Outcome at 14 years of extremely low birthweight infants: a regional study

An algorithm for identifying and classifying cerebral palsy in young children

OBJECTIVE

To develop an algorithm on the basis of data obtained with a reliable, standardized neurological examination and report the prevalence of cerebral palsy (CP) subtypes (diparesis, hemiparesis, and quadriparesis) in a cohort of 2-year-old children born before 28 weeks gestation.

STUDY DESIGN

We compared children with CP subtypes on extent of handicap and frequency of microcephaly, cognitive impairment, and screening positive for autism.

RESULTS

Of the 1056 children examined, 11.4% (120) were given an algorithm-based classification of CP. Of these children, 31% had diparesis, 17% had hemiparesis, and 52% had quadriparesis. Children with quadriparesis were 9 times more likely than children with diparesis (76% versus 8%) to be more highly impaired and 5 times more likely than children with diparesis to be microcephalic (43% versus 8%). They were more than twice as likely as children with diparesis to have a score <70 on the mental scale of the BSID-II (75% versus 34%) and had the highest rate of the Modified Checklist for Autism in Toddlers positivity (76%) compared with children with diparesis (30%) and children without CP (18%).

CONCLUSION

We developed an algorithm that classifies CP subtypes, which should permit comparison among studies. Extent of gross motor dysfunction and rates of co-morbidities are highest in children with quadriparesis and lowest in children with diparesis.

An overview of mortality and sequelae of preterm birth from infancy to adulthood

Survival rates have greatly improved in recent years for infants of borderline viability; however, these infants remain at risk of developing a wide array of complications, not only in the neonatal unit, but also in the long term. Morbidity is inversely related to gestational age; however, there is no gestational age, including term, that is wholly exempt. Neurodevelopmental disabilities and recurrent health problems take a toll in early childhood. Subsequently hidden disabilities such as school difficulties and behavioural problems become apparent and persist into adolescence. Reassuringly, however, most children born very preterm adjust remarkably well during their transition into adulthood. Because mortality rates have fallen, the focus for perinatal interventions is to develop strategies to reduce long-term morbidity, especially the prevention of brain injury and abnormal brain development. In addition, follow-up to middle age and beyond is warranted to identify the risks, especially for cardiovascular and metabolic disorders that are likely to be experienced by preterm survivors.

Associations of birth size, gestational age, and adult size with intellectual performance: evidence from a cohort of Norwegian men

The influences of prenatal and postnatal growth on intellectual performance are unclear. We examined the associations of birth size and gestational age with intellectual performance and explored whether these associations were influenced by adult body size and social factors. In this nationwide cohort study, the records of 317,761 male infants registered in the Medical Birth Registry of Norway (1967-1979) were linked to the Norwegian Conscript Service (1984-1999). The variation in intelligence test score at age 18 due to birth weight and birth length was evaluated using absolute and standardized (z scores) values. Mean intelligence score increased by gestational age, birth weight, and birth length. However, a decline in intellectual performance was observed for gestational age >41 wk and birth weight >4500 g. There was a strong interaction on intellectual performance between birth size and gestational age (p < 0.0005). Adjusting for adult size strongly attenuated the association of birth size with intellectual performance. The overall R of intellectual performance explained by birth size was <1%; however, adding adult body size and social factors to the model increased R to 12%. In conclusion, the association of birth size with intellectual performance was weak, but still present after adjustment for adult body size and social factors.

Clinical data predict neurodevelopmental outcome better than head ultrasound in extremely low birth weight infants

OBJECTIVE

To determine the relative contribution of clinical data versus head ultrasound scanning (HUS) in predicting neurodevelopmental impairment (NDI) in extremely low birth weight infants.

STUDY DESIGN

A total of 2103 extremely low birth weight infants (<1000 g) admitted to a National Institute of Child Health and Human Development Neonatal Research Network center who underwent HUS within the first 28 days, a repeat one around 36 weeks' postmenstrual age, and neurodevelopmental assessment at 18 to 22 months corrected age were selected. Multivariate logistic regression models were developed with clinical or HUS variables. The primary outcome was the predictive abilities of the HUS performed before 28 days after birth and closer to 36 weeks postmenstrual age, either alone or in combination with "Early" and "Late" clinical variables.

RESULTS

Models with clinical variables alone predicted NDI better than models with only HUS variables at both 28 days and 36 weeks (both P < .001), and the addition of the HUS data did not improve prediction. NDI was absent in 30% and 28% of the infants with grade IV intracranial hemorrhage or periventricular leukomalacia, respectively, but was present in 39% of the infants with a normal HUS result.

CONCLUSIONS

Clinical models were better than HUS models in predicting neurodevelopment.

Etiologies of hearing impairment among infants and toddlers: 1986-1987 versus 2001

OBJECTIVE

This study compares etiological factors for hearing loss, relevant neuro-sensory impairments and demographics between two groups of children referred for early hearing habilitation in Israel. Group I was referred in the years 1986-1987 (n=73) and group II was referred during 2001 (n=73).

METHODS

Family history, pregnancy, risk factors, developmental milestones, medical history, auditory brainstem response, tympanometry, otoacoustic emissions and behavioral audiometric results were retrospectively retrieved in 2003 from medical records at the MICHA Society for Deaf Children in Israel.

RESULTS

New referrals per year have doubled themselves over the 15 years that elapsed between 1986-1987 and 2001. No changes in gender and age at time of admission were found. The prevalence of mild-to-moderate hearing loss was higher in Group II while severe and profound hearing loss was more prevalent in Group I. Assisted reproductive technologies were involved only in Group II. There were more twin births and post-natal hypoxia in Group II. Rh incompatibility was reported only in Group I. Severe hearing loss was associated with younger age at admission. No significant associations were found between age at admission and etiology with the exception of the fact that children with genetic background were admitted at an earlier age. Since no significant association between genetic background and severity of hearing loss was found, it is conclude that the association between severity of hearing loss and age at admission did not account for changes in etiology in our sample.

