Neurodevelopmental outcome in very low birth weight infants at 24 months and 5 to 7 years of age: changing diagnosis

Ultrasound imaging of preterm brain injury: fundamentals and updates

Neurosonography has become an essential tool for diagnosis and serial monitoring of preterm brain injury. Preterm infants are at significantly higher risk of hypoxic-ischemic injury, intraventricular hemorrhage, periventricular leukomalacia and post-hemorrhagic hydrocephalus. Neonatologists have become increasingly dependent on neurosonography to initiate medical and surgical interventions because it can be used at the bedside. While brain MRI is regarded as the gold standard for detecting preterm brain injury, neurosonography offers distinct advantages such as its cost-effectiveness, diagnostic utility and convenience. Neurosonographic signatures associated with poor long-term outcomes shape decisions regarding supportive care, medical or behavioral interventions, and family members' expectations. Within the last decade substantial progress has been made in neurosonography techniques, prompting an updated review of the topic. In addition to the up-to-date summary of neurosonography, this review discusses the potential roles of emerging neurosonography techniques that offer new functional insights into the brain, such as superb microvessel imaging, elastography, three-dimensional ventricular volume assessment, and contrast-enhanced US.

Long-Term Neurodevelopmental and Growth Outcomes of Premature Infants Born at <29 week Gestational Age with Post-Hemorrhagic Hydrocephalus Treated with Ventriculo-Peritoneal Shunt

OBJECTIVE

To compare long-term neurodevelopmental and growth (NDG) outcomes at 3 y corrected gestational age (GA) in premature infants with grade ≥ III intraventricular hemorrhage (IVH) and post-hemorrhagic hydrocephalus who were treated with ventriculo-peritoneal shunt with those who were not treated with shunt.

METHODS

In a retrospective cohort study, NDG outcomes were compared between preterm infants of <29 wk GA with IVH treated with shunt (IVHS) and IVH with no shunt (IVHNS). This was a single centre study. The primary outcome was moderate to severe cerebral palsy (CP).

RESULTS

Of 1762 preterm infants who survived to discharge, 90 had grade ≥ III IVH. Infants in IVHS group had more grade IV IVH than IVHNS (p < 0.05). Seventy percent of the patients in IVHNS groups had no hydrocephalus. IVHS group had increased CP (76% vs. 30%; p 0.003), and higher odds of CP after controlling for GA and IVH grade [odds ratio (OR); 4.23 (1.38 to 13.00)]. Growth delay was not different between groups.

CONCLUSIONS

Infants with IVHS are at increased risk of CP but not growth delay.

Patient-reported outcomes measure for children born preterm: validation of the SOLE VLBWI Questionnaire, a new quality of life self-assessment tool

AIM

This study was conducted to develop and validate a new self-report questionnaire for measuring quality of life (QoL), at school age, in children with a very low birthweight (VLBW).

METHOD

Through a focus group approach, children were involved directly in defining the questionnaire items, which were presented as illustrations rather than written questions. This preliminary validation of the questionnaire was conducted in 152 participants with VLBW (aged 7-11y) randomly selected from the five participating Italian centres. The questionnaire was completed by children and parents separately; data on children's demographic and medical history, and intellectual, adaptive, and behavioural functioning were collected using standardized scales. All the children also completed the Paediatric Quality of Life Inventory (PedsQL), another Italian-language measure of QoL in children.

RESULTS

Our questionnaire was readily accepted and understood, and quick to complete. The Cronbach's alpha value showed it to be a reliable instrument. The child-compiled version correlated well with the PedsQL, whereas no correlations emerged with the other scales used, IQ, or degree of impairment. Conversely, these variables correlated significantly with the parent-compiled version. Children's and parents' answers were divergent on practically all the items.

INTERPRETATION

The results confirm the validity of the new instrument and highlight a poor overlap between parents' and children's perspectives.

Eight-Year Developmental Follow-up in Children with Birthweights 1,251–1,500g in KK Women's and Children's Hospital

Background:

Children of very low birth weight (VLBW, birth weight <1,500g) are at risk of developmental disability and learning difficulties. Regular follow-up to a school-going age allows timely diagnosis and intervention.

Methods:

The duration, developmental assessment and service utilisation of 41 VLBW children with birth weights between 1,251–1,500g born in 2001 were retrospectively analysed.

