Neurodevelopment and chronic illness: Mechanisms of disease and treatment

Differential Cortical Volume and Surface Morphometry in Youth With Chronic Health Conditions

Up to 1 in 3 youth in the United States have a childhood-onset chronic health condition (CHC), which can lead to neurodevelopmental disruptions in cognitive functioning and brain structure. However, the nature and extent of structural neurobiomarkers that may be consistent across a broad spectrum of CHCs are unknown. Thus, the purpose of this study was to identify potential differences in brain structure in youth with and without chronic physical health conditions (e.g., diabetes, hemophilia). Here, 49 T1 structural magnetic resonance imaging (MRI) images were obtained from youth with (n = 26) and without (n = 23) CHCs. Images were preprocessed using voxel-based morphometry (VBM) to generate whole-brain voxel-wise gray matter volume maps and whole-brain extracted estimates of cortical surface area and cortical thickness. Multi-scanner harmonization was implemented on surface-based estimates and linear models were used to estimate significant main effects of the group. We detected widespread decreases in brain structure in youth with CHCs as compared to controls in regions of the prefrontal, cingulate, and visual association areas. The insula exhibited the opposite effect, with cases having increased surface area as compared to controls. To our knowledge, these findings identify a novel structural biomarker of childhood-onset CHCs, with consistent alterations identified in gray matter of regions in the prefrontal cortex and insula involved in emotion regulation and executive function. These findings, while exploratory, may reflect an impact of chronic health stress in the adolescent brain, and suggest that more comprehensive assessment of stress and neurodevelopment in youth with CHCs may be appropriate.

Universal assessment and tiered intervention: A model of care to meet the pediatric oncology psychosocial standard of care for school support

OBJECTIVE

The feasibility and acceptability of a tiered intervention model of school intervention services was investigated in response to the publication of evidence-based Psychosocial Standards of Care for Children with Cancer and their Families.

METHOD

Children with newly diagnosed malignancy or transitioning to long-term survivorship care were eligible. Families received universal school needs assessment and intervention targeted at the level of risk identified. Academic risk and resource utilization data collected over 1 year were used to evaluate model feasibility and surveys evaluated family and medical provider satisfaction with the model.

RESULTS

One hundred and eight children were enrolled and had academic risk assessed at enrollment as high (25%), moderate (44.4%) or low (30.6%) risk. School liaison staff time spent providing intervention was related to the level of risk. 54.6% of patients reported a decrease in risk status at the end of 1 year of intervention. Parents (94%) and medical providers (100%) chose responses of "agree" or "strongly agree" when asked if they were satisfied with the intervention received over the year.

CONCLUSIONS

The tiered model of care identifies the students with the highest need for intervention, allows for more targeted use of resources, and successfully meets the Psychosocial Standard of Care for academic needs.

Adverse Childhood Experiences and Chronic Diseases: Identifying a Cut-Point for ACE Scores

Adverse Childhood Experiences (ACEs) contribute to many negative physiological, psychological, and behavioral health consequences. However, a cut-point for adverse childhood experience (ACE) scores, as it pertains to health outcomes, has not been clearly identified. This ambiguity has led to the use of different cut-points to define high scores. The aim of this study is to clarify a cut-point at which ACEs are significantly associated with negative chronic health outcomes. To accomplish this aim, a secondary analysis using data from a cross-sectional study was conducted. The Adverse Childhood Experiences-International Questionnaire (ACE-IQ) was used for data collection. Descriptive statistics, nonparametric regression, and logistic regression analyses were performed on a sample of 10,047 adults. Data from demographic and self-report health measures were included. The results showed that a cut-point of four or more ACEs was significantly associated with increased rates of chronic disease. Participants with at least one chronic disease were almost 3 times more likely (OR = 2.8) to be in the high ACE group. A standardized cut-point for ACE scores will assist in future research examining the impact of high ACEs across cultures to study the effect of childhood experiences on health.

Cognitive effects of low dose of ionizing radiation - Lessons learned and research gaps from epidemiological and biological studies

The last decades have seen increased concern about the possible effects of low to moderate doses of ionizing radiation (IR) exposure on cognitive function. An interdisciplinary group of experts (biologists, epidemiologists, dosimetrists and clinicians) in this field gathered together in the framework of the European MELODI workshop on non-cancer effects of IR to summarise the state of knowledge on the topic and elaborate research recommendations for future studies in this area. Overall, there is evidence of cognitive effects from low IR doses both from biology and epidemiology, though a better characterization of effects and understanding of mechanisms is needed. There is a need to better describe the specific cognitive function or diseases that may be affected by radiation exposure. Such cognitive deficit characterization should consider the human life span, as effects might differ with age at exposure and at outcome assessment. Measurements of biomarkers, including imaging, will likely help our understanding on the mechanism of cognitive-related radiation induced deficit. The identification of loci of individual genetic susceptibility and the study of gene expression may help identify individuals at higher risk. The mechanisms behind the radiation induced cognitive effects are not clear and are likely to involve several biological pathways and different cell types. Well conducted research in large epidemiological cohorts and experimental studies in appropriate animal models are needed to improve the understanding of radiation-induced cognitive effects. Results may then be translated into recommendations for clinical radiation oncology and imaging decision making processes.

