Children of birth weight less than 1000 g: changing outcome between ages 2 and 5 years

Systemic corticosteroids for the prevention of bronchopulmonary dysplasia, a network meta-analysis

BACKGROUND

Despite considerable improvement in outcomes for preterm infants, rates of bronchopulmonary dysplasia (BPD) remain high, affecting an estimated 33% of very low birthweight infants, with corresponding long-term respiratory and neurosensory issues. Systemic corticosteroids can address the inflammation underlying BPD, but the optimal regimen for prevention of this disease, balancing of the benefits with the potentially meaningful risks of systemic corticosteroids, continues to be a medical quandary. Numerous studies have shown that systemic corticosteroids, particularly dexamethasone and hydrocortisone, effectively treat or prevent BPD. However, concerning short and long-term side effects have been reported and the optimal approach to corticosteroid treatment remains unclear.

OBJECTIVES

To determine whether differences in efficacy and safety exist between high-dose dexamethasone, moderate-dose dexamethasone, low-dose dexamethasone, hydrocortisone, and placebo in the prevention of BPD, death, the composite outcome of death or BPD, and other relevant morbidities, in preterm infants through a network meta-analysis, generating both pairwise comparisons between all treatments and rankings of the treatments.

SEARCH METHODS

We searched the Cochrane Library for all systematic reviews of systemic corticosteroids for the prevention of BPD and searched for completed and ongoing studies in the following databases in January 2023: Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and clinical trial databases.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) in preterm infants (< 37 weeks' gestation) at risk for BPD that evaluated systemic corticosteroids (high-dose [≥ 4 mg/kg cumulative dose] dexamethasone, moderate-dose [≥ 2 to < 4 mg/kg] dexamethasone, low-dose [< 2 mg/kg] dexamethasone, or hydrocortisone) versus control or another systemic corticosteroid.

DATA COLLECTION AND ANALYSIS

Our main information sources were the systematic reviews, with reference to the original manuscript only for data not included in these reviews. Teams of two paired review authors independently performed data extraction, with disagreements resolved by discussion. Data were entered into Review Manager 5 and exported to R software for network meta-analysis (NMA). NMA was performed using a frequentist model with random-effects. Two separate networks were constructed, one for early (< seven days) initiation of treatment and one for late (≥ seven days) treatment initiation, to reflect the different patient populations evaluated. We assessed the certainty of evidence derived from the NMA for our primary outcomes using principles of the GRADE framework modified for application to NMA.

MAIN RESULTS

We included 59 studies, involving 6441 infants, in our analyses. Only six of the included studies provided direct comparisons between any of the treatment (dexamethasone or hydrocortisone) groups, forcing network comparisons between treatments to rely heavily on indirect evidence through comparisons with placebo/no treatment groups. Thirty-one studies evaluated early corticosteroid treatment, 27 evaluated late corticosteroid treatment, and one study evaluated both early and late corticosteroid treatments. Early treatment (prior to seven days after birth): Benefits:NMA for early treatment showed only moderate-dose dexamethasone to decrease the risk of BPD at 36 weeks' postmenstrual age (PMA) compared with control (RR 0.56, 95% CI 0.39 to 0.80; moderate-certainty evidence), although the other dexamethasone dosing regimens may have similar effects compared with control (high-dose dexamethasone, RR 0.71, 95% CI 0.50 to 1.01; low-certainty evidence; low-dose dexamethasone, RR 0.83, 95% CI 0.67 to 1.03; low-certainty evidence). Other early treatment regimens may have little or no effect on the risk of death at 36 weeks' PMA. Only moderate-dose dexamethasone decreased the composite outcome of death or BPD at 36 weeks' PMA compared with control (RR 0.77, 95% CI 0.60 to 0.98; moderate-certainty evidence).

HARMS

Low-dose dexamethasone increased the risk for cerebral palsy (RR 1.92, 95% CI 1.12 to 3.28; moderate-certainty evidence) compared with control. Hydrocortisone may decrease the risk of major neurosensory disability versus low-dose dexamethasone (RR 0.65, 95% CI 0.41 to 1.01; low-certainty evidence). Late treatment (at seven days or later after birth): Benefits: NMA for late treatment showed high-dose dexamethasone to decrease the risk of BPD both versus hydrocortisone (RR 0.66, 95% CI 0.51 to 0.85; low-certainty evidence) and versus control (RR 0.72, CI 0.59 to 0.87; moderate-certainty evidence). The late treatment regimens evaluated may have little or no effect on the risk of death at 36 weeks' PMA. High-dose dexamethasone decreased risk for the composite outcome of death or BPD compared with all other treatments (control, RR 0.69, 95% CI 0.59 to 0.80, high-certainty evidence; hydrocortisone, RR 0.69, 95% CI 0.58 to 0.84, low-certainty evidence; low-dose dexamethasone, RR 0.73, 95% CI 0.60 to 0.88, low-certainty evidence; moderate-dose dexamethasone, RR 0.76, 95% CI 0.62 to 0.93, low-certainty evidence).

HARMS

No effect was observed for the outcomes of major neurosensory disability or cerebral palsy. The evidence for the primary outcomes was of overall low certainty, with notable deductions for imprecision and heterogeneity across the networks.

AUTHORS' CONCLUSIONS

While early treatment with moderate-dose dexamethasone or late treatment with high-dose dexamethasone may lead to the best effects for survival without BPD, the certainty of the evidence is low. There is insufficient evidence to guide this therapy with regard to plausible adverse long-term outcomes. Further RCTs with direct comparisons between systemic corticosteroid treatments are needed to determine the optimal treatment approach, and these studies should be adequately powered to evaluate survival without major neurosensory disability.

Systemic corticosteroid regimens for prevention of bronchopulmonary dysplasia in preterm infants

BACKGROUND

Systematic reviews showed that systemic postnatal corticosteroids reduce the risk of bronchopulmonary dysplasia (BPD) in preterm infants. However, corticosteroids have also been associated with an increased risk of neurodevelopmental impairment. It is unknown whether these beneficial and adverse effects are modulated by differences in corticosteroid treatment regimens related to type of steroid, timing of treatment initiation, duration, pulse versus continuous delivery, and cumulative dose.

OBJECTIVES

To assess the effects of different corticosteroid treatment regimens on mortality, pulmonary morbidity, and neurodevelopmental outcome in very low birth weight infants.

SEARCH METHODS

We conducted searches in September 2022 of MEDLINE, the Cochrane Library, Embase, and two trial registries, without date, language or publication- type limits. Other search methods included checking the reference lists of included studies for randomized controlled trials (RCTs) and quasi-randomized trials.

