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![Page 1: Development of the Premature Infant: Through the Lens of the Pediatrician and Neonatologist Mark Bergeron, MD, MPH Associate Director, Neonatal Medicine.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cca5503460f94992dbc/html5/thumbnails/1.jpg)
Development of the Premature Infant: Through the Lens of the Pediatrician and Neonatologist
Mark Bergeron, MD, MPHAssociate Director, Neonatal Medicine and Neonatal Developmental Follow-up Clinic
Children’s Hospitals and Clinics of Minnesota – St. Paul
Assistant Professor, Pediatrics
University of Minnesota Medical School
2011 Strong Foundations Conference
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Objectives
• Discuss prematurity as public health issue– Review morbidity and
mortality data
• Highlight infant health issues resulting from prematurity
• Understand the impact of prematurity on infant/child development– Brain injury and
impairment
• Provide an overview of short- and long-term measures to address developmental issues
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What is Preterm?
• Term: ≥ 37 weeks postmenstrual age
• Late Preterm: 34-36 weeks
• Moderately Preterm: 32-33 weeks
• Very Preterm: 28-31 weeks
• Extremely Preterm < 28 weeks
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Preterm Birth Statistics
Data: PeriStats, March of Dimes
Photo: Children’s Hospitals and Clinics of Minnesota
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Cost of Preterm Birth
.
Data: PeriStats, March of Dimes
Photo: Children’s Hospitals and Clinics of Minnesota
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The First Hurdle: Survival
• Survival is inversely proportional to gestational age:– “Later is better!”
Data: Children’s Hospitals and Clinics of Minnesota
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Survival by Gestational Age
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The Second Hurdle: “Meaningful” Survival
Data: Children’s Hospitals and Clinics of Minnesota
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Health Problems Associated with Prematurity
• Heart and circulation• Lung function• Breathing• Feeding and Digestion• Lack of weight gain• Brain hemorrhages • Immature immune system
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Informed Consent to Treat: “NICU Alphabet Soup”
• PDA- Patent Ductus Arteriosis (heart)
• NEC- Necrotizing Enterocolitis (digestive)
• ROP- Retinopathy of Prematurity (eyes)
• RDS- Respiratory Distress Syndrome (lungs)
• CLD- Chronic Lung Disease (lungs)
• PVL- Periventricular Leukomalacia (brain)
• IVH- Intraventricular Hemorrhage (brain)
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Intraventricular Hemorrhage (IVH): A Marker for Developmental Problems
Data: Children’s Hospitals and Clinics of Minnesota
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The Impact of Prematurity
• Serious implications for parents, health care team:– Survival is NOT a given
– Risk of poor developmental outcome must be weighed carefully when making medical decisions
• Fundamental Question: What does prematurity mean for the baby’s developmental potential?
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Variables that affect the premature infant’s developmental trajectory:
• Gestational age• Birth weight• Incidence/severity of lung disease• Time spent on mechanical ventilation• Need for oxygen• White matter brain injury (IVH, PVL)• Overall length of time in the NICU• Weight gain
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Neurodevelopmental Issues in the Preterm Infant
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Brain growth in fetal life and infancy
• During specific times in gestation, different types of cells increase and mature structurally
• Almost all neurons are present by 18-20 weeks gestation (good and bad news)
• The cells that perform basic thinking and control functions of the brain are in place
• The total number of neurons increase only slightly, glial cells increase until 2 years of age
• Myelination continues until 4 years of age (longer?)
• Synaptic rearrangements occur for years
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Brain growth in the last trimester
• Growth of the cerebellum: muscles and coordination of movement
• Pattern of dendritic connections between neurons– Cerebellum is one of the most vulnerable areas for
preemies because it has a spurt of growth at 30-32 weeks gestation and is complete by 12 months of age
– When born prematurely, the dendritic connections are developing under different circumstances where nutrition and metabolic are key
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Brain Injury in infancy
• Fetuses and neonates are uniquely vulnerable to brain injury
• Decreased oxygen supply
• Increased oxygen supply
• Decreased blood flow
• Bleeding
• Infection
• Toxins
• Radiologic(?)
