Development monitoring and stimulation

in Preterm and low birth weight Infants

Dr. dr. Hesti Lestari SpA(K)

Bagian Ilmu Kesehatan Anak FK Unsrat-RSUP Kandou
Manado

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Outline
• Incident of preterm
• Longterm developmental outcome of preterm
• Developmental Screening
• Evidence of early intervention for preterm infants

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 DEFINITION & PREVALENCE
◉ Preterm : 32 – 37 weeks
◉ Very preterm : 28 – 32 weeks
◉ Extremely preterm : < 28 weeks

◉ LBW : < 2500 gram

◉ VLBW : < 1500 gram
◉ ELBW : < 1000 gram
◦ Every year, 15 million babies are born preterm
◦ Approximately 1 million children die each year due to complications of
preterm birth
◦ Indonesia ranked 5th in the world with 15,5 preterm per 100 live births
https://www.who.int/ 3
 CONSEQUENCES OF PRETERM BIRTH

Preterm babies → raises the • Continuous advances in medical

risk for physiologically technology mean that younger and
immature infants lighter babies can be saved
• Does this mean an increase in the
proportion of surviving babies who have
disabilities?

long – term complications

Adams CI, Amer R, Pierra et al. J.Pediatric. 2016. 4

Since 1990s:
Survival ↗
Mortality ↙
Disability steady

• More extreme
prematurity is associated
with greater risk
• As gestational age
increases, the risk of
significant disability
declines dramatically. Changes in outcome for babies born at 22-25 weeks’ gestation or less in
England in 1995 (EPICure) and 2006 (EPICure 2) cohorts.

Tamanna Moore et al. BMJ 2012;345:bmj.e7961 5

NEURODEVELOPMENTAL DISABILITIES
◉ At increased risk for developmental delays and disabilities
❖ Motor impairment and/or tone abnormalities
❖ Cerebral palsy
❖ Learning delay or disability
❖ Borderline low-average intelligence quotients (IQs)
❖ Autism or autism spectrum disorders
❖ Attention-deficit hyperactivity disorders (ADHD)
❖ Specific neuropsychological deficits (ie, visual motor
integration, executive dysfunction)
❖ Behavior problems (ie, internalizing problems, social
difficulties)

Fitzpatrick A. Peralta-Carcelen M, Kuban KC, et al. J.Pediatric. 2016.

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 PSYCHOSOCIAL ISSUES
◉ Bringing home a NICU graduate can be very challenging to
parents because of social, financial and psychological
stresses
◉ Need to screen for these stressors
◉ Provide support services
o Early child intervention services
o Support groups
o Social work services

Fitzpatrick A. Peralta-Carcelen M, Kuban KC, et al. J.Pediatric. 2016. 7

 Changes in brain volume and
maturation with increasing gestational
age.
Kugelman A, Colin AA. Pediatrics 2013;132:741-751

Pertumbuhan otak berlangsung pesat

pada trimester ke-3 gestasi, baik volume
otak dan terutama area permukaan
korteks

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Pertumbuhan Otak sejak intrauterine berlanjut
pada usia awal kehidupan, terutama 2 tahun
pertama kehidupan
• Saat lahir berat otak
bayi sekitar 25% berat
otak dewasa
• Usia 2 tahun meningkat
sampai 60% otak
dewasa
• Usia 6 tahun-meningkat
sampai 95%
• Peningkatan
berhubungan dengan
sinaptogenesis &
myelinisasi
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 Language outcomes from 2 to 13 years of age for children
born VP (open circles) and term controls (solid circles).

Luaran Bahasa anak lahir

premature tetap tertinggal
dibandingkan kontrol aterm

Thi-Nhu-Ngoc Nguyen et al. Pediatrics 2018;141:e20172831

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• Late preterm infants (34-36GA) compare to early term (37-38 GA)
and full term (39-40 GA)
• demonstrate comparable developmental outcomes at 24 months
• Less optimal reading outcomes at preschool and kindergarten
timepoints.

On going developmental surveillance for late preterm infants is

warranted into preschool and kindergarten.

Shah P et al Pediatrics 2016, 138 (2) DOI: https://doi.org/10.1542/peds.2015-3496

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 OUTCOME HIGH-RISK INFANTS
• Depends on:
• medical risk factors → birth weight, gestational age, periventricular leukomalacia
(PVL), intraventricular haemorrhage (IVH), respiratory distress syndrome (RDS),
necrotising enterocolitis (NEC)
• Non-medical factors → social class, parental education, parenting style, parental
mental health, family structure, family functioning, home environment

• → needs growth & development monitoring

Doyle LW, Saigal S. NeoReviews. 2009; 10:359.

