Motor learning and working memory in children born preterm: a systematic review

Timed fetal inflammation and postnatal hypoxia cause cortical white matter injury, interneuron imbalances, and behavioral deficits in a double-hit rat model of encephalopathy of prematurity

Extreme preterm birth-associated adversities are a major risk factor for aberrant brain development, known as encephalopathy of prematurity (EoP), which can lead to long-term neurodevelopmental impairments. Although progress in clinical care for preterm infants has markedly improved perinatal outcomes, there are currently no curative treatment options available to combat EoP. EoP has a multifactorial etiology, including but not limited to pre- or postnatal immune activation and oxygen fluctuations. Elucidating the underlying mechanisms of EoP and determining the efficacy of potential therapies relies on valid, clinically translatable experimental models that reflect the neurodevelopmental and pathophysiological hallmarks of EoP. Here, we expand on our double-hit rat model that can be used to study EoP disease mechanisms and therapeutic options in a preclinical setting. Pregnant Wistar dams were intraperitoneally injected with 10 μg/kg LPS on embryonic day (E)20 and offspring was subjected to hypoxia (140 min, 8% O2) at postnatal day 4. Rats exposed to fetal inflammation and postnatal hypoxia (FIPH) showed neurodevelopmental impairments, such as reduced nest-seeking ability, ultrasonic vocalizations, social engagement, and working memory, and increased anxiety and sensitivity. Impairments in myelination, oligodendrocyte maturation and interneuron development were examined as hallmarks for EoP, in different layers and coordinates of the cortex using histological and molecular techniques. Myelin density and complexity was decreased in the cortex, which partially coincided with a decrease in mature oligodendrocytes. Furthermore, interneuron populations (GAD67+ and PVALB+) were affected. To determine if the timing of inducing fetal inflammation affected the severity of EoP hallmarks in the cortex, multiple timepoints of fetal inflammation were compared. Inflammation at E20 combined with postnatal hypoxia gave the most severe EoP phenotype in the cortex. In conclusion, we present a double-hit rat model which displays various behavioral, anatomical and molecular hallmarks of EoP, including diffuse white matter injury. This double-hit model can be used to investigate pathophysiological mechanisms and potential therapies for EoP.

Optimizing Neonatal Prefeeding Habilitation: A Holistic Approach Integrating Neonatal Learning Behaviors, Motor Development, and Evidence-Based Interventions

Neonatal clinicians utilize prefeeding interventions with premature infants to promote a natural process of oral-sensory development, hoping to prepare the infant for future oral feeding. Prefeeding interventions require a holistic approach, ensuring infants are actively involved in learning. Therapists can achieve this by prioritizing the development of intentionality, which is the conscious pursuit of action driven by motivation. The authors present a conceptual model of six neonatal behavioral states of learning called the "Neonatal Intentional Capacities." This model illustrates how purposeful actions evolve into extended learning sequences and helps determine how well an infant can participate in learning experiences. The authors will elucidate the dynamic relationship between intentionality and the development of adaptive motor skills of prefeeding. Lastly, this article presents a consolidated and categorized grouping of current evidence-based prefeeding interventions. Utilizing the framework presented, the authors offer clinical guidance to support prefeeding treatment planning.

Care Pathways in Rehabilitation for Children and Adolescents with Cerebral Palsy: Distinctiveness of the Adaptation to the Italian Context

BACKGROUND

In 2020, a multiprofessional panel was set up in collaboration with the Italian FightTheStroke Foundation family association to produce evidence-based recommendations for the management and neuromotor rehabilitation of persons with cerebral palsy aged 2-18 years to implement in clinical practice in Italy.

METHODS

The recommendations of these care pathways were developed according to the American Academy for Cerebral Palsy and Developmental Medicine guidelines for Care Pathways Development and the Grading of Recommendations Assessment Development and Evaluation working group for adoption, adaptation, or de novo development of recommendations from high-quality guidelines (GRADE-ADOLOPMENT).

RESULTS

Four strong positive recommendations were developed regarding comprehensive management, and twenty-four addressed neuromotor treatment.

CONCLUSIONS

A holistic, individualized approach was affirmed in terms of both multidimensional patient profile and interdisciplinary management in a network with the school where children and adolescents are integrated. It was defined that all motor rehabilitation approaches must be individually tailored considering age and developmentally appropriate activities as interventions and goals, in light of the reference curves addressing prognosis for Gross Motor Function and Manual Ability Classification Systems. Intervention must be structured with adaptations of the task and/or of the context (objects and environment) based on the analysis of the child's skills to support motivation and avoid frustration.

Biological and environmental factors may affect children's executive function through motor and sensorimotor development: Preterm birth and cerebral palsy

Disruptive biological and environmental factors may undermine the development of children's motor and sensorimotor skills. Since the development of cognitive skills, including executive function, is grounded in early motor and sensorimotor experiences, early delays or impairments in motor and sensorimotor processing often trigger dynamic developmental cascades that lead to suboptimal executive function outcomes. The purpose of this perspective paper is to link early differences in motor/sensorimotor processing to the development of executive function in children born preterm or with cerebral palsy. Uncovering such links in clinical populations would improve our understanding of developmental pathways and key motor and sensorimotor skills that are antecedent and foundational for the development of executive function. This knowledge will allow the refinement of early interventions targeting motor and sensorimotor skills with the goal of proactively improving executive function outcomes in at-risk populations.

Evidence-based management and motor rehabilitation of cerebral palsy children and adolescents: a systematic review

Background

Evidence regarding the management of several aspects of cerebral palsy improved in recent years. Still, discrepancies are reported in clinical practice. Italian professionals and stakeholders expressed the need of setting up updated, evidenced-based, shared statements, to address clinical practice in cerebral palsy rehabilitation. The objective of the present study was to provide an updated overview of the state of knowledge, regarding the management and motor rehabilitation of children and young people with cerebral palsy, as the framework to develop evidence-based recommendations on this topic.

Methods

Guidelines and systematic reviews were searched, relative to evidence-based management and motor treatment, aimed at improving gross motor and manual function and activities, in subjects with cerebral palsy, aged 2-18 years. A systematic search according to the Patients Intervention Control Outcome framework was executed on multiple sites. Independent evaluators provided selection and quality assessment of the studies and extraction of data.

Results

Four guidelines, 43 systematic reviews, and three primary studies were included. Agreement among guidelines was reported relative to the general requirements of management and motor treatment. Considering the subject's multidimensional profile, age and developmentally appropriate activities were recommended to set individual goals and interventions. Only a few approaches were supported by high-level evidence (i.e., bimanual therapy and constraint-induced movement therapy to enhance manual performance). Several task-specific active approaches, to improve gross motor function and gait, were reported (mobility and gait training, cycling, backward gait, and treadmill), based on low-level evidence. Increasing daily physical activity and countering sedentary behavior were advised. Based on the available evidence, non-invasive brain stimulation, virtual reality, action-observation therapy, hydrotherapy, and hippotherapy might be complementary to task or goal-oriented physical therapy programs.

