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

Brain structure and function in the fourth decade of life after extremely low birth weight: An MRI and EEG study

OBJECTIVE

To examine potential long-term effects of extremely low birth weight (ELBW; ≤ 1000 g) on adult brain structure, brain function, and cognitive-behavioral performance.

METHODS

A subset of survivors from the prospectively-followed McMaster ELBW Cohort (n = 23, MBW = 816 g) and their peers born at normal birth weight (NBW; ≥ 2500 g; n = 14, MBW = 3361 g) provided T1-weighted magnetic resonance imaging (MRI) brain scans, resting electroencephalographic (EEG) recordings, and behavioral responses to a face-processing task in their early thirties.

RESULTS

Visual discrimination accuracy for human faces, resting EEG alpha power, and long-distance alpha coherence were lower in ELBW survivors than NBW adults, and volumes of white matter hypointensities (WMH) were higher. Across groups, face-processing performance was correlated positively with posterior EEG spectral power and long-distance alpha and theta coherence, and negatively with WMH. The associations between face-processing scores and parietal alpha power and theta coherence were reduced after adjustment for WMH.

CONCLUSIONS

Electrocortical activity, brain functional connectivity, and higher-order processing ability may be negatively affected by WMH burden, which is greater in adults born extremely preterm.

SIGNIFICANCE

Decrements in electrocortical activity and behavioral performance in adult ELBW survivors may be partly explained by increased WMH volumes in this vulnerable population.

Intellectual functioning in survivors of extremely low birthweight: Cognitive outcomes in childhood and adolescence

BACKGROUND

Infants born at extremely low birthweight (ELBW: ≤1000 g) are vulnerable to intellectual disabilities, but the factors that may distinguish between ELBW survivors with and without these impairments are not well understood. In this study, prospective associations between neonatal factors and functional outcomes in childhood and adolescence were compared in ELBW survivors with and without borderline intellectual functioning (BIF).

METHODS

Borderline intellectual functioning was defined by IQ < 85, assessed at 8 years. Among 146 ELBW survivors, 48 (33%) had IQ scores under 85, and 98 (67%) had scores equal to or over 85. Group differences in demographic and risk factors were assessed via t-test, chi-squared analysis or non-parametric tests. Neonatal factors that differed between ELBW groups were tested for association with adaptive behaviour assessed at age 5 years, and reading and arithmetic skills assessed at ages 8 and 15 years, using hierarchical regression models.

RESULTS

Extremely low birthweight survivors with BIF had significantly lower birthweights than ELBW survivors without BIF (790 vs. 855 g, P < 0.01) and were more likely to be born to mothers with lower socioeconomic status (SES) (78% vs. 48%, P < 0.01). These ELBW survivors also were more likely to be diagnosed with significant neurosensory impairment (NSI; 35% vs. 19%, P < 0.04), experienced more bronchopulmonary dysplasia (56% vs. 38%, P < 0.04), received more days of respiratory support (median 33 vs. 14 days, P < 0.01) and remained in hospital for longer periods (median 81 vs. 63 days, P < 0.03). Birthweight, familial SES, NSI and duration of respiratory support were significant predictors for one or more outcomes. Across groups, lower familial SES was associated with lower academic scores (Ps < 0.05), and NSI predicted lower adaptive functioning (Ps < 0.001). Other associations were moderated by group: among ELBW survivors with BIF, heavier birthweights predicted better arithmetic skills, the presence of NSI was associated with poorer arithmetic skills and more ventilation days predicted poorer reading skills.

CONCLUSIONS

At birth, ELBW survivors with BIF faced more physiological and social disadvantages and required more medical intervention than their ELBW peers without BIF. Smaller birth size, NSI burden and prolonged neonatal ventilatory support displayed gradients of risk for childhood and adolescent academic outcomes across groups. Whereas academic performance in ELBW survivors with BIF was sensitive to variation in birth size, NSI or ventilation days, ELBW survivors without BIF attained thresholds of intellectual ability that were sufficient to support higher levels of academic performance at both ages, regardless of their status on these factors. The findings are discussed in relation to Zigler's developmental theory of intellectual disability.

Cumulative risks predict epigenetic age in adult survivors of extremely low birth weight

Long-term sequelae of extremely low birth weight (ELBW; ≤1000 g) may contribute to accelerated biological aging. This hypothesis was examined by analyzing a range of risk factors with a molecular age marker in adults born at ELBW or normal birth weight (NBW; ≥2500 g). DNAm age-the weighted average of DNA methylation at 353 cytosine-phosphate-guanine (CpG) sites from across the genome-was derived from a sample of 45 ELBW (M_age  = 32.35 years) and 47 NBW control (M_age  = 32.44 years) adults, using the Illumina 850k BeadChip Array. At two assessments undertaken 9 years apart (at 23 and 32 years), cumulative risks were summed from six domains with potential to affect physiological and psychological health: resting respiratory sinus arrhythmia, blood pressure, basal cortisol, grip strength, body mass index, and self-esteem. At age 32 years, cumulative risks were differentially associated with epigenetic age in ELBW survivors (interaction, p < 0.01). For each additional risk factor they possessed, ELBW survivors (B = 1.43) were biologically 2.16 years older than NBW adults (B = -0.73), by the fourth decade of life. Developmental change, epigenetic maintenance, and intervention targets are discussed.

DNA methylation profiles in adults born at extremely low birth weight

Effects of stresses associated with extremely preterm birth may be biologically "recorded" in the genomes of individuals born preterm via changes in DNA methylation (DNAm) patterns. Genome-wide DNAm profiles were examined in buccal epithelial cells from 45 adults born at extremely low birth weight (ELBW; ≤1000 g) in the oldest known cohort of prospectively followed ELBW survivors (Mage = 32.35 years, 17 male), and 47 normal birth weight (NBW; ≥2500 g) control adults (Mage = 32.43 years, 20 male). Sex differences in DNAm profiles were found in both birth weight groups, but they were greatly enhanced in the ELBW group (77,895 loci) versus the NBW group (3,424 loci), suggesting synergistic effects of extreme prenatal adversity and sex on adult DNAm profiles. In men, DNAm profiles differed by birth weight group at 1,354 loci on 694 unique genes. Only two loci on two genes distinguished between ELBW and NBW women. Gene ontology (GO) and network analyses indicated that loci differentiating between ELBW and NBW men were abundant in genes within biological pathways related to neuronal development, synaptic transportation, metabolic regulation, and cellular regulation. Findings suggest increased sensitivity of males to long-term epigenetic effects of extremely preterm birth. Group differences are discussed in relation to particular gene functions.

Visual configural processing in adults born at extremely low birth weight

Being born at extremely low birth weight (ELBW; ≤1,000 g) is associated with enduring visual impairments. We tested for long-term, higher order visual processing problems in the oldest known prospectively followed cohort of ELBW survivors. Configural processing (spacing among features of an object) was examined in 62 adults born at ELBW (M_age  = 31.9 years) and 82 adults born at normal birth weight (NBW; ≥2,500 g: M_age  = 32.5 years). Pairs of human faces, monkey faces, or houses were presented in a delayed match-to-sample task, where non-matching stimuli differed only in the spacing of their features. Discrimination accuracy for each stimulus type was compared between birth weight groups, adjusting for neurosensory impairment, visual acuity, binocular fusion ability, IQ, and sex. Both groups were better able to discriminate human faces than monkey faces (p < .001). However, the ELBW group discriminated between human faces (p < .001), between monkey faces (p < .001), and to some degree, between houses (p < .06), more poorly than NBW control participants, suggesting a general deficit in perceptual processing. Human face discrimination was related to performance IQ (PIQ) across groups, but especially among ELBW survivors. Coding (a PIQ subtest) also predicted human face discrimination in ELBW survivors, consistent with previously reported links between visuo-perceptive difficulties and regional slowing of cortical activity in individuals born preterm. Correlations with Coding suggested ELBW survivors may have used a feature-matching approach to processing human faces. Future studies could examine brain-based anatomical and functional evidence for altered face processing, as well as the social and memory consequences of face-processing deficits in ELBW survivors.

