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