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Ford N, Bloomfield FH, Jiang Y, Cormack BE. Early hypophosphataemia and refeeding syndrome in extremely low birthweight babies and outcomes to 2 years of age: secondary cohort analysis from the ProVIDe trial. Arch Dis Child Fetal Neonatal Ed 2024:fetalneonatal-2024-327029. [PMID: 39122562 DOI: 10.1136/archdischild-2024-327029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 07/25/2024] [Indexed: 08/12/2024]
Abstract
OBJECTIVE To investigate in extremely low birthweight (ELBW; <1000 g) babies the associations between refeeding syndrome (serum phosphate <1.4 mmol·L-1 and serum total calcium>2.8 mmol·L-1) and hypophosphataemia in the first week and death or neurodisability at 2 years' corrected age (CA). DESIGN Secondary cohort analysis of the ProVIDe trial participants with serum biochemistry within 7 days of birth. At 2 years' CA, neurodisability was assessed by Bayley Scales of Infant Development Edition III and neurological examination. Associations between neurodisability and other variables were analysed using t-tests and logistic regression adjusted for sex and smallness-for-gestational age. SETTING Six tertiary neonatal intensive care units (NICUs) in New Zealand. PARTICIPANTS 352 ELBW babies born between 29 April 2014 and 30 October 2018. MAIN OUTCOME MEASURE Death or neurodisability at 2 years' CA. RESULTS Fifty-nine babies died, two after discharge from the NICU. Of the 336 babies who survived to 2 years' CA, 277 had neurodevelopmental assessment and 107 (39%) had a neurodisability. Death or neurodisability was more likely in babies who had refeeding syndrome (aOR 1.96 (95% CI 1.09 to 3.53), p=0.02) and in babies who had hypophosphataemia (aOR 1.74 (95% CI 1.09 to 2.79), p=0.02). Hypophosphataemia was associated with increased risk of death (aOR 2.07 (95% CI 1.09 to 3.95), p=0.03)) and severe hypophosphataemia (<0.9 mmol·L-1) with increased risk of death (aOR 2.67 (95% CI 1.41 to 5.00), p=0.002) and neurodisability (aOR 2.31 (95% CI 1.22 to 4.35), p=0.01). CONCLUSIONS In ELBW babies, refeeding syndrome and hypophosphataemia in the first week are associated with death or neurodisability. Until optimal phosphate requirements are determined through further research, monitoring for hypophosphataemia and mitigation strategies are indicated. TRIAL REGISTRATION NUMBER ACTRN12612001084875.
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Affiliation(s)
- Nadia Ford
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | | | - Yannan Jiang
- Department of Statisitics, University of Auckland, Auckland, New Zealand
| | - Barbara Elizabeth Cormack
- Liggins Institute, University of Auckland, Auckland, New Zealand
- Starship Child Health, Auckland City Hospital, Auckland, New Zealand
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李 燕, 陆 斯, 莫 艳, 经 连, 姚 丽, 谭 伟, 韦 秋. [Alterations in the intestinal microbiota of preterm infants with neurodevelopmental impairments: a prospective cohort study]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2023; 25:689-696. [PMID: 37529950 PMCID: PMC10414177 DOI: 10.7499/j.issn.1008-8830.2302130] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 05/10/2023] [Indexed: 08/03/2023]
Abstract
OBJECTIVES To investigate the difference in intestinal microbiota between preterm infants with neurodevelopmental impairment (NDI) and those without NDI. METHODS In this prospective cohort study, the preterm infants who were admitted to the neonatal intensive care unit of Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region from September 1, 2019 to September 30, 2021 were enrolled as subjects. According to the assessment results of Gesell Developmental Scale at the corrected gestational age of 1.5-2 years, they were divided into two groups: normal (n=115) and NDI (n=100). Fecal samples were collected one day before discharge, one day before introducing solid food, and at the corrected gestational age of 1 year. High-throughput sequencing was used to compare the composition of intestinal microbiota between groups. RESULTS Compared with the normal group, the NDI group had a significantly higher Shannon diversity index at the corrected gestational age of 1 year (P<0.05). The principal coordinate analysis showed a significant difference in the composition of intestinal microbiota between the two groups one day before introducing solid food and at the corrected gestational age of 1 year (P<0.05). Compared with the normal group, the NDI group had a significantly higher abundance of Bifidobacterium in the intestine at all three time points, a significantly higher abundance of Enterococcus one day before introducing solid food and at the corrected gestational age of 1 year, and a significantly lower abundance of Akkermansia one day before introducing solid food (P<0.05). CONCLUSIONS There are significant differences in the composition of intestinal microbiota between preterm infants with NDI and those without NDI. This study enriches the data on the characteristics of intestinal microbiota in preterm infants with NDI and provides reference for the microbiota therapy and intervention for NDI in preterm infants.