Trajectories of psychopathology in extremely low birth weight survivors from early adolescence to adulthood: a 20-year longitudinal study

BACKGROUND

Individuals born extremely preterm are exposed to significant perinatal stresses that are associated with an increased risk of psychopathology. However, a paucity of longitudinal studies has prevented the empirical examination of long-term, dynamic effects of perinatal adversity on mental health. Here, internalizing and externalizing problems from adolescence through adulthood were compared in individuals born at extremely low birth weight (ELBW; <1,000 g) and normal birth weight (NBW; >2,500 g).

METHODS

Internalizing and externalizing data were collected over 20 years in three waves, during adolescence, young adulthood, and adulthood. Growth models were used to compare longitudinal trajectories in a geographically based sample of 151 ELBW survivors and 137 NBW control participants born between 1977 and 1982 matched for age, sex, and socioeconomic status at age 8.

RESULTS

After adjusting for sex, socioeconomic and immigrant status, and family functioning, ELBW survivors failed to show the normative, age-related decline in internalizing problems over time relative to their NBW peers (β = .21; p < .01). Both groups exhibited small declines in externalizing problems over the same period. Self-esteem (but not physical health, IQ, or maternal mood) partially mediated the association between ELBW status and internalizing problems.

CONCLUSIONS

Extremely low birth weight survivors experienced a blunting of the expected improvement in depression and anxiety from adolescence to adulthood. These findings suggest that altered physiological regulatory systems supporting emotional and cognitive processing may contribute to the maintenance of internalizing problems in this population.

Socioeconomic Attainment of Extremely Low Birth Weight Survivors: The Role of Early Cognition

OBJECTIVES

To determine: (1) if childhood cognitive and academic abilities mediate the association between being born at extremely low birth weight (ELBW) and socioeconomic attainment at age 29 to 36 years; (2) which cognitive abilities (IQ, verbal abilities, fluid intelligence, mathematical abilities, or academic achievement) most strongly mediate this association; and (3) if the mediating role of cognition is different in ELBW survivors with significant neurosensory impairment (NSI).

METHODS

A prospective, longitudinal cohort of 100 Canadian ELBW survivors born between 1977 and 1982 and 89 normal birth weight comparison participants were used to examine the mediating role of childhood cognition by using 5 cognitive mediators assessed at age 8 years (overall IQ, verbal IQ, performance IQ, quantitative ability, and academic achievement) on socioeconomic attainment at adulthood. Socioeconomic attainment was defined as personal annual earnings and full-time employment assessed via self-report at age 29 to 36 years.

RESULTS

Mediation models revealed that childhood cognition mediated the association between ELBW status and income attainment, with mathematical abilities and overall IQ each accounting for 26% of the direct effect. Mediated effects were not statistically significant in full-time employment models. For both outcomes, the mediating effect of cognition was stronger for ELBW survivors with NSI.

CONCLUSIONS

Childhood cognitive abilities partially mediate associations between ELBW status and adult income attainment. Early life cognition is a critical predictor of socioeconomic attainment in ELBW survivors, particularly in those born with NSI. Interventions aimed at enhancing early cognition in ELBW survivors may help optimize their later socioeconomic attainment.

In their own words: Life at adulthood after very premature birth

Very premature infants born in the last century following the early days of post-neonatal intensive care have demonstrated an array of physical, emotional, and mental health problems as they approach their third and fourth decades. These outcomes have been well documented by several international investigators. However, there is a paucity of information on the personal perspectives of these individuals with regard to their own quality of life, their hopes and their fears. This article will focus on the objective information from the published literature and how it differs from the personal perspectives of former very premature infants.

Health-Related Quality of Life Trajectories of Extremely Low Birth Weight Survivors into Adulthood

OBJECTIVES

To compare the health-related quality of life (HRQL) trajectories of a regional cohort of extremely low birth weight (ELBW, <1000 g) survivors (births from 1977 to 1982) and a group of normal birth weight (NBW) controls, at 3 ages: 12-16 years, 22-26 years, and 29-36 years, spanning over 20 years. We hypothesized that the HRQL of the ELBW cohort would be significantly compromised compared with their NBW peers, and that neurosensory impairments (NSI) would have an additional negative effect.

STUDY DESIGN

We used the Health Utilities Index Mark 3, in which health status was self-assessed and utility scores were derived from community preferences; multilevel modeling was used to delineate trajectories of HRQL among ELBW survivors with (n = 37) and without NSI (n = 116), and NBW controls (n = 137).

RESULTS

Adjusting for participant sex and socioeconomic status at age 8 years, ELBW survivors with NSI had consistently lower HRQL compared with both ELBW survivors without NSI and NBW controls, from adolescence through to adulthood (β = -0.264; P < .001). ELBW survivors without NSI also had significantly lower HRQL compared with NBW controls (β = -0.092; P < .01). At all ages, differences seen in the Health Utilities Index Mark 3 scores between ELBW participants and NBW controls were clinically important, though there was no differential rate of decline between the 2 groups.

CONCLUSIONS

ELBW survivors manifest meaningfully poorer HRQL from their early teens through their mid-30s. Individuals with NSI appear to represent a distinct group of ELBW survivors with substantially lower HRQL at all ages. Information on HRQL can be helpful in prioritizing research and intervention strategies.

Risk of neurodevelopmental impairment for outborn extremely preterm infants in an Australian regional network

OBJECTIVE

To compare neurodevelopmental outcomes at 2-3 years in extremely premature outborn and inborn infants.

DESIGN

Population-based retrospective cohort study.

SETTING

Geographically defined area of New South Wales (NSW) and the Australian Capital Territory (ACT) served by a network of 10 neonatal intensive care units (NICUs).

PATIENTS

All premature infants <29 weeks gestation born between 1998 and 2004 in the setting.

INTERVENTION

At 2-3 years, corrected age, 1473 children were assessed with either the Griffiths Mental Developmental Scales (GMDS) or the Bayley Scales of Infant Development (BSID-II).

MAIN OUTCOME MEASURE

Moderate/severe functional disability (FD) defined as: developmental delay (GMDS general quotient (GQ) or BSID-II mental developmental index (MDI)) > 2 standard deviations (SD) below the mean; cerebral palsy (CP) requiring aids; sensorineural or conductive deafness (requiring amplification); or bilateral blindness (visual acuity <6/60 in better eye).

RESULTS

At 2-3 years, moderate/severe functional disability does not appear to be significantly different between outborn and inborn infants (adjusted OR 0.782; 95% CI 0.424-1.443). However, there were a significant number of outborn infants lost to follow up (23.3% versus 42.9%).

CONCLUSION

In this cohort, at 2-3 years follow up neurodevelopmental outcome does not appear to be significantly different between outborn and inborn infants. These results should be interpreted with caution given the limitation of this study.

The predictive value of lactate levels in vaginal fluid on the latent period in pregnant women with preterm premature rupture of membranes

The aim of the present study was to investigate the relationship between lactate level in vaginal fluid and the latent phase of labour in pregnancies complicated by preterm premature rupture of membranes (PPROM). Seventy pregnant women with PPROM during 28-34 weeks' gestation were selected for this prospective observational study. All subjects underwent a pelvic examination involving the insertion of a vaginal speculum, and lactate levels were measured in vaginal fluid samples. The relationship between the lactate levels in the vaginal fluid and the latent phase of the labour was analysed using a logistic regression test. Of the patients, 48 (68.6%) had a latent period of 48 h or less, and 22 patients (31.4%) had a latent period longer than 48 h. The median lactate level was 3.81 mmol/L in patients with a latent period ≤ 48 h, and 3.36 mmol/L in patients with a latent period > 48 h. The lactate level in vaginal fluid was not found to be distinctive in the differentiation of patients according to the duration of the latent phase (receiver operating characteristic or ROC: 0.509; 95% confidence interval or CI: 0.361-0.657; p = 0.904). There was no significant correlation between the lactate level in the vaginal fluid and the transition from the latent phase to the active phase of labour in pregnancies complicated by PPROM.

