Validation of a parent report measure of cognitive development in very preterm infants

Comparison of parent or caregiver-completed development screening tools with Bayley Scales of Infant Development: a systematic review and meta-analysis

BACKGROUND

Parent/caregiver-completed developmental testing (PCDT) is integral to developmental care in children; however, there is limited information on its accuracy. In this systematic review, we compared the diagnostic accuracy of PCDT with concurrently administered Bayley Scales of Infant Development for detection of developmental delay (DD) in children below 4 years of age.

METHODS

We searched databases PubMed, Embase, CINAHL, PsycINFO and Google Scholar until November 2023. Bivariate and multiple thresholds summary receiver operating characteristics were used to obtain the summary sensitivity and specificity with 95% CIs. The Quality Assessment of Diagnostic Accuracy Studies-2 tool was used for risk of bias assessment.

RESULTS

A total of 38 studies (31 in the meta-analysis) were included. Ages and Stages Questionnaire (ASQ) and Parent Report of Children's Abilities-Revised (PARCA-R) were the most commonly evaluated PCDTs. ASQ score >2 SD below the mean had an overall sensitivity of 0.72 (0.6, 0.82) and 0.63 (0.50, 0.75) at a median specificity of 0.89 (0.82, 0.94) and 0.81 (0.76, 0.86) for diagnosing moderate to severe DD and severe DD, respectively. PARCA- R had an overall sensitivity of 0.69 (0.51, 0.83) at median specificity of 0.75 (0.64, 0.83) for predicting severe DD. Participant selection bias and partial verification bias were found in over 50% of the studies. The certainty of evidence was low for the studied outcomes.

CONCLUSIONS

The most commonly studied parental tools, ASQ and PARCA-R, have moderate to low sensitivity and moderate specificity for detecting DD in young children. High risk of bias and heterogeneity in the available data can potentially impact the interpretation of our results.

PROSPERO REGISTRATION NUMBER

CRD42021268629.

Distinct Neurodevelopmental Trajectories in Groups of Very Preterm Children Screening Positively for Autism Spectrum Conditions

Very preterm (VPT; < 33 weeks' gestation) toddlers screening positively for autism spectrum conditions (ASC) may display heterogenous neurodevelopmental trajectories. Here we studied neonatal brain volumes and childhood ASC traits evaluated with the Social Responsiveness Scale (SRS-2) in VPT-born toddlers (N = 371; median age 20.17 months) sub-divided into three groups based on their Modified-Checklist for Autism in Toddlers scores. These were: those screening positively failing at least 2 critical items (critical-positive); failing any 3 items, but less than 2 critical items (non-critical-positive); and screening negatively. Critical-positive scorers had smaller neonatal cerebellar volumes compared to non-critical-positive and negative scorers. However, both positive screening groups exhibited higher childhood ASC traits compared to the negative screening group, suggesting distinct aetiological trajectories associated with ASC outcomes.

Cerebral oximetry monitoring versus usual care for extremely preterm infants: a study protocol for the 2-year follow-up of the SafeBoosC-III randomised clinical trial

BACKGROUND

In the SafeBoosC-III trial, treatment guided by cerebral oximetry monitoring for the first 72 hours after birth did not reduce the incidence of death or severe brain injury in extremely preterm infants at 36 weeks' postmenstrual age, as compared with usual care. Despite an association between severe brain injury diagnosed in the neonatal period and later neurodevelopmental disability, this relationship is not always strong. The objective of the SafeBoosC-III follow-up study is to assess mortality, neurodevelopmental disability, or any harm in trial participants at 2 years of corrected age. One important challenge is the lack of funding for local costs for a trial-specific assessment.

METHODS

Of the 1601 infants randomised in the SafeBoosC-III trial, 1276 infants were alive at 36 weeks' postmenstrual age and will potentially be available for the 2-year follow-up. Inclusion criteria will be enrollment in a neonatal intensive care unit taking part in the follow-up study and parental consent if required by local regulations. We aim to collect data from routine follow-up programmes between the ages of 18 and 30 months of corrected age. If no routine follow-up has been conducted, we will collect informal assessments from other health care records from the age of at least 12 months. A local co-investigator blinded to group allocation will classify outcomes based on these records. We will supplement this with parental questionnaires including the Parent Report of Children's Abilities-Revised. There will be two co-primary outcomes: the composite of death or moderate or severe neurodevelopmental disability and mean Bayley-III/IV cognitive score. We will use a 3-tier model for prioritisation, based on the quality of data. This approach has been chosen to minimise loss to follow-up assuming that little data is better than no data at all.

DISCUSSION

Follow-up at the age of 2 years is important for intervention trials in the newborn period as only time can show real benefits and harms later in childhood. To decrease the risk of generalisation and data-driven biased conclusions, we present a detailed description of the methodology for the SafeBoosC-III follow-up study. As funding is limited, a pragmatic approach is necessary.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05134116 . Registered on 24 November 2021.

Methods for Constructing Normalised Reference Scores: An Application for Assessing Child Development at 24 Months of Age

The use of the lambda-mu-sigma (LMS) method for estimating centiles and producing reference ranges has received much interest in clinical practice, especially for assessing growth in childhood. However, this method may not be directly applicable where measures are based on a score calculated from question response categories that is bounded within finite intervals, for example, in psychometrics. In such cases, the main assumption of normality of the conditional distribution of the transformed response measurement is violated due to the presence of ceiling (and floor) effects, leading to biased fitted centiles when derived using the common LMS method. This paper describes the methodology for constructing reference intervals when the response variable is bounded and explores different distribution families for the centile estimation, using a score derived from a parent-completed assessment of cognitive and language development in 24 month-old children. Results indicated that the z-scores, and thus the extracted centiles, improved when kurtosis was also modeled and that the ceiling effect was addressed with the use of the inflated binomial distribution. Therefore, the selection of the appropriate distribution when constructing centile curves is crucial.

Web-based follow-up tool (ePIPARI) of preterm infants-study protocol for feasibility and performance

BACKGROUND

Preterm infants have a risk of health and developmental problems emerging after discharge. This indicates the need for a comprehensive follow-up to enable early identification of these problems. In this paper, we introduce a follow-up tool "ePIPARI - web-based follow-up for preterm infants". Our future aim is to investigate whether ePIPARI is a feasible tool in the follow-up of preterm infants and whether it can identify children and parents in need of clinical interventions.

METHODS

ePIPARI includes eight assessment points (at term age and at 1, 2, 4, 8, 12, 18, and 24 months of corrected age) when the child´s health and growth, eating and feeding, neurodevelopment, and parental well-being are evaluated. ePIPARI consists of several widely used, standardized questionnaires, in addition to questions typically presented to parents in clinical follow-up visits. It also provides video guidance and written information about age-appropriate neurodevelopment for the parents. Parents of children born before 34 weeks of gestation during years 2019-2022 are being invited to participate in the ePIPARI study, in which web-based follow-up with ePIPARI is compared to clinical follow-up. In addition, the parents of children born before 32 weeks of gestation, who reached the corrected age of two years during 2019-2021 were invited to participate for the assessment point of 24 months of ePIPARI. The parents are asked to fill in the online questionnaires two weeks prior to each clinical follow-up visit.

DISCUSSION

The web-based tool, ePIPARI, was developed to acquire a sensitive and specific tool to detect infants and parents in need of further support and clinical interventions. This tool could allow individualized adjustments of the frequency and content of the clinical visits.

TRIAL REGISTRATION

ClinicalTrials.cov, NCT05238168 . Registered 11 April 2022 - Retrospectively registered.

Pilot feasibility study of a digital technology approach to the systematic electronic capture of parent-reported data on cognitive and language development in children aged 2 years

BACKGROUND

The assessment of language and cognition in children at risk of impaired neurodevelopment following neonatal care is a UK standard of care but there is no national, systematic approach for obtaining these data. To overcome these challenges, we developed and evaluated a digital version of a validated parent questionnaire to assess cognitive and language development at age 2 years, the Parent Report of Children's Abilities-Revised (PARCA-R).

METHODS

We involved clinicians and parents of babies born very preterm who received care in north-west London neonatal units. We developed a digital version of the PARCA-R questionnaire using standard software. Following informed consent, parents received automated notifications and an invitation to complete the questionnaire on a mobile phone, tablet or computer when their child approached the appropriate age window. Parents could save and print a copy of the results. We evaluated ease of use, parent acceptability, consent for data sharing through integration into a research database and making results available to the clinical team.

RESULTS

Clinical staff approached the parents of 41 infants; 38 completed the e-registration form and 30 signed the e-consent. The digital version of the PARCA-R was completed by the parents of 21 of 23 children who reached the appropriate age window. Clinicians and parents found the system easy to use. Only one parent declined permission to integrate data into the National Neonatal Research Database for approved secondary purposes.

DISCUSSION

This electronic data collection system and associated automated processes enabled efficient systematic capture of data on language and cognitive development in high-risk children, suitable for national delivery at scale.

Cost-Utility Analysis of Planned Early Delivery or Expectant Management for Late Preterm Pre-eclampsia (PHOENIX)

AIM

There is currently limited evidence on the costs associated with late preterm pre-eclampsia beyond antenatal care and post-natal discharge from hospital. The aim of this analysis is to evaluate the 24-month cost-utility of planned delivery for women with late preterm pre-eclampsia at 34⁺⁰-36⁺⁶ weeks' gestation compared to expectant management from an English National Health Service perspective using participant-level data from the PHOENIX trial.

METHODS

Women between 34⁺⁰ and 36⁺⁶ weeks' gestation in 46 maternity units in England and Wales were individually randomised to planned delivery or expectant management. Resource use was collected from hospital records between randomisation and primary hospital discharge following birth. Women were followed up at 6 months and 24 months following birth and self-reported resource use for themselves and their infant(s) covering the previous 6 months. Women completed the EQ-5D 5L at randomisation and follow-up.

RESULTS

A total of 450 women were randomised to planned delivery, 451 to expectant management: 187 and 170 women, respectively, had complete data at 24 months. Planned delivery resulted in a significantly lower mean cost per woman and infant(s) over 24 months (- £2711, 95% confidence interval (CI) - 4840 to - 637), with a mean incremental difference in QALYs of 0.019 (95% CI - 0.039 to 0.063). Short-term and 24-month infant costs were not significantly different between the intervention arms. There is a 99% probability that planned delivery is cost-effective at all thresholds below £37,000 per QALY gained.

