The course and support of sensorimotor development in a premature infant

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The course and support of sensorimotor development in a premature infant

Przebieg i wspieranie rozwoju sensomotorycznego dziecka urodzonego przedwcześnie

Agnieszka M. Zdzienicka-Chyła 1,2 (A,E,F), Krystyna Mitosek-Szewczyk ^{3 (A,E,F)}

1 Institute of Rehabilitation, Physiotherapy and Balneotherapy; Department of Rehabilitation and Physiotherapy, Faculty of Nursing and Health Sciences, Medical University in Lublin, Poland

2 Department of Physiotherapy, University Children’s Hospital in Lublin, Poland

3 Department of Neurology, Medical University of Lublin, Poland

Key words

premature infant, sensorimotor stimulation, rehabilitation Abstract

Introduction: Prematurely born babies account for nearly 7% of all infants coming into the world, and there are more and more extremely small premature babies being born. A report covering 184 countries shows that each year, 14.9 million children are born ahead of time. Maintaining life is the fi rst task faced by the medical service. The issue regarding development and the future of these children is the next stage of interest for both doctors and a number of specialists from related fi elds.

Aim: The aim of the study was to review literature concerning premature newborns in the fi eld of sensorimotor development within the fi rst years of life, taking into account the hazards and possible forms of early support. An attempt was made to present the current state of knowledge in the scope of recommended and used methods of conduct as well as to assess the long-term effects of undertaken interventions.

Methodology: A review of Polish-, English- and French-language literature was conducted, which concerned sensory motor development, introduction of early rehabilitation and support programmes for premature infants. Research papers and review works from the last 10 years included in databases (PubMed and websites of Polish medical publishing houses) were analysed.

The works were searched using the following keywords: premature baby, sensorimotor development.

Results and conclusions: The growing group of preemies requires adapted care. To counteract the indicated threats, a therapeutic intervention should be introduced precisely and in accordance with a child’s needs. There is a need to broaden knowledge about development in this group of children and to create a proven developmental support system that would be based on long-term research. Currently, support for babies born too early is heterogeneous, and the research carried out does not allow to design a single support model or clearly defi ned standards of conduct.

Słowa kluczowe

wcześniak, stymulacja sensoryczna, rehabilitacja Streszczenie

Wstęp: Noworodki urodzone przedwcześnie stanowią blisko 7% wszystkich urodzonych dzieci i przybywa dzieci urodzonych jako ekstremalnie małe wcześniaki. Raport obejmujący 184 kraje wskazuje, że każdego roku 14,9 miliona dzieci rodzi się przed czasem. Utrzymanie życia jest pierwszym zadaniem, które stoi przed służbą medyczną. Kwestia rozwoju i przyszłości tych dzieci to następny etap pozostający w kręgu zainteresowań zarówno lekarzy, jak i szeregu specjalistów z pokrewnych dziedzin.

Cel: Celem pracy było przeprowadzenie przeglądu piśmiennictwa dotyczącego noworodków urodzonych przedwcześnie w zakresie rozwoju sensomotorycznego w pierwszych latach życia, z uwzględnieniem występujących zagrożeń oraz możliwych form wczesnego wsparcia. Podjęto próbę przedstawienia aktualnego stanu wiedzy w zakresie zalecanych i wykorzystywanych metod postępowania, a także oceny długofalowych skutków podejmowanych interwencji.

The individual division of this paper was as follows: a – research work project; B – data col-lection; C – statistical analysis; D – data interpretation; E – manuscript compilation; F – publication search

Article received: 24 Jan. 2017; Accepted: 22 Nov. 2018

Please cite as: Zdzienicka-Chyła A.M., Mitosek-Szewczyk K. The course and support of sensorimotor development in a premature infant. Med Rehabil 2017; 21 (3): 64-69. DOI: 10.5604/01.3001.0011.6825

Wersja internetowa (pierwotna) / internet version (original): www.rehmed.pl

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should be subjected to monitoring until the corrected age of 2. Accord- ing to the guidelines of the NDT Bo- bath neurodevelopmental concept, age correction is recommended until the second year of a child’s life.

Generally, within the second year of age, the concept of corrected age is no longer used and the child’s development refers to the age of birth, however, opinions on this issue are ambiguous¹⁰. It is indicated that in some premature babies, certain functions, e.g. speech development, may be corrected even up to the age of 3¹¹.

SENSORY ASPECTS OF A PREMATURE INFANT’S DEVELOPMENT

According to currently adopted views, the development of an infant is a sensorimotor educational process¹². The child must be seen as a including respiratory failure, reti-

nopathy or thermoregulatory disorders⁴. About 15% of children born before the 26^th week of pregnancy with a weight of less than 1,000 g suffer from severe developmental disorders⁷. The need for interdisci- plinary support of premature babies to optimize their development is emphasized⁸. This is a special group of patients who, due to the disruption of physiological progress, often develop non-harmoniously and require special attention and aid.

