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I'd like to welcome you all to our Your Child's Health
University lecture this evening. I'm Nancy Sanchez from
Community Relations here at Packard Children's and it's my
pleasure each month to introduce our physician specialists
who have presentations for families and professionals in the
community. And you've been given as you come in the door a
list
with this spring's lectures. Do take a look and we welcome
you to all of those. And then on the back, there's a list of
those that are already in our online library, past lectures.
So you can go to lpch.org and you can see some of the
lectures from past years. That said, I want you to know that
we are as you can see, recording this lecture as
well so you can review the material later. It usually
takes us about two weeks to get it posted on our online
library. Also, because we're recording, we ask that you
maybe hold your questions to the end so your questions can
be
kept private and they will stop recording at the end of the
presentation. Okay? Just so you know. Jot them down and
then we'll have a question and answer period for you later.
So this evening, as you know, our topic is the
neurodevelopment
of preterm babies and it's my great pleasure to
introduce Dr Courtney Wusthoff to you this evening. She's a
new addition to LPCH's Child Neurology team. She's an
Assistant Professor of Neurology at Stanford University and
the lead neurologist for the neonatal neuro-intensive care
unit at Packard Children's, opening in the spring. She
received her BA in neuroscience and neurophysiology and
behavior from Columbia University in New York and her MD at
the University of California San Francisco. Dr.Wusthoff
completed her pediatrics residency at Children's Hospital
of Oakland and her neuro and neurophysiology training at
Children's Hospital of Philadelphia. Quite a resume. More
recently Dr.Wusthoff served as consultant in perinatology,
perinatal neurology at the Hammersmith Hospital and Imperial
College in London. She's now happily returned to the Bay
Area and joined us here at Packard Children's, and it's
our great pleasure to introduce her to you this evening. Dr.
Wusthoff,
thanks for your time. Alright. Thanks very much
for having me. It's really exciting to be able to come and
talk about
this topic because there's a lot that's going on right now
here at Packard, especially for looking at neurodevelopment
of our babies who are especially vulnerable, especially
fragile. And this is a particular passion of mine. So what
I'm gonna try to cover over the next 45 minutes or so
and leave us lots of time for questions. I'm gonna review
patterns of neurodevelopment, both in terms of the
physiology, the biology, and also the things that you see at
home with your baby. I'm gonna talk about things that are
different for babies who have been born early, things that
can be especially noticeable for them. And then I'm gonna
finish off by talking about, well what are the things we can
do to help foster neurodevelopment for babies who are born
preterm? So thinking about patterns of neurodevelopment.
What you see here is an MRI scan for a patient who's 27
weeks gestational age. That means the pregnancy lasted for
twenty-seven weeks and then the baby was born. And this MRI
was done as part of the research at the Hammersmith
Hospital, where I was recently. And you can see that for
this baby, who was born at about six one-half months into
the pregnancy, there's this outer layer, which is the gray
matter, that's where the actual brain cells live, the
neurons are. And then in between, there's this darker area
which is the developing white matter. That's like the
cables, the wiring between the different cells. It helps
link up different parts of the brain. And you can compare
that to this MRI scan. This is the same baby when
they're four months old, four months corrected age. This
still gets me. It's just really amazing in such a short
amount of time how much brain development there is. The
obvious thing is the head size gets much, much bigger. You
guys are familiar with that. But also you can see there's so
much detail that starts to develop in those early months.
Here you have the two halves of the brain, the hemispheres.
Those are pretty well separated, you can see there's a
little bit of folding in some parts of the brain. But by the
time baby's four months old there's a really rich, intricate
cortical folding and that's how the brain's developing. Even
after the size stops getting bigger and bigger, brain
development continues. The other things you can see on this
picture is you start to see these tracks, these pathways
that are developing in the brain. They're not really well
formed in babies who are preterm, but by a few
months they've started to develop. I should say on these
MRI scans for people who aren't used to looking at MRI
scans, you're looking almost like you're looking through the
baby's head so the ears will be out at the side. That's
actually the spinal cord coming down through there, the top
of the head. This is another view of a preterm baby's brain.
So this is a different baby, this is at 25 weeks, a baby who
the pregnancy lasted just six months before baby was born.
And
this is a different view looking through the top of the
baby's head. So this is the back of the baby's head laying
down inside the MRI scanner. The nose would be up here and
the eyes up here. And what you can see is again the two
halves of the brain are pretty well developed, but even
using an MRI scan we can actually see, you can see these
stripes, that sort of ribbon pattern. Those are actually
layers of nerves, of neurons that are going out to where
they
want to be ultimately in development. So lots of the neurons
that will eventually work their way to the outer surface of
the brain or the cortex, cortex actually means bark. They're
still inside the brain and they're finding their way out to
the right place. And this is just another level further down
in the brain, again back of the head. The front of the head
up there. You can see there's a little bit of folding.
