51
|
Postoperative brain volumes are associated with one-year neurodevelopmental outcome in children with severe congenital heart disease. Sci Rep 2019; 9:10885. [PMID: 31350426 PMCID: PMC6659678 DOI: 10.1038/s41598-019-47328-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 07/10/2019] [Indexed: 11/09/2022] Open
Abstract
Children with congenital heart disease (CHD) remain at risk for neurodevelopmental impairment despite improved perioperative care. Our prospective cohort study aimed to determine the relationship between perioperative brain volumes and neurodevelopmental outcome in neonates with severe CHD. Pre- and postoperative cerebral MRI was acquired in term born neonates with CHD undergoing neonatal cardiopulmonary bypass surgery. Brain volumes were measured using an atlas prior-based automated method. One-year neurodevelopmental outcome was assessed with the Bayley-III. CHD infants (n = 77) had lower pre- and postoperative total and regional brain volumes compared to controls (n = 44, all p < 0.01). CHD infants had poorer cognitive and motor outcome (p ≤ 0.0001) and a trend towards lower language composite score compared to controls (p = 0.06). Larger total and selected regional postoperative brain volumes were found to be associated with better cognitive and language outcomes (all p < 0.04) at one year. This association was independent of length of intensive care unit stay for total, cortical, temporal, frontal and cerebellar volumes. Therefore, reduced cerebral volume in CHD neonates undergoing bypass surgery may serve as a biomarker for impaired outcome.
Collapse
|
52
|
Alderliesten T, van Bel F, van der Aa NE, Steendijk P, van Haastert IC, de Vries LS, Groenendaal F, Lemmers P. Low Cerebral Oxygenation in Preterm Infants Is Associated with Adverse Neurodevelopmental Outcome. J Pediatr 2019; 207:109-116.e2. [PMID: 30577979 DOI: 10.1016/j.jpeds.2018.11.038] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 11/16/2018] [Accepted: 11/20/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To assess whether high and low levels of cerebral oxygenation (regional cerebral oxygenation [rScO2]) in infants born at <32 weeks of gestation were associated with adverse long-term outcome. STUDY DESIGN Observational cohort study including preterm infants born at <32 weeks of gestation at the Wilhelmina Children's Hospital, The Netherlands, between April 2006 and April 2013. The rScO2 was continuously monitored for 72 hours after birth using near-infrared spectroscopy. Outcome was assessed at 15 and 24 months of corrected age by certified investigators. An unfavorable composite outcome was defined as an outcome score below -1 SD or death. Various rScO2 thresholds were explored. RESULTS In total, 734 infants were eligible for analysis, 60 of whom died. Associations with an unfavorable cognitive outcome in multivariable analysis were comparable for time spent with a rScO2 below 55% and -1.5 SD (according to published reference values), with an OR of 1.4 (CI 1.1-1.7) for 20% of time below either threshold. Results at 15 months were comparable with results at 24 months. Results were not statistically significant for thresholds defining high values of rScO2. The composite motor outcome was not significantly related to either low or high values or rScO2. CONCLUSIONS Low, but not high, rScO2 was associated with an unfavorable cognitive outcome. This suggests the use of a threshold of rScO2 <55% for future clinical studies when using adult near-infrared sensors (rScO2 <65% for neonatal sensors, approximately).
Collapse
Affiliation(s)
- Thomas Alderliesten
- Department of Neonatology, Wilhelmina Children's Hospital, Utrecht University, Utrecht, The Netherlands.
| | - Frank van Bel
- Department of Neonatology, Wilhelmina Children's Hospital, Utrecht University, Utrecht, The Netherlands
| | - Niek E van der Aa
- Department of Neonatology, Wilhelmina Children's Hospital, Utrecht University, Utrecht, The Netherlands
| | - Paul Steendijk
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ingrid C van Haastert
- Department of Neonatology, Wilhelmina Children's Hospital, Utrecht University, Utrecht, The Netherlands
| | - Linda S de Vries
- Department of Neonatology, Wilhelmina Children's Hospital, Utrecht University, Utrecht, The Netherlands
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, Utrecht University, Utrecht, The Netherlands
| | - Petra Lemmers
- Department of Neonatology, Wilhelmina Children's Hospital, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
53
|
Skiöld B, Hallberg B, Vollmer B, Ådén U, Blennow M, Horsch S. A Novel Scoring System for Term-Equivalent-Age Cranial Ultrasound in Extremely Preterm Infants. ULTRASOUND IN MEDICINE & BIOLOGY 2019; 45:786-794. [PMID: 30611572 DOI: 10.1016/j.ultrasmedbio.2018.11.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 10/09/2018] [Accepted: 11/08/2018] [Indexed: 06/09/2023]
Abstract
The role of term-equivalent-age (TEA) cranial ultrasound (cUS) in predicting outcome in preterm infants is increasingly being recognized. However, a detailed quantitative scoring system that allows comparison of groups and comparison with TEA magnetic resonance imaging (MRI) scoring systems is lacking. Eighty-four extremely preterm infants underwent cUS and MRI at TEA. Cranial US was evaluated using a novel detailed scoring system. Agreement between cUS and MRI scores was good (Spearman's ρ = 0.51, p < 0.001). Outcome at 30 mo corrected was assessed in 66 of 84 preterm and 85 term-born infants. Sensitivity was the same for cUS and MRI in prediction of cerebral palsy (75%) and severe cognitive delay (100%); the specificity was slightly higher for MRI (cerebral palsy: 97% vs. 90%, severe cognitive delay: 95% vs. 90%). The proposed novel cUS scoring system is a helpful tool in quantitative assessment of cUS at TEA and prediction of outcome at 30 mo.
Collapse
Affiliation(s)
- Béatrice Skiöld
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden
| | - Boubou Hallberg
- Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden; Department Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Brigitte Vollmer
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Ulrika Ådén
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden
| | - Mats Blennow
- Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden; Department Clinical Science Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Sandra Horsch
- Department of Neonatology, Karolinska University Hospital, Stockholm, Sweden.
| |
Collapse
|
54
|
Leonetti C, Back SA, Gallo V, Ishibashi N. Cortical Dysmaturation in Congenital Heart Disease. Trends Neurosci 2019; 42:192-204. [PMID: 30616953 PMCID: PMC6397700 DOI: 10.1016/j.tins.2018.12.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 11/28/2018] [Accepted: 12/11/2018] [Indexed: 01/09/2023]
Abstract
Congenital heart disease (CHD) is among the most common birth defects. Children with CHD frequently display long-term intellectual and behavioral disability. Emerging evidence indicates that cardiac anomalies lead to a reduction in cerebral oxygenation, which appears to profoundly impact on the maturation of cerebral regions responsible for higher-order cognitive functions. In this review we focus on the potential mechanisms by which dysregulation of cortical neuronal development during early life may lead to the significant cognitive impairments that commonly occur in children with CHD. Further understanding of the mechanisms underlying cortical dysmaturation due to CHD will be necessary to identify strategies for neonatal neuroprotection and for mitigating developmental delays in this patient population.
Collapse
Affiliation(s)
- Camille Leonetti
- Center for Neuroscience Research, Children's National Health System, Washington, DC 20010, USA; Children's National Heart Institute, Children's National Health System, Washington, DC 20010, USA
| | - Stephen A Back
- Department of Pediatrics, Oregon Health and Science University, Portland, OR 97239, USA; Department of Neurology, Oregon Health and Science University, Portland, OR 97239, USA
| | - Vittorio Gallo
- Center for Neuroscience Research, Children's National Health System, Washington, DC 20010, USA.
| | - Nobuyuki Ishibashi
- Center for Neuroscience Research, Children's National Health System, Washington, DC 20010, USA; Children's National Heart Institute, Children's National Health System, Washington, DC 20010, USA.
| |
Collapse
|
55
|
van den Heuij LG, Fraser M, Miller SL, Jenkin G, Wallace EM, Davidson JO, Lear CA, Lim R, Wassink G, Gunn AJ, Bennet L. Delayed intranasal infusion of human amnion epithelial cells improves white matter maturation after asphyxia in preterm fetal sheep. J Cereb Blood Flow Metab 2019; 39:223-239. [PMID: 28895475 PMCID: PMC6365606 DOI: 10.1177/0271678x17729954] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Perinatal hypoxic-ischemic (HI) brain injury remains highly associated with neurodevelopmental disability after preterm birth. There is increasing evidence that disability is linked with impaired white matter maturation, but there is no specific treatment. In this study, we evaluated whether, in preterm fetal sheep, delayed intranasal infusion of human amnion epithelial cells (hAECs) given 1, 3 and 10 days after severe HI, induced by umbilical cord occlusion for 25 min, can restore white matter maturation or reduce delayed cell loss. After 21 days recovery, asphyxia was associated with reduced electroencephalographic (EEG) maturation, brain weight and cortical area, impaired maturation of oligodendrocytes (OLs), no significant loss of total OLs but a marked reduction in immature/mature OLs and reduced myelination. Intranasal infusion of hAECs was associated with improved brain weight and restoration of immature/mature OLs and fractional area of myelin basic protein, with reduced microglia and astrogliosis. Cortical EEG frequency distribution was partially improved, with reduced loss of cortical area, and attenuated cleaved-caspase-3 expression and microgliosis. Neuronal survival in deep grey matter nuclei was improved, with reduced microglia, astrogliosis and cleaved-caspase-3-positive apoptosis. These findings suggest that delayed intranasal hAEC administration has potential to alleviate chronic dysmaturation after perinatal HI.
