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

Early psychosocial parent-infant interventions and parent-infant relationships after preterm birth-a scoping review

Objective

Early psychosocial interventions for preterm infants and their parents are diverse. This study aimed to structure the knowledge on psychosocial parent-infant interventions and to identify gaps in the intervention studies.

Methods

We included studies on early (during first year of life) psychosocial parent-infant interventions with parent-infant relationship outcomes after preterm birth (< 37 weeks). We excluded studies that did not focus on preterm infants, failed to indicate the studied intervention and outcomes, were not written in English, were not controlled or peer-reviewed studies, or did not provide essential information for eligibility. The search included studies published between January 2000 and March 2024 in PubMed and PsycINFO. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed in reporting. Psychosocial parent-infant intervention studies were classified adapting the International Classification of Health Interventions (ICHI) and the Template for Intervention Description and Replication (TIDieR).

Results

The included 22 studies reported data from 18 different interventions with preterm infants (< 37 weeks). Studies excluded preterm infants with health risks (19/22, 86%), with very low gestational age and/or birth weight (7/22, 32%), and/or mothers with psychosocial risks (14/22, 64%). Of the 18 interventions, 12 (67%) were classified as counseling, 3 (17%) as emotional support, 2 (11%) as psychotherapeutic, and 1 (6%) as educational. The parent-child relationship was assessed using 30 different methods and varying time points up to 18 months of age. Most studies (17/22, 77%) reported positive changes in the parent-child relationship favoring the intervention group.

Conclusion

We identified four types of interventions to influence parenting behavior; the most used was counseling. All four intervention types showed positive effects on parent-infant relationships, although the preterm populations studied were selective, the effects were evaluated using different methods, and the follow-up periods were short. These findings indicate a need for studies with standardized methods, longer follow-up, and less-restricted preterm populations to develop guidelines for all families with preterm infants.

Burden of mental, behavioral, and neurodevelopmental disorders in the Finnish most preterm children: a national register study

Etiologies and the whole picture in childhood mental, behavioral, and neurodevelopmental disorders related to gestational age are unclear. This study included all Finnish children (N = 341,632) born between January 1, 2001, and December 31, 2006, whose data including their mothers (N = 241,284) were collected from national registers. Children with unclear gestational age (GA) (N = 1245), severe congenital malformations (N = 11,746), and moderate/severe/undefined cognitive impairment (N = 1140), and those who died during the perinatal period (N = 599) were excluded. The main outcome was the prevalence of mental and behavioral disorders (International Classification of Disorders) at 0 - 12 years of age in association with GA, adjusted for gender and prenatal variables. Out of all included (N = 326,902) children 16.6% (N = 54,270) were diagnosed to have any mental health disorder at 0 - 12 years. Adjusted Odd Ratio (OR) were for any disorder in preterm (< 37 weeks) 1.37 [1.28 - 1.46] and 4.03 [3.08 - 5.26] in extreme preterm (≤ 28 weeks) versus term born children, p < 0.05. The lower the GA at birth, the higher the risk for multiple disorders and earlier onset of disorder, p < 0.05. Adjusted ORs were for male/female 1.94 [1.90 - 1.99], maternal mental health disorder (yes/not) 1.99 [1.92 - 2.07], and smoking during pregnancy (yes/not) 1.58 [1.54 - 1.62], and these risks were more common in preterm versus term born children (p < 0.05). Extreme early birth was a strong risk factor per se for any or multiple and early shown mental health disorders. Other risk factors for mental health accumulated to preterm children.

[Changes in neonatal care : Implications for ophthalmological care]

BACKGROUND

Preterm infants are at risk of characteristic, sometimes life-threatening diseases and development of deficits related to immaturity. In the field of ophthalmology, retinopathy of prematurity (ROP) and vision impairment reflect structural and functional disturbances in this large group of patients. In high income countries, more and more very immature preterm infants survive into adolescence and adulthood.

OBJECTIVE

To characterize the impact of an increasing number of surviving individuals born preterm on the provision of ophthalmological care in Germany.

MATERIAL AND METHODS

A literature search and analysis of key figures and quality indicators published in national health registers were carried out.

RESULTS

Currently, about 60,000 preterm infants are born in Germany every year. Of these, approximately 3600 extremely immature preterm infants with a gestational age < 28 weeks are treated with a curative approach on neonatal units. The survival rate is around 80%. A rise in the proportion of infants suffering from severe ROP has not been observed in recent years in Germany. The incidences of other structural and functional visual impairments vary between 3% and 25% in high income countries.

CONCLUSION

The incidence of ROP apparently has not increased in Germany. However, specific peculiarities of the structure and function of the visual system of individuals born preterm have to be taken into account. Approximately 70,000 outpatient check-ups of infants and toddlers, who require both, ophthalmological and developmental neurological expertise, are estimated for Germany each year.

Taking Care Triple P for Foster Parents With Young Children in Foster Care: Results of a 1-Year Randomized Trial

Young children with a history of maltreatment or neglect in foster families often confront their caregivers with particularly challenging behaviors. This may lead to more parenting stress, an increased risk for the child in foster care to experience further maltreatment, and placement disruptions. We conducted a randomized controlled trial to investigate the efficacy of a parent group training tailored to the special needs of foster families. We hypothesized significant short- and long-term improvements regarding foster parents' parenting competencies, child mental health problems, and related outcomes. Eighty-one families with 87 children in foster care aged 2 to 7 years participated in the trial. For the intervention study, 44 randomly selected families (54%) were offered to participate in the parent group training. Intervention and control group families were reassessed three times over a period of 1 year. Contrary to our expectations, we found no advantages of the intervention group compared with the usual care control group on any outcome measure. Instead, we found some significant changes in both groups across time. Placement into foster care is associated with some favorable outcomes for children in foster care. Additional support for foster families beyond the services delivered in the youth welfare system to foster parents was not associated with more favorable outcomes. The present intervention is likely associated with a low risk of harm but also with a high likelihood of a lack of significant benefits for foster parents and their young children going beyond feeling satisfied about the delivered services. Participating foster families showed favorable baseline results on parenting measures which may have impeded intervention effects to unfold on these proximal variables.

Risk-Taking Propensity and Sensation Seeking in Survivors of Adverse Childhood Experiences

Risk-taking propensity and sensation seeking are developmentally meaningful traits for emerging adults, individuals ages 18 to 25 years. Adverse childhood experiences (ACEs) of childhood abuse and neglect, exposure to domestic violence, residing with a substance abusing or mentally ill caregiver, and growing up with an incarcerated family member negatively impact the well-being of emerging adults. However, the specific association between ACEs and risk-taking propensity and sensation seeking has not been previously examined in this age group. This study aims to determine whether ACEs are individually or cumulatively related to risk-taking propensity (assessed by the Domain-Specific Risk-Taking Scale) and sensation seeking (assessed by the Behavior Inhibition System/Behavior Approach System Scales) in a diverse sample of undergraduates, n = 436; M_age = 19.73 years (SD = 1.83 years); 67% female; 22% Hispanic. Multivariate ordinary least squares regressions were run to examine the association between ACEs and risk-taking propensity and sensation seeking. Individually, emotional abuse predicted greater inhibition (B = .28, p < .001), growing up with a mentally ill family member (B = -.12, p < .05) and emotional neglect (B = -.13, p < .05) predicted reduced motivation to pursue rewarding cues, and emotional neglect (B = -.12, p < .05) and witnessing domestic violence (B = -.10, p < .05) predicted less reward responsiveness. No cumulative effects were found. ACEs related to environmental instability may have a unique impact on sensation seeking domains in emerging adults. Clarifying the role of sensation seeking in emerging adults can contribute to better understanding of risk and resilience factors in this vulnerable population.