SELECTION CRITERIA

We included RCTs comparing two or more different treatment regimens of systemic postnatal corticosteroids in preterm infants at risk for BPD, as defined by the original trialists. The following comparisons of intervention were eligible: alternative corticosteroid (e.g. hydrocortisone) versus another corticosteroid (e.g. dexamethasone); lower (experimental arm) versus higher dosage (control arm); later (experimental arm) versus earlier (control arm) initiation of therapy; a pulse-dosage (experimental arm) versus continuous-dosage regimen (control arm); and individually-tailored regimens (experimental arm) based on the pulmonary response versus a standardized (predetermined administered to every infant) regimen (control arm). We excluded placebo-controlled and inhalation corticosteroid studies.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed eligibility and risk of bias of trials, and extracted data on study design, participant characteristics and the relevant outcomes. We asked the original investigators to verify if data extraction was correct and, if possible, to provide any missing data. We assessed the following primary outcome: the composite outcome mortality or BPD at 36 weeks' postmenstrual age (PMA). Secondary outcomes were: the components of the composite outcome; in-hospital morbidities and pulmonary outcomes, and long-term neurodevelopmental sequelae. We analyzed data using Review Manager 5 and used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included 16 studies in this review; of these, 15 were included in the quantitative synthesis. Two trials investigated multiple regimens, and were therefore included in more than one comparison. Only RCTs investigating dexamethasone were identified. Eight studies enrolling a total of 306 participants investigated the cumulative dosage administered; these trials were categorized according to the cumulative dosage investigated, 'low' being < 2 mg/kg, 'moderate' being between 2 and 4 mg/kg, and 'high' > 4 mg/kg; three studies contrasted a high versus a moderate cumulative dose, and five studies a moderate versus a low cumulative dexamethasone dose. We graded the certainty of the evidence low to very low because of the small number of events, and the risk of selection, attrition and reporting bias. Overall analysis of the studies investigating a higher dose versus a lower dosage regimen showed no differences in the outcomes BPD, the composite outcome death or BPD at 36 weeks' PMA, or abnormal neurodevelopmental outcome in survivors assessed. Although there was no evidence of a subgroup difference for the higher versus lower dosage regimens comparisons (Chi2 = 2.91, df = 1 (P = 0.09), I2 = 65.7%), a larger effect was seen in the subgroup analysis of moderate-dosage regimens versus high-dosage regimens for the outcome cerebral palsy in survivors. In this subgroup analysis, there was an increased risk of cerebral palsy (RR 6.85, 95% CI 1.29 to 36.36; RD 0.23, 95% CI 0.08 to 0.37; P = 0.02; I² = 0%; NNTH 5, 95% CI 2.6 to 12.7; 2 studies, 74 infants). There was evidence of subgroup differences for higher versus lower dosage regimens comparisons for the combined outcomes death or cerebral palsy, and death and abnormal neurodevelopmental outcomes (Chi2 = 4.25, df = 1 (P = 0.04), I2 = 76.5%; and Chi2 = 7.11, df = 1 (P = 0.008), I2 = 85.9%, respectively). In the subgroup analysis comparing a high dosage regimen of dexamethasone versus a moderate cumulative-dosage regimen, there was an increased risk of death or cerebral palsy (RR 3.20, 95% CI 1.35 to 7.58; RD 0.25, 95% CI 0.09 to 0.41; P = 0.002; I² = 0%; NNTH 5, 95% CI 2.4 to 13.6; 2 studies, 84 infants; moderate-certainty evidence), and death or abnormal neurodevelopmental outcome (RR 3.41, 95% CI 1.44 to 8.07; RD 0.28, 95% CI 0.11 to 0.44; P = 0.0009; I² = 0%; NNTH 4, 95% CI 2.2 to 10.4; 2 studies, 84 infants; moderate-certainty evidence). There were no differences in outcomes between a moderate- and a low-dosage regimen. Five studies enrolling 797 infants investigated early initiation of dexamethasone therapy versus a moderately early or delayed initiation, and showed no significant differences in the overall analyses for the primary outcomes. The two RCTs investigating a continuous versus a pulse dexamethasone regimen showed an increased risk of the combined outcome death or BPD when using the pulse therapy. Finally, three trials investigating a standard regimen versus a participant-individualized course of dexamethasone showed no difference in the primary outcome and long-term neurodevelopmental outcomes. We assessed the GRADE certainty of evidence for all comparisons discussed above as moderate to very low, because the validity of all comparisons is hampered by unclear or high risk of bias, small samples of randomized infants, heterogeneity in study population and design, non-protocolized use of 'rescue' corticosteroids and lack of long-term neurodevelopmental data in most studies.

AUTHORS' CONCLUSIONS

The evidence is very uncertain about the effects of different corticosteroid regimens on the outcomes mortality, pulmonary morbidity, and long term neurodevelopmental impairment. Despite the fact that the studies investigating higher versus lower dosage regimens showed that higher-dosage regimens may reduce the incidence of death or neurodevelopmental impairment, we cannot conclude what the optimal type, dosage, or timing of initiation is for the prevention of BPD in preterm infants, based on current level of evidence. Further high quality trials would be needed to establish the optimal systemic postnatal corticosteroid dosage regimen.

Systemic corticosteroid regimens for prevention of bronchopulmonary dysplasia in preterm infants

BACKGROUND

Cochrane systematic reviews show that systemic postnatal corticosteroids reduce the risk of bronchopulmonary dysplasia (BPD) in preterm infants. However, corticosteroids have also been associated with an increased risk of neurodevelopmental impairment. It is unknown whether these beneficial and adverse effects are modulated by differences in corticosteroid treatment regimens.

OBJECTIVES

To assess the effects of different corticosteroid treatment regimens on mortality, pulmonary morbidity, and neurodevelopmental outcome in very low birth weight (VLBW) infants.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 2) in the Cochrane Library (searched 21 March 2016), MEDLINE via PubMed (1966 to 21 March 2016), Embase (1980 to 21 March 2016), and CINAHL (1982 to 21 March 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomized controlled trials.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing two or more different treatment regimens of systemic postnatal corticosteroids in preterm infants at risk for BPD, as defined by the original trialists. Studies investigating one treatment regimen of systemic corticosteroids to a placebo or studies using inhalation corticosteroids were excluded.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed eligibility and quality of trials and extracted data on study design, participant characteristics and the relevant outcomes. We asked the original investigators to verify if data extraction was correct and, if possible, to provide any missing data. The primary outcomes to be assessed were: mortality at 36 weeks' postmenstrual age (PMA) or at hospital discharge; BPD defined as oxygen dependency at 36 weeks' PMA; long-term neurodevelopmental sequelae, including cerebral palsy, measured by the Bayley Mental Developmental Index (MDI); and blindness or poor vision. Secondary outcomes were: duration of mechanical ventilation and failure to extubate at day 3 and 7 after initiating therapy; rescue treatment with corticosteroids outside the study period; and the incidence of hypertension, sepsis and hyperglycemia during hospitalizations. Data were analyzed using Review Manager 5 (RevMan 5). We used the GRADE approach to assess the quality of evidence.

MAIN RESULTS

Fourteen studies were included in this review. Only RCTs investigating dexamethasone were identified. Eight studies enrolling a total of 303 participants investigated the cumulative dosage administered; three studies contrasted a high versus a moderate and five studies a moderate versus a low cumulative dexamethasone dose.Analysis of the studies investigating a moderate dexamethasone dose versus a high-dosage regimen showed an increased risk of BPD (typical risk ratio (RR) 1.50, 95% confidence interval (CI) 1.01 to 2.22; typical risk difference (RD) 0.26, 95% CI 0.03 to 0.49; number needed to treat for an additional harmful outcome (NNTH) 4, 95% CI 1.9 to 23.3; I² = 0%, 2 studies, 55 infants) as well as an increased risk of abnormal neurodevelopmental outcome (typical RR 8.33, 95% CI 1.63 to 42.48; RD 0.30, 95% CI 0.14 to 0.46; NNTH 4, 95% CI 2.2 to 7.3; I² = 68%, 2 studies, 74 infants) when using a moderate cumulative-dosage regimen. The composite outcomes of death or BPD and death or abnormal neurodevelopmental outcome showed similar results although the former only reached borderline significance.There were no differences in outcomes between a moderate- and a low-dosage regimen.Four other studies enrolling 762 infants investigated early initiation of dexamethasone therapy versus a moderately early or delayed initiation and showed no significant differences in the primary outcomes. The two RCTs investigating a continuous versus a pulse dexamethasone regimen showed an increased risk of the combined outcome death or BPD when using the pulse therapy. Finally, two trials investigating a standard regimen versus a participant-individualized course of dexamethasone showed no difference in the primary outcome and long-term neurodevelopmental outcomes.The quality of evidence for all comparisons discussed above was assessed as low or very low, because the validity of all comparisons is hampered by small samples of randomized infants, heterogeneity in study population and design, non-protocolized use of 'rescue' corticosteroids and lack of long-term neurodevelopmental data in most studies.

AUTHORS' CONCLUSIONS

Despite the fact that some studies reported a modulating effect of treatment regimens in favor of higher-dosage regimens on the incidence of BPD and neurodevelopmental impairment, recommendations on the optimal type of corticosteroid, the optimal dosage, or the optimal timing of initiation for the prevention of BPD in preterm infants cannot be made based on current level of evidence. A well-designed large RCT is urgently needed to establish the optimal systemic postnatal corticosteroid dosage regimen.

Neurological sequelae of healthcare-associated sepsis in very-low-birthweight infants: Umbrella review and evidence-based outcome tree

Sepsis is a frequent cause of death in very-low-birthweight infants and often results in neurological impairment. Its attributable risk of sequelae has not been systematically assessed. To establish an outcome tree for mapping the burden of neonatal sepsis, we performed systematic literature searches to identify systematic reviews addressing sequelae of neonatal sepsis. We included cohort studies and performed meta-analyses of attributable risks. Evidence quality was assessed using GRADE. Two systematic reviews met inclusion criteria. The first included nine cohort studies with 5,620 participants and five outcomes (neurodevelopmental impairment, cerebral palsy, vision impairment, hearing impairment, death). Pooled risk differences varied between 4% (95% confidence interval (CI):2-10) and 13% (95% CI:5-20). From the second review we analysed four studies with 472 infants. Positive predictive value of neurodevelopmental impairment for later cognitive impairment ranged between 67% (95% CI:22-96) and 83% (95% CI:36-100). Neonatal sepsis increases risk of permanent neurological impairment. Effect size varies by outcome, with evidence quality being low to very low. Data were used to construct an outcome tree for neonatal sepsis. Attributable risk estimates for sequelae following neonatal sepsis are suitable for burden estimation and may serve as outcome parameters in interventional studies.

