Functional Ophthalmic Factors Associated With Extreme Prematurity in Young Adults

IMPORTANCE

Children born preterm (<37 weeks' gestation) have a higher risk of visual impairment and ocular morbidities compared peers born at full term. However, the long-term ocular sequelae in adulthood for those born extremely preterm (EP), who have the highest risk of neonatal retinopathy, are unknown.

OBJECTIVE

To evaluate visual function and ocular morbidity in young adults born EP compared with controls born full term.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study of a geographically based birth cohort in the UK and Ireland born from March 1 through December 31, 1995, included 128 participants aged 19 years (born at 22-25 weeks' gestation) and 65 age-matched controls born at full term. Statistical analysis was performed from March 1, 2020, to November 26, 2021.

EXPOSURES

Participants underwent eye examinations as part of a comprehensive outcome evaluation.

MAIN OUTCOMES AND MEASURES

Best-corrected visual acuity, refractive status, contrast sensitivity, color vision, prevalence of strabismus and nystagmus, and patient-reported visual function, measured using the Health Utilities Index Mark 3.

RESULTS

The study comprised 128 participants (256 eyes; 68 female participants [53%]; mean [SD] age, 19.3 [0.5] years) and 65 age-matched controls born at full term (130 eyes; 40 female participants [62%]; mean [SD] age, 19.2 [0.5] years). Compared with control eyes, the mean (SD) best-corrected visual acuity among eyes in the EP group was significantly worse (monocular vision: -0.06 [0.14] logMAR in the control group vs 0.14 [0.38] logMAR in the EP group; P < .001; binocular vision: -0.14 [0.15] logMAR in the control group vs 0.06 [0.37] logMAR in the EP group; P < .001). Participants in the EP group had a significantly higher prevalence of strabismus (36% [46 of 127] vs 0%; P < .001), abnormal ocular motility (15% [19 of 125] vs 0%; P < .001), and nystagmus (13% [16 of 127] vs 0%; P < .001) than the control group. No significant differences between participants in the EP group and controls were observed for refractive error, contrast sensitivity, color vision, or patient-reported visual function. Among the participants in the EP group, 48% of eyes (120 of 250) had no retinopathy of prematurity (ROP), 39% (98 of 250) had ROP not requiring neonatal treatment, and 13% (32 of 250) received cryotherapy or laser ablation for ROP. Within the EP group, there was no significant difference in binocular visual function parameters, prevalence of ocular morbidity, and patient-reported visual function by neonatal ROP status.

CONCLUSIONS AND RELEVANCE

Extreme prematurity is associated with an increased prevalence of visual and ocular deficits in young adulthood; this study suggests that, for individuals born EP, visual and ocular deficits appear to be partially independent of ROP status in the neonatal period but reports similar overall visual function.

Birth outcomes between 22 and 26 weeks' gestation in national population-based cohorts from Sweden, England and France

AIM

We investigated the timing of survival differences and effects on morbidity for foetuses alive at maternal admission to hospital delivered at 22 to 26 weeks' gestational age (GA).

METHODS

Data from the EXPRESS (Sweden, 2004-07), EPICure-2 (England, 2006) and EPIPAGE-2 (France, 2011) cohorts were harmonised. Survival, stratified by GA, was analysed to 112 days using Kaplan-Meier analyses and Cox regression adjusted for population and pregnancy characteristics; neonatal morbidities, survival to discharge and follow-up and outcomes at 2-3 years of age were compared.

RESULTS

Among 769 EXPRESS, 2310 EPICure-2 and 1359 EPIPAGE-2 foetuses, 112-day survival was, respectively, 28.2%, 10.8% and 0.5% at 22-23 weeks' GA; 68.5%, 40.0% and 23.6% at 24 weeks; 80.5%, 64.8% and 56.9% at 25 weeks; and 86.6%, 77.1% and 74.4% at 26 weeks. Deaths were most marked in EPIPAGE-2 before 1 day at 22-23 and 24 weeks GA. At 25 weeks, survival varied before 28 days; differences at 26 weeks were minimal. Cox analyses were consistent with the Kaplan-Meier analyses. Variations in morbidities were not clearly associated with survival.

CONCLUSION

Differences in survival and morbidity outcomes for extremely preterm births are evident despite adjustment for background characteristics. No clear relationship was identified between early mortality and later patterns of morbidity.

Psychiatric disorders in individuals born very preterm / very low-birth weight: An individual participant data (IPD) meta-analysis

BACKGROUND

Data on psychiatric disorders in survivors born very preterm (VP; <32 weeks) or very low birthweight (VLBW; <1500 g) are sparse. We compared rates of psychiatric diagnoses between VP/VLBW and term-born, normal birthweight (term/NBW) control participants.

METHODS

This individual participant data (IPD) meta-analysis pooled data from eligible groups in the Adults born Preterm International Collaboration (APIC). Inclusion criteria included: 1) VP/VLBW group (birth weight <1500 g and/or gestational age <32 weeks), 2) normal birth weight/term-born control group (birth weight >2499 g and/or gestational age ≥37 weeks), and 3) structured measure of psychiatric diagnoses using DSM or ICD criteria. Diagnoses of interest were Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Disorder (ASD), Anxiety Disorder, Mood Disorder, Disruptive Behaviour Disorder (DBD), Eating Disorder, and Psychotic Disorder. A systematic search for eligible studies was conducted (PROSPERO Registration Number 47555).

