The association of prenatal exposure to intensive traffic with early preterm infant neurobehavioral development as reflected by the NICU Network Neurobehavioral Scale (NNNS)

A parent-administered sensorimotor intervention for oral feeding in infants born preterm: A randomized clinical study

AIM

To evaluate the effect of a parent-administered sensorimotor intervention (PASI) program on developmental outcomes of infants born preterm during their stay in the neonatal intensive care unit (NICU).

METHOD

A randomized clinical study was conducted with 94 infants (mean gestational age 31 weeks [SD 2.2 weeks]; 1658 g [SD 478 g]; 49 males, 45 females) initially enrolled and randomly assigned to an experimental or a control group. Infants in the experimental group received a PASI, consisting of tactile input to oral structures, trunk/limbs, and non-nutritive sucking for 15 minutes, once a day, for 10 days. Infants in the control group received standard care. Outcomes included attainment of complete oral feeds, occurrence of direct breastfeeding at hospital discharge, and motor function assessed using the Test of Infant Motor Performance (TIMP).

RESULTS

A total of 80 infants completed the study. Infants in the experimental group achieved complete oral feeds sooner (11.9 [SD 4.3] vs 15.3 [SD 6.5] days, p = 0.013), and a greater number of them received direct breastfeeds (22 vs 12, p = 0.010) than controls. Infants in both groups had equivalent motor functions scores on the TIMP (46.9 [SD 4.8], 46.8 [SD 8.4], p = 0.961).

INTERPRETATION

A PASI program may enhance an infant's oral feeding skills. These findings provide evidence to advocate for the institution of PASI in NICUs.

Longitudinal outcomes of a parent-administered sensorimotor intervention in preterm infants at 4 and 18 months

PURPOSE

Despite the increasing focus on early parent-delivered interventions in neonatal intensive care units to enhance infant development, there remains a research gap concerning the sustained benefits of such interventions in preterm infants. This study evaluated the impact of the parent-administered sensorimotor intervention (PASI) on developmental outcomes of infants previously enrolled in a randomized clinical trial (RCT).

METHOD

A prospective longitudinal follow-up study following the RCT at 4 and 18 months corrected gestational age (CGA) was conducted. A blinded examiner conducted the follow-up assessments. The study outcomes developmental outcome at both time points and the child's health-related quality of life at 18 months CGA using various means: Test of Infant Motor Performance (TIMP), the Feeding and Developmental Milestone Questionnaire (FDM), diagnosis of severe neurological disorder, the Infant Development Inventory (IDI) and Pediatric Quality of Life Inventory (PedsQL).

RESULTS

At 4 months CGA, 47 infants participated in the follow-up, with more infants in the experimental group receiving direct breastfeeds compared to the control group (38 % vs. 12 %, p = 0.032). At 18 months CGA, 51 infants were followed, showing no significant differences in developmental outcomes or health-related quality of life between groups. However, more parents in the control group reported developmental concerns about their child compared to those in the experimental group.

CONCLUSION

The PASI appears to have lasting positive effects on breastfeeding outcomes for infants and on parents' perceptions of developmental concerns. These findings underscore the importance of early postnatal experiences in influencing the long-term developmental trajectories of infants born preterm.

Neurobehavioral outcomes of preterm infants: toward a holistic approach

Children born very preterm (VPT; <32 weeks gestation) are at high risk for adverse developmental outcomes, yet not all children fare poorly. Some children born VPT have few or no neurodevelopmental concerns, while others have significant impairment in one or more domains. Historically, research has taken a variable-centered approach, reporting rates of impairment in single domains or single assessments as if they are independent of one another. More recently, child-centered approaches have been applied to studying outcomes for preterm children. Child-centered analyses allow us to integrate across multiple measures and domains to more holistically describe groups of children who vary in terms of the severity and co-occurrence of neurodevelopmental and behavioral strengths and difficulties. In this review, we will summarize current research that has taken a "whole child" approach to describing neurodevelopmental outcomes following preterm birth while highlighting the implications of this approach for research and clinical practice. We end by describing unanswered questions and areas that are in need of future research. IMPACT: Most research on outcomes for children born very preterm has reported rates of impairment in single domains or on single instruments. Recent findings suggest that a child-centered approach can identify unique phenotypes composed of multiple measures and domains that may be of clinical interest. A better understanding of unique combinations of neurodevelopmental and behavioral strengths and weaknesses could improve post-NICU care by emphasizing a personalized approach to intervention and treatment.

