Early psychomotor development of low-risk preterm infants: Influence of gestational age and gender

Latent motor growth trajectories of term and preterm infants based on caregiver report

Early motor development is a key predictor of development in other skill domains and specific neurodevelopmental disorders, but it is typically measured as achievement of milestones rather than rate of development. To explore the value of the latter approach, this study utilized a novel caregiver report method to examine differences in the developmental trajectory of motor development in term-born compared to preterm-born infants. Caregiver-infant dyads (331 term, 240 preterm) were followed from birth through 12 months (48% female; 6.4% Hispanic; 34.1% Black; 10.3% Mixed or Biracial; and 48.3% White). Longitudinal Item Response Theory (IRT) modeling was used to compare growth trajectories of motor skills between term and preterm infants. The moderating effects of biological sex on group differences also were examined. The main effect for term status was significant. Preterm infants exhibited slower rates of growth in motor ability over the first 12 months compared with term infants. Differences in rate of growth were significant by 6 months of age. In the term group only, females exhibited more rapid growth than males in motor ability. Findings indicate that caregiver report yields reliable estimates of growth in the latent trait of motor ability, with slower rate of growth in infants born preterm. Estimates of latent growth in motor ability may provide more sensitive measures of neurodevelopmental risk and a method to examine response to treatment.

Hammersmith Neonatal and Infant Neurological Examinations Scores in Typically Developing Infants Aged 1-6 Months

The Hammersmith Neonatal (HNNE) and Infant (HINE) Neurological Examinations are increasingly used to evaluate developing neuromotor control in infants at risk for physical disability, but there is no global consensus on score interpretation across the first 6 months after birth. We report scores for typically developing, full-term infants aged 1 month for the HNNE and aged 2-6 months for the HINE. The median HNNE and HINE scores are consistent with previously published data. These normative data can be used to aid in the interpretation of HNNE and HINE scores from infants at risk for neuromotor impairment.

Neuromotor Behavior of Infants at 3 and 6 Months Prenatally Exposed to SARS-CoV-2: a Brief Report

Prenatal SARS-CoV-2 infection may be a risk factor for neurological impairment. This study describes the neuromotor behavior of infants prenatally exposed to SARS-CoV-2 using gold standard tools for early detection of neurological impairment. Sixteen infants were included in this exploratory longitudinal study. Infants were assessed at 3 months using the Prechtl General Movement Assessment, and at 6 months using the Hammersmith Infant Neurological Examination. Infants might have presented neuromotor limitations at 3 months; however, they progressed to a low-risk outcome of neurological impairment at 6 months.

Nationwide status of progestogen treatment to prevent spontaneous preterm birth: A questionnaire survey for childbirth healthcare facilities in Japan

AIM

This study aimed to investigate the current status of progestogen treatment for pregnant women at a high risk for preterm birth (PTB) in childbirth healthcare facilities in Japan.

METHODS

A web-based nationwide questionnaire survey regarding progestogen use for prevention of PTB was conducted among childbirth healthcare facilities from 2019 to 2021.

RESULTS

Valid responses were obtained from 528 facilities (25.2% of those surveyed), including 155 tertiary perinatal facilities (making up 92.3% of all tertiary perinatal care facilities). In the survey period, progestogen treatment was implemented in 207 facilities (39.2%) for PTB prevention. Regarding types of progestogens, 17α-hydroxyprogesterone caproate was used in 170 facilities (82.1%), with a low dose (125 mg/week) administered in 62.9% of the facilities to comply with the regulations of the national health insurance system, although 250 mg/week is considered the best dose. Vaginal progesterone was used in 36 facilities (17.4%), although the cost of vaginal progesterone was not covered by health insurance. Of the facilities not administering progestogen treatment, approximately 40% expressed that vaginal progesterone would be their first choice for PTB prevention in daily practice if it would be covered by health insurance in the future.

CONCLUSIONS

Due to the current regulations of the Japanese health insurance system, 17α-hydroxyprogesterone caproate, rather than vaginal progesterone, was mainly used for PTB prevention. Despite global evidence supporting vaginal progesterone as the approach with the highest efficacy, only a limited number of facilities have utilized it due to the current drug use regulations in Japan.

Identifying and Evaluating Young Children with Developmental Central Hypotonia: An Overview of Systematic Reviews and Tools

Children with developmental central hypotonia have reduced muscle tone secondary to non-progressive damage to the brain or brainstem. Children may have transient delays, mild or global functional impairments, and the lack of a clear understanding of this diagnosis makes evaluating appropriate interventions challenging. This overview aimed to systematically describe the best available evidence for tools to identify and evaluate children with developmental central hypotonia aged 2 months to 6 years. A systematic review of systematic reviews or syntheses was conducted with electronic searches in PubMed, Medline, CINAHL, Scopus, Cochrane Database of Systematic Reviews, Google Scholar, and PEDro and supplemented with hand-searching. Methodological quality and risk-of-bias were evaluated, and included reviews and tools were compared and contrasted. Three systematic reviews, an evidence-based clinical assessment algorithm, three measurement protocols, and two additional measurement tools were identified. For children aged 2 months to 2 years, the Hammersmith Infant Neurological Examination has the strongest measurement properties and contains a subset of items that may be useful for quantifying the severity of hypotonia. For children aged 2-6 years, a clinical algorithm and individual tools provide guidance. Further research is required to develop and validate all evaluative tools for children with developmental central hypotonia.

Neurodevelopmental outcome of low-risk moderate to late preterm infants at 18 months

Background

Of the 15 million preterm births that occur worldwide each year, approximately 80% occur between 32 and 36 + 6 weeks gestational age (GA) and are defined as moderate to late preterm (MLP) infants. This percentage substantiates a need for a better understanding of the neurodevelopmental outcome of this group.

