Functional activation of the infant cortex during object processing

Infants can use temporary or scant categorical information to individuate objects

In a standard individuation task, infants see two different objects emerge in alternation from behind a screen. If they can assign distinct categorical descriptors to the two objects, they expect to see both objects when the screen is lowered; if not, they have no expectation at all about what they will see (i.e., two objects, one object, or no object). Why is contrastive categorical information critical for success at this task? According to the kind account, infants must decide whether they are facing a single object with changing properties or two different objects with stable properties, and access to permanent, intrinsic, kind information for each object resolves this difficulty. According to the two-system account, however, contrastive categorical descriptors simply provide the object-file system with unique tags for individuating the two objects and for communicating about them with the physical-reasoning system. The two-system account thus predicts that any type of contrastive categorical information, however temporary or scant it may be, should induce success at the task. Two experiments examined this prediction. Experiment 1 tested 14-month-olds (N = 96) in a standard task using two objects that differed only in their featural properties. Infants succeeded at the task when the object-file system had access to contrastive temporary categorical descriptors derived from the objects' distinct causal roles in preceding support events (e.g., formerly a support, formerly a supportee). Experiment 2 tested 9-month-olds (N = 96) in a standard task using two objects infants this age typically encode as merely featurally distinct. Infants succeeded when the object-file system had access to scant categorical descriptors derived from the objects' prior inclusion in static arrays of similarly shaped objects (e.g., block-shaped objects, cylinder-shaped objects). These and control results support the two-system account's claim that in a standard task, contrastive categorical descriptors serve to provide the object-file system with unique tags for the two objects.

Feasibility study of functional near-infrared spectroscopy in the ventral visual pathway for real-life applications

Significance

fNIRS-based neuroenhancement depends on the feasible detection of hemodynamic responses in target brain regions. Using the lateral occipital complex (LOC) and the fusiform face area (FFA) in the ventral visual pathway as neurofeedback targets boosts performance in visual recognition. However, the feasibility of utilizing fNIRS to detect LOC and FFA activity in adults remains to be validated as the depth of these regions may exceed the detection limit of fNIRS.

Aim

This study aims to investigate the feasibility of using fNIRS to measure hemodynamic responses in the ventral visual pathway, specifically in the LOC and FFA, in adults.

Approach

We recorded the hemodynamic activities of the LOC and FFA regions in 35 subjects using a portable eight-channel fNIRS instrument. A standard one-back object and face recognition task was employed to elicit selective brain responses in the LOC and FFA regions. The placement of fNIRS optodes for LOC and FFA detection was guided by our group's transcranial brain atlas (TBA).

Results

Our findings revealed selective activation of the LOC target channel (CH2) in response to objects, whereas the FFA target channel (CH7) did not exhibit selective activation in response to faces.

Conclusions

Our findings indicate that, although fNIRS detection has limitations in capturing FFA activity, the LOC region emerges as a viable target for fNIRS-based detection. Furthermore, our results advocate for the adoption of the TBA-based method for setting the LOC target channel, offering a promising solution for optrode placement. This feasibility study stands as the inaugural validation of fNIRS for detecting cortical activity in the ventral visual pathway, underscoring its ecological validity. We suggest that our findings establish a pivotal technical groundwork for prospective real-life applications of fNIRS-based research.

Towards imaging the infant brain at play

Infants' first-person experiences are crucial to early cognitive and neural development. To a vast extent, these early experiences involve play, which in infancy takes the form of object exploration. While at the behavioral level infant play has been studied both using specific tasks and in naturalistic scenarios, the neural correlates of object exploration have largely been studied in highly controlled task settings. These neuroimaging studies did not tap into the complexities of everyday play and what makes object exploration so important for development. Here, we review selected infant neuroimaging studies, spanning from typical, highly controlled screen-based studies on object perception to more naturalistic designs and argue for the importance of studying the neural correlates of key behaviors such as object exploration and language comprehension in naturalistic settings. We suggest that the advances in technology and analytic approaches allow measuring the infant brain at play with the use of functional near-infrared spectroscopy (fNIRS). Naturalistic fNIRS studies offer a new and exciting avenue to studying infant neurocognitive development in a way that will draw us away from our laboratory constructs and into an infant's everyday experiences that support their development.

