LONG TERM FOLLOW UP OF THE HIGH RISK VLBW INFANTS Dr Pratibha - PowerPoint PPT Presentation

LONG TERM FOLLOW UP OF THE HIGH RISK VLBW INFANTS Dr Pratibha Agarwal Senior Consultant, Department of Child Development KK Women’s and Children’s Hospital, Singapore

The High Risk Infant – Challenges and Opportunities

• Challenge for ALL newborns to make the leap from safe inutero to “hostile” exutero existence. • Establish independent body function – Thermoregulation – Cardiorespiratory – Cardiorespiratory – Metabolic • Learning / Motor skills, feeding, attachment and early communication cues.

High Risk Newborn • Any newborn who has greater than average chance of morbidity or mortality because of conditions superimposed on the normal course of birth events and postnatal adaptation. Postnatal Prenatal • Neonatal seizures. • Low birth weight. • Abnormal cranial ultrasound. • Gestational age <28weeks. • Chronic lung disease (CLD). • Intrauterine growth restriction • Infections. (IUGR). • ECMO. Male gender ( ♂ ). • ↓ Socioeconomic status • • Maternal depression

Classification of High Risk Newborns • High Risk Newborn According to size / Gestational Age Gestational Age Gestational Age & Birth weight * SGA (Wt <10 th centile) * Preterm (GA < 37 weeks) • Term 38 – 42 weeks AGA LGA (Wt > 90 th centile) • Post term > 42 weeks < 2500g – LBW < 1500g – VLBW < 1000g – ELBW ≥ 4 kg – Large

Prematurity stratification & incidence % of preterm Description Gestational age birth Extremely preterm Extremely preterm < 28 weeks < 28 weeks 6% 6% Very preterm 28 – 31 weeks 10% Moderately preterm 32 – 33 weeks 13% Late preterm 34 – 36 weeks 71%

High Risk Infants • Hypothesis – Significantly less developed brain structure & function (neurocognitive & behavioral) compared to controls. • Poorer cognitive, behavioral & developmental outcomes hypothesised to be related to – Lower grey & white matter volume – Poorer structural & functional connectivity (DTI & MRI) – Less mature metabolic profile (MRS)

High Risk Period • Encompasses period of growth and viability upto 28 days following birth… (upto 2 years) Structure – volumes, gyration, sulcation. 13 weeks 30 weeks 36 weeks 6 months 2 years

Preterm Infants • Period between preterm birth & term signifies the beginning of the brain growth spurt & is potentially vulnerable to ex-utero environmental & nutritional influences. Brain Brain • ↑ Total Brain Volume – 22ml/wk • Total grey matter - ↑ by 1.4% / week • ↑ cortical grey matter volume • No significant volume change in subcortical grey matter (basal ganglia thalamus) Ann Neurol 1998;224-235

“Programming” “The concept that a stimulus or insult, when applied at a critical or sensitive period in early life , may have a long term or life-time effect on the structure or function of the organism” (Lucas A 1991, Hales CN, Barker DJP2001)

Vulnerability vs Plasticity

Preterm Brain Increased Vulnerability • Rapidly growing tissues – Exaggerated effect of insult • Vascular instability • Watershed areas (Periventricular areas) • ↑ metabolic vulnerability in selective regions (hippocampus)

Mid – Late gestational insult • Alters frontal lobe development. • Effect on cerebellar development • Poorer executive function, planning & • Poorer executive function, planning & spatial memory. • Caudate volumes significantly affected by early nutrition & related to verbal IQ.

Neural Plasticity Intrinsic capacity of brain for remodeling due to overproduction & trimming (blooming & pruning) of neuronal connections Change in synaptic processess, neurogenesis & axon myelination Allows developing synaptic architecture of brain to capture & incorporate experiences Co-ordination neural network activity Supports development & learning

Postnatal Period • “Window of sensitivity” & reflect “Opportunity or exposure” for interventions to exert their effect. • Neural plasticity may mitigate effects of nutrient deficiencies on brain by adapting / compensating. compensating. • Experience in the NICU alters development. – Postnatal nutrition, – Sensory overload / underload.

Pre-school years (1 – 5 years) • Rapid & dramatic brain development • Neural plasticity • Fundamental of cognitive development – Working memory – Attention – Attention – Inhibitory Control – Interpersonal skills – Language – Motor co-ordination • Window of sensitivity – Nutrient or non-nutrient intervention may cause region specific changes & postnatal neural development.

WHAT DO WE NEED WE NEED TO KNOW?