Conclusion

A multiple-disciplinary family-centered evidence-based management is recommended. All motor rehabilitation approaches to minors affected by cerebral palsy must share the following fundamental characteristics: engaging active involvement of the subject, individualized, age and developmentally appropriate, goal-directed, skill-based, and preferably intensive and time-limited, but suitable for the needs and preferences of the child or young person and their family, and feasible considering the implications for themselves and possible contextual limitations.

Associations Between Preterm Birth, Inhibitory Control-Implicated Brain Regions and Tracts, and Inhibitory Control Task Performance in Children: Consideration of Socioeconomic Context

Preterm birth (PTB) is associated with increased risk for unfavorable outcomes such as deficits in attentional control and related brain structure alterations. Crucially, PTB is more likely to occur within the context of poverty. The current study examined associations between PTB and inhibitory control (IC) implicated brain regions/tracts and task performance, as well as the moderating role of early life poverty on the relation between PTB and IC-implicated regions/tracts/task performance. 2,899 children from the ABCD study were sampled for this study. Mixed effects models examined the relation between PTB and subsequent IC performance as well as prefrontal gray matter volume, white matter fractional anisotropy (FA), and mean diffusivity (MD). Household income was examined as a moderator. PTB was significantly associated with less improvement in IC task performance over time and decreased FA in left uncinate fasciculus (UF) and cingulum bundle (CB). Early life poverty moderated the relation between PTB and both CB FA and UF MD.

Electromyographic biofeedback-driven gaming to alter calf muscle activation during gait in children with spastic cerebral palsy

BACKGROUND

Children with cerebral palsy often show deviating calf muscle activation patterns during gait, with excess activation during early stance and insufficient activation during push-off.

RESEARCH QUESTION

Can children with cerebral palsy improve their calf muscle activation patterns during gait using one session of biofeedback-driven gaming?

METHODS

Eighteen children (6-17 y) with spastic cerebral palsy received implicit game-based biofeedback on electromyographic activity of the calf muscle (soleus or gastrocnemius medialis) while walking on a treadmill during one session. Biofeedback alternately aimed to reduce early stance activity, increase push-off activity, and both combined. Early stance and push-off activity and the double-bump-index (early stance divided by push-off activity) were determined during baseline and walking with feedback. Changes were assessed at group level using repeated measures ANOVA with simple contrast or Friedman test with post-hoc Wilcoxon signed rank test, as well as individually using independent t-tests or Wilcoxon rank sum tests. Perceived competence and interest-enjoyment were assessed through a questionnaire.

RESULTS

Children successfully decreased their electromyographic activity during early stance feedback trials (relative decrease of 6.8 ± 12.2 %, P = 0.025), with a trend during the combined feedback trials (6.5 ± 13.9 %, P = 0.055), and increased their electromyographic activity during push-off feedback trials (8.1 ± 15.8 %, P = 0.038). Individual improvements were seen in twelve of eighteen participants. All children experienced high levels of interest-enjoyment (8.4/10) and perceived competence (8.1/10).

SIGNIFICANCE

This exploratory study suggests that children with cerebral palsy can achieve small within-session improvements of their calf muscle activation pattern when provided with implicit biofeedback-driven gaming in an enjoyable manner. Follow-up gait training studies can incorporate this method to assess retention and long-term functional benefits of electromyographic biofeedback-driven gaming.

Altered development of structural MRI connectome hubs at near-term age in very and moderately preterm infants

Preterm infants may exhibit altered developmental patterns of the brain structural network by endogenous and exogenous stimuli, which are quantifiable through hub and modular network topologies that develop in the third trimester. Although preterm brain networks can compensate for white matter microstructural abnormalities of core connections, less is known about how the network developmental characteristics of preterm infants differ from those of full-term infants. We identified 13 hubs and 4 modules and revealed subtle differences in edgewise connectivity and local network properties between 134 preterm and 76 full-term infants, identifying specific developmental patterns of the brain structural network in preterm infants. The modules of preterm infants showed an imbalanced composition. The edgewise connectivity in preterm infants showed significantly decreased long- and short-range connections and local network properties in the dorsal superior frontal gyrus. In contrast, the fusiform gyrus and several nonhub regions showed significantly increased wiring of short-range connections and local network properties. Our results suggested that decreased local network in the frontal lobe and excessive development in the occipital lobe may contribute to the understanding of brain developmental deviances in preterm infants.

A model for using developmental science to create effective early intervention programs and technologies to improve children's developmental outcomes

Children born with a variety of environmental or medical risk factors may exhibit delays in global development. Very often, such delays are identified at preschool or school age, when children are severely overdue for effective early interventions that can alleviate the delays. This chapter proposes a conceptual model of child development to inform the creation of interventions and rehabilitative technologies that can be provided very early in development, throughout the first year of life, to optimize children's future developmental outcomes. The model suggests that early sensorimotor skills are antecedent and foundational for future motor, cognitive, language, and social development. As an example, this chapter describes how children's early postural control and exploratory movements facilitate the development of future object exploration behaviors that provide enhanced opportunities for learning and advance children's motor, cognitive, language, and social development. An understanding of the developmental pathways in the model can enable the design of effective intervention programs and rehabilitative technologies that target sensorimotor skills in the first year of life with the goal of minimizing or ameliorating the delays that are typically identified at preschool or school age. Specific examples of early interventions and rehabilitative technologies that have effectively advanced children's motor and cognitive development by targeting early sensorimotor skills and behaviors are provided.

Protease inhibitor-based antiretroviral therapy in pregnancy: effects on hormones, placenta, and decidua

The use of antiretroviral therapy (ART) in pregnancy is important for maternal health, and has been successful in reducing vertical transmission rates to almost zero in those taking effective ART regimens with good adherence. However, there are reports of higher rates of low birthweight and preterm births in women with HIV, which can be further exacerbated by ART usage in pregnancy. Protease inhibitors, and ritonavir-boosted lopinavir in particular, might directly contribute to placental and uteroplacental pathology in part by altering plasma concentrations of the essential steroid hormones of pregnancy, progesterone and oestradiol. In this Review, we collate the increasing evidence of dysregulated maternal endocrinology, reproductive physiology, and placental compromise associated with protease inhibitors. Based on findings of placental and decidual effects, we recommend that ritonavir-boosted lopinavir should be avoided in pregnancy, in line with US and European guidelines. Long-term follow-up of children exposed to protease inhibitors in utero is also recommended.