CONCLUSION

There is a high probability that planned delivery is cost-effective compared to expectant management. These results need to be considered alongside clinical outcomes and in the wider context of maternity care.

TRIAL REGISTRATION

ISRCTN registry ISRCTN01879376. Registered 25 November 2013.

Never‐breastfed children face a higher risk of suboptimal cognition at 2 years of corrected age: A multinational cohort of very preterm children

In a cohort of children born very preterm (VPT), we investigated the association between breast milk feeding (BMF) initiation and its duration on cognitive development at 2 years of corrected age. Data were obtained from the Effective Perinatal Intensive Care in Europe population‐based prospective cohort of children born <32 weeks of gestation, in 11 European countries, in 2011–2012. The study sample included 4323 children. Nonverbal cognitive ability was measured applying the Parental Report of Children's Abilities, except for France where the problem‐solving domain of the Ages & Stages Questionnaire was used. Verbal cognition was based on the number of words the child could say. To determine the association between BMF (mother's own milk) and nonverbal and verbal cognition (outcome categorized as optimal and suboptimal), adjusted risk ratios (aRRs) were estimated fitting Poisson regression models, with inverse probability weights to account for nonresponse bias. Overall, 16% and 11% of the children presented suboptimal nonverbal and verbal cognition, respectively. Never BMF was associated with a significantly increased risk for suboptimal nonverbal (aRR = 1.29, 95% confidence interval [CI] = 1.09–1.53) and verbal (aRR = 1.45, 95% CI = 1.09–1.92) cognitive development compared with those ever breastfed, after adjustment for perinatal and sociodemographic characteristics. Compared with children breastfed 6 months or more, children with shorter BMF duration exhibited a statistically nonsignificant elevated aRR. VPT children fed with breast milk had both improved nonverbal and verbal cognitive development at 2 years in comparison with never breastfed, independently of perinatal and sociodemographic characteristics. This study encourages targeted interventions to promote BMF among these vulnerable children.

In a European cohort of children born very preterm, 16% and 11% presented suboptimal nonverbal and verbal cognitive development, respectively.

Never‐breastfed children faced a higher risk of having suboptimal nonverbal and verbal cognition at 2 years of corrected age when compared with those who were breastfed, independently of perinatal and sociodemographic characteristics.

Breastfeeding support is a modifiable factor regardless of perinatal and sociodemographic characteristics, which reinforces the importance of specifically targeted interventions to protect, promote and support breast milk feeding in neonatal intensive care units and after discharge.

Systemic Steroids in Preventing Bronchopulmonary Dysplasia (BPD): Neurodevelopmental Outcome According to the Risk of BPD in the EPICE Cohort

BACKGROUND

Postnatal steroids (PNS) have been used to prevent bronchopulmonary dysplasia (BPD) in preterm infants but have potential adverse effects on neurodevelopment. These effects might be modulated by their risk of BPD. We aimed to compare patients' neurodevelopment with PNS treatment according to their risk of BPD in a European cohort.

METHODS

We developed a prediction model for BPD to classify infants born between 24 + 0 and 29 + 6 weeks of gestation in three groups and compared patients' neurological outcome at two years of corrected age using the propensity score (PS) method.

RESULTS

Of 3662 neonates included in the analysis, 901 (24.6%) were diagnosed with BPD. Our prediction model for BPD had an area under the ROC curve of 0.82. In the group with the highest risk of developing BPD, PNS were associated with an increased risk of gross motor impairment: OR of 1.95 after IPTW adjustment (95% CI 1.18 to 3.24, p = 0.010). This difference existed regardless of the type of steroid used. However, there was an increased risk of cognitive anomalies for patients treated with dexa/betamethasone that was no longer observed with hydrocortisone.

CONCLUSIONS

This study suggests that PNS might be associated with an increased risk of gross motor impairment regardless of the group risk for BPD. Further randomised controlled trials exploring the use of PNS to prevent BPD should include a risk-based evaluation of neurodevelopmental outcomes. This observation still needs to be confirmed in a randomised controlled trial.

Hammersmith Infant Neurological Examination and long-term cognitive outcome in children born very preterm

AIM

To study the association between the Hammersmith Infant Neurological Examination (HINE) at age 2 years and neurocognition at age 11 years in children born very preterm. We hypothesized that the HINE at 2 years would be associated with neurocognition, that is, neurological, motor, and cognitive outcomes at 11 years.

METHOD

A total of 174 children (mean gestational age 29.0wks, SD 2.7; minimum 23.0, maximum 35.9; 95 [55%] males, 79 [45%] females) born very preterm (birthweight ≤1500g/gestational age <32wks), were included in a prospective cohort recruited from 2001 to 2006 in Turku, Finland. The HINE was performed at 2 years' corrected age. Neurocognition at 11 years was assessed with the Touwen neurological examination, Movement Assessment Battery for Children, Second Edition (MABC-2), and full-scale IQ (Wechsler Intelligence Scale for Children, Fourth Edition).

RESULTS

The HINE global score was associated with the results of the Touwen neurological examination (odds ratio [OR]=0.9, 95% confidence interval [CI] 0.8-0.9, p=0.001), MABC-2 (β=1.4, 95% CI 0.7-2.2, p<0.001), and full-scale IQ (β=1.2, 95% CI 0.8-1.7, p<0.001), even when adjusted. When children with cerebral palsy (CP) were excluded, the HINE was still associated with full-scale IQ (unadjusted β=1.2, 95% CI 0.3-2.1, p=0.01).

INTERPRETATION

A higher HINE global score at 2 years was associated with better general intelligence at 11 years even in children without CP. The HINE may be a useful tool to detect children at risk for later cognitive impairment. What this paper adds A Hammersmith Infant Neurological Examination (HINE) global score at 2 years was associated with long-term neurocognitive function. Severe cognitive impairment was significantly more common in 11-year-old children with complex minor neurological dysfunction compared to typically developing children. The HINE performed at 2 years detects risks of cognitive impairment at 11 years in children born very preterm. A higher HINE score at 2 years was associated with better general intelligence at 11 years.

Performance of the German version of the PARCA-R questionnaire as a developmental screening tool in two-year-old very preterm infants

Objective

To validate and test a German version of the revised Parent Report of Children's Abilities questionnaire (PARCA-R).

Methods

Multicentre cross-sectional study. Parents of infants born <32 gestational weeks, completed the PARCA-R within three weeks before the follow-up assessment of their child at age two years. Infants were assessed using the Mental Development Index (MDI) of the Bayley Scales of Infant Development 2nd edition (BSID-II). Pearson correlation between the Parent Report Composite (PRC) of the PARCA-R and MDI was tested. The optimal PRC cut-off for predicting moderate-to-severe mental delay, defined as MDI<70, was identified through the receiver operating characteristic (ROC) curve.

Results

PARCA-R and BSID-II data were collected from 154 consecutive infants [51% girls, mean (SD) gestational age 29.0 (2.0) weeks, birth weight 1174 (345) grams] at 23.2 (1.6) months of corrected age. The PRC score [70.5 (31.1)] correlated with the MDI [92.2 (17.3); R = 0.54; p < 0.0001]. The optimal PRC cut-off for identifying mental delay was 44 with 0.81 (0.54–0.96) sensitivity (95%-CI), 0.81 (0.74–0.87) specificity, area under the ROC curve of 0.840 (0.729–0.952).

Conclusion

The German version of the PARCA-R had good validity with the BSID-II and PCR scores < 44 proved optimal discriminatory power for the identification of mental delay at two years of corrected age.

EPICE cohort: two-year neurodevelopmental outcomes after very preterm birth

OBJECTIVE

To determine whether the variation in neurodevelopmental disability rates between populations persists after adjustment for demographic, maternal and infant characteristics for an international very preterm (VPT) birth cohort using a standardised approach to neurodevelopmental assessment at 2 years of age.

DESIGN

Prospective standardised cohort study.

SETTING

15 regions in 10 European countries.

PATIENTS

VPT births: 22⁺⁰-31⁺⁶ weeks of gestation.

DATA COLLECTION

Standardised data collection tools relating to pregnancy, birth and neonatal care and developmental outcomes at 2 years corrected age using a validated parent completed questionnaire.

MAIN OUTCOME MEASURES

Crude and standardised prevalence ratios calculated to compare rates of moderate to severe neurodevelopmental impairment between regions grouped by country using fixed effects models.

RESULTS

Parent reported rates of moderate or severe neurodevelopmental impairment for the cohort were: 17.3% (ranging 10.2%-26.1% between regions grouped by country) with crude standardised prevalence ratios ranging from 0.60 to 1.53. Adjustment for population, maternal and infant factors resulted in a small reduction in the overall variation (ranging from 0.65 to 1.30).

CONCLUSION

There is wide variation in the rates of moderate to severe neurodevelopmental impairment for VPT cohorts across Europe, much of which persists following adjustment for known population, maternal and infant factors. Further work is needed to investigate whether other factors including quality of care and evidence-based practice have an effect on neurodevelopmental outcomes for these children.

Two speeds of increasing milk feeds for very preterm or very low-birthweight infants: the SIFT RCT

BACKGROUND

Observational data suggest that slowly advancing enteral feeds in preterm infants may reduce necrotising enterocolitis but increase late-onset sepsis. The Speed of Increasing milk Feeds Trial (SIFT) compared two rates of feed advancement.

OBJECTIVE

To determine if faster (30 ml/kg/day) or slower (18 ml/kg/day) daily feed increments improve survival without moderate or severe disability and other morbidities in very preterm or very low-birthweight infants.

DESIGN

This was a multicentre, two-arm, parallel-group, randomised controlled trial. Randomisation was via a web-hosted minimisation algorithm. It was not possible to safely and completely blind caregivers and parents.

SETTING

The setting was 55 UK neonatal units, from May 2013 to June 2015.

PARTICIPANTS

The participants were infants born at < 32 weeks' gestation or a weight of < 1500 g, who were receiving < 30 ml/kg/day of milk at trial enrolment.

INTERVENTIONS

When clinicians were ready to start advancing feed volumes, the infant was randomised to receive daily feed increments of either 30 ml/kg/day or 18 ml/kg/day. In total, 1400 infants were allocated to fast feeds and 1404 infants were allocated to slow feeds.

