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Neurodevelopmental Assessment and Care of Premature Infants Ma. Teresa C. Ambat, MD Neonatology-TTUHHSC 10/28/2008 PowerPoint PPT Presentation


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Neurodevelopmental Assessment and Care of Premature Infants Ma. Teresa C. Ambat, MD Neonatology-TTUHHSC 10/28/2008. Introduction. PCPs should be vigilant in following outcomes of prematurely born child

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Neurodevelopmental Assessment and Care of Premature Infants Ma. Teresa C. Ambat, MD Neonatology-TTUHHSC 10/28/2008

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Neurodevelopmental Assessment and Care of Premature Infants

Ma. Teresa C. Ambat, MD

Neonatology-TTUHHSC

10/28/2008


Introduction

  • PCPs should be vigilant in following outcomes of prematurely born child

  • Should integrate and adapt assessments of development, neurologic status and bahavior for each child at each encounter


Neurodevelopmental and Behavioral Outcomes

  • Long-term outcome arises from complex interplay of biologic, genetic, social and environmental factors

  • Additional or shifting developmental dysfunction over time, as more subtle disabilities become increasingly apparent and testable “new morbidities”


Prenatal

LBW

GA <28 wks

IUGR

Male gender

Postnatal

Neonatal seizures

Abnormal HUS (white matter injury,

PVL, Grade 3-4 IVH)

CLD Prolonged mechanical vent

Infections (NEC, sepsis, meningitis)

Feeding problems >34 wks PMA

ECMO

Low economic status

Maternal depression

Risk Factors for Developmetal and Behavioral Problems in the Preterm Infant


Prevalence of Significant Disabilities in VLBW


Correction for Prematurity

  • Correction for prematurity up to 2-3 years of age when considering neurologic, developemental or behavioral issues, otherwise indicated by a standardized evaluation


Pearls on Outcomes of Preterm Infants

  • More frequent and significant disabilities are associated with decreasing GA and BW

  • Cognitive deficits > motor deficits

  • Disabilities or delays may be subtle or appear latently

  • Deficits in cognitive, verbal, perceptual, motor and visuo-motor measures may not manifest until school age


Pearls on Outcomes of Preterm Infants

  • Up to 50% of infants born <25 wks may be found without disability at follow up over the 1st 3 yrs

  • Nearly all infants with normal findings on neurodevelopmental examination at the infant’s expected due date continue to develop normally

  • If no developmental delays during infancy, risk of MR or CP is low


Ophthalmologic Issues

  • Ophthalmologic problems of premature infants

    • ROP, strabismus, myopia – common

    • Higher incidence of visual impairment – 45-60%

    • Poor visual function may directly affect the development of motor and cognitive skills

  • Require specialized ophthalmologic testing and routine follow-up by pediatric ophthalmologist


ROP Screening

  • AAP recommendation for ROP screening

    • Indications

      • GA <30 wks or BW <1500g

      • Selected infants with BW 1500 – 2000g, GA >30 wks with severe cardiorespiratory instability

    • Examinations usually begin at 4-6wks postnatal age or at 31-32 wks postmenstrual age

    • Continue every 2 wks

    • Once ROP is noted at any stage, examinations become more frequent

    • Can be discontinued once the retinal vessels have reached the perimeter of Zone 3 – retina is “mature”


Outpatient Monitoring for Infants at Risk for ROP

  • Confirm that retinal maturation is complete

    • If mature, arrange for ophthalmologic ff up at 6-9 months to monitor for amblyopia, strabismus and or refractive errors

    • If immature, ophthalmologic ff-up per previous guidelines

  • All PT <32 wks, should undergo ophthalmologic screening at 6-9 months chronologoic age,

    • Whether or not they were screened for ROP, developed ROP or received tx for ROP

  • All PT should have formal visual acuity screening, at least once during preschool years

  • If visual difficulties are seen, refer to appropriate resources


Hearing Loss in Premature Infants

  • Overall incidence of severe congenital hearing loss:

    1-3/1000 live births

  • Hearing loss in premature infants: 2-4/100 infants born <32 wks


Risk Factors for Hearing Loss(Joint Committee on Infant Hearing)

  • Parental or caregiver concern re: hearing, speech, language or developmental delay

  • Family history of permanent childhood hearing loss

  • Stigmata associated with a syndrome known to cause hearing loss or eustachian tube dysfunction

  • Postnatal infection associated with SNHL – bacterial meningitis

  • Congenital infections – CMV, HSV, rubella, syphilis, HIV, toxoplasmosis

  • Syndromes associated with progressive hearing loss – NF, osteopetrosis, Usher syndrome


Risk Factors for Hearing Loss(Joint Committee on Infant Hearing)

  • Neonatal indicators – hyperbilirubinemia requiring exchange (TB >20, needs BAER at 2months), PPHN associated with mechanical ventilation or ECMO

  • Nuerodegenerative disorders – Hunter syndrome, Friedrich ataxia, Charcot-Marie Tooth

