Perinatal factors associated with the neurologic impairment of children born preterm

Development and validation of a nomogram prediction model for ADHD in children based on individual, family, and social factors

OBJECTIVES

A reliable, user-friendly, and multidimensional prediction tool can help to identify children at high risk for ADHD and facilitate early recognition and family management of ADHD. We aimed to develop and validate a risk nomogram for ADHD in children aged 3-17 years in the United States based on clinical manifestations and complex environments.

METHODS

A total of 141,356 cases were collected for the prediction model. Another 54,444 cases from a new data set were utilized for performing independent external validation. The LASSO regression was used to control possible variables. A final risk nomogram for ADHD was established based on logistic regression, and the discrimination and calibration of the established nomogram were evaluated by bootstrapping with 1000 resamples.

RESULTS

A final risk nomogram for ADHD was established based on 13 independent predictors, including behavioral problems, learning disabilities, age, intellectual disabilities, anxiety symptoms, gender, premature birth, maternal age at childbirth, parent-child interaction patterns, etc. The C-index of this model was 0.887 in the training set, and 0.862 in the validation set. Internal and external validation proved that the model was reliable.

CONCLUSIONS

A nomogram, a statistical prediction tool that assesses individualized ADHD risk for children is helpful for the early identification of children at high risk for ADHD and the construction of a conceptual model of society-family-school collaborative diagnosis, treatment, and management of ADHD.

Placental fetal vascular malperfusion, neonatal neurologic morbidity, and infant neurodevelopmental outcomes: a systematic review and meta-analysis

OBJECTIVE

This study aimed to evaluate the association of placental fetal vascular malperfusion lesions with neonatal brain injury and adverse infant neurodevelopmental outcomes.

DATA SOURCES

PubMed and Medline, Scopus, and Cochrane databases were searched from inception to July 2022.

STUDY ELIGIBILITY CRITERIA

We included cohort and case-control studies reporting the associations of fetal vascular malperfusion lesions with neonatal encephalopathy, perinatal stroke, intracranial hemorrhage, periventricular leukomalacia, and infant neurodevelopmental and cognitive outcomes.

METHODS

Data were analyzed by including fetal vascular malperfusion lesions as an exposure variable and brain injuries or neurodevelopmental impairment as outcomes using random-effects models. The effect of moderators, such as gestational age or study type, was assessed by subgroup analysis. Study quality and risk of bias were assessed by applying the Observational Study Quality Evaluation method.

RESULTS

Out of the 1115 identified articles, 26 were selected for quantitative analysis. The rates of neonatal central nervous system injury (neonatal encephalopathy or perinatal stroke) in term or near-term infants were more common among fetal vascular malperfusion cases (n=145) than among controls (n=1623) (odds ratio, 4.00; 95% confidence interval, 2.72-5.90). In premature deliveries, fetal vascular malperfusion lesions did not influence the risk of intracranial hemorrhage or periventricular leukomalacia (odds ratio, 1.40; 95% confidence interval, 0.90-2.18). Fetal vascular malperfusion-associated risk of abnormal infant neurodevelopmental outcome (314 fetal vascular malperfusion cases and 1329 controls) was modulated by gestational age being higher in term infants (odds ratio, 5.02; 95% confidence interval, 1.59-15.91) than in preterm infants (odds ratio, 1.70; 95% confidence interval, 1.13-2.56). Abnormal infant cognitive development and mental development were more common among fetal vascular malperfusion cases (n=241) than among controls (n=2477) (odds ratio, 2.14; 95% confidence interval, 1.40-3.27). The type of study (cohort vs case-control) did not influence the association between fetal vascular malperfusion and subsequent infant brain injury or abnormal neurodevelopmental outcome.

CONCLUSION

The findings of cohort and case-control studies indicate a considerable association between fetal vascular malperfusion placental lesions and increased risk of brain injury in term neonates, and neurodevelopmental impairment in both term and preterm infants. A diagnosis of placental fetal vascular malperfusion should be taken into consideration by both pediatricians and neurologists during the follow-up of infants at risk of adverse neurodevelopmental outcomes.