BIRTH AGE AND CORRECTED AGE

In the process of assessment of children’s development and rehabilitation, it is advisable to relate developmental assessment to the corrected age and not to the actual age of birth until the child is at least 18 months old, and the child’s development INTRODUCTION

Until the end of the 19^th century, the time when neither the paediatrician nor the obstetrician joined in the care of a child during the neonatal period gained the name “no man’s land”¹. Currently, the neonatal period is an area where not only the midwife and the paediatrician are involved, but also, among others, a neonatologist, neurologist, physiotherapist, a speech therapist in neurology and psycho- logist.

The aim of the study was to review the literature concerning premature newborns in the fi eld of sensory and motor development during the preschool period, taking the hazards and indicated forms of intervention into account. A review of Polish-, English- and French-language literature was conducted, which concerned sensorimotor development and early rehabilitation of premature babies.

Neonates born ahead of time are currently close to 7% of all children coming into the world². They consti- tute a large and diverse group of children, therefore, the introduced division is according to age and weight at birth. The classifi cation is presented in Figure 1^3,4. The development of ne- onatology allows us to keep smaller and increasingly born children alive.

At the same time, shortening the du- ration of pregnancy correlates with the increase in the level of central nervous system coordination disorders⁵.

Figure 2 presents the results of research conducted in France – children born between the 24^th and 28^th week of pregnancy almost 2.5 times more often require specialist support within the fi rst 5 years of life than children born full-term⁶.

Due to high immaturity, premature newborns have many problems,

Metodyka: Przeprowadzono przegląd piśmiennictwa polskiego, anglojęzycznego i francuskojęzycznego, które dotyczyły rozwoju sensomotorycznego, wprowadzania wczesnej rehabilitacji niemowląt urodzonych przedwcześnie oraz wprowadzanych programów wspierania. Analizowano prace badawcze i przeglądowe z ostatnich 10 lat zamieszczone w bazach danych (Pub Med i stronach polskich wydawnictw medycznych). Prace wyszukiwano posługując się słowami kluczowymi: noworodek urodzony przedwcześnie, rozwój sensomotoryczny.

Wyniki i wnioski: Rosnąca grupa noworodków urodzonych przedwcześnie wymaga dostosowanej opieki. Aby przeciwdziałać wskazanym zagrożeniom, należy precyzyjnie i zgodnie z potrzebami dziecka wprowadzać interwencję terapeutyczną. Istnieje potrzeba poszerzania wiedzy na temat rozwoju tej grupy dzieci i wypracowania sprawdzonego systemu wsparcia rozwoju, który byłby oparty na długofalowych badaniach naukowych. Obecnie podejmowane wsparcie dla noworodków urodzonych przed czasem jest niejednorodne, a przeprowadzone badania nie pozwalają na stworzenie jednego modelu wsparcia albo jasno określonych standardów postępowania.

Figure 1

Classifi cation of babies born prematurely^3,4 Hbd (Latin habdominalis – week of pregnancy)

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vincial Integrated Hospital in Toruń indicated that from a group of 50 premature babies, 64% required rehabilitation within their fi rst two years of life. Psychomotor development ad- equate to corrected age was achieved by 86% of children at the age of 2, while children born before the 29^th week of pregnancy usually required constant doctor’s care and rehabilitation²⁶. The research conducted at the Specialist Rehabilitation Clinic for Children of the Provincial Hospital in Rzeszów on a group of 64 prematurely born children systematically undergoing rehabilitation showed that the early introduction of motor rehabilitation infl uenced the equal- ization of development defi cits during the fi rst half of the year. However, it is often emphasized in literature that children born pre-term require long- term observation²⁷.

It is recommended that the sup- portive procedure begin already during the stay at the neonatal pathol- ogy department by stimulation as part of the care, and in the case of indications, to start rehabilitation, e.g. using the Vojta method²⁸. Other methods of early stimulation include the NDT Bobath concept, the Kine- siology Taping method particularly useful for this group of children, and the Neonatal Behavioral Assessment Scale (NBAS) developed by T.B. Bra- are considered to be irritating from

3,500 to 4,200 times during the en- tire period of hospitalization²¹.

REHABILITATION OF PREMATURE INFANTS

Another important aspect is the introduction of stimulation or rehabilitation in a child born prematurely.

Numerous authors warn against over- rehabilitation and emphasize that it is not necessary for every prematurely child born to undergo rehabilitation.