CONCLUSIONS

Classic risk factors for hearing loss among infants and toddlers have not changed much over time, and the few changes that have been noticed are probably due to expanded medical knowledge and improved technologies.

Newborns at risk for special education placement: a population-based study

OBJECTIVES

To establish the contributions of birth weight (BW), gender, socioeconomic status (SES), and parental age on risks for special education (SE) placements in school-age children.

METHODS

A population-based sample of 900 school-age children attending the following full-time SE groups: at level 1, children had isolated neurodevelopmental, physical, or other impairments; at level 2, borderline to mild intellectual disability (ID); and at level 3, moderate to severe ID. Three hundred and one children enrolled in mainstream education formed the control group (level 0). For all children with siblings, we defined familiar forms of learning disorders as having a sibling in one of the SE groupings. We performed our analysis for the entire cohort as well as comparing risk factors within the familial and non-familial types of SE groupings.

RESULTS

In multinomial logistic regression analysis, age of father 40 years, low BW (<2500g or <-2 SD), male sex, and parent's lower SES, all increased the probability of SE placement. In the familial forms of levels 2 and 3, the parental SES was lower and, in addition, in the level 2, the family size was bigger. Furthermore, in the non-familial form of level 2, both the low and the high (4000g) BW were more common.

CONCLUSIONS

Among the known risk factors for learning disabilities (LD), our study highlighted the importance of a higher paternal age and a lower SES especially in the familial forms of LD.

Neurodevelopmental outcome in extremely low birth weight infants: what is the minimum age for reliable developmental prognosis?

AIM

We present a longitudinal study on the neurodevelopmental outcome in preterm infants with extremely low birth weight <1000 g (ELBW) to answer the question at which age a developmental prognosis can be given.

METHODS

A group of 129 ELBW, median birth weight: 794 g (SD 123 g), gestational age: 27.0 weeks (SD 2.0 weeks), born between 1993 and 1998, were followed up to the age between 6 and 10 years (mean 8.5 years [SD 1.7 years]) and evaluated by neurodevelopmental and psychometric tests. The status of children without cerebral palsy was ranked into categories of major, minor and no developmental impairments.

RESULTS

At the time of the last follow-up examination 17% of the children showed a major impairment including 9% cerebral palsy, 42% a minor impairment and 41% were normally developed. The longitudinal analysis of cases without cerebral palsy reveals that an assessment 'at term' can only give the correct developmental prognosis in 49% of the cases. At the corrected age of 12 months the prognosis is correct in 59% of the cases, whereas at the corrected age of 3 years 70% proves to be right. Diagnosis of cerebral palsy could be confirmed at the corrected age of 2 years with sufficient reliability.

CONCLUSION

The neurodevelopmental evaluation of former preterm infants with a birth weight <1000 g demands a follow-up period of at least 6 years in order to make reliable statements. We are doubtful that follow-up testing completed prior to this age can yield reliable results.

Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth

BACKGROUND

Respiratory distress syndrome (RDS) is a serious complication of preterm birth and the primary cause of early neonatal mortality and disability.

OBJECTIVES

To assess the effects on fetal and neonatal morbidity and mortality, on maternal mortality and morbidity, and on the child in later life of administering corticosteroids to the mother before anticipated preterm birth.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 October 2005).

SELECTION CRITERIA

Randomised controlled comparisons of antenatal corticosteroid administration (betamethasone, dexamethasone, or hydrocortisone) with placebo or with no treatment given to women with a singleton or multiple pregnancy, expected to deliver preterm as a result of either spontaneous preterm labour, preterm prelabour rupture of the membranes or elective preterm delivery.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trial quality and extracted data independently.

MAIN RESULTS

Twenty-one studies (3885 women and 4269 infants) are included. Treatment with antenatal corticosteroids does not increase risk to the mother of death, chorioamnionitis or puerperal sepsis. Treatment with antenatal corticosteroids is associated with an overall reduction in neonatal death (relative risk (RR) 0.69, 95% confidence interval (CI) 0.58 to 0.81, 18 studies, 3956 infants), RDS (RR 0.66, 95% CI 0.59 to 0.73, 21 studies, 4038 infants), cerebroventricular haemorrhage (RR 0.54, 95% CI 0.43 to 0.69, 13 studies, 2872 infants), necrotising enterocolitis (RR 0.46, 95% CI 0.29 to 0.74, eight studies, 1675 infants), respiratory support, intensive care admissions (RR 0.80, 95% CI 0.65 to 0.99, two studies, 277 infants) and systemic infections in the first 48 hours of life (RR 0.56, 95% CI 0.38 to 0.85, five studies, 1319 infants). Antenatal corticosteroid use is effective in women with premature rupture of membranes and pregnancy related hypertension syndromes.

AUTHORS' CONCLUSIONS

The evidence from this new review supports the continued use of a single course of antenatal corticosteroids to accelerate fetal lung maturation in women at risk of preterm birth. A single course of antenatal corticosteroids should be considered routine for preterm delivery with few exceptions. Further information is required concerning optimal dose to delivery interval, optimal corticosteroid to use, effects in multiple pregnancies, and to confirm the long-term effects into adulthood.

Neonatology fellowship training in research pertaining to development and follow-up

The methodology of the study of the short- and long-term outcomes has changed over the 30-40 years since the indroduction of neonatal intensive care. The training of neonatal fellows in research pertaining to development and follow-up currently needs to include study of epidemiology and biostatistics, knowledge concerning normal and abnormal growth and development throughout the life span and clinical skills and/or knowledge concerning the assessment of neurologic and developmental outcomes.