MAIN OUTCOME MEASURES

The primary outcome was survival without moderate or severe neurodevelopmental disability at 24 months of age, corrected for gestational age. The secondary outcomes were mortality; moderate or severe neurodevelopmental disability at 24 months corrected for gestational age; death before discharge home; microbiologically confirmed or clinically suspected late-onset sepsis; necrotising enterocolitis (Bell's stage 2 or 3); time taken to reach full milk feeds (tolerating 150 ml/kg/day for 3 consecutive days); growth from birth to discharge; duration of parenteral feeding; time in intensive care; duration of hospital stay; diagnosis of cerebral palsy by a doctor or other health professional; and individual components of the definition of moderate or severe neurodevelopmental disability.

RESULTS

The results showed that survival without moderate or severe neurodevelopmental disability at 24 months occurred in 802 out of 1224 (65.5%) infants allocated to faster increments and 848 out of 1246 (68.1%) infants allocated to slower increments (adjusted risk ratio 0.96, 95% confidence interval 0.92 to 1.01). There was no significant difference between groups in the risk of the individual components of the primary outcome or in the important hospital outcomes: late-onset sepsis (adjusted risk ratio 0.96, 95% confidence interval 0.86 to 1.07) or necrotising enterocolitis (adjusted risk ratio 0.88, 95% confidence interval 0.68 to 1.16). Cost-consequence analysis showed that the faster feed increment rate was less costly but also less effective than the slower rate in terms of achieving the primary outcome, so was therefore found to not be cost-effective. Four unexpected serious adverse events were reported, two in each group. None was assessed as being causally related to the intervention.

LIMITATIONS

The study could not be blinded, so care may have been affected by knowledge of allocation. Although well powered for comparisons of all infants, subgroup comparisons were underpowered.

CONCLUSIONS

No clear advantage was identified for the important outcomes in very preterm or very low-birthweight infants when milk feeds were advanced in daily volume increments of 30 ml/kg/day or 18 ml/kg/day. In terms of future work, the interaction of different milk types with increments merits further examination, as may different increments in infants at the extremes of gestation or birthweight.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN76463425.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 18. See the NIHR Journals Library website for further project information.

Standardisation of the Parent Report of Children's Abilities-Revised (PARCA-R): a norm-referenced assessment of cognitive and language development at age 2 years

BACKGROUND

The Parent Report of Children's Abilities-Revised (PARCA-R) can be used to identify preterm born children at risk for developmental delay at age 24 months. However, standardised scores for assessing all children in the general population and quantifying development relative to the norm are unavailable, thus limiting the use of the questionnaire. We aimed to develop scores that are standardised by age and sex for the PARCA-R to assess children's cognitive and language development at age 24-27 months.

METHODS

Anonymised data from PARCA-R questionnaires that were completed by parents of 2-year-old children in three previous studies were obtained to form a standardisation sample that was representative of the UK general population. Anonymised data were obtained from three further studies to assess the external validity and clinical validity of the standardised scores. We used the lambda-mu-sigma (lambda for skewness, mu for median, sigma for the coefficient of variation) method to develop scores that are standardised by age and sex for three scales (non-verbal cognitive development, language development, and total parent report composite [PRC]) for children in four 1-month age bands, spanning age 23·5-27·5 months.

FINDINGS

We included 6402 children (mean age 25 months and 1 day [range 23 months and 16 days to 27 months and 15 days]) in the standardisation sample and 709 (mean age 24 months and 19 days [23 months and 16 days to 27 months and 15 days]) to test the external validity and 1456 (mean age 24 months and 8·5 days [23 months and 16 days to 27 months and 15 days]) to test the clinical validity of the standardised scores. For all PARCA-R scales, mean standardised scores approximated 100 (SD 15) in both sexes and all age groups. These scores were independent of socioeconomic status. Standardised scores were close to 100 (15) in the external validation sample, showing the validity of the scores. Standardised scores for the total PRC scale for children born very preterm (<32 weeks' gestation) were 0·47 SD lower on average than the normative mean, and for children with neonatal sepsis were 0·73 SD lower on average than the normative mean. These scores were equivalent to a standardised score of 93 (95% CI 91-94) for children born very preterm and 89 (88-91) for children with neonatal sepsis, thus showing clinical validity.

INTERPRETATION

The PARCA-R provides a norm-referenced, standardised assessment of cognitive and language development at 24-27 months of age. The questionnaire is available non-commercially in English with translations available in 14 other languages, thus providing clinicians and researchers with a cost-effective tool for assessing development and identifying children with delay.

FUNDING

Action Medical Research (Ref: GN2580).

Developing routinely recorded clinical data from electronic patient records as a national resource to improve neonatal health care: the Medicines for Neonates research programme

Background

Clinical data offer the potential to advance patient care. Neonatal specialised care is a high-cost NHS service received by approximately 80,000 newborn infants each year.

Objectives

(1) To develop the use of routinely recorded operational clinical data from electronic patient records (EPRs), secure national coverage, evaluate and improve the quality of clinical data, and develop their use as a national resource to improve neonatal health care and outcomes. To test the hypotheses that (2) clinical and research data are of comparable quality, (3) routine NHS clinical assessment at the age of 2 years reliably identifies children with neurodevelopmental impairment and (4) trial-based economic evaluations of neonatal interventions can be reliably conducted using clinical data. (5) To test methods to link NHS data sets and (6) to evaluate parent views of personal data in research.

Design

Six inter-related workstreams; quarterly extractions of predefined data from neonatal EPRs; and approvals from the National Research Ethics Service, Health Research Authority Confidentiality Advisory Group, Caldicott Guardians and lead neonatal clinicians of participating NHS trusts.

Setting

NHS neonatal units.

Participants

Neonatal clinical teams; parents of babies admitted to NHS neonatal units.

Interventions

In workstream 3, we employed the Bayley-III scales to evaluate neurodevelopmental status and the Quantitative Checklist of Autism in Toddlers (Q-CHAT) to evaluate social communication skills. In workstream 6, we recruited parents with previous experience of a child in neonatal care to assist in the design of a questionnaire directed at the parents of infants admitted to neonatal units.

Data sources

Data were extracted from the EPR of admissions to NHS neonatal units.

Main outcome measures

We created a National Neonatal Research Database (NNRD) containing a defined extract from real-time, point-of-care, clinician-entered EPRs from all NHS neonatal units in England, Wales and Scotland (n = 200), established a UK Neonatal Collaborative of all NHS trusts providing neonatal specialised care, and created a new NHS information standard: the Neonatal Data Set (ISB 1595) (see http://webarchive.nationalarchives.gov.uk/±/http://www.isb.nhs.uk/documents/isb-1595/amd-32–2012/index_html; accessed 25 June 2018).

Results

We found low discordance between clinical (NNRD) and research data for most important infant and maternal characteristics, and higher prevalence of clinical outcomes. Compared with research assessments, NHS clinical assessment at the age of 2 years has lower sensitivity but higher specificity for identifying children with neurodevelopmental impairment. Completeness and quality are higher for clinical than for administrative NHS data; linkage is feasible and substantially enhances data quality and scope. The majority of hospital resource inputs for economic evaluations of neonatal interventions can be extracted reliably from the NNRD. In general, there is strong parent support for sharing routine clinical data for research purposes.

Limitations

We were only able to include data from all English neonatal units from 2012 onwards and conduct only limited cross validation of NNRD data directly against data in paper case notes. We were unable to conduct qualitative analyses of parent perspectives. We were also only able to assess the utility of trial-based economic evaluations of neonatal interventions using a single trial. We suggest that results should be validated against other trials.

Conclusions

We show that it is possible to obtain research-standard data from neonatal EPRs, and achieve complete population coverage, but we highlight the importance of implementing systematic examination of NHS data quality and completeness and testing methods to improve these measures. Currently available EPR data do not enable ascertainment of neurodevelopmental outcomes reliably in very preterm infants. Measures to maintain high quality and completeness of clinical and administrative data are important health service goals. As parent support for sharing clinical data for research is underpinned by strong altruistic motivation, improving wider public understanding of benefits may enhance informed decision-making.

Future work

We aim to implement a new paradigm for newborn health care in which continuous incremental improvement is achieved efficiently and cost-effectively by close integration of evidence generation with clinical care through the use of high-quality EPR data. In future work, we aim to automate completeness and quality checks and make recording processes more ‘user friendly’ and constructed in ways that minimise the likelihood of missing or erroneous entries. The development of criteria that provide assurance that data conform to prespecified completeness and quality criteria would be an important development. The benefits of EPR data might be extended by testing their use in large pragmatic clinical trials. It would also be of value to develop methods to quality assure EPR data including involving parents, and link the NNRD to other health, social care and educational data sets to facilitate the acquisition of lifelong outcomes across multiple domains.

Study registration

This study is registered as PROSPERO CRD42015017439 (workstream 1) and PROSPERO CRD42012002168 (workstream 3).

Funding

The National Institute for Health Research Programme Grants for Applied Research programme (£1,641,471). Unrestricted donations were supplied by Abbott Laboratories (Maidenhead, UK: £35,000), Nutricia Research Foundation (Schiphol, the Netherlands: £15,000), GE Healthcare (Amersham, UK: £1000). A grant to support the use of routinely collected, standardised, electronic clinical data for audit, management and multidisciplinary feedback in neonatal medicine was received from the Department of Health and Social Care (£135,494).

Computerised interpretation of the fetal heart rate during labour: a randomised controlled trial (INFANT)

BACKGROUND

Continuous electronic fetal monitoring (EFM) in labour is widely used and computerised interpretation has the potential to increase its utility.

OBJECTIVES

This trial aimed to find out whether or not the addition of decision support software to assist in the interpretation of the cardiotocograph (CTG) reduced the number of poor neonatal outcomes, and whether or not it was cost-effective.

DESIGN

Two-arm individually randomised controlled trial. The allocations were computer generated using stratified block randomisation employing variable block sizes. The trial was not masked.

SETTING

Labour wards in England, Scotland and the Republic of Ireland.

PARTICIPANTS

Women in labour having EFM, with a singleton or twin pregnancy, at ≥ 35 weeks' gestation.

INTERVENTIONS

Decision support or no decision support.