Potentially avoidable neonatal retrievals in New South Wales: a retrospective analysis

OBJECTIVE

To identify areas for improvement in outcomes in retrieved newborns by reviewing newborn retrieval activity and evaluating potentially avoidable retrievals from each referring hospital stratified by the level of service delivery over the study period.

DESIGN

A retrospective analysis of newborn retrievals from 1 January 2006 to 31 December 2009.

SETTING

Newborn and Paediatric Emergency Transport Service (NETS).

PARTICIPANTS

Newborns less than 72 hours old retrieved by NETS in the study period. Each retrieval was classified as potentially avoidable, unavoidable or unclassified, based on predefined criteria.

MAIN OUTCOME MEASURES

Newborn retrieval rates (per 10,000 live births) and potentially avoidable retrievals for each referring hospital level and overall.

RESULTS

There were 2494 newborn retrievals over the study period, with an annual mean of 623 total and 30 potentially avoidable retrievals. There was a reduction in the potentially avoidable retrieval rate (per 10,000 live births) over the study period (from 3.9 in 2006 and 4.2 in 2007 to 2.2 in 2008 and 2.3 in 2009) despite an increase in the total retrieval rate over the same time. Discretionary caesarean, defined as elective (pre-labour) caesarean section without documented fetal or maternal indications before 39 completed weeks of gestation, accounted for two-thirds of the potentially avoidable retrievals.

CONCLUSIONS

Potentially avoidable retrievals were a small but significant proportion and are becoming less frequent. Discretionary caesarean is the most common cause of potentially avoidable retrieval. Strict implementation of the elective caesarean section policy directive has the potential to reduce morbidity and the costs related to retrieval.

Outcomes following periviable birth

This review is presented in three segments: (1) important background concepts, (2) recent reports from regional geographically defined cohorts, and (3) prognosis research from the National Institutes of Health Neonatal Research Network. Extending the use of intensive care to newborns of lower gestational ages will unavoidably result in a higher proportion and a higher absolute number of survivors with morbidity, unless other changes in practice offset the increased risk associated with decreasing gestational age. In geographically defined cohort studies, the proportion of periviable newborns delivered in perinatal centers and the practices around foregoing and withdrawing intensive care are two important determinants of outcomes following periviable birth. It is much easier to quantify the effect of the former than the latter. Decisions regarding comfort care vs. intensive are frequently based on gestational age as the sole predictor variable, although multiple factors can be readily used to more accurately assess the benefits and burdens of intensive care and facilitate better informed parental counseling and decision making.

Antenatal counselling for parents facing an extremely preterm birth: limitations of the medical evidence

When physicians are asked for a consult for women in premature labour, they face a complex set of challenges. Policy statements recommend that women be given detailed information about the risks of various outcomes, including death, long-term disability and various specific neonatal problems. Both personal narratives and studies suggest that parents also base their decisions on factors other than the probabilistic facts about expected outcomes. Statistics are difficult to understand at any time. Rational decision-making may be difficult when taking life-and-death decisions. Furthermore, the role of emotions is not discussed in peri-viability guidelines.

CONCLUSION

We argue against trying to tell parents every fact that we think might be relevant to their decision. This may be overwhelming for many parents. Instead, doctors should try to discern, on a case-by-case basis, what particular parents want and need. Information and delivery of information should be personalized. Unfortunately, evidence in this area is limited.

Neonatal personnel in Canada

Although the need for trained personnel to care for neonates with complex needs is recognized, there has been no systematic analysis of present or future personnel requirements. The Canadian Paediatric Society's Neonatal-Perinatal Medicine Section sponsored a symposium on neonatal personnel, inviting four Canadian experts to address issues related to future needs. Areas addressed included neonatal nurse practitioners providing increased patient care in some parts of the country as resident involvement in neonatal intensive care decreases, the extended roles of other health care personnel and increased direct patient care by neonatologists. There is no approved method to determine personnel needs, but paediatric department heads have indicated that the number of neonatologists needed is substantially greater than available funding allows. Considering economic factors and the need to educate perinatal care providers, it is important to assess present and future needs to ensure that quality care can be provided.

Neurological and developmental disabilities in ELBW and VLBW: follow-up at 2 years of age

OBJECTIVE

To establish the prevalence of neurodevelopmental disabilities among premature infants born in western Poland.

STUDY DESIGN

From 1999 to 2003, 640 extremely low birth weight (ELBW) and 777 very low birth weight (VLBW) infants were admitted to the tertiary care center in Poland. Discharged home were 302 and 671 of them, respectively. At 2 years corrected age, 165 ELBW and 285 VLBW children were diagnosed with neurosensory abnormality including cerebral palsy (CP) and evaluated with Bayley Scales of Infant Development II.

RESULT

Mental developmental index (MDI) score <70 was recorded in 104 children (23.1%). There were 75 (16.7%) cases of CP, 8 (1.7%) deafness/hearing loss, 22 (4.8%) blindness and 14 (3.1%) of epilepsy. Patients with abnormal neurosensory status had significantly lower MDI compared with those with normal development (83.8±9 vs 54.7±10). Severe intraventricular haemorrhage, periventricular leucomalacia, ventricular dilatation and hydrocephalus were the most important risk factors for neurologic abnormality.

CONCLUSION

Severe disability is more common among ELBW compared with VLBW infants and remains a major challenge for health-care providers.

Economic outcomes in young adulthood for extremely low birth weight survivors

OBJECTIVE

The goal was to compare educational attainment and labor market outcomes in young adulthood (21-26 years of age) for a Canadian, population-based cohort of 149 extremely low birth weight (ELBW) (<1000 g) survivors and a normal birth weight (NBW) cohort of 133 young adults from the same geographic area who were matched to the ELBW cohort in childhood.

METHODS

We estimated the effects of ELBW status, according to gender, on continuous outcomes through least-squares regression and those on binary outcomes through logistic regression. We controlled for family background and considered neurosensory impairment and IQ as mediating variables.

RESULTS

Controlling for family background, ELBW male subjects were less likely to complete high school or to attend a university than were their NBW counterparts, and their educational attainment was reduced by >1 year. Among subjects who were working, weekly earnings were ∼27% lower. ELBW female effects on education were not significant, but ELBW female subjects were less likely than NBW subjects to be employed or in school and they also seemed to experience lower earnings.

CONCLUSION

Our findings suggested that ELBW survivors are somewhat less productive as adults, on average, than are subjects born NBW and that effects are not confined to subjects with severe neurosensory impairments. In accord with other studies, however, we found that productivity deficits for most ELBW subjects were not large.

Impact of extreme prematurity on family functioning and maternal health 20 years later

OBJECTIVE

The goal was to examine the impact of illness on families and the long-term effects on the health of parents of young adults (YAs) who were born with extremely low birth weight (ELBW), compared with normal birth weight (NBW) control subjects.

METHODS

A longitudinal cohort study was performed. Participants were mothers of eligible ELBW and NBW YAs. Information was obtained with well-validated questionnaires.

RESULTS

At young adulthood, 130 (81%) of 161 ELBW group and 126 (89%) of 141 NBW group mothers participated. There were no significant differences in scores between groups with respect to marital disharmony, family dysfunction, maternal mood, state anxiety, social support, depression, and maternal physical and mental health. The finding of no differences was unchanged when 27 YAs with neurosensory impairment (NSI) were excluded, except for family dysfunction scores, which were paradoxically lower for families with YAs with NSI. Although the impact scores revealed that significantly more parents of ELBW YAs were negatively affected with respect to their jobs and educational or training opportunities, mothers of ELBW YAs reported that the experience of caring for their child brought their family closer together and that relatives and friends were more helpful and understanding, compared with mothers of NBW YAs. Significantly more mothers of ELBW YAs with NSI, compared with those without NSI, felt better about themselves for having managed their child's health.

CONCLUSION

It seems that, by young adulthood, there is a minimally negative long-term impact of having an ELBW child in the family, regardless of the presence of NSI.

