Neurodevelopmental surveillance in the first 2 years after extremely preterm birth: evidence, challenges, and guidelines

Shared and Separate Neuromuscular Underpinnings of Swallowing and Motor Speech Development in the School-Age Years

PURPOSE

Despite co-occurrence of swallowing and speech disorders in childhood, there is limited research on shared and separate neuromuscular underpinnings of these functions. The purpose of this study was to (a) compare neuromuscular control of swallowing and speech between younger and older children and (b) determine similarities and differences in neuromuscular control of swallowing and speech.

METHOD

Twenty-six typically developing children (thirteen 7- to 8-year-olds and thirteen 11- to 12-year-olds) completed this cross-sectional study. Neuromuscular control was evaluated using surface electromyography of submental muscles and superior and inferior orbicularis oris muscles during parallel tasks of swallowing and speech. Outcome measures included normalized mean amplitude, burst duration, time to peak amplitude, and bilateral synchrony, which were examined using mixed-effects models.

RESULTS

For normalized mean amplitude, burst duration, and time to peak amplitude, there were significant two- and three-way interactions between muscle group, task, and age group, indicating that older and younger children demonstrated different muscle activation patterns, and these patterns varied by muscle and task. No differences were noted between groups for bilateral synchrony. For parallel tasks, children demonstrated different magnitudes of normalized mean amplitude and time to peak amplitude of speech and swallowing. However, they demonstrated a similar pattern: increases in magnitude as task complexity increased.

CONCLUSIONS

Children continue to demonstrate refinement of their neuromuscular control of swallowing and speech between 7-8 and 11-12 years of age, and there are both shared and separate elements of neuromuscular control between these two vital functions. To improve generalizability of findings, future research should include longitudinal analysis of swallowing and speech development, as well as measures of central neurophysiology.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.23796258.

Classification Performance of the Ages and Stages Questionnaire: Influence of Maternal Education Level

(1) Background: The Ages and Stages Questionnaire—Third Edition (ASQ-3) is a parental screening questionnaire increasingly being used to evaluate the development of preterm children. We aimed to assess the classification performance of the ASQ-3 in preterm infant follow-up. (2) Methods: In this cross-sectional study, we included 185 children from the SEVE longitudinal cohort born <33 weeks of gestational age between November 2011 and January 2018, who had both an ASQ-3 score at 24 months of corrected age (CA) and a revised Brunet–Lézine (RBL) scale score at 30 months of CA. The ASQ-3 overall score and sub-scores were compared to the RBL developmental quotient (DQ) scores domain by domain. The diagnostic performance of the ASQ-3 was evaluated with the RBL as the reference method by calculating sensitivity, specificity, and positive and negative likelihood ratios. A multivariate analysis assessed the association between low maternal education level and incorrect evaluation with the ASQ-3. (3) Results: The ASQ-3 overall score had a specificity of 91%, a sensitivity of 34%, a positive likelihood ratio of 3.82, and a negative likelihood ratio of 0.72. Low maternal education level was a major risk factor for incorrectly evaluating children with the ASQ-3 (odds ratio 4.16, 95% confidence interval 1.47–12.03; p < 0.01). (4) Conclusions: Regarding the low sensitivity and the impact of a low maternal education level on the classification performance of the ASQ-3, this parental questionnaire should not be used alone to follow the development of preterm children

Feasibility and validity of the Health Status Classification System-Preschool (HSCS-PS) in a large community sample: the Generation R study

OBJECTIVES

To evaluate the feasibility, discriminant validity and concurrent validity of the Health Status Classification System-Preschool (HSCS-PS) in children aged 3 years in a large community sample in the Netherlands.

DESIGN/SETTING

A prospective population-based cohort in Rotterdam, the Netherlands.

PARTICIPANTS

A questionnaire was administrated to a sample of parents of 4546 children (36.7±1.5 months).

OUTCOME MEASURES

Health-related quality of life (HRQOL) of children was measured by HSCS-PS. The HSCS-PS consists of 10 original domains. Two single-item measures of 'General health' and 'Behavior' were added. A disability score was calculated by summing up all 10 original domains to describe the overall health status. Feasibility was assessed by the response rate, percentages of missing answers, score distributions and the presence of floor/ceiling effects. Discriminant validity was analysed between subgroups with predefined conditions: low birth weight, preterm birth, wheezing, Ear-Nose-Throat surgical procedures and behaviour problems. In the absence of another HRQOL measure, this study uses the single-items 'General health' and 'Behavior' as a first step to evaluate concurrent validity of the HSCS-PS.

RESULTS

Feasibility: response rate was 69%. Ceiling effects were observed in all domains. Discriminant validity: the disability score discriminated clearly between subgroups of children born with a 'very low birth weight', 'very preterm birth', with 'four or more than four times wheezing', 'at least one ear-nose-throat surgical procedures', 'behaviour problems present' and the 'reference' group. Concurrent validity: HSCS-PS domains correlated better with hypothesised parallel additional domains than with other non-hypothesised original domains.