Collapse
Affiliation(s)
- Lotte G van den Heuij
- 1 Department of Physiology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Mhoyra Fraser
- 1 Department of Physiology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Suzanne L Miller
- 2 The Ritchie Centre, Hudson Institute of Medical Research and Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
| | - Graham Jenkin
- 2 The Ritchie Centre, Hudson Institute of Medical Research and Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
| | - Euan M Wallace
- 2 The Ritchie Centre, Hudson Institute of Medical Research and Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
| | - Joanne O Davidson
- 1 Department of Physiology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Christopher A Lear
- 1 Department of Physiology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Rebecca Lim
- 2 The Ritchie Centre, Hudson Institute of Medical Research and Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
| | - Guido Wassink
- 1 Department of Physiology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Alistair J Gunn
- 1 Department of Physiology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Laura Bennet
- 1 Department of Physiology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| |
Collapse
|
56
|
Irzan H, O'Reilly H, Ourselin S, Marlow N, Melbourne A. A Framework For Memory Performance Prediction From Brain Volume In Preterm-Born Adolescents. PROCEEDINGS. IEEE INTERNATIONAL SYMPOSIUM ON BIOMEDICAL IMAGING 2019; 2019:400-403. [PMID: 34150185 DOI: 10.1109/isbi.2019.8759452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
With advances in medical care, higher numbers of extremely preterm-born babies are now surviving, however the rate of neurodevelopmental and neurological complications has not improved at the same rate and the relative rate of disabilities and health problems is increasing, with associated high costs for health care systems and education. Understanding brain development after early birth is of great importance to be able to make informed decisions. Many studies have associated different areas of the preterm brain with poor cognitive performance, however it is less clear whether these associations persist into adult life. In this study, we investigate how well cortical volumes describe memory performance in 133 19 year-old adolescents, 61% of whom were born extremely preterm. We employ LASSO to identify brain regions that better explain memory performance. The brain regions identified by LASSO explained 27% and 32% of the variance in the visual working memory scores and the visual short term memory respectively. Furthermore, the correlation between the predicted scores and validation scores is statistically significant and it is 58% for the visual working memory task and 56% for the visual short term memory task.
Collapse
Affiliation(s)
- Hassna Irzan
- Dept. Medical Physics and Biomedical Engineering, University College London.,Biomedical Engineering and Imaging Sciences, Kings College London
| | | | - Sebastien Ourselin
- Biomedical Engineering and Imaging Sciences, Kings College London.,Dept. Medical Physics and Biomedical Engineering, University College London
| | - Neil Marlow
- Institute for Women's Health, University College London
| | - Andrew Melbourne
- Biomedical Engineering and Imaging Sciences, Kings College London.,Dept. Medical Physics and Biomedical Engineering, University College London
| |
Collapse
|
57
|
Longitudinal study of neonatal brain tissue volumes in preterm infants and their ability to predict neurodevelopmental outcome. Neuroimage 2019; 185:728-741. [DOI: 10.1016/j.neuroimage.2018.06.034] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 05/08/2018] [Accepted: 06/09/2018] [Indexed: 12/13/2022] Open
|
58
|
Alexander B, Kelly CE, Adamson C, Beare R, Zannino D, Chen J, Murray AL, Loh WY, Matthews LG, Warfield SK, Anderson PJ, Doyle LW, Seal ML, Spittle AJ, Cheong JL, Thompson DK. Changes in neonatal regional brain volume associated with preterm birth and perinatal factors. Neuroimage 2019; 185:654-663. [DOI: 10.1016/j.neuroimage.2018.07.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 07/05/2018] [Accepted: 07/10/2018] [Indexed: 01/07/2023] Open
|
59
|
Mongerson CRL, Wilcox SL, Goins SM, Pier DB, Zurakowski D, Jennings RW, Bajic D. Infant Brain Structural MRI Analysis in the Context of Thoracic Non-cardiac Surgery and Critical Care. Front Pediatr 2019; 7:315. [PMID: 31428593 PMCID: PMC6688189 DOI: 10.3389/fped.2019.00315] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 07/11/2019] [Indexed: 01/20/2023] Open
Abstract
Objective: To determine brain magnetic resonance imaging (MRI) measures of cerebrospinal fluid (CSF) and whole brain volume of full-term and premature infants following surgical treatment for thoracic non-cardiac congenital anomalies requiring critical care. Methods: Full-term (n = 13) and pre-term (n = 13) patients with long-gap esophageal atresia, and full-term naïve controls (n = 19) < 1 year corrected age, underwent non-sedated brain MRI following completion of thoracic non-cardiac surgery and critical care treatment. Qualitative MRI findings were reviewed and reported by a pediatric neuroradiologist and neurologist. Several linear brain metrics were measured using structural T1-weighted images, while T2-weighted images were required for segmentation of total CSF and whole brain tissue using the Morphologically Adaptive Neonatal Tissue Segmentation (MANTiS) tool. Group differences in absolute (mm, cm3) and normalized (%) data were analyzed using a univariate general linear model with age at scan as a covariate. Mean normalized values were assessed using one-way ANOVA. Results: Qualitative brain findings suggest brain atrophy in both full-term and pre-term patients. Both linear and volumetric MRI analyses confirmed significantly greater total CSF and extra-axial space, and decreased whole brain size in both full-term and pre-term patients compared to naïve controls. Although linear analysis suggests greater ventricular volumes in all patients, volumetric analysis showed that normalized ventricular volumes were higher only in premature patients compared to controls. Discussion: Linear brain metrics paralleled volumetric MRI analysis of total CSF and extra-axial space, but not ventricular size. Full-term infants appear to demonstrate similar brain vulnerability in the context of life-saving thoracic non-cardiac surgery requiring critical care as premature infants.
Collapse
Affiliation(s)
- Chandler R L Mongerson
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Sophie L Wilcox
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Stacy M Goins
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Danielle B Pier
- Massachusetts General Hospital Child Neurology, Boston, MA, United States.,Harvard Medical School, Harvard University, Boston, MA, United States
| | - David Zurakowski
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States.,Harvard Medical School, Harvard University, Boston, MA, United States
| | - Russell W Jennings
- Harvard Medical School, Harvard University, Boston, MA, United States.,Department of Surgery, Boston Children's Hospital, Boston, MA, United States
| | - Dusica Bajic
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States.,Massachusetts General Hospital Child Neurology, Boston, MA, United States
| |
Collapse
|
60
|
Kostović I, Sedmak G, Judaš M. Neural histology and neurogenesis of the human fetal and infant brain. Neuroimage 2018; 188:743-773. [PMID: 30594683 DOI: 10.1016/j.neuroimage.2018.12.043] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 12/18/2018] [Accepted: 12/20/2018] [Indexed: 01/11/2023] Open
Abstract
The human brain develops slowly and over a long period of time which lasts for almost three decades. This enables good spatio-temporal resolution of histogenetic and neurogenetic events as well as an appropriate and clinically relevant timing of these events. In order to successfully apply in vivo neuroimaging data, in analyzing both the normal brain development and the neurodevelopmental origin of major neurological and mental disorders, it is important to correlate these neuroimaging data with the existing data on morphogenetic, histogenetic and neurogenetic events. Furthermore, when performing such correlation, the genetic, genomic, and molecular biology data on phenotypic specification of developing brain regions, areas and neurons should also be included. In this review, we focus on early developmental periods (form 8 postconceptional weeks to the second postnatal year) and describe the microstructural organization and neural circuitry elements of the fetal and early postnatal human cerebrum.
Collapse
Affiliation(s)
- I Kostović
- University of Zagreb School of Medicine, Croatian Institute for Brain Research, Centre of Excellence for Basic, Clinical and Translational Neuroscience, Šalata 12, 10000, Zagreb, Croatia.
| | - G Sedmak
- University of Zagreb School of Medicine, Croatian Institute for Brain Research, Centre of Excellence for Basic, Clinical and Translational Neuroscience, Šalata 12, 10000, Zagreb, Croatia.
| | - M Judaš
- University of Zagreb School of Medicine, Croatian Institute for Brain Research, Centre of Excellence for Basic, Clinical and Translational Neuroscience, Šalata 12, 10000, Zagreb, Croatia.
| |
Collapse
|
61
|
Ferreira-Vasques AT, Lamônica DAC. Avaliação instrumentalizada do desenvolvimento infantil: nova realidade brasileira. Codas 2018; 30:e20180056. [DOI: 10.1590/2317-1782/20182018056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 05/28/2018] [Indexed: 11/22/2022] Open
Abstract
RESUMO Objetivo Apresentar a Escala de Desenvolvimento Mental de Griffiths (EDMG), bem como sua adaptação transcultural para o Brasil. Método EDMG é um instrumento diagnóstico de avaliação do desenvolvimento infantil. O resultado de sua aplicação permite verificar se o desenvolvimento é típico ou se há diagnóstico de alteração em determinada área específica (motora grossa, pessoal-social, linguagem, motora fina-adaptativa e execução) ou do desenvolvimento global. Após contato com autores, permissão de utilização da EDMG e cumprimento dos aspectos éticos, a versão do instrumento em português europeu foi adaptada para o português brasileiro, com manutenção de equivalências semântica, idiomática, experimental e conceitual. A adaptação foi realizada por duas fonoaudiólogas, experientes em avaliação de lactentes, que realizaram o curso de capacitação para aplicar o instrumento. A versão final adaptada foi aplicada em 21 lactentes com desenvolvimento típico. Resultados Foram adaptados 39 itens, sem exclusão alguma. Todos os itens foram possíveis de serem aplicados, adequados à faixa etária alvo, sem ausência de resposta em nenhum item. Conclusão A EDMG é adaptada transculturalmente em diversos países e amplamente utilizada por realizar diagnóstico em faixa etária essencial para estimulação com a plasticidade cerebral em pleno desenvolvimento. Foi realizada a adaptação transcultural da EDMG para o Brasil, transformando o cenário brasileiro em relação à atenção a lactentes. Após normatização e verificação das medidas psicométricas, será possível, além de diagnóstico precoce, melhorar a qualidade dos atendimentos a esta população; realizar estudos transculturais e publicar em revistas internacionais com a viabilidade de a EDMG ser aceita e utilizada internacionalmente.
