De neuromotorische ontwikkeling van het matig premature kind Drs. Mathijs Binkhorst Kinderarts i.o. tot neonatoloog en Dr. Anjo Janssen Kinderfysiotherapeut

Inhoud Achtergrondinformatie Klinische problematiek Brein in ontwikkeling Risicofactoren Follow-up, motorische testen, ASQ Motorische ontwikkeling en kwaliteit bewegen Follow-up matig premature kind/Discussie Jeugdartsendag 27-01-2017

Achtergrondinformatie Extremely preterm (EPT) Very preterm (VPT) Moderately preterm (MPT) Term Postterm AD 24+0 – 25+6 26+0 – 31+6 32+0 – 36+6 37+0 – 41+6 ≥ 42 Aantal 265 1617 9694 152.416 2092 % 0.2 0.9 5.7 90 1.2 Perinatale sterfte (%) 59 17 1.8 Neonatale sterfte (%) 42 9.4 0.6 0.07 Opname (dagen) 62 ± 50 37 ± 29 13 ± 14 9 ± 9 7 ± 6 Perined. Perinatale Zorg in Nederland 2015. Jeugdartsendag 27-01-2017

Achtergrondinformatie Perined. Perinatale Zorg in Nederland 2015. Jeugdartsendag 27-01-2017

Achtergrondinformatie Perined. Perinatale Zorg in Nederland 2015. Jeugdartsendag 27-01-2017

Achtergrondinformatie Verschillen in definities MPT Toename percentage MPT Inleiding bij hoog-risico zwangerschappen Meer ‘assisted reproduction’ Levensstijl: later kinderen krijgen, obesitas Idee dat MPT niet nadelig is Morbiditeit Ademhaling & bloedsomloop Maag & darmen Infecties Stofwisseling Zenuwstelsel Andere termen gebruikt voor MPT: macropremies, mild preterm, near-term, late preterm (Proefschrift J. Kerstjens). Definitie MPT: ondergrens varieert van 32-34 weken, bovengrens van 34-37 weken (Proefschrift J. Kerstjens). WHO: extremely preterm (<28 weeks) very preterm (28 to <32 weeks) moderate to late preterm (32 to <37 weeks). Proefschrift J. Kerstjens 2013 Jeugdartsendag 27-01-2017

Klinische problematiek MPT Jeugdartsendag 27-01-2017

Extremely and very preterm infants Jeugdartsendag 27-01-2017

Term infants Jeugdartsendag 27-01-2017

Brein in ontwikkeling Jeugdartsendag 27-01-2017

Brein in ontwikkeling MRI Toename myelinisatie tot 35 jaar Key findings related to brain anatomical changes during childhood and adolescent are increases in white matter volumes throughout the brain and regionally specific inverted U-shaped trajectories of gray matter volumes. Brain morphometric measures are highly variable across individuals and there is considerable overlap amongst groups of boys versus girls, typically developing versus neuropsychiatric populations, and young versus old. 2006 MRI beelden tijdens de ontwikkeling gemaakt. Toename myelinisatie tot 35 jaar Jeugdartsendag 27-01-2017

Brein VPT: Meta-analyse Totale brein volume 0.58 SD lager dan à terme Gehele brein en niet specifieke regio’s Cerebellum effect size Cohens (d=0.74) Hippocampus (d=0.47) Corpus callosum (d=0.71) Corticale grijze stof (d=0.62) Witte stof (d=0.53) Groei vergelijkbaar met à terme Groei wel constant Mogelijke relatie met stoornissen Onderzoek uit Amsterdam. Uit deze meta-analyse blijkt dat tijdens de kindertijd en pubertijd het totale brein volume, de grijze en witte stof en diverse hersenstructuren significant kleiner zijn bij ex-very preterm infants ivm kinderen die voldragen waren. De Kieviet et al., DMCN 2012 Jeugdartsendag 27-01-2017