Adverse effects of exposure to fine particles and ultrafine particles in the environment on different organs of organisms

Particulate pollution is a global risk factor that seriously threatens human health. Fine particles (FPs) and ultrafine particles (UFPs) have small particle diameters and large specific surface areas, which can easily adsorb metals, microorganisms and other pollutants. FPs and UFPs can enter the human body in multiple ways and can be easily and quickly absorbed by the cells, tissues and organs. In the body, the particles can induce oxidative stress, inflammatory response and apoptosis, furthermore causing great adverse effects. Epidemiological studies mainly take the population as the research object to study the distribution of diseases and health conditions in a specific population and to focus on the identification of influencing factors. However, the mechanism by which a substance harms the health of organisms is mainly demonstrated through toxicological studies. Combining epidemiological studies with toxicological studies will provide a more systematic and comprehensive understanding of the impact of PM on the health of organisms. In this review, the sources, compositions, and morphologies of FPs and UFPs are briefly introduced in the first part. The effects and action mechanisms of exposure to FPs and UFPs on the heart, lungs, brain, liver, spleen, kidneys, pancreas, gastrointestinal tract, joints and reproductive system are systematically summarized. In addition, challenges are further pointed out at the end of the paper. This work provides useful theoretical guidance and a strong experimental foundation for investigating and preventing the adverse effects of FPs and UFPs on human health.

Place-Based Strategies Addressing Neighborhood Environments to Improve Perinatal and Preterm Infant Outcomes

Preterm birth (defined as birth <37 weeks of gestation) is a significant health concern globally, with lasting implications for individuals, families, and society. In the United States, high preterm birth rates among Black and low-income populations likely result from differences in environmental exposures. Structural racism and economic disadvantage have led to unequal distribution of polluting industrial sites and roadways across society as well as differential access to health-promoting resources which contribute to preterm birth risk. Once born, preterm infants remain at risk for numerous environmentally responsive adverse health outcomes that affect growth and development throughout childhood and adulthood. In this commentary, we describe associations of neighborhood environments with pregnancy and preterm infant health outcomes and propose strategies to address harmful exposures that affect families across the lifespan.

Prenatal and perinatal factors associated with neonatal neurobehavioral profiles in the ECHO Program

BACKGROUND

Single-cohort studies have identified distinct neurobehavioral profiles that are associated with prenatal and neonatal factors based on the NICU Network Neurobehavioral Scale (NNNS). We examined socioeconomic, medical, and substance use variables as predictors of NNNS profiles in a multi-cohort study of preterm and term-born infants with different perinatal exposures.

METHODS

We studied 1112 infants with a neonatal NNNS exam from the Environmental influences on Child Health Outcomes (ECHO) consortium. We used latent profile analysis to characterize infant neurobehavioral profiles and generalized estimating equations to determine predictors of NNNS profiles.

RESULTS

Six distinct neonatal neurobehavioral profiles were identified, including two dysregulated profiles: a hypo-aroused profile (16%) characterized by lethargy, hypotonicity, and nonoptimal reflexes; and a hyper-aroused profile (6%) characterized by high arousal, excitability, and stress, with low regulation and poor movement quality. Infants in the hypo-aroused profile were more likely to be male, have younger mothers, and have mothers who were depressed prenatally. Infants in the hyper-aroused profile were more likely to be Hispanic/Latino and have mothers who were depressed or used tobacco prenatally.

CONCLUSIONS

We identified two dysregulated neurobehavioral profiles with distinct perinatal antecedents. Further understanding of their etiology could inform targeted interventions to promote positive developmental outcomes.