Collapse
|
62
|
Preterm neuroimaging and neurodevelopmental outcome: a focus on intraventricular hemorrhage, post-hemorrhagic hydrocephalus, and associated brain injury. J Perinatol 2018; 38:1431-1443. [PMID: 30166622 PMCID: PMC6215507 DOI: 10.1038/s41372-018-0209-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 07/23/2018] [Accepted: 08/06/2018] [Indexed: 12/29/2022]
Abstract
Intraventricular hemorrhage in the setting of prematurity remains the most common cause of acquired hydrocephalus. Neonates with progressive post-hemorrhagic hydrocephalus are at risk for adverse neurodevelopmental outcomes. The goal of this review is to describe the distinct and often overlapping types of brain injury in the preterm neonate, with a focus on neonatal hydrocephalus, and to connect injury on imaging to neurodevelopmental outcome risk. Head ultrasound and magnetic resonance imaging findings are described separately. The current state of the literature is imprecise and we end the review with recommendations for future radiologic and neurodevelopmental research.
Collapse
|
63
|
Abstract
Predicting neurodevelopmental outcomes in high-risk neonates remains challenging despite advances in neonatal care. Early and accurate characterization of infants at risk for neurodevelopmental delays is necessary to best identify those who may benefit from existing early interventions and novel therapies that become available. Although neuroimaging is a promising biomarker in the prediction of neurodevelopmental outcomes in high-risk infants, it requires additional resources and expertise. Despite many advances in neonatal neuroimaging, there remain limitations in relating early neuroimaging findings with long-term outcomes; further studies are necessary to determine the optimal protocols to best identify high-risk patients and improve neurodevelopmental outcome prediction.
Collapse
|
64
|
Thomason ME, Hect J, Waller R, Manning JH, Stacks AM, Beeghly M, Boeve JL, Wong K, van den Heuvel MI, Hernandez-Andrade E, Hassan SS, Romero R. Prenatal neural origins of infant motor development: Associations between fetal brain and infant motor development. Dev Psychopathol 2018; 30:763-772. [PMID: 30068433 PMCID: PMC6261435 DOI: 10.1017/s095457941800072x] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Functional circuits of the human brain emerge and change dramatically over the second half of gestation. It is possible that variation in neural functional system connectivity in utero predicts individual differences in infant behavioral development, but this possibility has yet to be examined. The current study examines the association between fetal sensorimotor brain system functional connectivity and infant postnatal motor ability. Resting-state functional connectivity data was obtained in 96 healthy human fetuses during the second and third trimesters of pregnancy. Infant motor ability was measured 7 months after birth using the Bayley Scales of Infant Development. Increased connectivity between the emerging motor network and regions of the prefrontal cortex, temporal lobes, posterior cingulate, and supplementary motor regions was observed in infants that showed more mature motor functions. In addition, females demonstrated stronger fetal-brain to infant-behavior associations. These observations extend prior longitudinal research back into prenatal brain development and raise exciting new ideas about the advent of risk and the ontogeny of early sex differences.
Collapse
|
65
|
Wang S, Fan P, Xiong D, Yang P, Zheng J, Zhao D. Assessment of neonatal brain volume and growth at different postmenstrual ages by conventional MRI. Medicine (Baltimore) 2018; 97:e11633. [PMID: 30075544 PMCID: PMC6081163 DOI: 10.1097/md.0000000000011633] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Data regarding neonatal brain volumes represent a basis for monitoring early brain development, and large sample of neonatal brain volume data has not been well described. This study was focused on neonatal brain volumes at different postmenstrual ages (PMA) and postnatal age (PNA).A cohort of 415 neonates with PMA 30 to 43 weeks were recruited for the determination of brain volumes. Intracranial cavity (ICC), total brain tissue (TBT), and cerebrospinal fluid (CSF) were evaluated on the basis of T1-weighted sagittal plane magnetic resonance images. Brain magnetic resonance imaging was assessed using maturation scoring system and multiple linear regression analysis was conducted to forecast the effect factors of brain volumes.TBT volume reached a peak growth at 39 to 40 weeks, ICC volume presented peak growth later at around 43 to 44 weeks, and CSF had a cliff fallen at 37 to 38 weeks PMA at scan. The maturation score increased along with PMA, and the TBT and CSF volumes were significantly different between higher and lower gestational age (GA) groups. The ICC and TBT volumes in higher GA group were larger than lower GA group. Most infants in higher GA group had higher TMS than those in lower GA group. Gender, PMA, PNA, and birth weight were predictors of TBT and ICC volumes.Our results showed that premature volumes of ICC and TBT enlarged with the increasing PMA, while volumes of CSF decreased at 37 weeks. Premature earlier to leave the uterus can lead to brain mature retard although they had the same GA compared with those later birth neonates.
Collapse
Affiliation(s)
- Shouyi Wang
- Pediatrics and Neonatology Department, Children's Digital Health and Data Center, Zhongnan Hospital of Wuhan University
| | - Panpan Fan
- Pediatrics and Neonatology Department, Children's Digital Health and Data Center, Zhongnan Hospital of Wuhan University
| | - Dezhi Xiong
- State Key Laboratory of Magnetic Resonance and Atomic and Molecular Physics, Wuhan Institute of Physics and Mathematics, Chinese Academy of Sciences, Wuhan, P. R. China
| | - Pu Yang
- Pediatrics and Neonatology Department, Children's Digital Health and Data Center, Zhongnan Hospital of Wuhan University
| | - Junwen Zheng
- Pediatrics and Neonatology Department, Children's Digital Health and Data Center, Zhongnan Hospital of Wuhan University
| | - Dongchi Zhao
- Pediatrics and Neonatology Department, Children's Digital Health and Data Center, Zhongnan Hospital of Wuhan University
| |
Collapse
|
66
|
Drost FJ, Keunen K, Moeskops P, Claessens NHP, van Kalken F, Išgum I, Voskuil-Kerkhof ESM, Groenendaal F, de Vries LS, Benders MJNL, Termote JUM. Severe retinopathy of prematurity is associated with reduced cerebellar and brainstem volumes at term and neurodevelopmental deficits at 2 years. Pediatr Res 2018; 83:818-824. [PMID: 29320482 DOI: 10.1038/pr.2018.2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 12/24/2017] [Indexed: 11/09/2022]
Abstract
BackgroundTo evaluate the association between severe retinopathy of prematurity (ROP), measures of brain morphology at term-equivalent age (TEA), and neurodevelopmental outcome.MethodsEighteen infants with severe ROP (median gestational age (GA) 25.3 (range 24.6-25.9 weeks) were included in this retrospective case-control study. Each infant was matched to two extremely preterm control infants (n=36) by GA, birth weight, sex, and brain injury. T2-weighted images were obtained on a 3 T magnetic resonance imaging (MRI) at TEA. Brain volumes were computed using an automatic segmentation method. In addition, cortical folding metrics were extracted. Neurodevelopment was formally assessed at the ages of 15 and 24 months.ResultsInfants with severe ROP had smaller cerebellar volumes (21.4±3.2 vs. 23.1±2.6 ml; P=0.04) and brainstem volumes (5.4±0.5 ml vs. 5.8±0.5 ml; P=0.01) compared with matched control infants. Furthermore, ROP patients showed a significantly lower development quotient (Griffiths Mental Development Scales) at the age of 15 months (93±15 vs. 102±10; P=0.01) and lower fine motor scores (10±3 vs. 12±2; P=0.02) on Bayley Scales (Third Edition) at the age of 24 months.ConclusionSevere ROP was associated with smaller volumes of the cerebellum and brainstem and with poorer early neurodevelopmental outcome. Follow-up through childhood is needed to evaluate the long-term consequences of our findings.
Collapse
Affiliation(s)
- Femke J Drost
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, Netherlands
| | - Kristin Keunen
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, Netherlands
| | - Pim Moeskops
- Image Sciences Institute, University Medical Center Utrecht and Utrecht University, Utrecht, Netherlands
| | - Nathalie H P Claessens
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, Netherlands
| | - Femke van Kalken
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, Netherlands
| | - Ivana Išgum
- Image Sciences Institute, University Medical Center Utrecht and Utrecht University, Utrecht, Netherlands
| | | | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, Netherlands
| | - Linda S de Vries
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, Netherlands
| | - Manon J N L Benders
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, Netherlands
| | - Jacqueline U M Termote
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht and Utrecht University, Utrecht, Netherlands
| |
Collapse
|
67
|
Pascal A, Govaert P, Oostra A, Naulaers G, Ortibus E, Van den Broeck C. Neurodevelopmental outcome in very preterm and very-low-birthweight infants born over the past decade: a meta-analytic review. Dev Med Child Neurol 2018; 60:342-355. [PMID: 29350401 DOI: 10.1111/dmcn.13675] [Citation(s) in RCA: 219] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/02/2017] [Indexed: 11/26/2022]
Abstract
AIM The purpose of this systematic review was to provide an up-to-date global overview of the separate prevalences of motor and cognitive delays and cerebral palsy (CP) in very preterm (VPT) and very-low-birthweight (VLBW) infants. METHOD A comprehensive search was conducted across four databases. Cohort studies reporting the prevalence of CP and motor or cognitive outcome from 18 months corrected age until 6 years of VPT or VLBW infants born after 2006 were included. Pooled prevalences were calculated with random-effects models. RESULTS Thirty studies were retained, which included a total of 10 293 infants. The pooled prevalence of cognitive and motor delays, evaluated with developmental tests, was estimated at 16.9% (95% confidence interval [CI] 10.4-26.3) and 20.6% (95% CI 13.9-29.4%) respectively. Mild delays were more frequent than moderate-to-severe delays. Pooled prevalence of CP was estimated to be 6.8% (95% CI 5.5-8.4). Decreasing gestational age and birthweight resulted in higher prevalences. Lower pooled prevalences were found with the Third Edition of the Bayley Scales of Infant Development than with the Second Edition. INTERPRETATION Even though neonatal intensive care has improved over recent decades, there is still a wide range of neurodevelopmental disabilities resulting from VPT and VLBW births. However, pooled prevalences of CP have diminished over the years. WHAT THIS PAPER ADDS The Bayley Scales of Infant and Toddler Development, Third Edition reported lower pooled prevalences of motor and cognitive delays than the Second Edition. The pooled prevalence of cerebral palsy in infants born extremely preterm was reduced compared with previous meta-analyses.
