Neurodevelopmental outcome of the premature infant

Predictors of 2-year cognitive performance after laser surgery for twin-twin transfusion syndrome

OBJECTIVE

The purpose of this study was to determine risk factors for poor cognitive performance among children who are treated with in utero selective laser photocoagulation of communicating vessels for twin-twin transfusion syndrome.

STUDY DESIGN

This was a prospectively enrolled cohort study. Cognitive performance at age 2 years (±6 weeks) was assessed with the Battelle Developmental Inventory 2nd Edition (BDI-2). Multilevel regression models evaluated risk factors for poor cognitive performance at shared (pregnancy) and individual (child) levels. In addition to development, blindness, deafness, and cerebral palsy were assessed based on physical examination. A priori power analysis determined that a sample of ≥100 children was required for adequate statistical power (0.80).

RESULTS

One hundred children (57 families) were evaluated. Total BDI-2 score was within normal range (mean, 101.3 ± [SD]12.2); 1 child had a BDI-2 score of <70. Individual child-level risk factors for lower BDI-2 included male sex (β = -0.37; P < .01), lower head circumference (β = 0.28; P < .01), and higher diastolic blood pressure (β = -0.29; P < .01). At the pregnancy level, lower maternal education (β = 0.60; P < .001), higher Quintero stage (β = -0.36; P < .01), and lower gestational age at birth (β = 0.30; P < .01) were associated with worse cognitive outcomes. Donor/recipient status, gestational age at surgery, fetal growth restriction, and co-twin fetal death were not risk factors. The rate of neurodevelopmental impairment (blindness, deafness, cerebral palsy, and/or a BDI-2 score <70) was 4%.

CONCLUSION

Overall cognitive performance quotients were in the normal range, with risk factors for poor outcomes seen at the pregnancy and child levels. Clinical and socioeconomic characteristics can identify at-risk children who need additional interventions.

Omega-3 Fatty acids and gestational length in a high-risk psychiatric population due to psychiatric morbidity and medication exposure during pregnancy

OBJECTIVE

Premature birth is associated with infant morbidity and mortality. Women with psychiatric disorders represent an at-risk population for premature delivery and other obstetrical complications. The primary aim of this study was to assess the association between omega-3 fatty acid use and length of gestation.

METHODS

Data from the National Pregnancy Registry for Atypical Antipsychotics were used. This prospective study included pregnant women exposed and unexposed to atypical antipsychotics during pregnancy. The outcomes of gestational length, birth weight, and preeclampsia were examined in relation to omega-3 use during pregnancy. Omega-3 use was operationalized from a first-trimester interview as a dichotomous variable.

RESULTS

Of 361 women who were examined for eligibility, 233 women had a singleton birth as well as a valid response on the omega-3 item and information on at least one of the outcome measures. Ninety-seven (41.6%) women used omega-3 during pregnancy. Omega-3 users were older, more educated, and more likely to be married than nonusers. The users were less likely to have smoked during their first trimester and were marginally less likely to use antidepressant medications anytime during pregnancy. There were no significant differences in primary diagnoses or atypical antipsychotic, alcohol, or prenatal vitamin use. In an unadjusted model, there was a significant increase of between 4 and 5 days (0.65 weeks; 0.00-1.25) in gestational length among the omega-3 users. This result was no longer significant after adjusting for confounding variables, with an increase of approximately 4 days (0.53 weeks; -0.11 to 1.16). Omega-3 use was not significantly associated with a difference in birth weight or preeclampsia.

CONCLUSIONS

We found a trend for a modestly increased length of gestation among the omega-3 fatty acid users, although these were not significant after controlling for the exposures of smoking and antidepressant use. We did not find a decreased risk for preeclampsia among the users of omega-3 fatty acids or increased birth weight. In consideration of the risk factors for obstetrical and neonatal complications as well as implications for infant and child development, it would be clinically important to understand the variables that may additively decrease obstetrical risks in this population.

Bilateral hearing loss is associated with decreased nonverbal intelligence in US children aged 6 to 16 years

OBJECTIVES/HYPOTHESIS

To evaluate the association between hearing loss and nonverbal intelligence in US children.

STUDY DESIGN

The Third National Health and Nutrition Examination Survey (NHANES III) is a cross-sectional survey (1988-1994) that used complex multistage sampling design to produce nationally representative demographic and examination data.

METHODS

A total of 4,823 children ages 6 to 16 years completed audiometric evaluation and cognitive testing during NHANES III. Hearing loss was defined as low-frequency pure-tone average (PTA) >25 dB (0.5, 1, 2 kHz) or high-frequency PTA >25 dB (3, 4, 6, 8 kHz) and was designated as unilateral or bilateral. Nonverbal intelligence was measured using the Wechsler Intelligence Scale for Children-Revised block design subtest. Low nonverbal intelligence was defined as a standardized score <4, two standard deviations below the standardized mean of 10.

RESULTS

Mean nonverbal intelligence scores differed between children with normal hearing (9.59) and children with bilateral (6.87; P = .02) but not unilateral (9.12; P = .42) hearing loss. Non-Hispanic black race/ethnicity and family income <$20,000 were associated with 3.92 and 1.67 times higher odds of low nonverbal intelligence, respectively (odds ratio [OR]: 3.92; P < .001; OR: 1.67; P = .02). Bilateral hearing loss was independently associated with 5.77 times increased odds of low nonverbal intelligence compared to normal hearing children (OR: 5.77; P = .02). Unilateral hearing loss was not associated with higher odds of low nonverbal intelligence (OR: 0.73; P = .40).

CONCLUSIONS

Bilateral but not unilateral hearing loss is associated with decreased nonverbal intelligence in US children. Longitudinal studies are urgently needed to better understand these associations and their potential impact on future opportunities.

Neuroprotective effects of erythropoiesis-stimulating agents in term and preterm neonates

PURPOSE OF REVIEW

The use of erythropoiesis-stimulating agents (ESAs) such as erythropoietin and darbepoetin in preterm and term infants has been studied for over 20 years. Recent investigations have explored the potential neuroprotective effects of ESAs. We review the recent clinical trials and experimental animal models that provide evidence in support of using ESA to improve the neurodevelopmental outcomes in term and preterm infants.

RECENT FINDINGS

Continued work using animal models have confirmed the neuroprotective properties of ESAs, including promotion of oligodendrocyte development in the face of neuronal injury. Clinical studies in term and preterm infants have reported the neuroprotective effects following ESA administration, and improved neurodevelopmental outcomes have been reported in the studies of preterm infants.

SUMMARY

ESAs show great promise in preventing and treating brain injury in term and preterm infants.

Validation of a brain MRI relaxometry protocol to measure effects of preterm birth at a flexible postnatal age

BACKGROUND

Magnetic resonance imaging (MRI) is a useful tool to study brain growth and organization in preterm neonates for clinical and research purposes, but its practicality can be limited by time and medical constraints. The aim of this study was to determine if MRI relaxometry of the deep nuclei, as opposed to white matter, would reflect the influence of gestational age at birth on structures essential to motor development, regardless of postnatal age at the time of imaging.

RESULTS

This was a prospective observational study of infants without brain injury on conventional neuroimaging who were cared for in the neonatal intensive care unit (NICU) at Vanderbilt. Infants were studied using MRI relaxometry within a 2-month window of postmenstrual term age. In 45 infants, white matter MRI T1 relaxation times were influenced by both gestational age and postnatal age at imaging time (R(2) = 0.19 for gestational age vs. R(2) = 0.34 adjusting for both gestational age and age at imaging; all p < 0.01). Similar results were obtained with T2 relaxation times. In contrast, globus pallidus T1 reflected gestational age but was minimally affected by postnatal age (R(2) = 0.50 vs. 0.57, p < 0.001).

CONCLUSIONS

The results obtained using this imaging protocol are consistent with the slow maturation of the globus pallidus, essential to normal development of complex motor programs into adulthood. Globus pallidus MRI relaxometry measures the impact of gestational age at birth on brain development independent of postnatal age in preterm infants and should prove useful for predictive modeling in a flexible time-window around postmenstrual term age.

