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First Lessons

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Title: First Lessons


1
First Lessons
  • The Value of Healthy Regulation for Parent Baby
  • Paige Terrien Church, MD
  • Neonatologist Developmental Behavioral
    Pediatrician
  • Assistant Professor, Paediatrics

2
Disclosure
  • I have no actual or potential conflict of
    interest in relation to this program.
  • I also assume responsibility for ensuring the
    scientific validity, objectivity, and
    completeness of the content of my presentation

3
Objectives
  • At the end of this session you will be able to
  • Understand neurosensory development and critical
    periods
  • Explain normal attachment
  • Recognize impact of interrupted neurodevelopment
    on outcome

4
Introduction
  • It is easier to build strong children than to
    repair broken men. (Frederick Douglas)

5
Problem
  • 50-70 of very preterm infants have difficulty
    with school performance
  • Proposed factor complex amalgam of minor
    challenges
  • Behavioral
  • Motor (fine, gross, visual)
  • Cognitive (intellect, processing)

6
Behavioral Phenotype
  • Describes a constellation of behavioral,
    cognitive, motor, and social difficulties
    observed in a population with a common biological
    disorder
  • Premature survivors have a phenotype
  • Common biological disorderalterations in brain
    development
  • Hodapp RM, Fidler DJ. Special Education and
    Genetics Connections for the 21st Century. The J
    Spec Educ 1999 33 130-137.

7
Behavioral Phenotype of Prematurity
  • Majority of preterms with resolution of medical
    issues by school age
  • Motor delays common
  • Dystoniaearly sign
  • Breslau N, Chilcoat EO, Johnson EO, Andreski P,
    Lucia VC. Neurologic Soft Signs and Low
    Birthweight Their Association and
    Neuropsychiatric Implications. Biol Psychiatry
    2000 47 71-79.
  • Bracewell M, Marlowe N. Patterns of Motor
    Disability in the Very Preterm Children. Ment
    Dev Disabil Res Rev 2002 8 241-248.
  • Goyen T-A, Lui K. Developmental Coordination
    Disorder in apparently normal schoolchildren
    born extremely preterm. Arch Dis Child 2009 94
    298-302.

8
Behavioral Phenotype of Prematurity
9
Behavioral Phenotype of Prematurity
10
Behavioral Phenotype of Prematurity
11
Behavioral Phenotype of Prematurity
12
Behavioral Phenotype of Prematurity
13
Behavioral Phenotype of Prematurity
  • Social emotional dys-regulation greater in
    preterm
  • Labile
  • Internalizing conditions
  • Anxiety
  • Withdrawn
  • Socially awkward
  • Bhutta AT, Cleves MA, Casey PH, Cradock MM, Anand
    KJS. Cognitive and Behavioral Outcomes of
    School-Aged Children Who Were Born Preterm A
    Meta-Analysis. JAMA. 2002 288 728-737.
  • Spittle AJ, Treyvaud K, Doyle LW, et al. Early
    Emergence of Behavior and Social-Emotional
    Problems in the Very Preterm Infants. J. Am Acad
    Child Adolesc Psychiatry 2009 48 909-918.

14
Behavioral Phenotype of Prematurity
  • Preterms with greater
  • Executive dysfunction
  • Hyperactivity, inattention
  • ADHD/ADD
  • Bhutta AT, Cleves MA, Casey PH, Cradock MM, Anand
    KJS. Cognitive and Behavioral Outcomes of
    School-Aged Children Who Were Born Preterm A
    Meta-Analysis. JAMA. 2002 288 728-737.
  • Anderson PJ, Doyle LW, and Victorian Infant
    Collaborative Study Group. Executive Functioning
    in School-Aged Children Who Were Born Very
    Preterm or With Extremely Low Birth Weight in the
    1990s. Pediatrics 2004 114 50-57.

15
Behavioral Phenotype of Prematurity
  • Generally average abilities in
  • Receptive
  • Expressive
  • Subtle difficulties common with
  • Syntax
  • Complexity of language used understood
  • Foster-Cohen S, Edgin JO, Champion PR, Woodward
    LJ. Early delayed language in very preterm
    infants Evidence from the MacArthur-Bates CDI.
    J Child Lang 2007 34 655-675.
  • Foster-Cohen SH, Friesen MD, Champion PR,
    Woodward LJ. High Prevalence/Low Severity
    Language Delay in Preschool Children Born Very
    Preterm. J Dev Behav Pediatr 2010 31 658-667.

16
Behavioral Phenotype of Prematurity
  • Cognitive skills historically regarded as best
    marker of school success
  • Actually only a piece of puzzle
  • Preterm at particular risk with
  • Lower IQ than term
  • More likely to have borderline IQ
  • Marlowe NM, Wolke DM, Bracewell MA et al.
    Neurologic and Developmental Disability at Six
    Years of Age after Extremely Preterm Birth. NEJM
    2005 353 9-19.
  • Whitfield MF, Grunau RV, Holsti L. Extremely
    premature (lt 800g) schoolchildren multiple areas
    of hidden disability. Arch Dis Child 1997 77
    F85-90.
  • Saigal S, den Ouden L, Wolke D, et al. School Age
    Outcomes in Children Who Were Extremely Low Birth
    Weight From Four International Population-Based
    Cohorts. Pediatrics 2003 112 943-950.

