First LessonsThe Value of Healthy Regulation for Parent & BabyPaige Terrien Church, MDNeonatologist & Developmental Behavi...
2 ChurchDisclosureDisclosure• I have no actual or potential conflict of interest in relationI have no actual or potential ...
3 ChurchObjectivesObjectivesAt the end of this session you will be able to:At the end of this session you will be able to:...
4Introduction• “It is easier to buildstrong children thanto repair broken men.”(Frederick Douglas)Church
5 ChurchProblemProblem• 50-70% of very preterm infants have difficulty50-70% of very preterm infants have difficultywith s...
6 ChurchBehavioral PhenotypeBehavioral Phenotype• Describes a constellation of behavioral,Describes a constellation of beh...
7 ChurchBehavioral Phenotype of PrematurityBehavioral Phenotype of Prematurity• Majority of preterms withMajority of prete...
8 ChurchBehavioral Phenotype of PrematurityBehavioral Phenotype of Prematurity
9 ChurchBehavioral Phenotype of PrematurityBehavioral Phenotype of Prematurity
10Behavioral Phenotype of PrematurityBehavioral Phenotype of PrematurityJune 4, 2013 Church
11Behavioral Phenotype of PrematurityBehavioral Phenotype of PrematurityJune 4, 2013 Church
12Behavioral Phenotype of PrematurityBehavioral Phenotype of PrematurityJune 4, 2013 Church
13 ChurchBehavioral Phenotype of PrematurityBehavioral Phenotype of Prematurity• Social emotional dys-regulationSocial emo...
14 ChurchBehavioral Phenotype of PrematurityBehavioral Phenotype of Prematurity• Preterms with greater:Preterms with great...
15 ChurchBehavioral Phenotype of PrematurityBehavioral Phenotype of Prematurity• Generally average abilities in:Generally ...
16 ChurchBehavioral Phenotype of PrematurityBehavioral Phenotype of Prematurity• Cognitive skills historically regarded as...
17Behavioral Phenotype of PrematurityBehavioral Phenotype of Prematurity• Challenges with:– Language comprehension and exp...
18 June 4, 2013 Church
19NeurodevelopmentNeurodevelopmentJune 4, 2013 Church
20 ChurchNeurodevelopmentNeurodevelopment
21Neurodevelopment• Interplay between intrinsic brain development andInterplay between intrinsic brain development andexpe...
22Neurodevelopment• Extrinsic element=Neuronal plasticity• Experience expectant development– Experience leads to pruning– ...
23Neurosensory developmentNeurosensory development• Specific sequence– TactileVestibularChemicalAuditoryVisual• Interr...
24NeurodevelopmentAttachment• Begins in utero through sensory input– Sounds & smells• Wired to provide rapid learning• Ear...
25NeurodevelopmentImpact of PrematurityJune 4, 2013 Church
26 ChurchNeurodevelopmentImpact of Prematurity• Interruption of normal neurosensory developmentInterruption of normal neur...
27 ChurchNeurodevelopmentImpact of Prematurity• ““Normal” head ultrasound NOT guarantee ofNormal” head ultrasound NOT guar...
28 ChurchNeurodevelopmentImpact of Prematurity•3-4% with abnormality on HUS3-4% with abnormality on HUS•20-65% with abnorm...
29 ChurchNeurodevelopmentImpact of Prematurity• Developmental vulnerability with preterm birthDevelopmental vulnerability ...
30 ChurchNeurodevelopmentImpact of Prematurity• Cell death via:Cell death via:– NecrosisNecrosis– ApoptosisApoptosis• Can ...
31 ChurchNeurodevelopmentNeurodevelopmentImpact of PrematurityImpact of Prematurity• Altered synaptogenesisAltered synapto...
32NeurodevelopmentImpact of Prematurity• Loss of controlled sensory exposure• Alterations to timing (too much too soon, to...
33 ChurchNeuro-DevelopmentNeuro-Development• End result is:End result is:– Gray matter architecture distortedGray matter a...
34 June 4, 2013 Church
35 June 4, 2013 Church
36 ChurchTargets for InterventionTargets for InterventionLuciana M. Cognitive development in children born preterm: Implic...
37 ChurchTargets for InterventionTargets for InterventionHadders-Algra M. The Neuronal Group Selection Theory: a framework...
