Denver developmental screening test II for early identification of the infants who will develop major neurological deficit as a sequalea of hypoxic-ischemic encephalopathy

[Psychometric properties of the Brazilian version of the Denver II: developmental screening test]

The scope of the Denver II Developmental Screening Test is to assess the development of children between 0 and 6 years of age. The aim of this study was to verify evidence of intra- and inter-examiner reliability, concurrent validity, sensitivity and specificity of the Brazilian version of Denver II. It involved a cross-sectional methodological study. A total of 254 children, between 0 and 72 months with risk of developmental delay, participated in the study. Two examiners verified the Denver II intra- and inter-examiner reliability. Concurrent validity, sensitivity and specificity were checked against the Brazilian version of the Ages & Stages Questionnaires as a criterion-referenced test. Statistical analysis used the Intraclass Correlation Coefficient, Spearman's Correlation Test and Contingency Table, the level of significance being α=0.05. The results identified that intra and inter examiner reliability was excellent in all age groups. Concurrent validity showed moderate to very strong rates in the 13-to-60-month age group. The sensitivity and specificity indices ranged from 73-99% and 58-92%, respectively. The Brazilian version of Denver II has good rates of psychometric properties and is a reliable and valid instrument to be applied to Brazilian children at risk of developmental delay.

Effect of cerebrolysin on neurodevelopmental outcome of high risk preterm infants: A randomized controlled trial

BACKGROUND

A significant proportion of preterm infants experience developmental delay despite receiving a post discharge early interventional care. Cerebrolysin is a peptide mixture which acts similar to endogenous neurotrophic factors through promoting neurogenesis and enhancing neuronal plasticity.

OBJECTIVE

To compare the effect of Cerebrolysin plus routine intervention program versus routine intervention program alone on the outcome of preterm infants at high risk for neurodevelopmental delay.

METHODS

In a randomized controlled trial, high-risk preterm infants <  32 weeks' gestation who have abnormal neurological assessment at two months corrected post-natal age were randomized at 6 months corrected post natal age to receive either early intervention program or early intervention program plus Cerebrolysin injection of 0.1 mL/kg body weight every week for 3 months as an adjuvant therapy. The primary outcome was the rate of failure of the gross motor assessment at 12 months of corrected age and secondary outcomes included fine motor, language, and personal social development at 12 months corrected post-natal age as assessed by Denver Developmental Screening Test II.

RESULTS

Cerebrolysin group had a significant lower number of infants diagnosed with failed gross motor development compared to infants in the routine intervention group [10 (33%) versus 21 (70%), p = 0.009]. Cerebrolysin group had a significant lower number of infants diagnosed with failed fine motor, language and personal social development compared to infants in the routine intervention group.

CONCLUSION

Cerebrolysin, as an adjuvant therapy to routine early interventional care, may improve gross motor development of high-risk preterm infants at 12 months corrected post-natal age.

Temporal brain metabolite changes in preterm infants with normal development

OBJECTIVE

Preterm infants are at high risk for developmental delay, epilepsy, and autism spectrum disorders. Some reports have described associations between these conditions and gamma-aminobutyric acid (GABA) dysfunction; however, no study has evaluated temporal changes in GABA in preterm infants. Therefore, we assessed temporal changes in brain metabolites including GABA using single-voxel 3-Tesla (T) proton magnetic resonance spectroscopy (¹H-MRS) in preterm infants with normal development.

METHODS

We performed 3T ¹H-MRS at 37-46 postmenstrual weeks (PMWs, period A) and 64-73PMWs (period B). GABA was assessed with the MEGA-PRESS method. N-acetyl aspartate (NAA), glutamate-glutamine complex (Glx), creatine (Cr), choline (Cho), and myo-inositol (Ins) were assessed with the PRESS method. Metabolite concentrations were automatically calculated using LCModel.

RESULTS

Data were collected from 20 preterm infants for periods A and B (medians [ranges], 30 [24-34] gestational weeks, 1281 [486-2030]g birth weight). GABA/Cr ratio decreased significantly in period B (p=0.03), but there was no significant difference in GABA/Cho ratios (p=0.58) between the two periods. In period B, NAA/Cr, Glx/Cr, NAA/Cho, and Glx/Cho ratios were significantly increased (p<0.01), whereas Cho/Cr, Ins/Cr, and Ins/Cho ratios were significantly decreased (p<0.01). There was no significant difference for GABA or Cho concentrations (p=0.52, p=0.22, respectively). NAA, Glx, and Cr concentrations were significantly increased (p<0.01), whereas Ins was significantly decreased (p<0.01).