Netwerken brein beïnvloed door vroeggeboorte? Diffusion Tension Imaging (DTI) 4-jarige jongen The explanation for the exponential association between the risk of developmental delay and the number of weeks born too early might be found in the rapid growth of the brain during the third trimester of pregnancy. Between 24 and 40 weeks of gestation, cortical volume increases fourfold. This corresponds with increasing synaptogenesis, neuronal and axonal growth, myelination, and focused apoptosis, all leading to exponentially increasing brain connectivity. The conditions necessary for all the different maturational processes of the brain that lead to increased brain connectivity are more favourable in utero than after birth. Direct brain destruction caused by perinatal insults and maturational and trophic disturbances of normal brain development after preterm birth might be involved in the exponentially increasing risk of developmental delay. (Proefschrift J. Kerstjens, 2013). Spontane neurale activiteit brein MPT verminderd ten opzichte van a terme kinderen. Met name in de primaire sensorische en motorische schors. Oct;30(3):539-51. doi: 10.1007/s12640-016-9642-4. Epub 2016 Jun 17. Frequency of Spontaneous BOLD Signal Differences between Moderate and Late Preterm Newborns and Term Newborns. Wu X1, Wei L2, Wang N1, Hu Z1, Wang L1, Ma J1, Feng S1, Cai Y3, Song X3, Shi Y4. Abstract Little is known about the frequency features of spontaneous neural activity in the brains of moderate and late preterm (MLPT) newborns. We used resting-state functional magnetic resonance imaging (rs-fMRI) and the amplitude of low-frequency fluctuation (ALFF) method to investigate the frequency properties of spontaneous blood oxygen level-dependent (BOLD) signals in 26 MLPT and 35 term newborns. Two frequency bands, slow-4 (0.027-0.073 Hz) and slow-5 (0.01-0.027 Hz), were analyzed. Our results showed widespread differences in ALFF between the two bands; differences occurred mainly in the primary sensory and motor cortices and to a lesser extent in association cortices and subcortical areas. Compared with term newborns, MLPT newborns showed significantly altered neural activity predominantly in the primary sensory and motor cortices and in the posterior cingulate gyrus/precuneus. In addition, a significant interaction between frequency bands and groups was observed in the primary somatosensory cortex. Intriguingly, these primary sensory and motor regions have been proven to be the major cortical hubs during the neonatal period. Our results revealed the frequency of spontaneous BOLD signal differences between MLPT and term newborns, which contribute to the understanding of regional development of spontaneous brain rhythms of MLPT newborns. http://www.youtube.com/watch?v=ThO3FjxDx0Q Jeugdartsendag 27-01-2017

Ontwikkeling MPT Lang gedacht dat MPT niet tot nauwelijks at risk waren voor ontwikkelingsproblemen Recente studies laten zien dat MPT weldegelijk ontwikkelingsproblematiek kunnen hebben Problemen bij EPT en VPT vaak ernstiger, echter kleine groep kinderen (testen: ± 1220, 50% problemen ± 525 kk) Problemen bij MPT minder ernstig, echter veel grotere groep kinderen (screenen: ± 9460, 7% problemen ± 660 kk) Sociale en economische consequenties Proefschrift J. Kerstjens 2013 Jeugdartsendag 27-01-2017

Ontwikkeling MPT Recente epidemiologische studies vonden dat MPT i.v.m. à terme kinderen: Meer problemen hebben op de peuterleeftijd Minder ‘schoolbereidheid’ tonen Vaker doubleren in het reguliere onderwijs Vaker speciaal onderwijs nodig hebben Chyi et al., 2008; Van Baar et al.,2009; Huddy et al., 2001; Morse et al., 2009 Jeugdartsendag 27-01-2017

Risicofactoren MPT voor vertraagde ontwikkeling Dysmaturiteit Mannelijk geslacht Meerlingzwangerschap Maternale obesitas voor de zwangerschap Kerstjens J. et al., Obstet Gynecol. 2013 Jeugdartsendag 27-01-2017