Randomized outcome trial of nutrient-enriched formula and neurodevelopment outcome in preterm infants

Background

Preterm infants are at risk for adverse neurodevelopment. Furthermore, nutrition may play a key role in supporting neurodevelopment. The aim of this study was to evaluate whether a nutrient-enriched formula fed to preterm infants after hospital discharge could improve their neurodevelopment at 24 months (term-corrected age).

Methods

We conducted an observer-blinded, single-center, randomized controlled trial in infants admitted to the Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, University of Milan, Italy between 2009 and 2011. Inclusion criteria were gestational age < 32 weeks and/or birth weight < 1500 g, and being fed human milk for < 20% of the total milk intake. Exclusion criteria were congenital malformations or conditions that could interfere with growth or body composition. Included infants were randomized to receive a standard full-term formula or a nutrient-enriched formula up until 6 months of corrected age, using two computer-generated randomization lists; one appropriate for gestational age (AGA) and one for small for gestational age (SGA) infants. We assessed neurodevelopment at 24 months of corrected age using the Griffiths Mental Development Scale and related subscales (locomotor, personal-social, hearing and speech, hand and eye coordination, and performance).

Results

Of the 207 randomized infants, 181 completed the study. 52 AGA and 35 SGA infants were fed a nutrient-enriched formula, whereas 56 AGA and 38 SGA infants were fed a standard full-term formula. The general quotient at 24 months of corrected age was not significantly different between infants randomized to receive a nutrient-enriched formula compared with a standard term formula up until 6 months of corrected age (AGA infants: 93.8 ± 12.6 vs. 92.4 ± 10.4, respectively; SGA infants: 96.1 ± 9.9 vs. 98.2 ± 9, respectively). The scores of related subscales were also similar among groups.

Conclusions

This study found that feeding preterm infants a nutrient-enriched formula after discharge does not affect neurodevelopment at 24 months of corrected age, in either AGA or SGA infants, free from major comorbidities.

Trial registration

Current Controlled Trials (http://www.controlled-trials.com/ISRCTN30189842) London, UK.

Impact of the NICU environment on language deprivation in preterm infants

It is unclear whether the atypical language development commonly seen in preterm infants is a consequence of language deficiency experienced during their prolonged NICU stay. This review provides a novel viewpoint, which highlights the potential impact of the NICU design on the developmental origin of language disabilities in preterm infants.

CONCLUSION

Further research is needed to identify evidence-based design solutions for providing preterm infants with a healthier linguistic hospital environment that aids growth and development.

Behavior and well-being of extremely low birth weight teenagers in Iceland

BACKGROUND

Preterm children are at risk for behavioral and emotional problems.

AIMS

To evaluate behavior and emotional well-being of extremely low birth weight (ELBW) teenagers born in Iceland in 1991-1995.

METHODS

Participants, 30 of 35 ELBW survivors (25 girls, 5 boys, mean age 16.8 years), were interviewed, underwent medical examination and answered the Youth Self-Report for ages 11-18 (YSR) of the Achenbach System of Empirically Based Assessment (ASEBA). The ELBW parents answered the ASEBA Child Behavior Checklist for ages 6-18 and the Autism Spectrum Screening Questionnaire (ASSQ). A comparison group of 30 teenagers (23 girls, 7 boys, mean age 16.5 years) answered the YSR questionnaire and their parents answered the CBCL and ASSQ questionnaires.

RESULTS

ELBW teenagers and parents report more behavior problems than the full term comparison teenagers and parents. They score significantly higher on the YSR and CBCL syndrome scales except for YSR and CBCL rule-breaking behavior and CBCL thought problems. The ELBW teenagers self-report on total competence, activities, social participation and academic performance was not significantly lower than the comparison teenagers. Parents of ELBW teenagers rated total competence, social participation and school performance of their children significantly lower than parents of comparison teenagers. The YSR Positive Qualities Scale was not significantly different between the two teenage groups. Two ELBW teenagers scored above cut-off points on the ASSQ questionnaire and none of the comparison teenagers. Bullying was reported by 20% of ELBW parents compared to none of the comparison group.

CONCLUSION

ELBW teenagers experience emotional, behavior and social challenges. The teenagers value their positive qualities, activities and academic performance similar to peers.

A comparison between late preterm and term infants on breastfeeding and maternal mental health

The objective of this study was to compare breastfeeding, postpartum mental health, and health service utilization between a group of late preterm (LP) maternal infant pairs and term counterparts. Data was drawn from a prospective community-based cohort in Calgary, Alberta. Bivariate and multivariable analyses were performed. LP infants were more likely to have had a longer median length of stay after birth (P < 0.001) and a higher re-hospitalization rate at 4-months (P < 0.001) compared to term infants. Mothers of LP infants were more likely to report immediate breastfeeding difficulties (P < 0.001) and earlier cessation of breastfeeding at 4-months postpartum (P = 0.008). Multivariable analyses revealed that LP status was an independent risk factor for excessive symptoms of maternal anxiety (OR = 2.07; 95 % CI = 1.08,3.98), but not for depression, stress, or low parenting morale. LP infants and their families are a vulnerable population with unique developmental trajectories. Further longitudinal research is required.

Cortical speech sound differentiation in the neonatal intensive care unit predicts cognitive and language development in the first 2 years of life

AIM

Neurodevelopmental delay in childhood is common in infants born preterm, but is difficult to predict before infants leave the neonatal intensive care unit (NICU). We hypothesized that event-related potential (ERP) methodology characterizing the cortical differentiation of speech sounds in hospitalized infants would predict cognitive and language outcomes during early childhood.

METHODS

We conducted a prospective study of 57 infants in NICU (34 male, gestational age at birth 24-40wks), quantifying the amplitude of ERP responses to speech sounds before discharge (median gestational age 37.1wks), followed by standardized neurodevelopmental assessments at 12 months and 24 months. Analyses were performed using ordinary least squares linear regression.

RESULTS

Overall validity of constructs using all ERP variables, as well as sex, maternal education, gestational age, and age at ERP, was good and allowed significant prediction of cognitive and communication outcomes at 12 months and 24 months (R(2) =22-42%; p<0.05). Quantitative models incorporating specific ERPs, gestational age, and age at ERP explained a large proportion of the variance in cognition and receptive language on the Bayley Scales of Infant Development at 24 months (R(2) >50%; p<0.05).

INTERPRETATION

This study establishes ERP methodology as a valuable research tool to quantitatively assess cortical function in the NICU and to predict meaningful outcomes in early childhood.

Prediction of spontaneous preterm labour in at-risk pregnant women

The ability to recognise women who are at-risk of preterm labour (PTL) is often difficult. Over 50% of women who are identified with factors associated with an increased risk of preterm birth will ultimately deliver at term. The cervicovaginal fluid (CVF) comprises a range of proteins secreted by gestational tissues, making it an ideal candidate for the screening of differentially expressed proteins associated with PTL. CVF samples were collected from at-risk asymptomatic women. Two-dimensional gel electrophoresis techniques were used to examine the CVF proteome of women who spontaneously delivered preterm 11-22 days later compared with gestation-matched women who delivered at term. Five candidate biomarkers were selected for further validation in a larger independent cohort of asymptomatic women. Thioredoxin (TXN) and interleukin 1 receptor antagonist (IL1RN) concentrations in the CVF were found to be significantly reduced up to 90 days prior to spontaneous PTL compared with women who subsequently delivered at term. TXN was able to predict spontaneous PTL within 28 days after sampling with a high positive predictive value (PPV) and negative predictive value (NPV) of 75.0% and 96.4% respectively. IL1RN also showed comparable PPV and NPV of 72.7% and 95.7% respectively. The discovery of these differentially expressed proteins may assist in the development of a new predictive bedside test in identifying asymptomatic women who have an increased risk of spontaneous PTL.