Bayley-II Mental Developmental Index scores at 9 and 18 months for children under 1000 grams birthweight

This study identified selected perinatal and neonatal variables that place ELBW children at particularly high risk for cognitive delay. Forty children weighing less than 1000 grams (ELBW) at birth underwent developmentol assessment at 9 and 18 months on the Bayley II Mental Development lndex (MDI). Decline in MDI scores between these two ages was evident for infants under 26 weeks gestation at birth as well as for children categorised with an impairment (outcome categories I and II). At 9 months, MDI scores were significantly lower for children with chronic lung disease, for those who required formal developmental intervention, and for those hospitalised for respiratory problems. At 18 months, cognitive scores were significantly lower for children on four variables: gestational age less than 26 weeks; semi-skilled, unskilled, unemployed parents (levels 5 and 6); formal intervention; and admission to hospital for respiratory illness. Greater emphasis on intervention for these at-risk variables is recommended.

Predictive value of the Bayley scales of infant development on development of very preterm/very low birth weight children: a meta-analysis

BACKGROUND AND AIMS

The Bayley scales of infant development (BSID) is the most widely used measure to assess neurodevelopment of very preterm (gestational age ≤32 weeks) and very low birth weight (VLBW, ≤1500 g) infants in the first three years of life. This meta-analysis determines the predictive value of the mental developmental index (MDI) and the psychomotor developmental index (PDI)/motor composite, collectively referred to as Bayley motor scale, of the BSID-I, -II and Bayley-III for later cognitive and motor functioning in very preterm/VLBW children.

METHODS

Cochrane Library, PubMed, PsychINFO and CINAHL were searched for English-language peer-reviewed studies published before March 2013. Studies were included if they reported odds ratios or correlations between the MDI or Bayley motor scale scores obtained in the first three years of life, and standardized cognitive or motor assessment obtained later in life in very preterm/VLBW children. Meta-analytic methods were applied to aggregate available data.

RESULTS

A total of 16 studies met inclusion criteria. Across 14 studies (n=1330 children), MDI scores were strongly predictive for later cognitive functioning, r=0.61 (95% CI: 0.57-0.64), explained variance 37%, p<.001. The relationship between MDI scores and later cognitive function was not mediated by birth weight (p=.56), gestational age (p=.70), and time interval between assessments (p=.55). Across five studies (n=555 children), Bayley motor scale scores were moderately predictive for later motor function, r=0.34 (95% CI: 0.26-0.42), explained variance 12%, p<.001.

CONCLUSIONS

In very preterm/VLBW children, MDI scores explain 37% of the variance in later cognitive functioning, whereas Bayley motor scale scores explain 12% of later motor function. Thus a large proportion of the variance remains unexplained, underlining the importance of enhancing prediction of developmental delay in very preterm children.

Increased risk of adverse neurological development for late preterm infants

OBJECTIVE

To assess the risks of moderate prematurity for cerebral palsy (CP), developmental delay/mental retardation (DD/MR), and seizure disorders in early childhood.

STUDY DESIGN

Retrospective cohort study using hospitalization and outpatient databases from the Northern California Kaiser Permanente Medical Care Program. Data covered 141 321 children > or =30 weeks born between Jan 1, 2000, and June 30, 2004, with follow-up through June 30, 2005. Presence of CP, DD/MR, and seizures was based on International Classification of Diseases, Ninth Revision codes identified in the encounter data. Separate Cox proportional hazard models were used for each of the outcomes, with crude and adjusted hazard ratios calculated for each gestational age group.

RESULTS

Decreasing gestational age was associated with increased incidence of CP and DD/MR, even for those born at 34 to 36 weeks gestation. Children born late preterm were >3 times as likely (hazard ratio, 3.39; 95% CI, 2.54-4.52) as children born at term to be diagnosed with CP. A modest association with DD/MR was found for children born at 34 to 36 weeks (hazard ratio, 1.25; 95% CI, 1.01-1.54), but not for children in whom seizures were diagnosed.

CONCLUSIONS

Prematurity is associated with long-term neurodevelopmental consequences, with risks increasing as gestation decreases, even in infants born at 34 to 36 weeks.

Can the Griffiths scales predict neuromotor and perceptual-motor impairment in term infants with neonatal encephalopathy?

AIMS

To examine the predictive value of early developmental testing for identifying neuromotor and perceptual-motor impairment at school age in children with neonatal encephalopathy (NE).

METHODS

Eighty full term infants with NE were followed longitudinally. Where possible, children were tested on the Griffiths scales at 1 and 2 years and at 5-6 years, on the Touwen Examination, Movement ABC, and WPPSI. The relation between the Griffiths scores and later outcome measures was examined using correlation coefficients and sensitivity and specificity values.

RESULTS

By 2 years, 25 children with cerebral palsy were too severely impaired to be formally assessed and remained so at 5-6 years. Abnormal Griffiths scores were obtained by 12% and 7% of the children at 1 and 2 years respectively. At 5-6 years, 33% had poor Movement ABC scores and 15% poor WPPSI scores. The highest correlation between Griffiths scores and the outcome measures was for the Movement ABC (0.72), although this accounted for only 50% of the variance. Sensitivity scores for the Movement ABC were below 70% but specificity was 100%.

CONCLUSIONS

A poor score on the Griffiths scales at 1 and/or 2 years is a good predictor of impairment at school age. However, a normal score in the early years cannot preclude later neurological, perceptual-motor, or cognitive abnormalities.

A randomized trial of two dexamethasone regimens to reduce side-effects in infants treated for chronic lung disease of prematurity

OBJECTIVE

Dexamethasone has been widely used to reduce the incidence of chronic lung disease in preterm infants. However side-effects are common, and the ideal dose of dexamethasone has not been identified. We aimed to determine whether an individualized course of dexamethasone given to preterm babies at risk of chronic lung disease reduced the total dose of dexamethasone administered and reduced side-effects compared with a standard 42-day course.

METHODS

Thirty-three infants in a regional neonatal unit with a birthweight of < or =1250 g who required mechanical ventilation at 7 days of age were randomly assigned to a 42-day course of dexamethasone or an individualized course tailored to their respiratory status. The primary outcome was linear growth at 36 weeks corrected gestational age.

RESULTS

Infants in the individualized course received a 40% lower total dose of dexamethasone. However, there was no difference between the two groups in linear growth or in the incidence of any other side-effects of treatment. There was also no difference in respiratory status or neurodevelopmental outcome.

CONCLUSION

The individualized course of dexamethasone used in this study reduced the total dose of dexamethasone administered but did not significantly reduce side-effects of treatment or alter outcome in infants at risk of chronic lung disease.

Maternal antihypertensive therapy with beta-blockers associated with poor outcome in very-low birthweight infants

The progress of 36 very-low birthweight (less than or equal to 1500 g) infants born to mothers with pregnancy-induced hypertonia or pre-eclampsia was studied. During the first year of life, 7 out of 19 infants died when the mothers' antihypertensive regimen included beta-blockers. Four of the deaths occurred within 15 days. There were no deaths in 16 infants whose mothers were treated with other antihypertensive treatment (P = 0.006). These results suggest that maternal beta-blocker therapy may have adverse effects on the very-low birthweight infants.

[A comparative study of the perceptual and motor performance at school age of preterm and full term children]

The objective of this study was to compare the perceptualmotor performance in school age children who were born preterm and full term. Two groups of children, ages 5 to 7, participated in this study. Group I had 35 children, from low-income families, born up to the 34 week of gestation and/or weight bellow 1500 g. Group II had 35 full-term children, matched by age, gender and socioeconomic status to the children in Group I. Children were tested on the Bender gestalt, the motor accuracy test and on balance and postural responses measures. The preterm group obtained significantly lower scores in the majority of the tests. These besides reinforcing the importance of the follow-up of preterm children up to school age, also indicate the need to stimulate the fine motor and postural control Devment, even among preterm children who do not show evidence of neurological impairment.