Teenagers born at extremely low birth weight

Adolescence constitutes a major transition for extremely low birth weight (ELBW) teenagers. Recent studies of ELBW teenagers born in the 1980s have provided information about the growth and developmental characteristics of these individuals in adolescence and in early adulthood. ELBW teenagers are shorter and lighter than their full-term peers, and have a smaller head circumference. Cognitive and academic vulnerabilities documented during the school years, particularly difficulties with nonverbal intelligence and arithmetic, persist into late adolescence. Many ELBW children struggle in school and have lower academic achievement levels. The self-concept of ELBW teenagers is generally similar to that of their full-term peers, but their parents perceive them to be more vulnerable over a wide range of behavioural and psychosocial dimensions, particularly depression and attention. ELBW teenagers perceive themselves as needing more assistance in job seeking than do their peers. Physical activity levels and fitness in late adolescence are significantly lower in ELBW teenagers than in their full-term peers, constituting a potential additional health hazard in later life. The outcomes of ELBW teenagers are significantly influenced by socioeconomic, family and parenting factors.

Neurodevelopmental follow-up after preterm birth: follow up after two years

Marked differences are seen in neurological and health status, intellectual functioning, school performance and behaviour between children born prematurely and those born at term. Assessment in later childhood has identified more subtle problems than the severe disability or sensory deficits readily identifiable at two years. These problems include learning disabilities, specific neuropsychological deficits in executive function, difficulties in visual-motor integration and perception, selective language impairment, motor coordination disorders, behaviour problems, attention deficit hyperactivity disorder (ADHD), and reduced educational achievement. Follow-up to school entry and beyond is thus required to determine the true prevalence and nature of the neurodevelopmental problems arising from preterm birth. Consensus about the assessment used, definitions of disability and health status, age of assessment and who undertakes it are necessary and should allow comparison across populations; this may help to maximise outcomes for children clearly at biological risk. Assessment of outcome for children born preterm beyond two years is required for counselling parents, planning health and education provision, for evaluation of services and to facilitate understanding of the longer term effects of preterm birth on brain development.

Poor predictive validity of the Bayley Scales of Infant Development for cognitive function of extremely low birth weight children at school age

OBJECTIVE

The Bayley Scales of Infant Development, Second Edition (BSID II) are commonly used to assess outcomes of extremely low birth weight (ELBW) infants. We sought to assess the predictive validity of the BSID II Mental Developmental Index (MDI) for cognitive function at school age.

DESIGN/METHODS

Of 330 ELBW infants admitted in 1992-1995, 238 (72%) survived to the age of 8 years, of whom 200 (84%) were tested at both 20 months' corrected age (CA) and 8 years. Mean birth weight was 811 g, mean gestational age was 26.4 weeks, 41% were boys, and 60% were black. Measures included the BSID II at 20 months' CA and the Kaufman Assessment Battery for Children (KABC) Mental Processing Composite (MPC) at 8 years' postnatal age. BSID II MDI and MPC scores were compared and the predictive validity calculated for all 200 ELBW children and for the 154 ELBW neurosensory-intact subgroup. Predictors of stability or change in cognitive scores were examined via logistic regression adjusting for gender and sociodemographic status.

RESULTS

For all ELBW children, the mean MDI was 75.6 +/- 16 versus a mean KABC of 87.8 +/- 19. For the neurosensory-intact subgroup, the mean MDI was 79.3 +/- 16 and the mean KABC was 92.3 +/- 15. Rates of cognitive impairment, defined as an MDI or KABC of <70, dropped from 39% at 20 months' CA to 16% at 8 years for the total ELBW population and from 29% to 7% for the neurosensory-intact subgroup. The positive predictive value of having an MPC of <70 given an MDI of <70 was 0.37 (95% confidence interval [CI]: 0.27, 0.49) for all ELBW infants, 0.20 (95% CI: 0.10, 0.35) for the neurosensory-intact subgroup, and 0.61 (95% CI: 0.42, 0.77) for the neurosensory-impaired subgroup. The negative predictive values were 0.98, 0.99, and 0.85 for the 3 groups, respectively. Neurosensory impairment at 20 months' CA predicted lack of improvement of cognitive function (odds ratio: 6.9; 95% CI: 2.4, 20.2). Children whose cognitive scores improved between 20 months and 8 years had significantly better school performance than those whose scores stayed at <70, but they did less well than those whose scores were persistently >70.

CONCLUSIONS

The predictive validity of a subnormal MDI for cognitive function at school age is poor but better for ELBW children who have neurosensory impairments. We are concerned that decisions to provide intensive care for ELBW infants in the delivery room might be biased by reported high rates of cognitive impairments based on the use and presumptive validity of the BSID II MDI.

Neurodevelopmental outcomes of premature infants treated with inhaled nitric oxide

BACKGROUND

Chronic lung disease and severe intraventricular hemorrhage or periventricular leukomalacia in premature infants are associated with abnormal neurodevelopmental outcomes. In a previous randomized, controlled, single-center trial of premature infants with the respiratory distress syndrome, inhaled nitric oxide decreased the risk of death or chronic lung disease as well as severe intraventricular hemorrhage and periventricular leukomalacia. We hypothesized that infants treated with inhaled nitric oxide would also have improved neurodevelopmental outcomes.

METHODS

We conducted a prospective, longitudinal follow-up study of premature infants who had received inhaled nitric oxide or placebo to investigate neurodevelopmental outcomes at two years of corrected age. Neurologic examination, neurodevelopmental assessment, and anthropometric measurements were made by examiners who were unaware of the children's original treatment assignment.