FINDINGS

Data were obtained from 10 studies (1385 VP/VLBW participants, 1780 controls), using a range of instruments and approaches to assigning diagnoses. Those born VP/VLBW had ten times higher odds of meeting criteria for ASD (odds ratio [OR] 10·6, 95% confidence interval [CI] 2·50, 44·7), five times higher odds of meeting criteria for ADHD (OR 5·42, 95% CI 3·10, 9·46), twice the odds of meeting criteria for Anxiety Disorder (OR 1·91, 95% CI 1·36, 2·69), and 1·5 times the odds of meeting criteria for Mood Disorder (OR 1·51, 95% CI 1·08, 2·12) than controls. This pattern of findings was consistent within age (<18 years vs. ≥18 years) and sex subgroups.

INTERPRETATION

Our data suggests that individuals born VP/VLBW might have higher odds of meeting criteria for certain psychiatric disorders through childhood and into adulthood than term/NBW controls. Further research is needed to corroborate our results and identify factors associated with psychiatric disorders in individuals born VP/VLBW.

FUNDING

Australia's National Health & Medical Research Council; CAPES (Coordenação de Aperfeiçoamento de Pessoal deNível Superior) - International Cooperation General Program; Canadian Institutes of Health Research Team Grant; National Council for Scientific and Technological Development (CNPq); Academy of Finland; Sigrid Juselius Foundation; Signe and Ane Gyllenberg Foundation; European Union's Horizon 2020 research and innovation programme: Project RECAP-Preterm; European Commission Dynamics of Inequality Across the Life-course: structures and processes (DIAL); Neurologic Foundation of New Zealand; MRC programme grant; Health Research Council of New Zealand; National Institutes of Health, USA; The Research Council of Norway; Joint Research Committee between St. Olavs Hospital and Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU); Liaison Committee between Central Norway Regional Health Authority and NTNU.

Social Functioning in Adults Born Very Preterm: Individual Participant Meta-analysis

CONTEXT

There is a lack of research on individual perceptions of social experiences and social relationships among very preterm (VP) adults compared with term-born peers.

OBJECTIVE

To investigate self-perceived social functioning in adults born VP (<32 weeks' gestation) and/or with very low birth weight (VLBW) (<1500g) compared with term-born adults (≥37 weeks' gestation) using an individual participant data (IPD) meta-analysis.

DATA SOURCES

Two international consortia: Research on European Children and Adults born Preterm and Adults Born Preterm International Collaboration.

STUDY SELECTION

Cohorts with outcomes assessed by using the Adult Self-Report Adaptive Functioning scales (friends, spouse/partner, family, job, and education) in both groups.

DATA EXTRACTION

IPD from 5 eligible cohorts were collected. Raw-sum scores for each scale were standardized as z scores by using mean and SD of controls for each cohort. Pooled effect size was measured by difference (Δ) in means between groups.

RESULTS

One-stage analyses (1285 participants) revealed significantly lower scores for relationships with friends in VP/VLBW adults compared with controls (Δ -0.37, 95% confidence interval [CI]: -0.61 to -0.13). Differences were similar after adjusting for sex, age, and socioeconomic status (Δ -0.39, 95% CI: -0.63 to -0.15) and after excluding participants with neurosensory impairment (Δ -0.34, 95% CI: -0.61 to -0.07). No significant differences were found in other domains.

LIMITATIONS

Generalizability of research findings to VP survivors born in recent decades.

CONCLUSIONS

VP/VLBW adults scored their relationship with friends lower but perceived their family and partner relationships, as well as work and educational experiences, as comparable to those of controls.

Factors influencing perinatal outcomes in women with preterm preeclampsia: A secondary analysis of the PHOENIX trial

This secondary analysis of the PHOENIX trial (evaluating planned delivery against expectant management in late preterm preeclampsia) demonstrates that in women who started induction of labour, 63% of women delivered vaginally (56% at 34 weeks' gestation). Compared to expectant management, planned delivery was associated with higher rates of neonatal unit admission for prematurity (but lower proportions of small-for-gestational age infants); length of neonatal unit stay and neonatal morbidity (including respiratory support) were similar across both intervention groups at all gestational windows. Neonatal unit admission was increased by earlier gestation at delivery, development of severe preeclampsia, and being small-for-gestational age.

Neonatal nursing led research activity in the UK: a survey of current practice

Background

Neonatal nurses are ideally placed in practice to undertake research enhancing the care of families. More information is required, however, around neonatal nursing led research to advance leadership in this area. The aim of this study was to determine neonatal nursing led research activity within the UK.

Methods

The study used a web-based survey design and neonatal nurses were eligible if they were working at or towards Masters or Doctoral level qualification in the UK. The survey was distributed to members of the Neonatal Nurses Association, UK Schools of Nursing and shared on social media pages of authors and professional organisations. Results were analysed using descriptive and frequency statistics and content analysis.

Results

Of the 56 respondents, 14% (n = 8) had a Doctoral level qualification and 43% (n = 24) of participants held a Masters qualification. Lack of time and funding knowledge was the largest barrier to research. Only 30% (n = 3) of participants had a research mentor and only 18% (n = 3) were from a neonatal nursing background.