Systematic Review of the Longitudinal Sensitivity of Precision Tasks in Visual Working Memory

Precision of working memory (WM) refers to the objective performance of individuals when trying to recall the features of the encoded WM items. Studies of precision in VWM aim to identify whether differences in WM performance within individuals are sensitive to individual states or traits. In this systematic review, we study VWM precision and whether it reflects true differences in ability to accurately store information, and thereby possibly a more sensitive measure than discrete VWM span alone. Sifting through 327 abstracts, we identified 34 relevant articles. After assessing these articles with regard to our inclusion criteria to test participants at two separate time points and have a sample size of at least fifteen participants, we found four longitudinal studies regarding VWM precision. One review author and two reviewers independently assessed all studies in the screening and selection process and extracted outcome measures, study characteristics, and, when possible, test-retest reliability metrics. Given the small and heterogeneous sample, this systematic review could not yet provide conclusive evidence on the sensitivity of VWM precision paradigms. Future research of VWM should include longitudinal studies of precision, and address both test-retest reliability in healthy adults and changes in precision during key developmental trajectory periods and in clinical populations.

Feasibility and effectiveness of home-based therapy programmes for children with cerebral palsy: a systematic review

OBJECTIVE

To assess the feasibility and effectiveness of home-based occupational therapy and physiotherapy programmes in children with cerebral palsy (CP), focusing on the upper extremity and reporting on child-related and/or parent-related outcomes.

DESIGN

Systematic review.

DATA SOURCES

Electronic searches were performed in MEDLINE, EMBASE, CINAHL, PsycINFO, OTseeker and PEDro, and in ICTRP and CENTRAL trial registers, from inception to 6 June 2019.

ELIGIBLE CRITERIA

The review included all types of original studies concerning feasibility or effectiveness of home-based therapy in children aged <18 years with any type of CP. No language, publication status or publication date restrictions were applied.

DATA EXTRACTION AND SYNTHESIS

Study and intervention characteristics and the demographics of participating children and their parents were extracted. Feasibility was assessed by outcomes related to acceptability, demand, implementation, practicality, adaptation, expansion or integration. Regarding effectiveness, child-related outcome measures related to any level of the International Classification of Functioning, Disability and Health, or parent-related outcomes were investigated. Two authors independently extracted the data. Risk of bias was assessed using the Downs and Black checklist and the Joanna Briggs Institute Critical Appraisal Checklist.

RESULTS

The search resulted in a total of 92 records: 61 studies and 31 conference abstracts. Feasibility studies reported mainly on acceptability and implementation. Overall compliance to home-based training programmes (implementation) was moderate to high, ranging from 56% to 99%. In the effectiveness studies, >40 different child-related outcome measures were found. Overall, an improvement in arm-hand performance within group across time was shown. Only two studies reported on a parent-related outcome measure. No increase in parental stress was found during the intervention.

CONCLUSIONS

Based on the results of the included studies, home-based training programmes seem to be feasible. However, conclusions about the effectiveness of home programmes cannot be made due to the large variability in the study, patient and intervention characteristics, comparators, and outcome measures used in the included studies.

PROSPERO REGISTRATION NUMBER

CRD42016043743.

Play with objects in children with arthrogryposis: Effects of intervention with the Playskin Lift™ exoskeletal garment

Children with arthrogryposis multiplex congenita (AMC) often exhibit arm movement impairments that can negatively impact activities of daily living, such as reaching, object exploration, object play, and self-care. This study evaluated the effects of intervention involving the Playskin Lift™ (Playskin) exoskeletal garment on arm function during object play for children with AMC. Seventeen children with AMC (5 males; 6-35 months at the beginning of the study) were tested in their homes biweekly with and without the Playskin throughout a 1-month Baseline, 4-month Intervention, and 1-month Post-Intervention. Within sessions (assistive effects), children contacted and manipulated objects more while wearing the Playskin; they also showed greater intensity, complexity, and variability of behaviors performed during free play, as well as increased play space and reduced number of compensatory arm and trunk flings to facilitate reaching. Across time (rehabilitative effects), children significantly improved their visual-manual coupling as well as their ability to lift objects from a surface and to manipulate objects using one hand; in addition, children exhibited greater multimodality, variability, and intensity of their play behaviors. Current results suggest the Playskin Lift™ may serve as an effective assistive and rehabilitative device to improve play for children with arm movement impairments.

Upper limb impairments, process skills, and outcome in children with unilateral cerebral palsy

AIM

To examine the relationships between upper limb impairments and independence in self-care (ISC) in children with unilateral cerebral palsy (CP).

METHOD

One hundred and eight children with unilateral CP (46 females, 62 males; mean age 8y 7mo, SD 3y 9mo) recruited from a population register were assessed for upper limb muscle power, spasticity, sensation, motor control, and process skills, and for ISC as the functional outcome using structural equation modelling.

RESULTS

The model showed good fit indices and explained 90% of the variance in ISC. Direct effects were significant between manual ability and ISC (β=0.47), and process skills and ISC (β=0.63). Sensation had a significant positive indirect effect on ISC through manual ability (β=0.24) and a positive but marginally non-significant indirect effect through process skills (β=0.21, bootstrapped 95% confidence interval -0.05 to 0.55). Spasticity had a significant negative indirect effect on ISC through its effect on manual ability (β=-0.21). Age had a significant positive indirect effect on ISC, as did intellect, through their effect on process skills (β=0.34 and 0.21 respectively).

INTERPRETATION

ISC is affected by upper limb impairments and process skill. Sensation influences ISC through its effects on manual and process skill abilities. Both sensation and process skills require further evaluation to assist ISC in children with unilateral CP.

WHAT THIS PAPER ADDS

Process skills and manual ability most strongly positively influence independence in self-care (ISC) in children with unilateral cerebral palsy. Sensation influences ISC through manual ability and process skill.

Ailu: An Affordable Sensorized Toy for Detection of Neuro and Motor Delays in Infants

Early detection of neurodevelopmental disorders in infants is critical for early intervention to improve their long-term function. Integrating natural play with quantitative measurements of developmental milestones may help to quickly and efficiently identify infants at-risk for developmental delays. Ailu is a sensorized toy designed to elicit and measure natural infant play interactions. Ailu is part of the Play and Neuro Development Assessment (PANDA) gym, whose purpose is to serve as a universal and quantitative screening tool for detection of delays. This case study describes design considerations made developing Ailu and evaluates Ailu's potential in upper limb, lower limb, and parent-guided testing with a 3-month old infant. Ailu can encourage reaching, kicking, and grasping, and will be tested for distinguishing typical and atypical development with further infant trials.

Feasibility and Effectiveness of Intervention With the Playskin Lift Exoskeletal Garment for Infants at Risk

BACKGROUND

Infants born preterm and/or with brain injury often exhibit delays in the development of reaching and object exploration, increasing their risk of associated delays in cognitive development.

