Upload
mch-org-ua
View
179
Download
0
Tags:
Embed Size (px)
DESCRIPTION
International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)
Citation preview
Implementation of
neurodevelopmental monitoring
service for high risk newborns:
Republic of Moldova experience
A.М. Kurtyanu
Mother and Child Healthcare Research Institute
Kishinev, Republic of Moldova
Report goals
• Abstract on psychomotor development of
preterm infants on the basis of literature
data
• Structure and functions of Republican
Diagnostics and monitoring Service for
high risk neonates (Neonatal Follow-up).
• Internal study results
3
12,1%
10-12 %
Preterm
labour rates
Tracy SK et al, BJOG 2007,Langhoff-Roos, J et al BMJ 2006,
Grijbovski AM, Public Heath 2005
5,5 – 11,4 %
≥ 30%
The highest obsterical risks - annual results
Preterm labour 13 000 000
Costs 26 000 000 000 US$
According to findings of the study held in 184 countries (2010), the rates are as follow: R..
Moldova (11,0%), Ukraine (6,5%), Romania (7,3%), Switzerland (7,4%), USA (12,0%), Russia
(12,0%) worldwide (11,1%) (Born Too Soon: The Global Action Report on Preterm Birth, 2012).
% of preterm labours in R. of Moldova,
1990-2012
5
4,5
4,79
4,37
4,685,1
4
4,2
4,4
4,6
4,8
5
5,2
1990. 2000. 2005. 2010. 2011. 2012.
Prematurity & low birth weight (%)
Characteristic RM Ukraine Romania USA Russia
< 1,000 g
Most of the (99,3%)
preterm infants
(live-born)
0,4 0,4 0,3 0,7 0,28
1,000-2,500 g 63,9%
-preterm infants
5,6 4,7 5,6 7,2 5,48
> 2,500 g
7,6% - preterm infants
94,0 94,3 91,1 92,1 94,2
Survival rates of newborns with different weight
categories in R. of Moldova (2000-2012)
0,814 0,841
0,919 0,945 0,96 0,959
0,934 0,947 0,961 0,98 0,985 0,988
0,0164 0,0538
0,317
0,369
0,399
42,70%
0,522
0,601
0,777
85% 0,863
0,806
2000. 2005. 2009. 2010 2011. 2012.
1500-1999
2000-2499
500-999
1000-1499
Survival of neonates in MACH RI at different
gestational age , 2012
0
20
40
60
80
100
22 s
.g.
23 s
.g.
24 s
.g.
25 s
.g.
26 s
.g.
27 s
.g.
28 s
.g.
29 s
.g.
30 s
.g.
31 s
.g.
32 s
.g.
33 s
.g.
34 s
.g.
35
s.g
.
36 s
.g.
0
100
80
50 50
3234,8
9 7,1 6,12 0 2,1 4,1
0
0 2 5 8 14 25 23 2242
49 50 51 4748 54
00
2050 50
6865,2
91 92,9 94,9 98100
97,9 95,9100
Mortalitatea
nascuti
Supravetuirea
Concluzii: supravețuirea invers proporțională termenului de gestație:22 - 23 s.g. – supravețuire – 0% 26 – 28 s.g. – supravețuire - 61,0% 24 - 25 s.g. – supravețuire – 35,0% 29 – 32 s.g. – supravețuire - 96,2% 89,8%
Mortalitate
Nașteri
Supravețuirea
Conclusions: inverse proportion is observed between survival and gestational age
22-23 weeks – 0% 26-28 weeks – 61%
24-25 weeks – 35% 29-32 weeks – 96.2%
Abstract on psychomotor development
of preterm infants on the basis of
literature data
Psychomotor, neurosensory , cognitive and behavioural disfunctions.
Mercer BM. Obstet Gynecol 2003;101:178-93
Survival and short-term morbidity in
preterm infants
Healthresults for preterm infants
• Long-term
– 1 of 5 with mental
development delay
– 1 of 3 with poor vision
– 50% of infants with
cerebral palsy
– 5 times higher risk of
infant mortality:
• boys (22-32 weeks)
• girls (22-28 weeks)
• Intrauterine programming
– Weaker reproductive
health
– High risk of preterm
labour for descendants
– Diabetes mellitus
– Ishemic heart desease
RR 1.5
Spong CY et al, Obstet Gynecol 2009
Preterm infants health results
Survival with 23 weeks of GA.:
1/3 cerebral palsy with blindness/deafness.