CONCLUSIONS

Our results provide new information on normative values of brain metabolites in preterm infants.

Assessing Temporal Brain Metabolite Changes in Preterm Infants Using Multivoxel Magnetic Resonance Spectroscopy

PURPOSE

To investigate temporal changes in brain metabolites during the first year of life in preterm infants using multivoxel proton magnetic resonance spectroscopy ((1)H-MRS).

METHODS

Seventeen infants born at 29 (25-33) gestational week (median, range) weighing 1104 (628-1836) g underwent 1.5-T multivoxel (1)H-MRS at 42 postconceptional week (PCW) and at 3, 6, 9, and 12 months after. We measured N-acetyl aspartate (NAA)/creatine (Cr), choline (Cho)/Cr, myo-inositol (Ins)/Cr, NAA/Cho, and Ins/Cho ratios in the frontal lobe (FL) and basal ganglia and thalamus (BG + Th). Linear regression analyses were performed to identify longitudinal changes in infants showing normal imaging findings and normal development. We also evaluated ratios of subjects with abnormal imaging findings and/or development using the 95% confidence intervals (CIs) of regression equations in normal subjects.

RESULTS

In the 13 infants with normal development, NAA/Cr and NAA/Cho ratios showed significant positive correlations with PCWs in the FL (r = 0.64 and 0.83, respectively, both P < 0.01) and BG + Th (r = 0.79 and 0.87, respectively, both P < 0.01), while Cho/Cr and Ins/Cr ratios revealed significant negative correlations with PCWs in the FL (r =-0.69 and -0.58, respectively, both P < 0.01) and BG + Th (r =-0.74 and -0.72, respectively, both P < 0.01). Ins/Cho ratios in the FL did not significantly correlate with PCWs (r =-0.19, P = 0.18), while those in the BG + Th showed significant negative correlation with PCWs (r =-0.44, P < 0.01). The metrics in the abnormal group were within the normal group 95% CIs in all periods except a few exceptions.

CONCLUSIONS

Longitudinal multivoxel MRS is able to detect temporal changes in major brain metabolites during the first year of life in preterm infants.

Long-term neurodevelopmental outcome in high-risk newborns in resource-limited settings: a systematic review of the literature

BACKGROUND

Improving outcomes beyond survival for high-risk newborns in resource-limited settings is an emerging challenge. Global estimates demonstrate the scale of this challenge and significant gaps in morbidity outcome data in high mortality contexts. A systematic review was conducted to document the prevalence of neurodevelopmental impairment in high-risk newborns who were followed up into childhood in low- and middle-income countries.

METHODS

High-risk newborns were defined as low, very or extremely low birthweight, preterm infants or those surviving birth asphyxia or serious infections. Electronic databases were searched and articles screened for eligibility. Included articles were appraised according to STROBE criteria. Narrative review was performed and median prevalence of key neurodevelopmental outcomes was calculated where data quality allowed.

RESULTS

6959 articles were identified with sixty included in final review. At follow-up in early childhood, median estimated prevalence (inter-quartile range) of overall neurodevelopmental impairment, cognitive impairment and cerebral palsy were: for survivors of prematurity/very low birthweight 21.4% (11.6-30.8), 16.3% (6.3-29.6) and 11.2% (5.9-16.1), respectively, and for survivors of birth asphyxia 34.6% (25.4-51.5), 11.3% (7.7-11.8) and 22.8% (15.7-31.4), respectively. Only three studies reporting outcomes following newborn serious bacterial infections were identified. There was limited reporting of important outcomes such as vision and hearing impairment. Major challenges with standardised reporting of key exposure and developmental outcome variables and lack of control data were identified.

CONCLUSION

Understanding the limitations of the available data on neurodevelopmental outcome in newborns in resource-limited settings provides clear direction for research and efforts to improve long-term outcome in high-risk newborns in these settings.

Melatonin use for neuroprotection in perinatal asphyxia: a randomized controlled pilot study

OBJECTIVE

Melatonin has been shown to be neuroprotective in animal models. The objective of this study is to examine the effect of melatonin on clinical, biochemical, neurophysiological and radiological outcomes of neonates with hypoxic-ischemic encephalopathy (HIE).

