Neurodevelopmental outcome after extreme prematurity: a review of the literature

Executive and attentional functioning interventions in preterm children: a systematic review

OBJECTIVE

This systematic review, performed in accordance with the PRISMA guidelines, seeks to summarize the interventions that have been developed in order to improve executive functioning and attention in children born prematurely.

METHODS

The PICOS framework helped guide the structure and relevant terms selected for the study. Electronic systematic searches of the databases PubMed (NLM), Ovid Medline, Ovid All EBM Reviews, Ovid Embase, and Ovid PsycINFO were completed in March 2022. This review focuses on interventions that target attention and executive functioning in prematurely born children between birth and 12 years old, with outcome measures assessed between 3 and 12 years old, even if the age range in the study can exceed our own parameters. Data extraction included sample characteristics, country of recruitment, type of intervention, description of the intervention group and control group, outcome measures, and overall results. An assessment of the quality of methodology of studies was performed through an adaptation of the Downs and Black checklist for both randomized and nonrandomized studies in healthcare interventions. An assessment of the risk of bias was also presented using the Cochrane risk of bias tool for randomized trials 2.0.

RESULTS

A total of 517 premature children received an intervention at some point between birth and early adolescence. Eleven different interventions were assessed in 17 studies, with rating of the quality of methodology and outcomes ranging from lower quality studies (44% quality rating) to robust studies (96% quality rating) in terms of reporting standards, external and internal validity, and power. Five of those studies focused on interventions administered in the neonatal intensive care unit or shortly postdischarge (e.g., the Mother-Infant Transaction Program and the Newborn Individualized Developmental Care and Assessment Program, documented in two articles each [11%] or the Infant Behavioral Assessment and Intervention Program assessed in one study [about 5%]), while 12 articles reported on interventions administered between the ages of 1.5-12 years old [mostly computerized cognitive training programs such as Cogmed (23%) and BrainGame Brian (17%)]. Of the 17 articles examined, 12 (70%) showed positive short-term outcomes postintervention and 3 (17%) demonstrated positive long-term results with small to large effect sizes (0.23-2.3). Among included studies, 50% showed an overall high risk of bias, 21.4% showed some concerns, and 28.6% were low risk of bias.

CONCLUSIONS

Due to the heterogeneity of the programs reviewed, the presented findings should be interpreted as descriptive results. A careful and individualized selection from the various available interventions should be made based on the target population (i.e., age at intervention administration and outcome testing) before implementing these program protocols in clinical settings.

Limits of Viability: Perspectives of Portuguese Neonatologists and Obstetricians

INTRODUCTION

Advances in neonatal care have improved the prognosis in extremely preterm infants. The gestational age considered for active treatment has decreased globally. Despite implemented guidelines, several studies show variability in practice. The aim of this study was to understand theperspectives of Portuguese neonatologists and obstetricians regarding the management of extremely preterm infants.

METHODS

An online survey was sent through the Portuguese Neonatology Society and the Portuguese Society of Obstetrics and Maternal-Fetal Medicine from August to September 2023.

RESULTS

We obtained 117 responses: 53% neonatologists, 18% pediatricians, and 29% obstetricians, with 62% having more than 10 years of experience. The majority (80%) were familiar with the Portuguese Neonatology Society consensus on the limits of viability and 46% used it in practice; 62% were unaware of Portuguese morbidity-mortality statistics associated with extremely preterm infants. Most (91%) informed parents about morbiditymortality concerning the gestational age more frequently upon admission (64%) and considered their opinion in the limit of viability situations (95%). At 22 weeks gestational age, 71% proposed only comfort care, while at 25 and 26 weeks, the majority suggested active care (80% and 96%, respectively). Less consensus was observed at 23 and 24 weeks. At 24 weeks, most obstetricians offered active care with the option of comfort care by parental choice (59%), while the neonatology group provided active care (65%), p < 0.001. Regarding the lower limit of gestational age for in utero transfer, corticosteroid administration, cesarean section for fetal indication, neonatologist presence during delivery, and endotracheal intubation; neonatologists considered a lower gestational age than obstetricians (23 vs 24 weeks; p = 0.036; p < 0.001; p < 0.001; p = 0.021; p < 0.001, respectively).

CONCLUSION

Differences in perspectives between obstetricians and neonatologists in limits of viability situations were identified. Neonatologists considered a lower gestational age in various scenarios and proposed active care earlier. Standardized counseling for extremely preterm infants is crucial to avoid ambiguity, parental confusion, and conflicts in perinatal care.

Early interventions with parental participation and their implications on the neurodevelopment of premature children: a systematic review and meta-analysis

The occurrence of preterm birth is correlated with the potential emergence of disabilities in children. Early intervention programs are designed to promote better developmental outcomes. These interventions employ family-centered methodologies, wherein parents are instructed to facilitate neurodevelopment, thereby promoting heightened involvement of the child in their daily activities. The objective of this investigation was to evaluate the efficacy of early family-based interventions on motor, cognitive, and language development. A systematic review and meta-analysis was conducted utilizing the databases PubMed, Medline, PEDro, Scopus, CINAHL Complete, SciELO, and Open Grey. The search terms utilized included NDT (neuro-developmental treatment), Bobath, neurodevelopmental therapy, parents administered, family administered, physical therapy modalities, early intervention (educational), early intervention, premature infant, preterm, and premature. Randomized clinical trials and observational studies written in English or Spanish were taken into consideration. The initial search resulted in 420 articles. After removing duplicates and applying the selection criteria, 12 articles were selected for the systematic review and 5 articles were selected for the meta-analysis. The meta-analysis revealed a significant association between early intervention and enhanced cognitive function (p = 0.01) in this study. Additionally, the meta-analysis indicated improvements resulting from early family-based intervention (p = 0.02) in motor function. Early motor interventions that emphasize parent involvement and education in neurodevelopment show significant outcomes in motor and cognitive areas at 2 years of age in very premature or extremely premature infants. However, inconclusive effects have been found in the language area, which is the least studied domain. Due to the methodological heterogeneity observed, further research is needed to establish conclusive decisions regarding the administration of these interventions and the determination of key evaluation periods.

Reflections about being born extremely preterm in children and adolescents: A qualitative descriptive study

BACKGROUND

The survival of the smallest and most immature preterm infants, born at 23-24 weeks of gestation, has improved significantly. While there is a substantial amount of research on the neurocognitive and social outcomes of extremely premature birth, little is known about the survivors' subjective experience of being born preterm and its effect on later life.

AIMS

The purpose was to study the subjective experiences of school-aged children born at 23-24 weeks of gestation, in order to understand their perspectives on how being born extremely early had affected their life.

STUDY DESIGN

Qualitative descriptive study.

METHODS

18 school-aged children (12 girls and 6 boys, 7-15 years of age), born at 23 or 24 weeks of gestation, were interviewed. The semi-structured interview guide covered six topics about quality of life: somatic health, functioning, learning and memory, emotional health, social relations, experience of prematurity and its effect.

RESULTS

Most children reported memories, which were told to them by parents, about their premature birth and early life. Using qualitative thematic analysis, the narratives of the children were classified into three groups: 1) the go-with-the-flow children, who identified little or no effect of prematurity, 2) the ponderers, who reflected on some effects such as minor physical challenges, and 3) the hesitants, who either did not connect their challenges with prematurity, or did not produce much reflection overall.

CONCLUSIONS

Children had been told about their early life by the parents and repeated these memories indicating that prematurity had become a significant part of the family story. Differences were found how the children reflected on the impact of prematurity in their personal life. It is essential to include preterm survivors' own perspectives already during childhood and adolescence into the research of extreme prematurity.

Machine learning risk stratification for high-risk infant follow-up of term and late preterm infants

BACKGROUND

Term and late preterm infants are not routinely referred to high-risk infant follow-up programs at neonatal intensive care unit (NICU) discharge. We aimed to identify NICU factors associated with abnormal developmental screening and develop a risk-stratification model using machine learning for high-risk infant follow-up enrollment.

METHODS

We performed a retrospective cohort study identifying abnormal developmental screening prior to 6 years of age in infants born ≥34 weeks gestation admitted to a level IV NICU. Five machine learning models using NICU predictors were developed by classification and regression tree (CART), random forest, gradient boosting TreeNet, multivariate adaptive regression splines (MARS), and regularized logistic regression analysis. Performance metrics included sensitivity, specificity, accuracy, precision, and area under the receiver operating curve (AUC).

RESULTS

Within this cohort, 87% (1183/1355) received developmental screening, and 47% had abnormal results. Common NICU predictors across all models were oral (PO) feeding, follow-up appointments, and medications prescribed at NICU discharge. Each model resulted in an AUC > 0.7, specificity >70%, and sensitivity >60%.

CONCLUSION

Stratification of developmental risk in term and late preterm infants is possible utilizing machine learning. Applying machine learning algorithms allows for targeted expansion of high-risk infant follow-up criteria.

IMPACT

This study addresses the gap in knowledge of developmental outcomes of infants ≥34 weeks gestation requiring neonatal intensive care. Machine learning methodology can be used to stratify early childhood developmental risk for these term and late preterm infants. Applying the classification and regression tree (CART) algorithm described in the study allows for targeted expansion of high-risk infant follow-up enrollment to include those term and late preterm infants who may benefit most.

Early cognitive assessment in premature infants: the discriminatory value of eye-tracking vs. Bayley Scales

Introduction

The testing of visuocognitive development in preterm infants shows strong interactions between perinatal characteristics and cognition, learning and overall neurodevelopment evolution. The assessment of anticipatory gaze data of object-location bindings via eye-tracking can predict the neurodevelopment of preterm infants at the age of 3 years; little is known, however, about the early cognitive function and its assessment methods during the first year of life.