Suvival with 24 weeks of GA.:
Psychomotor development delay 22 - 45%.
Suvival with 25 weeks of GA.:
Multiple disfunctions of severe psychmotor development 12 - 35%.
These rates have not changed since 90-ies!!! Hack M; Fanaroff A
Psychomotor development deficit in preterm
infants born with extremely low birth weight
(ELBW) - global trends
Country / authors GA,
weeks Years
Age at
examination,
years
Values
Number %
Conclusion: cerebral palsy value varies per country
Number of neonates with severe form of psychomotor
development depending on GA <26 s.g.
Age, weeks. Cerebral palsy
distribution, %
Confidence
interval
23 34 Insufficient data
24 22-45 6-48, 28-64
25 12-35 3-27, 15-59
Total value 31
12 studies which investigated correlation between psychomotor development and GA, at 12 and 36 month of corrected age
Health results of preterm infants born live with
ELBW at 18-22 month
Normal develoment
Mild disorders
Severe disorders
Incomplete FU
Discontinued
Died
Mortality, morbidity and survival without
severe adverse outcomes
NICHD Neonatal Research Network centers (n = 16) [Fanaroff et all 2007]
Prospective study (120 days of life) from 01.1990 to 12.2002 in 16 centres of National Institute of Child
Health & Human Development Neonatal Research Network.
Survival factors • Gestational age: inverse ratio
• Birth weight: infants with SBW have the weakest results
• Gender: survival ↑ for girls
• Labours at third level institutes: ↑ survival
• Antenatal steroids: ↑ survival ; number of disabled is the same, at
postnatal period
• Labour conditions and intensive care: proper ↑ survival
• Treatment with surfactant: ↑ survival; number of disabled is the same
• Hypothermia prevention
• Postnatal steroids administration decrease: ↓IVH
• Monocyesis
• Weight growth
• Multiple birth: ↓ survival and ↑ morbidity
• Sepsis: ↓ survival
• Cesarean section (pelvic presentation): controversial data
[4446 births at 22-25 weeks of GA Tyson et all 2008]
Factors that affect the development
of cerebral damage
• Its development is influenced by the start,
duration and severity of injury
– Term / preterm infant
– Extensive / local injury
– Acute / chronic
– Number of available injuring mechanisms
(strokes)
Prognosis factors MDI < 70
NICHD Data -- 1151 infants < 1000 g.
Prognosis factors PDI < 70
NICHD Data -- 1151 infants < 1000 g.
Proliferation
Structuring of neurons
Migration Myelination
Weeks
of gestation 10 15 20 25 30 35 40
Subplate
Cortical folding
Latal, 2003 23 40
Glial cells differentiation
Cerebral development phases
Term infant
(IRM ponderee T2)
Preterm infant (25 weeks)
Cortical development and differentiation
Cortical development (surface)
27 weeks 32 weeks 35 weeks
Effects of clinical interventions on CNS
development • More detailed studies are needed to investigate
the effectiveness and damaging impact of clinical
interventions on CNS – For example, the use of corticosteroids at postnatal period
Cortical gray matter volume 35% in
preterm infant treated with
dexametazone
Cerebral cortical gray matter volumes.
Term Preterm @ Term Preterm @ Term No Steroids Steroids
Cer
ebra
lcor
tical
gra
y m
atte
r vo
lum
e (c
c)
0
50
100
150
200
250
300
Murphy BP et al 2001
Other factors affecting the
development of CNS
• Future development depends rather on gestational age than on the birth weight (BW) – The literature is mostly based on BW, which influences
the results accuracy of the studies (bias)
• The range and severity of development disorders are often underestimated if observation stops in the early childhood.