38Targets for InterventionTargets for InterventionJune 4, 2013 Church
39Targets for Intervention: NICUJune 4, 2013 Church
40 ChurchTargets for Intervention: NICU“Kangaroo care is crucial for babies to grow and develop and isalso medicine for th...
41Targets for Intervention: NICUTargets for Intervention: NICUJune 4, 2013 Church
42Targets for Intervention: NICUHack MB. Commentary: Care of Preterm Infants in the Neonatal Intensive Care Unit. Pediatri...
43Targets for Intervention: NICU• Randomized controlled trial with standard care and family carerooms (2 units)• Family ca...
44Targets for Intervention: NICU• Neuronal Group Selection Theory– Nesting versus containment• Skin to skin• Cluster non-e...
45Targets for Intervention: NICUJune 4, 2013 Church
46Targets for Intervention: NICU• Non-nutritive sucking• Breast milk• Holding with feeds (NG or PO)• Environment– Fosters ...
47Targets for InterventionNeonatal Follow UpJune 4, 2013 Church
48Targets for InterventionNeonatal Follow UpJune 4, 2013 Church
49 ChurchTargets for InterventionNeonatal Follow Up• Follow up not only surveillance for outcomesFollow up not only survei...
50Targets for InterventionNeonatal Follow UpJune 4, 2013 Church
51 ChurchTargets for InterventionNeonatal Follow Up• Awareness of statistics not equivalent to childAwareness of statistic...
52 Church
53 ChurchTargets for InterventionNeonatal Follow Up• Collaboration with schools criticalCollaboration with schools critica...
54Targets for InterventionNeonatal Follow UpJune 4, 2013 Church
55 ChurchFuture DirectionsFuture Directions• Emphasis shift in NICUEmphasis shift in NICU– Minimize stressMinimize stress–...
56 ChurchFuture DirectionsFuture Directions• Ongoing research neededOngoing research needed– Correlation to neuroimaging p...
57 ChurchThank You!Thank You!• Sunnybrook Health Sciences CentreSunnybrook Health Sciences Centre• Neonatal Follow Up Clin...
58 ChurchSourcesSources• Anderson PJ et al. Executive Functioning in School Aged Children Who Were Born Very Preterm or Wi...
59 ChurchSourcesSources• Laptook AR et al. Adverse Neurodevelopmental outcomes among extremely low birth weight infants wi...
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First lessons 6 13

  1. 1. First LessonsThe Value of Healthy Regulation for Parent & BabyPaige Terrien Church, MDNeonatologist & Developmental BehavioralPediatricianAssistant Professor, Paediatrics
  2. 2. 2 ChurchDisclosureDisclosure• I have no actual or potential conflict of interest in relationI have no actual or potential conflict of interest in relationto this program.to this program.• I also assume responsibility for ensuring the scientificI also assume responsibility for ensuring the scientificvalidity, objectivity, and completeness of the content ofvalidity, objectivity, and completeness of the content ofmy presentationmy presentationJune 4, 2013
  3. 3. 3 ChurchObjectivesObjectivesAt the end of this session you will be able to:At the end of this session you will be able to:1.1. Understand neurosensory development and criticalUnderstand neurosensory development and criticalperiodsperiods2.2. Explain normal attachmentExplain normal attachment3.3. Recognize impact of interrupted neurodevelopment onRecognize impact of interrupted neurodevelopment onoutcomeoutcome
  4. 4. 4Introduction• “It is easier to buildstrong children thanto repair broken men.”(Frederick Douglas)Church
  5. 5. 5 ChurchProblemProblem• 50-70% of very preterm infants have difficulty50-70% of very preterm infants have difficultywith school performancewith school performance• Proposed factor: complex amalgam of minorProposed factor: complex amalgam of minorchallengeschallenges– BehavioralBehavioral– Motor (fine, gross, visual)Motor (fine, gross, visual)– Cognitive (intellect, processing)Cognitive (intellect, processing)
  6. 6. 6 ChurchBehavioral PhenotypeBehavioral Phenotype• Describes a constellation of behavioral,Describes a constellation of behavioral,cognitive, motor, and social difficulties observedcognitive, motor, and social difficulties observedin a population with a common biologicalin a population with a common biologicaldisorderdisorder• Premature survivors have a phenotypePremature survivors have a phenotype– Common biological disorder=alterations inCommon biological disorder=alterations inbrain developmentbrain developmentHodapp RM, Fidler DJ. Special Education and Genetics: Connections for the 21Hodapp RM, Fidler DJ. Special Education and Genetics: Connections for the 21ststCentury. The J Spec EducCentury. The J Spec Educ1999; 33: 130-137.1999; 33: 130-137.