Breastfeeding difficulties and exclusivity among late preterm and term infants: results from the all our babies study

OBJECTIVE

To compare breastfeeding difficulties attributable to the baby and mother/milk and exclusive breastfeeding between a group of late preterm (LP) infants and term infants.

METHODS

We utilized data from a prospective community-based cohort (n=2977) in Calgary, Alberta, and performed bivariate and multivariable analyses to identify demographic, obstetric, maternal and infant health indicators that were independently associated with term status and breastfeeding outcomes.

RESULTS

Multivariable analyses found that LP status was an independent risk factor for breastfeeding difficulties attributable to the baby (OR 1.72, 95% CI 1.24-2.38), but not for difficulties due to mother/milk (defined as not producing enough milk or having flat or inverted nipples). Among women who were breastfeeding at hospital discharge, mothers of LP infants were less likely to report exclusive breastfeeding at 4 months (OR 0.67, 95% CI 0.46-0.97), after controlling for household income level, mode of delivery and postpartum maternal physical health.

CONCLUSIONS

Mothers of LP infants need increased support to establish successful breastfeeding outcomes and to ensure that these infants receive the full benefits of breast milk.

The early prediction of neonatal morbidity and mortality in singleton small for gestational age infants with a birthweight < 1,500 g

OBJECTIVE

Identify factors for discrimination of "high" and "low risk" small for gestational age infants.

STUDY DESIGN

Singleton infants born small for gestational age with a birthweight  <1,500 g between 1999 and 2007 were included. Maternal, placental, and infant related factors were analyzed with regard to mortality and morbidity. Patients who died or suffered from complications were defined "high risk" as opposed to "low risk". Parameters associated with "high risk" were identified and an equation established to predict the minimal expected probability to die or suffer from neonatal morbidity.

RESULTS

Around 231 patients showed a mortality rate of 12.6 %, respiratory distress syndrome in 35.5 %, necrotizing enterocolitis in 8.2 % and neurological morbidities in 6.5 %. Of these, 58.9 % survived without complications. The factors for discrimination of "high" and "low risk" were Z-score of birth weight, gestational age, and pH.

CONCLUSION

We facilitate prognostication by classifying small for gestational age preterms into "low" and "high risk".

Re-evaluating preterm infants with the Bayley-III: patterns and predictors of change

This study investigates the Third Edition of the Bayley Scales of Infant and Toddler Development (Bayley-III) and (1) mean difference scores, (2) test-retest correlation coefficients, (3) changes in rates of delay and classification from "delayed" to "not delayed," and (4) infant birth, neonatal and sociodemographic predictors of change in scores from the first to second year of life among 131 preterm infants. Cognitive, Receptive Language and Fine Motor Subscale scores decrease and mean Gross Motor Subscale scores remain consistent from the first to second year of life. Bayley-III test-retest reliability ranged from small/fair to moderate from 8 to 20 months corrected age. Classification of delay is not stable over the first two years of life. One in 6 infants' Language Index scores changed from a classification of not delayed at 8 months to delayed at 20 months. One in 10 infants' Gross Motor Subscale scores changed from a classification of delayed at 8 months to not delayed at 20 months. Small for gestational age status predicts improved to nearly consistent Bayley Language Index and Receptive Subscale scores. Public insurance and history of sepsis predict decline in Bayley Language Index and Receptive Subscale scores from 8 to 20 months. Lower gestational age, race, and history of necrotizing enterocolitis and/or intestinal perforation also predict decline in Bayley Cognitive Index from 8 to 20 months. Predictors of decline in performance confirm known neonatal risk factors, are consistent with emerging evidence of detrimental immune related processes, and highlight the importance of inclusion of sociodemographic variables in understanding development in preterm infants.

Brain development in infants born preterm: looking beyond injury

Infants born very preterm are high risk for acquired brain injury and disturbances in brain maturation. Although survival rates for preterm infants have increased in the last decades owing to improved neonatal intensive care, motor disabilities including cerebral palsy persist, and impairments in cognitive, language, social, and executive functions have not decreased. Evidence from neuroimaging studies exploring brain structure, function, and metabolism has indicated abnormalities in the brain development trajectory of very preterm-born infants that persist through to adulthood. In this chapter, we review neuroimaging approaches for the identification of brain injury in the preterm neonate. Advances in medical imaging and availability of specialized equipment necessary to scan infants have facilitated the feasibility of conducting longitudinal studies to provide greater understanding of early brain injury and atypical brain development and their effects on neurodevelopmental outcome. Improved understanding of the risk factors for acquired brain injury and associated factors that affect brain development in this population is setting the stage for improving the brain health of children born preterm.

The Ethics of Neonatal Resuscitation

Decisions about initiating resuscitation are often based on the best-interest principle, which considers the chance of survival, pain of attempted resuscitation, and subsequent benefits or burdens that continued living with potential disability may bring. For neonates at 23–25 weeks gestation, this decision is difficult given the uncertain prognosis. It is thus reasonable to defer to parental wishes given that the family has to bear the burden of taking care of the child. Adequate and early antenatal counselling is important to enable parents to make an informed decision. Further studies of local long-term outcomes are needed to identify better markers for outcomes to help guide resuscitation decisions.

Neonatal sepsis due to coagulase-negative staphylococci

Neonates, especially those born prematurely, are at high risk of morbidity and mortality from sepsis. Multiple factors, including prematurity, invasive life-saving medical interventions, and immaturity of the innate immune system, put these infants at greater risk of developing infection. Although advanced neonatal care enables us to save even the most preterm neonates, the very interventions sustaining those who are hospitalized concurrently expose them to serious infections due to common nosocomial pathogens, particularly coagulase-negative staphylococci bacteria (CoNS). Moreover, the health burden from infection in these infants remains unacceptably high despite continuing efforts. In this paper, we review the epidemiology, immunological risk factors, diagnosis, prevention, treatment, and outcomes of neonatal infection due to the predominant neonatal pathogen CoNS.

A systematic review of tests to predict cerebral palsy in young children

AIM

This systematic review evaluates the accuracy of predictive assessments and investigations used to assist in the diagnosis of cerebral palsy (CP) in preschool-age children (<5 y).

METHOD

Six databases were searched for studies that included a diagnosis of CP validated after 2 years of age. The validity of the studies meeting the criteria was evaluated using the Standards for Reporting Diagnostic Accuracy criteria. Where possible, results were pooled and a meta-analysis was undertaken.

RESULTS

Nineteen out of 351 studies met the full inclusion criteria, including studies of general movements assessment (GMA), cranial ultrasound, brain magnetic resonance imaging (MRI), and neurological examination. All studies assessed high-risk populations including preterm (gestational range 23-41 wks) and low-birthweight infants (range 500-4350 g). Summary estimates of sensitivity and specificity of GMA were 98% (95% confidence interval [CI] 74-100%) and 91% (95% CI 83-93%) respectively; of cranial ultrasound 74% (95% CI 63-83%) and 92% (95% CI 81-96%) respectively; and of neurological examination 88% (95% CI 55-97%) and 87% (95% CI 57-97%) respectively. MRI performed at term corrected age (in preterm infants) appeared to be a strong predictor of CP, with sensitivity ranging in individual studies from 86 to 100% and specificity ranging from 89 to 97% There was inadequate evidence for the use of other predictive tools.

SUMMARY

This review found that the assessment with the best evidence and strength for predictive accuracy is the GMA. MRI has a good predictive value when performed at term-corrected age. Cranial ultrasound is as specific as MRI and has the advantage of being readily available at the bedside. Studies to date have focused on high-risk infants. The accuracy of these tests in low-risk infants remains unclear and requires further research.

