Social variables predict gains in cognitive scores across the preschool years in children with birth weights 500 to 1250 grams

Neurodevelopmental outcome at 5.5 years in Dutch preterm infants born at 24-26 weeks' gestational age: the EPI-DAF study

OBJECTIVE

After lowering the Dutch threshold for active treatment from 25 to 24 completed weeks' gestation, survival to discharge increased by 10% in extremely preterm live born infants. Now that this guideline has been implemented, an accurate description of neurodevelopmental outcome at school age is needed.

DESIGN

Population-based cohort study.

SETTING

All neonatal intensive care units in the Netherlands.

PATIENTS

All infants born between 240/7 and 266/7 weeks' gestation who were 5.5 years' corrected age (CA) in 2018-2020 were included.

MAIN OUTCOME MEASURES

Main outcome measure was neurodevelopmental outcome at 5.5 years. Neurodevelopmental outcome was a composite outcome defined as none, mild or moderate-to-severe impairment (further defined as neurodevelopmental impairment (NDI)), using corrected cognitive score (Wechsler Preschool and Primary Scale of Intelligence Scale-III-NL), neurological examination and neurosensory function. Additionally, motor score (Movement Assessment Battery for Children-2-NL) was assessed. All assessments were done as part of the nationwide, standardised follow-up programme.

RESULTS

In the 3-year period, a total of 632 infants survived to 5.5 years' CA. Data were available for 484 infants (77%). At 5.5 years' CA, most cognitive and motor (sub)scales were significantly lower compared with the normative mean. Overall, 46% had no impairment, 36% had mild impairment and 18% had NDI. NDI-free survival was 30%, 49% and 67% in live born children at 24, 25 and 26 weeks' gestation, respectively (p<0.001).

CONCLUSIONS

After lowering the threshold for supporting active treatment from 25 to 24 completed weeks' gestation, a considerable proportion of the surviving extremely preterm children did not have any impairment at 5.5 years' CA.

Socioeconomic disadvantage and parental mood/affective problems links negative parenting and executive dysfunction in children born very preterm

Poverty increases the risk of poorer executive function (EF) in children born full-term (FT). Stressors associated with poverty, including variability in parenting behavior, may explain links between poverty and poorer EF, but this remains unclear for children born very preterm (VPT). We examine socioeconomic and parental psychosocial adversity on parenting behavior, and whether these factors independently or jointly influence EF in children born VPT. At age five years, 154 children (VPT = 88, FT = 66) completed parent-child interaction and EF tasks. Parental sensitivity, intrusiveness, cognitive stimulation, and positive and negative regard were coded with the Parent-Child Interaction Rating Scale. Socioeconomic adversity spanned maternal demographic stressors, Income-to-Needs ratio, and Area Deprivation Index. Parents completed measures of depression, anxiety, inattention/hyperactivity, parenting stress, and social-communication interaction (SCI) problems. Parental SCI problems were associated with parenting behavior in parents of children born VPT, whereas socioeconomic adversity was significant in parents of FT children. Negative parenting behaviors, but not positive parenting behaviors, were related to child EF. This association was explained by parental depression/anxiety symptoms and socioeconomic adversity. Results persisted after adjustment for parent and child IQ. Findings may inform research on dyadic interventions that embed treatment for parental mood/affective symptoms and SCI problems to improve childhood EF.

All Care is Brain Care: Neuro-Focused Quality Improvement in the Neonatal Intensive Care Unit

Neonates requiring intensive care are in a critical period of brain development that coincides with the neonatal intensive care unit (NICU) hospitalization, placing these infants at high risk of brain injury and long-term neurodevelopmental impairment. Care in the NICU has the potential to be both harmful and protective to the developing brain. Neuro-focused quality improvement efforts address 3 main pillars of neuroprotective care: prevention of acquired injury, protection of normal maturation, and promotion of a positive environment. Despite challenges in measurement, many centers have shown success with consistent implementation of best and potentially better practices that may improve markers of brain health and neurodevelopment.

Neonatal motor functional connectivity and motor outcomes at age two years in very preterm children with and without high-grade brain injury

Preterm-born children have high rates of motor impairments, but mechanisms for early identification remain limited. We hypothesized that neonatal motor system functional connectivity (FC) would relate to motor outcomes at age two years; currently, this relationship is not yet well-described in very preterm (VPT; born <32 weeks' gestation) infants with and without brain injury. We recruited 107 VPT infants - including 55 with brain injury (grade III-IV intraventricular hemorrhage, cystic periventricular leukomalacia, post-hemorrhagic hydrocephalus) - and collected FC data at/near term-equivalent age (35-45 weeks postmenstrual age). Correlation coefficients were used to calculate the FC between bilateral motor and visual cortices and thalami. At two years corrected-age, motor outcomes were assessed with the Bayley Scales of Infant and Toddler Development, 3rd edition. Multiple imputation was used to estimate missing data, and regression models related FC measures to motor outcomes. Within the brain-injured group only, interhemispheric motor cortex FC was positively related to gross motor outcomes. Thalamocortical and visual FC were not related to motor scores. This suggests neonatal alterations in motor system FC may provide prognostic information about impairments in children with brain injury.

