Daphna Yasova Barbeau, MD

We're continuing on today with our life course perspectives. We are joined in the studio by some psychiatry experts. So lovely to have more mental health professionals on this podcast. Today we have Dr. Richard Shaw, professor in the division of child psychiatry at Stanford, and Dr. Soudabeh Givrad, also professor in the division of child psychiatry at Weill Cornell Medical College. Welcome to both of you.

Richard Shaw

Thank you.

Soudabeh Givrad

Hi, we're happy to be here.

Daphna Yasova Barbeau, MD

Now your article is entitled “Neurodevelopmental Mental Health and Parenting Issues in Preterm Infants.” Such an important topic. I'm so glad that this was included. I think that the community is starting to understand how mental health impacts the NICU admission. I love how you’ve broken this up into kind of bite-sized sections so that we can really dive deep into the problem at hand.

The first section really talks about how, as our mortality outcomes have improved over time, we're finally shifting the outcomes to things like neurodevelopment. So I’ll start maybe with you, Dr. Givrad. Tell us a little bit about the biggest challenges faced in terms of development for children born preterm.

Soudabeh Givrad

Sure. We know that toward the end of gestation, there is a very rapid growth in the brain, and for preterm children, they face challenges when they're born earlier in terms of some of this brain development. There can be stressors from procedures, pain, and separation from parents, and the NICU environment can all affect them. In some sense, they’re more vulnerable to environmental and biological factors. Depending also on some of the medical comorbidities that they might have or challenges that they face, these all can impact neurodevelopment.

The first two years of life are when there’s very rapid neurodevelopment happening in the brain, and that development is really dependent on the environment and the inputs the child’s brain receives. All of that creates more vulnerability for some of the neurodevelopmental outcomes. Research is not always homogeneous, but we do see issues in terms of motor, language, and cognitive development, not in every child who’s born prematurely, but more so than in children who are born full term.

These outcomes are affected by various factors such as parenting, ongoing medical issues, and interventions. Some children experience delays or ongoing problems, but we don’t always know the long-term outcomes because many studies have focused only on early childhood. It would be important to look longitudinally to see what might be missing in longer-term outcomes for these children.

Daphna Yasova Barbeau, MD

I think we sometimes forget that even when we have this critically ill baby in the NICU, the brain is still growing and developing. It's not like an adult patient in the ICU. The brain is laying down connections all the while we’re doing these painful procedures, high-frequency ventilation, and there’s separation from parents. I think one of the good things you highlight is that we have an opportunity to impact them positively if we consider that every interaction we have with the baby is part of what’s being laid down in their brains. I think that’s so exciting. Dr. Shaw, what were you going to say?

Richard Shaw

I agree with Dr. Givrad. One thing I might add, which has become a topic of recent interest nationally, is delirium in premature infants in the NICU. There used to be a belief that very young children couldn’t feel pain; we now know that’s not true. Until relatively recently, people didn’t even recognize that infants might, because of the medications they’re on and their medical issues, become confused or disoriented, or even have experiences of seeing or hearing things. The focus now is really on trying to understand the infant experience.

Daphna Yasova Barbeau, MD

I love that. I do want to highlight some of the problems specifically. In the article, we see that cognitive disabilities represent the most common neurodevelopmental impairment, including difficulties in executive function, language processing, and working memory. Rates are higher in extremely preterm infants, with a pooled prevalence of 29% in recent studies, and 10.9% being moderate or severe. Very preterm children show a 14% rate of cognitive impairment, with about 6% being moderate to severe.

You highlight that motor disturbances are among the earliest described and may encompass cerebral palsy and movement disorders. Thankfully, the rates of cerebral palsy are falling, but still persist at about 7% in preterm children. They’re also at increased risk for poor outcomes in language. I wanted to make sure we listed those specifically.