Empowering Parents Early Intervention for Preterm Infants Dr - - PowerPoint PPT Presentation

Empowering Parents –

Early Intervention for Preterm Infants Dr Alicia Spittle Click to edit Master title style

Victorian Infant Brain Study (VIBeS)

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Disclaimer

• Every baby is different!
• Please talk to your Paediatrician, MCHN or

relevant health professional

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What, why, who, how and when of Early Intervention

Question

How do you define preterm - is it related to how many weeks early the baby was delivered? Is it related to the baby's weight

• r a combination of these factors?

Prematurity definitions

Gestational age at birth

• Term = 37 -42 weeks
• Preterm = less than 37 weeks
• Late or moderate preterm = 32 to 36 weeks
• Very preterm = less than 32 weeks
• Very preterm = less than 32 weeks
• Extremely preterm = less than 28 weeks

Birth weight

• Low birth weight = less than 2500g
• Very low birth weight = less than 1500g
• Extremely low birth weight = less than 1000g

How do prem babies grow up?

• Developmental problems are related to gestational age
• Early childhood:

neurodevelopmental delay and recurrent health problems

• School age:

academic difficulties and behavioural problems

• Adulthood:

most children born preterm adjust remarkably well Saigal and Doyle, Lancet, 2007

Early Childhood

Delay or difficulties

• Gross motor
• Fine motor
• Feeding
• Language
• Cognitive
• Cognitive

Impairments or diagnosis

• Cerebral palsy
• Autism
• ADHD
• Intellectual impairment

What is Early Intervention (EI)?

DEFINITION

EI consists of multidisciplinary services provided to children 0-5…promote child health, enhance emerging competencies…minimize delays… remediate

CHILD FAMILY MOTOR COGNITIVE

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competencies…minimize delays… remediate emerging disabilities….prevent deterioration…promote family functioning Shonkoff et al, 2000

COGNITIVE SOCIAL PREMATURE DISABILITY LOW SES AT RISK

Why is “early” important?

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Question

Early results of the LaPrem study indicate that late preterm babies have smaller brains? Is a smaller brain less effective or just smaller?

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2nd Trimester Term

Developing in the womb versus neonatal intensive care

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Early experiences alters brain development

Control Group Intervention Group

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Als, Pediatrics, 2004

Who needs EI?

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Early Childhood

• Delay or difficulties
• Gross motor
• Fine motor
• Feeding
• Language
• Cognitive

Prevention

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• Impairments or diagnosis
• Cerebral palsy
• Autism
• ADHD
• Blind
• Deaf

Targeted early intervention

VIBeS Plus

• Children in study either receive standard care or our

– unique home intervention program

• Our team visits the home to help improve parental mental

health, parental-infant bonding and the infants’ development

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Behavioural problems at 2 years

20% 0% 0%

Intervention

Impairment No impairments 0% 0%

Control

Impairment No impairments

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80% 50% 50% Pediatrics 2009

Parental anxiety at 2 years

21% 0% 0%

Intervention

Anxiety No anxiety 43% 0% 0%

Control

Anxiety No anxiety

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79% 57%

What is the evidence for early intervention for infants born preterm?

• Cochrane review
• Included

– randomised controlled trials – infants <37 weeks gestation

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– infants <37 weeks gestation – Early intervention began within first 12 months – Focus on motor and/or cognitive

Spittle A, Cochrane Database Systematic review, 2012

Cognitive outcome - infant age (<3 years)

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Cognitive outcome - preschool age (3-5 years)

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Cognitive outcome - School age (6-13 years)

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Motor outcome - infant age (<3 years)

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Question

What are the day to day, practical things that you can do to help your prem develop post the first year. What is the research saying in this area? It feels like there is a big hole in the literature about how to support your prem baby (and child!), when they might not have any ongoing medical problems. What can be

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might not have any ongoing medical problems. What can be done to proactively help your prem thrive in the first three years

• f their lives?

I am ready to learn!

Infant discovery learning

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What do we know about discovery learning with infants?

• Tasks are defined by adults
• Infants discover the tasks that are relevant
• The “relevance” of tasks can be influenced by

environment

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environment

• How should we characterize the feedback from the

environment?