An overview of mortality and sequelae of preterm birth from infancy to adulthood

Survival rates have greatly improved in recent years for infants of borderline viability; however, these infants remain at risk of developing a wide array of complications, not only in the neonatal unit, but also in the long term. Morbidity is inversely related to gestational age; however, there is no gestational age, including term, that is wholly exempt. Neurodevelopmental disabilities and recurrent health problems take a toll in early childhood. Subsequently hidden disabilities such as school difficulties and behavioural problems become apparent and persist into adolescence. Reassuringly, however, most children born very preterm adjust remarkably well during their transition into adulthood. Because mortality rates have fallen, the focus for perinatal interventions is to develop strategies to reduce long-term morbidity, especially the prevention of brain injury and abnormal brain development. In addition, follow-up to middle age and beyond is warranted to identify the risks, especially for cardiovascular and metabolic disorders that are likely to be experienced by preterm survivors.

Is there evidence that long-term outcomes have improved with intensive care?

Advances in perinatal interventions over the past three decades, such as antenatal steroid therapy, ventilator techniques, surfactant therapy, and enhanced nutrition have resulted in a dramatic improvement in the survival of very low birth weight (VLBW) infants. Simultaneously, other advances in reproductive technology procedures have resulted in greater numbers of preterm and multiple births. These extremely premature births account for the vast majority of infant mortality and morbidity in the developed world. Despite the innovative interventions, VLBW infants remain at substantial risk for a wide spectrum of long-term morbidity including cerebral palsy (CP), mental retardation, developmental delay, school problems, behavioral issues, growth failure, and overall poor health status. Recently, ethical concerns have been expressed that improved survival rates for the most immature infants may result in increased rates of disability with substantial resource utilization and declining quality of life for the survivors. This chapter critically evaluates the available neurodevelopmental and health outcomes of very premature infants from the developed world in an attempt to determine if there is evidence that long-term outcomes have improved with neonatal intensive care. Studies on the rates of neurodevelopmental impairment including CP, early childhood and school age functional problems, and special health care issues are surveyed in order to evaluate changes over time and provide an assessment of the success of neonatal intensive care over the past three decades.

Moral distress in the neonatal intensive care unit: caregiver's experience

BACKGROUND

The Neonatal Intensive Care Unit (NICU) can be ethically charged, which can create challenges for health-care workers.

OBJECTIVE

To determine the frequency with which nurses and residents have experienced ethical confrontations and what factors are associated with increased frequency.

DESIGN/METHODS

An anonymous questionnaire was distributed to nurses in a university center, a high-risk obstetric service, a maternity hospital NICU with 85% in-born patients and an outborn NICU, most of whose preterm admissions are those with surgical complications. Obstetric and pediatric residents in the four universities of the province also received the questionnaire, which included demographics, opinions regarding the gestational age threshold at which resuscitation of a premature infant with bradycardia was appropriate, knowledge of cerebral palsy (CP) outcomes (as an indicator of knowledge about long-term sequelae of prematurity) and questions about ethical confrontation in the NICU.

RESULTS

Two hundred and seventy-nine caregivers participated (115 full time nurses and 164 residents). All the distributed questionnaires were completed. Frequent ethical confrontation was reported by 35% of the nurses and 19% of the residents. Among the nurses, moral distress differed significantly between work environments. Nurses working in an out-born NICU and obstetric nurses were more likely to overestimate CP prevalence (P<0.05). Nurses who overestimated CP rates had higher thresholds for resuscitation and were more likely to experience ethical confrontations. Of the residents, 60% were pediatric and 40% obstetric. All groups of residents frequently overestimated the prevalence of CP, and knowledge differed significantly by residency program (P<0.05). The residents who overestimated CP rates had higher thresholds for resuscitation, had more incorrect answers regarding prematurity outcomes and were less likely to have ethical confrontations.

CONCLUSIONS

A large proportion of nurses and residents report frequent ethical confrontations. Many residents and nurses have limited knowledge of outcomes and high threshold for resuscitation. Ethical confrontation is more common among nurses with poor knowledge about outcomes, and less common in residents with poor knowledge about outcomes.

Comparison of current health, functional limitations, and health care use of young adults who were born with extremely low birth weight and normal birth weight

OBJECTIVE

The objective of this study was to compare the current health status, physical ability, functional limitations, and health care use of extremely low birth weight and normal birth weight young adults.

METHODS

A longitudinal study was conducted of a population-based cohort of 166 extremely low birth weight survivors (501-1000 g birth weight; 1977-1982 births) and a group of 145 sociodemographically comparable normal birth weight individuals. Current health status, history of illnesses, hospitalizations, use of health resources, and physical self-efficacy were assessed through questionnaires that were administered to the young adults by masked interviewers.

RESULTS

Individuals completed the assessments at a mean age of 23 years. Neurosensory impairments were identified in 27% of extremely low birth weight and 2% of normal birth weight individuals. No differences were reported in the current health status for physical or mental summary scores. Extremely low birth weight young adults reported a higher prevalence of chronic health conditions in the past 6 months. A significantly higher proportion of extremely low birth weight individuals had functional limitations in seeing, hearing, and dexterity and experienced clumsiness and learning difficulties. Except for prescription glasses, medications for depression, and home-care services for extremely low birth weight individuals, there were no significant differences between groups in use of health care resources. Extremely low birth weight individuals had significantly weaker hand grip strength and lower scores for physical self-efficacy, perceived physical ability, and physical self-confidence.

CONCLUSIONS

Extremely low birth weight young adults seem to enjoy similar current health status to their normal birth weight peers. However, they continue to have significantly poorer physical abilities and a higher prevalence of chronic health conditions and functional limitations. Contrary to expectations, they do not pose a significant burden to the health care system at young adulthood.

Establishing neonatal networks: the reality

Managed clinical networks for neonatal care were established in England from 2004. Their structure and effectiveness varies widely over the country. Changes in medical manpower and the scarcity of neonatal nurses make the move towards networks urgent, but there is little evidence of a coordinated approach to improving capacity in the tertiary centres, who will have to absorb the activity that follows reconfiguration. Changes in the governance of hospitals, NHS authority boundaries and in commissioning specialist services, with the drive towards reducing health costs, places the process at some considerable risk. Despite these challenges, the development of coordinated clinical networks will be an important force in improving outcome for very preterm babies in the UK. The development of some form of national coordination of network activities and greater sharing of good practice would enhance the value of the managed clinical neonatal networks.

Growth trajectories of extremely low birth weight infants from birth to young adulthood: a longitudinal, population-based study

We compared sex-specific growth attainment of a population-based cohort of 147/166 (89%) extremely low birthweight (ELBW < 1000 g) and 131/145 (90%) sociodemographically comparable normal birthweight (NBW) cohort at young adulthood, and examined the pattern of growth trajectories and correlates of growth at ages 1, 2, 3, and 8 y, and teen and young adulthood (mean age, 23.3 versus 23.6 y). The proportion considered small for gestational age was ELBW 25% versus NBW 3%; and 26% versus 2% had neurosensory impairments. Weight for age z-scores for ELBW showed substantial decline to age 3 y, with subsequent significant catch-up to adolescence and smaller gains to adulthood. Height for age z-scores showed both sexes of ELBW were disadvantaged at every age compared with NBW and their expected mid-parental height. The BMI z-scores for ELBW showed a sustained incline from age 3 to adulthood, where both sexes normalized to above zero, and were comparable to their peers. ELBW children showed growth failure during infancy, followed by accelerated weight gain and crossing of BMI percentiles at adolescence, a pattern that may increase the risk of insulin resistance and coronary heart disease. However, normalization of BMI for both sexes at adulthood suggests that final growth was proportionate.

Eye-hand co-ordination skills in very preterm infants <29 weeks gestation at 3 years: Effects of preterm birth and retinopathy of prematurity

INTRODUCTION

Preterm infants are known to have low gross motor and fine motor skills. We questioned whether poor eye-hand coordination skills are associated with moderate to severe stages of Retinopathy of Prematurity (ROP).

AIMS

The aim of this study was to examine development, with specific reference to eye-hand coordination skills, among preterm infants <29 weeks gestation with different stages of ROP at 3 years of age.