A phase II randomized clinical trial on cerebral near-infrared spectroscopy plus a treatment guideline versus treatment as usual for extremely preterm infants during the first three days of life (SafeBoosC): study protocol for a randomized controlled trial

Background

Every year in Europe about 25,000 infants are born extremely preterm. These infants have a 20% mortality rate, and 25% of survivors have severe long-term cerebral impairment. Preventative measures are key to reduce mortality and morbidity in an extremely preterm population. The primary objective of the SafeBoosC phase II trial is to examine if it is possible to stabilize the cerebral oxygenation of extremely preterm infants during the first 72 hours of life through the application of cerebral near-infrared spectroscopy (NIRS) oximetry and implementation of an clinical treatment guideline based on intervention thresholds of cerebral regional tissue saturation rStO₂.

Methods/Design

SafeBoosC is a randomized, blinded, multinational, phase II clinical trial. The inclusion criteria are: neonates born more than 12 weeks preterm; decision to conduct full life support; parental informed consent; and possibility to place the cerebral NIRS oximeter within 3 hours after birth. The infants will be randomized into one of two groups. Both groups will have a cerebral oximeter monitoring device placed within three hours of birth. In the experimental group, the cerebral oxygenation reading will supplement the standard treatment using a predefined treatment guideline. In the control group, the cerebral oxygenation reading will not be visible and the infant will be treated according to the local standards. The primary outcome is the multiplication of the duration and magnitude of rStO₂ values outside the target ranges of 55% to 85%, that is, the ‘burden of hypoxia and hyperoxia’ expressed in ‘%hours’. To detect a 50% difference between the experimental and control group in %hours, 166 infants in total must be randomized. Secondary outcomes are mortality at term date, cerebral ultrasound score, and interburst intervals on an amplitude-integrated electroencephalogram at 64 hours of life and explorative outcomes include neurodevelopmental outcome at 2 years corrected age, magnetic resonance imaging at term, blood biomarkers at 6 and 64 hours after birth, and adverse events.

Discussion

Cerebral oximetry guided interventions have the potential to improve neurodevelopmental outcome in extremely preterm infants. It is a logical first step to test if it is possible to reduce the burden of hypoxia and hyperoxia.

Trial registration

ClinicalTrial.gov, NCT01590316

No improvement in socioeconomic inequalities in birthweight and preterm birth over four decades: a population-based cohort study

BACKGROUND

Birthweight and gestational age are associated with socioeconomic deprivation, but the evidence in relation to temporal changes in these associations is sparse. We investigated changes in the associations between socioeconomic status (SES) and birthweight and gestational age in Newcastle upon Tyne, North of England, during 1961-2000.

METHODS

We used population-based data from hospital neonatal records on all singleton births to mothers resident in Newcastle (births with complete covariate information n = 113,182). We used linear regression to analyse the associations between neighbourhood SES and birthweight over the entire 40-year period and by decade, and logistic regression for associations with low birthweight (LBW) and preterm birth, adjusting for potential confounders.

RESULTS

There was a significant interaction between SES and decade of birth for birthweight (p = 0.028) and preterm birth (p < 0.001). Socioeconomic gradients were similar in each decade for birthweight outcomes, but for preterm birth, socioeconomic disparities were more evident in the later decades [for 1961-70, odds ratio (OR) was 1.1, 95% CI 0.9, 1.3, for the most deprived versus the least deprived quartile, while for 1991-2000, the corresponding OR was 1.5, 95% CI 1.3, 1.7]. In each decade, there was a significant decrease in birthweight adjusted for gestational age for the most deprived compared to the least deprived SES group [1961-1970: -113.4 g (95% CI-133.0, -93.8); 1991-2000: -97.5 g (95% CI-113.0, -82.0)], while there was a significant increase in birthweight in each SES group over time.

CONCLUSIONS

Socioeconomic inequalities did not narrow over the four decades for birthweight and widened for preterm birth. Mean birthweight adjusted for gestational age increased in all socioeconomic groups, suggesting an overall increase in fetal growth.

Feasibility of a caregiver-assisted exercise program for preterm infants

Mounting evidence shows that low-birth-weight and prematurity are related to serious health problems in adulthood, including increased body fat, decreased fitness, poor bone mineralization, pulmonary problems, and cardiovascular disease. There are data to suggest that increasing physical activity in preterm infants will have effects on short-term muscle mass and fat mass, but we also hypothesized that increasing physical activity early in life can lead to improved health outcomes in adulthood. Because few studies have addressed the augmentation of physical activity in premature babies, the objective of this study was to evaluate the feasibility of whether caregivers (mostly mothers) can learn from nurses and other healthcare providers to implement a program of assisted infant exercise following discharge. Ten caregivers of preterm infants were taught by nurses, along with occupational therapists and other healthcare providers, to perform assisted infant exercise and instructed to conduct the exercises daily for approximately 3 weeks. The researchers made home visits and conducted qualitative interviews to understand the caregivers' experiences with this exercise protocol. Quantitative data included a caregiver's daily log of the exercises completed to measure adherence as well as videotaped caregiver sessions, which were used to record errors as a measure of proficiency in the exercise technique. On average, the caregivers completed a daily log on 92% of the days enrolled in the study and reported performing the exercises on 93% of the days recorded. Caregivers made an average of 1.8 errors on 2 tests (with a maximum of 23 or 35 items on each, respectively) when demonstrating proficiency in the exercise techniques. All caregivers described the exercises as beneficial for their infants, and many reported that these interventions fostered increased bonding with their babies. Nearly all reported feeling "scared" of hurting their babies during the first few days of home exercise but stated that fears were alleviated by practice in the home and further teaching and learning. Caregivers were willing and able to do the exercises correctly, and they expressed a belief that the intervention had positive effects on their babies and on caregiver-infant interactions. These findings have important implications for nursing practice because nurses are in key positions to teach and encourage caregivers to practice these exercises with their newborn babies.

Neurogenesis continues in the third trimester of pregnancy and is suppressed by premature birth

Premature infants exhibit neurodevelopmental delay and reduced growth of the cerebral cortex. However, the underlying mechanisms have remained elusive. Therefore, we hypothesized that neurogenesis in the ventricular and subventricular zones of the cerebral cortex would continue in the third trimester of pregnancy and that preterm birth would suppress neurogenesis. To test our hypotheses, we evaluated autopsy materials from human fetuses and preterm infants of 16-35 gestational weeks (gw). We noted that both cycling and noncycling Sox2(+) radial glial cells and Tbr2(+) intermediate progenitors were abundant in human preterm infants until 28 gw. However, their densities consistently decreased from 16 through 28 gw. To determine the effect of premature birth on neurogenesis, we used a rabbit model and compared preterm [embryonic day 29 (E29), 3 d old] and term (E32, <2 h old) pups at an equivalent postconceptional age. Glutamatergic neurogenesis was suppressed in preterm rabbits, as indicated by the reduced number of Tbr2(+) intermediate progenitors and the increased number of Sox2(+) radial glia. Additionally, hypoxia-inducible factor-1α, vascular endothelial growth factor, and erythropoietin were higher in term than preterm pups, reflecting the hypoxic intrauterine environment of just-born term pups. Proneural genes, including Pax6 and Neurogenin-1 and -2, were higher in preterm rabbit pups compared with term pups. Importantly, neurogenesis and associated factors were restored in preterm pups by treatment with dimethyloxallyl glycine, a hypoxia mimetic agent. Hence, glutamatergic neurogenesis continues in the premature infants, preterm birth suppresses neurogenesis, and hypoxia-mimetic agents might restore neurogenesis, enhance cortical growth, and improve neurodevelopmental outcome of premature infants.

School-age effects of the newborn individualized developmental care and assessment program for preterm infants with intrauterine growth restriction: preliminary findings

BACKGROUND

The experience in the newborn intensive care nursery results in premature infants' neurobehavioral and neurophysiological dysfunction and poorer brain structure. Preterms with severe intrauterine growth restriction are doubly jeopardized given their compromised brains. The Newborn Individualized Developmental Care and Assessment Program improved outcome at early school-age for preterms with appropriate intrauterine growth. It also showed effectiveness to nine months for preterms with intrauterine growth restriction. The current study tested effectiveness into school-age for preterms with intrauterine growth restriction regarding executive function (EF), electrophysiology (EEG) and neurostructure (MRI).