CONCLUSIONS

This study supports the feasibility and validity of the HSCS-PS among preschoolers in community settings. We recommend developing a utility-based scoring algorithm for the HSCS-PS. Further empirical studies and repeated evaluations in varied populations are recommended.

Long-Term Functioning and Participation Across the Life Course for Preterm Neonatal Intensive Care Unit Graduates

To understand the trajectories of risk and resilience in the vulnerable preterm and neonatal brain, clinicians must go beyond survival and critically examine on a population basis the functional outcomes of children, adolescents, and adults across their life course. Evaluations must go well beyond Bayley assessments and counts of neonatal morbidities, such as bronchopulmonary dysplasia, retinopathy of prematurity, sonographic brain injury, sepsis, and necrotizing enterocolitis. Proactively providing support to families and developmental and educational supports to children can optimize academic functioning and participation in adult learning, physical and behavioral health activities, community living, relationships, and employment.

Hearing-loss-associated gene detection in neonatal intensive care unit

OBJECTIVE

To investigate the frequency and mutation spectrum of hearing loss-associated gene mutation in Neonatal Intensive Care Unit (NICU).

METHODS

Neonates (n=2305) admitted to NICU were enrolled in this study. Nine prominent hearing loss-associated genes, GJB2 (35 del G, 176 del 16,235 del C, 299 del AT), GJB3 (538 C > T), SLC26A4 (IVS7-2A > G, 2168 A > G) and mtDNA 12S rRNA(1555 A > G, 1494 C > T), were detected.

RESULT

There were 73 cases hearing-loss-associated gene mutation among 2305 cases, the mutation frequency was 3.1%, with 40 cases GJB2 (235del C) mutation (54.8%), 6 cases GJB2 (299 del AT) mutation (8.2%), 21 cases SLC26A4 (IVS 7-2 A > G) mutation (28.7%), 4 cases SLC26A4 (2168 A > G) mutation (5.5%), 2 cases of GJB2 (235del C) combined SLC26A4 (IVS 7-2 A > G, 2168 A > G) mutation (2.8%). Among 73 gene mutation cases, preterm neonates presented in 18 cases, accounting for 24.7% (18/73); hyperbilirubinemia in 13 cases, accounting for 17.8% (13/73); Torch Syndrome in 15 cases, with 12 cases CMV, 2 cases rubella, 1 case toxoplasm, respectively, totally accounting for 20.54% (15/73); neonatal pneumonia in 12 cases, accounting for 16.4% (12/73); birth asphyxia in 5 cases, accounting for 6.9% (5/73); sepsis in 5 cases, accounting for 6.9% (5/73); others in 5 cases, accounting for 6.8% (5/73) .

CONCLUSIONS

The frequency of hearing loss-associated gene mutation was higher in NICU.There were hearing loss-associated gene mutations in the NICU, suggesting this mutation may complicate with perinatal high-risk factors.

Health Disparities and Child Development After Prematurity

There is increased recognition that preterm neonates require sequential surveillance to capture the spectrum of coordination, communication, learning, and behavior regulation disorders that may occur in the first 5 years of life and beyond. In particular, the framework of follow-up needs to go beyond the detection of cerebral palsy, blindness, and deafness in the first 2 years of life for only those at highest preterm risk (ie, <28 weeks gestation, with combinations of severe cranial sonographic abnormalities, bronchopulmonary dysplasia, and retinopathy of prematurity). In addition, there are numerous barriers for diverse families in accessing quality, comprehensive early intervention and early child education supports. This article highlights recent research on the long-term impact of preterm birth with a focus on disparities in resource access and in outcomes at entry to kindergarten and early educational trajectories. Across all degrees of prematurity, children from disadvantaged backgrounds face significant disparities both in access to comprehensive and continuous supports and in long-term academic outcomes. Ten key recommendations are provided for ensuring proactive management strategies for the long-term academic, behavioral, and social success of these at-risk children. [Pediatr Ann. 2017;46(10):e360-e364.].

Follow-up at two years of age and early predictors of non-compliance in a cohort of very preterm infants

AIM

To examine the rates of follow-up at two years of age and perinatal factors associated with non-compliance in an observational population-based cohort of very preterm children enrolled in a routine follow-up program.

METHOD

Data review of infants born between 2008 and 2012 in the Observatoire de La Grande Prématurité, Reunion Island cohort. All singletons born alive before 33weeks of gestational age and resident on the island at two years of age were included. Patients were considered compliant if they were timely evaluated between 20-28months of age, or non-compliant if they were not evaluated or evaluated after 28months of age.

RESULTS

Of the 802 survivors (mean gestational age of 30.3±2.0months, mean birthweight of 1364±396g), 468 (58.4%) were examined between 20-28months, 119 (14.8%) after 28months of age, and 215 (26.8%) were never evaluated, respectively. In multivariate analysis, factors associated with non-compliance were higher parity (>2), past history of preterm delivery, maternal diabetes (preexisting or gestational), appropriate for gestational status, and centre of birth.