A self-comfort oriented pattern of regulatory behavior and avoidant attachment are more likely among infants born moderate-to-late preterm

Infants born preterm (<37 gestational weeks, GW) are at increased risk for regulatory difficulties and insecure attachment. However, the association between infants' regulatory behavior patterns and their later attachment organization is understudied in the preterm population. We addressed this gap by utilizing a Portuguese sample of 202 mother-infant dyads. Specifically, we compared the regulatory behavior patterns of 74 infants born moderate-to-late preterm (MLPT, 32-36 GW) to those of 128 infants born full-term (FT, 37-42 GW) and evaluated the associations of these regulatory patterns with later attachment. Infants' regulatory behavior patterns (Social-Positive Oriented, Distressed-Inconsolable, or Self-Comfort Oriented) were evaluated in the Face-to-Face-Still-Face paradigm at 3 months, and their attachment organization (secure, insecure-avoidant, or insecure-ambivalent) was evaluated in the Strange Situation at 12 months corrected age. In both samples, the Social-Positive-Oriented regulatory pattern was associated with secure attachment; the Distressed-Inconsolable pattern with insecure-ambivalent attachment; and the Self-Comfort-Oriented pattern with insecure-avoidant attachment. However, compared to FT infants, infants born MLPT were more likely to exhibit a Self-Comfort-Oriented pattern and avoidant attachment. Most perinatal and demographic variables were not related to infant outcomes. However, infants with a higher 1-min Apgar were more likely to exhibit the Social-Positive-Oriented regulatory pattern and secure attachment.

Completeness of Retention Data and Determinants of Attrition in Birth Cohorts of Very Preterm Infants: A Systematic Review

Background: Birth cohorts provided essential knowledge for clinical and public health decision-making. However, little is known about retention and determinants of attrition in these specific longitudinal studies, although characterizing predictors of attrition sets the path to mitigate its occurrence and to promote valid inferences. We systematically reviewed retention in follow-ups of birth cohorts of very preterm or very low birth weight infants and the determinants of attrition. PROSPERO registration number: CRD42017082672. Methods: Publications were identified through PubMed®, Scopus, Web of Science, and Cochrane Library databases from inception to December 2017. Studies were included when reporting at least one of the following: retention at follow-ups, reasons for attrition, or characteristics of non-participants. Quality assessment was conducted using the completeness of the report of participation features in the articles. Non-participant's characteristics were presented using descriptive statistics. Local polynomial regression was used to describe overall retention trends over years of follow-up. Results: We identified 57 eligible publications, reporting on 39 birth cohorts and describing 83 follow-up evaluations. The overall median retention was 87% (p25-p75:75.8-93.6), ranging from 14.6 to 100%. Overall, retention showed a downward trend with increasing child age. Completeness of retention report was considered "enough" in only 36.8% of publications. Considering the 33 (57.9%) publications providing information on participants and non-participants, and although no formal meta-analysis was performed, it was evident that participants lost to follow-up were more often male, had foreign-born, multiparous, and younger mothers, and with a lower socioeconomic status. Conclusion: This systematic review evidenced a lack of detailed data on retention, which may threaten the potential use of evidence derived from cohort studies of very preterm infants for clinical and public health purpose. It supports the requirement for a standardized presentation of retention features responding to current guidelines.

Academic Outcomes of School-Aged Children Born Preterm: A Systematic Review and Meta-analysis

IMPORTANCE

Children born preterm are at an elevated risk of academic underachievement. However, the extent to which performance across domain-specific subskills in reading and mathematics is associated with preterm birth remains unclear.

OBJECTIVE

To conduct a systematic review and meta-analysis of academic outcomes of school-aged children born preterm, compared with children born at term, appraising evidence for higher- and lower-order subskills in reading and mathematics.

DATA SOURCES

PubMed/MEDLINE, PsycINFO, and the Cumulative Index of Nursing and Allied Health Literature electronic databases from January 1, 1980, to July 30, 2018, were searched for population, exposure, and outcome terms such as child (population), preterm birth (exposure), and education* (outcome).

STUDY SELECTION

Peer-reviewed English-language publications that included preterm-born children and a comparison group of term-born children aged 5 to 18 years and born during or after 1980 and that reported outcomes on standardized assessments from cohort or cross-sectional studies were screened. Of the 9833 articles screened, 33 unique studies met the inclusion criteria.

DATA EXTRACTION AND SYNTHESIS

Data were analyzed from August 1 to September 29, 2018. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. Two reviewers independently screened the databases and extracted sample characteristics and outcomes scores. Pooled mean differences (MDs) were analyzed using random-effects models.

MAIN OUTCOMES AND MEASURES

Performance on standardized assessment of higher-order subskills of reading comprehension and applied mathematics problems; lower-order reading subskills of decoding, pseudoword decoding, and word identification; and lower-order mathematics subskills of knowledge, calculation, and fluency.

RESULTS

Outcomes data were extracted for 4006 preterm and 3317 term-born children, totaling 7323 participants from 33 unique studies. Relative to children born at term, children born preterm scored significantly lower in reading comprehension (mean difference [MD], -7.96; 95% CI, -12.15 to -3.76; I2 = 81%) and applied mathematical problems (MD, -11.41; 95% CI, -17.57 to -5.26; I2 = 91%) assessments. Across the assessments of lower-order skills, children born preterm scored significantly lower than their term-born peers in calculation (MD, -10.57; 95% CI, -15.62 to -5.52; I2 = 92%), decoding (MD, -10.18; 95% CI, -16.83 to -3.53; I2 = 71%), mathematical knowledge (MD, -9.88; 95% CI, -11.68 to -8.08; I2 = 62%), word identification (MD, -7.44; 95% CI, -9.08 to -5.80; I2 = 69%), and mathematical fluency (MD, -6.89; 95% CI, -13.54 to -0.23; I2 = 72%). The associations remained unchanged after sensitivity analyses for reducing heterogeneity.

CONCLUSIONS AND RELEVANCE

These findings provide evidence that preterm birth is associated with academic underperformance in aggregate measures of reading and mathematics, as well as a variety of related subskills.

Parenting style associations with sensory threshold and behaviour: a prospective cohort study in term/preterm infants

AIM

Early-life atypical sensory functioning and behavioural profiles are often associated with long-term developmental problems, especially in former preterm infants. We tested whether parenting style is associated with atypical sensory threshold or behavioural outcomes in preterm and term infants assessed during early childhood.

METHODS

We prospectively evaluated parenting style for a cohort of term and preterm infants who had previous assessments of sensory development and behaviour. We used standardised tools to evaluate parenting style, sensory neurological threshold at one year, and internalising and externalising behavioural tendencies at two years. Covariates included gestational age, sex and maternal education.

RESULTS

For the entire cohort (n = 82), children of more permissive parents were 2.7 times more likely to demonstrate abnormal sensory neurological thresholds compared to children of parents with less permissive styles (CI: 1.4-4.9). More permissive parenting scores were also associated with 2.4 times increased internalising (CI: 1.3-4.2) and 3.0 times increased externalising (CI: 1.6-5.6) tendencies. In the preterm group only, higher authoritative parenting scores were associated with fewer behavioural problems.