Methods

The current study presents data from a novel assessment tool, a Delayed Match Retrieval (DMR) paradigm via eye-tracking was used to measure visual working memory (VWM) and attention skills. The eye-tracking task that was designed to measure infants' ability to actively localize objects and to make online predictions of object-location bindings. 63 infants participated in the study, 39 preterm infants and 24 healthy full term infants - at a corrected age of 8-9 months for premature infants and similar chronological age for full term infants. Infants were also administered the Bayley Scales of Infant and Toddler Development.

Results

The analysis of the Bayley scores showed no significant difference between the two groups while the eye-tracking data showed a significant group effect on all measurements. Moreover, preterm infants' VWM performance was significantly lower than full term's. Birth weight affected the gaze time on all Areas Of Interest (AOIs), overall VWM performance and the scores at the Cognitive Bayley subscale. Furthermore, preterm infants with fetal growth restriction (FGR) showed significant performance effects in the eye-tracking measurements but not on their Bayley scores verifying the high discriminatory value of the eye gaze data.

Conclusion

Visual working memory and attention as measured via eye-tracking is a non-intrusive, painless, short duration procedure (approx. 4-min) was found to be a significant tool for identifying prematurity and FGR effects on the development of cognition during the first year of life. Bayley Scales alone may not pick up these deficits. Identifying tools for early neurodevelopmental assessments and cognitive function is important in order to enable earlier support and intervention in the vulnerable group of premature infants, given the associations between foundational executive functional skills and later cognitive and academic ability.

Assessment of extremely premature lambs supported by the Extrauterine Environment for Neonatal Development (EXTEND)

BACKGROUND

Our team has previously reported physiologic support by the EXTra-uterine Environment for Neonatal Development (EXTEND) of 105 to 117 days gestational age (GA) lambs for up to 28 days with normal organ maturation. However, the fetal lamb brain matures more rapidly, requiring the study of 90-105 day GA fetal lambs to assess more neurodevelopmentally equivalent lambs to the 23-25 week GA extreme premature infant.

METHODS

Extremely preterm lambs (90-95 days of GA) were delivered by C-section and supported by EXTEND. Estimated circuit flows were maintained at around 325 ml/kg/min. After support on EXTEND, MRI and histopathologic analysis were performed and compared to 105-112 days GA control lambs.

RESULTS

The extremely preterm group includes 10 animals with a mean GA of 91.6 days, a mean weight at cannulation of 0.98 kg and a mean length of stay on EXTEND of 13.5 days (10-21 days). Hemodynamics and oxygenation showed stable parameters. Animals showed growth and physiologic cardiac function. MRI volumetric and diffusion analysis was comparable to controls. Histologic brain analysis revealed no difference between study groups.

CONCLUSION

EXTEND appears to support brain and cardiac development in an earlier gestation, less mature, lamb model.

IMPACT

Prolonged (up to 21 days) physiological support of extremely preterm lambs of closer neurodevelopmental equivalence to the 24-28 gestational week human was achieved using the EXTEND system. EXTEND treatment supported brain growth and development in extremely preterm fetal lambs and was not associated with intraventricular hemorrhage or white matter injury. Daily echocardiography demonstrated physiologic heart function, absence of cardiac afterload, and normal developmental increase in cardiac chamber dimensions. This study demonstrates hemodynamic and metabolic support by the EXTEND system in the extremely preterm ovine model.

Impact of COVID-19 pandemic on neurodevelopmental outcomes of premature infants: a retrospective national cohort study

OBJECTIVE

To compare the neurodevelopmental outcomes of preterm infants before and during the COVID-19 pandemic.

DESIGN

Premature infants born in 2018 were assigned to the pre-pandemic group, while those born in 2019 were assigned to the during-pandemic group.

SETTING

Nationwide cohort study.

PATIENTS

Very low birthweight premature infants registered in the Taiwan Premature Infant Follow-up Network database.

INTERVENTIONS

Anti-epidemic measures, including quarantine and isolation protocols, social distancing, the closure of public spaces and restrictions on travel and gatherings during COVID-19 pandemic.

MAIN OUTCOME MEASURES

Outcomes were measured by Bayley Scales of Infant and Toddler Development Third Edition at corrected ages of 6, 12 and 24 months old. Generalised estimating equation (GEE) was applied to incorporate all measurements into a single model.

RESULTS

Among the 1939 premature infants who were enrolled, 985 developed before the pandemic, while 954 developed during the pandemic. Premature infants whose development occurred during the pandemic exhibited better cognitive composite at the corrected age of 6 months (beta=2.358; 95% CI, 1.07 to 3.65; p<0.001), and motor composite at corrected ages of 12 months (beta=1.680; 95% CI, 0.34 to 3.02; p=0.014). GEE analysis showed that infants who had grown during the pandemic achieved higher scores in cognitive composite (beta=1.416; 95% CI, 0.36 to 2.48; p=0.009).

CONCLUSION

Premature infants in Taiwan who developed during the pandemic showed better neurodevelopment compared with those born before the pandemic.

The Experiences of Young People with Intellectual Disability, Parents and Professionals in Relationships and Sexuality Education Programmes: Findings from a Qualitative Study

People with intellectual disability want friendships and meaningful relationships, and some want intimacy. However, the expression of sexuality is an area where potential freedoms are often limited and restricted compared to their peers. While some relationships and sexuality education programmes do exist for this population, most focus on knowledge acquisition regarding sexuality and sex but lack in their focus on relationships, informed choices and decision-making. The aim of this study was to identify good practices and methods of delivery in relationships and sexuality education for children and young people with intellectual disability. A qualitative design was undertaken. Information about our study was distributed to eight special schools in the UK. Semi-structured interviews and focus groups were employed for data collection. Data from 37 pupils with intellectual disability, 11 parents and 16 healthcare and other professionals were thematically analysed. Following data analysis, three themes emerged: (i) seeking and sharing information; (ii) protecting and keeping safe; and (iii) learning for the future. The findings highlight that pupils are keen to learn about life changes and societal influences and want reliable information. Parents and professionals recognise that children and young people with intellectual disability will develop into adults and may be vulnerable when they leave the security of the school setting. They recognise that children and young people need to know about socialising, puberty, consent and contraception. Evidence-based programmes should be designed with these stakeholders to ensure children and young people with intellectual disability receive developmentally appropriate information to make happy and safe decisions about their relationships.

Supervised contrastive learning enhances graph convolutional networks for predicting neurodevelopmental deficits in very preterm infants using brain structural connectome

Very preterm (VPT) infants (born at less than 32 weeks gestational age) are at high risk for various adverse neurodevelopmental deficits. Unfortunately, most of these deficits cannot be accurately diagnosed until the age of 2-5 years old. Given the benefits of early interventions, accurate diagnosis and prediction soon after birth are urgently needed for VPT infants. Previous studies have applied deep learning models to learn the brain structural connectome (SC) to predict neurodevelopmental deficits in the preterm population. However, none of these models are specifically designed for graph-structured data, and thus may potentially miss certain topological information conveyed in the brain SC. In this study, we aim to develop deep learning models to learn the SC acquired at term-equivalent age for early prediction of neurodevelopmental deficits at 2 years corrected age in VPT infants. We directly treated the brain SC as a graph, and applied graph convolutional network (GCN) models to capture complex topological information of the SC. In addition, we applied the supervised contrastive learning (SCL) technique to mitigate the effects of the data scarcity problem, and enable robust training of GCN models. We hypothesize that SCL will enhance GCN models for early prediction of neurodevelopmental deficits in VPT infants using the SC. We used a regional prospective cohort of ∼280 VPT infants who underwent MRI examinations at term-equivalent age from the Cincinnati Infant Neurodevelopment Early Prediction Study (CINEPS). These VPT infants completed neurodevelopmental assessment at 2 years corrected age to evaluate cognition, language, and motor skills. Using the SCL technique, the GCN model achieved mean areas under the receiver operating characteristic curve (AUCs) in the range of 0.72∼0.75 for predicting three neurodevelopmental deficits, outperforming several competing models. Our results support our hypothesis that the SCL technique is able to enhance the GCN model in our prediction tasks.

Predicting 2-year neurodevelopmental outcomes in preterm infants using multimodal structural brain magnetic resonance imaging with local connectivity

The neurodevelopmental outcomes of preterm infants can be stratified based on the level of prematurity. We explored brain structural networks in extremely preterm (EP; < 28 weeks of gestation) and very-to-late (V-LP; ≥ 28 and < 37 weeks of gestation) preterm infants at term-equivalent age to predict 2-year neurodevelopmental outcomes. Using MRI and diffusion MRI on 62 EP and 131 V-LP infants, we built a multimodal feature set for volumetric and structural network analysis. We employed linear and nonlinear machine learning models to predict the Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III) scores, assessing predictive accuracy and feature importance. Our findings revealed that models incorporating local connectivity features demonstrated high predictive performance for BSID-III subsets in preterm infants. Specifically, for cognitive scores in preterm (variance explained, 17%) and V-LP infants (variance explained, 17%), and for motor scores in EP infants (variance explained, 15%), models with local connectivity features outperformed others. Additionally, a model using only local connectivity features effectively predicted language scores in preterm infants (variance explained, 15%). This study underscores the value of multimodal feature sets, particularly local connectivity, in predicting neurodevelopmental outcomes, highlighting the utility of machine learning in understanding microstructural changes and their implications for early intervention.

Successful Twin Delivery Through In Vitro Fertilization in a High-Gestation Age Kidney Transplant Recipient: A Case Report

BACKGROUND

Numerous successful pregnancy outcomes have been reported after kidney transplantation, but until now, there have been no reports of healthy twin deliveries through in vitro fertilization treatment in high-gestation aged women with a long post-transplant duration. In our report, we present a case of a high-gestation aged kidney transplant recipient who successfully delivered healthy twins with the aid of in vitro fertilization.