RESULTS

A total of 138 children (82 percent of survivors) were evaluated. In the group given inhaled nitric oxide, 17 of 70 children (24 percent) had abnormal neurodevelopmental outcomes, defined as either disability (cerebral palsy, bilateral blindness, or bilateral hearing loss) or delay (no disability, but one score of less than 70 on the Bayley Scales of Infant Development II), as compared with 31 of 68 children (46 percent) in the placebo group (relative risk, 0.53; 95 percent confidence interval, 0.33 to 0.87; P=0.01). This effect persisted after adjustment for birth weight and sex, as well as for the presence or absence of chronic lung disease and severe intraventricular hemorrhage or periventricular leukomalacia. The improvement in neurodevelopmental outcome in the group given inhaled nitric oxide was primarily due to a 47 percent decrease in the risk of cognitive impairment (defined by a score of less than 70 on the Bayley Mental Developmental Index) (P=0.03).

CONCLUSIONS

Premature infants treated with inhaled nitric oxide have improved neurodevelopmental outcomes at two years of age.

Extremely low birthweight neonates with protracted ventilation: mortality and 18-month neurodevelopmental outcomes

OBJECTIVE

To compare duration of ventilation to mortality and adverse neurodevelopmental outcomes among extremely low birth weight (ELBW; 501-1000 g) infants.

STUDY DESIGN

Retrospective analysis of prospectively collected data from 5364 infants with a birthweight of 501 to 1000 g born at National Institute of Child Health and Human Development (NICHD) Neonatal Research Network centers from 1995 to 1998. The main outcome measures were: survival, duration of mechanical ventilation, and neurodevelopmental outcome.

RESULTS

Overall survival was 71%. The median duration of ventilation for survivors was 23 days; 75% were free of mechanical ventilation by 39 days, and 7% were ventilated for > or = 60 days. Of those ventilated for > or = 60 days, 24% survived without impairment. Of those ventilated for > or = 90 days, only 7% survived without impairment. Of those ventilated > or = 120 days, all survivors were impaired.

CONCLUSIONS

The prognosis for ELBW with protracted ventilation remains grim. The cohort who remain intubated have diminished survival and high rates of impairment. Parents of these infants should be informed of changes in prognosis as the time of ventilation increases.

Neonatal antecedents for cerebral palsy in extremely preterm babies and interaction with maternal factors

BACKGROUND

Preterm delivery is associated with an increased risk of cerebral palsy (CP). The greatest risk is for infants born <28 weeks' gestation.

AIMS

To identify significant neonatal risk factors for CP and explore the interactions between antenatal and neonatal risk factors, among extremely preterm infants of 27 weeks' gestation or less.

STUDY DESIGN

Nested case control design.

METHODS

Infants born between 1989 and 1996, at 24-27 weeks' gestation, were evaluated: 30 with CP at 2 years corrected age and 120 control infants matched for gestation age. Neonatal variables were compared using matched analyses with the interaction between antenatal and neonatal factors being examined using logistic regression analyses.

RESULTS

Risk factors for CP on matched analyses included patent ductus arteriosus requiring surgical ligation, peri-intraventricular haemorrhage, moderate to severe ventricular dilatation, periventricular leukomalacia (PVL) and need for home oxygen. Independent neonatal predictors were ventricular dilatation (OR 7.3; 95% CI 1.6, 32.3), PVL (OR 29.8; 95% CI 5.6, 159.1) and home oxygen use (OR 3.4; 95% CI 1.2, 9.4). No interaction terms in the logistic models were significant between the previously identified pregnancy risk factors of absence of antenatal steroids and intrauterine growth restriction and the neonatal risk factors.

CONCLUSIONS

PVL is the most powerful independent predictor of CP in extremely preterm infants of 27 weeks' gestation or less and appears to be uninfluenced by antenatal factors.

Outcome at 7 years of children diagnosed with autism at age 2: predictive validity of assessments conducted at 2 and 3 years of age and pattern of symptom change over time

OBJECTIVE

To examine the predictive validity of symptom severity, cognitive and language measures taken at ages 2 and 3 years to outcome at age 7 in a sample of children diagnosed with autism at age 2.

METHOD

Twenty-six children diagnosed with autism at age 2 were re-assessed at ages 3 and 7 years. At each age symptom severity, cognitive and language assessments were completed.

RESULTS

The pattern of autistic symptom severity varied over time by domain. Across time, children moved across diagnostic boundaries both in terms of clinical diagnosis and in terms of instrument diagnosis on the Autism Diagnostic Interview-Revised (ADI-R). On all measures group variability in scores increased with age. Although non-verbal IQ (NVIQ) for the group as a whole was stable across the 3 assessments, this masked considerable individual instability. Standard assessments at age 2 did not predict outcome at age 7 even within the same domain of functioning. In contrast, standard assessments at age 3 did predict outcome. However, a measure of rate of non-verbal communicative acts taken from an interactive play-based assessment at age 2 was significantly associated with language, communication and social outcomes at age 7.

CONCLUSIONS

The trajectory of autism symptoms over time differed in different domains, suggesting that they may be, at least in part, separable. Variability in language, NVIQ and symptom severity increased over time. Caution is required when interpreting the findings from assessments of children with autism at age 2 years. At this age measures of rate of non-verbal communication might be more informative than scores on standard psychometric tests. Predictive validity of assessments at age 3 years was greater.