CONCLUSION

Permissive parenting is associated with worse infant sensory and behavioural outcomes. Authoritative parenting is associated with fewer behavioural problems in preterm children. Modification of parenting style may improve sensory development and behavioural outcomes.

Resilience in Extremely Preterm/Extremely Low Birth Weight Kindergarten Children

OBJECTIVES

Research on developmental outcomes of preterm birth has traditionally focused on adverse effects. This study investigated the prevalence and correlates of resilience in 146 extremely preterm/extremely low birth weight (EPT/ELBW) children (gestational age &lt;28 weeks and/or birth weight &lt;1000 g) attending kindergarten and 111 term-born normal birth weight (NBW) controls.

METHODS

Adaptive competence (i.e., "resilience" in the EPT/ELBW group) was defined by scores within grade expectations on achievement tests and the absence of clinically elevated parent ratings of child behavior problems. The "adaptive" children who met these criteria were compared to the "maladaptive" children who did not on child and family characteristics. Additional analyses were conducted to assess the conjoint effects of group (ELBW vs. NBW) and family factors on adaptive competence.

RESULTS

A substantial minority of the EPT/ELBW group (45%) were competent compared to a majority of NBW controls (73%), odds ratio (95% confidence interval)=0.26 (0.15, 0.45), p&lt;.001. Adaptive competence was associated with higher cognitive skills, more favorable ratings of behavior and learning not used to define adaptive competence, and more advantaged family environments in both groups, as well as with a lower rate of earlier neurodevelopmental impairment in the EPT/ELBW group. Higher socioeconomic status and more favorable proximal home environments were associated with competence independent of group, and group differences in competence persisted across the next two school years.

CONCLUSIONS

The findings document resilience in kindergarten children with extreme prematurity and highlight the role of environmental factors as potential influences on outcome. (JINS, 2019, 25, 362-374).

Behavior problems and executive function impairments in preterm compared to full term preschoolers

BACKGROUND

Children born preterm (PT) are at high risk for behavior problems and deficits in executive function (EF), a set of cognitive processes that guide goal-directed behaviors. Behavior differences have been found as early as 2 years in PT children; EF differences have been found in infancy. Whether behavior problems and EF deficits co-occur at young ages has not been fully investigated.

AIMS

To determine whether (1) PT children have more behavior problems and EF impairment than full term (FT) children and (2) larger proportions of PT children show behavior problems or EF impairments.

DESIGN/METHODS

PT (≤34 wks, n = 82) and FT (n = 79) preschoolers (mean age 4.4 years) completed an EF battery. Parents completed rating scales of behavior problems and EF skills. Mean scores and proportions with impairment were compared between groups. Logistic regression predicting to impairment defined odds ratios for PT/FT groups.

RESULTS

PT compared to FT had more problems on most behavior and EF scales and poorer EF scores on all tasks and greater proportion with impairments on most behavior scales, all EF ratings, and all EF tasks, p < .05. PT had elevated odds for impaired performance-based EF, parent-rated EF and CBCL scores compared to FT, p < .05. Within the PT group, EF impairments were twice as common as behavior impairment.

CONCLUSIONS

We recommend early identification of EF impairments in PT children. Future research should evaluate whether EF impairments serve as better early markers for later functional difficulties compared to behavior problems, as well as targets for intervention.

A multifactorial approach of nutritional, intellectual, brain development, cardiovascular risk, socio-economic, demographic and educational variables affecting the scholastic achievement in Chilean students: An eight- year follow-up study

The aim of this study was to quantitate the relative impact of nutritional, intellectual, brain development, cardiovascular risk, socio-economic, demographic and educational variables on the results of the 2009 Quality Education Measurement System (SIMCE) tests of language and mathematics for scholastic achievement (SA) applying a multifactorial approach, in school-age children of the 2010 5th elementary school grade (5ESG) and of the 1st grade of high school (1HSG). The purposes were: i) to test the hypothesis that intellectual ability, the level of SA of the educational establishments in the 2009 SIMCE tests, sex, parental schooling levels, and head circumference-for-age Z-score are the most relevant parameters associated with 2009 SIMCE outcomes; ii) to determine the predictive ability of the 2009 SIMCE results in determining the 2013 SIMCE outcomes for the 2010 5ESG cohort (when they graduated from elementary school, 8th grade) and for determining the 2013 University Selection Test (PSU) outcomes for the 2010 1HSG group (for university admission, when they graduated from high school, 4th grade); iii) to determine the association between the 2009 SIMCE results with the 2017 PSU outcomes for the 2010 5ESG group (for university admission, when they graduated from high school, 4th grade). A representative, proportional and stratified sample of 33 schools of the Metropolitan Region of Chile was randomly chosen. In these schools, 1,353 school-age children of both sexes, of the 2010 5ESG (n = 682; mean age = 10.8 years, SD = 0.6) and of the 2010 1HSG (n = 671; mean age = 14.8 years, SD = 0.6) participated. In both grades and tests, the findings confirm the hypotheses formulated. 2009 SIMCE outcomes were positively and significantly associated with 2013 SIMCE and with 2017 PSU and, with 2013 PSU outcomes in school-age children from 2010 5ESG and 1HSG, respectively. These findings may be useful for educational and health planning in Chile and countries in a comparable stage of development.

The interplay between prematurity, maternal stress and children's intelligence quotient at age 11: A longitudinal study

Very premature children (<33 weeks of gestational age (GA)) experience greater academic difficulties and have lower, though normal-range, intelligence quotients (IQs) versus their full-term peers. These differences are often attributed to GA or familial socio-economic status (SES). However, additional factors are increasingly recognized as likely contributors. Parental stress after a child's premature birth can present as post-traumatic stress disorder (PTSD) symptoms and can in turn reinforce difficulties in parent-child interaction pattern. Following a longitudinal design, we studied the interplay between a premature child's perinatal history and maternal PTSD symptoms on intelligence abilities assessed at 11 years of age. Thirty-three very preterm and 21 full-term mother-children dyads partook in the study. Children's perinatal risk was evaluated at hospital discharge, maternal PTSD symptoms were assessed when the children were 18 months old, and children's IQ was measured at 11 years old. IQ was significantly lower for preterm than full-term children, without reliable influences from perinatal risk scores. However, lower maternal PTSD symptoms predicted higher IQ in preterm children. This preliminary study highlights the importance detecting maternal PTSD symptoms after a preterm birth and suggests interventions should target reducing maternal PTSD symptoms during early childhood to enhance very preterm children's intelligence development.

The Impact of Prematurity on Social and Emotional Development

Behavioral and emotional problems are one of the most frequent chronic conditions diagnosed among children born prematurely. The high prevalence of these pathologies is a matter of concern because of their impact on family life, school performance, and social interaction, but also because of current limitations in early detection and access to treatment. This is a review of the various mechanisms by which premature birth affects social and emotional development, and a discussion about strategies that may help support emotional and social development in this high-risk population.