METHODS AND MATERIALS

Fifteen preterm infants (<29 weeks gestation) who developed Stage 3 ROP were matched for gestation, birthweight and gender with infants who developed Stage 2 and Stage 1/no ROP. Developmental (Griffiths Mental Development Scales and Peabody Developmental Motor Scales) and ophthalmic assessments in the 3 matched groups of 15 were performed at 3 years of age.

RESULTS

1) Whilst the eye-hand coordination scores and Peabody fine motor scores were lower in the Stage 3 ROP group, they were not significantly lower than the other ROP groups. 2) Locomotor, Peabody gross motor skills and hearing and speech were significantly lower in the infants with Stage 3 ROP. The other developmental domains were not significantly different to the severe ROP group. 3) All 3 groups (of preterm infants) had lower eye-hand coordination and Peabody fine motor scores compared to test norms. 4) There were 8 of 15 infants with Stage 3 ROP who developed moderate visual problems by 3 years of age.

CONCLUSION

In preterm infants, low eye-hand coordination/fine motor scores are likely to be due to their extreme prematurity.

Improved outcomes of extremely premature outborn infants: effects of strategic changes in perinatal and retrieval services

OBJECTIVE

The goal was to evaluate the impact of statewide coordinated changes in perinatal support and retrieval services on the outcomes of extremely premature births occurring outside perinatal centers in the state of New South Wales, Australia.

METHODS

The intervention included additional, network-coordinated, perinatal telephone advice to optimize in utero transfers and centralization of the neonatal retrieval system, with preferential admission of retrieved infants (outborn infants) to perinatal centers instead of freestanding pediatric hospitals, from the middle of 1995. Population birth and NICU admission cohorts of infants of 23 to 28 weeks of gestation were studied. Outcomes of epoch 1 (1992 to the middle of 1995; 1778 births and 1100 NICU admissions) were compared with those of epoch 2 (1997-2002; 3099 births and 2100 NICU admissions), after an 18-month washout period.

RESULTS

There were 25% fewer nontertiary hospital live births (19.7% vs 14.9%) and more prenatal steroid use. Despite an 11.4% average annual increase in NICU admissions between the 2 epochs, fewer infants were outborn (12.0% vs 9.3%) and outborn mortality rates decreased significantly (39.4% vs 25.1%), particularly for those between 27 and 28 weeks of gestation. The overall improvement was equivalent to 1 extra survivor per 16 New South Wales births. There were also significantly fewer serious outcome morbidities in outborn infants during epoch 2, over the improvements in inborn infants.

CONCLUSIONS

Statewide coordinated strategies in reducing nontertiary hospital births and optimizing transport of outborn infants to perinatal centers have improved considerably the outcomes of extremely premature infants. These findings have vital implications for health outcomes and resource planning.

Self-perceived health-related quality of life of former extremely low birth weight infants at young adulthood

OBJECTIVES

The goals were to compare the self-reported, health-related quality of life of former extremely low birth weight and normal birth weight infants at young adulthood and to determine whether there were any changes over time.

METHODS

A prospective, longitudinal, population-based study with concurrent control subjects was performed. We interviewed 143 of 166 extremely low birth weight survivors (birth weight: 501-1000 g; 1977-1982 births) and 130 of 145 sociodemographically comparable, normal birth weight, reference subjects. Neurosensory impairments were present for 27% extremely low birth weight and 2% normal birth weight young adults. Health Utilities Index 2 was used to assess health status, and standard gamble technique was used to measure directly the self-reported, health-related, quality of life and 4 hypothetical health states.

RESULTS

Extremely low birth weight young adults reported more functional limitations in cognition, sensation, mobility, and self-care, compared with control subjects. There were no differences between groups in the mean self-reported, health-related, quality of life or between impaired (n = 38) and nonimpaired (n = 105) extremely low birth weight subjects. However, with a conservative approach of assigning a score of 0 for 10 severely disabled, extremely low birth weight subjects, the mean health-related quality of life was significantly lower than control values. Repeated-measures analysis of variance to compare health-related quality-of-life measurements obtained for young adults and teens showed the same decline in scores over time for both groups. There were no differences between groups in the ratings provided for the hypothetical health states.

CONCLUSIONS

At young adulthood, health-related quality of life was not related to size at birth or to the presence of disability. There was a small decrease in health-related quality-of-life scores over time for both groups.

Neonatology fellowship training in research pertaining to development and follow-up

The methodology of the study of the short- and long-term outcomes has changed over the 30-40 years since the indroduction of neonatal intensive care. The training of neonatal fellows in research pertaining to development and follow-up currently needs to include study of epidemiology and biostatistics, knowledge concerning normal and abnormal growth and development throughout the life span and clinical skills and/or knowledge concerning the assessment of neurologic and developmental outcomes.

Evaluation of neonatal intensive care for extremely-low-birth-weight infants

Neonatal intensive care for extremely-low-birth-weight (ELBW, 500-999 g) infants must be evaluated to determine that it is effective, efficient, and available to those who need it. From the late 1970s until the late 1990s in the state of Victoria, Australia, neonatal intensive care has been increasingly effective, with large increases in the long-term survival rate from 25% in 1979-1980 to 73% in 1997, and in the quality-adjusted survival rate from 19% to 59% over the same time. Its efficiency has been relatively high and stable over time, comparing favourably with many other health-care programmes. It is increasingly available, with fewer than 10% of ELBW infants born outside level III perinatal centres in the latest era, and proportionally more ELBW infants being offered intensive care over time. Neonatal intensive care should be re-evaluated at intervals in the future to ensure that its effectiveness, efficiency and availability are maintained.

Improved survival rates with increased neurodevelopmental disability for extremely low birth weight infants in the 1990s

BACKGROUND

Advances in perinatal care have resulted in increased survival rates for extremely low birth weight children. We sought to examine the relative changes in rates of survival and neurodevelopmental impairment at 20 months of corrected age among 500- to 999-g birth weight infants born at our perinatal center during 2 periods, before and after the introduction of surfactant therapy in 1990.

METHODS

Four hundred ninety-six infants with birth weights of 500 to 999 g were born at our perinatal center during period I (1982-1989) (mean body weight: 762 g; mean gestational age: 25.8 weeks) and 682 during period II (1990-1998) (mean body weight: 756 g; mean gestational age: 25.5 weeks). Rates of death and survival with and without neurodevelopmental impairment at 20 months of corrected age for the 2 periods were compared with logistic regression analyses, with adjustment for gestational age.

RESULTS

Survival rates increased from 49% during period I to 67% during period II. Neonatal morbidity rates also increased during period II, including rates of sepsis (from 37% to 51%), periventricular leukomalacia (from 2% to 7%), and chronic lung disease, defined as oxygen dependence at 36 weeks of corrected age (from 32% to 43%). Rates of severe cranial ultrasound abnormalities were similar (22% vs 22%). Among children monitored, the rate of neurologic abnormalities, including cerebral palsy, increased from 16% during period I to 25% during period II and the rate of deafness increased from 3% to 7%. The overall rate of neurodevelopmental impairment (major neurosensory abnormality and/or Bayley Mental Developmental Index score of <70) increased from 26% to 36%. Compared with period I, in period II there were decreased rates of death (odds ratio [OR]: 0.3; 95% confidence interval [CI]: 0.2-0.4) and increased rates of survival with impairment (OR: 2.3; 95% CI: 1.7-3.3) but also increased rates of survival without impairment (OR: 1.7; 95% CI: 1.3-2.2). Compared with period I, for every 100 infants with birth weights of 500 to 999 g born in period II, 18 additional infants survived, of whom 7 were unimpaired and 11 were impaired.

CONCLUSIONS

The improved survival rates in the 1990s occurred with an increased risk of significant neurodevelopmental impairment. Prospective parents of extremely low birth weight infants should be advised of this substantial risk, to facilitate decision-making in the delivery room.

Changing availability of neonatal intensive care for extremely low birthweight infants in Victoria over two decades

OBJECTIVE

To determine the changes in availability of neonatal intensive care for extremely low birthweight (ELBW) infants, and the consequences of a lack of availability.