Aim

To describe neurodevelopmental outcome at 18 months in a cohort of healthy low-risk MLP infants admitted to the neonatal unit at birth and to compare the neurodevelopmental outcome to that of a healthy term-born infant group.

Study design and method

This single-centre observational study compared the neurodevelopmental outcome of healthy MLP infants to a group of healthy term control (TC) infants recruited during the same period using the Griffith's III assessment at 18 months.

Results

Seventy-five MLP infants and 92 TC infants were included. MLP infants scored significantly lower in the subscales: Eye-hand coordination (C), Personal, Social and Emotional Development (D), Gross Motor Development (E) and General Developmental (GD) (p < 0.001 for each) and Foundations of Learning (A), (p = 0.004) in comparison to the TC infant group with Cohen's d effect sizes ranging from 0.460 to 0.665. There was no statistically significant difference in mean scores achieved in subscale B: Language and Communication between groups (p = 0.107).

Conclusion

MLP infants are at risk of suboptimal neurodevelopmental outcomes. Greater surveillance of the neurodevelopmental trajectory of this group of at-risk preterm infants is required.

Correlation Analysis of Attention and Intelligence of Preterm Infants at Preschool Age: A Premature Cohort Study

OBJECTIVE

Developmental delay in neurocognitive function has been reported in premature children. This cohort study prospectively followed preterm infants following birth, and herein we present the four-year longitudinal follow-up data of cognitive development at preschool age and analyze correlated factors.

METHODS

Term and preterm children received regular clinical evaluations and development assessments after birth, and at age 4 ± 1 years, they received the Wechsler-preschool and primary scale of intelligence, Fourth Edition (WPPSI-IV), excluding those with full-scale intelligence quotient < 70. A total of 150 participants received Conners Kiddie Continuous Performance Test (K-CPT), while 129 participants received ophthalmic evaluation. We adopted Chi-square test, ANOVA, and post hoc analysis to compare group differences. Correlations with K-CPT and WPPSI-IV were analyzed using Pearson's correlation.

RESULTS

Group 1 consisted of 25 full-term children, group 2 had 94 preterm children with birth-weight of ≥ 1500 g, and group 3 had 159 preterm children with birth-weight of < 1500 g. Group 1 was the healthiest group and had the best performance in attention and intelligence, while group 3 had the worst physical condition and cognitive performance. The correlation analysis revealed that perinatal factors, including gestational age, birth weight, Apgar scores, and physical conditions, significantly correlated with WPPSI-IV and K-CPT variables. Gender significantly correlated with object assembly of WPSSI-IV and clinical index of K-CPT. Among vision-related variables, best corrected visual acuity correlated most with K-CPT, including clinical index, Omission, and hit reaction time standard error of K-CPT, as well as significantly correlated with information and bug search of WPPSI-IV.

CONCLUSIONS

Preterm children at preschool age still had poorer cognitive performance than full-term children, especially those with birth BW less than 1500 g. Gender and vision are correlated with cognitive deficits. Continuous monitoring with comprehensive assessments is recommended.

Long-term predictivity of early neurological assessment and developmental trajectories in low-risk preterm infants

Prematurity represents 10.6% of all births, and although preterm infants usually show adequate neurodevelopmental outcomes, some may develop significant and long-lasting neurological sequelae. Many studies have analyzed predictive factors for developing severe neurodevelopmental impairments (cerebral palsy, other motor and socio-relational disorders such as autism). In this study, 148 preterm infants were enrolled to investigate the neurodevelopmental trajectories in a population of low-risk premature infants using standardized assessment methods. Significant correlations were found between the general movements, the Hammersmith Infant Neurological Examination, and the Griffiths Mental and Development Scales. Moreover, this study showed their validity and predictivity for adverse neurodevelopmental outcomes even in low-risk infants.

Hammersmith Infant Neurological Examination in low-risk infants born very preterm: a longitudinal prospective study

AIM

To describe the profile of global and single items of the Hammersmith Infant Neurological Examination (HINE) in a population of low-risk infants born very preterm during the first year of life.

METHOD

The HINE was performed at 3, 6, 9, and 12 months' corrected age in a population of low-risk infants born preterm with a gestational age of fewer than 32 weeks and with normal or minimal changes on neuroimaging.

RESULTS

A total of 174 infants born preterm (96 males, 78 females; mean gestational age = 27 weeks [SD = 1.8], range 23-31 weeks) fulfilled the inclusion criteria. The 10th centile cut-off score with median and range was reported for the HINE global and subsection scores. A progressive increase in global HINE scores was observed. Most of the single items, especially those related to tone, posture, and reflexes, showed progressive maturation.

INTERPRETATION

Our results, which provide longitudinal data for single-item and global scores in a population of low-risk infants born very preterm, can be used as a reference in both clinical and research settings to monitor early neurological signs in these infants. These data could be used as normative data when examining low-risk infants born preterm.

Hammersmith Infant Neurological Examination in infants born at term: Predicting outcomes other than cerebral palsy

AIM

We explored the ability of the Hammersmith Infant Neurological Examination (HINE) to identify cognitive performance delay at 2 years in a large cohort of infants born at term.

METHOD

We conducted a retrospective study of infants born at term at risk of neurodevelopmental impairments assessed using the HINE between 3 and 12 months post-term age and compared them with a cohort of typically developing infants born at term. All infants performed a neurodevelopmental assessment at 2 years of age using the Mental Development Index (MDI) of the Bayley Scales of Infant Development, Second Edition; the presence of cerebral palsy (CP) was also reported. The infants were classified as being cognitively normal/mildly delayed or significantly delayed (MDI < 70). The predictive validity of HINE scores for significantly delayed cognitive performance, in infants with and without CP, was calculated using specific cut-off scores according to age at assessment.