  • Head trauma

  • Recurrent or persistent OM with effusion for at least 3 months

  • Prolonged use of potentially ototoxic drugs


Screening Tests

  • Universal hearing screening recommended for all newborns

  • Methodologies for physiologic screening for hearing in newborns

    • Auditory brainstem response (ABR)

    • Evoked otoacoustic emission (EOAE)


Follow-up Testing and Medical Evaluation

  • Infants who refer in both ears  diagnostic ABR within 2 wks

  • Unilateral abnormal results  ff-up testing within 3 months

  • Ff-up testing: full diagnostic frequency ABR to measure threshold, evaluation of middle ear function, observation of behavioral response to sound, parental report of emerging communication and auditory behaviors


Follow-up Testing and Medical Evaluation

  • Any infants at risk for progressive or delayed hearing loss  close audiologic monitoring at least q6 months for the first 3 years)

  • Hearing assessment at 1 year in all infants born at < 32 wks (even if hearing screen is passed)

  • PCP should monitor all infants for normal hearing and language development and refer any infant with delays for hearing assessment


Referrals

  • Once an infant is diagnosed with a true hearing loss, the following referrals should be made:

  • Complete evaluation by an otolaryngology or otology specialist who has experience with infants

  • Genetic evaluation and counseling (hearing loss with no definite etiology)

  • Pediatric ophthalmology (evaluate for additional sensory loss)

  • Developmental pediatric, neurology, cardiology, and or nephrology as indicated by other clinical findings and known associated problems with syndromes


Habilitation/Management

  • Early intervention services to enhance acquisition of developmentally appropriate language skills

  • Amplification systems – hearing aids

  • Cochlear implant: profound, bilateral SNHL, no benefit from hearing aids, no medical conditions that will interfere with procedure, realistic expectations from family

  • “Stimulation” or “mapping” sessions


White Matter Injury

  • Periventricular leukomalacia (PVL) – white matter injury in preterm infants

  • Results from insults to the developing brain 23-32 wks

  • Incidence: 5-15% of those born GA<32 wks

  • US: echodensity in periventricular white matter adjacent to lateral ventricles  cystic changes

  • Outcomes: MR, CP, developmental delay, visual impairments


Intraventricular Hemorrhage

  • Occurs in ~35-50% of infants born <35 wks

  • Grade III IVH associated with 30% risk of CP/MR and 50% risk of developmental disability

  • Intraparenchymal hemorrhage associated with 70% risk of CP/MR and 90% risk for developmental disability


Care and Assessment of Shunted Neonates

  • Closely observe for long-term complications

  • Over-drainage related problems

    •  collapse of thin cortex, subdural effusion/hematoma, craniosynostosis

    • Evidenced by sunken fontanel, overlapping sutures

    • MX: positional precautions, upgrade or readjustment of valve settings

  • Wound breakdown

  • Shunted infants with myelomeningocele

    • Arnold-Chiari II malformation

    • Risk for brainstem dysfunction secondary to compression (retropulsion of head, stridor, drooling, increased tone in extremities)


Neurologic Surveillance

  • Perform periodic neurologic examinations

  • Tone (passive resistance)

  • Strength (active resistance)

  • DTR

  • Coordination, station and gait

  • Use assessments over time to establish prognosis

  • Single encounters provide a mere snapshot of ongoing developmental trajectories


Neurologic Surveillance

  • Abnormal tone can be suggestive of CP or

  • Maybe transient  resolve in the 1st year w/o sequelae

  • May evolve from one form to another (hypotonia  hypertonia)

  • Multidisciplinary evaluation

  • Extensive evaluations as necessary: MRI, cytogenetic studies, metabolic work-up


Hypotonia

Exaggerated head lag

Excessive ‘slip through’ when held at the shoulders

Poor head control

Poor truncal tone  exaggerated curve in ventral suspension

Persistent hypotonia + decreased DTRs

Hypertonia

Spastic form

Dyskinetic form with rigid extension

Early rolling over

Hypertonia with leg extension

Absent weight bearing

Persistent/early feeding problems

Findings of Abnormal Tone


Neurologic Surveillance

  • Assess for persistence or delay of reflexes

  • Primitive reflexes

    • Moro, tonic labyrynthe, asymmetric tonic neck

    • Appear and readily elicited in the 1st 3 months  disappear by 6-8 months

  • Postural reflexes

    • Complex, self-protective reflexes involving righting, protection and equilibrium movements

    • Slow to evolve in children with CNS injury


Developmental Surveillance

  • Assess neurodevelopmental and behavioral status

    • Developmental tools – screening tools, not diagnostic tools

    • Parent questionnaires, history and discussion during clinical encounter

  • Consult appropriate specialists if results are concerning


AAP Algorithm for Developmental Surveillance and ScreeningPediatrics Vol 118, July 2006

  • Developmental surveillance incorporated at every well-child visit

  • If any concerns  standardized developmental screening tests

  • Regular screening tests: 9, 18 and 30 (24) month visits

  • Children diagnosed with developmental disorders: children with special health care needs requiring chronic condition management


Developmental Surveillance


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