DESIGN AND SETTING

Population-based cohort study of consecutive ELBW infants born in the state of Victoria during four distinct eras.

PARTICIPANTS

All livebirths weighing 500-999 g in Victoria in the calendar years 1979-1980 (n = 351), 1985-1987 (n = 560), 1991-1992 (n = 429), and 1997 (n = 233).

MAIN OUTCOME MEASURES

Changes over time in the proportions of ELBW infants offered intensive care, the proportions that were "outborn" (born outside level 3 perinatal centres), and their survival rates and quality of survival compared with "inborn" infants.

RESULTS

The proportions of ELBW infants offered intensive care increased over time and were significantly higher in heavier infants. The proportion of outborn ELBW infants was 30% in 1979-1980, falling to 9% by 1997. The difference in survival rates between inborn and outborn infants widened progressively over time: the survival advantages for inborn infants over outborn infants were 12.0% in 1979-1980, 30.1% in 1985-1987, 36.5% in 1991-1992, and 43.6% in 1997. For survivors, the quality of life was significantly better for inborn infants in two of the four eras.

CONCLUSIONS

Neonatal intensive care has been increasingly available for ELBW infants in Victoria over the period 1979 to 1997. The gap in survival rates between outborn and inborn infants has widened, and the quality of life of outborn survivors is inferior.

Evaluation of neonatal intensive care for extremely low birth weight infants in Victoria over two decades: I. Effectiveness

CONTEXT

Although individual components of neonatal intensive care have proven efficacy, doubts remain about its overall effectiveness.

OBJECTIVE

To determine the changes in effectiveness of neonatal intensive care for extremely low birth weight (ELBW) infants over 2 decades.

DESIGN

Population-based cohort study of consecutive ELBW infants born during 4 distinct eras: 1979-1980, 1985-1987, 1991-1992, and 1997, all followed to at least 2 years of age.

SETTING

The state of Victoria, Australia.

PATIENTS

All ELBW live births of birth weight 500 to 999 g in the state in the calendar years indicated (1979-1980 [n = 351]; 1985-1987 [n = 560]; 1991-1992 [n = 429]; 1997 [n = 233]). Survivors were assessed at 2 years of age by pediatricians and psychologists blinded to perinatal details. The follow-up rates were high for each ELBW cohort (1979-1980: 100% [89 of 89]; 1985-1987: 100% [212 of 212]; 1991-1992: 98% [237 of 241]; 1997: 99% [168 of 170]).

MAIN OUTCOME MEASURES

Survival and quality-adjusted survival rates at 2 years of age.

RESULTS

The survival rate to 2 years of age improved significantly between successive eras (absolute increase and 95% confidence interval: 1985-1987 vs 1979-1980, 12.5% and 6.3%-18.4%; 1991-1992 vs 1985-1987, 18.3% and 12.1%-24.4%; 1997 vs 1991-1992, 16.8% and 9.2%-23.9%), as did the quality-adjusted survival rate (absolute increase: 1985-1987 vs 1979-1980, 12.4%; 1991-1992 vs 1985-1987, 13.8%; 1997 vs 1991-1992, 13.2%). Overall, the survival rate increased from approximately 1 in 4 (25%) in 1979-1980 to 3 in 4 (73%) in 1997, and the quality-adjusted survival rate also increased threefold, from 19% in 1979-1980 to 59% in 1997. The biggest gains in survival and quality-adjusted survival in the most recent era were in infants in lighter birth-weight subgroups.

CONCLUSION

The effectiveness of neonatal intensive care for ELBW infants in Victoria improved progressively from the late 1970s to the late 1990s.

School-age outcomes in children who were extremely low birth weight from four international population-based cohorts

OBJECTIVE

The aim of this study was to determine whether learning and school problems in extremely low birth weight (ELBW) and reference children differ between cohorts in different countries.

METHODS

Participants were 4 international population-based cohorts of ELBW survivors who were 500 to 1000 g birth weight from New Jersey, central-west Ontario, Bavaria, and Holland (n = 532) and were followed longitudinally from birth. Psychometric data were collected independently and prospectively and included at least 1 measure of cognitive status and 1 measure of achievement administered to the children between the ages of 8 and 11 years. Adjustments were made for comparison of all measures based on reference norms within each country. Information on special educational assistance and grade repetition was obtained from the parents.

RESULTS

The overall follow-up rate was 84% (range: 74%-90%; n = 436). The proportion of children who performed within the normal range (> or =85) were as follows: IQ between 44% and 62%; reading between 46% and 81%; arithmetic between 31% and 76%; and spelling between 39% and 65%. Children from New Jersey had the lowest rates of cognitive and achievement deficits, and Bavarian children did less well in achievement scores relative to their peers and other cohorts. Despite these differences, more than half of all cohorts required special educational assistance and/or repeated a grade.

CONCLUSIONS

School difficulties were found to be a serious sequelae of ELBW in all 4 countries, an observation that has social and economic implications.

Psychopathology and social competencies of adolescents who were extremely low birth weight

BACKGROUND

We have previously shown that infants who were extremely low birth weight (ELBW) are particularly vulnerable to problems related to inattention and hyperactivity at school age. It is not known whether these problems persist to adolescence.

OBJECTIVE

To explore and compare the levels of psychopathology in a regional cohort of ELBW infants and sociodemographically matched term controls as reported by teens and their parents.

DESIGN/METHODS

Cross-sectional cohort study/geographically defined region.

PARTICIPANTS

TEENS: ELBW 141/169 (83%) and control 122/145 (84%), aged 12 to 16 years. PARENTS: ELBW 143/169 (85%) and control 123/145 (85%). Both cohorts and their parents completed the Ontario Child Health Study-Revised questionnaire with 6 behavioral subsca1es: conduct disorder, oppositional defiant disorder, attention-deficit/hyperactivity disorder (ADHD), overanxious, separation anxiety, and depression.

RESULTS

By teen self-report, there were no significant differences between ELBW and control teens on any of the 6 subscale scores. However, parents of ELBW teens reported significantly higher scores than parents of control for depression and ADHD based on 2-way analysis of variance (group x gender). Comparison within teen/parent dyads showed that both cohorts of teens reported significantly higher scores than their parents. Multivariable analyses on behavioral subscale scores demonstrated a number of variables that were significant predictors by parent report: group (ELBW vs control), gender, family function, developmental quotient, maternal mood, and socioeconomic status; no predictors were significant by teen report. There were no statistically significant interaction effects for any of the models. These models explained a greater percent of the variance in behavioral scores for parents than for teens (12.5%-22.0% vs 3.4%-8.2%). Results were similar when teens with neurosensory impairment were excluded.

CONCLUSIONS

This study is unique in the inclusion of both parent and teen self-report of behaviors. Significant differences were apparent only by parent report for ADHD and depression among ELBW teens. Significant predictors of behavioral scores for parents include group, gender, family function, developmental quotient, maternal mood, and socioeconomic status.

Preterm outcomes research: a critical component of neonatal intensive care

While early preterm outcome studies described the lives of preterm survivors to justify the efforts required to save them, subsequent studies demonstrated their increased incidence of cerebral palsy, mental retardation, sensory impairments, minor neuromotor dysfunction, language delays, visual-perceptual disorders, learning disability and behavior problems compared to fullterm controls. Because infants born at the lower limit of viability require the most resources and have the highest incidence of neurodevelopmental disability, there is concern that resources have gone primarily to neonatal intensive care and are not available for meeting the followup, health, educational and emotional needs of these fragile infants and their families. Despite many methodological concerns, preterm outcome studies have provided insight into risk factors for and causes of CNS injury in preterm infants. Nevertheless, it remains difficult to predict neurodevelopmental outcome for individual preterm infants. Perinatal and neonatal risk factors are inadequate proxies for neurodevelopmental disability. Recent randomized controlled trials with one to five year neurodevelopmental followup have provided valuable information about perinatal and neonatal treatments. Recognizing adverse longterm neurodevelopmental effects of pharmacological doses of postnatal steroids is a sobering reminder of the need for longterm neurodevelopmental followup in all neonatal randomized controlled trials. Ongoing longterm preterm neurodevelopmental studies, analysis of changes in outcomes over time and among centers, and evaluation of the longterm safety, efficacy and effectiveness of many perinatal and neonatal management strategies and proposed neuroprotective agents are all necessary for further medical and technological advances in neonatal intensive care.