17
Behavioral Phenotype of Prematurity
  • Challenges with
  • Language comprehension and expression
  • (Verbal and nonverbal communication)
  • Spatial relationships
  • Eye contact
  • Impulse control
  • Organizational abilities
  • Physical attributes
  • Motor coordination
  • Anxiety (separation anxiety)
  • Emotional lability

18
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19
Neurodevelopment
20
Neurodevelopment
21
Neurodevelopment
  • Interplay between intrinsic brain development and
    experience
  • Intrinsic driven by genetic code with
    proliferation and migration
  • Critical cells
  • Subplate neurons
  • Pre-oligodendrocytes
  • External granule cells
  • Kolb B, Gibb R. Brain Plasticity and Behaviour in
    the Developing Brain. J Can Acad Child Adolesc
    Psychiatry 2011 20 265-276.
  • Volpe JJ. Brain injury in preterm infants a
    complex amalgam of destructive and developmental
    disturbances. J Lancet 2009 8 110-124.
  • Volpe JJ. Subplate NeuronsMissing Link in Brain
    Injury in the Premature Infant? Pediatrics 1996
    97 112-113.
  • Volpe JJ. Cerebellum of the Premature Infant
    Rapidly Developing, Vulnerable, Clinically
    Important. J Child Neurol 2009 24 1085-1104.

22
Neurodevelopment
  • Extrinsic elementNeuronal plasticity
  • Experience expectant development
  • Experience leads to pruning
  • Critical period with early synapse development
  • Experience dependent development
  • Sensitive period with synapse formation/pruning
  • Specific regions of brain
  • Kolb B, Gibb R. Brain Plasticity and Behaviour in
    the Developing Brain. J Can Acad Child Adolesc
    Psychiatry 2011 20 265-276.

23
Neurosensory development
  • Specific sequence
  • Tactile?Vestibular?Chemical?Auditory?Visual
  • Interrelated and redundant nature of sensory
    perception
  • Contributes to later perceptual organization
  • Impact of stimulation mediated by
  • Timing
  • Developmental trajectory
  • Lickliter R. The Integrated Development of
    Sensory Development. Clin Perinatol
    201138591-603.

24
NeurodevelopmentAttachment
  • Begins in utero through sensory input
  • Sounds smells
  • Wired to provide rapid learning
  • Early purposesurvival
  • Keep infant close to mother
  • Guide brain development
  • Provides secure base for future exploration
  • Sullivan R, Perry R, Sloan A, Kleinhaus K,
    Burtchen N. Infant Bonding and Attachment to the
    Caregiver Insights from Basic and Clinical
    Science. Clin Perinatol 201138643-55.

25
NeurodevelopmentImpact of Prematurity
26
NeurodevelopmentImpact of Prematurity
  • Interruption of normal neurosensory development
  • Developmental susceptibility
  • Plastic system at critical point
  • Injury or atypical input
  • Epigenetic changes
  • Volpe JJ. Brain injury in preterm infants a
    complex amalgam of destructive and developmental
    disturbances. J Lancet 2009 8 110-124.
  • Lickliter R. The Integrated Development of
    Sensory Development. Clin Perinatol
    201138591-603.

27
NeurodevelopmentImpact of Prematurity
  • Normal head ultrasound NOT guarantee of normal
    outcome
  • 9 with CP
  • 25 with MDI less than 70
  • Laptook AR, OShea TM, Shankaran S, Bhaskar B.
    Adverse Neurodevelopmental outcomes among
    extremely low birth weight infants with a normal
    head ultrasound prevalence and antecedents.
    Pediatrics. 2005 115 673-680.

28
NeurodevelopmentImpact of Prematurity
  • 3-4 with abnormality on HUS
  • 20-65 with abnormality on MRI
  • Inder TE, Wells SJ, Mogridge NB, Spencer C, Volpe
    JJ. Defining the Nature of the Cerebral
    Abnormalities in the Premature Infant A
    Qualitative Magnetic Resonance Imaging Study. J
    Pediatr 2003 143 171-179.

29
NeurodevelopmentImpact of Prematurity
  • Developmental vulnerability with preterm birth
  • Critical cells in preterm brain lack protection
    from injury
  • Subplate neurons
  • Interneurons
  • Pre-oligodendrocytes
  • External granule cells
  • Volpe JJ. Brain injury in preterm infants a
    complex amalgam of destructive and developmental
    disturbances. J Lancet 2009 8 110-124.
  • Volpe JJ. Subplate NeuronsMissing Link in Brain
    Injury in the Premature Infant? Pediatrics 1996
    97 112-113.
  • Volpe JJ. Cerebellum of the Premature Infant
    Rapidly Developing, Vulnerable, Clinically
    Important. J Child Neurol 2009 24 1085-1104.