RESULTS

A total of 446 at-risk and 235 typically developing infants (345 males, 336 females; mean [SD] gestational age 38.7 weeks [1.4], range 37-43 weeks) were included. Of the at-risk infants, 408 did not have CP at 2 years; 243 had a normal/mild delayed MDI and 165 had an MDI less than 70. Of the at-risk infants, 38 developed CP. HINE scores showed a good sensitivity and specificity, mainly after 3 months, for identifying significantly delayed cognitive performance in infants without CP. In those with CP, the score was associated with their cognitive performance. The comparison group had the highest HINE scores.

INTERPRETATION

The HINE provides evidence about the risk of delayed cognitive performance at age 2 years in infants born at term with and without CP.

Effect of family integrated care on physical growth and language development of premature infants: a retrospective study

BACKGROUND

Premature birth (PTB) increases the long-term risk of diseases such as hypertension, heart disease, and diabetes in adulthood. It is an independent disease with the largest global burden in terms of high mortality and lifelong negative health impacts. The purpose of this study was to analyze the physical growth and language development of premature infants (PIs) at the age of 18 months, and to explore the impact of family integrated care (FIcare) on PI.

METHODS

This study retrospectively included mothers and their PIs born in the Neonatal Pediatrics Department, Affiliated Hospital of Nantong University from January 2018 to September 2020 and hospitalized in the neonatal intensive care unit (NICU) within 24 hours after birth. The weight, head circumference, body length, and language development of each child were followed up at the age of 1, 3, 6, 12, and 18 months and recorded, and the relationship between FIcare and physical growth and language development of PIs was evaluated.

RESULTS

The development quotient (DQ) score and language development score of the FIcare group were always higher than those of the control group from 6 to 18 months, and the difference was statistically significant (P<0.05). Multiple regression analysis showed that the body length of the FIcare group participants was longer than that of control group participants. The head circumference of infants was positively correlated with gestational age, birth head circumference, and family average monthly income. The head circumference of FIcare group participants was longer than that of control group participants. The DQ score was positively correlated with gestational age, and the FIcare group participants scored higher than control group participants. Logistic regression analysis showed that early language milestone (ELM) scale score and gestational age were positively correlated with mother's education, and the score of FIcare group participants was higher than that of control group participants (P<0.05).

CONCLUSIONS

Compared with the traditional nursing model, the implementation of FIcare for the hospitalized PIs in the NICU can actively promote the physical growth and language development of infants.

Association among postpartum posttraumatic stress disorder, family coping, neurodevelopment, and language development in high-risk infants: a retrospective study

BACKGROUND

A high-risk infant (HRI) is a child whose fetal, neonatal, and infant development is impacted by adverse factors that may cause cognitive, sensory, behavioral, or language defects. The complex situation in the treatment process is a continuous challenge and stressor for parents. If parents fail to take appropriate coping styles, it will have an adverse impact on the health of parents and the growth and development of children. The purpose of this study was to explore the impact of clinical characteristics, postpartum posttraumatic stress disorder (PTSD), and family coping on the neurodevelopment and language development of HRIs as a reference for targeted intervention.

METHODS

This study retrospectively recruited 211 children who were hospitalized in the neonatal intensive care unit (NICU) of Suzhou Kowloon Hospital from January 2018 to December 2021. HRI and their mother were interviewed by telephone with general information questionnaire, Perinatal Post-traumatic Stress Disorder Questionnaire, medical coping modes questionnaire, Bayley Scales of Infant Development the Early Language Milestone Scale to investigate HRI and their mothers; Logistic regression was used to analyze the relationship between HRI mothers' emotions and family coping with neurodevelopment and language development.

RESULTS

The neurodevelopmental scores of HRIs differed according to gestational week of delivery, birth weight, and disease diagnosis. The language development scores of HRIs differed according to gestational week of delivery, birth weight, disease diagnosis, and maternal education. Multiple stepwise regression analysis showed that the neurodevelopmental scores were affected by gestational week of delivery, postpartum PTSD score, and family coping. Logistic regression analysis showed that the language development scores were affected by maternal education and neurodevelopmental level. The correlation analysis showed that the postpartum PTSD scores were negatively correlated with family coping, neurodevelopment, and language development, and that family coping was positively correlated with the neurodevelopment and language development scores (P<0.05).

CONCLUSIONS

The neurodevelopment and language development of HRIs were affected by the gestational week of delivery, maternal education, the child's birth weight, and disease diagnosis. NICU wards can promote the healthy development of HRIs by providing mothers with targeted health education concerning the child's condition, postpartum PTSD, and family coping strategies.

Reference Material for Hammersmith Infant Neurologic Examination Scores Based on Healthy, Term Infants Age 3-7 Months

OBJECTIVE

To provide a valid, continuous reference interval, including a 10th percentile cut-off, for Hammersmith Infant Neurological Examination (HINE) scores based on 3- to 7-month-old term infants with weight appropriate for gestational age.

STUDY DESIGN

In a prospective study, we examined 168 Norwegian infants at one timepoint with HINE at 3-7 months of age. In 134 of these infants Ages and Stages Questionnaire was completed by their parents at 2 years of age to ensure typical motor development. We calculated a reference interval for HINE scores with the 10th percentile as cut-off for age-dependent optimal scores.

RESULTS

The best fitting mean model for HINE total score was 78.1358 + 9659.231∗1/age in weeks²-5104.174∗natural logarithm(age in weeks)/age in weeks², which explained 49.8% of the variance. The HINE total score 10th percentile cut-off corresponded to 52.1 points at age 12 weeks, 55.6 points at 16 weeks, 59.0 points at 20 weeks, 61.8 points at 24 weeks, and 63.8 points at 28 weeks. We found an excellent intraclass correlation coefficient of 0.953 (0.931-0.968) between 2 examiners. The infants had a typical motor development at 2 years follow-up.