CONCLUSION

Sustainable follow-up of vulnerable neonates remains a challenge in clinical practice. Early predictors of non-compliance can be used to define individualized and local follow-up strategies in these infants at high risk for developmental disabilities.

A longitudinal ICF-CY-based evaluation of functioning and disability of children born with very low birth weight

This paper aims to describe the longitudinal changes in disability, defined by the International Classification of Functioning, Disability, and Health - Children and Youth version (ICF-CY) biopsychosocial model, and developmental outcomes in a cohort of 56 very low birth weight children over 14-20 months. We used a neurofunctional assessment, the Griffiths Mental Development Scales-Revised: 2-8 years (Griffiths 2-8) to evaluate psychomotor development and the ICF-CY questionnaire for ages 0-3 and 3-6 to address children's disability. Extension indexes on the basis of ICF-CY categories were computed, and longitudinal change was tested. Complete follow-up was available for 55 children (mean age 36.7 months, SD 6.7). Considering the sample as a whole, neurofunctional assessment, Griffiths score and disability were basically stable. When the subsample of children with the higher baseline functioning was taken into account, some degree of worsening, in terms of an increase in the number of impairments and limitations, was found. Our results show that disability profiles, neurofunctional assessment and global development were basically stable, except for the subgroup of children who were in the intermediate/high-functioning cluster at baseline. The increased disability among these children might be because of the possibility to observe a wider set of age-specific problems, such as emotional, regulation and social abilities that are not detectable at an early stage of development and that might lead to reduced participation in social activities.

Challenges of neurodevelopmental follow-up for extremely preterm infants at two years

AIM

This study examined the rates of follow-up for a cohort of extremely preterm (EP -<28weeks gestation) and/or extremely low birthweight (ELBW -<1000g) children at two years with related perinatal and geographical factors. The secondary aim was to determine the rates of developmental delay and disability.

METHODS

A retrospective review of two year follow-up data for all EP and/or ELBW infants born in a large tertiary neonatal hospital over a two year period was undertaken. Neurodevelopmental outcome was assessed using the Bayley Scales of Infant and Toddler Development Scale - 3rd edition (Bayley-III) and neurosensory disability was assessed by a paediatrician using a standard proforma. Rates of delay (composite score≥1SD below mean) were determined using the Bayley-III test norms and a local cohort normative group. Attrition rates and reasons for loss to follow-up were determined.

RESULTS

Only 50% (109/219) of eligible children participated in the follow-up. The follow-up rate for children engaged in an ongoing research project was excellent at 98% (58/59), however it was only 32% (51/160) for children following the clinical pathway. The main reason for not attending the follow-up was loss of contact. Factors associated with attendance included a lower gestation, sepsis and living in the metropolitan areas. The rates of delay in this cohort were greater with reference to local cohort normative data compared to Bayley-III test norms with an overall rate of delay of 72% (95%CI, 63% to 81%) compared to 38% (95%CI, 29% to 50%).

CONCLUSIONS

Follow-up of EP/ELBW infants to two years is an important part of clinical care, however the high rate of attrition in routine clinical follow-up and consequent difficulty in accurately determining rates of delay highlight challenges for centres providing ongoing care.

Developmental outcomes of very preterm infants with tracheostomies

OBJECTIVES

To evaluate the neurodevelopmental outcomes of very preterm (<30 weeks) infants who underwent tracheostomy.

STUDY DESIGN

Retrospective cohort study from 16 centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network over 10 years (2001-2011). Infants who survived to at least 36 weeks (N = 8683), including 304 infants with tracheostomies, were studied. Primary outcome was death or neurodevelopmental impairment (NDI; a composite of ≥1 of developmental delay, neurologic impairment, profound hearing loss, severe visual impairment) at a corrected age of 18-22 months. Outcomes were compared using multiple logistic regression. We assessed the impact of timing by comparing outcomes of infants who underwent tracheostomy before and after 120 days of life.

RESULTS

Tracheostomies were associated with all neonatal morbidities examined and with most adverse neurodevelopmental outcomes. Death or NDI occurred in 83% of infants with tracheostomies and 40% of those without (OR adjusted for center 7.0, 95% CI 5.2-9.5). After adjustment for potential confounders, odds of death or NDI remained higher (OR 3.3, 95% CI 2.4-4.6), but odds of death alone were lower (OR 0.4, 95% CI 0.3-0.7) among infants with tracheostomies. Death or NDI was lower in infants who received their tracheostomies before, rather than after, 120 days of life (aOR 0.5, 95% CI 0.3-0.9).

CONCLUSIONS

Tracheostomy in preterm infants is associated with adverse developmental outcomes and cannot mitigate the significant risk associated with many complications of prematurity. These data may inform counseling about tracheostomy in this vulnerable population.

Usefulness of ICF-CY to define functioning and disability in very low birth weight children: a retrospective study

BACKGROUND

Preterm birth is associated with variable degrees of brain injury, adverse neurodevelopmental outcomes and continuing special health care needs.