Early neurodevelopmental follow-up in the NICHD neonatal research network: Advancing neonatal care and outcomes, opportunities for the future

At the inception of the Eunice Kennedy Shriver National Institute of Child Health and Development Neonatal Research Network (NRN), provision of care for extremely preterm (EPT) infants was considered experimental. The NRN Follow-up Study Group, initiated in 1993, developed infrastructure with certification processes and standards, allowing the NRN to assess 2-year outcomes for EPT and to provide important metrics for randomized clinical trials. This chapter will review the NRN Follow-up Study Group's contributions to understanding factors related to improved neurodevelopmental, behavioral, and social-emotional outcomes of EPT infants. We will also discuss follow up challenges, including reassessing which outcomes are most meaningful for parents and investigators. Finally, we will explore how outcome studies have informed clinical decisions and ethical considerations, given limitations of prediction of complex later childhood outcomes from early neurodevelopmental findings.

Association of Prenatal Exposure to Early-Life Adversity With Neonatal Brain Volumes at Birth

Importance

Exposure to early-life adversity alters the structural development of key brain regions underlying neurodevelopmental impairments. The association between prenatal exposure to adversity and brain structure at birth remains poorly understood.

Objective

To examine whether prenatal exposure to maternal social disadvantage and psychosocial stress is associated with neonatal global and regional brain volumes and cortical folding.

Design, Setting, and Participants

This prospective, longitudinal cohort study included 399 mother-infant dyads of sociodemographically diverse mothers recruited in the first or early second trimester of pregnancy and their infants, who underwent brain magnetic resonance imaging in the first weeks of life. Mothers were recruited from local obstetric clinics in St Louis, Missouri from September 1, 2017, to February 28, 2020.

Exposures

Maternal social disadvantage and psychosocial stress in pregnancy.

Main Outcomes and Measures

Confirmatory factor analyses were used to create latent constructs of maternal social disadvantage (income-to-needs ratio, Area Deprivation Index, Healthy Eating Index, educational level, and insurance status) and psychosocial stress (Perceived Stress Scale, Edinburgh Postnatal Depression Scale, Everyday Discrimination Scale, and Stress and Adversity Inventory). Neonatal cortical and subcortical gray matter, white matter, cerebellum, hippocampus, and amygdala volumes were generated using semiautomated, age-specific, segmentation pipelines.

Results

A total of 280 mothers (mean [SD] age, 29.1 [5.3] years; 170 [60.7%] Black or African American, 100 [35.7%] White, and 10 [3.6%] other race or ethnicity) and their healthy, term-born infants (149 [53.2%] male; mean [SD] infant gestational age, 38.6 [1.0] weeks) were included in the analysis. After covariate adjustment and multiple comparisons correction, greater social disadvantage was associated with reduced cortical gray matter (unstandardized β = -2.0; 95% CI, -3.5 to -0.5; P = .01), subcortical gray matter (unstandardized β = -0.4; 95% CI, -0.7 to -0.2; P = .003), and white matter (unstandardized β = -5.5; 95% CI, -7.8 to -3.3; P < .001) volumes and cortical folding (unstandardized β = -0.03; 95% CI, -0.04 to -0.01; P < .001). Psychosocial stress showed no association with brain metrics. Although social disadvantage accounted for an additional 2.3% of the variance of the left hippocampus (unstandardized β = -0.03; 95% CI, -0.05 to -0.01), 2.3% of the right hippocampus (unstandardized β = -0.03; 95% CI, -0.05 to -0.01), 3.1% of the left amygdala (unstandardized β = -0.02; 95% CI, -0.03 to -0.01), and 2.9% of the right amygdala (unstandardized β = -0.02; 95% CI, -0.03 to -0.01), no regional effects were found after accounting for total brain volume.

Conclusions and Relevance

In this baseline assessment of an ongoing cohort study, prenatal social disadvantage was associated with global reductions in brain volumes and cortical folding at birth. No regional specificity for the hippocampus or amygdala was detected. Results highlight that associations between poverty and brain development begin in utero and are evident early in life. These findings emphasize that preventive interventions that support fetal brain development should address parental socioeconomic hardships.