IMPACT

Prior research on predictors of neonatal neurobehavior have included single-cohort studies, which limits generalizability of findings. In a multi-cohort study of preterm and term-born infants, we found six distinct neonatal neurobehavioral profiles, with two profiles being identified as dysregulated. Hypo- and hyper-aroused neurobehavioral profiles had distinct perinatal antecedents. Understanding perinatal factors associated with dysregulated neurobehavior could help promote positive developmental outcomes.

Environmental influences on child health outcomes: cohorts of individuals born very preterm

The National Institutes of Health's Environmental influences on Child Health Outcomes (ECHO) Program was designed to address solution-oriented research questions about the links between children's early life environment and their risks of pre-, peri-, and post-natal complications, asthma, obesity, neurodevelopmental disorders, and positive health. Children born very preterm are at increased risk for many of the outcomes on which ECHO focuses, but the contributions of environmental factors to this risk are not well characterized. Three ECHO cohorts consist almost exclusively of individuals born very preterm. Data provided to ECHO from cohorts can be used to address hypotheses about (1) differential risks of chronic health and developmental conditions between individuals born very preterm and those born at term; (2) health disparities across social determinants of health; and (3) mechanisms linking early-life exposures and later-life outcomes among individuals born very preterm. IMPACT: The National Institutes of Health's Environmental Influences on Child Health Outcomes Program is conducting solution-oriented research on the links between children's environment and health. Three ECHO cohorts comprise study participants born very preterm; these cohorts have enrolled, to date, 1751 individuals born in 14 states in the U.S. in between April 2002 and March 2020. Extensive data are available on early-life environmental exposures and child outcomes related to neurodevelopment, asthma, obesity, and positive health. Data from ECHO preterm cohorts can be used to address questions about the combined effects of preterm birth and environmental exposures on child health outcomes.

Exposure to PM10, PM2.5, and NO2 and gross motor function in children: a systematic review and meta-analysis

Air pollution exposure has been related to negative gross motor development in children. However, there is currently a lack of conclusive evidence for such a relationship. We carried out a systematic review and meta-analysis using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria to examine whether exposure to air pollution has an impact on children's gross motor development. Of the 9746 papers found, 7 studies examined the impact of air pollutant characteristics, such as PM_2.5, PM₁₀, and NO₂, on children's gross motor development. The results of the study reveal a significant association between air pollutants and an increased likelihood of negative gross motor development. PM₁₀ was discovered to be considerably riskier for children's gross motor development (effect: - 1.83, 95% CI: - 3.04, - 0.62, p value = 0.002). Additionally, NO₂ exhibited indications of a tendency to be connected to a detrimental impact on children's gross motor development (effect - 0.18, 95% CI: - 0.42, 0.07, p value = 0.097).  Conclusion: Our study indicates that exposure to PM₁₀, PM_2.5, and NO₂, especially PM_2.5 and PM₁₀, is negatively associated with children's gross motor development. However, further research is required to determine how exposure to prenatal air pollution affects children's gross motor development. What is Known - What is New: • In this study, we provide an overview of emerging data related to PM10, PM2.5, and NO2 exposure in child development, especially on the gross motor function that continues to emerge, and key findings are highlighted. • Additionally, we summarize the evidence on the underlying effect of air pollution on gross motor function from human studies.. • Overall, we emphasize that evidence from human studies is critical in suggesting detrimental child health outcomes of an action to promote preventive strategies that will effectively protect children's health..

NICU-based stress response and preterm infant neurobehavior: exploring the critical windows for exposure

BACKGROUND

Exposure to maternal stress in utero negatively impacts cognitive and behavioral outcomes of children born at term. The neonatal intensive care unit (NICU) can be stressful for preterm infants during a developmental period corresponding to the third trimester of gestation. It is unknown whether stress in the NICU contributes to adverse neurodevelopment among NICU graduates. The aim was to examine the association between salivary cortisol and early neurodevelopment in preterm infants.

METHODS

We examined the association between cortisol levels during the NICU hospitalization and subsequent performance on the NICU Network Neurobehavioral Scales (NNNS), estimating time-specific associations and considering sex differences.