METHODS

Twenty-three 9-year-old former growth-restricted preterms, randomized at birth to standard care (14 controls) or to the Newborn Individualized Developmental Care and Assessment Program (9 experimentals) were assessed with standardized measures of cognition, achievement, executive function, electroencephalography, and magnetic resonance imaging. The participating children were comparable to those lost to follow-up, and the controls to the experimentals, in terms of newborn background health and demographics. All outcome measures were corrected for mother's intelligence. Analysis techniques included two-group analysis of variance and stepwise discriminate analysis for the outcome measures, Wilks' lambda and jackknifed classification to ascertain two-group classification success per and across domains; canonical correlation analysis to explore relationships among neuropsychological, electrophysiological and neurostructural domains at school-age, and from the newborn period to school-age.

RESULTS

Controls and experimentals were comparable in age at testing, anthropometric and health parameters, and in cognitive and achievement scores. Experimentals scored better in executive function, spectral coherence, and cerebellar volumes. Furthermore, executive function, spectral coherence and brain structural measures discriminated controls from experimentals. Executive function correlated with coherence and brain structure measures, and with newborn-period neurobehavioral assessment.

CONCLUSION

The intervention in the intensive care nursery improved executive function as well as spectral coherence between occipital and frontal as well as parietal regions. The experimentals' cerebella were significantly larger than the controls'. These results, while preliminary, point to the possibility of long-term brain improvement even of intrauterine growth compromised preterms if individualized intervention begins with admission to the NICU and extends throughout transition home. Larger sample replications are required in order to confirm these results.

CLINICAL TRIAL REGISTRATION

The study is registered as a clinical trial. The trial registration number is NCT00914108.

Sensory processing issues in young children presenting to an outpatient feeding clinic

OBJECTIVES

The aim of the study was to describe the relation between sensory issues and medical complexity in a series of patients presenting to an outpatient multidisciplinary feeding team for evaluation, by a standardized measure of sensory-processing abilities.

METHODS

A retrospective chart review of all of the patients seen from 2004 to 2009 on 2 key variables: medical diagnostic category and short sensory profile (SSP) score.

RESULTS

On the SSP, 67.6% of children scored in the clinical ("definite difference") range. The most common diagnostic categories were developmental (n = 23), gastrointestinal (n = 16), and neurological (n = 13). Behavioral and cardiorespiratory medical diagnostic categories were significantly related to SSP total score and SSP definite difference score.

CONCLUSIONS

Children who present for feeding evaluation do indeed tend to have clinically elevated scores regarding sensory processing, and these elevated scores are significantly related to certain medical diagnostic categories. Future research is needed to determine why these significant relations exist as well as their implications for treatment of feeding-related issues.

Psychometric testing of the modified breastfeeding self-efficacy scale (short form) among mothers of ill or preterm infants

OBJECTIVE

To psychometrically assess the modified Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF) among mothers of ill or preterm infants.

DESIGN

Methodological study.

SETTING

Three neonatal intensive care units (NICUs) located in two hospitals in a central Canadian city.

PARTICIPANTS

One hundred forty-four (144) breastfeeding mothers of ill or preterm infants.

METHODS

Mothers completed the BSES-SF modified for mothers of ill or preterm infants, the Hill and Humenick (H&H) Lactation Scale, and demographic questions.

RESULTS

The Cronbach's alpha coefficient for internal consistency for the BSES-SF revised for mothers of ill or preterm infants was 0.88. Construct validity was assessed using comparison of contrasted groups (mothers who continued to breastfeed and those who discontinued) and correlation with the construct of maternal perceptions of insufficient milk supply. Support for predictive validity was demonstrated through significant mean differences between mothers who were breastfeeding (M = 83.44, SD = 8.23) and those who discontinued breastfeeding and breast pumping (M = 75.51, SD = 10.08) at 6-weeks post-infant hospital discharge.

CONCLUSION

Demographic response patterns suggest that the modified BSES-SF is a unique tool to identify breastfeeding mothers of ill or preterm infants at risk of prematurely discontinuing. This study provides evidence that the modified BSES-SF may be a valid and reliable measure of breastfeeding self-efficacy among a sample of mothers of ill or preterm infants.

Effect of delayed intermittent ventricular drainage on ventriculomegaly and neurological deficits in experimental neonatal hydrocephalus

PURPOSE

Evidence-based guidelines do not indicate when ventricular reservoirs should be placed in children with neonatal hydrocephalus, and delayed intervention is common. We hypothesize that delayed ventricular drainage has adverse effects on structural development and functional outcomes.

METHODS

Using a well-established animal model of kaolin-induced obstructive hydrocephalus, we evaluated neurologic deficit after early (~1 week post-kaolin) or late (~2 weeks post-kaolin) placement of ventricular reservoirs which were tapped according to strict neurologic criteria.

RESULTS

Progressive ventriculomegaly was similar in early- and late-reservoir implantation groups. The average neurologic deficit scores (NDSs) over the experimental period were 0 (n=6), 2.74 (n=5), and 2.01 (n=3) for the control, early-, and late-reservoir groups, respectively. At reservoir placement, early-group animals displayed enlarged ventricles without neurologic deficits (mean NDS=0.17), while the late group displayed ventriculomegaly with clinical signs of hydrocephalus (mean NDS=3.13). The correlation between ventriculomegaly severity and NDS in the early group was strongly positive in the acute (before surgery to 3 weeks post-reservoir placement) (R(2)=0.65) and chronic (6 to 12 weeks post-reservoir placement) (R(2)=0.65) phases, while the late group was less correlated (acute R(2)=0.51; chronic R(2)=0.19).

CONCLUSIONS

Current practice favors delaying reservoir implantation until signs of elevated intracranial pressure and neurologic deficit appear. Our results demonstrate that animals in early and late groups undergo the same course of ventriculomegaly. The findings also show that tapping reservoirs in these neonatal hydrocephalic animals based on neurologic deficit does not halt progressive ventricular enlargement and that neurologic deficit correlates strongly with ventricular enlargement.

Evaluating preterm infants with the Bayley-III: patterns and correlates of development

This study investigates the Third Edition of the Bayley Scales of Infant and Toddler Development (Bayley-III) and: (1) early patterns of neurodevelopmental performance among preterm infants 8-12 months of age; and (2) correlations between known risk factors and neurodevelopmental outcome of preterm infants in this cohort. Mean Language Index (LI; 91±15) and Motor Index (MI; 94±17) were significantly lower than the Cognitive Index (CI; 102±15, p<.01). For the majority (53%) of infants, language development was their weakest domain; for another 39%, motor skills were the weakest area of development. Almost one-quarter (22%) of this cohort had mildly delayed language and motor skills, while 7% had significantly delayed language and motor skills. Regression models revealed severely abnormal head ultrasound significantly predicted MI, LI, and CI. Oxygen dependence at discharge predicted CI, LI, and race/ethnicity predicted LI, MI. Results support the addition of the Language Index to the newly revised Bayley-III Scales. Prediction models of developmental performance confirm known neonatal risk factors and reveal sociodemographic risk factors that call for additional research.

An overview of risk factors for poor neurodevelopmental outcome associated with prematurity

BACKGROUND

Preterm birth is a major cause of neonatal mortality and morbidity. While advances in medical care have improved the survival of preterm infants, neurodevelopmental problems persist in this population. This article aims to review factors associated with their neurodevelopmental outcomes.

DATA SOURCES

English language studies of neurodevelopmental outcomes in preterm infants were retrieved from PubMed. A total of 100 related publications were included.

RESULTS

Early gestational age and birth weight are the most significant predictors of poor long-term neurological outcome. Structural changes of the brain, infection, male gender and neonatal intensive care unit course are also important factors affecting eventual outcome. Other complex biological and socio-economic factors, which extend from prenatal through postnatal periods, up through and including adulthood, also affect the trajectory of brain development in preterm infants.