Neurocognitive Functioning among Children with Sickle Cell Anemia Attending SCA Clinic at MNH, Dar es Salaam, Tanzania

Background

Children with sickle cell anemia are at a higher risk of developing neurological sequelae like abnormal intellectual functioning, poor academic performance, abnormal fine motor functioning, and attentional deficits. There is a paucity of data about neurocognitive impairment among children with sickle cell anemia in Tanzania. Recognition of the magnitude of neurocognitive impairment will help to provide insight in the causative as well as preventive aspects of the same. Therefore, this study was carried out to determine the prevalence and factors associated with neurocognitive impairment in children with sickle cell anemia.

Methods

This is a cross-sectional comparative study between children with SCA and a control group of the hemoglobin AA sibling. It was carried out in Muhimbili National Hospital during a five-month period. The Rey–Osterrieth Complex Figure test (ROCF) which is used to test memory and visual special functions and KOH block design tools that have been previously validated through another study locally were used. Additional information on demographic characteristics was also collected using a predetermined questionnaire. Proportions and comparisons of means were used to examine associations between neurocognitive impairment and independent variables for associated factors.

Results

A total of 313 children were included in the final analysis. Among all the participants, the majority of the participants in the sickle cell group were of the age group 14-15 years (45.9%). In the comparison group, the majority were of the age group 9-10 years (43.8%). The neurocognitive scores in children with sickle cell anemia were significantly different from the normal siblings. In the copy ROCF, the neurocognitive function in SCA participants was 68.2% below the mean as compared to 45% of their counterparts, p ≤ 0.001. Additionally, there was no difference in memory in children with SCA compared to normal siblings (14.8% vs. 12.5%, respectively, p=0.606). Children with SCA had a higher proportion of impaired IQ (85.4%) as compared to children without SCA (72.5%), and the difference was statistically significant, p=0.009. Factors associated with neurocognitive impairment were age above 13 years, BMI, and absenteeism from school. Conclusion and Recommendation. Children with SCA had more impairment in terms of copying and IQ. We recommend assessment at the younger age group, increased sample size in future studies, and long-term cohort follow-up.

Adolescents With Chronic Medical Conditions and High School Completion: The Importance of Perceived School Belonging

Students with chronic medical conditions often experience barriers to academic progress, including impact of disease and treatment, increased school absence, and altered expectations of teachers and parents. School belonging is an important element of academic success and can be promoted by positive relationships, structure, and support in the school environment. One aim of this study was to explore group differences in perceived school belonging and rate of on-time high school completion for students with chronic medical conditions as compared to their healthy peers. The second goal was to analyze relations between belonging, health status, and on-time completion of high school. Restricted data from Add Health was used to answer the study questions. Results showed that students with chronic medical conditions reported lower levels of perceived school belonging than their healthy peers (t(1056) = 3.69, p < .001, d = 0.23). Students with chronic medical conditions also attained lower levels of on-time high school graduation than their healthy peers (t(1056) = 2.60, p = .005, d = 0.16). Perceived school belonging had a different impact for students with chronic medical conditions than for those who had no health concerns. Each unit increase in belonging for students with health impairment was related to a 63% increased likelihood of on-time high school graduation (OR = 1.629, p = .003). School belonging is especially important for students living with chronic medical conditions. Finding ways to facilitate a stronger sense of school belonging may be a way to support desired academic outcomes.

Neurocognitive and functional outcomes at 5 years of age after renal transplant in early childhood

BACKGROUND

Clinicians often use information about developmental outcomes in decision-making around offering complex, life-saving interventions in children such as dialysis and renal transplant. This information in children with end-stage renal disease (ESRD) is limited, particularly when ESRD onset is in infancy or early childhood.

METHODS

Using data from an ongoing prospective, longitudinal, inception cohort study of children with renal transplant before 5 years of age, we evaluated (1) the risk of adverse neurocognitive and functional outcomes at 5 years of age and (2) predictors of developmental outcomes.

RESULTS

We found evidence of neurocognitive sequelae of ESRD in very young children; however, developmental outcomes appear remarkably better when compared with findings of two or three decades ago. Less time on dialysis predicted higher developmental scores, and hemodialysis was associated with poorer developmental outcomes.