On the other hand, the importance of early physical therapy, proper nursing and stimulation of the child’s development by parents has been increasingly appreciated in recent years²². The importance of parents’ education regarding the principles of proper care and stimulation as an important element of the treatment process is emphasized²³. For this reason, the

“Programme for early stimulation and developmental care of a newborn” was created, which was based on the assumptions of the NDT-Bo- bath²⁴ neurodevelopmental school of therapy.

The importance of early rehabilitation, emphasizing signifi cant benefi ts especially in patients with central nervous system damage, is underlined²⁵. The research conducted at the Pro- whole due to the indissolubility of

sensory and motor systems, and dis- turbances within one of these systems may affect the development of the second one¹³. Pre-term delivery and low birth weight are indicated as one of the main causes of sensory processing disorders¹⁴. According to the stance of the Polish Gynae- cological Society, “health is shaped from the early stages of individual life, so the physical and intellectual development of a child depends on the proper course of pregnancy and childbirth”¹⁵. In a child born prematurely, the fi rst sensations are often signifi cantly different than in a full- term newborn, and it is emphasized that the fi rst sensory experiences of the child, which arise through both touching and being touched, affect the development of the sensation of touch at later stages of life, motor development and the way of perceiv- ing the physical world¹⁶. Children staying at Intensive Neonatal Care Wards receive excess stimulation as- sociated with medical procedures, and too little gentle stimulation to support development. Research indicates that appropriate stimulation (in the form of a customized mas- sage, gentle continuous touch, kan- garoo care) conducted a few min- utes a day improves health (among others, improvement of saturation, increase in liveliness, weight gain, shortening hospitalization by an av- erage of 6 days)¹⁷. Numerous studies confi rm the positive effect of tactile stimulation on the development of premature babies; however, the study lacks information on adverse events during such interventions, as well as specifi c standards of such stimulation¹⁸. It is emphasized that the introduction of adapted tactile (both in the oral area and beyond) and kinaesthetic stimulation in premature babies infl uences building the food-feeding competence¹⁹.

It is also recommended to modify the child’s environmental charac- teristics, including light and noise intensity, exposure to aromas, tactile stimuli or changes in position²⁰. Premature babies born between 24 and 26 weeks of foetal life may be exposed to olfactory sensations that

Figure 2

Children requiring specialist support, taking age at birth into account Hbd − (Latin habdominalis – week of pregnancy)

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which was intended for children with very low birth weight (Infant Behavioral Assessment & Interven- tion Program – IBAIP). Within this programme, the child (from birth to 6 months) and their parents un- derwent 6 to 8 consultations at their place of residence with a specially trained physiotherapist. The parents received information on proper care and support of the child’s development on a constant basis. The children included in the programme achieved better prognosis in the fi eld of motor development⁴¹. Within the Polish (Wrocław) context, in the in- terdisciplinary scientifi c community (doctors, psychologists, pedagogues and physiotherapists), the idea of early diagnosis and therapy of children with developmental disorders was created (also addressed to the growing number of premature newborns) – the Wrocław Rehabilitation Model (WRM). The key elements of the programme are: sensory integration, speech stimulation, education of motor patterns and behaviours, as well as building independence and social development of an individual.

The foundation of this programme is also cooperation with parents and support from birth^43,44.

The importance of the early intervention programme as support for the whole family and not just the child itself, is necessary to focus on the parent-child relationship. Shap- ing the support programme in the family also brings functional benefi ts in terms of the child’s cognitive and motor development⁴⁵. Parents of newborns born prematurely are at risk of improper functioning as a mother or father due to the extremely intense emotions and situations that affect cognitive, emotional and social spheres⁴⁶. At the same time, family is a place where a child sati- ates physiological and psychological needs, and experiencing a safe relationship and adapted care creates the prospect of optimal development⁴⁷. Support provided to parents in the form of care and appreciation of their efforts will help them de- termine their place and give them some faith in their parental compe- tences⁴⁸.

measure in osteopenia³⁷. In children born before 32 weeks of gestation, there is a greater risk of developing symmetrical and asymmetrical skull deformities (compared to children born on time and to children born between 32 and 37 weeks of pregnancy), and therefore, it is necessary to prevent deformities already in the fi rst period of a child’s life at the hospital³⁸.

PROGRAMMES AND SYSTEMS SUPPORTING DEVELOPMENT Due to the perceived need for specialist care in children born prematurely, the “Newborn Individualized Developmental Care and Assessment Program” (NIDCAP) was created at Boston Children’s Hospital. This programme, which is undergoing mo- difi cations, is distributed not only within the United States of Amer- ica, but also in Europe and South America. The aim of the programme is to provide the child with optimal care and comfort (despite the introduction of medical procedures).