  7. 7. 7 ChurchBehavioral Phenotype of PrematurityBehavioral Phenotype of Prematurity• Majority of preterms withMajority of preterms withresolution of medicalresolution of medicalissues by school ageissues by school age• Motor delays commonMotor delays common• Dystonia=early signDystonia=early sign• Breslau N, Chilcoat EO, Johnson EO, Andreski P, Lucia VC.Breslau N, Chilcoat EO, Johnson EO, Andreski P, Lucia VC.Neurologic Soft Signs and Low Birthweight: Their Association andNeurologic Soft Signs and Low Birthweight: Their Association andNeuropsychiatric Implications. Biol Psychiatry 2000; 47: 71-79.Neuropsychiatric Implications. Biol Psychiatry 2000; 47: 71-79.• Bracewell M, Marlowe N. Patterns of Motor Disability in the VeryBracewell M, Marlowe N. Patterns of Motor Disability in the VeryPreterm Children. Ment Dev Disabil Res Rev 2002; 8: 241-248.Preterm Children. Ment Dev Disabil Res Rev 2002; 8: 241-248.• Goyen T-A, Lui K. Developmental Coordination Disorder inGoyen T-A, Lui K. Developmental Coordination Disorder in“apparently normal” schoolchildren born extremely preterm. Arch Dis“apparently normal” schoolchildren born extremely preterm. Arch DisChild 2009; 94: 298-302.Child 2009; 94: 298-302.
  8. 8. 8 ChurchBehavioral Phenotype of PrematurityBehavioral Phenotype of Prematurity
  9. 9. 9 ChurchBehavioral Phenotype of PrematurityBehavioral Phenotype of Prematurity
  10. 10. 10Behavioral Phenotype of PrematurityBehavioral Phenotype of PrematurityJune 4, 2013 Church
  11. 11. 11Behavioral Phenotype of PrematurityBehavioral Phenotype of PrematurityJune 4, 2013 Church
  12. 12. 12Behavioral Phenotype of PrematurityBehavioral Phenotype of PrematurityJune 4, 2013 Church
  13. 13. 13 ChurchBehavioral Phenotype of PrematurityBehavioral Phenotype of Prematurity• Social emotional dys-regulationSocial emotional dys-regulationgreater in pretermgreater in preterm– LabileLabile• Internalizing conditionsInternalizing conditions– AnxietyAnxiety– WithdrawnWithdrawn– Socially awkwardSocially awkward– Bhutta AT, Cleves MA, Casey PH, Cradock MM, Anand KJS. Cognitive andBhutta AT, Cleves MA, Casey PH, Cradock MM, Anand KJS. Cognitive andBehavioral Outcomes of School-Aged Children Who Were Born Preterm: ABehavioral Outcomes of School-Aged Children Who Were Born Preterm: AMeta-Analysis. JAMA. 2002; 288: 728-737.Meta-Analysis. JAMA. 2002; 288: 728-737.– Spittle AJ, Treyvaud K, Doyle LW,Spittle AJ, Treyvaud K, Doyle LW, et alet al. Early Emergence of Behavior and Social-. Early Emergence of Behavior and Social-Emotional Problems in the Very Preterm Infants. J. Am Acad Child AdolescEmotional Problems in the Very Preterm Infants. J. Am Acad Child AdolescPsychiatry 2009; 48: 909-918.Psychiatry 2009; 48: 909-918.