Results:

The median follow-up duration was 5 years 11 months. 56% were followed-up till preschool entry. Gross motor, fine motor and language domains were assessed in more than 95% of children. Information on behavioural and learning problems was only sought for in approximately 50% of children.

Conclusions:

A significant proportion of these high-risk children were either not followed-up long enough or were not adequately assessed for learning and behavioural problems, thus justifying the development of a new standardised follow-up program for larger VLBW children.

Neurodevelopmental outcome of preterm very low birth weight infants born from 2005 to 2007

OBJECTIVE

To evaluate short-term neurodevelopmental outcome (at 24 months of corrected age) and correlations with obstetric and neonatal factors in a sample of preterm very low birth weight infants born and admitted to an Italian tertiary centre between 2005 and 2007.

METHODS

156 infants with a birth weight ≤ 1500 g (gestational age, range: 27-31 weeks) were followed at regular intervals through neurodevelopmental (neurological and psychomotor) assessment up to 24 months of corrected age. A statistical analysis was conducted in order to look for correlations between pre- and perinatal variables and neuropsychomotor outcome at 24 months.

RESULTS

131 children were classified as normal and the other 25 presented sequelae classified as "minor" in 17 cases and as "major" in eight. The most significant risk factors for a poor outcome were preterm premature rupture of the membranes, bronchodysplasia, late-onset sepsis, postnatal steroid therapy and male gender. The presence of severe abnormalities on brain ultrasound scan and of an abnormal neurological assessment at 40 weeks at term equivalent age were strong predictors of poor outcome.

CONCLUSIONS

Our study is one of the few investigating the short-term outcome of preterm VLBW Italian children born in the second half of the 2000s. Neurodevelopmental assessment at 24 months revealed a marked reduction in major sequelae. Several risk factors for a poor neurodevelopmental outcome identified in children born in earlier periods were confirmed in these children born in recent years.

Outcome of extremely low birth weight infants: what's new in the third millennium? Neuropsychological profiles at four years

BACKGROUND

Extremely low birth weight (ELBW) infants, even those not presenting severe neuromotor sequelae, continue to be at risk of developing multiple, complex disorders involving the cognitive, emotional and behavioural domains. Follow-up protocols are able, in the short term, to identify subjects at risk of developing major sequelae, however they fail to identify all children at risk of developing disorders.

AIMS

To investigate the cognitive, neuropsychological and behavioural outcomes of a sample of ELBW children at the age of four years in order to identify characteristic profiles.

STUDY DESIGN

Longitudinal study.

SUBJECTS

16 healthy ELBW children born in 2005 and followed up until the age of four.

OUTCOME MEASURE

Performances on standardised tests evaluating intelligence, memory, cognitive visual functions, attention, and executive functions.

RESULTS

General intelligence was within normal range. Cognitive profile showed mild or moderate deficits with different levels of involvement in many of the examined functions, in particular executive functions, attention and naming.

CONCLUSION

There emerged a wide-ranging spectrum of weaknesses and deficits involving all the functions examined, which together give rise to a dysexecutive syndrome. Analysis of cognitive profiles showed that the sample could be divided into two subgroups of subjects that differ in the quality of their global cognitive and behavioural functioning. Our results confirm the need to continue follow up of ELBW children until school age, as this will allow early detection of at-risk children and the planning of timely preventive interventions.

Developmental outcome of very low birth weight infants in a developing country

Background

Advances in neonatal care allow survival of extremely premature infants, who are at risk of handicap. Neurodevelopmental follow up of these infants is an essential part of ongoing evaluation of neonatal care. The neonatal care in resource limited developing countries is very different to that in first world settings. Follow up data from developing countries is essential; it is not appropriate to extrapolate data from units in developed countries. This study provides follow up data on a population of very low birth weight (VLBW) infants in Johannesburg, South Africa.

Methods

The study sample included all VLBW infants born between 01/06/2006 and 28/02/2007 and discharged from the neonatal unit at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). Bayley Scales of Infant and Toddler Development Version 111 (BSID) 111 were done to assess development. Regression analysis was done to determine factors associated with poor outcome.