Cortical Activation to Social and Mechanical Stimuli in the Infant Brain

From the early days of life infants distinguish between social and non-social physical entities and have different expectations for the way these two entities should move and interact. At the same time, we know very little about the cortical systems that support this early emerging ability. The goal of the current research was to assess the extent to which infant's processing of social and non-social physical entities is mediated by distinct information processing systems in the temporal cortex. Using a cross-sectional design, infants aged 6-9 months (Experiment 1) and 11-18 months (Experiment 2) were presented with two types of events: social interaction and mechanical interaction. In the social interaction event (patterned after Hamlin et al., 2007), an entity with googly eyes, hair tufts, and an implied goal of moving up the hill was either helped up, or pushed down, a hill through the actions of another social entity. In the mechanical interaction event, the googly eyes and hair tufts were replaced with vertical black dots and a hook and clasp, and the objects moved up or down the hill via mechanical interactions. FNIRS was used to measure activation from temporal cortex while infants viewed the test events. In both age groups, viewing social and mechanical interaction events elicited different patterns of activation in the right temporal cortex, although responses were more specialized in the older age group. Activation was not obtained in these areas when the objects moved in synchrony without interacting, suggesting that the causal nature of the interaction events may be responsible, in part, to the results obtained. This is one of the few fNIRS studies that has investigated age-related patterns of cortical activation and the first to provide insight into the functional development of networks specialized for processing of social and non-social physical entities engaged in interaction events.

Catastrophic individuation failures in infancy: A new model and predictions

Comparison of infant findings from the physical-reasoning and object-individuation literatures reveals a contradictory picture. On the one hand, physical-reasoning results indicate that young infants can use featural information to guide their actions on objects and to detect interaction violations (when objects interact in ways that are not physically possible) as well as change violations (when objects spontaneously undergo featural changes that are not physically possible). On the other hand, object-individuation results indicate that young infants typically cannot use featural information to detect individuation violations (when the number of objects revealed at the end of an event is less than the number of objects introduced during the event). In this article, we attempt to reconcile these two bodies of research. In a new model of early individuation, we propose that two systems help infants individuate objects in physical events: the object-file and physical-reasoning systems. Under certain conditions, disagreements between the systems result in catastrophic individuation failures, leading infants to hold no expectation at all about how many objects are present. We report experiments with 9- to 11-month-old infants (N = 216) that tested predictions from the model. After two objects emerged in alternation from behind a screen, infants detected no violation when the screen was lowered to reveal no object. Similarly, after two objects emerged in alternation from inside a box, which was then shaken, infants detected no violation when the box remained silent, as though empty. We end with new directions, suggested by our model, for research on early object representations. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

A review on neuroimaging studies of genetic and environmental influences on early brain development

The past decades witnessed a surge of interest in neuroimaging study of normal and abnormal early brain development. Structural and functional studies of normal early brain development revealed massive structural maturation as well as sequential, coordinated, and hierarchical emergence of functional networks during the infancy period, providing a great foundation for the investigation of abnormal early brain development mechanisms. Indeed, studies of altered brain development associated with either genetic or environmental risks emerged and thrived. In this paper, we will review selected studies of genetic and environmental risks that have been relatively more extensively investigated-familial risks, candidate risk genes, and genome-wide association studies (GWAS) on the genetic side; maternal mood disorders and prenatal drug exposures on the environmental side. Emerging studies on environment-gene interactions will also be reviewed. Our goal was not to perform an exhaustive review of all studies in the field but to leverage some representative ones to summarize the current state, point out potential limitations, and elicit discussions on important future directions.

Visual working memory in early development: a developmental cognitive neuroscience perspective

In this article, we review the literature on the development of visual working memory (VWM). We focus on two major periods of development, infancy and early childhood. First, we discuss the innovative methods that have been devised to understand how the development of selective attention and perception provide the foundation of VWM abilities. We detail the behavioral and neural data associated with the development of VWM during infancy. Next, we discuss various signatures of development in VWM during early childhood in the context of spatial and featural memory processes. We focus on the developmental transition to more adult-like VWM properties. Finally, we discuss computational frameworks that have explained the complex patterns of behavior observed in VWM tasks from infancy to adulthood and attempt to explain links between measures of infant VWM and childhood VWM.

