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Neurodevelopmental Challenges of Neurodevelopmental Challenges of Premature InfantsPremature Infants
Nathalie Maitre, MD, PhD
Identify factors in the intensive care Identify factors in the intensive care nursery which influence the development nursery which influence the development of premature infants.of premature infants.
Understand the prevalence of various Understand the prevalence of various neurodevelopmental impairments of neurodevelopmental impairments of premature infants.premature infants.
Review selected therapies with evidence Review selected therapies with evidence for effect in premature infants.for effect in premature infants.
GoalsGoals
Goal 1Goal 1
Identify factors in the intensive care Identify factors in the intensive care nursery which influence the development nursery which influence the development of premature infants.of premature infants.
Pathogenesis of Impairment in Premature Pathogenesis of Impairment in Premature InfantsInfants
Immature Neural Development
NICU environment Perinatal Injury
Remodeling of Neural PathwaysMICU CourseInterventions
Complications
Cognitive Impairment
MotorImpairment
ExecutiveDysfunction
Neurosensory Impairment
In the BeginningIn the Beginning
Insults to CNS developmentInsults to CNS development
Maternal infectionsMaternal infections IVH/PVLIVH/PVL Hypoxic ischemic encephalopathyHypoxic ischemic encephalopathy ReperfusionReperfusion Excitotoxicity, oxidative stress, Excitotoxicity, oxidative stress,
inflammationinflammation Inherited deficitsInherited deficits MedicationsMedications
The NICU environmentThe NICU environment
VentilatorsVentilators
Neurodevelopmental outcomes worsen Neurodevelopmental outcomes worsen the longer an infant is on a ventilatorthe longer an infant is on a ventilator
Oral/sensory consequencesOral/sensory consequences Physical consequencesPhysical consequences CLD and long-term functionCLD and long-term function
TouchTouch
Effect of immature Effect of immature system on perception system on perception of touchof touch
Perception of painPerception of pain Efficacy of pain Efficacy of pain
managementmanagement Lasting effectsLasting effects
SoundSound
Average sound background in NICUsAverage sound background in NICUs Sound toxicitySound toxicity
LightLight
Circadian rhythms affect the HPA axisCircadian rhythms affect the HPA axis Darkness vs. cycled lightDarkness vs. cycled light PhototherapyPhototherapy
Positive influencesPositive influencesin the NICUin the NICU
Developmental CareDevelopmental Care
•NIDCAP•Stimulation interventions
•decrease hospitalization duration•some studies of long-term effects•many show positive short term effects
Kangaroo CareKangaroo Care
Positive effects on growth, sleep, feeding and stress levels
SummarySummary
Premature infants are at high risk for Premature infants are at high risk for perinatal insults to the CNS.perinatal insults to the CNS.
The intensive care environment The intensive care environment contributes to the altered development of contributes to the altered development of the premature brain.the premature brain.
Few interventions in the intensive care Few interventions in the intensive care nursery are positive input to the nursery are positive input to the developing nervous system.developing nervous system.
Understand the prevalence of various Understand the prevalence of various neurodevelopmental impairments of neurodevelopmental impairments of premature infantspremature infants
Goal 2Goal 2
The more premature the infant, the The more premature the infant, the more likely there will be an more likely there will be an adverse outcome.adverse outcome.
Adverse outcomes:Adverse outcomes:
Low incidence - High severity Low incidence - High severity
High incidence – Low severityHigh incidence – Low severity
What is a severe disability?What is a severe disability?
Extreme variation in Extreme variation in definitionsdefinitions
Severe: combinations Severe: combinations of MDI<70 or 50, PDI of MDI<70 or 50, PDI <70 or 50, IQ <70, CP, <70 or 50, IQ <70, CP, neurosensory deficit.neurosensory deficit.
Can’t run, wash hands Can’t run, wash hands or make a 3 word or make a 3 word sentence at the age of sentence at the age of 3 years.3 years.
Severe disabilitySevere disability
Major Disabilities Based Upon Major Disabilities Based Upon Birth WeightBirth Weight
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
FT LBW VLBW ELBW
Cognitive AbilitiesCognitive Abilities
“ “ The mental faculty of knowing, which includes The mental faculty of knowing, which includes perceiving, recognizing, conceiving, judging, perceiving, recognizing, conceiving, judging, reasoning, and imagining.”reasoning, and imagining.”
