The optimality concept

The role of fidgety movements and early motor repertoire in predicting mobility outcomes in infants with myelomeningocele

OBJECTIVE

To describe fidgety movements and co-occurring movements and postures in infants with myelomeningocele (MMC) and their association with mobility at preschool ages.

METHODS

A retrospective cohort with early assessment via general movement assessment, followed by mobility assessment between 36 and 70 months of age.

RESULTS

Twelve infants were included; 12 of 12 had fidgety movements in the upper limbs, with seven exhibiting them also in the hips and three in both the hips and ankles. The presence of fidgety movements in the lower limbs, kicking, a non-flat posture, a non-monotonous movement character, and a non-absent age-adequate movement repertoire were independently associated with mobility using the Hoffer modified classification and functional mobility scale (FMS) at 5 and 50 m. An optimality score was calculated based on leg movements and postures, ranging from 0 to 10 points. Infants who scored at least 4 points achieved household ambulation and FMS (5 m) of at least level 4. Community ambulation and an FMS (50 m) of level 5 were achieved with a score of at least 7.5.

CONCLUSIONS

Assessing fidgety movements with other leg movements and postures in infants with MMC provided relevant information that could potentially predict mobility at preschool age and thus could be used for early intervention planning.

The General Movement Optimality Score-Revised (GMOS-R) with Socioeconomically Stratified Percentile Ranks

Background: The general movement optimality score (GMOS) quantifies the details of general movements (GMs). We recently conducted psychometric analyses of the GMOS and developed a revised scoresheet. Consequently, the GMOS-Revised (GMOS-R) instrument necessitated validation using new percentile ranks. This study aimed to provide these percentile ranks for the GMOS-R and to investigate whether sex, preterm birth, or the infant's country of birth and residence affected the GMOS-R distribution. Methods: We applied the GMOS-R to an international sample of 1983 infants (32% female, 44% male, and 24% not disclosed), assessed in the extremely and very preterm period (10%), moderate (12%) and late (22%) preterm periods, at term (25%), and post-term age (31%). Data were grouped according to the World Bank's classification into lower- and upper-middle-income countries (LMICs and UMICs; 26%) or high-income countries (HICs; 74%), respectively. Results: We found that sex and preterm or term birth did not affect either GM classification or the GMOS-R, but the country of residence did. A lower median GMOS-R for infants with normal or poor-repertoire GMs from LMICs and UMICs compared with HICs suggests the use of specific percentile ranks for LMICs and UMICs vs. HICs. Conclusion: For clinical and scientific use, we provide a freely available GMOS-R scoring sheet, with percentile ranks reflecting socioeconomic stratification.

Early Intervention Guided by the General Movements Examination at Term Corrected Age-Short Term Outcomes

BACKGROUND AND AIM

The early identification of the former premature neonates at risk of neurologic sequelae could lead to early intervention and a better prognosis. This pilot study aimed to investigate whether the General Movement patterns observed at term-equivalent age in former premature infants could serve as predictors for guiding early intervention and improving prognosis.

MATERIALS AND METHODS

In a population of 44 premature neonates (mean gestational age 33.59 weeks (+2.43 weeks)) examined at term-equivalent age, 10 neonates with a cramped-synchronized General Movements motor pattern were identified. These neonates were included in an early intervention program consisting of physiotherapy executed both by the therapist and by the parents at home. They were again examined at a corrected age of 12 weeks. The presence or absence of fidgety movements and the MOS-R (motor optimality score revised) was noted. The examinations were performed by certified specialists.

RESULTS

Normal fidgety movements and a MOS-R of 20-24 were presented in 9/10 of the former premature infants, with normal foot to foot contact present in 7/10, and normal hand to hand contact present in 5/10. The atypical patterns noted were side to side movements of the head in 5/10, a non-centered head in 9/10, asymmetric tonic neck reflex in 9/10 and jerky movements in 10/10. One patient presented with no fidgety movements and a MOS-R score of 9.

CONCLUSION

Early intervention in our group of patients allowed for an improvement in the neurologic status, demonstrated by the presence of fidgety movements. We suggest that early intervention should be indicated in all premature infants that present with a cramped-synchronized GM pattern during examination at term-equivalent age. However, due to the small sample size, the absence of statistical analysis and a control group, and the limited follow-up period, the conclusions must be approached with caution.

A Study of General Movement Assessment and Its Association With Neurodevelopmental Outcome at Age 12 to 15 Months Among Term Neonates With Hyperbilirubinemia

BACKGROUND

To determine the association between optimality score at term age and age three to five months and neurodevelopmental outcome among neonates with hyperbilirubinemia.

METHODS

Fifty infants with and without hyperbilirubinemia were enrolled. The motor repertoires of the infants were evaluated through general movement assessment (GMA) at term age and three to five months post-term. The association between the General Movement Optimality Score (GMOS), Motor Optimality Score (MOS), and Development Assessment Scale for Indian Infants (DASII) at age 12 to 15 months was also assessed.

RESULTS

During term age, the median GMOS was significantly lower among infants in the study group when compared with the control group (40 [29 to 42] vs 42 [42 to 42], P < 0.001). However, at age three to five months, there was no significant difference between the groups. Significantly higher number of neonates had abnormal motor repertoire at term age and age three to five months in the study group when compared with the control group (18 [36%] vs 2 [4%], P = 0.001, at term age and 6 [12.2%] vs 1 [2%], P =0.04, at age three to five months). Among neonates with hyperbilirubinemia, the median GMOS and MOS were significantly lower at term age and age three to five months in infants with motor and mental developmental quotient scores <85 when compared with ≥85.

CONCLUSIONS

GMA including GMOS and MOS performed in neonates with hyperbilirubinemia during the neonatal period and early infancy is associated with neurodevelopmental outcomes in the first year of life. GMA can help initiate early intervention in such neonates.

Motor repertoire in 3- to 5- month-old infants with prenatal exposure to syphilis and toxoplasmosis

AIM

To characterize the motor repertoire of 3- to 5-month-old infants who were prenatally exposed to the infectious agents of syphilis and toxoplasmosis.

METHODS

Exploratory observational study that evaluated 15 exposed infants (34.4 ± 3.5 weeks gestation) recruited from a referral center. Age assessment ranged 12-20 (median 12) weeks post-term. General Movement Assessment, including the Motor Optimality Score-Revised (MOS-R), was used to assess the global quality of fidgety movements (FMs) and to quantify and detail coexisting motor patterns. Clinical variables were also collected. Later motor outcomes were obtained from medical reports when possible.

RESULTS

MOS-R ranged 10-26 (median 24). There was a higher proportion of infants with normal (80.0 %) than aberrant FMs, but the proportion of infants with reduced MOS-R (80.0 %) was higher compared to optimal MOS-R. One infant with aberrant FMs was later diagnosed with cerebral palsy. Only 13.3 % of the infants showed smooth and fluent movement character. All observed tongue movements were abnormal.

CONCLUSION

Infants had predominantly normal FMs, but with reduced MOS-R and abnormalities in the coexisting motor repertoire.

