Optimizing neurodevelopment in severe bronchopulmonary dysplasia

Increased survival of premature infants with severe bronchopulmonary dysplasia (BPD) has led to new challenges in optimizing both clinical management and neurodevelopmental outcomes. Numerous studies have shown a strong association between severe BPD and neurocognitive dysfunction at follow-up. Data demonstrate substantial differences between similar centers within the same neonatal network in the United States. Presumably, variations in outcome are related to differences in care practices, which suggests that improvements in care practices could result in improvement in respiratory and/or neurocognitive outcomes. Emerging questions regarding optimal management include the following: 1) What is the optimal respiratory strategy? 2) What is the optimal timing for undergoing tracheostomy placement? 3) What is the best way to address comfort needs? 4) What is the optimal environment for promoting neurodevelopmental progress? Here we discuss the benefits of achieving and maintaining a progrowth, prodevelopment state in infants with severe BPD. It is increasingly clear that growth and development overlap considerably, and each are related to a number of physiologic, nutritional, and environmental factors. A progrowth, prodevelopment state is best reached by achieving a complex balance of adequate respiratory support, consistent oxygenation, and positive, age-appropriate social and developmental experiences. Moreover, optimal management is achieved by minimizing pain and stress, inflammation, infection, and medications that suppress lung and brain growth. Because the care of these infants is chronic and progressive, it is important to use an interdisciplinary team model, with consistent feedback loops to monitor and maintain these goals.