Quality of life of 6-year-old survivors from a regional neonatal unit

OBJECTIVE

Quality of life (QOL) of children who required treatment in a national neonatal intensive care unit (NICU) during the first week of life was determined at 6 years of age.

METHOD

QOL was assessed using a standardized questionnaire employing a multi-attribute scoring system including the functions: hearing, vision, speech, mobility, emotion, learning, self-care and pain. After excluding those with congenital neurodevelopmental disorders, questionnaire returns were analyzed from 177 children treated in the NICU in 1990 and a comparative age-matched group of 230 children who did not require neonatal care. Of these, returns were obtained from 143 (81%) cases and 171 (74%) of the non-treated group.

RESULTS

There was no difference in overall ability between the two groups, with 95 (66%) of cases and 126 (74%) of the comparison group reporting normal scores in all functions. Children treated in the NICU had decreased scores in individual functions including speech (p = 0.04), mobility (p = 0.009) and self-care (p = 0.006). For the study population, males had lower function in speech (p = 0.04) and learning (p = 0.001), with significantly worse function overall (p = 0.02) when compared with female cases. When compared with same-gender children who did not require NICU care, overall function was also significantly worse for male but not female cases (p = 0.0002), and this was largely contributed to by impairment in speech (p = 0.03), mobility (p = 0.04), learning abilities (p = 0.02) and self-care (p = 0.03). Eleven (7.7%) cases compared with just two (1.2%) children who were not treated in the NICU required assistance at school (p = 0.009). No difference was observed when QOL was assessed according to gestational age and birth weight.

CONCLUSION

Using a simple scoring system this study has shown that, for survivors who required early neonatal intensive care, the QOL at 6 years compared favorably with that of children not treated in the NICU, especially for girls.

Longitudinal motor development of "apparently normal" high-risk infants at 18 months, 3 and 5 years

BACKGROUND

Motor development appears to be more affected by premature birth than other developmental domains, however few studies have specifically investigated the development of gross and fine motor skills in this population.

AIM

To examine longitudinal motor development in a group of "apparently normal" high-risk infants.

SETTING

Developmental follow-up clinic in a perinatal centre.

STUDY DESIGN

Longitudinal observational cohort study.

SUBJECTS

Fifty-eight infants born less than 29 weeks gestation and/or 1000 g and without disabilities detected at 12 months.

OUTCOME MEASURES

Longitudinal gross and fine motor skills at 18 months, 3 and 5 years using the Peabody Developmental Motor Scales. The HOME scale provided information of the home environment as a stimulus for development.

RESULTS

A large proportion (54% at 18 months, 47% at 3 years and 64% at 5 years) of children continued to have fine motor deficits from 18 months to 5 years. The proportion of infants with gross motor deficits significantly increased over this period (14%, 33% and 81%, p<0.001), particularly for the 'micropreemies' (born <750 g). In multivariate analyses, gross motor development was positively influenced by the quality of the home environment.

CONCLUSIONS

A large proportion of high-risk infants continued to have fine motor deficits, reflecting an underlying problem with fine motor skills. The proportion of infants with gross motor deficits significantly increased, as test demands became more challenging. In addition, the development of gross and fine motor skills appears to be influenced differently by the home environment.

Outcome of very-low-birth-weight (< 1,500 grams) infants born to mothers with diabetes

Premature delivery is common in pregnancies complicated by maternal diabetes. However, the outcome of very-low-birth-weight infants (VLBWI) born to mothers with diabetes is not known. Employing a matched double-cohort design, we investigated the influence of maternal diabetes on the outcome of VLBWI born in Winnipeg from 1988 to 1994. We compared mortality rates and early and late morbidity rates in VLBWI born to mothers with diabetes mellitus (DM) (cases, n = 43, 23 with gestational DM and 20 with pregestational DM) and without DM (controls, n = 539). Controls were matched for gestational age (GA), sex, and the year of birth. All subjects were enrolled in the Newborn Follow-Up Program. Relative risks and 95% confidence limits were calculated for each variable and Chi 2 analysis, Student t-test, and Mann-Whitney test were used as appropriate for analysis. Diabetes mellitus control was assessed by conventional criteria. There were no differences between cases and controls in mode of delivery, birth weight (mean +/- SD, 1,160 +/- 25 g vs 1,110 +/- 26 g), GA (29 +/- 2.8 wk vs 29 +/- 2.4 wk), smallness for gestational age (35% vs 30%), head circumference (26.5 +/- 1.9 vs 26.2 +/- 2.2 cm), length (38.8 +/- 2.8 vs 37.5 +/- 3.7 cm), Apgar score < 4 at 1 min (42% vs 40%) and < 7 at 5 min (37% vs 42%). Incidence of hyaline membrane disease (60% vs 71%), bronchopulmonary dysplasia (33% vs 31%), patent ductus arteriosus (30% vs 43%), necrotizing enterocolitis (12% vs 12%), sepsis (23% vs 25%), acute renal failure (9% vs 10%), intraventricular hemorrhage--all grades (74% vs 64%), retinopathy of prematurity--all stages (30% vs 26%), median days on ventilator (4 vs 4 days), and median days on supplemental oxygen (46 vs 42 days) were similar in both groups (p = NS, 95% confidence limits included 1 for all of these variables). There was no significant difference in mortality (21% vs 15%) or the incidence of major congenital anomalies. Weight, head circumference, and length at 6, 12, and 18 months were similar in both groups. There were no group differences in developmental quotients, prevalence of neurodevelopmental impairments, respiratory morbidity, or number of hospitalizations up to the last follow-up (18 months). Our data suggest that with contemporary perinatal care there is no significant increase in mortality rates or early and late morbidity rates between VLBWI born to mothers with DM and VLBWI of nondiabetic mothers. It seems that with reasonable diabetic control, prematurity rather than the diabetic state determines the neonatal outcome, and this knowledge can be useful in parental counselling.

Follow up of a randomised trial of two different courses of dexamethasone for preterm babies at risk of chronic lung disease

OBJECTIVES

To report 18 month outcome of a randomised trial of two courses of dexamethasone to prevent chronic lung disease of prematurity.

STUDY DESIGN

Babies of birth weight 1250 g or less ventilated at 7 days of age were randomised to a 42 day reducing course (long) or a 3 day pulsed (pulse) course of dexamethasone. Growth, cardiovascular status, and respiratory and neurodevelopmental outcomes were assessed at 18 months.

RESULTS

Seventy six babies were enrolled. Nine died and three were lost to follow up. Babies receiving the long course were weaned off oxygen more quickly than those receiving the pulse course (47% v 69% on oxygen at 28 days; p = 0.01), but there were no differences in 18 month outcomes. However, children averaged -1 SD for growth parameters, half had moderate or severe disability, and 35% and 19% respectively required oxygen at 36 weeks and discharge.

CONCLUSIONS

The dexamethasone course used did not influence long term outcome. However, entry criteria for this study selected a group of babies at high risk of poor long term outcome.

Longitudinal neurologic follow-up in neonatal intensive care unit survivors with various neonatal morbidities

OBJECTIVE

The purpose of this prospective longitudinal study was to examine neurocognitive and school performance outcomes of low birth weight infants with reference to neonatal morbidity and socioeconomic status. We further evaluated the cognition and school performance based on their neurologic status at the time of assessment.

METHODS

One hundred eighty-eight children (39 healthy full-term and 149 preterm infants) were classified into 4 subgroups based on their neonatal medical status: healthy, sick (without neurologic complications), small for gestational age, and neurologically compromised infants. Neurologic status was classified as normal, suspect, or abnormal at hospital discharge, 18 months, 30 months, 4 years, and 8 years of age. Socioeconomic status, cognitive, and school performances were assessed.

RESULTS

Neurologically, both full-term and healthy preterm groups did well during the 8-year period. There were significant fluctuations between suspect and abnormal neurologic classifications among the 3 preterm groups with neonatal complications. Preterms with neurologic abnormality during the neonatal period did the poorest with 45% of the group remaining abnormal at 8 years of age. Children who were neurologically normal had higher cognitive scores at ages 4 and 8 than those categorized as suspect or abnormal. Preterm infants with neurologic abnormality required significantly more academic resources in the school. Reading and math achievement scores were the lowest for the preterm groups classified as neurologically suspect or abnormal.

CONCLUSIONS

Neonatal morbidities exert a significant impact in neurologic outcomes among preterm children during the 8 years of assessment. Compromised neurologic status adversely affects cognitive and school performances. Neonatal medical status is an important variable indicating neurocognitive and school performance outcomes in low birth weight infants.