Rezeptive und produktive Sprachentwicklungsleistungen frühgeborener Kinder im Alter von zwei Jahren

Zusammenfassung. Ziel der vorliegenden Studie war eine standardisierte Bestimmung des Sprachentwicklungsstands frühgeborener Kinder im Alter von 2 Jahren. Stichprobe: 39 Frühgeborene (geb. 1999) ohne schwere neurologische Auffälligkeiten, die postnatal im Rahmen eines neonatologisch erbetenen Konsils zur Hördiagnostik an die Abt. Phoniatrie/Pädaudiologie am Universitätsklinikum Göttingen überwiesen und als normalhörig befundet worden waren (Click-BERA). Mittl. Gestationsalter: 30,46 Wochen (Min 25, Max 34), mittl. Geburtsgewicht: 1342,18 g (Min 390, Max 2590 g). Methode: Entwicklungsanamnese und Sprachentwicklungstest für 2-jährige Kinder (SETK-2; Grimm, 2000 ), Ergebnisdarstellung in T-Werten (T-W; M = 50, SD = 10). Ergebnisse: Der Sprechbeginn erster Worte war kaum (durchschnittlich mit 14,7 ± 3,8 Monaten), der Beginn der 2-Wort-Kombination etwas verzögert (durchschnittlich mit 21,2 ± 4,3 Monaten). Die durchschnittlichen Leistungen im SETK-2 lagen fast alle im Normbereich. Wortverstehen war am besten ausgebildet (T-W: 52,7 ± 12,7), gefolgt vom Satzverstehen (T-W: 48,1 ± 12,4) und von der Wortproduktion (T-W: 43,6 ± 12,9). Die Satzproduktion dagegen lag deutlich unter der Altersnorm (T-W: 37,9 ± 9,8). Biologische Parameter der Frühgeburt wie Gestationsalter oder Geburtsgewicht korrelierten nicht signifikant mit den SETK-2-Ergebnissen. Extremgruppen-Vergleiche nach biologischer Risikobelastung zeigten keine signifikanten Unterschiede in den Sprachleistungen, hingegen bzgl. des Zeitpunkts des freien Laufens und der 2-Wort-Kombination für die Gruppen mit extrem niedrigem Geburtsgewicht bzw. extrem niedrigen Gestationsalter. Subgruppenvergleiche (Jungen vs. Mädchen, Einzelkinder vs. Geschwisterkinder, Kinder von Müttern mit niedrigem vs. hohem Bildungsabschluss) deckten ebenfalls keine statistisch relevanten Unterschiede in den Ergebnissen des SETK-2 auf bis auf eine Ausnahme: Ältere Kinder (30-35 Monate alt) zeigten bessere Verstehensleistungen als jüngere. Fazit: Frühgeburtlichkeit geht nicht zwangsläufig mit geminderten Sprachentwicklungsleistungen im 2. Altersjahr einher, was die Komplexität von Entwicklungsleistungen betont. Deckeneffekte (Wortverstehen, Wortproduktion) wie auch ein Bodeneffekt (Satzproduktion) im SETK-2 können allerdings niedrige Korrelationen bewirkt haben.

Psychosocial and academic characteristics of extremely low birth weight (< or =800 g) adolescents who are free of major impairment compared with term-born control subjects

OBJECTIVE

To compare academic and cognitive ability, attention, attitudes, and behavior of extremely low birth weight (ELBW) adolescents who are free of major impairments at 17 years of age with term-born control subjects.

METHODS

Between January 31, 1981, and February 9, 1986, 250 infants of < or =800 g were admitted for intensive care in British Columbia, 98 (39%) of whom survived to late adolescence. Teens with major sensorimotor handicaps and/or IQ <70 were excluded (n = 19). Of the 79 eligible ELBW teens, 53 (67%) were assessed at 17.3 (16.3-19.7) years (birth weight: 720 [520-800 g]; gestation: 26 [23-29] weeks). The test battery screened the following areas: cognitive (Wechsler Intelligence Scale for Adults Third Edition, 3 subtests), academic (Wide Range Achievement Test-3), attention (Connors' Continuous Performance Task), self-report (Harter Self-Perception Profile for Adolescents; Job Search Attitude Inventory), and parent report (Child Behavior Check List). A comparison group of term born control subjects (n = 31) were also assessed (birth weight: 3506 [3068-4196] g; gestation: 40 [39-42] weeks) at age 17.8 (16.5-19.0) years. Multivariate analysis of variance (group x gender) was conducted for each domain (cognitive, academic, self-report, and parent report).

RESULTS

The ELBW group showed lower cognitive scores (vocabulary, block design, and digit symbol) and academic skills (reading and arithmetic) compared with control subjects, with no gender differences. There were no differences in attention between the 2 groups using a repetitive computer task. ELBW teens reported lower scholastic, athletic, job competence, and romantic confidence and viewed themselves as more likely to need help from others in finding a job. In the behavioral domain, parents reported their ELBW teens to display more internalizing, more externalizing, and more total problems than the control teens, with ELBW boys showing more problems. ELBW teens showed a higher percentage of clinically significant behavior problems than control subjects.

CONCLUSIONS

In a provincial cohort of unimpaired survivors of birth weight < or =800 g, psychosocial and educational vulnerabilities persist into late adolescence and may complicate the transition to adult life compared with their peers.

Outcome of extremely-low-birth-weight infants at highest risk: gestational age < or =24 weeks, birth weight < or =750 g, and 1-minute Apgar < or =3

OBJECTIVE

The purpose of this study was to evaluate neurodevelopmental outcome in extremely-low-birth-weight (ELBW) infants, all of whom had 3 characteristics: gestational age (GA) < or =24 weeks, birth weight < or =750 g, and 1-minute Apgar score < or =3.

STUDY DESIGN

Surviving infants were evaluated at 18 to 22 months' corrected age with a neurologic examination and the Bayley II Mental and Psychomotor Developmental Index (MDI and PDI).

RESULTS

Between 1993 and 1999, 1016 infants had GA < or =24 weeks, birth weight < or =750 g, and 1-minute Apgar score < or =3. Of 246 survivors, 30% had cerebral palsy (CP), 5% had hearing impairment, and 2% were blind. MDI was > or =85 in 33% and < 70 in 46% of infants, while PDI was > or =85 in 41% and < 70 in 36% infants. Predictors of MDI < 70 were grade III-IV ICH, cystic periventricular leukomalacia (PVL), male gender, black race, and Medicaid insurance. Two-parent household was associated with an MDI >70. Predictors of PDI < 70 were grade III-IV ICH, PVL, steroids for bronchopulmonary dysplasia (BPD), and Medicaid insurance. CP was associated with grade III-IV ICH and PVL.

