First lessons: the value of healthy regulation in mother and baby

First Lessons

The Value of Healthy Regulation for Parent & Baby

Paige Terrien Church, MD

Neonatologist & Developmental Behavioral

Pediatrician

Assistant Professor, Paediatrics

Disclosure

• I have no actual or potential conflict of interest in relation to this program.

• I also assume responsibility for ensuring the scientific validity, objectivity, and completeness of the content of my presentation

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Objectives

At the end of this session you will be able to:

1. Understand neurosensory development and critical periods

2. Explain normal attachment

3. Recognize impact of interrupted neurodevelopment on outcome

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Introduction

• “It is easier to build strong children than to repair broken men.”

(Frederick Douglas)

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Problem

• 50-70% of very preterm infants have difficulty with school performance

• Proposed factor: complex amalgam of minor challenges

– Behavioral

– Motor (fine, gross, visual)

– Cognitive (intellect, processing)

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Behavioral Phenotype

• Describes a constellation of behavioral, cognitive, motor, and social difficulties observed in a population with a common biological disorder

• Premature survivors have a phenotype

– Common biological disorder=alterations in brain development

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Hodapp RM, Fidler DJ. Special Education and Genetics: Connections for the 21 st

1999; 33: 130-137.

Century. The J Spec Educ

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Behavioral Phenotype of Prematurity

• Majority of preterms with resolution of medical issues by school age

• Motor delays common

• Dystonia=early sign

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• Breslau N, Chilcoat EO, Johnson EO, Andreski P, Lucia VC.

Neurologic Soft Signs and Low Birthweight: Their Association and

Neuropsychiatric Implications. Biol Psychiatry 2000; 47: 71-79.

Bracewell M, Marlowe N. Patterns of Motor Disability in the Very

Preterm Children. Ment Dev Disabil Res Rev 2002; 8: 241-248.

Goyen T-A, Lui K. Developmental Coordination Disorder in

“apparently normal” schoolchildren born extremely preterm. Arch Dis

Child 2009; 94: 298-302.

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• Social emotional dys-regulation greater in preterm

– Labile

• Internalizing conditions

– Anxiety

– Withdrawn

– Socially awkward

– Bhutta AT, Cleves MA, Casey PH, Cradock MM, Anand KJS. Cognitive and

Behavioral Outcomes of School-Aged Children Who Were Born Preterm: A Meta-

Analysis. JAMA. 2002; 288: 728-737.

– Spittle AJ, Treyvaud K, Doyle LW, et al . Early Emergence of Behavior and Social-

Emotional Problems in the Very Preterm Infants. J. Am Acad Child Adolesc

Psychiatry 2009; 48: 909-918.

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• Preterms with greater:

– Executive dysfunction

– Hyperactivity, inattention

– ADHD/ADD

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– Bhutta AT, Cleves MA, Casey PH, Cradock MM, Anand KJS. Cognitive and Behavioral Outcomes of 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-

Aged Children Who Were Born Very Preterm or With Extremely Low Birth Weight in the 1990’s. Pediatrics

2004; 114: 50-57.

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• Generally average abilities in:

– Receptive

– Expressive

• Subtle difficulties common with:

– Syntax

– Complexity of language used & understood

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.

Foster-Cohen SH, Friesen MD, Champion PR, Woodward LJ. High Prevalence/Low Severity Language Delay in

Preschool Children Born Very Preterm. J Dev Behav Pediatr 2010; 31: 658-667.

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• Cognitive skills historically regarded as best marker of school success

– Actually only a piece of puzzle

• Preterm at particular risk with:

– Lower IQ than term

– More likely to have borderline IQ

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Marlowe NM, Wolke DM, Bracewell MA et al. Neurologic and Developmental Disability at Six

Years of Age after Extremely Preterm Birth. NEJM 2005; 353: 9-19.

Whitfield MF, Grunau RV, Holsti L. Extremely premature (< 800g) schoolchildren: multiple areas of hidden disability. Arch Dis Child 1997; 77: F85-90.

Saigal S, den Ouden L, Wolke D, et al . School Age Outcomes in Children Who Were Extremely

Low Birth Weight From Four International Population-Based Cohorts. Pediatrics 2003; 112:

943-950.