STUDY AND AIMS

This observational, retrospective and cross-sectional study aims to describe the functional features of VLBW infants using the ICF-CY classification and to identify the association between gender, twinship, birth weight, gestational age, adjusted age and functioning as defined by the ICF biopsychosocial model.

SAMPLE

56 VLBW infants (corrected age of 12-24 months) were consecutively enrolled.

INSTRUMENTS

Three assessment tools were used: a neuro-functional assessment (NFA); the Griffiths Mental Development Scales-Revised: Birth to 2 years (Griffiths 0-2) to evaluate psychomotor development and the ICF-CY questionnaire for ages 0-3.

RESULTS

A two-step cluster component analysis with the Bayesian information criterion was conducted based on NFA and Griffiths 0-2 scores and four groups of infant's functioning (very low, low, intermediate, high) emerged. Study findings demonstrate that the traditional assessment tools tend to poorly evaluate the interaction between the person's functioning and environment factors (EF), even thought EF results to be relevant for VLBW infants. The higher number of symptoms, more difficulties in activities and participations and the higher number of environmental facilitators maximize the difference between infants with very low and those with intermediate or higher functioning. The distribution of gender or the presence of siblings is not significantly associated to any group.

CONCLUSION

This study shows that a more complete evaluation of functioning of VLBW children, based on the biopsychosocial approach, is needed and can be successfully implemented in the follow-up routine through ICF-CY questionnaire.

Neurological assessment in infants discharged from a neonatal intensive care unit

BACKGROUND

Longitudinal motor assessment in infants at different neurodevelopmental risk has not been previously evaluated using structured assessments.

AIM

To verify if the Hammersmith Infant Neurological Examination (HINE) is a good tool to predict the neuromotor outcome in infants discharged from a level II-III Neonatal Intensive Care Unit (NICU) METHODS: In this cohort analysis, 1541 infants discharged from our NICU between January of 2002 and the April 2006 were enrolled and assessed using the HINE at 3, 6, 9, 12 months. At two years, these infants were further assessed, and grouped into infants with normal outcome (1150), with mild disability (321) and with cerebral palsy (70),

RESULTS

Correlation analysis of Spearman showed a significant (p < 0.0001) and moderate (r(2) = -0.55 to -0.73) negative correlation between HINE scores (3, 6, 9, 12 months) and neurological outcome at two years. Cut-off scores for each assessment' age were provided as predictive value for cerebral palsy.

DISCUSSION

This study mainly showed that HINE, as soon as the first months of life, helps in the process of prediction of neurological outcome at two years of age in a heterogeneous population of infants discharged from an NICU.

Injury to the premature cerebellum: outcome is related to remote cortical development

Cerebellar injury is an important complication of preterm birth with far-reaching neuropsychiatric sequelae. We have previously shown a significant association between isolated injury to the premature cerebellum and subsequent impairment of regional volumetric growth in the contralateral cerebrum. In the current study, we examine the relationship between these remote regional impairments of cerebral volumetric growth and domain-specific functional deficits in these children. In 40 ex-preterm infants with isolated cerebellar injury, we performed neurodevelopmental evaluations and quantitative magnetic resonance imaging (MRI) studies at a mean age of 34 months. We measured cortical gray matter volumes in 8 parcellated regions of each cerebral hemisphere, as well as right and left cerebellar volumes. We show highly significant associations between early signs of autism and dorsolateral prefrontal cortex volume (P < 0.001); gross motor scores and sensorimotor cortical volumes (P < 0.001); and cognitive and expressive language scores and premotor and mid-temporal cortical volumes (P < 0.001). By multivariate analyses, each unit increase in the corresponding regional cerebral volume was associated with lower odds of abnormal outcome score, adjusted for age at MRI and contralateral cerebellar volume. This is the first report linking secondary impairment of remote cerebral cortical growth and functional disabilities in survivors of prematurity-related cerebellar brain injury.

Very preterm children free of disability or delay at age 2: predictors of schooling at age 8: a population-based longitudinal study

AIM

To study the predictive value of a developmental assessment at 2 years corrected age (CA) for schooling at age 8 in children born very preterm and free of disability or delay; to identify other factors associated with schooling in this population.

METHODS

244 children born before 33 weeks in 1997, part of the population-based EPIPAGE cohort study, free of disability or delay, had their developmental quotient (DQ) evaluated with the Brunet-Lezine scale at 2 years CA. The mental processing composite (MPC) score was evaluated at age 5 with the K-ABC battery. Data on schooling were obtained at age 8 by postal questionnaire. Schooling was considered appropriate if the child was attending age-appropriate grade level in a regular classroom environment without support at school.

RESULTS

Schooling was appropriate for 172 (70%) children. The predictive value of a DQ≥100 for appropriate schooling was 0.80 [0.75;0.85]. In children with a DQ at age 2<100, schooling varied significantly according to their MPC score at age 5 whereas it didn't in children with a DQ≥100. In multivariate analysis, the rate of appropriate schooling was significantly related to global DQ at age 2 (p<0.01), gestational age≥29 weeks (p<0.05), head circumference at age 2 (p<0.05) and mother's educational level (p<0.05).