CONCLUSION

We have presented a valid, continuous reference interval and a 10th percentile cut-off for HINE scores for infants age 3-7 months.

Deep learning-based quantitative analyses of spontaneous movements and their association with early neurological development in preterm infants

This study aimed to develop quantitative assessments of spontaneous movements in high-risk preterm infants based on a deep learning algorithm. Video images of spontaneous movements were recorded in very preterm infants at the term-equivalent age. The Hammersmith Infant Neurological Examination (HINE) was performed in infants at 4 months of corrected age. Joint positional data were extracted using a pretrained pose-estimation model. Complexity and similarity indices of joint angle and angular velocity in terms of sample entropy and Pearson correlation coefficient were compared between the infants with HINE < 60 and ≥ 60. Video images of spontaneous movements were recorded in 65 preterm infants at term-equivalent age. Complexity indices of joint angles and angular velocities differed between the infants with HINE < 60 and ≥ 60 and correlated positively with HINE scores in most of the joints at the upper and lower extremities (p < 0.05). Similarity indices between each joint angle or joint angular velocity did not differ between the two groups in most of the joints at the upper and lower extremities. Quantitative assessments of spontaneous movements in preterm infants are feasible using a deep learning algorithm and sample entropy. The results indicated that complexity indices of joint movements at both the upper and lower extremities can be potential candidates for detecting developmental outcomes in preterm infants.

Profile of minor neurological findings after perinatal asphyxia

Aim

To characterise the spectrum of findings in sequential neurological examinations, general movements (GM) assessment and magnetic resonance imaging (MRI) of infants with perinatal asphyxia.

Methods

The prospective cohort study of term infants with perinatal asphyxia treated at Helsinki University Hospital's neonatal units in 2016–2020 used Hammersmith Neonatal Neurological Examination (HNNE) and brain MRI at 2 weeks and Hammersmith Infant Neurological Examination (HINE) and GM assessment at 3 months of age.

Results

Analysis included 50 infants: 33 displaying perinatal asphyxia without hypoxic‐ischaemic encephalopathy (HIE), seven with HIE1 and 10 with HIE2. Of the infants with atypical HNNE findings, 24/25 perinatal asphyxia without HIE cases, 5/6 HIE1 cases and all 10 HIE2 cases showed atypical findings in the HINE. The HINE identified atypical spontaneous movements significantly more often in infants with white matter T2 hyperintensity.

Conclusion

In this cohort, most infants with perinatal asphyxia, with or without HIE, presented atypical neurological findings in sequential examinations. The profile of neurological findings for children with perinatal asphyxia without HIE resembled that of children with HIE. White matter T2 hyperintensity was associated with atypical spontaneous movements in the HINE and was a frequent MRI finding also in perinatal asphyxia without HIE.

Hammersmith Infant Neurological Examination for infants born preterm: predicting outcomes other than cerebral palsy

AIM

We explored the ability of the Hammersmith Infant Neurological Examination (HINE) to identify typical and delayed cognitive performance in a large population of infants born preterm, both with and without cerebral palsy (CP).

METHOD

We conducted a retrospective study of infants born preterm who had repeated HINEs between 3 and 12 months corrected age. At 2 years, cognition was assessed using the Mental Development Index (MDI; from the Bayley Scales of Infant Development, Second Edition) and the presence and severity of CP was determined. All children were classified as cognitively typical/mildly delayed or significantly delayed (MDI <70) and CP. The predictive validity of HINE scores for significantly delayed cognitive performance, in children with and without CP, was calculated using specific cut-off scores according to age at assessment.

RESULTS

Of 1229 eligible infants (gestational age 25-36wks, mean [SD] 34.9 [2.3]; 646 males, 583 females), 1108 did not develop CP, 891 had an MDI that was typical/mildly delayed, and 217 had an MDI less than 70. Of the 121 infants who developed CP, the MDI was typical in 28, mildly delayed in 27, and less than 70 in 66. HINE scores showed a good sensitivity and specificity, especially after 3 months, for detecting significantly delayed cognitive performance in infants without CP. In those who developed CP, the score was associated with their cognitive level.

INTERPRETATION

The HINE provides information about the risk of delayed cognitive performance in infants born preterm with and without CP. What this paper adds The Hammersmith Infant Neurological Examination (HINE) can be used in the first year to identify infants born preterm at risk for delayed cognitive performance. Age-dependent HINE cut-off scores are proposed for detecting increased risk of delayed cognitive performance.

Sex influences on the neurocognitive outcome of preterm children

This article presents a revision of the literature regarding the influence of sex differences on the recovery and long-term behavioral and cognitive outcomes of preterm children. After initial discussion of some methodological concerns, the literature regarding the concept of "male disadvantage," which is often used when talking about early neurological and psychomotor outcomes in preterm children, is presented. Subsequently, the literature data on sex-related differences in preterm children are discussed, focusing on their influence on the developmental pathways of cognition, language, executive function, behavior and affect, and response to rehabilitation therapies. Finally, evidence about brain structural and connectivity correlates of sex differences in the brain of preterm survivors is taken into account. Although visuo-spatial and visuo-perceptual functioning is widely studied in the preterm child and is strongly sex specific, little to no data are available regarding male-female differences in preterm children and the interaction effect between sex and preterm birth. For this reason, original data analyses of male-female differences in visuo-spatial performance from a small sample of preterm children are also presented.

Predictors of persistent and changing developmental problems of preterm children

BACKGROUND

Accurate prediction of persistent and emerging developmental problems in preterm-born children may lead to targeted interventions.