Conclusions

There are limited numbers of neonatal nurses undertaking or leading nursing research in the UK. Further support is required to enhance clinical academic career trajectories to ensure research is a viable pathway for future generations of neonatal nurses.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-021-00719-8.

1266 Digital Rectal Examination: Do You Still Put Your Foot in It If You Don’t Put Your Finger in It?

Introduction

Most surgical trainees are familiar with the aphorism ‘if you don’t put your finger in it, you put your foot in it’, with regards to digital rectal examination (DRE). This commonly taught maxim, attributed to Bailey and Love in their Short Practice of Surgery, was coined to highlight the folly of neglecting DRE in patients with histories suggestive of malignant anorectal pathology. However, data are lacking on the diagnostic yield of DRE for detecting anorectal cancer in patients with lower gastrointestinal bleeding (LGIB), whilst advances in biomarker and imaging technology beg the question: is there still a role for DRE in the assessment of patients with LGIB?

Method

We designed a clinical coding search strategy to identify all adult patients with acute LGIB referred to general surgery at a UK university hospital from January to July 2020. Electronic patient records were interrogated to identify history and examination findings, diagnoses and clinical outcomes.

Results

169 patients (median age 63 (16-94) years, 54.4% male) were identified, 74.6% (126/169) with bright red bleeding, 23.7% (40/169) with altered blood and 1.8% (3/169) with melaena. DRE was performed in 91.1% (154/169) of patients, identifying blood in 42.9% (66/154) of cases and suspicious lesions, which were subsequently confirmed as anorectal malignancy, in 1.3% (2/154).

Conclusions

DRE represents a possibly stigmatising and uncomfortable examination for patients and clinicians alike. These data support the utility of DRE in patients with LGIB and may inform the discussion at the bedside to facilitate the timely diagnosis of anorectal malignancy.

Health-Related Quality of Life from Adolescence to Adulthood Following Extremely Preterm Birth

OBJECTIVE

To examine self-reported and parent-reported health-related quality of life (HRQL) in adults born extremely preterm compared with control participants born at term and to evaluate trajectories of health status from adolescence to early adulthood.

STUDY DESIGN

The EPICure study comprises all births <26 weeks of gestation in the United Kingdom and Ireland in 1995 and control participants born at term recruited at age 6 years. In total, 129 participants born extremely preterm and 65 control participants were followed up at the 19-year assessment. HRQL was measured by the Health Utilities Index Mark 3 multiattribute utility (MAU) scores. Only parent-reported HRQL was available at 11 years of age.

RESULTS

Participants born extremely preterm without neurodevelopmental impairment had significantly lower MAU scores at 19 years than controls (median [IQR]: 0.91 [0.79, 0.97] vs 0.97 [0.87, 1.00], P = .008); those with impairment had the lowest scores (0.74 [0.49, 0.90]). A 0.03-0.05 difference is considered clinically significant. Parent-reported findings were similar. Participants born extremely preterm with impairment rated their health significantly better than their parents did (0.74 vs 0.58, P = .01), in contrast to those without impairment and controls. Between 11 and 19 years, median parent-reported MAU scores decreased from 0.87 to 0.77 for participants born extremely preterm (P = .01) and from 1.00 to 0.97 for control participants (P = .02).

CONCLUSIONS

Among young adults born extremely preterm, both participants and parents rated their health status less favorably than control participants born at term. The decline in MAU scores from adolescence to early adulthood following extremely preterm birth indicates continuing health issues in young adult life.

Neurological and developmental outcomes following neonatal encephalopathy treated with therapeutic hypothermia

In randomized trials, therapeutic hypothermia (TH) is associated with reduced prevalence of the composite outcome mortality or neurodevelopmental morbidity in infants with neonatal encephalopathy (NE). Following systematic review, the reduction in prevalence of both mortality and infant neuromorbidity is clear. Among three trials reporting school age outcomes, the effects of NE and TH suggest that such benefit persists into middle childhood, but none of the major trials were powered to detect differences in these outcomes. Cognitive, educational and behavioural outcomes are all adversely affected by NE in children without moderate or severe neuromorbidity. High-quality longitudinal studies of neurocognitive and educational outcomes following NE in the era of TH, including studies incorporating multimodal neuroimaging assessments, are required to characterise deficits more precisely so that robust interventional targets may be developed, and resource planning can occur. Understanding the impact of NE on families and important educational, social, and behavioural outcomes in childhood is critical to attempts to optimise outcomes through interventions.

Development of standard definitions and grading for Maternal and Fetal Adverse Event Terminology

OBJECTIVE

Adverse event (AE) monitoring is central to assessing therapeutic safety. The lack of a comprehensive framework to define and grade maternal and fetal AEs in pregnancy trials severely limits understanding risks in pregnant women. We created AE terminology to improve safety monitoring for developing pregnancy drugs, devices and interventions.

METHOD

Existing severity grading for pregnant AEs and definitions/indicators of 'severe' and 'life-threatening' conditions relevant to maternal and fetal clinical trials were identified through a literature search. An international multidisciplinary group identified and filled gaps in definitions and severity grading using Medical Dictionary for Regulatory Activities (MedDRA) terms and severity grading criteria based on Common Terminology Criteria for Adverse Event (CTCAE) generic structure. The draft criteria underwent two rounds of a modified Delphi process with international fetal therapy, obstetric, neonatal, industry experts, patients and patient representatives.