Risicofactoren MPT voor vertraagde ontwikkeling Univariate analyse, gecorrigeerd voor SGA, AD en geslacht Hypoglycemie en asfyxie (niet strikt gedefinieerd) Multivariate analyse, gecorrigeerd voor SGA, AD en geslacht Hypoglycemie Onderzocht zijn: Apgar scores, asphyxia, tertiary NICU admission, hospital transfer, circulatory insufficiency, hypoglycemia, septicemia, mechanical ventilation, continuous positive airway pressure, apneas, caffeine treatment, and hyperbilirubinemia. Definitie asfyxie: in de conclusie van de ontslagbrief werd asfyxie genoemd. We found that the effects of SGA status and male gender were more important than all the neonatal morbidities we examined. Our study, therefore, does not support the view that neonatal morbidities have a large influence on developmental outcome in the group of moderately preterm-born children. Kerstjens J. et al., Pediatrics 2012 Jeugdartsendag 27-01-2017

Follow-up Landelijk protocol (LNF): jan 2015 Inclusie < 30 wkn en/of < 1000 g Uitgebreid protocol op 6, 12 en 24 mnd en 2 , 5 en 8 jaar Zeer wisselend per centrum uitgevoerd Radboudumc nu op 6 mnd en 2 jaar Steeds meer multidisciplinaire poli’s met kinderarts in perifere ziekenhuizen: Inclusie < 32 wkn en/of < 1500 g MPT kinderen (32-37 weken) worden niet standaard in 1e of 2e lijn gevolgd Jeugdartsendag 27-01-2017

Motorische testen Alberta Infant Motor Scale (AIMS) 0 – 18 mnd Bayley Scales of Infant Development-III (BSID-III-NL) Motorische Schaal 0 – 42 mnd Movement ABC-2 (MABC) 3 – 18 jaar Jeugdartsendag 27-01-2017

Verschil BSID-III USA---/NL Steenis et al., Plos one 2015 Jeugdartsendag 27-01-2017

Voorbeelden items BSID-III (motoriek) PDF/bestand van BSID-III-NL openen. Jeugdartsendag 27-01-2017

Ages and Stages Questionnaires-3 Screeningsinstrument Vragenlijsten voor ouders 21 leeftijdsversies 1 maand tot 5 jaar Invullen circa 10-15 min. Score berekenen 3 min. ASQ-3-NL nog niet gevalideerd The original ASQ has been proven to be reliable and cost-effective with excellent psychometric properties. Concurrent validity ranges from 76 to 88%. Overall sensitivity and specificity are 75% and 86%, respectively. In a recent multinational trial involving 18 countries in Asia, Africa, Europe, North- and South-America, sensitivity was 88% and specificity was 82.5%. Test–retest reliability within two weeks was 94% for the original version. Interobserver reliability between parents and professional examiners was 94%. (Kerstjens et al. 2009) Jeugdartsendag 27-01-2017

ASQ-3 Vijf domeinen, 6 vragen per domein Communicatie Fijne motoriek Grove motoriek Probleemoplossend vermogen Persoonlijke/sociale vaardigheden PDF van ASQ openen. Ook scoringstabel en adviezen voor verwijzing aan einde van de ASQ laten zien. Jeugdartsendag 27-01-2017

Voorbeelden ASQ-3 (motoriek) Jeugdartsendag 27-01-2017

Voorbeelden ASQ-3 (motoriek) Jeugdartsendag 27-01-2017

Ontwikkelingsproblemen op ASQ 43-49 mnd. 37% In Figure 1 we present the prevalence rates of abnormal ASQ total-problems scores by week of gestation. The prevalence rate of abnormal ASQ total-problems scores increased with decreasing gestational age below 36 weeks. Overall, the prevalence rate rose from 4.2% among term-born children to 37% among children born at 24 to 25 weeks’ gestation. The same pattern of increasing prevalence of developmental delay with decreasing gestational age from 36 weeks was reflected in the scores on all ASQ domains. Adjustment for covariates did not alter the pattern of exponential increase in developmental risk with decreasing gestational age. 2002 and 2003 Mean age 48 maanden is 4 jaar completed the Ages and Stages Questionnaire (ASQ) when their child was 43 to 49 months old. 4,2% Kerstjens et al., Dev Med Child Neurol 2012 Jeugdartsendag 27-01-2017

