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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 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. • I also assume responsibility for ensuring the scientific validity, objectivity, and completeness of the content of my presentation Church
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
Introduction • “It is easier to build strong children than to repair broken men.” (Frederick Douglas) Church
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
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
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
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of Prematurity • Social emotional dys-regulation greater in preterm • Labile • Internalizing conditions • Anxiety • Withdrawn • Socially awkward • Bhutta AT, Cleves MA, Casey PH, Cradock MM, Anand KJS.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
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
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
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
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
Neurodevelopment Church
Neurodevelopment Church
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
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
Neurosensory development • Specific sequence • TactileVestibularChemicalAuditoryVisual • 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
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
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
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
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
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
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
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
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
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
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
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
Targets for Intervention Church
Targets for Intervention: NICU“Kangaroo care is crucial for babies to grow and develop and is also medicine for the souls of parents” Church
Targets for Intervention: NICUHack MB. Commentary: Care of Preterm Infants in the Neonatal Intensive Care Unit. Pediatrics 2009;123:1246. Church
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
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
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
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