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Varela-Moraga V, Diethelm-Varela B, Pérez-Pereira M. Effect of biomedical complications on very and extremely preterm children's language. Front Psychol 2023; 14:1163252. [PMID: 37484104 PMCID: PMC10361768 DOI: 10.3389/fpsyg.2023.1163252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 06/05/2023] [Indexed: 07/25/2023] Open
Abstract
Introduction Very and extremely preterm children have been found to show delays in the development of language in early years. In some investigations, however, a rigorous control of biomedical complications, such as Periventricular Leukomalacia (PVL), Intraventricular Hemorrhage (IVH) or Bronchopulmonary Dysplasia (BPD), does not always exist. For that reason, a confounding effect of low gestational age and biomedical complications may lead to erroneous conclusions about the effect of gestational age. Methods In this investigation we compare language development [use of words, sentence complexity and mean length of the three longest utterances (MLU3)] of three groups of Chilean children at 24 months of age (corrected age for preterm children). The first group was composed of 42 healthy full-term children (Full term group: FT), the second group of 60 preterm children born below 32 gestational weeks without medical complications (low risk preterm group: LRPT), and the third group was composed of 64 children below 32 gestational weeks who had medical complications (High risk preterm group: HRPT). The three groups were similar in terms of gender distribution, maternal education, and socio-economic environment. The instrument used to assess language was the Communicative Development Inventories (CDI). In addition, the Ages and Stages Questionnaire-3 (ASQ-3) was also used to assess other developmental dimensions. Results The results indicate that HRPT and LRPT children obtained significantly lower results than the FT group in the three language measures obtained through the CDI. No significant differences were observed between the HRPT and the LRPT groups, although the HRPT obtained the lowest results in the three CDI measures. The results obtained through the administration of the ASQ-3 confirm the delay of both preterm groups in communicative development when compared to the FT group. No significant differences between the FT and the PT groups were observed in gross motor, fine motor and problem solving dimensions of the ASQ-3. The LRPT group obtained results that were significantly higher than those of the FT group and the HRPT group in gross motor development. Discussion These results seem to indicate that the area of language development is particularly influenced by very or extremely low gestational age.
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Affiliation(s)
- Virginia Varela-Moraga
- Departamento de Fonoaudiología, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Benjamín Diethelm-Varela
- Department of Molecular Genetics and Microbiology, School of Biological Sciences, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Miguel Pérez-Pereira
- Departamento de Psicoloxía Evolutiva e da Educación, Universidade de Santiago de Compostela, Santiago de Compostela, Spain
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Li Y, Zhang Z, Mo Y, Wei Q, Jing L, Li W, Luo M, Zou L, Liu X, Meng D, Shi Y. A prediction model for short-term neurodevelopmental impairment in preterm infants with gestational age less than 32 weeks. Front Neurosci 2023; 17:1166800. [PMID: 37168928 PMCID: PMC10166208 DOI: 10.3389/fnins.2023.1166800] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/03/2023] [Indexed: 05/13/2023] Open
Abstract
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.