Pre-/perinatal reduced optimality and neurodevelopment at 1 month and 3 years of age: Results from the Japan Environment and Children's Study (JECS)

Neurodevelopmental disorders (NDDs) in children are associated with a complex combination of genetic and/or environmental factors. Pre-/perinatal events are major known environmental suboptimal factors, and their individual and combined contributions vary. This study investigated the association between pre-/perinatal reduced optimality and child development observed by parents at 1 month, as well as NDDs at 3 years of age (i.e., motor delay, intellectual disability, developmental language disorder, and autism spectrum disorder), in the context of the Japan Environment and Children's Study. The study also assessed whether child development at 1 month predicted NDDs at 3 years of age. Associations between 25 pre-/perinatal factors and (a) developmental concerns at 1 month of age and (b) NDDs at 3 years were analyzed (n = 71,682). Binomial regression models were used to investigate risk ratios of the developmental outcome at each time point for total pre-/perinatal reduced optimality scale scores, as well as for individual pre-/perinatal factors of the reduced optimality scale. Finally, we assessed the ability of parental observations of offspring development at 1 month to predict NDDs at 3 years. Total reduced optimality scores were positively associated with 1-month developmental concerns and 3-year NDDs, with higher scores (i.e., a reduction in optimality) associated with an increased risk of both NDDs and earlier parental concerns. Neonatal transportation, epidural analgesia, advanced maternal age, cesarean section delivery, Apgar score ≤8, and hyperbilirubinemia were identified as individual risk factors for 3-year NDDs, overlapping with 14 risk factors for 1-month developmental concerns except Apgar score ≤8. Among six developmental items assessed at 1 month of age, concerns about gross motor function and difficulty holding/trouble calming down had the strongest associations with later-diagnosed motor delay and autism spectrum disorder, respectively. Five perinatal factors and advanced maternal age were associated with NDD at 3 years of age, as were early parental developmental concerns regarding their offspring's overall development, indicating the importance of careful follow-up of offspring born with pre-/perinatal reduced optimality. The results also implicated early parental concerns, as early as 1 month, may also be a useful indicator of later NDD status.

Infants prenatally exposed to SARS-CoV-2 show the absence of fidgety movements and are at higher risk for neurological disorders: A comparative study

Congenital viral infections are believed to damage the developing neonatal brain. However, whether neonates exposed to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) show manifestations of such damage remains unclear. For neurodevelopment evaluation, general movement assessments have been shown to be effective in identifying early indicators of neurological dysfunction, including the absence of fidgety movements. This study compared the early motor repertoire by general movement assessment at three to five months of age in neonates who were or were not prenatally exposed to SARS-CoV-2 to determine whether infants prenatally exposed to SARS-CoV-2 are at risk of developing neurological disorders. Fifty-six infants, including 28 in the exposed group of mothers without vaccination who had no need for intensive care and likely had SARS-CoV-2 infection close to the time of pregnancy resolution and 28 infants in the nonexposed group, were videotaped to compare their detailed early motor repertoires, in which a motor optimality score-revised (MOS-R) was calculated using Prechtl’s method by using the chi-square or Mann–Whitney U tests. In the exposed group, 3 (11%) infants showed the absence of fidgety movements with a total MOS-R<14 points, and 3 (11%) other infants showed abnormal fidgety movements. Between groups, atypical body symmetry (p = 0.009) and MOS-R values were significantly lower (Z = -3.08, p = 0.002), with a large size effect (Cohen’s d = 0.97). The consequences of this new virus go beyond the health of the pregnant mother, and these consequences in some of the infants in the exposed group are likely not transitory because of the absence of fidgety movements between 3–5 months; thus, these babies are at increased risk of developing a serious neurological disorder.

Early Spontaneous Movements and Postural Patterns in Infants With Extremely Low Birth Weight

BACKGROUND

Extremely-low-birth-weight (ELBW) infants are at high risk of morbidity, mortality, and long-term neurodevelopmental disorders. Evaluating infants' early spontaneous movements and postural patterns could facilitate the early detection of neurological dysfunction. This study aimed to analyze the results of global-and detailed-General Movements Assessment (GMA) in ELBW infants at a corrected age of three to five months and to compare with normal-birth-weight (NBW) infants.

METHODS

Fifty-two ELBW infants (median birth weight = 915.5 g) and 50 NBW infants were included. All infants were assessed according to GMA using Motor Optimality Score for 3- to 5-Month-Old Infants-Revised score sheet (MOS-R). In addition, later diagnoses of ELBW infants with atypical development were presented.

RESULTS

Fidgety movements were observed in 36 (69.2%) of ELBW infants and all NBW infants. MOS-R scores were lower in the ELBW group (median = 24) compared with the NBW group (median = 26). The ELBW infants scored lower than NBW infants in all MOS-R subcategories. Twenty-three (44.2%) of ELBW infants were diagnosed as atypical in the later period, although all control infants had normal development.

CONCLUSIONS

The study indicated that ELBW might increase the risk of atypical development in infants. The MOS-R could help us to find the risk of atypical development in infants with ELBW.

Clinical Implications of the General Movement Optimality Score: Beyond the Classes of Rasch Analysis

This article explores the clinical implications of the three different classes drawn from a Rasch analysis of the general movements optimality scores (GMOS) of 383 infants. Parametric analysis of the class membership examines four variables: age of assessment, brain injury presence, general movement patterns, and 2-year-old outcomes. GMOS separated infants with typical (class 3) from atypical development, and further separated cerebral palsy (class 2) from other neurodevelopmental disorders (class 1). Each class is unique regarding its quantitative and qualitative representations on the four variables. The GMOS has strong psychometric properties and provides a quantitative measure of early motor functions. The GMOS can be confidently used to assist with early diagnosis and predict distinct classes of developmental outcomes, grade motor behaviors, and provide a solid base to study individual general movement developmental trajectories.

Gestational Age-Specific Distribution of the Hammersmith Neonatal Neurological Examination Scores Among Low-Risk Neonates in Ghana

OBJECTIVE

To describe gestational age-specific distribution of scores for the Hammersmith Neonatal Neurological Examination (HNNE) up to 48 h after birth in a low-risk, term-born, single-center sample in Ghana.

STUDY DESIGN

This is a nested substudy of a larger prospective study (IMPRINT: Impact of Malaria in Pregnancy on Infant Neurodevelopment) comprising 140 low-risk, term-born neonates at Korle Bu Teaching Hospital in Accra, Ghana, between November 2018 and February 2019. The sample was stratified into three gestational age groups: early-term (37 + 0-38 + 6, weeks + days; n = 61), full-term (39 + 0-40 + 6, weeks + days; n = 52), and late/post-term (41 + 0-42 + 6, weeks + days; n = 27). Neonates were administered the 34-item HNNE by trained physicians. As per the original British scoring system, raw scores for the Ghanaian sample were plotted and scores > 10th centile were assigned a score of 1, 5th-10th centile 0.5, and < 5th centile 0.

RESULTS

The range of raw scores for 16/34 HNNE items varied with gestational age. Specifically, 100% (7/7), 50% (5/10), 33% (1/3), 33% (1/3), 20% (1/5), and 14% (1/7) of items within the orientation and behavior, tone, abnormal signs/patterns, movements, tone patterns, and reflexes subdomain, respectively showed a different distribution of scores above the 10th centile across the three gestational age groups.