Cognitive Outcomes Following Intravitreal Bevacizumab for Retinopathy of Prematurity: 4- to 6-Year Outcomes in a Prospective Cohort

PURPOSE

To determine the long-term cognitive outcomes in children who underwent intravitreal bevacizumab (IVB) for retinopathy of prematurity (ROP).

DESIGN

Prospective cohort study.

METHODS

This single-center study enrolled 186 children between 3 and 6 years of age and included 101 children in the final analysis: premature without ROP (group 1), ROP not needing treatment (group 2), IVB monotherapy (group 3), IVB plus laser therapy (group 4), and laser monotherapy (group 5). The Full-Scale Intelligence Quotient (FSIQ) was evaluated by the Wechsler Preschool and Primary Scale of Intelligence Test at baseline and then annually for 1-2 years and compared among groups.

RESULTS

The age at cognitive evaluation was 4.5-4.9 years at baseline and 6.1-7.0 years at the last follow-up. The FSIQ was comparable among the groups at both time points (P = .08 and .50, respectively). Severe cognitive impairment (FSIQ < 70) was more common in group 4 at baseline (4%, 22%, 13%, 33%, and 0% in groups 1-5, respectively; P = .03) but did not differ among the groups at the last follow-up (6%, 0%, 4%, 22%, and 0%; P = .22). After adjusting for sex, Apgar score, neonatal adverse events, and days on mechanical ventilation, IVB was not associated with FSIQ either at baseline or at the last follow-up.

CONCLUSIONS

At 4.5 to beyond 6 years of age, children who underwent IVB monotherapy had comparable cognitive outcomes compared to the other premature children without prior IVB. Children who underwent IVB plus laser showed higher severe cognitive impairment at 4.5 years of age.

Placental programming, perinatal inflammation, and neurodevelopment impairment among those born extremely preterm

Individuals born extremely preterm are at significant risk for impaired neurodevelopment. After discharge from the neonatal intensive care, associations between the child's well-being and factors in the home and social environment become increasingly apparent. Mothers' prenatal health and socioeconomic status are associated with neurodevelopmental outcomes, and emotional and behavioral problems. Research on early life risk factors and on mechanisms underlying inter-individual differences in neurodevelopment later in life can inform the design of personalized approaches to prevention. Here, we review early life predictors of inter-individual differences in later life neurodevelopment among those born extremely preterm. Among biological mechanisms that mediate relationships between early life predictors and later neurodevelopmental outcomes, we highlight evidence for disrupted placental processes and regulated at least in part via epigenetic mechanisms, as well as perinatal inflammation. In relation to these mechanisms, we focus on four prenatal antecedents of impaired neurodevelopment, namely, (1) fetal growth restriction, (2) maternal obesity, (3) placental microorganisms, and (4) socioeconomic adversity. In the future, this knowledge may inform efforts to detect and prevent adverse outcomes in infants born extremely preterm. IMPACT: This review highlights early life risk factors and mechanisms underlying inter-individual differences in neurodevelopment later in life. The review emphasizes research on early life risk factors (fetal growth restriction, maternal obesity, placental microorganisms, and socioeconomic adversity) and on mechanisms (disrupted placental processes and perinatal inflammation) underlying inter-individual differences in neurodevelopment later in life. The findings highlighted here may inform efforts to detect and prevent adverse outcomes in infants born extremely preterm.

Early developmental interventions for infants born very preterm - what works?

Interventions are needed to enhance early development and minimise long-term impairments for children born very preterm (VP, <32 weeks' gestation) and their families. Given the role of the environment on the developing brain, the potential for developmental interventions that modify the infant's hospital and home environments to improve outcomes is high. Although early developmental interventions vary widely in focus, timing, and mode of delivery, evidence generally supports the effectiveness of these programs to improve specific outcomes for children born VP and their families. However, little is known about mechanisms for effectiveness, cost- and long-term effectiveness, which programs might work better for whom, and how to provide early intervention services equitably. This information is critical to facilitate systematic integration of effective developmental interventions into clinical care for infants born very preterm and their families.

Predicting School-Aged Cognitive Impairment in Children Born Very Preterm

BACKGROUND AND OBJECTIVES

Children born very preterm (VPT) are at high risk of cognitive impairment that impacts their educational and social opportunities. This study examined the predictive accuracy of assessments at 2, 4, 6, and 9 years in identifying preterm children with cognitive impairment by 12 years.

METHODS

We prospectively studied a regional cohort of 103 children born VPT (≤32 weeks' gestation) and 109 children born term from birth to corrected age 12 years. Cognitive functioning was assessed by using age-appropriate, standardized measures: Bayley Scales of Infant Development, Second Edition (age 2); Wechsler Preschool and Primary Scale of Intelligence (ages 4 and 6); and Wechsler Intelligence Scale for Children, Fourth Edition (ages 9 and 12).

