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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

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Neurodevelopmental Assessment and Care of Premature Infants

Ma. Teresa C. Ambat, MD



  • 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
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”
risk factors for developmetal and behavioral problems in the preterm infant


GA <28 wks


Male gender


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


Low economic status

Maternal depression

Risk Factors for Developmetal and Behavioral Problems in the Preterm Infant
correction for prematurity
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
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 infants8
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 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
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
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
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
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 hearing14
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
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
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 evaluation17
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
  • 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
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
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
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
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 surveillance26
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
findings of abnormal tone

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


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 surveillance28
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
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 screening pediatrics vol 118 july 2006
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