– EPICURE ( 26 weeks of gestation):
• No severe adverse effects at 30 months : 76% vs 63% at 6 years (sustainable result stays by 11 years)
[Marlow et al 2009]
Mortality / morbidity
• Antenatal corticosteroid therapy:
– 20%: 1990-1991
– 79%: 1997-2002
• Ante/ intrapartum antibiotic therapy:
– 31%: 1990-1991
– 70% 1997-2002
• I (1982–1989) (n = 496)
• II (1990–1999) (n = 749)
• III (2000–2002) (n = 233)
– At 20 months of corrected age • Between I and II: survival from 49% to 68% = morbidity
• Between II и III: CP from 13% to 5% morbidity from 35% to 23%
[Wilson-Costello et al 2007]
Differences between the studies (I) Characteristic EPICURE
(short-term)
EPICURE
(long-term)
1995
EPIPAGE
(long-term)
1997
Suede
1992-1998
Ulm
1996-
1999
Survival rate at
25 weeks of GA
424
424 119 103 48
Examination age 30 months 6 years 5 years
3 years
5.6 years
No poor
outcomes within
study period ( % of
infants admitted to
NICU)
142 (76%) 118 (63%) Data available
only for 24-28
SA group total :
92% (out of
examined infants)
70 (89%) 29 (71%)
No poor
outcomes ( % of
examined neonates)
35 (24%) Data available
only for 24-28
SA group total
52%
Mid-term and long-term results in infants born at 25 weeks of GA in population studies and in one
specialized centre
Differences between the studies (II)
• Severe retardation is often diagnosed
– < 2 years
– by a well-trained pediatrician
• Mild and moderate underdevelopment are
diagnosed later and should be discovered
– Specialized consultation
Results / cerebral palsy
• Severe retardation - about 10%
• Moderate and mild development deficit - 30 - 50%
• No retardation
Cerebral palsy
• < 1500 g – 5%
• < 1000 g – 15-20%
• Decreasing?
[ Platt MJ et al 2007]
Chronic lungs desease and survival in 385 neonates
with ELBW in 11 centres of South America
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
A B C D E F G H I J K TOTAL
Survival at RDS
BPD
Mortality
50%
30%
20%
GRUPO COLABORATIVO NEOCOSUR, J. Perinatol 2002;22:2-7
According to the studies
development is mostly influenced
by respiratory
disfunctions than by cerebral ones
Structure and functions of Republican
Diagnostics and Monitoring Service for
neonates from high risk groups (Neonatal
Follow-up).
3 development phases
1. Establishment
2. Regionalizitation and reinforcement
3. Monitoring of functions as a part of
Early Intervention Service
Implementation of advanced technologies into
intensive and routine neonatal care system
1/01/2008, the Rupublic of Moldova adopted WHO and EU criteria and standards
of live-born neonates registration
1. Standards. Documents issued within the framework of Neonatal
Diagnostics and Monitoring Service
• As a result, Order No. 455/137/131 of December 10, 2007 was jointly issued by the Ministry of Healthcare, Ministry of Information Technologies and National Bureau of Statistics in order to start official statistical registration of labours and neonates with birth weight over 500 g and gestational age over 22 weeks.
• In order to comply with the requirements of Declaration of Millenium Development Goals and according to the activities regulated by National Healthcare Policy for 2007-2021 and Healthcare System Development Strategy for 2008-2017, there was a Republican Neonatal Diagnostics and Monitoring Service established and implemented according to the Order No. 118 of 19/02/2010 of the Ministry of Healthcare which covered high risk infants groups up to 2 years of corrected age.
Standards (2). Documents issued within the framework of Neonatal
Diagnostics and Monitoring Service
1. Regulations on the Republican Neonatal Monitoring System for infants up to two years.
2. Functional responsibilities of the person in charge from the Centre of Family Physicians who coordinates the operation of Neonatal Monitoring System.
3. Instructions for family doctor and pediatrician regulating their responsibilities within the Neonatal Monitoring System.
4. Documents regulating the introduction of Neonatal Monitoring Service into early development system for children up to five years.
2. Regionalization of Diagnostics and Monitoring Service for
high risk neonates.