RESULTS

Fetal AEs were defined as being diagnosable in utero with potential to harm the fetus, and were integrated into MedDRA. AE severity was graded independently for the pregnant woman and her fetus. Maternal (n = 12) and fetal (n = 19) AE definitions and severity grading criteria were developed and ratified by consensus.

CONCLUSIONS

This Maternal and Fetal AE Terminology version 1.0 allows systematic consistent AE assessment in pregnancy trials to improve safety.

Etiology of persistent mathematics difficulties from childhood to adolescence following very preterm birth

Children born very preterm (VP; <32 weeks' gestation) have poorer mathematics achievement than term-born peers. This study aimed to determine whether VP children's mathematics difficulties persist from primary to secondary school and to explore the nature of mathematics difficulties in adolescence. For this study, 127 VP and 95 term-born adolescents were assessed at age 11-15 years. Mathematics achievement was assessed using the Wechsler Individual Achievement Test-II. Specific mathematics skills and general cognitive skills were assessed using standardized and experimental tests. VP adolescents had poorer mathematics achievement than term-born adolescents (-10.95 points; 95% CI -16.18, -5.73) and poorer number fact knowledge, understanding of arithmetic concepts, written arithmetic, counting, reading and writing large numbers, and algebra. Between-group differences in mathematics skills were no longer significant when working memory and visuospatial skills were controlled for (p's >0.05), with the exception of writing large numbers and conceptual understanding of arithmetic. In a previous study, 83 of the VP adolescents and 49 of the term-born adolescents were assessed at age 8-10 years using measures of the same skills. Amongst these, the between-group difference in mathematics achievement remained stable over time. This study extends findings of a persistent deficit in mathematics achievement among VP children over the primary and secondary school years, and provides evidence of a deficit in factual, procedural and conceptual mathematics skills and in higher order mathematical operations among VP adolescents. We provide further evidence that VP children's mathematics difficulties are driven by deficits in domain-general rather than domain-specific cognitive skills.

2-year outcomes of ranibizumab versus laser therapy for the treatment of very low birthweight infants with retinopathy of prematurity (RAINBOW extension study): prospective follow-up of an open label, randomised controlled trial

BACKGROUND

Intravitreal injection of vascular endothelial growth factor (VEGF) inhibitors is increasingly used to treat retinopathy of prematurity (ROP) in the absence of evidence about long-term efficacy or safety. In this prespecified interim analysis of the RAINBOW extension study, we aimed to prospectively assess outcomes at age 2 years.

METHODS

RAINBOW was an open-label, randomised trial that compared intravitreal ranibizumab (at 0·1 mg and 0·2 mg doses) with laser therapy for the treatment of ROP in very low birthweight infants (<1500 g). Families of the 201 infants that completed the RAINBOW core study were approached for consent to enter the extension study, which evaluates treatment outcomes prospectively through to 5 years of age. At age 20-28 months corrected for prematurity, participants had ophthalmic, development, and health assessments. The primary outcome was the absence of structural ocular abnormalities; secondary outcomes included vision-related quality of life (reported by parents using the Children's Visual Function Questionnaire), development (assessed with the Mullen Scales of Early Learning), motor function, and health status. Investigator-determined ocular and non-ocular serious and other adverse events were recorded. This study is registered with ClinicalTrials.gov, NCT02640664.

FINDINGS

Between June 16, 2016, and Jan 22, 2018, 180 infants were enrolled in the RAINBOW extension study, and 153 (85%) were evaluated at 20-28 months of age. No child developed new ocular structural abnormalities. Structural abnormalities were present in one (2%) of 56 infants in the ranibizumab 0·2 mg group, one (2%) of 51 infants in the 0·1 mg group, and four (9%) of 44 infants in the laser therapy group. The odds ratio of no structural abnormality was 5·68 (95% CI 0·60-54·0; p=0·10) for ranibizumab 0·2 mg versus laser therapy, 4·82 (0·52-45·0; p=0·14) for ranibizumab 0·1 mg versus laser therapy, and 1·21 (0·07-20; p=0·90) for ranibizumab 0·2 mg vs 0·1 mg. High myopia (-5 dioptres or worse) was less frequent after 0·2 mg ranibizumab (five [5%] of 110 eyes) than with laser therapy (16 [20%] of 82; odds ratio 0·19, 95% CI 0·05-0·69; p=0·012). Composite vision-related quality of life scores seemed higher among the ranibizumab 0·2 mg group (mean 84, 95% CI 80-88) compared with laser therapy (77, 72-83; p=0·063). Mullen Scales T-scores for visual reception, receptive and expressive language were distributed similarly between the three trial groups and there were similar proportions of infants with motor and hearing problems among treatment groups. The proportion of infants with respiratory symptoms and Z scores of standing height, weight, and head circumference were similarly distributed in the treatment groups. There were no adverse events considered by the investigator to be related to the study intervention.

INTERPRETATION

2-year outcomes following ranibizumab 0·2 mg for the treatment of ROP confirm the ocular outcomes of the original RAINBOW trial and show reduced high myopia, with possibly better vision-related quality of life. This treatment did not appear to affect non-ocular infant development.

FUNDING

Novartis Pharma AG.