MAIN OUTCOME MEASURES

The primary outcomes were (1) a composite of poor neonatal outcome {intrapartum stillbirth or early neonatal death (excluding lethal congenital anomalies), or neonatal morbidity [defined as neonatal encephalopathy (NNE)], or admission to a neonatal unit within 48 hours for ≥ 48 hours (with evidence of feeding difficulties, respiratory illness or NNE when there was evidence of compromise at birth)}; and (2) developmental assessment at the age of 2 years in a subset of surviving children.

RESULTS

Between 6 January 2010 and 31 August 2013, 47,062 women were randomised and 46,042 were included in the primary analysis (22,987 in the decision support group and 23,055 in the no decision support group). The short-term primary outcome event rate was higher than anticipated. There was no evidence of a difference in the incidence of poor neonatal outcome between the groups: 0.7% (n = 172) of babies in the decision support group compared with 0.7% (n = 171) of babies in the no decision support group [adjusted risk ratio 1.01, 95% confidence interval (CI) 0.82 to 1.25]. There was no evidence of a difference in the long-term primary outcome of the Parent Report of Children's Abilities-Revised with a mean score of 98.0 points [standard deviation (SD) 33.8 points] in the decision support group and 97.2 points (SD 33.4 points) in the no decision support group (mean difference 0.63 points, 95% CI -0.98 to 2.25 points). No evidence of a difference was found for health resource use and total costs. There was evidence that decision support did change practice (with increased fetal blood sampling and a lower rate of repeated alerts).

LIMITATIONS

Staff in the control group may learn from exposure to the decision support arm of the trial, resulting in improved outcomes in the control arm. This was identified in the planning stage and felt to be unlikely to have a significant effect on the results. As this was a pragmatic trial, the response to CTG alerts was left to the attending clinicians.

CONCLUSIONS

This trial does not support the hypothesis that the use of computerised interpretation of the CTG in women who have EFM in labour improves the clinical outcomes for mothers or babies.

FUTURE WORK

There continues to be an urgent need to improve knowledge and training about the appropriate response to CTG abnormalities, including timely intervention.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN98680152.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) HTA programme and will be published in full in Health Technology Assessment; Vol. 22, No. 9. See the NIHR Journals Library website for further project information. Sara Kenyon was part funded by the NIHR Collaboration for Leadership in Applied Health Research and Care West Midlands.

Mentoring, Bullying, and Educational Outcomes Among US School-Aged Children 6-17 Years

BACKGROUND

Ensuring the optimum development of all children and their attainment of age-appropriate educational outcomes is of great interest to public health researchers and professionals. Bullying and mentoring have opposite effects on child development and educational attainment. Mentoring exerts protective effects on youths against risky behaviors; however, the protective effects of community-oriented natural or informal mentoring on educational outcomes and bullying are largely underexplored. We examine associations between mentoring, bullying, and educational outcomes among US school-aged children 6-17 years.

METHODS

We analyzed the 2011-2012 National Survey of Children's Health (N = 65,593) to estimate prevalence and odds of repeating a grade in school, lower school engagement, and bullying perpetration according to mentoring receipt and sociodemographic characteristics.

RESULTS

Overall, 5.4% of US school-aged children without a mentor perpetrated bullying against other children; 11.4% repeated more than one grade in school; and 23.0% had low school engagement. Children without mentors had 2.1 and 1.3 times higher adjusted odds, respectively, of bullying other children and low school engagement than those with mentors. Proportion of children who bullied others or repeated grades was higher among minority children.

CONCLUSIONS

Findings indicate that mentoring may be a pathway for providing programs that prevent bullying and improve educational outcomes among school-aged children.

Planned delivery or expectant management for late preterm pre-eclampsia: study protocol for a randomised controlled trial (PHOENIX trial)

Background

Pre-eclampsia is a pregnancy disorder, characterised by hypertension and multisystem complications in the mother. The adverse outcomes of pre-eclampsia include severe hypertension, stroke, renal and hepatic injury, haemorrhage, fetal growth restriction and even death. The optimal time to instigate delivery to prevent morbidity when pre-eclampsia occurs between 34 and 37 weeks’ gestation, without increasing problems related to infant immaturity or complications, remains unclear.

Methods/design

The PHOENIX trial is a non-masked, randomised controlled trial, comparing planned early delivery (with initiation of delivery within 48 h of randomisation) with usual care (expectant management) in women with pre-eclampsia between 34^+ 0 and 36^+ 6 weeks’ gestation. The primary objectives of the trial are to determine if planned delivery reduces adverse maternal outcomes, without increasing the short-term harm to infants (composite of perinatal deaths or neonatal unit admissions up to infant hospital discharge) or impacting long-term infant neurodevelopmental status at 2 years corrected age (Parent Report of Cognitive Abilities-Revised).

Discussion

Current practice in the UK at the time of trial commencement for management of pre-eclampsia varies by gestation. Previous trials have shown that in women with pre-eclampsia after 37 weeks of gestion, delivery is initiated, as maternal complications are reduced without increasing fetal risks. Prior to 34 weeks of gestation, usual management aims to prolong pregnancy for fetal benefit, unless severe complications occur, necessitating preterm delivery. This trial aims to address the uncertainty for women where the balance of benefits and risks of delivery compared to expectant management are uncertain. Previous trials in this area have been undertaken, but have not provided a definitive answer, and the research question remains active. The results of this trial are expected to influence clinical practice internationally, through direct adoption and by incorporation into guidelines in countries with similar settings.

Trial registration

ISRCTN01879376. Registered on 25 November 2013.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3150-1) contains supplementary material, which is available to authorized users.

Validity of neurodevelopmental outcomes of children born very preterm assessed during routine clinical follow-up in England

OBJECTIVE

To determine the validity of assessing and recording the neurodevelopmental outcome of very preterm infants during routine clinical follow-up in England.

DESIGN

Children born <30 weeks gestation, attending routine clinical follow-up at post-term ages 20-28 months, were recruited. Data on neurodevelopmental outcomes were recorded by the reviewing clinician in a standardised format in the child's electronic patient record, based on a set of key questions designed to be used without formal training or developmental testing. Using a predefined algorithm, each participant was classified as having 'no', 'mild/moderate' or 'severe' impairment in cognitive, communication and motor domains. All participants also received a research assessment by a single assessor using the Bayley Scales of Infant Development, third edition (Bayley-III). The sensitivity and specificity of routine data in capturing impairment (any Bayley-III score <85) or severe impairment (any Bayley-III score <70) was calculated.

RESULTS

190 children participated. The validity of routine assessments in identifying children with no impairment and no severe impairment was high across all domains (specificities 83.9%-100.0% and 96.6%-100.0%, respectively). However, identification of impairments, particularly in the cognitive (sensitivity 69.7% (55.1%-84.3%)) and communication (sensitivity (53.2% (42.0%-64.5%)) domains, was poor.

CONCLUSIONS

Neurodevelopmental status determined during routine clinical assessment lacks adequate sensitivity in cognitive and communication domains. It is uncertain whether this reflects the assessment or/and the recording of findings. As early intervention may improve education and social outcomes, this is an important area for healthcare quality improvement research.

Neurodevelopmental outcomes in children with large temporal arachnoid cysts

OBJECTIVE Management of children with large temporal arachnoid cysts (TACs) remains controversial, with limited data available on their neurodevelopmental outcome. The aim of this study was to examine neurodevelopmental outcomes in children with large TACs. METHODS In this medical center-based cohort study, 25 patients (19 males) who were diagnosed in childhood with large TACs (9 patients [36%] with a Galassi type II and 16 patients [64%] with a Galassi type III TAC) were examined. The mean ± SD age at assessment was 11.1 ± 5.6 years (range 2.7-22 years). Twelve patients (48%) had right-sided, 12 (48%) had left-sided, and 1 (4%) had bilateral cysts. Nine patients (36%) underwent surgery for the cyst. The siblings of 21 patients (84%) served as control participants. Neurodevelopmental function was assessed using the Adaptive Behavior Assessment System (ABAS), Vanderbilt Behavioral Rating Scale (VBRS), and Developmental Coordination Disorder Questionnaire (DCDQ), and quality of life was measured using the treatment-oriented screening questionnaire (TOSQ). The results of all instruments except for TOSQ were compared with those of the sibling control participants. RESULTS The mean ± SD ABAS score of the patients was 93.3 ± 20.09 compared with 98.3 ± 18.04 of the sibling control participants (p = 0.251). Regarding the incidence of poor outcome (ABAS score < 80), there was a trend for more patients with TAC to have poor outcome than the sibling controls (p = 0.058). Patients who underwent surgery scored significantly worse with regard to the VBRS total score compared with those who did not (p = 0.020), but not on ABAS, DCD, or TOSQ. The mean score of the cognitive and psychological items on TOSQ was lower than that for the physical items (p < 0.001). CONCLUSIONS Children with a large TAC performed similarly to their sibling control participants in neurodevelopmental function. However, a subgroup of those with cysts did have an increased risk for poor outcomes in general function. Neurodevelopmental assessment should be part of the management of all patients with TAC.

Differentiating the Preterm Phenotype: Distinct Profiles of Cognitive and Behavioral Development Following Late and Moderately Preterm Birth

OBJECTIVES

To explore patterns of comorbidity in cognitive and behavioral outcomes at 2 years' corrected age among children born late or moderately preterm (LMPT) and to identify predictors of different patterns of comorbidity.

STUDY DESIGN

Geographical, prospective population-based cohort study of 1139 infants born LMPT (32^0/7 to 36^6/7 weeks' gestation) and 1255 infants born at term (37^0/7 to 42^6/7 weeks' gestation). Parent questionnaires were obtained to identify impaired cognitive and language development, behavioral problems, delayed social-emotional competence, autistic features, and clinically significant eating difficulties at 24 months corrected age for 638 (57%) children born LMPT and 765 (62%) children born at term.

RESULTS

Latent class analysis revealed 2 profiles of development among the term group: optimal (84%) and a profile of social, emotional, and behavioral impairments termed "nonoptimal" (16%). These 2 profiles were also identified among the LMPT group (optimal: 67%; nonoptimal: 26%). In the LMPT group, a third profile was identified (7%) that was similar to the phenotype previously identified in infants born very preterm. Nonwhite ethnicity, socioeconomic risk, and not receiving breast milk at hospital discharge were risk factors for nonoptimal outcomes in both groups. Male sex, greater gestational age, and pre-eclampsia were only associated with the preterm phenotype.