CONCLUSIONS

Our data suggest that renal replacement therapies in young children are associated with acceptable developmental outcome. Programs to identify those with developmental delays and provide early intervention may allow achievement of the child's full potential.

Low risk of neurodevelopmental impairment among perinatally acquired HIV-infected preschool children who received early antiretroviral treatment in Thailand

INTRODUCTION

Antiretroviral therapy (ART) is recommended in perinatally HIV-infected (PHIV) infants immediately upon diagnosis. We aimed to compare neurodevelopmental outcomes between PHIV children who initiated ART within 12 months of life and perinatally HIV-exposed uninfected (PHEU) children and to assess neurodevelopmental outcomes by timing of ART.

METHODS

This prospective cohort study included Thai children aged 12 to 56 months who were assessed with the Mullen Scales of Early Learning (MSEL) at enrolment and at 48 weeks. Global Developmental Impairment (GDI) was defined as Early Learning Composite (ELC) ≤ 70 on the MSEL; typical developmental pattern was defined as ELC > 70 at both visits. Logistic regression was used to compare prevalence of any GDI. Predictors of changing ELC scores were analysed with generalized estimating equations linear regression model.

RESULTS

From 2016 to 2017, 50 PHIV (twenty-seven early ART within three months and twenty-three standard ART within three to twelve months) and 100 PHEU children were enrolled. Median (IQR) age at first assessment was 28 (19 to 41) months. PHIV children had lower age-relevant Z scores for weight, height and head circumference compared to the PHEU group (p < 0.05). The prevalence of overall GDI was 18% (95% CI 11 to 27) and 32% (95% CI 20 to 47) in PHEU and PHIV children respectively (p = 0.06). In subgroup analysis, 22% (95% CI 9 to 42) of early ART PHIV children and 44% (95% CI 23 to 66) of standard ART PHIV children had overall GDI. There was a higher rate of GDI in standard ART PHIV children (p = 0.01), but not in the early ART group (p = 0.62) when compared with PHEU children. The standard ART PHIV group demonstrated lower typical developmental pattern than both the early ART PHIV group and the PHEU group (57% vs. 77% vs. 82% respectively). Non-attendance at nursery school was associated with changes in ELC score during study participation (adjusted coefficient -3.8; 95% CI -6.1 to -1.6, p = 0.001).

CONCLUSIONS

Preschool children with HIV who initiated ART in the first three months of life had a similar rate of GDI as PHEU children. Lack of nursery school attendance predicted poor developmental trajectory outcomes among PHIV children.

Intellectual and academic outcomes after pediatric liver transplantation: Relationship with transplant-related factors

As survival rates for pediatric liver transplant continue to increase, research attention is turning toward long-term functional consequences, with particular interest in whether medical and transplant-related factors are implicated in neurocognitive outcomes. The relative importance of different factors is unclear, due to a lack of methodological uniformity, inclusion of differing primary diagnoses, varying transplant policies, and organ availability in different jurisdictions. This cross-sectional, single-site study sought to address various methodological limitations in the literature and the paucity of studies conducted outside of North America and Western Europe by examining the intellectual and academic outcomes of Australian pediatric liver transplant recipients (N = 40). Participants displayed significantly poorer intellectual and mathematical abilities compared with the normative population. Greater time on the transplant waitlist was a significant predictor of poorer verbal intelligence, working memory, mathematical abilities, and reading but only when considering the subgroup of children with biliary atresia. These findings support reducing the time children wait for a transplant as a priority.

Intelligence and Academic Achievement of Adolescents with Craniofacial Microsomia

BACKGROUND

The authors compared the IQ and academic achievement of adolescents with craniofacial microsomia (cases) and unaffected children (controls). Among cases, the authors analyzed cognitive functioning by facial phenotype.

METHODS

The authors administered standardized tests of intelligence, reading, spelling, writing, and mathematics to 142 cases and 316 controls recruited from 26 cities across the United States and Canada. Phenotypic classification was based on integrated data from photographic images, health history, and medical chart reviews. Hearing screens were conducted for all participants.

RESULTS

After adjustment for demographics, cases' average scores were lower than those of controls on all measures, but the magnitude of differences was small (standardized effect sizes, -0.01 to -0.3). There was little evidence that hearing status modified case-control group differences (Wald p > 0.05 for all measures). Twenty-five percent of controls and 38 percent of cases were classified as having learning problems (adjusted OR, 1.5; 95 percent CI, 0.9 to 2.4). Comparison of cases with and without learning problems indicated that those with learning problems were more likely to be male, Hispanic, and to come from lower income, bilingual families. Analyses by facial phenotype showed that case-control group differences were largest for cases with both microtia and mandibular hypoplasia (effect sizes, -0.02 to -0.6).