Collapse
Affiliation(s)
- Aurelie Pascal
- Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent, Belgium.,Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Paul Govaert
- Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Ghent, Belgium
| | - Ann Oostra
- Center for Developmental Disorders, University Hospital Ghent, Ghent, Belgium
| | - Gunnar Naulaers
- Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Els Ortibus
- Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium
| | | |
Collapse
|
68
|
Wei FF, Raaijmakers A, Zhang ZY, van Tienoven TP, Huang QF, Yang WY, Thijs L, Struijker-Boudier HA, Verhamme P, Allegaert K, Staessen JA. Association between cognition and the retinal microvasculature in 11-year old children born preterm or at term. Early Hum Dev 2018; 118:1-7. [PMID: 29413869 PMCID: PMC5885985 DOI: 10.1016/j.earlhumdev.2018.01.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 12/07/2017] [Accepted: 01/29/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Retinal microvessels can be visualized non-invasively and mirror the status of the cerebral microvasculature. AIMS To investigate whether in young children born prematurely or at term cognitive performance is related to retinal microvascular traits. STUDY DESIGN, SUBJECTS In 93 prematurely born infants (birth weight < 1000 g) and 87 controls born at term, we measured head circumference (HC) and determined intelligence quotient (IQ) by combining matrix reasoning and spatial span (Wechsler Non-Verbal test, Dutch version) and post-processed retinal photographs using Singapore I Vessel Assessment software (version 3.6). OUTCOME MEASURES, RESULTS Compared with controls, cases had smaller HC (51.7 vs 53.4 cm; p < 0.001), lower IQ (93.9 vs 109.2; p < 0.001), smaller retinal arteriolar (CRAE; 162.7 vs 174.0 μm; p < 0.001) and venular (CRVE; 234.9 vs 242.8 μm; p = 0.003) diameters and CRAE/CRVE ratio (0.69 vs 0.72; p = 0.001). A 1-SD decrease in CRAE was associated with smaller HC (-0.53 cm; p < 0.001) and lower total IQ (-3.74; p < 0.001), matrix reasoning (-1.77; p = 0.004) and spatial span (-2.03; p = 0.002). These associations persisted after adjustment for sex and age and risk factors for cognitive impairment, including blood pressure, body mass index and parental educational attainment. CONCLUSIONS HC, total IQ, matrix reasoning and spatial span decrease with smaller retinal arteriolar diameter. Our findings suggest that maldevelopment of the cerebral microcirculation, as mirrored by the retinal microvasculature, has lasting effects on the growth of the brain and cognitive performance of prematurely born children.
Collapse
Affiliation(s)
- Fang-Fei Wei
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Siciences, University of Leuven, Leuven, Belgium
| | - Anke Raaijmakers
- Department of Development and Regeneration, University of Leuven, Belgium
| | - Zhen-Yu Zhang
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Siciences, University of Leuven, Leuven, Belgium
| | | | - Qi-Fang Huang
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Siciences, University of Leuven, Leuven, Belgium
| | - Wen-Yi Yang
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Siciences, University of Leuven, Leuven, Belgium
| | - Lutgarde Thijs
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Siciences, University of Leuven, Leuven, Belgium
| | | | - Peter Verhamme
- Centre for Molecular and Vascular Biology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Karel Allegaert
- Department of Development and Regeneration, University of Leuven, Belgium,Department of Pediatric Surgery and Intensive Care, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Jan A. Staessen
- Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Siciences, University of Leuven, Leuven, Belgium,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands,Corresponding author at: Studies Coordinating Centre, Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Campus Sint Rafaël, Kapucijnenvoer 35, Box 7001, BE-3000 Leuven, Belgium.Studies Coordinating CentreResearch Unit Hypertension and Cardiovascular EpidemiologyKU Leuven Department of Cardiovascular SciencesUniversity of LeuvenCampus Sint Rafaël, Kapucijnenvoer 35Box 7001LeuvenBE-3000Belgium
| |
Collapse
|
69
|
Schneider J, Fischer Fumeaux CJ, Duerden EG, Guo T, Foong J, Graz MB, Hagmann P, Chakravarty MM, Hüppi PS, Beauport L, Truttmann AC, Miller SP. Nutrient Intake in the First Two Weeks of Life and Brain Growth in Preterm Neonates. Pediatrics 2018; 141:peds.2017-2169. [PMID: 29440285 DOI: 10.1542/peds.2017-2169] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/12/2017] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Optimizing early nutritional intake in preterm neonates may promote brain health and neurodevelopment through enhanced brain maturation. Our objectives were (1) to determine the association of energy and macronutrient intake in the first 2 weeks of life with regional and total brain growth and white matter (WM) maturation, assessed by 3 serial MRI scans in preterm neonates; (2) to examine how critical illness modifies this association; and (3) to investigate the relationship with neurodevelopmental outcomes. METHODS Forty-nine preterm neonates (21 boys, median [interquartile range] gestational age: 27.6 [2.3] weeks) were scanned serially at the following median postmenstrual weeks: 29.4, 31.7, and 41. The total brain, basal nuclei, and cerebellum were semiautomatically segmented. Fractional anisotropy was extracted from diffusion tensor imaging data. Nutritional intake from day of life 1 to 14 was monitored and clinical factors were collected. RESULTS Greater energy and lipid intake predicted increased total brain and basal nuclei volumes over the course of neonatal care to term-equivalent age. Similarly, energy and lipid intake were significantly associated with fractional anisotropy values in selected WM tracts. The association of ventilation duration with smaller brain volumes was attenuated by higher energy intake. Brain growth predicted psychomotor outcome at 18 months' corrected age. CONCLUSIONS In preterm neonates, greater energy and enteral feeding during the first 2 weeks of life predicted more robust brain growth and accelerated WM maturation. The long-lasting effect of early nutrition on neurodevelopment may be mediated by enhanced brain growth. Optimizing nutrition in preterm neonates may represent a potential avenue to mitigate the adverse brain health consequences of critical illness.
Collapse
Affiliation(s)
- Juliane Schneider
- Department of Paediatrics, University of Toronto and The Hospital for Sick Children, Toronto, Canada.,Department of Woman-Mother-Child, Clinic of Neonatology and
| | | | - Emma G Duerden
- Department of Paediatrics, University of Toronto and The Hospital for Sick Children, Toronto, Canada
| | - Ting Guo
- Department of Paediatrics, University of Toronto and The Hospital for Sick Children, Toronto, Canada
| | - Justin Foong
- Department of Paediatrics, University of Toronto and The Hospital for Sick Children, Toronto, Canada
| | | | - Patric Hagmann
- Department of Radiology, Clinic of Neuroradiology, University Hospital Center and University of Lausanne, Lausanne, Switzerland
| | - M Mallar Chakravarty
- Douglas Mental Health University Institute, Montreal, Canada.,Departments of Psychiatry and Biological and Biomedical Engineering, McGill University, Montreal, Canada; and
| | - Petra S Hüppi
- Division of Development and Growth, Department of Paediatrics, University Hospital of Geneva, Geneva, Switzerland
| | - Lydie Beauport
- Department of Woman-Mother-Child, Clinic of Neonatology and
| | | | - Steven P Miller
- Department of Paediatrics, University of Toronto and The Hospital for Sick Children, Toronto, Canada;
| |
Collapse
|
70
|
Bolk J, Padilla N, Forsman L, Broström L, Hellgren K, Åden U. Visual-motor integration and fine motor skills at 6½ years of age and associations with neonatal brain volumes in children born extremely preterm in Sweden: a population-based cohort study. BMJ Open 2018; 8:e020478. [PMID: 29455171 PMCID: PMC5855250 DOI: 10.1136/bmjopen-2017-020478] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES This exploratory study aimed to investigate associations between neonatal brain volumes and visual-motor integration (VMI) and fine motor skills in children born extremely preterm (EPT) when they reached 6½ years of age. SETTING Prospective population-based cohort study in Stockholm, Sweden, during 3 years. PARTICIPANTS All children born before gestational age, 27 weeks, during 2004-2007 in Stockholm, without major morbidities and impairments, and who underwent MRI at term-equivalent age. MAIN OUTCOME MEASURES Brain volumes were calculated using morphometric analyses in regions known to be involved in VMI and fine motor functions. VMI was assessed with The Beery-Buktenica Developmental Test of Visual-Motor Integration-sixth edition and fine motor skills were assessed with the manual dexterity subtest from the Movement Assessment Battery for Children-second edition, at 6½ years. Associations between the brain volumes and VMI and fine motor skills were evaluated using partial correlation, adjusted for total cerebral parenchyma and sex. RESULTS Out of 107 children born at gestational age <27 weeks, 83 were assessed at 6½ years and 66/83 were without major brain lesions or cerebral palsy and included in the analyses. A representative subsample underwent morphometric analyses: automatic segmentation (n=34) and atlas-based segmentation (n=26). The precentral gyrus was associated with both VMI (r=0.54, P=0.007) and fine motor skills (r=0.54, P=0.01). Associations were also seen between fine motor skills and the volume of the cerebellum (r=0.42, P=0.02), brainstem (r=0.47, P=0.008) and grey matter (r=-0.38, P=0.04). CONCLUSIONS Neonatal brain volumes in areas known to be involved in VMI and fine motor skills were associated with scores for these two functions when children born EPT without major brain lesions or cerebral palsy were evaluated at 6½ years of age. Establishing clear associations between early brain volume alterations and later VMI and/or fine motor skills could make early interventions possible.
Collapse
Affiliation(s)
- Jenny Bolk
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Neonatal Unit, Sachs’s Children and Youth Hospital, Stockholm, Sweden
| | - Nelly Padilla
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
| | - Lea Forsman
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
| | - Lina Broström
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
| | - Kerstin Hellgren
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Neuropediatric Department, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Ulrika Åden
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Neonatal Unit, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
71
|
Gilmore JH, Knickmeyer RC, Gao W. Imaging structural and functional brain development in early childhood. Nat Rev Neurosci 2018; 19:123-137. [PMID: 29449712 PMCID: PMC5987539 DOI: 10.1038/nrn.2018.1] [Citation(s) in RCA: 460] [Impact Index Per Article: 76.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
In humans, the period from term birth to ∼2 years of age is characterized by rapid and dynamic brain development and plays an important role in cognitive development and risk of disorders such as autism and schizophrenia. Recent imaging studies have begun to delineate the growth trajectories of brain structure and function in the first years after birth and their relationship to cognition and risk of neuropsychiatric disorders. This Review discusses the development of grey and white matter and structural and functional networks, as well as genetic and environmental influences on early-childhood brain development. We also discuss initial evidence regarding the usefulness of early imaging biomarkers for predicting cognitive outcomes and risk of neuropsychiatric disorders.