Postnatal Microstructural Developmental Trajectory of Corpus Callosum Subregions and Relationship to Clinical Factors in Very Preterm Infants

Our objectives were to define the microstructural developmental trajectory of six corpus callosum subregions and identify perinatal clinical factors that influence early development of these subregions in very preterm infants. We performed a longitudinal cohort study of very preterm infants (32 weeks gestational age or younger) (N = 36) who underwent structural MRI and diffusion tensor imaging serially at four time points - before 32, 32, 38, and 52 weeks postmenstrual age. We divided the corpus callosum into six subregions, performed probabilistic tractography, and used linear mixed effects models to evaluate the influence of antecedent clinical factors on its microstructural growth trajectory. The genu and splenium demonstrated the most rapid developmental maturation, exhibited by a steep increase in fractional anisotropy. We identified several factors that favored greater corpus callosum microstructural development, including advancing postmenstrual age, higher birth weight, and college level or higher maternal education. Bronchopulmonary dysplasia, low 5-minute Apgar scores, caffeine therapy/apnea of prematurity and male sex were associated with reduced corpus callosum microstructural integrity/development over the first six months after very preterm birth. We identified a unique postnatal microstructural growth trajectory and associated clinical factor profile for each of the six corpus callosum subregions that is consistent with the heterogeneous functional role of these white matter subregions.

Multiple Postnatal Infections in Newborns Born Preterm Predict Delayed Maturation of Motor Pathways at Term-Equivalent Age with Poorer Motor Outcomes at 3 Years

OBJECTIVES

To evaluate whether the number of postnatal infections is associated with abnormal white matter maturation and poorer motor neurodevelopmental outcomes at 36 months of corrected age.

STUDY DESIGN

A prospective longitudinal cohort study was undertaken of 219 newborns born preterm at 24-32 weeks of gestational age recruited between 2006 and 2013 with magnetic resonance imaging of the brain both early in life and at term-equivalent age. Postnatal infection was defined as any clinical infection or positive culture ≥72 hours after birth. White matter maturation was assessed by magnetic resonance spectroscopic imaging, magnetic resonance diffusion tensor imaging, and tract-based spatial statistics. Neurodevelopmental outcomes were assessed in 175 (82% of survivors) infants with Bayley Scales of Infant and Toddler Development-III composite scores and Peabody Developmental Motor Scales at 35 months of corrected age (IQR 34-37 months). Infection groups were compared via the Fisher exact test, Kruskal-Wallis test, and generalized estimating equations.

RESULTS

Of 219 neonates born preterm (median gestational age 27.9 weeks), 109 (50%) had no postnatal infection, 83 (38%) had 1 or 2 infections, and 27 (12%) had ≥3 infections. Infants with postnatal infections had more cerebellar hemorrhage. Infants with ≥3 infections had lower N-acetylaspartate/choline in the white matter and basal ganglia regions, lower fractional anisotropy in the posterior limb of the internal capsule, and poorer maturation of the corpus callosum, optic radiations, and posterior limb of the internal capsule on tract-based spatial statistics analysis as well as poorer Bayley Scales of Infant and Toddler Development-III (P = .02) and Peabody Developmental Motor Scales, Second Edition, motor scores (P < .01).

CONCLUSIONS

In newborns born preterm, ≥3 postnatal infections predict impaired development of the motor pathways and poorer motor outcomes in early childhood.

Short-term costs of preeclampsia to the United States health care system

BACKGROUND

Preeclampsia is a leading cause of maternal morbidity and mortality and adverse neonatal outcomes. Little is known about the extent of the health and cost burden of preeclampsia in the United States.

OBJECTIVE

This study sought to quantify the annual epidemiological and health care cost burden of preeclampsia to both mothers and infants in the United States in 2012.

STUDY DESIGN

We used epidemiological and econometric methods to assess the annual cost of preeclampsia in the United States using a combination of population-based and administrative data sets: the National Center for Health Statistics Vital Statistics on Births, the California Perinatal Quality Care Collaborative Databases, the US Health Care Cost and Utilization Project database, and a commercial claims data set.

RESULTS

Preeclampsia increased the probability of an adverse event from 4.6% to 10.1% for mothers and from 7.8% to 15.4% for infants while lowering gestational age by 1.7 weeks (P < .001). Overall, the total cost burden of preeclampsia during the first 12 months after birth was $1.03 billion for mothers and $1.15 billion for infants. The cost burden per infant is dependent on gestational age, ranging from $150,000 at 26 weeks gestational age to $1311 at 36 weeks gestational age.

CONCLUSION

In 2012, the cost of preeclampsia within the first 12 months of delivery was $2.18 billion in the United States ($1.03 billion for mothers and $1.15 billion for infants), and was disproportionately borne by births of low gestational age.

Predictors of Poor School Readiness in Children Without Developmental Delay at Age 2

BACKGROUND AND OBJECTIVES

Current recommendations emphasize developmental screening and surveillance to identify developmental delays (DDs) for referral to early intervention (EI) services. Many young children without DDs, however, are at high risk for poor developmental and behavioral outcomes by school entry but are ineligible for EI. We developed models for 2-year-olds without DD that predict, at kindergarten entry, poor academic performance and high problem behaviors.

METHODS

Data from the Early Childhood Longitudinal Study, Birth Cohort (ECLS-B), were used for this study. The analytic sample excluded children likely eligible for EI because of DDs or very low birth weight. Dependent variables included low academic scores and high problem behaviors at the kindergarten wave. Regression models were developed by using candidate predictors feasibly obtainable during typical 2-year well-child visits. Models were cross-validated internally on randomly selected subsamples.

RESULTS

Approximately 24% of all 2-year-old children were ineligible for EI at 2 years of age but still had poor academic or behavioral outcomes at school entry. Prediction models each contain 9 variables, almost entirely parental, social, or economic. Four variables were associated with both academic and behavioral risk: parental education below bachelor's degree, little/no shared reading at home, food insecurity, and fair/poor parental health. Areas under the receiver-operating characteristic curve were 0.76 for academic risk and 0.71 for behavioral risk. Adding the mental scale score from the Bayley Short Form-Research Edition did not improve areas under the receiver-operating characteristic curve for either model.

CONCLUSIONS

Among children ineligible for EI services, a small set of clinically available variables at age 2 years predicted academic and behavioral outcomes at school entry.

A simple screen performed at school entry can predict academic under-achievement at age seven in children born very preterm

AIM

We aimed to compare the academic outcomes of a cohort of children born very preterm (VPT, <32 weeks of gestation) and children born at term at age 7 years and assess the ability of a pre-academic skill screen at age five to predict later academic impairment in children born VPT at age seven.

METHODS

One hundred ninety-four children born VPT (born with either gestational age <30 weeks or birthweight <1250 g) and 70 controls born at term from a prospective birth cohort were compared on academic outcomes (Wide Range Achievement Test, WRAT4) at age seven using regression analyses. Receiver-operating characteristic curves were used to determine whether pre-academic skills (Kaufman Survey of Early Academic and Language Skills, K-SEALS) at age five predicted academic impairment at age seven in 174 of the VPT cohort.

RESULTS

At the age of 7 years, children born VPT had lower mean word reading (-9.7, 95% CI: -14.7 to -4.6), spelling (-8.3, 95% CI: -13.3 to -3.3) and math computation (-10.9, 95% CI: -15.3 to -6.5) scores (all P-values ≤0.001) compared with controls born at term, even after adjusting for social risk and time since school commencement. In terms of pre-academic screening, the Numbers, Letters and Words subtest of the K-SEALS had adequate sensitivity and specificity (70-80%) for predicting children with academic impairment at age seven.