Ontwikkeling MPT: ASQ 43-49 mnd n = 512 EPT, n = 927 MPT, n = 544 fullterm infants MPT: met name problemen in fijne motoriek, communicatie en sociaal functioneren, dus niet in grove motoriek (univariate analyse) Kerstjens J. et al., J Pediatr. 2011 Jeugdartsendag 27-01-2017

Ontwikkeling MPT: ASQ 43-49 mnd Confounders Laag opleidingsniveau ouders Moeder niet in Nederland geboren Dysmaturiteit Mannelijk geslacht Meerlingzwangerschap Twee-ouder gezin (?!) Beinvloeden niet de exponentiele relatie Nota bene In groep MPT geen 36-37 weken en in à terme groep geen 37-38 weken Op kalenderleeftijd Correctie in het model van de confounders geen invloed Kerstjens J. et al., J Pediatr. 2011 Jeugdartsendag 27-01-2017

Ontwikkeling MPT: BSID-III-NL 2 jaar n = 116 MPT; n = 99 term Niet gecorrigeerd voor vroeggeboorte Cognitie ( 8.97 ± 2.11 vs 10.68 ± 2.35, p<0.001) Fijne motoriek (10.33 ± 2.15 vs 11.96 ± 2.15, p<0.001) Grove Motoriek ( 8.47 ± 2.55 vs 9.39 ± 2.80, p=0.05) Taalbegrip (10.09 ± 2.48 vs 12.02 ± 2.74, p<0.001) Taalproductie (10.33 ± 2.43 vs 11.49 ± 2.51, p=0.005) Echter, op gecorrigeerd leeftijd alleen voor Taalbegrip (11.05 ± 2.58 vs 12.02 ± 2.74, p=0.02) Meer internaliserende gedragsproblemen Arch Dis Child. 2015 Jun;100(6):548-53. doi: 10.1136/archdischild-2014-307016. Epub 2015 Jan 14. Behaviour and development in 24-month-old moderately preterm toddlers. de Jong M, Verhoeven M, Lasham CA, Meijssen CB, van Baar AL. Abstract OBJECTIVE: Moderately preterm children (gestational age 32-36+6 weeks) are at risk of cognitive and behaviour problems at school age. The aim of this study was to investigate if these problems are already present at the age of 2 years. STUDY DESIGN: Developmental outcome was assessed at 24-months (corrected age) with the Bayley-III-NL in 116 moderately preterm (M=34.66 ± 1.35 weeks gestation) and 99 term born children (M=39.45 ± 0.98 weeks gestation). Behaviour problems were assessed with the Child Behaviour Checklist. RESULTS: With age corrected for prematurity, moderately preterm children scored below term peers on Receptive Communication skills (11.05 ± 2.58 vs 12.02 ± 2.74, p=0.02). Without correcting age for prematurity, moderately preterm children scored below term born peers on Cognition (8.97 ± 2.11 vs 10.68 ± 2.35, p<0.001), Fine Motor (10.33 ± 2.15 vs 11.96 ± 2.15, p<0.001), Gross Motor (8.47 ± 2.55 vs 9.39±2.80, p=0.05), Receptive Communication (10.09 ± 2.48 vs 12.02 ± 2.74, p<0.001) and Expressive Communication (10.33 ± 2.43 vs 11.49 ± 2.51, p=0.005) skills. Compared with term peers, more moderately preterm children showed a (mild) delay (ie, scaled score <7) in gross motor skills with age uncorrected for prematurity (20.7% vs 11.2%, p=0.04). Moderately preterm children had more internalising behaviour problems than term children (44.76 ± 8.94 vs 41.54 ± 8.56, p=0.03). No group differences were found in percentages of (sub)clinical scores. CONCLUSIONS: At the age of 2 years, uncorrected for prematurity, differences in cognition, communication, and motor development were present in moderately preterm children compared with term born peers. After correcting age for prematurity, a difference was only found for receptive communication skills. In addition, moderately preterm children show more internalising behaviour problems. De Jong et al., Arch Dis Child. 2015 Jeugdartsendag 27-01-2017