CONCLUSION

Differences in gestational age-specific results within our sample in comparison to the original British sample could be, albeit unlikely, due to misclassification of gestational age, unmeasured maternal or fetal morbidity, or perhaps more likely, variation in testing or test conditions, or some combination of these. Genetic variation in neurological development is also a possibility. Further research is warranted to determine the reasons for differences. Our findings highlight the need to determine the accuracy and reliability of standardized neurologic assessments in predicting neurodevelopmental risk for infants in low- and middle-income countries.

General Movements and Developmental Functioning in an Individual with Rhizomelic Chondrodysplasia Punctata within the First Months of the Life: A Case Report

AIMS

Rhizomelic chondrodysplasia punctata (RCDP) is an autosomal recessive inherited disorder. Individuals with RCDP have a wide range of neurodevelopmental outcomes, but there are limited descriptions of their early motor development before 5 months of age. This study aimed to describe in detail the age-specific spontaneous movements and examine the developmental functioning in an individual with RCDP.

METHODS

A female infant (born at 39 weeks' gestation), diagnosed with RCDP at 3 weeks of age, was assessed at 4 and 16 weeks for general movements (GMs) and concurrent motor repertoire; the Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III) was also applied at the same ages.

RESULTS

At 4 weeks, the infant showed poor repertoire GMs, with a detailed General Movement Optimality Score of 16/42. At 16 weeks, age-specific fidgety movements were absent, and the movement character was monotonous and stiff; the detailed Motor Optimality Score was severely reduced (7/28). All Bayley-III scores were <2 SD, that is <70 indicating severe developmental delay.

CONCLUSION

Functional assessments such as the GM assessment and age-specific detailed assessment could be complementary to neuroimaging assessments to predict the neurodevelopmental outcomes in infants with RCDP.

Cerebral Palsy: Early Markers of Clinical Phenotype and Functional Outcome

The Prechtl General Movement Assessment (GMA) has become a cornerstone assessment in early identification of cerebral palsy (CP), particularly during the fidgety movement period at 3-5 months of age. Additionally, assessment of motor repertoire, such as antigravity movements and postural patterns, which form the Motor Optimality Score (MOS), may provide insight into an infant's later motor function. This study aimed to identify early specific markers for ambulation, gross motor function (using the Gross Motor Function Classification System, GMFCS), topography (unilateral, bilateral), and type (spastic, dyskinetic, ataxic, and hypotonic) of CP in a large worldwide cohort of 468 infants. We found that 95% of children with CP did not have fidgety movements, with 100% having non-optimal MOS. GMFCS level was strongly correlated to MOS. An MOS > 14 was most likely associated with GMFCS outcomes I or II, whereas GMFCS outcomes IV or V were hardly ever associated with an MOS > 8. A number of different movement patterns were associated with more severe functional impairment (GMFCS III-V), including atypical arching and persistent cramped-synchronized movements. Asymmetrical segmental movements were strongly associated with unilateral CP. Circular arm movements were associated with dyskinetic CP. This study demonstrated that use of the MOS contributes to understanding later CP prognosis, including early markers for type and severity.

Identifying Atypical Development: A Role of Day-Care Workers?

Identifying the early signs of developmental disability is important for ensuring timely diagnosis and early intervention. Day-care workers may be in a prime position to notice potential developmental deviations, but it is unclear if they can accurately recognize subtle early signs of atypical development. Sixty day-care workers examined home-videos of very young children with fragile X syndrome and typically developing children. Results indicated that most day-care workers can distinguish typical and atypical development in general and might therefore have an important role in early identification. Special work experience and advanced pedagogical training appeared to boost day-care workers' sensitivity to detect atypical features in early development and to provide effective daily surveillance.

Development of the Labor and Delivery Outcome Scale (LDOS): Validity and reliability of an intrapartal measurement tool for research use in developed nations

Despite numerous scholarly attempts to understand and improve the health outcomes of childbearing in highly technical, developed countries, a theoretical and methodological deficit persists in regard to capturing a woman and her newborn's intrapartal experience. In an effort to construct a criterion measure and research tool that is not limited to one or two aspects of the labor and delivery experience, the authors created the Labor and Delivery Outcome Scale (LDOS). The LDOS survey was mailed to a nationwide, random sample of 1500 experienced U.S. accoucheurs, including nurse-midwives, family practice physicians, and obstetricians, and they were asked to rate 102 physiological and psychosocial events and outcomes along a Likert scale regarding their relationship to the overall intrapartal experience. The goal of this forced-choice format was to have practitioners quantify the quality of individual labor and delivery experiences. The authors received a total of 391 questionnaires, representing an overall response rate of 26.1%. On a scale of -16 to +16 the scores ranged from -15.7 (SD = 1.5) for the outcome of infant born as fetal demise (stillbirth) to +12.6 (SD = 4.4) for active involvement of support person(s) in assisting woman during labor. Reliability of the instrument was demonstrated with a Cronbach's alpha score of r = 0.92. Criterion-related validity was established, since the LDOS scores were significantly related to type of delivery (vaginal versus Cesarean-section), Apgar scores at 1 and 5 min, gestational age, and the total number of labor and delivery complications experienced. The creation of the LDOS, and the subsequent testing of its reliability and validity as described here, has been an important step toward quantifying for research purposes the intrapartal experience of women in highly technical, developed countries. Potential uses for the LDOS are discussed.

Developmental outcome of 9-year-old children born after PGS: follow-up of a randomized trial

STUDY QUESTION

Does Day-3 cleavage-stage PGS affect neurodevelopment of 9-year-old IVF offspring?

SUMMARY ANSWER

We did not find evidence of adverse consequences of Day-3 cleavage-stage PGS on neurodevelopment of 9-year-old IVF offspring, although children born after IVF with or without PGS often had a non-optimal neurological condition.

WHAT IS KNOWN ALREADY

Knowledge on long-term sequelae for development and health of children born following PGS is lacking. This is striking as evidence accumulates that IVF itself is associated with increased risk for impaired health and development in the offspring.

STUDY DESIGN SIZE, DURATION

This prospective, assessor-blinded, multicentre, follow-up study evaluated development and health of 9-year-old IVF children born to women who were randomly assigned to IVF with PGS (PGS group) or without PGS (control group). The follow-up examination at 9 years took place between March 2014 and May 2016.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In total, 408 women were included and randomly assigned to IVF with or without Day-3 cleavage-stage PGS. This resulted in 52 ongoing pregnancies in the PGS group and 74 in the control group. In the PGS group, 59 children were born alive; in the control group, 85 children were born alive. At the age of 9 years, 43 children born after PGS and 56 control children participated in the study. Our primary outcome was the neurological optimality score, a sensitive measure of neurological condition assessed with a standardized, age-specific test (Touwen test). Secondary outcomes were adverse neurological condition (neurologically abnormal and the complex form of minor neurological dysfunction), cognitive development (intelligence quotient and specific domains), behaviour (parental and teacher's questionnaires), blood pressure and anthropometrics.

MAIN RESULTS AND THE ROLE OF CHANCE

Neurodevelopmental outcome of PGS children did not differ from that of controls; the neurological optimality scores (mean values [(95% CI]: PGS children 51.5 [49.3; 53.7], control children 53.1 [50.5; 55.7]) were not significantly different. The prevalences of adverse neurological outcome (in all but one child implying the presence of the complex form of minor neurological dysfunction) did not differ between the groups (PGS group 17/43 [40%], control group 19/56 [34%]), although the prevalence of complex minor neurological dysfunction in both groups was rather high. Also intelligence quotient scores of the two groups were not significantly different (PGS group 114 [108; 120]); control group 117 [109; 125]), and the behaviour, blood pressure and anthropometrics of both groups did not differ. Mean blood pressures of both groups were above the 60th percentile.