CONCLUSIONS

Children born VPT underperformed in academic outcomes at age seven compared with controls born at term. A pre-academic screening tool used at school entry can predict children born VPT at risk of academic impairment at age seven who could benefit from targeted early intervention.

Mental health outcomes at age 11 of very low birth weight infants in Ireland

Aim To compare mental health (MH) outcomes of and service use by children born under 1500 g in Ireland with a matched control group.

METHOD

Using a retrospective cohort design, semi-structured and standardised MH assessments were conducted with parents, teachers and youth.

RESULTS

A total of 64 of 127 surviving children from a very low birth weight (VLBW) cohort from a National Maternity Hospital participated at a mean age of 11.6 years (s.d. 1.0), along with 51 matched controls. More VLBW children received clinical or borderline scores when rated by parents [χ 2 (1, n=114)=7.3, p=0.007] or youths [χ 2 (1, n=114)=4.83, p=0.028], but not by teachers [χ 2 (1, n=114)=1.243, p=0.463]. There was no increase in the use of MH services. A main effect of birth weight remained on the parent Strengths and Difficulties Questionnaire [F (1, 88)=5.07, p<0.05) after controlling for intelligence quotient (IQ) and socio-economic status (SES), but only on hyperactivity in males. SES, rather than IQ or birth weight, predicted identification of problems by teachers [F (1, 82)=6.99, p=0.01). Interpretations Teachers miss MH difficulties and are influenced more by SES than by IQ or birth weight. This has implications for MH service access. Initial perinatal investment needs to be matched with ongoing surveillance and psychoeducation to ensure that disorders are recognised early and offered appropriate interventions.

Impact of a Father Figure's Presence in the Household on Children's Psychiatric Diagnoses and Functioning in Families at High Risk for Depression

The consequences of living in single-parent households on children's wellbeing are well documented, but less is known about the impact of living in single-mother households among children with high familial risk for depression. Utilizing data from an ongoing three-generation study of high-risk families, this preliminary study examined a sample of 161 grandchildren of probands diagnosed with major depressive disorder, comparing those in single-parent households to those in dual-parent households with household status defined as the full-time presence of a resident male in the home. High-risk children were compared across households in terms of psychiatric diagnoses (measured by Schedule for Affective Disorders and Schizophrenia for School-Age Children; K-SADS-PL) and global functioning (assessed by Global Assessment Scale, child version; C-GAS). Results indicated that high-risk children in single-parent households had 4.7 times greater odds for developing a mood disorder and had significantly lower mean C-GAS scores (p = 0.01) compared to those in dual-parent households. Differences remained significant when controlling for household income, child's age, and either parent's depression status. There were no significant differences between high-risk children across households when household status was instead defined as legal marital status. This study has several limitations: sample size was small, pro-bands were recruited from a clinical population, and participants had not passed completely through the period of risk for adult psychiatric disorders. These findings point towards the importance of identifying and closely monitoring children at risk for depression, particularly if they reside in households without a resident father figure.

Postnatal Depressive Symptoms Among Mothers and Fathers of Infants Born Preterm: Prevalence and Impacts on Children's Early Cognitive Function

OBJECTIVE

Preterm birth is associated with lower cognitive functioning. One potential pathway is postnatal parental depression. The authors assessed depressive symptoms in mothers and fathers after preterm birth, and identified the impacts of both prematurity and parental depressive symptoms on children's early cognitive function.

METHOD

Data were from the nationally representative Early Childhood Longitudinal Study, Birth Cohort (n = 5350). Depressive symptoms at 9 months were assessed by the Center for Epidemiologic Studies Depression Scale (CESD) and children's cognitive function at 24 months by the Bayley Short Form, Research Edition. Weighted generalized estimating equation models examined the extent to which preterm birth, and mothers' and fathers' postnatal depressive symptoms impacted children's cognitive function at 24 months, and whether the association between preterm birth and 24-month cognitive function was mediated by parental depressive symptoms.

RESULTS

At 9 months, fathers of very preterm (<32 weeks gestation) and moderate/late preterm (32-37 weeks gestation) infants had higher CESD scores than fathers of term-born (≥37 weeks gestation) infants (p value = .02); preterm birth was not associated with maternal depressive symptoms. In multivariable analyses, preterm birth was associated with lower cognitive function at 24 months; this association was unaffected by adjustment for parental depressive symptoms. Fathers', but not mothers', postnatal depressive symptoms predicted lower cognitive function in the fully adjusted model (β = -0.11, 95% confidence interval, -0.18 to -0.03).

CONCLUSION

Fathers of preterm infants have more postnatal depressive symptomology than fathers of term-born infants. Fathers' depressive symptoms also negatively impact children's early cognitive function. The national findings support early identification and treatment of fathers of preterm infants with depressive symptoms.

Social development of children born very preterm: a systematic review

AIM

To review systematically studies examining the development of social competence in children born very preterm (VPT) (gestation <33 wks) and identify neonatal and family predictors.

METHOD

Peer-reviewed original articles were extracted from PubMed and PsycINFO following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Selection criteria included children born VPT and comparison children born at term, sample born after 1990, and children assessed between 0 and 17 years on at least one measure of social competence spanning social adjustment, performance, and/or social skills.

RESULTS

Twenty-three studies were included. Seven focused on social competence and another 16 examined social competence within a range of outcomes. Study quality was low. Limitations included reliance on single informant data, cross-sectional measurement, use of brief screening tools, absence of child or peer report, and no conceptual model. In terms of social adjustment, 16 out of 21 studies found children born VPT had more peer problems and social withdrawal. Findings of social performance were mixed, with some studies suggesting differences in prosocial behavior (4/14) and others not. Social skills were assessed in four studies and showed children born VPT had poorer skills than children born at term. Predictors of social competence included gestational age, neonatal brain abnormalities, and family socio-economic status.

INTERPRETATION

Children born VPT have poorer social competence. These difficulties emerge early and persist throughout childhood.

School performance after preterm birth

BACKGROUND

An increased risk of poor school performance for children born preterm has been shown in many studies, but whether this increase is attributable to preterm birth per se or to other factors associated with preterm birth has not been resolved.

METHODS

We used data from the Swedish Medical Birth Register, the Longitudinal Integration Database for Sickness Insurance and Labor Market Study, the Swedish Multigeneration Register, and the National School Register to link records comprising the Swedish birth cohorts from 1974 through 1991. Linear regression was used to assess the association between gestational duration and school performance, both with and without controlling for parental and socioeconomic factors. In a restricted analysis, we compared siblings only with each other.

RESULTS

Preterm birth was strongly and negatively correlated with school performance. The distribution of school grades for children born at 31-33 weeks was on average 3.85 (95% confidence interval = -4.36 to -3.35) centiles lower than for children born at 40 weeks. For births at 22-24 weeks, the corresponding figure was -23.15 (-30.32 to -15.97). When taking confounders into account, the association remained. When restricting the analysis to siblings, however, the association between school performance and preterm birth after week 30 vanished completely, whereas it remained, less pronounced, for preterm birth before 30 weeks of gestation.

CONCLUSIONS

Our study suggests that the association between school performance and preterm birth after 30 gestational weeks is attributable to factors other than preterm birth per se.

Comparison in outcomes at two-years of age of very preterm infants born in 2000, 2005 and 2010

Objective

To investigate alteration in 2-year neurological/behavioral outcomes of very preterm infants born in a French level three neonatal intensive care unit.