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Brain Injury: Intraventricular Hemorrhage (IVH)
• ssf
pediatriceducation.org
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Brain Injury: Periventricular Leukomalacia (PVL)
radiologyassistant.nl
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Preterm Brain Injury: Long Term Effects
• Motor– Hypotonia (initially)
– Hypertonia• Cerebral palsy
– Spastic diplegia
– Delays• Gross
• Fine
• Cognitive– Delays
– MR
• Speech/Language– Delays
• Expressive
• Receptive
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Physiological Regulation and Development
• Preterm birth is a tremendous physiological stress– Uterus vs. NICU incubator
• The preterm infant is developmentally unprepared for the change from the intrauterine environment– Sights _ Sounds
– Smells _ Pain
• Response to stimulation is altered– Preemies have instability of respiratory, heart rates and
temperature which become learned responses to stimulation
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Mitigating Factors - NICU
• Family-centered care– Encourage family
presence and involvement
• Kangaroo care
• Developmentally-appropriate environment– Sound– Light– Temperature
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Family-centered NICU Care
• Video: "NICU: the Garden of Hope"
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Long-term Follow-up: A Multidisciplinary Approach
• Primary care provider– Well baby care
• Routine developmental assessments
• Home health nursing• Local programming
– Early Intervention
• Specialty care– i.e. pulmonology
• NICU Follow-up Clinic– Scheduled developmental
assessment• Bayley Scales of Infant
• Rossetti Infant – Toddler Language Scale
• Wechsler Preschool and Primary Scale of Intelligence - Revised
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NICU Follow-up Clinic Referral CriteriaChildren’s – St. Paul
• Birthweight ≤ 1500g• ≤ 30 weeks GA• > 48 hrs mechanical
ventilation• Seizures• Neurologic abnormality• Grade 3-4 IVH• BPD
• IUGR• Congenital infection• Exchange transfusion• Therapeutic
hypothermia for HIE• Other
– Neonatologists’ discretion
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NICU Follow-up Clinic Team
• Pediatric Nurse Practitioner
• Occupational Therapist
• Developmental Psychologist
• Speech/Language Pathologist
• Neonatologist
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Developmental Expectations
• Chronologic vs. “Adjusted” age?– Developmental milestones and growth parameters
should be benchmarked against norms corrected for prematurity.
• i.e. subtract the “weeks or months born early” from chronological age.
– Example: Now 6 m.o. infant born at 32 weeks (2 months preterm):
6 months. – 2 months = 4 months corrected age
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Developmental Expectations, continued
• Conventionally, adjusted age is utilized until 24 months in clinical settings
– Developmental testing
– NICU Follow-up clinic
• Practically, adjusted age remains useful
– Early Intervention (many preemies eligible until age 3)
– Decisions regarding preschool and kindergarten readiness
• Physical
• Cognitive
• Emotional
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Learning Behaviors-Special Considerations
• When development is measured early on, former preemies may not do as well due to greater difficulty focusing attention on task completion
– Altered learning patterns?
• Altered response to stress/stimulation
• May need more repetitive play to learn skills
• Special risks
– ADHD
– Autism spectrum disorders (controversial)
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Summary
• Preterm birth remains an important public health issue
• As extreme preterm birth-related mortality has decreased, morbidity, especially neurologic, has increased
• Much has been done to support premature infants’ developmental needs, both in the short- and long-term
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Resources
• American Academy of Pediatrics
– www.aap.org
• American Academy of Pediatrics Section on Perinatal Pediatrics
– www.aap.org/sections/perinatal/index.html
• March of Dimes
– www.modimes.org
• Children’s Hospitals and Clinics of Minnesota Neonatal Cornerstone Program
– www.childrensmn.org/Services/Neonatal/
• Associates in Newborn Medicine, P.A.
– www.newbornmed.com
• Minnesota Perinatal Organization and Minnesota Prematurity Coalition
– www.minnesotaperinatal.org