WHAT%20IS%20NEXT%20FOR%20PRETERM%20INFANTS?

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WHAT IS NEXT FOR PRETERM INFANTS?

• Melissa R. Johnson, Ph.D.
• WakeMed
• November 2008

2
DEVELOPMENTAL CHALLENGES

• Medical
• Social
• Environmental

3
MEDICAL ISSUES

• Respiratory issues
• Respiratory Distress Syndrome (RDS)
• Chronic Lung Disease (CDL)
• Bronchopulmonary Dysplasia (BPD)
• Pneumothorax

4
NEUROLOGIC ISSUES

• Intraventricular hemorrhage (IVH)
• Grades I-IV (some dont use)
• Outcome NOT certain
• Periventricular leukomalacia (PVL)
• Very worrisome but NOT certain- symmetry matters
• Hypoxic-ischemic encephalopathy
• (HIE)
• Cerebral palsy (CP) / Chronic encephalophy

5
VISUAL ISSUES

• Retinopathy of prematurity (ROP)
• Cause still debated
• Therapies still improving
• Close follow-up often critical

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Other medical issues

• Necrotizing enterocolitis (NEC)
• Other infections
• Other causes of prolonged illness, poor nutrition

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PSYCHOSOCIAL CHALLENGES

• Poverty and other chronic stressors
• Substance abuse
• Maltreatment history in family of origin
• Domestic violence
• Parental mental illness

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• Attachment difficulties
• Other family and community stresses
• Child care
• Siblings
• Language
• Transportation
• Education

9
ENVIRONMENTAL CHALLENGES

• NICU environment
• Sound, light, handling, positioning, parental
  access
• Loss of expected environment for brain
  development

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DEVELOPMENTAL TRENDS IN OUTCOME

• Literature keeps growing
• Babies are surviving smaller, younger
• Doctors have more tools to help
• High frequency ventilators, better CPAP
• Artificial surfactants
• Better nutrition strategies

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A look at the research

• Complicated, but still helpful
• Rapidly evolving
• Variability- numbers, SES, percent followed,
  location, size at birth, age at follow-up, source
  of FU info, control group, etc etc etc
• Below a few of best studies from 90s and some
  from 2000-2008

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20 MO. OUTCOME OF ELBW

• 114 premies from 500-750 g
• Born 1990-1992 compared to 82-88
• Survival from 600-700 grams increased from 23 to
  43
• 20 MDI lt70, 10 CP
• Hack et al, JAMA vol. 276, 1996

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PATTERNS OF COGNITIVE DEVELOPMENT

• Looked for patterns - under 1500 g N203 to age
  6
• 37 stayed in average range
• 42 declined from average to below average-
  mostly after age 2
• Only 8 improved
• Koller et al, Pediatrics vol 99, 1997

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ELBW OUTCOME AT 8 YEARS

• 156 survivors 501-1000 compared to matched
  controls in Ontario, CN
• Used multiattribute health status classification

15

• 14 had no functional limitation 58 had reduced
  function in one or more areas 28 had three
  areas affected. Controls 50, 48, 2
• Areas most likely to be affected cognition,
  sensation
• Saigal et al, J. Peds, vol 125, 1994

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ELBW BEHAVIORAL OUTCOME AT 8 YEARS

• 81 survivors 800 g or less matched controls
• Lower global IQs, fm skills
• Trouble with persistence, easily discouraged,
  needed much adult support and approval
• Subtle organizing problems
• Grunau (quoted in Aug 1995 Peds News)

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MATERNAL COMPLIANCE AND OUTCOME

• 152 infants under 1000 g 110 compliant, 42
  noncompliant w/ EI fu
• MDI scores compliant 75.59 noncompliant
  68.24
• PDI scores compliant 82.97
  noncompliant 74.54
• Bonnet et al, Pediatrics supplement, 1998

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ELBW OUTCOME AT 18 MO.