3. Equipment supply
Regional Centre Regional
Centre
MACH RI Republican Centre of Neonatal Diagnostics
and Monitoring
Municipal Hospital No. 1,
Municipal Centre
Regional Centre
Bălţi
Kishinev
Kishinev
Cahul Ceadir-Lunga
Structure of the Republican Centre of
diagnistocs and monitoring for high-risk
neonates
Doctor's room. Database Active invitation
Ultrasound screening room
EEG examination room
Screening cabinet (audiometry and ophthalmoscopy)
Pediatric examination room with BSID tools Lo
w a
nd
ve
ry lo
w b
irth
we
igh
t n
eo
nat
es
care
un
it
Ne
on
atal
ne
uro
logi
c u
nit
Pediatric examination room with BINS tools
• Theoretical and practical workshop on Neurological pathologies in term and preterm neonates, 2007- 40 neonatologists (33%)
• 2 workshops on Neural development assessment for neonates discharged from NICU (with support of US instructors) – Giuleşti Hospital, Bucharest, Romania, 2007 – 3 specialists
– MACHI, 2009 - 25 neonatologists and neonatal neurologists
• 2 internships (1 neurologist) on EEG use - Giulesti hospital, Bucharest, Romania (2007), Follow up, clinical and social rehabilitation of neonates from hight risk groups, France - 1 month.
• 1 training in the Centre Follow up, RCIT, Jaşi, Romania – 3 specialists
• Visit that included theoretical and practical training at the working place (Dr. R.Ha Vin Leutcher, HUG, Switzerland, (2010), 12 specialists from MACI, HospitalNo. 1 Kishinev, and Beltz Rehabilitation Centre
4. Medical personnel training
4. Materials for medical personnel
1. Neonatal observation map
2. Booklet on Neonatal Diagnostic and Monitoring
Centre operation
3. Poster on Neonatal Diagnostic
and Monitoring Centre
4. Materials for medical personnel and
mothers (1)
4. Preterm infants care basics
5. Kinetic therapy for preterm infants
6. Guideline for mothers of preterm infants
Goals of the Republican Centre of diagnistocs
and monitoring for high-risk neonates
↝Specialized medical support for infants with high risk of
poor neurological outcomes.
↝Definition of poor neurological outcomes risks using
BINS and BSID tools.
↝Admission of infants with medium or high risk of poor
neurological outcomes to the monitoring programme.
↝Specialized neural examination of infants having high risk
of poor neurological outcomes
↝Paraclinical examinations: ultrasound, EEG, audiometry,
ophthalmoscopy.
The list of high risk neonates eligible for
Monitoring Programme
↝ Preterm infants with birth weight ≤ 1500g
↝ Fetal growth and development delay (two standard deviations)
↝ Visual and audial disorders
↝ Hypoxic-ishemic encephalopathy (Sarnat II-III)
↝ Seaizures at neonatal period
↝ Respiratory support (ALV or CPAP )
↝ Intraventricular hemorrhage (grades III-IV)
↝ Periventricular leukomalacia
↝ Severe hyperbilirubinemia (170 mmol/l within 24 hours or 300 mmol/l within 48 hours after delivery)
↝ CNS infections (meningitis, encephalitis)
↝ Ulcerous necrotizing enterocolitis
↝ Bronchopulmonary dysplasia
↝ Clear neurological symptoms at discharge
Personnel of the Republican Centre of
diagnistocs and monitoring for high-risk
neonates
• Neonatologist
• Neurologist
• Rehabilitation / kinetic therapy specialist
• Audiologist
• Ophthalmologist
• Ultrasound diagnostician
• EEG specialist
• Psychologist
• Speech therapist
Follow-up neonatal Database
(2009-2012)
• Total number of infants included into the database -
1265
• Including 527 (41,7%) preterm infants with birth
weight <1500 g
• Number of infants who did not visit the centre
"Follow-up neonatal" – 320 (25,3%)
• 631 (49,8%) infants who survived up to 24 month of
corrected age
• 40 (31.6%) dead infants out of those who were
included into the Follow-up
Poor neurologic outcomes assessment
tools - BINS and BSID
Neurologic functions (muscle tone, movement /
asymmetry)
Expressive functions (motor functions)
Receptive functions (visual, audial, speech)
Cognitive functions
Screening tests for risk assessment
(1-24 months)
Infants development scale
(1-42 months)
The test includes 5 components:
Cognitive functions
Communication (receptive, expressive)
Motor function
Social-emotional status
Adaptive status
Neonatal examinations calendar
• At admission to resuscitation unit and at discharge
• 3 months
• 6 months
• 12 months
• 18 months
• 24 months
Corrected age is calculated for preterm infants at 34 weeks of gestation.
Corrected age = Actual age + Gestational age - 40 weeks
Psychomotor development results in infants at
24 months of corrected age (155 cases) in RM.