OBJECTIVE

The objective of this study was to longitudinally evaluate feasibility of use of the novel Playskin Lift exoskeletal garment (Playskin; developed and trademarked by Dr. Lobo's Super Suits FUNctional Fashion and Wearable Technology Program at the University of Delaware, Newark, DE, USA), the assistive and rehabilitative effects of intervention with the garment on reaching and object exploration ability, and to relate changes in reaching and object exploration to changes in cognition during intervention for infants at risk for developmental delays.

DESIGN

A multiple baseline single-case design with 1- to 2-month Baseline, 4-month Intervention, and 1-month Postintervention phases was implemented.

METHODS

Ten infants born preterm and/or with brain injury, mean [SD] age 2.2 [1.3] months at the beginning of the study, were assessed biweekly throughout the study both with and without the Playskin Lift. Assessments included a Reaching Assessment and the cognitive subscale of the Bayley Scales of Infant and Toddler Development. Reaching and object exploration behaviors were coded from videos of the Reaching Assessment. Results were analyzed using multilevel modeling in SAS.

RESULTS

The Playskin Lift improved infants' reaching ability, hand orientation for grasp and object exploration, and multimodal object exploration when worn within sessions, especially during the Intervention phase. The garment also improved independent reaching and object exploration across time during the Intervention phase, with retention of gains in the Postintervention phase. Improvement in reaching ability was positively related to changes in cognitive outcomes during the Intervention phase.

LIMITATIONS

Limitations included modest sample size and the potential confounds of development and experience with time.

CONCLUSIONS

The Playskin Lift can serve as a feasible, effective, and accessible assistive and rehabilitative device to advance reaching, object exploration, and cognition for infants at risk for future delays.

Neuromuscular synergies in motor control in normal and poststroke individuals

Muscle synergies are proposed to function as motor primitives that are modulated by frontal brain areas to construct a large repertoire of movement. This paper reviews the history of the development of our current theoretical understanding of nervous system-based motor control mechanisms and more specifically the concept of muscle synergies. Computational models of muscle synergies, especially the nonnegative matrix factorization algorithm, are discussed with specific reference to the changes in synergy control post-central nervous system (CNS) lesions. An alternative approach for motor control is suggested, exploiting a combination of synergies control or flexible muscle control used for gross motor skills and for individualized finger movements. Rehabilitation approaches, either supporting or inhibiting the use of basic movement patterns, are discussed in the context of muscle synergies. Applications are discussed for the use of advanced technologies that can promote the recovery and functioning of the human CNS after stroke.

Prematurity may negatively impact means-end problem solving across the first two years of life

Preterm infants are at risk for delays in motor, perceptual, and cognitive development. While research has shown preterm infants may exhibit learning delays in the first months of life, these delays are commonly under-diagnosed. The purpose of this study was to longitudinally evaluate behavioral performance and learning in two means-end problem-solving tasks for 30 infants born preterm (PT) and 23 born full-term (FT). Infants were assessed at 6, 9, 12, 18, and 24 months-old in tasks that required towel pulling or turntable rotation to obtain a distant object. PT infants performed more non-goal-directed and less goal-directed behavior than FT infants throughout the study, resulting in a lower success rate among PT infants. PT infants showed delayed emergence of intentionality (prevalence of goal-directed behaviors) compared to FT infants in both tasks. Amount and variability of behavioral performance significantly correlated with task success differentially across age. The learning differences documented between PT and FT infants suggest means-end problem-solving tasks may be useful for the early detection of learning delays. The identification of behaviors associated with learning and success across age may be used to guide interventions aimed at advancing early learning for infants at risk.

Infants Born Preterm Demonstrate Impaired Exploration of Their Bodies and Surfaces Throughout the First 2 Years of Life

BACKGROUND

Non-object-oriented exploratory behaviors infants perform with their bodies and surfaces have been proposed to be key precursors of infants' object exploration, early learning, and future cognitive development. Little is known about the developmental trajectories of these behaviors, especially for infants born preterm.

OBJECTIVE

The purpose of the study was to longitudinally compare non-object-oriented exploratory behaviors performed by full-term and preterm infants.

DESIGN

The study followed 24 full-term and 30 preterm infants (6 with significant brain injury) performing non-object-oriented exploratory behaviors in prone, supine, and sitting from birth through 24 months.

METHODS

Infants were observed without objects or direct social interaction for 3 minutes in prone and supine (0 through 9 months) and in sitting (3 through 24 months). Behavioral coding produced data that were analyzed using hierarchical linear modeling. Developmental trajectories of behaviors were compared among full-term infants, preterm infants without significant brain injury, and preterm infants with significant brain injury.

RESULTS

Compared to full-term peers, preterm infants showed poorer postural control (less head lifting in prone), midline behavior (holding the head in midline, holding both hands in midline), hand-to-mouth and visual-motor behaviors against gravity, and more asymmetrical one-handed fisting. Preterm infants performed fewer bouts of non-object-oriented exploratory behaviors, and their behaviors were less variable with fewer combinations.

LIMITATIONS

There was a limited sample of infants born preterm with significant brain injury.

CONCLUSIONS

Non-object-oriented exploratory behaviors are important for early perceptual-motor development. Key differences were noted in these behaviors for infants born preterm. These differences may lead to impaired reaching, object exploration, and cognition. Early intervention programs should utilize assessments and interventions that target these very early non-object-oriented exploratory behaviors.

Development of an Age Band on the ManuVis for 3-Year-Old Children with Visual Impairments

AIM

To compare fine motor performance of 3-year-old children with visual impairment with peers having normal vision, to provide reference scores for 3-year-old children with visual impairment on the ManuVis, and to assess inter-rater reliability.

METHOD

26 children with visual impairment (mean age: 3 years 7 months (SD 3 months); 17 boys) and 28 children with normal vision (mean age: 3 years 7 months (SD 4 months); 14 boys) participated in the study. The ManuVis age band for 3-year-old children comprised two one-handed tasks, two two-handed tasks, and a pre-writing task.

RESULTS

Children with visual impairment needed more time on all tasks (p < .01) and performed the pre-writing task less accurately than children with normal vision (p < .001). Children aged 42-47 months performed significantly faster on two tasks and had better total scores than children aged 36-41 months (p < .05). Inter-rater reliability was excellent (Intra-class Correlation Coefficient = 0.96-0.99).

CONCLUSIONS

The ManuVis age band for 3-year-old children is appropriate to assess fine motor skills, and is sensitive to differences between children with visual impairment and normal vision and between half-year age groups. Reference scores are provided for 3-year-old children with visual impairment to identify delayed fine motor development.

Unimanual versus bimanual therapy in children with unilateral cerebral palsy: Same, same, but different

BACKGROUND

There is high-level evidence supporting constraint-induced movement therapy (CIMT) and bimanual therapy for children with unilateral cerebral palsy. Evidence-based intervention includes time-limited, goal-directed, skills-based, intensive blocks of practice based on motor learning theory.