STUDY DESIGN

We conducted a prospective trial on 45 newborns, 30 with HIE and 15 healthy controls. HIE infants were randomized into: hypothermia group (N=15; received 72-h whole-body cooling) and melatonin/hypothermia group (N=15; received hypothermia and five daily enteral doses of melatonin 10 mg kg(-1)). Serum melatonin, plasma superoxide dismutase (SOD) and serum nitric oxide (NO) were measured at enrollment for all infants (N=45) and at 5 days for the HIE groups (N=30). In addition to electroencephalography (EEG) at enrollment, all surviving HIE infants were studied with brain magnetic resonance imaging (MRI) and repeated EEG at 2 weeks of life. Neurologic evaluations and Denver Developmental Screening Test II were performed at 6 months.

RESULT

Compared with healthy neonates, the two HIE groups had increased melatonin, SOD and NO. At enrollment, the two HIE groups did not differ in clinical, laboratory or EEG findings. At 5 days, the melatonin/hypothermia group had greater increase in melatonin (P<0.001) and decline in NO (P<0.001), but less decline in SOD (P=0.004). The melatonin/hypothermia group had fewer seizures on follow-up EEG and less white matter abnormalities on MRI. At 6 months, the melatonin/hypothermia group had improved survival without neurological or developmental abnormalities (P<0.001).

CONCLUSION

Early administration of melatonin to asphyxiated term neonates is feasible and may ameliorate brain injury.

Evaluation of clinical course and neurocognition in children with self-limited infantile epilepsy in a Turkish cohort study

The outcome of children with self-limited infantile epilepsy was reported to be normal psychosocial and cognitive development as a characteristic criterion. We aimed to investigate the clinical course and neurocognitive outcome in children with self-limited infantile epilepsy in a Turkish cohort. The clinical course, electroencephalographic (EEG) characteristics, neuroimaging, treatment, and outcome of children with self-limited infantile epilepsy were retrospectively analyzed. All infants were reevaluated with the Denver Developmental Screening Test in addition to neurologic examination. Of 44 patients, self-limited familial infantile epilepsy was diagnosed in 8 infants (18.2%) and self-limited nonfamilial infantile epilepsy in 28 (63.6%). Interictal EEGs and neurologic examinations were normal in all cases. Fine motor and gross motor skills, language, adaptive personal/social skills were near-normal in all patients with self-limited familial infantile epilepsy. Delay in language parameters was observed in 2 infants with self-limited nonfamilial infantile epilepsy. Language skills should be thoroughly evaluated with detailed neurocognitive screening tests in patients with self-limited infantile epilepsy.

Evaluation of the psychometric properties of the Spanish version of the Denver Developmental Screening Test II

The objective of this study was to examine the psychometric properties of the Spanish version of the Denver Developmental Screening Test II in a population of Spanish children. Two hundred children ranging from 9 month to 6 years were grouped into two samples (healthy/with psychomotor delay) and screened in order to check whether they suffered from psychomotor delay. Children from three Early Intervention Centres and three schools participated in this study. Criterion validity was calculated by the method of extreme groups, comparing healthy children to those with development delay. Interobserver and intraobserver reliability were calculated using Cohen Kappa coefficient, and internal consistency was calculated via the Kuder-Richardson coefficient. The scale demonstrated 89% sensitivity, 92% specificity, a positive predicted value of 91% and a negative predicted value of 89%, whereas the positive and negative likelihood ratio was 11.12 and 0.12, respectively. Intraobserver reliability ranged from 0.662 to 1, and interobserver reliability ranged from 0.886 to 1. The Kuder-Richardson coefficient values ranged from 87.5 to 97.6%.

CONCLUSION

The Spanish version of the Denver Developmental Screening Test II was found to have a good criterion validity, reliability and internal consistency and is a suitable screening test for use in a population of Spanish children.

Intrapartum-related neonatal encephalopathy incidence and impairment at regional and global levels for 2010 with trends from 1990

BACKGROUND

Intrapartum hypoxic events ("birth asphyxia") may result in stillbirth, neonatal or postneonatal mortality, and impairment. Systematic morbidity estimates for the burden of impairment outcomes are currently limited. Neonatal encephalopathy (NE) following an intrapartum hypoxic event is a strong predictor of long-term impairment.

METHODS

Linear regression modeling was conducted on data identified through systematic reviews to estimate NE incidence and time trends for 184 countries. Meta-analyses were undertaken to estimate the risk of NE by sex of the newborn, neonatal case fatality rate, and impairment risk. A compartmental model estimated postneonatal survivors of NE, depending on access to care, and then the proportion of survivors with impairment. Separate modeling for the Global Burden of Disease 2010 (GBD2010) study estimated disability adjusted life years (DALYs), years of life with disability (YLDs), and years of life lost (YLLs) attributed to intrapartum-related events.