There's these normal pockets of fluid inside the brain. And
you can see, just if you look real hard, that there's these
ribbons of neurons that are migrating out to the place
that they need to be. Now in a term infant this is not the
same baby but similar views just a few weeks later. Same
position. Back of the head, front of the head. Huge
difference in how much the brain's developed. You have much
more detailed folding of the brain on the outside. The
cortex
is really starting to get wrinkled. You don't see
the same ribbons that you see up here because all of the
neurons have gone out to where they need to be. But you do
start to see changes in the white matter as the different
pathways are developing. And in this image you can see
again, compared to up here where there's just a little bit
of folding in, much more detailed folding, much more
intricate. There's a lot that's going on in those weeks. You
have the movement of the neurons of the brain cells out to
the locations where they need to go. You have development of
those white matter tracks or white matter pathways. And they
develop in a predictable fashion. We know what to expect of
babies of different ages. We know that for example the
folding should be at a certain point at certain ages. We
know that the brain, the white matter connections, they get
myelinated or insulated from the back first and then
towards the front. So all the parts of the brain that have
to do with sensation, like vision, those develop first and
then the parts that have to do with more complicated things
like
paying attention and following directions, those develop
last. So there it's a lot that's going on in those early
weeks and months. And the way that that's reflected at the
pediatrician's visits is in head growth. So, lots of people
have seen this before. This is the CDC's chart for how head
circumference should change over the first months. So if you
look down here, this is at birth, six months, twelve
months, and then up here is how big the head should be
around, in terms of centimeters or inches, depending on what
you prefer. And what you can see on this curve is there's a
huge amount of head growth that happens in that first year
or so, and then it starts to slow down. And that's really
reflecting what's happening with the brain inside. That most
of the brain development is happening in these early months.
By three to five years, most brain development has happened.
Then after five years there's some fine tuning, and that's
how we get to hopefully where we are as adults. Head size is
largely driven by brain growth in babies and that's one of
the reasons that the pediatrician keeps checking it is
because if the head's growing well then that's really
reassuring that the brain's growing well. But if there's any
difference in head growth, you have to take a closer look to
try to understand is there something different about the
way the brain's growing? Most children, by the time they're
age five their head circumference is gonna be about 90% of
what it's gonna be as adults. So really, that's a lot of
brain growth, a lot of head growth happening in the first
years. This picture's a little bit complicated, but I love
it because it's got so much illustration on it. So this is
from
a study that Olga Kapellou did a few years ago, where they
studied a bunch of babies, volunteers in the nursery, pre-
term babies. The families agreed to let them have MRI scans
done so that the researchers could get a better idea of how
exactly the brain is developing over time. So, down here,
this is the gestational age in weeks, how old the baby was
at the time that the pictures are. They did this in many
different babies. The pictures are obviously just taken from
one particular example. So somethings you can see are just
the brain size at 26 weeks. It's much smaller than once she
get out to that term equivalent age of 40 weeks. You can see
that the degree of folding gradually increases. Each point
along the trajectory. So, even a difference of one or
two weeks changes what you expect to see on an MRI scan or
an ultrasound scan. And then, the more subtle things that
we see are some of the pathways that start to develop in the
white matter as babies get older. These charts up here,
they're showing how brain growth is changing over that same
period of time. So in the beginning at about 26 weeks you
have this as brain volume, meaning like how big overall the
brain is and this is brain surface area, the amount that
that cover, the cortex is. And Brain volume gets bigger and
bigger from 26 weeks up until about term, but even more than
that, it's the folding that really takes off, that really
skyrockets in those last months and weeks of pregnancy. And
again that reflects that the head can only get so big
while, especially while baby's growing inside of mum, but
the brain keeps developing, because the surface of the brain
becomes more and more intricately folded and well-developed.