Collapse
Affiliation(s)
- John H Gilmore
- Department of Psychiatry, CB# 7160, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Rebecca C Knickmeyer
- Department of Psychiatry, CB# 7160, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Wei Gao
- Biomedical Imaging Research Institute, Department of Biomedical Sciences and Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medicine, University of California, Los Angeles, CA, USA
| |
Collapse
|
72
|
Gunkel J, de Vries LS, Jongmans M, Koopman-Esseboom C, van Haastert IC, Eijsermans MCJ, van Stam C, van Zanten BGA, Wolfs TFW, Nijman J. Outcome of Preterm Infants With Postnatal Cytomegalovirus Infection. Pediatrics 2018; 141:peds.2017-0635. [PMID: 29330315 DOI: 10.1542/peds.2017-0635] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/30/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To assess whether preterm infants with postnatal cytomegalovirus infection develop neurologic sequelae in early childhood. METHODS Infants <32 weeks' gestation were prospectively screened for cytomegalovirus (CMV) at term-equivalent age. Neurodevelopment was compared between CMV-positive and CMV-negative infants by using the Griffiths Mental Development Scales (GMDS) at 16 months' corrected age (CA); the Bayley Scales of Infant and Toddler Development, Third Edition or the GMDS at 24 to 30 months' CA; and the Wechsler Preschool and Primary Scale of Intelligence, Third Edition and Movement Assessment Battery for Children, Second Edition at 6 years of age. At 6 years old, hearing was assessed in CMV-positive children. RESULTS Neurodevelopment was assessed in 356 infants at 16 months' CA, of whom 49 (14%) were infected and 307 (86%) were noninfected. Infected infants performed significantly better on the GMDS locomotor scale. There were no differences at 24 to 30 months' CA on the Bayley Scales of Infant and Toddler Development, Third Edition or GMDS. At 6 years of age, infected children scored lower on the Wechsler Preschool and Primary Scale of Intelligence, Third Edition, but mean scores were within normal range, reaching significance only in verbal IQ (96 [SD 17] vs 103 [SD 15] points; P = .046). Multiple regression indicated no impact of CMV status but significant influence of maternal education and ethnicity on verbal IQ. No significant differences in motor development were found and none of the infected children developed sensorineural hearing loss. CONCLUSIONS In this cohort study, postnatal cytomegalovirus infection in preterm children did not have an adverse effect on neurodevelopment within the first 6 years of life.
Collapse
Affiliation(s)
| | | | - Marian Jongmans
- Departments of Neonatology.,Child, Family, and Education Studies
| | | | | | - Maria C J Eijsermans
- Child Development and Exercise Center, University Medical Center Utrecht, Utrecht, Netherlands
| | | | | | | | | |
Collapse
|
73
|
Hüning B, Storbeck T, Bruns N, Dransfeld F, Hobrecht J, Karpienski J, Sirin S, Schweiger B, Weiss C, Felderhoff-Müser U, Müller H. Relationship between brain function (aEEG) and brain structure (MRI) and their predictive value for neurodevelopmental outcome of preterm infants. Eur J Pediatr 2018; 177:1181-1189. [PMID: 29789947 PMCID: PMC6061051 DOI: 10.1007/s00431-018-3166-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 04/30/2018] [Accepted: 05/02/2018] [Indexed: 11/26/2022]
Abstract
UNLABELLED To improve the prediction of neurodevelopmental outcome in very preterm infants, this study used the combination of amplitude-integrated electroencephalography (aEEG) within the first 72 h of life and cranial magnetic resonance imaging (MRI) at term equivalent age. A single-center cohort of 38 infants born before 32 weeks of gestation was subjected to both investigations. Structural measurements were performed on MRI. Multiple regression analysis was used to identify independent factors including functional and structural brain measurements associated with outcome at a corrected age of 24 months. aEEG parameters significantly correlated with MRI measurements. Reduced deep gray matter volume was associated with low Burdjalov Score on day 3 (p < 0.0001) and day 1-3 (p = 0.0012). The biparietal width and the transcerebellar diameter were related to Burdjalov Score on day 1 (p = 0.0111; p = 0.0002). The final multiple regression analysis revealed independent predictors of neurodevelopmental outcome: intraventricular hemorrhage (p = 0.0060) and interhemispheric distance (p = 0.0052) for mental developmental index; Burdjalov Score day 1 (p = 0.0201) and interhemispheric distance (p = 0.0142) for psychomotor developmental index. CONCLUSION Functional aEEG parameters were associated with altered brain maturation on MRI. The combination of aEEG and MRI contributes to the prediction of outcome at 24 months. What is Known: • Prematurity remains a risk factor for impaired neurodevelopment. • aEEG is used to measure brain activity in preterm infants and cranial MRI is performed to identify structural gray and white matter abnormalities with impact on neurodevelopmental outcome. What is New: • aEEG parameters observed within the first 72 h of life were associated with altered deep gray matter volumes, biparietal width, and transcerebellar diameter at term equivalent age. • The combination of aEEG and MRI contributes to the prediction of neurodevelopmental outcome at 2 years of corrected age in very preterm infants.
Collapse
Affiliation(s)
- Britta Hüning
- 0000 0001 2187 5445grid.5718.bDepartment of Pediatrics I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Tobias Storbeck
- Department of Pediatrics I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany.
| | - Nora Bruns
- 0000 0001 2187 5445grid.5718.bDepartment of Pediatrics I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Frauke Dransfeld
- 0000 0001 2187 5445grid.5718.bDepartment of Pediatrics I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Julia Hobrecht
- 0000 0001 2187 5445grid.5718.bDepartment of Pediatrics I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Julia Karpienski
- 0000 0001 2187 5445grid.5718.bDepartment of Pediatrics I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Selma Sirin
- 0000 0001 2187 5445grid.5718.bInstitute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Bernd Schweiger
- 0000 0001 2187 5445grid.5718.bInstitute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Christel Weiss
- 0000 0001 2190 4373grid.7700.0Department of Medical Statistics and Biomathematics, University Hospital Mannheim, University of Heidelberg, Ludolf-Krehl-Straße 13-17, 68167 Mannheim, Germany
| | - Ursula Felderhoff-Müser
- 0000 0001 2187 5445grid.5718.bDepartment of Pediatrics I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Hanna Müller
- 0000 0001 2187 5445grid.5718.bDepartment of Pediatrics I, Neonatology, Pediatric Intensive Care, Pediatric Neurology, University Hospital Essen, University Duisburg-Essen, Hufelandstr. 55, 45147 Essen, Germany ,0000 0001 2107 3311grid.5330.5Division of Neonatology and Pediatric Intensive Care, Department of Pediatrics and Adolescent Medicine, Friedrich-Alexander-University of Erlangen-Nürnberg, Loschgestr. 15, 91054 Erlangen, Germany
| |
Collapse
|
74
|
Cerebellar-dependent associative learning is impaired in very preterm born children and young adults. Sci Rep 2017; 7:18028. [PMID: 29269751 PMCID: PMC5740078 DOI: 10.1038/s41598-017-18316-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 12/08/2017] [Indexed: 11/21/2022] Open
Abstract
Preterm birth incorporates an increased risk for cerebellar developmental disorders likely contributing to motor and cognitive abnormalities. Experimental evidence of cerebellar dysfunction in preterm subjects, however, is sparse. In this study, classical eyeblink conditioning was used as a marker of cerebellar dysfunction. Standard delay conditioning was investigated in 20 adults and 32 preschool children born very preterm. Focal lesions were excluded based on structural magnetic resonance imaging. For comparison, an equal number of matched term born healthy peers were tested. Subgroups of children (12 preterm, 12 controls) were retested. Preterm subjects acquired significantly less conditioned responses (CR) compared to controls with slower learning rates. A likely explanation for these findings is that preterm birth impedes function of the cerebellum even in the absence of focal cerebellar lesions. The present findings are consistent with the assumption that prematurity results in long-term detrimental effects on the integrity of the cerebellum. It cannot be excluded, however, that extra-cerebellar pathology contributed to the present findings.
Collapse
|
75
|
Claessens NHP, Kelly CJ, Counsell SJ, Benders MJNL. Neuroimaging, cardiovascular physiology, and functional outcomes in infants with congenital heart disease. Dev Med Child Neurol 2017; 59:894-902. [PMID: 28542743 DOI: 10.1111/dmcn.13461] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2017] [Indexed: 01/12/2023]
Abstract
This review integrates data on brain dysmaturation and acquired brain injury using fetal and neonatal magnetic resonance imaging (MRI), including the contribution of cardiovascular physiology to differences in brain development, and the relationship between brain abnormalities and subsequent neurological impairments in infants with congenital heart disease (CHD). The antenatal and neonatal period are critical for optimal brain development; the developing brain is particularly vulnerable to haemodynamic disturbances during this time. Altered cerebral perfusion and decreased cerebral oxygen delivery in the antenatal period can affect functional and structural brain development, while postnatal haemodynamic fluctuations may cause additional injury. In critical CHD, brain dysmaturation and acquired brain injury result from a combination of underlying cardiovascular pathology and surgery performed in the neonatal period. MRI findings in infants with CHD can be used to evaluate potential clinical risk factors for brain abnormalities, and aid prediction of functional outcomes at an early stage. In addition, information on timing of brain dysmaturation and acquired brain injury in CHD has the potential to be used when developing strategies to optimize neurodevelopment.
