Features of early mental development of premature infants with critically low birth weight and perinatal central nervous system damage

Why is this happening?

Your baby was in a hurry to be born and was born ahead of schedule - what to do? First of all, don't panic. According to WHO statistics, in civilized countries, 9 out of 10 premature babies survive and subsequently develop successfully. And don't think it's just you: about 15 million babies are born prematurely every year, or about 1 in 10.

Of course, every woman who becomes an “early bird” mother is primarily concerned with why this happened.

The causes of prematurity are not fully understood, but several factors increase the chance of preterm birth:

• History of abortion or premature birth;
• Multiple pregnancy;
• Infection while expecting a baby;
• Preeclampsia;
• Placental abruption;
• Diabetes mellitus in mother;
• Hypertension and heart disease;
• Smoking and drinking alcohol during pregnancy;
• Poor maternal nutrition;
• Pregnancy at too young or late age.

Degrees of prematurity

Babies born before the 37th week of pregnancy, weighing up to 2500 g and height less than 45 - 47 cm are considered premature. Doctors distinguish four degrees of prematurity:

Babies born before 28 weeks are tiny and often weigh less than a kilogram. Externally, they are very different from ordinary newborns: they have thin skin of a red-violet color, and their entire body is covered with hairs (lanugo). Typically, such babies require artificial ventilation and intravenous nutrition. There is no need to be afraid of this: after gaining weight, the child will learn to suck on his own, and special medications will help his respiratory system mature. Expect that the baby will spend several weeks, or even months, in the hospital, but then he will develop without problems at home.

If the baby was born between the 28th and 31st weeks, he will also look like a small alien. But babies from the third group weigh a little more and are sometimes able to drink breast milk or formula through a tube. Some of them know how to cry and grab an adult’s finger, as well as move their arms and legs.

Babies born between 32 and 34 weeks look like miniature full-term babies. Most can breathe on their own, although they sometimes need supplemental oxygen. And some are able to suckle at the breast or bottle from birth.

According to statistics, children from the first group of prematurity (born at 35 - 37 weeks) end up at home the fastest. They have problems with thermoregulation and feeding, but otherwise they very quickly catch up with babies born at term.

Photo "Before and after"

For details on the features of caring for premature babies, watch the following video.

by Nata · October 19, 2015

Premature babies have to overcome many more difficulties on their way to adulthood than babies born at term. Their courageous struggle for life and will to overcome problems are truly admirable! That's why Quebec photographer Red Methot created a series of stunning portraits of premature babies immediately after their birth and several years later.

These portraits touch to the core. As a consequence of premature birth, such babies often have not fully developed internal organs, and they have to spend quite a long time in intensive care units, as a rule, until their organs are fully developed.

Nursing a premature baby: the first weeks

Not all children who are in a hurry to be born need special nursing. With a moderate degree of prematurity and good health, the child is discharged home a few days after birth, like his full-term peers.

But of course, most often the baby requires special care. It begins already in the delivery room: the baby is received in warm sterile diapers and all medical procedures are carried out on a heated table - keeping warm is especially important for a premature baby. From the delivery room the baby is transferred to the intensive care unit or intensive care unit. With a high degree of prematurity, the first days of life the child is in a special incubator that imitates the mother's womb.

The next stage is nursing the baby in the hospital department for premature babies. He will be transferred there when he can breathe on his own and eat through a feeding tube. Premature babies spend anywhere from a few days to a few weeks in the hospital, depending on their condition.

Premature babies

Prematurity is determined not so much by anthropometric indicators as by morphofunctional immaturity of vital organs and systems of the body.

Characteristic features of the respiratory system in premature infants are the narrowness of the upper respiratory tract, the high position of the diaphragm, the compliance of the chest, and the perpendicular position of the ribs relative to the sternum. These morphological features of premature babies cause shallow, frequent, weakened breathing (40-70 per minute), a tendency to apnea lasting 5-10 seconds (apnea of ​​prematurity). Due to underdevelopment of the elastic tissue of the lungs, immaturity of the alveoli, and reduced surfactant content, respiratory distress syndrome (congestive pneumonia, respiratory distress syndrome) easily occurs in premature infants.

Immaturity of the cardiovascular system is characterized by pulse lability, tachycardia 120-180 per minute, muffled heart sounds, arterial hypotension (55-65/20-30 mm Hg). In the presence of congenital heart defects (patent ductus Botall, patent foramen ovale), murmurs may be heard. Due to the increased fragility and permeability of vascular walls, hemorrhages easily occur (subcutaneous, in internal organs, in the brain).