CONCLUSIONS

The highest risk of cognitive-academic problems was observed in patients with combined microtia and mandibular hypoplasia. Developmental surveillance of this subgroup is recommended, especially in the context of high socioeconomic risk and bilingual families. Given the early stage of research on craniofacial microsomia and neurodevelopment, replication of these findings is needed.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Young adults perinatally infected with HIV perform more poorly on measures of executive functioning and motor speed than ethnically matched healthy controls

Perinatal HIV is associated with significant neurocognitive morbidities, but few studies have examined cognitive impact of early HIV infection on patients surviving to adulthood. The purpose of this study was to evaluate neurocognitive outcomes among a cohort of perinatally infected young adults. Individuals between the ages of 18 and 24 with perinatal infection were recruited for this cross-sectional study along with similarly aged healthy controls. Participants completed an MRI and brief neuropsychological assessment battery. Multivariate analysis of covariance controlling for age, gender, race/ethnicity, and education was completed to detect differences between the HIV+ and control groups. Multivariable linear regression was performed to assess HIV-associated factors potentially impacting neuropsychological findings among the HIV+ group. Twenty-nine HIV+ young adults and 13 healthy controls were included in the study. After adjusting for age and sociodemographic variables, the HIV+ group scored lower on attention/working memory (Digit Span (p = .008) and Letter-Number Sequencing (p = .038)), set-shifting (DKEFS Trail Making Test Condition 4 (p = .026) and motor speed (DKEFS Trail Making Test Condition 5 (p = .003)). For the HIV+ group, nadir CD4 was associated with better Letter-Number Sequencing score (p = .029) and use of highly active antiretroviral therapy was associated with better performance on Category Fluency (p = .040). After controlling for sociodemographic variables, executive dysfunction persists among young adults with perinatal HIV infection in comparison to controls. Future studies to further elucidate the impact of executive dysfunction on independent living and functional outcomes are indicated.

The role of neuropsychology in UK pediatric HIV care: Relevance to clinical practice and research

There has been a dramatic improvement in the survival of children with perinatally-acquired HIV (PHIV) following the introduction of effective treatment in 1990s. The care for children living with PHIV is now focused on more accurately understanding the effects of both HIV and HIV treatment on the developing body and brain. An evaluation of current HIV neuroimaging, and neurocognitive research, when combined with clinical experience in the area of HIV, could help to inform United Kingdom (UK) PHIV service provision. This paper argues that an understanding from a neuropsychological perspective will help these young people to optimize their health, quality of life, and future functioning. The aim of the paper is to bring together research and clinical understanding of HIV and its treatment effects on the developing brain, together with an understanding of other potential neurological risk factors. It is argued here that there is a need for targeted neuropsychology assessment and preventative interventions, supported by clinical and preliminary research on the neurocognitive effects of HIV and its treatments.

Perinatal HIV Status and Executive Function During School-Age and Adolescence: A Comparative Study of Long-Term Cognitive Capacity Among Children From a High HIV Prevalence Setting

The aim of this study was to determine whether perinatal HIV infection (PHIV), HIV-exposed uninfected (PHEU) versus HIV-unexposed (PHU) status predicted long-term executive function (EF) deficit in school-aged Ugandan children.Perinatal HIV status was determined by 18 months via DNA polymerase chain reaction test and confirmed at cognitive assessment between 6 and 18 years using HIV rapid-diagnostic test. Primary outcome is child EF measured using behavior-rating inventory of executive function questionnaire across 8 subscales summed to derive the global executive composite (GEC). EF was proxy-reported by caregivers and self-reported by children 11 years or older. Descriptive analyses by perinatal HIV status included derivation of mean, standard deviations (SD), number, and percent (%) of children with EF deficits warranting clinical vigilance. Raw scores were internally standardized by age and sex adjustment. EF scores warranting clinical vigilance were defined as ≥ mean + 1.5SD. t Tests for mean score differences by perinatal HIV status and linear-regression models were implemented in SAS version 9.4 to derive HIV status-related EF deficits (β) and 95% confidence intervals (CIs).Proxy-reported and self-reported EF were assessed in 166 and 82 children, respectively. GEC deficit was highest for PHIV (mean = 121.9, SD = 29.9), intermediate for PHEU (mean = 107.5, SD = 26.8), and lowest for PHU (mean = 103.4, SD = 20.7; P-trend < 0.01). GEC deficit levels warranting clinical vigilance occurred in 9 (15.8%), 5 (9.3%) and 0 (0%) PHIV, PHEU, and PHU children, respectively (P-trend = 0.01). Nineteen percent (n = 32) children had deficits requiring clinical vigilance in ≥2 proxy-reported EF subscales. Of these, multisubscale deficits occurred in 35.1%, 13.0%, and 9.3% of PHIV, PHEU, and PHU respectively (P-trend = 0.001). Multivariable analyses find significantly higher GEC deficits for PHIV compared with PHU and PHEU children regardless of respondent (all P values <0.01). Proxy-reported EF performance was similar for PHEU compared with PHU; however, child self-reported GEC scores were elevated by 12.8 units (95% CI: 5.4-25.5) for PHEU compared with PHU.PHIV had long-term EF deficits compared with other groups. Furthermore, PHEU ≥11 years may have long-term EF deficits compared with PHU, but future studies are needed to clarify this relationship. Cognitive remediation interventions with emphasis on EF may translate to improvements in long-term functional survival in HIV-affected children from sub-Saharan Africa.