CONCLUSIONS

Among children born LMPT with parent-reported cognitive or behavioral impairments, most had problems similar to the profile of difficulties observed in children born at term. A smaller proportion of children born LMPT had impairments consistent with the "very preterm phenotype" which are likely to have arisen through a preterm pathway. These results suggest that prematurity may affect development through several etiologic pathways in the late and moderately preterm population.

Effect of MRI on preterm infants and their families: a randomised trial with nested diagnostic and economic evaluation

BACKGROUND

We tested the hypothesis that routine MRI would improve the care and well-being of preterm infants and their families.

DESIGN

Parallel-group randomised trial (1.1 allocation; intention-to-treat) with nested diagnostic and cost evaluations (EudraCT 2009-011602-42).

SETTING

Participants from 14 London hospitals, imaged at a single centre.

PATIENTS

511 infants born before 33 weeks gestation underwent both MRI and ultrasound around term. 255 were randomly allocated (siblings together) to receive only MRI results and 255 only ultrasound from a paediatrician unaware of unallocated results; one withdrew before allocation.

MAIN OUTCOME MEASURES

Maternal anxiety, measured by the State-Trait Anxiety inventory (STAI) assessed in 206/214 mothers receiving MRI and 217/220 receiving ultrasound. Secondary outcomes included: prediction of neurodevelopment, health-related costs and quality of life.

RESULTS

After MRI, STAI fell from 36.81 (95% CI 35.18 to 38.44) to 32.77 (95% CI 31.54 to 34.01), 31.87 (95% CI 30.63 to 33.12) and 31.82 (95% CI 30.65 to 33.00) at 14 days, 12 and 20 months, respectively. STAI fell less after ultrasound: from 37.59 (95% CI 36.00 to 39.18) to 33.97 (95% CI 32.78 to 35.17), 33.43 (95% CI 32.22 to 34.63) and 33.63 (95% CI 32.49 to 34.77), p=0.02. There were no differences in health-related quality of life. MRI predicted moderate or severe functional motor impairment at 20 months slightly better than ultrasound (area under the receiver operator characteristic curve (CI) 0.74; 0.66 to 0.83 vs 0.64; 0.56 to 0.72, p=0.01) but cost £315 (CI £295-£336) more per infant.

CONCLUSIONS

MRI increased costs and provided only modest benefits.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01049594 https://clinicaltrials.gov/ct2/show/NCT01049594. EudraCT: EudraCT: 2009-011602-42 (https://www.clinicaltrialsregister.eu/).

Language difficulties and internalizing problems: Bidirectional associations from 18 months to 8 years among boys and girls

Studies have shown that early language difficulties are associated with later internalizing problems. Less is known about the nature of the association: the bidirectional relationship over time, the role of different types of language difficulties, and gender differences. The present study examined bidirectional longitudinal associations between parent-rated language difficulties and internalizing problems in a four-wave cross-lagged model from 18 months to 8 years. Data from the Norwegian Mother and Child Cohort Study were used (N = 114,000). Gender-specific dichotomized language variables were created, and associations were investigated uniquely for boys and girls. Logistic regression analyses showed that all cross-lagged associations from 18 months to 5 years were significant for girls (odds ratios [ORs] = 1.48-1.94). For boys, only internalizing problems at 3 years predicted change in language difficulties (OR = 2.33). From 5 to 8 years, the cross-lagged associations between semantic language difficulties and internalizing problems were significant and strong for girls (ORs = 1.92-2.97) and nonsignificant for boys. The results suggest that the associations between language difficulties and internalizing problems are bidirectional from an early age, and that girls are especially vulnerable for developing co-occurring language difficulties and internalizing problems during the years of transition to school.

Computerised interpretation of fetal heart rate during labour (INFANT): a randomised controlled trial

BACKGROUND

Continuous electronic fetal heart-rate monitoring is widely used during labour, and computerised interpretation could increase its usefulness. We aimed to establish whether the addition of decision-support software to assist in the interpretation of cardiotocographs affected the number of poor neonatal outcomes.

METHODS

In this unmasked randomised controlled trial, we recruited women in labour aged 16 years or older having continuous electronic fetal monitoring, with a singleton or twin pregnancy, and at 35 weeks' gestation or more at 24 maternity units in the UK and Ireland. They were randomly assigned (1:1) to decision support with the INFANT system or no decision support via a computer-generated stratified block randomisation schedule. The primary outcomes were poor neonatal outcome (intrapartum stillbirth or early neonatal death excluding lethal congenital anomalies, or neonatal encephalopathy, admission to the neonatal unit within 24 h for ≥48 h with evidence of feeding difficulties, respiratory illness, or encephalopathy with evidence of compromise at birth), and developmental assessment at age 2 years in a subset of surviving children. Analyses were done by intention to treat. This trial is completed and is registered with the ISRCTN Registry, number 98680152.

FINDINGS

Between Jan 6, 2010, and Aug 31, 2013, 47 062 women were randomly assigned (23 515 in the decision-support group and 23 547 in the no-decision-support group) and 46 042 were analysed (22 987 in the decision-support group and 23 055 in the no-decision-support group). We noted no difference in the incidence of poor neonatal outcome between the groups-172 (0·7%) babies in the decision-support group compared with 171 (0·7%) babies in the no-decision-support group (adjusted risk ratio 1·01, 95% CI 0·82-1·25). At 2 years, no significant differences were noted in terms of developmental assessment.

INTERPRETATION

Use of computerised interpretation of cardiotocographs in women who have continuous electronic fetal monitoring in labour does not improve clinical outcomes for mothers or babies.

FUNDING

National Institute for Health Research.

The Speed of Increasing milk Feeds: a randomised controlled trial

Background

In the UK, 1–2% of infants are born very preterm (<32 weeks of gestation) or have very low birth weight (<1500 g). Very preterm infants are initially unable to be fed nutritional volumes of milk and therefore require intravenous nutrition. Milk feeding strategies influence several long and short term health outcomes including growth, survival, infection (associated with intravenous nutrition) and necrotising enterocolitis (NEC); with both infection and NEC being key predictive factors of long term disability. Currently there is no consistent strategy for feeding preterm infants across the UK. The SIFT trial will test two speeds of increasing milk feeds with the primary aim of determining effects on survival without moderate or severe neurodevelopmental disability at 24 months of age, corrected for prematurity. The trial will also examine many secondary outcomes including infection, NEC, time taken to reach full feeds and growth.

Methods/design

Two thousand eight hundred very preterm or very low birth weight infants will be recruited from approximately 30 hospitals across the UK to a randomised controlled trial. Infants with severe congenital anomaly or no realistic chance of survival will be excluded. Infants will be randomly allocated to either a faster (30 ml/kg/day) or slower (18 ml/kg/day) rate of increase in milk feeds. Data will be collected during the neonatal hospital stay on weight, infection rates, episodes of NEC, length of stay and time to reach full milk feeds. Long term health outcomes comprising vision, hearing, motor and cognitive impairment will be assessed at 24 months of age (corrected for prematurity) using a parent report questionnaire.

Discussion

Extensive searches have found no active or proposed studies investigating the rate of increasing milk feeds. The results of this trial will have importance for optimising incremental milk feeding for very preterm and/or very low birth weight infants. No additional resources will be required to implement an optimal feeding strategy, and therefore if successful, the trial results could rapidly be adopted across the NHS at low cost.

Trial registration

ISRCTN Registry; ISRCTN76463425 on 5 March, 2013.

Early psychomotor development of low-risk preterm infants: Influence of gestational age and gender

BACKGROUND

The influence of gestational age and gender in the neurodevelopment of infants during the first year of age is not yet fully elucidated.

AIMS

The purpose of this study was to identify the early occurrence of neurodevelopmental differences, between very preterm, late preterm and term born infants and the possible influence of the gender on the neurodevelopment in early infancy.

METHODS

A total of 188 low-risk infants, 69 very preterms, 71 late-preterms, and 48 term infants were assessed at 3, 6, 9, 12 months corrected age using the Hammersmith Infant Neurological Examination (HINE). At two years of age infants performed the Mental Developmental Index (MDI) of the Bayley Scales of Infant Development.

RESULTS

The main results indicate that both very preterms and late-preterms showed significant lower global scores than term born infants at each evaluation (p < 0.001) at HINE and namely, at 3 months for the subsections "cranial nerve" and "posture" and at every age for "tone"; no gender differences has been evidenced in neurological performances. At the MDI, very preterms showed significant lower scores (p < 0.01) than both late-preterm and term born infants; gender differences were observed for preterms only (very and late), with best performances for females.

CONCLUSIONS

Our results point out the presence of gestational age and gender-dependent differences in the development of infants assessed during the first 2 years of life.

Evaluation of the use of a parent questionnaire to provide later health status data: the PANDA study

BACKGROUND

Routine comparable outcome data collection relating to the later health status of babies born very preterm has long been considered important, but has not been achieved in the UK.

AIM

To test the potential for a parental questionnaire to provide these data for all eligible babies from a geographical population.

METHODS

Consent for follow-up by questionnaire (using the Parent Report of Children's Abilities-Revised combined with questions derived from the Oxford minimum dataset) was sought for all babies ≤30 weeks of gestation, discharged from a hospital in the East Midlands and Yorkshire regions of the UK, having been born between 1 January 2007 and 31 December 2011.

RESULTS

The rate of consent to participate in follow-up showed a steady increase over time to 83.1% in 2011. However, the response rate in terms of completion and return of the questionnaire at 2 years, as a proportion of those eligible, showed little change over time, varying between 42% and 46%. Among those children where a questionnaire was returned, the rate of disability was broadly consistent over time: lowest in 2009, 21.0% (95% CI 16.8% to 25.6%) and highest in 2011, 25.5% (95% CI 21.5% to 31.2%). The instruments used appeared effective with the capability of discriminating between children with physical and/or cognitive disability.

CONCLUSIONS

The overall response rate in terms of returned questionnaires was disappointing and inadequate to recommend for implementation. It is possible that response rates would have been higher had clinical follow-up been linked to the data obtained from the questionnaires rather than running as a parallel process.

Who Receives Speech/Language Services by 5 Years of Age in the United States?

