Biological and Social Influences on the Neurodevelopmental Outcomes of Preterm Infants

Assessing parental comprehension of online resources on childhood pain

We aimed to examine the patient education materials (PEMs) on the internet about "Child Pain" in terms of readability, reliability, quality and content. For our observational study, a search was made on February 28, 2024, using the keywords "Child Pain," "Pediatric Pain," and "Children Pain" in the Google search engine. The readability of PEMs was assessed using computer-based readability formulas (Flesch Reading Ease Score [FRES], Flesch-Kincaid Grade Level [FKGL], Automated readability index (ARI), Gunning Fog [GFOG], Coleman-Liau score [CL], Linsear Write [LW], Simple Measure of Gobbledygook [SMOG]). The reliability and quality of websites were determined using the Journal of American Medical Association (JAMA) score, Global Quality Score (GQS), and DISCERN score. 96 PEM websites included in our study. We determined that the FRES was 64 (32-84), the FKGL was 8.24 (4.01-15.19), ARI was 8.95 (4.67-17.38), GFOG was 11 (7.1-19.2), CL was 10.1 (6.95-15.64), LW was 8.08 (3.94-19.0) and SMOG was 8.1 (4.98-13.93). The scores of readability formulas showed that, the readability level of PEMs was statistically higher than sixth-grade level with all formulas (P = .011 for FRES, P < .001 for GFOG, P < .001 for ARI, P < .001 for FKGL, P < .001 for CL and P < .001 for SMOG), except LW formula (P = .112). The websites had moderate-to-low reliability and quality. Health-related websites had the highest quality with JAMA score. We found a weak negative correlation between Blexb score and JAMA score (P = .013). Compared to the sixth-grade level recommended by the American Medical Association and the National Institutes of Health, the readability grade level of child pain-related internet-based PEMs is quite high. On the other hand, the reliability and quality of PEMs were determined as moderate-to-low. The low readability and quality of PEMs could cause an anxious parent and unnecessary hospital admissions. PEMs on issues threatening public health should be prepared with attention to the recommendations on readability.

The relationship between neonatal stress in preterm infants and developmental outcomes at the corrected age of 24-30 months

Aim

The aim of research was to study the relationship between the stress experienced by preterm infants in the neonatal intensive care unit (NICU) and developmental status in the follow up, and to establish factors, associated with their neurodevelopment.

Methods

The first stage of research involved measuring stress markers (cortisol, melatonin) in infants (n = 56) during their NICU stay; the second phase assessed the developmental status at the corrected age of 24-30 months.

Results

The total ASQ-3 score, communication, problem solving, and personal-social skills scores at the corrected age of 24-30 months were positively correlated with melatonin level determined in the neonatal period (r = 0.31, p = 0.026; r = 0.36, p = 0.009; r = 0.30, p = 0.033, and r = 0.32; p = 0.022 respectively). In the same time, ASQ-3 communication and personal-social scores were negatively correlated with cortisol level (r = -0.31, p = 0.043; r = -0.35, p = 0.022). The ROC-curve analysis revealed that a decrease of melatonin below 3.44 ng/mL and 3.71 ng/mL during the neonatal period could predict communication and problem-solving delay, respectively. An increase in cortisol above 0.64 mcg/dl is predictive in personal-social delay. Negative correlation was identified between the NICU and total hospital stay duration and ASQ-3 communication scores in the follow-up (r = -0.27; p = 0.049 and r = -0.41; p = 0.002, respectively). The duration of mechanical ventilation was negatively correlated with gross motor scores (r = -0.46; p = 0.043). Apgar score was positively correlated with ASQ-3 communication (r = 0.29; p = 0.032) and personal-social scores (r = 0.28; p = 0.034); maternal age-with ASQ-3 total (r = 0.29; p = 0.034), communication (r = 0.37; p = 0.006), and personal-social scores (r = 0.29; p = 0.041). Positive correlations were observed between gestational age and communication scores (r = 0.28; p = 0.033). Infants who suffered neonatal sepsis had significantly often delay of communication (p = 0.014) and gross motor skills (p = 0.016). Children who required mechanical ventilation were more likely to have communication delay (p = 0.034).

Conclusion

Developmental outcomes in preterm infants at the corrected age of 24-30 months were associated with neonatal stress. Correlations between the communication, problem-solving and personal-social development in the follow up and cortisol and melatonin levels determined in the neonatal period supported this evidence. Factors as low gestational age, duration of hospital and NICU stay, mechanical ventilation, and sepsis were associated with more frequent delays in communication, gross motor and problems-solving skills.

Cortical growth from infancy to adolescence in preterm and term-born children

Early life experiences can exert a significant influence on cortical and cognitive development. Very preterm birth exposes infants to several adverse environmental factors during hospital admission, which affect cortical architecture. However, the subsequent consequence of very preterm birth on cortical growth from infancy to adolescence has never been defined; despite knowledge of critical periods during childhood for establishment of cortical networks. Our aims were to: chart typical longitudinal cortical development and sex differences in cortical development from birth to adolescence in healthy term-born children; estimate differences in cortical development between children born at term and very preterm; and estimate differences in cortical development between children with normal and impaired cognition in adolescence. This longitudinal cohort study included children born at term (≥37 weeks' gestation) and very preterm (<30 weeks' gestation) with MRI scans at ages 0, 7 and 13 years (n = 66 term-born participants comprising 34 with one scan, 18 with two scans and 14 with three scans; n = 201 very preterm participants comprising 56 with one scan, 88 with two scans and 57 with three scans). Cognitive assessments were performed at age 13 years. Cortical surface reconstruction and parcellation were performed with state-of-the-art, equivalent MRI analysis pipelines for all time points, resulting in longitudinal cortical volume, surface area and thickness measurements for 62 cortical regions. Developmental trajectories for each region were modelled in term-born children, contrasted between children born at term and very preterm, and contrasted between all children with normal and impaired cognition. In typically developing term-born children, we documented anticipated patterns of rapidly increasing cortical volume, area and thickness in early childhood, followed by more subtle changes in later childhood, with smaller cortical size in females than males. In contrast, children born very preterm exhibited increasingly reduced cortical volumes, relative to term-born children, particularly during ages 0-7 years in temporal cortical regions. This reduction in cortical volume in children born very preterm was largely driven by increasingly reduced cortical thickness rather than area. This resulted in amplified cortical volume and thickness reductions by age 13 years in individuals born very preterm. Alterations in cortical thickness development were found in children with impaired language and memory. This study shows that the neurobiological impact of very preterm birth on cortical growth is amplified from infancy to adolescence. These data further inform the long-lasting impact on cortical development from very preterm birth, providing broader insights into neurodevelopmental consequences of early life experiences.

Impact of Parent Presence and Engagement on Stress in NICU Infants

BACKGROUND

Infants in neonatal intensive care units (NICUs) are exposed to frequent stressors that impact their neurodevelopmental outcomes. Parent presence and engagement are considered critical to improving infant outcomes, yet associations between cumulative NICU parent presence, engagement, and infant stress are infrequently examined.

PURPOSE

To examine associations between NICU infant stress and the amount (hours per week) or frequency (days per week) of parent presence and skin-to-skin care (SSC).

METHODS

A secondary analysis of a data set representing 78 NICU families was conducted. Infant acuity was measured using Neonatal Medical Index (NMI) scores. Parent presence and SSC data were collected from electronic medical records. Infant stress was measured using resting salivary cortisol levels collected at NICU discharge (median = 33 days of life).

RESULTS

More cumulative SSC was associated with lower discharge cortisol in NICU infants for SSC measured in hours per week (P = .03) or days per week (P = .05). Cumulative parent presence was not significantly associated with infant cortisol at discharge. Hierarchical regression analyses examining timing of parent presence supported a model including admission cortisol, NMI score, and parent presence during weeks 1 to 4 of life for explaining infant stress at discharge (R2 = 0.44, P = .004). Analyses examining timing of SSC supported a model including admission cortisol, NMI score, and frequency of SSC during week 1 for explaining infant stress at discharge (R2 = 0.21, P = .04).

IMPLICATIONS FOR PRACTICE AND RESEARCH

Early, frequent SSC to mitigate stress in NICU infants was supported. Results suggested that timing of parent presence impacts NICU infant stress; however, additional study is recommended.

Sex differences in the risk of retinopathy of prematurity: a systematic review, frequentist and Bayesian meta-analysis, and meta-regression

BACKGROUND

Retinopathy of prematurity (ROP) is generally considered to be more frequent in males than in females. However, it is not known whether sex differences in ROP affect all degrees of the condition, are global and have changed as neonatology has developed. We aimed to conduct a systematic review and meta-analysis of studies addressing sex differences in the risk of developing ROP.

METHODS

PubMed/MEDLINE and Embase databases were searched. The frequentist, random-effects risk ratio (RR) and 95% confidence interval (CI) were calculated. Bayesian model averaged (BMA) meta-analysis was used to calculate the Bayes factors (BFs). The BF10 is the ratio of the probability of the data under the alternative hypothesis (H1) over the probability of the data under the null hypothesis (H0).

