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First Lessons

First Lessons. The Value of Healthy Regulation for Parent & Baby. Paige Terrien Church, MD Neonatologist & Developmental Behavioral Pediatrician Assistant Professor, Paediatrics. Disclosure. I have no actual or potential conflict of interest in relation to this program.

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First Lessons

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  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 Church

  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 Church

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

  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) Church

  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 disorder=alterations in brain development Hodapp RM, Fidler DJ. Special Education and Genetics: Connections for the 21st Century. The J Spec Educ 1999; 33: 130-137. Church

  7. Behavioral Phenotype of Prematurity • Majority of preterms with resolution of medical issues by school age • Motor delays common • Dystonia=early 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. Church

  8. Behavioral Phenotype of Prematurity Church

  9. Behavioral Phenotype of Prematurity Church

  10. Behavioral Phenotype of Prematurity Church

  11. Behavioral Phenotype of Prematurity Church

  12. Behavioral Phenotype of Prematurity Church

  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. Church

  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 1990’s. Pediatrics 2004; 114: 50-57. Church

  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 BehavPediatr 2010; 31: 658-667. Church

  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 (< 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. Church

  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 Church

  18. Church

  19. Neurodevelopment Church

  20. Neurodevelopment Church

  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 Neurons—Missing 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. Church

  22. Neurodevelopment • Extrinsic element=Neuronal 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. Church

  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 2011;38:591-603. Church

  24. NeurodevelopmentAttachment • Begins in utero through sensory input • Sounds & smells • Wired to provide rapid learning • Early purpose=survival • 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 2011;38:643-55. Church

  25. NeurodevelopmentImpact of Prematurity Church

  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. ClinPerinatol 2011;38:591-603. Church

  27. NeurodevelopmentImpact of Prematurity • “Normal” head ultrasound NOT guarantee of normal outcome • 9% with CP • 25% with MDI less than 70 • Laptook AR, O’Shea 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. Church

  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. Church

  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 Neurons—Missing 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. Church

  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. Church

  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. Church

  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 2011;38:591-603. Church

  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. Church

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  36. Targets for InterventionLuciana M. Cognitive development in children born preterm: Implications for theories of brain plasticity following early injury. DevelPsychopathol 2003;15:1017-47 Church

  37. Targets for Intervention Hadders-Algra M. The Neuronal Group Selection Theory: a framework to explain variation in normal development. Dev Med Child Neurol 2000;42:566-72. Church

  38. Targets for Intervention Church

  39. Targets for Intervention: NICU Church

  40. Targets for Intervention: NICU“Kangaroo care is crucial for babies to grow and develop and is also medicine for the souls of parents” Church

  41. Targets for Intervention: NICU Church

  42. Targets for Intervention: NICUHack MB. Commentary: Care of Preterm Infants in the Neonatal Intensive Care Unit. Pediatrics 2009;123:1246. Church

  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 Church

  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 Church

  45. Targets for Intervention: NICU Church

  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 Church

  47. Targets for InterventionNeonatal Follow Up Church

  48. Targets for InterventionNeonatal Follow Up Church

  49. Targets for InterventionNeonatal Follow Up • Follow up not only surveillance for outcomes • Need assessment, diagnosis and intervention • Homework critical—small steps • Reports with clear language Church

  50. Targets for InterventionNeonatal Follow Up Church

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