CASE PRESENTATION

At the age of 29, a woman with end-stage kidney disease caused by immunoglobin A nephropathy underwent kidney transplantation. She had a history of premature ovarian failure and had been on continuous ambulatory peritoneal dialysis since the age of 18. Eleven years after starting dialysis, she received a cadaveric kidney transplant. Despite being infertile for 7 years after transplantation, she wished to have children. In vitro fertilization embryo transfer was conducted after failure of ovarian stimulation, considering her age and premature ovarian failure. The patient successfully delivered twins at 29 weeks gestation via cesarean section, as the first fetus presented in breech position. The first newborn weighed 945 g and the second weighed 855 g, with no other congenital abnormalities found. One year after childbirth, neither the recipient nor her babies experienced any fatal complications.

CONCLUSIONS

A woman who underwent kidney transplantation and has stage 3 CKD may successfully deliver healthy twins through in vitro fertilization embryo transfer, even if she is of advanced maternal age and has a long post-transplant period. However, there is a risk of preterm premature rupture of membrane in such cases.

Safe care for premature babies at home: Parenting and stimulating development

Parental daily care and adequate stimuli are extremely important for development and safety of premature babies at home. This study aimed to analyze safe home care for babies born under 32 weeks from parents' perspectives, with a view to a longitudinal promotion of baby development. A qualitative study, based on philosophical hermeneutic approach proposed by Hans-Georg Gadamer, in which dialogue as a principle provides understanding and fusion of experiences and knowledge. Semi-structured interviews were conducted with 18 parents of premature babies under 1 year of age. Thematic analysis proposed by Braun and Clarke was applied using an inductive approach. Elements related to safe care were identified: home arrival, safe home care: preserving baby health and development, support for safe home care, and development of parental care to promote baby safety. These elements can provide a basis for safe home care that needs to be reinforced longitudinally to increase particularities of baby protection, avoid accidents and illnesses, and improve appropriate developmental stimuli and positive parenting.

Prenatal tobacco smoke exposure and risk for cognitive delays in infants born very premature

Prenatal tobacco smoke exposure (TSE) and prematurity are independent risk factors for abnormal neurodevelopment. The objectives were to compare differences in Bayley-III cognitive, language, and motor scores at 2 years corrected age (CA) in 395 infants born very preterm (≤ 32 weeks gestation) with and without prenatal TSE. We performed multivariable linear regression analyses to examine associations between prenatal TSE and neurodevelopmental outcomes and a mediation analysis to estimate direct effects of prenatal TSE on outcomes and indirect effects through preterm birth. In total, 50 (12.6%) infants had prenatal TSE. Infants with prenatal TSE had lower mean [95% CI] Cognitive score (82.8 [78.6, 87.1]) vs. nonexposed infants (91.7 [90.1, 93.4]). In children with and without prenatal TSE, there were significant differences in mean [95% CI] Language scores (81.7 [76.0, 87.4] vs. 92.4 [90.2, 94.6], respectively) and mean [95% CI] Motor scores (86.5 [82.2, 90.7] vs. 93.4 [91.8, 95.0], respectively); scores remained significant after controlling for confounders. Preterm birth indirectly mediated 9.0% of the total effect of prenatal TSE on Cognitive score (P = NS). However, 91% of the remaining total effect was significant and attributable to TSE's direct harmful effects on cognitive development (β = - 5.17 [95% CI - 9.97, - 0.38]). The significant association is largely due to TSE's direct effect on cognitive development and not primarily due to TSE's indirect effect on preterm birth.

Risk of Developmental Disorders in Children Born at 32 to 38 Weeks' Gestation: A Meta-Analysis

CONTEXT

Very preterm birth (<32 weeks) is associated with increased risk of developmental disorders. Emerging evidence suggests children born 32 to 38 weeks might also be at risk.

OBJECTIVES

To determine the relative risk and prevalence of being diagnosed with, or screening positive for, developmental disorders in children born moderately preterm, late preterm, and early term compared with term (≥37 weeks) or full term (39-40/41 weeks).

DATA SOURCES

Medline, Embase, Psychinfo, Cumulative Index of Nursing, and Allied Health Literature.

STUDY SELECTION

Reported ≥1 developmental disorder, provided estimates for children born 32 to 38 weeks.

DATA EXTRACTION

A single reviewer extracted data; a 20% sample was second checked. Data were pooled using random-effects meta-analyses.

RESULTS

Seventy six studies were included. Compared with term born children, there was increased risk of most developmental disorders, particularly in the moderately preterm group, but also in late preterm and early term groups: the relative risk of cerebral palsy was, for 32 to 33 weeks: 14.1 (95% confidence intervals [CI]: 12.3-16.0), 34 to 36 weeks: 3.52 (95% CI: 3.16-3.92) and 37 to 38 weeks: 1.44 (95% CI: 1.32-1.58).

LIMITATIONS

Studies assessed children at different ages using varied criteria. The majority were from economically developed countries. All were published in English. Data were variably sparse; subgroup comparisons were sometimes based on single studies.

CONCLUSIONS

Children born moderately preterm are at increased risk of being diagnosed with or screening positive for developmental disorders compared with term born children. This association is also demonstrated in late preterm and early term groups but effect sizes are smaller.

Preterm Newborn Adaptive Responses to Daily Nursing during Neonatal Intensive Care Unit Stay, Associate with Neurodevelopment, 2 Years Later

OBJECTIVE

This study aimed to evaluate if adaptive responses of very preterm newborns to neonatal intensive care unit (NICU) daily nursing, specifically bathing and weighing procedures are associated with their neurodevelopment after 2 years.

STUDY DESIGN

Twenty-six very preterm newborns, with a gestational age <32 weeks, were enrolled. Infants' adaptive responses to daily nursing were evaluated, at 30 to 32 to 35 postmenstrual age (PMA) weeks by an observational sheet. Neurodevelopment was assessed at 24 months of corrected age by the Bayley Scales of Infant and Toddler Development, third edition. Autonomic, motor, and self-regulatory responses to NICU nursing were analyzed by Spearman's correlation coefficient and multivariate linear regression with Bayley's cognitive, language, and motor scales.

RESULTS

Significant (p < 0.05) positive correlations of self-regulatory and autonomic responses to nursing with all Bayley's scales were found at 30- and 32-week PMA. At 35-week PMA, only self-regulatory responses had significant positive correlations with all Bayley's scales. When adjusted for birth weight and sex, the significant associations were confirmed only at 30- and 32-week PMA.

CONCLUSION

Very preterm newborn adaptive responses to NICU daily nursing reveal to be positively related to forthcoming neurodevelopment 2 years later, as early as the 30-week PMA. Helping preterm babies to adapt to daily NICU nursing may promote their future neurobehavior.

KEY POINTS

· Preterm adaptation to nursing was studied.. · Adaptation positively relates to neurodevelopment.. · Such relation is detected since 30-week PMA..

Risk assessment of survival and morbidity of infants born at <24 completed weeks of gestation

BACKGROUND

Infants born at the threshold of viability have a high risk of mortality and morbidity. The British Association of Perinatal Medicine (BAPM) provided updated guidance in 2019 advising a risk-based approach to balancing decisions about active versus redirected care at birth.

AIMS

To determine survival and morbidity of infants born between 22 and 24 completed weeks of gestation. To develop a scoring system to categorise infants at birth according to risk for mortality or severe adverse outcome.

METHODS

A retrospective, single centre observational study of infants who received neonatal care from 2011 to 2021. Data were collected on mortality, morbidity and two-year neurodevelopmental outcomes. Each infant was risk categorised utilising the proposed tools in the BAPM (2019) framework. A composite adverse score for either dying or surviving with severe impairment was created.

RESULTS

Four infants born at 22 weeks, 49 at 23 weeks and 105 at 24 weeks of gestation were included. The mortality rate was 23.4 %. Following risk categorisation there were 8 (5.1 %) extremely high risk, 44 (27.8 %) high risk and 106 (67.1 %) moderate risk infants. The rate of dying or surviving with severe impairment for extremely high risk, high risk and moderate risk were 100 %, 88.9 % and 53 % respectively. The proportions with the composite adverse outcome differed significantly according to the risk category (p < 0.001).

CONCLUSIONS

When applying a scoring system to risk categorise infants at birth, high rates of dying or surviving with severe impairment were found in infants born at 22 or 23 weeks of gestation.

Language Outcomes of Children Born Very Preterm in Relation to Early Maternal Depression and Anxiety

Unaddressed maternal psychological distress within the first year postpartum is known to have numerous negative consequences on the child's developmental outcomes, including language acquisition. This study examined the relationship between early maternal psychosocial factors and the language outcomes of children born very preterm (VPT; ≤32 weeks gestational age). It used data from the Cincinnati Infant Neurodevelopment Early Prediction Study, an ongoing National-Institutes-of-Health-funded prospective, multicenter cohort investigation of VPT infants. A total of 243 (125 boys; 118 girls) children born VPT (M = 29.03 weeks of gestation; SD = 2.47) and their corresponding 207 mothers (34 with multiple infants) were included in this study. We did not find an association between maternal depression or anxiety and Bayley-III (M = 92.3, SD = 18.9) language scores. Additionally, maternal grit and self-efficacy did not modify the relationship between depression and anxiety and language scores. A higher level of maternal education and infant female sex were significantly associated with higher language scores. While preterm birth typically results in higher rates of depression and anxiety for parents, the findings suggest that maternal depression, anxiety, and grit and the self-efficacy of the mothers in this sample did not relate to the language development of their children, independent of maternal education and infant female sex.

Neurodevelopmental Outcomes Among Infants Born Preterm Fed With Mother's Own Milk: A Comparison of Singletons and Twins

OBJECTIVE

To examine associations between early exposure to mother's own milk (MOM) and neurodevelopmental outcomes among preterm infants, and to compare these associations between singletons and twins.