RESULTS

By 12 years, children born VPT were more likely to have severe (odds ratio 3.9; 95% confidence interval 1.1-13.5) or any (odds ratio 3.2; 95% confidence interval 1.8-5.6) cognitive impairment compared with children born term. Adopting a severe cognitive impairment criterion at age 2 under-identified 44% of children born VPT with later severe impairment, whereas a more inclusive earlier criterion identified all severely affected children at 12 years. Prediction improved with age, with any delay at age 6 having the highest sensitivity (85%) and positive predictive value (66%) relative to earlier age assessments. Inclusion of family-social circumstances further improved diagnostic accuracy.

CONCLUSIONS

Cognitive risk prediction improves with age, with assessments at 6 years offering optimal diagnostic accuracy. Intervention for children with early mild delay may be beneficial, especially for those raised in socially disadvantaged family contexts.

Small-for-Gestational Age Birth Confers Similar Educational Performance through Middle School

OBJECTIVE

To estimate the association between small for gestational age (SGA) at birth and educational performance on standardized testing and disability prevalence in elementary and middle school.

STUDY DESIGN

Through linked birth certificates and school records, surviving infants born at 23-41 weeks of gestation who entered Florida's public schools 1998-2009 were identified. Twenty-three SGA definitions (3rd-25th percentile) were derived. Outcomes were scores on Florida Comprehensive Assessment Test (FCAT) and students' disability classification in grades 3 through 8. A "sibling cohort" subsample included families with at least 2 siblings from the same mother in the study period. Multivariable models estimated independent relationships between SGA and outcomes.

RESULTS

Birth certificates for 80.2% of singleton infants were matched to Florida public school records (N = 1 254 390). Unadjusted mean FCAT scores were 0.236 SD lower among <10th percentile SGA infants compared with non-SGA infants; this difference declined to -0.086 SD after adjusting for maternal and infant characteristics. When siblings discordant in SGA status were compared within individual families, the association declined to -0.056 SD. For SGA <10th percentile infants, the observed prevalence of school-age disability was 15.0%, 7.7%, and 6.3% for unadjusted, demographics-adjusted, and sibling analyses, respectively. No inflection or discontinuity was detected across SGA definitions from 3rd to 25th percentile in either outcome, and the associations were qualitatively similar.

CONCLUSIONS

The associations between SGA birth and students' standardized test scores and well-being were quantitatively small but persisted through elementary and middle school. The observed deficits were largely mitigated by demographic and familial factors.

Cognitive Development Trajectories in Preterm Children With Very Low Birth Weight Longitudinally Followed Until 11 Years of Age

Background: There is a high prevalence of cognitive dysfunction in very low birthweight (500–1250 g) infants (VLBW). Understanding long-term risk factors associated with cognitive development in preterm children requires longitudinal characterization. Thus, follow-up evaluations, including identification of risks and resilience influences–are important to promote health and cognitive abilities of children born preterm.

Aim: To examine changes in cognitive development from birth until 11 years of age in preterm children with very low birthweight.

Methods: 24 VLBW infants, at the Karolinska University Hospital, Stockholm, were assessed with regards to cognitive functioning at three times during development at 18 months, 5 and 11 years of age using standardized tests. Longitudinal data were analyzed using Generalized Estimating Equation (GEE) univariate and multivariate models.

Results: The follow-up rate was 100%. Level of cognitive functioning at 18 months and at 11 years was similar. Females had higher cognitive scores than males at all three timepoints. We found that intraventricular hemorrhage (IVH) and prolonged invasive ventilatory support (>7 days) had a negative effect on cognitive functioning. Higher levels of parental education had a favorable influence on cognitive functioning over time.

Conclusion: Level of cognitive development at 18 months was highly predictive of level of cognitive function at 11 years of age and differences in assessment scores between male and female VLBW infants persisted. Additional longitudinal studies, performed before school entry and across childhood, are needed to further elucidate the cognitive trajectories of preterm children.

Neurodevelopmental Follow-up of Preterm Infants: What Is New?

There is increasing evidence of ongoing changes occurring in short-term and long-term motor and language outcomes in former premature infants. As rates of moderate to severe cerebral palsy (CP) have decreased, there has been increased awareness of the impact of mild CP and of developmental coordination disorder on the preterm population. Language delays and disorders continue to be among the most common outcomes. In conjunction with medical morbidities, there is increased awareness of the negative impact of family psycho-socioeconomic adversities on preterm outcomes and of the importance of intervention for these adversities beginning in the neonatal ICU.