Collapse
Affiliation(s)
- Nathalie H P Claessens
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Christopher J Kelly
- Centre for the Developing Brain, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
| | - Serena J Counsell
- Centre for the Developing Brain, Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
| | - Manon J N L Benders
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| |
Collapse
|
76
|
Keunen K, Benders MJ, Leemans A, Fieret-Van Stam PC, Scholtens LH, Viergever MA, Kahn RS, Groenendaal F, de Vries LS, van den Heuvel MP. White matter maturation in the neonatal brain is predictive of school age cognitive capacities in children born very preterm. Dev Med Child Neurol 2017; 59:939-946. [PMID: 28675542 DOI: 10.1111/dmcn.13487] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2017] [Indexed: 11/30/2022]
Abstract
AIM To investigate the association between white matter organization in the neonatal brain and cognitive capacities at early school age in children born very preterm. METHOD Thirty children born very preterm (gestational age median 27.5wks, interquartile range [IQR] 25.5-29.5; 18 males, 12 females) were included in this retrospective observational cohort study. Diffusion-weighted imaging (DWI) had been performed on a 3T system in the neonatal period (median 41.3 [IQR 40.0-42.6]wks) and cognitive functioning was formally assessed at age 5 years and 7 months (IQR 5.4-5.9y) using the Wechsler Preschool and Primary Scale of Intelligence. Structural connectivity maps were reconstructed from the DWI data using deterministic streamline tractography. Network metrics of global and local communication and mean fractional anisotropy of white matter pathways were related to IQ and processing speed at age 5 years using linear regression analyses. RESULTS Mean fractional anisotropy was significantly related to Performance IQ at age 5 years (F=8.48, p=0.007). Findings persisted after adjustment for maternal education level. INTERPRETATION Our findings provide evidence that the blueprint of later cognitive achievement is already present at term-equivalent age and suggest that white matter connectivity strength may be a valuable predictor for long-term cognitive functioning.
Collapse
Affiliation(s)
- Kristin Keunen
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands.,Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Manon J Benders
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands.,Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Alexander Leemans
- Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands.,Image Sciences Institute, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Petronella C Fieret-Van Stam
- Department of Medical Psychology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Lianne H Scholtens
- Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Psychiatry, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Max A Viergever
- Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands.,Image Sciences Institute, University Medical Center Utrecht, Utrecht, the Netherlands
| | - René S Kahn
- Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Psychiatry, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Psychiatry, Icahn School of Medicine Mount Sinai, NY, USA
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands.,Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Linda S de Vries
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands.,Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Martijn P van den Heuvel
- Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Psychiatry, University Medical Center Utrecht, Utrecht, the Netherlands
| |
Collapse
|
77
|
Amplitude-Integrated Electroencephalography Improves the Identification of Infants with Encephalopathy for Therapeutic Hypothermia and Predicts Neurodevelopmental Outcomes at 2 Years of Age. J Pediatr 2017; 187:34-42. [PMID: 28549636 DOI: 10.1016/j.jpeds.2017.04.041] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 03/20/2017] [Accepted: 04/20/2017] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To examine whether using an amplitude-integrated electroencephalography (aEEG) severity pattern as an entry criterion for therapeutic hypothermia better selects infants with hypoxic-ischemic encephalopathy and to assess the time-to-normal trace for aEEG and magnetic resonance imaging (MRI) lesion load as 24-month outcome predictors. STUDY DESIGN Forty-seven infants meeting Norwegian therapeutic hypothermia guidelines were enrolled prospectively. Eight-channel EEG/aEEG was recorded from 6 hours until after rewarming, and read after discharge. Neonatal MRI brain scans were scored for summated (range 0-11) regional lesion load. A poor outcome at 2 years was defined as death or a Bayley Scales of Infant-Toddler Development cognitive or motor composite score of <85 or severe hearing or visual loss. RESULTS Three severity groups were defined from the initial aEEG; continuous normal voltage (CNV; n = 15), discontinuous normal voltage (DNV; n = 18), and a severe aEEG voltage pattern (SEVP; n = 14). Any seizure occurrence was 7% CNV, 50% DNV, and 100% SEVP. Infants with SEVP with poor vs good outcome had a significantly longer median (IQR) time-to-normal trace: 58 hours (9-79) vs 18 hours (12-19) and higher MRI lesion load: 10 (3-10) vs 2 (1-5). A poor outcome was noted in 3 of 15 infants with CNV, 4 of 18 infants with DNV, and 8 of 14 infants with SEVP. Using multiple stepwise linear regression analyses including only infants with abnormal aEEG (DNV and SEVP), MRI lesion load significantly predicted cognitive and motor scores. For the SEVP group alone, time-to-normal trace was a stronger outcome predictor than MRI score. No variable predicted outcome in infants with CNV. CONCLUSIONS Selection of infants with encephalopathy for therapeutic hypothermia after perinatal asphyxia may be improved by including only infants with an early moderate or severely depressed background aEEG trace.
Collapse
|
78
|
Paviotti G, De Cunto A, Zennaro F, Boz G, Travan L, Cont G, Bua J, Demarini S. Higher growth, fat and fat-free masses correlate with larger cerebellar volumes in preterm infants at term. Acta Paediatr 2017; 106:918-925. [PMID: 28295577 DOI: 10.1111/apa.13829] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 01/15/2017] [Accepted: 03/07/2017] [Indexed: 12/12/2022]
Abstract
AIM Smaller cerebellar volumes in very low-birthweight (VLBW) infants at term have been related to adverse cognitive outcomes, and this study evaluated whether these volumes were associated with a growth in body composition during hospital stays. METHODS We prospectively recruited 42 VLBW infants from an Italian neonatal unit between January 2013 and August 2015. Cerebellar volumes and body composition were measured by magnetic resonance imaging (MRI) and air-displacement plethysmography, respectively, at 40 weeks of gestational age and anthropometric and nutritional data were collected. We also included 20 term-born controls. RESULTS The mean gestational age and birthweight of the VLBW infants were 29.4 (±1.9) weeks and 1120 (±290) g. There was a positive correlation between cerebellar volumes and daily weight gain from birth to term (R2 = 0.26, p = 0.001), weight (R2 = 0.25, p = 0.001), length (R2 = 0.16, p = 0.01), fat mass (R2 = 0.15, p = 0.01) and fat-free mass at term (R2 = 0.20, p = 0.003). In multiple regression analysis, daily weight gain, mechanical ventilation and postconceptional age at MRI were independently associated with cerebellar volumes. Anthropometric data and cerebellar volumes were similar between VLBW and control infants. CONCLUSION Higher growth, higher fat mass and fat-free mass were associated with larger cerebellar volumes in VLBW infants at term.
Collapse
Affiliation(s)
- Giulia Paviotti
- Division of Neonatology; Institute for Maternal and Child Health - IRCCS Burlo Garofolo; Trieste Italy
| | - Angela De Cunto
- Division of Neonatology; Institute for Maternal and Child Health - IRCCS Burlo Garofolo; Trieste Italy
| | - Floriana Zennaro
- Pediatric Radiology; Institute for Maternal and Child Health - IRCCS Burlo Garofolo; Trieste Italy
| | - Giulia Boz
- Division of Neonatology; Institute for Maternal and Child Health - IRCCS Burlo Garofolo; Trieste Italy
| | - Laura Travan
- Division of Neonatology; Institute for Maternal and Child Health - IRCCS Burlo Garofolo; Trieste Italy
| | - Gabriele Cont
- Division of Neonatology; Institute for Maternal and Child Health - IRCCS Burlo Garofolo; Trieste Italy
| | - Jenny Bua
- Division of Neonatology; Institute for Maternal and Child Health - IRCCS Burlo Garofolo; Trieste Italy
| | - Sergio Demarini
- Division of Neonatology; Institute for Maternal and Child Health - IRCCS Burlo Garofolo; Trieste Italy
| |
Collapse
|
79
|
Prediction of cognitive and motor outcome of preterm infants based on automatic quantitative descriptors from neonatal MR brain images. Sci Rep 2017; 7:2163. [PMID: 28526882 PMCID: PMC5438406 DOI: 10.1038/s41598-017-02307-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 04/10/2017] [Indexed: 11/08/2022] Open
Abstract
This study investigates the predictive ability of automatic quantitative brain MRI descriptors for the identification of infants with low cognitive and/or motor outcome at 2-3 years chronological age. MR brain images of 173 patients were acquired at 30 weeks postmenstrual age (PMA) (n = 86) and 40 weeks PMA (n = 153) between 2008 and 2013. Eight tissue volumes and measures of cortical morphology were automatically computed. A support vector machine classifier was employed to identify infants who exhibit low cognitive and/or motor outcome (<85) at 2-3 years chronological age as assessed by the Bayley scales. Based on the images acquired at 30 weeks PMA, the automatic identification resulted in an area under the receiver operation characteristic curve (AUC) of 0.78 for low cognitive outcome, and an AUC of 0.80 for low motor outcome. Identification based on the change of the descriptors between 30 and 40 weeks PMA (n = 66) resulted in an AUC of 0.80 for low cognitive outcome and an AUC of 0.85 for low motor outcome. This study provides evidence of the feasibility of identification of preterm infants at risk of cognitive and motor impairments based on descriptors automatically computed from images acquired at 30 and 40 weeks PMA.
Collapse
|
80
|
Bergström A, Kaalund SS, Skovgaard K, Andersen AD, Pakkenberg B, Rosenørn A, van Elburg RM, Thymann T, Greisen GO, Sangild PT. Limited effects of preterm birth and the first enteral nutrition on cerebellum morphology and gene expression in piglets. Physiol Rep 2017; 4:4/14/e12871. [PMID: 27462071 PMCID: PMC4962075 DOI: 10.14814/phy2.12871] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 06/30/2016] [Indexed: 01/07/2023] Open
Abstract
Preterm pigs show many signs of immaturity that are characteristic of preterm infants. In preterm infants, the cerebellum grows particularly rapid and hypoplasia and cellular lesions are associated with motor dysfunction and cognitive deficits. We hypothesized that functional brain delays observed in preterm pigs would be paralleled by both structural and molecular differences in the cerebellum relative to term born piglets. Cerebella were collected from term (n = 56) and preterm (90% gestation, n = 112) pigs at 0, 5, and 26 days after birth for stereological volume estimations, large‐scale qPCR gene expression analyses (selected neurodevelopmental genes) and western blot protein expression analysis (Sonic Hedgehog pathway). Memory and learning was tested using a T‐maze, documenting that preterm pigs showed delayed learning. Preterm pigs also showed reduced volume of both white and gray matter at all three ages but the proportion of white matter increased postnatally, relative to term pigs. Early initiation of enteral nutrition had limited structural or molecular effects. The Sonic Hedgehog pathway was unaffected by preterm birth. Few differences in expression of the selected genes were found, except consistently higher mRNA levels of Midkine, p75, and Neurotrophic factor 3 in the preterm cerebellum postnatally, probably reflecting an adaptive response to preterm birth. Pig cerebellar development appears more affected by postconceptional age than by environmental factors at birth or postnatally. Compensatory mechanisms following preterm birth may include faster white matter growth and increased expression of selected genes for neurotrophic factors and regulation of angiogenesis. While the pig cerebellum is immature in 90% gestation preterm pigs, it appears relatively mature and resilient toward environmental factors.