STUDY DESIGN

Retrospective cohort study that included low-risk infants born at <32 weeks gestational age. Nutrition was documented over a 3-day period at mean ages of 14 and 28 days of life; an average of the 3 days was calculated. The Griffiths Mental Development Scales (GMDS) were administered at 12 months corrected age.

RESULTS

Preterm infants (n = 131) with median gestational age of 30.6 weeks were included; 56 (42.7%) were singletons. On days 14 and 28 of life, 80.9% and 77.1% were exposed to MOM, respectively. Exposure rate was comparable, but MOM intake (mL/kg/day) was higher among singletons than among twins (P < .05). At both time points, MOM-exposed infants scored higher on personal-social, hearing-language, and total GMDS assessments than nonexposed infants. These differences were significant for the entire cohort and for twins (P < .05). MOM intake correlated with total GMDS score for both singletons and twins. Any exposure to MOM was associated with additional 6-7 points on total GMDS score or 2-3 additional points for every 50 mL/kg/day of MOM.

CONCLUSIONS

The study supports the positive association between early MOM exposure among low-risk preterm infants and neurodevelopmental outcomes at 12 months corrected age. The differential effects of MOM exposure on singletons vs twins need further exploration.

Spiritual and cultural influences on end-of-life care and decision-making in NICU

Understanding and respecting the spiritual beliefs, ethnic roots, cultural norms and customs of individual families is essential for neonatologists to provide clinically appropriate and humane end-of-life care. This review describes the religious/philosophical principles, cultural-related practices/rituals, and traditions in end-of-life care in major spiritual groups of today's multi-cultural, multi-faith societies. The spiritual groups include Christians, Muslims, Jewish Judaism believers and Asian religious/philosophy followers such as Buddhists, Hindus, Taoists, Confucianism devotees and ancestral worshippers. It is vital to understand that substantial variation in views and practices may exist even within the same religion and culture in different geographic locations. Ethical views and cultural practices are not static elements in life but behave in a fluidic and dynamic manner that could change with time. Interestingly, an evolving pattern has been observed in some Asian and Middle East countries that more parents and/or religious groups are beginning to accept a form of redirection of care most compatible with their spiritual belief and culture. Thus, every family must be assessed and counseled individually for end-of-life decision-making. Also, every effort should be made to comply with parents' requests and to treat infants/parents of different religions and cultures with utmost dignity so that they have no regret for their irreversible decisions.

Neurodevelopmental Outcome of Very Low Birth Weight Infants in the Northern District of Israel: A Cross-Sectional Study

BACKGROUND

Currently, no local database in Israel collects neurodevelopmental outcomes of very low birth weight (VLBW) preterm infants. We investigated neurodevelopmental outcomes in one district of the largest healthcare organization in Israel.

METHODS

A cross-sectional study including all VLBW (<1500 g) preterm infants born between 1 January 2006 and 31 December 2016 who were followed in any of seven child development centers in Israel's Northern District. Data were retrospectively collected from the computerized medical record database.

RESULTS

Out of 436 participants, 55.1% had normal developmental outcomes. A total of 8.9% had cerebral palsy (CP), 12.2% had a global developmental delay (GDD), and 33.4% had a language delay. Out of the extremely preterm infants (n = 109), 20.2% had CP, 22.0% had GDD, and 44.9% had language delay. We found a statistically significant higher rate of abnormal neurodevelopment outcomes in non-Jews compared to Jews (57% vs. 37.8%, respectively, p < 0.0001).

CONCLUSIONS

We found a relatively high overall rate of CP in our local population and a significant difference in neurodevelopmental outcomes between Jews and non-Jews. This study emphasizes the need for an expanded and detailed national database collecting post-discharge outcomes, as well as an assessment of national healthcare resource allocation and inequalities in preterm infants' post-discharge care.

Survival and Neurodevelopmental Outcome of Extremely-Low-Birth-Weight Infants at One Year of Age-A Prospective, Descriptive Study

OBJECTIVES

To study the survival rates at discharge and neurodevelopmental outcome at 1 y of corrected age (CA) of extremely-low-birth-weight ELBW neonates.

METHODS

This prospective, descriptive study was conducted in a tertiary care level III extramural NICU of a teaching hospital. Forty-nine extremely-low-birth-weight (ELBW) neonates were enrolled in the study from July 2017 to June 2018. Baseline demographic data, morbidities during NICU stay, and survival at discharge for the enrolled neonates were recorded. The enrolled infants were followed up to 1 y of CA at three-monthly intervals. During the follow-up, anthropometry, developmental screening by Denver Developmental Screening Test (DDST), and tone assessment by Amiel-Tison scale were done. Developmental Assessment Scale for Indian Infants (DASII) was administered at CA of 12 mo.

RESULTS

Thirty-seven (75.5%) neonates survived to discharge. Survival rate of neonates with birth weight > 750 g and with gestational age ≥ 26 wk was 90.2% and 85.7%, respectively. Amongst those < 750 g or < 26 wk (n = 8), none survived. Abnormal developmental quotient (DQ < 70%) was seen in 6 infants out of 33 infants (18.1%) followed at 1 y of CA.

CONCLUSION

Overall, 3/4^th of ELBW infants survived to discharge and 80% of those who were followed up at 1 y of CA had normal neurodevelopmental outcome. However, survival rates of neonates born at < 26 wk and/or with birth weight < 750 g  were less and needs to be improved.

Associations of preterm and early-term birth with suspected developmental coordination disorder: a national retrospective cohort study in children aged 3-10 years

BACKGROUND

This study analyzed the motor development and suspected developmental coordination disorder of very and moderately preterm (< 34+0 gestational age), late preterm (34+0-36+6 gestational week), and early-term (37+0-38+6 gestational week) children compared to their full-term peers with a national population-based sample in China.

METHODS

A total of 1673 children (799 girls, 874 boys) aged 3-10 years old were individually assessed with the Movement Assessment Battery for Children-second edition (MABC-2). The association between gestational age and motor performance of children was analyzed using a multilevel regression model.

RESULTS

The global motor performance [β =  - 5.111, 95% confidence interval (CI) =  - 9.200 to - 1.022; P = 0.015] and balance (β =  - 5.182, 95% CI =  - 5.055 to - 1.158; P = 0.003) for very and moderately preterm children aged 3-6 years old were significantly lower than their full-term peers when adjusting for confounders. Late preterm and early-term children showed no difference. Moreover, very and moderately preterm children aged 3-6 years had a higher risk of suspected developmental coordination disorder (DCD) (≤ 5 percentile of MABC-2 score) when adjusting for potential confounders [odds ratio (OR) = 2.931, 95% CI = 1.067-8.054; P = 0.038]. Late preterm and early-term children showed no difference in motor performance from their full-term peers (each P > 0.05).

CONCLUSIONS

Our findings have important implications for understanding motor impairment in children born at different gestational ages. Very and moderately preterm preschoolers have an increased risk of DCD, and long-term follow-up should be provided for early detection and intervention.

Exploring the impact of COVID-19 on newborn neurodevelopment: a pilot study

The COVID-19 pandemic can seize the opportunity to explore the hypothesis of prenatal exposure to viral infections increases the risk for neurodevelopmental disorders. Advancing our knowledge in this regard would improve primary prevention of mental disorders in children. For this pilot study, six-week-old infants born to mothers exposed (n = 21) or unexposed (n = 21) to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were assessed in Santander-Cantabria (Spain) using the Neonatal Behavioral Assessment Scale (NBAS). Groups comparisons were performed to explore the effects that infection and timing of exposure (in terms of the three trimesters of pregnancy). The infants' competencies and performances on the NBAS were generally similar in the exposed and unexposed to SARS-CoV-2 groups. The most significant difference found was a less optimally response to cuddliness (item on the state regulation domain) particularly in infants born to mothers exposed in the third trimester of pregnancy, and in pull-to-sit (item on the motor system domain). Although our interpretations must be careful, these preliminary results highlight the possible association between prenatal SARS-CoV-2 exposure and poorer development in motor skills and infant interactive behavior. Further longitudinal studies are needed to explore these relationships and disentangle the biological mechanisms implicated.

Developmental assessment of infants with congenital heart disease: a cross-sectional study

Background

Recently, marked improvement of medical and surgical care for infants with congenital heart disease led to a growing population with a high risk of developmental delay. We aimed to identify developmental delay in these infants and its risk factors. So, we performed a cross-sectional study on 100 infants with congenital heart disease to assess their development by using Vineland Adaptive Behaviour Scale. We searched for risk factors for developmental delay in these infants. Correlations were conducted between the degree of developmental delay and the potential risk factors. To our knowledge, this study has not been conducted in developing countries before.

Results

The median age of the study group is 12.5 months, but it is equivalent to 9.5 months by using Vineland Adaptive Behaviour Scale. There was a statistically significant developmental delay in infants who had risk factors such as prematurity, history of neonatal intensive care unit admission, anemia, stunted growth, underweight, central cyanosis, or abnormal electroencephalographic.

Conclusions

Developmental delay is a common complication in infants with congenital heart disease. It has many risk factors; some of them could be modifiable as anemia, stunted growth, and underweight. Thus, early screening for developmental delay and its risk factors is of a great value. This could help in applying preventive measures and early intervention programs. Vineland Adaptive Behaviour Scale is a reliable tool in determination of developmental delay in infants with congenital heart disease.

Machine learning for understanding and predicting neurodevelopmental outcomes in premature infants: a systematic review

BACKGROUND

Machine learning has been attracting increasing attention for use in healthcare applications, including neonatal medicine. One application for this tool is in understanding and predicting neurodevelopmental outcomes in preterm infants. In this study, we have carried out a systematic review to identify findings and challenges to date.