Biology versus environment in the extremely low-birth weight infant

This article examines the role of biologic and environmental factors in determining the long-term outcomes of extremely low-birth weight infants. Research focusing on follow-up to at least 4 years of age is reviewed. Methodologic issues related to sampling, the use of control groups, and diagnostic criteria are also discussed. The use of cumulative models of risk for examining the relative contribution of environmental and biologic factors is presented.

Can cerebral MRI at age 1 year predict motor and intellectual outcomes in very-low-birthweight children?

This follow-up study reports on cerebral MRI findings in 20 very-low-birthweight (VLBW) infants without disabilities at age 1 year in relation to motor, intellectual, and perceptual function at age 6 years. MRI findings, anthropometrics, and Bayley Scales of Infant Development scores at age 1 year as predictors of psychomotor status at age 6 years are also evaluated and compared. Outcome parameters were the Peabody Developmental Motor Scales and the Wechsler Preschool and Primary Scale of Intelligence. The results show that infants with myelin hyperintensities including the centrum semiovale or with occipital hyperintensities with associated ventricular dilatation at age 1 scored lower on the Peabody Gross Motor Locomotion Scale at age 6 than infants with normal myelination or with isolated occipital hyperintensities. This may indicate damage to motor fibers caused by perinatal periventricular leukomalacia. No relation was found between abnormal MRI findings at age 1 and later fine motor, intellectual, and perceptual function. Comparing different age 1-year predictors, an abnormality score defined by MRI was used as an independent predictor of gross motor locomotion function at age 6 years. However, the Bayley Mental Development Index scores and weight at age 1 were more important predictors of later motor and intellectual outcome, respectively, than MRI findings. It is recommended that cerebral MRI should not be used routinely to examine VLBW infants without disabilities at 1 year of age.

Neuropsychological analysis of the visuomotor problems in children born preterm at < or = 32 weeks of gestation: a 5-year prospective follow-up

Forty-six intellectually normal children born preterm (< or =32 weeks of gestation) without major neurological disabilities and a control group of term children matched for age, sex, and parental educational and occupational status were assessed at the age of 5 years using neuropsychological tests emphasizing perceptual and visuomotor functions. The results show that in terms of cognitive functions these preterm children are a very heterogenous group, but many of them still have problems in visuospatial and sensorimotor functions. The preterm children achieved lower mean scores in tests where coordination and voluntary control of hands in combination with tactile, kinaesthetic, and visuospatial perception were needed. They had most difficulty with drawing directions of lines and in integrating two or more forms. They also had problems with 3-dimensional constructions as well as visual perception of rotated shapes or slopes of lines.

Outcome of extremely low birth weight infants (500 to 999 grams) over a 12-year period

OBJECTIVE

Advances in neonatology have contributed to improved survival for extremely low birth weight (ELBW) infants. Neurodevelopmental outcome is usually reported for a single large group of infants rather than according to smaller birth weight groups because of small numbers. Our purpose was to review the neurodevelopmental outcome of a large group of ELBW infants and examine differential outcome according to birth weight.

STUDY DESIGN

A total of 446 infants born between 1979 and 1991, with a birth weight of 500 to 999 g, were followed to mean age 55 months +/- 33 standard deviation. Univariate analyses of medical risk factors of birth weight, gestational age, year of birth, growth retardation, gender, inborn/outborn status, days on oxygen, intracranial hemorrhage, and social risk in relation to outcome were conducted on the group as a whole. Neurologic/developmental outcome was also analyzed by 100-g weight groups.

RESULTS

A total of 61% of all infants were completely normal, with no neurologic, neurosensory, or cognitive deficits. There was no association between outcome and birth weight. There was a strong association between intracranial hemorrhage (ICH) grade III or IV and/or cystic periventricular leukomalacia (PVL) and abnormal outcome (Somers' D = .17) and ICH III/IV and/or cystic PVL and cognitive outcome (Kendall's tau = .15). Mild to moderate cognitive delays were associated with chronic lung disease (oxygen >60 days) (Kruskal-Wallis chi2 = 17.53) or high social risk (Kruskal-Wallis chi2 = 22.17).

CONCLUSION

In this study of ELBW infants, low birth weight was not associated with abnormal outcome. The risk factors of ICH III-IV/cystic PVL, chronic lung disease, and high social risk were associated with abnormal outcome.

Influence of obstetric management on outcome of extremely preterm growth retarded infants

AIM

To describe the long term outcome of extremely preterm growth retarded infants in relation to obstetric management and various perinatal events.

METHODS

A cohort study was undertaken in two tertiary care centres with different obstetric management. All infants with fetal growth retardation due to placental insufficiency and resulting in fetal distress at 26 to 32 weeks of gestation, were included for the years 1984-89. Main outcome measures were impairment, disability, or handicap at 2 years corrected age and at school age (4 1/2 to 10 1/2 years).

RESULTS

One hundred and twenty five (98%) were followed up until 2 years corrected age in the outpatient department; 114 (90%) were assessed at school age. Impairments were found in 37% and disabilities or handicaps in 9% of the assessed infants, with no difference between centres. All disabled or handicapped children had already been identified by 2 years corrected age.

CONCLUSIONS

Disability or handicap were related to neonatal complications (intracerebral haemorrhage or bronchopulmonary dysplasia) and not to obstetric variables, thus making antenatal prediction impossible. The incidence of disability or handicap in these growth retarded infants was comparable with that of other preterm infants.

Evaluation of neurodevelopmental outcome in high-risk infants in Australia

An understanding of the neurodevelopmental outcome of long-term survivors of neonatal intensive care is essential for the informed management of preterm or high risk infants. This annotation looks at the current status of neonatal follow-up services in Australasia and highlights problems in the collection and interpretation of data. It suggests that we should work towards achieving a consensus on standard definitions and test regimes and on national data collection.

Predictive value of the Griffiths assessment in extremely low birthweight infants

OBJECTIVE

To assess the relationship between the Griffiths Mental Development Scales at 1 and 3 years and the Stanford-Binet Intelligence Scale (S-B) and Beery Test of Visual-Motor Integration (VMI) at 5 years in extremely low birthweight (ELBW) children.

METHODOLOGY

Prospective study of 45 ELBW infants, without severe neurosensory impairment, cared for in a single Level III neonatal intensive care unit.

RESULTS

At 5 years, 36 (80%) children were of average intelligence, 8 (18%) had borderline intelligence and one was mentally retarded. The Griffiths general quotient (GQ) at 1 year had a weak correlation with the 5 year IQ (corr. coeff. = 0.47), with only 17% of children with a GQ < -1 s.d. at 1 year receiving an IQ < -1 s.d. at 5 years. In contrast, the Griffiths GQ at 3 years correlated strongly with 5 year IQ (corr. coeff. = 0.78). Among those children with a 3 year GQ < -1 s.d., 67% had a 5 year IQ < -1 s.d. and all had a 5 year 1Q < 89. The 3 year hearing and speech subscale correlated strongly with the 5 year S-B verbal comprehension factor (corr. coeff. = 0.753) and the 3 year combined eye/hand co-ordination/performance quotient had a moderate correlation with the S-B non-verbal reasoning factor (corr. coeff. = 0.597) and with the Beery VMI (corr. coeff. = 0.49).

CONCLUSIONS

The 3 year Griffiths GQ is a good predictor of 5 year S-B IQ in ELBW children and can be used to identify children who may benefit from intervention prior to school entry.

Improving outcome for Western Australian infants with birthweights 500-999 g

OBJECTIVE

To assess changes in survival and disability in liveborn extremely low birthweight infants (500-999 g) in Western Australia, 1980-1987.

DESIGN

Cohort study comparing two periods, 1980-1983 (P1) and 1984-1987 (P2).

PARTICIPANTS

All 586 liveborn extremely low birthweight infants in WA in 1980-1987 (266 in P1, 320 in P2).

MAIN VARIABLES EXAMINED

Birthweight, place of birth, age at death, neurosensory examination findings and scores on the Griffiths Mental Development Scales or other standardised test results.

RESULTS

482/586 infants (82%) were born at King Edward Memorial Hospital (KEMH), a level III referral centre, and a further 4% were transferred there after birth. The proportion born at KEMH increased from 78% in P1 to 86% in P2. Survival increased from 35% to 43% overall. In those below 800 g birthweight, survival doubled from 14% to 29%. There was no change in the age at death for non-survivors. Follow-up information was known for 222 of the 229 survivors at median ages of 46 months (P1) and 43 months (P2). Disability rates in infants below 800 g birthweight remained static (P1, 26%; P2, 28%), but fell in those of 800-999 g birthweight from 24% to 13%. Overall, survival free of disability increased from 26% to 34%.