Imaging structural and functional brain development in early childhood

In humans, the period from term birth to ∼2 years of age is characterized by rapid and dynamic brain development and plays an important role in cognitive development and risk of disorders such as autism and schizophrenia. Recent imaging studies have begun to delineate the growth trajectories of brain structure and function in the first years after birth and their relationship to cognition and risk of neuropsychiatric disorders. This Review discusses the development of grey and white matter and structural and functional networks, as well as genetic and environmental influences on early-childhood brain development. We also discuss initial evidence regarding the usefulness of early imaging biomarkers for predicting cognitive outcomes and risk of neuropsychiatric disorders.

Prefrontal Hemodynamics in Toddlers at Rest: A Pilot Study of Developmental Variability

Functional near infrared spectroscopy (fNIRS) is a non-invasive functional neuroimaging modality. Although, it is amenable to use in infants and young children, there is a lack of fNIRS research within the toddler age range. In this study, we used fNIRS to measure cerebral hemodynamics in the prefrontal cortex (PFC) in 18-36 months old toddlers (n = 29) as part of a longitudinal study that enrolled typically-developing toddlers as well as those "at risk" for language and other delays based on presence of early language delays. In these toddlers, we explored two hemodynamic response indices during periods of rest during which time audiovisual children's programming was presented. First, we investigate Lateralization Index, based on differences in oxy-hemoglobin saturation from left and right prefrontal cortex. Then, we measure oxygenation variability (OV) index, based on variability in oxygen saturation at frequencies attributed to cerebral autoregulation. Preliminary findings show that lower cognitive (including language) abilities are associated with fNIRS measures of both lower OV index and more extreme Lateralization index values. These preliminary findings show the feasibility of using fNIRS in toddlers, including those at risk for developmental delay, and lay the groundwork for future studies.

Somatic stimulation causes frontoparietal cortical changes in neonates: a functional near-infrared spectroscopy study

Palmar and plantar grasp are the foremost primitive neonatal reflexes and functions. Persistence of these reflexes in infancy is a sign of evolving cerebral palsy. Our aims were to establish measurement feasibility in a clinical setting and to characterize changes in oxyhemoglobin (HbO) and deoxyhemoglobin (HbD) concentration in the bilateral frontoparietal cortex in unsedated neonates at the crib-side using functional near-infrared spectroscopy (fNIRS). We hypothesized that bilateral concentration changes will occur upon somatic central and peripheral somatic stimulation. Thirteen preterm neonates (five males) underwent time 1, and six (two males) returned for time 2 (mean [Formula: see text] and 47.0 weeks, respectively). Signals from a total of 162 somatic stimuli responses were measured. Response amplitude, duration, and latency were log-transformed and compared between palmar, plantar, and oromotor stimuli using linear mixed models, adjusted for cap, electroencephalogram abnormality, time (1 versus 2), and Sarnat score, if necessary. The oromotor stimulus resulted in a 50% greater response than the palmar or plantar stimuli for HbO left and right hemisphere duration ([Formula: see text]). There were no other statistically significant differences between stimuli for any other outcome ([Formula: see text]). Utilizing fNIRS in conjunction with occupational and physical therapy maneuvers is efficacious to study modifiable and restorative neurophysiological mechanisms.

Off to a Good Start: The Early Development of the Neural Substrates Underlying Visual Working Memory

Current neuroscientific models describe the functional neural architecture of visual working memory (VWM) as an interaction of the frontal-parietal control network and more posterior areas in the ventral visual stream (Jonides et al., 2008; D'Esposito and Postle, 2015; Eriksson et al., 2015). These models are primarily based on adult neuroimaging studies. However, VWM undergoes significant development in infancy and early childhood, and the goal of this mini-review is to examine how recent findings from neuroscientific studies of early VWM development can be reconciled with this model. We surveyed 29 recent empirical reports that present neuroimaging findings in infants, toddlers, and preschoolers (using EEG, fNIRS, rs-fMRI) and neonatal lesion studies in non-human primates. We conclude that (1) both the frontal-parietal control network and the posterior cortical storage areas are active from early infancy; (2) this system undergoes focalization and some reorganization during early development; (3) and the MTL plays a significant role in this process as well. Motivated by both theoretical and methodological considerations, we offer some recommendations for future directions for the field.

fNIRS: An Emergent Method to Document Functional Cortical Activity during Infant Movements