Neurocognitive function of 10-year-old multiples born less than 28 weeks of gestational age

INTRODUCTION

Few studies have examined the relationship between birth plurality and neurocognitive function among children born extremely preterm.

STUDY DESIGN

We compared rates of Z-scores ≤-2 on 18 tests of neurocognitive function and academic achievement at age 10 years in 245 children arising from twin pregnancies, 55 from triplet pregnancies, and 6 from a septuplet pregnancy to that of 568 singletons, all of whom were born before the 28th week of gestation.

RESULTS

In total, 874 children were evaluated at the age of 10 years. After adjusting for confounders, children of multifetal pregnancies performed significantly better on one of six subtests of executive function than their singleton peers. Performance was similar on all other assessments of intelligence, language, academic achievement, processing speed, visual perception, and fine motor skills.

CONCLUSION

We found no evidence that children born of multifetal pregnancies had worse scores than their singleton peers on assessments of neurocognitive and academic function.

Patient, Family, and Center-Based Factors Associated with Attrition in Neonatal Clinical Research: A Prospective Study

BACKGROUND

Attrition, or loss to follow-up, presents a significant threat to the integrity and validity of longitudinal clinical research. Little is known about predictors of attrition in neonatal clinical research, and no prior studies have examined how families' experiences participating in research with their infants influences study compliance.

OBJECTIVE

To identify novel factors that were associated with attrition over 1 year of study follow-up among preterm infants enrolled in the multicenter Prematurity and Respiratory Outcomes Program (PROP) observational study.

METHODS

At discharge, research coordinators estimated the likelihood of attrition. The parents completed questionnaires about their experience with the study at discharge and at 1 year corrected age. The primary endpoint was completion of 4 PROP interviews during the first year. Logistic models were used to evaluate the associations between infant, family, and center-based characteristics and attrition.

RESULTS

Among 318 children, 283 (89%) met the primary endpoint. In bivariate analyses, lower maternal education, more people in the household, public insurance, and site were associated with attrition (p < 0.05). Parent survey responses, infant characteristics, and site characteristics were unrelated to attrition. Coordinators' prediction of attrition was associated with completion of early study interviews; this effect waned over time. In multivariable analyses, lower maternal education and more people in the household were the factors most strongly associated with attrition.

CONCLUSION

Future neonatal research should evaluate novel strategies to decrease the burden associated with study participation and reinforcement of study goals with families who have lower educational levels to facilitate participation and decrease attrition bias.

Social Adversity and Cognitive, Language, and Motor Development of Very Preterm Children from 2 to 5 Years of Age

OBJECTIVE

To assess the extent to which social and family factors explain variability in cognitive, language, and motor development among very preterm (<30 weeks of gestation) children from 2 to 5 years of age.

STUDY DESIGN

As part of a longitudinal study, very preterm children recruited as neonates were assessed at 2 (n = 87) and 5 (n = 83) years of age using standardized tests of cognitive, language, and motor ability alongside demographically matched full term (FT) children (n = 63). For very preterm children, developmental change scores were calculated for each domain to assess within-individual variability to 5 years of age. Multivariate regression and mixed-effect models examined social risk index, parenting stress, family functioning, and maternal intellectual ability as predictors of developmental variation among very preterm children.

RESULTS

Very preterm children demonstrated poorer cognitive, language, and motor abilities than FT children at 2 (P ≤ .001) and 5 (P < .002) years of age. Social adversity was associated with cognitive (P < .001) and language (P < .001) outcomes at both ages, with parenting stress also related to cognitive outcomes (P = .03). Infant medical risk was associated with motor outcome at 5 years (P=.01). Very preterm children showed considerable within-individual variation between assessments. Among very preterm children, neonatal white matter abnormalities predicted worsening cognitive (P=.04) and motor development (P = .01). Social risk index predicted worsening language development (P = .04), but this association was subsequently explained by dysfunctional maternal affective involvement (P = .01) and lower maternal intellectual ability (P = .05).

CONCLUSIONS

Both clinical and socioenvironmental factors are associated with cognitive, language, and motor developmental variation among very preterm children from infancy to early school age.

Prediction of long-term neurodevelopmental outcome in preterm infants using trajectories of general movement assessments

OBJECTIVE

To assess the predictive value of trajectories and individual assessment of quality of general movements (AQGM) for identification of neurodevelopmental impairment (NDI) at 18-24 months corrected age (CA) in infants <30 weeks gestational age and/or birth weight <1500 g.