LIMITATIONS REASONS FOR CAUTION

The power analysis of the study was not based on the number of children needed for the follow-up study, but on the number of women who were needed to detect an increase in ongoing pregnancy rates after PGS. In addition, our study evaluated embryo biopsy in the form of PGS at cleavage stage (Day-3 embryo biopsy), while currently PGS at blastocyst stage (Day-5 embryo biopsy) is recommended and increasingly being used.

WIDER IMPLICATIONS OF THE FINDINGS

Our findings indicate that PGS in cleavage stage embryos is not associated with adverse effects on neurological, cognitive and behavioural development, blood pressure and anthropometrics of offspring at 9 years. This is a reassuring finding as embryo biopsy in the forms of PGS and PGD is increasingly applied. However, both groups of IVF offspring showed high prevalences of the clinically relevant form of minor neurological dysfunction, which is a point of concern for the IVF community. In addition, our study confirms findings of others that IVF offspring may be at risk of an unfavourable cardiovascular outcome. These findings are alarming and highlight the importance of research on the underlying mechanisms of unfavourable neurodevelopmental and cardiovascular outcomes in IVF offspring.

STUDY FUNDING/COMPETING INTEREST(S)

The randomized controlled trial was financially supported by the Organization for Health Research and Development (ZonMw), The Netherlands (Grant number 945-03-013). The follow-up was financially supported by the University Medical Center Groningen (Grant number: 754510), the Cornelia Foundation, and the graduate schools BCN and Share, Groningen, The Netherlands. The sponsors of the study had no role in study design, data collection, data analysis, data interpretation or writing of the report. There are no conflicts of interest.

TRIAL REGISTRATION NUMBER

ISRCTN76355836.

Creating an Optimality Index - Netherlands: a validation study

BACKGROUND

At present, the maternity care system in the Netherlands is being reorganized into an integrated model of care, shifting the focus of midwives to include increasing numbers of births in hospital settings and clients with medium risk profiles. In light of these changes, it is useful for midwives to have a tool which may help them in reflecting upon care practices that promote physiological childbirth practices. The Optimality Index-US is an evidence based tool, designed to measure optimal perinatal care processes and outcomes. It has been validated for use in the United States (OI-US), United Kingdom (OI-UK) and Turkey (OI-TR). The objective of this study was to adapt the OI-US for the Dutch maternity care setting (OI-NL).

METHODS

Translation and back translation were applied to create the OI-NL. A panel of maternity care experts (n = 10) provided input for face validation items in the OI-NL. Assessment of inter-rater reliability and ease of use was also conducted. Following this, the OI-NL was used prospectively to collect data on 266 women who commenced intrapartum care under the responsibility of a midwife. Twice groups were compared, based on parity and on care-setting at birth. Mean scores between these groups, corrected for perinatal background factors were assessed for discriminant validity.

RESULTS

Face validity was established for OI-NL on the basis of expert input. Discriminant validity was confirmed by conducting multiple regressions analyses for parity (β = 6.21, P = 0.00) and for care-setting (β = 12.1, p = 0.00). Inter-rater reliability was 98%, with one item (Apgar score) sensitive to scoring differences.

CONCLUSION

OI-NL is a valid and reliable tool for use in the Dutch maternity care setting. In addition to its value for assessing evidence-based maternity care processes and outcomes, there is potential for use for learning and reflection. Against the backdrop of a changing maternity care system, and due to the specificity of its items OI-NL may be of value as a tool for detecting subtle changes indicative of escalating medicalization of childbirth in the Netherlands.

The general movement assessment in non-European low- and middle-income countries

Abnormal general movements are among the most reliable markers for cerebral palsy. General movements are part of the spontaneous motor repertoire and are present from early fetal life until the end of the first half year after term. In addition to its high sensitivity (98%) and specificity (91%), the assessment of general movements is non-invasive and time- and cost-efficient. It is therefore ideal for assessing the integrity of the young nervous system, most notably in lowresource settings. Studies on the general movements assessment in low- and middle-income countries such as China, India, Iran, or South Africa are still rare but increasing. In Brazil, too, researchers have demonstrated that the evaluation of general movements adds to the functional assessment of the young nervous system. Applying general movements assessment in vulnerable populations in Brazil is therefore highly recommended.

Development of the Optimality Index-NL2015, an Instrument to Measure Outcomes of Maternity Care

INTRODUCTION

An optimality index is a composite tool to measure maximum outcome with minimal intervention. It focuses on optimality instead of on normality and is useful in comparing differences in processes and perinatal outcomes for women at low risk of complications. The latest Dutch version dates from 2 decades ago, and international versions of the optimality index are not directly applicable to the Dutch maternity system. Most data for perinatal research in the Netherlands are derived from a national perinatal database: the Netherlands Perinatal Registry. The aim of this study was to develop a new Dutch version of the optimality index (OI-NL2015) that could be calculated from data derived from this national perinatal database and to assess the reliability of these data for use in the index.

METHODS

Potential items were collected by a thorough comparison of earlier (inter)national optimality indexes and the current data collection of the national database. All items were reviewed by 2 experts in maternity care and assessed for importance, relevance for the Dutch maternity care system, and feasibility to retrieve information on these items. For each item a criterion for optimality was formulated based on evidence-based or consensus-based effectiveness of care in pregnancy and childbirth. All selected items were scored on potential problems, with reliability by 20 randomly selected community midwives. The level of agreement was calculated comparing these 2 data sets, which included data of the same women.

RESULTS

The final OI-NL2015 consists of 31 items in 3 different components: 22 intrapartum, 7 neonatal, and 2 postpartum. Of the 7 items that were examined because of expected potential problems with reliability, in 6 items a level of 90% agreement was found.

DISCUSSION

An optimality index is not a standard measurement instrument but must be validated and adapted to local circumstances and available data.

Neurological condition assessed with the Hempel examination and cognition and behaviour at 4years

AIM

To investigate associations between neurological condition, assessed with the Hempel examination, in terms of minor neurological dysfunction (MND) and neurological optimality, and cognition and behaviour at 4years.

STUDY DESIGN

Cross-sectional analyses within a prospective, assessor-blinded follow-up study.

SUBJECTS

Four-year-old singletons born to subfertile parents (n=235; 120 boys).

OUTCOME MEASURES

Outcome parameters were complex minor neurological dysfunction (complex MND) and the neurological optimality score (NOS). Cognitive outcome was evaluated with the Kaufman Assessment Battery for Children, resulting in a total intelligence quotient (IQ). Behavioural outcome was evaluated with the Child Behavior Checklist, resulting in a total problem T-score.

RESULTS

Fifty-seven (24.3%) children had complex MND. None of the children showed fine motor dysfunction, suggesting a ceiling effect of the Hempel assessment. Complex MND was not correlated with IQ or total problem T-score. Nevertheless, a higher NOS was correlated with a higher IQ and a lower total problem T-score (adjusted mean estimate [95% confidence interval]: cognition: 0.445 [0.026; 0.865], p=0.038; behaviour: -0.458 [-0.830; -0.087], p=0.016).

