Integrated follow-up of former extremely preterm infants: how to do it?

Extremely preterm (EP) infants, defined as those born before 28 weeks of gestation or weighing less than 1000 g, face high rates of long-term complications despite improved neonatal survival. This narrative review summarizes current evidence and international consensus on the post-discharge follow-up of EP infants, with emphasis on neurodevelopment, somatic growth, pulmonary and sensory outcomes, and family-centered care. Key domains include early identification of cerebral palsy using neurological assessments such as the General Movements and Hammersmith scales, cognitive monitoring with standardized tools (e.g., Bayley Scales), nutritional and growth surveillance beyond anthropometrics, structured respiratory evaluations including immunoprophylaxis, and timely screening for vision and hearing deficits. In addition, the integration of caregiver-reported outcomes and mental health screening is essential to tailor follow-up strategies and support parental wellbeing. Models of care vary globally, from tertiary-based programs to hybrid and community-integrated approaches, highlighting the need for adaptable, interdisciplinary frameworks. Coordinated long-term follow-up that extends into early childhood is vital to reduce disparities and optimize functional outcomes in this vulnerable population. What is Known: • Extremely preterm infants are at high risk for long-term neurodevelopmental, respiratory, nutritional, and sensory complications, even when neonatal survival improves. • Neurodevelopmental tools such as the Bayley, General Movements, and Hammersmith Scales are widely used for early screening of cognitive and motor outcomes. What is New: • It highlights the importance of Patient-Reported Outcome Measures in complementing clinical surveillance with caregiver perspectives. • It underscores the limitations of early assessments alone and supports extending developmental monitoring into the preschool and school-age years.