NEUROSCIENCE MEETS NURTURE: Challenges of prematurity and the critical role of family- centred and developmental care as a key part of the neuroprotection care bundle.
Soni R, et al. Arch Dis Child Fetal Neonatal Ed 2021;0:F1-F8.doi:10.1136/archdischild-2020-319450
This very recent review article is worth a read, as the nature versus nurture paradigm meets neuroscience in this article. Understanding is essential and underpins what therapists do in the neonatal population and we can be involved in the non-pharmacological therapies. There are many up to date references which can be used for evidence of why therapists ae involved in family integrated care and developmental care.
Nearly 15 million babies are born preterm (under 37 weeks gestation) every year globally. In this review the authors examine the developmental milestones of foetal brain development and how preterm birth can disrupt this. Although drug based and cell based neuroprotective therapies for the preterm brain are under intense study, they outline basic sustainable and effective, non-medical, family centred and developmental care strategies which have the potential to improve neurodevelopmental outcomes for this population.
They explain in detail why the understanding of preterm brain development is important. The prolonged developmental course from the fourth post-conceptual week to the 3rd postnatal year allows the environment to shape the development of the human nervous system. Prematurity is one of many biological or environmental insults that can push the trajectory of the developing brain to an atypical path, with the resultant increased prevalence of neurodevelopmental and neuropsychiatric disorders.
They summarise preterm brain development and the brain MRI abnormalities associated with prematurity. Although brain growth is rapid between 25 and 40 weeks gestation in a preterm baby on the NICU, the growth trajectory is less than a healthy foetus for the same duration. MRI studies of preterm infants have identified reduced cortical and sub cortical grey matter volumes, diminished cerebellar volumes and alterations in thalamo cortical development at term equivalent age.
Neurodevelopmental outcomes of preterm infants: The moderately preterm infants have more favourable developmental trajectories compared to the extremely preterm and very preterm infants across all domains of development. Globally, an estimated 0.9 million post-neonatal survivors suffer long term neurodevelopmental impairment with 5-15% of very preterm survivors affected with severe neurological disability.
Impairment is often defined as a composite of neurosensory and development outcomes. Of babies born in the UK before 27 weeks gestation age in 2006, 13.4% (n=77) were categorised as having a severe impairment and 11.8% (n=68) with moderate impairment at three years. The authors highlight the strategies to improve outcomes, medical as well as non-medical, especially the critical role of family centred and development care.
Researchers around the world are keenly focused on developing pharmacological therapies to protect the preterm brain. Here in the UK, we are aware of the recommended use of corticosteroids and magnesium sulphate antenatally and the role of caffeine for neuro protection. Stem cell or exosomal therapies are particularly promising for protection, regeneration and repair of the injured developing brain; however further clinical research is needed.
Family centred and developmental care practices are promising therapies with the potential to enhance the preterm baby experience and the MRI signature associated with prematurity.
Developmental care interventions decrease the stress of the preterm neonates in the NICU and are designed to allow optimal neuro-behavioural development of the infant. They give an overview of some of the most studied interventions; Neonatal Individualised Developmental Care (NIDCAP), skin to skin contact, kangaroo care and breast feeding – we are aware there are many more, these are just what the authors used and is not an exhaustive list and we are not saying these are best/and or only approaches. Improved long term outcomes in infant cognitive motor and emotional functioning due to NIDCAP in the NICU have been reported up to school age. A multitude of positive effects have been observed with skin to skin contact and kangaroo care such as supporting infant physiological stability, preventing pain, strongly promoting infant growth and neuro behavioural development, improving breastfeeding, reducing neonatal morbidities, parental anxiety, neonatal stress scores, nosocomial infections, hypothermia and length of stay. Breastfeeding is known to have a range of social, emotional and health benefits for both the term and preterm infant and mother. The positive impact of breastfeeding on intellectual development has subsequently been established with improvement in cognitive impairment even greater in preterm and VLBW infants.
The authors conclude that family centred care and developmental care promote parent-infant interaction and are safe and feasible in most settings and socio economic conditions. They have the potential to enhance the preterm baby experience and improve neuro developmental outcomes globally in the high risk preterm population.
Maleka Jariwala- APCP Neonatal Committee