C-STICH2: emergency cervical cerclage to prevent miscarriage and preterm birth-study protocol for a randomised controlled trial

Background

Cervical cerclage is a recognised treatment to prevent late miscarriage and pre-term birth (PTB). Emergency cervical cerclage (ECC) for cervical dilatation with exposed unruptured membranes is less common and the potential benefits of cerclage are less certain. A randomised control trial is needed to accurately assess the effectiveness of ECC in preventing pregnancy loss compared to an expectant approach.

Methods

C-STICH2 is a multicentre randomised controlled trial in which women presenting with cervical dilatation and unruptured exposed membranes at 16 + 0 to 27 + 6 weeks gestation are randomised to ECC or expectant management. Trial design includes 18 month internal pilot with embedded qualitative process evaluation, minimal data set and a within-trial health economic analysis.

Inclusion criteria are ≥16 years, singleton pregnancy, exposed membranes at the external os, gestation 16 + 0–27 + 6 weeks, and informed consent. Exclusion criteria are contraindication to cerclage, cerclage in situ or previous cerclage in this pregnancy.

Randomisation occurs via an online service in a 1:1 ratio, using a minimisation algorithm to reduce chance imbalances in key prognostic variables (site, gestation and dilatation). Primary outcome is pregnancy loss; a composite including miscarriage, termination of pregnancy and perinatal mortality defined as stillbirth and neonatal death in the first week of life. Secondary outcomes include all core outcomes for PTB. Two-year development outcomes will be assessed using general health and Parent Report of Children’s Abilities-Revised (PARCA-R) questionnaires. Intended sample size is 260 participants (130 each arm) based on 60% rate of pregnancy loss in the expectant management arm and 40% in the ECC arm, with 90% power and alpha 0.05. Analysis will be by intention-to-treat.

Discussion

To date there has been one small trial of ECC in 23 participants which included twin and singleton pregnancies. This small trial along with the largest observational study (n = 161) found ECC to prolong pregnancy duration and reduce deliveries before 34 weeks gestation. It is important to generate high quality evidence on the effectiveness of ECC in preventing pregnancy loss, and improve understanding of the prevalence of the condition and frequency of complications associated with ECC. An adequately powered RCT will provide the highest quality evidence regarding optimum care for these women and their babies.

Trial registration

ISRCTN Registry ISRCTN12981869. Registered on 13th June 2018.

Association of Very Preterm Birth or Very Low Birth Weight With Intelligence in Adulthood: An Individual Participant Data Meta-analysis

IMPORTANCE

Birth before 32 weeks' gestation (very preterm [VPT]) and birth weight below 1500 g (very low birth weight [VLBW]) have been associated with lower cognitive performance in childhood. However, there are few investigations of the association of neonatal morbidities and maternal educational levels with the adult cognitive performance of individuals born VPT or VLBW (VPT/VLBW).

OBJECTIVE

To assess differences in adult IQ between VPT/VLBW and term-born individuals and to examine the association of adult IQ with cohort factors, neonatal morbidities, and maternal educational level among VPT/VLBW participants.

DATA SOURCES

Systematic review of published data from PubMed and meta-analysis of individual participant data (IPD) of cohorts from 2 consortia (Research on European Children and Adults Born Preterm [RECAP] and Adults Born Preterm International Collaboration [APIC]).

STUDY SELECTION

The meta-analysis included prospective longitudinal cohort studies that assessed the full-scale IQ of adults born VPT or VLBW and respective control groups comprising term-born adults.

DATA EXTRACTION AND SYNTHESIS

The study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline for analyses of individual participant data and identified 8 studies that provided data from 2135 adults (1068 VPT/VLBW and 1067 term-born participants) born between 1978 and 1995. Meta-analyses of IPD were performed using a 1-stage approach, treating VPT birth or VLBW and cohort as random effects.

MAIN OUTCOMES AND MEASURES

Full-scale IQ scores were converted to z scores within each cohort using the combined SD of VPT/VLBW participants and a control group of term-born participants, with scores centered on the mean of the control group.

RESULTS

A total of 426 records were identified and screened. After exclusions, 13 studies were included in the aggregate meta-analysis. The IPD meta-analysis included 8 of the 9 RECAP and APIC cohorts with adult IQ data. The mean (SD) age among the 8 IPD cohorts was 24.6 (4.3) years, and 1163 participants (54.5%) were women. In unadjusted analyses, VPT/VLBW participants had mean adult IQ scores that were 0.78 SD (95% CI, -0.90 to -0.66 SD) lower than term-born participants, equivalent to a difference of 12 IQ points. Among VPT/VLBW participants, lower gestational age (score difference per week of gestation, 0.11; 95% CI, 0.07-0.14), lower birth weight z scores (score difference per 1.0 SD, 0.21; 95% CI, 0.14-0.28), the presence of neonatal bronchopulmonary dysplasia (score difference, -0.16; 95% CI, -0.30 to -0.02) or any grade of intraventricular hemorrhage (score difference, -0.19; 95% CI, -0.33 to -0.05), and lower maternal educational level (score difference, 0.26; 95% CI, 0.17-0.35) were all significantly associated with lower IQ scores in adulthood.

CONCLUSIONS AND RELEVANCE

In this IPD meta-analysis, lower gestational age, lower weight for gestational age, neonatal morbidities, and lower maternal educational levels were all important risk factors associated with lower IQ among young adults born VPT or VLBW.