CONCLUSION

Perinatologists and neonatologists should be aware of the risk of morbidity and mortality in this high-risk ELBW group.

Larger corpus callosum size with better motor performance in prematurely born children

The objective of this study is to determine the relation between the size of the corpus callosum (CC) and motor performance in a population-based cohort of preterm children. Preterm born children (n = 221) with a gestational age less than or equal to 32 weeks and/or a birth weight below 1500 g were eligible for this study. At the age of 7 or 8 years, frontal, middle, posterior, and total areas (mm2) of the corpus callosum were measured on true midsagittal MRI. Due to anxiety of 10 children and motion artifacts in 7 other children, 204 MRIs could be assessed in the preterm group (mean GA 29.4 weeks, sd 2.0,mean BW 1200 g, sd 323). The preterm group consisted of 15 children with cerebral palsy (CP) and 189 children without CP. Motor function was established by using the Movement Assessment Battery for Children, and the Developmental Test of Visual Motor Integration was obtained. The same examinations were performed in 21 term born children. The mean total cross-sectional CC area was significantly smaller in preterm born infants compared with their term born controls (338 mm2 versus 422 mm2, P < 0.0001). The preterm children with CP had significantly smaller mean CC areas compared with the preterms who did not develop CP (P < 0.0001-P < 0.002). However, the preterms born without CP also had significantly smaller body, posterior, and total CC areas compared with term born controls (P < 0.0001-P < 0.002). Only the difference in frontal area measurements dilrc) -3.3 mm2/score point (95% CI -4.5, -2.1). The association existed in all parts of the CC but increased in the direction of the posterior part: frontal: lrc -0.8 mm2/score point (-1.2, -0.4), middle: lrc -1.1 mm2/score point (-1.7, -0.5) and posterior: lrc -1.4 mm2/score point (-1.8, -0.9). An association between CC area and its subareas and the standard scores of the VMI was also found. A larger CC was strongly related t o better scores onthe VMI test total area CC: lrc 0.05 score/mm2 (95% CI 0.03, 0.07), frontal: lrc 0.12 score/mm2 (0.05,0.19), middle: lrc 0.10 score/mm2 (0.05, 0.15) and posterior: lrc 0.12 score/mm2 (0.06, 0.18). After adjustment for gestational age, birth weight, and total cerebral area, these associations were still significant. There is a strong association between the size of the corpus callosum (total midsagittal cross area as well as frontal, middle, and posterior area) and motor function in preterm children, investigated at school age. A poorer score on the Movement ABC was related to a smaller CC. A larger CC was strongly associated with better VMI standard scores.

Regionalized long-term follow-up

The importance of population-based long-term follow-up studies of geographically determined cohorts to evaluate the effectiveness, efficiency and availability of a regionalized perinatal-neonatal care programme is demonstrated by the Victorian Infant Collaborative Study Group. The survival and quality of survival of consecutively born extremely-low-birthweight infants below 1000 g or extremely preterm infants below 28 weeks' gestation in the state of Victoria were assessed up to 14 years of age over four distinctive eras: 1979-1989, 1985-1987, 1991-1992 and 1997. Both survival and quality-adjusted survival rates rose progressively in all birth weight and gestation subgroups, associated with progressively more such infants being born in level III perinatal centres. Cost-effectiveness and cost-utility ratios remained stable overall, with efficiency gains in the smaller infants over time. Regionalized long-term follow-up provides unique information that is not available from institution-based studies, which is vital to the regional organization of perinatal-neonatal care.

Annual summary of vital statistics--2002

The crude birth rate in 2002 was 13.9 births per 1000 population, the lowest ever reported for the United States. The number of births, the crude birth rate, and the fertility rate (64.8) all declined slightly (by 1% or less) from 2001 to 2002. Fertility rates were highest for Hispanic women (94.0), followed by black (65.4), Asian or Pacific Islander (63.9), Native American (58.0), and non-Hispanic white women (57.5). Fertility rates declined slightly for all race/ethnic groups from 2001 to 2002. The birth rate for teen mothers continued to fall, dropping 5% from 2001 to 2002 to 42.9 births per 1000 women aged 15 to 19 years, another record low. The teen birth rate has fallen 31% since 1991; declines were more rapid for younger teens aged 15 to 17 (40%) than for older teens aged 18 to 19 (23%). The proportion of all births to unmarried women remained approximately the same at one third. Smoking during pregnancy continued to decline; smoking rates were highest among teen mothers. In 2002, 26.1% of births were delivered by cesarean section, up 7% since 2001 and 26% since 1996. The primary cesarean rate has risen 23% since 1996, whereas the rate of vaginal birth after a previous cesarean delivery has fallen 55%. The use of timely prenatal care increased slightly to 83.8% in 2002. From 1990 to 2002, the use of timely prenatal care increased by 6% (to 88.7%) for non-Hispanic white women, by 24% (to 75.2%) for black women, and by 28% (to 76.8%) for Hispanic women, thus narrowing racial disparities. The percentage of preterm births rose to 12.0% in 2002, from 10.6% in 1990 and 9.4% in 1981. Increases were largest for non-Hispanic white women. The percentage of low birth weight (LBW) births also increased to 7.8% in 2002, up from 6.7% in 1984. Twin and triplet/+ birth rates both increased by 3% from 2000 to 2001. Multiple births accounted for 3.2% of all births in 2001. The infant mortality rate (IMR) was 6.9 per 1000 live births (provisional data) in 2002 compared with 6.8 in 2001 (final data). The ratio of the IMR among black infants to that for white infants was 2.5 in 2001, the same as in 2000. Racial differences in infant mortality remain a major public health concern. The role of LBW in infant mortality remains a major issue. New Hampshire, Utah, and Massachusetts had the lowest IMRs. State-by-state differences in IMR reflect racial composition, the percentage of LBW, and birth weight-specific neonatal mortality rates for each state. The United States continues to rank poorly in international comparisons of infant mortality. Expectation of life at birth reached a record high of 77.2 years for all sex and race groups combined in 2001. Death rates in the United States continue to decline. Between 2000 and 2001, death rates declined for the 3 leading causes of death: diseases of the heart, malignant neoplasms, and cerebrovascular diseases. Death rates for children ages 1 to 19 years decreased for unintentional injuries by 3.3% in 2001; the death rate for chronic lower respiratory diseases decreased by 25% in 2001. Cancer and suicide levels did not change for children ages 1 to 19. A large proportion of childhood deaths continue to occur as a result of preventable injuries.

