Significance of prenatal, perinatal and postnatal factors in the development of AGA preterm infants at five to seven years

Dysmorphic features in 2-year-old IVF/ICSI offspring

BACKGROUND

An increased risk of major congenital abnormalities after IVF and ICSI has been described, but underlying mechanisms are unclear. This study evaluates the effects of ovarian hyperstimulation, the in vitro procedure and time to pregnancy (TTP) - as proxy for the severity of subfertility - on the prevalence of dysmorphic features.

DESIGN/METHODS

Participants were singletons born following controlled ovarian hyperstimulation-IVF/ICSI (COH-IVF/ICSI; n=66), or modified natural cycle-IVF/ICSI (MNC-IVF/ICSI; n=56), or to subfertile couples who conceived naturally (Sub-NC; n=86). Dysmorphic features were assessed according to the method of Merks et al., and are classified into 'minor variants' (minor anomalies or common variants) and 'abnormalities' (clinically relevant or irrelevant abnormalities). We focussed on minor anomalies as they indicate altered embryonic development and because they have the advantage of a higher prevalence.

RESULTS

The prevalences of any of the outcome measures were similar in the three groups. One or more minor anomalies, our primary outcome measure, occurred in 50% of COH-IVF/ICSI, 54% of MNC-IVF/ICSI and 53% of Sub-NC children. TTP in years was significantly associated with abnormalities (adjustedOR=1.20; 95%CI=1.02-1.40), especially with clinically relevant abnormalities (adjustedOR=1.22; 95%CI=1.01-1.48).

CONCLUSIONS

The study indicates that ovarian hyperstimulation and the in vitro procedure are not associated with an increase in dysmorphic features. The positive association between TTP and clinically relevant abnormalities suggests a role of the underlying subfertility and its determinants in the genesis of dysmorphic features.

Health-related quality of life in the aftermath of child maltreatment: follow-up study of a hospital sample

OBJECTIVE

In the aftermath of child maltreatment or neglect, the health-related quality of life (HRQoL) in children is likely to be affected. However, research on quality of life in maltreated children is lacking. The aim of this study is to compare the HRQoL in a follow-up sample of children referred to an interdisciplinary hospital child protection team (CPT) to match controls and to explore correlates of HRQoL.

METHOD

Of the 319 in- and outpatient children referred to the CPT at the University Children's Hospital Zurich between 2005 and 2006, an eligible sample of 180 children was contacted for a follow-up. HRQoL was assessed for 42 former patients using the self- and proxy-rated KIDSCREEN-27 for children above the age of 6 years and the TAPQOL parent report for children younger than 6 years. HRQoL-scores in the maltreatment group were compared with HRQoL in 39 matched controls.

RESULTS

Self-reported HRQoL in maltreated children above the age of 6 years was significantly impaired compared to matched controls. The caregiver-rated HRQoL of maltreated children, however, was not affected. Low socioeconomic status and number of life events were associated with impaired self-reported HRQoL. Analyzed together with these factors, maltreatment lost its predictive power on HRQoL.

CONCLUSION

Maltreated children and adolescents suffer from impaired HRQoL even after the maltreatment has been disclosed and targeted by interventions. The impact of socioeconomic environment reinforces the importance of a multidisciplinary and systemic approach to maltreatment as applied by the CPT. Although the nature of discordance between child and caregiver report is not known, researchers and clinicians are strongly encouraged to assess the victim's self-reported HRQoL independently of their proxies' view.

Health-related quality of life and behavior of triplets at adolescent age

OBJECTIVES

To assess health-related quality of life (HRQoL) and behavior of triplets compared with matched singletons at adolescent age and to identify medical and sociodemographic predictors of outcome.

STUDY DESIGN

Fifty-four triplets (19 sets, mean [SD] gestational age 32.0 [2.4] weeks, birth weight 1580 [450] g) and 51 gestational age-, birth weight-, and sex-matched singleton controls self-rated their HRQoL at age 14.5 (0.3) years. Proxy reports about HRQoL and behavior were obtained by parents and teachers. HRQoL was measured with the Kidscreen-52 questionnaire child and parent form, and behavior with the Achenbach Child Behavior Checklist.

RESULTS

Self- and parent-reported HRQoL values was similar in both groups except for the dimensions "mood and emotions" and "autonomy," which were better (P = .001, P = .03) in triplets. Parents reported significantly less behavioral problems in triplets compared with controls. Compared with community norms, both HRQoL and behavior measures in triplets were in the normal range. Parent-reported HRQoL was predicted by dichorionicity.

CONCLUSIONS

HRQoL and behavioral outcome in adolescent triplets was good in our study and was, in some aspects, better than in matched singleton controls. Dichorionicity is an important outcome determinant.

Cycled light exposure reduces fussing and crying in very preterm infants

OBJECTIVE

To examine whether cycled lighting (CL) conditions during neonatal care in very preterm infants (<32 weeks' gestational age [GA]) decrease crying and fussing behavior, improve the consolidation of sleep, and influence activity behavior at 5 and 11 weeks' postterm corrected age (CA) compared with preterm infants cared for in dim lighting (DL) conditions.

METHODS

Thirty-seven preterm infants were randomly assigned to CL (7 am-7 pm lights on, 7 pm-7 am lights off [n = 17; mean GA: 30.6 ± 0.95 weeks; 9 girls]) or DL (lights off whenever the child is asleep [n = 20; GA: 29.5 ± 2.1 weeks; 8 girls]) conditions. Sleeping, crying, and activity behavior was recorded by using parental diaries and actigraphy at 5 and 11 weeks' CA.

RESULTS

A significant reduction of fussing (59.4 minutes/24 hours [± 25.8 minutes]) and crying (31.2 minutes/24 hours [± 14.4 minutes]) behavior and a trend to higher motor activity during daytime was found in CL-exposed infants at 5 and 11 weeks' CA compared with infants cared for in DL conditions. No significant difference between groups was observed for sleep behavior at 5 and 11 weeks' CA. Infants in CL conditions showed a trend to improved daily weight gain (average: 3.6 g/d) during neonatal care compared with DL conditions.

CONCLUSIONS

CL conditions in neonatal care have beneficial effects on infant's fussing and crying behavior and growth in the first weeks of life. This study supports the introduction of CL care in clinical neonatal practice.

Psychobiological effects of prenatal glucocorticoid exposure in 10-year-old-children

BACKGROUND

Prenatal stress seems to have long-lasting effects on biological and psychological processes of the offspring. However, to date, there have been no studies investigating the effects of prenatal glucocorticoid exposure on psychological, endocrine, and autonomic responses to a standardized psychosocial stress test in children.

METHODS

A sample of 115 healthy, 10-year-old children was examined. The Glucocorticoids + Tocolytics group was characterized by tocolytic treatment of the mothers due to preterm labor (n = 43). In addition, the pregnant women received glucocorticoid treatment in order to accelerate fetal lung maturation in case of preterm birth. The first comparison group (Tocolytics) consisted of children whose mothers also experienced preterm labor, but did not receive glucocorticoid treatment (n = 35). In the second comparison group (CONTROL), children whose mothers had a complication-free pregnancy were assessed (n = 37). Psychological parameters (stress appraisal and mood) using self-report questionnaires as well as salivary cortisol, salivary alpha-amylase, and heart rate were measured during a standardized psychosocial stress test (Trier Social Stress Test for Children).

RESULTS

Group comparisons revealed that a subscale of stress appraisal, control expectancies, significantly differed in children who were prenatally exposed to glucocorticoids as compared to both comparison groups (F = 4.889, p = 0.009). Furthermore, significant differences between the groups were revealed for salivary cortisol. With respect to overall stress appraisal and heart rate, trends toward significance were observed between the three groups.