RESULTS

Eight hundred and forty salivary cortisol levels were measured from 139 infants. Average cortisol levels were inversely associated with NNNS Regulation scores for both male and female infants (β = -0.19; 95% CI: -0.44, -0.02). Critical developmental windows based on postmenstrual age were identified, with cortisol measured <30 weeks PMA positively associated with Habituation and Lethargy scores (β = 0.63-1.04). Critical developmental windows based on chronological age were identified, with cortisol measured in the first week of life inversely associated with Attention score (β = -1.01 for females; -0.93 for males).

CONCLUSIONS

Stress in the NICU at specific developmental time points may impact early preterm infant neurodevelopment.

IMPACT

Stress in the neonatal intensive care unit can impact the neurodevelopmental trajectory of premature infants. The impact of stress is different at different points in development. The impact of stress is sexually dimorphic.

Analysis of Neonatal Neurobehavior and Developmental Outcomes Among Preterm Infants

IMPORTANCE

The ability to identify poor outcomes and treatable risk factors among very preterm infants remains challenging; improving early risk detection and intervention targets to potentially address developmental and behavioral delays is needed.

OBJECTIVE

To determine associations between neonatal neurobehavior using the Neonatal Intensive Care Unit (NICU) Network Neurobehavioral Scale (NNNS), neonatal medical risk, and 2-year outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter cohort enrolled infants born at less than 30 weeks' gestation at 9 US university-affiliated NICUs. Enrollment was conducted from April 2014 to June 2016 with 2-year adjusted age follow-up assessment. Data were analyzed from December 2019 to January 2022.

EXPOSURES

Adverse medical and psychosocial conditions; neurobehavior.

MAIN OUTCOMES AND MEASURES

Bayley Scales of Infant and Toddler Development, third edition (Bayley-III), cognitive, language, and motor scores of less than 85 and Child Behavior Checklist (CBCL) T scores greater than 63. NNNS examinations were completed the week of NICU discharge, and 6 profiles of neurobehavior were identified by latent profile analysis. Generalized estimating equations tested associations among NNNS profiles, neonatal medical risk, and 2-year outcomes while adjusting for site, maternal socioeconomic and demographic factors, maternal psychopathology, and infant sex.

RESULTS

A total of 679 enrolled infants had medical and NNNS data; 2-year follow-up data were available for 479 mothers and 556 infants (mean [SD] postmenstrual age at birth, 27.0 [1.9] weeks; 255 [45.9%] female). Overall, 268 mothers (55.9%) were of minority race and ethnicity, and 127 (26.6%) lived in single-parent households. The most common neonatal medical morbidity was BPD (287 [51.7%]). Two NNNS behavior profiles, including 157 infants, were considered high behavioral risk. Infants with at least 2 medical morbidities (n = 123) were considered high medical risk. Infants with high behavioral and high medical risk were 4 times more likely to have Bayley-III motor scores less than 85 compared with those with low behavioral and low medical risk (adjusted relative risk [aRR], 4.1; 95% CI, 2.9-5.1). Infants with high behavioral and high medical risk also had increased risk for cognitive scores less than 85 (aRR, 2.7; 95% CI, 1.8-3.4). Only infants with high behavioral and low medical risk were in the clinical range for CBCL internalizing and total problem scores (internalizing: aRR, 2.3; 95% CI, 1.1-4.5; total: aRR, 2.5; 95% CI, 1.2-4.4).

CONCLUSIONS AND RELEVANCE

In this study, high-risk neonatal neurobehavioral patterns at NICU discharge were associated with adverse cognitive, motor, and behavioral outcomes at 2 years. Used in conjunction with medical risk, neonatal neurobehavioral assessments could enhance identification of infants at highest risk for delay and offer opportunities to provide early, targeted therapies.

Neonatal Intensive Care Unit Network Neurobehavioral Scale Profiles in Full-Term Infants: Associations with Maternal Adversity, Medical Risk, and Neonatal Outcomes

OBJECTIVES

To examine healthy, full-term neonatal behavior using the Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS) in relation to measures of maternal adversity, maternal medical risk, and infant brain volumes.