CONCLUSIONS

Neurodevelopmental problems continue to affect the preterm population. There is a critical need for collaboration among geneticists, obstetricians, pediatricians, and neuroimaging and rehabilitation experts to determine early predictive factors and neuroprotective therapies to properly treat or prevent poor neurodevelopmental outcomes in these infants.

Epigenetics and family-centered developmental care for the preterm infant

Adverse experiences early in life have the potential to disrupt normal brain development and create stress response channels in preterm infants that are different from those observed in term infants. Animal models show that epigenetic modifications mediate the effects of maternal separation and environmental stress on susceptibility to disease and psychobehavioral problems later in life. Epigenetic research has the potential to lead to the identification of biological markers, gene expression profiles, and profile changes that occur overtime in response to early-life experiences. Combined with knowledge gained through the use of advanced technologies, epigenetic studies have the promise to refine our understanding about how the brain matures and functions from multiple perspectives including the effect of the environment on brain growth and maturation. Such an understanding will pave the way for care practices that will allow the premature brain to develop to its full capacity and will lead to the best possible outcomes. Neonatal epigenetic research is emerging and rapidly advancing. As scientists overcome biological, technical, and cost-related challenges, such research has a great potential in determining key environmental factors that affect the preterm genome, allowing for targeted interventions. The purpose of this article is to explore existing literature related to epigenetic mechanisms that potentially mediate the effects of the environment on preterm infant brain development.

The infant behavioral assessment and intervention program in very low birth weight infants; outcome on executive functioning, behaviour and cognition at preschool age

BACKGROUND

The Infant Behavioral Assessment and Intervention Program (IBAIP©) improved motor function at 24 months, and mental and behavioural development in high risk subgroups of very low birth weight (VLBW) infants.

AIM

To determine IBAIP's effects on executive functioning, behaviour and cognition at preschool age.

STUDY DESIGN

Follow-up of a randomised controlled trial (RCT).

SUBJECTS

At 44 months corrected age, all 176 VLBW infants were invited for follow-up. Forty-one term born children were assessed for comparison.

OUTCOME MEASURES

Visual Attention Task (VAT), Gift delay, Peabody Picture Vocabulary Test III-NL (PPVT), Visual motor integration tests and Miller assessment for preschoolers. Parents completed Behavior Rating Inventory of Executive Function-Preschool (BRIEF-P) and Child Behavior Checklist (CBCL).

RESULTS

At preschool age, 76 (88%) children of the intervention group and 75 (83%) children of the control group participated. There were no significant differences between the intervention and the control group. However, positive interaction effects between intervention and infants with bronchopulmonary dysplasia, infants born at gestational age<28 weeks, and infants of low educated mothers were found on CBCL, CBCL and BRIEF-P, and PPVT respectively. Most interaction effects exceeded 1 standard deviation in favour of the intervention children. The 151 VLBW children performed significantly worse than the term born children on the VAT, BRIEF-P and CBCL.

CONCLUSION

IBAIP effects in VLBW children did not sustain until preschool age on executive functioning, behaviour and cognition. However, the most vulnerable children had a clinical relevant profit from IBAIP. VLBW children performed worse than the term born children. This study is a follow-up at preschool age of the multi-centre RCT of IBAIP versus usual care in VLBW infants. The RCT was performed in Amsterdam, The Netherlands (IBAIP).

Neurodevelopmental outcomes of premature infants at a tertiary care center in Pakistan

The low gestational ages and morbidities of premature neonates in neonatal intensive care units exert a significant impact on neurodevelopmental outcomes. This longitudinal cohort study assessed the neurodevelopmental status of premature neonates after discharge from neonatal intensive care units in resource-limited countries such as Pakistan. Developmental assessment involved the Denver Development Screening Test II. One hundred and ten infants discharged from our neonatal intensive care unit completed follow-up at age 6 months. Overall developmental delay was evident in 32% of infants. Birth weight and gestational age exerted significant impacts on development. The mean gestational age of developmentally normal infants was 34 weeks, whereas that of delayed infants was 30.7 weeks (P < 0.01). The mean birth weight of developmentally normal infants was 2.17 kg vs 1.27 kg in delayed infants (P < 0.01). Neonates who developed complications such as respiratory distress syndrome, intraventricular hemorrhage, thrombocytopenia, hypoglycemia, hyponatremia, or hypothermia in neonatal intensive care units proved to be delayed at age 6 months (P < 0.05). Prematurity and its associated complications are linked to adverse neurodevelopmental outcomes.

Expression of angiogenesis-related factors and inflammatory cytokines in placenta and umbilical vessels in pregnancies with preeclampsia and chorioamnionitis/funisitis

We hypothesized that gene expression in placenta and umbilical vessels are affected by intrauterine environment and some of the expression in umbilical vessels originating from the fetus could reflect fetal condition of these complicated pregnancies. Expression of angiogenesis-related factors and inflammatory cytokines were examined in placenta and umbilical vessels to clarify the effects of intrauterine environment of pregnancies complicated by preeclampsia and chorioamnionitis/funisitis. Forty-six preterm cesarean section deliveries were classified into three groups based on maternal condition during prenatal monitoring: preeclampsia (PE) (n = 11), chorioamnionitis/funisitis (CAM) (n = 8), and preterm control (PC) (n = 27). Angiogenesis-related factors and inflammatory cytokines in placentas, umbilical arteries and umbilical veins were analyzed by RT-PCR and immunohistochemistry. We demonstrated that Ang-2, Tie-2, and Dll4 increase in the placentas of PE compared to PC for the first time, and we confirmed the findings of previous reports showing the high expression of HIF-1α, sFlt-1, endoglin, leptin, and AT1R. Expression of angiogenesis-related factors, including HIF-1α, VEGF, angiopoietin, and TGF-β systems, and inflammatory cytokines, such as TNF-α and IL-6, increased in umbilical vessels of PE. Umbilical veins of CAM showed a higher Dll4 level than did PC. In preeclampsia, abnormal expressions of angiogenesis-related factors related to lifestyle diseases in adulthood were seen in the placenta and umbilical vessels as compared to PC. Chorioamnionitis/funisitis showed only upregulation of DII4 in umbilical veins.

The association of preterm birth and small birthweight for gestational age on childhood disability screening using the Ten Questions Plus tool in rural Sarlahi district, southern Nepal

CONTEXT

The Ten Questions tool was developed in 1984 as a low-cost, simple screen for childhood disability and referral for diagnosis in low-resource settings, and its use in Nepal has not been previously evaluated. Preterm birth and intrauterine growth restriction are potential risk factors for child disability and loss of developmental potential, but there are few studies examining this relationship from developing settings.

OBJECTIVE

  To examine the associations of small for gestational age and preterm birth as predictors of Ten Questions Plus positivity.

DESIGN, SETTING AND PARTICIPANTS

The Ten Questions Plus questionnaire was administered to caregivers of 680 children between 2 and 5 years of age from August 2007 to March 2008 in rural Sarlahi, southern Nepal. Participants had previously been enrolled in a randomized trial of chlorhexidine cleansing at birth. At 1 month of age, children were then enrolled into a randomized 2 × 2 factorial trial of daily iron and zinc supplementation between October 2001 and January 2006.

INTERVENTION

None.

MAIN OUTCOME MEASURE

Positive screen on the Ten Questions Plus tool defined as a positive response to one or more questions.

RESULTS

Of preterm children, 37 (33.6%) had a positive response to at least one question on the Ten Questions Plus and were considered at risk for disability. One hundred and seventy term children (29.8%) were at risk for disability.

CONCLUSIONS

The Ten Questions Plus tool can be used in this rural Nepali setting to identify children at increased risk for mental and physical disability to be targeted for further examination. The prevalence of parent-reported disabilities is high in this population (almost one-third of children); children who are both preterm and small-for-gestational age are at increased risk for motor milestone delay, reported learning difficulty, speech and behavioural problems. Intrauterine growth restriction may affect child development and result in disabilities later in childhood.