AIMS

To determine whether specific perinatal and social factors were associated with persistent, emerging, and resolving developmental problems of early-preterm (EPs) and moderately-and-late-preterm children (MLPs) from before to after school entry.

STUDY DESIGN

Observational longitudinal cohort study, part of the LOLLIPOP cohort-study.

SUBJECTS

341 EPs and 565 MLPs.

OUTCOME MEASURES

Developmental problems using the Ages and Stages Questionnaire at ages 4 and 5. We collected data on perinatal and social factors from medical records. Using logistic regression analyses we assessed associations between 48 factors and persistent, emerging, and resolving problems.

RESULTS

Of EPs, 8.7% had persistent and 5.1% emerging problems; this was 4.3% and 1.9% for MLPs, respectively. Predictors for persistent problems included chronic mental illness of the mother, odds ratio (95% confidence interval) 8.01 (1.85-34.60), male sex 4.96 (2.28-10.82), being born small-for-gestational age (SGA) 2.39 (1.15-4.99), and multiparity 3.56 (1.87-6.76). Predictors for emerging problems included MLP birth with prolonged premature rupture of membranes (PPROM) 5.01 (1.38-18.14). Including all predictors in a single prediction model, the explained variance (Nagelkerke R²) was 21.9%, whereas this was 3.0% with only EP/MLP birth as predictor.

CONCLUSIONS

Only few perinatal and social factors had associations with persistent and emerging developmental problems for both EPs and MLPs. For children with specific neonatal conditions such as SGA, and PPROM in MLPs, problems may persist. Insight in risk factors largely improved the prediction of developmental problems among preterm children.

Neurodevelopmental outcomes of neonatal non-epileptic paroxysmal events: a prospective study

AIM

To report on psychomotor development and outcomes in term born neonates with non-epileptic paroxysmal events (NEPEs).

METHOD

From October 2017 to March 2019 we enrolled 38 consecutive term born neonates (22 males, 16 females; aged between 0-28d), born at the University Hospital San Marco in Catania, Italy, with NEPEs. We performed the Hammersmith Neonatal Neurological Examination scale (at enrolment), the Hammersmith Infant Neurological Examination (HINE) scale (at age 3, 6, 9, and 12mo), and the Griffiths scale (at age 12mo).

RESULTS

The age at onset of first paroxysmal manifestations ranged from birth to 4 days. We recorded a suboptimal global score in 18 out of 38 patients at enrolment and in 10 out of 38 patients at age 3 months (>70% of these infants were male); all events disappeared within 6 months of life. At age 6, 9, and 12 months, all infants scored within normal values on the HINE and Griffiths scale.

INTERPRETATION

Patients with NEPEs achieve neurodevelopment optimal scores within their first year of life.

WHAT THIS PAPER ADDS

Neonates experiencing non-epileptic paroxysmal events (NEPEs) can be examined with the Hammersmith Neonatal Neurological Examination, Hammersmith Infant Neurological Examination, and Griffiths scale at follow-up. Newborn infants with NEPEs achieve optimal scores within the first year of life.

Development of a Prediction Model to Identify Children at Risk of Future Developmental Delay at Age 4 in a Population-Based Setting

Our aim was to develop a prediction model for infants from the general population, with easily obtainable predictors, that accurately predicts risk of future developmental delay at age 4 and then assess its performance. Longitudinal cohort data were used (N = 1983), including full-term and preterm children. Development at age 4 was assessed using the Ages and Stages Questionnaire. Candidate predictors included perinatal and parental factors as well as growth and developmental milestones during the first two years. We applied multiple logistic regression with backwards selection and internal validation, and we assessed calibration and discriminative performance (i.e., area under the curve (AUC)). The model was evaluated in terms of sensitivity and specificity at several cut-off values. The final model included sex, maternal educational level, pre-existing maternal obesity, several milestones (smiling, speaking 2–3 word sentences, standing) and weight for height z score at age 1. The fit was good, and the discriminative performance was high (AUC: 0.837). Sensitivity and specificity were 73% and 80% at a cut-off probability of 10%. Our model is promising for use as a prediction tool in community-based settings. It could aid to identify infants in early life (age 2) with increased risk of future developmental problems at age 4 that may benefit from early interventions.

Early Neurological Assessment and Long-Term Neuromotor Outcomes in Late Preterm Infants: A Critical Review

Background and Objectives: Late preterm (LP) infants (born between 34 and 36 weeks of gestational age) are considered at higher risk of neonatal morbidities, mortality, and neurological impairments than full-term born infants (FT). The aim of this study was to provide a critical review of the literature outlining the different aspects of neurological function reported both in the neonatal period and in the follow up of late preterm infants. Materials and Methods: A comprehensive search of the MEDLINE, Embase, PsycINFO, and CINAHL electronic databases was made, using the following search terms: ‘Late preterm infants’, ‘Near term infants’, ‘neurological assessment’, ‘neurological outcome’, ‘neuromotor outcome’, cerebral palsy’, ‘CP’, ‘motor impairment’, including all the studies reporting clinical neurological assessment of LP (including both neonatal period and subsequent ages). Results: A total of 35 articles, comprising 301,495 children, were included as fulfilling the inclusion criteria: ten reported neonatal neurological findings, seven reported data about the first two years after birth, eighteen reported data about incidence of CP and motor disorder during the infancy. Results showed a more immature neurological profile, explored with structured neurological assessments, in LP infants compared with FT infants. The LP population also had a higher risk of developing cerebral palsy, motor delay, and coordination disorder. Conclusion: LP had a higher risk of neurological impairments than FT infants, due to a brain immaturity and an increased vulnerability to injury, as the last weeks of gestational age are crucial for the development of the brain.