• Learning takes practice
• Trial and error

Play with your baby

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Practice

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Sitting

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Baby walkers

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Encourage independence

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Jolly Jumpers

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Read to your baby

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Plagiocephaly

• http://www.rch.org.au/kidsinfo/fact_sheets/Pl

agiocephaly_misshapen_head/

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Look after yourself

• Next webinar

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Question

Would you recommend all prems have regular reviews with staff who specialize in prematurity? For example, our GP/MHCN say early intervention not required for our daughter yet she is not meeting all milestones.

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Correct for prematurity

• http://raisingchildren.net.au/articles/prematu

re_baby_corrected_age.html

• Corrected age = Chronological age – number
• f weeks preterm

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• f weeks preterm
• For example, a one-year-old who was born

three months early would have a corrected age of nine months.

Question

• Do general illnesses such as colds/flus/ear infections etc add

extra time onto development details? For example, our daughter is healthy, however she regularly has illnesses which knock her around.

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Delay vs impairment

Difficulty lifting head Stiff legs with little or no movement Pushes back with head Keeps hands fisted and lacks arm movement

Signs to Watch for in Physical Development*

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www.pathways.org

Rounded back Unable to lift head up Poor head control Difficult to bring arms forward to reach out Arches back and stiffens legs Uses one hand predominately Rounded back Poor use of arms in sitting Difficulty crawling Uses only one side of body to move Arms held back Stiff legs Inability to straighten back Cannot take weight on legs

Chronic Disease Management — GP services

• http://www.health.gov.au/internet/main/publ

ishing.nsf/Content/mbsprimarycare- chronicdiseasemanagement

• GP coordinates plan

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• GP coordinates plan

Question

What is the most important thing that midwives can do to support parents with a premature baby?

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Support parents and infant

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Question

Our baby was born at 32wks, no health concerns at birth but has been diagnosed with CP at 10 months. Four months down the line we are still waiting for intake with ECIS, VPRS and a proper diagnosis.

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Why is it so difficult? We're currently doing everything privately but we're still looking for some therapy that focus on neuroplasticity, can you make a recommendation please

Question

My ex28 weeker son who is now 4 was not referred for early intervention services. I have spent the last year getting him in the see all of the different types of therapists due to his obvious development delays and having mild cp and epilepsy.

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What is the best way for me to coordinate his intervention so that he can have the best life possible. He is such a beautiful loving boy that his differences can be often overlooked by professionals.

Definition of CP

• CP describes a group of disorders of the development of

movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain

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Cerebral Palsy

• Term = 0.1%
• 32- 36 weeks = 0.7%
• 28-31 weeks = 6.2%
• 22-27 weeks = 14.6%
• Average age of diagnosis = 19 months

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• Average age of diagnosis = 19 months

Risk of Cerebral Palsy

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NOVAK, 2014

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• Collaborative goal setting
• Analysis of goal limiting factors
• Scaffolding of tasks for optimising

self generated motor activity

• Minimisation of handling (passive)

Goal Oriented Activity Based Motor Training

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• Minimisation of handling (passive)
• Trial and error
• Encourage active movement
• Early weight bearing + reach and

grasp

• Increasing complexity
• Written home programme

Shepherd, 2013; Lobo, 2013, Fetters 2010; Novak 2009

• Parent coaching in simple
• bservation
• Optimisation of awake time for

learning

• Active practice focus
• Increasing complexity and variability

Parent Education

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• Increasing complexity and variability
• ver time
• Allowing trial and error
• Delivery of prognostic information

and specific information about CP

• Practice motor training with feedback

Novak 2006; Whittingham 2014; Mahoney 2004

Environmental enrichment

• Toy selection to match motor

task

• Evidence based early learning

stimulation

• Sleep/feeding routines

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• Sleep/feeding routines
• Variable daily experience
• Inclusion of extended family
• Construction of home play

environment

Greaves 2012; Bradley and Caldwell, 1984

Useful websites for CP

• Cerebral Palsy Alliance

www.cerebralpalsy.org.au

• Early Childhood Intervention Services

http://www.education.vic.gov.au/childhood/parents/needs/page s/ecis.aspx

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s/ecis.aspx

• Better Start

http://betterstart.net.au

Better Start

• The Better Start for Children with Disability

initiative provides funding for early intervention services.