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Affiliation(s)
- Yan Li
- Department of Neonatology, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Zhihui Zhang
- Department of Applied Mathematics, The Hong Kong Polytechnic University, Kowloon, Hong Kong SAR, China
| | - Yan Mo
- Neonatal Medical Centre, Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
- Guangxi Clinical Research Center for Pediatric Diseases, Nanning, China
| | - Qiufen Wei
- Neonatal Medical Centre, Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
- Guangxi Clinical Research Center for Pediatric Diseases, Nanning, China
| | - Lianfang Jing
- Neonatal Medical Centre, Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Wei Li
- Neonatal Medical Centre, Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Mengmeng Luo
- Department of Biological Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Linxia Zou
- Neonatal Medical Centre, Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
- Guangxi Clinical Research Center for Pediatric Diseases, Nanning, China
| | - Xin Liu
- Neonatal Medical Centre, Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Danhua Meng
- Neonatal Medical Centre, Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Yuan Shi
- Department of Neonatology, Children’s Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
- *Correspondence: Yuan Shi,
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Caporali C, Longo S, Tritto G, Perotti G, Pisoni C, Naboni C, Gardella B, Spinillo A, Manzoni F, Ghirardello S, Borgatti R, Orcesi S. Neurodevelopmental outcome of Italian preterm ELBW infants: an eleven years single center cohort. Ital J Pediatr 2022; 48:117. [PMID: 35854369 PMCID: PMC9297614 DOI: 10.1186/s13052-022-01303-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/15/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Preterm extremely low birth weight infants (ELBWi) are known to be at greater risk of developing neuropsychiatric diseases. Identifying early predictors of outcome is essential to refer patients for early intervention. Few studies have investigated neurodevelopmental outcomes in Italian ELBWi. This study aims to describe neurodevelopmental outcome at 24 months of corrected age in an eleven-year single-center cohort of Italian ELBWi and to identify early risk factors for adverse neurodevelopmental outcomes. METHODS All infants born with birth weight < 1000 g and admitted to the Neonatal Intensive Care Unit of the "Fondazione IRCCS Policlinico San Matteo" hospital in Pavia, Italy, from Jan 1, 2005 to Dec 31, 2015 were eligible for inclusion. At 24 months, Griffiths' Mental Developmental Scales Extended Revised (GMDS-ER) were administered. Neurodevelopmental outcome was classified as: normal, minor sequelae (minor neurological signs, General Quotient between 76 and 87), major sequelae (cerebral palsy; General Quotient ≤ 75; severe sensory impairment). Univariate and multivariate multinomial logistic regression models were performed to analyze the correlation between neonatal variables and neurodevelopmental outcome. RESULTS 176 ELBWi were enrolled (mean gestational age 26.52 weeks sd2.23; mean birthweight 777.45 g sd142.89). 67% showed a normal outcome at 24 months, 17% minor sequelae and 16% major sequelae (4.6% cerebral palsy on overall sample). The most frequent major sequela was cognitive impairment (8.52%). In the entire sample the median score on the Hearing-Speech subscale was lower than the median scores recorded on the other subscales and showed a significantly weaker correlation to each of the other subscales of the GMDS-ER. Severely abnormal cUS findings (RRR 10.22 p 0.043) and bronchopulmonary dysplasia (RRR 4.36 p 0.008) were independent risk factors for major sequelae and bronchopulmonary dysplasia for minor sequelae (RRR 3.00 p 0.018) on multivariate multinomial logistic regression. CONCLUSIONS This study showed an improvement in ELBWI survival rate without neurodevelopmental impairment at 24 months compared to previously reported international cohorts. Cognitive impairment was the most frequent major sequela. Median scores on GMDS-ER showed a peculiar developmental profile characterized by a selective deficit in the language domain. Severely abnormal cUS findings and bronchopulmonary dysplasia were confirmed as independent risk factors for major sequelae.