CONCLUSION

At the age of ten, those children who have been exposed to prenatal maternal glucocorticoids show changed psychobiological stress reactivity to a standardized psychosocial stress test as compared to control children.

The role of birthweight discordance in the intellectual and motor outcome for triplets at early school age

AIM

We assessed motor and intellectual outcome in triplets at school age and investigated the predictive value of perinatal and demographic factors.

METHODS

Seventy-one live-born newborn infants (24 triplet pregnancies) were prospectively enrolled at birth. At the age of 6 years, 58 children (31 males, 27 females; mean gestational age 31.2 wks [SD 2.2 wks]; mean birthweight 1622 g [SD 440 g]) returned for a neurodevelopmental examination. A comparison group for triplets born before 32 gestational weeks comprising 26 gestational age-, birthweight-, and sex-matched singletons was also recruited (mean gestational age 30.1 wk [SD 1.5 wk]; mean birthweight 1142 g [SD 210 g]; 12 males, 14 females). The Zurich Neuromotor Assessment was used to examine motor performance, and intellectual abilities were assessed with the Kaufman Assessment Battery for Children (K-ABC).

RESULTS

Motor performance and movement quality in these individuals was significantly reduced compared with the test norms for all motor tasks (p<0.001) other than static balance. The mean values on the Mental Processing Composite (95.3, SD 8.4) and the Achievement Scale (90.1, SD 13.8) of the K-ABC were also lower than those in the test reference (p<0.05 and p<0.01 respectively). Triplets born at less than 32 weeks' gestation showed poorer pure motor and adaptive gross motor performance (both p<0.05) than, but similar intellectual performance to, the gestational age-, birthweight- and sex-matched singletons. Poor outcome was predicted by low socio-economic status and by intertriplet birthweight discordance (both p<0.01).

INTERPRETATION

Triplets were at an increased risk of mild motor and intellectual impairments. This finding is important for tailoring therapeutic interventions for these children and for parental counselling. Very preterm triplets showed similar outcomes to the singleton comparison children, except that they had poorer motor performance. Low socio-economic status was a major risk factor for impaired intellectual development. In addition, birthweight discordance may also be considered a predictor for poor long-term motor and intellectual outcome in triplets.

Structural brain lesions in adolescents with congenital heart disease

OBJECTIVES

To assess long-term neurodevelopmental outcome of adolescents with congenital heart disease after open-heart surgery and to evaluate whether deficits are associated with cerebral injury detectable on magnetic resonance imaging (MRI).

STUDY DESIGN

We conducted a cohort study with longitudinal follow-up of 53 adolescents (mean age, 13.7 years; range, 11.4 to 16.9 years) who had undergone open-heart surgery with full-flow cardiopulmonary bypass during childhood and compared them with 41 age-matched controls. Assessment included conventional MRI and neurodevelopmental testing.

RESULTS

MRI abnormalities were detected in 11 of the 53 patients (21%), comprising predominately white matter abnormalities and volume loss. Neurodevelopmental outcome was impaired in several domains, including neuromotor, intellectual, and executive functions, as well as visuomotor perception and integration. Adolescents with cerebral abnormalities had greater impairment in most neurodevelopmental domains compared with those without cerebral abnormalities.

CONCLUSIONS

Cerebral abnormalities can be detected in a significant proportion of adolescents with corrected congenital heart disease. These abnormalities are found predominately in the white matter and are apparently of hypoxic-ischemic origin, most likely acquired during the neonatal period.

The sleep EEG as a marker of intellectual ability in school age children

STUDY OBJECTIVES

To investigate the within-subject stability in the sleep EEG and the association between the sleep EEG and intellectual abilities in 9- to 12-year-old children.

DESIGN

Intellectual ability (WISC-IV, full scale, fluid, and verbal IQ, working memory, speed of processing) were examined and all-night polysomnography was performed (2 nights per subject).

SETTING

Sleep laboratory.

PARTICIPANTS

Fourteen healthy children (mean age 10.5 ± 1.0 years; 6 girls).

MEASUREMENTS AND RESULTS

Spectral analysis was performed on artifact-free NREM sleep epochs (C3/A2). To determine intra-individual stability and inter-individual variability of the sleep EEG, power spectra were used as feature vectors for the estimation of Euclidean distances, and intraclass correlation coefficients (ICC) were calculated for the 2 nights. Sleep spindle peaks were identified for each individual and individual sigma band power was determined. Trait-like aspects of the sleep EEG were observed for sleep stage variables and spectral power. Within-subject distances were smaller than between-subject distances and ICC values ranged from 0.72 to 0.96. Correlations between spectral power in individual frequency bins and intelligence scores revealed clusters of positive associations in the alpha, sigma, and beta range for full scale IQ, fluid IQ, and working memory. Similar to adults, sigma power correlated with full scale (r = 0.67) and fluid IQ (r = 0.65), but not with verbal IQ. Spindle peak frequency was negatively related to full scale IQ (r = -0.56).

CONCLUSIONS

The sleep EEG during childhood shows high within-subject stability and may be a marker for intellectual ability.

Risk factors for neurodevelopmental deficits in congenital hypothyroidism after early substitution treatment

Neurodevelopment in children with congenital hypothyroidism who receive early treatment is generally good. However, subtle neurological deficits still exist in some patients. The aim of this investigation was to evaluate factors that may influence neurodevelopmental outcome in congenital hypothyroidism patients. The developmental quotient (DQ) of 155 children with congenital hypothyroidism was evaluated at 24 months of age, using Gesell Developmental Schedules (GDS), and compared with that of 310 healthy controls. Mean DQ scores in congenital hypothyroidism patients were 7.5 points lower for adaptive behavior than in control patients (p < 0.01). Patients with severe congenital hypothyroidism had the lowest DQ scores compared with two other congenital hypothyroidism subgroups and controls (p < 0.01). Children with congenital hypothyroidism who also had a low level of serum T(4) at diagnosis or exhibited a longer thyroid stimulating hormone (TSH) normalization time had lower adaptive behavior scores (p < 0.0003). Bivariate correlation and multiple regression analyses found that the severity of congenital hypothyroidism and parental socioeconomic status correlated with DQ scores. TSH normalization time was negatively related to adaptive behavior scores (p < 0.01). Neurodevelopmental deficits in children with congenital hypothyroidism correlate with the severity of congenital hypothyroidism, TSH normalization time, and parental socioeconomic status.

Do Parental Expectations Play a Role in Children's Sleep and Mothers' Distress? An Exploration of the Goodness of Fit Concept in 54 Mother-Child Dyads

This study describes parental expectations for sleep-wake patterns in healthy kindergarten children and explores their relation to children's sleep quality and parental distress. Data analysis of 54 mother-child dyads (age range of the children: 4–7 years) indicated that parental expectations for children's sleep-wake patterns differ between scheduled and free days and depend on children's chronotype. Mothers of children with late chronotype showed less adequate expectations for children's sleep onset time than mothers of children with early chronotype (e.g., morning types). Furthermore, children of mothers with less adequate expectations for children's sleep onset time on scheduled days had longer settling periods during which sleep rituals may take place (r = 0.31, P ≤ 0.05), spent more time in bed than they actually sleep (r = 0.35, P ≤ 0.01), and had more frequently difficulties falling asleep (r = 0.33, P ≤ 0.01). However, less adequate expectations for children's sleep onset time were not associated with parental distress (P > 0.05). We conclude that parental expectations about their children's sleep play a key role in understanding normal and abnormal sleep during childhood.