Internal study results
Goal / Materials and methods
• Goal: to study the outcomes of neurological
development in preterm infants with BW ≤ 1500
g at 2 years of corrected age.
• Methods. Design. Retrospective descriptive
study at MACH RI from 01/01/2008 to 31/12/
2009.
• Analysis of health records of 93 newborns and 6
follow-up visits with the last one at 24 months.
Profiles of the study population
Total of premature infants with weight
≤ 1500 g born or referred to IIIrd level -
337
Died during neonatal
period - 49
Survived / dishcarged - 288
Enrolled in Follow up program - 265
Died during Follow up
period
13
Never
came 11
Came
once 1
Came ≥
once l
Lost to Follow-up program
159
Never
came 58
1 visit
35
2 visits
28
3 visits
15
4 visits
18
NDFU <1 y- 56
NDFU ≥1 y - 45
5 visits
5
Enrolled in
follow-up
study at 2 y -
93
Gestational age of newborns enrolled in the
study
GA, weeks Number %
34-32 17 18,2
31-29 44 47,3
28-27 28 30,1
26-25 4 4,3
Total 93 100
77,4%
Morbidity of examined newborns at
discharge Pathology abs. nr. %
Early sepsis 13 13,9
Late-onset sepsis 2 2,1
Meningitis 7 7,2
Pneumonia 66 70,9
NEC 4 4,3
RDS: Severe 8 8,6
Medium 36 38,7
Mild 18 19,4
IVH gr. I 16 17,2
IVH gr. II 12 12,9
IVH gr. III 2 2,1
PVL 2 2,1
47,3%
15%
16%
Results of psychological assessment using BSID III
at 2 years of corrected age, 93 infants
Test
Explanation Cognitiv Speech
Motor
function
Nr. % Nr. % Nr. %
>85 Norm 79 84,9 73 78,4 80 85,4
70-84 Development
delay
5 5,3 11 11,8 2 2,1
69 Severe
psychomotor
delay
9 9,6 9 9,6 11 11,8
Conclusions: at 24 month of corrected age mostly cognitive (14.9%) and
speech (21.4%) functions have been observed, 85.4% of examined
participants had normal neurological development.
Neurological disorders discovered at 12, 18 and 24
months
Nr. Pathology 12 months 18 months 24 months
abs % abs % abs %
1 Healthy 69 53% 83 63,8% 100 76,9%
2 Minimal brain dysfunction 25 19,2% 24 18,4% 13 10 %
3 Moderate disorders (of
muscle tone)
18 13,8% 7 5,3% 1 0,7%
4 Severe disorders 18 13,8% 16 12,3% 16 12,3%
--- Cerebral palsy 9 6,9% 10 7,6% 11 8,4%
---Hydrocephalus/
Ventriculomegaly
5 3,8% 3 2,3% 3 2,3%
5 ROP 2 1,5%
6 Partial atrophy of optic nerve 0 3 2,6% 3 3,2%
--- Microcephaly 1 0,7% 1 0,7% 1 0,7%
--- Psihomot. retard. 3 2,3% 2 1,5% 1 0,7%
Minimal and moderate dysfunctions discovered at 12,18 and 24 dynamically decrease
and by 2 years of corrected age transform into the norm in 76.9% of all cases. Severe
disorders discovered at 1 year stay unchanged by 2 years. Morbidities observed most
often: cerebral palsy, ventriculomegaly / hydrocephalus.
Conclusions • Survival of preterm neonates at ultimate vitality (over 26 weeks of
gestation) is low (~5,4% in 2005 and 42,7% in 2012).
• Development of national management standards for women with high risk of preterm labour and deeply premature newborns (from GA of 22-26 weeks) allowed to improve medical services quality, lower adverse effects including poor neurological outcomes for these neonates.
• In our study of neural development disorders we received the results comparable with other authors which were influenced by low number of infants with GA before 26 weeks.
• In terms of implementation of advanced technologies into resuscitation service and ELBW infants care, to establish Diagnostics and Monitoring System for high risk groups of infants is an important stage in supporting their psychomotor and somatic development.
• Integration of Follow-up centres into early intervention service will improve and diversify these services, while regionalization of Follow-up service will contribute to lower numbers of disabled children.