• Up to $12,000 (maximum $6,000 per year)

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• Up to $12,000 (maximum $6,000 per year)
• Need to register before child turns 6 years old

(funding until they turn 7 to access funding)

Question

Is Asperger's common in premature babies?

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Autism Spectrum Disorder (ASD)

• Characterised by

– Impaired communication and social interaction – Restricted, repetitive patterns of behaviour, interests or activities

• Unknown cause

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• Unknown cause

– Associated with changes in brain development. – A combination of genetic and environmental factors

• Rates in Australia

– 1 out of 100 - 110 children in Australia – 4 of 100 children born very preterm

Early signs of ASD

• Research conducted in the general community

– Eye contact – Social smiling – Joint attention – Use of gestures

raisingchildren.net.au

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– Use of gestures

• More work needed to identify early signs of ASD in premie

children

• If you are worried about ASD, contact your health care

provider

Early intervention for ASD

• Starting early is most effective in helping the development of

children with ASD

• Many types of interventions:

– Behavioural

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– Behavioural – Medical – Developmental – Family based – Therapy based – Alternative approaches

Further information

• www.raisingchildren.net.au/children_with_au

tism_landing.html

• www.amaze.org.au

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• www.amaze.org.au

(previously Autism Victoria)

• Helping children with Autism

Question

When do you consider a referral for Early Childhood Intervention Services? Is the referral made on the assumption that the child has a risk

• f developmental delay which is not overly evident at the point
• f developmental delay which is not overly evident at the point
• f referral or the referral is made when it is evident that there

will be need for an ongoing long term service.

Question

In a child born preterm who appears to be progressing with age appropriate normal development, at what point can you begin to "relax" ? ie is there a time at which all complications of bring premature will have declared themselves?

Question

• My twins girls were born 26 weeks. They are now 3 years old

and attend an early intervention centre.

• When they go to school, do u think premature will be delay

their studying?

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their studying?

The VIBeS Family

Paediatrics

Terrie Inder Lex Doyle Rod Hunt Jeanie Cheong Gehan Roberts Jennifer Walsh Noni Davis Julianne Duff

Nursing

Merilyn Bear Physiotherapy Alicia Spittle Lucy Lorefice Katy de Valle Jane Orton Ros Boyd Leesa Allinson

Occupational Therapy

Nisha Brown

Psychology

Peter Anderson Karli Treyvaud Megan Spencer-Smith Leona Singam Carly Molloy Jeremy Lim Natalie Reidy Shannon Scratch Alexandra Ure Carmel Ferretti Anastasiya Suetin

Neuro-imaging

Deanne Thompson Jeffrey Neil Chris Smyser David Van Essen Jim Alexopoulos Yuning Zhang Meredith Estep Michael Kean Marc Seal Zohra Ahmadzai Claire Kelly

Biostatistics

Katherine Lee

Office Manager

Debbie Cations Merilyn Bear Emma McInnes Kate Callanan Marion McDonald Nisha Brown Abbey Eeles Joy Olsen

Speech Pathology

Angela Morgan

Funding support

NHMRC, National Institutes of Health, Jack Brockhoff Foundation, Murdoch Childrens Research Institute, Howard Florey Institute, Royal Women’s Hospital Foundation, Thyne Reid Foundation, Myer Foundation, CP Foundation, CCRE Newborn Medicine Anastasiya Suetin Carmen Pace Cristina Omizzolo Sacha Stokes Cody Potter Andrea McInnes Michelle Wilson-Ching Claire Kelly Lillian Gabra Fam Linda Chan Dolly Thai

Neuroscience

Sandra Rees

Collaborating Centres

Murdoch Childrens Research Institute, The Royal Women’s Hospital, The University of Melbourne, Washington University (St Louis), Children’s MRI Centre (Royal Children’s Hospital)

Thank you