'We did everything we could'- a qualitative study exploring the acceptability of maternal-fetal surgery for spina bifida to parents

Objective

To explore the concepts and strategies parents employ when considering maternal-fetal surgery (MFS) as an option for the management of spina bifida (SB) in their fetus, and how this determines the acceptability of the intervention.

Methods

A two-centre interview study enrolling parents whose fetuses with SB were eligible for MFS. To assess differences in acceptability, parents opting for MFS (n = 24) were interviewed at three different moments in time: prior to the intervention, directly after the intervention and 3-6 months after birth. Parents opting for termination of pregnancy (n = 5) were interviewed only once. Themes were identified and organised in line with the framework of acceptability.

Results

To parents opting for MFS, the intervention was perceived as an opportunity that needed to be taken. Feelings of parental responsibility drove them to do anything in their power to improve their future child’s situation. Expectations seemed to be realistic yet were driven by hope for the best outcome. None expressed decisional regret at any stage, despite substantial impact and, at times, disappointing outcomes. For the small group of participants, who decided to opt for termination of pregnancy (TOP), MFS was not perceived as an intervention that substantially could improve the quality of their future child’s life.

Conclusion

Prospective parents opting for MFS were driven by their feelings of parental responsibility. They recognise the fetus as their future child and value information and care focusing on optimising the child’s future health. In the small group of parents opting for TOP, MFS was felt to offer insufficient certainty of substantial improvement in quality of life and the perceived severe impact of SB drove their decision to end the pregnancy.

Disturbed sleep in children born extremely preterm is associated with behavioural and emotional symptoms

AIM

To determine whether children born extremely preterm are at increased risk for sleep disturbances and to explore relationships between extremely preterm birth, sleep and attention-deficit/hyperactivity disorder (ADHD) symptoms and emotional symptoms.

METHOD

EPICure2 cohort study. Parents of 165 children born ≤26 weeks' gestation (53% male) and 121 children born at term (43% male) completed the Children's Sleep Habits Questionnaire, sleep disordered breathing subscale of the Pediatric Sleep Questionnaire, the emotional problems scale of the Strengths and Difficulties Questionnaire and the ADHD Rating Scale-5 at 11 years of age.

RESULTS

Extremely preterm children had greater habitual snoring (adjusted odds ratio 6.8; 95% confidence interval 2.3, 20.3), less frequently fell asleep within 20 minutes (Cohen's d 0.33), higher night wakings (d 0.44) and daytime sleepiness scores (d 0.40) than term-born children; there was no between-group difference in sleep duration scores. Among children without severe disability, night wakings scores partially mediated the relationship between preterm birth and inattention (additional 5% of variance explained), hyperactivity/impulsivity (13%) and emotional problems (9%). Snoring partially mediated the relationship between preterm birth, hyperactivity/impulsivity and inattention (additional 1-5% of variance).

CONCLUSION

Children born extremely preterm are at increased risk of disturbed sleep compared to term-born children. As night wakings partially mediated the relationship between preterm birth and ADHD symptoms and emotional problems, reducing sleep disturbance may improve sleep and reduce attention and emotional problems in this population.

Hypotension in Preterm Infants (HIP) randomised trial

OBJECTIVE

To determine whether restricting the use of inotrope after diagnosis of low blood pressure (BP) in the first 72 hours of life affects survival without significant brain injury at 36 weeks of postmenstrual age (PMA) in infants born before 28 weeks of gestation.

DESIGN

Double-blind, placebo-controlled randomised trial. Caregivers were masked to group assignment.

SETTING

10 sites across Europe and Canada.

PARTICIPANTS

Infants born before 28 weeks of gestation were eligible if they had an invasive mean BP less than their gestational age that persisted for ≥15 min in the first 72 hours of life and a cerebral ultrasound free of significant (≥ grade 3) intraventricular haemorrhage.

INTERVENTION

Participants were randomly assigned to saline bolus followed by either a dopamine infusion (standard management) or placebo (5% dextrose) infusion (restrictive management).

PRIMARY OUTCOME

Survival to 36 weeks of PMA without severe brain injury.

RESULTS

The trial terminated early due to significant enrolment issues (7.7% of planned recruitment). 58 infants were enrolled between February 2015 and September 2017. The two groups were well matched for baseline variables. In the standard group, 18/29 (62%) achieved the primary outcome compared with 20/29 (69%) in the restrictive group (p=0.58). Additional treatments for low BP were used less frequently in the standard arm (11/29 (38%) vs 19/29 (66%), p=0.038).

CONCLUSION

Though this study lacked power, we did not detect major differences in clinical outcomes between standard or restrictive approach to treatment. These results will inform future studies in this area.

TRIAL REGISTRATION NUMBER

NCT01482559, EudraCT 2010-023988-17.

No change in neurodevelopment at 11 years after extremely preterm birth

OBJECTIVE

To determine whether improvements in school age outcomes had occurred between two cohorts of births at 22-25 weeks of gestation to women residents in England in 1995 and 2006.

DESIGN

Longitudinal national cohort studies.

SETTING

School-based or home-based assessments at 11 years of age.