Ontwikkeling MPT: 7 jaar n = 248 MPT, n = 130 term infants Neuropsychologische tests op de leeftijd van 7 jaar MPT vs. term infants significant lager(e) Totaal IQ Performaal IQ Visuospatiële vaardigheden Aandacht Inhibitie en executieve functies Geen verschil in verbaal IQ , verbaal geheugen en motorische ontwikkeling In our study, although their scores were in the normal range, the preterm children as a group scored 2.7 IQ points lower than full-term age-mates. The differences in performances between moderately preterm born and term-born children were only clinically relevant on measures of visuospatial reasoning and executive functioning. Pediatrics. 2012 Oct;130(4):e838-46. doi: 10.1542/peds.2011-2079. Epub 2012 Sep 3. Functioning of 7-year-old children born at 32 to 35 weeks' gestational age. Cserjesi R, Van Braeckel KN, Butcher PR, Kerstjens JM, Reijneveld SA, Bouma A, Geuze RH, Bos AF. Abstract OBJECTIVE: To compare neuropsychological functions in moderately preterm (32-35 weeks' gestation) and full-term children at the age of 7 years and identify gender differences. METHODS: Community-based prospective cohort study of 248 moderately preterm children (138 boys) and 130 full-term children (58 boys). Neuropsychological tests included IQ, memory, attention, visual perception, motor skills, visuomotor skills, and parental report of executive functioning. RESULTS: The moderately preterm group performed significantly worse on total and performance IQ, visuospatial reasoning, attention control, inhibition, and executive functioning. No differences were found in verbal IQ, verbal memory, and visuomotor and motor skills. Preterm children were at higher risk for scores <10th percentile on intelligence, visuospatial reasoning (relative risk ratio both: 1.69 [95% confidence interval: 1.29-2.28]), and executive functioning problems (relative risk: 1.94 [95% confidence interval: 1.51-2.57]). Using gender-specific norms, preterm boys performed significantly worse than full-term boys on visuospatial reasoning (P < .01); preterm girls performed significantly worse than full-term girls on visuospatial reasoning, intelligence, attention, and executive functioning (P < .05). CONCLUSIONS: Moderately preterm birth is associated with lower intelligence and poorer neuropsychological functioning at early school age. No differences in motor skills and verbal memory were found. Using gender-specific norms, our data suggest that moderately preterm boys catch up, whereas moderately preterm girls lag behind their peers on various neuropsychological functions by the age of 7 years. Cserjesi R. et al., Pediatrics 2012 Jeugdartsendag 27-01-2017

Ontwikkeling MPT: 7 jaar Bewijs voor slechte coördinatie: OR 1.41 (1.14-1.74) Hoger risico op CP: OR 6.38 (2.28-17.76) Echter, MPT kinderen die vaginaal geboren zijn, met goede groei en in goede conditie, dan verzwakken de associaties Dus antenatale, intrapartum en neonatale ‘causal pathways’ zijn van belang om kinderen te detecteren met een verhoogd risico. Acta Paediatr. 2013 Sep;102(9):876-82. doi: 10.1111/apa.12320. Epub 2013 Jul 12. Movement outcomes of infants born moderate and late preterm. Odd DE, Lingam R, Emond A, Whitelaw A. Abstract AIM: To investigate whether children born between 32 and 36 weeks of gestation have an increased risk of motor coordination difficulties or cerebral palsy (CP) at age 7 years. METHODS: A cohort study based on the Avon Longitudinal Study of Parents and Children (ALSPAC). The primary outcomes were poor motor coordination, defined as an ALSPAC coordination test score <5th centile or the presence of CP. Exposure groups were defined as moderate or late preterm (32-36 weeks of gestation) or term (37-42 weeks). Regression models were used to investigate the association between gestational age and outcomes. Multiple imputation was used to account for missing covariate data. RESULTS: In the fully adjusted model, there was strong evidence that children born at moderate or late preterm had worse coordination (OR 1.41 (1.14-1.74)) and higher risk of CP (OR 6.38 (2.28-17.76)) than term peers. However, restricting the analysis to well-grown infants born vaginally, in good condition, the associations attenuated substantially. CONCLUSIONS: Moderate or late preterm infants were at increased risk of developing coordination problems and cerebral palsy. After restricting the analysis to 'well' infants the associations of gestation with the coordination measures and CP reduced substantially, suggesting that antenatal, intrapartum and neonatal causal pathways are likely to be involved. Odd et al., Acta Paediatr. 2013 Jeugdartsendag 27-01-2017