  14. 14. 14 ChurchBehavioral Phenotype of PrematurityBehavioral Phenotype of Prematurity• Preterms with greater:Preterms with greater:– Executive dysfunctionExecutive dysfunction– Hyperactivity, inattentionHyperactivity, inattention– ADHD/ADDADHD/ADD– Bhutta AT, Cleves MA, Casey PH, Cradock MM, Anand KJS. Cognitive and Behavioral Outcomes ofBhutta AT, Cleves MA, Casey PH, Cradock MM, Anand KJS. Cognitive and Behavioral Outcomes ofSchool-Aged Children Who Were Born Preterm: A Meta-Analysis. JAMA. 2002; 288: 728-737.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-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. PediatricsAged Children Who Were Born Very Preterm or With Extremely Low Birth Weight in the 1990’s. Pediatrics2004; 114: 50-57.2004; 114: 50-57.
  15. 15. 15 ChurchBehavioral Phenotype of PrematurityBehavioral Phenotype of Prematurity• Generally average abilities in:Generally average abilities in:– ReceptiveReceptive– ExpressiveExpressive• Subtle difficulties common with:Subtle difficulties common with:– SyntaxSyntax– Complexity of language used & understoodComplexity of language used & understoodFoster-Cohen S, Edgin JO, Champion PR, Woodward LJ. Early delayed language in very preterm infants: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.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 inFoster-Cohen SH, Friesen MD, Champion PR, Woodward LJ. High Prevalence/Low Severity Language Delay inPreschool Children Born Very Preterm. J Dev Behav Pediatr 2010; 31: 658-667.Preschool Children Born Very Preterm. J Dev Behav Pediatr 2010; 31: 658-667.
  16. 16. 16 ChurchBehavioral Phenotype of PrematurityBehavioral Phenotype of Prematurity• Cognitive skills historically regarded as bestCognitive skills historically regarded as bestmarker of school successmarker of school success– Actually only a piece of puzzleActually only a piece of puzzle• Preterm at particular risk with:Preterm at particular risk with:– Lower IQ than termLower IQ than term– More likely to have borderline IQMore likely to have borderline IQMarlowe NM, Wolke DM, Bracewell MA et al. Neurologic and Developmental Disability at SixMarlowe NM, Wolke DM, Bracewell MA et al. Neurologic and Developmental Disability at SixYears of Age after Extremely Preterm Birth. NEJM 2005; 353: 9-19.Years of Age after Extremely Preterm Birth. NEJM 2005; 353: 9-19.Whitfield MF, Grunau RV, Holsti L. Extremely premature (Whitfield MF, Grunau RV, Holsti L. Extremely premature (<< 800g) schoolchildren: multiple areas800g) schoolchildren: multiple areasof hidden disability. Arch Dis Child 1997; 77: F85-90.of hidden disability. Arch Dis Child 1997; 77: F85-90.Saigal S, den Ouden L, Wolke D,Saigal S, den Ouden L, Wolke D, et alet al. School Age Outcomes in Children Who Were Extremely. School Age Outcomes in Children Who Were ExtremelyLow Birth Weight From Four International Population-Based Cohorts. Pediatrics 2003; 112:Low Birth Weight From Four International Population-Based Cohorts. Pediatrics 2003; 112:943-950.943-950.
  17. 17. 17Behavioral Phenotype of PrematurityBehavioral 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 labilityChurch
  18. 18. 18 June 4, 2013 Church
  19. 19. 19NeurodevelopmentNeurodevelopmentJune 4, 2013 Church
  20. 20. 20 ChurchNeurodevelopmentNeurodevelopment
  21. 21. 21Neurodevelopment• Interplay between intrinsic brain development andInterplay between intrinsic brain development andexperienceexperience• Intrinsic: driven by genetic code with proliferation andIntrinsic: driven by genetic code with proliferation andmigrationmigration• Critical cellsCritical cells– Subplate neuronsSubplate neurons– Pre-oligodendrocytesPre-oligodendrocytes– External granule cellsExternal granule cells• Kolb B, Gibb R. Brain Plasticity and Behaviour in the Developing Brain. J Can Acad Child Adolesc Psychiatry 2011; 20: 265-276.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. 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. 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.Volpe JJ. Cerebellum of the Premature Infant: Rapidly Developing, Vulnerable, Clinically Important. J Child Neurol 2009; 24: 1085-1104.June 4, 2013 Church
  22. 22. 22Neurodevelopment• 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.Kolb B, Gibb R. Brain Plasticity and Behaviour in the Developing Brain. J Can Acad Child Adolesc Psychiatry 2011; 20: 265-276.June 4, 2013 Church
  23. 23. 23Neurosensory developmentNeurosensory development• Specific sequence– TactileVestibularChemicalAuditoryVisual• 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.June 4, 2013 Church
  24. 24. 24NeurodevelopmentAttachment• 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 ClinicalScience. Clin Perinatol 2011;38:643-55.June 4, 2013 Church
  25. 25. 25NeurodevelopmentImpact of PrematurityJune 4, 2013 Church
  26. 26. 26 ChurchNeurodevelopmentImpact of Prematurity• Interruption of normal neurosensory developmentInterruption of normal neurosensory development• Developmental susceptibilityDevelopmental susceptibility– Plastic system at critical pointPlastic system at critical point• Injury or atypical inputInjury or atypical input• Epigenetic changesEpigenetic changes• Volpe JJ. Brain injury in preterm infants: a complex amalgam of destructive and developmental disturbances. J Lancet 2009; 8: 110-124.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. Clin Perinatol 2011;38:591-603.