Neurological condition of infants born after in vitro fertilization with preimplantation genetic screening

Aim of this study was to evaluate the effect of preimplantation genetic screening (PGS) on neurodevelopmental outcome in children. We conducted a prospective follow-up study of children born to women randomly assigned to in vitro fertilization with or without PGS. Primary outcome was adverse neurologic outcome at 18 mo; secondary outcomes were types of minor neurologic dysfunction (MND), neurologic outcome before 18 mo, neonatal intensive care admission, and congenital malformations. Twenty women in the PGS group participated with 25 children and 26 women in the control group participated with 31 children. Five PGS pregnancies (25%) and four control pregnancies (15%) resulted in birth of at least one child with an adverse neurologic outcome (adjusted odds ratio: 2.3 [0.4-12.0]). Dysfunction in fine motor abilities and posture and muscle tone dysregulation tended to be present more frequently after PGS. Neurologic outcome before 18 mo, neonatal intensive care admission, and prevalence of congenital malformations were similar in study and control pregnancies. Nevertheless, at child level, rates of adverse outcome were higher after PGS. In conclusion, outcome in pregnancies after in vitro fertilization (IVF) with and without PGS was similar. The small sample size precludes the conclusion that PGS is not associated with less favorable neurologic outcome. Safety of new assisted reproductive techniques should be evaluated before large-scale implementation.

Attentional networks efficiency in preterm children

Recent studies have reported specific executive and attentional deficits in preterm children. However, the majority of this research has used multidetermined tasks to assess these abilities, and the interpretation of the results lacks an explicit theoretical backdrop to better understand the origin of the difficulties observed. In the present study, we used the Child Attention Network Task (Child ANT; Rueda et al. 2004) to assess the efficiency of the alerting, orienting and executive control networks. We compared the performance of 25 preterm children (gestational age < or = 32 weeks) to 25 full-term children, all between 5(1/2) and 6(1/2) years of age. Results showed that, as compared to full-term children, preterm children were slower on all conditions of the Child ANT and had a specific deficit in executive control abilities. We also observed a significantly higher correlation between the orienting and executive control networks in the preterm group, suggesting less differentiation of these two networks in this population.

Reduced fetal movements and maternal medication - new pregnancy risk factors for neurodevelopmental disability in childhood

A case-control study was undertaken of 471 children on the Nottingham Special Needs Register (SNR) who were born in one of the two maternity units in the city between 1987 and 1993 (inclusive). Controls were selected as the next infant born at the same hospital following each index case. The aim of the study was to identify risk factors on the Nottingham Obstetric Database for a baby subsequently appearing on the SNR. Disability was analysed by both ICD-9 coding and functional assessment. Factors which independently and significantly predicted a child's likelihood of being on the SNR were breech presentation (adjusted odds ratio (OR) = 4.0), congenital abnormality (OR=4.9), intrapartum fetal distress (OR=1.7), fetal growth restriction (OR=2.0), socioeconomic deprivation (OR=1.8), prematurity (OR=2.2), reduced fetal movements (OR=2.5) and medication in pregnancy (OR=10.4). To our knowledge the last two factors have not previously been reported as risk predictors for neurodevelopmental disability.

Unimpaired outcomes for extremely low birth weight infants at 18 to 22 months

OBJECTIVE

The goal was to identify, among extremely low birth weight (

METHODS

Unimpaired outcome was defined as Bayley Scales of Infant Development II scores of >or=85, normal neurologic examination findings, and normal vision, hearing, swallowing, and walking. Outcomes were determined for 5250 (86%) of 6090 extremely low birth weight inborn infants.

RESULTS

Of the 5250 infants whose outcomes were known at 18 months, 850 (16%) were unimpaired, 1153 (22%) had mild impairments, 1147 (22%) had moderate/severe neurodevelopmental impairments, and 2100 (40%) had died. Unimpaired survival rates varied according to birth weight, from <1% for infants

CONCLUSIONS

Although <1% of live-born infants of Collapse

Key Words

• extremely low birth weight
• outcomes
• neurodevelopmental impairment

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MESH Headings

• Child Development
• Female
• Follow-Up Studies
• Gestational Age
• Humans
• Infant, Extremely Low Birth Weight
• Infant, Newborn
• Infant, Newborn, Diseases/epidemiology
• Male
• Regression Analysis
• Risk Factors
• Social Class

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Grants

• U10 HD27851 NICHD NIH HHS
• U10 HD021385 NICHD NIH HHS
• U10 HD021364 NICHD NIH HHS
• U10 HD53109 NICHD NIH HHS
• KL2 RR24149 NCRR NIH HHS
• M01 RR2635 NCRR NIH HHS
• M01 RR16587 NCRR NIH HHS
• U10 HD027856 NICHD NIH HHS
• U10 HD40689 NICHD NIH HHS
• U10 HD021373 NICHD NIH HHS
• UL1 RR024139 NCRR NIH HHS
• U10 HD40492 NICHD NIH HHS
• U10 HD53119 NICHD NIH HHS
• M01 RR59 NCRR NIH HHS
• M01RR80 NCRR NIH HHS
• U10 HD053124 NICHD NIH HHS
• U10 HD053119 NICHD NIH HHS
• U10 HD53124 NICHD NIH HHS
• U10 HD21364 NICHD NIH HHS
• U10 HD34216 NICHD NIH HHS
• U01 HD036790 NICHD NIH HHS
• M01 RR6022 NCRR NIH HHS
• U10 HD027880 NICHD NIH HHS
• U10 HD040521 NICHD NIH HHS
• M01RR54 NCRR NIH HHS
• M01 RR002172 NCRR NIH HHS
• U10 HD053109 NICHD NIH HHS
• U10 HD40521 NICHD NIH HHS
• M01 RR2172 NCRR NIH HHS
• U10 HD27880 NICHD NIH HHS
• M01 RR008084 NCRR NIH HHS
• M01 RR125 NCRR NIH HHS
• U10 HD27904 NICHD NIH HHS
• M01 RR2588 NCRR NIH HHS
• U10 HD040461 NICHD NIH HHS
• U10 HD40498 NICHD NIH HHS
• M01 RR016587 NCRR NIH HHS
• M01 RR1032 NCRR NIH HHS
• M01 RR002635 NCRR NIH HHS
• U10 HD53089 NICHD NIH HHS
• U10 HD27871 NICHD NIH HHS
• UL1 RR024128 NCRR NIH HHS
• M01 RR7122 NCRR NIH HHS
• U10 HD040689 NICHD NIH HHS
• U10 HD040492 NICHD NIH HHS
• M01 RR001032 NCRR NIH HHS
• U10 HD027853 NICHD NIH HHS
• U10 HD027904 NICHD NIH HHS
• UL1 RR24148 NCRR NIH HHS
• U10 HD021397 NICHD NIH HHS
• U10 HD27856 NICHD NIH HHS
• KL2 RR024149 NCRR NIH HHS
• M01RR64 NCRR NIH HHS
• U10 HD034167 NICHD NIH HHS
• U10 HD40461 NICHD NIH HHS
• M01RR39 NCRR NIH HHS
• U10 HD27853 NICHD NIH HHS
• M01RR44 NCRR NIH HHS
• M01 RR30 NCRR NIH HHS
• UL1 TR000454 NCATS NIH HHS
• U10 HD027871 NICHD NIH HHS
• UL1 RR024148 NCRR NIH HHS
• M01 RR007122 NCRR NIH HHS
• U10 HD027851 NICHD NIH HHS
• U10 HD21397 NICHD NIH HHS
• U01 HD36790 NICHD NIH HHS
• M01 RR750 NCRR NIH HHS
• M01 RR8084 NCRR NIH HHS
• U10 HD21415 NICHD NIH HHS
• U10 HD21373 NICHD NIH HHS
• UL1RR24128 NCRR NIH HHS
• M01 RR997 NCRR NIH HHS
• M01RR70 NCRR NIH HHS
• UL1 RR025008 NCRR NIH HHS
• U10 HD21385 NICHD NIH HHS
• M01RR633 NCRR NIH HHS
• M01 RR32 NCRR NIH HHS
• U10 HD034216 NICHD NIH HHS
• UL1 RR24139 NCRR NIH HHS
• U10 HD040498 NICHD NIH HHS
• U10 HD27881 NICHD NIH HHS
• M01 RR006022 NCRR NIH HHS
• U10 HD053089 NICHD NIH HHS