INTERPRETATION

At age 4, complex MND assessed with the Hempel assessment was not associated with cognition and behaviour, presumably due to a ceiling effect in the Hempel domain of fine motor function. A more optimal neurological condition was associated with higher IQ and better behaviour.

Very low birth weight infants in China: the predictive value of the motor repertoire at 3 to 5months for the motor performance at 12months

BACKGROUND

Studies on motor performance and its early markers are rare in China, especially in very low birth weight (VLBW) infants.

OBJECTIVE

Apart from the assessment of the inter-scorer agreement, we aimed to analyze to what extent the motor repertoire at 10 to 18weeks postterm was related to neonatal complications, and gross and fine motor performance at 12months after term.

STUDY DESIGN

Exploratory prospective study.

SUBJECTS

Seventy-four VLBW infants (58 males; mean gestational age=29weeks; mean birth weight=1252g).

METHOD

Five-minute video recordings were performed at 10 to 18weeks after term; fidgety movements and the concurrent motor patterns (resulting in a motor optimality score) were assessed according to the Prechtl general movements assessment (GMA). The gross and fine motor performance was assessed by means of the Peabody Developmental Motor Scales, second edition, at 12months.

RESULTS

Reliability was excellent. Pneumonia was associated with absent fidgety movements; the motor optimality score was lower in infants with pneumonia and/or bronchopulmonary dysplasia. Both absent fidgety movements and a lower motor optimality score were associated with a poor or very poor gross and fine motor performance at the 12-month-assessment.

CONCLUSION

Both the assessment of fidgety movements and the evaluation of the concurrent motor repertoire contribute significantly to an identification of VLBW children with a poor gross and fine motor outcome at 12months. The results of this study document the need for an early identification of infants at high risk for a poor motor performance.

The general movement optimality score: a detailed assessment of general movements during preterm and term age

AIM

To explore the appropriateness of applying a detailed assessment of general movements and characterize the relationship between global and detailed assessment.

METHOD

The analysis was based on 783 video recordings of 233 infants (154 males, 79 females) who had been videoed from 27 to 45 weeks postmenstrual age. Apart from assessing the global general movement categories (normal, poor repertoire, cramped-synchronized, or chaotic general movements), we scored the amplitude, speed, spatial range, proximal and distal rotations, onset and offset, tremulous and cramped components of the upper and lower extremities. Applying the optimality concept, the maximum general movement optimality score of 42 indicates the optimal performance.

RESULTS

General movement optimality scores (GMOS) differentiated between normal general movements (median 39 [25-75th centile 37-41]), poor repertoire general movements (median 25 [22-29]), and cramped-synchronized general movements (median 12 [10-14]; p<0.01). The optimality score for chaotic general movements (mainly occurring at late preterm age) was similar to those for cramped-synchronized general movements (median 14 [12-17]). Short-lasting tremulous movements occurred from very preterm age (<32wks) to post-term age across all general movement categories, including normal general movements. The detailed score at post-term age was slightly lower compared to the scores at preterm and term age for both normal (p=0.02) and poor repertoire general movements (p<0.01).

INTERPRETATION

Further research might demonstrate that the GMOS provides a solid base for the prediction of improvement versus deterioration within an individual general movement trajectory.

The projected effect of scaling up midwifery

We used the Lives Saved Tool (LiST) to estimate deaths averted if midwifery was scaled up in 78 countries classified into three tertiles using the Human Development Index (HDI). We selected interventions in LiST to encompass the scope of midwifery practice, including prepregnancy, antenatal, labour, birth, and post-partum care, and family planning. Modest (10%), substantial (25%), or universal (95%) scale-up scenarios from present baseline levels were all found to reduce maternal deaths, stillbirths, and neonatal deaths by 2025 in all countries tested. With universal coverage of midwifery interventions for maternal and newborn health, excluding family planning, for the countries with the lowest HDI, 61% of all maternal, fetal, and neonatal deaths could be prevented. Family planning alone could prevent 57% of all deaths because of reduced fertility and fewer pregnancies. Midwifery with both family planning and interventions for maternal and newborn health could avert a total of 83% of all maternal deaths, stillbirths, and neonatal deaths. The inclusion of specialist care in the scenarios resulted in an increased number of deaths being prevented, meaning that midwifery care has the greatest effect when provided within a functional health system with effective referral and transfer mechanisms to specialist care.

Longitudinal development of mother-infant interaction during the first year of life among mothers with substance abuse and psychiatric problems and their infants

The quality of mother-infant interaction during the first year may be hampered by maternal substance abuse and co-existing non-optimal factors such as psychiatric problems and difficult relational experiences. In the present study three groups of women were recruited during pregnancy: One group with substance abuse problems from residential treatment centers (n = 28), a second group from psychiatric outpatient treatment centers (n = 22), and a third group from well-baby clinics (n = 30). Four maternal optimality indexes were assessed (substance abuse, psychiatric problems, relational experiences and SES). Mother-infant interaction was observed at 3 and 12 months. The substance abuse group showed the most disturbed mother-infant interaction at 12 months. Low maternal optimality as well as impairments in maternal affective involvement at 3 months influenced negatively both on infant and dyadic affective behavior in interaction at 12 months. Long-term interventions are needed to promote affective reciprocity among mother-baby pairs with low optimality.

Using an Optimality Index to Understand Perinatal Health Disparities: A Pilot Study With Latina Immigrants

PURPOSE

This study demonstrates preliminary evidence of the utility of an optimality index as a simple tool for monitoring complications across the perinatal period.

METHOD

The medical records of 147 Latina women participating in a preventive randomized controlled trial for perinatal depression were reviewed for outcomes across the perinatal period.

RESULTS

Application of the optimality index found optimality scores ranging from 77.3% to 97.7% in a Latina immigrant population known to have low rates of low-birthweight infants and preterm birth. Optimality scores were significantly lower among women who had a preterm birth or low-birthweight infant.

DISCUSSION

The ability of optimality indices to capture within-group variability will allow for a more nuanced understanding of the antecedents and sequelae of negative birth outcomes.

IMPLICATIONS FOR PRACTICE

Increasing reliance on electronic medical records will facilitate the calculation of optimality scores that can be used to track patterns of perinatal health disparities.

The influence of maternal optimality and infant temperament on parenting stress at 12 months among mothers with substance abuse and psychiatric problems

The present prospective longitudinal study aimed to investigate the long-term impact of maternal optimality assessed during pregnancy on parenting stress at infant age 12 months. In this study the concept of optimality was utilized to investigate maternal variations regarding resources during pregnancy in relation to later parenting stress, among three different groups of mothers that were recruited from substance abuse treatment, psychiatric outpatient treatment and well-baby clinics respectively. The influence of infant temperament on parenting stress was also examined. All mothers were interviewed during pregnancy. At 12 months, infant temperament (Colorado Childhood Temperament Inventory; Rowe & Plomin, 1977) and stress in the parent and child domain (Parenting Stress Index; Abidin, 1955) were assessed. Results demonstrated higher levels of parenting stress among mothers in the clinical groups, compared to the non-clinical group. Furthermore, it was the maternal psychiatric optimality index in combination with child temperament characteristics (child emotionality) that contributed uniquely to stress in the parent domain, while stress in the child domain was significantly associated only with child temperament characteristics (both child emotionality and soothability). The association between maternal psychiatric optimality assessed in pregnancy, infant temperament and parenting stress when the infants were 12 months old, points to the importance of simultaneously addressing the mothers' own psychological distress, and to support positive mother-infant interactions. Each woman's individual optimality profile may be used to display needs of follow-up in order to prevent enduring effects of non-optimality on parenting stress.