STUDY DESIGN

This was a prospective, longitudinal, observational cohort study of pregnant mothers followed from the first trimester and their healthy, full-term infants. Infants underwent an NNNS assessment and high-quality magnetic resonance imaging 2-5 weeks after birth. A latent profile analysis of NNNS scores categorized infants into neurobehavioral profiles. Univariate and multivariate analyses compared differences in maternal factors (social advantage, psychosocial stress, and medical risk) and neonatal characteristics between profiles.

RESULTS

The latent profile analysis of NNNS summary scales of 296 infants generated 3 profiles: regulated (46.6%), hypotonic (16.6%), and fussy (36.8%). Infants with a hypotonic profile were more likely to be male (χ2 = 8.601; P = .014). Fussy infants had smaller head circumferences (F = 3.871; P = .022) and smaller total brain (F = 3.522; P = .031) and cerebral white matter (F = 3.986; P = .020) volumes compared with infants with a hypotonic profile. There were no differences between profiles in prenatal maternal health, social advantage, or psychosocial stress.

CONCLUSIONS

Three distinct neurobehavioral profiles were identified in healthy, full-term infants with hypotonic and fussy neurobehavioral features related to neonatal brain volumes and head circumference, but not prenatal exposure to socioeconomic or psychosocial adversity. Follow-up beyond the neonatal period will determine if identified profiles at birth are associated with subsequent clinical or developmental outcomes.

A Neurologist's Guide to Neonatal Neurodevelopmental Assessments and Preterm Brain Injury

Despite advances in medical care and improved survival of extremely preterm infants, rates of neurodevelopmental impairment remain high. Outcomes are significantly improved with early intervention, but infants must be appropriately identified to facilitate services. Neuroimaging provides important information regarding neurodevelopmental outcomes but prognosticating and communicating risk remains challenging. Standardized neonatal neurodevelopmental assessments provide supplemental information to aid in the identification of high-risk infants and counseling for their families.

Effects of prenatal exposures to air sulfur dioxide/nitrogen dioxide on toddler neurodevelopment and effect modification by ambient temperature

Emerging evidence suggests that prenatal exposure to ambient SO2 or NO2 induces fetal brain-damage. However, effects of prenatal exposure to SO2 or NO2 on toddler neurodevelopment and the effect-modification by ambient temperature remain unclear. Therefore, a prospective birth-cohort study was conducted from 2010 to 2012 in Shanghai, and 225 mother-child pairs were followed-up from mid-to-late pregnancy until 24-36 months postpartum. During the whole pregnancy, daily SO2/NO2 and temperature levels were obtained for each woman. Gesell-Development-Schedule was used to assess toddler neurodevelopment in the domains of gross-motor, fine-motor, adaptive-behavior, language and social-behavior. Distributed-lag-nonlinear-models simultaneously accounting for exposure-response and lag-response associations were applied to assess the impacts of prenatal SO2/NO2 exposure on neurodevelopment. Each 10-μg/m3 increase in weekly average SO2 concentrations had adverse associations with gross-motor in gestational-weeks 1-6, with adaptive-behavior in weeks 26-30, and with language in weeks 30-36 (developmental-quotient changes: - 1.17% to - 0.12%, P-values < 0.05). Each 10-μg/m3 increase in weekly average NO2 concentrations had adverse associations with gross-motor in gestational-weeks 33-36, with fine-motor in weeks 26-36 and with social-behavior in weeks 31-36 (developmental-quotient changes: - 0.91% to - 0.20%, P-values < 0.05). The cumulative effects for the whole pregnancy showed that each 10-μg/m3 increase in SO2 induced significant deficits in gross-motor and adaptive-behavior (developmental-quotient changes: - 4.71% and - 4.06%, respectively, P < 0.05). We found prenatal cumulative SO2 exposure induced more deficits in low temperature in language and adaptive-behavior than in high/moderate temperature. Thus, prenatal ambient SO2/NO2 exposure in specific time-windows (1st and 3rd trimesters for SO2; 3rd trimester for NO2) could impair toddler neurodevelopment and low temperature may aggravate the SO2-induced neurotoxicity.