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Affiliation(s)

Regina A. Gargus University of Arkansas Medical Sciences, Little Rock, AR
Betty R. Vohr Women and Infants Hospital The Warren Alpert Medical School of Brown University
Jon E Tyson University of Texas Houston Medical School
Pamela High The Warren Alpert Medical School of Brown University Hasbro Children's Hospitals
Rosemary D. Higgins Neonatal Research Network, National Institute of Child Health and Human Development
Lisa A. Wrage RTI International
Kenneth Poole RTI International

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Collaborators Collapse

Prediction of neurodevelopmental outcome after preterm birth

Prediction of outcome after preterm birth is critical, but remains difficult, particularly in the early postnatal period. The ability to predict outcome improves parental counseling and selection of infants for early therapeutic strategies aiming at preventing or ameliorating cerebral injury. This review gives an overview of the spectrum and severity of neurodevelopmental, behavioral, and psychosocial outcomes, with discussion of predictors of outcome and, in particular, the clinical, electrophysiological, and imaging predictors. A detailed neurologic examination of infants is a valuable predictive tool in terms of later moderate to severe neurodevelopmental impairments; however, it may be limited in the immediate newborn period. Electrophysiological, neuroimaging, and clinical risk factors for adverse neurodevelopmental outcome have been identified. Good prediction is usually achieved for major functional disabilities in early childhood, but is poorer for moderate or mild long-term outcome. Future research should focus on the long-term quality of life, academic achievement, and the influence of the sociocultural environment. More emphasis should be placed on genetic diversity as a modifying factor for the large variability in outcome.

Children with congenital hypothyroidism: long-term intellectual outcome after early high-dose treatment

We aim to determine long-term intellectual outcome of adolescents with early high-dose treated congenital hypothyroidism (CH). Sixty-three prospectively followed children with CH were assessed at age of 14 y with the Wechsler Intelligence Scale for Children-Revised and compared with 175 healthy controls. Median age at onset of treatment was 9 d (range 5-18 d) and median starting dose of levothyroxine (L-T4) was 14.7 microg/kg/d (range 9.9-23.6 microg/kg/d). Full-scale intelligence quotient (IQ) was significantly lower than in controls after adjustment for socioeconomic status (SES) and gender (101.7 versus 111.4; p < 0.0001). Children with athyreosis had a lower performance IQ than those with dysgenesis (adjusted difference 7.6 IQ scores, p < 0.05). Lower initial thyroxine (T4) levels correlated with poorer IQ (r = 0.27, p = 0.04). Lower SES was associated with poorer IQ, in particular in children with CH (interaction, p = 0.03). Treatment during childhood was not related to IQ at age 14 y. Adolescents with CH manifest IQ deficits when compared with their peers despite early high-dose treatment and optimal substitution therapy throughout childhood. Those adolescents with athyreosis and lower SES are at particular risk for adverse outcome. Therefore, early detection of intellectual deficits is mandatory in children with CH.

Outcome after renal transplantation. Part I: intellectual and motor performance

Comprehensive information on neurodevelopmental outcome in children and adolescents with chronic kidney disease is still limited. Intellectual performance (IP) and motor performance (MP) were systematically assessed in 27 patients at a median age of 14.1 years (range 6.5-17) and 6 years (range 0.5-12.7) after renal transplantation (RTPL). IP was analyzed with the Wechsler Intelligence Scale for Children-III (WISC-III) in 25 patients and by the Kaufman Assessment Battery for Children in two patients. MP was evaluated by the Zurich Neuromotor Assessment. Median full- scale intelligent quotient (FSIQ) was 97 (range 49-133). Twenty-one patients had an FSIQ >or= 85 (i.e. >or= mean-1 standard deviation). The five patients with neurological comorbidity had a median FSIQ of 81 (range 49-101). Verbal IQ (VIQ) (median 104; range 50-146) was significantly (p < 0.01) higher than performance IQ (PIQ) (median 88; range 48-117). The PIQ was significantly lower compared with controls (p < 0.007), and patients scored significantly lower compared with controls in five of 11 subtests of the Wechsler Scale. All MP tasks were significantly (p < 0.01) lower than in controls, and also in children without neurological comorbidity. Socioeconomic status was significantly correlated with FSIQ (p = 0.03). IP after RTPL was within the normal range for the majority of children. PIQ was lower compared with VIQ, and MP was significantly affected in all children after RTPL.

Outcome after renal transplantation. Part II: quality of life and psychosocial adjustment

Knowledge of health-related quality of life (QOL) and psychosocial adjustment (PA) in children after renal transplantation (RTPL) is limited. QOL and PA were evaluated by standardized tests in patients after RTPL. Thirty-seven children of median age 14.5 years (range 6.5-17 years) were investigated a mean 4.5 years (range 0.5-12.8 years) after RTPL. Child- and parent-rated QOL was evaluated with the Child Quality of life Questionnaire of The Netherlands Organization for Applied Scientific Research Academical Medical Centre (TNO-AZL). PA was assessed by the Child Behaviour Checklist (CBCL) providing parental reports of a child's behaviour. In patients' self-ratings, the QOL dimension physical complaints (P < 0.0005) scored significantly better than that of healthy controls, whereas the dimension positive emotional functioning was impaired (P = 0.02). Parents rated motor functioning (P = 0.002), autonomy (P = 0.01), cognition (P = 0.04) and positive emotions (P < 0.0005) as significantly impaired. Parents also assessed PA significantly (P = 0.02) impaired with regard to internalizing behaviour. Dialysis duration, young age at RTPL, living-related donation, steroid treatment, adverse family relationships and maternal distress had a significantly negative impact on QOL and PA (P < 0.05). Patients rated QOL higher than did healthy controls. Parents evaluated their children's QOL and PA more pessimistically than did the patients themselves. Both illness-related variables and family environment played an important role.

Surgery-related posttraumatic stress disorder in parents of children undergoing cardiopulmonary bypass surgery: a prospective cohort study

OBJECTIVE

We aimed at evaluating surgery-related posttraumatic stress disorder (PTSD) in parents of children undergoing cardiopulmonary bypass surgery. Risk factors for parental PTSD symptoms were explored.

DESIGN

A prospective cohort study was performed assessing PTSD symptoms immediately after discharge and 6 months after cardiopulmonary bypass surgery.

SETTING

Recruitment took place at a tertiary pediatric medical center in Switzerland.

SUBJECTS

German-speaking parents of children with congenital heart defects aged between 0 and 16 yrs undergoing cardiopulmonary bypass surgery were eligible (n = 228). After child discharge, 135 mothers and 98 fathers of 139 children (response rate 61.0%) participated. Six months after surgery, 121 mothers and 92 fathers of 128 children (response rate, 56.1%) took part in the study.

INTERVENTIONS

Assessment via a screening instrument and self-rating scale, and extraction of data from charts.