PURPOSE

We sought to identify factors predictive of or associated with receipt of speech/language services during early childhood. We did so by analyzing data from the Early Childhood Longitudinal Study-Birth Cohort (ECLS-B; Andreassen & Fletcher, 2005), a nationally representative data set maintained by the U.S. Department of Education. We addressed two research questions of particular importance to speech-language pathology practice and policy. First, do early vocabulary delays increase children's likelihood of receiving speech/language services? Second, are minority children systematically less likely to receive these services than otherwise similar White children?

METHOD

Multivariate logistic regression analyses were performed for a population-based sample of 9,600 children and families participating in the ECLS-B.

RESULTS

Expressive vocabulary delays by 24 months of age were strongly associated with and predictive of children's receipt of speech/language services at 24, 48, and 60 months of age (adjusted odds ratio range = 4.32-16.60). Black children were less likely to receive speech/language services than otherwise similar White children at 24, 48, and 60 months of age (adjusted odds ratio range = 0.42-0.55). Lower socioeconomic status children and those whose parental primary language was other than English were also less likely to receive services. Being born with very low birth weight also significantly increased children's receipt of services at 24, 48, and 60 months of age.

CONCLUSION

Expressive vocabulary delays at 24 months of age increase children's risk for later speech/language services. Increased use of culturally and linguistically sensitive practices may help racial/ethnic minority children access needed services.

Towards reducing variations in infant mortality and morbidity: a population-based approach

Background

Our aims were (1) to improve understanding of regional variation in early-life mortality rates and the UK’s poor performance in international comparisons; and (2) to identify the extent to which late and moderately preterm (LMPT) birth contributes to early childhood mortality and morbidity.

Objective

To undertake a programme of linked population-based research studies to work towards reducing variations in infant mortality and morbidity rates.

Design

Two interlinked streams: (1) a detailed analysis of national and regional data sets and (2) establishment of cohorts of LMPT babies and term-born control babies.

Setting

Cohorts were drawn from the geographically defined areas of Leicestershire and Nottinghamshire, and analyses were carried out at the University of Leicester.

Data sources

For stream 1, national data were obtained from four sources: the Office for National Statistics, NHS Numbers for Babies, Centre for Maternal and Child Enquiries and East Midlands and South Yorkshire Congenital Anomalies Register. For stream 2, prospective data were collected for 1130 LMPT babies and 1255 term-born control babies.

Main outcome measures

Detailed analysis of stillbirth and early childhood mortality rates with a particular focus on factors leading to biased or unfair comparison; review of clinical, health economic and developmental outcomes over the first 2 years of life for LMPT and term-born babies.

Results

The deprivation gap in neonatal mortality has widened over time, despite government efforts to reduce it. Stillbirth rates are twice as high in the most deprived as in the least deprived decile. Approximately 70% of all infant deaths are the result of either preterm birth or a major congenital abnormality, and these are heavily influenced by mothers’ exposure to deprivation. Births at < 24 weeks’ gestation constitute only 1% of all births, but account for 20% of infant mortality. Classification of birth status for these babies varies widely across England. Risk of LMPT birth is greatest in the most deprived groups within society. Compared with term-born peers, LMPT babies are at an increased risk of neonatal morbidity, neonatal unit admission and poorer long-term health and developmental outcomes. Cognitive and socioemotional development problems confer the greatest long-term burden, with the risk being amplified by socioeconomic factors. During the first 24 months of life each child born LMPT generates approximately £3500 of additional health and societal costs.

Conclusions

Health professionals should be cautious in reviewing unadjusted early-life mortality rates, particularly when these relate to individual trusts. When more sophisticated analysis is not possible, babies of < 24 weeks’ gestation should be excluded. Neonatal services should review the care they offer to babies born LMPT to ensure that it is appropriate to their needs. The risk of adverse outcome is low in LMPT children. However, the risk appears higher for some types of antenatal problems and when the mother is from a deprived background.

Future work

Future work could include studies to improve our understanding of how deprivation increases the risk of mortality and morbidity in early life and investigation of longer-term outcomes and interventions in at-risk LMPT infants to improve future attainment.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Outcomes of Two Trials of Oxygen-Saturation Targets in Preterm Infants

BACKGROUND

The safest ranges of oxygen saturation in preterm infants have been the subject of debate.

METHODS

In two trials, conducted in Australia and the United Kingdom, infants born before 28 weeks' gestation were randomly assigned to either a lower (85 to 89%) or a higher (91 to 95%) oxygen-saturation range. During enrollment, the oximeters were revised to correct a calibration-algorithm artifact. The primary outcome was death or disability at a corrected gestational age of 2 years; this outcome was evaluated among infants whose oxygen saturation was measured with any study oximeter in the Australian trial and those whose oxygen saturation was measured with a revised oximeter in the U.K. trial.

RESULTS

After 1135 infants in Australia and 973 infants in the United Kingdom had been enrolled in the trial, an interim analysis showed increased mortality at a corrected gestational age of 36 weeks, and enrollment was stopped. Death or disability in the Australian trial (with all oximeters included) occurred in 247 of 549 infants (45.0%) in the lower-target group versus 217 of 545 infants (39.8%) in the higher-target group (adjusted relative risk, 1.12; 95% confidence interval [CI], 0.98 to 1.27; P=0.10); death or disability in the U.K. trial (with only revised oximeters included) occurred in 185 of 366 infants (50.5%) in the lower-target group versus 164 of 357 infants (45.9%) in the higher-target group (adjusted relative risk, 1.10; 95% CI, 0.97 to 1.24; P=0.15). In post hoc combined, unadjusted analyses that included all oximeters, death or disability occurred in 492 of 1022 infants (48.1%) in the lower-target group versus 437 of 1013 infants (43.1%) in the higher-target group (relative risk, 1.11; 95% CI, 1.01 to 1.23; P=0.02), and death occurred in 222 of 1045 infants (21.2%) in the lower-target group versus 185 of 1045 infants (17.7%) in the higher-target group (relative risk, 1.20; 95% CI, 1.01 to 1.43; P=0.04). In the group in which revised oximeters were used, death or disability occurred in 287 of 580 infants (49.5%) in the lower-target group versus 248 of 563 infants (44.0%) in the higher-target group (relative risk, 1.12; 95% CI, 0.99 to 1.27; P=0.07), and death occurred in 144 of 587 infants (24.5%) versus 99 of 586 infants (16.9%) (relative risk, 1.45; 95% CI, 1.16 to 1.82; P=0.001).

CONCLUSIONS

Use of an oxygen-saturation target range of 85 to 89% versus 91 to 95% resulted in nonsignificantly higher rates of death or disability at 2 years in each trial but in significantly increased risks of this combined outcome and of death alone in post hoc combined analyses. (Funded by the Australian National Health and Medical Research Council and others; BOOST-II Current Controlled Trials number, ISRCTN00842661, and Australian New Zealand Clinical Trials Registry number, ACTRN12605000055606.).

Eating difficulties in children born late and moderately preterm at 2 y of age: a prospective population-based cohort study

BACKGROUND

Very preterm (<32 wk of gestation) infants are at increased risk of eating difficulties compared with their term-born peers. Little is known about the impact of late and moderately preterm (LMPT; 32-36 wk of gestation) birth on eating difficulties in early childhood.

OBJECTIVES

The aims were to assess the prevalence of eating difficulties in infants born LMPT at 2 y corrected age and to explore the impact of neonatal and neurodevelopmental factors.

DESIGN

A geographic population-based cohort of 1130 LMPT and 1255 term-born controls was recruited at birth. The parents of 651 (59%) LMPT and 771 (62%) term-born infants completed questionnaires at 2 y corrected age to assess neurodevelopmental outcomes. Parents also completed a validated questionnaire to assess eating behaviors in 4 domains: refusal/picky eating, oral motor problems, oral hypersensitivity, and eating behavior problems. Infants with scores >90th percentile were classified with eating difficulties in each domain. Neonatal data were collected at discharge, and sociodemographic information was collected via maternal interview. Poisson regression was used to assess between-group differences in eating difficulties and to explore associations with neonatal factors and neurodevelopmental outcomes at 2 y of age.

RESULTS

In unadjusted analyses, LMPT infants were at increased risk of refusal/picky eating (RR: 1.53; 95% CI: 1.03, 2.25) and oral motor problems (RR: 1.62; 95% CI: 1.06, 2.47). Prolonged nasogastric feeding >2 wk (RR: 1.87; 95% CI: 1.07, 3.25), behavior problems (RR: 2.95; 95% CI: 1.93, 4.52), and delayed social competence (RR: 2.28; 95% CI: 1.49, 3.48) were independently associated with eating difficulties in multivariable analyses. After adjustment for these factors, there was no excess of eating difficulties in LMPT infants.

CONCLUSIONS

Infants born LMPT are at increased risk of oral motor and picky eating problems at 2 y corrected age. However, these are mediated by other neurobehavioral sequelae in this population. This trial was registered on the UK Clinical Research Network Portfolio at http://public.ukcrn.org.uk/search/ as UKCRN Study ID 7441.

A study of an intelligent system to support decision making in the management of labour using the cardiotocograph - the INFANT study protocol

BACKGROUND

Continuous electronic fetal heart rate monitoring in labour is widely used but its potential for improving fetal and neonatal outcomes has not been realised. The most likely reason is the difficulty of interpreting the fetal heart rate trace correctly during labour. Computerised interpretation of the fetal heart rate and intelligent decision-support has the potential to deliver this improvement in care. This trial will test whether the addition of decision support software to aid the interpretation of the cardiotocogram (CTG) during labour will reduce the number of 'poor neonatal outcomes' in those women judged to require continuous electronic fetal heart rate monitoring.

METHODS AND DESIGN

An individually randomised controlled trial of 46,000 women who are judged to require continuous electronic fetal monitoring in labour.

ELIGIBILITY CRITERIA

Women admitted to a participating labour ward who are judged to require continuous electronic fetal monitoring, have a singleton or twin pregnancy, are ≥ 35 weeks' gestation, have no known gross fetal abnormality and are ≥ 16 years of age.

EXCLUSION CRITERIA

Triplets or higher order pregnancy, elective caesarean section prior to the onset of labour, planned admission to NICU. Trial interventions: Computerised interpretation of the CTG with decision-support.

PRIMARY OUTCOMES

Short term: A composite of 'poor neonatal outcome' including stillbirth after trial entry, early neonatal death except deaths due to congenital anomalies, significant morbidity: neonatal encephalopathy, admissions to the neonatal unit with 48 h for > 48 h with evidence of feeding difficulties, respiratory illness or encephalopathy where there is evidence of compromise at birth. Long term: Developmental assessment at the age of 2 years in a subset of 7000 surviving babies.