METHODS

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Four databases were searched in February 2022, with articles then screened in a non-blinded manner by two authors.

RESULTS

The literature search returned 278 studies, with 11 meeting the eligibility criteria for inclusion. Convolutional neural networks were the most common machine learning approach, with most studies seeking to predict neurodevelopmental outcomes from images and connectomes describing brain structure and function. Studies to date also sought to identify features predictive of outcomes; however, results varied greatly.

CONCLUSIONS

Initial studies in this field have achieved promising results; however, many machine learning techniques remain to be explored, and the consensus is yet to be reached on which clinical and brain features are most predictive of neurodevelopmental outcomes.

IMPACT

This systematic review looks at the question of whether machine learning can be used to predict and understand neurodevelopmental outcomes in preterm infants. Our review finds that promising initial works have been conducted in this field, but many challenges and opportunities remain. Quality assessment of relevant articles is conducted using the Newcastle-Ottawa Scale. This work identifies challenges that remain and suggests several key directions for future research. To the best of the authors' knowledge, this is the first systematic review to explore this topic.

Gentle as a mother's touch: C-tactile touch promotes autonomic regulation in preterm infants

Preterm infants are challenged to adapt to an extrauterine milieu, while their interoceptive system and autonomic regulation capacity is still immature. Caressing parental touch is known to foster parasympathetic regulation in infants by stimulating C-tactile (CT) afferents and in preterm infants, slow stroking stimulation also leads to a heart rate decrease. The particular impact of maternal stroking has not yet been investigated and factors influencing the maturation of the CT system in preterm infants remain unclear. We therefore analysed 53 standardized events in which preterm infants (24 to 36 weeks gestational age at birth) were stroked by their mothers. Video analysis revealed that mothers use CT optimal velocities to stroke their preterm child. Analysis of pulse oximetric data showed no effect of stroking on infantile blood oxygenation, but a significant decrease of the heart rate. Compared to term-born children, this decrease was delayed by about two minutes. Furthermore, our data suggested that more immature preterm infants benefited less from stroking than more mature ones. We conclude that maternal stroking touch targets CT afferents in preterm infants and that the preterm CT system is not yet mature.

Association Between Retinopathy of Prematurity in Very-Low-Birth-Weight Infants and Neurodevelopmental Impairment

PURPOSE

To evaluate the impact of retinopathy of prematurity (ROP) severity and the treatment of very-low-birth-weight infants (VLBWIs) on neurodevelopmental impairment in early childhood.

DESIGN

Prospective cohort study.

METHOD

This was a prospective cohort study. The data were obtained from the Korean Neonatal Network (KNN), a nationwide registry for VLBWIs. Infants who were born from 2013 to 2015 and underwent ROP evaluation at birth and neurodevelopmental examinations at corrected ages of 18 to 24 months were included in the study. Infants with a history of meningitis or severe congenital anomalies were excluded. The VLBWI patients were grouped into no ROP, no treatment-requiring ROP (non-TR-ROP), and treatment-requiring ROP (TR-ROP) groups. Neurodevelopmental impairment was defined as participants who had at least 1 developmental problem according to the Bayley Scales of Infant and Toddler Development-2nd Edition (Bayley-II; <70), Bayley Scales of Infant and Toddler Development-3rd Edition (Bayley-III; <70), and Korean Developmental Screening Test (K-DST) tests (below -1 SD), and the Korean Ages and Stages Questionnaire (K-ASQ) (below the threshold) and Gross Motor Function Classification System (GMFCS; at level 2 or above). Multivariable logistic regression analysis was performed to evaluate the association between ROP and neurodevelopmental impairment.

RESULT

Among 3132 infants, 1093 (34.9%) had ROP. Among the ROP infants, 644 were not treated for ROP (non-TR-ROP group) and 449 received ROP treatments (TR-ROP group). The patients in the TR-ROP group had an increased risk of developing neurodevelopmental problems compared to those in the no ROP group (odds ratio [OR] = 1.72, 95% CI = 1.33-2.21). The TR-ROP group had a higher risk of all 3 types of neurodevelopmental problems: mental (OR = 1.62, 95% CI = 1.25-2.09), social (OR = 1.62, 95% CI = 1.12-2.09), and motor (OR = 1.69, 95% CI = 1.31-2.18). The risk of neurodevelopmental problems in patients treated with laser therapy did not differ from that in patients treated with anti-vascular endothelial growth factor (anti-VEGF) therapy (OR = 1.17, 95% CI = 0.73-1.88).

CONCLUSION

ROP was independently associated with neurodevelopmental impairment in early childhood. The type of ROP treatment (anti-VEGF or laser treatment) did not affect neurodevelopmental impairment in patients in the TR-ROP group.

The impact of breast milk feeding on early brain development in preterm infants in China: An observational study

BACKGROUND

The prevailing consensus from large epidemiological studies is that breastfeeding is associated with improved IQ and cognitive functioning in later childhood and adolescence. Current research is exploring the association between breastfeeding and early brain development in preterm infants.

OBJECTIVE

To explore the differences in brain gray matter between breastmilk-fed and formula-fed preterm infants using structural and functional magnetic resonance imaging.

METHODS

A convenience sample of breastmilk-fed preterm infants(n = 34) and formula-fed infants (n = 22) aged approximately 32 weeks. At near term-equivalent age, MR scanning was performed. Gray matter structural and functional differences between the two groups were assessed using MATLAB software for voxel-based morphometry (VBM) and amplitude of low-frequency fluctuation (ALFF) analysis.

RESULTS

Maternal and neonatal demographic characteristics showed no significant difference between the two groups. Breastmilk-fed infants had greater regional gray matter volume on MRI than formula-fed infants in multiple brain regions, including the bilateral frontal lobe (BA11, BA46), right temporal lobe (BA37), and left caudate nucleus, at a statistical threshold of p<0.01 (AlphaSim corrected) with a cluster size of >40 voxels. Compared with formula-fed infants, breastmilk-fed infants showed increased brain activation on fMRI in the right superior temporal gyrus (BA41).

CONCLUSION

Breastmilk-fed infants had greater regional gray matter development and increased regional gray matter function compared with formula-fed infants at near term-equivalent age, suggesting breastmilk feeding in the early period after birth may have some degree of influence on early brain development in preterm infants.

Early feeding behaviours of extremely preterm infants predict neurodevelopmental outcomes

BACKGROUND

Infants born extremely preterm are at high risk for early feeding difficulties, as well as poor neurodevelopmental outcomes in childhood. Feeding, a complex motor skill, may be predictive of later neuromotor outcomes.

AIMS

To determine the relationship between feeding behaviours of extremely preterm-born infants (<28 weeks gestational age) at 4-months corrected age (CA) and neurodevelopmental outcomes at 4-5 years.

STUDY DESIGN

Retrospective cohort design with prospectively collected data.

SUBJECTS

Infants born extremely preterm from September 1999 - October 2013 [n = 412, mean gestational age 25.4 (1.3) weeks; mean birth weight 771 (168) grams]. Oral feeding was assessed at 4-months CA by an experienced occupational therapist; infants were classified as either having poor suck-swallow ('feeding difficulties') or no feeding difficulties.

OUTCOME MEASURES

Motor outcomes were assessed at 4-5 years using the Movement Assessment Battery for Children (MABC). Children were categorized as: (1) typical motor development (TMD; n = 214); (2) Developmental Coordination Disorder (DCD; n = 116); or (3) major neurodevelopmental disorder (MND; n = 82).

RESULTS

Feeding behaviour at 4-months CA predicted DCD (OR = 2.95, CI 1.13-7.68) and MND (OR = 3.67, CI 1.35-9.96) after controlling for confounders. Infants with feeding difficulties were more likely to be diagnosed with DCD (40 % of poor feeders) or MND (36 %) at 4-5 years, compared to infants without feeding issues.

CONCLUSIONS

Early feeding behaviours significantly predicted motor outcomes at 4-5 years. Infants born extremely preterm with early feeding difficulties should be identified as at high risk for poor motor outcomes later in childhood and screened for early diagnosis and intervention.

Micro-preemie Parents' Perceptions of Trauma-Informed Developmental Neuroprotective Care and Nursing Support

BACKGROUND

Preterm birth is traumatic for both the infant and parents. Trauma-informed developmental neuroprotective care (TIDNC) may positively influence the outcomes for micro-preemie infants (infants born before 26 weeks' gestation) as well as support parents in crisis.

PURPOSE

To explore how TIDNC influences micro-preemie parents' perceptions of nursing care and support.

METHODS

A descriptive cross-sectional study was conducted at a 56-bed level III neonatal intensive care unit (NICU). A convenience sample of micro-preemie parents (n = 16, 46%) completed the Nurse Parent Support Tool (NPST) questionnaire, which included 2 open-ended questions.

RESULTS

These parents scored high scores on the NPST (mean = 4.62 ± 0.24), indicating most parents felt support from the nursing staff and perceived individualized family-centered high-quality nursing care. Subscale scores were higher than all previous studies. Parents perceived high levels of support most of the time to almost always. Although 4 themes were closely associated with the subscales, the fifth theme, Praise has not been previously documented. Parents were grateful for nurses who provided compassionate care and support during one of the most difficult times of their lives.

IMPLICATIONS FOR PRACTICE

TIDNC encourages robust nurse-parent authentic caring relationships, which are foundational to the parents' perceptions of nursing care and support. These relationships, built on mutual trust, respect, and genuine listening, appear to foster an exceptionally high degree of support.

IMPLICATIONS FOR RESEARCH

More research is needed to examine how unit culture, characteristics of nurses, parents, and infants as well as infant outcomes influence micro-preemie parents' perception of care and further explore the nature of support.

