Журнал «Здоровье ребенка» 6 (57) 2014
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Extremely premature infants follow-up
Авторы: О. S. Yablon, D. Y. Vlasenko - Vinnitsa national medical university named after N. I. Pyrohov; D. P. Sergeta, К. T. Bertsun, О. V. Kharchuk - Vinnitsa regional clinical paediatric hospital; N. А. Shovkoplias - Vinnitsa city clinical hospital «Mother and child center»; Т. А. Vlasenko - Vinnitsa clinical maternity hospital №2
Рубрики: Педиатрия/Неонатология
Разделы: Клинические исследования
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Introduction
Premature birth is the leading problem of world and national neonatology over the past several decades. Today, progress has been made in this area: babies with extremely low birth weight (500-999 g) and extremely low gestational age (22-28 weeks) have a good chance for life through the development and introduction of new technologies and practices of perinatal nursing. Currently in our country there are no clear guidelines and instructions for follow-up observation of children with birth weight less than 1000 g and gestational age less than 28 weeks, and, accordingly, no registration consequences of neonatal problems.
This category refers to children with the highest risk for the formation of organic pathology in the form of cerebral palsy, blindness, deafness, delayed mental development, autism spectrum disorders, social-emotional problems and postneonatal death. One of the most dangerous effects is cerebral palsy whose frequency among extremely premature infants 70-80 times higher than in full-term, and, according to various authors, ranges from 7.2% to 13.4% compared to 0.13%-0.19%. This abnormality is a result of the neonatal intraventricular hemorrhage and severe periventricular leukomalacia. Another motor dysfunction in extremely premature infants look like focal disorder, delayed development of large motor skills, muscular dystonia, gait abnormality.
About 40% of extremely premature babies have cognitive deficits, delayed perception, speech problems, attention deficit and academic failure. In adulthood less flexibility of abstract thought processes, slow purposeful executive activities, difficulty in making decisions, planning and organization, attention and memory exhaustion are marked. Now developed a large number of methods for assessing cognitive development, starting from the first months of life. Normalized scales by Bayley, Mullen, Wechsler et al. make it possible to calculate the equivalent indices of mental development based on corrected age.
The frequency of sensory disorders in extremely preterm infants are high too. Thus, bilateral blindness as a result of retinopathy of prematurity occurs in 7.4% of them. Other problems include crossed eyes, violation of refraction, amblyopia, defects in visual fields. Sensoneural hearing loss is recorded in 8.7% of extremely premature infants. Early screening and correction can prevent the retardation of development of hearing and speech, cognitive problems and social dysadaptation.
Among children with extremely low birth weight is twicely higher frequency of behavior problems such as hyperactivity syndrome and attention deficit, affective states, aggression, isolation, sleeping disorders. Identifing them is possible by using the child behavior checklist (CBCL 1.5-5), children's survey of efforts and difficulties (SDQ), the scale of social-emotional development (ASQ:SE), questionnaires for autism screening: ADOS, M-CHAT-R/F, VABS.
Dynamic monitoring should also include the problems of nutrition, tolerance to food, deficient states (anemia, rickets), problems of immunological status and allergy incidence of infections and hospital admissions in infancy.
The purpose of this study was to improve the quality of clinical supervision for very premature children.
Materials and Methods
The study involved 78 premature infants with birth weight < 1000 g and gestational age ≤ 28 weeks. The main group consisted of 42 children who subsequently conducted an in-depth dynamic monitoring of definition of parameters of physical, psychological and neurological status and morbidity. Comparison group consisted of 36 children who were observed in a standart way. Clinical supervision was opening immediately after discharge and lasted at least until they reach the corrected age of 18 months.