RESULTS

We included 205 studies (867,252 infants). Frequentist meta-analysis showed a positive association between male sex and severe ROP (113 studies, RR = 1.14, 95% CI = 1.07-1.22) but no association with any ROP (144 studies, RR = 1.00, 95% CI = 0.96-1.03). BMA showed extreme evidence in favor of H1 for severe ROP (BF10 = 71,174) and strong evidence in favor of H0 for any ROP (BF10 = 0.05). The association between male sex and severe ROP remained stable over time and was present only in cohorts from countries with a high or high-middle sociodemographic index.

CONCLUSIONS

Our study confirms the presence of a male disadvantage in severe ROP but not in less severe forms of the disease. There are variations in the sex differences in ROP, depending on geographical location and sociodemographic level of the countries.

Pharmacokinetics and safety of prolonged paracetamol treatment in neonates: An interventional cohort study

AIMS

To investigate the pharmacokinetics and safety of prolonged paracetamol use (>72 h) for neonatal pain.

METHODS

Neonates were included if they received paracetamol orally or intravenously for pain treatment. A total of 126 samples were collected. Alanine aminotransferase and bilirubin were measured as surrogate liver safety markers. Paracetamol and metabolites were measured in plasma. Pharmacokinetic parameters for the parent compound were estimated with a nonlinear mixed-effects model.

RESULTS

Forty-eight neonates were enrolled (38 received paracetamol for >72 h). Median gestational age was 38 weeks (range 25-42), and bodyweight at inclusion was 2954 g (range 713-4750). Neonates received 16 doses (range 4-55) over 4.1 days (range 1-13.8). The median (range) dose was 10.1 mg/kg (2.9-20.3). The median oxidative metabolite concentration was 14.6 μmol/L (range 0.12-113.5) and measurable >30 h after dose. There was no significant difference (P > .05) between alanine aminotransferase and bilirubin measures at <72 h or >72 h of paracetamol treatment or the start and end of the study. Volume of distribution and paracetamol clearance for a 2.81-kg neonate were 2.99 L (% residual standard error = 8, 95% confidence interval 2.44-3.55) and 0.497 L/h (% residual standard error = 7, 95% confidence interval 0.425-0.570), respectively. Median steady-state concentration from the parent model was 50.3 μmol/L (range 30.6-92.5), and the half-life was 3.55 h (range 2.41-5.65).

CONCLUSION

Our study did not provide evidence of paracetamol-induced liver injury nor changes in metabolism in prolonged paracetamol administration in neonates.

A Bibliometric Analysis of Neonatal Pain Management Research From 2010 to 2022

BACKGROUND

Research related to neonatal pain management has received increasing attention in recent years. Effective pain management contributes to the maintenance of the healthy physical and mental growth of the newborn. To better understand this research topic, we analyzed the current state of development in this field over the past thirteen years by bibliometric analysis and provide directions for future research.

METHODS

Original articles were collected from the Web of Science Core Collection (WoSCC) between January 1, 2010, to December 31, 2022, the title and abstract clearly stating 'neonatal pain management' or its alternative search keywords. CiteSpace, VOSviewer, and the WoS analysis tool were used to analyze and present the data.

RESULTS

A total of 967 articles met the inclusion criteria. Significant growth of the number of publications increased roughly fourfold from 2010 to 2022. Overall, the United States and Canada were the highest contributors to neonatal pain management research. Weak cooperation was observed in international research (developing and developed countries) and cross-institutional cooperation. Neonatal pain-related research was the most common focus. Pain education and interventions for parents and medical personnel have also received increasing attention recently.

CONCLUSION

The current study revealed that research in terms of publications on neonatal pain management has rapidly increased for more than the past ten years. Developed countries, especially the United States and Canada, were more concerned with this topic than developing countries. More international research and cross-institutional cooperation are required to promote the development of neonatal pain medicine in the future.

[Formula: see text] Perinatal and social risk of poor language, memory, and learning outcomes in a cohort of extremely and very preterm children

Children born extremely preterm (EPT) or very preterm (VPT) are at risk of neurodevelopmental impairment. How the interaction between biological and social risk factors affects cognitive development has not yet been completely understood. The objectives of this study are to analyze and compare the language, memory, and learning outcomes of five-year-old children born EPT (<28 weeks' gestational age) and VPT (28-31+6 weeks' gestational age) and to determine the risk of having poor outcomes attending to perinatal and maternal characteristics. The analysis included 377 children born VPT (n = 284) and EPT (n = 93) in 2011-2012. Maternal, neonatal, and clinical information was obtained at birth, and maternal education was obtained at five years using a parental questionnaire. At five years, the language, memory, and learning outcomes were assessed with the developmental NEuroPSYchological assessment second edition (NEPSY-II®). Logistic regression models were applied to assess the association of biological and social risk factors with performance below the expected level for the child's age in language, memory, and learning subtests. Lower maternal age and education increased the odds of having language performance below the expected level for the child's age, while lower maternal educational level and gestational age increased the likelihood of having memory performance below the expected level. Children living in the most social disadvantage contexts are at a higher risk of suboptimal cognitive development. Implementing intervention programs in disadvantaged contexts and targeting specific cognitive domains may enable EPT and VPT children to reach and fulfill their potential in society.

Narrative Review of the Complex Interaction between Pain and Trauma in Children: A Focus on Biological Memory, Preclinical Data, and Epigenetic Processes

The incidence and collective impact of early adverse experiences, trauma, and pain continue to increase. This underscores the urgent need for translational efforts between clinical and preclinical research to better understand the underlying mechanisms and develop effective therapeutic approaches. As our understanding of these issues improves from studies in children and adolescents, we can create more precise preclinical models and ultimately translate our findings back to clinical practice. A multidisciplinary approach is essential for addressing the complex and wide-ranging effects of these experiences on individuals and society. This narrative review aims to (1) define pain and trauma experiences in childhood and adolescents, (2) discuss the relationship between pain and trauma, (3) consider the role of biological memory, (4) decipher the relationship between pain and trauma using preclinical data, and (5) examine the role of the environment by introducing the importance of epigenetic processes. The ultimate scope is to better understand the wide-ranging effects of trauma, abuse, and chronic pain on children and adolescents, how they occur, and how to prevent or mitigate their effects and develop effective treatment strategies that address both the underlying causes and the associated physiological and psychological effects.

Outcomes of Preterm Infants: Shifting Focus, Extending the View

Advances in perinatal care have led to remarkable long-term survival for infants who are born preterm. This article reviews the broader context of follow-up care, highlighting the need to reenvision some areas, such as improving parental support by embedding parental involvement in the neonatal intensive care unit, incorporating parental perspectives about outcomes into follow-up care models and research, supporting their mental health, addressing social determinants of health and disparities, and advocating for change. Multicenter quality improvement networks allow identification and implementation of best practices for follow-up care.

Predicting 2-year neurodevelopmental outcomes in extremely preterm infants using graphical network and machine learning approaches

Background

Infants born extremely preterm (<28 weeks' gestation) are at high risk of neurodevelopmental impairment (NDI) with 50% of survivors showing moderate or severe NDI when at 2 years of age. We sought to develop novel models by which to predict neurodevelopmental outcomes, hypothesizing that combining baseline characteristics at birth with medical care and environmental exposures would produce the most accurate model.

Methods

Using a prospective database of 692 infants from the Preterm Epo Neuroprotection (PENUT) Trial, which was carried out between December 2013 and September 2016, we developed three predictive algorithms of increasing complexity using a Bayesian Additive Regression Trees (BART) machine learning approach to predict both NDI and continuous Bayley Scales of Infant and Toddler Development 3rd ed subscales at 2 year follow-up using: 1) the 5 variables used in the National Institute of Child Health and Human Development (NICHD) Extremely Preterm Birth Outcomes Tool, 2) 21 variables associated with outcomes in extremely preterm (EP) infants, and 3) a hypothesis-free approach using 133 potential variables available for infants in the PENUT database.

Findings

The NICHD 5-variable model predicted 3-4% of the variance in the Bayley subscale scores, and predicted NDI with an area under the receiver operator curve (AUROC, 95% CI) of 0.62 (0.56-0.69). Accuracy increased to 12-20% of variance explained and an AUROC of 0.77 (0.72-0.83) when using the 21 pre-selected clinical variables. Hypothesis-free variable selection using BART resulted in models that explained 20-31% of Bayley subscale scores and AUROC of 0.87 (0.83-0.91) for severe NDI, with good calibration across the range of outcome predictions. However, even with the most accurate models, the average prediction error for the Bayley subscale predictions was around 14-15 points, leading to wide prediction intervals. Higher total transfusion volume was the most important predictor of severe NDI and lower Bayley scores across all subscales.

