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
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Behavioral Phenotype of Prematurity
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Behavioral Phenotype of Prematurity
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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.

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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

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Neurodevelopment
20
Neurodevelopment
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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.

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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.

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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.

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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.

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NeurodevelopmentImpact of Prematurity
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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.

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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.

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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.

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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.

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Targets for InterventionLuciana M. Cognitive
development in children born preterm
Implications for theories of brain plasticity
following early injury. Devel Psychopathol
2003151017-47
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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.
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Targets for Intervention
39
Targets for Intervention NICU
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Targets for Intervention NICUKangaroo care is
crucial for babies to grow and develop and is
also medicine for the souls of parents
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Targets for Intervention NICU
42
Targets for Intervention NICUHack MB.
Commentary Care of Preterm Infants in the
Neonatal Intensive Care Unit. Pediatrics
20091231246.
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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

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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

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Targets for Intervention NICU
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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

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Targets for InterventionNeonatal Follow Up
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Targets for InterventionNeonatal Follow Up
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Targets for InterventionNeonatal Follow Up

• Follow up not only surveillance for outcomes
• Need assessment, diagnosis and intervention
• Homework criticalsmall steps
• Reports with clear language

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Targets for InterventionNeonatal Follow Up
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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

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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

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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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  Pediatrics. 200411450-57
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  School Age Children Born Extremely Low Birth
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59
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