ENACT (ENvironmental enrichment for infants; parenting with Acceptance and Commitment Therapy): a randomised controlled trial of an innovative intervention for infants at risk of autism spectrum disorder

INTRODUCTION

Autism spectrum disorder (ASD) is a heterogeneous neurodevelopmental condition with impacts on behaviour, cognition, communication, social interaction and family mental health. This paper reports the protocol of a randomised controlled trial (RCT) of a very early intervention, ENACT (ENvironmental enrichment for infants; parenting with Acceptance and Commitment Therapy), for families of infants at risk of ASD.

METHODS AND ANALYSIS

We aim to recruit 66 mothers of infants at risk of ASD (ie, infants with a sibling or parent diagnosed with ASD) to this RCT. Families will be randomly assigned to care-as-usual or ENACT. ENACT is a very early intervention, leveraging parent-child interactions to improve early social reciprocity, while supporting parental mental health and the parent-child relationship through Acceptance and Commitment Therapy. Intervention content is delivered online (approximately 8 hours) and supported by more than 7 consultations with a clinician. Parents will perform the social reciprocity intervention with their child (30 min per day). Assessments at four time points (baseline, 3 months, 6 months, and 12 months corrected age) will assess parent-infant interaction, parental mental health, infant development and early ASD markers. Analysis will be by intention to treat using general linear models for RCTs.

ETHICS AND DISSEMINATION

This protocol has been approved by the Children's Health Queensland Hospital and Health Service Human Research Ethics Committee (HREC/19/QCHQ/50131) and the University of Queensland Human Research Ethics Committee (2019000558). If efficacy is demonstrated, the intervention has the potential for wide and accessible dissemination.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12618002046280).

Inflammatory mediators of stress exposure and neurodevelopment in very preterm infants: Protocol for the stress neuro-immune study

AIMS

(a) Determine relationships among stress exposure, inflammation, and neurodevelopment in very preterm infants and determine the mediated effect of inflammation on the relationship between stress exposure and neurodevelopment; (b) describe cytokine trajectories following birth and determine the effect of stress exposure on these trajectories; and (c) examine relationships between stress exposure and chronic stress responses in very preterm infants.

DESIGN

Non-experimental, repeated measures.

METHODS

Very preterm infants born 28-31 weeks post menstrual age will be enrolled. Cumulative stress exposure over the first 14 days of life will be measured using the Neonatal Infant Stressor Scale. Blood will be collected weekly for the quantification of cytokines. Neurodevelopment will be assessed using the Neurobehavioral Assessment of the Preterm Infant and hair for quantification of hair cortisol will be collected at 35 weeks post menstrual age. Multiple linear regression and conditional process analysis will be used to analyse the relationships among stress exposure, inflammation and neurodevelopment. Linear mixed models will be used to determine inflammatory trajectories over time. IRB approval for the study was received May 2017, and funding from the National Institute of Nursing Research was awarded July 2017.

DISCUSSION

This study will determine the extent to which inflammation mediates the relationship between stress exposure and neurodevelopment. Interventions to attenuate inflammation in preterm infants may improve outcomes.

IMPACT

Determining the potentially modifiable mediators of stress exposure and neurodevelopment in preterm infants is critical to improving long-term outcomes.

An Integrative Review of Cytokine/Chemokine Predictors of Neurodevelopment in Preterm Infants

Preterm infants are at risk of brain injury and poor neurodevelopmental outcomes including impairments in cognition, behavioral functioning, sensory perception, and motor performance. Systemic inflammation has been identified as an important, potentially modifiable precursor of neurologic and neurodevelopmental impairments. Inflammation is typically measured by quantifying circulating cytokines and chemokines. However, it is unclear which specific cytokines/chemokines most consistently predict neurodevelopment in preterm infants. In this integrative review, we evaluated and analyzed the literature (N = 37 publications) to determine the cytokines/chemokines most predictive of neurodevelopment in preterm infants, the optimal timing for these measurements, and the ideal source for collecting cytokines/chemokines. Synthesis of the findings of these studies revealed that interleukin (IL)-6, IL-1β, IL-8, and tumor necrosis factor (TNF)-α collected during the first 3 weeks of life are most predictive of subsequent neurodevelopment. Methodological variation among studies hinders more specific analysis, including the evaluation of cytokine thresholds and meta-analyses, that would allow for the use of cytokines/chemokines to predict neurodevelopment. Future research should focus on identifying explicit cytokine values, specifically for IL-6, IL-1β, IL-8, and TNF-α, that are most predictive for identifying preterm infants most at risk of impairment, keeping in mind that longitudinal measures of cytokines/chemokines may be more predictive of future outcomes than single-time point measures.

Male sex is an independent risk factor for poor neurodevelopmental outcome at 20 months' corrected age, in human milk-fed very preterm infants: a cohort study

Objective:

To determine associations between sex and neurodevelopmental outcomes in human milk-fed very preterm infants, adjusted to early measured nutrient intakes and other neonatal cofactors.

Methods:

Consecutive inborn human milk-fed infants, with gestational age <33 weeks, were eligible. In-hospital energy and protein intakes have relied on measured human milk composition. The Bayley Scales of Infant Development II mental and psychomotor developmental indexes were used to assess neurodevelopment at 20 months’ corrected age. After univariate analysis, some covariables were used for linear multiple regression.

Results:

Thirty-two infants were included, with a mean (standard deviation) gestational age of 29.8 (1.8) weeks, and a median birth weight of 1168g (interquartile range 990-1419g). Minimum recommended intakes were achieved in 63.6% and 15.2% of infants for protein and energy, respectively. The mental and psychomotor developmental indexes were within normal limits in 93.8% of infants. The mean mental and psychomotor developmental indexes were significantly lower in males. Only male sex negatively and significantly affected the mental and psychomotor developmental indexes (B=-9.44; 95%CI: -17.64- -1.23; adjusted r²=0.17; p=0.026), adjusted to gestational age and measured energy intake.