Neurocognitive outcomes in pediatric diabetes: a developmental perspective

The impact of diabetes on the developing brain is well-accepted. Effects on neurocognitive functioning are moderate but have larger functional implications, especially when considered through a developmental lens. Pathophysiological factors such as severe hypoglycemia and chronic hyperglycemia can alter developmental trajectories in early childhood and perhaps at later periods. In this paper, we selectively review neurocognitive outcomes in pediatric diabetes (largely type 1), integrating recent research from developmental neuroscience and neuroimaging. We examine the effects of diabetes at different stages and place findings within a neurodevelopmental diathesis/stress framework. Early-onset diabetes is associated with specific effects on memory and more global cognitive late-effects, but less is known about cognitive outcomes of diabetes in later childhood and in adolescence, a time of increased neurobehavioral vulnerability that has received relatively limited empirical attention. Studies are also needed to better elucidate risk and protective factors that may moderate neurodevelopmental outcomes in youth with diabetes.

Discordance of cognitive and academic achievement outcomes in youth with perinatal HIV exposure

BACKGROUND

To evaluate achievement in youth with perinatally acquired HIV (PHIV) compared with HIV-exposed uninfected peers (HEU) and to examine differential effects of HIV on cognition-achievement concordance.

METHODS

Cognition and achievement were assessed using standardized measures. Intelligence quotient-derived predicted achievement scores were subtracted from observed achievement scores to calculate discrepancy values. Linear regression models were used to compare achievement discrepancies between PHIV and HEU, adjusting for demographic covariates.

PARTICIPANTS

295 PHIV and 167 HEU youth; 71% black, 48% male, mean age 13.1 and 11.3 years, respectively. PHIV youth were relatively healthy (mean CD4%, 32%; viral load ≤400 copies/mL, 72%). PHIV and HEU youth had cognitive and achievement scores significantly below population norm means (P < 0.001), but did not differ in cognition (mean full scale IQ = 86.7 vs. 89.4, respectively). In unadjusted models, HEU outperformed PHIV youth on total achievement (mean = 89.2 vs. 86.0, P = 0.04) and numerical operations (mean = 88.8 vs. 82.9, P < 0.001); no differences remained after adjustment. Mean observed-predicted achievement discrepancies reflected "underachievement". History of encephalopathy predicted poorer achievement (P = 0.039) and greater underachievement, even after adjustment. PHIV showed greater underachievement than HEU for numerical operations (P < 0.001) and total achievement (P = 0.03), but these differences did not persist in adjusted models.

CONCLUSIONS

Both PHIV and HEU youth demonstrated lower achievement than normative samples and underachieved relative to predicted achievement scores. Observed-predicted achievement discrepancies were associated with prior encephalopathy, older age and other non-HIV factors. PHIV youth with prior encephalopathy had significantly lower achievement and greater underachievement compared with PHIV without encephalopathy and HEU youth, even in adjusted models.

Developmental function in toddlers with sickle cell anemia

BACKGROUND

Neurocognitive impairment occurs in children and adults with sickle cell anemia, but little is known about neurodevelopment in very young children. We examined the neurodevelopmental status of infants participating in the Pediatric Hydroxyurea Phase III Clinical Trial (Baby Hug) to determine relationships with age, cerebral blood flow velocity, and hemoglobin concentration.

METHODS

Standardized measures of infant neurodevelopment were administered to 193 infants with hemoglobin SS or hemoglobin S-β(0) thalassemia between 7 and 18 months of age at the time of their baseline evaluation. Associations between neurodevelopmental scores and age, family income, parent education, hemoglobin concentration, and transcranial Doppler velocity were examined.

RESULTS

Mean functioning on the baseline neurodevelopment scales was in the average range. There were no mental development scores <70 (impaired); 22 children had scores in the clinically significant range, 11 with impaired psychomotor scores and 11 with problematic behavior rating scores. Significantly poorer performance was observed with older age at baseline. Behavior rating scores were an average of 2.82 percentile points lower per month of age, with similar patterns observed with parent report using adaptive behavior scales. Parent-reported functional abilities and hemoglobin were negatively associated with higher transcranial Doppler velocities.

