Hami is a 3-year-old boy who is a former premature 25-week infant with a birth weight of 1 pound 9 ounces. He had a relatively smooth Neonatal Intensive Care Unit (NICU) course; he required intubation for 1 month and went home on room air. He had a left Grade I intraventricular hemorrhage that was resolved by 2 months of life. He had 7 blood transfusions for anemia over the first 3 months of life. A brainstem auditory evoked potential test was normal at hospital discharge, and he showed no evidence of retinopathy of prematurity. He never had seizure activity.
He was discharged to home at 3 months where he did well and thrived on a high calorie formula. He walked at 17 months and spoke his first words at 2 years. He was enrolled in Early Intervention at the time of discharge from hospital; monthly home visits were increased to weekly visits by an early childhood educator at 12 months. When he was 12 months, he was enrolled in a family day care with 4 other children younger than 3 years. Hami's language development was slow; at 2.5 years of age, he was beginning to make 2 word combinations. Early intervention services were increased to include an additional hour of speech and language therapy as well as a play group.
Hami's mother is 33 years old, and this is her first child. She worked as an accounting assistant, but she was able to be home with Hami for the first year of his life. She returned to full-time work on his first birthday. Hami's father is 35 years old and works for the national electrical grid as a manager. They are not married but have lived together for the last 5 years. Dad works evenings and cares for Hami from 4 to 6 pm after childcare; mom returns from work at 6 pm. Dad leaves for work at 7 pm and works till 2 am. Their relationship has been strained by the child care demands, their work schedules, and Hami's developmental progress.
Hami's primary care pediatrician specializes in children with complex medical problems. The parents express concern at the 3-year-old visit that Hami's language is not progressing as it should be. They are concerned that he is much more active than the other 3 year olds in his child care setting. Early intervention has initiated the transition process to a public school placement, and the parents are very concerned that he is too young, too active, and too much of a handful to be “in the big public school.” What would you do next?
From the *Comprehensive Care Clinic, Boston Medical Center, Boston University, School of Medicine; †The Good Grief Program, Boston Medical Center; ‡Division of Developmental and Behavioral Pediatrics, Boston Medical Center, Boston University School of Medicine, Boston, MA.
The next case is posted at www.jdbp.org for discussion on the Clinical Conversations blog.