Conclusion:

In human milk-fed very preterm infants, males had a significantly lower mental and psychomotor developmental indexes score at 20 months’ corrected age, adjusted for gestational age and measured energy intake.

Impact of Neonatal Intensive Care Unit oral feeding on neuropsychomotor outcomes at 9 months of corrected age in Chinese low-birthweight preterm infants: A retrospective study

AIMS AND OBJECTIVES

To examine the changes in neuropsychomotor development and investigate the effect of feeding progression in Neonatal Intensive Care Unit (NICU) on neuropsychomotor outcomes in low-birthweight preterm infants within 9 months of corrected age.

BACKGROUND

Low-birthweight (LBW) preterm infants (<37 weeks of gestation and birthweight <2,500 g) are at a high risk for neuropsychomotor development delay. Therefore, exploring NICU practices related to neuropsychomotor development is important.

DESIGN

This is a retrospective hospital-based cohort study.

METHODS

This study included 196 LBW preterm infants who were admitted to the NICU between January 2014-March 2016 and attended the follow-up growth evaluation in the clinic after discharge. The neuropsychomotor development of preterm infants was assessed every 3 months to a corrected age of 9 months using the paediatric neuropsychomotor diagnostic scale (PNDS). Generalised linear mixed models (GLMM) were performed.

RESULTS

The total PNDS scores had a downward trend, but the difference on pairwise comparison was not statistically significant. In total, 18.1%, 15.2% and 9.7% of preterm infants were examined for neuropsychomotor disorders at 3, 6 and 9 months of corrected age, respectively. The result of GLMM showed that the early initiation of oral feeding with breast milk was associated with optimal neuropsychomotor development. The first 3 months of corrected age is the critical period for neurodevelopmental disorders.

CONCLUSIONS

This study showed the importance of the early initiation of oral feeding with breast milk as early as possible within the NICU setting and highlighted the importance of close developmental follow-up.

RELEVANCE TO CLINICAL PRACTICE

The early initiation of oral feeding with breast milk may be recommended to promote neuropsychomotor development of LBW preterm infants within the NICU setting. Early identification of neuropsychomotor developmental delays within the first 3 months may guide early interventions.

Relationship between Epigenetic Maturity and Respiratory Morbidity in Preterm Infants

OBJECTIVE

To assess associations between epigenetic maturity of extremely preterm babies (born at less than 28 weeks of gestation), neonatal interventions, and respiratory outcomes, including the administration of surfactant and postnatal corticosteroids, duration of assisted ventilation, and development of bronchopulmonary dysplasia (BPD).

STUDY DESIGN

DNA was extracted from neonatal blood spots collected after birth from 143 extremely preterm infants born 1991-1992 in Victoria, Australia and used to determined DNA methylation (DNAm). A DNAm based gestational age was determined using our previously published method. The residual of DNAm gestational age and clinically estimated gestational age (referred to as "gestational age acceleration") was used as a measure to assess developmental maturity. Associations between gestational age acceleration and respiratory interventions and morbidities were determined.

RESULTS

Infants with higher gestational age acceleration were less likely to receive surfactant (P = .009) or postnatal corticosteroids (P = .008), had fewer days of assisted ventilation (P = .01), and had less BPD (P = .02). Respiratory measures are known to correlate with gestational age; however, models comparing each with clinically estimated gestational age were improved by the addition of the gestational age acceleration measure in the model.

CONCLUSIONS

Gestational age acceleration correlates with respiratory interventions and outcomes of extremely preterm babies. Surfactant and postnatal corticosteroid use, assisted ventilation days, and BPD rates were all lower in babies who were epigenetically more mature than their obstetrically estimated gestational age. This suggests that gestational age acceleration is a clinically relevant metric of developmental maturity.

Chinese handwriting performance in preterm children in grade 2

Background

First graders born prematurely perform poorly on handwriting speed and legibility. However, whether there are specific legibility factors in which preterm children demonstrate difficulty remains unknown. In addition, handwriting performance beyond the first grade and the influence of sex on handwriting performance in preterm children are still unclear. We aimed to investigate the influence of prematurity and sex on multiple dimensions of handwriting in grade two and to identify the contributors to performance.

Methods

Sixty-three preterm (34 boys and 29 girls) and 67 full-term (27 boys and 40 girls) peers in grade two were included. Class teachers were asked to complete the Chinese Handwriting Evaluation Form. A subgroup of 39 preterm children received assessments on intelligence, visual perception, tactile and kinesthetic sensation, and fine motor skills. Their inattention behavior was rated using a maternal self-report with a behavioral scale.

Results

Boys born prematurely exhibited poorer performance in the speed dimension than full-term boys (p = 0.008), whereas there was comparable performance in the two groups of girls (p = 0.221). In the dimensions related to legibility, preterm boys (32.4%) had a higher percentage of children with difficulty in the construction dimension than the other groups (preterm girls: 6.9%, full-term boys: 7.4%, full-term girls: 5.0%). However, no group difference was found in the dimensions of accuracy and directionality. Of the sensory-perceptual-motor factors, attention was the most significant predictor of accuracy in performance (p = 0.046) and speed dimensions (p = 0.001) in preterm children.

Conclusions

Boys appear to be vulnerable to the adverse impacts of preterm birth in terms of performance in the dimensions of speed and construction in grade two. Based on the significant contribution of attention to handwriting performance in preterm children, assessment and intervention in the area of attention is strongly suggested for preterm children with handwriting problems.