AIM AND METHODS

Using supporting literature and clinical insight, we provide a theoretical rationale to highlight previously unreported differences between CIMT and bimanual therapy.

DISCUSSION

The current emphasis on total dosage of practice for achieving positive outcomes fails to recognise the influence of other critical concepts within motor learning. Limitations exist in the application of motor learning principles using CIMT due to its unimanual nature. CIMT is effective for development of unimanual actions brought about by implicit learning, however it is difficult to target explicit learning that is required for learning how to use two hands together. Using bimanual therapy, object properties can be adapted to trigger goal-related perceptual and cognitive processes required for children to learn to recognise when two hands are required for task completion.

CONCLUSION

CIMT and bimanual should be viewed as complementary. CIMT could be used to target unimanual actions. Once these actions are established, bimanual therapy could be used for children to learn how to use these actions for bimanual skill development.

Implicit and explicit motor sequence learning in children born very preterm

BACKGROUND

Motor skills can be learned explicitly (dependent on working memory (WM)) or implicitly (relatively independent of WM). Children born very preterm (VPT) often have working memory deficits. Explicit learning may be compromised in these children.

AIMS

This study investigated implicit and explicit motor learning and the role of working memory in VPT children and controls.

METHODS

Three groups (6-9 years) participated: 20 VPT children with motor problems, 20 VPT children without motor problems, and 20 controls. A nine button sequence was learned implicitly (pressing the lighted button as quickly as possible) and explicitly (discovering the sequence via trial-and-error).

RESULTS

Children learned implicitly and explicitly, evidenced by decreased movement duration of the sequence over time. In the explicit condition, children also reduced the number of errors over time. Controls made more errors than VPT children without motor problems. Visual WM had positive effects on both explicit and implicit performance.

CONCLUSION

VPT birth and low motor proficiency did not negatively affect implicit or explicit learning. Visual WM was positively related to both implicit and explicit performance, but did not influence learning curves. These findings question the theoretical difference between implicit and explicit learning and the proposed role of visual WM therein.

Working memory in very-low-birthweight children at the age of 11 years

The aim of this study is to investigate the working memory (WM) of very-low-birthweight (VLBW, ≤ 1500 g) children at the age of 11 years using Baddeley's WM model. A regional cohort of 95 VLBW children was assessed for the domains of the WM model (central executive [CE], visuospatial sketchpad [VS], and phonological loop [PL]) using subtests from the Working Memory Test Battery for Children (WMTB-C) and the Wechsler Intelligence Scale for Children - Fourth Edition (WISC-IV). VLBW children were categorized into three groups according to their degree of brain pathology (normal, minor, or major) in neonatal brain magnetic resonance imaging at the term age, and the WM performance was compared between groups to test norms. The structure of the WM model was studied by analyzing correlations among domains. Even VLBW children with normal cognitive development (general ability index ≥ 85) performed worse compared to the test norms (M = 100, SD = 15) on CE (M = 87.64, SD = 20.54, p < .001) and VS (M = 91.65, SD = 11.03, p < .001), but their performance on PL was above the norm (M = 110.79, SD = 13.79, p < .001). VLBW children with major brain pathology performed significantly worse on VS and PL compared to the other groups. The correlations among the WM domains of the VLBW children differ from earlier findings in normative populations. To conclude, the WM of the VLBW children in the study differ-especially in the CE and VS subtest scores-from the normative population irrespective of the degree of brain pathology and level of cognitive development.

Infant born preterm have delayed development of adaptive postural control in the first 5 months of life

Infants born preterm are at increased risk of developmental disabilities, that may be attributed to their early experiences and ability to learn. The purpose of this paper was to evaluate the ability of infants born preterm to adapt their postural control to changing task demands.

METHODS

This study included 18 infants born at 32 weeks of gestation or less whose posture was compared in supine under 2 conditions, with and without a visual stimulus presented. The postural variability, measured with root mean squared displacement of the center of pressure, and postural complexity, measured with the approximate entropy of the center of pressure displacement were measured longitudinally from 2.5 to 5 months of age.

RESULTS AND DISCUSSION

The infants looked at the toys in midline for several months prior to adapting their postural variability in a manner similar to full term infants. Only after postural variability was reduced in both the caudal cephalic and medial lateral direction in the toy condition did the infants learn to reach for the toy. Postural complexity did not vary between conditions. These findings suggest that infants used a variety of strategies to control their posture. In contrast to research with infants born full term, the infants born preterm in this study did not identify the successful strategy of reducing movement of the center of pressure until months after showing interest in the toy. This delayed adaptation may impact the infants ability to learn over time.

The influence of errors during practice on motor learning in young individuals with cerebral palsy

The aim of this study was to investigate the effect of errors during practice on motor skill learning in young individuals with cerebral palsy (CP). Minimizing errors has been validated in typically developing children and children with intellectual disabilities as a method for implicit learning, because it reduces working memory involvement during learning. The present study assessed whether a practice protocol that aims at minimizing errors can induce implicit learning in young individuals with CP as well. Accordingly, we hypothesized that reducing errors during practice would lead to enhanced learning and a decrease in the dependency of performance on working memory. Young individuals with CP practiced an aiming task following either an error-minimizing (N=20) or an error-strewn (N=18) practice protocol. Aiming accuracy was assessed in pre-, post- and retention test. Dual task performance was assessed to establish dependency on working memory. The two practice protocols did not invoke different amounts or types of learning in the participants with CP. Yet, participants improved aiming accuracy and showed stable motor performance after learning, irrespective of the protocol they followed. Across groups the number of errors made during practice was related to the amount of learning, and the degree of conscious monitoring of the movement. Only participants with relatively good working memory capacity and a poor initial performance showed a rudimentary form of (most likely, explicit) learning. These new findings on the effect of the amount of practice errors on motor learning in children of CP are important for designing interventions for children and adolescents with CP.

Effectiveness of Home Visits in Pregnancy as a Public Health Measure to Improve Birth Outcomes

BACKGROUND

Birth outcomes, such as preterm birth, low birth weight (LBW), and small for gestational age (SGA), are crucial indicators of child development and health.

PURPOSE

To evaluate whether home visits from public health nurses for high-risk pregnant women prevent adverse birth outcomes.

METHODS

In this quasi-experimental cohort study in Kyoto city, Japan, high-risk pregnant women were defined as teenage girls (range 14-19 years old), women with a twin pregnancy, women who registered their pregnancy late, had a physical or mental illness, were of single marital status, non-Japanese women who were not fluent in Japanese, or elderly primiparas. We collected data from all high-risk pregnant women at pregnancy registration interviews held at a public health centers between 1 July 2011 and 30 June 2012, as well as birth outcomes when delivered from the Maternal and Child Health Handbook (N = 964), which is a record of prenatal check-ups, delivery, child development and vaccinations. Of these women, 622 women were selected based on the home-visit program propensity score-matched sample (pair of N = 311) and included in the analysis. Data were analyzed between January and June 2014.