Early neurological outcome of young infants exposed to selective serotonin reuptake inhibitors during pregnancy: results from the observational SMOK study

Background

Use of selective serotonin reuptake inhibitors (SSRI) during pregnancy is common while the effect on the infant’s neurological outcome is unknown. Our objective was to determine the effects of prenatal SSRI-exposure on the infants’ neurological functioning, adjusted for maternal mental health.

Methods

A prospective observational study from May 2007 to April 2010. The study groups comprised 63 SSRI-exposed infants (SSRI group) and 44 non-exposed infants (non-SSRI group). Maternal depression and anxiety were measured using questionnaires. The main outcome measures during the first week after birth and at three to four months were the quality of the infants’ general movements (GMs) according to Prechtl and a detailed motor optimality score. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) for abnormal GM quality in the SSRI and non-SSRI groups, and adjusted for maternal depression, anxiety, and other confounders. The study was registered under 53506435 in the ISRCTN.

Findings

All infants were born around term. During the first week, abnormal GMs occurred more frequently in the SSRI group than in the non-SSRI group (59% versus 33%) and the median MOS was lower (13 versus 18). The OR for abnormal GMs in the SSRI versus the non-SSRI group was 3·0 (95% CI, 1.3 to 6.9) and increased after adjustment for confounders. At three to four months, more SSRI-exposed infants had monotonous movements (48% versus 20%) with lower median MOSs (26 versus 28). The OR for monotonous movements was 3·5 (95% CI, 1.5 to 8.6) and increased after adjusting for confounders.

Interpretation

Prenatal exposure to SSRI had an adverse effect on early neurological functioning as reflected by GM quality, irrespective of maternal depression and anxiety, and other confounders. Physicians should take this into account in consultation with parents.

The effect of preimplantation genetic screening on neurological, cognitive and behavioural development in 4-year-old children: follow-up of a RCT

STUDY QUESTION

Does embryo biopsy inherent to preimplantation genetic screening (PGS) affect neurological, cognitive and behavioural development of 4-year-old children?

SUMMARY ANSWER

PGS does not seem to affect neurological, cognitive and behavioural development of 4-year-old singletons; however, our data suggest that it may be associated with altered neurodevelopment in twins.

WHAT IS KNOWN ALREADY

Evidence concerning the safety of PGS on neurodevelopmental outcome in offspring is scarce. The present study provides information on neurodevelopmental, cognitive and behavioural outcome of 4-year-old PGS offspring.

STUDY DESIGN, SIZE, DURATION

A prospective, assessor-blinded follow-up study of children born to women who participated in a multi-centre RCT on the effect of IVF with or without PGS.

PARTICIPANTS/MATERIALS, SETTING, METHODS

At 4 years, 49 children (31 singletons, 9 sets of twins) born following IVF with PGS and 64 children (42 singletons, 11 sets of twins) born following IVF without PGS (controls) were assessed (post-natal attrition 18%). Neurological development was evaluated with the standardized, age-specific and sensitive neurological examination according to Hempel, resulting in a neurological optimality score (NOS), a fluency score and the rate of adverse neurological outcome. Primary outcome was the fluency score, as fluency of movements is easily reduced by subtle dysfunction of the brain. Cognitive development was evaluated with the Kaufman Assessment Battery for Children; behavioural development was evaluated with the Child Behavior Checklist. The effect of PGS was analysed with a mixed effects model.

MAIN RESULTS AND THE ROLE OF CHANCE

Based on the intention to treat analysis, neurodevelopmental outcome of PGS children was similar to that of controls. However, additional analyses indicated that PGS affected neurodevelopmental outcome of twins in a different way than that of singletons. The fluency score of singletons born following PGS was similar to that of control singletons [mean values, 95% confidence intervals (CIs): 12.2 (11.5;12.8) and 12.2 (11.6;12.8)], respectively, P = 0.977) that was also true for the other neurodevelopmental parameters. The fluency score of PGS twins was significantly lower than that of control twins [mean values, 95% CIs: 10.6 (9.8;11.3) and 12.3 (11.5;13.1)], respectively, P = 0.001); the same was true for the NOS. In addition, PGS in twins was associated with a higher sequential intelligence quotient score. On the other hand, other neurodevelopmental parameters were similar for PGS twins and control twins. Post hoc sample size calculation for the primary outcome parameter, the fluency score, indicated that the study groups, including the subgroups of singletons and twins, were adequately powered.

LIMITATIONS, REASONS FOR CAUTION

We assessed singletons and twins who contributed to the generalizability of the study. A limitation of our study is the relative small size of our study groups and the selective dropout in both groups (dropouts PGS group: higher gestational age; control group: less well-educated parents). These preclude the conclusion that PGS per se is not associated with neurodevelopmental, cognitive and behavioural problems in singletons and the conclusion that PGS is associated with altered neurodevelopmental outcome in twins.

WIDER IMPLICATIONS OF THE FINDINGS

The need for careful long-term monitoring of children born following embryo biopsy remains, as it is still applied in the form of PGD and it is still unknown whether embryo biopsy affects long-term neurodevelopmental outcome.

Adolescent emotional and behavioural outcomes of nonparental preschool childcare

PURPOSE

This study aimed to identify whether nonparental preschool childcare was associated with adolescent mental health outcomes as measured by the strengths and difficulties questionnaire (SDQ).

METHOD

This study was a secondary analysis of data from the Croydon Assessment of Learning Study. From a general population sample of 2,726 adolescents tested for cognitive ability, additional data were collected from a stratified sub-sample of 197 subjects. A semi-structured interview asked parents about preschool childcare and early development concerns. Parent and teacher SDQ and IQ data were collected. Complete data were available from 167 subjects. Using nonparental preschool childcare as the 'treatment' effect and parental childcare as the 'control', propensity score matching analyses were used to analyse the effect of nonparental childcare on adolescent SDQ outcomes.

RESULTS

Nonparental childcare was reported by 49% of the sample and was not significantly associated with conduct, emotional, peer or prosocial SDQ subscales, but was found to have a significant average treatment effect on symptoms of attention/hyperactivity, on average raising the symptom subscale score by 1.8 (95% confidence interval 0.12-3.65). The propensity score analysis ensures the results could not be explained by the available measures that influenced receiving nonparental care. Increased time spent in nonparental childcare was associated with greater attention/hyperactivity symptoms.

CONCLUSIONS

Nonparental preschool care showed little association with generalized psychopathology but may be associated with hyperactivity and inattention problems. Replication of these findings in prospective studies is required.

Pediatric physical therapy in infancy: from nightmare to dream? A two-arm randomized trial

BACKGROUND

Systematic reviews have suggested that early intervention by means of specific motor training programs and general developmental programs in which parents learn how to promote infant development may be the most promising ways to promote infant motor and cognitive development of infants with or at high risk for developmental motor disorders.