KK Women’s and Children’s Hospital • Largest tertiary care perinatal centre in Singapore (NICU– 37 beds, L2 – 60 beds). • Annual delivery 13000 per year. • VLBW – 200/year, ELBW – 90/year. • Provide care to > 2/3 of ELBW infants in Singapore. • In utero and outborn neonatal transfer (local and regional)

Our Interest groups • Very Preterm –VLBW < 32 weeks • Late Preterm infants- 34-36 weeks • Late Preterm infants- 34-36 weeks • Term IUGR • Breast Fed Infants

Implications of the Prematurity: As incidence increases, so does the cost • Economic – High risk obstetric & NICU care – Long term health & developmental concerns • Societal • Societal – ↑ Cost in education & care – ↓ Productivity of parents • Personal / Interpersonal – Stress, Disruption – ↑ family demands

Survival

Neonatal survival in VLBW infants @ KKH 100% 91% 96% 90% (95%*) 80% (88%*) 70% 59% 60% (55%*) 50% 50% 40% 30% 27% 20% 10% 0% < 500 501 - 750 751 - 1000 1000 - 1500 Survival • n = 2105 Overall survival – 88% • 2000 – 2010 (*) – NICHD data

Neonatal Mortality Rates according to Gestational Age •OR (95%CI) of survival with high gestational age = 1.50 (1.29-1.74) p < 0.001 •OR (95%CI) of mortality with high gestational age = 0.82 (0.70-0.90) p = 0.022 •OR (95%CI) of comfort care with high gestational age = 0.21 (0.13-0.34) p < 0.001 •P values and OR(95%)CI were determined for difference according to gestational age with adjustment for birth weight; year and birth

BEYOND SURVIVAL….. • How should patients and their families be counselled about the morbidity associated with extremely preterm infants? • Parents want to know whether their child will survive + ability to survive with/without a major disability - Neonatal Morbidity - Childhood Neurodevelopmental Outcome

BEYOND SURVIVAL NEONATAL MORBIDITY Poor mental development ↑ Cerebral palsy Visual - Diplegia Major NN Impairment / morbidity - Hemiplegia Blindness Blindness - Quadriplegia Low motor development scores Major neonatal morbidities have an impact on later development & growth in childhood (IVH/CLD/NEC/Sepsis/ROP)

Neurocognitive outcome – Effects of neonatal morbidity Neonatal morbidity % with disability No morbidity 18% 1 morbidity (BPD / IVH / ROP) 42% 2 morbidities 62% 3 morbidities 88% Schmidt et al JAMA 2003:289;1124 - 1129

Neonatal Morbidity and Mortality in ELBW Infants KKH Data: 2000 - 2010 <500 501 – 750 751-1000 1001-1500 Total (n=37) (n=307) (n=502) (n=1254) (n=2105) Survival 10 (27%) 178 (59%) 458 (91%) 96% 88% Sepsis 45% 45% 19% 6% 15% Severe IVH 21% 18% 9% 2.5% 6% Severe 25% 44% 16% 0.7% 10% ROP in survivors NEC 11% 11% 8% 4% 6% BPD in 61% 58% 23% 4% 15% survivors

Long Term Follow Up of the preterm NICU graduate Neurodevelopmental outcome after preterm birth is the MOST IMPORTANT measure of NICU success!!!

Learning Objectives • Discuss benefits of neonatal follow up program for the NICU graduate. • Define optimal ages of follow up assessment. • Define challenges in long term • Define challenges in long term Follow up. • Newer assessment needs

Questions to be Answered • Survival of high risk neonates is improving? • What lies beyond survival of NICU graduate ? • Do LBW infants with normal IQ range, make greater use of special education tools compared to full term peers ?

Questions to be Answered • Quality of life is more important than mere survival? • Can they live independently & support themselves? • Do they develop normal social & family relationships? • What are long term metabolic & cardiovascular implications?

Benefits of long term follow up 1. Early Detection of Developmental Disturbances ↓ Appropriate & adequate intervention & support ↓ Improved Outcome for Child & Family 2. Surveillance/Quality Improvement Tool (QI) • To audit perinatal & neonatal practices • Target neonatal morbidity associated with poor long term outcome 3. Perinatal Counselling • Antenatal counselling & development of guidelines for resuscitation & care of infants at borderline viability 4. Research

Early Detection & Management of Medical & Developmental disturbances • Infant & Family – Early Identification Appropriate & Adequate Early intervention & support Improved Outcome Involved physician Improve quality of care