And this is another study that followed on that, that
just confirmed what was suspected. That if you take a look
at babies' head circumferences, the size around their head
that that matches up really well with how big their
brain is when you do the MRI scan. And you do all the
calculations to figure out what the volume of the baby's
brain is. So, the head size is a really good reflection of
how the brain is growing on the inside. So that's how the
structure of the brain changes over the first weeks and then
months in a baby either before or after they are born. Other
things that are evolving at the same time are the function
of the brain. So I always describe it as, you know the
structure of the brain or the parts, all being in the right
place and getting connected in the right way. The function
is how it's actually working. You may look at your computer
and all the parts are in the right way, but that doesn't
necessarily tell you that everything is working in the way
that you would expect. So, there's two ways that we've
studied and tried to understand how brain function changes
in newborns. One way, and a way that I'm particularly
interested in is EEG or electroencepholography. And this is
a picture of a baby having an EEG done. These little
electrodes are just like the stickers you get on your chest
if you have an EKG done for your heart, but we put them on
the head. They work in the same way. An EKG is looking to
see the difference in electricity in different parts of
the chest. The EEG is looking to see electrical differences
in different parts of the head caused by brain activity, by
brain function. There's different ways of doing EEG. A newer
way is amplitude integrated EEG or AEEG. And some of the
people from the NICU may have seen this. It's something that
we're using more and more in our own nursery. When
you don't need the information from all twenty of those
stickers all around the head sometimes we'll just use three
sometimes just five stickers to get an idea of what's
happening overall in this baby's brain and if there's a
reason to look in more detail then we'll use the rest of the
electrodes. So this is what the actual information we get
looks like. So this is an EEG from a baby who's 27 weeks
gestation. At this early age, this is what we would expect
to see. This whole screen would be about twenty
seconds worth of time. And so you can have up to ten seconds
at a time where there's not a lot of brain activity that you
can measure on the surface using your EEG. And then you'll
get a little burst of brain waves that'll last for maybe a
second or two and then things will be quiet again. And that'
s
just how the brain is working at that early age. By the
time you get up to 40 weeks, or term, things are much more
active. Now you've got activity every single second within
any period that you're looking, whether the baby's awake,
whether the baby's asleep. It's changing within a second,
from second to second. There's always something going on.
It's different in different parts of the brain. It's not
sort
of quiet pauses that you see in a preterm baby. So just
as the structure of the brain is developing over those
first few weeks, the function of the brain is evolving as
well. And then we take that sort of information and we
process it in different ways and you can compare it in
different ways. And you start to really get patterns for
what to expect in terms of brain development. So, this is a
graph, if anybody is a engineer out there looking at
the voltage or the amplitude of the electrical signal and
the brain waves. And then, looking at, well over an hour,
how does that change? And then in a preterm baby, it's all
over the place. Sometimes, it's five microvolts. Sometimes
it's up at 50. But by the time a baby gets to 55 weeks, or a
few months after term age things are a little bit neater.
They're a little more consistent. You have more normal
patterns, changing whether the baby's awake or asleep. And
we
can do lots of different analysis like this especially using
some of the newer equipment to try to not just look at
pictures of how the brain is developing but actually
measuring how it's functioning. So, that's all good and
well, that's sort of medically and biologically how we think
about brain development, but neurodevelopment is bigger
than that and more importantly is what do you see when you'
re
looking at the baby, as the baby's getting older, both in
the nursery and later. So there's lots of different ways to
break down neurodevelopment, people categorize it in
different ways. I'm gonna talk about one system. Certainly
not the only system. but it's just one that, that I like.
So, there's motor skills. This is one of the first things
that you can look at, to see how a baby's neurodevelopment's
coming along. We talk about gross motor skills. For example,
holding the head up. By about two month's age, a baby
should be able to lift their head up for a little bit
at a time. Rolling over, by about four, five months, babies
will start doing that. Lots of babies start sitting by the
time they're six months and then taking those first steps,
maybe with a little bit of help, by the time they're a year
old. There's also the fine motor skills. Gross motor skills
are the big movements; fine motor skills are the more
delicate, more precise movements. So, that's things like
holding an object when it's placed in the baby's hand.
Bringing the hands to the mouth is a great milestone
because now the baby has a way to experience things in a
whole new way. And the pincer grasp, people hear that,
that's when you can use your thumb and your finger to pick
up an
object rather than just grabbing it with your whole hand.
Another domain or another area of neurodevelopment is
language and communication. So, those are a little bit
different and I try to make those distinctions because there
are some children who have difficulty with either
communication or one aspect of language but are really doing
quite well in other areas. So, communication starts before
the baby's using words. That's the noises the baby makes.
Whether the baby listens when somebody's talking, seems to
respond to music or sounds, making eye contact, looking
toward mom or dad when they say the baby's name or when mom
or dad are talking. And eventually ending up with first
words. After that, language starts to develop, receptive
language, understanding the language that's spoken. You tell
the baby to go get a book, understanding what that means and
being able to follow that direction. And that's different
than expressive language which is being able to use the
words that the baby wants to use. Another area or domain of
neurodevelopment is social and personal skills. Sometimes
people will say personal and emotional skills. These are
skills that have to do with how the baby functions in
their own environment. So, part of that is social
development. Recognizing parents, particularly as different
than other adults. That happens in the first few months
where baby smiles at mom or dad but isn't quite so sure
about doctor when I come in the room. Smiling that's very
early, in the first few weeks for a lot of babies. Being
able to smile back when somebody smiles at baby. Laughing,
play. By about six to nine months, you get that really nice
play of peek-a-boo or repeating things in a sort of
interaction. Personal skills, what's meant by that is things
like looking in a mirror and recognizing yourself, helping
with things like putting on clothes, reaching for shoes, and
trying to feed yourself. Another area or domain of
development is perception. So, this is a little tricky.
