Optimizing Growth and Development of

Preterm and low birth weight Infants

Dr. dr. Hesti Lestari SpA(K)

Bagian Ilmu Kesehatan Anak FK Unsrat-RSUP Kandou
Manado

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Outline
• Definition and prevalence of preterm
• Longterm developmental outcome of preterm
• Developmental Screening
• Evidence of early intervention for preterm infants

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DEFINITION & PREVALENCE
• Preterm is defined as babies born alive
before 37 weeks of pregnancy
• extremely preterm (less than 28
weeks)
• very preterm (28 to less than 32
weeks)
• moderate to late preterm (32 to 37
weeks)
• Low birth weight infant
• LBW <2500 gr
• VLBW <1500 gr
• ELBW < 1000 gr
https://www.who.int/
◦ An estimated 13.4 million babies were
born too early in 2020 - Of every 10 babies
born, 1 is preterm - and every 40 seconds,
1 of those babies dies
• In Indonesia, 779,000 babies are born too
soon each year
• The impacts of conflict, climate change,
COVID-19 are increasing risks for women
and babies
• Many survivors face a lifetime of disability,
including learning disabilities and visual
and hearing problems
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 CONSEQUENCES OF PRETERM BIRTH

Preterm babies → raises the • Continuous advances in medical

risk for physiologically technology mean that younger and
immature infants lighter babies can be saved
• Does this mean an increase in the
proportion of surviving babies who have
disabilities?

long – term complications

Adams CI, Amer R, Pierra et al. J.Pediatric. 2016.

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 Developmental processes
occurring in the human brain

• During fetal life and

the first two years
postnatally, the brain
shows strong
developmental
activity, the peak
occurs in the second
half of gestation and
three months post
term.

Hadders-Algra M. J Clin Med 2021. 5

 Changes in brain volume and
maturation with increasing gestational
age.
Kugelman A, Colin AA. Pediatrics 2013;132:741-751

Pertumbuhan otak, baik volume dan

terutama area permukaan korteks,
berlangsung pesat pada trimester
ke-3 gestasi

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Since 1990s:
Survival ↗
Mortality ↙
Disability steady

• More extreme
prematurity is associated
with greater risk
• As gestational age
increases, the risk of
significant disability
declines dramatically. Changes in outcome for babies born at 22-25 weeks’ gestation or less in
England in 1995 (EPICure) and 2006 (EPICure 2) cohorts.

Tamanna Moore et al. BMJ 2012;345:bmj.e7961 7

 OUTCOME HIGH-RISK INFANTS
• Depends on:
• medical risk factors → birth weight, gestational age, periventricular leukomalacia
(PVL), intraventricular haemorrhage (IVH), respiratory distress syndrome (RDS),
necrotising enterocolitis (NEC)
• Non-medical factors → social class, parental education, parenting style, parental
mental health, family structure, family functioning, home environment

• → needs growth & development monitoring

Doyle LW, Saigal S. NeoReviews. 2009; 10:359.

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 Risk of pretem babies
◉ Increased risk for developmental delays and disabilities
❖ Motor impairment and/or tone abnormalities
❖ Cerebral palsy
❖ Language and speech problems
❖ Learning delay or disability
❖ Borderline low-average intelligence quotients (IQs)
❖ Autism or autism spectrum disorders
❖ Attention-deficit hyperactivity disorders (ADHD)
❖ Specific neuropsychological deficits (ie, visual motor integration,
executive dysfunction)
❖ Behavior problems (ie, internalizing problems, social difficulties)

Fitzpatrick A. Peralta-Carcelen M, Kuban KC, et al. J.Pediatric. 2016.

