nicu child development and education€¦ · nicu child development and education dr rebecca mann,...
TRANSCRIPT
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NICU Child Development and Education
Dr Rebecca Mann, Consultant Paediatrician, Musgrove Park Hospital, Taunton
14th November 2019
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• Long term development and Educational progress for the ex preterm infant……
• What should we tell parents?
• When should we tell them?
• What can we do to help? – babies
– parents
– teachers
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HEALTH WARNING
• The data are risks only – Do not relate to every baby
– Every baby and every family are individuals
• Important things: – Outcomes are getting better
– To inform and empower parents
– We can do better for parents
– We can do better with education
– We can do better for babies and children
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Overview
What can we improve?
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A refresher……..
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Born just a few weeks early…..does it matter?
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Is survival the only important outcome?
Wiltshire’s smallest babies........
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Brain development / long term?
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Neurodevelopment
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Learning problems are the most common disability
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Cognitive problems are not just low IQ
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Behaviour problems?
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Different kinds of problems in preterm children….
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Types of extra support required at 11y
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Specific difficult areas:
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Key stage 1…..
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Early years?
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That was the complicated news…
• What should we tell parents?
• When should we tell them?
• What can we do to help?
– babies
– parents
– teachers
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• What should we tell parents?
• When should we tell them?
• Parents should be offered information on everything relating to their child at the right time for them – Pre-delivery?
– Early PN period?
– Pre discharge?
– In clinic?
– At school?
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It’s a difficult balancing act……
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What can we do to help
– babies
– parents
– teachers
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What can we do to help Babies…..?
• Deliver better care – Research / new treatments
• Steroids
• Magnesium sulphate
– Higher standards of established care • Lower infection rates
• Breastmilk
• Baby centred care
• Family integrated care
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Numbers of survivors with disability or normal outcome 1995 vs 2006
• 44% increase in number of babies admitted to NICU for care
• More survive without disability • Increase in number of children with severe
disability NOW: Survival has improved further Outcomes also improving….. Your baby’s outcome will be better again…
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Newer treatments???
• Trial in Colombia 1993-1996
• A new treatment for preterm and low birth weight infants
• 716 babies
• Benefits of new treatment on survival, development, and the quality of mother–infant bonding were measured
• 494 (69%) identified between 2012-2014 20y later
• 441 young adults assessed, of whom 264 <1800g
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methods • 20 year follow up
• Assessed a range of measures of…
– Social
– Familial
– Educational
– Employment
– Behavioural outcomes
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Treatment group
control P value
Corrected mortality 3.5% 7.7% 0.04
IQ 87 88 NS
Subjected to violence at school 26 35 0.07
Working 43% 33% 0.06
With disability 12% 38% 0.04
Educationally related
Absenteeism 0.07 0.17 0.01
Wages 4.77 3.13 0.02
Connors hyperactivity* 62 74 0.13
Connors agressivity* 54 64 0.04
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Results: headline outcomes for treatment group…
• Lower mortality (3.5% vs 7.7%)
• Better school attendance
• Lower aggression, less hyperactivity
• Higher cerebral / intellectual development
• 53% higher salary / income
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What type of therapy….?
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“We don’t do it like this anymore……. Only if the babies are really ill……”
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Other findings…
• MRI: Larger cerebral volumes of grey matter, cortex and left caudate nucleus
• Biggest improvements in poorest families
• “Families were more dedicated to their baby’s care…and the effects were permanent”
• “Families in treatment group became more supporting, stimulating and protective”
• No difference in hearing / visual disability or cerebral palsy – intervention not neuroprotective
• Aggression / hyperactivity and externalisation scores all significantly lower in treatment group
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Authors conclusion…
• “The success is due to a multidisciplinary approach involving skin to skin care, breastfeeding, education of the mother and family, and post discharge support over first 12m of life”
• “Babies became less stressed”
• “Parents became progressively more aware of their child and more prone to sensitive caring”
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Introduction to
Family Integrated Care
in the Neonatal Intensive Care Unit
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What can we do to help….. parents • Give high quality information at the right time
– Anticipate problems
– Identify extra needs
– Put support in place promptly
• Information – Today?
– 2 year follow up?
– ???? Preschool assessment
• Resources – Support: physio / OT / SAL
– Access to high quality information
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What does NICE say?
• @Further developmental assessment at 4 years (uncorrected age) for children born before 28+0 weeks' gestation:
• 1.3.13 Provide a face-to-face developmental assessment at 4 years (uncorrected age) for all children born before 28+0 weeks' gestation@
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Nice online resource: raisingchildren.net.au
• Raising Youngsters Australian style
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What can we do to help teachers……?
– We need to better inform teachers and wider colleagues in the education system about the issues they need to be aware of in preterm infants
– Better information
– Better communication
– Better transition
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Challenges for the early years
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Proportion of participants who agreed with statements about confidence in supporting the
learning of children born preterm before and after using the e-learning resource (n=61).
Samantha Johnson et al. BMJ Open 2019;9:e029720
©2019 by British Medical Journal Publishing Group
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Summary (1): learning issues
• The most common difficulties are associated with mathematical ability, social and emotional skills, and attention
• Children are more likely to have cognitive difficulties: – poor working memory – deficits in visuospatial ability – processing speed and executive function
• Children born preterm are at greater risk of attention difficulties, difficulties interacting with peers and maintaining friendships – and being shy, anxious or withdrawn
• Ex preterm children will often have a number of difficulties that co-occur
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Summary (2)
• Every child is different, born preterm or not
• Every child will have their own strengths and weaknesses
• The risks we associate with preterm babies are groups of babies and averages – some children will have very different outcomes – but we can identify patterns of outcomes for these children
• Prematurity is a risk factor, not a diagnosis, for difficulties later in life
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Summary (3)
• The outlook for preterm infants in terms of survival and outcomes is improving all the time
• We must continue to strive to improve the standard of care we offer
• Prematurity is only a risk factor for educational difficulties, not every child will have problems
• We need to assess all preterm infants in detail before school entry: 4 years of age
• We need to focus more on providing parents and teachers with much more specific information about each child– “pass the baton”
• Parent power is vital at all stages in the baby’s care
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Thankyou……Any questions??
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Educational and health care plans
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Behavioural outcomes?
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Impact on learning and school performance
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Academic attainment