MEASUREMENTS AND MAIN RESULTS

The Posttraumatic Diagnostic Scale was applied to estimate self-reported symptoms of PTSD. Following discharge, 16.4% of mothers and 13.3% of fathers met diagnostic criteria for acute PTSD. Another 15.7% of mothers and 13.3% of fathers experienced significant symptoms of posttraumatic stress. Six months after surgery, PTSD rates were 14.9% and 9.5%, respectively. Mothers experienced more severe symptoms of PTSD, but gender differences were not detected with regard to the frequency of PTSD at either time. After controlling for socioeconomic status and child preoperative morbidity, PTSD symptom severity after discharge remained the only significant predictor of PTSD severity at 6 months. Pre-, peri-, and postoperative factors did not predict parental PTSD.

CONCLUSIONS

Parents of children undergoing cardiopulmonary bypass surgery are at increased risk for intermediate and long-term psychological malfunctioning. Acute symptoms of PTSD in parents shortly after discharge of their child are a major risk factor for the development of chronic PTSD. Clinicians need to identify parents at risk at an early stage to provide them with systematic support.

Long-term outcome of preterm infants treated with nasal continuous positive airway pressure

This study's aim was to assess neurodevelopmental and growth outcome until the age of 4 years of premature infants placed on early nCPAP, in the setting of the neonatal intensive care unit (NICU) and follow-up program of the Division of Neonatology of the Department of Pediatrics of the University Hospital, Lausanne, Switzerland. All consecutive inborn infants weighing <1500 g or <32 weeks of gestational age admitted to the NICU during two periods of 12 months-7.1996-6.1997 and 7.1998-6.1999-were compared before and after the systematic application of early nCPAP. Of 172 infants admitted to the NICU, 150 (87%) survived. 126 (84%) were tested at 6 months' corrected age, 121 (81%) at 18 months' corrected age, and 117 (78%) at the age of 4 years. Detailed perinatal data were collected. Follow-up included neurological examination, developmental testing and measurement of growth parameters. Statistical analyses were performed. Early application of nCPAP and avoidance of mechanical ventilation showed no adverse effects on neurodevelopment and growth. A significantly higher developmental quotient was found in the nCPAP group at 18 months' corrected age. Several trends were also noted in the nCPAP group with a decrease of intraventricular hemorrhage and in "abnormal neurodevelopment" at 6 months corrected age, a bigger head circumference at all different tested ages and a greater height at 6 and 18 months corrected ages. In conclusion, our study of developmental outcome documents the absence of any harmful effect of early application of nCPAP to treat respiratory failure in very low birthweight infants.

Improved outcome for very low birth weight multiple births

This study describes time trends for very low birth weight multiple births in relation to very low birth weight singletons. Two cohorts of very low birth weight (less than 1250 gm) children recruited between 1983-85 (cohort 1, n = 115) and 1992-94 (cohort 2, n = 144) were compared. The Bayley Scales of Infant Development and a standardized neurologic examination were administered at 2 years corrected age. Neurodevelopmental outcome did not change between cohort 1 and 2 for singletons. For multiple births, mean Mental Developmental Index increased after adjustment for neonatal risk factors [adjusted mean (standard deviation) 81.8 (11.7) to 96.5 (18.6), analysis of covariance P = 0.007]. The prevalence of cerebral palsy decreased, however not significantly [adjusted odds ratio (95% confidence interval) 0.3 (0.1-1.5), P = 0.14]. The proportion of disease-free survival (no cerebral palsy and no developmental delay) increased for multiple births (7-37%, P = 0.002), but not for singletons. In cohort 2, neurodevelopmental outcome of multiple births was similar to that of singletons. The cognitive outcome of very low birth weight multiple births improved, possibly because of changes in perinatal practice. However, neurodevelopmental outcome was similar to that of very low birth weight singletons who were unaffected by changes in neonatal care with high proportions of motor delay and cerebral palsy.

Variability of Cerebral Hemoglobin Concentration in Very Preterm Infants During the First 6 Hours of Life

Cerebral hemoglobin concentration (cHbc), a major determinant of oxygen transport capacity in the brain, shows a considerable variability due to physiological and methodological factors. In order to determine the (relative) contribution of these factors, the cHbc variability within the first 6 hours of life was studied in 28 very preterm infants using near infrared spectrophotometry (NIRS). Mean cHbc values were 46.4 +/- 14.1 micromol/l (2.75 +/- 0.84 ml/100 g). Is the variability in cHbc related to the methodology of cHbc measurements or to physiological variables? A statistical model of stepwise regression (backward selection) with 13 independent variables and with cHbc as a dependent variable showed that, from the total variability of +/- 14.1 micromol/l, only 3.7 micromol/l (26%) were of methodological origin, while the major portion, 9.3 micromol/l (66%) were related to four physiological variables: birth weight, gestational age, blood glucose and transcutaneous carbon dioxide tension. The remaining 1.1 micromol/l (7.8%) were unexplained. We conclude that NIRS, which allows continuous monitoring of cerebral oxygenation and metabolism even in the first hours of postnatal life, is a valid technique to measure cHbc in very preterm infants. The major portion of the large variability of early cHbc registrations can be attributed to physiological factors.

Parental post-traumatic reactions after premature birth: implications for sleeping and eating problems in the infant

BACKGROUND

Progress in perinatal medicine has made it possible to increase the survival of very or extremely low birthweight infants. Developmental outcomes of surviving preterm infants have been analysed at the paediatric, neurological, cognitive, and behavioural levels, and a series of perinatal and environmental risk factors have been identified. The threat to the child's survival and invasive medical procedures can be very traumatic for the parents. Few empirical reports have considered post-traumatic stress reactions of the parents as a possible variable affecting a child's outcome. Some studies have described sleeping and eating problems as related to prematurity; these problems are especially critical for the parents.

OBJECTIVE

To examine the effects of post-traumatic reactions of the parents on sleeping and eating problems of the children.

DESIGN

Fifty families with a premature infant (25-33 gestation weeks) and a control group of 25 families with a full term infant participated in the study. Perinatal risks were evaluated during the hospital stay. Mothers and fathers were interviewed when their children were 18 months old about the child's problems and filled in a perinatal post-traumatic stress disorder questionnaire (PPQ).

RESULTS

The severity of the perinatal risks only partly predicts a child's problems. Independently of the perinatal risks, the intensity of the post-traumatic reactions of the parents is an important predictor of these problems.

CONCLUSIONS

These findings suggest that the parental response to premature birth mediates the risks of later adverse outcomes. Preventive intervention should be promoted.

Postnatal growth in VLBW infants: significant association with neurodevelopmental outcome

OBJECTIVE

To study the significance of growth status at birth and postnatal growth on neurodevelopmental outcome in very low birth weight (VLBW) infants.

STUDY DESIGN

Growth and neurodevelopment were examined in 219 VLBW (<1250 g) children, 94 small for gestational age (SGA) (<10th percentile) and 125 appropriate for gestational age (AGA) (>10th percentile). Outcome at age 2 was assessed with the Bayley Scales of Infant Development (Mental Developmental Index [MDI], Psychomotor Developmental Index [PDI]) and a standardized neurologic examination.

RESULTS

SGA status was not associated with poor neurodevelopmental outcome. However, after adjustment for covariables including cerebral palsy (CP), SGA children with weight <10th percentile at age 2 had lower mean PDI than SGA children with catch-up growth to weight >10th percentile (mean [SD], 89.9 [17.4] versus 101.8 [14.5]; P<.001). AGA children with catch-down growth (weight <10th percentile at age 2) were, independent of CP, more likely to have lower mean MDI (94.9 vs 101.7, P=.05) and PDI (81.9 vs 95.1; P<.001) than AGA children remaining >10th percentile at age 2. They also more frequently had severe CP (22.9% vs 1.2%; P=.008).