Health and school performance of teenagers born before 29 weeks gestation

OBJECTIVE

To ascertain the health and school performance of teenagers born before 29 weeks gestation (extremely low gestational age (ELGA)) and to compare those in mainstream school with classroom controls.

METHODS

Three geographically defined cohorts of babies born in 1983 and 1984 were traced at the age of 15-16 years. Their health, abilities, and educational performance were ascertained using postal questionnaires to the teenagers themselves, their parents, their general practitioners, and the teachers of those in mainstream school. Identical questionnaires were sent to classroom controls.

RESULTS

Of the 218 teenagers surviving to the age of 16 years, information was obtained on 179. Of these, 29 were in special schools and 150 in mainstream school, 10 of whom had severe motor or sensory impairment. Using the Child Health Questionnaire, parents of teenagers in mainstream school reported a higher incidence of problems than controls in physical functioning (difference in mean scores 9.0 (95% confidence interval (CI) 4.9 to 13.1)) and family life (difference in mean scores for family cohesion 7.0 (95% CI 1.6 to 12.4)). In all areas of learning, teachers rated the ability of the ELGA teenagers in mainstream school lower than the control group. Parents of teenagers in special schools reported a higher rate of problems in most areas.

CONCLUSIONS

One in six ELGA survivors at age 16 years have severe disabilities and are in special schools. Most ELGA survivors are in mainstream school and are coping well as they enter adult life, although some will continue to need additional health, educational, and social services.

Measuring functional outcomes after prematurity: developmental impact of very low birth weight and extremely low birth weight status on childhood disability

Our purpose was to describe functional outcomes in essential activities in preschool, school-age, and adolescent children who were born very (<32 weeks gestation) and extremely (<28 weeks gestation) prematurely. Very low birth weight (VLBW; 1000-1499 g), or extremely low birth weight (ELBW;<1000 g) populations are the focus of our analysis. We describe models of disablement and enablement for specifying the complexity of childhood outcomes using a framework of pathophysiology, impairment, functional limitation and functional strengths, disability in social roles and social participation, societal limitations and environmental facilitators. Representative early childhood, preschool, school-age, and adolescent studies were examined in terms of describing children's functional strengths and challenges after VLBW and ELBW survival. In early childhood, disability was assessed by diagnosing neurosensory impairments and delays on developmental testing. Instruments for measuring functional status in essential activities of self-care, mobility, communication and learning are described. Rates of neurosensory disability in the first three years among recent ELBW survivors ranged from 9-26% for cerebral palsy, 1-15% for blindness, 0-9% for deafness, and 6-42% for evolving cognitive disability (MDI <70). Rates of preschool functional limitation were 5-27% motor, 5-30% self-care, and 5-22% communicative. Rates of school-age functional educational disabilities exceeded 50%. Rates of adolescent activity limitation were 13-32% and vocational limitations were 27-71%. By examining the functional strengths and challenges of children with major neurodevelopmental impairments after very or extremely preterm birth, we can examine causal pathways that lessen the risk of severe functional disability. Among children with mild to moderate disability, we can enhance functional outcomes, optimize community participation, and provide quality family supports. In order to assess the changing outcomes of this vulnerable population of survivors, combinations of clinical and survey based methodologies are required.

Patterns of motor disability in very preterm children

Motor development in very preterm children differs in several important ways from that of children born at full term. Variability is common, although the anatomic and physiologic bases for that variability are often poorly understood. Motor patterns over the first postnatal year may depend on behaviours learned during often long periods of neonatal intensive care. The normal pattern of development may be modified by disturbances of brain function caused both by the interruption of normal brain maturation ex-utero and the superimposition of focal brain injuries following very preterm birth. Abnormal patterns of development over the first year may evolve into clear neuromotor patterns of cerebral palsy or resolve, as "transient dystonias." Cerebral palsy is associated with identified patterns of brain injury secondary to ischaemic or haemorrhagic lesions, perhaps modified by activation of inflammatory cytokines. Cerebral palsy rates have not fallen as might be expected over the past 10 years as survival has improved, perhaps because of increasing survival at low gestations, which is associated with the highest prevalence of cerebral palsy. Children who escape cerebral palsy are also at risk of motor impairments during the school years. The relationship of these impairments to perinatal factors or to neurological progress over the first postnatal year is debated. Neuromotor abnormalities are the most frequent of the "hidden disabilities" among ex-preterm children and are thus frequently associated with poorer cognitive ability and attention deficit disorders. Interventions to prevent cerebral palsy or to reduce these late disabilities in very preterm children are needed.

School-age outcomes of very low birth weight infants in the indomethacin intraventricular hemorrhage prevention trial

OBJECTIVE

The cohort consisted of 328 very low birth weight infants (600-1250 g birth weight) who were enrolled in the low-dose prophylactic indomethacin prevention trial and were intraventricular hemorrhage (IVH) negative at 6 postnatal hours. The objective was to determine the effects of both IVH and indomethacin on cognitive, language, and achievement performance at 8 years of age.

METHODS

The cohort was divided into 4 subgroups for analysis: indomethacin plus IVH, indomethacin no IVH, saline plus IVH, and saline with no IVH. The children were evaluated prospectively at 8 years of age with a neurologic assessment, history of school performance, and a battery of cognitive, academic, behavioral, and functional assessments.