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How great the opportunity
Course of developmental delay over 2 years period in relation to
various prenatal and perinatal factors
Thomaidis L, et al. BMC Pediatr 2014:14;40

• Prematurity and IUGR were significantly related to the severity of

GDD
• Poorer 2-year developmental outcome was associated with IUGR, low
socioeconomic status and non compliance to habilitation
• Prompt identification combined with an early supportive
intervention strategy may have significant implications on the
long-term outcome of developmental disability

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 Early detection and longterm follow up
• Identify specific medical problems of the infants
◉ Feeding difficulties
◉ Severe infections
◉ Respiratory Distress Syndrome
◉ Jaundice
◉ Brain Injury (intraventricular hemorrhage)
◉ Necrotizing enterocolitis
◉ Retinopathy of prematurity
◉ Anemia of prematurity

Fitzpatrick A. Peralta-Carcelen M, Kuban KC, et al. J.Pediatric. 2016. 14

Early Identification of developmental disorder:

- Crucial : early intervention – brain plasticity opportunity

- Challenging
• Notoriously difficult – rapid & extensive changes
• Diversity in techniques or tools available
• Heterogeneity in predictive validity
• Influenced by many factors (biological / socio-environmental)

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Developmental
monitoring
Algoritme pemilihan instrumen

(Dimodifikasi dan disarikan dari AAP 2001, 2006; Drotar, 2008) 16

Corrected Age
• Corrected Age = Chronological Age – Prematurity
• Terms:
• chronological age <2 years
• length of prematurity> 2 weeks (calculated from 40 weeks' gestation)

The application of the corrected for preterm children <28 weeks, the
application of the corrected age can be up to the chronological age of 3
years

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The Optimal Ages of Assessment
• < 1 year corrected : 3-4 and 6-8 months corrected age
• 12 months corrected age
• 18-24 months corrected age
• 3-4 years
• 6 years
• 8 years

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Vision and Hearing Screening
• High risk infants prone to retinopathy prematurity (ROP), visual
impairment, strabismus, visual field impairment.
• Hearing impairment prevalence in high-risk infants > 10-20 more
than normal infants

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ROP screening recommendations
• American Academy of pediatrics, American Academy of Ophthalmology,
and American Association for Pediatric Ophthalmology and Strabismus
recommended :
• Infant BW < 1500 g or GA <32 weeks
• Infant BW 1500-2000 g and GA >32 weeks with clinically unstable
• When to perform?
• First screening at clinically stable infant →2 weeks CA or 32-33 weeks
GA
• Further eye exam : usia 1-2 year, 3-4 year, 4-5 year, and 5-6 year

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 INFANTS HEARING SCREENING
Newborn > 24 hour, perform OAE before discharge

Pass/lulus Refer

3 months age : otoscopy,

tympanometry, distortion
product OAE, AABR

Risk factor (-) Risk factor (+) Pass/lulus Refer

Evaluation : audiology
No further Speech development and and ABR clicks +
evaluation audiology monitoring toneburst 500 Hz and/or
every 6 months for 3 ASSR
years
Habilitation before 6
Suwento R. KONAS PERHATI XIV. 2007. months age 24
How great the opportunity
Course of developmental delay over 2 years period in relation to
various prenatal and perinatal factors
Thomaidis L, et al. BMC Pediatr 2014:14;40

• Prematurity and IUGR were significantly related to the severity of

GDD
• Poorer 2-year developmental outcome was associated with IUGR, low
socioeconomic status and non compliance to habilitation
• Prompt identification combined with an early supportive
intervention strategy may have significant implications on the
long-term outcome of developmental disability

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What is Early Intervention?
• Early Intervention consists of multidisciplinary services provided to
children from birth to 5 years of age
• to promote child health and well-being
• enhance emerging competencies
• minimize developmental delays
• remediate existing or emerging disabilities
• prevent functional deterioration
• promote adaptive parenting and overall family functioning.
• These goals are accomplished by individualized developmental,
educational, and therapeutic services for children provided in
conjunction with mutually planned support for their families.
Shonkoff JP, Meisels SJ, editors. (2000) Handbook of Early Childhood Intervention
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Rationale of Early developmental intervention
programmes for preterm
1. The prenatal events may have affected the infant’s brain.
• Direct effect –a lesion of the brain, periventricular leukomalacia or a cortical
infarction
• Indirect effect, for instance caused by the pain and stress related to NICU

2. The early life has the highest potential to counteract the negative
sequelae because of the high plasticity of the young brain
3. Family needs guidance and assistance to cope with their preterm
and to learn the behaviour of the infant that may differ from infants
with typical development
Spittle A, et al. Cochrane Database Syst Rev 2015; 11: CD005495. 27
How is the evidence
• Developmental problems preterm infants may wide range, and there is great diversity
in the range of early intervention programs available for infants born preterm
• When the intervention commenced (immediately after birth versus post-hospital
discharge)
• Where the intervention delivery (clinic based versus home based)
• Who is professional delivering the intervention (e.g.,nurse, psychologist, physical
therapist, and pediatrician)
• What is focus of the intervention (e.g., infant versus parent– infant relationship)
• Dosage of intervention (e.g., 4 sessions versus 4100 sessions)
• length of intervention
Spittle A, 2016. The role of early developmental intervention to influence
neurobehavioral outcomes of children born preterm

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How is the evidence
• There is increasing evidence that early developmental interventions with a
preventative focus improved cognitive, behavior, and motor out comes for
infants born preterm.
• For those children or parents with a specific impairment, such as a child
with cerebral palsy or parent with significant post-natal depression,
targeted intervention programs are needed
• Early interventions to support parents’ mental health and parenting may
promote positive brain development processes and result in better
outcomes
• The effects of preterm birth are long term, and further intervention,
including possible “booster” sessions or special education support, maybe
required at school age

Spittle A, 2016. The role of early developmental intervention to influence

neurobehavioral outcomes of children born preterm 29
 CONCLUSION
◉ High risk infants are prone to have neurodevelopmental problem
◉ Families of high risk infants should be guided to comprehensive
follow-up and early intervention
◉ Close monitoring is needed to identify, stimulate/intervene to have
positive neurodevelopmental outcome

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