DATA COLLECTION

For all participating women and babies, labour variables and outcomes will be stored automatically and contemporaneously onto the Guardian® system.

DISCUSSION

The results of this trial will have importance for pregnant women and for health professionals who provide care for them.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN98680152 assigned 30.09.2008.

Preterm Cognitive Function Into Adulthood

BACKGROUND

Very preterm (VP; gestational age <32 weeks) and very low birth weight (VLBW; <1500 g) births are related to impaired cognitive function across the life span. It is not known how stable cognitive functions are from childhood to adulthood for VP/VLBW compared with term-born individuals and how early adult cognitive function can be predicted.

METHODS

The Bavarian Longitudinal Study is a prospective geographically defined cohort study that followed 260 VP/VLBW and 229 term-born individuals from birth to adulthood. Data on cognitive function were assessed with developmental and IQ tests at 5 and 20 months and at 4, 6, 8, and 26 years of age.

RESULTS

Across all assessments, VP/VLBW individuals had significantly lower IQ scores than term-born controls, even when individuals with severe cognitive impairment (n = 69) were excluded. IQ scores were found to be more stable over time for VP/VLBW than term-born individuals, yet differences in stability disappeared when individuals with cognitive impairment were excluded. Adult IQ could be predicted with fair certainty (r > 0.50) from age 20 months onward for the whole VP/VLBW sample (n = 260) and from 6 years onward for term-born individuals (n = 229).

CONCLUSIONS

VP/VLBW individuals more often suffer from cognitive problems across childhood into adulthood and these problems are relatively stable from early childhood onward. VP/VLBW children's risk for cognitive problems can be reliably diagnosed at the age of 20 months. These findings provide strong support for the timing of cognitive follow-up at age 2 years to plan special support services for children with cognitive problems.

Comparison of Griffiths-II and Bayley-II tests for the developmental assessment of high-risk infants

INTRODUCTION

Two important risk factors for abnormal neurodevelopment are preterm birth and neonatal hypoxic ischemic encephalopathy. The new revisions of Griffiths Mental Development Scale (Griffiths-II, [1996]) and the Bayley Scales of Infant Development (BSID-II, [1993]) are two of the most frequently used developmental diagnostics tests. The Griffiths-II is divided into five subscales and a global development quotient (QD), and the BSID-II is divided into two scales, the Mental scale (MDI) and the Psychomotor scale (PDI). The main objective of this research was to establish the extent to which developmental diagnoses obtained using the new revisions of these two tests are comparable for a given child.

MATERIAL AND METHODS

Retrospective study of 18-months-old high-risk children examined with both tests in the follow-up Unit of the Clinic of Neonatology of our tertiary care university Hospital between 2011 and 2012. To determine the concurrent validity of the two tests paired t-tests and Pearson product-moment correlation coefficients were computed. Using the BSID-II as a gold standard, the performance of the Griffiths-II was analyzed with receiver operating curves.

RESULTS

61 patients (80.3% preterm, 14.7% neonatal asphyxia) were examined. For the BSID-II the MDI mean was 96.21 (range 67-133) and the PDI mean was 87.72 (range 49-114). For the Griffiths-II, the QD mean was 96.95 (range 60-124), the locomotors subscale mean was 92.57 (range 49-119). The score of the Griffiths locomotors subscale was significantly higher than the PDI (p<0.001). Between the Griffiths-II QD and the BSID-II MDI no significant difference was found, and the area under the curve was 0.93, showing good validity. All correlations were high and significant with a Pearson product-moment correlation coefficient >0.8.

CONCLUSIONS

The meaning of the results for a given child was the same for the two tests. Two scores were interchangeable, the Griffiths-II QD and the BSID-II MDI.

Neurodevelopmental outcomes following late and moderate prematurity: a population-based cohort study

OBJECTIVE

There is a paucity of data relating to neurodevelopmental outcomes in infants born late and moderately preterm (LMPT; 32(+0)-36(+6) weeks). This paper present the results of a prospective, population-based study of 2-year outcomes following LMPT birth.

DESIGN

1130 LMPT and 1255 term-born children were recruited at birth. At 2 years corrected age, parents completed a questionnaire to assess neurosensory (vision, hearing, motor) impairments and the Parent Report of Children's Abilities-Revised to identify cognitive impairment. Relative risks for adverse outcomes were adjusted for sex, socio-economic status and small for gestational age, and weighted to account for over-sampling of term-born multiples. Risk factors for cognitive impairment were explored using multivariable analyses.

RESULTS

Parents of 638 (57%) LMPT infants and 765 (62%) controls completed questionnaires. Among LMPT infants, 1.6% had neurosensory impairment compared with 0.3% of controls (RR 4.89, 95% CI 1.07 to 22.25). Cognitive impairments were the most common adverse outcome: LMPT 6.3%; controls 2.4% (RR 2.09, 95% CI 1.19 to 3.64). LMPT infants were at twice the risk for neurodevelopmental disability (RR 2.19, 95% CI 1.27 to 3.75). Independent risk factors for cognitive impairment in LMPT infants were male sex, socio-economic disadvantage, non-white ethnicity, preeclampsia and not receiving breast milk at discharge.

CONCLUSIONS

Compared with term-born peers, LMPT infants are at double the risk for neurodevelopmental disability at 2 years of age, with the majority of impairments observed in the cognitive domain. Male sex, socio-economic disadvantage and preeclampsia are independent predictors of low cognitive scores following LMPT birth.

Parent ratings of child cognition and language compared with Bayley-III in preterm 3-year-olds

BACKGROUND

Parent ratings on questionnaires may provide valid and cost-effective tools for screening cognitive development of children at risk of developmental delay.

AIMS

In this study, we examined the convergent validity of combining parent-based reports of non-verbal cognitive abilities (PARCA3) and verbal abilities (CDI-III) in relation to the Bayley-III cognitive scale in 3-year-olds born late pre-term.

METHODS

Mothers of 185 late-preterm children were asked to complete the PARCA3 and the CDI-III shortly before children reached age three; children were then assessed using the Bayley-III close to their third birthday.

RESULTS

The two maternal questionnaires were significantly and moderately correlated with the Bayley-III cognitive scores. Together the maternal ratings accounted for 15% of the variance in the Bayley-III cognitive scores, after controlling for other covariates in regression analysis. In particular, the PARCA3 contributed significantly to explain variance in the Bayley-III cognitive scores when controlling for the CDI-III. However, the CDI-III was also independently associated with the Bayley-III cognitive scores.

CONCLUSIONS

Parent ratings of child cognition and language together may provide cost-effective screening of development in "at risk" preschoolers.

Infants born late/moderately preterm are at increased risk for a positive autism screen at 2 years of age

OBJECTIVES

To assess the prevalence of positive screens using the Modified Checklist for Autism in Toddlers (M-CHAT) questionnaire and follow-up interview in late and moderately preterm (LMPT; 32-36 weeks) infants and term-born controls.

STUDY DESIGN

Population-based prospective cohort study of 1130 LMPT and 1255 term-born infants. Parents completed the M-CHAT questionnaire at 2-years corrected age. Parents of infants with positive questionnaire screens were followed up with a telephone interview to clarify failed items. The M-CHAT questionnaire was re-scored, and infants were classified as true or false positives. Neurosensory, cognitive, and behavioral outcomes were assessed using parent report.

RESULTS

Parents of 634 (57%) LMPT and 761 (62%) term-born infants completed the M-CHAT questionnaire. LMPT infants had significantly higher risk of a positive questionnaire screen compared with controls (14.5% vs 9.2%; relative risk [RR] 1.58; 95% CI 1.18, 2.11). After follow-up, significantly more LMPT infants than controls had a true positive screen (2.4% vs 0.5%; RR 4.52; 1.51, 13.56). This remained significant after excluding infants with neurosensory impairments (2.0% vs 0.5%; RR 3.67; 1.19, 11.3).

CONCLUSIONS

LMPT infants are at significantly increased risk for positive autistic screen. An M-CHAT follow-up interview is essential as screening for autism spectrum disorders is especially confounded in preterm populations. Infants with false positive screens are at risk for cognitive and behavioral problems.

Cognitive assessment of very low birth weight infants using the Dutch version of the PARCA-R parent questionnaire

OBJECTIVE

Very low birth weight (VLBW) infants are at an increased risk of long-term cognitive impairment. Early identification and timely interventions are important. We aimed to validate the Dutch version of the revised Parent Report of Children's Abilities (PARCA-R) questionnaire.

METHODS

The subjects were survivors from the Belgian participating centers to the NIRTURE trial. As part of a study-related follow-up, PARCA-R was sent out at the age of 2 years. As part of a normal hospital follow-up, these infants were assessed by the Bayley Scales of Infant Development - second edition (BSID-II) at the age of 9, 18 and 36 months. MRI was performed at term in the group of VLBW infants of ZOL Genk as standard care.

RESULTS

PARCA-R was sent out to 193 surviving infants. BSID-II was performed in 36% (n=70) at 9 months, in 30% (n=58) at 18 months and in 12% (n=23) at 36 months. MRI was available for 32 infants. We received 86 responses to the PARCA-R. Parent report composite (PRC) scores were significantly correlated with the Mental Development Index (MDI) (p<0.0001 (9 months); p=0.003 (18 months); p=0.01 (36 months)). PRC scores were significantly lower in those with an abnormal MRI (92 vs.124; p=0.04).

CONCLUSION

We support the use of the PARCA-R as a time and cost efficient alternative for identifying cognitive delay.

PRACTICE IMPLICATIONS

We suggest that the combination of BSID-II, MRI at term and PARCA-R would be the ideal testing method for identifying VLBW infants at risk for cognitive developmental delay by two years of age.

A parent questionnaire for developmental screening in infants born late and moderately preterm

BACKGROUND

The Parent Report of Children's Abilities-Revised (PARCA-R) is a questionnaire for assessing cognitive and language development in very preterm infants. Given the increased risk of developmental delay in infants born late and moderately preterm (LMPT; 32-36 weeks), this study aimed to validate this questionnaire as a screening tool in this population.