Methods

We conducted a prospective, comparative study of very preterm infants born before 33 weeks’ gestation at 5-year intervals in 2000, 2005 and 2010 at Rouen University Hospital. Neonatal mortality/morbidities, ante- and neonatal treatments, and at age 2 years motor, cognitive and behavioral data were collected by standardized questionnaires.

Results

We included 536 very preterm infants. Follow-up rates at two years old were 78% in 2000, 93% in 2005 and 92% in 2010 respectively. No difference in gestational age, birthweight, neonatal mortality/morbidities was observed except a decrease in low grade subependymal/intraventricular hemorrhages. Care modifications concerned use of antenatal magnesium sulfate, breast-feeding and post-natal corticosteroid therapy. Significant improvement in motor outcome and dramatic decrease in cerebral palsy rates (12% in 2000, 6% in 2005, 1% in 2010, p<0.001) were observed, as were improvements in feeding behavior. Although a non significant difference to better psychosocial behavior was reported, there was no difference in cognitive outcome.

Conclusions

Improvement in neuromotor outcome and behavior was reported. This could be due to multiple modifications in care: including administration of magnesium sulfate to women at risk of preterm birth, increase in breast-feeding, decrease in low grade subependymal/intraventricular hemorrhages, and decrease in post-natal corticosteroid therapy, all of which require further investigation in other studies. Extended follow-up until school age is mandatory for better detection of cognitive, learning and behavioral disorders.

Functional plasticity in childhood brain disorders: when, what, how, and whom to assess

At every point in the lifespan, the brain balances malleable processes representing neural plasticity that promote change with homeostatic processes that promote stability. Whether a child develops typically or with brain injury, his or her neural and behavioral outcome is constructed through transactions between plastic and homeostatic processes and the environment. In clinical research with children in whom the developing brain has been malformed or injured, behavioral outcomes provide an index of the result of plasticity, homeostasis, and environmental transactions. When should we assess outcome in relation to age at brain insult, time since brain insult, and age of the child at testing? What should we measure? Functions involving reacting to the past and predicting the future, as well as social-affective skills, are important. How should we assess outcome? Information from performance variability, direct measures and informants, overt and covert measures, and laboratory and ecological measures should be considered. In whom are we assessing outcome? Assessment should be cognizant of individual differences in gene, socio-economic status (SES), parenting, nutrition, and interpersonal supports, which are moderators that interact with other factors influencing functional outcome.

Postpartum depression on the neonatal intensive care unit: current perspectives

As the most common complication of childbirth affecting 10%–15% of women, postpartum depression (PPD) goes vastly undetected and untreated, inflicting long-term consequences on both mother and child. Studies consistently show that mothers of infants in the neonatal intensive care unit (NICU) experience PPD at higher rates with more elevated symptomatology than mothers of healthy infants. Although there has been increased awareness regarding the overall prevalence of PPD and recognition of the need for health care providers to address this health issue, there has not been adequate attention to PPD in the context of the NICU. This review will focus on an overview of PPD and psychological morbidities, the prevalence of PPD in mothers of infants admitted to NICU, associated risk factors, potential PPD screening measures, promising intervention programs, the role of NICU health care providers in addressing PPD in the NICU, and suggested future research directions.

Predictive validity of the Bayley, Third Edition at 2 years for intelligence quotient at 4 years in preterm infants

OBJECTIVE

To determine the predictive validity of the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) at age 2 years for cognitive abilities in preschool children born at ≤ 30 weeks' gestation.

METHODS

This prospective regional study included all 187 liveborn infants ≤ 30 weeks' gestation born between July 2005 and June 2006. Of the 172 children who survived to 4 years, 156 (91%) were evaluated at 2 and 4 years. A socioeconomically matched term control group also was recruited to provide normative data. The predictive validity of the Bayley-III cognitive and language scales for the Weschler Preschool and Primary Scale of Intelligence-III (WPPSI-III) was examined through correlation coefficients and sensitivity and specificity of the Bayley-III to predict normal and abnormal cognitive outcomes.

RESULTS

Correlations of the WPPSI-III intelligence quotient (IQ) score with the Bayley-III cognitive and language scores were .81 and .78, respectively. The preterm children were classified as normal (Bayley Scales of Infant Development-Third Edition [BSID-III] cognitive score or WPPSI-III IQ score not lower than 1 SD below the control group mean), mild to moderately delayed (scores between 1 and 2 SD deviations below the control group mean), or severely delayed (scores greater than 2 SD below the control group mean). At 2 and 4 years, 126 (81%) preterm children retained the same developmental classification.

CONCLUSIONS

In contrast with previous editions of the BSID, the Bayley-III has strong predictive validity for WPPSI-III IQ at age 4 years in preterm children. This has important implications for more timely evaluation of perinatal interventions, establishment of guidelines for neonatal care, and counseling parents.

Mathematics difficulties in children born very preterm: current research and future directions

Children born very preterm have poorer attainment in all school subjects, and a markedly greater reliance on special educational support than their term-born peers. In particular, difficulties with mathematics are especially common and account for the vast majority of learning difficulties in this population. In this paper, we review research relating to the causes of mathematics learning difficulties in typically developing children, and the impact of very preterm birth on attainment in mathematics. Research is needed to understand the specific nature and origins of mathematics difficulties in very preterm children to target the development of effective intervention strategies.

Risk of developmental delay increases exponentially as gestational age of preterm infants decreases: a cohort study at age 4 years

AIM

The aim of the study was to assess the influence of decreasing gestational age on the risk of developmental delay in various domains at age 4 years among children born at a wide range of gestational ages.

METHOD

In a community-based cohort, the parents of 1439 preterm-born children (24 0/7 to 35 6/7 wks) and 544 term-born children (38 0/7 to 41 6/7 wks') born in 2002 and 2003 completed the Ages and Stages Questionnaire (ASQ) when their child was 3 years 7 months to 4 years 1 month old. The prevalence rates of abnormal scores on the ASQ-total problems scale were compared in preterm and term-born children and the resulting odds ratios for gestational age groups were calculated and adjusted for social and biological covariates.

RESULTS

The prevalence rates of abnormal scores on the ASQ-total problems scale increased with decreasing gestational age: from 4.2% among term-born children to 37.5% among children born at 24-25 weeks' gestation (p<0.001). The risk of an abnormal ASQ-total score increased exponentially with decreasing gestational age compared with children born at term (odds ratio per week of gestation 1.14, 95% confidence interval 1.09-1.19). A similar exponential pattern was seen on all underlying ASQ domains, both before and after adjustment.

INTERPRETATION

The risk of developmental delay increases exponentially with decreasing gestational age below 36 weeks' gestation on all developmental domains of the ASQ. Adjustment for covariates did not alter the pattern of exponential increase in developmental risk with decreasing gestational age. We speculate that both direct perinatal cerebral injuries and tropic and maturational brain disturbances are involved.

Executive function skills are associated with reading and parent-rated child function in children born prematurely

BACKGROUND

Preterm children are at risk for executive function (EF) problems, which have been linked to behavior and learning problems in full term children. In this study, we examine the relationship between EF and functional outcomes in preterm children.

AIM

To evaluate (1) EF skills of 9- to 16-year-old children born across the spectrum of gestational age (GA), (2) relationship of degree of prematurity to EF skills, and (3) contributions of EF skills to two functional outcomes - reading scores and parent-rated child function.