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.

A simple, efficient and inexpensive program for preventing prematurity

Prevention of prematurity and of low birth weight is--because of the associated increased risk of mortality and morbidity--one of the most urgent tasks of perinatal medicine. Whereas the rate of prematures all over the world does not vary very much (5-10%), the rate of infants born with low birth weight lies between 3.6% and 10% in the industrial countries and between 9.8% and 43% in the developing countries, where the main cause of low birth weight is intrauterine malnutrition. As there are different causes for prematurity and low birth weight, but also because various countries have different resources and have therefore to set their priorities differently, there is no global solution. The situation in each country must be considered individually. However, as far as basic means are available for the majority--such as basic health care, monitoring the nutritional state of the mothers and acting to prevent infectious diseases (malaria in particular can cause prematurity)--determined prevention of prematurity should take the form of screening and the treatment of disturbances of the vaginal milieu or genital infections. This policy can be recommended because one of the most important avoidable causes of prematurity is ascending genital infection (mostly combined with bacterial vaginosis), which very frequently starts with a disturbance of the vaginal milieu and then often takes its course asymptomatically. Regular screening for signs of such a disturbance using vaginal pH-measurements (and if necessary further diagnostics and therapy) makes possible the detection of an "early marker" to prevent prematurity in an effective and inexpensive way. Our prematurity-prevention-program, which has been successful for many years, is based on an anamnestic assessment of prematurity risk, the early detection of warning signs (including regular measurement of the vaginal pH) and, if necessary, the appropriate therapeutic measures. In cases of disturbance of the vaginal milieu, the latter consists of a therapy with lactobacillus preparations or in a combination of lactobacillus preparation with an acidifying therapy which may lead to earlier normalization of the vaginal milieu. In cases of bacterial vaginosis local therapy, for example with metronidazol or clindamycin, is undertaken, and in other infections specific treatment. It is encouraging to note that particularly the rate of the very small prematures is reduced when pregnant patients take part in our self-care-program, measuring their own vaginal pH-value twice a week, and also searching for any other warning signs. In this way in our collective the rate of very small low birth weight infants could be reduced from 7.8% in the immediate previous pregnancy to 1.3%. In a prospective study performed in Erfurt the rate of very early premature births (< 32 + 0 gw) amounted to only 0.3% in contrast to 3.3% in a control group who had not taken part in the self-care activity. According to a differentiated classification of the control group the success of the self-care activity was even clearer: In patients who did not take part because their doctors did not support the self-care activity, the rate of very early premature births amounted to 4.1%. In patients who did not take part in the self-care activity, but who were in the care of doctors who were interested and had taken part in the prevention-program, the rate was 2.2%; in the group with active participation in the self-care activity it was only 0.3%. To date measurement of the vaginal pH-value was performed intravaginally using either indicator strips or pH-measuring test gloves. A short time ago we developed a panty liner coated with an indicator strip, which enables reading of the pH-value by just checking the indicator on the panty liner. First results with this panty liner are very promising.

The measurement of health-related quality of life (HRQL) in children with cerebral palsy

The measurement of health-related quality of life (HRQL) in children with cerebral palsy is part of an emerging discipline. Theoretical models of disability and chronic illness developed by the World Health Organization, the National Center for Medical Rehabilitation Research and others are being adapted for children. Development of HRQL measures in paediatrics lags behind the work completed with adults due to challenges unique to children, such as what domains to measure, whose perspective to address and the developmental changes inherent to children. The descriptive HRQL studies of children with moderate to severe cerebral palsy and comparisons of children with quadriplegia vs. diplegia and hemiplegia are presented. Consistent with the functional measures, no significant difference in HRQL by treatment was documented in children with spastic diplegia participating in a randomized clinical trial of selective dorsal rhizotomy. HRQL measures that are specifically tailored to cerebral palsy need to be developed. Generic and individualized measures of HRQL are currently available and while limited, may be useful for evaluating the effect of different treatments for spasticity on the quality of life in children with cerebral palsy.

Physical growth and current health status of infants who were of extremely low birth weight and controls at adolescence

OBJECTIVES

To compare the physical growth, current health status, and utilization of health care resources by extremely low birth weight (ELBW) and control (C) adolescents and to look at changes over time.

METHODS

A longitudinal regional cohort study was conducted. Growth measures were converted to z scores on the National Center for Health Statistics growth curves. Information regarding current health status/health care utilization was obtained by parental interviews.

RESULTS

A total of 154 (91%) of 169 ELBW survivors between 12 and 16 years and 125 (86%) of 145 controls participated. Neurosensory impairments were present in 28% of ELBW survivors and 2% of control participants. Mean z scores for both height and weight were below 0 for ELBW survivors (weight: -0.35; height: -0.55) compared with control participants (weight: 0.40; height: 0.28). However, among ELBW survivors, significant catch-up growth occurred in both parameters between age 8 and adolescence but remained stable among control participants. ELBW survivors had a higher prevalence of visual problems (57% vs 21%), seizures (7% vs 1%), developmental delay (26% vs 1%), learning disabilities (34% vs 10%), and hyperactivity (9% vs 2%) and used more specialists and community resources than did control participants.

CONCLUSIONS

Although physical growth continues to be compromised and substantial morbidity remains among ELBW survivors at adolescence, there seems to be some catch-up growth, a reduction in the prevalence of acute health problems, and a decrease in the utilization of medical resources.

Attitudes of parents and health care professionals toward active treatment of extremely premature infants

OBJECTIVES

To compare the attitudes of neonatologists, neonatal nurses, the parents of extremely low birth weight (ELBW) children, and the parents of normal birth weight children toward saving infants of borderline viability and who should be involved in the decision-making process and to compare physicians' and nurses' estimates of the proportion of infants who are born at various gestational ages with regard to survival, morbidity, and treatment.

METHODS

A questionnaire was given to 169 parents of ELBW children and 123 parents of term children, who were part of a longitudinal study of the outcome of ELBW infants. A similar questionnaire was completed by 98 Canadian neonatologists and 99 neonatal nurses.

RESULTS

Physicians tended to be more optimistic than nurses regarding the probability of survival and freedom from serious disabilities and would recommend to parents life-saving interventions for their child at earlier gestational ages. A significant majority of parents believed that attempts should be made to save all infants, irrespective of condition or weight at birth, compared with only 6% of health professionals who endorsed this. In contrast to parents, health professionals believed that economic costs to society should be a factor in deciding whether to save an ELBW infant. However, health professionals did not believe that the economic status of the parents should be a factor, although the stress of raising an infant with disabilities should be. Most respondents believed that the parents and physicians should make the final decision but that other bodies, such as ethics committees or the courts, should not.

CONCLUSION

Health care professionals must recognize that their attitudes toward saving ELBW infants differ from those of parents. Parents, whether of term or extremely premature children, are more in favor of intervening to save the infant irrespective of its weight or condition at birth than are professionals. It therefore is imperative that there be joint decision making, combining the knowledge of the physician with the wishes of the parents.

Impact of family structure and stability on academic outcome in preterm children at 10 years of age

OBJECTIVE

To compare school performance at age 10 years in a cohort of extremely preterm children and term control subjects and to examine the impact of family composition and stability on performance.

STUDY DESIGN

Prospective, longitudinal follow-up from birth to 10 years of age of a regional cohort of children born at 24 to 31 weeks of gestational age and sociodemographically matched term control subjects. Family composition, extent of parental care giving, and family moves were tracked sequentially. At 10 years, academic achievement and school performance were ascertained for 118 of 125 (94%) preterm survivors and 119 of 125 (95%) term children.