RESULTS

In the propensity score-matched sample, women who received the home-visit program had lower odds of preterm birth (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.39 to 0.98) and showed a 0.55-week difference in gestational age (95% CI: 0.18 to 0.92) compared to the matched controlled sample. Although the program did not prevent LBW and SGA, children born to mothers who received the program showed an increase in birth weight by 107.8 g (95% CI: 27.0 to 188.5).

CONCLUSION

Home visits by public health nurses for high-risk pregnant women in Japan might be effective in preventing preterm birth, but not SGA.

Navigation strategies as revealed by error patterns on the Magic Carpet test in children with cerebral palsy

Introduction: Short-term memory develops differently in navigation vs. manual space. The Magic Carpet (MC) is a novel navigation test derived from the Walking Corsi Test and the manual Corsi Block-tapping Task (CBT). The MC requires mental rotations and executive function. In Cerebral Palsy (CP), CBT, and MC scores relate differently to clinical and lesional factors. Hypotheses of this study are: that frontal lesion specifically affect navigation in CP; that brain lesions affect MC cognitive strategies.

Materials and Methods: Twenty-two children with spastic CP, aged 5 to 14 years, 14 with a unilateral and 8 with a bilateral form, underwent the CBT and the MC. Errors were classified into seven patterns by a recently described algorithm. Brain lesions were quantified according to a novel semi-quantitative MRI scale. Control data were partially drawn from a previous study on 91 typically developing children.

Results: Children with CP performed worse than controls on both tests. Right hemispheric impairment correlated with spatial memory. MC span was reduced less than CBT span and was more selectively related to right middle white-matter and frontal lesions. Error patterns were differently distributed in CP and in typical development, and depended on right brain impairment: children with more extensive right lesions made more positional than sequential errors.

Discussion: In CP, navigation is affected especially by extensive lesions involving the right frontal lobe. In addition, these are associated with abnormal cognitive strategies. Whereas in typical development positional errors, preserving serial order, increase with age and performance, in CP they are associated with poorer performance and more extensive right-brain lesions. The explanation may lie in lesion side: right brain is crucial for mental rotations, necessary for spatial updating. Left-lateralized spatial memory strategies, relying on serial order, are not efficient if not accompanied by right-brain spatial functions.

Long-Term Outcomes of Very Preterm Birth

Very preterm birth has become more frequent during the past decades due to progress in reproductive medicine, more frequent indicated preterm births due to maternal illnesses, and increasing maternal age. Moreover, survival rates of very preterm children have increased due to improved neonatal management. However, very preterm-born children, adolescents, and young adults are at increased risk for poor cognitive function and socio-emotional problems, which is of growing public health concern. Very premature birth has been studied to unravel consequences of a nonoptimal environment during a developmental period which under normal circumstances would be the last trimester of fetal development. For very preterm children, this developmental period partly occurs outside the womb, which leads to major distress for the immature newborn. For the cerebral cortex, the last trimester of pregnancy is a particularly sensitive period during which cortical folding takes place and the volume increases 4fold. During this period, even minor insults may cascade into disturbances of brain development. The most frequent complication after very preterm birth is related to insufficient functioning of the lungs, which may lead to hypoxic-ischemic incidences and damage to nervous tissue. This review presents evidence for long-term sequels of very premature birth regarding neurocognitive, academic, socio-emotional, and mental health development. Then it discusses possible underlying mechanisms including alterations in brain development, programming of the hypothalamic-pituitary-adrenal axis and circadian rhythmicity, as well as affected parent-child interaction patterns in families with very preterm children. Finally, intervention approaches to improve outcomes after very preterm birth are discussed and directions for future research presented.

Infants born preterm demonstrate impaired object exploration behaviors throughout infancy and toddlerhood

BACKGROUND

Object exploration behaviors form the foundation for future global development, but little is known about how these behaviors are exhibited by infants born preterm.

OBJECTIVE

The study objective was to longitudinally compare a comprehensive set of object exploration behaviors in infants born preterm and infants born full-term from infancy into toddlerhood.

DESIGN

Twenty-two infants born full-term and 28 infants born preterm were monitored as they interacted with objects throughout their first 2 years.

METHODS

Infants were provided up to 30 seconds to interact with each of 7 objects across 9 visits. Experimenters coded videos of infants' behaviors. Growth modeling and t tests were used to compare how much infants exhibited behaviors and how well they matched their behaviors to the properties of objects.

RESULTS

Infants born preterm explored objects less in the first 6 months, exhibited less visual-haptic multimodal exploration, displayed reduced variability of exploratory behavior in a manner that reflected severity of risk, and were less able to match their behaviors to the properties of objects in a manner that reflected severity of risk. Infants born preterm with significant brain injury also had impaired bimanual abilities.

LIMITATIONS

There was a limited sample of infants born preterm with significant brain injury.

CONCLUSIONS

Infants born preterm have impaired abilities to interact with objects even in the first months of life. This impairment likely limits the knowledge they acquire about objects and about how they can act on them; this limited knowledge may, in turn, impair their early learning abilities. These results highlight the need for assessment and intervention tools specific for object exploration in young infants.

Hyper-responsiveness to acute stress, emotional problems and poorer memory in former preterm children

The prevalence of preterm birth (PTB) is high worldwide, especially in developing countries like Brazil. PTB is marked by a stressful environment in intra- as well as extrauterine life, which can affect neurodevelopment and hormonal and physiological systems and lead to long-term negative outcomes. Nevertheless, little is known about PTB and related outcomes later on in childhood. Thus, the goals of the current study were threefold: (1) comparing cortisol and alpha-amylase (sAA) profiles, including cortisol awakening response (CAR), between preterm and full-term children; (2) evaluating whether preterm children are more responsive to acute stress and (3) assessing their memory skills and emotional and behavioral profiles. Basal cortisol and sAA profiles, including CAR of 30 preterm children, aged 6 to 10 years, were evaluated. Further, we assessed memory functions using the Wide Range Assessment of Memory and Learning, and we screened behavior/emotion using the Strengths and Difficulties Questionnaire. The results of preterm children were compared to an age- and sex-matched control group. One week later, participants were exposed to a standardized laboratory stressor [Trier Social Stress Test for Children (TSST-C)], in which cortisol and sAA were measured at baseline, 1, 10 and 25 min after stressor exposure. Preterm children had higher cortisol concentrations at awakening, a flattened CAR and an exaggerated response to TSST-C compared to full-term children. These alterations were more pronounced in girls. In addition, preterm children were characterized by more emotional problems and poorer memory performance. Our findings illustrate the long-lasting and in part sex-dependent effects of PTB on the hypothalamic-pituitary-adrenal (HPA) axis, internalizing behavior and memory. The findings are in line with the idea that early adversity alters the set-point of the HPA axis, thereby creating a more vulnerable phenotype.