Interpretation

While the machine learning BART approach meaningfully improved predictive accuracy above a widely used prediction tool (NICHD) as well as a model utilizing NDI-associated clinical characteristics, the average error remained approximately 1 standard deviation on either side of the true value. Although dichotomous NDI prediction using BART was more accurate than has been previously reported, and certain clinical variables such as transfusion exposure were meaningfully predictive of outcomes, our results emphasize the fact that the field is still not able to accurately predict the results of complex long-term assessments such as Bayley subscales in infants born EP even when using rich datasets and advanced analytic methods. This highlights the ongoing need for long-term follow-up of all EP infants.

Funding

Supported by the National Institute of Neurological Disorders and StrokeU01NS077953 and U01NS077955.

Ultrasonographic evaluation of the early brain growth pattern in very low birth weight infants

BACKGROUND

Preterm infants develop smaller brain volumes compared to term newborns. Our aim is to study early brain growth related to perinatal factors in very low birth weight infants (VLBWI).

METHODS

Manual segmentation of total brain volume (TBV) was performed in weekly 3D-ultrasonographies in our cohort of VLBWI. We studied the brain growth pattern related to term magnetic resonance image (term-MRI).

RESULTS

We found different brain growth trajectories, with smaller brain volumes and a decrease in brain growth rate in those VLBWI who would later have an abnormal term-MRI (mean TBV 190.68 vs. 213.9 cm3; P = 0.0001 and mean TBV growth rate 14.35 (±1.27) vs. 16.94 (±2.29) cm3/week; P = 0.0001). TBV in those with normal term-MRI was related to gestational age (GA), being small for gestational age (SGA), sex, and duration of parenteral nutrition (TPN) while in those with abnormal term-MRI findings it was related to GA, SGA, TPN, and comorbidities. We found a deceleration in brain growth rate in those with ≥3 comorbidities.

CONCLUSIONS

An altered brain growth pattern in VLBWI who subsequently present worst scores on term-MRI is related to GA, being SGA and comorbidities. Early ultrasonographic monitoring of TBV could be useful to detect deviated patterns of brain growth.

IMPACT STATEMENT

We describe the brain growth pattern in very low birth weight infants during their first postnatal weeks. Brain growth may be affected in the presence of certain perinatal factors and comorbidities, conditioning a deviation of the normal growth pattern. The serial ultrasound follow-up of these at-risk patients allows identifying these brain growth patterns early, which offers a window of opportunity for implementing earlier interventions.

A prediction model for short-term neurodevelopmental impairment in preterm infants with gestational age less than 32 weeks

Introduction

Early identification and intervention of neurodevelopmental impairment in preterm infants may significantly improve their outcomes. This study aimed to build a prediction model for short-term neurodevelopmental impairment in preterm infants using machine learning method.

Methods

Preterm infants with gestational age  < 32 weeks who were hospitalized in The Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, and were followed-up to 18 months corrected age were included to build the prediction model. The training set and test set are divided according to 8:2 randomly by Microsoft Excel. We firstly established a logistic regression model to screen out the indicators that have a significant effect on predicting neurodevelopmental impairment. The normalized weights of each indicator were obtained by building a Support Vector Machine, in order to measure the importance of each predictor, then the dimension of the indicators was further reduced by principal component analysis methods. Both discrimination and calibration were assessed with a bootstrap of 505 resamples.

Results

In total, 387 eligible cases were collected, 78 were randomly selected for external validation. Multivariate logistic regression demonstrated that gestational age(p = 0.0004), extrauterine growth restriction (p = 0.0367), vaginal delivery (p = 0.0009), and hyperbilirubinemia (0.0015) were more important to predict the occurrence of neurodevelopmental impairment in preterm infants. The Support Vector Machine had an area under the curve of 0.9800 on the training set. The results of the model were exported based on 10-fold cross-validation. In addition, the area under the curve on the test set is 0.70. The external validation proves the reliability of the prediction model.

Conclusion

A support vector machine based on perinatal factors was developed to predict the occurrence of neurodevelopmental impairment in preterm infants with gestational age  < 32 weeks. The prediction model provides clinicians with an accurate and effective tool for the prevention and early intervention of neurodevelopmental impairment in this population.

Bronchopulmonary dysplasia is not related to neurofilament light for neuroaxonal damage in preterm infants

BACKGROUND

Neurofilament light (NfL) has been identified as a biomarker for neuroaxonal damage in preterm infants, but its relation with bronchopulmonary dysplasia (BPD) has not been established. We hypothesized that BPD is associated with increased NfL levels at an early stage, indicative of early neuroaxonal damage.

METHODS

We included preterm infants born <30 weeks of gestation for assessment of NfL levels from cord blood and blood obtained at postnatal days 3, 7, 14, and 28. We used linear regression analysis to compare NfL levels between infants with moderate/severe BPD and infants with no/mild BPD, and linear mixed model analysis to compare the effect of time on NfL levels between groups.

RESULTS

Sixty-seven infants with a gestational age (GA) of 27 ± 1.3 weeks were included for analysis, of whom 19 (28%) developed moderate/severe BPD. Although NfL levels were higher at every time point in infants with BPD, statistical significance was lost after adjustment for GA, small for gestational age (SGA) and intraventricular hemorrhage (IVH). Groups did not differ in NfL change over time.

CONCLUSIONS

The positive association between BPD and NfL in the first weeks of life could be explained by GA, SGA and IVH rather than by development of BPD.

IMPACT

Neurofilament light chain (NfL) is a known biomarker for neuroaxonal damage. Biomarkers for brain damage during the first weeks of life in preterm infants developing BPD are lacking. NfL levels obtained during the first weeks of life did not differ between infants with and without BPD in analyses adjusted for GA, SGA, and IVH.

Short-term neurodevelopment and growth outcomes of very and moderate preterm Indian infants

OBJECTIVE

To study the growth and neurodevelopmental outcome of very and moderate preterm infants (VMPT) compared to term appropriate-for-age (term AGA) infants at 18-months corrected age.

METHODS

This prospective cohort study enrolled consecutively born 212 VMPT infants and 250 term AGA controls delivered during study period.

OUTCOME MEASURES

Major neurodevelopmental impairment (NDI) defined as any one of cerebral palsy, motor (MoDQ) or mental developmental quotient (MoDQ) <70 on Developmental Assessment Scale for Indian infants, visual or hearing impairment, or epilepsy, and growth outcomes.

RESULTS

Among 195 VMPT and 240 term AGA infants who completed follow-up, the frequency of major NDI was 12.8% and 2.5% respectively (RR 5.1; 95% CI [2.13-12.19]). Major NDI was higher among infants <28 weeks gestation (39%) and birthweight <1000 grams (27%). A quarter of VMPT infants exhibited wasting and 18% stunting than 7% each among controls.

CONCLUSION

VMPT infants had a higher frequency of major NDI and growth failure at 18-months.

Development of neonatal high-risk preterm infants in comparison to full-term counterparts

Studies on preterm infants usually exclude high-risk neonatal infants with neurological problems. However, it is important to study high-risk preterm infants to better understand later developmental problems. Therefore, this cross-sectional study aimed to compare the cognitive, motor, language, and social-emotional development of high-risk preterm (PT) infants with infants born full-term (FT) with no biological vulnerabilities during early development (up to the first 15 months of age). The sample comprised 133 infants (54 born PT and 79 born FT) assessed in independent subsamples at 6-8 and 12-15 months of age, considering the corrected age for prematurity in the PT infants. Infant development (cognitive, motor, language, and social-emotional) was evaluated using the Bayley-III Scales. Medical charts were reviewed to obtain the clinical history. A multivariate analysis of variance and analysis of variance tests were performed to examine the differences between groups related to infant developmental indicators, controlling for age and socioeconomic variables. Although the PT infants performed significantly more poorly than their FT counterparts, the scores of the PT group were still within the normal range on all Bayley-III domains (cognitive, language, motor, and social-emotional) than their FT counterparts. The findings of the present study provide a better understanding of the developmental prognosis of high-risk PT infants and extend support for preventive intervention programs to improve early childhood development.

Early brain activity: Translations between bedside and laboratory

Neural activity is both a driver of brain development and a readout of developmental processes. Changes in neuronal activity are therefore both the cause and consequence of neurodevelopmental compromises. Here, we review the assessment of neuronal activities in both preclinical models and clinical situations. We focus on issues that require urgent translational research, the challenges and bottlenecks preventing translation of biomedical research into new clinical diagnostics or treatments, and possibilities to overcome these barriers. The key questions are (i) what can be measured in clinical settings versus animal experiments, (ii) how do measurements relate to particular stages of development, and (iii) how can we balance practical and ethical realities with methodological compromises in measurements and treatments.

Prevalence and characteristics of children with cerebral palsy according to socioeconomic status of areas of residence in a French department

Aim

To study the association between the socioeconomic environment of area of residence and prevalence and characteristics of children with cerebral palsy (CP).

Method

Data on 8-year-old children with CP born in 2000–2011 (n = 252) were extracted from a regional population-based register in France. The European Deprivation Index (EDI), available at census block level, characterised socioeconomic deprivation in the child’s area of residence at age of registration. The prevalence of CP was estimated in each group of census units defined by EDI distribution tertiles in the general population. The association between deprivation level and CP severity was assessed according to term/preterm status.