A self-training deep neural network for early prediction of cognitive deficits in very preterm infants using brain functional connectome data

BACKGROUND

Deep learning has been employed using brain functional connectome data for evaluating the risk of cognitive deficits in very preterm infants. Although promising, training these deep learning models typically requires a large amount of labeled data, and labeled medical data are often very difficult and expensive to obtain.

OBJECTIVE

This study aimed to develop a self-training deep neural network (DNN) model for early prediction of cognitive deficits at 2 years of corrected age in very preterm infants (gestational age ≤32 weeks) using both labeled and unlabeled brain functional connectome data.

MATERIALS AND METHODS

We collected brain functional connectome data from 343 very preterm infants at a mean (standard deviation) postmenstrual age of 42.7 (2.5) weeks, among whom 103 children had a cognitive assessment at 2 years (i.e. labeled data), and the remaining 240 children had not received 2-year assessments at the time this study was conducted (i.e. unlabeled data). To develop a self-training DNN model, we built an initial student model using labeled brain functional connectome data. Then, we applied the trained model as a teacher model to generate pseudo-labels for unlabeled brain functional connectome data. Next, we combined labeled and pseudo-labeled data to train a new student model. We iterated this procedure to obtain the best student model for the early prediction task in very preterm infants.

RESULTS

In our cross-validation experiments, the proposed self-training DNN model achieved an accuracy of 71.0%, a specificity of 71.5%, a sensitivity of 70.4% and an area under the curve of 0.75, significantly outperforming transfer learning models through pre-training approaches.

CONCLUSION

We report the first self-training prognostic study in very preterm infants, efficiently utilizing a small amount of labeled data with a larger share of unlabeled data to aid the model training. The proposed technique is expected to facilitate deep learning with insufficient training data.

Maternal and dietary behavior-related factors associated with preterm birth in Southeastern Terai, Nepal: A cross sectional study

Background

Preterm birth (PTB) is a global issue although its burden is higher in low- and middle-income countries. This study examined the risk factors of PTB in Southeastern Terai, Nepal.

Methods

In this community-based cross-sectional study, a total of 305 mothers having children under the age of 6 months were selected using systematic random sampling. Data were collected by structured interviewer-administered questionnaires and maternal antenatal cards from study participants for some clinical information. Predictors of PTB were identified using multi-level logistic regression analysis at a P-value < 0.05.

Results

Of the total 305 mother-live-born baby pairs, 13.77% (42/305) had preterm childbirth. Maternal socio-demographic factors such as mothers from Dalit caste/ethnicity [adjusted odds ratio (AOR) = 12.16, 95% CI = 2.2-64.61] and Aadibasi/Janajati caste/ethnicity (AOR = 3.83, 95% CI = 1.01-14.65), family income in the first tercile (AOR = 6.82, 95% CI = 1.65-28.08), than their counterparts, were significantly positively associated with PTB. Likewise, other maternal and dietary factors, such as birth order first-second (AOR = 9.56, 95% CI = 1.74-52.53), and birth spacing ≤ 2 years (AOR = 5.16, 95% CI = 1.62-16.42), mothers who did not consume additional meal (AOR = 9.53, 95% CI = 2.13-42.55), milk and milk products (AOR = 6.44, 95% CI = 1.56-26.51) during pregnancy, having <4 antenatal (ANC) visits (AOR = 4.29, 95% CI = 1.25-14.67), did not have intake of recommended amount of iron and folic acid tablets (IFA) (<180 tablets) (AOR = 3.46, 95% CI = 1.03-11.58), and not having adequate rest and sleep (AOR = 4.83, 95% CI = 1.01-23.30) during pregnancy had higher odds of having PTB than their counterparts.

Conclusion

Some socio-demographic, maternal, and dietary behavior-related factors were independently associated with PTB. These factors should be considered while designing targeted health interventions in Nepal. In addition, we recommend specific measures such as promoting pregnant women to use available antenatal care and counseling services offered to them, as well as having an adequate diet to a level that meets their daily requirements.

Normal variant residual germinal matrix in extremely premature infants: radiographic features and imaging pitfalls

BACKGROUND

As radiology volume from premature patients increases, previously undescribed imaging findings may be identified, posing diagnostic dilemma to the pediatric radiologist.

OBJECTIVE

The primary goal of our study is to characterize the previously undescribed imaging finding of subependymal echogenicity at the floor of the frontal horns, which we postulate represents normal variant embryologic remnant residual germinal matrix. Furthermore, we hope to equip the pediatric radiologist with diagnostic criteria to distinguish this normal variant from pathology.

MATERIALS AND METHODS

Retrospective review of neonates at our institution over a 10 year period was performed to identify extremely premature infants who received head ultrasounds during their hospital stay. Clinical data from EPIC was collected on these patients in addition to retrospective review of their head ultrasound images.

RESULTS

Literature review of neuroembryology and observed involution of the frontal horn subependymal echogenicity on sequential imaging inform our hypothesis that this imaging finding represents normal variant residual germinal matrix. Two-thirds of the 210 included extremely premature infants demonstrated this finding, which was frequently misinterpreted as grade 1 germinal matrix, intra-choroidal or intra-ventricular hemorrhage. Residual matrix was concomitantly present with additional pathology in 29.4% of the patients.

CONCLUSION

Previously undescribed subependymal echogenicity at the floor of the frontal horns is favored to represent normal variant embryologic remnant residual germinal matrix. Since this finding may be misinterpreted as germinal matrix, intra-choroidal or intra-ventricular hemorrhage, it is essential for the interpreting radiologist to be aware of this normal variant and not confuse it for pathology.

The landscape of circular RNA in preterm birth

Background

Preterm birth (PTB) is a multifactorial syndrome that seriously threatens the health of pregnant women and babies worldwide. Recently, circular RNAs (circRNAs) have been understood as important regulators of various physiological and pathological processes. However, the expression pattern and potential roles of circRNAs in PTB are largely unclear.

Methods

In this study, we extracted and analyzed the circRNA expression profiles in maternal and fetal samples of preterm and term pregnancies, including maternal plasma, maternal monocytes, myometrium, chorion, placenta, and cord blood. We identified the circRNAs which is associated with PTB in different tissues and explored their relationships from the perspective of the overall maternal-fetal system. Furthermore, co-expression analysis of circRNAs and mRNAs, target microRNAs (miRNAs), and RNA-binding proteins (RBPs), provided new clues about possible mechanisms of circRNA function in PTB. In the end, we investigated the potential special biofunctions of circRNAs in different tissues and their common features and communication in PTB.

Results

Significant differences in circRNA types and expression levels between preterm and term groups have been proved, as well as between tissues. Nevertheless, there were still some PTB-related differentially expressed circRNAs (DECs) shared by these tissues. The functional enrichment analysis showed that the DECs putatively have important tissue-specific biofunctions through their target miRNA and co-expressed mRNAs, which contribute to the signature pathologic changes of each tissue within the maternal-fetal system in PTB (e.g., the contraction of the myometrium). Moreover, DECs in different tissues might have some common biological activities, which are mainly the activation of immune-inflammatory processes (e.g., interleukin1/6/8/17, chemokine, TLRs, and complement).

Conclusions

In summary, our data provide a preliminary blueprint for the expression and possible roles of circRNAs in PTB, which lays the foundation for future research on the mechanisms of circRNAs in PTB.

Reflecting the trends in the academic landscape of special education using probabilistic dynamic topic modeling

Purpose

Special education is the education segment that deals with the students facing hurdles in the traditional education system. Research data have evolved in the domain of special education due to scientific advances. The present study aims to employ text mining to extract the latent patterns from the scientific data.

Design/methodology/approach

This study examined the 12,781 Scopus-indexed titles, abstracts and keywords published from 1987 to 2021 through an integrated text-mining and topic modeling approach. It combines dynamic topic models with highly cited reviews of this domain. It facilitates the extraction of topic clusters and communities in the topic network.

Findings

This methodology discovered children’s communication and speech using gaming techniques, mental retardation, cost effect on infant birth, involvement of special education children and their families, assistive technology information for special education, syndrome epilepsy and the impact of group study on skill development peers or self as the hottest topic of research in this domain. In addition to finding research hotspots, it further explores annual topic proportion trends, topic correlations and intertopic research areas.

Originality/value

The results provide a comprehensive summary of the popularity of research topics in special education in the past 34 years, and the results can provide useful insights and implications, and it could be used as a guide for contributors in special education form a structured view of past research and plan future research directions.

Association of Delivery Room and Neonatal Intensive Care Unit Intubation, and Number of Tracheal Intubation Attempts with Death or Severe Neurological Injury among Preterm Infants

OBJECTIVE

The study aimed to assess the association of tracheal intubation (TI) and where it is performed, and the number of TI attempts with death and/or severe neurological injury (SNI) among preterm infants.

STUDY DESIGN

Retrospective cohort study of infants born 23 to 32 weeks, admitted to a single level-3 neonatal intensive care unit (NICU) between 2015 and 2018. Exposures were location of TI (delivery room [DR] vs. NICU) and number of TI attempts (1 vs. >1). Primary outcome was death and/or SNI (intraventricular hemorrhage grade 3-4 and/or periventricular leukomalacia). Multivariable logistic regression analysis was used to assess association between exposures and outcomes and to adjust for confounders.

RESULTS

Rate of death and/or SNI was 2.5% (6/240) among infants never intubated, 12% (13/105) among NICU TI, 32% (31/97) among DR TI, 20% (17/85) among infants with one TI attempt and 23% (27/117) among infants with >1 TI attempt. Overall, median number of TI attempts was 1 (interquartile range [IQR]: 1-2). Compared with no TI, DR TI (adjusted odds ratio [AOR]: 9.04, 95% confidence interval [CI]: 3.21-28.84) and NICU TI (AOR: 3.42, 95% CI: 1.21-10.61) were associated with higher odds of death and/or SNI. The DR TI was associated with higher odds of death and/or SNI compared with NICU TI (AOR: 2.64, 95% CI: 1.17-6.22). The number of intubation attempts (1 vs. >1) was not associated with death and/or SNI (AOR: 0.95, 95% CI: 0.47-2.03).

