Case in Progress
Salvador - Year 1
Salvador is a little boy of Hispanic descent who was born 13 weeks prematurely. His mother's pregnancy was notable for premature labor at 22 weeks due to a cervical cerclage. Two doses of antenatal steroids were given. Complications during labor and delivery included premature onset of labor and premature rupture of membranes. The baby was born by vaginal delivery under no anesthesia. At birth, Salvador weighed 0.813 kg. At this time the estimated length of gestation was 24 weeks, 4 days.
Immediately after delivery, Salvador was transferred to the neonatal intensive care unit, (NICU). Because of his extreme prematurity, he was suffering from respiratory distress and possible sepsis. His APGAR scores were 7 at 1 minute and 9 at 5 minutes, which is remarkably good for a baby of this significant prematurity. At this time it was determined that Salvador's gestation was more likely 26-27 weeks, rather than the 24 weeks previously thought.
Salvador's respiratory distress was taken care of with intubation from birth until January 20, five days short of two full months. On February 2nd he demonstrated increased respiratory distress and was reintubated. Salvador's development was noted for increased irritability and extension posturing.
Babies with extreme prematurity are at risk for many delays. One of the most notable is Retinopathy of Prematurity. Salvador's sight was followed very closely, and on March 3rd it was discovered that his sight had regressed in his left eye. A laser procedure was performed in which the nonvascularized retina was "burned" to create a more normal vascularization and increase sight. Salvador tolerated the procedure well.
Just prior to discharge from the NICU to home, Salvador had a hearing test that he had passed on his right ear, but his left ear needed further testing. Follow up was continuing with the pediatric ophthalmologist and progress with his sight was evident.
When Salvador was sent home from the hospital, his parents were told about Early Start services. It was recommended that Salvador begin an in-home therapy program as soon as possible to address developmental and possible delays.
Pediatric Services first assessed him on April 9, when he was chronologically 17 weeks old, but his adjusted age was 4 weeks. Salvador weighed 7 pounds, 12 ounces at this time. He had had an inguinal hernia repair 15 days earlier and had tolerated the procedure well.
At the adjusted age of 4 weeks, Salvador's perceptual/fine motor skills were at four weeks. He focused on faces and light, and kept his hands fisted.
His cognitive development was also at 4 weeks - he used adaptive movement rather than being bound by reflexive movements. His mother had been told not to let him bring his hands to his mouth, and it was explained to her that that is a developmental function that we wanted him to be able to do.
Salvador's communication skills were between 4 and 6 weeks - he moved his head, limbs and eyes in response to a voice, and he cried and cooed to get attention, and then would quiet himself. His social/emotional development was also at 4-6 weeks - he quieted when picked up and maintained brief eye contact.
In terms of adaptive/self-help development he was at 4-6 weeks - he appeared to have a coordinated suck/swallow/breathe. He was taking 4 2 ounces of formula every 2 hours and gaining weight in the acceptable range.
Gross motor skills and abnormal tone were our first major concerns. It was felt that because of the length of time that Salvador was intubated, he showed a strong preference to keep his head turned to one side. His neck musculature was tight and he greatly resisted turning his head to the other side.
Salvador also exhibited a great deal of extension throughout his body, making him a rather stiff baby, and not cuddly. His head was also in this extended position during feeding, which can be quite dangerous, making him prone to aspiration and pneumonia. Finally, Salvador was also a very irritable child and difficult to console. He preferred quiet, low light and minimal stimulation.
Initially when we began working with Salvador we focused on his gross motor skills and his ability to sustain attention. He had his hearing re-checked and it was determined that he had a mild general hearing loss. He was a good candidate for hearing aids and was scheduled to be fitted to increase his ability to hear low tones. Salvador was also fitted with glasses, which he was actually good about wearing in the beginning due to consistency of the parents in having him wear them. He continued to suffer from chronic lung/respiratory illnesses, and he used an in-home breathing apparatus (nebulizer).
Pediatric Services re-assessed Salvador at the chronological age of 11.5 months (8 months or 32 weeks adjusted age). Following the first six months of physical therapy Salvador was able to sit erect for up to five minutes, began to creep on the floor, and to stand holding on to furniture. These skills placed him solidly at 30 weeks for gross motor skills, with 50% of skills at 32 weeks.
In the area of cognitive skills, Salvador was solidly at 30 weeks, 90% at 32 weeks, and emerging at 36 weeks. He could remove a cube from a cup, overcome an obstacle to get a toy, and play with a variety of toys to produce different effects.
His fine motor and visual/perceptual skills were solidly at 36 weeks - Salvador could explore and manipulate an object with his fingers, and look toward an object, visually direct his reach and adjust it as necessary.
Salvador's communication skills were solid at 24 weeks, but emerging between 28-32 weeks. He had not received his hearing aids at the time of the assessment, and it was felt that this had some influence on his communication. Both he and his parents had begun to use simple signs for communication.
Salvador had done very well in the area of self-care - he had begun to eat mashed table foods, which he loved, and was chewing with a rotary motion.
Salvador physical health remained fragile and was very compromised in the following months. Children of his significant pre-maturity often suffer from continued respiratory problems, and this was the case with Salvador.
Come back next month to see how Salvador continues to progress in the next year.
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