Results

CP prevalence differed between deprivation risk groups showing a J-shaped form with the prevalence in the most deprived tertile (T3) being the highest but not significantly different of the prevalence in the least deprived one (T1). However, the prevalence in the medium deprivation tertile (T2) was significantly lower than that in the most deprived one with a prevalence risk ratio (PRR) of: PRRT2/T3 = 0.63 95% CI [0.44–0.89]). Prevalences of CP with associated intellectual disability (ID) and CP with inability to walk were significantly higher in the most deprived tertile compared to the least deprived one (respectively PRRT3/T1 = 1.86 95% CI [1.19–2.92] and PRRT3/T1 = 1.90 95% CI [1.07–3.37]). Compared to children living in the least deprived areas, children with CP born preterm living in the most deprived areas had more severe forms of motor impairment, such as an inability to walk or a combination of an inability to walk and moderate to severe impairment of bimanual function. They also had more associated intellectual disability. No associations were observed among term-born children.

Interpretation

A significant association between area deprivation group and CP severity was observed among preterm children but not among term-born children.

Early Speech Sound Production and Its Trajectories in Very Preterm Children From 2 to 4 Years of Age

PURPOSE

Very preterm (VPT) children are at risk for speech and language problems throughout school age. However, little is known about early speech sound production in these children. This study aims to present a detailed description of early speech sound production and its trajectories in VPT children from 2 to 4 years of age. In addition, this study aimed to determine if early speech sound production is associated with speech production and expressive language function at 4 years of age.

METHOD

In 63 VPT children (< 32 weeks of gestation, 41 boys, mean gestational age = 28.8 weeks, mean birth weight = 1,135 g), speech sound production was assessed by naturalistic speech analysis at 2 years of corrected age and speech and language function by standardized tests at 4 years of age.

RESULTS

Speech sound production was found to be abnormal in 49% of the VPT children at 2 years of age and in 19% at 4 years of age. Four different speech production trajectories from 2 to 4 years of age could be identified: a normal trajectory, an abnormal trajectory, a catch-up trajectory, and a growing-into-deficit trajectory. Early speech production, defined by the number of acquired consonants at 2 years of age, significantly predicted the word production score at 4 years of age and the sentence production score at 4 years of age.

CONCLUSIONS

Compared to the general population, an alarmingly high proportion of VPT children showed speech production problems at 2 years of age. About half of these children showed persistent speech problems at 4 years of age. Moreover, these problems were associated with expressive language problems at the age of 4 years.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19310822.

Exceeding expectations after perinatal risks for poor development: associations in term- and preterm-born preschoolers

OBJECTIVE

To define parenting/social characteristics associated with better-than-expected cognitive and motor outcomes in preschoolers at similar perinatal biological risk-level including various gestational ages at birth (GA) and perinatal complications.

STUDY DESIGN

Prospective cohort study (n = 87) of children at four years, median GA 29 weeks (IQR 26, 38). Assessments included Differential Ability Scales, Movement Assessment Battery, parenting styles, and social risk scores. Perinatal risk factors were weighted based on regression models for each outcome; individual calculated risk scores became predictors to extract standardized residuals from the mean (>1 SD above mean = better-than-expected). Mixed-effect regressions examined associations between positive adaptation and parenting/social factors.

RESULT

Perinatal risk scores explained 21-53% outcome variability. Children across all GA displayed positive adaptation. Children of parents with higher authoritarian scores had higher odds of better-than-expected outcomes (OR 1.17, p = 0.0002).

CONCLUSION

Parental structure may promote positive adaptation at preschool age in children with perinatal risk factors for poor development, including extreme prematurity.

Early Motor Repertoire of Very Preterm Infants and Relationships with 2-Year Neurodevelopment

The Motor Optimality Score, revised (MOS-R) is an extension of the Prechtl General Movements Assessment. This study aims to determine the relationship between MOS-R and 2-year neurodevelopmental outcomes in a cohort of 169 infants born very preterm (<31 weeks’ gestational age), and to examine the predictive validity of the MOS-R at 3−4 months’ corrected age (CA) above perinatal variables associated with poor outcomes, including Prechtl fidgety movements. Development at 2 years’ CA was assessed using Bayley Scales of Infant and Toddler Development, Third edition (Bayley-III) (motor/cognitive impairment: Bayley-III ≤ 85) and Neurological, Sensory, Motor, Developmental Assessment (NSMDA) (neurosensory motor impairment: NSMDA ≥ 12). Cerebral palsy (CP) was classified at 2 years as definite or clinical. The MOS-R was related to 2-year outcomes: Bayley-III motor (BMOS-R = 1.24 95% confidence interval (0.78, 1.70)), cognitive (BMOS-R = 0.91 (0.48, 1.35)), NSMDA scores (BMOS-R = −0.34 (−0.42, −0.25)), definite CP (odds ratio [OR] 0.67 (0.53, 0.86)), clinical CP (OR 0.74 (0.66, 0.83)) for each 1-point increase in MOS-R. MOS-R ≤ 23 predicted motor (sensitivity 78% (60−91%); specificity 63% (54−72%)) and neurosensory motor impairment (sensitivity 86% (64−97%); specificity 59% (51−68%)). The MOS-R is strongly related to CP and motor and cognitive delay at 2 years and is a good predictor of motor and neurosensory motor impairment.

Protecting brains and saving futures guidelines: A prospective, multicenter, and observational study on the use of telemedicine for neonatal neurocritical care in Brazil

Background

Management of high-risk newborns should involve the use of standardized protocols and training, continuous and specialized brain monitoring with electroencephalography (EEG), amplitude integrated EEG, Near Infrared Spectroscopy, and neuroimaging. Brazil is a large country with disparities in health care assessment and some neonatal intensive care units (NICUs) are not well structured with trained personnel able to provide adequate neurocritical care. To reduce this existing gap, an advanced telemedicine model of neurocritical care called Protecting Brains and Saving Futures (PBSF) Guidelines was developed and implemented in a group of Brazilian NICUs.

Methods

A prospective, multicenter, and observational study will be conducted in all 20 Brazilian NICUs using the PBSF Guidelines as standard-of-care. All infants treated accordingly to the guidelines during Dec 2021 to Nov 2024 will be eligible. Ethical approval was obtained from participating centers. The primary objective is to describe adherence to the PBSF Guidelines and clinical outcomes, by center and over a 3-year period. Adherence will be measured by quantification of neuromonitoring, neuroimaging exams, sub-specialties consultation, and clinical case discussions and videoconference meetings. Clinical outcomes of interest are detection of seizures during hospitalization, use of anticonvulsants, inotropes, and fluid resuscitation, death before hospital discharge, length of hospital stay, and referral of patients to specialized follow-up.

Discussion

The study will provide evaluation of PBSF Guidelines adherence and its impact on clinical outcomes. Thus, data from this large prospective, multicenter, and observational study will help determine whether neonatal neurocritical care via telemedicine can be effective. Ultimately, it may offer the necessary framework for larger scale implementation and development of research projects using remote neuromonitoring.

Trial registration

NCT03786497, Registered 26 December 2018, https://www.clinicaltrials.gov/ct2/show/NCT03786497?term=protecting+brains+and+saving+futures&draw=2&rank=1.

The Impact of Increased Maternal sFlt-1/PlGF Ratio on Motor Outcome of Preterm Infants

BACKGROUND

The sFlt-1 (soluble fms-like tyrosine kinase-1)/PlGF (placental growth factor) ratio serves as a clinical biomarker to predict the hypertensive, placenta-derived pregnancy disorder pre-eclampsia which is often associated with placental dysfunction and fetal growth restriction. Additionally elevated levels also indicate an increased risk for prematurity. However, its predictive value for subsequent neonatal neurological outcome has not been studied.

OBJECTIVE

This study aimed to evaluate the correlation of maternal sFlt-1/PlGF ratio with early motor outcome of preterm infants. Design/Methods: 88 preterm infants (gestational age ≤ 34 + 0) born between February 2017 and August 2020 at the Department of Obstetrics and Gynecology, University Hospital Essen in Germany, were included, when the following variables were available: maternal sFlt-1/PlGF levels at parturition and general movement assessment of the infant at the corrected age of 3 to 5 months. The infants were stratified into high and low ratio groups according to maternal sFlt-1/PlGF cut-off values of 85. To investigate the early motor repertoire and quality of spontaneous movements of the infant, the Motor Optimality Score (MOS-R) based on antigravity movements and posture patterns, was applied. In the given age, special attention was paid to the presence of fidgety movements. Linear regressions were run to test differences in infants motor repertoire according to the maternal sFlt-1/PIGF ratio.

RESULTS

Linear regression analysis showed that the sFlt-1/PlGF ratio does not predict the MOS-R score (β=≤0.001; p=0.282). However, children with birth weight below the 10th percentile scored significantly lower (mean 20.7 vs 22.7; p=0.035). These children were 91% in the group with an increased ratio, which in turn is a known predictor of low birth weight (β= -0.315; p <0.001). In the group with a high sFlt-1/PLGF ratio above 85 the mothers of female infants had a lower average sFlt-1/PlGF ratio compared to a male infant (median: 438 in female vs. 603 in male infant, p=0.145).

