Developmental Monitoring: do 28-29 weekers deserve close monitoring? Debbie Paris Specialist Physiotherapist Aneurin Bevan University Health Board October 2014

Background Physiotherapists are experts in age appropriate movement and postural control, allowing early identification of gross motor dysfunction and optimisation of brain development…. (BAPM, 2010) National guidelines state neonatal units should have access to physiotherapists for neurodevelopmental, orthopaedic, respiratory, and follow up roles (All Wales Neonatal Standards 2013; NHS & Department of Health, 2009; BAPM, 2010). But….the amount of input required to provide sufficient quality of care has not been ascertained and provision of services varies greatly. The evolution of medicine has seen survival of preterminfants increase to 66% (EPIcure, 2001-2011), and with this comes additional medical and developmental sequelae. A study of infants (n=810) born at <25 weeks gestation demonstrated that upon reaching one year of age 18% had developmental problems and 17% had neurological impairments (EPIcure, 2001-2011). At 30 months of age a larger proportion of infants (51%) had a disability of which 22% were classified as ‘severe’ (Wood et al, 2005). With early and timely physiotherapy intervention the problems associated with an immature nervous system can be addressed (Symington and Pinelli, 2001) to improve functional outcomes in later childhood (Blackman, 2002; Gardner, 2005).

Developing Referral Criteria Physiotherapy Review – (Eldridge, 2011) Consensus <30 weeks gestation <1200g birth weight IVH grade III/IV, PVL HIE II or III IUGR <2nd centile CLD/home O2 Persistent neurological signs, abnormal posturing/tone, any condition/syndrome affecting GM development These babies are reviewed by PT until walking

Service Review Would reducing referral criteria to <28 weeks decrease referral numbers, but remain as clinically effective? Parental Feedback

Method All babies referred 2011-13 routinely reviewed at 1 yr corrected age (CGA) Babies with emerging neurological or significant developmental delay (<5th percentile Alberta Infant Motor Scale) requiring regular Physiotherapy, were identified Anonymous Parental Feedback questionnaires distributed

Results n=128 Gestation No. Babies 23-27+6 wks 49 28-29+6 wks 41 13 38-42 wks 25

Cerebral Palsy 14%

Results 17 diagnosed with Cerebral Palsy 8 of whom were 28-29+6 weeks GA 6 of those would not have been identified as ‘at risk’ (from CUSS, <1200g birth wt or CLD) 29 had significant motor delay 5 of whom were 28-29+6 weeks GA 2 of those would not have been identified as ‘at risk’

Gestation and Input Received

Parental Feedback 13 of 15 forms returned (CGA 12.7, range 6-18.5 months) 100% rated service as Helpful to understand motor development Advice given useful Appt frequency ‘about right’

Comments included…. ..like to say how fantastic I have found service, help for my daughter has been wonderful, as well as advice and support for me, forever grateful this service has been absolutely vital to my daughter and our family …overall this service has been invaluable, very grateful to personal service we received...to know your children are progressing and understand their development is key as parents, very helpful tips and exercises to aid development … correct information and advice needed to keep us on track with his development.. …offers advice on how child should be developing….keeps you understanding where your child should be in developmental status….gives you advice so all these things can be constructive   … sessions extremely valuable, specific exercises helped her development… supported and relieved my anxieties surrounding development, as well as providing strategies on how to promote developmental milestones …gave me such reassurance knowing physical development being closely monitored and I could seek advice about his development play ideas. Thank you for a great service!

Conclusions Service Aim - early identification and more importantly early therapy input Service Review shown - 13 babies (8 with CP) may not have received early intervention if referral criteria revised to <28 wks Service highly valued by parents