Motorisch niveau VPT Cohort 1 Cohort 2 1996 / 2001 24 mnd. en 5 jaar 2003 / 2006 6, 12, 24 mnd. en 5 jaar Motoriek percentage At school age, 40% to 60% of early preterms have problems due to a lower IQ, and problems with visual-motor functioning, attention, memory, executive functioning, and gross or fine motor functioning Behavioral problems like ADHD also exist quite often These problems may occur singly, but quite often combinations of developmental and behavioral problems are present 50% to70% of early preterms have special educational needs at school The developmental problems of early preterms quite often deteriorate or the problems only emerge after they become older, when more difficult tasks are required of them Perceptie ouders klopt (motorische) ontwikkeling gaat langzamer maar het komt wel goed.

Meta-analyse VPT Geïncludeerd 41 studies: n = 9653 Laten een afname zien van het vertraagde motorisch niveau op de BSID-II in de eerste jaren Op de MABC en Bruininks-Oseretsky test een toename van de problemen met toename van de leeftijd Zet ouders op verkeerde been, het komt wel goed, maar net als ze denken dat ze er zijn, worden taken complexer en blijkt bewegen minder geautomatiseerd waardoor problemen JAMA. 2009 Nov 25;302(20):2235-42. doi: 10.1001/jama.2009.1708. Motor development in very preterm and very low-birth-weight children from birth to adolescence: a meta-analysis. de Kieviet JF, Piek JP, Aarnoudse-Moens CS, Oosterlaan J. Abstract CONTEXT: Infants who are very preterm (born < or = 32 weeks of gestation) and very low birth weight (VLBW) (weighing < or = 1500 g) are at risk for poor developmental outcomes. There is increasing evidence that very preterm birth and VLBW have a considerable effect on motor development, although findings are inconsistent. OBJECTIVE: To investigate the relationship between very preterm birth and VLBW and motor development. DATA SOURCES: The computerized databases EMBASE, PubMed, and Web of Knowledge were used to search for English-language peer-reviewed articles published between January 1992 and August 2009. STUDY SELECTION: Studies were included if they reported motor scores of very preterm and VLBW children without congenital anomalies using 1 of 3 established and widely used motor tests: the Bayley Scales of Infant Development II (BSID-II), the Movement Assessment Battery for Children (MABC), and the Bruininks-Oseretsky Test of Motor Proficiency (BOTMP). Forty-one articles were identified, encompassing 9653 children. RESULTS: In comparison with term-born peers, very preterm and VLBW children obtained significantly lower scores on all 3 motor tests: BSID-II: d = -0.88 (95% confidence interval [CI], -0.96 to -0.80; P < .001), MABC: d = -0.65 (95% CI, -0.70 to -0.60; P < .001), and BOTMP: d = -0.57 (95% CI, -0.68 to -0.46; P < .001). Whereas motor outcomes on the BSID-II show a catch-up effect in the first years of development (r = 0.50, P = .01), the results on the MABC demonstrate a nonsignificantly greater deficit with increasing age during elementary school and early adolescence (r = -0.59, P = .07). CONCLUSION: Being born preterm or VLBW is associated with significant motor impairment persisting throughout childhood. De Kieviet et al., JAMA 2009 Jeugdartsendag 27-01-2017