METHODS

In this retrospective cohort study, AQGM at 6 weeks and 3 months CA were scored and categorized as normal (N) or abnormal (A). AQGM measures were compared with degree of NDI and Bayley Scales of Infant Development, Third Edition (BSID-III) composite motor and cognitive scores. 'Persistently abnormal' AQGM included both mildly abnormal (MA) and definitely abnormal (DA) assessments. A "modified AQGM" where MA assessments were considered normal variant/transient injury was used to conduct post-hoc analysis.

RESULTS

Across 244 cases, persistently abnormal AQGM trajectory predicted the level of NDI (OR 2.5, 95% CI 1.2, 5.1) compared to AQGM trajectory that normalized. However, using the "modified AQGM", persistently DA trajectories were associated with significantly lower BSID-III composite motor and cognitive scores (p < 0.001 and p = 0.039, respectively).

CONCLUSION

Categorizing MA assessments as transient injury increased the predictive value of AQGM trajectories and significantly predicted lower cognitive and motor scores at 18-24 months CA.

What Are We Measuring as Outcome? Looking Beyond Neurodevelopmental Impairment

Outcomes of neonatal intensive care unit (NICU) graduates have been categorized by rates of neurodevelopmental impairment at 2 years old. Although useful as metrics for research, these early childhood assessments may underestimate or overestimate later functional capabilities. Often overlooked are less severe but more prevalent neurobehavioral dysfunctions seen later in childhood, and chronic health concerns that may impact the child's quality of life (QoL). Comprehensive NICU follow-up should include measures of less severe cognitive/learning delays, physical/mental well-being, and the promotion of resilience in children and families. Studies are needed to identify QoL measures that will optimize children's assessments and outcomes.

Neurodevelopmental Outcomes of Preterm Children at School Age and Beyond

Despite improved survival of preterm infants, there has not been an equivalent improvement in long-term neurodevelopmental outcomes. Adverse neurodevelopmental outcome rates and severity are inversely related to the degree of prematurity, but only 1.6% are born very preterm and the motor, cognitive, behavioral, and psychiatric disabilities in the large moderate and late preterm population have a greater impact. The disability-free preterm adult has a lower educational achievement and income but similar health-related quality of life to term controls. Reducing the long-term neurodevelopmental impact of prematurity is the next frontier of neonatal care.

Do preterm infants with a birth weight ≤1250 g born to single-parent families have poorer neurodevelopmental outcomes at age 3 than those born to two-parent families?

OBJECTIVE

Investigate neurodevelopmental outcomes at 3 years corrected age in infants with a birth weight ≤1250 g born to single parents.

STUDY DESIGN

Infants born between 1995 and 2010 with a birth weight ≤1250 g were considered eligible. Primary outcome was neurodevelopmental impairment; considered present if a child had any of the following: cerebral palsy, cognitive delay, visual impairment, or deafness/neurosensory hearing impairment. Univariate and multivariate analyses were performed.

RESULT

A total of 1900 infants were eligible for inclusion. Follow-up data were available for 1395; 88 were born to a single parent. Infants in the single-parent group had higher mortality (18% vs. 11%, p = 0.009), IQ ≥1 SD below the mean (40% vs. 21%, p = 0.001) and any neurodevelopmental impairment (47% vs. 29%, p = 0.003). Single-parent family status, maternal education, bronchopulmonary dysplasia and severe neurological injury were significant predictors of intellectual impairment at 3 years corrected age.

CONCLUSION

Preterm infants with a birth weight ≤1250 g born to single parents at birth have poorer intellectual functioning at 3 years corrected age.

The impact of prematurity and maternal socioeconomic status and education level on achievement-test scores up to 8th grade

BACKGROUND

The relative influence of prematurity vs. maternal social factors (socioeconomic status and education level) on academic performance has rarely been examined.

OBJECTIVE

To examine the impact of prematurity and maternal social factors on academic performance from 3rd through 8th grade.

METHODS

We conducted a retrospective cohort study of infants born in 1998 at the University of Arkansas for Medical Sciences. The study sample included 58 extremely low gestational age newborns (ELGANs, 23‒<28 weeks), 171 preterm (≥28‒<34 weeks), 228 late preterm (≥34‒<37 weeks), and 967 term ((≥37‒<42 weeks) infants. Neonatal and maternal variables were collected including maternal insurance status (proxy measure for socioeconomic status) and education level. The primary outcomes were literacy and mathematics achievement-test scores from 3rd through 8th grade. Linear mixed models were used to identify significant predictors of academic performance. All two-way interactions between grade level, gestational-age (GA) groups, and social factors were tested for statistical significance.