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• 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 lability

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Neurodevelopment



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• Interplay between intrinsic brain development and experience

• Intrinsic: driven by genetic code with proliferation and migration

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• Critical cells

– Subplate neurons

– Pre-oligodendrocytes

– External granule cells

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. 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.



• Extrinsic element=Neuronal plasticity

• Experience expectant development

– Experience leads to pruning

– Critical period with early synapse development

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• 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.


Neurosensory 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.



Attachment

• 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 Clinical

Science. Clin Perinatol 2011;38:643-55.



Impact of Prematurity


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• Interruption of normal neurosensory development

• Developmental susceptibility

– Plastic system at critical point

• Injury or atypical input

• Epigenetic changes

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• 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.

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• “Normal” head ultrasound NOT guarantee of normal outcome

– 9% with CP

– 25% with MDI less than 70

• Laptook AR, O’Shea TM, Shankaran S, Bhaskar B. Adverse Neurodevelopmental outcomes among extremely low birth weight infants with a normal head ultrasound: prevalence and antecedents. Pediatrics. 2005; 115: 673-680.

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•3-4% with abnormality on HUS

•20-65% with abnormality on MRI

Inder TE, Wells SJ, Mogridge NB, Spencer C, Volpe JJ. Defining the Nature of the Cerebral Abnormalities in the

Premature Infant: A Qualitative Magnetic Resonance Imaging Study. J Pediatr 2003; 143: 171-179.

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• Developmental vulnerability with preterm birth

• Critical cells in preterm brain lack protection from injury

– Subplate neurons

– Interneurons

– Pre-oligodendrocytes

– External granule cells

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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. Cerebellum of the Premature Infant: Rapidly Developing, Vulnerable, Clinically Important. J Child Neurol 2009; 24: 1085-1104.

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• Cell death via:

– Necrosis

– Apoptosis

• Can occur on:

– Macroscopic (IVH,

PVL, PVHI)

– Microscopic level

(diffuse injury)


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• Altered synaptogenesis

– Experience expectant versus experience dependent

– Similar experience with different effects

• Plasticity can be good or bad

• Neuronal 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.

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• Loss of controlled sensory exposure

• Alterations to timing (too much too soon, too little too late)

– 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.


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Neuro-Development

• End result is:

– Gray matter architecture distorted

– White matter connectivity altered

– Cerebellum under-developed

• Leads to secondary cortical dysplasia


• Alyward GP. Neurodevelopmental Outcomes of Infants Born Prematurely. J Dev Behav Pediatr

2005; 26: 427-440.

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Targets for Intervention

Luciana M. Cognitive development in children born preterm: Implications for theories of brain plasticity following early injury. Devel

Psychopathol 2003;15:1017-47

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Hadders-Algra M. The Neuronal Group Selection Theory: a framework to explain variation in normal development. Dev Med Child Neurol 2000;42:566-72.

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Targets for Intervention: NICU



“

Kangaroo care is crucial for babies to grow and develop and is also medicine for the souls of parents”

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Targets for Intervention: NICU

Hack MB. Commentary: Care of Preterm Infants in the Neonatal Intensive Care Unit. Pediatrics 2009;123:1246.



• Randomized controlled trial with standard care and family care rooms (2 units)

• Family care resulted in:

– Decreased length of stay

– No effect on mortality

– Trend toward decreased BPD


Targets 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 care





• 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 hospitalization



Neonatal Follow Up





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• Follow up not only surveillance for outcomes

– Need assessment, diagnosis and intervention

• Homework critical—small steps

• Reports with clear language

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• Awareness of statistics not equivalent to child becoming statistic

• Should provide heightened surveillance and attention to ‘small’ problems

• Constant contextualization

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• Collaboration with schools critical

• Parents need to be educated in positive advocacy

– Education on transition to schools

– Special education resources

– Major morbidities and minor morbidities not mutually exclusive

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Future Directions

• Emphasis shift in NICU

– Minimize stress

– Normalize environmental exposure-Parents ideal environment

• Extended follow up ideal model with collaboration with emphasis on intervention

• Specialized training essential

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Future Directions

• Ongoing research needed

– Correlation to neuroimaging patterns

– Neonatal care & impacts on outcome

– Outcomes

• Particularly School based and school interventions!

– Functional outcome measurements needed

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Thank You!