CONCLUSION

Increased survival rates occurred without any increase in the rate or severity of disability in survivors.

Decreasing perinatal mortality: unchanged infantile spasm morbidity

The present study examined whether changes in the incidence of infantile spasms could be used to evaluate changes in the quality of pre- and perinatal care over time. 107 children in 1960 to 1976, and 102 in 1977 to 1991, developed infantile spasms in southern Finland. The number of small-for-gestational age (SGA) infants and infants with neonatal hypoglycaemia decreased significantly. Brain malformations, malformation syndromes and patients with tuberous sclerosis increased; this probably reflects the development of more refined neuroradiological screening methods. SGA infants are probably more apt to develop infantile spasms than preterm infants appropriate for gestational age. Early prenatal factors seem to play a major role in the genesis of infantile spasms. Little can be done to reduce the incidence of infantile spasms, but every effort should be made to reduce the number of SGA infants by good prenatal care. Treatment of hypoglycaemia is important because infantile spasms might be preventable in these infants.

Outcome of neonates transported between Level III centres depends upon centre of care

This study aimed to clarify whether the adverse outcomes seen in babies transported between New Zealand Level III intensive care nurseries were due to the transport itself or to possible differences in care in different centres. The outcomes of 34 infants inborn at National Women's Hospital, Auckland but transported to other centres were compared with those of 68 matched controls inborn at the receiving centres and with 68 controls inborn and cared for at National Women's Hospital. Transport was associated with a transient (non-significant) deterioration in respiratory status but no increase in chronic lung disease. However, infants cared for elsewhere, whether transported or control, had more periventricular hemorrhage than Auckland babies (23% and 29% vs 15%, P = 0.03) and worse neurodevelopmental outcome (70% and 66% vs 88% of those whose outcomes were known were normal at follow up, P = 0.002). We conclude that differences in care between centres may be more important than the transport itself in determining the long-term outcome of transported neonates.

Comparison of mortality and rates of cerebral palsy in two populations of very low birthweight infants

Comparisons of mortality and rates of cerebral palsy in different populations can be confusing. This is illustrated by comparing two populations of very low birthweight infants born in the 1980s, one from the Netherlands, the other from the UK (Oxford region). Although a number of biases were controlled for while comparing two large geographically defined populations, by assessing the survivors at similar ages and describing their health status in a standard way, some problems in interpretation of outcome remained. Differences in registration practice of live births at early gestational ages, as well as differences in withholding or withdrawing treatment, which occurred in about half of the cases of neonatal death in the Netherlands and in about one third of those in the Oxford region, may have influenced the incidence of registered live births, neonatal mortality, and the rate of cerebral palsy.

Dynamic model for preventing mental retardation in the population: the importance of poverty and deprivation

A dynamic simulation model is used to answer the question, "What is the most effective child health policy initiative for the prevention of mental retardation (MR)?" The impact of medical strategies is contrasted with social interventions to see how they affect the prevalence of MR in the general population. The model is based on data from four U.S. Census and California Vital Statistics reports (1960, 1970, 1980, 1990). An interstate comparison (California and South Carolina) uses 1990 data. The results of the simulations reveal that medical interventions to improve the developmental outcome of low birth weight (LBW) infants did not cause a reduction in the rate of MR in the population after a 24-year trial period. In contrast, reducing the proportion of children living in poverty who are exposed to environmental deprivation significantly decreased (10%) MR at the end of the model's time period. This analysis supports the view that long-term reduction in MR prevalence is attainable by modifying public policies that influence children's development. Effective MR prevention calls for public policy committed to multifaceted health and educational services for both affected parents and their young children.

Advances in neonatology. View from a practicing pediatrician

After reviewing the many problems that may be seen by the physician in follow-up care of the preterm infant and family, it is important to take a step back and evaluate the infant as a whole. In the vast majority of instances, the preterm infant will turn out to be normal. In an unfortunate minority, there may be difficult problems that the baby, parents, and caretakers must face. The pediatrician must remain diligent to attend to those problems that are correctable and to assist patients to their full potential.

Extremely low birthweight infants at 3 years: a developmental profile

This study documents the neurodevelopmental outcome at 3 years of 52 of 55 extremely low birthweight (ELBW) survivors (survival rate 49%) born in a tertiary maternity centre from July 1985 through December 1988, and examines more closely the developmental profile of the neurologically normal survivors. At 3 years, 6 (12%) children had severe neurodevelopmental impairment (severe cerebral palsy, blindness, deafness or a General Quotient (GQ) < 70 on the Griffiths Scales), 11 (21%) had mild to moderate impairment and 35 (67%) had no neurosensory impairment and normal development (GQ > or = 85). Significant risk factors for severe impairment were stage 3 or 4 retinopathy of prematurity (odds ratio [OR] 21.5), treatment with postnatal steroids (OR 21), grade III or IV intraventricular haemorrhage (OR 11) and supplemental oxygen at 'term' (OR 6.4). The developmental profile of the 35 neurologically normal children revealed a significant weakness in eye and hand coordination skills and a relative strength in hearing and speech skills. Early recognition of this developmental profile may allow implementation of more appropriate preschool programmes for ELBW children.

Adverse effects of neonatal transport between level III centres

The effect of neonatal transport between level III intensive care nurseries was studied by comparing the outcome of 40 infants inborn at a regional level III centre but transported to other level III nurseries for intensive care, with 80 matched inborn controls. Transport appeared to affect respiratory status adversely but transiently. However, transported infants grew less well than control infants (32% were below 3rd centile for weight at 36 weeks vs 15% of controls), were more likely to suffer periventricular haemorrhage (40 vs 21% of controls) and had a worse neurodevelopmental outcome (70% normal at follow up vs 83% of controls). It can be concluded that for infants inborn at the National Women's Hospital, Auckland, transport to another level III centre for intensive care is associated with an increased risk of adverse outcome.

The relationship between psychosocial factors and developmental outcome for very low and extremely low birthweight infants: a review

Over the last quarter century, the improved survival rate of very low birthweight infants has sharpened questions about their residual disabilities. Longitudinal studies have devoted attention to the cognitive and neurodevelopmental outcome of these infants, but much less is known about their long-term social and emotional development. Psychiatrists consulting to neonatal intensive care units and assessing these infants in their families, will be assisted by a better understanding of the developmental and psychological outcomes of such infants. This paper reviews the state of knowledge in both of these areas. It argues the paramount importance of psychosocial factors to the infants' developmental outcome, and the importance of longitudinal research in further clarifying the predictive value of these factors. In a subsequent paper, we consider the efficacy of interventions with this group.

Evaluation of care for the preterm infant: review of literature on follow-up of preterm and low birthweight infants. Report from the collaborative Project on Preterm and Small for Gestational Age Infants (POPS) in The Netherlands

Since the introduction of neonatal intensive care in the 1960s, mortality in very preterm and very low birthweight infants has been decreasing steadily. Consequently, interest in the outcome of surviving infants is growing. Restriction of health care resources has stressed the need for information concerning the effect of individual treatment components on mortality and morbidity. Concern about the quality in apparently normal survivors has been increasing as well. The current flood of papers on these subjects illustrates the interest in these issues. The first part of this paper reviews the methodology used in follow-up studies in the past decades. It aims at methodological problems that hamper comparison between studies and preclude unequivocal conclusions. New treatment techniques seldom were but should be evaluated by randomised trials. To monitor the combined effects of changing obstetric and neonatal techniques on perinatal outcome, studies in geographically defined populations are recommended using data from early pregnancy until at least preschool age. Comparability of outcomes could be enhanced by international agreement on standardisation of assessment methods and outcome measures. In the second part the results concerning gestational age- and birthweight-specific mortality, impairments and disabilities and the risk factors for such disorders are discussed. Increased survival of even the tiniest infants is clearly established. This increase in survival has not yet been accompanied by an apparent increase in major morbidity. However, many minor impairments are reported, occurring often in combination and predisposing these children to deviations of normal development. Important changes in the manifestation of brain damage appear to occur during development. These findings stress the importance of long-term follow-up studies.