The neural basis underlying the emergence of goal-directed actions in infants has been severely understudied, with minimal empirical evidence for hypotheses proposed. This was largely due to the technological constraints of traditional neuroimaging techniques. Recently, functional near-infrared spectroscopy (fNIRS) technology has emerged as a tool developmental scientists are finding useful to examine cortical activity, particularly in young children and infants due to its greater tolerance to movements than other neuroimaging techniques. fNIRS provides an opportunity to finally begin to examine the neural underpinnings as infants develop goal-directed actions. In this methodological paper, I will outline the utility, challenges, and outcomes of using fNIRS to measure the changes in cortical activity as infants reach for an object. I will describe the advantages and limitations of the technology, the setup I used to study primary motor cortex activity during infant reaching, and example steps in the analyses processes. I will present exemplar data to illustrate the feasibility of this technique to quantify changes in hemodynamic activity as infants move. The viability of this research method opens the door to expanding studies of the development of neural activity related to goal-directed actions in infants. I encourage others to share details of techniques used, as well, including analyticals, to help this neuroimaging technology grow as others, such as EEG and fMRI have.

Functional Activation in the Ventral Object Processing Pathway during the First Year

Infants' capacity to represent objects in visual working memory changes substantially during the first year of life. There is a growing body of research focused on identifying neural mechanisms that support this emerging capacity, and the extent to which visual object processing elicits different patterns of cortical activation in the infant as compared to the adult. Recent studies have identified areas in temporal and occipital cortex that mediate infants' developing capacity to track objects on the basis of their featural properties. The current research (Experiments 1 and 2) assessed patterns of activation in posterior temporal cortex and occipital cortex using fNIRS in infants 3–13 months of age as they viewed occlusion events. In the occlusion events, either the same object or featurally distinct objects emerged to each side of a screen. The outcome of these studies, combined, revealed that in infants 3–6 months, posterior temporal cortex was activated to all events, regardless of the featural properties of the objects and whether the event involved one object or two (featurally distinct) objects. Infants 7–8 infants months showed a waning posterior temporal response and by 10–13 months this response was negligible. Additional analysis showed that the age groups did not differ in their visual attention to the events and that changes in HbO were better explained by age in days than head circumference. In contrast to posterior temporal cortex, robust activation was obtained in occipital cortex across all ages tested. One interpretation of these results is that they reflect pruning of the visual object-processing network during the first year. The functional contribution of occipital and posterior temporal cortex, along with higher-level temporal areas, to infants' capacity to keep track of distinct entities in visual working memory is discussed.

Object processing in the infant: lessons from neuroscience

Object identification is a fundamental cognitive capacity that forms the basis for complex thought and behavior. The adult cortex is organized into functionally distinct visual object-processing pathways that mediate this ability. Insights into the origin of these pathways have begun to emerge through the use of neuroimaging techniques with infant populations. The outcome of this work supports the view that, from the early days of life, object-processing pathways are organized in a way that resembles that of the adult. At the same time, theoretically important changes in patterns of cortical activation are observed during the first year. These findings lead to a new understanding of the cognitive and neural architecture in infants that supports their emerging object-processing capacities.

BrainSignals Revisited: Simplifying a Computational Model of Cerebral Physiology

Multimodal monitoring of brain state is important both for the investigation of healthy cerebral physiology and to inform clinical decision making in conditions of injury and disease. Near-infrared spectroscopy is an instrument modality that allows non-invasive measurement of several physiological variables of clinical interest, notably haemoglobin oxygenation and the redox state of the metabolic enzyme cytochrome c oxidase. Interpreting such measurements requires the integration of multiple signals from different sources to try to understand the physiological states giving rise to them. We have previously published several computational models to assist with such interpretation. Like many models in the realm of Systems Biology, these are complex and dependent on many parameters that can be difficult or impossible to measure precisely. Taking one such model, BrainSignals, as a starting point, we have developed several variant models in which specific regions of complexity are substituted with much simpler linear approximations. We demonstrate that model behaviour can be maintained whilst achieving a significant reduction in complexity, provided that the linearity assumptions hold. The simplified models have been tested for applicability with simulated data and experimental data from healthy adults undergoing a hypercapnia challenge, but relevance to different physiological and pathophysiological conditions will require specific testing. In conditions where the simplified models are applicable, their greater efficiency has potential to allow their use at the bedside to help interpret clinical data in near real-time.