Maternal age as a risk factor for cerebral palsy

The relationship between maternal age and the occurrence of cerebral palsy is still highly controversial. The aim of the study was to examine the effect of maternal age on the risk of CP development, taking into account all significant risk factors and the division into single, twin, full-term, and pre-term pregnancies.

The survey covered 278 children with CP attending selected educational institutions in Poland. The control group consisted of data collected from the medical records of 435 children born at Limanowa county hospital, Poland. The analyses included socio-economic factors, factors related to pregnancy and childbirth, and factors related to the presence of comorbidities and diseases in the child. Constructed logistic regression models were used for statistical analyses.

For all age categories included in the estimated models (assessing the effect of demographic factors on the development of CP), only the category of ≤24 years of age (in the group of all children) was significant. It was estimated that in this mother’s age category, the risk of CP is lower (OR 0.6, 95% CI: 0.3–1.0) in comparison to mothers aged 25-29 (p = 0.03). However, estimation with the use of a complex logistic regression model did not show any significant effect of maternal age on the incidence of CP in groups from different pregnancies types.

It became apparent that maternal age is a weak predictor of CP, insignificant in the final logistic regression model. It seems correct to assume that the studies conducted so far, showing a significant effect of maternal age in this respect, may be associated with bias in the estimators used to assess the risk of CP due to the fact that other important risk factors for CP development were not included in the research.

Maternal Infection During Pregnancy and Risk of Cerebral Palsy in Children: A Systematic Review and Meta-analysis

BACKGROUND AND AIM

The association between maternal infection during pregnancy and the risk of cerebral palsy has been previously reported. However, their results were relatively inconsistent. This systematic review and meta-analysis were carried out to investigate the association between maternal infection during pregnancy and the risk of cerebral palsy in children.

METHODS

PubMed, Scopus, and Web of Sciences databases were searched from inception to October 28, 2019. Heterogeneity was assessed using the I² value. In case of substantial heterogeneity (I² > 50%), a random effects model was applied, otherwise, a fixed effects model was used. The pooled associations were expressed as relative risks (RRs) and 95% confidence intervals (CIs). Publication bias and quality of studies included in the systematic review were checked using the Egger's regression test and Newcastle-Ottawa Scale (NOS), respectively.

RESULTS

Thirty-seven studies were included in the systematic review. Among them, 21 studies were eligible for the meta-analysis. The pooled RR of cerebral palsy risk was 2.50 (95% CI 1.94, 3.21; I² = 88.7%, P < .001) among children born to mothers who had any infection during pregnancy. The risk was increased to 2.85 (95% CI 1.96, 4.15; I² = 75.9%, P < .001) when the mother was diagnosed with chorioamnionitis. Publication bias tests suggested no evidence of potential publication bias and 76% of the studies included in the meta-analysis were of high quality (NOS ≥ 6).

CONCLUSION

This systematic review and meta-analysis provides evidence that maternal infection during pregnancy may be associated with an increased risk of cerebral palsy in children.

The influence of neonatal infections on the development of cerebral palsy

One of the most significant biological factors predisposing to cerebral palsy (CP) are infections. The paper aims to analyze neonatal infections’ influence in the risk of CP development with consideration of all significant risk factors including single, twin, full-term and pre-term pregnancies.

278 children with CP attending the chosen school-educational centers in Poland were included in the questionnaire. The control group included data obtained from the medical documentation of 435 children born in Limanowa County Hospital, Poland. Socio-economic factors, factors connected with pregnancy, and the coexisting disorders and diseases in children were taken into consideration. Constructed models of logistic regression were applied in the statistical analysis.

Neonatal infections increase the risk of CP development in all children (odds ratio (OR) 5.1, 95% confidence interval (CI) 2.6–9.8), children from single pregnancies (OR 5.8, 95% CI: 3.0–11.29), full-term (OR 6.2, 95% CI: 3.2–12.3), and single full-term pregnancies (OR 6.0, 95% CI: 3.0–12.0). The influence of neonatal infections in the risk of CP development in children from pre-term and single premature pregnancies was not indicated.