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Early Identification and Detection

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How great the opportunity
Course of developmental delay over 2 years period in relation to
various prenatal and perinatal factors
Thomaidis L, et al. BMC Pediatr 2014:14;40

• Prematurity and IUGR were significantly related to the severity of

GDD
• Poorer 2-year developmental outcome was associated with IUGR, low
socioeconomic status and non compliance to habilitation
• Prompt identification combined with an early supportive
intervention strategy may have significant implications on the
long-term outcome of developmental disability

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Identify specific medical problems of the infants
◉ Feeding difficulties
◉ Severe infections
◉ Respiratory Distress Syndrome
◉ Jaundice
◉ Brain Injury (intraventricular hemorrhage)
◉ Necrotizing enterocolitis
◉ Retinopathy of prematurity
◉ Anemia of prematurity

Risk for Growth Impairment and Developmental delay

Fitzpatrick A. Peralta-Carcelen M, Kuban KC, et al. J.Pediatric. 2016. 12
 PSYCHOSOCIAL ISSUES OF PARENTS
◉ Bringing home a NICU graduate can be very challenging to
parents because of social, financial and psychological stresses
◉ Need to screen for these stressors
◉ Provide support services
o Early child intervention services
o Support groups
o Social work services

Fitzpatrick A. Peralta-Carcelen M, Kuban KC, et al. J.Pediatric. 2016.

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Early Identification of Developmental Disorders
• High developmental activities of the brain in the early life implies high
neuroplasticity, offers great opportunities for early intervention to
improve the child’s developmental outcome
• The most relevant clinical methods of early detection of developmental
disorders :
• Neuroimaging
• Neurological assessment
• Motor assessment
• Developmental assessment

Hadders-Algra M. J Clin Med 2021. 14

Neuroimaging
• The predictive value of neuroimaging focused on neonatal assessments
in infants with HIE and preterm infants.
• MRI is the gold standard in neonatal neuroimaging
• When neonatal MRI facilities are not available, use Cranial Ultrasounds
Hadders-Algra M. J Clin Med 2021
Annink KV. Pediatr Res 2022

• Indonesia :
• Skrining USG Kepala terutama bayi lahir <34 minggu atau
sesuai indikasi (sakit berat, trauma lahir dll)
• Minimal 1 kali selama perawatan atau sebelum rawat jalan,
atau sesuai indikasi klinis pemeriksaan dokter anak

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Developmental
monitoring
Algoritme pemilihan instrumen

(Dimodifikasi dan disarikan dari AAP 2001, 2006; Drotar, 2008) 16

 Corrected Age
• Corrected Age = Chronological Age – Prematurity
• Terms:
• chronological age <2 years
• length of prematurity> 2 weeks (calculated from 40 weeks' gestation)

The application of the corrected for preterm children less than 28 weeks,
the application of the corrected age can be up to the chronological age
of 3 years

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Kerangka Konsep Pemantauan
Tumbuh Kembang Balita dan
Anak Prasekolah
What assessment tools can help?
Surveilens Perkembangan dengan Buku KIA
usia
3 bulan

● Lakukan pemantauan
perkembangan dengan
ceklis ini
● Beri tanda Centang Ya atau
Tidak sesuai perkembangan
bayi anda

● Jika pada usia 3 bulan

bayi belum bisa melakukan
SALAH SATU dari ceklis,
segera bawa bayi ke
Puskesmas/fasilitas Kesehatan
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24
M-CHAT
Autism’s check list

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PEDS QL

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The Optimal Ages of Assessment
• < 1 year corrected : 3-4 and 6-8 months corrected age
• 12 months corrected age
• 18-24 months corrected age
• 3-4 years
• 6 years
• 8 years

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Vision and Hearing Screening
• High risk infants prone to retinopathy prematurity (ROP), visual
impairment, strabismus, visual field impairment.
• Hearing impairment prevalence in high-risk infants > 10-20 more
than normal infants

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ROP Screening
• Indonesia :
• Penapisan Retinopathy of Prematurity terutama bayi lahir
<34 minggu atau < 1500 gr atau sakit berat (sepsis, asfiksia)
• Minimal 1 kali sebelum rawat jalan, selambatnya usia koreksi
0 bulan, selanjutnya sesuai hasil pemeriksaan dokter
spesialis mata