Results

178 infants were discharged, 26 were not available for follow up, 9 of the remaining 152 (5.9%) died before an assessment was done; 106 of the remaining 143 (74.1%) had a BSID 111 assessment. These 106 patients form the study sample; mean birth weight and mean gestational age was 1182 grams (SD: 197.78) and 30.81 weeks (SD: 2.67) respectively. The BSID (111) was done at a median age of 16.48 months. The mean cognitive subscale was 88.6 (95% CI: 85.69 - 91.59), 9 (8.5%) were < 70, mean language subscale was 87.71 (95% CI: 84.85 - 90.56), 10 (9.4%) < 70, and mean motor subscale was 90.05 (95% CI: 87.0 - 93.11), 8 (7.6%) < 70. Approximately one third of infants were identified as being at risk (score between 70 and 85) on each subscale. Cerebral palsy was diagnosed in 4 (3.7%) of babies. Factors associated with poor outcome included cystic periventricular leukomalacia (PVL), resuscitation at birth, maternal parity, prolonged hospitalisation and duration of supplemental oxygen. PVL was associated with poor outcome on all three subscales. Birth weight and gestational age were not predictive of neurodevelopmental outcome.

Conclusion

Although the neurodevelopmental outcome of this group of VLBW infants was within the normal range, with a low incidence of cerebral palsy, these results may reflect the low survival of babies with a birth weight below 900 grams. In addition, mean subscale scores were low and one third of the babies were identified as "at risk", indicating that this group of babies warrants long-term follow up into school going age.

Early delayed language development in very preterm infants: evidence from the MacArthur-Bates CDI

This study examined the effects of being born very preterm on children's early language development using prospective longitudinal data from a representative regional cohort of 90 children born very preterm (gestational age <33 weeks and/or birth weight <1,500 grams) and a comparison sample of 102 children born full term (gestational age 38-41 weeks). The MacArthur-Bates Communicative Development Inventory: Words and Sentences (CDI-WS) was used to assess children's language development at age 2;0 (corrected for gestational age at birth). Clear linear relationships were found between gestational age at birth and later language outcomes, with decreasing gestational age being associated with poorer parent-reported language skills. Specifically, children born extremely preterm (<28 weeks' gestation) tended to perform less well than those born very preterm (28-32 weeks' gestation), who in turn performed worse than children born full term (38-41 weeks' gestation). This pattern of findings was evident across a range of outcomes spanning vocabulary size and quality of word use, as well as morphological and syntactic complexity. Importantly, associations between gestational age at birth and language outcomes persisted after statistical control for child and family factors correlated with both preterm birth and language development. These findings demonstrate the presence of pervasive delays in the early language development of children born very preterm. They also highlight the importance of gestational age in predicting later language risk in this population of infants.

A Long-term, epidemiological survey of outcome and adjustment of children with developmental disabilities

The medical, educational, and psychosocial outcomes of 3224 subjects (age range, 7-33 years; mean age, 20.06 years; SD, 5.74) diagnosed and treated in the Institute for Child Development in Tel Aviv between the years 1975 and 1994 were assessed by a telephone interview. Results indicate that only 9% of the subjects are seriously disabled, and 8% are mentally retarded. Over the years, subjects were referred to the Child Development Center at an increasingly younger age, probably reflecting greater professional and parental awareness of the importance of early intervention. The nature of interventions changed, so that physiotherapy, occupational therapy, and psychological guidance were more often provided. While more children were referred to special education at kindergarten, the percentage of those graduating from regular schools has increased. Most completed 12 years of schooling and successfully acquired full or partial matriculation certificates. As adults, most function independently; fulfill civic obligations, such as their army service; are fully employed; and express satisfaction with their life. These results suggest that children with developmental disabilities who receive early intervention are likely to be functionally independent and to be satisfied with their lives, although they continue to need medical services and require some government support. Further studies are essential to examine the correlation of specific risk factors and early interventions with outcome.