Collapse
Affiliation(s)
- Anders Bergström
- Comparative Pediatrics and Nutrition, Department of Clinical Veterinary and Animal Science, Faculty of Health and Medical Sciences, University of Copenhagen, Frederiksberg, Denmark
| | - Sanne S Kaalund
- Comparative Pediatrics and Nutrition, Department of Clinical Veterinary and Animal Science, Faculty of Health and Medical Sciences, University of Copenhagen, Frederiksberg, Denmark Research Laboratory for Stereology and Neuroscience, Bispebjerg-Frederiksberg Hospitals, Copenhagen, Denmark
| | - Kerstin Skovgaard
- Veterinary Institute, Technical University of Denmark, Frederiksberg, Denmark
| | - Anders D Andersen
- Comparative Pediatrics and Nutrition, Department of Clinical Veterinary and Animal Science, Faculty of Health and Medical Sciences, University of Copenhagen, Frederiksberg, Denmark
| | - Bente Pakkenberg
- Research Laboratory for Stereology and Neuroscience, Bispebjerg-Frederiksberg Hospitals, Copenhagen, Denmark
| | - Ann Rosenørn
- Comparative Pediatrics and Nutrition, Department of Clinical Veterinary and Animal Science, Faculty of Health and Medical Sciences, University of Copenhagen, Frederiksberg, Denmark
| | - Ruurd M van Elburg
- Danone Nutricia Early Life Nutrition, Nutricia Research, Utrecht, the Netherlands Emma Children's Hospital, Academic Medical Center, Amsterdam, the Netherlands
| | - Thomas Thymann
- Comparative Pediatrics and Nutrition, Department of Clinical Veterinary and Animal Science, Faculty of Health and Medical Sciences, University of Copenhagen, Frederiksberg, Denmark
| | - Gorm O Greisen
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Per T Sangild
- Comparative Pediatrics and Nutrition, Department of Clinical Veterinary and Animal Science, Faculty of Health and Medical Sciences, University of Copenhagen, Frederiksberg, Denmark Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
| |
Collapse
|
81
|
Botellero VL, Skranes J, Bjuland KJ, Håberg AK, Lydersen S, Brubakk AM, Indredavik MS, Martinussen M. A longitudinal study of associations between psychiatric symptoms and disorders and cerebral gray matter volumes in adolescents born very preterm. BMC Pediatr 2017; 17:45. [PMID: 28143492 PMCID: PMC5286868 DOI: 10.1186/s12887-017-0793-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 01/17/2017] [Indexed: 12/13/2022] Open
Abstract
Background Being born preterm with very low birthweight (VLBW ≤ 1500 g) poses a risk for cortical and subcortical gray matter (GM) abnormalities, as well as for having more psychiatric problems during childhood and adolescence than term-born individuals. The aim of this study was to investigate the relationship between cortical and subcortical GM volumes and the course of psychiatric disorders during adolescence in VLBW individuals. Methods We followed VLBW individuals and term-born controls (birth weight ≥10th percentile) from 15 (VLBW;controls n = 40;56) to 19 (n = 44;60) years of age. Of these, 30;37 individuals were examined longitudinally. Cortical and subcortical GM volumes were extracted from MRPRAGE images obtained with the same 1.5 T MRI scanner at both time points and analyzed at each time point with the longitudinal stream of the FreeSurfer software package 5.3.0. All participants underwent clinical interviews and were assessed for psychiatric symptoms and diagnosis (Schedule for Affective Disorders and Schizophrenia for School-age Children, Children’s Global Assessment Scale, Attention-Deficit/Hyperactivity Disorder Rating Scale-IV). VLBW adolescents were divided into two groups according to diagnostic status from 15 to 19 years of age: persisting/developing psychiatric diagnosis or healthy/becoming healthy. Results Reduction in subcortical GM volume at 15 and 19 years, not including the thalamus, was limited to VLBW adolescents with persisting/developing diagnosis during adolescence, whereas VLBW adolescents in the healthy/becoming healthy group had similar subcortical GM volumes to controls. Moreover, across the entire VLBW group, poorer psychosocial functioning was predicted by smaller subcortical GM volumes at both time points and with reduced GM volume in the thalamus and the parietal and occipital cortex at 15 years. Inattention problems were predicted by smaller GM volumes in the parietal and occipital cortex. Conclusions GM volume reductions in the parietal and occipital cortex as well as smaller thalamic and subcortical GM volumes were associated with the higher rates of psychiatric symptoms found across the entire VLBW group. Significantly smaller subcortical GM volumes in VLBW individuals compared with term-born peers might pose a risk for developing and maintaining psychiatric diagnoses during adolescence. Future research should explore the possible role of reduced cortical and subcortical GM volumes in the pathogenesis of psychiatric illness in VLBW adolescents. Electronic supplementary material The online version of this article (doi:10.1186/s12887-017-0793-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Violeta L Botellero
- Department of Laboratory Medicine, Children's and Women's Health, Norwegian University of Science and Technology, Medical Technology Research Center, P.O. Box 8905, NO-7491, Trondheim, Norway.
| | - Jon Skranes
- Department of Laboratory Medicine, Children's and Women's Health, Norwegian University of Science and Technology, Medical Technology Research Center, P.O. Box 8905, NO-7491, Trondheim, Norway.,Department of Pediatrics, Sørlandet Hospital, Arendal, Norway
| | - Knut Jørgen Bjuland
- Department of Laboratory Medicine, Children's and Women's Health, Norwegian University of Science and Technology, Medical Technology Research Center, P.O. Box 8905, NO-7491, Trondheim, Norway
| | - Asta Kristine Håberg
- Department of Neuroscience, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Medical Imaging, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Stian Lydersen
- Regional Center for Child and Youth Mental Health and Child Welfare, Norwegian University of Science and Technology, Trondheim, Norway
| | - Ann-Mari Brubakk
- Department of Laboratory Medicine, Children's and Women's Health, Norwegian University of Science and Technology, Medical Technology Research Center, P.O. Box 8905, NO-7491, Trondheim, Norway.,Department of Pediatrics, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Marit S Indredavik
- Regional Center for Child and Youth Mental Health and Child Welfare, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Child and Adolescent Psychiatry, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Marit Martinussen
- Department of Laboratory Medicine, Children's and Women's Health, Norwegian University of Science and Technology, Medical Technology Research Center, P.O. Box 8905, NO-7491, Trondheim, Norway.,Department of Gynecology and Obstetrics, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| |
Collapse
|
82
|
Benavente‐Fernandez I, Lubián‐Gutierrez M, Jimenez‐Gomez G, Lechuga‐Sancho AM, Lubián‐López SP. Ultrasound lineal measurements predict ventricular volume in posthaemorrhagic ventricular dilatation in preterm infants. Acta Paediatr 2017; 106:211-217. [PMID: 27783429 DOI: 10.1111/apa.13645] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 10/24/2016] [Indexed: 11/30/2022]
Abstract
AIM Posthaemorrhagic ventricular dilatation (PHVD) is monitored by conventional two-dimensional ultrasound (2DUS). The aims of this study were to determine the volume of the lateral ventricles using three-dimensional ultrasound (3DUS) in preterm infants with PHVD and to evaluate the relationship between volume and linear measurements. METHODS Serial 2DUSs and 3DUSs were performed on preterm infants with PHVD admitted to the neonatal intensive care unit at Puerta del Mar Hospital, Cádiz, Spain, from January 2013 to December 2014. The ventricular index, anterior horn width and thalamo-occipital distance were used as ventricular lineal measurements. Ventricular volume was calculated offline. RESULTS Serial ultrasounds from seven preterm infants were measured. Each linear measurement was significantly associated with volume, and an equation was obtained through a significant multilevel mixed-effects lineal regression model: ventricular volume (cm3 ) = -11.02 + 0.668*VI + 0.817*AHW + 0.256*TOD. Intra-observer and interobserver agreement was excellent with an intraclass correlation coefficient of 0.99. CONCLUSION Lateral ventricular volumes of preterm infants with PHVD could be reliably determined using 3DUS. Ventricular volume could be accurately estimated using three lineal measurements. More studies are needed to address the importance of volume determination in PHVD.