Assessment of motor and cognitive development was carried out on a quarterly basis using the scale MSEL (Mullen Scales of Early Learning, 1995), which includes an assessment of large and fine motor skills, visual reception, receptive and expressive language. Social-emotional development was assessed at each visit of the child through questionnaires M-CHAT-R/F and child behavior checklist CBCL 1?-5 after the child reaches the age of 16 months adjusted age. These profiles enable to identify internalized, externalized behavior problems, and assess the risk of autism. An objective assessment of vision function included eye examination with ophthalmoscopy. Screening for hearing impairment was performed for all children before discharge from the hospital by otoacoustic emission. In addition, at each visit was assessed physical growth, nutritional status, neurosonography. Children were consulted by narrow specialists.
Results and discussion
Children of the groups did not differ significantly. Birth weight ranged from 570 to 999 g, the average in the main group was 890.7 ± 14.6 g, in a comparison group – 947.1 ± 12.3 g. In the study group 14.3% of children were born weighing less than 750 grams, while in the comparison group, there were no such children. Gestational age was within 23-28 weeks, mean values in the reference and comparison group consisted of 26.9 ± 0.4 and 28.0 ± 0.3, respectively. Children of 23-25 weeks of gestation were 33.3% in the study group and 2.8% in the comparison group. In both groups is likely dominated girls - 11:31 and 11:25 in the main in the comparison group.
Table 1.
Structure of the outcomes of neonatal pathology in children with extremely low birth weight at adjusted age ≥ 18 months
| Groups Outcomes | Study group, n=42 | Comparison group, n=36 |
| Postneonatal death, % | 7,1 | 13,9 |
| Cerebral palsy, % | 11,9 | 19,4 |
| Bilateral blindness, % | 2,4 | 2,8 |
| Sensoneural deafness, % | 4,8 | 5,6 |
These data indicate a high incidence of disability among extremely preterm infants in early childhood (one in five children (19.1 ± 6.1%) of the main group and almost one third (27.8 ± 7.5%) - of comparison group ). However, the incidence of postneonatal mortality decreased by almost half (from 13.9% to 7.1%), the incidence of cerebral palsy decreased in 1.6 times (7.5%). Remains stable the frequency of blindness and hearing loss, but it is worth noting that all children of the main group were prosthetic at early age (up to 1 year), and their intellectual and language development showed no significant lag, while in the comparison group deaf children developed secondary silence, which is almost impossible to eliminate even after successful restoration of function of hearing.
About half of children with a main group had motor (45.2 ± 7.7%) and cognitive (54.7 ± 7.7%) delay, over 60% of the cases showing combined version of it. Behavioral problems accompanying the development of extremely premature infants in every third child (31.0 ± 7.1%) of the main group. Dominated internalized disorders, autistic symptoms, anxiety.
Today, Ukraine is preparing to approve a national protocol for follow-up for children at high perinatal risk. After discharge from the hospital to the dynamic monitoring will be involved a pediatrician/neonatologist, psychologist, neurologist, ophthalmologist, audiologist, dietician, medical social workers, physical therapist, speech therapist, occupational therapist. Evaluation of motor, intellectual and social-emotional development will be performed with Bayley scales, ASQ:SE, M-CHAT. Early intervention initiative will include customized training programs, ranging from the neonatal period, the rehabilitation of impaired capacity, correction of sensory functions, assistance in establishing nutrition, psychological and social support for families.
World experience shows decline in disability at adjusted age of 2.5 years from 37-44% in 1995 to 13-18% in 2011 with the introduction of regionalization of care and active follow-up support of extremely preterm children.
Conclusions
A qualitative follow-up allows to detect abnormalities in sensory, motor, cognitive and social-emotional development in time, apply the techniques of early rehabilitation and reduce disability in extremely premature infants.
Assessment of motor, cognitive and social-emotional development by the scale MSEL (Mullen Scales of Early Learning, 1995) and using questionnaires M-CHAT-R/F CBCL 1.5-5 allows to get an objective information on the characteristics of individual development.
The study demonstrated reduction in the incidence of postneonatal mortality in twice and the incidence of cerebral palsy was decrease in 1.6 times.
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