• 1151 babies 401-1000 g.
• Only 1/3 under 900 g had MDI gt85
• 60 901-1000 g gt 85
• Neuro exams, walking, etc better
• Best predictors IVH, BPD, family ed
• Vohr et al, SPR abstract, 1998

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OUTCOME FOR SWEDISH ELBW CHILDREN

• 633 babies followed prospectively
• survival over 23 wks- 59
• 362 assessed at 36 mo
• 25 had CP, 16 blind
• 86 functionally nl- range from 69 for 23-24
  wks to 91 for gt27 wks
• Finnstrom et al, Acta Paediatrica 1998

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SCHOOL-AGE OUTCOME

• 68 lt750 g 65 between 750-1499 g
• Neonatal risk index predicted outcome better than
  social risk index (surprise) but proximal social
  risk more sig.
• Of hi NRI kids, only 15 had IQ gt85
• Of lo NRI kids, 33 had IQ gt 85
• 38/26 had behavior problems
• Taylor et al, Devel. Behav Peds, 1998

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UNDER 801 G- AGE 5 OUTCOME

• Compared survivors from 83-85 vs 86-89 (
  survival the same- more under 600 g)
• No sig. difference between cohorts
• 21 had severe disabilities
• Sig. factors ICH and SES
• Kilbride Daily, J. Perinatology, 1998

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OUTCOME FOR 12 YO VLBW CHILDREN

• 138 children under 1250 g and 93 under 1500 g
  born from 80-83 (UK)
• Compared to matched controls, 8 pts lower IQ-
  mainly due to Performance .

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• 12 of VLBW and 7 of controls below 70. Gaps
  widened from age 6 to 12.
• 35 of VLBW needed remediation (12 of controls)
• Botting et al, Devel Med Child Neuro, 1998

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TEEN SCHOOL OUTCOMES

• 150 500-1000 g survivors, controls
• Born 1977-1982
• Neurosensory impairments in 28 of ELBW, 1 of
  controls
• Mean IQ 89
• Spec. Ed or retained 58 vs. 13
• Saigal et al, Peds, 2000

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OUTCOME FOR ELBW TODDLERS

• 1151 4001-1000 g survivors in NICH network, seen
  at 18-22 mo, b. 1993-1994 (78) f/u
• 25 had abnl neuro exam
• 37 Bayley II MDI lt 70
• 29 Bayley II PDI , 70
• 9 vision impairment
• 11 hearing impairment
• Vohr et al, Pediatrics, 2000

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MORE ELBW TODDLERS

• Born 92-95, seen at 20 mo
• 24 major abnormalities
• 42 Bayley II MDI , 70
• Neurosensory abnormalities and/or low MDI 48
• Hack et al, Seminars in Neonat, 2000

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SWEDISH LBW OUTCOME AT 10

• 61 of 65 10 y.o. survivors b. at under 29 wks
  compared to controls (b. 85-86)
• Mean IQ of preterms 90 controls 106
• 38 of preterms below grade level
• 32 had behavior problems 10 of controls

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• 20 had ADHD, 8 of controls
• 30 in SE, 1.6 of controls
• Sternqvist, Ab Initio Intl, 2001-2002
• www.childrenshospital.org/brazelton/abinitio/art2
  .html

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VLBW OUTCOME AT 20

• 242 survivors from 1977-1979 , controls
• HS grads 74 of preterms, 83 of controls
• Men, but not women, less likely to continue
  studies
• 10 had neurosensory impairments
• 1 of controls

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• Preterms had lower rates of ETOH, drugs,
  pregnancy, even without impaired group.
• Hack et al, NEJM, 2002

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15 YR F/U OF PRETERMS AFTER SURFACTANT

• lt 29 wks b. 1985-87 followed at 7 and 14
  (126/132)
• At 7, 31 nonimpaired 21 severe impairment
  32 in self-contained SE
• 19 CGI lt 70 15 CP

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• As teens, CP same 29 SE 19 had 1 severe
  disability 41 had no impairment.
• Conclusion even with surfactant, sig minority
  will have ongoing compromise
• DAngio, Pediatrics, Dec. 2002

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Chance for improvement?!

