Neuromotor Concerns in Premature Infants

Sampers, Cooley, Cornelius, & Shook (1996, 2005) suggest that prematurity has been identified as the number one risk factor for cerebral palsy (also see Bennet, 1999; Pinto-Martin, Whitaker, Feldman, Van Rossem & Paneth, 2000; Majnemer, Riley, Shevell, Birnbaum, Greenstone, & Coats, 2000; McCormick, McCaron, Tonacia, & Brooks, 1993). It has been reported that 5-15% of children born at less than 1500 grams showed severe neurological abnormalities, primarily cerebral palsy (Volpe 1995).

In children with cerebral palsy or motor dysfunction, many have a history of intraventricular hemorrhage (IVH), or bleeding into the ventricles of the brain. Further, the type and extent of IVH is correlated with the degree of motor involvement. There are four grades of IVH, with Grade IV representing the most severe form. Bleeding into the brain of premature babies is most frequently caused by immaturity in the blood flow regulating system to the brain and these resulting fluctuations in blood flow to the brain can be detrimental. Infants with Grade III or IV IVH are most frequently affected with developmental problems. Those infants who develop subsequent hydrocephalus carry the greatest risk of permanent brain injury. Infants identified with IVH during the postnatal period should be evaluated for motor symptoms/deficits and other developmental concerns during follow-up visits to the clinician.

Periventricular Leukomalacia (PVL) is an additional condition that is seen in the pre-term infant. It is even more concerning when the PVL is cystic in nature. PVL, when present, is often found in the motor strip, an area just outside the ventricles of the brain. Any infant with a history of PVL requires close follow-up and monitoring for motor problems.

In reviewing the infant's history, there are other conditions that may add to the infant's risk for subsequent neuromotor and/or neurobehavioral dysfunction. These conditions include: hypoxia; risk related to breathing problems like bronchopulmonary dysplasia (BPD), more currently referred to as chronic lung disease (CLD); pauses in breathing with apnea, or bradycardia; metabolic concerns such as hypothyroxinemia of prematurity and hyperbilirubinemia; and neonatal environmental factors such as nutrition and over-stimulating environment of the NICU. Well-child exams should include an evaluation of the infant's history for signs of risk as well as a thorough neuromuscular assessment.

The above material was taken in part from Baby Awareness and Support through Interactive Computer Systems (BASICS), a project supported by the U.S. Dept of Education and the University of Kentucky.

References

Bennet, F.C. (1999). Diagnosing cerebral palsy-the earlier the better. Contemporary Pediatrics 16(7), 121-129.

Bracewell, M., and Marlow, N. (2002). Patterns of motor disability in very preterm children. Mental Retardation and Developmental Research Reviews. 8(4), 241-248.

Hoekstra, R.E., Ferrara, T.B., Couser, R.J., Payne, N.R., & Connett, J.E. (2004). Survival and long-term neurodevelopmental outcome of extremely premature infants born at 23-26 weeks gestational age at a tertiary center. Pediatrics, 113(1), e1-e6.,

Majnemer, A., Riley, P., Shevell, M., Birnbaum, R., Greenstone, H., & Coats, A.L. (2000). Servere bronchopulmonary dysplasia incrases risk for later neurological and motor sequelae in preterm survivors. Developmental Medicine and Child Neurology, 42, 53-60.

McCormick, M.C., McCarton, C., Tonascia, J., & Brooks-Gunn, J. (1993). Early educational intervention for very low birth weight infants: Results from the Infant Health and Developmental Program. Journal of Pediatrics, 123, 527-533.

Perlman, J. (2001). Neurobehavioral deficits in premature graduates of intensive care-potential medical and neonatal environmental risk factors. Pediatrics, 108(6), 1-19.

Pinto-Martin, J.A., Whitaker, A.H., Feldman, J.F., Van Rossem, R., & Paneth, N. (2000). Relation of cranial untrasound abnormalities in low-birthweight infants to motor or cognitive performance at ages 2, 6, 9 years. Developmental Medicine and Child Neurology, 41, 826-833.

Sampers, J., Anderson, C., & Shook, L. (2005). Early predictors of poor motor outcomes in extremely premature infants. Unpublished manuscript; University of Kentucky at Lexington.

Sampers, J., Cooley, G., Cornelius, K., & Shook, L. (1996) Utilizing clinical judgment in the early identification of premature infants with motor difficulties. Infant Toddler Intervention, 6, 117-124.

Volpe, J.J. (1995). The neurology of the newborn. Philadelphia: W.B. Saunders Company.