Progesterone to prevent spontaneous preterm birth

Preterm birth is the leading cause of perinatal morbidity and mortality worldwide, and its prevention is an important healthcare priority. Preterm parturition is one of the 'great obstetrical syndromes' and is caused by multiple etiologies. One of the mechanisms of disease is the untimely decline in progesterone action, which can present as a clinically silent sonographic short cervix in the midtrimester. The detection of a short cervix in the midtrimester is a powerful risk factor for preterm delivery. Vaginal progesterone can reduce the rate of preterm delivery by 45% and the rate of neonatal morbidity (admission to the neonatal intensive care unit, respiratory distress syndrome, need for mechanical ventilation, etc.). To prevent one case of spontaneous preterm birth <33 weeks of gestation, 11 patients with a short cervix would need to be treated (based on an individual patient meta-analysis). Vaginal progesterone reduces the rate of spontaneous preterm birth in women with a short cervix, both with and without a prior history of preterm birth. In patients with a prior history of preterm birth, vaginal progesterone is as effective as cervical cerclage to prevent preterm delivery. 17α-Hydroxyprogesterone caproate has not been shown to be effective in reducing the rate of spontaneous preterm birth in women with a short cervix.

Instability of delay classification and determination of early intervention eligibility in the first two years of life

The purpose of this study was to determine the effectiveness of the Bayley Scales of Infant Development, Third Edition (Bayley-III) to track development and classify delays in low- and high-risk infants across the first two years of life. We assessed cognitive, language, and motor development in 24 low-risk full-term and 30 high-risk preterm infants via seven assessments performed between 3 and 24 months corrected age. The Bayley-III resulted in highly unstable delay classifications, low sensitivities, and poor positive predictive values across time. The results highlight that early intervention professionals, researchers, and policy makers should: (1) emphasize clinical opinion and prevalence of risk factors rather than standardized assessment findings when classifying delays and determining eligibility for services, and (2) develop more effective developmental assessments for infants and young children.

Transdermal nitroglycerin for the treatment of preterm labor: a systematic review and metaanalysis

OBJECTIVE

The purpose of this study was to evaluate the efficacy and safety of transdermal nitroglycerin as a tocolytic agent in women with preterm labor.

STUDY DESIGN

We conducted a systematic review and metaanalysis of randomized controlled trials.

RESULTS

Thirteen studies were included (1302 women) comparing transdermal nitroglycerin vs placebo (2 studies; n = 186); β2-adrenergic receptor agonists (9 studies; n = 1024); nifedipine (1 study; n = 50); and magnesium sulfate (1 study; n = 42). There were no significant differences between transdermal nitroglycerin and placebo for delivery within 48 hours of the initiation of treatment or at <28, <34, or <37 weeks of gestation, adverse neonatal outcomes, and neurodevelopmental status at 24 months of life. Nevertheless, 1 study found a marginally significant reduction in the risk of a composite outcome of major neonatal morbidity and perinatal death (3/74 [4.1%] vs 11/79 [13.9%]; relative risk, 0.29; 95% confidence interval, 0.08-1.00). When compared with β2-adrenergic receptor agonists, transdermal nitroglycerin was associated with a significant reduction in the risk of preterm birth at <34 and <37 weeks of gestation, admission to the neonatal intensive care unit, use of mechanical ventilation, and maternal side effects. There were no significant differences between transdermal nitroglycerin and nifedipine and magnesium sulfate in delivery within 48 hours of treatment and pregnancy prolongation, respectively. Overall, women who received transdermal nitroglycerin had a higher risk of headache.

CONCLUSION

Although transdermal nitroglycerin appears to be more effective than β2-adrenergic receptor agonists, the current evidence does not support its routine use as a tocolytic agent for the treatment of preterm labor. Further double-blind placebo-controlled trials are needed.

The effect of a short bout of practice on reaching behavior in late preterm infants at the onset of reaching: a randomized controlled trial

The purpose of this study was to examine the effects of a short bout of practice on reaching behavior in late preterm infants at the onset of goal-directed reaching. The study was designed as a blind, three-arm parallel-group, randomized controlled, clinical trial. Thirty-six late preterm infants were recruited from a maternity hospital and allocated according to computer generated randomization into groups that received reaching practice based on either a blocked schedule, a serial schedule, or no practice. Practice consisted of a 4 min session of induced reaching using a toy in three activities guided by a physical therapist. The activities were elicited in separate blocks for the blocked practice group and in a pre-established order for the serial practice group. The control group stayed in the physical therapist's lap but was not stimulated to reach. The infants were assessed 3.3±1.4 days after the onset of goal-directed reaching in three tests: pre-test (immediately before practice), post-test (immediately after practice), and retention test (24 h after post-test). During assessments, the infants were seated in a baby chair and a toy was presented at his/her midline within reaching distance for 2 min. Changes in the number of reaches, proportions of uni/bimanual reaches and kinematic parameters of reaching were main outcome measures. From pre- to post-test, the amount of reaches and bimanual reaches increased in the serial practice group, but the increase was not maintained in the retention test. Kinematic parameters were not affected by practice. Changes in the reaching behavior of late preterm infants can be triggered after the first few minutes of toy-oriented experience based on a serial practice schedule. These changes are not consolidated one day later.

Associations of preterm births with child health and development: Japanese population-based study

OBJECTIVE

To examine associations between the duration of gestation and health and development outcomes at 2.5 years and 5.5 years using a Japanese population-based longitudinal survey (n = 47 015).

STUDY DESIGN

Hospitalization was used as an indicator of physical health, and responses to questions about age-appropriate behaviors were used as an indicator of behavioral development. We conducted logistic regression analyses controlling for a set of neonatal and family factors. We also estimated population-attributable fractions.

RESULTS

We observed a steady increase toward shorter duration of gestation in the risk of hospitalizations at age 2.5 years and 5.5 years and developmental delays at 2.5 years (Plinear trend < .001 for all outcomes). We found associations only between extremely preterm birth and delayed behavioral development at age 5.5 years.

CONCLUSION

There is a linear relationship between shorter duration of gestation and increased risk of later health and developmental problems. In line with Rose's "population paradox," the population-attributable risks for these problems are greater for moderately preterm infants compared with extremely preterm infants.

Analysis of epigenetic changes in survivors of preterm birth reveals the effect of gestational age and evidence for a long term legacy

Background

Preterm birth confers a high risk of adverse long term health outcomes for survivors, yet the underlying molecular mechanisms are unclear. We hypothesized that effects of preterm birth can be mediated through measurable epigenomic changes throughout development. We therefore used a longitudinal birth cohort to measure the epigenetic mark of DNA methylation at birth and 18 years comparing survivors of extremely preterm birth with infants born at term.