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Hearing impairment Screening
• Indonesia :
• Penapisan Gangguan Pendengaran minimal sebelum bayi
dipulangkan, selambatnya sebelum usia koreksi 3 bulan

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 INFANTS HEARING SCREENING
Newborn > 24 hour, perform OAE before discharge

Pass/lulus Refer

3 months age : otoscopy,

tympanometry, distortion
product OAE, AABR

Risk factor (-) Risk factor (+) Pass/lulus Refer

Evaluation : audiology
No further Speech development and and ABR clicks +
evaluation audiology monitoring toneburst 500 Hz and/or
every 6 months for 3 ASSR
years
Habilitation before 6
Suwento R. KONAS PERHATI XIV. 2007. months age 31
Early Interventions

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Importance of Early Detection and Intervention
1. The prenatal events may have affected the infant’s
brain.
• Direct effect –a lesion of the brain, periventricular
leukomalacia or a cortical infarction
• Indirect effect -caused by the pain and stress related to
NICU

2. The early life has the highest potential to counteract

the negative sequelae because of the high plasticity
of the young brain
3. Family needs guidance and assistance to cope with
their preterm and to learn the behaviour of the infant
that may differ from infants with typical development

Spittle A, et al. Cochrane Database Syst Rev 2015; 11: CD005495. 33

Intervensi dini
1. Intervensi dini penyimpangan perkembangan tidak harus menunggu
diagnosis etiologi ditegakkan
2. Intervensi dini bersifat spesifik usia dan spesifik perkembangan.
3. Dilakukan secara intensif dan tepat. Petugas memberikan contoh
bentuk intervensi dini yang dilakukan oleh orang tua.
4. Intervensi dini bertujuan untuk mengurangi gejala dan meningkatkan
fungsi
5. Evaluasi hasil intervensi dini dalam waktu 2-4 minggu atau
selambatnya 4 minggu. Rujuk jika tahapan perkembangan sesuai
umur belum tercapai atau masih ada masalah yang muncul

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How is the evidence
• Early developmental interventions with a preventative focus improved
cognitive, behavior, and motor outcomes for infants born preterm.
• For those children or parents with a specific impairment, such as a child
with cerebral palsy or parent with significant post-natal depression,
targeted intervention programs are needed
• Early interventions to support parents’ mental health and parenting may
promote positive brain development processes and result in better
outcomes
• The effects of preterm birth are long term, and further intervention,
including possible “booster” sessions or special education support, maybe
required at school age

Spittle A, 2016. The role of early developmental intervention to influence

neurobehavioral outcomes of children born preterm 35
• Late preterm infants (34-36GA) compare to early term (37-38 GA) and
full term (39-40 GA)
• demonstrate comparable developmental outcomes at 24 months
• Less optimal reading outcomes at preschool and kindergarten
timepoints.

On going developmental surveillance for late preterm infants is

warranted into preschool and kindergarten.

Shah P et al Pediatrics 2016, 138 (2) DOI: https://doi.org/10.1542/peds.2015-3496

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• Children born VP
continue to display
language difficulties
compared with term
controls at 13 years of
age, with no evidence
of developmental
“catch-up.”
• Given the functional
implications associated
with language deficits,
early language-based
interventions should be
considered for children Language outcomes from 2 to 13 years of age for children
born VP born VP (open circles) and term controls (solid circles).

Thi-Nhu-Ngoc Nguyen et al. Pediatrics 2018;141:e20172831

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Involve the Family

• Family involvement in the routine care of preterm or low-birth-weigh infants in

health-care facilities is recommended
• Ensure the mother and family take the pivotal role in their baby’s care.
• Mothers and newborns should remain together from birth and not be separated
unless the baby is critically ill.
• Needs for improvements in family support including education and counselling,
peer support and home visits by trained health-care providers

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https://www.who.int/
 CONCLUSION
◉ Preterm infants are prone to have neurodevelopmental problem
◉ Families should be guided to comprehensive follow-up and early
intervention
◉ Close monitoring is needed to identify, stimulate/intervene to have
positive neurodevelopmental outcome

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