Sensation is the five senses. Hearing, touch, smell, taste,
vision. Perception is understanding all of the information
that comes in. So sensory development is largely just how
well are the eyes working, how well are the ears working.
But then it's more complicated than that when the brain has
to put together all of that information. So, initially
babies have great senses of smell. They can recognize Mom's
breast milk as compared to other kinds of breast milk even
when they're only a few days old. They understand their
world largely from touch and from taste, that's why
everything goes right into the mouth. Hearing and vision
start to come along shortly after. A baby who's term age,
when there held in Mom's arms, is able to see about as far
as from Mom's arms to the face, or Mom's arms to the breast.
As the baby get's older, their able to see a little bit
further and make out a little more detail. Perception is
understanding the things you see. So visual processing, for
example, is taking that extra step from, I see this
blob and it's circle-shaped and it looks familiar to
recognizing that's mom's face. Understanding that the sounds
that the baby's hearing have a pattern to them and then
taking that next step to recognizing it as language. And
then the really complicated stuff comes in a few years
later with visual spatial skills. Recognizing a pattern
that's a shape and then identifying that as a letter, for
example. And then, things that start very early on, but
maybe aren't as often recognized, and become much more
important later are attention and behavior skills. So
attention stars out early. Visual attention is actually one
of the most sensitive indicators of babies who are doing,
gonna do really well later on. So, babies who've had a rocky
start. When you take a look at how well they're able to pay
attention to a picture or to a face that's in front of
them, if they're able to do that well when they're at a term
age then those babies almost always go on to do very well
without any problems. And that's just the earliest form of
attention. Being interested in stimuli around them and being
able to concentrate on one thing at a time. It sounds silly
to think about babies concentrating, but you can actually
see it, that they'll look at a face, they'll stay looking at
that face, they'll follow it when it starts to move in
different directions. As children get older, that gets more
complicated. It's self regulation, learning how to calm down
when you're angry or learning how to express yourself if
you're sad or frustrated. And executive function is things
like making plans for what you wanna do. Or holding things
in your memory and then using that information. So that's a
quick overview of neurodevelopment. A little bit of the
biology behind it, a little bit of the things that you see.
And I'm gonna talk now about well, what things do we know
about preterm babies and their neurodevelopment? So I
should say here that when I talk about age for the rest of
the talk, there's chronologic age which is just how long it'
s
been since you were born. If you were born three days ago,
you're three days old. There's conceptional age, like I've
been using so far. And that's the date from conception. So,
if a pregnancy lasted for 24 weeks and then a baby was born
three weeks ago, then 24 + 3 is 27 weeks conceptional
age. We use that a lot in the NICU. Corrected age is when
you correct up for when a baby's due date was. So if a baby
was due in December and now it's January, that baby's
corrected age is one month, even if they were born early.
Everybody's a little bit different, but most of the time
corrected age is used when you're talking about development
until the baby's about two year's old. It's a little
arbitrary. Some people will use three years. Some people
will use a year and a half. Most people correct up until
about two years. You can't correct forever. We obviously
don't talk about people being 34 years corrected age. But
the catch about this, and something that's actually really
commonly worrying for parents and for some physicians,
is that you can seem to have great development up until age
two and then you stop correcting. And suddenly, it looks
like there's this huge drop-off in development. And it's
actually just that you've stopped sort of grading on that
curve and now you're using a more strict standard for the
baby's development. Again it's arbitrary but that's the
age that most people use. So, we're learning more and more
about how the brain structure actually develops in preterm
babies. This is an MRI scan from a baby who was born at
29 weeks and is now 40 weeks conceptional age or term
equivalent age. They're at their due date. And this is a
baby who is just born at their due date. So these babies are
at the same point in time, but you can see that their
brains look different. I think the most obvious thing that
people see is the difference in the head shape. That's
really common in babies who are born preterm that, in the
beginning, before they're able to sit up and move around as
much that they might have a longer, more oval shape to the
head than term babies who might have a more round, circle
shape to the head. That gets a little bit better as they get
older. As they're laying on their back more, it helps shape
the head. But it can persist to a degree. And then they
grow up and have hair and you don't notice it as much.
But there's more that's different in this brain. If you look
a little bit closer. So, one thing I'll point out is that,
if you look again at this outside surface of the brain, the
cortex, that outer layer and you compare the amount of
folding in the baby who was born early to the baby who was
born on their due date. There's just a little bit more
folding here. It's not the sort of thing that you would
necessarily jump out at you in the picture. But once you
start to compare and you compare dozens of
babies and hundreds of babies, it's a pattern that we see.