RESULTS

Children in both IVH groups had more cerebral palsy; more hearing impairment; lower daily living skills scores; lower IQ, vocabulary, and reading and mathematics achievement test scores; and greater educational resource needs. With logistic regression analyses grade 3 to 4 IVH, periventricular leukomalacia and/or ventriculomegaly, male gender, maternal education, and language spoken in the home contributed to outcomes. No effects of indomethacin or gestational age were identified.

CONCLUSIONS

Although biological factors including IVH, ventriculomegaly, and periventricular leukomalacia contribute significantly to school age outcomes among very low birth weight survivors at 8 years of age, social and environmental factors including maternal level of education and primary language spoken in the home are also important contributors to outcome.

Cognitive and behavioral deficits in premature graduates of intensive care

A substantial number of VLBW graduates of intensive care develop cognitive and behavioral problems, even in the absence of neuroimaging abnormalities. Although this article has highlighted the potential, important, contributing role of medical and stressful, neonatal, environmental conditions to the development of these deficits, it is not all-encompassing, and there are additional prenatal (ie, in utero stress, drug exposure) and neonatal (ie, infectious) contributing factors. The long-term, outcome data presented in this article are pertinent to the more mature, VLBW infant, and it remains unclear and critically important to delineate the long-term, neurobehavioral outcome of those extremely low birth-weight survivors born at the cutting limit of viability.

Annual summary of vital statistics--2001

The number of births, the crude birth rate (14.5 in 2001), and the fertility rate (67.2 in 2001) all declined slightly (by 1% or less) from 2000 to 2001. Fertility rates were highest for Hispanic women (107.4), followed by Native American (70.7), Asian or Pacific Islander (69.4), black (69.3), and non-Hispanic white women (58.0). During the early to mid 1990s, fertility declined for non-Hispanic white, black, and American Indian women. Rates for these population groups have changed relatively little since 1995; however, fertility has increased for Asian or Pacific Islander and Hispanic women. The birth rate for teen mothers continued to fall, dropping 5% from 2000 to 2001 to 45.9 births per 1000 females aged 15 to 19 years, another record low. The teen birth rate has fallen 26% since 1991; declines were more rapid (35%) for younger teens aged 15 to 17 years than for older teens aged 18 to 19 years (20%). The proportion of all births to unmarried women remained about the same at one-third. Smoking during pregnancy continued to decline; smoking rates were highest among teen mothers. The use of timely prenatal care increased slightly to 83.4% in 2001. From 1990 to 2001, the use of timely prenatal care increased by 6% (to 88.5%) for non-Hispanic white women, by 23% (to 74.5%) for black women, and by 26% (to 75.7%) for Hispanic women. The number and rate of twin births continued to rise, but the triplet/+ birth rate declined for the second year in a row. For the first year in almost a decade, the preterm birth rate declined (to 11.6%); however, the low birth weight rate was unchanged at 7.6%. The total cesarean delivery rate jumped 7% from 2000 to 2001 to 24.4% of all births, the highest level reported since these data became available on birth certificates (1989). The primary cesarean rate rose 5%, whereas the rate of vaginal birth after a previous cesarean delivery tumbled 20%. In 2001, the provisional infant mortality rate was 6.9 per 1000 live births, the same as in 2000. Racial differences in infant mortality remain a major public health concern, with the rate for infants of black mothers 2.5 times those for infants of non-Hispanic white or Hispanic mothers. In 2000, 66% of all infant deaths occurred among the 7.6% of infants born low birth weight. Among all states, Maine and Massachusetts had the lowest infant mortality rates. The United States continues to rank poorly in international comparisons of infant mortality. The provisional death rate in 2001 was 8.7 deaths per 1000 population, the same as the 2000 final rate. In 2000, unintentional injuries and homicide remained the leading and second-leading causes of death for children 1 to 19 years of age, although the death rate for homicide decreased by 10% from 1999 to 2000. Among unintentional injuries to children, two-thirds were motor vehicle-related; among homicides, two-thirds were firearm-related.

Longitudinal, 15-year follow-up of children born at less than 29 weeks' gestation after introduction of surfactant therapy into a region: neurologic, cognitive, and educational outcomes

OBJECTIVE

To measure the primary and secondary school-age neurologic, cognitive, and educational outcomes in a cohort of extremely premature infants born after the introduction of exogenous surfactant therapy in a circumscribed region.

METHODS

Two hundred thirteen infants born at <29 weeks' gestation were cared for at a regional referral center during 1985-1987. At primary school age, neurologic and cognitive outcomes, educational achievement, school placement, health status, and socioeconomic status were determined by follow-up visit. At secondary school age, school placement and health status were evaluated by telephone interview.

RESULTS

One hundred thirty-two infants survived to school age, of whom 127 (96%) were evaluated in 1992-1995 and 126 (95%) were evaluated in 2000. Mean ages were 7.0 years at first follow-up and 14.1 years at second follow-up. At primary-school age follow-up, 19 children (15%) had cerebral palsy, 24 (19%) had a general cognitive index <70, and 41 (32%) were placed in a self-contained, special classroom. Thirty-nine children (31%) had no physical or educational impairment, whereas 27 (21%) had at least 1 severe disability. At secondary school age, cerebral palsy incidence remained unchanged, whereas 36 children (29%) were placed in a special classroom. Fifty-one children (41%) had no physical or educational impairment, whereas 24 (19%) had at least 1 severe disability. Neonatal intraventricular hemorrhage and low socioeconomic status were the strongest predictors of adverse outcomes.

CONCLUSIONS

Premature infants born in the surfactant era remain at high risk of neurodevelopmental compromise. Although many of these children do well, a significant minority will require intensive special educational services through secondary school age.