METHOD

Preterm children <36 weeks gestation (n=72) were compared to full term children (n=42) of similar age, gender and SES, on measures of EF, reading, and parent-ratings of child function. Multiple regression models evaluated contributions to EF skills and functional outcomes.

RESULTS

Compared to full term controls, preterm children had poorer EF performance on a complex planning and organization task and did not increase planning time as task difficulty increased. Their spatial memory capacity was not different. GA contributed to EF skills, but was mediated by IQ. EF contributed to the variance in reading skills but did not add to the variance in reading when IQ was considered. EF skills significantly contributed to the variance in parent-rated child function, but IQ did not.

CONCLUSION

EF skills contribute to measures of functional outcome in this high-risk population. The use of EF skills as an early marker for learning and functional problems and as a target for intervention in children born preterm warrants future study.

[Nursing diagnoses in in-rooming units]

The use of nursing diagnoses in the rooming unit aims to guide nursing actions, qualifying the assistance. The aim was to identify the Nursing Diagnoses (ND) according to the taxonomy NANDA II 2007/2008, in newborns, and to describe the facts related to it and the risk factors. It is an exploratory descriptive study, conducted with 35 newborns, in January 2008. After physical examination, one identified the ND. The data were organized in charts. Out of the results the most common diagnoses were efficient and inefficient breastfeeding, risk of infection and damaged skin integrity. The use of ND makes nursing service more structured, favoring the nurse's autonomy in the care rendered to the newborn.

Special care and school difficulties in 8-year-old very preterm children: the Epipage cohort study

OBJECTIVES

To investigate school difficulties, special care and behavioral problems in 8 year-old very preterm (VPT) children.

PATIENT AND METHODS

Longitudinal population-based cohort in nine regions of France of VPT children and a reference group born at 39-40 weeks of gestation (WG). The main outcome measures were information about school, special care and behavioral problems using Strengths and Difficulties Questionnaire from a questionnaire to parents.

RESULTS

Among the 1439 VPT children, 5% (75/1439) were in a specialised school or class, 18% (259/1439) had repeated a grade in a mainstream class and 77% (1105/1439) were in the appropriate grade-level in mainstream class; these figures were 1% (3/327) , 5% (16/327) and 94% (308/327) , respectively, for the reference group. Also, 15% (221/1435) of VPT children in a mainstream class received support at school versus 5% (16/326) of reference group. More VPT children between the ages of five and eight years received special care (55% (794/1436)) than children born at term (38% (124/325)); more VPT children (21% (292/1387)) had behavioral difficulties than the reference group (11% (35/319)). School difficulties, support at school, special care and behavioral difficulties in VPT children without neuromotor or sensory deficits varied with gestational age, socioeconomic status, and cognitive score at the age of five.

CONCLUSIONS

Most 8-year-old VPT children are in mainstream schools. However, they have a high risk of difficulty in school, with more than half requiring additional support at school and/or special care. Referral to special services has increased between the ages of 5 and 8 years, but remained insufficient for those with borderline cognitive scores.

Behavior problems of 9-16 year old preterm children: biological, sociodemographic, and intellectual contributions

BACKGROUND

Preterm children are at risk for behavior problems. Studies examining contributions of intellectual and environmental factors to behavior outcomes in preterm children are mixed.

AIMS

(1) To identify the nature of maladaptive behaviors in preterm children age 9 to 16 years born across the spectrum of gestational age and birth weight (BW). (2) To examine contributions of BW as a biological factor, socioeconomic status as an environmental factor, and intelligence quotient (IQ) as indicative of intellectual ability to behavior outcomes.

METHOD

Using the Child Behavior Checklist, parent reports of behavior for 63 preterm children (gestational age 24 to <36 weeks) were compared to 29 full term children of similar age, gender and socioeconomic status. Multiple regression models evaluated effects of prematurity, socioeconomic status, and intellectual ability on behavioral symptom scores.

RESULTS

Preterm children had higher total and internalizing problem scores compared to full term children. They also had lower IQ. BW was a significant predictor of total and internalizing behavior problems. Among the syndrome scales, anxious/depressed and attention problems were elevated. Socioeconomic status did not contribute to behavior scores. IQ contributed to total, but not to internalizing or externalizing, scores. IQ contributed to attention problems, but not to anxious/depressed scores.

CONCLUSION

Preterm children had increased behavior problems, especially symptoms of inattention and anxiety. Lower BW predicted more behavior problems. IQ acted as a mediator between BW and attention scores, but not anxiety scores. These findings alert health care providers to assess anxiety in all preterm children regardless of intellectual ability and additional study on the influence of intellectual ability on behavioral outcomes in preterm children is needed.

Specific language and reading skills in school-aged children and adolescents are associated with prematurity after controlling for IQ

Although studies of long-term outcomes of children born preterm consistently show low intelligence quotient (IQ) and visual-motor impairment, studies of their performance in language and reading have found inconsistent results. In this study, we examined which specific language and reading skills were associated with prematurity independent of the effects of gender, socioeconomic status (SES), and IQ. Participants from two study sites (N=100) included 9-16-year old children born before 36 weeks gestation and weighing less than 2500 grams (preterm group, n=65) compared to children born at 37 weeks gestation or more (full-term group, n=35). Children born preterm had significantly lower scores than full-term controls on Performance IQ, Verbal IQ, receptive and expressive language skills, syntactic comprehension, linguistic processing speed, verbal memory, decoding, and reading comprehension but not on receptive vocabulary. Using MANCOVA, we found that SES, IQ, and prematurity all contributed to the variance in scores on a set of six non-overlapping measures of language and reading. Simple regression analyses found that after controlling for SES and Performance IQ, the degree of prematurity as measured by gestational age group was a significant predictor of linguistic processing speed, β=-.27, p<.05, R(2)=.07, verbal memory, β=.31, p<.05, R(2)=.09, and reading comprehension, β=.28, p<.05, R(2)=.08, but not of receptive vocabulary, syntactic comprehension, or decoding. The language and reading domains where prematurity had a direct effect can be classified as fluid as opposed to crystallized functions and should be monitored in school-aged children and adolescents born preterm.

Predictors of the risk of cognitive deficiency in very preterm infants: the EPIPAGE prospective cohort

Aim

To assess cerebral lesions and other medical as well as social characteristics as predictors of risk of mild and severe cognitive deficiencies in very preterm infants.

Methods

As part of the EPIPAGE population-based prospective cohort study, perinatal data and cognitive outcome at 5 years of age were recorded for 1503 infants born before 33 weeks of gestation in nine regions of France in 1997. Mild cognitive deficiency was defined as a Mental Processing Composite score on the Kaufman Assessment Battery for Children test of between 70 and 84, and severe cognitive deficiency as a score of <70.

Results

After controlling for cerebral lesions and other medical as well as social factors, low parental socio-economic status and lack of breastfeeding were significant predictors of mild and severe cognitive deficiencies, whereas presence of cerebral lesions, being small for gestational age and having a large number of siblings were predictors of severe cognitive deficiency.

Conclusion

Predictors of poor cognitive outcome in very preterm infants are low social status, lack of breastfeeding, presence of cerebral lesions on ultrasound scan, being born small for gestational age and having a high number of siblings. Social factors predicted both mild and severe cognitive deficiencies, whereas medical factors predicted mostly severe cognitive deficiencies.