Preventive interventions for preterm children: effectiveness and developmental mechanisms

This article provides an integrative review of the effectiveness of and possible developmental mechanisms associated with preventive interventions for preterm children. An analysis of randomized clinical trials carried out within the last 15 years was framed within a contemporary developmental model emphasizing the role of parental adjustments to preterm children's characteristics. Evidence suggested positive outcomes could be understood in terms of improvements in developmental pathways associated with parental sensitive-responsiveness and child participation in intensive intervention-oriented child care. Implications for the critical role of the Medical Home model for preventive interventions for preterm children were discussed.

Outcome of extremely low birth weight infants: what's new in the third millennium? Neuropsychological profiles at four years

BACKGROUND

Extremely low birth weight (ELBW) infants, even those not presenting severe neuromotor sequelae, continue to be at risk of developing multiple, complex disorders involving the cognitive, emotional and behavioural domains. Follow-up protocols are able, in the short term, to identify subjects at risk of developing major sequelae, however they fail to identify all children at risk of developing disorders.

AIMS

To investigate the cognitive, neuropsychological and behavioural outcomes of a sample of ELBW children at the age of four years in order to identify characteristic profiles.

STUDY DESIGN

Longitudinal study.

SUBJECTS

16 healthy ELBW children born in 2005 and followed up until the age of four.

OUTCOME MEASURE

Performances on standardised tests evaluating intelligence, memory, cognitive visual functions, attention, and executive functions.

RESULTS

General intelligence was within normal range. Cognitive profile showed mild or moderate deficits with different levels of involvement in many of the examined functions, in particular executive functions, attention and naming.

CONCLUSION

There emerged a wide-ranging spectrum of weaknesses and deficits involving all the functions examined, which together give rise to a dysexecutive syndrome. Analysis of cognitive profiles showed that the sample could be divided into two subgroups of subjects that differ in the quality of their global cognitive and behavioural functioning. Our results confirm the need to continue follow up of ELBW children until school age, as this will allow early detection of at-risk children and the planning of timely preventive interventions.

Clinical studies of lactoferrin in children

Much has been learned in recent years about the mechanisms by which breastfeeding improves child health and survival. However, there has been little progress in using these insights to improve pediatric care. The aim of this study was to review all clinical studies of lactoferrin (LF) in children in an effort to determine which interventions may improve pediatric care or require further research. We conducted a systematic and critical review of published literature and found 19 clinical studies that have used human or bovine LF for different outcomes: iron metabolisms and anemia (6 studies), fecal flora (5 studies), enteric infections (3 studies), common pediatric illnesses (1 study), immunomodulation (3 studies), and neonatal sepsis (1 study). Although the efficacies have varied in each trial, the main finding of all published studies is the safety of the intervention. Protection against enteric infections and neonatal sepsis are the most likely biologically relevant activities of LF in children. Future studies on neonatal sepsis should answer critically important questions. If the data from these sepsis studies are proven to be correct, it will profoundly affect the treatment of low birth weight neonates and will aid in the reduction of child mortality worldwide.

Memory processes in learning disability subtypes of children born preterm

The purpose of this study was to evaluate immediate auditory and visual memory processes in learning disability subtypes of 40 children born preterm. Three subgroups of children were examined: (a) primary language disability group (n = 13), (b) perceptual-motor disability group (n = 14), and (c) no learning disability diagnosis group without identified language or perceptual-motor learning disability (n = 13). Between-group comparisons indicate no significant differences in immediate auditory or visual memory performances between language and perceptual-motor learning disability groups. Within-group comparisons revealed that both learning disability groups performed significantly lower on a task of immediate memory when the mode of stimulus presentation and mode of response were visual.

Is neonatal jaundice associated with Autism Spectrum Disorders: a systematic review

Using guidelines of the Meta-analysis of Observational Studies in Epidemiology Group, we systematically reviewed the literature on neonatal jaundice (unconjugated hyperbilirubinemia) and Autism Spectrum Disorder (ASD) in term and preterm infants. Thirteen studies were included in a meta-analysis. Most used retrospective matched case-control designs. There was significant heterogeneity (Q = 31, p = 0.002) and no evidence of publication bias (p = 0.12). Overall, jaundice, assessed by total serum bilirubin (TSB), was associated with ASD (OR, 1.43, 95% CI 1.22-1.67, random effect model). This association was not found in preterms (OR 0.7, 95% CI 0.38-1.02) but deserves further investigation since other measures of bilirubin such as unbound unconjugated bilirubin may be better predictors of neurotoxicity than TSB in preterms.

Influence of gestational age and postnatal age on speech sound processing in NICU infants

The study examined the effect of gestational (GA) and postnatal (PNA) age on speech sound perception in infants. Auditory event-related potentials (ERPs) were recorded in response to speech sounds (syllables) in 50 infant NICU patients (born at 24-40 weeks gestation) prior to discharge. Efficiency of speech perception was quantified as absolute difference in mean amplitudes of ERPs in response to vowel (/a/-/u/) and consonant (/b/-/g/, /d/-/g/) contrasts within 150-250, 250-400, 400-700 ms after stimulus onset. Results indicated that both GA and PNA affected speech sound processing. These effects were more pronounced for consonant than vowel contrasts. Increasing PNA was associated with greater sound discrimination in infants born at or after 30 weeks GA, while minimal PNA-related changes were observed for infants with GA less than 30 weeks. Our findings suggest that a certain level of brain maturity at birth is necessary to benefit from postnatal experience in the first 4 months of life, and both gestational and postnatal ages need to be considered when evaluating infant brain responses.

Neonatal assessments for the preterm infant up to 4 months corrected age: a systematic review

AIM

The aim of this study was to systematically review the clinimetric properties of longitudinal neonatal neurobehavioural and neuromotor assessments for preterm infants.

METHOD

Twenty-seven assessment measures were identified. The following eight measures met the study inclusion criteria: Assessment of Preterm Infants' Behaviour (APIB), Neonatal Intensive Care Unit Network Neurobehavioural Scale (NNNS), Test of Infant Motor Performance (TIMP), Prechtl's Assessment of General Movements (GMs), Neurobehavioural Assessment of the Preterm Infant (NAPI), Dubowitz Neurological Assessment of the Preterm and Full-term Infant (Dubowitz), Neuromotor Behavioural Assessment (NMBA), and the Brazelton Neonatal Behavioural Assessment Scale (NBAS). The primary purposes included prediction (TIMP, GMs, Dubowitz), discrimination (all assessments), and evaluation of change (TIMP, NAPI). Measures of assessment were included in the study if they were (1) primarily neurobehavioural or neuromotor assessments that were suitable for use with preterm infants (<37 weeks gestation) up to 4 months corrected age and were discriminative, predictive, or evaluative; (2) standardized procedures designed for serial/longitudinal use; or (3) criterion or norm referenced. However, all assessment tools that were not published in English in a peer-reviewed journal or were primarily neurological assessments, one-time evaluations, screening tools, or not commercially available were not used.

RESULTS

All of the measures included in the review demonstrated adequate content and construct validity. Concurrent validity was reported for APIB, NNNS, Dubowitz, and GMs. Predictive validity was high for GMs with studies reporting up to 100% senstivity for predicting cerebral palsy at the age of 12 to 24 months. Interrater reliability was strong for the TIMP (intraclass correlation=0.95), GMs (K=0.8), and moderate for the NAPI (r=0.67-0.97). Clinical utility was variable for ease of scoring, interpretability, cost, and access.

INTERPRETATION

In the absence of a criterion standard for neonatal neuromotor assessments, the NNNS and APIB have strong psychometric qualities with better utility for research. Similarly, the GMs, TIMP, and NAPI have strong psychometric qualities but better utility for clinical settings. The GMs has best prediction of future outcome and the TIMP has best evaluative validity.