  27. 27. 27 ChurchNeurodevelopmentImpact of Prematurity• ““Normal” head ultrasound NOT guarantee ofNormal” head ultrasound NOT guarantee ofnormal outcomenormal outcome– 9% with CP9% with CP– 25% with MDI less than 7025% with MDI less than 70• Laptook AR, O’Shea TM, Shankaran S, Bhaskar B. Adverse Neurodevelopmental outcomes among extremelyLaptook AR, O’Shea TM, Shankaran S, Bhaskar B. Adverse Neurodevelopmental outcomes among extremelylow birth weight infants with a normal head ultrasound: prevalence and antecedents. Pediatrics. 2005; 115: 673-low birth weight infants with a normal head ultrasound: prevalence and antecedents. Pediatrics. 2005; 115: 673-680.680.
  28. 28. 28 ChurchNeurodevelopmentImpact of Prematurity•3-4% with abnormality on HUS3-4% with abnormality on HUS•20-65% with abnormality on MRI20-65% with abnormality on MRIInder TE, Wells SJ, Mogridge NB, Spencer C, Volpe JJ. Defining the Nature of the Cerebral Abnormalities in theInder TE, Wells SJ, Mogridge NB, Spencer C, Volpe JJ. Defining the Nature of the Cerebral Abnormalities in thePremature Infant: A Qualitative Magnetic Resonance Imaging Study. J Pediatr 2003; 143: 171-179.Premature Infant: A Qualitative Magnetic Resonance Imaging Study. J Pediatr 2003; 143: 171-179.
  29. 29. 29 ChurchNeurodevelopmentImpact of Prematurity• Developmental vulnerability with preterm birthDevelopmental vulnerability with preterm birth• Critical cells in preterm brain lack protectionCritical cells in preterm brain lack protectionfrom injuryfrom injury– Subplate neuronsSubplate neurons– InterneuronsInterneurons– Pre-oligodendrocytesPre-oligodendrocytes– External granule cellsExternal 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. 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. 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.Volpe JJ. Cerebellum of the Premature Infant: Rapidly Developing, Vulnerable, Clinically Important. J Child Neurol 2009; 24: 1085-1104.
  30. 30. 30 ChurchNeurodevelopmentImpact of Prematurity• Cell death via:Cell death via:– NecrosisNecrosis– ApoptosisApoptosis• Can occur on:Can occur on:– Macroscopic (IVH,Macroscopic (IVH,PVL, PVHI)PVL, PVHI)– Microscopic levelMicroscopic level(diffuse injury)(diffuse injury)• Volpe JJ. Brain injury in preterm infants: aVolpe JJ. Brain injury in preterm infants: acomplex amalgam of destructive andcomplex amalgam of destructive anddevelopmental disturbances. J Lancet 2009;developmental disturbances. J Lancet 2009;8: 110-124.8: 110-124.
  31. 31. 31 ChurchNeurodevelopmentNeurodevelopmentImpact of PrematurityImpact of Prematurity• Altered synaptogenesisAltered synaptogenesis– Experience expectant versus experienceExperience expectant versus experiencedependentdependent– Similar experience with different effectsSimilar experience with different effects• Plasticity can be good or badPlasticity can be good or bad• Neuronal Group Selection TheoryNeuronal 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.Kolb B, Gibb R. Brain Plasticity and Behaviour in the Developing Brain. J Can Acad Child Adolesc Psychiatry 2011; 20: 265-276.