Voorspellen vertraagd motorisch niveau 50% normaal motorisch niveau op 2 jaar op de BSID-II/BSID-III 65% normaal motorisch niveau op 5 jaar op de M-ABC Meta-analyse VPT 12% verklaarde variantie voor later motor functioneren Early Hum Dev. 2013 Jul;89(7):487-96. doi: 10.1016/j.earlhumdev.2013.03.008. Epub 2013 Apr 15. Predictive value of the Bayley scales of infant development on development of very preterm/very low birth weight children: a meta-analysis. Luttikhuizen dos Santos ES, de Kieviet JF, Königs M, van Elburg RM, Oosterlaan J. Abstract BACKGROUND AND AIMS: The Bayley scales of infant development (BSID) is the most widely used measure to assess neurodevelopment of very preterm (gestational age ≤32 weeks) and very low birth weight (VLBW, ≤1500 g) infants in the first three years of life. This meta-analysis determines the predictive value of the mental developmental index (MDI) and the psychomotor developmental index (PDI)/motor composite, collectively referred to as Bayley motor scale, of the BSID-I, -II and Bayley-III for later cognitive and motor functioning in very preterm/VLBW children. METHODS: Cochrane Library, PubMed, PsychINFO and CINAHL were searched for English-language peer-reviewed studies published before March 2013. Studies were included if they reported odds ratios or correlations between the MDI or Bayley motor scale scores obtained in the first three years of life, and standardized cognitive or motor assessment obtained later in life in very preterm/VLBW children. Meta-analytic methods were applied to aggregate available data. RESULTS: A total of 16 studies met inclusion criteria. Across 14 studies (n=1330 children), MDI scores were strongly predictive for later cognitive functioning, r=0.61 (95% CI: 0.57-0.64), explained variance 37%, p<.001. The relationship between MDI scores and later cognitive function was not mediated by birth weight (p=.56), gestational age (p=.70), and time interval between assessments (p=.55). Across five studies (n=555 children), Bayley motor scale scores were moderately predictive for later motor function, r=0.34 (95% CI: 0.26-0.42), explained variance 12%, p<.001. CONCLUSIONS: In very preterm/VLBW children, MDI scores explain 37% of the variance in later cognitive functioning, whereas Bayley motor scale scores explain 12% of later motor function. Thus a large proportion of the variance remains unexplained, underlining the importance of enhancing prediction of developmental delay in very preterm children. Copyright © 2013 Elsevier Ltd. All rights reserved. Luttikhuizen dos Santos et al., Early Hum Dev. 2013 Jeugdartsendag 27-01-2017

Kwaliteit motoriek Wat observeren kinderfysiotherapeuten? Complexiteit ?? Variatie ?? Dissociatie ?? Timing ?? Isoleren ?? Vrijheidsgraden ?? Jeugdartsendag 27-01-2017

Kwaliteit bewegen preterm Meer extensie extremiteiten Na vroeggeboorte neemt flexietonus toe tot à terme leeftijd Echter flexietonus blijft minder dan bij à terme geboren kinderen Jeugdartsendag 27-01-2017

Kwaliteit bewegen preterm Alternerend hogere trappel frequentie benen maar kortere flexiefase (bij preterm < 30 wkn, echo brein g.a.) Lopen op lopende band meer extensie van benen tijdens standfase Fallang et. al. 2005 Jeugdartsendag 27-01-2017