CONCLUSION

A DQ≥100 cannot be solely used for the prediction of appropriate schooling at age 8. Mother's educational level, gestational age and head circumference at age 2 could be taken account. These factors could be used to individualise follow-up.

Neurodevelopmental outcome at 12 and 18 months in late preterm infants

BACKGROUND

Late-preterms represent the 70% of the whole preterm population and are reported to be at higher risk for mortality and morbidity than term infants.

AIMS

To assess neurodevelopmental outcome in low-risk late-preterm infants at 12 and 18 months corrected age, to compare results of corrected and uncorrected age to those of term-born infants, to analyse the possible influence of gender on outcome.

METHODS

Sixty-one healthy infants born between 33 and 36 weeks gestational age without major brain lesions were assessed at 12 and 18 months corrected age using the Bayley II scale. A control group of 60 low-risk term born infants underwent the same assessment.

RESULTS

At 12 and 18 months corrected age late preterms showed a mean mental developmental index (MDI) similar to term infants. Comparing the results of the uncorrected age with term infants, the scores were significantly lower at both 12 and 18 months. No gender differences were observed in term-born infants, while male late-preterm infants showed lower MDI than peer females at both ages.

CONCLUSIONS

When correcting age for prematurity late-preterms have similar MDI scores to those obtained in term-born infants at 12 and 18 months. In contrast, when using chronological age there is a number of infants with low MDI. As cognitive abnormalities are reported at school age in late preterm infants, our findings raise the question on whether the results obtained using scores uncorrected for age may early identify the infants who will show cognitive difficulties at school age.

Neurodevelopment of children born very preterm and free of severe disabilities: the Nord-Pas de Calais Epipage cohort study

AIM

To describe the development of very preterm children free of cerebral palsy or severe sensory impairment in the domains of gross and fine motor functions, language and sociability at a corrected age of 2 years; to identify factors associated with performances in each domain.

METHODS

A total of 347 children born in 1997 before 33 weeks of gestation, part of the EPIPAGE population-based cohort study, had their psychomotor development assessed with the Brunet-Lezine scale.

RESULTS

The study population had a mean gestational age of 30.1 +/- 2.0 weeks. Lower developmental quotients (DQ) were observed in the study group compared to the reference sample (96 +/- 13 vs 104 +/- 8, p < 0.01). Fine motor function, language and sociability were all affected with a p value <0.01. Multivariate analysis showed that duration of intubation and parents' educational and occupational levels were the only variables significantly related to each developmental domain (p < 0.01).

CONCLUSIONS

Children very preterm and free of severe disabilities had mild delays in multiple areas of development. The mechanisms by which neonatal factors played a role need further investigation. However socioeconomic status had a great impact on development and our results underline the need for improved support of socioeconomically disadvantaged parents after a preterm birth.

Interexaminer reliability of Amiel-Tison neurological assessments

Both the Amiel-Tison Neurological Assessment at Term and the Amiel-Tison Neurological Assessment From Birth to 6 Years Old are based on the same conceptual framework and both can be used throughout childhood; however, interobserver reliability must be evaluated before these assessments can be introduced into neurodevelopmental follow-up. The aim of this study was to evaluate the interobserver reliability of both assessments. Infants between 29 and 37 weeks gestation were examined with the Amiel-Tison Neurological Assessment at Term (n = 33) and with the Amiel-Tison Neurological Assessment From Birth to 6 Years Old (n = 26). The infants were assessed by two examiners, one after and in the absence of the other. The kappa coefficient and percentage of agreement were calculated. The majority of items in both assessments showed an excellent reliability. The kappa coefficient for the final synthesis was also excellent in both cases. Future studies on the predictive validity of both assessments are required to determine their utility in predicting long-term neurodevelopmental outcome.

Quantitative tissue echogenicity of the neonatal brain assessed by ultrasound imaging

The aim of this study was to propose a method for measuring the echogenicity of several neonatal brain structures for quantitative interpretation of ultrasound images. To do this, 40 preterm neonates (24-34 weeks' gestation) with adequate birth weight for gestational age were studied. On the third day after delivery, anterior fontanelle ultrasound imaging of the brain was performed in standard coronal and sagittal views. Four regions-of-interest (ROIs) were identified: periventricular, choroid plexus, cerebellar vermis and basal ganglia. Two consecutive images from each ROI were digitally stored. For off-line analysis, the ROI corresponding to each structure was delineated and the mean pixel brightness (PB) calculated. In addition, the brightness of bone tissue obtained at the same depth of the studied ROI was calculated. This value was considered as the maximum possible echogenicity for that individual image. The relative echogenicity (RE) was then calculated as: PB ROI/PB BONE( *)100. Differences in RE between the ROIs and RE variations according to gestational age and reliability reproducibility were determined. We found that among the studied structures, RE values (mean/SD) were significantly higher in the choroid plexus (mean [SD] 56.38 [6.0] and in the cerebellar vermis 51.20 [6.0] than in the basal ganglia 37.29 [5.7] and the periventricular area 37.04 [5.6]) (p<0.05). These values showed no variation in relation to gestational age at birth. Interobserver reproducibility was 0.91 in the choroid plexus, 0.89 in the cerebellar vermis, 0.82 in basal ganglia and 0.77 in the anterior periventricular area. In conclusion, semiquantitative estimation of RE offers a reproducible method for evaluating at-risk areas of the neonatal brain.