OBJECTIVE

The purpose of this study was to investigate the effects of a recently developed pediatric physical therapy intervention program ("Coping With and Caring for Infants With Special Needs" [COPCA]) on the development of infants at high risk for developmental disorders using a combined approach of a 2-arm randomized trial and process evaluation.

SETTING

The study was conducted at the University Medical Center Groningen in the Netherlands.

PARTICIPANTS AND INTERVENTION

Forty-six infants at high risk for developmental disorders were randomly assigned to receive COPCA (a family-centered program) (n=21) or traditional infant physical therapy (TIP) (n=25) between 3 to 6 months corrected age (CA). Developmental outcome was assessed by blinded assessors at 3, 6, and 18 months CA with a neurological examination, the Alberta Infant Motor Scales, the Pediatric Evaluation of Disability Inventory, and the Mental Developmental Index (MDI) of the Bayley Scales of Infant Development. Contents of the intervention were analyzed by a quantitative video analysis of therapy sessions. Quantified physical therapy actions were correlated to evaluate associations between intervention and developmental outcome components.

RESULTS

The trial revealed that developmental outcome in both groups was largely identical. Process evaluation showed that typical COPCA actions-(1) family involvement and educational actions, (2) application of a wide variation in challenging the infant to produce motor behavior by himself or herself and allowing the infant to continue this activity, and (3) stimulation of motor behavior at the limit of the infant's capabilities-had positive correlations with developmental outcome at 18 months CA. The use of handling techniques was negatively associated with the Pediatric Evaluation of Disability Inventory outcome at 18 months CA.

LIMITATIONS

Major limitations were the limited size of the groups studied and the differences between the groups in frequency and duration of physical therapy sessions.

CONCLUSION

Extending the randomized trial with process evaluation was needed to obtain insight into associations between the components of intervention and developmental outcome. Specific therapist behaviors of parent coaching are associated with improved developmental outcome measures. Further studies are needed to examine whether these associations are caused by therapist behavior or whether therapist behavior is modified by children's motor skills.

Movements and postures of infants aged 3 to 5 months: to what extent is their optimality related to perinatal events and to the neurological outcome?

BACKGROUND

The quality of spontaneous general movements (GMs), assessed in the individual infant, has emerged as one of the most reliable and valid predictors especially of severe neurological impairments.

AIMS

To implement a more detailed assessment of GMs and co-existing movements and postural patterns in a rehabilitation clinic, and to examine to what extend is the optimality of movements and postures of infants aged 3 to 5 months related to perinatal events and the neurological outcome.

STUDY DESIGN

Prospective study of 41 infants (15 boys and 26 girls; 11 infants born preterm) admitted to the Department of Paediatric Neurology and Rehabilitation of the St. Joseph's Hospital in Kyoto (Japan).

OUTCOME MEASURES

Clinical, neurological and psychological status at age 5.

RESULTS

Motor optimality at age 3 to 5 months correlated positively with neonatal optimality (r=0.48, p<0.01), especially regarding factors associated with hypoxic events. A non-optimal motor performance (lowest possible scores) predicted cerebral palsy with 100% accuracy. Other adverse outcomes such as developmental delays, developmental coordination disorders, pervasive developmental disorder or attention deficit hyperactivity disorder turned out not to be associated with early motor performance. In 13% of cases absence of fidgety movements proved to be false positives, but their normal appearance along with a smooth concurrent motor performance was solely found in infants with a normal neurological development.

CONCLUSION

Assessing the quality of motor performance at age 3 to 5 months considerably improves our ability to identify infants at risk for maldevelopment.

Intrauterine growth-restricted neonates born at term or preterm: how different?

Late onset intrauterine growth restriction is a common form of growth restriction, mainly caused by placenta-vascular insufficiency. Whether the intrauterine or extrauterine environment offers a better long-term outcome for the growth-restricted fetus remains unclear. We compared the risk factors and long-term outcomes of late onset growth-restricted neonates delivered between 31-36 weeks of gestation vs those delivered at term. This prospective cohort study included 114 preterm and 193 term born growth-restricted neonates. They underwent a neurobehavioral examination (neonatal period), a neurodevelopmental assessment and the Bayley Scales of Infant Development (age 2 years), and neuromotor assessment and the Wechsler Preschool and Primary Scale of Intelligence (age 6 years). Growth-restricted neonates born prematurely exhibited a significantly higher incidence of maternal hypertension, a maternal history of abortions and stillbirths, increased intrapartum and postnatal complication rates, and abnormal neonatal neurobehavioral scores than expected. Both preterm and term born growth-restricted groups, however, exhibited comparable long-term neurodevelopmental and cognitive outcomes at ages 2 and 6 years. Although prematurely born neonates undergo an earlier growth restriction process and exhibit a higher perinatal risk factor profile, their long-term outcomes are comparable to those of growth-restricted neonates born at term.

The Groningen LCPUFA study: no effect of postnatal long-chain polyunsaturated fatty acids in healthy term infants on neurological condition at 9 years

Long-chain PUFA (LCPUFA) supplementation of formula can have beneficial effects on neurodevelopmental outcome in early infancy, but uncertainty exists regarding effects after 6 months. The present study is the first to investigate whether consumption by term infants of formula containing LCPUFA for the first 2 months after birth improves neurological condition of these children at 9 years of age. A prospective, double-blind, randomised control study was performed in two groups of healthy term infants: a control group with standard formula (n 169) and a LCPUFA-supplemented group (LF; n 146). A breast-fed group (BF; n 159) served as a reference. At age 9 years, children were neurologically assessed according to Touwen, resulting in a Neurological Optimality Score and information on severity and type of minor neurological dysfunction (MND). Information on potential confounders was collected at enrollment and follow-up. Multivariate analyses were carried out to evaluate the effect of nutrition while adjusting for confounders. Attrition (28 %) was selective: drop-outs in the LF group were more often boys and had a significantly lower mental developmental index at 18 months. Neurological optimality and severity and type of MND at 9 years did not differ between the two formula groups. Children in the BF group showed significantly less often fine manipulative dysfunction than formula-fed children. In conclusion, LCPUFA supplementation of formula during the first 2 postnatal months in healthy term infants does not alter neurological function at school age. The study confirmed that breast-fed infants have a slightly better neurodevelopmental outcome than formula-fed infants.

Maternal anxiety is related to infant neurological condition, paternal anxiety is not

BACKGROUND

Parental anxiety and stress may have consequences for infant neurological development.

AIMS

To study relationships between parental anxiety or well-being and infant neurological development approximately one year after birth.

STUDY DESIGN

Longitudinal study of a birth cohort of infants born to subfertile couples.

SUBJECTS

206 parent-child dyads.

OUTCOME MEASURES

Infant neurology was assessed with the Touwen Infant Neurological Examination (TINE) at 10 months and a developmental questionnaire at 12 months. Parental measures included trait anxiety measured by the State-Trait Anxiety Inventory (STAI) and well-being measured by the General Health Questionnaire (GHQ).

RESULTS

Maternal trait anxiety was associated with a less optimal neurological condition (r(s)= -0.19, p<0.01) of the infant. This association persisted after adjusting for confounders and results were confirmed by the outcome of the developmental questionnaire. Paternal trait anxiety and parental well-being were not related to the infant's neurodevelopmental outcome.