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Affiliation(s)
- Camilla Caporali
- Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy.,Child Neurology and Psychiatry Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Stefania Longo
- Neonatal Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giovanna Tritto
- Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy.,Fondazione Stella Maris Mediterraneo, Chiaromonte, Potenza, Italy
| | - Gianfranco Perotti
- Neonatal Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Camilla Pisoni
- Neonatal Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Cecilia Naboni
- Child Neurology and Psychiatry Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Barbara Gardella
- Department of Obstetrics and Gynecology, IRCCS Foundation Policlinico San Matteo and University of Pavia, Pavia, Italy.,Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
| | - Arsenio Spinillo
- Department of Obstetrics and Gynecology, IRCCS Foundation Policlinico San Matteo and University of Pavia, Pavia, Italy.,Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
| | - Federica Manzoni
- Biometry and Clinical Epidemiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,Health Promotion - Environmental Epidemiology Unit, Hygene and Health Prevention Department, Health Protection Agency, Pavia, Italy
| | - Stefano Ghirardello
- Neonatal Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Renato Borgatti
- Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy.,Child Neurology and Psychiatry Unit, IRCCS Mondino Foundation, Pavia, Italy
| | - Simona Orcesi
- Department of Brain and Behavioural Sciences, University of Pavia, Pavia, Italy.,Child Neurology and Psychiatry Unit, IRCCS Mondino Foundation, Pavia, Italy
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Ninan K, Liyanage SK, Murphy KE, Asztalos EV, McDonald SD. Evaluation of Long-term Outcomes Associated With Preterm Exposure to Antenatal Corticosteroids: A Systematic Review and Meta-analysis. JAMA Pediatr 2022; 176:e220483. [PMID: 35404395 PMCID: PMC9002717 DOI: 10.1001/jamapediatrics.2022.0483] [Citation(s) in RCA: 63] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 12/01/2021] [Indexed: 01/11/2023]
Abstract
Importance Animal studies have found that antenatal corticosteroids affect many organs across multiple stages of life. However, the long-term outcomes in human children are not well understood. Objective To conduct a systematic review and meta-analysis of long-term outcomes associated with preterm exposure to antenatal corticosteroids compared with no exposure in all children as well as children with preterm and full-term birth. Data Sources Academic databases were searched for articles published from January 1, 2000, to October 29, 2021, including Ovid MEDLINE, Ovid Embase, PsycInfo, CINAHL (Cumulative Index of Nursing and Allied Health Literature), Web of Science, ClinicalTrials.gov, and Google Scholar. References of articles were also searched for relevant studies. Study Selection Randomized clinical trials (RCTs), quasi-RCTs, and cohort studies that assessed long-term neurodevelopmental, psychological, or other outcomes at 1 year or older in those who had preterm exposure to antenatal corticosteroids were included. No language restrictions were set. Data Extraction and Synthesis Two reviewers independently extracted data using a piloted data extraction form. Data on study population, pregnancy characteristics, exposure to antenatal corticosteroids, and outcomes were collected. Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guidelines were followed, and random-effects models were used for the meta-analysis. Main Outcomes and Measures The primary outcome was an author-defined composite of any adverse neurodevelopmental and/or psychological disorder. The secondary outcomes included specific measures of psychological disorders; neurodevelopmental delay; and anthropometric, metabolic, and cardiorespiratory outcomes. Results A total of 30 studies met the inclusion criteria, and involved more than 1.25 million children who were at least 1 year of age when the outcomes were assessed. Exposure to a single course of antenatal corticosteroids for children with extremely preterm birth was associated with a significant reduction in risk of neurodevelopmental impairment (adjusted odds ratio, 0.69 [95% CI, 0.57-0.84]; I2 = 0%; low certainty). For children with late-preterm birth, exposure to antenatal corticosteroids was associated with a higher risk of investigation for neurocognitive disorders (n = 25 668 children; adjusted hazard ratio [aHR], 1.12 [95% CI, 1.05-1.20]; low certainty). For children with full-term birth, exposure to antenatal corticosteroids was associated with a higher risk of mental or behavioral disorders (n = 641 487 children; aHR, 1.47 [95% CI, 1.36-1.60]; low certainty) as well as proven or suspected neurocognitive disorders (n = 529 205 children; aHR, 1.16 [95% CI, 1.10-1.21]; low certainty). Conclusions and Relevance Results of this study showed that exposure to a single course of antenatal corticosteroids was associated with a significantly lower risk of neurodevelopmental impairment in children with extremely preterm birth but a significantly higher risk of adverse neurocognitive and/or psychological outcomes in children with late-preterm and full-term birth, who made up approximately half of those with exposure to antenatal corticosteroids. The findings suggest a need for caution in administering antenatal corticosteroids.
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Affiliation(s)
- Kiran Ninan
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Sugee K. Liyanage
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Kellie E. Murphy
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth V. Asztalos
- Division of Neonatology, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Sarah D. McDonald
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Radiology, McMaster University, Hamilton, Ontario, Canada
- Division of Maternal-Fetal Medicine, McMaster University, Hamilton, Ontario, Canada
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Abstract
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.
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Affiliation(s)
- Estefani Hee Chung
- Homer Stryker MD School of Medicine, Western Michigan University, Kalamazoo, MI, USA
| | - Jesse Chou
- Homer Stryker MD School of Medicine, Western Michigan University, Kalamazoo, MI, USA
| | - Kelly A Brown
- Homer Stryker MD School of Medicine, Western Michigan University, Kalamazoo, MI, USA
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