RESULTS

Prematurity, social factors, gender, race, gravidity, and Apgar score at one minute were critical determinants of academic performance. Favorable social factors were associated with a significant increase in both literacy and mathematic scores, while prematurity was associated with a significant decrease in mathematic scores. Examination of GA categories and social factors interaction suggested that the impact of social factors on test scores was similar for all GA groups. Furthermore, the impact of social factors varied from grade to grade for literacy, while the influence of either GA groups or social factors was constant across grades for mathematics. For example, an ELGAN with favorable social factors had a predicted literacy score 104.1 (P <.001), 98.2 (P <.001), and 76.4 (P <.01) points higher than an otherwise similar disadvantaged term infant at grades 3, 5, and 8, respectively. The difference in their predicted mathematic scores was 33.4 points for all grades (P <.05).

CONCLUSION

While there were significant deficits in academic performance for ELGANs compared to PT, LPT, and term infants, the deficit could be offset by higher SES and better-educated mothers. These favorable social factors were critical to a child's academic achievement. The role of socioeconomic factors should be incorporated in discussions on outcome with families of preterm infants.

Maternal educational status at birth, maternal educational advancement, and neurocognitive outcomes at age 10 years among children born extremely preterm

BackgroundTo determine if a key marker of socioeconomic status, maternal education, is associated with later neurocognitive and academic outcomes among children born extremely preterm (EP).MethodEight hundred and seventy-three children born at 23 to 27 weeks of gestation were assessed for cognitive and academic ability at age 10 years. With adjustments for gestational age (GA) and potential confounders, outcomes of children whose mothers had fewer years of education at the time of delivery and children whose mother advanced in education between birth and 10 years were examined.ResultsChildren of mothers in the lowest education stratum at birth were significantly more likely to score ≥2 SDs below normative expectation on 17 of 18 tests administered. Children of mothers who advanced in education (n=199) were at reduced risk for scoring ≥2 SDs on 15 of 18 measures, but this reduction was statistically significant on only 2 of 18 measures.ConclusionAmong EP children, socioeconomic disadvantage at birth, indexed by maternal education, is associated with significantly poorer neurocognitive and academic outcomes at 10 years of age, independently of GA. Maternal educational advancement during the child's first 10 years of life is associated with modestly improved neurocognitive outcomes.

How do childhood intelligence and early psychosocial adversity influence income attainment among adult extremely low birth weight survivors? A test of the cognitive reserve hypothesis

Perinatal and later postnatal adversities have been shown to adversely affect socioeconomic trajectories, while enhanced early cognitive abilities improve them. However, little is known about the combined influence of these exposures on social mobility. In this study, we examined if childhood IQ moderated the association between four different types of postnatal adversity (childhood socioeconomic disadvantage, childhood sexual abuse, lifetime psychiatric disorder, and trait neuroticism) and annual earnings at 30-35 years of age in a sample of 88 extremely low birth weight survivors. Our results suggested that higher childhood IQ was associated with greater personal income at age 30-35. Extremely low birth weight survivors who did not face psychological adversities and who had higher childhood IQ reported higher income in adulthood. However, those who faced psychological adversity and had higher childhood IQ generally reported lower income in adulthood. Our findings suggest that cognitive reserve may not protect preterm survivors against the complex web of risk factors affecting their later socioeconomic attainment.

Pain coping strategies: Neonatal intensive care unit survivors in adolescence

BACKGROUND

Data on long-term consequences of preterm birth on pain coping later in life are limited.

AIM

To assess whether gestational age, birth weight and neonatal disease severity have effect on pain coping style in adolescents born preterm or with low birth weight.

STUDY DESIGN

Observational, longitudinal study (Project On Preterm and SGA-infants, POPS-19).

SUBJECTS

We analyzed data of 537 adolescents at the age of 19 years, who were born at a gestational age <32 weeks or with a birth weight <1500g.

OUTCOME MEASURES

Participants completed the pain coping questionnaire (PCQ) that assesses pain coping strategies in three higher-order factors: approach ("to deal with pain"), problem-focused avoidance ("to disengage from pain") and emotion-focused avoidance ("expression of pain"). Furthermore, their pain coping effectiveness, pain controllability and emotional reactions to pain were assessed. All participants completed an IQ test.

RESULTS

Univariate analysis showed no significant correlation between length of stay, sepsis and necrotizing enterocolitis and any of the higher-order factors. Approach was only correlated with IQ. Problem-focused avoidance was, in the multiple regression analysis (including gestational age, IVH and IQ), only correlated with IQ. For emotion-focused avoidance (including birth weight, SGA, IVH, respiratory support and IQ) three independent predictors remained: IVH was positively correlated, while respiratory support and IQ were negatively correlated with emotion-focused avoidance.

CONCLUSIONS

Early neonatal characteristics and neonatal disease severity have limited effect on pain coping style in adolescence. Higher IQ was associated with the use of adaptive coping strategies, while maladaptive strategies were used less.