Neonatal infections are an independent risk factor for CP development in newborns from full-term pregnancy (>37 weeks of pregnancy). The patho-mechanism of CP is different in children from full-term and premature pregnancy and results from interrelating factors are discussed in this paper.

Should the diagnostic criteria for suspected clinical chorioamnionitis be changed?

Purpose of review: The criteria for the diagnosis of intra-amniotic infection (IAI) were derived from a study of women at term in labor but is currently used as the main diagnostic tool for clinical chorioamnionitis. Regarding the inconsistent usage of the term, the diagnostic utility of clinical chorioamnionitis needs to be revisited. In this review, we addressed the critical issues on why the diagnostic criteria of suspected clinical chorioamnionitis should be changed.Recent findings: Overall, the accuracy of clinical chorioamnionitis to detect intra-amniotic infection (IAI) is not high, around 50%. The accuracy of each diagnostic criteria to diagnose IAI is, for example, 51.1% with maternal tachycardia, 57.8% with fetal tachycardia, and 55.6% with maternal leukocytosis. However, it needs to be reminded that these diagnostic performances had been obtained from term pregnancies but not from preterm pregnancies. Since there is a difference between clinical chorioamnionitis and histologic chorioamnionitis or even IAI, the diagnostic criteria of clinical chorioamnionitis would be ideal if it could directly predict the development of neonatal infectious outcomes. In fact, multiple definitions of clinical chorioamnionitis either in more lenient or stringent manner are currently used, which is responsible for inconsistent association of clinical chorioamnionitis with long-term neonatal outcomes. Whereas the diagnosis of clinical chorioamnionitis in preterm is followed by expeditious delivery, the diagnosis of clinical chorioamnionitis at term pregnancy is usually conducted in laboring women and requires additional neonatal evaluation for sepsis, which suggests different implications of clinical chorioamnionitis in preterm and term pregnancy.Summary: Current diagnostic criteria of clinical chorioamnionitis should be revised, specifically in terms of sensitivity in preterm pregnancy and specificity in term pregnancy.

Nutritional interventions to reduce symptoms in children and adults with attention deficit hyperactivity disorder: a scoping review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this scoping review is to examine and map reported nutritional interventions and their outcomes in relieving symptoms of attention deficit hyperactivity disorder (ADHD) in the daily lives of children and adults. A further objective is to determine if experiences of people diagnosed with ADHD, their relatives or staff in being on a diet or having to eat or avoid eating specific food items have been reported in the existing literature.Specifically the scoping review questions are.

Chorioamnionitis in the Development of Cerebral Palsy: A Meta-analysis and Systematic Review

CONTEXT

Chorioamnionitis (CA) has often been linked etiologically to cerebral palsy (CP).

OBJECTIVES

To differentiate association from risk of CA in the development of CP.

DATA SOURCES

PubMed, Cochrane Library, Embase, and bibliographies of original studies were searched by using the keywords (chorioamnionitis) AND ((cerebral palsy) OR brain).

STUDY SELECTION

Included studies had to have: (1) controls, (2) criteria for diagnoses, and (3) neurologic follow-up. Studies were categorized based on: (1) finding incidence of CP in a CA population, or risk of CP; and (2) incidence of CA in CP or association with CP.

DATA EXTRACTION

Two reviewers independently verified study inclusion and extracted data.

RESULTS

Seventeen studies (125 256 CA patients and 5 994 722 controls) reported CP in CA. There was significantly increased CP inpreterm histologic chorioamnionitis (HCA; risk ratio [RR] = 1.34, P < .01), but not in clinical CA (CCA). Twenty-two studies (2513 CP patients and 8135 controls) reported CA in CP. There was increased CCA (RR = 1.43, P < .01), but no increase in HCA in preterm CP. Increased HCA was found (RR = 4.26, P < .05), as well as CCA in term/near-term CP (RR = 3.06, P < .01).

CONCLUSIONS

The evidence for a causal or associative role of CA in CP is weak. Preterm HCA may be a risk factor for CP, whereas CCA is not. An association with term and preterm CP was found for CCA, but only with term CP for HCA.