CONCLUSIONS

In our cohort, especially low birth weight, which correlated with an elevated sFlt-1/PlGF ratio, had a negative effect on the outcome in the MOS-R. A direct correlation between an increased ratio and a worse motor outcome was not demonstrated.

Early aEEG can predict neurodevelopmental outcomes at 12 to 18 month of age in VLBWI with necrotizing enterocolitis: a cohort study

Background

Studies have shown that neurological damage is common in necrotizing enterocolitis (NEC) survivors. The purpose of the study was to investigate the predictive value of amplitude-integrated electroencephalogram (aEEG) for neurodevelopmental outcomes in preterm infants with NEC.

Methods

Infants with NEC were selected, and the control group was selected based on 1:1–2 pairing by gestational age. We performed single-channel (P3–P4) aEEG in the two groups. The Burdjalov scores were compared between the two groups. Cranial magnetic resonance imaging (MRI) was performed several months after birth. The neurological outcomes at 12 to 18 months of age were compared with the Gesell Developmental Schedules (GDS). The predictive value of aEEG scores for neurodevelopmental delay was calculated.

Results

There was good consistency between the two groups regarding general conditions. In the 1st aEEG examination, the patients in NEC group had lower Co (1.0 (0.0, 2.0) vs. 2.0 (2.0, 2.0), P = 0.001), Cy (1.0 (0.0, 2.0) vs. 3.0 (3.0, 4.0), P < 0.001), LB (1.0 (0.0, 2.0) vs. 2.0 (2.0, 2.0), P < 0.001), B (1.0 (1.0, 2.0) vs. 3.0 (3.0, 3.5), P < 0.001) and T (3.0 (2.0, 8.0) vs. 10.0 (10.0, 11.5), P < 0.001), than the control group. Cranial MRI in NEC group revealed a widened interparenchymal space with decreased myelination. The abnormality rate of cranial MRI in the NEC group was higher than that in the control group (P = 0.001). The GDS assessment indicated that NEC children had inferior performance and lower mean scores than the control group in the subdomains of gross motor (71 (SD = 6.41) vs. 92 (SD = 11.37), P < 0.001), fine motor (67 (SD = 9.34) vs. 96 (SD = 13.69), adaptive behavior (76 (SD = 9.85) vs. 95 (SD = 14.38), P = 0.001), language (68 (SD = 12.65) vs. 95 (SD = 11.41), P < 0.001), personal-social responses (80 (SD = 15.15) vs. 93(SD = 14.75), P = 0.037) and in overall DQ (72 (SD = 8.66) vs. 95 (SD = 11.07), P < 0.001). The logistic binary regression analysis revealed that the NEC patients had a significantly greater risk of neurodevelopmental delay than the control group (aOR = 27.00, 95% CI = 2.561–284.696, P = 0.006). Confirmed by Spearman’s rank correlation analysis, neurodevelopmental outcomes were significantly predicted by the 1st aEEG Burdjalov score (r = 0.603, P = 0.001). An abnormal 1st Burdjalov score has predictive value for neurodevelopmental delay with high specificity (84.62%) and positive predictive value (80.00%).

Conclusions

Children with NEC are more likely to develop neurodevelopmental delay. There is high specificity and PPV of early aEEG in predicting neurodevelopmental delay.

Retinal ganglion cell complex thickness at school-age, prematurity and neonatal stressors

PURPOSE

To investigate the association between the ganglion cell complex (GCC) thickness at early school-age and prematurity and other neonatal factors.

METHODS

Cross-sectional study. The sample included very preterm children with gestational age (GA) below 32 weeks or birthweight below 1500 g enrolled in a follow-up program (n = 101) and a comparison group of term-born children (n = 49). Ganglion cell complex (GCC) thickness was measured at 4-8 years using high-quality optical coherence tomography (OCT) images. Data on neonatal and postnatal features were extracted from clinical records; analyses included mixed linear models.

RESULTS

Ganglion cell layer (GCL) and retinal nerve fiber layer (mRNFL) were thicker in term than in preterm born children (2.9 μm and 2.4 μm respectively, p < 0.001). Within the preterm group, lower GA was associated with a decrease in total GCL (0.7 μm per week, p < 0.001). Being small for GA was associated with further thinning in both layers (1.4 and 2.8 µm). Postnatal corticosteroids therapy and severe brain lesion were associated with thinning in the total GCL of 6 µm (p < 0.001) and 4.1 µm (p = 0.002), respectively, and shock was associated with thinning in total mRNFL of 6 µm (p < 0.001).

CONCLUSIONS

Lower GA or birthweight are associated with thinning of GCC layers. When performing an OCT examination at school-age and a decrease in GCC thickness is observed, it may be relevant to ask about a history of prematurity, and further enquire about neonatal shock, postnatal corticosteroids therapy or severe brain lesion that are related to additional decrease in GCC thickness.

Are multidisciplinary neurodevelopmental profiles of children born very preterm at age 2 relevant to their long-term development? A preliminary study

To identify distinctive multidisciplinary neurodevelopmental profiles of relatively healthy children born very preterm (VPT) and describe the longitudinal course of these profiles up to age 10. At 2 years of corrected age, 84 children born VPT underwent standardized testing for cognitive, language, speech, motor, behavioral, and auditory nerve function. These data were submitted to factor and cluster analysis. Sixty-one of these children underwent cognitive, language, and behavioral assessment again at age 10. Descriptive statistics were used to analyze longitudinal trajectories for each profile. Four neurodevelopmental profiles were identified at age 2. Profile 1 children (n = 22/26%) had excellent cognitive-language-motor function, normal behavioral and auditory nerve function, but showed an unexpected severe decline up to age 10. Profile 2 children (n = 16/19%) had very low behavioral function, low cognitive-language-motor function, and accelerated auditory nerve function. Their scores remained low up until age 10. Profile 3 children (n = 17/20%) had delayed auditory nerve function, low behavioral function, and slightly lower cognitive-language-motor function. They showed the most increasing trajectory. Profile 4 children (n = 29/35%) had very low cognitive-language-motor function, normal behavioral and auditory nerve function, but showed wide variation in their trajectory. Our preliminary study showed that a multidisciplinary profile-oriented approach may be important in children born VPT to improve counseling and provide targeted treatment for at risk children. High performers at age 2 may not be expected to maintain their favorable development. Behavioral problems might negatively impact language development. Delayed auditory nerve function might represent a slow start and catch-up development.

Randomized clinical trial investigating the effect of consistent, developmentally-appropriate, and evidence-based multisensory exposures in the NICU

OBJECTIVE

Evaluate the effect of a manualized multisensory program, applied across NICU hospitalization, on infant and parent outcomes.

STUDY DESIGN

Seventy parent-infant dyads (born ≤32 weeks gestation) in a Level IV NICU were randomized at birth to the multisensory program or standard-of-care. Parents in the multisensory group administered prespecified amounts of age-appropriate, evidence-based sensory interventions to their infants each day during NICU hospitalization according to the Supporting and Enhancing NICU Sensory Experiences (SENSE) program.

RESULTS

Infants who received the SENSE program had more lethargy on the NICU Network Neurobehavioral Scale (NNNS) (p = 0.05), even after controlling for medical and social risk (p = 0.043), and had higher Communication scores on the Ages and Stages Questionnaire (p = 0.04) at 1-year corrected age, but this relationship failed to reach significance after controlling for medical and social risk (p = 0.12).

CONCLUSION

The SENSE program shows promise for improving outcomes, but more research with larger sample sizes is needed.

Potential benefits of melatonin to control pain in ventilated preterm newborns: An updated review

Infants admitted to neonatal intensive care units are repeatedly stimulated by painful events, especially if intubated. Preterm infants are known to have greater pain perception than full term infants due to immaturity of descending inhibitory circuits and poor noxious inhibitory modulation. Newborns exposed to repetitive painful stimuli are at high risk of impairments in brain development and cognition. Chronic pain is induced and supported by proinflammatory cytokines, free radicals, and reactive oxygen species creating a self‐ sustaining vicious circle. Melatonin is a neurohormone secreted by the pineal gland with antioxidant and anti‐inflammatory functions. This review describes the in‐depth beneficial effects of melatonin for pain control in ventilated preterm newborns. As yet, a minimal amount of literature has been undertaken to consider all its promising bioactivities. The rationale behind the use of melatonin for pain control has also been taken into account in this review. Besides, this review addresses safety concerns and dosages. The potential benefits of melatonin have been assessed against neurological disorders, respiratory distress, microbial infections, and as analgesic adjuvant during ventilation. Additionally, a possible approach for the use of melatonin in ventilated newborns will be discussed.