30
NeurodevelopmentImpact of Prematurity
  • Cell death via
  • Necrosis
  • Apoptosis
  • Can occur on
  • Macroscopic (IVH, PVL, PVHI)
  • Microscopic level (diffuse injury)
  • Volpe JJ. Brain injury in preterm infants a
    complex amalgam of destructive and developmental
    disturbances. J Lancet 2009 8 110-124.

31
NeurodevelopmentImpact of Prematurity
  • Altered synaptogenesis
  • Experience expectant versus experience dependent
  • Similar experience with different effects
  • Plasticity can be good or bad
  • Neuronal Group Selection Theory
  • Kolb B, Gibb R. Brain Plasticity and Behaviour in
    the Developing Brain. J Can Acad Child Adolesc
    Psychiatry 2011 20 265-276.

32
NeurodevelopmentImpact of Prematurity
  • Loss of controlled sensory exposure
  • Alterations to timing (too much too soon, too
    little too late)
  • Impact perceptual organization
  • Loss of redundancy
  • Impacts selective attention, perceptual
    organization, learning
  • Lickliter R. The Integrated Development of
    Sensory Development. Clin Perinatol
    201138591-603.

33
Neuro-Development
  • End result is
  • Gray matter architecture distorted
  • White matter connectivity altered
  • Cerebellum under-developed
  • Leads to secondary cortical dysplasia
  • Volpe JJ. Brain injury in preterm infants a
    complex amalgam of destructive and developmental
    disturbances. J Lancet 2009 8 110-124.
  • Alyward GP. Neurodevelopmental Outcomes of
    Infants Born Prematurely. J Dev Behav Pediatr
    2005 26 427-440.

34
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35
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36
Targets for InterventionLuciana M. Cognitive
development in children born preterm
Implications for theories of brain plasticity
following early injury. Devel Psychopathol
2003151017-47
37
Targets for Intervention
Hadders-Algra M. The Neuronal Group Selection
Theory a framework to explain variation in
normal development. Dev Med Child Neurol
200042566-72.
38
Targets for Intervention
39
Targets for Intervention NICU
40
Targets for Intervention NICUKangaroo care is
crucial for babies to grow and develop and is
also medicine for the souls of parents
41
Targets for Intervention NICU
42
Targets for Intervention NICUHack MB.
Commentary Care of Preterm Infants in the
Neonatal Intensive Care Unit. Pediatrics
20091231246.
43
Targets for Intervention NICU
  • Randomized controlled trial with standard care
    and family care rooms (2 units)
  • Family care resulted in
  • Decreased length of stay
  • No effect on mortality
  • Trend toward decreased BPD

44
Targets for Intervention NICU
  • Neuronal Group Selection Theory
  • Nesting versus containment
  • Skin to skin
  • Cluster non-emergent care
  • Pain management (non-pharmacological if possible)
  • Family integrated care

45
Targets for Intervention NICU
46
Targets for Intervention NICU
  • Non-nutritive sucking
  • Breast milk
  • Holding with feeds (NG or PO)
  • Environment
  • Fosters family presence
  • Sensory protection (ambient light exposure,
    sounds, smells)
  • Primary nursing
  • Infants can have up to 120 care providers in
    hospitalization

47
Targets for InterventionNeonatal Follow Up
48
Targets for InterventionNeonatal Follow Up
49
Targets for InterventionNeonatal Follow Up
  • Follow up not only surveillance for outcomes
  • Need assessment, diagnosis and intervention
  • Homework criticalsmall steps
  • Reports with clear language

50
Targets for InterventionNeonatal Follow Up
51
Targets for InterventionNeonatal Follow Up
  • Awareness of statistics not equivalent to child
    becoming statistic
  • Should provide heightened surveillance and
    attention to small problems
  • Constant contextualization

52
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53
Targets for InterventionNeonatal Follow Up
  • Collaboration with schools critical
  • Parents need to be educated in positive advocacy
  • Education on transition to schools
  • Special education resources
  • Major morbidities and minor morbidities not
    mutually exclusive

54
Targets for InterventionNeonatal Follow Up
55
Future Directions
  • Emphasis shift in NICU
  • Minimize stress
  • Normalize environmental exposure-Parents ideal
    environment
  • Extended follow up ideal model with collaboration
    with emphasis on intervention
  • Specialized training essential

56
Future Directions
  • Ongoing research needed
  • Correlation to neuroimaging patterns
  • Neonatal care impacts on outcome
  • Outcomes
  • Particularly School based and school
    interventions!
  • Functional outcome measurements needed

57
Thank You!
  • Sunnybrook Health Sciences Centre
  • Neonatal Follow Up Clinic
  • Marion DeLand, RN
  • Maureen Luther, PT
  • Pat Maddalena, PNP
  • Laura Cooper, OT
  • Rudaina Banihani, MD and Jessie VanDyk, MD
    (neonatal fellows)
  • Vanessa Warsh, administrator
  • Carol Grenade, administrator

58
Sources
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    School Aged Children Who Were Born Very Preterm
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  • Aylward GP. Neurodevelopmental Outcomes of
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