Patterned feeding experience for preterm infants: study protocol for a randomized controlled trial

BACKGROUND

Neurobehavioral disabilities occur in 5-15% of preterm infants with an estimated 50-70% of very low birth weight preterm infants experiencing later dysfunction, including cognitive, behavioral, and social delays that often persist into adulthood. Factors implicated in poor neurobehavioral and developmental outcomes are hospitalization in the neonatal intensive care unit (NICU) and inconsistent caregiving patterns. Although much underlying brain damage occurs in utero or shortly after birth, neuroprotective strategies can stop lesions from progressing, particularly when these strategies are used during the most sensitive periods of neural plasticity occurring months before term age. The purpose of this randomized trial is to test the effect of a patterned feeding experience on preterm infants' neurobehavioral organization and development, cognitive function, and clinical outcomes.

METHODS

This trial uses an experimental, longitudinal, 2-group design with 120 preterm infants. Infants are enrolled within the first week of life and randomized to an experimental group receiving a patterned feeding experience from the first gavage feeding through discharge or to a control group receiving usual feeding care experience. The intervention involves a continuity of tactile experiences associated with feeding to train and build neuronal networks supportive of normal infant feeding experience. Primary outcomes are neurobehavioral organization as measured by Neurobehavioral Assessment of the Preterm Infant at 3 time points: the transition to oral feedings, NICU discharge, and 2 months corrected age. Secondary aims are cognitive function measured using the Bayley Scales of Infant and Toddler Development, Third Edition at 6 months corrected age, neurobehavioral development (sucking organization, feeding performance, and heart rate variability), and clinical outcomes (length of NICU stay and time to full oral feeding). The potential effects of demographic and biobehavioral factors (perinatal events and conditions of maternal or fetal/newborn origin and immunologic and genetic biomarkers) on the outcome variables will also be considered.

DISCUSSION

Theoretically, the intervention provided at a critical time in neurologic system development and associated with a recurring event (feeding) should enhance neural connections that may be important for later development, particularly language and other cognitive and neurobehavioral organization skills.

TRIAL REGISTRATION

NCT01577615 11 April 2012.

Environment as a risk factor in delayed development in premature, low-birthweight and mild asphyxia children

BACKGROUND

Premature infants with low birthweight (LBW) and asphyxia are at high risk of delay of language and visual-motor development. Environmental risk factors contributing to the delay include parents' education, family income, number of children in the family, exclusive breast-feeding, and the mother's parenting time. Lack of research in Indonesia on premature, LBW and mild asphyxia children minimizes information to parents on the importance of an optimal environment. The aim of this study was to observe the role of the environment as a risk factor for delay in language and visual-motor development.

METHODS

A cross-sectional study was carried out from June to December 2011 of 12-24-month-old children born premature, with LBW and mild asphyxia at the Hasan Sadikin, Bandung City, and Muhammadiyah Hospitals. Language and visual-motor development were measured by Capute scales. Risk factors were analyzed using chi-squared test and multivariate logistic regression analysis.

RESULTS

Of the 70 subjects, 49% had language and visual-motor delay. Environmental factors related to the delay were low parental education, low family income, non-exclusive breast-feeding (P < 0.001) and full-time maternal parenting (P < 0.05). On multivariate analysis non-exclusive breast-feeding was associated with a 175-fold risk (prevalence rate [PR], 174.756; 95% confidence interval [CI]: 10.407-2934.516, P < 0.001), and low family income, a 0.042-fold risk (PR 0.042; 95%CI: 0.005-0.321, P < 0.05).

CONCLUSION

Low family income and non-exclusive breast-feeding are risk factors for delay in language and visual-motor development in 12-24-month-old children born premature, with LBW and mild asphyxia.

Chorioamnionitis and cerebral palsy: lessons from a patient registry

AIM

The fetal neuroinflammatory response has been linked to the development of brain injury in newborns and subsequent neurologic impairment. We aimed to explore the maternal and child factors associated with histologic chorioamnionitis in cerebral palsy.

METHODS

We conducted an observational study on a cohort of children with cerebral palsy who were identified from the Quebec Cerebral Palsy Registry. Placental pathology was reported prospectively. Maternal and child factors associated with histological chorioamnionitis were explored.

