I-CAN-development
Infant and Child Assessment of Neuro-development
Comprehensive neurodevelopmental assessment and follow-up for infants and children
Neurodevelopmental outcomes of preterm babies
Preterm infants are at higher risk of adverse neurodevelopmental outcomes when compared to those born at full-term. During the last trimester of pregnancy there is a rapid increase in brain development and formation of connections (cortical synapses). Being born prematurely disrupts brain development, and although the brain continues to mature after birth the trajectory of maturation is different from in-utero. Brain maturation is different because of the conditions outside the uterus (including the NICU environment); in addition, a baby may be necessarily exposed to adverse experiences and interventions.
Although the majority of children born preterm have good developmental outcomes, compared with full term babies those born preterm and very low birth weight perform less well in a variety of cognitive and psychological tests. These children may require support from therapists to optimise their development and many have an increased requirement for extra educational assistance during childhood.
Children born preterm are at increased risk for language, cognitive (intellectual), sensory, and motor deficits (including cerebral palsy) as well as behavioural problems. Younger gestational age at birth and lower birth weight is associated with a higher risk of developmental delay. Conditions of prematurity such as severe intraventricular haemorrhage, necrotising enterocolitis, sepsis and chronic lung disease are more likely to lead to cerebral palsy and cognitive delay.
Children born preterm and at highest risk of adverse neurodevelopmental outcomes should receive follow-up until 2 years of age as recommended by the National Institute for Health and Care Excellence https://www.nice.org.uk/guidance/ng72
Neurodevelopmental problems
Children born preterm may have problems that become apparent during child development. These can range from very specific limitations of function in one developmental domain to global impairments of movement, communication, social skills and cognition.
Cerebral palsy
Cerebral palsy is the name used for a group of neurological conditions affecting muscle tone, movement, posture and co-ordination due to abnormal development or injury of the brain, before, during or after birth. It is a non-progressive, permanent disorder that causes limitation of activity.
Cerebral palsy (CP) usually occurs in approximately 2–2.5 per 1000 live births but babies born preterm are at increased risk. The overall rate of cerebral palsy in preterm children is 1-10% depending on gestation - the risk of CP increases with decreasing gestational age.
Independent risk factors are :
- Grade 3 or 4 intraventricular haemorrhage
- Cystic periventricular leukomalacia
- Neonatal sepsis
- Necrotising enterocolitis
- Chronic lung disease still needing mechanical ventilation at 36 weeks' corrected gestational age
- No antenatal steroids
- Postnatal steroids administration before 32+0 weeks' corrected gestation
Babies at risk of developing CP can be assessed using the General Movements Assessment to identify absent or abnormal general movements. This can be highly predictive of cerebral palsy by about 3-4 months of age (corrected for prematurity) enabling intervention to start early. The advantage is potentially better outcomes if an infant is diagnosed as at risk of cerebral palsy using the General Movements Assessment.
Intellectual disability
(cognitive delay)
Speech, language and communication disorders
Children born preterm can have developmental difficulties that can affect their behaviour and ability to learn. These difficulties occur not only in children born extremely preterm but also in those born very and moderately preterm. Rates of mild disabilities are 39%, 36%, and 34% among children born extremely, very and moderately preterm respectively. Increasing evidence suggests a small but significant risk of neurodevelopmental impairment after late preterm birth, even in the absence of acute neonatal complications.
Preterm children can experience difficulties with visual-spatial and working memory and can find it difficult to receive, process, store, and retrieve information. They may have difficulty paying attention, planning and executing tasks; these difficulties may all contribute to learning difficulties.
Children born preterm are at increased risk of speech, language and communication problems and disorders. Parents may notice that they reach their speech and language milestones later than babies born at full term. Milestones are related to language understanding (receptive language) sound production (speech), expressive language (including words, signs and gestures) and social interaction (communication).
Some preterm children's language development will catch up with time however early severe language delays, most likely to be seen in the lowest gestational age, are more likely to persist throughout the preschool years.
Babies born preterm tend to develop gestures, words and language understanding at a slower rate and have a smaller vocabulary at 3 years of age compared with babies born full term. Without identifying this and providing support, this gap can continue to widen through preschool and school age. At two years of corrected age, speech delay is evident in approximately 15-35% of children born preterm.
Preterm birth and low birthweight (<2500 g) have been identified as risk factors for autism spectrum disorders (ASD). They are more likely to have delayed socio-emotional development and behavioural problems
The earlier a baby is born, the higher the likelihood of having autism:
- 6 percent of babies born extremely preterm
- 2.6 percent of babies born very preterm
- 2 percent of babies born between moderate-late preterm
- 1.4 percent of babies born around full-term
Children born preterm are also at increased risk of feeding problems (eg problems with sucking and chewing); this increased risk can last until school-age in children born < 26 weeks' gestation.
Feeding problems
Behaviour
Many parents of children born preterm report problems with behaviour. Examples include: defiance, impulsivity, hyperactivity, and aggression, inattention, withdrawal and anxiety.