Risk factors affecting school readiness in premature infants with respiratory distress syndrome

OBJECTIVE

With advances in neonatal care, more children born prematurely are successfully reaching school age. It is unknown how many will be ready for school and what factors affect school readiness. Our objective was to assess readiness of children born prematurely for entry into public school, and determine risk factors associated with lack of school readiness in this population.

METHODS

This was a single-center prospective cohort study. Follow- up data were collected for 135 of 167 (81%) surviving premature infants with RDS requiring surfactant-replacement therapy. The children were seen between July 2005 and September 2006 (average age: 5.7 +/- 1.0 years) and underwent standardized neurodevelopmental and health assessments and socioeconomic status classification. A 4-level school-readiness score was constructed by using each child's standardized scores on assessments of basic concepts (Bracken School-Readiness Assessment), perceptual skills (Visual-Motor Integration Test), receptive vocabulary (Peabody Picture Vocabulary Test, Third Edition), daily living functional skills (Pediatric Functional Independence Measure), and presence of sensory impairments or autism. Proportional odds models were used to identify risk factors predicting lower school-readiness levels.

RESULTS

Mean birth weight was 1016 +/- 391 g, and mean gestational age was 27.5 +/- 2.6 weeks. Ninety-one (67%) children were school-ready. Using multivariate analysis, male gender, chronic lung disease, and severe intraventricular hemorrhage or periventricular leukomalacia were associated with lower school-readiness levels. However, the most powerful factor determining school-readiness level was low socioeconomic status.

CONCLUSION

Interventions targeting neonatal morbidities may be much less effective at improving overall performance at school age compared with the effect of the impoverished social environment.

Outcomes for the extremely premature infant: what is new? And where are we going?

Two approaches were taken to determine what is new and where we are going in terms of outcomes for the extremely premature infant: publications from 2004 to 2007 were reviewed, and the 30-year outcome at the authors' institutions was assessed. Recent literature documents improving early childhood outcomes in the face of improved survival. Childhood cerebral palsy prevalence rates have been reported to be as low as 19 per 1000 live births for infants born at 20-27 weeks gestation. Vision and hearing loss have been reported in fewer than 1% of survivors. The rate of overall intellectual impairment has not improved, although impairment was reduced in a recent trial of caffeine therapy for apnea of prematurity, and this remains an important area for study. In sum, recent findings herald a more positive perspective on the outcome for extremely premature survivors. It can thus be expected that new intensive-care trials will attempt to reduce the proportion of survivors with adverse outcomes. Childhood assessments will have a greater focus on function and participation. Information on improved outcomes for preterm infants will inform guidelines of decision making used to help parents to determine what is best for their child. The audit component of follow-up studies will expand and more cohort and trial studies will become multicenter, national, and international.

Influence of behaviour and risk factors on motor performance in preterm infants at age 2 to 3 years

The aim of this cross-sectional study was to determine the influence of test-taking behaviour and risk factors for delayed motor performance in 437 preterm infants (244 males, 193 females; < or = 32 weeks of gestation) at the corrected age of 2 to 3 years (mean 29mo [SD 3.3]). Other mean (SD) sample demographics were: postmenstrual age 29(+5) weeks (1(+5)), range 25(+0)-32(+0); birthweight 1213.7g (331.7), range 468-2350; and days in the neonatal intensive care unit 21.1 (21.3), range 1-165. Children (n=23) with a severe disability were excluded. We assessed motor performance and behaviour during testing with the Motor Scale and the Behaviour Rating Scale (BRS) of the Bayley Scales of Infant Development, 2nd edition (BSID-II). Risk factors were tested against delayed motor performance as the dependent variable in binary logistic regression analysis. Median score on the Motor Scale in terms of the BSID-II Psychomotor Developmental Index (PDI) was 86. 'Delayed' motor performance was observed in 46.5% of the children tested, and behaviour was 'not-optimal' in 31.4%. The Motor Scale and BRS scores were significantly correlated (r(s)=0.62, p<0.01). Risk factors for delayed motor performance were: neonatal convulsions (odds ratio [OR] 4.5; 95% confidence interval [CI] 1.6-12.9), low maternal educational level (OR 3.3; 95% CI 1.7-6.5), male sex (OR 2.8; 95% CI 1.8-4.3), and chronic lung disease (OR 2.1; 95% CI 1.1- 4.1). We conclude that preterm infants are at high risk of delayed motor performance and non-optimal test-taking behaviour.