Improving health status in extremely low birthweight children between two and five years

The 5-year outcome of 101 extremely low birthweight (ELBW, < 1000 g) children discharged from the Neonatal Intensive Care Unit was reported. Over this period, there were four post-discharge deaths. The neurodevelopmental impairment rate was 18% overall: cerebral palsy 7%, blindness 3%, deafness 3% and developmental delay 10%. Seventy-one percent of children were readmitted to hospital. The mean number of admissions was 2.4 per child and the mean duration of total hospital stay was 11.3 days per child in the 5-year period. A trend was observed in a reduction in the readmission rate and hospital days in the 2-5-year period compared to the period between discharge and 2 years, though the differences were not statistically significant. The most common reason for readmission was for surgical procedures, primarily aural ventilation tube insertion and tonsillectomy and adenoidectomy. Significant health problems included recurrent wheezing episodes, stridor and croup in the period up to 2 years and otitis media and tonsillitis between 2 and 5 years. There was some catch-up growth, especially in height, between 2 and 5 years. Children with < 800 g birthweight had similar rates of neurodevelopmental impairment and hospital readmission to those of 800-999 g birthweight. However, they experienced more otitis media and pneumonia, had more ear, nose and throat operations, and at 5 years of age, more were below the 3rd centile for weight. This study showed that the health status of ELBW children had improved between 2 and 5 years, but they continued to experience recurrent health problems and hospital readmissions which would have resulted in added financial and emotional burdens to their families.

Standardised method of follow-up assessment of preterm infants at the age of 5 years: use of the WHO classification of impairments, disabilities and handicaps. Report from the collaborative Project on Preterm and Small for gestational age infants (POPS) in The Netherlands, 1983

A nationwide, prospective study was initiated in The Netherlands in 1983, involving 1338 liveborn infants with a gestational age less than 32 weeks and/or a birthweight less than 1500 g. Pre- and perinatal data, methods and results of follow-up until the corrected age of 2 years have been published previously. In this paper, methods of follow-up at the age of 5 years are described. At that age, 966 children were alive, of which 927 (96%) were assessed during a home visit 2 to 6 weeks after their fifth birthday by three specially trained paediatricians. A questionnaire served to collect data on medical history, respiratory function, behaviour and socio-economic factors. Standardised tests were carried out covering the following 10 areas: congenital malformations, neuromotor function, mental development, hearing, visual function, language and speech development, behaviour, musculoskeletal system, respiratory tract and ENT problems, and growth. The outcome was recorded for separate areas and for the child as a whole using the WHO classification of impairments, disabilities and handicaps.

The Scottish low birthweight study: I. Survival, growth, neuromotor and sensory impairment

Of all 908 livebirths weighing less than 1750 g at birth who were born in Scotland in 1984, 896 (99%) were enrolled in a prospective study to document survival and determine the prevalence of neuromotor and sensory impairments and disability. At the age of 4.5 years, 636 (71%) had survived and 611 (96%) were assessed. Overall 16% were disabled; 47 had cerebral palsy (52.5/1000 livebirths), seven were blind (7.8/1000 livebirths), and 11 were deaf and using aids (12.3/1000 livebirths). Among those not overtly disabled, the prevalence of poor neuromotor competence was high and related to birth weight. All growth measures had mean values below the standard population mean indicating a downward shift in the distribution which was related to birth weight. In addition the height distribution was negatively skewed.

Risk factors for major neurodevelopmental impairments and need for special education resources in extremely premature infants

The purpose of this cohort study was to determine the incidence of and risk factors for major neurodevelopmental impairments among survivors of extreme prematurity. The study cohort comprised 100 infants born between 24 and 28 weeks of gestational age at one tertiary center from 1983 to 1984. Twenty-five infants (25%) died; 75 (75%) survived until follow-up (mean, 60 months). Standardized neurodevelopmental and psychometric assessments were performed in blind fashion on 68 of the 75 surviving children (91% follow-up). Informal assessments (parent, teacher, and physician reports) were obtained instead for seven (9%) children who had relocated outside of the area. Overall, 19 children (25%) had one or more major impairments: mental retardation, 9; cerebral palsy, 4; multiple impairments, 5; and blindness, 1. Despite a high prevalence of impairments, 95% of children (n = 71) were functionally independent [corrected]. Special educational resources were definitely necessary for seven (9%) and possibly needed for 36 (48%) additional children. Univariate analyses revealed four significant risk factors for cerebral palsy: hydrocephalus (relative risk = 12.2), grades III and IV intraventricular hemorrhage (relative risk = 5.8), 5-minute Apgar score lower than 7 (relative risk = 5.7), and bronchopulmonary dysplasia (relative risk = 5.5). Hydrocephalus was the only significant risk factor observed for mental retardation (relative risk = 5.4). Risk factors predicting a need for special education resources included sepsis (relative risk = 24.9), low socioeconomic status (relative risk = 16.3), and nonwhite race (relative risk = 3.0). Thus our data suggest that biomedical factors appear to confer the greatest risk of major impairments; sociodemographic factors appear to have a significant impact on educational risk in extremely premature infants who do not die. Continued follow-up with biomedical and developmental-social interventions appears warranted to decrease the risk of educational underachievement in this population.

Neonatal follow-up of very low birthweight/extremely low birthweight infants to school age: a critical overview

Neonatal follow-up studies of school age children, published in the last decade, were critically reviewed. Nine studies examined extremely low birthweight infants (less than or equal to 1000 g) and 16 involved very low birthweight infants (less than or equal to 1500 g). The majority of children had age appropriate I.Q. scores, however, there was a greater variability of test scores. There was an increased need for special education or remedial therapy. Visual-motor integration deficits were frequently reported. Behavioural difficulties were described. Fine and gross motor incoordination was identified. There was no conclusive correlation between perinatal course and school outcome. Gender did appear to influence outcome, in the small percent of studies which examined this variable, with females generally faring better. Low socioeconomic status was the most frequently reported predictor of poor outcome. Identified methodological limitations included heterogeneous samples, lack of control groups, high attrition, variable diagnostic criteria and lack of consensus regarding correction for prematurity.

Impairments, disabilities, and handicaps of very preterm and very-low-birthweight infants at five years of age. The Collaborative Project on Preterm and Small for Gestational Age Infants (POPS) in The Netherlands

The Project On Preterm and Small for gestational age infants (POPS) was started in the Netherlands in 1983 to investigate the relation between prenatal/perinatal factors and mortality/morbidity in very preterm and very-low-birthweight infants. Of the 1338 liveborn infants (less than 32 weeks and/or less than 1500 g) 966 were enrolled in the five-year (chronological age) follow-up programme; 96% of these children were assessed during a home visit. The overall outcome was expressed as impairments, disabilities, and handicaps according to World Health Organisation criteria. Of the assessed children, 13% had a disability and 14% were handicapped, which are much higher frequencies than those found in the general population. Handicaps were due mainly to abnormalities of neuromotor function, mental development, or language and speech development. Compared with the handicap frequency in the same cohort at two years of age, a more favourable outcome at five years of age was seen in 10%, and a less favourable outcome in 7% of the children. The findings show that most of those high-risk children survived without handicap or serious disability at preschool age.

Changing two-year outcome of infants weighing 500 to 999 grams at birth: a hospital study

Survival and neurodevelopmental outcome to 2 years were determined for two cohorts of infants weighing 500 to 999 gm at birth, born in a tertiary maternity hospital. Live births increased over time from an annual average of 48.7 in the first era (January 1977 to March 1982) to 64.6 in the second era (January 1985 to December 1987), largely from referrals of additional mothers with pregnancy complications. In the first era, 33.6% (86/256) of infants survived to 2 years; the survival rate improved significantly to 45.9% (89/194) in era 2. After adjustment for birth weight, the odds ratio for survival in era 2 versus era 1 was 1.39 (95% confidence interval = 1.12, 1.73; p less than 0.01). One known survivor in each era was not seen at 2 years of age. In the first era, 59.3% (51/86) of 2-year-old children were free of disability compared with 68.5% (61/89) in era 2 (NS), but the Mental Development Index of the Bayley Scales improved significantly, from 90.0 in era 1 to 98.0 in era 2. For infants weighing less than 800 gm at birth, not only did the 2-year survival rate improve, adjusted for birth weight (odds ratio = 1.53; 95% confidence interval = 1.06, 2.20; p less than 0.05), but there was also a significant reduction in neurologic disabilities in survivors (p = 0.03). For infants weighing 800 to 999 gm at birth, there was a significant improvement in the survival rate, adjusted for birth weight (odds ratio = 1.37; 95% confidence interval = 1.04, 1.79; p less than 0.05), but the rate of neurologic disabilities was unchanged. Increased survival in our tertiary maternity center was achieved without increasing the annual number of severely disabled 2-year-old survivors.