PARTICIPANTS

EPICure2 cohort of births at 22-26 weeks of gestation in England during 2006: a sample of 200 of 1031 survivors were evaluated; outcomes for 112 children born at 22-25 weeks of gestation were compared with those of 176 born in England during 1995 from the EPICure cohort. Classroom controls for each group acted as a reference population.

MAIN OUTCOME MEASURES

Standardised measures of cognition and academic attainment were combined with parent report of other impairments to estimate overall neurodevelopmental status.

RESULTS

At 11 years in EPICure2, 18% had severe and 20% moderate impairments. Comparing births at 22-25 weeks in EPICure2 (n=112), 26% had severe and 21% moderate impairment compared with 18% and 32%, respectively, in EPICure. After adjustment, the OR of moderate or severe neurodevelopmental impairment in 2006 compared with 1995 was 0.76 (95% CI 0.45 to 1.31, p=0.32). IQ scores were similar in 1995 (mean 82.7, SD 18.4) and 2006 (81.4, SD 19.2), adjusted difference in mean z-scores 0.2 SD (95% CI -0.2 to 0.6), as were attainment test scores. The use of multiple imputation did not alter these findings.

CONCLUSION

Improvements in care and survival between 1995 and 2006 are not paralleled by improved cognitive or educational outcomes or a reduced rate of neurodevelopmental impairment.

The Arabin pessary to prevent preterm birth in women with a twin pregnancy and a short cervix: the STOPPIT 2 RCT

BACKGROUND

Preterm birth is common in twins and accounts for significant mortality and morbidity. There are no effective preventative treatments. Some studies have suggested that, in twin pregnancy complicated by a short cervix, the Arabin pessary, which fits around the cervix and can be inserted as an outpatient procedure, reduces preterm birth and prevents neonatal morbidity.

OBJECTIVE

STOPPIT 2 aimed to evaluate the clinical utility of the Arabin cervical pessary in preventing preterm birth in women with a twin pregnancy and a short cervix.

DESIGN

STOPPIT 2 was a pragmatic, open label, multicentre randomised controlled trial with two treatment group - the Arabin pessary plus standard care (intervention) and standard care alone (control). Participants were initially recruited into the screening phase of the study, when cervical length was measured. Women with a measured cervical length of ≤ 35 mm were then recruited into the treatment phase of the study. An economic evaluation considered cost-effectiveness and a qualitative substudy explored the experiences of participants and clinicians.

SETTING

Antenatal clinics in the UK and elsewhere in Europe.

PARTICIPANTS

Women with twin pregnancy at < 21 weeks' gestation with known chorionicity and gestation established by scan at ≤ 16 weeks' gestation.

INTERVENTIONS

Ultrasound scan to establish cervical length. Women with a cervical length of ≤ 35 mm at 18^+ 0-20^+ 6 weeks' gestation were randomised to standard care or Arabin pessary plus standard care. Randomisation was performed by computer and accessed through a web-based browser.

MAIN OUTCOME MEASURES

Obstetric - all births before 34^+ 0 weeks' gestation following the spontaneous onset of labour; and neonatal - composite of adverse outcomes, including stillbirth or neonatal death, periventricular leukomalacia, early respiratory morbidity, intraventricular haemorrhage, necrotising enterocolitis or proven sepsis, all measured up to 28 days after the expected date of delivery.

RESULTS

A total of 2228 participants were recruited to the screening phase, of whom 2170 received a scan and 503 were randomised: 250 to Arabin pessary and 253 to standard care alone. The rate of the primary obstetric outcome was 18.4% (46/250) in the intervention group and 20.6% (52/253) in the control group (adjusted odds ratio 0.87, 95% confidence interval 0.55 to 1.38; p = 0.54). The rate of the primary neonatal outcome was 13.4% (67/500) and 15.0% (76/506) in the intervention group and control group, respectively (adjusted odds ratio 0.86, 95% confidence interval 0.54 to 1.36; p = 0.52). The pessary was largely well tolerated and clinicians found insertion and removal 'easy' or 'fairly easy' in the majority of instances. The simple costs analysis showed that pessary treatment is no more costly than standard care.

LIMITATIONS

There was the possibility of a type II error around smaller than anticipated benefit.

CONCLUSIONS

In this study, the Arabin pessary did not reduce preterm birth or adverse neonatal outcomes in women with a twin pregnancy and a short cervix. The pessary either is ineffective at reducing preterm birth or has an effect size of < 0.4.

FUTURE WORK

Women with twin pregnancy remain at risk of preterm birth; work is required to find treatments for this.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN98835694 and ClinicalTrials.gov NCT02235181.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 44. See the NIHR Journals Library website for further project information.

Extremely preterm birth and autistic traits in young adulthood: the EPICure study

Background

A high prevalence of autism spectrum disorder is reported in children born extremely preterm (EP), but an even larger proportion of survivors are affected by subclinical difficulties than meet diagnostic criteria. The aims of this study were to investigate autistic traits associated with the broader autism phenotype in a cohort of young adults born EP, and explore how these traits relate to emotion recognition, empathy and autism symptom presentation in childhood. The prevalence of autism diagnoses was also investigated.

Methods

One hundred and twenty-nine young adults born before 26 weeks of gestation and 65 term-born controls participated in the 19-year follow-up phase of the EPICure studies. In addition to a clinical interview, participants completed the Broader Autism Phenotype Questionnaire (BAPQ), the Empathy Quotient questionnaire, and the Frankfurt Test and Training of Facial Affect Recognition. The Social Communication Questionnaire (SCQ) was completed by the participants’ parents at age 11 years.