Healthy preterm infant responses to taped maternal voice

This study was a repeated measures design, examining behavioral and physiologic responses of premature infants to taped maternal voice. Fourteen stable, premature infants, 31 to 34 weeks' gestation and serving as their own controls, were monitored and videotaped 4 times each day for 3 consecutive days during the first week of their life. There were no significant differences found in heart rate or oxygen saturation between study conditions. Behavioral data revealed less motor activity and more wakefulness, while hearing the maternal tape, suggesting some influence on infant state regulation. Attending behaviors were significantly greater, with more eye brightening and facial tone. Minimal distress was seen throughout the study, as indicated by stable heart rate and oxygen saturation and by the absence of behaviors such as jitteriness, loss of tone, or loss of color. The results of this preliminary study suggest that premature infants are capable of attending to tape recordings of their mother's voice.

Visuo-motor coordination in 8-year-old children born pre-term before and after 28 weeks of gestation

PURPOSE

This study compared the visuo-motor abilities between pre-term and full-term children.

METHODS

Twenty-three 8-year-old children participated, five being born under 28 weeks gestational age (wGA) referred to as Preterms1 (mean=8 years 5 months [SD 0.3]), nine Preterms2 of 28-35 wGA (mean=7 years 9 months [SD 0.7]) and nine typically developing full-term controls (mean=8 years 6 months [SD 0.7]). All children were studied in an interhemispheric transfer time and in a visuo-manual pointing-task to test motor programming time in three conditions: unimanual pointing (dominant, non-dominant hands), mirror bimanual pointing (same direction for both hands) and opposite bimanual pointing.

RESULTS

Significant differences were detected between Preterms 1 and 2, the latter being similar to controls. Preterms1 presented increases in interhemispheric time, suggesting an alteration in the transcallosal pathways. Programming time was significantly lengthened (p50.01) for dominant hand unilateral pointing and opposite bilateral pointing and it was the shortest for mirror pointing.

CONCLUSIONS

A faulty programming of visuo-manual tasks is suspected in Preterms1 with potential difficulty inhibiting the non-dominant limb mirror movement. This may result from an impaired interhemispheric inhibition owing to potential corpus callosum thinning. Such measures may be used to help follow-up subtle changes in fine motor control and detect pre-terms at risk of developing long-term deficits.

Neuropsychological screening of a group of preterm twins: comparison with singletons

OBJECTS

Perform neuropsychological screening of a group of preterm twins without major brain pathology and compare it with a control group of similarly preterm children born as singletons.

MATERIALS AND METHODS

Twenty-three preterm twins born at fewer than 32 weeks of gestation were tested for rapid evaluation of cognitive functions at the age of 4 years. The tests evaluated language, non-verbal performances, learning and attention deficit disorders. Cognitive profiles were established. Links between perinatal factors, clinical follow-up and cognitive outcome were investigated. Their cognitive outcome was then compared with the cognitive outcome of 31 preterm singletons with the same gestational periods.

CONCLUSION

The twins' neuropsychological outcome was not more marked than that of the singletons. Birth weight discordance and chorionicity were the only predictive perinatal factors with worse outcome in the twin population.

Neuromotor development in infants with cerebral palsy investigated by the Hammersmith Infant Neurological Examination during the first year of age

BACKGROUND

The Hammersmith Infant Neurological Examination (HINE) is a simple and scorable method for assessing infants between 2 and 24 months of age.

AIMS

The purpose of this retrospective study was firstly, to evaluate the neuromotor development of infants with cerebral palsy (CP) by the HINE, during the first year of age; secondly, to correlate the scoring of this neurological tool with levels of the Gross Motor Function Classification System (GMFCS).

METHODS

A cohort of 70 infants with a diagnosis of CP at 2 years of age was evaluated by the HINE at 3, 6, 9 and 12 months of corrected age and by GMFCS at 2 years of age.

RESULTS

The main results indicate that at 3-6 months, infants with quadriplegia (IV and V levels of GMFCS) and those with severe diplegia (III level) scored below 40, whereas those with mild or moderate diplegia (I-II level) and hemiplegia (I-II level) mainly scored between 40-60. Interestingly, the 26% of infants with hemiplegia scored > or =67 at 12 months. We observed a strong (r=-0.82) and significant (p<0.0001) negative correlation between the scores of the neurological examination and the levels of GMFCS.

CONCLUSIONS

Our results point out that the HINE can give additional information about neuromotor development of infants with CP from 3-6 months of age, strictly related to the gross motor functional abilities at 2 years of age.

Outcome at 3 years of age in a population-based cohort of extremely preterm infants

OBJECTIVE

To assess health and neurodevelopmental outcome at 3 years of age in neonatal intensive care unit (NICU)-surviving children who were born at 26 or fewer weeks of gestation in a geographically defined region of Belgium from 1999 through 2000.

METHODS

The study included a clinical examination and a standardized neurologic and developmental assessment. Disabilities were defined by international criteria. In 97% (92 of 95) of the children, accurate information on the presence of overall disability could be collected.