Eight-year outcome in infants with birth weight of 500 to 999 grams: continuing regional study of 1979 and 1980 births. Victorian Infant Collaborative Study Group

The outcome at a mean age of 8.3 years was determined for 88 of 89 surviving children with birth weights of 500 to 999 gm who were born in Victoria in 1979 and 1980; the condition of the untraced child, severely disabled at 5 years of age, was assumed to be unchanged at 8 years. Principal impairments in the children at 8 years of age were cerebral palsy 8 (9%); bilateral blindness 6 (6.7%) and poor vision in another 4 (4.5%); bilateral deafness requiring amplification 5 (5.6%); and epilepsy 2 (2.2%). The Full Scale score of the Weschler Intelligence Scales for Children--Revised was available for 77 children: 5 scores (6.5%) were less than 71 (low IQ), and 9 (11.7%) were between 71 and 85 (borderline IQ). Severe disability in 16 children (18%) was due to severe cerebral palsy, bilateral blindness, or low IQ. Mild or moderate disability was present in another 18 children (20.2%) with borderline IQ, mild or moderate cerebral palsy, poor vision, deafness, or epilepsy. Significantly more outborn children (10/18, 55.6%) than inborn children (24/71, 33.8%) were disabled. Ten children required special schooling; reading accuracy or comprehension was at least 18 months behind chronologic age in 17 (23%) of 75 children in normal school who were tested. The 2-year assessment correctly estimated the category of disability at 8 years of age in 55 (62%), overestimated it in 24 (27%), and underestimated it in 10 (11%). For the 82 children also seen at 5 years age, the category of disability at 8 years of age was correctly identified in 69 children (84%), overestimated in 4 (5%), and underestimated in 9 (11%). Change in psychologic test scores was the principal reason for reclassifying children. We conclude that the 2-yar assessment was valuable in the early identification of most of the severely disabled children, but developmental delay at 2 years of age did not always portend intellectual impairment at 8 years of age.

Survival and outcome of infants weighing less than 800 grams at birth

This study reports on two aspects of outcome in a sample of infants whose birth weights ranged from 500 to 799 gm. First, maternal and early neonatal variables were analyzed by means of stepwise logistic regression. Five-minute Apgar score and initial pH were the only variables that predicted mortality at p less than or equal to 0.05. Second, the surviving infants were examined at ages ranging from 17 months to 7 years. The majority (72%) had neurologic and/or developmental examinations in the suspect or abnormal range and required rehabilitation or early intervention services.

Intellectual and functional status at school entry of children who weighed 1000 grams or less at birth: a regional perspective of births in the 1980s

The intellectual and functional status of a regional cohort of children who weighed 501 to 1000 gm when born between 1980 and 1982 was evaluated at a mean age of 5 1/2 years by standard psychometric tests. Of 90 long-term survivors (survival rate 49%), 78 children (87%) had the full test battery, 5 children (6%) had other tests (4 were blind), and one child was untestable. Most of the mean scores were within 1 SD of the test norms; the lowest scores were in the McCarthy Motor scale and in the Beery Test of Visual-Motor Integration. Children without neurologic impairments and those with an IQ greater than or equal to 68 (n = 60) had higher overall scores but still performed poorly on the Motor subscale and the Beery test. Children who weighed less than 800 gm at birth (n = 28) were similar to those who weighed greater than 800 gm (n = 50), except in the Memory and Motor subscales, in which they performed significantly less well. At a functional level, determined by the Vineland Adaptive Behaviour Scales, two thirds of the children were performing in the adequate range and the remainder in the moderately low to low range. Of the 43 children with no neurosensory impairments and an IQ greater than or equal to 84, 49% were identified (by the Florida Kindergarten Screening Battery) to be at mild to high risk for future learning disabilities. The data from this unselected population provide an unbiased estimate of the prevalence of intellectual and functional problems in children who weighed less than or equal to 1000 gm at birth.

Normative data and the effect of correction for prematurity on test scores in the psychomotor development of extremely low birthweight infants

This study was concerned with the problem how we should allow for gestational age at birth when evaluating psychomotor development in extremely low birthweight (ELBW) infants. The consequences of the use of corrected and uncorrected developmental test scores as to the degree of prematurity were studied in 27 consecutive ELBW children who had been categorized as being normal on neurological and psychological testing at 5 1/2 years. The present study provides evidence that the overall trend of psychomotor development in normal ELBW children is not accelerated, but is guided by maturation of the central nervous system. This study also suggests that there are no significant differences in the predictive value of corrected and uncorrected DQ scores after 2 years of age with respect to IQ scores at 5 1/2 years.

Correction of developmental and intelligence test scores for premature birth

When using tests of infant development and intelligence in children born prematurely, the subject's age is commonly corrected for the degree of prematurity. However, there is disagreement: first, on whether this correction should ever be applied, and second, at what age to discontinue the adjustment. In a theoretical model, the difference between corrected and uncorrected scores in early infancy was massive and the difference remained clinically important until the age of 8.5 years in children who were born extremely prematurely. The clinical implications of using corrected or uncorrected scores were then evaluated in 174 very low birthweight children without severe sensorineural disabilities and with paired Bayley Mental Development Index (MDI) and Wechsler Preschool and Primary Scales of Intelligence (WPPSI) full scale scores. Failure to correct for prematurity reduced the mean MDI by 12.1 points but reduced the mean WPPSI by only 4.1 points. The disparity between individual MDI and WPPSI scores increased significantly with decreasing gestational age if uncorrected scores were used (P = 0.015) but not if scores were corrected. Using corrected scores, the MDI correctly predicted the WPPSI category in 86.1% of children (P less than 0.001) but in only 54.6% using uncorrected scores (the difference was not significant). It is suggested that a practical solution to the dilemma is to correct test scores for prematurity in the age range 2-8.5 years recognizing that only in extremely immature infants will uncorrected scores be substantially lower than corrected ones at a later age.

Decreased disability rate among 3-year-old survivors weighing 501 to 1000 grams at birth and born to residents of a geographically defined region from 1981 to 1984 compared with 1977 to 1980

In this article we report the survival and morbidity rates for all live-born infants weighing 501 to 1000 gram at birth and born to residents of a defined geographic region from 1977 to 1980 (n = 255) compared with 1981 to 1984 (n = 266). During these periods, there were no changes in the proportion of infants delivered at the tertiary care center or community hospitals (171/84 vs 194/72); use of the tertiary care center increased only slightly, from 84% to 91%; and changes in neonatal management were mainly in improvements in diagnostic and monitoring techniques. When infants were grouped according to birth weights in 100 gm increments, survival improved significantly only for infants weighing between 501 and 600 gm at birth (2% vs 20% p less than 0.001). There were no differences in the overall survival rates to hospital discharge (46% vs 48%). The prevalence of neurosensory impairments was 24% in period 1 and 17% in period 2. There was a significant improvement in the proportion of infants considered to have disabilities by a functional classification assigned at 3 years corrected age (50% vs 27%, p less than 0.001), but only for infants weighing more than 800 gm at birth (49% vs 22%, p less than 0.001). Infants delivered at the community hospitals had a higher prevalence of neurosensory impairments compared with infants delivered at the tertiary care center (period 1, 35% vs 21%, not significant; period 2, 37% vs 14%, p less than 0.05). These data are encouraging; further efforts should be directed toward assessing which, if any, components of perinatal care are contributing to the improvement in morbidity rates.

EEG diagnoses of neonatal seizures: clinical correlations and outcome

Electroencephalographic seizures were evaluated in 112 neonates. The first portion of the study involved 80 neonates with clinically identified abnormal movements, 8 of whom (10%) had electroencephalographic evidence of seizures coincident with this activity. Patients with abnormal movements (90%) had no concurrent electrical seizures. In the second part of the study, 40 infants who had electrical seizures were investigated. Eight of these infants had been identified during the first part of the study. Two-thirds of the patients (25) were premature. Sixteen patients (40%) died; 90% had brain lesions documented by computed tomography and/or postmortem study. Cerebral infarction and intraventricular hemorrhage were the most common lesions. One-third of the survivors (8 of 24 patients) were normal at a mean age of 3 years, while two-thirds had significant neurologic and developmental abnormalities. Neonatal seizures often are subtle, not associated with observable clinical expression, and associated with adverse development. Electroencephalographic confirmation is important in the evaluation of neonatal seizures.