Intervention for infants with brain injury: results of a randomized controlled study

A randomized clinical trail (RCT) employed a 12-month individualized cognitive/sensorimotor stimulation program to look at the efficacy of the intervention on 62 infants with suspected brain injury. The control group infants received the State-funded follow-up program provided by the Los Angeles (LA) Regional Centers while the intervention group received intensive stimulation using the Curriculum and Monitoring System (CAMS) taught by public health nurses (PHNs). The developmental assessments and outcome measures were performed at 6, 12 and 18 months corrected age and included the Bayley motor and mental development, the Home, mother-infant interaction (Nursing Child Assessment Feeding Scale (NCAFS) and Nursing Child Assessment Teaching Scale (NCATS)), parental stress and social support. At 18 months, 43 infants remained in the study. The results indicate that the intervention had minimal positive effects on the Bayley mental and motor development scores of infants in the intervention group. Likewise, the intervention did not contribute to less stress or better mother-infant interaction at 12 or 18 months although there were significant differences in the NCAFS scores favoring the intervention group at 6 months. There was a significant trend, however, for the control group to have a significant decrease over time on the Bayley mental scores. Although the sample was not large and attrition was at 31%, this study provides further support to the minimal effects of stimulation and home intervention for infants with brain injury and who may have more significant factors contributing to their developmental outcome.

Absent or reverse end-diastolic flow in the umbilical artery: intellectual development at school age

OBJECTIVE

This study was designed to establish whether, in growth-retarded fetuses, absent or reverse end-diastolic (ARED) flow velocity in the umbilical artery can be predictive of an increased incidence of long-term neurological and intellectual impairment.

STUDY DESIGN

A total of 14 children with intra-uterine growth retardation (IUGR) and ARED flow in the umbilical artery and 11 children without this velocimetric pattern were examined by pediatric neuropsychiatrists at a median age of 8.7 years to evaluate and compare their neurological and intellectual development.

RESULTS

The incidence of major neurological sequelae was higher in the children with ARED velocity in the umbilical artery (21%) than in those without this velocimetric pattern (9%), as was the incidence of mild neurological sequelae (35% versus 27%). No differences in mean intelligence quotient (IQ) as evaluated by mean of Intelligence Scale for Children-Revised (WISC-R) scale were found between the two groups of children at school age.

CONCLUSIONS

Our data demonstrate that Doppler velocimetry in the umbilical artery is a reliable predictor for neurological sequelae when ARED flow is present but cannot be considered a good predictor of intellectual performance at school.

Germinal matrix-intraventricular hemorrhage in the premature newborn: management and outcome

Germinal matrix-intraventricular hemorrhage (GMH-IVH) in the premature newborn results from rupture of fragile capillaries in the germinal matrix. Its pathogenesis is multifactorial and relates principally to a pressure-passive cerebral circulation, fluctuations in cerebral blood flow, and derangements of coagulation and fragility of the germinal matrix microvasculature. Several interventions have beneficial effects for prevention of GMH-IVH. Outcome after GMH-IVH relates largely to the severity of hemorrhage, the extent of hemorrhagic and ischemic parenchymal involvement, and complications (e.g., posthemorrhagic hydrocephalus). Even in the absence of neuroimaging abnormalities, VLBW infants have a high incidence of academic and behavioral problems which persist into adolescence and early adulthood.

[Medical, cognitive and affective status of four-year-old very premature babies without severe disability. A case-control study]

AIM

To determine cognitive performances and affective development of a cohort of very premature babies at the age of 4 years.

POPULATION AND METHODS

Longitudinal case-control study. Newborns less than 33 weeks gestation were included from 1992 to 1994 and were matched with two full-term newborns. At 4 years of age, they have been evaluated for medical status, cognitive functions with the K-ABC test and affective condition with the PSA and Conners' tests.

RESULTS

The preterm group was significantly different from the controls for: a smaller height, (P < 0.01), a lower socioeconomic level (P = 0.027), a lower nursery school level (44% versus 27,6%, P = 0.05), the incapacity to draw "a bonhomme" (55,3% versus 93%, P < 0.001), lower performances for the K-ABC and PSA tests, a pathologic Conners score (20.4% versus 2.4%, P < 0.001). Multivariate analysis by logistic regression showed a similar neuropsychological results: a lower score of K-ABC (< 80, P = 0.0006, odds-ratio = 33.2), and a lower social competence score of PSA (< 45, P = 0.004, odds-ratio = 35.9).

CONCLUSION

Follow-up of premature babies is required, and measures to prevent or minimize cognitive and social disabilities are mandatory.

Perinatal factors affecting survival and survival without disability of extreme premature infants at two years of age

OBJECTIVE

To study obstetrical factors leading to very preterm delivery (between 24 and 28 weeks) and to relate these factors to neonatal outcome and psychomotor development at two years.