RESULTS

In 2010, 1.15 million babies (uncertainty range: 0.89-1.60 million; 8.5 cases per 1,000 live births) were estimated to have developed NE associated with intrapartum events, with 96% born in low- and middle-income countries, as compared with 1.60 million in 1990 (11.7 cases per 1,000 live births). An estimated 287,000 (181,000-440,000) neonates with NE died in 2010; 233,000 (163,000-342,000) survived with moderate or severe neurodevelopmental impairment; and 181,000 (82,000-319,000) had mild impairment. In GBD2010, intrapartum-related conditions comprised 50.2 million DALYs (2.4% of total) and 6.1 million YLDs.

CONCLUSION

Intrapartum-related conditions are a large global burden, mostly due to high mortality in low-income countries. Universal coverage of obstetric care and neonatal resuscitation would prevent most of these deaths and disabilities. Rates of impairment are highest in middle-income countries where neonatal intensive care was more recently introduced, but quality may be poor. In settings without neonatal intensive care, the impairment rate is low due to high mortality, which is relevant for the scale-up of basic neonatal resuscitation.

Desenvolvimento neuropsicomotor: o teste de Denver na triagem dos atrasos cognitivos e neuromotores de pré-escolares

O objetivo deste estudo foi verificar a prevalência e fatores associados no que se refere ao desempenho anormal do desenvolvimento neuropsicomotor de crianças matriculadas na educação infantil pública em Feira de Santana, Bahia, Brasil, em 2009 (n = 438). Esta é uma pesquisa epidemiológica de corte transversal, com amostragem por conglomerado e sorteio das escolas e crianças. Foram verificados os fatores associados por meio de aplicação de questionário às mães e de teste Denver II ao filho. A análise estatística realizou o teste χ2 com intervalo de 95% de confiança e α = 5%. A prevalência de desempenho anormal do desenvolvimento foi 46,3%. Na análise de regressão logística, as variáveis estatisticamente significantes associadas foram: sexo masculino (RP = 1,43; p = 0,00), cinco anos de idade (RP = 1,42; p = 0,00), não realização de pré-natal (RP = 1,41; p = 0,00), início do pré-natal > 3 meses (RP = 1,25; p = 0,00) e consumo alcoólico na gestação (RP = 1,55; p = 0,00). A prevalência foi elevada, apontando a necessidade de pré-natal precoce, alertando sobre o consumo alcoólico, e de vigilância nos primeiros anos de vida, visando a prevenir ou tratar precocemente as alterações.

Neurodevelopmental outcomes following ganciclovir therapy in symptomatic congenital cytomegalovirus infections involving the central nervous system

BACKGROUND

Ganciclovir protects against hearing deterioration in infants with symptomatic congenital cytomegalovirus (CMV) disease involving the central nervous system (CNS).

OBJECTIVES

To assess the neurodevelopmental impact of ganciclovir therapy in this population.

STUDY DESIGN

100 neonates were enrolled into a controlled Phase III study of symptomatic congenital CMV involving the CNS, and were randomized to either 6 weeks of intravenous ganciclovir or no treatment. Denver developmental tests were performed at 6 weeks, 6 months, and 12 months. For each age, developmental milestones that > or =90% of normal children would be expected to have achieved were identified. The numbers of milestones not met ("delays") were determined for each subject. The average number of delays per subject was compared for each treatment group.

RESULTS

At 6 months, the average number of delays was 4.46 and 7.51, respectively, for ganciclovir recipients and "no treatment" subjects (p=0.02). At 12 months, the average number of delays was 10.06 and 17.14, respectively (p=0.007). In a multivariate regression model, the effect of ganciclovir therapy remained statistically significant at 12 months (p=0.007).

CONCLUSIONS

Infants with symptomatic congenital CMV involving the CNS receiving intravenous ganciclovir therapy have fewer developmental delays at 6 and 12 months compared with untreated infants. Based on these data as well as the previously published data regarding ganciclovir treatment and hearing outcomes, 6 weeks of intravenous ganciclovir therapy can be considered in the management of babies with symptomatic congenital CMV disease involving the CNS. If treatment is initiated, it should be started within the first month of life and patients should be monitored closely for toxicity, especially neutropenia. Since existing data only address the treatment of symptomatic congenital CMV disease involving the CNS, these data cannot be extrapolated to neonates with other manifestations of CMV disease, including asymptomatic babies and symptomatic babies who do not have CNS involvement.