RESULTS

Thirty-six percent (95% confidence interval [CI] 25-47%) of the formally assessed children (28 of 77) had deficient neuromotor development, with 5% of them showing severe sensory-communicative impairment. Mean (+/-standard deviation) scores on the Mental Developmental Index and Psychomotor Developmental Index were 81.2 (18.8) and 73.2 (17.8), respectively. Seventy percent (95% CI 60-80%) had a mental (Mental Developmental Index) or psychomotor (Psychomotor Developmental Index) impairment or both, assessed to be more than 1 standard deviation below the population mean. Mental and psychomotor outcome did not differ significantly when compared according to either gestational age, gender, or multiple birth (all P>.05). When either minor central dysfunction or cerebral palsy was not taken into account, normal mental development was recorded in 62% of the subjects. The cumulative of poor outcome (ie, disability- or prematurity-related death) among the 95 infants discharged alive was estimated to be 58% (95% CI 48-68%), representing 25 (26%) mildly-to-moderately disabled and 28 (29%) severely disabled toddlers, including two infants whose postdischarge deaths were directly related to prematurity.

CONCLUSION

The average developmental outcome is poor in children born as extremely preterm infants. Finding early predictors of adverse outcome is a major challenge.

Twelve-month neurofunctional assessment and cognitive performance at 36 months of age in extremely low birth weight infants

OBJECTIVE

The objective of this study was to investigate whether an early neurofunctional assessment (at 12 months' corrected age) is predictive of cognitive outcome at 36 months of age in extremely low birth weight infants.

METHODS

We conducted an observational longitudinal study. Neurodevelopmental outcome by means of a neurofunctional assessment was evaluated at 12 months' corrected age and 36 months' chronological age in 141 extremely low birth weight children. Cognitive outcome was assessed with use of the Griffiths Mental Developmental Scale.

RESULTS

A significant association was found between the 12-month neurofunctional status and cognitive performance at 36 months. A higher general quotient on the Griffiths Mental Developmental Scale at 36 months was observed in infants who exhibited normal (score: < or = 1) neurodevelopment compared with children who exhibited minor (score: 2) and major (score: > or = 3) dysfunctions at the 12-month neurofunctional evaluation (99 +/- 6.8 vs 85.3 +/- 16.3 vs 57.3 +/- 22.0). A score of > or = 2 at the 12-month neurofunctional assessment, abnormal brain MRI results at term, and chronic lung disease remained predictive of cognitive delay at 36 months of age and also after adjustment for confounders.

CONCLUSIONS

The 12-month neurofunctional evaluation may be an additional useful clinical tool in predicting later cognitive outcome in extremely low birth weight children.

Prevalence of neonatal ultrasound brain lesions in premature infants with and without intrauterine growth restriction

AIM

To compare the prevalence of transient periventricular echodensities (TPE), periventricular leukomalacia (PVL) and haemorrhagic brain lesions (HBL) in singleton intrauterine growth-restricted (IUGR) infants and in those appropriate for gestational age (AGA).

METHODS

Thirty-five IUGR and 35 AGA singleton infants born between 24- and 34-week gestational age were studied. The presence of TPE, PVL and HBL was assessed with ultrasound (US) at day 3 (US-I), 2 weeks (US-II) after delivery and at term-equivalent age (US-III).

RESULTS

IUGR neonates had an increased prevalence of TPE at US-I (18/35 vs. 8/35, p= 0.02) and an increased prevalence of PVL at US-II (8/32 vs. 1/31, p = 0.03) and US-III (8/29 vs. 1/29, p = 0.02). No significant differences in the prevalence of HBL were found between the two groups.

CONCLUSIONS

IUGR is associated with an increased prevalence of white matter damage on US brain scans in preterm neonates.

Placental lesions as predictors of cerebral palsy and abnormal neurocognitive function at school age in extremely low birth weight infants (<1 kg)

Extremely low birth weight (ELBW) infants (<1 kg) have high rates of neurodisability. Although previous studies have implicated placental lesions in adverse short-term neurologic outcomes in this population, none have assessed their effects in these children once they reach school age. We conducted a secondary analysis of placental pathology in a cohort study of inborn singleton ELBW infants born between 1992 and 1995 and evaluated for cerebral palsy (CP) and abnormal neurocognitive testing at 8 years of age (N = 129). The neurocognitive tests were the Kaufman Assessment Battery for Children (K-ABC) and 6 subtests of the NEPSY: A Developmental Neuropsychological Assessment. We found that placental lesions associated with maternal vascular underperfusion (increased syncytial knots and acute atherosis) were risk factors for CP, while villous edema was associated with low scores on both neurocognitive tests. Histologic chorioamnionitis (HCA) was not predictive of outcome in the population as a whole, but a severe fetal vascular response was associated with a lower NEPSY score in the subpopulation with HCA (N = 69). Placentas with increased syncytial knots, villous edema, and those with neither finding constituted nonoverlapping subgroups with distinct pathologic and perinatal characteristics. Among infants with villous edema (N = 25), those with neurologic impairment had lower gestational ages and more severe degrees of HCA. However, by logistic regression these other factors were not independent risk factors for abnormal neurocognitive testing, and only HCA with a severe fetal vascular response decreased the association of villous edema with low test scores for NEPSY, but not K-ABC.