The guinea pig as an animal model for studying perinatal changes in microvascular function

INTRODUCTION

Microvascular dysfunction, characterized by inappropriate vasodilatation and high blood flow in the peripheral microcirculation, is linked to physiologic instability and poor outcome in neonates. Specifically, preterm neonates have significantly higher levels of baseline microvascular blood flow than term neonates at 24 h postnatal age. Because of similarities between human and guinea pig endocrine profiles and maturity at birth, we hypothesized that preterm guinea pig neonates would provide a suitable model for studying the mechanisms underlying transitional microvascular function.

RESULTS

Guinea pigs that were delivered preterm showed immaturity and had markedly reduced viability. Baseline microvascular blood flow was significantly higher in preterm animals than in term animals. No effect of intrauterine growth restriction or birth weight on baseline microvascular blood flow was observed in either preterm or term animals.

DISCUSSION

These results are consistent with recent clinical findings and support the use of the guinea pig as a suitable model for future studies of the mechanisms underlying perinatal microvascular behavior.

METHODS

Guinea pigs were delivered either prematurely or at term. Laser Doppler flowmetry was used to study microvascular blood flow at 23 h postnatal age.

The use of mobile robotic telemedicine technology in the neonatal intensive care unit

OBJECTIVE

To describe the use of a wireless, mobile, robotic telecommunications system in the Neonatal Intensive Care Unit (NICU).

STUDY DESIGN

In this prospective study utilizing 304 patient encounters on 46 preterm and term neonates in a level IIIa NICU, a bedside neonatologist ('on-site neonatologist'; ONSN) and a neonatologist at a distant location ('off-site neonatologist'; OFFSN) evaluated selected demographic information, laboratory data and clinical and radiological findings of the subjects. The OFFSN used a commercial wireless, mobile, robotic telecommunications system controlled from a remote site. The two physicians were blinded to each other's findings and agreement rates of the evaluations between the ONSN and the OFFSN were compared using kappa statistics. Agreement rates between two ONSNs using the same protocol with 39 patient encounters served as the reference standard. The dependability and timeliness of data transmission were also assessed.

RESULT

Excellent or intermediate-to-good agreements were noted for all but a few physical examination assessments between both the ONSN and OFFSN and the two ONSNs. Poor agreements were found for certain physical examination parameters (breath-, heart- and bowel-sounds and capillary refill time) with or without the use of telemedicine. The median duration of the encounters by the ONSN and OFFSN and the two ONSNs was similar. Five encounters were excluded from the analysis because of technical difficulties. No complications associated with the use of the mobile robot were noted.

CONCLUSION

Our findings indicate that the use of mobile robotic telemedicine technology is feasible for neonates in the NICU.

Long-term morbidity after fetal endoscopic surgery for severe twin-to-twin transfusion syndrome

BACKGROUND/PURPOSE

Severe twin-to-twin transfusion syndrome (TTTS) leads to 80% to 100% dual mortality. Endoscopic laser coagulation of connecting vessels improves outcome to 80% survival of at least 1 twin. There is limited long-term follow-up of surviving TTTS patients. The aim of this study was to analyze gestational age-stratified, long-term morbidity in these patients.

METHODS

A retrospective case-control study of TTTS surviving patients (38 patients, 72% follow-up rate) from one center. Perinatal and pediatric records were reviewed, and outcomes were compared with published reports and gestational age-matched controls.

RESULTS

Forty percent (15/38) had at least 1 major sequela, all but 6 of which were fully resolved at a median follow-up of 4.4 years. There were no permanent cardiac, genitourinary, renal, or respiratory sequelae. All major complications were in patients born <29 weeks. There were no significant differences in complications between this cohort of patients and gestational age (GA)-matched control patients.

CONCLUSIONS

The long-term morbidity of monochorionic twins after fetal laser surgery for severe TTTS is 13%. At a median follow-up of more than 4 years, these children fare no worse than gestational age-matched, non-operated twins and singletons. The degree of prematurity at birth is the best predictor of temporary or permanent sequela in this group of patients.

Prevalence of psychiatric diagnoses in preterm and full-term children, adolescents and young adults: a meta-analysis

BACKGROUND

Preterm (PT) birth and low birth weight (LBW) are high-prevalence events that are associated with adverse outcomes in the longer term, with vulnerability increasing as maturity at birth decreases. Psychiatric symptomatology appears heightened in PT/LBW survivors, though there are some discordant findings from studies using questionnaire measures, particularly with respect to anxiety and depressive symptoms.

METHOD

This article synthesises findings from research using clinical psychiatric diagnostic criteria in PT/LBW individuals aged 10-25 years compared with term-born peers. Key outcomes of interest were the rates of individuals receiving any psychiatric diagnosis and the number of diagnoses of anxiety or depressive disorders.

RESULTS

A literature search for studies reporting prevalence of 'any diagnosis' yielded five studies that met inclusion criteria, with a total of 565 PT/LBW and 533 control individuals. Also, five studies were found that reported rates of anxiety/depression (692 PT/LBW and 605 control individuals). The risk of these outcomes was increased for PT/LBW individuals compared with controls [any diagnosis: odds ratio (OR) 3.66, 95% confidence interval (CI) 2.57-5.21; anxiety or depressive disorder: OR 2.86, 95% CI 1.73-4.73].

CONCLUSIONS

The studies reviewed here indicate that, in addition to monitoring and management of medical and cognitive sequelae, the psychological well-being of PT/LBW individuals should be a key part of ongoing care.

Could audiovisual training be used to improve cognition in extremely low birth weight children?

AIM

To study whether a dyslexia remediation programme, Audilex, improves cognition in extremely low birth (ELBW) children.

METHODS

Six-year-old ELBW children were allocated to a 5-week training with Audilex or playing control computer games. Before and after intervention, auditory event-related brain potentials (ERP) to sound changes were recorded and reading related skills assessed. Primary outcome was the mismatch negativity (MMN) component of ERP. Secondary outcomes were Audilex Test (ability to perform the Audilex games), the reading skills after the intervention and 2 years later. Of eligible children, 39 (54%) consented and 22 (30%) completed the protocol.

RESULTS

The MMN responses to the frequency (p = 0.02) and duration deviants (p < 0.01) increased after Audilex training (n = 11), but not after control game playing (n = 11). Audilex Test performance was similar in both groups. The reading skills were similar after intervention and 2 years later; word reading score 59.7, 66.8 and 74.9 and comprehensive reading score 8.1, 8.8 and 9.4 in Audilex, Control and healthy class-mate children, respectively.

CONCLUSIONS

Although all children did not complete the protocol, the results suggest that training with Audilex dyslexia programme might be beneficial for enhancing neural-level sound discrimation and possibly reading skills in ELBW children. A larger trial is warranted.

The impact of psoriasis on pregnancy outcomes

Psoriasis is an inflammatory disease that affects women in their reproductive years. Other similar diseases have been associated with adverse pregnancy outcomes. We sought to assess whether pregnant women with psoriasis are at higher risk of developing complications, such as preterm birth (PTB) and low birth weight (LBW). A retrospective cohort, performed at two large tertiary centers, evaluated the outcomes of 162 pregnancies in 122 women with psoriasis and 501 pregnancies in 290 women without psoriasis. Univariable and multivariable analyses, adjusting for important demographic factors, comorbidities, or a propensity score, were performed to evaluate the association of psoriasis and a poor outcome composite (POC), including PTB (<37 gestational weeks) and LBW (<2,500  g). Repeated measures analysis was used to account for the multiple pregnancies per woman. Cesarean delivery, preeclampsia/eclampsia, and spontaneous abortion were also evaluated. For women with psoriasis, there was a 1.89-fold increase in odds of POC (95% CI 1.06-3.39) in the univariable analysis. This effect remained statistically significant in the multivariable analyses. Psoriasis was not associated with cesarean delivery, preeclampsia/eclampsia, and spontaneous abortion. This study has shown higher odds of POC in patients with psoriasis. Further larger population-based studies are required to confirm these findings.