Morphological signs of central nervous system immaturity in premature infants are poor differentiation of gray and white matter, smoothness of the sulci of the brain, incomplete myelination of nerve fibers, and poor vascularization of the subcortical zones. Muscle tone in premature babies is weak, physiological reflexes and motor activity are reduced, the reaction to stimuli is slow, thermoregulation is impaired, and there is a tendency to both hypo- and hyperthermia. In the first 2-3 weeks, a premature baby may experience transient nystagmus and strabismus, tremor, shuddering, and foot clonus.

Premature babies have functional immaturity of all parts of the gastrointestinal tract and low enzyme secretion activity. In this regard, premature babies are prone to regurgitation, flatulence, and dysbacteriosis. Jaundice in premature infants is more intense and persists longer than in full-term newborns. Due to the immaturity of liver enzyme systems, increased permeability of the blood-brain barrier and rapid breakdown of red blood cells, bilirubin encephalopathy can easily develop in premature infants.

Functional immaturity of the kidneys in premature infants leads to changes in electrolyte balance (hypocalcemia, hypomagnesemia, hypernatremia, hyperkalemia), decompensated metabolic acidosis, a tendency to edema and rapid dehydration with inadequate care.

The activity of the endocrine system is characterized by a delay in the formation of the circadian rhythm of hormone release and rapid depletion of glands. In premature infants, low synthesis of catecholamines is observed, transient hypothyroidism often develops, and a sexual crisis rarely occurs in the first days of life (physiological mastitis, physiological vulvovaginitis in girls).

Premature babies develop early anemia at a faster rate than full-term babies, and there is an increased risk of developing septicemia (sepsis) and septicopyemia (purulent meningitis, osteomyelitis, ulcerative necrotizing enterocolitis).

During the first year of life, the increase in body weight and length in premature infants occurs very intensively. However, according to anthropometric indicators, premature children catch up with their peers born at term only by 2-3 years (sometimes by 5-6 years). The lag in psychomotor and speech development in premature infants depends on the degree of prematurity and concomitant pathology. In a favorable scenario for the development of a premature baby, leveling occurs in the 2nd year of life.

Further physical and psychomotor development of premature infants may be on par with peers or delayed.

Neurological disorders are more common among premature children than among their full-term peers: astheno-vegetative syndrome, hydrocephalus, convulsive syndrome, vegetative-vascular dystonia, cerebral palsy, hyperactivity, functional dyslalia or dysarthria. Almost a third of premature babies have vision pathology - myopia and astigmatism of varying severity, glaucoma, strabismus, retinal detachment, optic nerve atrophy. Premature babies are prone to frequent repeated acute respiratory viral infections and otitis media, against which hearing loss may develop.

Women born prematurely often suffer from menstrual irregularities and signs of sexual infantilism in adulthood; they may be at risk of spontaneous abortion and premature birth.

Together with mom

For a premature baby, the presence of the mother is especially important. Today, many hospitals are equipped with “mother and child” wards, where you can be with your child around the clock, care for him, feed him and support him during various procedures. If this is not possible, try to make the most of the permitted visiting hours: talk to the baby, pick him up (when the situation allows), sing songs. This will help the child recover faster.

The kangaroo method is considered very useful - skin-to-skin contact between the mother and the baby. To do this, a naked baby is placed on the mother’s chest, positioned on his tummy in the “frog” position. You can start with 20–40 minutes twice a day, gradually increasing the duration of the session to several hours. In this case, it is necessary to control the baby’s body temperature: to keep warm, you need to cover it with a blanket on top and put a hat on its head. It has been proven that the kangaroo method works wonders: the baby’s sleep and wakefulness phases are normalized, breathing and blood circulation improve. Proximity to the mother's breast contributes to the development of normal reflexes of the newborn: sucking, swallowing and searching.

Psychological aspect

If your baby was born prematurely, you probably spend hours searching for information about how he will develop and how to help him. But try to stop for a second and think about your own mood and well-being. Most “hurried” mothers experience a huge feeling of guilt in front of their child, lack of self-confidence, and dissatisfaction with their body. Be sure to talk about your condition with your loved ones, because they are also scared and confused. Don’t be shy about asking your family for help, delegate as many household chores to them as possible, and get plenty of rest. If the baby is still in the hospital, gradually prepare a dowry for him and arrange a nursery: this will lift your spirits and give you confidence that you will soon be reunited with your little fighter.

Features of care

Babies born prematurely require special care. They are cared for step by step with the help of neonatologists and pediatricians, first in the maternity hospital, then in the hospital, and then at home under the supervision of specialists. The most important components of baby care:

• Ensure optimal temperature and humidity in the room.
• Carry out rational treatment.
• Ensure feeding adequate to needs.
• Provide contact with the mother using the kangaroo method.
• After discharge, limit contact with strangers.
• Bath and walk with the baby after the doctor's permission.
• Perform gymnastics with the baby and conduct massage courses after the permission of the pediatrician.