RESULTS

Term children were more likely to demonstrate optimal school outcome (appropriate grade level without additional classroom assistance) than were preterm children (odds ratio 3.4, 95% CI 1.9-6.0). Medical complications related to prematurity had little impact on school outcome. Among preterm children, optimal school outcome was significantly associated with increased parental education, child rearing by 2 parents (regardless of marital status), and stability in family composition and geographic residence over 10 years. These environmental influences were less pronounced among term control subjects.

CONCLUSION

Although preterm children performed less well in school than term children, family factors were stronger predictors of school performance than were perinatal complications.

Impact of extreme prematurity on families of adolescent children

OBJECTIVES

To compare the impact of burden of illness on families of teenaged children who were extremely low birth weight (ELBW) with that of members of a term control group (C) and to determine whether the attitudes toward active treatment of very immature infants differ between the 2 cohorts.

DESIGN

In a cross-sectional survey, parents of 145 (86%) of 169 members of an ELBW cohort and 123 (85%) of 145 members of a control cohort completed a 23-item self-completed questionnaire encompassing occupational, marital, and family-related issues and attitudes toward treatment of infants of borderline viability.

RESULTS

Both positive (P =.0003) and negative (P <.005) effects on marriage were higher in parents of the ELBW group; although more parents in the ELBW group felt that their child had brought their families closer together (P =.0001), their child's health had adversely affected their emotional health (P =.02) and that of other children in the family (P =.003). Despite this result, a significant proportion of parents from both cohorts supported saving all infants (ELBW 68%; C 58%) and favored the role of parents in decision making (ELBW 98%; C 97%).

CONCLUSIONS

In the long term, it appears that parents of ELBW children have adjusted fairly well to their work and family life. Although some negative effects were identified, there was still considerable support for active treatment of infants of borderline viability.

Perception of health status and quality of life of extremely low-birth weight survivors. The consumer, the provider, and the child

In neonatal intensive care, parents make important clinical management decisions in conjunction with health professionals. Little information is available in the literature, however, on whether the preferences of health care professionals, parents, and children differ for the resulting health outcomes. This article compares the preferences of these stakeholders for four to five hypothetical health states that are common to extremely low-birth weight infants. The findings have conceptual and practical implications for decision making in the neonatal intensive care unit.

Economics of prematurity in the era of managed care

Both the acute intensive care of premature infants and the management of their long-term medical and educational sequelae are costly. Because neonatal intensive care is very effective in reducing mortality, however, its cost effectiveness as described previously is actually quite favorable when compared with other well-accepted medical interventions, such as coronary artery bypass grafting and renal dialysis. This article has highlighted the relatively scant literature on which those estimates of costs and cost effectiveness of both neonatal intensive care and its component interventions rest. This is particularly true with respect to long-term resource use by graduates of NICUs. Without such information, we cannot hope to allocate resources in a way that ensures optimal care of this vulnerable population.

Follow-up of very low birthweight babies to adolescence

Reports on the school-age outcomes and behavioural difficulties at adolescence of infants who were very low birthweight (VLBW) are only just emerging. Studies which compare VLBW with same age controls consistently show significantly poorer performance, with average scores between 8 and 13 points lower. Even children with no neurological impairments have scores which are significantly lower on cognitive and achievement measures. The extremely low birthweight (ELBW) adolescents fare worse on all measures and perform particularly poorly in mathematics. A high proportion of VLBW adolescents (15%-20%), and an even higher proportion of ELBW adolescents (30%-50%), are receiving remedial assistance and/or have failed a grade. There are conflicting reports on whether the behavioural problems increase or improve with age, but most studies show that at adolescence the problems are still significantly greater in the VLBW cohort than in their peers. Methodologically rigorous studies of the current survivors to school-age should be conducted to determine whether the technological innovations in the 1990s have contributed to a reduction in psychoeducational and behavioural difficulties. Future research should also be directed towards early identification of school difficulties and development of intervention strategies targeted to the most vulnerable infants.

Racial differences in temporal changes in newborn viability and survival by gestational age

This study examines trends in the rates of very preterm, moderately preterm and gestational age-specific neonatal mortality, and in the gestational age limit of viability in South Carolina (SC) from 1975 to 1994. We also investigate whether trends were similar between African-Americans and Whites. We hypothesised that disproportionate reductions in gestational age-specific mortality, rather than any major changes in the gestational age distributions of either race group, underlie any increasing racial disparity in overall mortality rates. During 1975-94, single livebirths, who were born to mothers resident in SC and were either White or African-American based on recorded maternal race, were selected for the investigation. We define the gestational age limit of viability as the gestational age at which > or = 50% of infants in the population died within 28 days of life. Although preterm percentages have not improved, there was a marked decline in neonatal mortality. Gestational age-specific neonatal mortality decreased for both race groups, although there were greater reductions for White preterm infants. By the end of the study period, the African-American neonatal mortality rate was 2.3 times that of Whites and the gestational age at which 50% of newborns died within 28 days of life was 24.5 weeks for Whites and 23.9 weeks for African-Americans. The ongoing decline in neonatal mortality continues to be mainly due to reductions in gestational age-specific neonatal mortality, probably related to high-risk obstetric and neonatal care. Technological developments in these areas may have differentially benefited Whites, resulting in an increasing racial disparity in neonatal mortality rates. Preterm African-American infants no longer have a marked survival advantage over White infants, even at the gestational age limit of viability.

School difficulties at adolescence in a regional cohort of children who were extremely low birth weight

OBJECTIVES

To compare measures of psychometric assessment and school difficulties in a cohort of extremely low birth weight (ELBW) teenagers and term controls, and to determine whether there is stability in psychometric measures between age 8 and the teen years.

STUDY DESIGN

Longitudinal follow-up; geographically defined region.

PARTICIPANTS

150 of 169 (89%) ELBW survivors born between 1977 and 1982 and 124 of 145 (86%) sociodemographically matched term controls between 12 and 16 years of age. Psychometric measures: Wechsler Intelligence Scale for Children-Revised, Wide Range Achievement Test-Revised, and a validated parent questionnaire.

RESULTS

Neurosensory impairments were present in 28% of ELBW and 1% of controls. The mean Wechsler Intelligence Scale for Children-Revised scores were ELBW: 89 +/- 19 and controls: 102 +/- 13. ELBW children did less well on Wide Range Achievement Test-Revised Reading, Spelling, and Arithmetic measures with mean scores in the range from 75 to 85. ELBW children <750 g were more disadvantaged, compared with those >/=750 g. A significantly higher proportion of ELBW children were receiving special educational assistance and/or had repeated a grade (ELBW: 58%; controls: 13%; odds ratio: 9.0). Paired analysis of within-cohort data at age 8 and teen years showed that for both cohorts Arithmetic scores declined, but there were small improvements in other measures, predominantly in the term children.

CONCLUSIONS

Differences of 13 to 18 points in psychometric measures in ELBW teens compared with controls are both statistically significant and clinically relevant. Decreasing birth weight was associated with increased risk on all measures. The high utilization of special educational resources has economic implications, and the incremental cost attributable to being extremely premature needs to be determined.

Anaerobic performance in 5- to 7-yr-old children of low birthweight

PURPOSE

This study was intended to determine whether anaerobic muscle performance is deficient in 5- to 7-yr-old children of extremely low birthweight (ELBW, 500-999 g) and very low birthweight (VLBW, 1000-1499 g).

METHODS

Fourteen ELBW and 20 VLBW children were compared with 24 normal birthweight (NBW, >2500 g) term controls. Peak (PP) and mean (MP) muscle power were determined by the Wingate anaerobic test. Bioimpedance analysis and anthropometry were done to assess fat-free mass (FFM) and lean cross-sectional area of the thigh and calf.

RESULTS

The ELBW group had significantly lower MP and PP, compared with the VLBW and, in particular, with the NBW group. This lower performance was apparent also when values were corrected for total body mass (MP) and FFM (MP and PP), but not when corrected for cross-sectional area of thigh and calf.

CONCLUSION

The lower anaerobic muscle performance in ELBW children may be partly due to their smaller muscle mass, but may also reflect a low percentage of fast-twitch muscle fibers, low muscle phosphagen content, or deficiency in motor control.