Gestational age and child development at school entry

Studies have reported a dose-dependent relationship between gestational age and poorer school readiness. The study objective was to quantify the risk of developmental vulnerability for children at school entry, associated with gestational age at birth and to understand the impact of sociodemographic and other modifiable risk factors on these relationships. Linkage of population-level birth registration, hospital, and perinatal datasets to the Australian Early Development Census (AEDC), enabled follow-up of a cohort of 64,810 singleton children, from birth to school entry in either 2009, 2012, or 2015. The study outcome was teacher-reported child development on the AEDC with developmental vulnerability defined as domain scores < 10th percentile of the 2009 AEDC cohort. We used modified Poisson Regression to estimate relative risks (RR) and risk differences (RD) of developmental vulnerability between; (i) preterm birth and term-born children, and (ii) across gestational age categories. Compared to term-born children, adjustment for sociodemographic characteristics attenuated RR for all preterm birth categories. Further adjustment for modifiable risk factors such as preschool attendance and reading status at home had some additional impact across all gestational age groups, except for children born extremely preterm. The RR and RD for developmental vulnerability followed a reverse J-shaped relationship with gestational age. The RR of being classified as developmentally vulnerable was highest for children born extremely preterm and lowest for children born late-term. Adjustment for sociodemographic characteristics attenuated RR and RD for all gestational age categories, except for early-term born children. Children born prior to full-term are at a greater risk for developmental vulnerabilities at school entry. Elevated developmental vulnerability was largely explained by sociodemographic disadvantage. Elevated vulnerability in children born post-term is not explained by sociodemographic disadvantage to the same extent as in children born prior to full-term.

A protocol to develop a standard guideline for neonatal pain management

BACKGROUND

Hospitalized newborns experience a high frequency of painful procedures. Undertreated pain has a series of adverse physical and psychosocial effects on newborns. Guidelines successfully applied in clinical practice can effectively improve pain management in NICUs and reduce the incidence of pain. Neonatal care providers in China are in urgent need of a high-quality, evidence-based guideline for the treatment and management of neonatal pain. The National Clinical Research Center for Child Health and Disorders is leading the development of a standard guideline for neonatal pain management suitable for the medical environment in China providing empirical support and safety guarantees for clinical practice. The WHO Collaborating Centre for Guideline Implementation and Knowledge Translation will provide technical support and guidance. The purpose of this paper is to outline the detailed methodology and technical route of guideline development.

METHODS

We will follow the WHO principles and methods for the formulation of standard guidelines. The critical steps for developing the guideline are as follows: (I) definition of the guideline Scope; (II) establishment of guideline working groups; (III) selection of the clinical questions; (IV) performance of systematic reviews; (V) grading the quality of the body of evidence; and (VI) formulating recommendations and reaching consensus.

DISCUSSION

This protocol would ensure that the process of guideline development is normative, scientific, and transparent. The standard guideline for neonatal pain management based on the available high-quality evidence and tailored to the Chinese health care system will help neonatal caregivers in NICUs effectively manage neonatal pain.

GUIDELINE REGISTRATION

The guideline was registered at the International Practice Guidelines Registry Platform. The registration No. is IPGRP-2021CN044.

White matter injury in infants with intraventricular haemorrhage: mechanisms and therapies

Intraventricular haemorrhage (IVH) continues to be a major complication of prematurity that can result in cerebral palsy and cognitive impairment in survivors. No optimal therapy exists to prevent IVH or to treat its consequences. IVH varies in severity and can present as a bleed confined to the germinal matrix, small-to-large IVH or periventricular haemorrhagic infarction. Moderate-to-severe haemorrhage dilates the ventricle and damages the periventricular white matter. This white matter injury results from a constellation of blood-induced pathological reactions, including oxidative stress, glutamate excitotoxicity, inflammation, perturbed signalling pathways and remodelling of the extracellular matrix. Potential therapies for IVH are currently undergoing investigation in preclinical models and evidence from clinical trials suggests that stem cell treatment and/or endoscopic removal of clots from the cerebral ventricles could transform the outcome of infants with IVH. This Review presents an integrated view of new insights into the mechanisms underlying white matter injury in premature infants with IVH and highlights the importance of early detection of disability and immediate intervention in optimizing the outcomes of IVH survivors.

Less invasive surfactant administration is associated with a higher need for nonpharmacological pain-relieving interventions compared to the intubation-surfactant extubation technique in preterm infants

Aim

LISA is a promising method in improving preterm outcome. The aim of this study was to assess whether the INSURE (intubation-surfactant extubation) technique or LISA (less invasive surfactant administration) procedure for surfactant administration is associated with more pain-relieving interventions after the intervention in preterm infants.

Methods

Preterm infants born at <32 weeks gestational age admitted to the Neonatal Intensive Care Unit of Innsbruck University hospital between Jan 2012 and June 2017 subjected to INSURE or LISA were included in the study, which was performed as a retrospective analysis of routinely collected data. Pain assessments were made bedside using the Bernese Pain Scale for Neonates.

Results

During the study period 15 preterm infants (median gestational age 30.7 weeks; range: 25.9-32.0 weeks) were subjected to INSURE technique and 59 (median gestational age 29.4 weeks; range: 25.1-31.4 weeks) to LISA. Infants subjected to LISA showed a higher need for nonpharmacological pain-relieving interventions in the first three days of life.

Conclusion

LISA procedure compared to INSURE technique was associated with a higher need for pain-relieving interventions in the first three days of life. Prospective randomized controlled trials are needed to optimize this less invasive method for surfactant application with special focus on pain in neonates.

School-age outcomes following intraventricular haemorrhage in infants born extremely preterm

OBJECTIVE

To determine the associations of different grades of intraventricular haemorrhage (IVH), particularly grades 1 and 2, with neurodevelopmental outcomes at 8 years of age in children born extremely preterm.

DESIGN

Population-based cohort study.

SETTING

State of Victoria, Australia.

PATIENTS

Survivors born at <28 weeks' gestational age (n=546) and matched term-born controls (n=679) from three distinct eras, namely, those born in 1991-1992, 1997 and 2005.

EXPOSURE

Worst grade of IVH detected on serial neonatal cranial ultrasound.

OUTCOME MEASURES

Intellectual ability, executive function, academic skills, cerebral palsy and motor function at 8 years.

RESULTS

There was a trend for increased motor dysfunction with increasing severity of all grades of IVH, from 24% with no IVH, rising to 92% with grade 4 IVH. Children with grade 1 or 2 IVH were at higher risk of developing cerebral palsy than those without IVH (OR 2.24, 95% CI 1.21 to 4.16). Increased rates of impairment in intellectual ability and academic skills were observed with higher grades of IVH, but not for grade 1 and 2 IVH. Parent-rated executive functioning was not related to IVH.

CONCLUSION

While low-grade IVH is generally considered benign, it was associated with higher rates of cerebral palsy in school-aged children born EP, but not with intellectual ability, executive function, academic skills or overall motor function. Higher grades of IVH were associated with higher rates and risks of impairment in motor function, intellectual ability and some academic skills, but not parental ratings of executive function.

Supporting Play, Exploration, and Early Development Intervention (SPEEDI) for preterm infants: A feasibility randomised controlled trial in an Australian context

BACKGROUND

An early intervention that enhances early development in infants born preterm, called 'Supporting Play, Exploration and Early Development Intervention' (SPEEDI) has been shown to be feasible in Virginia, United States, in a pilot study. Infants receive 10 therapy sessions until 3 months' corrected age (CA) (Phase 1[5 hospital sessions] and Phase 2[5 home-based sessions]) in addition to usual care.

AIMS

To determine the feasibility of SPEEDI for very preterm infants in an Australian context.

STUDY DESIGN

Prospective pilot feasibility randomised controlled trial.

SUBJECTS

Infants born <30 weeks' gestation (GA), recruited between 34 and 38⁺⁶ weeks' postmenstrual age.

OUTCOME MEASURES

Primary outcome was feasibility of SPEEDI, including recruitment rate, participant retention, sessions delivered, and therapy fidelity. Secondary outcome measures were developmental outcomes, including the Bayley Scales of Infant and Toddler Development - 3rd Edition (BSID-III) at 4 months' CA.

RESULTS

Of 19 eligible infants, 17 consented, SPEEDI n = 8 and usual care n = 9 (mean GA = 26.7 weeks [SD 1.4], male n = 10). All participants completed the study, with 80% of SPEEDI therapy sessions completed (90% Phase 1; 72% Phase 2). On average, therapists and parents used 78% and 77% of SPEEDI strategies in each session respectively. Infants in the SPEEDI group had higher scores on the BSID-III for gross motor, and expressive and receptive language subscales at 4 months' CA.

CONCLUSIONS

SPEEDI is a feasible intervention to deliver, and preliminary results suggest that SPEEDI may lead to improved motor and language outcomes at 4 months' CA, with results supporting future larger clinical trials.

Neurodevelopmental Outcomes after Bevacizumab Treatment for Retinopathy of Prematurity: A Meta-analysis

PURPOSE

To evaluate neurodevelopmental outcomes after intravitreal bevacizumab (IVB) therapy in retinopathy of prematurity (ROP) infants compared with those not exposed to IVB.