T2 Relaxometry MRI Predicts Cerebral Palsy in Preterm Infants

BACKGROUND AND PURPOSE

T2-relaxometry brain MR imaging enables objective measurement of brain maturation based on the water-macromolecule ratio in white matter, but the outcome correlation is not established in preterm infants. Our study aimed to predict neurodevelopment with T2-relaxation values of brain MR imaging among preterm infants.

MATERIALS AND METHODS

From January 1, 2012, to May 31, 2015, preterm infants who underwent both T2-relaxometry brain MR imaging and neurodevelopmental follow-up were retrospectively reviewed. T2-relaxation values were measured over the periventricular white matter, including sections through the frontal horns, midbody of the lateral ventricles, and centrum semiovale. Periventricular T2 relaxometry in relation to corrected age was analyzed with restricted cubic spline regression. Prediction of cerebral palsy was examined with the receiver operating characteristic curve.

RESULTS

Thirty-eight preterm infants were enrolled for analysis. Twenty patients (52.6%) had neurodevelopmental abnormalities, including 8 (21%) with developmental delay without cerebral palsy and 12 (31.6%) with cerebral palsy. The periventricular T2-relaxation values in relation to age were curvilinear in preterm infants with normal development, linear in those with developmental delay without cerebral palsy, and flat in those with cerebral palsy. When MR imaging was performed at >1 month corrected age, cerebral palsy could be predicted with T2 relaxometry of the periventricular white matter on sections through the midbody of the lateral ventricles (area under the receiver operating characteristic curve = 0.738; cutoff value of >217.4 with 63.6% sensitivity and 100.0% specificity).

CONCLUSIONS

T2-relaxometry brain MR imaging could provide prognostic prediction of neurodevelopmental outcomes in premature infants. Age-dependent and area-selective interpretation in preterm brains should be emphasized.

Long term cognitive outcomes of early term (37-38 weeks) and late preterm (34-36 weeks) births: A systematic review

Background: There is a paucity of evidence regarding long-term outcomes of late preterm (34-36 weeks) and early term (37-38 weeks) delivery.  The objective of this systematic review was to assess long-term cognitive outcomes of children born at these gestations.

Methods: Four electronic databases (Medline, Embase, clinicaltrials.gov and PsycINFO) were searched.  Last search was 5 ^th August 2016.  Studies were included if they reported gestational age, IQ measure and the ages assessed.  The protocol was registered with the International prospective register of systematic reviews (PROSPERO Record CRD42015015472).  Two independent reviewers assessed the studies.  Data were abstracted and critical appraisal performed of eligible papers.

Results: Of 11,905 potential articles, seven studies reporting on 41,344 children were included.  For early term births, four studies (n = 35,711) consistently showed an increase in cognitive scores for infants born at full term (39-41 weeks) compared to those born at early term (37-38 weeks) with increases for each week of term (difference between 37 and 40 weeks of around 3 IQ points), despite differences in age of testing and method of IQ/cognitive testing.  Four studies (n = 5644) reporting childhood cognitive outcomes of late preterm births (34 – 36 weeks) also differed in study design (cohort and case control); age of testing; and method of IQ testing, and found no differences in outcomes between late preterm and term births, although risk of bias was high in included studies.

Conclusion:  Children born at 39-41 weeks have higher cognitive outcome scores compared to those born at early term (37-38 weeks).  This should be considered when discussing timing of delivery.  For children born late preterm, the data is scarce and when compared to full term (37-42 weeks) did not show any difference in IQ scores.

Preterm birth rates in Japan from 1979 to 2014: Analysis of national vital statistics

AIM

Secular trends of preterm birth in Japan between 1979 and 2014 were examined to determine whether changes could be explained by a shift in the distribution of maternal age at delivery and parity and/or by changes in age-specific preterm birth rates.

METHODS

Live birth data for 1979 to 2014 were obtained from the Japanese Ministry of Health, Labour and Welfare. Analyses were limited to singleton children born in Japan (n = 43 632 786). Preterm birth was defined using two cut-offs at < 37 or < 34 weeks of gestation. Crude and standardized rates of preterm birth were calculated for firstborn and later-born singletons by maternal age at delivery for specific time periods.

RESULTS

Throughout the study period, the rates of preterm birth (both at < 37 and < 34 weeks of gestation) were higher among mothers aged 20 and younger, and mid-30s and older, compared to mothers in their 20s or early 30s. The rates of preterm birth at < 37 (but not at < 34) weeks decreased for mothers aged in their late 30s and 40s, and increased for mothers in their 20s and early 30s. Standardized rates of preterm birth showed a secular increase for preterm births at < 37 but not < 34 weeks of gestation.

CONCLUSION

The rates of preterm birth among mothers aged in their 20s and early 30s increased between 1979 and 2014, which contributed to the secular increase in rates of preterm birth at < 37 weeks.

Implementation of the Hammersmith Infant Neurological Examination in a High-Risk Infant Follow-Up Program

BACKGROUND

High-risk infant follow-up programs provide early identification and referral for treatment of neurodevelopmental delays and impairments. In these programs, a standardized neurological examination is a critical component of evaluation for clinical and research purposes.

METHODS

To address primary challenges of provider educational diversity and standardized documentation, we designed an approach to training and implementation of the Hammersmith Infant Neurological Examination with precourse materials, a workshop model, and adaptation of the electronic medical record.

CONCLUSIONS

Provider completion and documentation of a neurological examination were evaluated before and after Hammersmith Infant Neurological Examination training. Standardized training and implementation of the Hammersmith Infant Neurological Examination in a large high-risk infant follow-up is feasible and effective and allows for quantitative evaluation of neurological findings and developmental trajectories.