CONCLUSIONS

Whereas overall functioning was in the normal range, behavioral and adaptive function was poorer with older age, even in this very young group of children. Explanatory mechanisms for this association between poorer developmental function and older age need to be identified.

Predictors of Academic Achievement for School Age Children with Sickle Cell Disease

BACKGROUND

Children with sickle cell disease (SCD) are at risk for neurocognitive impairment and poor academic achievement, although there is limited research on factors predicting academic achievement in this population. This study explores the relative contribution to academic achievement of a comprehensive set of factors, such as environmental (socioeconomic status), disease-related (stroke, transfusion therapy, adherence), and psychosocial variables (child behavior, child quality of life (QoL)), controlling for intellectual functioning (IQ).

METHODS

Eighty-two children with SCD completed measures assessing IQ and academic achievement, while parents completed questionnaires assessing adherence, child behavior, and child quality of life. Medical chart reviews were conducted to determine disease-related factors.

RESULTS

Hierarchical regression analyses indicated that 55% of the variance in academic skills was accounted for by IQ, parent education, chronic transfusion status, and QoL [R² = .55, F(5, 77) = 18.34, p < .01]. Follow-up analyses for broad reading [R² = .52, F(5, 77) = 16.37, p < .01], and math calculation [R² = .44, F(5, 77) = 12.14, p < .01] were also significant.

CONCLUSION

The findings suggest a significant contribution of factors beyond IQ to academic achievement. Findings allow for identification of children with SCD at risk for academic difficulties for whom psychoeducational interventions may enhance academic achievement.

Neurodevelopment in children born to HIV-infected mothers by infection and treatment status

BACKGROUND

We reviewed the impact of HIV, HIV exposure, and antiretroviral therapy/prophylaxis on neurodevelopmental outcomes of HIV-infected and HIV-exposed-uninfected infants and children.

METHODS

A literature search of Medline, Embase, PsychINFO, Web of Science, PubMed, and conference Web sites (1990-March 2011) using the search terms, infant, child, HIV, neurodevelopment, cognition, language, and antiretroviral therapy, identified 31 studies of HIV/antiretroviral exposure using standardized tools to evaluate infant/child development as the main outcome. Articles were included if results were reported in children <16 years of age who were exposed to HIV and antiretrovirals in fetal/early life, and excluded if children did not acquire HIV from their mothers or were not exposed to antiretrovirals in fetal/early life.

RESULTS

Infants who acquired HIV during fetal and early life tended to display poorer mean developmental scores than HIV-unexposed children. Mean motor and cognitive scores were consistently 1 to 2 SDs below the population mean. Mean scores improved if the infant received treatment before 12 weeks and/or a more complex antiretroviral regimen. Older HIV-infected children treated with highly active antiretroviral therapy demonstrated near normal global mean neurocognitive scores; subtle differences in language, memory, and behavior remained. HIV-exposed-uninfected children treated with antiretrovirals demonstrated subtle speech and language delay, although not universally.

CONCLUSIONS

In comparison with resource-rich settings, HIV-infected and HIV-exposed-uninfected infants/children in resource-poor settings demonstrated greater neurodevelopmental delay compared with HIV-unexposed infants. The effects on neurodevelopment in older HIV-infected children commenced on antiretroviral therapy from an early age and HIV-exposed-uninfected children particularly in resource-poor settings remain unclear.

School outcomes in children registered in the studies for pediatric liver transplant (SPLIT) consortium

School performance is an important aspect of functional outcomes for pediatric liver transplant (LT) recipients. This longitudinal analysis conducted through the Studies of Pediatric Liver Transplantation (SPLIT) research consortium examines several indicators of school function in these patients. A total of 39 centers participated in data collection using a semistructured questionnaire designed specifically for this study. The survey queried school attendance, performance and educational outcomes including the need for special educational services. Participants included 823 of 1133 (73%) eligible patients, mean age 11.34 +/- 3.84 years, 53% female, median age at LT 4.6 (range 0.05-17.8) years, and mean interval from transplant was 5.42 +/- 2.79. Overall, 34% of patients were receiving special educational services and 20% had repeated a grade, with older participants more likely to have been held back (P = 0.0007). Missing more than 10 days of school per year was reported by one-third of the group, with this level of absence being more common in older participants (P = 0.0024) and children with shorter intervals from LT (P < 0.0001). Multivariate analysis revealed the following factors were associated with the need for special educational services; type of immunosuppression at 6 months post-LT, cyclosporine A (odds ratio [OR] = 1.8, confidence interval [CI] = 1.1-3.1), or other (OR = 4.9, 95% CI = 1.4-17.6) versus tacrolimus, symptomatic cytomegalovirus infection within 6 months of liver transplantation (OR = 3.1, CI = 1.6-6.1), and pretransplant special educational services (OR = 22.5, CI = 8.6-58.4).