Ascorbic acid combined with ibuprofen in hypoxic ischemic encephalopathy: a randomized controlled trial

OBJECTIVE

Free oxygen radicals and proinflammatory cytokines are important causes for brain injury in neonates with hypoxic ischemic encephalopathy (HIE). Our objectives were to test the hypothesis that a combination of antioxidants (ascorbic acid) and anti-inflammatory agents (ibuprofen) can ameliorate the brain injury in HIE and improve neurodevelopmental outcomes when given to term infants immediately after birth.

STUDY DESIGN

In a prospective, randomized, double-blinded controlled trial, 60 asphyxiated term infants were assigned to one of two groups, intervention and control. The intervention group (n=30) received intravenous ascorbic acid and oral ibuprofen for 3 days; and the control group (n=30) received similar volumes of a placebo. We measured a panel of cytokines at enrollment and administered the treatment drugs within 2 h after birth. Neurological evaluations and developmental screenings were performed for all survivors at 6 months of age.

RESULT

The Intervention and Control groups did not differ in the severity of HIE at enrollment, the concentrations of IL-1 beta and IL-6, the incidence of mortality (37 vs 33%), the incidence of neurological abnormalities at hospital discharge (47 vs 55%) and the incidence of developmental delay at 6 months of age (32 vs 40%), respectively. None of the observed complications were related to intervention. Serum interleukin (IL)-1 beta and IL-6 concentrations correlated positively with the severity of HIE at birth (P<0.01), whereas only serum IL-6 correlated with neurodevelopmental outcome at 6 months (P<0.001).

CONCLUSION

Early administration of ascorbic acid and ibuprofen did not affect outcomes in infants with perinatal asphyxia. This study does not explain whether our intervention was not effective in blocking free radicals and inflammatory cytokines, if the dosing and route of administration were inadequate, or if other mediators existed that could have a more powerful role in brain injury during hypoxia-ischemia.

A review of developmental outcomes of term infants with post-asphyxia neonatal encephalopathy

BACKGROUND/AIMS

Post-asphyxia neonatal encephalopathy (NE) is one of the main causes of disabilities in term-born infants. This review attempted to investigate the developmental outcomes of term-born infants with post-asphyxia NE.

METHOD

An electronic search on various databases identified 13 empirical studies against the selection criteria modified from the consensus statement from the International Cerebral Palsy Task Force.

RESULTS

The overall quality of methodology of these studies was average. The random effect meta-estimate of the proportion of infants having adverse developmental outcomes such as death, cognitive impairment, sensory-motor impairments was 47% (95% CI 36-57%). Significant heterogeneity (I(2)=87.7%, p<0.00001) between studies indicated variations in number of subjects in studies and their characteristics. For those studies using the Sarnat grading of NE, the proportion of infants with adverse outcomes was nil in stage 1 (mild) NE, 32% in stage 2 (moderate) and almost 100% in stage 3 (severe) NE.

CONCLUSIONS

At present, researchers are using very loose diagnostic criteria of perinatal asphyxia and post-asphyxia NE, making the study samples heterogeneous. Clinicians and researchers are urged to make use of the recent consensus statement regarding diagnostic criteria for intrapartum asphyxia and to identify these high-risk infants for early intervention.

Relation between predischarge auditory brainstem responses and clinical factors in high-risk infants

BACKGROUND

Advances in perinatal medicine have increased the survival rate of infants admitted to neonatal intensive care units (NICU). Some of the infants will have health problems including hearing disorder and/or brainstem dysfunction, and may have associated communicative and cognitive difficulties and/or repeated apnea attacks that require therapy or care.

METHODS

In this study, the authors measured mean thresholds and mean I-V interpeak latencies in 56 high-risk infants and 30 controls who were about to be discharged from NICU. The authors retrospectively investigated whether predischarge auditory brainstem response (ABR) data, which seem to be related to a number of clinical factors affecting neonates, are useful for detecting hearing disorder and/or brainstem dysfunction, and we investigated six clinical factors.

RESULTS

The results showed that the positive risk factors for hearing impairment in infants who are about to be discharged from the NICU are: receiving mechanical ventilation (including for a period of <1 day) and the administration of five or more different antibiotics, especially in extremely low-birthweight (ELBW) infants. Another result showed that the high-risk mature infants had a significant high risk factor for brainstem dysfunction.

CONCLUSIONS

The findings of the study emphasize the importance of performing ABR examinations in high-risk infants, even in infants who are about to be discharged from an NICU. ABR examinations are especially important in ELBW infants or mature infants who have received mechanical ventilation or who have received five or more different antibiotics.