  32. 32. 32NeurodevelopmentImpact of Prematurity• Loss of controlled sensory exposure• Alterations to timing (too much too soon, too little toolate)– 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.June 4, 2013 Church
  33. 33. 33 ChurchNeuro-DevelopmentNeuro-Development• End result is:End result is:– Gray matter architecture distortedGray matter architecture distorted– White matter connectivity alteredWhite matter connectivity altered– Cerebellum under-developedCerebellum under-developed• Leads toLeads to secondary cortical dysplasiasecondary cortical dysplasia• Volpe JJ. Brain injury in preterm infants: a complex amalgam of destructive and developmentalVolpe JJ. Brain injury in preterm infants: a complex amalgam of destructive and developmentaldisturbances. J Lancet 2009; 8: 110-124.disturbances. J Lancet 2009; 8: 110-124.• Alyward GP. Neurodevelopmental Outcomes of Infants Born Prematurely. J Dev Behav PediatrAlyward GP. Neurodevelopmental Outcomes of Infants Born Prematurely. J Dev Behav Pediatr2005; 26: 427-440.2005; 26: 427-440.
  34. 34. 34 June 4, 2013 Church
  35. 35. 35 June 4, 2013 Church
  36. 36. 36 ChurchTargets for InterventionTargets for InterventionLuciana M. Cognitive development in children born preterm: Implications for theories of brain plasticity following early injury. DevelLuciana M. Cognitive development in children born preterm: Implications for theories of brain plasticity following early injury. DevelPsychopathol 2003;15:1017-47Psychopathol 2003;15:1017-47
  37. 37. 37 ChurchTargets for InterventionTargets for InterventionHadders-Algra M. The Neuronal Group Selection Theory: a framework to explain variation in normalHadders-Algra M. The Neuronal Group Selection Theory: a framework to explain variation in normaldevelopment. Dev Med Child Neurol 2000;42:566-72.development. Dev Med Child Neurol 2000;42:566-72.
  38. 38. 38Targets for InterventionTargets for InterventionJune 4, 2013 Church
  39. 39. 39Targets for Intervention: NICUJune 4, 2013 Church
  40. 40. 40 ChurchTargets for Intervention: NICU“Kangaroo care is crucial for babies to grow and develop and isalso medicine for the souls of parents”
  41. 41. 41Targets for Intervention: NICUTargets for Intervention: NICUJune 4, 2013 Church
  42. 42. 42Targets for Intervention: NICUHack MB. Commentary: Care of Preterm Infants in the Neonatal Intensive Care Unit. Pediatrics 2009;123:1246.June 4, 2013 Church
  43. 43. 43Targets for Intervention: NICU• Randomized controlled trial with standard care and family carerooms (2 units)• Family care resulted in:– Decreased length of stay– No effect on mortality– Trend toward decreased BPDJune 4, 2013 Church
  44. 44. 44Targets 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 careJune 4, 2013 Church
  45. 45. 45Targets for Intervention: NICUJune 4, 2013 Church
  46. 46. 46Targets 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 hospitalizationJune 4, 2013 Church
  47. 47. 47Targets for InterventionNeonatal Follow UpJune 4, 2013 Church
  48. 48. 48Targets for InterventionNeonatal Follow UpJune 4, 2013 Church
  49. 49. 49 ChurchTargets for InterventionNeonatal Follow Up• Follow up not only surveillance for outcomesFollow up not only surveillance for outcomes– Need assessment, diagnosis and interventionNeed assessment, diagnosis and intervention• Homework critical—small stepsHomework critical—small steps• Reports with clear languageReports with clear language
  50. 50. 50Targets for InterventionNeonatal Follow UpJune 4, 2013 Church
  51. 51. 51 ChurchTargets for InterventionNeonatal Follow Up• Awareness of statistics not equivalent to childAwareness of statistics not equivalent to childbecoming statisticbecoming statistic• Should provide heightened surveillance andShould provide heightened surveillance andattention to ‘small’ problemsattention to ‘small’ problems• Constant contextualizationConstant contextualization
  52. 52. 52 Church