Health-related quality of life of children with mild to moderate chronic kidney disease

OBJECTIVE

To compare the health-related quality of life (HRQoL) of children with chronic kidney disease (CKD) with healthy children; to evaluate the association between CKD severity and HRQoL; and to identity demographic, socioeconomic, and health-status variables that are associated with impairment in HRQoL in children with mild to moderate CKD.

METHODS

This was a cross-sectional assessment of HRQoL in children who were aged 2 to 16 and had mild to moderate CKD using the Pediatric Inventory of Quality of Life Core Scales (PedsQL). Overall HRQoL and PedsQL domain means for parents and youth were compared with previously published norms by using independent sample t tests. Study participants were categorized by kidney disease stage (measured by iohexol-based glomerular filtration rate [iGFR]), and group differences in HRQoL were evaluated by using analysis of variance and Cuzick trend tests. The association between hypothesized predictors of HRQoL and PedsQL scores was evaluated with linear and logistic regression analyses.

RESULTS

The study sample comprised 402 participants (mean age: 11 years, 60% male, 70% white, median iGFR: 42.5 mL/min per 1.73 m(2), median CKD duration: 7 years). Youth with CKD had significantly lower physical, school, emotional, and social domain scores than healthy youth. iGFR was not associated with HRQoL. Longer disease duration and older age were associated with higher PedsQL scores in the domains of physical, emotional, and social functioning. Older age was associated with lower school domain scores. Maternal education > or =16 years was associated with higher PedsQL scores in the domains of physical, school, and social functioning. Short stature was associated with lower scores in the physical functioning domain.

CONCLUSIONS

Children with mild to moderate CKD, in comparison with healthy children, reported poorer overall HRQoL and poorer physical, school, emotional, and social functioning. Early intervention to improve linear growth and to address school functioning difficulties is recommended.

An explorative study on quality of life and psychological and cognitive function in pediatric survivors of septic shock

OBJECTIVE

To evaluate self-reported health-related quality of life, anxiety, depression, and cognitive function in pediatric septic shock survivors.

DESIGN

A retrospective cohort study.

SETTING

A 14-bed tertiary pediatric intensive care unit.

PATIENTS

Children aged >or=8 yrs at the time of the follow-up who were admitted between 1995 and 2004 for septic shock. Inotropic and or vasoconstrictive agents were administered to these patients for >or=24 hrs.

INTERVENTION

Health-related quality of life was assessed with the KIDSCREEN-52, anxiety with the State Trait Anxiety Inventory for Children, depression with the Children's Depression Inventory, and cognitive function with the cognitive scale of the TNO-AZL Children's Quality of Life Questionnaire Child Form.

MEASUREMENTS AND MAIN RESULTS

Fifty of 82 eligible pediatric septic shock survivors were evaluated. The median age of the children at pediatric intensive care unit admission was 4.2 yrs (range, 0.0-17.0 yrs); the median age at follow-up was 10.7 yrs (range, 8.0-20.4 yrs). Health-related quality of life and anxiety scores were comparable to the age-related Dutch norm population. Depression scores were significantly better than the norm population, whereas cognitive function was significantly lower than the norm population. We found that 44% of the children had cognitive scores <25% of the norm population. Young age at the time of pediatric intensive care unit admission was predictive of cognitive problems, and cognitive problems were associated with lower emotional function.

CONCLUSIONS

In this group of septic shock survivors, health-related quality of life, anxiety, and depression are equal to or slightly better than the age-related Dutch norm population. Cognitive function is decreased, especially in children admitted at younger ages. Follow-up studies with adequate neuropsychological testing are warranted to evaluate the association between septic shock, cognitive function, and risk factors for cognitive problems.

Bilirubin as a determinant for altered neurogenesis, neuritogenesis, and synaptogenesis

Elevated levels of serum unconjugated bilirubin (UCB) in the first weeks of life may lead to long-term neurologic impairment. We previously reported that an early exposure of developing neurons to UCB, in conditions mimicking moderate to severe neonatal jaundice, leads to neuritic atrophy and cell death. Here, we have further analyzed the effect of UCB on nerve cell differentiation and neuronal development, addressing how UCB may affect the viability of undifferentiated neural precursor cells and their fate decisions, as well as the development of hippocampal neurons in terms of dendritic and axonal elongation and branching, the axonal growth cone morphology, and the establishment of dendritic spines and synapses. Our results indicate that UCB reduces the viability of proliferating neural precursors, decreases neurogenesis without affecting astrogliogenesis, and increases cellular dysfunction in differentiating cells. In addition, an early exposure of neurons to UCB decreases the number of dendritic and axonal branches at 3 and 9 days in vitro (DIV), and a higher number of neurons showed a smaller growth cone area. UCB-treated neurons also reveal a decreased density of dendritic spines and synapses at 21 DIV. Such deleterious role of UCB in neuronal differentiation, development, and plasticity may compromise the performance of the brain in later life.