Voorkeursrotatie hoofd preterm ≤30 Naar rechts 71% Matige tot ernstige voorkeur in 79% Met medische factoren geassocieerd Gerelateerd met matige fijn motorische coördinatie op 2 jaar Dus in tegenstelling tot à terme kinderen voorkeursrotatie hoofd bij prematuren indicatie om kinderen langer te volgen Early Hum Dev. 2016 May;96:53-60. doi: 10.1016/j.earlhumdev.2016.02.002. Epub 2016 Apr 8. Defining the nature and implications of head turn preference in the preterm infant. Dunsirn S, Smyser C, Liao S, Inder T, Pineda R. Abstract AIM: To determine the relationship of head turn preference in the preterm infant to: 1) perinatal medical factors, 2) neonatal neurobehavior, and/or 3) infant neurodevelopmental outcomes. METHODS: Seventy preterm infants born ≤30weeks gestation were enrolled at birth. Detailed information regarding neonatal intensive care unit (NICU) medical course was compiled for each infant. Neurobehavioral testing was performed during NICU hospitalization. Head turn preference was quantified at term equivalent age using a newly developed scale. Infants returned at age two years for standardized developmental testing. RESULTS: All infants demonstrated a head turning preference, with most preferring the right side (n=51, 77%). Fifty-five infants (79%) had moderate to severe head turn preference. Head turn preference was associated with 1) medical severity (hours of inotrope use, p=0.02; oxygen requirement at 36weeks postmenstrual age, p=0.03), 2) worse neurobehavioral performance (decreased self-regulation, p=0.007; more sub-optimal reflexes p=0.006), and 3) worse developmental outcome at age two years (poorer fine motor, p=0.02). INTERPRETATION: Medical factors in the NICU appear to be associated with the development of a head turn preference. Increased severity of head turn preference may be a marker for poor developmental outcome. Early identification may inform therapeutic interventions designed to minimize symptoms and optimize neurodevelopmental outcome. Dunsirn et. al. Early Hum Dev. 2016 Jeugdartsendag 27-01-2017

Kwaliteit bewegen preterm Fijne motoriek Tendens: 5 jaar snelle reiktaken, langzamer uitgevoerd (pen op Digitizer tablet). Tijd nodig zelfs langer dan bij à terme geboren van 3 jaar Klein doel 3 jarigen tendens naar meer gesegmenteerde minder vloeiend bewegen Jeugdartsendag 27-01-2017

Fijne motoriek Reiken op 4 mnd. minder succesvol, en grijpen minder variatie op 6 mnd. Relatie met coördinatie- en handvaardigheidsproblemen op 6 jr The results demonstrated that in preterm children without cerebral palsy, a lack of successful reaching at 4 mo and a nonoptimal quality of reaching at 6 mo are related to the development of a complex form of minor neurologic dysfunction (MND) and fine manipulative disability at 6 y. Thus, these early signs indicate the presence of clinically significant brain dysfunction. A relatively immobile postural behavior at 4 mo was associated with simple MND, coordination problems, and at 6 mo with a worse score on the Movement ABC and internalizing behavior. This suggests that a relatively immobile postural behavior points to a mild form of brain dysfunction. Fallang et. al. 2005 Jeugdartsendag 27-01-2017

3-D Traject van de hand Coördinatie van de gewrichtsrotaties tussen de schouder/elleboog (graden) Coördinatie van de dynamische torques tussen de schouder/elleboog (Nm/N) Jeugdartsendag 27-01-2017 41

Conclusies Kinderen met goede motoriek en kwaliteit van bewegen, zonder neonatale risicofactoren, vervolgen niet nodig/geen kft Kinderen met goede motoriek maar neonatale risicofactoren, blijven volgen en evt. wel kft Kinderen met atypische/afwijkende motoriek, kwantiteit en/of kwaliteit wel vervolgen en kft Voorkeurshouding voorbode van mogelijke motorische problemen Kwaliteit bewegen belangrijk Jeugdartsendag 27-01-2017

Discussie Wie volgt MPT? Grote aantallen kinderen JGZ Tot 4 jaar CB Daarna? Kinderarts Combinatie Met welke meetinstrumenten? ASQ, (18-42 mnd. beste sensitiviteit en specificiteit) Van Wiechenschema 9694 MPT kinderen in Nederland per jaar, verdeeld over 1282 CB’s, zou ongeveer 7-8 MPT kinderen per CB zijn. Steenis et al., Early Human Dev, 2015 Jeugdartsendag 27-01-2017

Vragen? Mathijs.Binkhorst@radboudumc.nl Anjo.Janssen@radboudumc.nl Jeugdartsendag 27-01-2017