That, sometimes, for babies who are born early, it takes
them a little bit longer to have that degree of folding that
you would expect. For most babies, this catches up by the
time they're two or three years old. But it is a difference
just in the way that the brain is built in those early weeks
and months. The other difference, which I think is much more
subtle, is that the white matter which is this part here, is
brighter in babies who have been born preterm as compared to
babies who are born at their due date. And that reflects
that that white matter, the connections in between
different parts of the brain, it's just a little bit
immature. It hasn't quite developed the same degree of
connection. It hasn't evolved in the same way as the baby
that was born on their due date. And this is something that
more and more people are recognizing as important. Because
the degree of immaturity in the white matter is very useful
in trying to understand what to expect for the future. And
I'll talk more about that in a second. Now, some babies who
are born preterm unfortunately have extra risk factors for
having neurodevelopmental difficulties. This is a picture
of an MRI scan from a baby who had a bleed inside in of
the brain, an intra-ventricular hemorrhage that affected
actually part of the brain tissue. And so babies who are
born extremely early, 24, 25 weeks, we know that they are at
a higher risk for having neurodevelopmental problems later
on. And we watch after them extra, extra closely. Babies who
are very low birth weight, who are under 500 grams when they
are first born, we know that they are at a higher risk
for having neurodevelopmental problems later. And then
babies who have complications in those first weeks. If they
have infections of the brain or meningitis early on, if
there's bleeding in the brain from any cause. and a
condition called periventricular leukomalacia, which effects
fortunately many fewer babies than it used to but
is also seen in preterm babies and cause injury to the
developing brain, which might make neurodevelopment more
difficult later on. So one of the things that we do in the
nursery is we look to see are there any early warning signs
that any of these things might be going on in a baby. And
again because I like EEG, I like looking at the brain waves,
that's something I'm particularly interested in. And if you
think back to that picture of the nice pretty tight
brainwave pattern in the baby who was born on their due
date, this is an example of what a brainwave pattern might
look like in a baby who has brain injury. And this is before
you can see the brain injury if you take a picture. But you
get some early warning signs in the way that the brain is
functioning, the way that the electrical signals are being
transmitted. So that's one thing that we can look for is we
try to understand among the babies who are born early which
ones might be at higher risk. So this is part where I
always stop and try to remind everyone that most babies who
are born preterm go on to lead lives without neuro-
disability.
And I think that's really important because as
physicians, our job is to worry about the worst case
scenario. We always want to make sure that we're watching
out for anything that we can prevent and anything we can
protect against. And sometimes we justice to the majority of
babies who are born preterm who go on to do very well. So,
I'll go through now, we talked before about some of those
areas of development. I'm gonna talk about those areas of
development again, and talk about what are the things that
are just a little bit different in preterm babies. And for
these next few slides, I'm talking about babies who've don't
have particular complications during their NICU stay, but
just preterm babies over all, what do we see. So, this
picture is a baby who was born at 29 weeks, who is now at
their due date, who is now at term equivalent age. And this
is a picture of a baby who was born on his due date. And you
can see a difference just in their posture and their tone.
This is an older picture. Fortunately, you won't see this in
our NICUs anymore, but this is what it might look like for a
baby who's left in a cot or a crib for those first months
after being born early. They have a posture from instead of
being curled up inside of mom's uterus, they get a posture
where the back is straighter, where the shoulders are drawn
back a little bit. They don't have the same
tightness in their posture and tone. And that can persist
for
up to a year. It's really common when I see a baby who's
been born early and they're now six months, nine months a
year old and you start to see how their muscle tone is and
how their joints are, that they might be a little bit loose,
that they're not quite as high in their tone. Usually it's
subtle but if you look for it it's there. What does that
mean? Well, most babies catch up by the time again that
they're two or three years old, but it can mean that some of
the things that require that extra curved-up posture like
sitting, for example, might come a little bit late even
after you correct for gestational age or correct for pre-
maturity. Because some preterm babies will have that
tendency to hold their backs straight, their trunks
straight, you can have a tendency to keep going backwards
and some parents will describe it as a rocketing backwards,
especially when baby is angry or crying or fussing. And I've
had a couple of parents who, it's just so sad they'll, they'
ll
see this when baby is upset and think that baby is trying
to get away from them. It's not that at all. It's that if
you have a normal tendency to hold your back straight and
then you get upset and that's more and more exaggerated,
then babies will sometimes push themselves backwards. The
shoulders being back as compared to a baby who's born on
time means that some babies need a little more encouragement
to reach for objects. You can imagine if your shoulders are
back more that it's gonna be a little bit more effort to
reach out for something that's in front of you as compared
to if your hands are always in front of you. That's
something that a lot of our therapies help try to
encourage. And so even in the NICU, before baby goes home,
now there's a real focus on developmental care, about
getting physical therapy input for how can we promote good
motor development in those early days and weeks, so that
things are as completely optimal as they can be when baby
goes home. Some differences in behavior, so definitely
sleep-wake cycles are disrupted in the nursery. As much as
we try,
there's lights, there's noises, there's alarms, nursing
doctors, and it's hard enough to try to get babies into a
regular sleep-wake cycle in those first weeks and months,
and for preterm babies it's harder. And that can last for
the first three to four months. It's hard. There's not,
unfortunately a magic cure for it. But I think the most
important thing to know is that it's not a sign that the
baby has a brain injury. It's not a sign that there's
something wrong with your baby's development. It's something
that we know happens with preterm babies. And, and it doesn'
t
mean that there's anything more ominous underneath. The
same is true for crying, especially if you have a baby whose
just been very sick for the first weeks or months and
hasn't really had that opportunity to express themselves as
much. They go home, things are different. They're ready to
express themselves and there can be lots of crying, and
crying for no apparent reason. And again this is really
common in babies who are born early and have no brain
problems, whose neurodevelopment goes on to be completely
normal. But, especially when your first coming home after
you've been through so much in the nursery, it's
understandable that a lot of parents are worried about that.