CONCLUSIONS

In VLBW children, the course of postnatal growth rather than the appropriateness of weight for gestational age at birth determines later neurodevelopmental outcome.

Intellectual outcome in children and adolescents with acute lymphoblastic leukaemia treated with chemotherapy alone: age- and sex-related differences

One of the most relevant concerns in long-term survivors of paediatric acute lymphoblastic leukaemia (ALL) is the development of neuropsychological sequelae. The majority of the published studies report on patients treated with chemotherapy and prophylactic central nervous system (CNS) irradiation, little is known about the outcome of patients treated with chemotherapy-only regimens. Using the standardised clinical and neuropsychological instruments of the SPOG Late Effects Study, the intellectual performance of 132 paediatric ALL patients treated with chemotherapy only was compared to that of 100 control patients surviving from diverse non-CNS solid tumours. As a group, ALL and solid tumour survivors showed normal and comparable intellectual performances (mean global IQ 104.6 in both groups). The percentage of patients in the borderline range (global IQ between 70 and 85) was comparable and not higher as expected (10% cases and 13% controls, expected 16%). Only 2 (2%) of the former ALL and 1 (1%) of the solid tumour patients were in the range of mental retardation (global IQ<70). Former known risk factors described in children treated with prophylactic CNS irradiation, like a younger age at diagnosis of ALL and female gender, remained valid in chemotherapy-only treated patients. The abandonment of prophylactic CNS irradiation and its replacement by a more intensive systemic and intrathecal chemotherapy led to a reduction, but not the disappearance of late neuropsychological sequelae.

Muscle power development during the first year of life predicts neuromotor behaviour at 7 years in preterm born high-risk infants

The aim of the study was to find if neurological function during the first year of life could predict neuromotor behaviour at 7 years of age in children born preterm with a high risk. A follow-up study of neuromotor behaviour in 52 children at a mean age of 3, 6, 12 months (corrected age) and 7 years was performed. All children were born with a gestational age less than 32 weeks and/or a birthweight under 1500 g and the infants were categorised according to their medical history in the three highest categories of the 'Neonatal Medical Index' (NMI, from category I to V, from few to serious complications). In addition, neonatal cerebral ultrasound abnormalities were used to divide the infants further into the different NMI categories. At 3 and 6 months, the relationship between active and passive muscle power was measured in shoulders, trunk and legs and (a)symmetry between right and left was noted. The results at 3 and 6 months were ranged from 1 for optimal to 5 for poor muscle power regulation. At 12 months of age, a neurological examination was done with special emphasis on the assessment of postural control, spontaneous motility, hand function and elicited infantile reactions with special attention to (a)symmetry. Outcome at 12 months was expressed as percentage of the optimal score on each subcategory. At 7 years, the motor behaviour study based on Touwen's examination for minor neurological dysfunction was performed. This investigation focuses on different functions, such as hand function, quality of walking, posture, passive muscle tone, coordination and diadochokinesis. The outcome was expressed as percentage of the optimal score on the combined subcategories. The best prediction of neuromotor behaviour at 7 years was assessed with stepwise linear multiple regression, using as potential predictors perinatal factors and outcome of motor behaviour at the corrected age of 3, 6 and 12 months. At 7 years none of the children scored 100% on the combined subcategories, 15 children (29%) scored between 75% and 99%, whereas 15 children scored less than 50%. Neuromotor behaviour at 7 years could be predicted by the NMI categorisation and gender with a sensitivity of 92% (specificity 47%; positive and negative predictive value 81% and 70%). No direct relation was found between neuromotor behaviour and cerebral ultrasound classification only, days on the ventilator and/or continuous positive airway pressure, birthweight, gestational age and dysmaturity. The best predictor of neuromotor behaviour at 7 years was the combination of outcome of muscle power in shoulders and legs at 3 months and postural control at 12 months, taking into account the gender of the child (sensitivity 95%; specificity 40%; positive predictive value 80%; negative predictive value 75%).

[Reliability of the WPPSI-R test in the evaluation of cognitive development in preschool children]

The WPPSI-R scale (Wechsler Preschool and Primary Scale of Intelligence - Revised) is a psychometric test chosen as the evaluation tool in a study on preschool-age cognitive development in a cohort of very low birth weight (VLBW) premature children from the Fernandes Figueira Institute (IFF), applied by four previously trained psychologists. The objective of this study was to verify inter-observer reliability in the test application. Two types of reliability study design were used: balanced incomplete blocks, to verify agreement in the application of the scale, and crossed design, to verify agreement in scoring of items. We studied 12 preschool children born at IFF (birthweight < 1,500g). The intraclass correlation coefficients (ICC) were: 0.82 (full-scale IQ), 0.89 (verbal IQ), and 0.91 (performance IQ), in the incomplete block design study, and 0.99, 0.98, and 0.99, respectively, in the crossed design study, indicating good reliability. Application of the WPPSI-R scale in the study of cognitive development of VLBW premature children at IFF proved adequate, as shown by these results.

Phenotypic heterogeneity of growth and psychometric intelligence in Prader-Willi syndrome: variable expression of a contiguous gene syndrome or parent-child resemblance?

Phenotypic variability in children with Prader-Willi syndrome (PWS) was investigated with respect to variable expression of the contiguous gene syndrome and trait variance. In a prospective study, parent/child resemblance of anthropometric and psychometric measures was analyzed in 22 children with PWS (11 females and 11 males; 18 deletions, 4 uniparental disomy (UPD)) and in a control group (88 females and 88 males). The average child-midparent Z-score difference for height in females was -1.9 and in males -0.9, head circumference -1.7 and -1.0, and body mass index (BMI) 2.3 and 2.7, respectively. Intellectual performance of females and males was, on average, -2.7 and -2.6 below maternal performance. Range and standard deviation were moderately increased for height and head circumference, doubled for BMI, and unchanged for IQ. Parent/child correlations for anthropometric and psychometric measurements in the study group did not significantly differ from those of the control group. Exceptions were higher correlations between mothers and daughters for height (P < 0.05) and BMI (P < 0.01), and lower correlations for head circumference between midparent values and daughters (P < 0.05) than in the control group. In conclusion, parent-child resemblance in growth and intellectual development among children with PWS was found to be comparable to that noted in the normal population, indicating a strong determination by trait variance. Children with PWS differed significantly with respect to a lower trait level and-with the exception of IQ-a larger variability. The latter may indicate a variable expression of the contiguous gene syndrome.

Visual-motor function of very low birth weight and full-term children at 3 1/2 to 4 years of age

Improvements in perinatal and neonatal management have not only led to a higher survival rate of very low birth weight infants (VLBW; < or = 1,500 g or < 32 weeks gestational age), but also to a better outcome of these children. However the percentage of VLBW children who need special education because of later school problems remains high even in children considered neurologically normal during infancy. We assessed 40 VLBW children and 83 healthy full-term children at age 3 to 4 years by means of a simple and short test for visual-motor deficits. The test included the copying and cutting-out of geometric shapes, the building of models, the recognition of colours and the observation of the concentration and cooperation during the test. All VLBW children had had a good perinatal outcome and had been considered neurologically normal at one year of age. Most VLBW children scored within 1 standard deviation (S.D.) of the test mean, but on average the VLBW children scored significantly lower than the full-term infants in the copying of figures, the cutting-out of geometric forms, the building of models and in the overall concentration and cooperation during the test. Children who attended a nursery school achieved significantly better test results. Girls tended to have better results, but this was not statistically significant. Social factors and age had a significantly greater impact on results than perinatal factors. In summary, VLBW children scored significantly less in almost every test item compared to their term peers. Our test battery could serve as a short introductory test to screen for deficits in visual-motor skills, especially in VLBW children.