CLINICAL RELEVANCE

The primary concern regarding IVB treatment of ROP is the potential systemic side effects, especially the risk of causing severe neurodevelopmental impairment (sNDI). Results regarding neurodevelopmental outcomes after IVB therapy are conflicting.

METHODS

We conducted a meta-analysis and searched PubMed, Embase, and Web of Science for related publications from inception through March 12, 2020. The eligibility criteria were as follows: comparative studies of ROP patients that (1) included IVB as a treatment arm, (2) included a control group without bevacizumab treatment, and (3) reported on at least 1 neurodevelopmental outcome, such as sNDI, Bayley Scales of Infant and Toddler Development, Third Edition (Bayley III), composition scores, or cerebral palsy (CP). The primary outcome was sNDI, with the odds ratio (OR) calculated. Secondary outcomes were mean differences (MDs) for cognitive, language, and motor scores (Bayley III) and OR for CP. The quality of evidence was assessed using the Grades of Recommendation, Assessment, Development, and Evaluation approach.

RESULTS

Eight studies, 6 including laser-controlled ROP infants and 2 including ROP infants not requiring treatment, were included. The weighted OR for sNDI in the IVB group was 1.39 (95% confidence interval [CI], 0.98-1.97). The weighted MDs were -1.92 (95% CI, -4.73 to 0.88), -1.32 (95% CI, -4.65 to 1.99), and -3.66 (95% CI, -6.79 to -0.54) for cognitive, language, and motor scores in Bayley III, respectively. The OR for CP was 1.20 (95% CI, 0.56-2.55). No differences were observed between the preset subgroups comprising laser-controlled ROP infants and ROP infants not requiring treatment. The current quality of evidence was rated as low (sNDI and all Bayley III scores) to very low (CP).

CONCLUSIONS

Risk of sNDI was not increased in ROP patients after IVB treatment. Bayley III scores were similar in the IVB and control groups, except for a minor difference in motor performance. These findings suggest that the risk of additional sNDI after IVB treatment is low. Randomized trials are warranted to provide a higher quality of evidence.

Factors associated with postmenstrual age at full oral feeding in very preterm infants

Aim

We aimed to identify variables associated with gestational age at full oral feeding in a cohort of very preterm infants.

Methods

In this retrospective study, all infants born below 32 weeks of gestation and admitted to a level III neonatal unit in 2015 were included. We dichotomized our population of 122 infants through the median age at full oral feeding, and explored which variables were statistically different between the two groups. We then used linear regression analysis to study the association between variables known from the literature and variables we had identified and age at full oral feeding.

Results

The median postnatal age at full oral feeding was 36 6/7weeks post menstrual age (Q1-Q3 35 6/7-392/7), and was associated with the duration of hospital of stay. In the univariable linear regression, the variables significantly associated with full oral feeding were gestational age, socioeconomic status, sepsis, patent ductus arteriosus, duration of supplementary oxygen, of non-invasive and invasive ventilation, and bronchopulmonary dysplasia. In the multivariable regression analysis, duration of non-invasive ventilation and oxygen therapy, bronchopulmonary dysplasia, and patent ductus arteriosus were associated with an older age at full oral feeding, with bronchopulmonary dysplasia the single most potent predictor.

Discussion

Lung disease severity is a major determinant of age at full oral feeding and thus length of stay in this population. Other factors associated with FOF include socioeconomic status and patent ductus arteriosus, There is a need for research addressing evidence-based bundles of care for these infants at risk of long-lasting feeding and neurodevelopmental impairments.

A systematic review of outcomes reported inpediatric perioperative research: A report from the Pediatric Perioperative Outcomes Group

The Pediatric Perioperative Outcomes Group (PPOG) is an international collaborative of clinical investigators and clinicians within the subspecialty of pediatric anesthesiology and perioperative care which aims to use COMET (Core Outcomes Measures in Effectiveness Trials) methodology to develop core outcome setsfor infants, children and young people that are tailored to the priorities of the pediatric surgical population.Focusing on four age-dependent patient subpopulations determined a priori for core outcome set development: i) neonates and former preterm infants (up to 60 weeks postmenstrual age); ii) infants (>60 weeks postmenstrual age - <1 year); iii) toddlers and school age children (>1-<13 years); and iv) adolescents (>13-<18 years), we conducted a systematic review of outcomes reported in perioperative studies that include participants within age-dependent pediatric subpopulations. Our review of pediatric perioperative controlled trials published from 2008 to 2018 identified 724 articles reporting 3192 outcome measures. The proportion of published trials and the most frequently reported outcomes varied across pre-determined age groups. Outcomes related to patient comfort, particularly pain and analgesic requirement, were the most frequent domain for infants, children and adolescents. Clinical indicators, particularly cardiorespiratory or medication-related adverse events, were the most common outcomes for neonates and infants < 60 weeks and were the second most frequent domain at all other ages. Neonates and infants <60 weeks of age were significantly under-represented in perioperative trials. Patient-centered outcomes, heath care utilization, and bleeding/transfusion related outcomes were less often reported. In most studies, outcomes were measured in the immediate perioperative period, with the duration often restricted to the post-anesthesia care unit or the first 24 postoperative hours. The outcomes identified with this systematic review will be combined with patient centered outcomes identified through a subsequent stakeholder engagement study to arrive at a core outcome set for each age-specific group.

Early Neonatal Pain-A Review of Clinical and Experimental Implications on Painful Conditions Later in Life

Modern health care has brought our society innumerable benefits but has also introduced the experience of pain very early in life. For example, it is now routine care for newborns to receive various injections or have blood drawn within 24 h of life. For infants who are sick or premature, the pain experiences inherent in the required medical care are frequent and often severe, with neonates requiring intensive care admission encountering approximately fourteen painful procedures daily in the hospital. Given that much of the world has seen a steady increase in preterm births for the last several decades, an ever-growing number of babies experience multiple painful events before even leaving the hospital. These noxious events occur during a critical period of neurodevelopment when the nervous system is very vulnerable due to immaturity and neuroplasticity. Here, we provide a narrative review of the literature pertaining to the idea that early life pain has significant long-term effects on neurosensory, cognition, behavior, pain processing, and health outcomes that persist into childhood and even adulthood. We refer to clinical and pre-clinical studies investigating how early life pain impacts acute pain later in life, focusing on animal model correlates that have been used to better understand this relationship. Current knowledge around the proposed underlying mechanisms responsible for the long-lasting consequences of neonatal pain, its neurobiological and behavioral effects, and its influence on later pain states are discussed. We conclude by highlighting that another important consequence of early life pain may be the impact it has on later chronic pain states-an area of research that has received little attention.

Neurodevelopmental outcomes of preterm infants: a recent literature review

BACKGROUND

Over the past several decades, improvements in technology in the Neonatal Intensive Care Unit (NICU) have led to improved survival of preterm infants. Some studies have found that premature infants are at higher risk of behavioral problems, motor and sensory abnormalities, developmental delay, and poorer academic performance, while other studies have found no significant difference.

METHODS

A literature search was conducted through PubMed for articles published between January 2018 and September 2019. Studies that concentrated on preterm infants with relatively uncomplicated NICU courses and without extensive medical interventions were selected.

RESULTS

Historically, preterm infants have been found to be at increased risk for the inattentive subtype of attention deficit hyperactivity disorder (ADHD), depression, anxiety, autism spectrum disorder (ASD), avoidant personality, and anti-social personality, when compared to full term infants. However, some studies found that this difference between the two groups decrease as they enter adolescence and adulthood. Preterm infants are at increased risk for language, cognitive, sensory and motor deficits. Greater gestational age (GA) at birth and higher birth weight is associated with a lower risk of developmental delay. Cohort studies focusing on motor development showed that the degree of impairment decreased over time. Adverse childhood experiences (ACEs) have a negative correlation on multiple domains of development. The overall outcome of these infants may be influenced by socioeconomic status (SES), neonatal morbidities, demographics and parental education. Hearing and vision deficits are relatively infrequent among premature infants. A significant risk factor for hearing impairment involves the use of ototoxic agents such as gentamicin and infants with a patent ductus arteriosus (PDA).

CONCLUSIONS

Preterm infants are at higher risk of adverse neurodevelopmental outcomes when compared to their full-term counter parts. However, in recent years it appears that rates of certain neurologic and developmental conditions are occurring in rates lower than historically noted. Premature individuals with possible developmental or mental health concerns should be identified early on so that interventions can be implemented immediately. Those meeting developmental milestone should continue to be monitored closely as deficits may develop later.