Results

EP born young adults scored significantly higher on the BAPQ in comparison with their term-born peers, indicating greater autistic traits. Among EP participants, BAPQ scores were correlated with SCQ scores in childhood (r = 0.484, p < 0.001). EP young adults had significantly lower scores in emotion recognition and empathy in comparison with controls; however, this effect was mediated by IQ. At 19 years, a diagnosis of autism was reported by 10% of EP participants versus 1.6% of controls, whereas 31% of EP participants scored above the cut-off for the broader autism phenotype in comparison with 8.5% of term-born controls.

Limitations

The high attrition of EP participants from lower socio-economic backgrounds and with lower cognitive functioning may have led to an underrepresentation of those presenting with difficulties associated with autism.

Conclusions

A larger proportion of EP survivors are affected by difficulties associated with autism than have confirmed diagnoses, with a moderate correlation between autism symptom scores in childhood and autistic traits in young adulthood. EP young adults had significantly higher autism symptom scores and a larger proportion had a diagnosis of autism than controls. Screening for autistic traits at set points throughout childhood will help identify those EP individuals at risk of social difficulties who may benefit from intervention.

Supplementary information

The online version contains supplementary material available at 10.1186/s13229-021-00414-0.

White matter analysis of the extremely preterm born adult brain

The preterm brain has been analysed after birth by a large body of neuroimaging studies; however, few studies have focused on white matter alterations in preterm subjects beyond infancy, especially in individuals born at extremely low gestation age - before 28 completed weeks. Neuroimaging data of extremely preterm young adults are now available to investigate the long-term structural alterations of disrupted neurodevelopment. We examined white matter hierarchical organisation and microstructure in extremely preterm young adults. Specifically, we first identified the putative hubs and peripheral regions in 85 extremely preterm young adults and compared them with 53 socio-economically matched and full-term born peers. Moreover, we analysed Fractional Anisotropy (FA), Mean Diffusivity (MD), Neurite Density Index (NDI), and Orientation Dispersion Index (ODI) of white matter in hubs, peripheral regions, and over the whole brain. Our results suggest that the hierarchical organisation of the extremely preterm adult brain remains intact. However, there is evidence of significant alteration of white matter connectivity at both the macro- and microstructural level, with overall diminished connectivity, reduced FA and NDI, increased MD, and comparable ODI; suggesting that, although the spatial configuration of WM fibres is comparable, there are less WM fibres per voxel. These alterations are found throughout the brain and are more prevalent along the pathways between deep grey matter regions, frontal regions and cerebellum. This work provides evidence that white matter abnormalities associated with the premature exposure to the extrauterine environment not only are present at term equivalent age but persist into early adulthood.

European Standards of Care for Newborn Health-A project protocol

AIM

Among children who receive hospital care, preterm infants are Europe's largest group, whose numbers are continually increasing. Currently, no pan-European standards of care for preterm or critically ill infants are available, except for a few specific topics, and practices vary widely in different regions.

METHODS

The European Foundation for the Care of Newborn Infants (EFCNI) has initiated a transdisciplinary collaboration project to provide agreed standards for high-quality perinatal and neonatal care, whose implementation will ensure fairer and more equitable care across Europe. This will improve care for these vulnerable infants and their families, ameliorate the long-term conditions found in preterm and critically ill infants and enhance the quality of family life of affected families. More than 220 experts-healthcare professionals, patient representatives and other relevant stakeholders-have come together for the first time to develop a broad reference guidance in neonatology and associated fields.

RESULTS

Ninety-six standards on 11 overarching topic areas were developed and endorsed.

CONCLUSION

This reference framework serves as a basis for the development of binding national standards for high-quality care. A robust translation and implementation strategy is facilitated, with the goal of improved health outcomes following preterm birth all around Europe.

No Excess of Mathematics Anxiety in Adolescents Born Very Preterm

OBJECTIVE

To assess whether adolescents born very preterm (VP; <32 weeks' gestation) have an excess of mathematics anxiety compared with their classmates born at term.

METHODS

This cohort study included 127 adolescents born VP (51% male, mean age 13.9 years, SD 0.7) and 95 term-born classmates (56% male, mean age 13.7 years, SD 0.7) who completed the Wechsler Individual Achievement Test Second UK Edition and the Mathematics Anxiety Scale-UK at the age of 11 to 15 years. Self-reported trait anxiety was assessed using a composite of 3 items from the Strengths and Difficulties Questionnaire.

RESULTS

Adolescents born VP had significantly poorer mathematics attainment than adolescents born at term (difference in means: -0.64 SD; 95% confidence interval -0.95 to -0.34). However, there were no between-group differences in self-reported mathematics anxiety or trait anxiety. There were significant moderate associations between mathematics anxiety and mathematics attainment for adolescents born VP (rho: -0.45) and at term (rho: -0.54), after controlling for trait anxiety.

CONCLUSION

Adolescents born VP do not have heightened mathematics anxiety compared with their term-born classmates, despite poorer attainment in mathematics. Improving domain-general cognitive skills and scaffolding learning in the classroom may be more promising avenues for intervention than attempting to reduce mathematics anxiety.