[Near-infrared spectroscopy as an auxiliary tool in the study of child development]

OBJECTIVE:

To investigate the applicability of Near-Infrared Spectroscopy (NIRS) for cortical hemodynamic assessment tool as an aid in the study of child development.

DATA SOURCE:

Search was conducted in the PubMed and Lilacs databases using the following keywords: ''psychomotor performance/child development/growth and development/neurodevelopment/spectroscopy/near-infrared'' and their equivalents in Portuguese and Spanish. The review was performed according to criteria established by Cochrane and search was limited to 2003 to 2013. English, Portuguese and Spanish were included in the search.

DATA SYNTHESIS:

Of the 484 articles, 19 were selected: 17 cross-sectional and two longitudinal studies, published in non-Brazilian journals. The analyzed articles were grouped in functional and non-functional studies of child development. Functional studies addressed the object processing, social skills development, language and cognitive development. Non-functional studies discussed the relationship between cerebral oxygen saturation and neurological outcomes, and the comparison between the cortical hemodynamic response of preterm and term newborns.

CONCLUSIONS:

NIRS has become an increasingly feasible alternative and a potentially useful technique for studying functional activity of the infant brain.

fNIRS in the developmental sciences

With the introduction of functional near-infrared spectroscopy (fNIRS) into the experimental setting, developmental scientists have, for the first time, the capacity to investigate the functional activation of the infant brain in awake, engaged participants. The advantages of fNIRS clearly outweigh the limitations, and a description of how this technology is implemented in infant populations is provided. Most fNIRS research falls into one of three content domains: object processing, processing of biologically and socially relevant information, and language development. Within these domains, there are ongoing debates about the origins and development of human knowledge, making early neuroimaging particularly advantageous. The use of fNIRS has allowed investigators to begin to identify the localization of early object, social, and linguistic knowledge in the immature brain and the ways in which this changes with time and experience. In addition, there is a small but growing body of research that provides insight into the neural mechanisms that support and facilitate learning during the first year of life. At the same time, as with any emerging field, there are limitations to the conclusions that can be drawn on the basis of current findings. We offer suggestions as to how to optimize the use of this technology to answer questions of theoretical and practical importance to developmental scientists.

Cortical activation to object shape and speed of motion during the first year

A great deal is known about the functional organization of cortical networks that mediate visual object processing in the adult. The current research is part of a growing effort to identify the functional maturation of these pathways in the developing brain. The current research used near-infrared spectroscopy to investigate functional activation of the infant cortex during the processing of featural information (shape) and spatiotemporal information (speed of motion) during the first year of life. Our investigation focused on two areas that were implicated in previous studies: anterior temporal cortex and posterior parietal cortex. Neuroimaging data were collected with 207 infants across three age groups: 3-6 months (Experiment 1), 7-8 months (Experiment 2), and 10-12 months (Experiments 3 and 4). The neuroimaging data revealed age-related changes in patterns of activation to shape and speed information, mostly involving posterior parietal areas, some of which were predicted and others that were not. We suggest that these changes reflect age-related differences in the perceptual and/or cognitive processes engaged during the task.

The effect of color priming on infant brain and behavior

Behavioral studies have identified select experiences that can prime infants to attend to color information as the basis for individuating objects prior to the time they do so spontaneously. For example, viewing pretest events in which the color of an object predicts the function in which it will engage leads 9-month-olds (who typically do not attend to color differences) to demonstrate increased sensitivity to color information in a subsequent individuation task (Wilcox and Chapa, 2004). In contrast, viewing pretest events in which the color of an object predicts distinct object motions, but the motions are not functionally relevant, does not produce color priming. The purpose of the present research was to identify the cortical underpinnings of these behavioral effects. Infants aged 8 and 9 months viewed function or motion pretest events and then their capacity to individuate-by-color was assessed in an object individuation task. Behavioral and neuroimaging data were collected. Two main findings emerged. First, as predicted, the infants who viewed the function but not the motion pretest events showed prolonged looking to the test event, a behavioral indicator of object individuation. In addition, they evidenced increased activation in anterior temporal cortex, thought to be a cortical signature of object individuation. A second and unexpected finding was that viewing either type of pretest events led to increased activation in the posterior temporal cortex, as compared to infants who did not see pretest events, revealing that prior exposure to the motion pretest events does influence infants' processing of the test event, even though it is not evident in the behavioral results. The cognitive processes involved, and the cortical structures that mediate these processes, are discussed.