The vulnerabilities of premature children: home and institutional contexts

ABSTRACT Objective: To analyze situations in which premature children are vulnerable in home care, in the first six months after hospital discharge. Method: Qualitative study, from the perspective of philosophical hermeneutics, carried out in a Brazilian city on the border. In-depth interviews were conducted, with a data analysis considering the method of interpretation of meanings. 18 mothers of premature children discharged from a hospital unit participated. 25 home visits and 56 calls were made. Results: The reports from the mothers express situations of vulnerability, concerns, needs for care, singularities of the development of the premature baby, and repercussions of institutional routines in home care. Final considerations: There are vulnerable circumstances in prematurity that reaffirm interconnected individual, social, and institutional dimensions. It is important to highlight that the institutional dimension involves the responsibility of health professionals not to increase individual and social vulnerabilities, but to promote care and seek to reduce situations that generate risks, uncertainties, concerns, and damages.

Impact of prematurity on neurodevelopment

The consequences of prematurity on brain functional development are numerous and diverse, and impact all brain functions at different levels. Prematurity occurs between 22 and 36 weeks of gestation. This period is marked by extreme dynamics in the physiologic maturation, structural, and functional processes. These different processes appear sequentially or simultaneously. They are dependent on genetic and/or environmental factors. Disturbance of these processes or of the fine-tuning between them, when caring for premature children, is likely to induce disturbances in the structural and functional development of the immature neural networks. These will appear as impairments in learning skills progress and are likely to have a lasting impact on the development of children born prematurely. The level of severity depends on the initial alteration, whether structural or functional. In this chapter, after having briefly reviewed the neurodevelopmental, structural, and functional processes, we describe, in a nonexhaustive manner, the impact of prematurity on the different brain, motor, sensory, and cognitive functions.

Association of WIC Participation and Growth and Developmental Outcomes in High-Risk Infants

The objective of this study was to describe the association of enrollment in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), the Supplemental Nutrition Assistance Program (SNAP), and infant growth and neurodevelopmental outcomes. Z scores and Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III) and Vineland Adaptive/Behavior Scale-II (VABS-II) scores represented primary outcomes. We conducted bivariate analyses and linear regression. Children who were enrolled in WIC or WIC/SNAP had weight z scores U (95% confidence interval [CI]) that were 1.32 (0.42-2.21) or 1.19 (0.16-2.23) units higher. Enrollment in WIC or WIC/SNAP was associated with a higher score (95% CI) of 11.7 U (1.2-22.2 U) or 11.5 (0.1-22.9) for Bayley-III cognitive score and 10.1 U (1.9-19.1 U) or 10.3 (0.9-19.7) for the VABS-II composite score. These findings support increased advocacy for participation in WIC or WIC/SNAP for families with high-risk infants.

Interaction Between Prematurity and the MAOA Gene on Mental Development in Children: A Longitudinal View

This study aimed to examine the association of dopamine-related genes with mental and motor development and the gene-environment interaction in preterm and term children. A total of 201 preterm and 111 term children were examined for their development at 6, 12, 18, 24, and 36 months and were genotyped for 15 single-nucleotide polymorphisms (SNPs) in dopamine-related genes (DRD2, DRD3, DAT1, COMT, and MAOA). An independent sample of 256 preterm children was used for replication. Since the developmental age trends of preterm children differed from those of term children, the analyses were stratified by prematurity. Among the 8 SNPs on the MAOA gene examined in the whole learning sample, the results of linkage disequilibrium analysis indicated that they were located in one block (all D' > 0.9), and rs2239448 was chosen as the tag (r² > 0.85). In the analysis of individual SNPs in each dopamine-related gene, the tag SNP (rs2239448) in MAOA remained significantly associated with the mental scores of preterm children for the interaction with age trend (p < 0.0001; largest effect size of 0.65 at 24 months) after Bonferroni correction for multiple testing. Similar findings for rs2239448 were replicated in the independent sample (p = 0.026). However, none of the SNPs were associated with the motor scores of preterm children, and none were related to the mental or motor scores of term children. The genetic variants of the MAOA gene exert influence on mental development throughout early childhood for preterm, but not term, children.

Socioeconomic status and brain injury in children born preterm: modifying neurodevelopmental outcome

Improved intensive care therapies have increased the survival of children born preterm. Yet, many preterm children experience long-term neurodevelopmental sequelae. Indeed, preterm birth remains a leading cause of lifelong neurodevelopmental disability globally, posing significant challenges to the child, family, and society. Neurodevelopmental disability in children born preterm is traditionally linked to acquired brain injuries such as white matter injury and to impaired brain maturation resulting from neonatal illness such as chronic lung disease. Socioeconomic status (SES) has long been recognized to contribute to variation in outcome in children born preterm. Recent brain imaging data in normative term-born cohorts suggest that lower SES itself predicts alterations in brain development, including the growth of the cerebral cortex and subcortical structures. Recent evidence in children born preterm suggests that the response to early-life brain injuries is modified by the socioeconomic circumstances of children and families. Exciting new data points to the potential of more favorable SES circumstances to mitigate the impact of neonatal brain injury. This review addresses emerging evidence suggesting that SES modifies the relationship between early-life exposures, brain injury, and neurodevelopmental outcomes in children born preterm. Better understanding these relationships opens new avenues for research with the ultimate goal of promoting optimal outcomes for those children born preterm at highest risk of neurodevelopmental consequence.

Movement Imitation Therapy for Preterm Babies (MIT-PB): a Novel Approach to Improve the Neurodevelopmental Outcome of Infants at High-Risk for Cerebral Palsy

To improve the neurodevelopmental outcome in infants with high grade intraventricular haemorrhage and cramped-synchronised (CS) general movements (GMs). Four very preterm infants with intraventricular haemorrhage grade III (n = 3) or intraventricular haemorrhage with apparent periventricular haemorrhagic infarction (n = 1) were diagnosed with CS GMs at 33 to 35 weeks postmenstrual age. A few days later MIT-PB [Movement Imitation Therapy for Preterm Babies], an early intervention programme, was commenced: the instant an infant showed CS movements, the therapist intervened by gently guiding the infant's limbs so as to manoeuvre and smoothen the movements, thereby imitating normal GM sequences as closely as possible (at least for 10 min, 5 times a day, with increasing frequency over a period of 10 to 12 weeks). After a period of consistent CS GMs, the movements improved. At 14 weeks postterm age, the age specific GM pattern, fidgety movements, were normal in three infants, one infant had abnormal fidgety movements. At preschool age, all participants had a normal neurodevelopmental outcome. This report on four cases demonstrates that mimicking normal and variable GM sequences might have a positive cascading effect on neurodevelopment. The results need to be interpreted with caution and replication studies on larger samples are warranted. Nonetheless, this innovative approach may represent a first step into a new intervention strategy.

Long-term effects of neonatal pain

Pain experienced during neonatal intensive care management can influence neurodevelopmental outcome and the somatosensory and/or emotional components of pain response in later life. Alterations in biological factors (e.g. peripheral and central somatosensory function and modulation, brain structure and connectivity) and psychosocial factors (e.g. gender, coping style, mood, parental response) that influence pain have been identified in children and young adults born very preterm or extremely preterm. Earlier gestational age at birth and cumulative pain exposure from tissue-breaking procedures and/or neonatal surgery influence the degree of change. In neonatal rodents, repeated needle insertion or hindpaw incision identify developmentally-regulated and activity-dependent long term alterations in nociceptive processing, and the efficacy of novel or current analgesic interventions can be compared. As prior neonatal experience and sex may influence current pain experience or the risk of persistent pain, these factors should be considered within the biopsychosocial assessment and formulation of pain in later life.

Association of Socioeconomic Status and Brain Injury With Neurodevelopmental Outcomes of Very Preterm Children

IMPORTANCE

Studies of socioeconomic status and neurodevelopmental outcome in very preterm neonates have not sensitively accounted for brain injury.

OBJECTIVE

To determine the association of brain injury and maternal education with motor and cognitive outcomes at age 4.5 years in very preterm neonates.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study of preterm neonates (24-32 weeks' gestation) recruited August 16, 2006, to September 9, 2013, at British Columbia Women's Hospital in Vancouver, Canada. Analysis of 4.5-year outcome was performed in 2018.

MAIN OUTCOMES AND MEASURES

At age 4.5 years, full-scale IQ assessed using the Wechsler Primary and Preschool Scale of Intelligence, Fourth Edition, and motor outcome by the percentile score on the Movement Assessment Battery for Children, Second Edition.

RESULTS

Of 226 survivors, neurodevelopmental outcome was assessed in 170 (80 [47.1%] female). Based on the best model to assess full-scale IQ accounting for gestational age, standardized β coefficients demonstrated the effect size of maternal education (standardized β = 0.21) was similar to that of white matter injury volume (standardized β = 0.23) and intraventricular hemorrhage (standardized β = 0.23). The observed and predicted cognitive scores in preterm children born to mothers with postgraduate education did not differ in those with and without brain injury. The best-performing model to assess for motor outcome accounting for gestational age included being small for gestational age, severe intraventricular hemorrhage, white matter injury volume, and chronic lung disease.

CONCLUSIONS AND RELEVANCE

At preschool age, cognitive outcome was comparably associated with maternal education and neonatal brain injury. The association of brain injury with poorer cognition was attenuated in children born to mothers of higher education level, suggesting opportunities to promote optimal outcomes.