A question I get asked a lot about are, what's
the risk of ADHD; what's the risk of autism after preterm
birth? I think we're starting to understand more about that.
There's conflicting evidence about attention problems.
There's some studies where babies who are born earlier have
higher instances of problems like ADHD and then there's
other research studies where they say, no that's not true.
The same is true for autism. There's some studies where
babies who are born, particularly babies who are born very
early have a higher rate of autism than babies who are born
on their due date. But then there's other researchers who
say that it's the same in both groups. So that's an area
where we need to learn more, where we need to do more
research. Coordination, so just like the brain development
takes a little bit longer, needs to catch up. Coordination
skills can often be a little rough especially in the first
months or years. This is usually described as you know, he's
just clumsy. I hear that a lot. A lot of that can have to do
with visual-spatial perception. So, understanding where
objects are in space and trying to control the way that
your body is moving towards them, is a lot more complicated
than be recognize as we're doing it. We take that for
granted. But for a baby who's been born preterm, they have
to work at it a little bit harder. The way that this might
come out is much later on, for example, having bad
handwriting,
being reluctant to participate in sports because they've got
this label of clumsy. Practice does help. Occupational
therapy can help if it's enough, if it's significant enough
that it's interfering with regular activities And for
sports the most important thing is to help kids find
something that they enjoy, and to really emphasize that it's
fun to go out and play and to do games rather than
performance and always being number one in classroom
sports. So, that's a sort of, again an overview for the
different domains of development. What are some of the
things that can be different for preterm babies and what
are some of the things that families notice? Again, most
babies who are born preterm go on to have no neuro-
disability.
Lots of babies who are born preterm will
have to work a little bit harder in the beginning and may
have some differences, especially in those early months and
years. But the reason that I love my job, that I love being
a neonatal neurologist is that there's so much that's
changing in those first five years in the way that the brain
is growing and developing. We have tons of opportunities to
help change things as the brain's growing. Babies brains are
just amazing. The kinds of things that they recover from and
cope with compared to adults where unfortunately most of
your brain developments finish by the time that you are
sixteen.
All right. So, for the last few minutes what I am going to
talk about, is how can we help nerve development of babies
who
are born preterm? So, I think the first thing is that brain
care starts in the nursery, starts in the NICU. And there's
lots of different evidence about this. This slide is from a
paper that just came out very recently, just in the last
month. And what these researchers did, is they processed the
MRI images like you saw in the first slides, and the colors
indicate different measures of how the volume is and how
well developed that part of the brain is. And they compared
babies who were born preterm who had poor growth, they just
weren't gaining weight, they weren't getting bigger, to
babies who had normal growth, expected growth. And they
found that the brain development was better in the babies
who had good growth after being born preterm. So there's
lots of reasons to make sure that you take care of things
like nutrition in the NICU and brain development is just one
more. It's not just about getting up to certain number for
weight. It's about really giving the body what it needs to
form those connections and have that neurodevelopment going
on. I think one thing that we're really lucky to have here
are fantastic NICU nurses and as we open up our neurology
NICU this spring, we're training people to recognize what
are
the early signs that this baby might be an especially high
risk for neurodevelopmental problems. How can we pick up on
those signs before injury is already done? And what can we
do differently to try to ameliorate that? One of the tools
that we use is brain monitoring, and that's something that
we're extending now in our nursery to babies who are born in
those risk groups. Babies who are born especially early,
babies who are very, extremely low birth weight when they
are born. Babies who have infections, or where you
know that there's been stroke or other brain injury. Two of
the types of brain monitoring that we use, so this is EEG
again. We're now using more and more EEG that you leave
those electrodes on, maybe overnight, maybe for a couple of
days. And you like to see how is the brain function
happening maybe not just at this twenty seconds where I'm
looking at the screen, but over the day, over the night. Is
the baby having normal brain activity when they're falling
asleep, when they're waking up? Are they responding
normally,
their brainwaves to being touched, to being held? Another
tool that we're introducing, that we're gonna be using more
and more, is something called NIRS, near-infrared
spectroscopy. So what this is, is a tool, it's actually a
quite small sensor that goes on the baby's forehead. And it