CONCLUSION

The DR TI is associated with higher odds of death and/or SNI compared with NICU TI, and may help identify higher risk infants. There was no association between the number of TI attempts and death and/or SNI.

KEY POINTS

· Delivery room intubation correlates with morbidity.. · Less than 2 intubation attempts are not associated with IVH.. · Provider training reduces intubation attempts..

Mother-Infant Dyadic Synchrony in the NICU Context

BACKGROUND

Dyadic synchrony is a co-constructed social process relating to the back and forth interactions between mothers and infants that are strongly associated with neurodevelopment, self-regulation, and attachment. In the neonatal intensive care unit (NICU), this process may become interrupted because of the physiological state of the infant, the emotional state of the mother, and the physical environment of the NICU.

PURPOSE

In applying Feldman's Biobehavioral Model of Synchrony, this empirical review deconstructs the process of dyadic synchrony in the NICU context and provides a conceptual approach to guide both research and clinical practice.

METHODS

First, we examine the theoretical and empirical literature to explicate the primary structural and biophysiological components of synchrony and relate these constructs to the extant research on premature infants. Next, we synthesize the maternal, infant, and contextual factors that facilitate or inhibit the ontogenesis of dyadic synchrony in the NICU. The final section highlights the state of the science in dyadic synchrony in the NICU including gaps and recommendations for future research.

FINDINGS

An empirical review synthesis presents a visual conceptual framework to illustrate multiple processes that depict maternal, infant, and contextual influences of mother-infant synchrony in the NICU.

IMPLICATIONS FOR PRACTICE/RESEARCH

Despite the challenges posed to mother-infant relationships in the NICU, high-quality mother-infant interactions are possible, dyadic synchrony can emerge, and premature infants can develop secure attachments. Clinicians and researchers can apply this conceptual framework of mother-infant dyadic synchrony in the NICU to promote evidence-based research and clinical practice.

Maternal Milk Provision in the Neonatal Intensive Care Unit and Mother–Infant Emotional Connection for Preterm Infants

Maternal milk (MM) intake during neonatal intensive care unit (NICU) hospitalization is associated with improved neurodevelopment in preterm infants. Underlying mechanisms may include stronger mother–infant emotional connection. This paper examines associations between MM provision in the NICU with maternal connection to her infant using three factors validated in our sample: maternal sensitivity, emotional concern, and positive interaction/engagement. We studied 70 mothers of infants born <1500 g and/or <32 weeks’ gestation. Associations between MM provision and mother–infant connection were modeled using median regression adjusted for clustering. Mothers who provided exclusive MM (i.e., 100% MM, no other milk) reported higher levels of maternal sensitivity by a median score of 2 units (β = 2.00, 95% CI: 0.76, 3.24, p = 0.002) than the mixed group (i.e., MM < 100% days, other milk ≥1 days), as well as greater emotional concern (β = 3.00, 95% CI: −0.002, 6.00, p = 0.05). Among mothers of very preterm infants, greater milk provision was associated with greater maternal sensitivity, but also with greater emotional concern about meeting the infant’s needs. These findings highlight the importance of supporting MM provision and early infant care as an integrated part of lactation support. The findings may also provide insight into links between MM provision in the NICU and infant neurodevelopment.

Ranibizumab in retinopathy of prematurity - one-year follow-up of ophthalmic outcomes and two-year follow-up of neurodevelopmental outcomes from the CARE-ROP study

Purpose:

The primary endpoint results from the comparing alternative ranibizumab dosages for safety and effcacy in retinopathy of prematurity (CARE-ROP) core study identified ranibizumab as an effective treatment to control acute retinopathy of prematurity (ROP). This study reports the 1- and 2-year follow-up data focusing on long-term functional outcomes and safety.

Methods:

The CARE-ROP trial compared 0.12 mg versus 0.20 mg ranibizumab in 20 infants with ROP in a multicentric, prospective, randomized, double-blind, controlled study design. Sixteen patients entered the follow-up period. An ophthalmologic assessment at one year postbaseline was acquired from all 16 patients and a neurodevelopmental assessment at two years postbaseline was acquired from 15 patients.

Results:

Fifteen of 16 infants were able to fixate and follow moving objects at one year postbaseline treatment. One child progressed to stage 5 ROP bilaterally between the end of the core study and the 1-year follow-up (first seen at PMA 75 weeks). Mean spherical equivalents were −1.9 diopters (D) and −0.75 D in the 0.12 mg and the 0.20 mg treatment arms. Strabismus was present in seven and nystagmus in five out of 16 infants. Mental development scores were within normal limits in six out of ten patients with available data. No statistically significant difference was observed between the two treatment arms.

Conclusion:

Neurodevelopmental and functional ocular outcomes 1 and 2 years after treatment with ranibizumab are reassuring regarding long-term safety. Late reactivation of ROP, however, represents a challenge during the follow-up phase and it is of utmost importance that regular follow-ups are maintained.

Expert consensus on the clinical practice of neonatal brain magnetic resonance imaging

In recent years, magnetic resonance imaging (MRI) has been widely used in evaluating neonatal brain development, diagnosing neonatal brain injury, and predicting neurodevelopmental prognosis. Based on current research evidence and clinical experience in China and overseas, the Neonatologist Society of Chinese Medical Doctor Association has developed a consensus on the indications and standardized clinical process of neonatal brain MRI. The consensus has the following main points. (1) Brain MRI should be performed for neonates suspected of hypoxic-ischemic encephalopathy, intracranial infection, stroke and unexplained convulsions; brain MRI is not considered a routine in the management of preterm infants, but it should be performed for further evaluation when cranial ultrasound finds evidence of brain injury; as for extremely preterm or extremely low birth weight infants without abnormal ultrasound findings, it is recommended that they should undergo MRI examination at term equivalent age once. (2) Neonates should undergo MRI examination in a non-sedated state if possible. (3) During MRI examination, vital signs should be closely monitored to ensure safety; the necessity of MRI examination should be strictly evaluated for critically ill neonates, and magnetic resonance compatible incubator and ventilator can be used. (4) At present, 1.5 T or 3.0 T equipment can be used for neonatal brain MRI examination, and the special coil for the neonatal head should be used to improve signal-to-noise ratio; routine neonatal brain MRI sequences should at least include axial T1 weighted image (T1WI), axial T2 weighted imaging (T2WI), diffusion-weighted imaging, and sagittal T1WI or T2WI. (5) It is recommended to use a structured and graded reporting system, and reports by at least two reviewers and multi-center collaboration are recommended to increase the reliability of the report.

Study protocol for reducing disparity in receipt of mother's own milk in very low birth weight infants (ReDiMOM): a randomized trial to improve adherence to sustained maternal breast pump use

BACKGROUND

Black very low birth weight (VLBW; < 1500 g birth weight) and very preterm (VP, < 32 weeks gestational age, inclusive of extremely preterm, < 28 weeks gestational age) infants are significantly less likely than other VLBW and VP infants to receive mother's own milk (MOM) through to discharge from the neonatal intensive care unit (NICU). The costs associated with adhering to pumping maternal breast milk are borne by mothers and contribute to this disparity. This randomized controlled trial tests the effectiveness and cost-effectiveness of an intervention to offset maternal costs associated with pumping.

METHODS

This randomized control trial will enroll 284 mothers and their VP infants to test an intervention (NICU acquires MOM) developed to facilitate maternal adherence to breast pump use by offsetting maternal costs that serve as barriers to sustaining MOM feedings and the receipt of MOM at NICU discharge. Compared to current standard of care (mother provides MOM), the intervention bundle includes three components: a) free hospital-grade electric breast pump, b) pickup of MOM, and c) payment for opportunity costs. The primary outcome is infant receipt of MOM at the time of NICU discharge, and secondary outcomes include infant receipt of any MOM during the NICU hospitalization, duration of MOM feedings (days), and cumulative dose of MOM feedings (total mL/kg of MOM) received by the infant during the NICU hospitalization; maternal duration of MOM pumping (days) and volume of MOM pumped (mLs); and total cost of NICU care. Additionally, we will compare the cost of the NICU acquiring MOM versus NICU acquiring donor human milk if MOM is not available and the cost-effectiveness of the intervention (NICU acquires MOM) versus standard of care (mother provides MOM).

DISCUSSION

This trial will determine the effectiveness of an economic intervention that transfers the costs of feeding VLBWand VP infants from mothers to the NICU to address the disparity in the receipt of MOM feedings at NICU discharge by Black infants. The cost-effectiveness analysis will provide data that inform the adoption and scalability of this intervention.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04540575 , registered September 7, 2020.

Neurodevelopmental Outcomes of Extremely Low Birth Weight Survivors in Johannesburg, South Africa

BACKGROUND

Improved survival in extremely low birth weight infants (ELBWI) in Sub-Saharan Africa has raised the question whether these survivors have an increased chance of adverse neurodevelopmental outcomes.

OBJECTIVES

To describe neurodevelopmental outcomes of ELBWI in a neonatal unit in South Africa.

METHODS

This was a prospective follow-up study. All ELBWI who survived to discharge between 1 July 2013 and 31 December 2017 were invited to attend the clinic. Bayley Scales of Infant and Toddler Development (version III) were conducted at 9 to 12 months and 18 to 24 months.