RESULTS

Placental reports were available in 455 of 534 (85%) children with cerebral palsy, and of these 12% had histological signs of chorioamnionitis on reports. These children were more likely to have large placentas over 90th percentile for gestational age (53.7% versus 30.7%, p = 0.001) and were born significantly more prematurely (<32 weeks in 51.9% vs 24.1%, p = 0.007) than children without chorioamnionitis. A clinical sign of perinatal infection was reported in 61.1% of children with chorioamnionitis, however each clinical sign was seen in a minority of these children. Children with chorioamnionitis were more likely to have spastic diplegic cerebral palsy subtype (37% vs 19.2%, p = 0.003) and periventricular white matter injury on neuroimaging (52.9% vs 35.8%, p = 0.004). However no differences in neuroimaging or subtypes were seen when stratified by prematurity.

DISCUSSION

Histological chorioamnionitis was a frequent pathological finding in children with cerebral palsy born prematurely, with larger placentas relative to gestation and birth weight. Future case control studies are needed to shed light on the role of inflammatory placental findings in pregnancy outcomes.

Cerebral palsy in Al-Quseir City, Egypt: prevalence, subtypes, and risk factors

Cerebral palsy (CP) is the most frequent cause of motor handicap. The present door-to-door survey was conducted in Al-Quseir City, Egypt, to investigate the epidemiology of CP. All inhabitants were screened by three neurologists. Medical and neurological examinations were performed for all residents and suspected cases of CP were confirmed by meticulous neurological assessment, brain magnetic resonance imaging, electroencephalography, and testing with the Stanford-Binet Intelligence Scale. Forty-six of 12,788 children aged ≤18 years were found to have CP, yielding a childhood prevalence of 3.6 (95% confidence interval 1.48-2.59) per 1,000 live births. Five adults (aged 19-40 years) among 13,056 inhabitants had CP, giving an adult prevalence of 0.4 (95% confidence interval 0.04-0.72) per 1,000. The risk factors for CP identified in this study were premature birth, low birth weight, neonatal jaundice, neonatal seizures, and recurrent abortion in mothers of children with CP.

A model of neurodevelopmental risk and protection for preterm infants

The purpose of this article is to introduce a model of neurodevelopmental risk and protection that may explain some of the relationships among biobehavioral risks, environmental risks, and caregiving behaviors that potentially contribute to neurobehavioral and cognitive outcomes. Infants born before 30 weeks of gestation have the poorest developmental prognosis of all infants. These infants have lengthy hospitalization periods in the neonatal intensive care unit (NICU,) an environment that is not always supportive of brain development and long-term developmental needs. The model supports the premise that interventions focused on neuroprotection during the neonatal period have the potential to positively affect long-term developmental outcomes for vulnerable very preterm infants. Finding ways to better understand the complex relationships among NICU-based interventions and long-term outcomes are important to guiding caregiving practices in the NICU.

Neuropsychological Evaluation of High-Risk Children from Birth to Seven Years of Age

High Risk Children (HRC) are those with an increased risk of abnormal development due to any factor affecting neurological growth. Those factors have been the focus of most studies in this area. However, little is known about their long-term consequences over the course of child development. Objectives: the goal was to study the cognitive, emotional and academic outcomes of 7-year-old children diagnosed as HRC at birth. Method: We compared 14 HRC and 20 healthy children using the WISC-IV, BASC and Brunet-Lezine tests. Results: HRC showed cognitive, emotional and academic deficits compared with healthy children. However, Brunet-Lezine scores obtained over the course of development (6, 12, 18 and 24 months) were not predictive of the children's' current psychological status. Conclusions: long-term follow-up with HRC should be maintained until 7 years of age, at which point an appropriate treatment should be implemented.

The relationship between attention deficit hyperactivity disorder and premature infants in Taiwanese: a case control study

BACKGROUND

Preterm survivors from the neonatal intensive care unit (NICU) are considered to be at risk for some neurobehavioral disorders such as attention-deficit/hyperactivity disorder (ADHD). The current study aimed to explore the relationship between ADHD and premature infants in Taiwan.