Adaptation of Western measures of cognition for assessing 5-year-old semi-urban Ugandan children

BACKGROUND

The majority of available psychometric tests originates from the Western World and was designed to suit the culture, language, and socio-economic status of the respective populations. Few tests have been validated in the developing world despite the growing interest in examining effects of biological and environmental factors on cognitive functioning of children in this setting.

AIMS

The present study aimed at translating and adapting Western measures of working memory, general cognitive ability, attention, executive function, and motor ability in order to obtain a cognitive instrument suitable for assessing 5-year-old semi-urban Ugandan children. This population represents a particular assessment challenge as school enrolment is highly variable at this age in this setting and many children are unused to a formal educational setting.

METHODS

Measures of the above domains were selected, translated, and modified to suit the local culture, education, and socio-economic background of the target population. The measures were piloted and then administered to semi-urban Ugandan children aged 4;6-5;6, who included children who had started and not yet started school.

RESULTS

Analysis of validity and reliability characteristics showed that 8 (at least one from each domain) out of the 11 measures were successfully adapted on the basis that they showed adequate task comprehension, optimum levels of difficulty to demonstrate individual and group differences in abilities, sensitivity to effects of age and education, and good internal as well as test-retest reliability.

CONCLUSION

Translation and adaptation are realistic and worthwhile strategies for obtaining valid and reliable cognitive measures in a resource-limited setting.

Adverse neonatal outcomes: examining the risks between preterm, late preterm, and term infants

OBJECTIVE

There is a relative paucity of data regarding neonatal outcomes in the late preterm cohort (34 to 36 6/7 weeks). This study sought to assess differences in adverse outcomes between infants delivering 32 to 33 6/7, 34 to 36 6/7 weeks, and 37 weeks or later.

STUDY DESIGN

Data were collected as part of a retrospective cohort study of preterm labor patients (2002-2005). Patients delivering 32 weeks or later were included (n = 264). The incidence of adverse outcomes was assessed. Significant associations between outcomes and gestational age at delivery were determined using chi(2) analyses and Poisson regression modeled cumulative incidence and controlled for confounders.

RESULTS

Late preterm infants have increased risk of adverse outcomes, compared with term infants. Controlling for confounders, there was a 23% decrease in adverse outcomes with each week of advancing gestational age between 32 and 39 completed weeks (relative risk 0.77, P < .001, 95% confidence interval, 0.71-0.84).

CONCLUSION

Further investigation regarding obstetrical management and long-term outcomes for this cohort is warranted.

Late consequences of chronic pediatric illness

There are many challenges in coping with and adapting to life with a chronic disease, and increased survival cannot be assumed to be associated with increased quality of life. A recent systematic review shows there is wide variation in outcomes depending on the definitions and measurements used to estimate the prevalence of chronic health conditions, making the impact of disability on children's health and social functioning difficult to assess; various authors have called for an international consensus about the conceptual definition of chronic health conditions in childhood. It frequently is difficult to determine if problems in psychosocial functioning are caused by the underlying illness, by treatment, or by the resultant effects of either illness or treatment on physical growth or cognitive development. Assessment and treatment of mental health should be an integral component of the comprehensive care of chronically ill children and adolescents. Transition of care is an important process that addresses significant changes from child-oriented to adult-oriented care. Adults who have chronic health conditions should continue to be evaluated periodically for late consequences of the childhood illness and early medical care, and attention should be paid to their ongoing psychosocial, psychiatric, educational, and vocational needs.

Neurocognitive outcomes in pediatric HIV

Cognitive impairment has long been associated with the natural history of HIV among vertically infected children. In children, HIV may have a direct or indirect impact on the developing brain, may lead to global or highly specific consequences, and may be responsible for minor cognitive consequences or, conversely, long-term and severe disability. This differential impact is related to multiple factors that influence the individual expression of the virus in any given child. This review provides an overview of the relevant literature on neurocognitive outcomes for infants, children, and youth vertically infected with HIV, with attention to those factors impacting neurocognitive outcome within a developmental framework. Research findings in both the era preceding and following the introduction of combined therapies are reviewed, since many of the issues identified prior to state-of-the-art treatment currently available in the United States and other developed countries still apply in much of the developing world. Intervention issues and directions for future research are also discussed.