Collapse
Affiliation(s)
- Isabel Benavente‐Fernandez
- Neonatology Department “Puerta del Mar” University Hospital Cadiz Spain
- Fundación Nene (Neonatal Neurology Research Group) Madrid Spain
| | | | | | | | - Simon P. Lubián‐López
- Neonatology Department “Puerta del Mar” University Hospital Cadiz Spain
- Fundación Nene (Neonatal Neurology Research Group) Madrid Spain
| | | |
Collapse
|
83
|
Naud A, Schmitt E, Wirth M, Hascoet JM. Determinants of Indices of Cerebral Volume in Former Very Premature Infants at Term Equivalent Age. PLoS One 2017; 12:e0170797. [PMID: 28125676 PMCID: PMC5268368 DOI: 10.1371/journal.pone.0170797] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 01/11/2017] [Indexed: 01/07/2023] Open
Abstract
Conventional magnetic resonance imaging (MRI) at term equivalent age (TEA) is suggested to be a reliable tool to predict the outcome of very premature infants. The objective of this study was to determine simple reproducible MRI indices, in premature infants and to analyze their neonatal determinants at TEA. A cohort of infants born before 32 weeks gestational age (GA) underwent a MRI at TEA in our center. Two axial images (T2 weighted), were chosen to realize nine measures. We defined 4 linear indices (MAfhlv: thickness of lateral ventricle; CSI: cortex-skull index; VCI: ventricular-cortex index; BOI: bi occipital index) and 1 surface index (VS.A: volume slice area). Perinatal data were recorded. Sixty-nine infants had a GA (median (interquartile range)) of 30.0 weeks GA (27.0; 30.0) and a birth weight of 1240 grams (986; 1477). MRI was done at 41.0 (40.0; 42.0) weeks post menstrual age (PMA). The inter-investigator reproducibility was good. Twenty one MRI (30.5%) were quoted abnormal. We observed an association with retinopathy of prematurity (OR [95CI] = 4.205 [1.231-14.368]; p = 0.017), surgery for patent ductus arteriosus (OR = 4.688 [1.01-21.89]; p = 0.036), early onset infection (OR = 4.688 [1.004-21.889]; p = 0.036) and neonatal treatment by cefotaxime (OR = 3.222 [1.093-9.497]; p = 0.03). There was a difference for VCI between normal and abnormal MRI (0.412 (0.388; 0.429) vs. 0.432 (0.418; 0.449); p = 0,019); BOI was higher when fossa posterior lesions were observed; VS.A seems to be the best surrogate for cerebral volume, 80% of VS.As' variance being explained by a multiple linear regression model including 7 variables (head circumference at birth and at TEA, PMA, dopamine, ibuprofen treatment, blood and platelets transfusions). These indices, easily and rapidly achievable, seem to be useful but need to be validated in a large population to allow generalization for diagnosis and follow-up of former premature infants.
Collapse
Affiliation(s)
- Aurelie Naud
- Department of Neonatology, Maternité Régionale, CHRU NANCY, France
| | | | - Maelle Wirth
- EA 3450 - DevAH, Université de Lorraine, Nancy, France
| | - Jean-Michel Hascoet
- Department of Neonatology, Maternité Régionale, CHRU NANCY, France
- EA 3450 - DevAH, Université de Lorraine, Nancy, France
| |
Collapse
|
84
|
Koo JH, Lee KN, Kim HG, Lee KM, Choi YS. Can Treatment of Patent Ductus Arteriosus with Ibuprofen Compared to Supportive Management Affect Regional Brain Volume in Very Low Birth Weight Infants? A Pilot Study. NEONATAL MEDICINE 2017. [DOI: 10.5385/nm.2017.24.2.83] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Jae Hoe Koo
- Department of Pediatrics, Kyung Hee University School of Medicine, Seoul, Korea
| | - Keum Nho Lee
- Department of Pediatrics, Kyung Hee University School of Medicine, Seoul, Korea
| | - Hyug-Gi Kim
- Department of Radiology, Kyung Hee University School of Medicine, Seoul, Korea
| | - Kyung Mi Lee
- Department of Radiology, Kyung Hee University School of Medicine, Seoul, Korea
| | - Yong-Sung Choi
- Department of Pediatrics, Kyung Hee University School of Medicine, Seoul, Korea
| |
Collapse
|
85
|
Bouyssi-Kobar M, du Plessis AJ, McCarter R, Brossard-Racine M, Murnick J, Tinkleman L, Robertson RL, Limperopoulos C. Third Trimester Brain Growth in Preterm Infants Compared With In Utero Healthy Fetuses. Pediatrics 2016; 138:peds.2016-1640. [PMID: 27940782 PMCID: PMC5079081 DOI: 10.1542/peds.2016-1640] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/23/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Compared with term infants, preterm infants have impaired brain development at term-equivalent age, even in the absence of structural brain injury. However, details regarding the onset and progression of impaired preterm brain development over the third trimester are unknown. Our primary objective was to compare third-trimester brain volumes and brain growth trajectories in ex utero preterm infants without structural brain injury and in healthy in utero fetuses. As a secondary objective, we examined risk factors associated with brain volumes in preterm infants over the third-trimester postconception. METHODS Preterm infants born before 32 weeks of gestational age (GA) and weighing <1500 g with no evidence of structural brain injury on conventional MRI and healthy pregnant women were prospectively recruited. Anatomic T2-weighted brain images of preterm infants and healthy fetuses were parcellated into the following regions: cerebrum, cerebellum, brainstem, and intracranial cavity. RESULTS We studied 205 participants (75 preterm infants and 130 healthy control fetuses) between 27 and 39 weeks' GA. Third-trimester brain volumes were reduced and brain growth trajectories were slower in the ex utero preterm group compared with the in utero healthy fetuses in the cerebrum, cerebellum, brainstem, and intracranial cavity. Clinical risk factors associated with reduced brain volumes included dexamethasone treatment, the presence of extra-axial blood on brain MRI, confirmed sepsis, and duration of oxygen support. CONCLUSIONS These preterm infants exhibited impaired third-trimester global and regional brain growth in the absence of cerebral/cerebellar parenchymal injury detected by using conventional MRI.
Collapse
Affiliation(s)
- Marine Bouyssi-Kobar
- The Developing Brain Research Laboratory, Departments of Diagnostic Imaging and Radiology,,Institute for Biomedical Sciences, George Washington University, Washington, District of Columbia
| | | | - Robert McCarter
- Department of Epidemiology and Biostatistics, Children’s National Health System, Washington, District of Columbia
| | - Marie Brossard-Racine
- Department of Pediatrics Neurology, Montreal Children’s Hospital–McGill University Health Center, Montreal, Quebec, Canada; and
| | - Jonathan Murnick
- The Developing Brain Research Laboratory, Departments of Diagnostic Imaging and Radiology
| | - Laura Tinkleman
- The Developing Brain Research Laboratory, Departments of Diagnostic Imaging and Radiology
| | - Richard L. Robertson
- Department of Radiology, Children’s Hospital Boston/Harvard Medical School, Boston, Massachusetts
| | | |
Collapse
|
86
|
The motor profile of preterm infants at 11 y of age. Pediatr Res 2016; 80:389-94. [PMID: 27074125 DOI: 10.1038/pr.2016.90] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 03/03/2016] [Indexed: 11/08/2022]
Abstract
BACKGROUND Preterm infants are at a higher risk for poor motor outcome than term infants. This study aimed to describe the long-term motor profile in very preterm born children. METHODS A total of 98 very preterm infants were included. Volumetric brain magnetic resonance imaging (MRI) was performed at term age, and the Movement Assessment Battery for Children-Second Edition (The Movement ABC-2) was employed at 11 y of age. The diagnosis of Developmental Coordination Disorder (DCD) was determined at 11 y of age according to the International Classification of Diseases. RESULTS Eighty-two of 98 (84%) very preterm infants had normal motor development at 11 y of age. In these children, the mean percentile for the total test score in the Movement ABC-2 examinations was 42 (SD 20). Eight (8%) children had DCD. The mean percentile in these children was 4 (SD 2). Eight (8%) children had CP. Their mean percentile was 6 (SD 14). Decreased volumes in all brain regions associated with lower Movement ABC-2 total scores. CONCLUSION The majority of the very preterm infants had normal motor development at 11 y of age. Volumetric brain MRI at term age provides a potential tool to identify risk groups for later neuromotor impairment.
Collapse
|
87
|
Jeong HJ, Shim SY, Cho HJ, Cho SJ, Son DW, Park EA. Cerebellar Development in Preterm Infants at Term-Equivalent Age Is Impaired after Low-Grade Intraventricular Hemorrhage. J Pediatr 2016; 175:86-92.e2. [PMID: 27283462 DOI: 10.1016/j.jpeds.2016.05.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 04/04/2016] [Accepted: 05/04/2016] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To investigate cerebellar development in preterm infants at term-equivalent age compared with healthy full-term infants and to examine the effect of a low-grade intraventricular hemorrhage (IVH) on cerebellar development. STUDY DESIGN This study used 3T magnetic resonance and diffusion tensor imaging (DTI) at 36-41 weeks' postmenstrual age (PMA) in 72 preterm infants without severe brain injury and 16 full-term infants. Cerebellar volumes and DTI parameters of the cerebellar peduncles including fractional anisotropy (FA), apparent diffusion coefficient (ADC), axial diffusivity, and radial diffusivities were measured. Clinical variables that may affect brain development were collected. RESULTS Compared with full-term infants, preterm infants showed smaller cerebellar volumes and a lower FA, greater ADC, and increased radial diffusivities in the cerebellar peduncles (all P < .05). This cerebellar impairment was associated significantly with PMA and IVH grade 2 but was independent of gestational age at birth. When we adjusted for clinical variables, an IVH grade 2 was related with 1.73 cm(3) reduction in cerebellar volumes and altered DTI parameters in the cerebellar peduncles, including decreased FA and increased radial diffusivities in the superior cerebellar peduncle and increases in ADC, axial diffusivity, and radial diffusivities of the middle cerebellar peduncle (all P < .05). Cerebellar hemispheric volumes were associated with both ipsilateral and contralateral IVH grade 2. CONCLUSION Preterm infants without severe brain abnormalities showed impaired cerebellar development at term-equivalent age after we controlled for PMA at the time of the scan, and this is associated with IVH grade 2. These findings suggest that even a low-grade IVH has potential harmful effects on cerebellar development.
Collapse
Affiliation(s)
- Hye Jin Jeong
- Neuroscience Research Institute, Gachon University, Incheon, Korea
| | - So-Yeon Shim
- Division of Neonatology, School of Medicine, Ewha Womans University, Seoul, Korea.
| | - Hye Jung Cho
- Division of Neonatology, Gachon University, Gil Hospital, Incheon, Korea
| | - Su Jin Cho
- Division of Neonatology, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Dong Woo Son
- Division of Neonatology, Gachon University, Gil Hospital, Incheon, Korea
| | - Eun Ae Park
- Division of Neonatology, School of Medicine, Ewha Womans University, Seoul, Korea
| |
Collapse
|