  53. 53. 53 ChurchTargets for InterventionNeonatal Follow Up• Collaboration with schools criticalCollaboration with schools critical• Parents need to be educated in positiveParents need to be educated in positiveadvocacyadvocacy– Education on transition to schoolsEducation on transition to schools– Special education resourcesSpecial education resources– Major morbidities and minor morbidities not mutuallyMajor morbidities and minor morbidities not mutuallyexclusiveexclusive
  54. 54. 54Targets for InterventionNeonatal Follow UpJune 4, 2013 Church
  55. 55. 55 ChurchFuture DirectionsFuture Directions• Emphasis shift in NICUEmphasis shift in NICU– Minimize stressMinimize stress– Normalize environmental exposure-Parents idealNormalize environmental exposure-Parents idealenvironmentenvironment• Extended follow up ideal model withExtended follow up ideal model withcollaboration with emphasis on interventioncollaboration with emphasis on intervention• SpecializedSpecialized training essentialtraining essential
  56. 56. 56 ChurchFuture DirectionsFuture Directions• Ongoing research neededOngoing research needed– Correlation to neuroimaging patternsCorrelation to neuroimaging patterns– Neonatal care & impacts on outcomeNeonatal care & impacts on outcome– OutcomesOutcomes• Particularly School based and school interventions!Particularly School based and school interventions!– Functional outcome measurements neededFunctional outcome measurements needed
  57. 57. 57 ChurchThank You!Thank You!• Sunnybrook Health Sciences CentreSunnybrook Health Sciences Centre• Neonatal Follow Up ClinicNeonatal Follow Up Clinic– Marion DeLand, RNMarion DeLand, RN– Maureen Luther, PTMaureen Luther, PT– Pat Maddalena, PNPPat Maddalena, PNP– Laura Cooper, OTLaura Cooper, OT– Rudaina Banihani, MD and Jessie VanDyk, MD (neonatalRudaina Banihani, MD and Jessie VanDyk, MD (neonatalfellows)fellows)– Vanessa Warsh, administratorVanessa Warsh, administrator– Carol Grenade, administratorCarol Grenade, administrator
  58. 58. 58 ChurchSourcesSources• Anderson PJ et al. Executive Functioning in School Aged Children Who Were Born Very Preterm or With Extremely Low Birth Weight in the 1990’s.Anderson PJ et al. Executive Functioning in School Aged Children Who Were Born Very Preterm or With Extremely Low Birth Weight in the 1990’s.Pediatrics. 2004;114:50-57Pediatrics. 2004;114:50-57• Anderson P, Doyle L. Neurobehavioral Outcomes of School Age Children Born Extremely Low Birth Weight or Very Preterm in the 1990’s. JAMA.Anderson P, Doyle L. Neurobehavioral Outcomes of School Age Children Born Extremely Low Birth Weight or Very Preterm in the 1990’s. JAMA.2003;289:3264-3272.2003;289:3264-3272.• Aylward GP. ADHD in Children with Disabilities: Etiologic, Diagnostic, and Psychopharmacologic Issues. Lecture, AACPDM, September 2005.Aylward GP. ADHD in Children with Disabilities: Etiologic, Diagnostic, and Psychopharmacologic Issues. Lecture, AACPDM, September 2005.• Aylward GP. Cognitive and Neuropsychological Outcomes: More than IQ Scores. Mental Retardation and Developmental Disabilities ResearchAylward GP. Cognitive and Neuropsychological Outcomes: More than IQ Scores. Mental Retardation and Developmental Disabilities ResearchReviews. 2002;8:234-240.Reviews. 2002;8:234-240.• Aylward GP. Neurodevelopmental Outcomes of Infants Born Prematurely. JDBP. 2005;26:427-440.Aylward GP. Neurodevelopmental Outcomes of Infants Born Prematurely. JDBP. 2005;26:427-440.• Aylward GP. Presidential Address. Prediction of Function from Infancy to Early Childhood: Implications for Pediatric Psychology. Journal of PediatricAylward GP. Presidential Address. Prediction of Function from Infancy to Early Childhood: Implications for Pediatric Psychology. Journal of PediatricPsychology. 2004;29:555-564Psychology. 2004;29:555-564• Berlin CI et al. Auditory neuropathy/dyssynchrony: Its diagnosis and management. Pediatric Clinics of North America. 2003;50:331-340.Berlin CI et al. 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