Some tips on how to avoid problems in the development of babies born prematurely are described in the video:

What to do if there are alarming symptoms?

If anything worries the mother, she should definitely seek medical help. A specialist will be needed when:

• The child's reluctance to breastfeed or eat from a bottle.
• Attacks of vomiting.
• Long-term jaundice.
• Constant loud crying.
• Stopping breathing.
• Severe pallor.
• Painful reaction of a child to sounds, sights or touches over the age of 1.5 months.
• Absence of a reciprocal gaze at the age of more than 2 months.

Here we are at home!

The baby will be discharged from the hospital as soon as he no longer needs constant medical supervision. Several more conditions must be met: stable weight gain, normal thermoregulation (the baby must maintain temperature without additional heating for 24 to 48 hours), the ability to feed independently (breast milk or formula). And most importantly, you must be able to care for your baby without outside help.

Here are some general tips to help during your first weeks at home.

• Remember the peculiarities of thermoregulation of premature babies. The room should not be too hot or too cold. The optimal temperature is 24 – 26 degrees. The room needs to be ventilated regularly; a humidifier won’t hurt either;
• Try to create soft lighting in your baby’s room and avoid harsh noise, because his nervous system has not yet matured;
• At first, you should not invite guests: for the baby this is additional stress and a potential source of infection;
• When bathing, you need to take into account the degree of prematurity: with moderate prematurity, you can wash the baby in the bath from the 7th to 10th day of life, with deep prematurity - from the 3rd to 4th week. To avoid drying out your baby’s thin skin, use special moisturizers and avoid soap;
• It is better to plan walks with a premature baby a week or two after discharge. If it’s not very cold outside, start with 10–15 minutes, gradually increasing the duration of “exercise” to an hour and a half a day.

results

The results of the examination using the GMDS-ER 2-8 scale [7] are given in table. 3.

Table 3. Age equivalent development on the GMDS-ER scale 2-8 in patients of groups 1 and 2 compared with controls Note. Significance of differences with the control group: * - p<0.05; ** — p<0.01.

GQ values ​​of neuropsychic development turned out to be statistically significantly lower in patients born with ELBW (73.4±2.1) compared to healthy ones (80.9±2.1; p

=0.036).
In the group of VLBW patients, GQ also tended to decrease and amounted to 73.1±3.0 ( p
=0.101). As for the lag from normal age indicators in a differentiated analysis in 6 areas, in the 1st group the decrease in indicators reached statistically significant differences in the subscales “motor activity” and “performing actions”, in the 2nd group - in the subscales “performing actions” , “practical thinking.” At the same time, no significant differences were found between the groups of patients born with ELBW and VLBW, either in GQ values ​​or assessments in all 6 areas.

GMDS-ER 2-8 scores were also analyzed for gender differences. At the same time, boys with ELBW and VLBW showed much lower results compared to controls than girls (see Table 3). In particular, the GQ values ​​of neuropsychic development were significantly lower (80.5±2.8) compared to the control group in boys with ELBW (70.5±3.4, p

=0.034) and VLBW (65.4±4.6,
p
=0.022). At the same time, male patients had significantly lower scores on the GMDS-ER scale 2-8, and a statistically significant decrease in scores was detected in group 1 on the “motor activity” and “speech” subscales, in group 2 - on subscales “speech”, “visual-motor coordination”, “practical thinking”.

Unlike boys born with ELBW, girls showed results that were less different from the corresponding indicators in healthy people. A statistically significant decrease in their scores was detected only on the “performing actions” scale. In girls born with VLBW, all indicators were close to those in the control group.

It should be noted that in the control group there were no significant differences between boys and girls in the indicators studied using GMDS-ER 2-8; There was only a tendency for boys to outstrip the development of skills on the “motor activity” subscale, and in girls - on the “performing actions” subscale.

In patients with ELBW, the value of the general GQ indicator in girls was higher than in boys, and at the same time, there was a tendency for boys to lag behind in the development of skills in 5 out of 6 areas (except for the area of ​​“performing actions”), although these differences did not reach a significant level.

Among patients born with VLBW, girls compared to boys showed statistically significantly higher results on the “speech” subscales ( p

=0.045), “hand-eye coordination” (
p
=0.011), “practical thinking” (
p
=0.009) and GQ (
p
=0.021). To some extent, this could be due to the uneven age distribution in group 2, where girls were 10.3 months older than boys. However, gender differences in scores, which reflect the age equivalent of development in areas in months, were more significant for the subscales: “speech” - 12.7, “hand-eye coordination” - 17.2, “practical thinking” - 13 ,2, GQ - 13.8.

