hack, M. 2005; 38 (2): 130-141


    This study examined achievement, neuropsychological, and intervention outcomes at a mean age of 11 years in children with very low birthweight (VLBW, <1500 g) compared with a term-born control group. To assess the prevalence and correlates of specific learning disabilities (LD), the sample was limited to children without neurosensory disorders who had at least low average IQ. Participants included 31 children with <750 g birthweight, 41 with 750-1499 g birthweight, and 52 controls. The <750 g group obtained lower scores in math, IQ, and perceptual-organizational skills than the term-born group. The < 750 g group also had higher rates of past and present LD than the controls. Despite these differences, the groups did not differ significantly in rates of special education or tutorial/remedial assistance. These findings suggest that children with extremely low birthweight without gross physical or intellectual impairments are at higher risk for LD and cognitive deficiencies than their term-born peers and that further efforts are needed to improve identification and treatment of these learning problems.

    View details for DOI 10.1177/00222194050380020301

    View details for Web of Science ID 000227477900003

    View details for PubMedID 15813595