• Longitudinal data on PPVT-R on 296 children under
  1250 g
• Scores increased from 88 at 36 months to 99 at 96
  months similar for IQ verbal and FS scores
• Mat ed and 2 parents helped
• NOT for children with worse IVH
• Ment et al., 2003

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Academics at ages 11 and 17

• Detroit area preterm children tested on
  Woodcock-Johnson
• 3-5 point deficits independent of family factors
  and urban/suburban
• At 17, preterms 50 more likely to score below
  the mean in both reading and math cog deficits
  noted at age 6
• Breslau, Paneth Lucia, 2004

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ELBW infants with NL HUS

• Babies born 95-99 under 1000 g with NORMAL head
  ultrasounds
• Nearly 30 had either CP or MDI ? 70
• Lung problems (pneumothorax, long vent) and low
  SES were related
• Laptook et al, 2005

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Behavioral outcomes

• Large French study compared preterm to term
  children at age 3
• Preterms had much higher levels of behavior
  problems Children in high total range- 20 of
  preterms, 9 of term.
• Delobel-Ayoub et al, 2006

37
Emotional regulation and development

• ER scale from Bayley II attention, frustration
  tol, coop, activity, hypersensitivity
• Income and ER influenced MDI
• Poorer ER associated with lower MDI even
  controlling for income
• Lowe, Woodward Papile, 2005

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Outcome for families

• Study of impact of ELBW birth on families at
  school age
• Impact greater in ELBW than controls
• High parent/SES risk, neurodevel outcome, and
  functional impact of chronic conditions predicted
  greatest family impact
• Drotar et al, 2006

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NEC and development

• Babies under 1000 g vs controls
• More babies with NEC had lowered PDI
• Entire preterm group had lower MDI compared to
  controls
• Salhab et al., 2004

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Infections and development

• Multicenter study of children under 1000 g
• Infections predicted more CP, lower MDI and PDI
  scores, and more vision impairment
• Stoll et al, 2004

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How many domains?

• Under 30 week sample of 157 children seen at age
  5 (Dutch)
• 39 normal
• 17 single disability
• 44 multiple disabilities
• Van Baar et al., 2005

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8 year f/u of under 1000 g

• Born 92-95, 219 children, controls
• Need for services 65 vs 27
• Functional limitations 64 vs 20
• CP 14 vs 0, IQ ? 85 38 vs 14
• Sig impact on motor skills, academics, adaptive,
  health
• Hack et al, 2005

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What about bigger premies?

• Study of 32-33, 34-36, and term babies
• Followed K-5
• Bigger premies had a range of academic delays
  compared to term more special ed, more teacher
  concerns
• Chyi et al, 2008

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Prematurity and later mental health

• F/U to teens of non-handicapped preterms-
  increase in psych sx, esp anxiety and depression
  (Schothorst et al, 2007)
• Lg group in adulthood- increased depression
  (Nokumura et al, 2007)
• LBW predicted depression in NC teen girls, not
  boys (Costello et al, 2007)

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BUT some GOOD news

• Compared group of 501-1000 g with term births at
  ages 22-25 (Canada)
• 90 follow up
• Similar grad HS (82-87)
• 33-34 in post-secondary ed
• Except for disabled, similar working or in
  school, living on own, married, parents
• Saigal et al, 2006

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WHAT WE DONT KNOW AND WHY

• Why disability rates have stayed high
• How any individual baby will do, as specifically
  as families need
• For certain, what interventions are most
  effective, when and why

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WHY SO HARD TO ANSWER?

• Research varies as to age and size group, timing
  of follow-up, size of N, use of controls,
  followed, instruments used, definitions
• Research published now based on babies born
  several years ago
• Interaction of medical, social and environmental
  variables

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• Inconsistency of early intervention
• Inconsistency of special ed eligibility,
  definitions and services
• CONCLUSION THESE BABIES ARE SPECIAL. LETS
  OFFER AS MUCH HELP AS POSSIBLE!