turns out that if you use infrared light, it goes down just
less than a centimeter into the surface of the brain,
different oxygen levels in the blood will change the way
that that light gets absorbed. And so, if you have normal
oxygen levels in your blood, the light's gonna get absorbed
differently than if you don't have enough oxygen in your
blood. It's the same principle as the pulse oximeter,
the monitor that goes on your finger that tells
you what the oxygen level is in somebody where you're
worried about their lungs for example. But this is actually
telling us real time what the information is about how is
blood flow coming to this baby's brain. Are they getting
enough oxygen to that tissue? In babies for example who have
heart or lung problems, is this effecting the way
that their brain is getting oxygen? Right now, an emphasis
that we have in many NICU's is developmental care. So there'
s
lots of medical stuff that we focus on, the infections,
the cardiac care, the pulmonary care. But encompassing all
of that, how can we help promote the baby's development
during the time that they're in the NICU? So that's
modifying the physical environment, trying to reduce stress.
Do we really need to do that extra blood draw, or could we
maybe wait and get that test the next time that we have to
get a blood sample? Regulating light and sound. Making sure
that baby gets a break, gets some quiet time during the day.
It's about the baby's immediate environment not just
the NICU but where the baby is in space, helping support the
baby's position. You'll see a lot of swaddling and a lot of
the rolls under the baby to help mimic that curled up
position of the baby who's born at their due date, so they
don't get into that habit of having that extensor
posturing. Skin to skin care or kangaroo care. There's lots
of evidence that this is really important for babies'
development. Having that touch, that contact with their
parents. It's very soothing. They have better heart rates,
better brainwave patterns. All of these things are improved
with skin to skin or kangaroo care. And then, recognizing
cues. Our developmental specialists and our nurses are
fantastic at saying, Doc, I know you want to examine the
baby, but he just fell asleep and you're gonna have to come
back an hour later. And that's great, that's what I need. I
need someone to point out those cues to me to let the baby
have some sort of normal sleep-wake cycle, so that things
are easier when you go home. Recognizing that, right now,
the baby's calm and so that might be a good time to play and
to see how the vision is. And not trying to examine a baby
when they're already stressed and upset. For parents, I
get asked a lot well what can we do at home to help
with our baby's neurodevelopment? I think overall the
blanket statements that would apply to every baby is that
the interaction between the family and the baby is the most
important thing of all and that's something you're already
doing whether you're thinking about it or not. The quality
of that interaction is so important. I think that
in terms of specific interventions there's a few things that
we know definitely help and I'll touch on those. There's
some
things where we don't know yet, maybe they help but we don't
have proof and then there's a few things where there's
pretty good evidence that it's not going to work out. In the
real world for all of us, you only have so many hours in the
day, you only have so much energy in the day, and so you
really want to focus those efforts on well, what does my
baby need help with, and what are the things that are most
likely to help with my baby's development. So part of what I
do in the NICU is I examine babies, I look at their MRI
scans, I look at their EEG tests. And I help understand what
particular risks there might be, and where a baby might
need extra help. It's not about trying to look into a
crystal ball, it's about saying well I know that from what
we know about this type of brain condition that these babies
might be adextrous in their motor development. Or we know
that these babies might need extra help with their
visual development. And that way you can really focus your
therapies and your interventions on the things that are
gonna matter most. Every baby has their own temperament. It'
s
really hard when you're trying to make sure you're baby's
doing well to separate out, well, maybe my baby is just a
quiet baby. Maybe my baby's a fussy baby, and it has nothing
to do with being preterm. I think that's a
challenge that's really hard for parents. Some babies do
have additional medical concerns that you have to take into
account. Maybe baby's going home on oxygen. Maybe there's
other medical equipment that you have to accommodate in
promoting development. This is what our high risk infant
follow program is especially good at. Whether that's done
here, it's done locally at a lot of different hospitals
across California and across the country. It's a change for
families to come check in a few months after you've gone
home from the hospital, see how things are coming along,
and to take into account all of these factors to know
well, what can we do best for this child to help their
development? In the meantime, there's tons of checklists of
milestones to help watch in general, for a child's
development. I like the CDC checklists, in particular. If
you just Google "CDC preterm development" these'll come
up. And lots of doctors' offices give these out as well.