STUDY DESIGN

Among 144 infants born alive before 28 weeks of gestation at a single perinatal center between January 1993 and December 1996, we analyzed the influence on neonatal outcome and on psychomotor development at 24 months of a variety of perinatal and neonatal factors. Psychomotor development at two years was classified as: normal, borderline, or moderately or severely handicapped.

RESULTS

During the study period, 114 women delivered live infants before 28 weeks' gestation: 87 singletons, 25 sets of twins, 1 set of triplets and 1 set of quadruplets. All 144 live-born infants received neonatal resuscitation: 50 died before discharge. At two years of age, 6 of the 94 survivors were lost to follow-up. Assessments of the psychomotor development of the other 88 was normal for 52%; borderline for 20%, moderately handicapped for 20%, and severely handicapped for 8%. Multivariate analysis found that two factors affected survival: birthweight and fetal heart rate. (The 42% of infants with a birthweight below 700 g survived versus 83% above 900 g, P<0.001, OR=5.2, 95% CI (confidence interval) [2.4-11.2].)

CONCLUSION

These data show the influence of perinatal factors on the outcome of very preterm infants; birthweight and fetal heart rate are strongly correlated with survival. Gestational age is a good predictor of psychomotor development at two years.

Infant cerebral ventricle volume: a comparison of 3-D ultrasound and magnetic resonance imaging

Enlargement of the cerebral lateral ventricles is observed in several neuropsychiatric disorders with origins in early brain development. Lateral ventricle size is also predictive of poor neurodevelopmental outcome in premature infants. Three-dimensional (3-D) ultrasound (US) offers an improved methodology for the study of lateral ventricle volume in neonates and infants. To assess the validity of ventricle volume measures obtained with 3-D US, we compared the volumes obtained by 3-D US with magnetic resonance imaging (MRI) in seven infants. Ventricle volumes were determined using a computer-assisted image analysis program, IRIS. There was excellent correlation between ventricle volumes obtained with 3-D US and those obtained with MRI (intraclass correlation coefficient 0.92, F = 23.28, p = 0.00027), indicating that 3-D US provides valid measures of overall lateral ventricle volume compared to the "gold standard" of MRI. 3-D US can provide an economical and practical means of studying lateral ventricle volume in neonates, a neurostructural marker of abnormal brain development.

Cognitive development, temperament and behavior at 2 years as indicative of language development at 4 years in pre-term infants

This study focuses on the early temperamental (TTQ = toddler temperament questionnaire), behavioral (IBR = infant behavior record), and cognitive precursors of impaired language functioning in preschool-age pre-terms infants. The study group consisted of 63 pre-term infants with a mean birth weight of 1246 +/- 437 g born in 1989-1991 in the University Central Hospital of Helsinki. Children with major disabilities (CP or mental retardation) were excluded. At the age of 4 years, 22% showed impaired language function. Logistic regression analysis showed that the Bayley MDI score was the best predictor in identifying an increased risk for language impairment. Behavioral characteristics were more strongly associated with subsequent language impairment than temperament.

Maternal age, social changes, and pregnancy outcome in Ribeirão Preto, southeast Brazil, in 1978-79 and 1994

This study focused on changes in demographic, social, and health-care patterns and pregnancy outcome related to maternal age from 1978-79 to 1994 in Ribeirão Preto, São Paulo State, Brazil. Information on pregnancy outcome was obtained from two cohorts of singleton live births, 6,681 births in 1978/79 and 2,839 births in 1994. A standardized questionnaire was submitted to mothers after delivery, and demographic information was collected from official records. There was a significant increase in teenage pregnancies (from 5.1% to 7.4%) and a decrease in infant mortality (36/1,000 to 17/1,000). There were significant decreases in the proportion of mothers with low schooling (24.5% to 14.4%), smoking (28.9% to 21.%), and multiparity (14.7% to 9.0%). Prenatal coverage improved (from 23.4% to 9.0% of patients with fewer than 4 prenatal visits), while cesareans increased (from 30.6% to 50.8%), as did preterm delivery (7.2% to 13.6%) and low birthweight (7.2% to 10.6%). Despite significant improvements in some maternal characteristics, the proportion of teenage pregnancies, preterm deliveries, low birthweight, and cesareans increased, raising concerns about the health costs and consequences for mothers and infants.