The American Heritage® Medical Dictionary Copyright © 2007, 2004 by The American Heritage® Medical Dictionary Copyright © 2007, 2004 by Houghton Mifflin Company.Houghton Mifflin Company.
Cognitive Impairment:Cognitive Impairment:IQ <70IQ <70
9.54x greater in children 9.54x greater in children
who were born < 750 gwho were born < 750 g 2.15x greater in those 751-1499 g2.15x greater in those 751-1499 g 10 points < sibling controls10 points < sibling controls
Motor DifficultiesMotor DifficultiesCerebral palsyCerebral palsy
The Definition and Classification of Cerebral Palsy (2007)Developmental Medicine & Child Neurology
Cerebral PalsyCerebral Palsy
Overall 40-50% of children with CP were Overall 40-50% of children with CP were born prematurely.born prematurely.
The more premature the higher risk of CP.The more premature the higher risk of CP. Periventricular leukomalacia and severe Periventricular leukomalacia and severe
grades of IVH increases the risk of CP.grades of IVH increases the risk of CP.
High prevalence / low severity High prevalence / low severity dysfunctiondysfunction
Learning disabilities (30-60%)Learning disabilities (30-60%) Low average or borderline IQ (15-40%)Low average or borderline IQ (15-40%) ADHD (9-10%)ADHD (9-10%) Neuro-psychological deficitsNeuro-psychological deficits Behavioral disordersBehavioral disorders
Executive functionExecutive function
Processes responsible for purposeful, Processes responsible for purposeful, goal directed behavior which impact on goal directed behavior which impact on cognitive, emotional, behavioral and cognitive, emotional, behavioral and social functionssocial functions
Normal IQ does not exclude executive Normal IQ does not exclude executive dysfunction dysfunction
Executive function in ELBWExecutive function in ELBW
significant significant dysfunction in dysfunction in metacognition and metacognition and in behavioral in behavioral regulation compared regulation compared to NBWto NBW
NOT more impulsiveNOT more impulsive
Anderson, Doyle 04
Speech ImpairmentsSpeech Impairments
Apraxia of speechApraxia of speech Speech delaySpeech delay Feeding disordersFeeding disorders StutteringStuttering Language delay Language delay
(receptive/expressive)(receptive/expressive) Articulation impairmentArticulation impairment
Attention and Behavior Attention and Behavior ImpairmentsImpairments
Delobel, EPIPAGE 06
Sensory functionSensory function
VisualVisual BlindnessBlindness Refractive errorsRefractive errors StrabismusStrabismus NystagmusNystagmus
Hearing Hearing Sensory integrationSensory integration
SummarySummary
Premature infants are at high risk for major Premature infants are at high risk for major and minor impairments.and minor impairments.
The frequency and severity of impairments The frequency and severity of impairments increases as gestational age decreasesincreases as gestational age decreases
Review selected therapies with evidence Review selected therapies with evidence for effect in premature infantsfor effect in premature infants
Goal 3Goal 3
InterventionsInterventionsModalitiesModalities
ProgramsPrograms TherapistsTherapists EquipmentEquipment MedicationsMedications SurgerySurgery Educational supportEducational support
Evidence-based therapiesEvidence-based therapies
Constraint induced movement therapyConstraint induced movement therapy
Evidence-based therapiesEvidence-based therapies
Functional electrical stimulation or Functional electrical stimulation or neuromuscular electrical stimulationneuromuscular electrical stimulation
Evidence-based therapiesEvidence-based therapies
Body weight supported treadmill trainingBody weight supported treadmill training
Interventions and assistive Interventions and assistive devicesdevices
Botox injectionsBotox injections SurgerySurgery Orthotics, splints, walkersOrthotics, splints, walkers
Sensory integration therapy
Speech TherapySpeech Therapy
Feeding therapy
Therapy for apraxia
AcknowledgementsAcknowledgements
At UNC Hospitals: Janice Wereszczak, At UNC Hospitals: Janice Wereszczak, Diane Marshall and the entire SICC teamDiane Marshall and the entire SICC team
At Duke University: Ricki Goldstein, Lylie At Duke University: Ricki Goldstein, Lylie Bonzani, Kara LardinoisBonzani, Kara Lardinois