Urban environment and cognitive and motor function in children from four European birth cohorts

BACKGROUND

The urban environment may influence neurodevelopment from conception onwards, but there is no evaluation of the impact of multiple groups of exposures simultaneously. We investigated the association between early-life urban environment and cognitive and motor function in children.

METHODS

We used data from 5403 mother-child pairs from four population-based birth-cohorts (UK, France, Spain, and Greece). We estimated thirteen urban home exposures during pregnancy and childhood, including: built environment, natural spaces, and air pollution. Verbal, non-verbal, gross motor, and fine motor functions were assessed using validated tests at five years old. We ran adjusted multi-exposure models using the Deletion-Substitution-Addition algorithm.

RESULTS

Higher greenness exposure within 300 m during pregnancy was associated with higher verbal abilities (1.5 points (95% confidence interval 0.4, 2.7) per 0.20 unit increase in greenness). Higher connectivity density within 100 m and land use diversity during pregnancy were related to lower verbal abilities. Childhood exposure to PM2.5 mediated 74% of the association between greenness during childhood and verbal abilities. Higher exposure to PM2.5 during pregnancy was related to lower fine motor function (-1.2 points (-2.1, -0.4) per 3.2 μg/m3 increase in PM2.5). No associations were found with non-verbal abilities and gross motor function.

DISCUSSION

This study suggests that built environment, greenness, and air pollution may impact child cognitive and motor function at five years old. This study adds evidence that well-designed urban planning may benefit children's cognitive and motor development.

Application of the Neonatal Behavioral Assessment Scale to Evaluate the Neurobehavior of Preterm Neonates

Background: The neonatal behavioral assessment scale (NBAS) was primarily developed to aid in the assessment of full-term neonates. The aim of this study was to detect if the NBAS was also valuable in the assessment of preterm neonates. Materials and Methods: We assessed 112 infants at a neonatal unit using the NBAS, 4th edition. The inclusion criteria included an oxygen saturation level between 88–95% and a heartrate of 100–205 beats per minute. Infant neurobehavior was assessed using the NBAS. Results: For full-term and preterm neonates, we observed that the NBAS enabled us to assess both groups of infants and gave relevant information pertaining to them. We found a significant correlation between the average week of gestation and response to touch, sensory input, peak of excitement, cost of attention, hand-to-mouth, and quality of alertness. Conclusions: The NBAS is a valuable scale for evaluating the neurobehavior of preterm neonates. The week of gestation at birth affects certain aspects of neurobehavior, such as response to sensory input, putting hand to mouth, peak of excitement, and cost of attention. The NBAS as an individually structured assessment may help in planning for early rehabilitation and intervention for this vulnerable population.

A hybrid approach to predict daily NO2 concentrations at city block scale

Estimating the ambient concentration of nitrogen dioxide (NO2) is challenging because NO2 generated by local fossil fuel combustion varies greatly in concentration across space and time. This study demonstrates an integrated hybrid approach combining dispersion modeling and land use regression (LUR) to predict daily NO2 concentrations at a high spatial resolution (e.g., 50 m) in the New York tri-state area. The daily concentration of traffic-related NO2 was estimated at the Environmental Protection Agency's NO2 monitoring sites in the study area for the years 2015-2017, using the Research LINE source (R-LINE) model with inputs of traffic data provided by the Highway Performance and Management System and meteorological data provided by the NOAA Integrated Surface Database. We used the R-LINE-predicted daily concentrations of NO2 to build mixed-effects regression models, including additional variables representing land use features, geographic characteristics, weather, and other predictors. The mixed model was selected by the Elastic Net method. Each model's performance was evaluated using the out-of-sample coefficient of determination (R2) and the square root of mean squared error (RMSE) from ten-fold cross-validation (CV). The mixed model showed a good prediction performance (CV R2: 0.75-0.79, RMSE: 3.9-4.0 ppb). R-LINE outputs improved the overall, spatial, and temporal CV R2 by 10.0%, 18.9% and 7.7% respectively. Given the output of R-LINE is point-based and has a flexible spatial resolution, this hybrid approach allows prediction of daily NO2 at an extremely high spatial resolution such as city blocks.