These results suggest that premature boys born with ELBW and VLBW develop more severe cognitive and motor impairments compared to girls. This fact confirms the existence of previously described gender differences in the formation of perinatal lesions of the central nervous system and their consequences associated with the higher vulnerability of the developing brain of boys [8].

Since the values ​​of scores on the GMDS-ER scale 2-8 varied in the groups of children with ELBW and VLBW, it is important not only to analyze the average values, but also their individual assessment in the examined patients.

In 12 patients, a study using subscales of the GMDS-ER scale 2-8 revealed a general lag in neuropsychic development (the Z value for GQ was -2 and lower compared to age standards, which corresponds to a significant lag): 6 (16.7%) children in group 1, 6 (16.7%) in group 2. Of these, based on the results of a clinical examination and taking into account the results of testing using the GMDS-ER 2-8 scale, patients born with ELBW were diagnosed with general intellectual development retardation (2 girls), early childhood autism (1 boy, who also had cerebral palsy in the form of spastic diplegia), atypical autism (1 boy and 2 girls) were observed. Among 6 patients born with VLBW and having values ​​of the general GQ indicator below age standards, a general retardation of intellectual development was confirmed (1 boy with concomitant focal epilepsy and 4 girls, of which 1 with cerebral palsy in the form of spastic diplegia), early childhood autism (1 boy).

Cerebral palsy (spastic diplegia) without a general delay in intellectual development was observed in 3 boys of the 2nd group. Their GQ values ​​corresponded to the norm, although their scores on the subscales “motor activity” and “visual-motor coordination” were very low, and in 1, also on the subscale “performing actions.”

Attention deficit hyperactivity disorder (ADHD) was confirmed as the main diagnosis in 13 (36.1%) patients of the 1st group and 11 (30.6%) of the 2nd group. Among children with ADHD, there were no patients with GQ values ​​below normal, but for some they were in the “moderate delay” range (with Z values ​​from –1 to –2), including 4 boys in group 1, 2 boys and 1 girl in the 2nd group. At the same time, a moderate lag was determined in a number of patients with ADHD on the subscales “motor activity” (5 children in group 1, 4 in group 2), “personal-social” (3 and 2 in groups 1 and 2). groups, respectively), “speech” (5 in group 1), “hand-eye coordination” (7 and 5), “performing actions” (4 and 3), “practical thinking” (3 and 3).

High-functioning autism was observed in 5 (13.9%) patients in group 1 and 3 (8.3%) in group 2. Of these, the majority (5 children in group 1, 1 in group 2) had GQ values ​​in the “moderate lag” range (with Z values ​​from –1 to –2), as well as scores on the “motor activity” subscales "(4 and 3 - in the 1st and 2nd groups, respectively), "visual-motor coordination" (2 and 3), "performing actions" (4 and 3), "practical thinking" (4 - in 1- th group).

Many patients with ADHD and all children with high-functioning autism had clinical manifestations of static-locomotor deficiency (developmental dyspraxia), accompanied by low individual scores on the subscales “motor activity,” “visual-motor coordination,” and “execution of actions.”

Features of feeding

Breast milk is the best thing a mother can give to her baby born prematurely. Healthy babies with first degree prematurity are often put to the breast immediately after birth. A child born before the 33rd - 34th week will be fed through a tube, since he is still too weak to feed on his own. Sometimes feeding from a spoon, from a syringe or a special cup is used - these methods stimulate the sucking reflex.

At first, the baby will drink very little milk - only 2 - 5 ml every 2 hours. Subsequently, the volume will, of course, increase.

Try to avoid bottle feeding - this may interfere with natural feeding in the future.

Your task is to help the baby as much as possible by preserving the milk. Do not hesitate to ask the medical staff for help: let them teach you how to pump correctly, and then feed the baby and put him to the breast.

Complementary feeding for premature babies is introduced after at least six months, and sometimes later if the baby was born much earlier than the due date. A child’s first “human” food is usually porridge made with breast milk or formula: it promotes rapid weight gain.

How to catch up with peers?

This question worries any mother very much, but there is no need to worry too much: in the first year of life, the baby’s body is able to recover in record time. Of course, the child cannot do without your help, and one of the best methods is massage. It can be started when the baby’s weight reaches 2500 g: first simple stroking, then more intense movements. Be sure to consult with your pediatrician - he will show you special massage techniques.

Skills Comparison Chart

Sometimes experts also recommend infant swimming, water gymnastics and physiotherapy, but these procedures can only be carried out after consultation with a doctor. Of course, every mother wants her baby to develop “according to the books,” but, first of all, he needs time and your care. You'll see: by the age of two, your child will certainly catch up with his peers, and there will be no trace left of the difficult start.