NIDCAP is both a philosophy and practice, where despite high immaturity, the newborn is an entity and cooperation with him/her and his/

her parents is the basis of the whole programme. The results of the study indicated that in relation to growth- weight parameters and psychomotor development, children undergoing the programme show more effi cient functioning^39,40.

As demonstrated by French experi- ments among prematurely born children and their families, an early-care programme is extremely important for parents as it reduces their level of anxiety and improves the relationship between the parents and child⁴¹. Proper care, feeding, carrying a newborn and fun in a proper way will not affect the relationship between mother and child and may be included in the physiological day schedule while becoming a great way to support and stimulate the development of a child⁴².

The University of Amsterdam exa- mined the impact of the early assessment and intervention programme, zelton, which enables diagnostic and

therapeutic interventions²⁹. NBAS is a valuable tool for both medical staff and parents, allowing assessment with regard to the personality of the newborn, its sleep and wake- fulness cycle and habituation skills³⁰. Prematurely born children can also be assessed using Prechtl’s method as a valuable complementary tool to classic neurological examination of a child³¹. It is indicated that neither the change of gravity after birth nor CNS maturation affect the occurrence of motor patterns assessed in this method, only global movements in premature babies may have higher ampli- tude and velocity³². In recent years, the introduction of OMT (Osteo- pathic Manipulative Treatment) tech- niques has been undertaken in work with prematurely born children, and, as the fi rst research results show, it causes, inter alia, a signifi cant reduc- tion in the time of hospitalization³³. The literature also presents the positive effects of music therapy observed in the studies (including regulation of heart rhythm, regulation of the suck- ing refl ex, shortening hospitalization period)³⁴. Some studies also indicate that music therapy reduces physiological and behavioural pain responses during and after blood collection³⁵. All physiotherapeutic interventions should be conducted in cooperation with a neonatologist and midwife in order to properly interpret the moni- tored functions so that the procedures are safe for the child³⁶.

Due to premature interventions in children, reduced bone density observed in this group of children and reduced mineral content are extremely signifi cant. About 10-12% of these children show cracks and frac- tures during the fi rst period of their lives. The introduction of physical stimulation and rehabilitation must be adapted to the child’s health con- dition. The bone mineral content in premature babies may be near proper parameters at approximately 12 months of age. However, as research shows, physical exercise in the form of passive exercise, performed ev- eryday as part of premature baby care, stimulates the synthesis of the bone matrix, becoming a preventive

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ment regarding the special needs required by this group, as well as the challenges faced when caring for the really little ones. In numerous publications, the authors point out that prematurity is not only a medical but also social problem. We also fi nd ex- amples of interventions supporting sensorimotor development of a premature infant. Nevertheless, there are still no unambiguous standards of conduct in their implementation.

Few studies are conducted in the long term and provide an opportu- nity to assess a child’s development in the context of specifi c interventions or improvement programmes, which would allow the development of the most effective models of support.

Confl ict of interest: none

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PREMATURE INFANTS AT PRESCHOOL AND EARLY- SCHOOL AGE

Today, research programmes focus on extending the observation period so that children born prematurely are not covered only by short-term studies, but refer to pre-, school-age, and even adulthood. The authors indicate that at school-age, children born with extremely low birth weight, have cognitive development disorders statisti- cally more often. Research carried out in the Małopolska area (including a group of 275 children with birth weight below 1,000g) carried out after children reached the age of 7 indicated non-harmonious development and reduced level of manual effi cacy⁴⁹. Studies carried out in the Tri- city on a group of 4 and 5-year-olds showed, among others, that children born prematurely more often than their peers born full-term presented not fully integrated asymmetrical and symmetrical tonic cervical refl ex, as well as a reduced level of labyrinth- visual coordination⁵⁰. Research on the development of premature babies at an early-school age indicated that in the group of children born prematurely or extremely prematurely, showed that there is a delay in speech development at the age of 6 in 30%, at the age of 9 in 45% (compared to 15% of 6-year-olds, and 16% of 9-year-olds born full-term)⁵¹.

CONCLUSIONS

In the presented publications, there is a limited amount of information per- taining to the quality of motor function of children born prematurely.

Few studies show the functioning of a prematurely born child with regard to various areas of development (e.g., gross motor skills, independence, per- ception). Performance and endurance in later life are also not assessed. At present, there are no explicit guidelines regarding the application of corrected age.

The development and use of support programmes in the group of premature newborns indicates high awareness of the medical environ-

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Address for correspondence Agnieszka Zdzienicka-Chyła

ul. Gościnna 11/15, 20-532 Lublin, Poland e-mail: agnieszka.zdzienicka@interia.pl tem of premature in fants. Osteopenia of pre-

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