Methods

Using 12 extreme preterm birth cases and 12 matched, term controls, we extracted DNA from archived neonatal blood spots and blood collected in a similar way at 18 years of age. DNA methylation was measured at 347,789 autosomal locations throughout the genome using Infinium HM450 arrays. Representative methylation differences were confirmed by Sequenom MassArray EpiTYPER.

Results

At birth we found 1,555 sites with significant differences in methylation between term and preterm babies. At 18 years of age, these differences had largely resolved, suggesting that DNA methylation differences at birth are mainly driven by factors relating to gestational age, such as cell composition and/or maturity. Using matched longitudinal samples, we found evidence for an epigenetic legacy associated with preterm birth, identifying persistent methylation differences at ten genomic loci. Longitudinal comparisons of DNA methylation at birth and 18 years uncovered a significant overlap between sites that were differentially-methylated at birth and those that changed with age. However, we note that overlapping sites may either differ in the same (300/1,555) or opposite (431/1,555) direction during gestation and aging respectively.

Conclusions

We present evidence for widespread methylation differences between extreme preterm and term infants at birth that are largely resolved by 18 years of age. These results are consistent with methylation changes associated with blood cell development, cellular composition, immune induction and age at these time points. Finally, we identified ten probes significantly associated with preterm individuals and with greater than 5% methylation discordance at birth and 18 years that may reflect a long term epigenetic legacy of preterm birth.

fMRI: blood oxygen level-dependent activation during a working memory-selective attention task in children born extremely preterm

BACKGROUND

Extremely preterm (EPT)/extremely low-birth-weight (ELBW) children attaining school age and adolescence often have problems with executive functions such as working memory and selective attention. Our aim was to investigate a hypothesized difference in blood oxygen level-dependent (BOLD) activation during a selective attention-working memory task in EPT/ELBW children as compared with term-born controls.

METHODS

A regional cohort of 28 EPT/ELBW children and 28 term-born controls underwent functional magnetic resonance imaging (fMRI) scanning at 11 y of age while performing a combined Stroop n-back task. Group differences in BOLD activation were analyzed with Statistical Parametric Mapping 8 analysis software package, and reaction times (RTs) and response accuracy (RA) were compared in a multifactorial ANOVA test.

RESULTS

The BOLD activation pattern in the preterm group involved the same areas (cingulate, prefrontal, and parietal cortexes), but all areas displayed significantly less activation than those in the control group, particularly when the cognitive load was increased. The RA results corresponded with the activation data in that the preterm group had significantly fewer correct responses. No group difference was found regarding RTs.

CONCLUSION

Children born EPT/ELBW displayed reduced working memory and selective attention capacity as compared with term-born controls. These impairments had neuronal correlates with reduced BOLD activation in areas responsible for online stimulus monitoring, working memory, and cognitive control.

Cognition, behavior and social competence of preterm low birth weight children at school age

OBJECTIVE

The aim of this study was to assess the cognitive and behavioral development of preterm and low birth weight newborns living in a disadvantageous socioeconomic environment at school age.

METHODS

This cross-sectional study included children aged 6-7 from a historical birth cohort of preterm (gestational age <37 weeks) and low birth weight (<2,500 g) infants. The Wechsler Intelligence Scale for Children III (WISC-III) was administered by a psychologist while the parents completed the Child Behavior Checklist. The results were compared to the test's reference. The perinatal information and follow-up data were collected from the hospital files. The demographic data were collected from the parents. The current performance was compared with the results from the Denver II and Bayley II tests, which were administered during the first years of life.

RESULTS

The total intelligence quotient varied from 70 to 140 (mean 98.7±15.8). The borderline intelligence quotient was observed in 9.3% of the children. The Child Behavior Checklist indicated a predominance of social competence problems (27.8%, CI 19.2 to 37.9) compared with behavioral problems (15.5%, CI 8.9 to 24.2). Both the Child Behavior Checklist domains, such as schooling, social and attention problems, and the cognitive scores were significantly associated with maternal education and family income. The results of the Denver and Bayley tests were associated with the cognitive performance (p<0.001) and the Child Behavior Checklist social profile, including aggressive and externalizing behavior (p<0.001).

CONCLUSIONS

Our data suggest that even low-risk preterm newborns are at risk for developing disturbances in early school age, such as mild cognitive deficits and behavioral disorders. This risk might increase under unfavorable socioeconomic conditions.

Assessment and stability of early learning abilities in preterm and full-term infants across the first two years of life

Infants born preterm have increased risk for learning disabilities yet we lack assessments to successfully detect these disabilities in early life. We followed 23 full-term and 29 preterm infants from birth through 24 months to assess for differences in and stability of learning abilities across time. Measures included the Bayley-III cognitive subscale, the mobile paradigm assessment, and a means-end learning assessment. Preterm infants had poorer performance on measures of cognition and learning across the first two years of life. Learning performance at 3-4 months was consistent with learning performance at 12-24 months of age. At 3-4 months, the mobile paradigm had better sensitivity and predictive values for predicting 24-month cognitive delays on the Bayley-III than did the Bayley-III itself. At 12-18 months, the means-end learning assessment had better sensitivity than the Bayley-III for identifying 24-month cognitive delays on the Bayley-III. The results suggest that: (1) infants born preterm may demonstrate learning differences as early as the first few months of life, (2) learning differences identified in the first months of life are likely to persist throughout the second year of life, and (3) learning assessments that measure how infants and toddlers use their typical behaviors to problem-solve to control external events may be more effective than traditional standardized assessment tools for detecting early learning delays.

Neurodevelopment in children with and without congenital heart block born to anti-Ro/SSA-positive mothers

OBJECTIVE

To define factors influencing neurodevelopment in children with and without complete congenital heart block (CHB) born to mothers with Ro/SSA autoantibodies.

PATIENTS AND METHODS

Medical records of a population-based cohort of siblings with (n = 60) and without (n = 54) CHB born 1974-2009 to anti-Ro/SSA-positive mothers were retrieved from children primary healthcare centres and school health services and used to extract data on neurodevelopment.

RESULTS

Impaired neurodevelopment was reported in 16% of the children (18/114) during the follow-up time of 13.0 (8.2-17.5) years, median (quartiles). Reported problems included speech (9%), motor (8%) and learning (8%) impairment, attention deficit (5%) and behavioural impairment (4%). Impairment in motor skill development was more common in boys (p < 0.001) if the child was born preterm (p < 0.001). Learning impairment was significantly influenced by maternal SLE (p < 0.005), while attention deficits was influenced by both maternal SLE (p < 0.05) and CHB in the child (p < 0.05).

CONCLUSIONS

Our data indicate that in addition to well-established factors such as male sex and being born preterm, both maternal SLE and CHB may influence neurodevelopment. Follow-up of neurodevelopment should therefore be considered for children with CHB, especially if the mother is diagnosed with SLE.