RESULTS

There were 723 ELBWI admissions during the study period, 292 (40.4%) survived to hospital discharge and 85/292 (29.1%) attended the neonatal follow up clinic. The mean birth weight was 857.7 g (95% CI: 838.2-877.2) and the mean gestational age was 27.5 weeks (95% CI 27.1-27.9). None of the infants had any major complication of prematurity. A total of 76/85 (89.4%) of the infants had a Bayley-III assessment at a mean corrected age of 17.21 months (95% CI: 16.2-18.3). The mean composite scores for cognition were 98.4 (95% CI 95.1-101.7), language 89.9 (95% CI 87.3-92.5) and motor 97.6 (95% CI 94.5-100.6). All mean scores fell within the normal range, The study found 28 (36.8%) infants to be "at risk" for neurodevelopmental delay.

CONCLUSION

Our study demonstrates good neurodevelopmental outcome in a small group of surviving ELBWI, but these results must be interpreted in the context of the high mortality in this group of infants.

Association between Term Equivalent Brain Magnetic Resonance Imaging and 2-Year Outcomes in Extremely Preterm Infants: A Report from the Preterm Erythropoietin Neuroprotection Trial Cohort

OBJECTIVES

To compare the term equivalent brain magnetic resonance imaging (MRI) findings between erythropoietin (Epo) treated and placebo control groups in infants 24^0/7-27^6/7 weeks of gestational age and to assess the associations between MRI findings and neurodevelopmental outcomes at 2 years corrected age.

STUDY DESIGN

The association between brain abnormality scores and Bayley Scales of Infant Development, Third Edition at 2 years corrected age was explored in a subset of infants enrolled in the Preterm Erythropoietin Neuroprotection Trial. Potential risk factors for neurodevelopmental outcomes such as treatment assignment, recruitment site, gestational age, inpatient complications, and treatments were examined using generalized estimating equation models.

RESULTS

One hundred ten infants were assigned to Epo and 110 to placebo groups. 27% of MRI scans were rated as normal, and 60%, 10%, and 2% were rated as having mild, moderate, or severe abnormality. Brain abnormality scores did not significantly differ between the treatment groups. Factors that increased the risk of higher brain injury scores included intubation; bronchopulmonary dysplasia; retinopathy of prematurity; opioid, benzodiazepine, or antibiotic treatment >7 days; and periventricular leukomalacia or severe intraventricular hemorrhage diagnosed on cranial ultrasound. Increased global brain abnormality and white matter injury scores at term equivalent were associated with reductions in cognitive, motor, and language abilities at 2 years of corrected age.

CONCLUSIONS

Evidence of brain injury on brain MRIs obtained at term equivalent correlated with adverse neurodevelopmental outcomes as assessed by the Bayley Scales of Infant and Toddler Development, Third Edition at 2 years corrected age. Early Epo treatment had no effect on the MRI brain injury scores compared with the placebo group.

Early Detection of Cognitive, Language, and Motor Delays for Low-Income Preterm Infants: A Brazilian Cohort Longitudinal Study on Infant Neurodevelopment and Maternal Practice

Aim: This study examined the neurodevelopment trajectories, the prevalence of delays, and the risks and protective factors (adverse outcomes, environment, and maternal factors) associated with cognitive, motor, and language development for preterm infants from 4– to 24-months.

Method: We assessed 186 preterm infants (24.7% extremely preterm; 54.8% very preterm; 20.4% moderate/late preterm) from 4– to 24-months using the Bayley Scales of Infant Development – III. Maternal practices and knowledge were assessed using the Daily Activities of Infant Scale and the Knowledge of Infant Development Inventory. Birth risks and adverse outcomes were obtained from infant medical profiles.

Results: A high prevalence of delays was found; red flags for delays at 24-months were detected at 4– and 8-months of age. The neurodevelopmental trajectories showed steady scores across time for cognitive composite scores for extremely- and very-preterm infants and for language composite scores for the extremely- and moderate/late-preterm; a similar trend was observed for the motor trajectories of moderate/late preterm. Changes over time were restricted to motor composite scores for extremely- and very-preterm infants and for cognitive composite scores for moderate/late preterm; declines, stabilization, and improvements were observed longitudinally. Positive, strong, and significant correlations were for the neurodevelopment scores at the first year of life and later neurodevelopment at 18 and 24 months. The cognitive, language, and motor composite scores of extremely and very preterm groups were associated with more risk factors (adverse outcomes, environment, and maternal factors). However, for moderate/late preterm infants, only APGAR and maternal practices significantly explained the variance in neurodevelopment.

Discussion: Although adverse outcomes were strongly associated with infant neurodevelopment, the environment and the parents’ engagement in play and breastfeeding were protective factors for most preterm infants. Intervention strategies for preterm infants should start at 4– to 8-months of age to prevent unwanted outcomes later in life.

The ability of Bayley-III scores to predict later intelligence in children born extremely preterm

AIM

To investigate the ability of the Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III), scores to predict later Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV), performances in a cohort of children born extremely preterm.

METHODS

323 children, born <27 gestational weeks, were tested with the Bayley-III at corrected age 2.5 years and with the WISC-IV at 6.5 years. Regression analyses investigated the association between Bayley-III scores and WISC-IV full-scale intelligence quotient (IQ). The ability of Bayley-III Cognitive Index scores to predict low IQ was evaluated using receiver operating characteristic curves.

RESULTS

Bayley-III Cognitive Index scores and IQ had a moderately positive correlation and accounted for 38% of the IQ variance. Using a Bayley-III cut-off score of 70, the sensitivity to detect children with IQ<70 was 18%, and false positive rate was 7%. A Bayley-III cut-off score of 85 corresponded to sensitivity and false positive rates of 44% and 7%, respectively.

CONCLUSIONS

Results emphasise the relative importance of Bayley-III Cognitive Index scores as predictors of IQ. An 85 score cut-off for suspecting subnormal IQ is supported. A less conservative threshold would increase identification of true cases yet increase the risk of wrongly diagnosing children.

Parental Book-Reading to Preterm Born Infants in NICU: The Effects on Language Development in the First Two Years

Background: After preterm birth, infants are at high risk for delays in language development. A promising intervention to reduce this risk is represented by the exposure to parental voices through book-reading in Neonatal Intensive Care Units (NICU). This study investigated the possible advantages of book-reading to preterm neonates during their NICU stay on their subsequent language development. Methods: 100 families of preterm infants were recruited. The parents of 55 preterm infants (Reading Group) received a colored picture-book on NICU admission and were supported to read to their neonate as often as possible and to continue after hospital discharge. Forty-five infants (Control Group) were recruited before the beginning of the intervention. Infant language development was assessed with the Hearing and Language quotients of the Griffith Mental Development Scale at the corrected ages of 3, 6, 9, 12, 18 and 24 months. Results: Regardless of group membership, Hearing and Language mean quotients decreased between 9 and 18 months; nevertheless, this decrease was considerably reduced in the Reading group, compared to the Control Group. Conclusions: Reading in NICUs represents a suitable intervention that could positively influence language development and parent-infant relationships in preterm children. The study findings support its implementation as a preventive measure.

Apnoea of Prematurity and Neurodevelopmental Outcomes: Current Understanding and Future Prospects for Research

Infants who are born prematurely are at significant risk of apnoea. In addition to the short-term consequences such as hypoxia, apnoea of prematurity has been associated with long-term morbidity, including poor neurodevelopmental outcomes. Clinical trials have illustrated the importance of methylxanthine drugs, in particular caffeine, in reducing the risk of long term adverse neurodevelopmental outcomes. However, the extent to which apnoea is causative of this secondary neurodevelopmental delay or is just associated in a background of other sequelae of prematurity remains unclear. In this review, we first discuss the pathophysiology of apnoea of prematurity, previous studies investigating the relationship between apnoea and neurodevelopmental delay, and treatment of apnoea with caffeine therapy. We propose a need for better methods of measuring apnoea, along with improved understanding of the neonatal brain's response to consequent hypoxia. Only then can we start to disentangle the effects of apnoea on neurodevelopment in preterm infants. Moreover, by better identifying those infants who are at risk of apnoea, and neurodevelopmental delay, we can work toward a risk stratification system for these infants that is clinically actionable, for example, with doses of caffeine tailored to the individual. Optimising treatment of apnoea for individual infants will improve neonatal care and long-term outcomes for this population.

Deep Multimodal Learning From MRI and Clinical Data for Early Prediction of Neurodevelopmental Deficits in Very Preterm Infants

The prevalence of disabled survivors of prematurity has increased dramatically in the past 3 decades. These survivors, especially, very preterm infants (VPIs), born ≤ 32 weeks gestational age, are at high risk for neurodevelopmental impairments. Early and clinically effective personalized prediction of outcomes, which forms the basis for early treatment decisions, is urgently needed during the peak neuroplasticity window—the first couple of years after birth—for at-risk infants, when intervention is likely to be most effective. Advances in MRI enable the noninvasive visualization of infants' brains through acquired multimodal images, which are more informative than unimodal MRI data by providing complementary/supplementary depicting of brain tissue characteristics and pathology. Thus, analyzing quantitative multimodal MRI features affords unique opportunities to study early postnatal brain development and neurodevelopmental outcome prediction in VPIs. In this study, we investigated the predictive power of multimodal MRI data, including T2-weighted anatomical MRI, diffusion tensor imaging, resting-state functional MRI, and clinical data for the prediction of neurodevelopmental deficits. We hypothesize that integrating multimodal MRI and clinical data improves the prediction over using each individual data modality. Employing the aforementioned multimodal data, we proposed novel end-to-end deep multimodal models to predict neurodevelopmental (i.e., cognitive, language, and motor) deficits independently at 2 years corrected age. We found that the proposed models can predict cognitive, language, and motor deficits at 2 years corrected age with an accuracy of 88.4, 87.2, and 86.7%, respectively, significantly better than using individual data modalities. This current study can be considered as proof-of-concept. A larger study with external validation is important to validate our approach to further assess its clinical utility and overall generalizability.