• Sunnybrook Health Sciences Centre

• Neonatal Follow Up Clinic

– Marion DeLand, RN

– Maureen Luther, PT

– Pat Maddalena, PNP

– Laura Cooper, OT

– Rudaina Banihani, MD and Jessie VanDyk, MD (neonatal fellows)

– Vanessa Warsh, administrator

– Carol Grenade, administrator

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Sources

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Anderson PJ et al. Executive Functioning in School Aged Children Who Were Born Very Preterm or With Extremely Low Birth Weight i n the 1990’s.

Pediatrics. 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.

2003;289:3264-3272.

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 Research Reviews.

2002;8:234-240.

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 Pediatric

Psychology. 2004;29:555-564

Berlin CI et al. Auditory neuropathy/dyssynchrony: Its diagnosis and management. Pediatric Clinics of North America. 2003;50:331-340.

Bracewell M et al. Patterns of Motor Disability in Very Preterm Children. Mental Retardation and Developmental Disabilities Research Reviews.

2002;8:241-248.

Brandt I et al. Transient abnormal neurologic signs (TANS) in a longitudinal study of very low birth weight preterm infants. Early Human Development.

2000;59:107-126.

Breslau N et al. Neurologic Soft Signs and Low Birth Weight: Their Association and Neuropsychiatric Implications. Biol Psychiatry. 2000;47:71-79 deGraaf-Peters VB, Hadders-Algra M. Ontogeny of the human central nervous system: What is happening when? Early Human Development 2006;

82:257-266.

Delobel-Ayoub M et al. Behavioral Problems and Cognitive Performance at 5 Years of Age After Very Preterm Birth: The EPIPAGE Study. Pediatrics.

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Goyen T-

A. Developmental Coordination Disorder in ‘Apparently Normal’ School Children Born Extremely Preterm.

Hack M et al. Poor Predictive Validity of BSID for Cognitive Function of Extemely Low Birth Weight Children at School Age. Pediatrics. 2005;116:333-

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Hack M. School Age Outcomes in Children with Birth Weights Under 750 g. NEJM. 1994;331:753-759.

Harris LL et al. School Readiness. Up to Date. 2010.

High PC et al. School Readiness. Pediatrics 2008;121:e1008-e1015.

Inder TE et al. Defining the Nature of the Cerebral Abnormalities in the Premature Infant: A Qualitative Magnetic Resonance Imaging Study. Journal of

Pediatrics. 2003;171-179.

Klein N, Hack M, Gallagher J, Fanaroff AA. Preschool Performance of Childrein with Normal Intelligence Who Were very Low-Birth-Weight Infants.

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Kuban KCK et al. Positive Screening on the Modified Checklist for Autism in Toddlers (M-CHAT) in Extremely Low Birth Gestational Age Newborns.

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Lian WB, Ying SHK et al. Preschool Teachars’ Knowledge, attitudes, and practices on childhood developmental and behavioural disorders in Singapore. J. of Paediatrics and Child Health. 2008;44:187-194.

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Behavioral Pediatrics. 2005;26:209-213.

Marlow N et al. Motor and Executive Function at 6 Years of Age After Extremely Preterm Birth. Pediatrics. 2007;120:793-804.

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Saigal S. School-Age Outcomes in Children Who Were Extremely Low Birth Weight From Four International Population-Based Cohorts.

Pediatrics. 2003;112:943-950.

Samara M et al. Pervasive behavior problems at 6 years of age in a total population sample of children born at <25 weeks of gestation

(EPICure). Pediatrics. 2008;122:562-573.

Spittle AJ et al. Early emergence of behavior and social-emotional problems in the very preterm infants. J. Am. Acad Child Adoles.

Psychiatry. 2009;909-917.

Volpe JJ. Brain injury in premature infants: a complex amalgam of destructive and developmental disturbances. The Lancet. 2009;8:110-

124.

Woodward LJ et al. Neonatal MRI to Predict Neurodevelopmental Outcomes in Preterm Infants. NEJM. 2006;355:685-694.

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First lessons: the value of healthy regulation in mother and baby

Disclosure

Targets for Intervention

Targets for Intervention: NICU

Targets for Intervention: NICU

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First lessons: the value of healthy regulation in mother and baby

Disclosure

Targets for Intervention

Targets for Intervention: NICU

Targets for Intervention: NICU

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