Babies born prematurely are at a greater risk of problems with focusing attention, including development of signs and symptoms associated with Attention Deficit/Hyperactivity Disorder (ADHD). These signs and symptoms can have negative impact on their social, intellectual, and academic development.
Classification of preterm birth
Children born preterm may have problems that become apparent during child development. These can range from very specific limitations of function in one developmental domain to global impairments of movement, communication, social skills and cognition.
Extremely preterm
(< 28 weeks gestation)
Infants born extremely preterm are at high risk of neurodevelopmental impairment with approximately 50% of survivors born at <26 weeks’ gestation showing severe or moderate neuromotor and sensory disabilities at 2 years of age.
Very preterm (28 to 31+6 weeks gestation)
Very preterm infants have a higher risk of cerebral palsy, cognitive delay, deafness and blindness, and autism spectrum disorder when compared with term controls. Those born <30 weeks should receive NHS follow-up until 2 years of age.
Moderately preterm
(32 to 33+6 wks gestation)
The risk of developmental delay and mild disability is increased in children born moderately preterm compared to those born full-term. Most children will do well and neonatal follow-up is generally not offered by NHS neonatal services; babies and toddlers are seen by Health Visitors.
Late preterm 34 to 36+6 (weeks gestation)
Most children born late preterm will not have required any specialist treatment following birth and are unlikely to have been admitted to a NICU (Neonatal Intensive Care Unit) or SCBU (Special Care Baby Unit). The vast majority of children will have normal developmental outcomes but there will be some who have developmental delay related to prematurity.
Extremely Preterm and Very Preterm Babies
Extremely preterm
< 28 weeks
gestation
Very preterm
28 to 31+6 weeks gestation
The risk of severe impairment increases with increasingly preterm birth and is currently approximately one in ten at 26weeks of gestation, one in seven at 24 weeks of gestation, and one in four at 23 weeks of gestation for those babies born who survive.
The risk of moderate and severe delay in survivors born at 22, 23, 24, 25 and 26 weeks of gestation was 60%, 51%, 34%, 27%, and 16% respectively
The overall rate of cerebral palsy for extremely preterm infants is 5-10%.
Very preterm infants have a higher risk of cerebral palsy, cognitive delay, deafness and blindness, and autism spectrum disorder when compared with term controls. The presence of Grade 3 or 4 intraventricular haemorrhage or necrotising enterocolitis increased the risk of cerebral palsy, while magnesium sulphate for threatened preterm labour decreased the risk in the surviving neonate.
The overall rate of cerebral palsy for very preterm infants is approximately 5%
NICE recommendations
Regular review of developmental progress, neurological and general examination, and neurodevelopmental assessment is recommended for all children born <30 weeks of gestation by National Institute for Health & Care Excellence from NICU discharge until 2 years of age when a formal neurodevelopmental assessment is recommended. https://www.nice.org.uk/guidance/ng72
Most of the neurodevelopmental conditions can be diagnosed in early childhood through regular follow-up.
Photo: Kristina Bessolova
Moderate and Late Preterm Babies
Many moderate and most late preterm babies will not have been admitted to NICU after birth but remain at risk of neurodevelopmental impairment in comparison with babies born at full term. Moderate-to-late premature babies face much higher rates of developmental and behavioural delays than previously thought and although some of these will manifest as attention and educational difficulties in later childhood, some children will have developmental or behavioural difficulties that can be detected in the first 2 years of life, allowing early intervention.
Moderately preterm
32 to 33+6 weeks gestation
Survival without severe or moderate neuromotor and sensory disabilities at 2 years corrected age is 97.5% for children born at 32-34 weeks’ gestation. Intellectual and behavioural problems are more common in this group.
The overall rate of cerebral palsy for moderately preterm infants is approximately 1-2%.
At two years of corrected age, speech delay is evident in approximately 18% of infants.
Late preterm
34 to 36+6 weeks gestation
Children born late preterm are three times more likely to have delays in their language and motor skills development, twice as likely to have delays in cognitive development such as ability to perform tasks and follow directions and be more likely to have difficulty coping in different social settings compared with those born full-term.
Follow-up programme
Regular follow-up for children at risk of developmental delay
Preterm infants with possible developmental concerns should be identified early on so that interventions can be implemented in a timely manner in order to optimize outcome. Even preterm infants that appear to be meeting developmental milestones should continue to be monitored closely as deficits may develop later. This can affect their quality of life all the way into adulthood.Regular review of developmental progress, neurological and general examination, and neurodevelopmental assessment is available from NICU discharge until 2 - 3 years of age. Optimal information about neurological status and development is gained by formal, standardised neurodevelopmental assessments and general review of neurological examination consisting of: General Movement Assessment with Motor Optimality Score at 3-4 months, regular review of neurology and assessment of development and a full standardised assessment (BSID) at around 2 years of age.
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Infant and Child Assessment of Neuro-development
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