Especially for first time parents it's a nice way to check
in, make sure things are progressing. If you have worries
compare to what other babies might be expected to do at that
age. So I said I'd mention well what are some of the things
we know help with development? We mentioned skin to skin
contact. There's lots of reasons that's helpful. So even
though it's intimidating in the early days in the NICU to
hold your baby when they're so small, we know it's helpful.
It's great for mom and dad and it's great for baby. We
really promote that. Breastfeeding is really important as
much as possible, to get breast milk to your child. Reading
is huge. The more you read to your baby,
there's lots of things that are better later on. Not just
language development, but attention span, concentration,
behavior, lots of skills. And then in preterm
follow up programs, it has been shown that where there is a
preterm follow up program, overall, babies do better. There
is a reason that we drag people back after a couple of
months to check in. In terms of motor skills, if motor
skills are a particular concern, then some of the important
thing to look out for are making sure that baby has a little
bit of tummy time every day. Lots of preterm babies really
don't like this. But it's important because, even if he
doesn't like it, the only way that he's gonna learn to hold
his head up is having that experience. So spending time
laying down on the tummy. Some babies skip crawling, that's
okay. That's really common especially in babies who've been
born preterm. So that's not emphasized as much as some of
the other milestones. I get asked a lot about walkers. It
turns out that those don't speed up walking development.
And there's some suggestion that it might slow it down
because instead of oops, sorry, instead of getting the
practice of walking along the baby's practicing putting all
of his weight down on the walker. For toddlers, I think
that's the most difficult group because they're not going
to do what you asked them to do. They choose the activities,
is that working? Okay. They choose the activities from the
options that you provide. Just like everything for a
toddler. They may not eat what you want them to eat but if
you give them a few choices, they're going to have to choose
something. For sensation and perception, I think visual
development, the key points to remember are that babies
first see best in black and white and in solid colors. So,
the baby blankets and the toys that have a million colors
and the glitter and the flashing lights, they're really
pretty but actually are much harder to recognize visually.
So, in those first few weeks and months it's easier for a
baby to practice their visual development if you use simple
pictures or images like sharp contrast between black and
white or a one solid color or faces. And again, a baby
who's at the due date should be able to take a look at mom's
face when held in her arms. And that's a warning sign if
that's not something that's happening, baby doesn't seem
able to focus. Another thing that you can do to help promote
vision, again, it all goes back to reading. Even before baby
understands the words, sharing those picture books. Getting
in the habit of looking at something and trying to
understand it. For sounds, letting baby see your face when
you're talking gives them practice understanding the facial
movements that go along with speech and practicing making
sounds. Talking with a baby's really important for their
language development. Not just talking at them. That helps a
little in hearing speech but interacting with them. They
point to a ball. Yes, that's a ball, that's a red ball.
Repeating, giving feedback on the words that they use.
Attention and concentration, a lot of parents ask about TV
time. So, the American Academy of Pediatrics recommends no
screen time in the first two years. This is hard but that's
the recommendation. So, no computers, video games,
television. And then after that, only 30 minutes a day for
the first few years after two years. The most important
thing for TV is actually the quality of the interaction that
goes around TV. So just like you expect children who watch a
lot of TV and that's the only stimulation that they get,
they're gonna have a rough time trying to have development,
as compared to babies who sit with their parents and watch
TV together and you talk about what's happening on the
screen. It's the interaction again, that interaction between
the family and the baby that's most important. And then the
last thing for attention span. There's a lot to be said for
helping practice development of attention span. So we
all want our babies to do well. You spoil them. You give
them all the toys that you can because you want them to
have fun and enjoy it. But actually, having one object at a
time, and practicing focusing on that, without any
distractions, that helps build up the attention span. And
then preschool can be particularly useful for babies who are
at risk for having learning problems for lots of different
conditions. It's quality preschool that's the key factor and
First 5 California, again, if you Google "First 5
California"
they're an organization that's committed to
helping people find quality preschool. They have great
checklists for what do I look for when I'm visiting a
preschool. What are the kinds of things that are appropriate
for children of different ages. And so these are some nice
additional resources. Again, First 5, focusing on the first
five years of any child's life, not just for preterm babies.
March of Dimes is a non-profit organization that helps with
babies who are critically ill when they're first born. They
have
some lovely information on their website about what to
expect
when a baby is in the NICU, what to expect after you go
home,
what are the kinds of things that you look for, and the
kinds of interventions
that are useful after being born early. And then, specific
to children who do have neurodevelopmental disabilities, My
Child Without Limits is a great site that has a host of
information about different conditions. And it's put
together largely by parents and by families with some
medical input for how to help again, make the most of
every day. So, I am almost within time. I'll stop there for
any questions.