METHODS

A total of 195 children (157 males and 38 females) diagnosed with ADHD based on DSM-IV and aged between 6 to 12 years and a control group of 212 (164 males, 48 females) age- and sex-matched healthy children were enrolled. The ADHD-Rating scale and CGI severity were performed by child psychiatrists. Demographic data of the children, including birth history, perinatal neurological and respiratory problems were collected to facilitate the investigation of whether a correlation exists between ADHD and prematurity.

RESULTS

The ADHD group had a significantly higher rate of prematurity and significantly higher rate of low birth body weight (defined as <2500 g) than the control group (both P=0.003). Pearson correlation showed a significantly negative correlation between gestational age and ADHD-RS score, inattentive score, hyperactivity and CGI-S score (P=0.004, 0.013, 0.015 and 0.002, respectively). However, only a CGI-S score (P=0.018) showed a significantly correlation between low birth weight and ADHD.

CONCLUSIONS

Premature infants have significantly more severe symptoms of ADHD at school age and they were highly correlated. Further study is necessary to determine the main effect and pathogenesis of moderate as well as extreme preterm birth on the development of ADHD.

Developmental outcome of very low birth weight infants in a developing country

Background

Advances in neonatal care allow survival of extremely premature infants, who are at risk of handicap. Neurodevelopmental follow up of these infants is an essential part of ongoing evaluation of neonatal care. The neonatal care in resource limited developing countries is very different to that in first world settings. Follow up data from developing countries is essential; it is not appropriate to extrapolate data from units in developed countries. This study provides follow up data on a population of very low birth weight (VLBW) infants in Johannesburg, South Africa.

Methods

The study sample included all VLBW infants born between 01/06/2006 and 28/02/2007 and discharged from the neonatal unit at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). Bayley Scales of Infant and Toddler Development Version 111 (BSID) 111 were done to assess development. Regression analysis was done to determine factors associated with poor outcome.

Results

178 infants were discharged, 26 were not available for follow up, 9 of the remaining 152 (5.9%) died before an assessment was done; 106 of the remaining 143 (74.1%) had a BSID 111 assessment. These 106 patients form the study sample; mean birth weight and mean gestational age was 1182 grams (SD: 197.78) and 30.81 weeks (SD: 2.67) respectively. The BSID (111) was done at a median age of 16.48 months. The mean cognitive subscale was 88.6 (95% CI: 85.69 - 91.59), 9 (8.5%) were < 70, mean language subscale was 87.71 (95% CI: 84.85 - 90.56), 10 (9.4%) < 70, and mean motor subscale was 90.05 (95% CI: 87.0 - 93.11), 8 (7.6%) < 70. Approximately one third of infants were identified as being at risk (score between 70 and 85) on each subscale. Cerebral palsy was diagnosed in 4 (3.7%) of babies. Factors associated with poor outcome included cystic periventricular leukomalacia (PVL), resuscitation at birth, maternal parity, prolonged hospitalisation and duration of supplemental oxygen. PVL was associated with poor outcome on all three subscales. Birth weight and gestational age were not predictive of neurodevelopmental outcome.

Conclusion

Although the neurodevelopmental outcome of this group of VLBW infants was within the normal range, with a low incidence of cerebral palsy, these results may reflect the low survival of babies with a birth weight below 900 grams. In addition, mean subscale scores were low and one third of the babies were identified as "at risk", indicating that this group of babies warrants long-term follow up into school going age.

A model of neurodevelopmental risk and protection for preterm infants

The purpose of this article is to introduce a model of neurodevelopmental risk and protection that may explain some of the relationships among biobehavioral risks, environmental risks, and caregiving behaviors that potentially contribute to neurobehavioral and cognitive outcomes. Infants born before 30 weeks of gestation have the poorest developmental prognosis of all infants. These infants have lengthy hospitalization periods in the neonatal intensive care unit (NICU,) an environment that is not always supportive of brain development and long-term developmental needs. The model supports the premise that interventions focused on neuroprotection during the neonatal period have the potential to positively affect long-term developmental outcomes for vulnerable very preterm infants. Finding ways to better understand the complex relationships among NICU-based interventions and long-term outcomes are important to guiding caregiving practices in the NICU.