METHODS

Parents of 219 children born LMPT completed the PARCA-R questionnaire and the Brief Infant Toddler Social and Emotional Assessment when children were 24 months corrected age (range, 24 months-27 months). The children were subsequently assessed by using the cognitive and language scales of the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III).

RESULTS

An average Bayley-III, cognitive and language (CB-III) score and a total PARCA-R Parent Report Composite (PRC) score were computed. There was a large association between PRC and CB-III scores (r = 0.66, P < .001) indicating good concurrent validity. Using Youden index, the optimum PARCA-R cutoff for identifying children with moderate/severe developmental delay (CB-III scores < 80) was PRC scores < 73. This gave sensitivity 0.90 (95% confidence interval: 0.75-1.00) and specificity 0.76 (95% confidence interval: 0.70-0.82), indicating good diagnostic utility. Approximately two-thirds of the children who had a PRC score < 73 had false-positive screens. However, these children had significantly poorer cognitive and behavioral outcomes than children with true negative screens.

CONCLUSIONS

The PARCA-R has good concurrent validity with a gold standard developmental test and can be used to identify LMPT infants who may benefit from a clinical assessment. The PARCA-R has potential for clinical use as a first-line cognitive screening tool for this sizeable population of infants in whom follow-up may be beneficial.

Randomized controlled trial of oxygen saturation targets in very preterm infants: two year outcomes

OBJECTIVE

To assess whether an oxygen saturation (Spo2) target of 85%-89% compared with 91%-95% reduced the incidence of the composite outcome of death or major disability at 2 years of age in infants born at <28 weeks' gestation.

STUDY DESIGN

A total 340 infants were randomized to a lower or higher target from <24 hours of age until 36 weeks' gestational age. Blinding was achieved by targeting a displayed Spo2 of 88%-92% using a saturation monitor offset by ±3% within the range 85%-95%. True saturations were displayed outside this range. Follow-up at 2 years' corrected age was by pediatric examination and formal neurodevelopmental assessment. Major disability was gross motor disability, cognitive or language delay, severe hearing loss, or blindness.

RESULTS

The primary outcome was known for 335 infants with 33 using surrogate language information. Targeting a lower compared with a higher Spo2 target range had no significant effect on the rate of death or major disability at 2 years' corrected age (65/167 [38.9%] vs 76/168 [45.2%]; relative risk 1.15, 95% CI 0.90-1.47) or any secondary outcomes. Death occurred in 25 (14.7%) and 27 (15.9%) of those randomized to the lower and higher target, respectively, and blindness in 0% and 0.7%.

CONCLUSIONS

Although there was no benefit or harm from targeting a lower compared with a higher saturation in this trial, further information will become available from the prospectively planned meta-analysis of this and 4 other trials comprising a total of nearly 5000 infants.

Telephone interviews and online questionnaires can be used to improve neurodevelopmental follow-up rates

Background

Maximising response rates to neurodevelopmental follow-up is a key challenge for paediatric researchers. We have investigated the use of telephone interviews and online questionnaires to improve response rates, reduce non-response bias, maintain data completeness and produce unbiased outcomes compared with postal questionnaires when assessing neurodevelopmental outcomes at 2 years.

Methods

A prospective cohort study of babies born ≥32 weeks gestation. Neurodevelopmental outcomes were assessed at 2 years of age using a parent questionnaire completed via post, telephone or online. Relative Risks with 95% confidence intervals (RR; 95% CI) were calculated to identify participant characteristics associated with non-response and questionnaire response mode (postal vs. telephone/online). The proportion of missing data and prevalence of adverse outcomes was compared between response modes using generalized linear models.

Results

Offering telephone/online questionnaires increased the study response rate from 55% to 60%. Telephone/online responders were more likely to be non-white (RR 1.6; [95% CI 1.1, 2.4]), non-English speaking (1.6; [1.0, 2.6]) or have a multiple birth (1.6; [1.1, 2.3]) than postal responders. There were no significant differences in the prevalence of adverse neurodevelopmental outcomes between those who responded via post vs. telephone/online (1.1; [0.9, 1.4]). Where parents attempted all questionnaire sections, there were no significant differences in the proportion of missing data between response modes.

Conclusions

Where there is sufficient technology and resources, offering telephone interviews and online questionnaires can enhance response rates and improve sample representation to neurodevelopmental follow-up, whilst maintaining data completeness and unbiased outcomes.

French version of the Brief Infant-Toddler Social and Emotional Assessment questionnaire-BITSEA

OBJECTIVE

The aim of the present study was to examine the psychometric properties of the French version of the Brief Infant-Toddler Social and Emotional Assessment (BITSEA).

METHODS

The sample consisted of 589 low-risk infants aged 12-36 months and their parents. Parents completed the BITSEA, the Child Behavior Checklist 1½-5 (CBCL - 18 months to 5 years version), and the Parenting Stress Index - Short Form (PSI-SF).

RESULTS

Multitrait-multimethod and confirmatory factor analyses revealed adequate psychometric properties for the French version of the BITSEA. Scores on the BITSEA Problem scale were positively correlated to all CBCL and PSI-SF subscales, whereas negative correlations were found between BITSEA Competence scale and CBCL and PSI-SF subscales. The BITSEA Problem score significantly increased with level of parental worry, examined through a single-item question that is part of the BITSEA.

CONCLUSION

Findings support the validity of the French version of the BITSEA. However, additional work on the clinical validity of the BITSEA, including with at-risk children, is warranted.

Predictive value of the parent-completed ASQ for school difficulties in preterm-born children <35 weeks' GA at five years of age

BACKGROUND

Preterm infants are at greater risk of developmental impairment and require close follow-up for early and optimal care.

OBJECTIVES

The objective of the present study was to determine from which age the parental Ages and Stages Questionnaire (ASQ) allows detection of school difficulties in preterm children <35 weeks' gestational age.

METHODS

Preterm children from the regional Loire Infant Follow-up Team network were evaluated with the Global School Adaptation (GSA) assessment tool at 5 years of age and at least one parental-completed ASQ at 18, 24, or 36 months. Children belonging to the first decile of the GSA score (<38) were considered to have severe school difficulties. Using overall ASQ scores as continuous variables, receiver operating characteristic (ROC) curves were generated at every age in order to identify preterm children with severe school difficulties.

RESULTS

GSA scores were obtained in 1,775 infants at 5 years of age, and at least one ASQ score at 18, 24, or 36 months was completed. Upon ROC analysis, we observed that the 18-, 24-, and 36-month ASQ scores produced respective area under the ROC curve values of 0.66 (0.64-0.69), 0.72 (0.70-0.75), and 0.77 (0.75-0.80) for predicting a GSA score in the first decile. An ASQ cutoff value of 255 at 36 months showed optimal discriminatory power for identifying significant school difficulties at 5 years of age.

CONCLUSIONS

The 36-month ASQ is a simple and cost-effective tool that can be employed to help predict future severe school difficulties at 5 years of age in preterm-born children.

Performance of the Parent Report of Children's Abilities-Revised (PARCA-R) versus the Bayley Scales of Infant Development III

BACKGROUND

The Parent Report of Children's Abilities-Revised (PARCA-R) assesses cognitive and language development at 24 months. It was validated against the Mental Development Index of the Bayley Scales of Infant Development II (BSID II), but this has now been superseded by BSID III.

OBJECTIVE

To compare the PARCA-R against the BSID III.

METHODS

PARCA-R and BSID III assessments scheduled at 24 months of age (corrected for prematurity) were completed in 204 infants with suspected or proven neonatal sepsis in the International Neonatal Immunotherapy Study. Associations between the scales were measured and the predictive accuracy of the PARCA-R for moderate cognitive delay and moderate language delay was assessed using Receiver Operating Characteristic (ROC) analysis.

RESULTS

Median birthweight was 911 g, median gestational age at birth was 27 weeks and 100 (49.0%) were girls. 4.4% and 8.4% met standard BSID III criteria for cognitive delay and language delay, respectively. These rates increased to 19.6% and 12.6% when an independent sample of normal term infants were used as the reference group suggesting standard BSID III reference norms may tend to underestimate delay. The Spearman correlation between PARCA-R and BSID scales were 0.43 for cognition and 0.71 for language. The PARCA-R successfully predicted cases of cognitive delay and language delay with the area under the ROC curves ranging from 0.83 to 0.97 depending on reference norms used.

CONCLUSIONS

The results support the PARCA-R as a practical tool for the identification of appreciable cognitive and language delay at 24 months among critically ill premature and extremely low birthweight neonates.

Neonatal ECMO study of temperature (NEST): a randomized controlled trial

BACKGROUND

Despite evidence to support the use of extracorporeal membrane oxygenation (ECMO) in defined groups of newborn infants, rates of impairment among survivors remain high. Therapeutic hypothermia has been shown to provide neuroprotection in mature infants exposed to perinatal asphyxia. We hypothesized that therapeutic hypothermia during ECMO would reduce the proportion of infants with brain injury, and thus later impairment.

METHODS

We conducted a randomized trial in the United Kingdom to compare ECMO with cooling (34°C for the first 48 to 72 hours) with standard ECMO (37°C). The primary outcome was the cognitive composite score of the Bayley Scales of Infant and Toddler Development, 3rd edition, at 2 years. Prespecified secondary outcomes included death, neonatal morbidity, and other neurodevelopmental and behavioral outcomes at 2 years.

RESULTS

A total of 111 infants were entered into the study, 14 died before 2 years of age (16% who received ECMO with cooling vs 9% who received ECMO alone). Two infants were lost to follow-up, and 8 were unable to complete the full range of tests. For 45 evaluated infants who received ECMO with cooling, mean cognitive scores at 2 years were 88.0 (SD: 16.2) compared with 90.6 (SD: 13.1) for 48 infants receiving ECMO only (difference in means: -2.6; 95% confidence interval: -8.7 to 3.4). The various secondary outcomes were not significantly different between the groups, but most favored ECMO without cooling.

CONCLUSIONS

In newborn infants treated by ECMO, the use of mild hypothermia for the first 48 to 72 hours did not result in improved outcomes up to 2 years of age.

Measuring neurodevelopmental outcome in neonatal trials: a continuing and increasing challenge

The need for outcome evaluations as part of clinical trials has never been greater. In this paper, issues around the design and data collection of such outcome evaluations are discussed in relation to how they may be best collected and the options available. There is a need for organisation of such evaluations and consistency of measures between trials to optimise efficiency.