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
Download ReportTranscript 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
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”
Risk Factors for Developmetal and Behavioral Problems in the Preterm Infant
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
Prevalence of Significant Disabilities in VLBW
Mental retardation CP Blindness Deafness Motor delay Language problems ADHD Need for special education Psychological/behavioral problems 10-20% 5-21% 2-11% 1-3% 24% 23-42% 7-10% 9-28% 25%
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 1 st 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) 1.
2.
3.
4.
5.
6.
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) 7.
8.
9.
10.
11.
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 1.
Methodologies for physiologic screening for hearing in newborns Auditory brainstem response (ABR) 2.
Evoked otoacoustic emission (EOAE)
Follow-up Testing and Medical Evaluation
1.
Infants who refer in both ears wks diagnostic ABR within 2 2.
Unilateral abnormal results months ff-up testing within 3 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
3.
Any infants at risk for progressive or delayed hearing loss close audiologic monitoring at least q6 months for the first 3 years) 4.
Hearing assessment at 1 year in all infants born at < 32 wks (even if hearing screen is passed) 5.
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: 1.
2.
3.
4.
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
1.
2.
3.
4.
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 1 st 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
1.
2.
3.
4.
5.
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 3.
4.
5.
6.
1.
2.
Hypertonia Spastic form Dyskinetic form with rigid extension Early rolling over Hypertonia with leg extension Absent weight bearing Persistent/early feeding problems
Neurologic Surveillance
Assess for persistence or delay of reflexes Primitive reflexes Moro, tonic labyrynthe, asymmetric tonic neck Appear and readily elicited in the 1 6-8 months st 3 months disappear by 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 Screening
Pediatrics Vol 118, July 2006 Developmental surveillance incorporated at every well child visit If any concerns screening tests standardized developmental 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