CONCLUSIONS

Infants of mothers with high trait anxiety have an increased vulnerability to develop a non-optimal nervous system. The association may be mediated in part by early programming of monoaminergic systems. Future research should include an exploration of specific windows of vulnerability to maternal anxiety.

Fetal Habituation

One aim of obstetric practice is to ensure the wellbeing of the fetus. This is by no means an easy task and recent years have seen the development of a variety of tests, with varying degrees of success, to evaluate fetal health.

Fetal wellbeing may be assessed at a variety of levels: genetic/cellular, physical/structural or functional. Ideally the evaluation of fetal health should provide information about the functional outcome of any particular condition, especially the performance of the central nervous system. Current tests may not do this. Thus, whilst tests of the fetal chromosomal or genetic constitution may determine the presence of particular genetic/chromosomal conditions, they may not predict functional outcome especially the functioning of the cerebral cortices, the ultimate arbiter of excellence in man. For example, Down's syndrome may be accurately diagnosed by analysis of fetal cells to detect the presence of Trisomy 21 but this in itself provides little information on the subsequent functional performance of the individual. The development of tests of fetal heart function such as antenatal cardiotocography have provided a means of assessing cardiac function and, to a certain extent, the functioning of parts of the autonomic nervous system. However such tests can only indirectly assess cortical function.

Motor testing at 1 year improves the prediction of motor and mental outcome at 2 years after perinatal hypoxic-ischaemic encephalopathy

AIM

To investigate the predictive value of motor testing at 1 year for motor and mental outcome at 2 years after perinatal hypoxic-ischaemic encephalopathy (HIE) in term neonates.

METHOD

Motor and mental outcome at 2 years was assessed with the Bayley Scales of Infant Development, 2nd edition (BSID-II) in 32 surviving children (20 males, 12 females; mean gestational age 40.2 wk, SD 1.4; mean birthweight 3217g, SD 435) participating in a prospective cohort study of HIE. The predictive value of three motor tests (Alberta Infant Motor Scale [AIMS], BSID-II, and the Neurological Optimality Score [NOS]) at 1 year was analysed, in addition to predictions based on neonatal Sarnat staging and magnetic resonance imaging (MRI). Poor motor test results were defined as an AIMS z-score of <-2, a psychomotor developmental index of the BSID-II of <70, or a NOS of <26. Poor motor and poor mental outcome at 2 years was defined as a psychomotor developmental index or mental developmental index of the BSID-II of <70.

RESULTS

Twelve children, all with Sarnat grade II, had a poor motor outcome and 12 children, of whom one had Sarnat grade I, had a poor mental outcome at 2 years. Nine children had cerebral palsy, of whom five had quadriplegia, three had dyskinesia, and one had hemiplegia. Poor motor tests at 1 year increased the probability of a poor motor outcome from 71% (range 92 to 100%), and a poor mental outcome from 59% (range 77 to 100%) in children with Sarnat grade II and abnormal MRI, assessed with the AIMS and BSID-II or NOS respectively.

INTERPRETATION

Additional motor testing at 1 year improves the prediction of motor and mental outcome at 2 years in children with Sarnat grade II and abnormal MRI.

Measuring the best outcome for the least intervention: can the Optimality Index-US be applied in the UK?

OBJECTIVE

to pilot the Optimality Index-US (OI-US) for the first time within a UK maternity setting in a sample of women at mixed risk.

DESIGN

a multidisciplinary group reviewed the items and evidence base of the OI-US. A pilot study was undertaken to compare the availability and quality of data from maternity records to complete the OI-US. Data were collected from maternity records.

SETTING

a maternity unit of an inner city teaching hospital in England.

PARTICIPANTS

clinical midwives, research midwives, midwifery lecturers and consultant obstetricians (n=10) reviewed the items and evidence base of the OI-US. Data were collected from the maternity records of 97 women receiving caseload care and 103 women receiving standard care.

MEASUREMENTS AND FINDINGS

when the multidisciplinary group reviewed the items and evidence base of the OI-US, it was noted that some social and clinical factors should be considered for inclusion as part of the Perinatal Background Index (PBI) and OI. The results suggest that the inclusion of women at higher risk in this sample within the UK maternity setting has not been captured by the OI-US.

KEY CONCLUSIONS

the following social and clinical factors should be included as part of the PBI and OI for the UK setting: measure of social deprivation, woman's ability to speak and understand English in relation to accessing maternity care, mental health problems during pregnancy and history of domestic violence during pregnancy

IMPLICATIONS FOR PRACTICE

availability of items in electronic records is poor and it is recommended that the OI-UK version is a useful research tool in prospective data collection. The development of an international version would be valuable for comparison of background risk and outcomes across a range of care settings.

The Groningen ART cohort study: ovarian hyperstimulation and the in vitro procedure do not affect neurological outcome in infancy

BACKGROUND

Due to the growing number of children born following assisted reproduction technology, even subtle changes in the children's health and development are of importance to society at large. The aim of the present study was to evaluate the specific effects of ovarian hyperstimulation and the in vitro procedure on neurological outcome in 4-18-month-old children.

METHODS

In this prospective assessor-blinded cohort study, we included singletons born following controlled ovarian hyperstimulation in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) (COH-IVF; n = 68) or modified natural cycle-IVF/ICSI (MNC-IVF; n = 57) or naturally conceived singletons of subfertile couples (NC; n = 90). Children were assessed with standardized, age-specific and sensitive neurological assessments (TINE and Hempel assessment) at 4, 10 and 18 months. Neurological examination resulted in a neurological optimality score (NOS), a fluency score and a clinical neurological classification. Fluency of movements is easily affected by neurological dysfunction and is therefore a sensitive measure for minimal changes in neuromotor development.

RESULTS

The NOS and the fluency score were similar in COH-IVF, MNC-IVF and NC children. None of the children showed major neurological dysfunction and rates of minor neurological dysfunction at the three ages were not different between the three conception groups.

CONCLUSIONS

We found no effects of ovarian hyperstimulation or the in vitro procedure itself on neurological outcome in children aged 4-18 months. The findings of our study are reassuring, nevertheless it should be kept in mind that subtle neurodevelopmental disorders may emerge when children grow older. Continuation of follow-up in older and larger groups of children is therefore still needed.

Does HPA-axis activity mediate the relationship between obstetric complications and externalizing behavior problems? The TRAILS study

To examine whether HPA-axis activity mediates the relationship between obstetric complications (OCs) and externalizing behavior problems, and to investigate whether this model is different for boys and girls. In a population-based cohort of 1,768 10- to 12-year-old early adolescents, we assessed the cortisol awakening response and evening cortisol levels. Externalizing behavior problems were assessed using the Child Behavior Checklist and the Youth Self-Report. OCs were retrospectively assessed in a parent interview. OCs significantly predicted externalizing behavior problems, but OCs did not predict HPA-axis activity. Thus, the mediation model was not supported. In addition to the relationship between HPA-axis activity and externalizing behavior problems, which is specific for girls, there is also a relationship between OCs and externalizing behavior problems. However, these two mechanisms are not related to each other indicating that HPA-axis activity is not a mediator in the relationship between OCs and externalizing behavior problems. Future research should focus on understanding the mechanism through which OCs cause externalizing behavior problems.