School-Aged Outcomes following Prenatal Methamphetamine Exposure: 7.5-Year Follow-Up from the Infant Development, Environment, and Lifestyle Study

OBJECTIVE

To assess the relationship between prenatal methamphetamine exposure (PME) and behavior problems at age 7.5 years and the extent to which early adversity mediated this relationship.

STUDY DESIGN

The multicenter, longitudinal Infant Development, Environment, and Lifestyle study enrolled 412 mother-infant pairs at 4 sites. Methamphetamine-exposed participants (n = 204) were identified by self-report and/or gas chromatography/mass spectrometry confirmation of amphetamine and metabolites in infant meconium. Matched participants (n = 208) denied methamphetamine use and had a negative meconium screen. At the 7.5-year follow-up, 290 children with complete Child Behavior Checklist data and an early adversity index score were available for analysis (n = 146 exposed).

RESULTS

PME was significantly associated with an increased early adversity index score (P < .001) and with increased externalizing, rule-breaking behavior, and aggressive behavior (P < .05). Early adversity was also associated with higher externalizing behavior scores. Early adversity significantly mediated the relationship between PME and behavioral problems. After adjusting the mediation model for sex, prenatal tobacco, alcohol, and marijuana exposures, and study site, the association of PME with early adversity remained significant.

CONCLUSIONS

Though PME is associated with behavioral problems, early adversity may be a strong determinant of behavioral outcome for children exposed to methamphetamine in utero. Early adversity significantly mediated the relationship between PME and behavioral problems.

Short- and Long-Term Outcomes for Extremely Preterm Infants

Prematurity is the leading cause of infant mortality worldwide. In developed countries, extremely preterm infants contribute disproportionately to both neonatal and infant mortality. Survival of this high-risk population has incrementally improved in recent years. Despite these improvements, approximately one in four extremely preterm infants dies during the birth hospitalization. Among those who survive, respiratory and other morbidities are common, although their effect on quality of life is variable. In addition, long-term neurodevelopmental impairment is a large concern for patients, clinicians, and families. However, the interplay of multiple factors contributes to neurodevelopmental impairment, with measures that change over time and outcomes that can be difficult to define and predict. Understanding outcomes of extremely preterm infants can help better counsel families regarding antenatal and postnatal care and guide strategies to improve survival without morbidity. This review summarizes recent evidence to provide an overview into the short- and long-term outcomes for extremely preterm infants.

Mortality and Major Morbidity of Very-Low-Birth-Weight Infants in Germany 2008-2012: A Report Based on Administrative Data

BACKGROUND

Expectant parents of very preterm infants, physicians, and policy makers require estimates for chances of survival and survival without morbidity. Such estimates should derive from a large, reliable, and contemporary data base of easily available items known at birth.

OBJECTIVE

To determine short-term outcome and risk factors in very-low-birth-weight preterm infants based on administrative data.

METHODS

Anonymized routine data sets transmitted from hospital administrations to statutory health insurance companies were used to assess survival and survival free of major morbidities in a large cohort of preterm infants in Germany.

RESULTS

After exclusion of infants with lethal malformations, there were 13,147 infants with a birth weight below 1,500 g admitted to neonatal care 2008-2012, of whom 1,432 infants (10.9%) died within 180 days. Estimated 180 days survival probabilities were 0.632 (95% confidence interval 0.583-0.677) for infants with 250-499 g birth weight, 0.817 (0.799-0.834) for 500-749 g, 0.931 (0.920-0.940) for 750-999 g, 0.973 (0.967-0.979) for 1,000-1,249 g, and 0.985 (0.981-0.988) for 1,250-1,499 g. Estimated probabilities for survival without major morbidity (surgically treated intraventricular hemorrhage, necrotizing enterocolitis, intestinal perforation, or retinopathy) were 0.433 (0.384-0.481) for 250-499 g, 0.622 (0.600-0.643) for 500-749 g, 0.836 (0.821-0.849) for 750-999 g, 0.938 (0.928-0.946) for 1,000-1,249 g, and 0.969 (0.964-0.974) for 1,250-1,499 g, respectively. Prediction of survival and survival without major morbidities was moderately improved by adding sex, small for gestational age, and severe or moderate congenital malformation, increasing receiver operating characteristic areas under the curve from 0.839 (0.827-0.850) to 0.862 (0.852-0.874) (survival) and from 0.827 (0.822-0.842) to 0.852 (0.846-0.863) (survival without major morbidities), respectively.

CONCLUSION

The present analysis encourages attempts to use administrative data to investigate the association between risk factors and outcome in preterm infants.