Small-world network properties in prefrontal cortex correlate with predictors of psychopathology risk in young children: a NIRS study

Near infrared spectroscopy (NIRS) is an emerging imaging technique that is relatively inexpensive, portable, and particularly well suited for collecting data in ecological settings. Therefore, it holds promise as a potential neurodiagnostic for young children. We set out to explore whether NIRS could be utilized in assessing the risk of developmental psychopathology in young children. A growing body of work indicates that temperament at young age is associated with vulnerability to psychopathology later on in life. In particular, it has been shown that low effortful control (EC), which includes the focusing and shifting of attention, inhibitory control, perceptual sensitivity, and a low threshold for pleasure, is linked to conditions such as anxiety, depression and attention deficit hyperactivity disorder (ADHD). Physiologically, EC has been linked to a control network spanning among other sites the prefrontal cortex. Several psychopathologies, such as depression and ADHD, have been shown to result in compromised small-world network properties. Therefore we set out to explore the relationship between EC and the small-world properties of PFC using NIRS. NIRS data were collected from 44 toddlers, ages 3-5, while watching naturalistic stimuli (movie clips). Derived complex network measures were then correlated to EC as derived from the Children's Behavior Questionnaire (CBQ). We found that reduced levels of EC were associated with compromised small-world properties of the prefrontal network. Our results suggest that the longitudinal NIRS studies of complex network properties in young children hold promise in furthering our understanding of developmental psychopathology.

Using neuroimaging to understand the cortical mechanisms of auditory selective attention

Over the last four decades, a range of different neuroimaging tools have been used to study human auditory attention, spanning from classic event-related potential studies using electroencephalography to modern multimodal imaging approaches (e.g., combining anatomical information based on magnetic resonance imaging with magneto- and electroencephalography). This review begins by exploring the different strengths and limitations inherent to different neuroimaging methods, and then outlines some common behavioral paradigms that have been adopted to study auditory attention. We argue that in order to design a neuroimaging experiment that produces interpretable, unambiguous results, the experimenter must not only have a deep appreciation of the imaging technique employed, but also a sophisticated understanding of perception and behavior. Only with the proper caveats in mind can one begin to infer how the cortex supports a human in solving the "cocktail party" problem. This article is part of a Special Issue entitled Human Auditory Neuroimaging.

Somatosensory evoked changes in cerebral oxygen consumption measured non-invasively in premature neonates

The hemodynamic functional response is used as a reliable marker of neuronal activity in countless studies of brain function and cognition. In newborns and infants, however, conflicting results have appeared in the literature concerning the typical response, and there is little information on brain metabolism and functional activation. Measurement of all hemodynamic components and oxygen metabolism is critical for understanding neurovascular coupling in the developing brain. To this end, we combined multiple near infrared spectroscopy techniques to measure oxy- and deoxy-hemoglobin concentrations, cerebral blood volume (CBV), and relative cerebral blood flow (CBF) in the somatosensory cortex of 6 preterm neonates during passive tactile stimulation of the hand. By combining these measures we estimated relative changes in the cerebral metabolic rate of oxygen consumption (rCMRO2). CBF starts increasing immediately after stimulus onset, and returns to baseline before blood volume. This is consistent with the model of pre-capillary arteriole active dilation driving the CBF response, with a subsequent CBV increase influenced by capillaries and veins dilating passively to accommodate the extra blood. rCMRO2 estimated using the steady-state formulation shows a biphasic pattern: an increase immediately after stimulus onset, followed by a post-stimulus undershoot due to blood flow returning faster to baseline than oxygenation. However, assuming a longer mean transit time from the arterial to the venous compartment, due to the immature vascular system of premature infants, reduces the post-stimulus undershoot and increases the flow/consumption ratio to values closer to adult values reported in the literature. We are the first to report changes in local rCBF and rCMRO2 during functional activation in preterm infants. The ability to measure these variables in addition to hemoglobin concentration changes is critical for understanding neurovascular coupling in the developing brain, and for using this coupling as a reliable functional imaging marker in neonates.