Development of postural adjustments during reaching in preterm infants

Preterm infants often show postural abnormalities, such as hyperextension of neck and trunk, which can interfere with motor and cognitive development. Little is, however, known on the pathophysiology of postural development in preterm infants. Therefore, we longitudinally studied the development of postural adjustments during reaching movements in 12 preterm infants between the (corrected) ages of 4 and 18 mo. Five infants showed minor neurological dysfunctions at 18 mo, such as a mild diffuse hypotonia, a mild hypertonia of the legs, or a mild asymmetry in posture and motility, and seven infants were neurologically normal. Each assessment consisted of a simultaneous recording of video-data and surface electromyograms of arm, neck, trunk, and leg muscles during reaching in various lying and sitting positions. Comparable data on postural development in ten full-term infants were available. The preterm infants showed an excessive amount of postural activity during reaching movements at all ages studied. Moreover, the postural adjustments were temporally disorganized and could not be modulated with respect to the velocity of the arm movement and the initial sitting position. We hypothesized that the preterms' disability to modulate their postural adjustments might be due to a reduced capacity to learn from prior experience. In our small group the postural dysfunctions were not related to the presence of hyperextension at early ages, to the neurological outcome at 18 mo, or to the lesions found on the neonatal brain ultrasound scans.

Neuromotor ability in 5- to 7-year-old children with very low or extremely low birthweight

This study was intended to determine the effects of extremely low birthweight (ELBW, 500 to 999 g) and very low birthweight (VLBW, 1000 to 1499 g) on neuromotor ability in 5- to 7-year-old children. Fourteen ELBW and 20 VLBW children were compared with 24 term control children of normal birthweight (NBW, >2500 g). Using quantitative assessment instruments, the following data were collected: maximal cycling speed during 30 seconds of cycling at 'zero' resistance, simple reaction time of the legs, and performance on components of a whole-body coordination test. The main findings were a slower reaction time, lower maximal cycling speed, and lower coordination scores in the ELBW group compared with the NBW group and, for some variables, with the VLBW group. The reduced motor performance in these children appears for the most part to be a reflection of impaired neuromotor control and motor development, rather than merely a smaller body or muscle size.

Neuropsychological analysis of the visuomotor problems in children born preterm at < or = 32 weeks of gestation: a 5-year prospective follow-up

Forty-six intellectually normal children born preterm (< or =32 weeks of gestation) without major neurological disabilities and a control group of term children matched for age, sex, and parental educational and occupational status were assessed at the age of 5 years using neuropsychological tests emphasizing perceptual and visuomotor functions. The results show that in terms of cognitive functions these preterm children are a very heterogenous group, but many of them still have problems in visuospatial and sensorimotor functions. The preterm children achieved lower mean scores in tests where coordination and voluntary control of hands in combination with tactile, kinaesthetic, and visuospatial perception were needed. They had most difficulty with drawing directions of lines and in integrating two or more forms. They also had problems with 3-dimensional constructions as well as visual perception of rotated shapes or slopes of lines.

The Relationship Between Multiple Birth Children’s Early Phonological Skills and Later Literacy

Previous studies have shown that multiple birth children (MBC) are prone to early phonological difficulties and later literacy problems. However, to date, there has been no systematic long-term follow-up of MBC with phonological difficulties in the preschool years to determine whether these difficulties predict later literacy problems. In this study, 20 MBC whose early speech and language skills had been previously documented were compared to normative data and 20 singleton controls on tasks assessing phonological processing and literacy. The major findings indicated that MBC performed significantly more poorly on some tasks of phonological processing than singleton controls did. Further, the early phonological skills of MBC (i.e., the number of inappropriate phonological processes used) were correlated with poor performance on visual rhyme recognition, word repetition, and phoneme detection tasks 5 years later. There was no significant relationship between early biological factors (birth weight and gestation period) and performance on the phonological processing and literacy-related subtests. These results support the hypothesis that MBC’s early speech and language difficulties are not merely a transient phase of development, but a real disorder, with consequences for later academic achievement.

Speech perception and speech comprehension investigations of pre-term newborns and high-risk neonates of pre-school age

The purpose of this study is to establish whether there is any connection between neonatal morbidity and speech perception and comprehension in children of pre-school age who have previously been treated as newborn infants in an intensive care unit. The test applied is a method invented in Hungary for the analysis of global hearing, speech perception and comprehension. The authors summarize the results of their follow-up studies of 52 children with respiratory disorders as newborns, some of whom were born as pre-term and some as full-term newborns with asphyxia. The children have been put into three groups according to their maturity and their birthweight. Newborns with hearing loss and mental retardation were excluded from this study. Of the various neonatal factors the results show: complications of delivery, birthweight, hypoxia, persistent ductus arteriosus, duration of ventilation and complications of respiratory treatment are found to be correlated to perception and comprehension. Incidences of poor achievement obtained in the most characteristic subtests have been compared among the different groups of newborns. The intelligence level of pre-school children is found to be closely correlated to speech perception and comprehension.

Developmental outcome of infants born with biological and psychosocial risks

The significance of prenatal and perinatal complications (biological risk) and of family adversity (psychosocial risk) on early child development was examined in a prospective study. Developmental outcome of 350 infants was assessed by measures of motor, cognitive, and social-emotional functioning at 3, 24, and 54 months. Results indicated a differential impact of risk factors on specific outcomes. Whereas psychosocial risks became more prominent with growing age and were related to poorer child outcome in all areas of functioning, biological risks decreased in influence and predominantly resulted in poorer motor development. The contributions of biological and psychosocial risks on outcomes were additive. A number of individual risk factors emerged as significant predictors of later maladaptation.

Differential effects of preterm birth and small gestational age on cognitive and motor development

AIMS

To determine the differential effects of preterm birth and being small for gestational age on the cognitive and motor ability of the child.

METHODS

A longitudinal cohort of all infants of gestational age < or = 32 weeks born to mothers resident in the counties of Cheshire and Merseyside in 1980-1 was studied. The children were assessed at the age of 8 to 9 years using the Wechsler Intelligence Scale for Children, the Neale analysis of reading ability, and the Stott-Moyes-Henderson test of motor impairment. Adequacy of fetal growth was determined by the birthweight ratio--that is, the ratio of the observed birthweight to the expected birthweight for a given gestational age. Children with clinically diagnosed motor, learning or sensory disabilities were excluded. Information on social variables was obtained by a questionnaire completed by the parents. Of the 182 children, 158 were assessed.

RESULTS

IQ was positively correlated with birthweight ratio but not with birthweight or gestational age. Motor ability was associated with birthweight, gestational age, and birthweight ratio. Reading comprehension was associated with birthweight ratio, but reading rate and accuracy were best explained by social variables and sex. IQ remained associated with birthweight ratio, after adjusting for maternal education, housing status, and number of social service benefits received. Reading ability was related to these social variables but motor ability was not.

CONCLUSIONS

The effects of SGA and preterm birth differed: SGA was associated with cognitive ability, as measured by IQ and reading comprehension; motor ability was additionally associated with preterm birth. Reading rate and accuracy were not associated with SGA or preterm birth but were socially determined.

The contribution of risk factors to the effect of early otitis media with effusion on later language, reading, and spelling

A cohort of 946 children who were screened for otitis media with effusion (OME) from the ages of 2 to 4 were studied for language, reading, and spelling at 7 years of age. The effects of OME in combination with single risk factors and with increasing numbers of risk factors were investigated. An interaction with an additional risk factor was found only for gender and OME, with boys' spelling influenced negatively by a history of OME. OME in combination with preterm birth and low birthweight also appears to put children at risk for later language and educational problems. Although a negative linear relation between the number of risk factors and later functioning was found, it is suggested that OME, even when combined with a number of other risk factors, produces only minor effects on later language, reading, and spelling.

Diagnostic and prognostic value of cerebral 31P magnetic resonance spectroscopy in neonates with perinatal asphyxia

The impact of depressed neonatal cerebral oxidative phosphorylation for diagnosing the severity of perinatal asphyxia was estimated by correlating the concentrations of phosphocreatine (PCr) and ATP as determined by magnetic resonance spectroscopy with the degree of hypoxic-ischemic encephalopathy (HIE) in 23 asphyxiated term neonates. Ten healthy age-matched neonates served as controls. In patients, the mean concentrations +/- SD of PCr and ATP were 0.99 +/- 0.46 mmol/L (1.6 +/- 0.2 mmol/L) and 0.99 +/- 0.35 mmol/L (1.7 +/- 0.2 mmol/L), respectively (normal values in parentheses). [PCr] and [ATP] correlated significantly with the severity of HIE (r = 0.85 and 0.9, respectively, p < 0.001), indicating that the neonatal encephalopathy is the clinical manifestation of a marred brain energy metabolism. Neurodevelopmental outcome was evaluated in 21 children at 3, 9, and 18 mo. Seven infants had multiple impairments, five were moderately handicapped, five had only mild symptoms, and four were normal. There was a significant correlation between the cerebral concentrations of PCr or ATP at birth and outcome (r = 0.8, p < 0.001) and between the degree of neonatal neurologic depression and outcome (r = 0.7). More important, the outcome of neonates with moderate HIE could better be predicted with information from quantitative 31P magnetic resonance spectroscopy than from neurologic examinations. In general, the accuracy of outcome predictability could significantly be increased by adding results from 31P magnetic resonance spectroscopy to the neonatal neurologic score, but not vice versa. No correlation with outcome was found for other perinatal risk factors, including Apgar score.

Low birthweight and neuromotor development: a population based, controlled study

The aims of the study were to investigate: (a) the relationship between low birthweight (LBW) and pre-school neuromotor development; and (b) the predictive value of various pre-, peri-, and neonatal factors for neuromotor development in LBW pre-school children. A population based sample of 144 5-year-old LBW children (birthweight < 2000 g) with no major handicaps was compared with a random sample of 163 normal birthweight term controls. Using the Peabody Developmental Motor Scales, impaired performance on the balance scale was seen more often in LBW boys than in controls (odds ratio 5.5, 95% CI 1.5-20.3), while performance on the eye-hand coordination and locomotor scales was comparable for the two groups. LBW girls were comparable to controls on all these scales. On neurological examination, an increased frequency of minor neurological signs was found in LBW boys, while increased ankle tone and/or leg hyperreflexia was more common in LBW girls compared to controls. Small head circumference at birth was associated with an increased frequency of minor neurological signs in LBW boys, and lack of breastmilk in the neonatal period with impaired balance in LBW boys. None of the other pre-, peri- or neonatal factors were predictive of neuromotor development. We conclude that motor functions essential for daily activities are intact in most LBW preschoolers.

The organization of leg movements in preterm and full-term infants after term age

In a sample of 13 full-term and 10 preterm infants, the development of kicking movements was studied at 6, 12, and 18 weeks (corrected) age. In healthy full-term infants some characteristics are strikingly stable, such as the duration of the flexion and extension phase and the within-joint organization. These parameters did not differ in preterm compared to full-term infants. For other features, however, developmental changes and differences were observed. Full-term infants tended to decrease their kick frequencies slightly with age. In preterm infants much higher initial kick rates were found, followed by a steep decrease, which resulted in kick frequencies comparable to the full-term levels after the (corrected) age of 12 weeks. There is a tight coupling between the movements in the different joints of the leg in full-term newborns. Preterm infants, in contrast, initially show much lower cross-correlations between hip and ankle and between knee and ankle. This is particularly the case for those preterm infants who were born before 32 weeks gestation. Again, the differences resolved after the age of 12 weeks, which might be related to a transformation in neural functions reported previously around this age. The initial differences in the characteristics of kicking appeared to be more readily explainable by differences in neurological condition than by contrasts in leg volume or postural control.

Parental factors in cognitive outcome of non-handicapped low birthweight infants

A population based cohort of 144 children weighing less than 2000 g who were without major handicap, and a random control sample of 163 children born at term and weighing over 3000 g were investigated. The aim was to assess the relative importance for cognitive development at 5 years of age, of birthweight, parental demographic factors, and factors related to the environment in which the child was reared. The mean non-verbal IQ was 6.1 points lower (95% CI, 2.3 to 10) for the low birthweight (LBW) group, but the difference was reduced to 4.8 points (95% CI, 1.1 to 8.5) after adjusting for confounding parental demographic and childrearing factors. The verbal IQ was similar for the two groups after such adjustment. Paternal education was the main confounding variable, and demographic factors such as parental education and family income were much stronger predictors of child IQ than birthweight or factors related to the childrearing environment. There was no evidence that the cognitive development of low birthweight children was more sensitive to a non-optimal childrearing environment than that of normal birthweight children. These findings indicate that the risk of impaired cognitive development increases with decreasing socioeconomic status, and that this risk is much larger than, and independent of, the small risk attributable to low birthweight.

Influence of perinatal, developmental and environmental factors on cognitive abilities of preterm children without major impairments at 5 years

The relative role of perinatal factors (birthweight, gestational age, gender, asphyxia, mechanical ventilation and cerebral lesions), developmental factors (neuromotor development during the first 18 months of life) and environmental factors (socio-economic status and bilingualism) on cognitive abilities was evaluated in a cohort of preterm children who had been prospectively examined for haemorrhage (PVH) and periventricular leucomalacia (PVL) and followed-up to 5 years of age. Standardized neurological examinations and development assessment including tests of cognitive function were carried out. Major impairments could be ascribed to the presence of large PVL changes. Among the 226 children without major impairment, the overall incidence of neuropsychological anomalies (neuromotor, language, visual, auditory and behaviour anomalies) was 46.5% and did not differ within ultrasound groups (normal scans, PVH and small PVL). However, children with small changes of PVL presented more abnormal neuromotor development within the first 18 months of life and had more complex neuropsychological anomalies at 5 years. The multiple regression analysis (General Intellectual Index (GII) predicted = 113.7 - coefficient x social class - 8.5 x bilingualism - 5.5 x dystonia + 1.4 x gestational age + 8 x mechanical ventilation) showed that socioeconomic status was the most important factor affecting the General Intellectual Index (GII). The contribution of sex and cerebral lesions was not significant. As children grew-up, environmental factors seemed to overcome perinatal factors.

The development of head position preference in preterm infants beyond term age

Healthy full-term infants show a developmental trend in head position from an initial right-sided preference to one with the head in midline around the age of 12 weeks. We studied the effects of intrauterine growth retardation (IUGR) and the degree of prematurity on both aspects of development from 35 weeks postmenstrual age to 18 weeks corrected age in 35 preterm infants without overt neurological abnormalities and whose gestational ages ranged from 27 to 34 weeks. Our data reveal that, during the preterm period, infants born after pregnancies of 32 weeks or less showed a lack of right-sided preferences for head turning after release from midline but not for the subsequent maintenance of a position. IUGR did not seem to affect either preference. After term age a right-sided preference diminished while a head midline position increased. The latter was not significantly delayed in relation to birth before 32 weeks gestation or IUGR. However, when infants were classified on the basis of neurological differences as reflected in a (mildly) abnormal movement quality, a delay in the attainment of a midline posture was observed, which suggests it is related to a suboptimal neurological condition. This delay, however, was also accounted for by the side-to-side flattening of the skull.