A neurobehavioral intervention and assessment program in very low birth weight infants: outcome at 24 months

OBJECTIVE

To determine whether the Infant Behavioral Assessment and Intervention Program (IBAIP) improves development and behavior in very low birth weight (VLBW) infants at 24-month corrected age.

STUDY DESIGN

In a multicenter, randomized, controlled trial 86 infants received postdischarge intervention until 6-month corrected age. The intervention consisted of supporting infants' self-regulation and development, and facilitating sensitive parent-infant interactions; 90 control infants received regular care. At 6 months, positive intervention effects were found. At 24 months, development and behavior were evaluated with the Bayley Scales of Infant Development-II (BSID-II) and the Child Behavior Check List (CBCL).

RESULTS

Eighty-three intervention and 78 control infants were available for follow-up. After adjustment for differences in perinatal characteristics, an intervention effect of 6.4 points (+/- standard error, 2.4) on the Psychomotor Developmental Index favored the intervention infants. Groups did not differ on the Mental Developmental Index, the Behavioral Rating Scale of the BSID-II, or on the CBCL. Subgroup analyses revealed improved motor as well as improved mental outcomes in intervention infants with bronchopulmonary dysplasia and with combined biological and social risk factors.

CONCLUSIONS

The IBAIP shows sustained motor improvement in VLBW infants until 2-year corrected age.

Feeding preterm infants milk with a higher dose of docosahexaenoic acid than that used in current practice does not influence language or behavior in early childhood: a follow-up study of a randomized controlled trial

BACKGROUND

The visual and mental development of preterm infants improved after feeding them milk enriched with docosahexaenoic acid (DHA) in amounts matching the fetal accretion rate.

OBJECTIVE

The objective was to evaluate whether feeding preterm infants milk with a higher DHA content than that used in current practice influences language or behavior in early childhood.

DESIGN

This was a follow-up study in a subgroup of infants enrolled in the DINO (Docosahexaenoic acid for the Improvement in Neurodevelopmental Outcome) trial. In a double-blind randomized controlled trial, infants born at <33 wk of gestation were fed milk containing 1% of total fatty acids as DHA (higher-DHA group) or approximately 0.3% DHA (control group) until reaching full-term equivalent age. The longer-term effects of the intervention on language, behavior, and temperament were measured by using the MacArthur Communicative Development Inventory (MCDI) at 26-mo corrected age, the Strengths and Difficulties Questionnaire (SDQ), and the Short Temperament Scale for Children (STSC) between 3- and 5-y corrected age.

RESULTS

Mean (+/-SD) MCDI scores did not differ significantly (adjusted P = 0.8) between the higher-DHA group (308 +/- 179, n = 60) and the control group (316 +/- 192, n = 67) per the Vocabulary Production subscale. Composite scores on the SDQ and STSC did not differ between the higher-DHA group and the control group [SDQ Total Difficulties: higher-DHA group (10.3 +/- 6.0, n = 61), control group (9.5 +/- 5.5, n = 64), adjusted P = 0.5; STSC score: higher-DHA group (3.1 +/- 0.7, n = 61), control group (3.0 +/- 0.7, n = 64), adjusted P = 0.3].

CONCLUSIONS

Feeding preterm infants milk containing 3 times the standard amount of DHA did not result in any clinically meaningful change to language development or behavior when assessed in early childhood. Whether longer-term effects of dietary DHA supplementation can be detected remains to be assessed. This trial was registered with the Australia and New Zealand Clinical Trial Registry at www.anzctr.org.au as 12606000327583.

Outcome of extreme prematurity: a prospective comparison of 2 regional cohorts born 20 years apart

OBJECTIVE

To determine changes that have occurred over the past 20 years in perinatal characteristics, neonatal treatments, morbidities, and early neurodevelopmental outcomes of infants born at < or =30 weeks' gestation.

METHODS

This was a prospective regional study including all live-born infants < or =30 weeks' gestation born between July 1985 and June 1986 (cohort 1) and July 2005 and June 2006 (cohort 2). Sociodemographically matched term controls were recruited for each cohort. Perinatal characteristics, mortality rates, and survival with and without impairments at 24 months' corrected age were compared.

RESULTS

There was a 35% increase in the number of live-born preterm births (138 in cohort 1 and 187 in cohort 2) despite a >10% decline in total births in the region (P < .001). Assisted fertility (rarely available for mothers in cohort 1) was responsible for 20% of pregnancies in cohort 2. Survival to hospital discharge increased over 20 years from 82% to 93% (P = .002), primarily because of higher survival for infants born at <27 weeks' gestation (63% vs 88%; P = .004). Changes in management in cohort 2 included the use of surfactant (62% of infants) and increased use of postnatal steroids (39% vs 9%; P < .001), that were associated with a shorter median duration of mechanical ventilation (13 vs 21 days; P < .001); however, the incidence of bronchopulmonary dysplasia was higher in cohort 2 (56% vs 35%; P < .001). There was a significant decrease in incidence of severe ultrasound abnormalities from 17% in cohort 1 to 7% in cohort 2 (P = .008). At 24 months of age, 7% of cohort 1 and 5% of cohort 2 had an abnormal neurologic exam. Bayley cognitive scores were improved in cohort 2 (significantly closer to the mean of their controls). As a result, survival without severe neurodevelopmental impairment increased from 62% in cohort 1 to 81% in cohort 2 (P < .001).

CONCLUSION

Over 20 years, there has been a significant increase in live births at < or =30 weeks' gestational age, with a greater percentage of these neonates surviving without severe neurodevelopmental impairment at 24 months.

Meta-analysis of neurobehavioral outcomes in very preterm and/or very low birth weight children

OBJECTIVE

Sequelae of academic underachievement, behavioral problems, and poor executive function (EF) have been extensively reported for very preterm (<or=33 weeks' gestation) and/or very low birth weight (VLBW) (<or=1500 g) children. Great variability in the published results, however, hinders the field in studying underlying dysfunctions and developing intervention strategies. We conducted a quantitative meta-analysis of studies published between 1998 and 2008 on academic achievement, behavioral functioning, and EF with the aim of providing aggregated measures of effect size for these outcome domains.

METHODS

Suitable for inclusion were 14 studies on academic achievement, 9 studies on behavioral problems, and 12 studies on EF, which compared a total of 4125 very preterm and/or VLBW children with 3197 term-born controls. Combined effect sizes for the 3 outcome domains were calculated in terms of Cohen's d. Q-test statistics were performed to test homogeneity among the obtained effect sizes. Pearson's correlation coefficients were calculated to examine the impact of mean birth weight and mean gestational age, as well as the influence of mean age at assessment on the effect sizes for academic achievement, behavioral problems, and EF.

RESULTS

Combined effect sizes show that very preterm and/or VLBW children score 0.60 SD lower on mathematics tests, 0.48 SD on reading tests, and 0.76 SD on spelling tests than term-born peers. Of all behavioral problems stacked, attention problems were most pronounced in very preterm and/or VLBW children, with teacher and parent ratings being 0.43 to 0.59 SD higher than for controls, respectively. Combined effect sizes for parent and teacher ratings of internalizing behavior problems were small (<0.28) and for externalizing behavior problems negligible (<0.09) and not significant. Combined effect sizes for EF revealed a decrement of 0.57 SD for verbal fluency, 0.36 SD for working memory, and 0.49 SD for cognitive flexibility in comparison to controls. Mean age at assessment was not correlated with the strength of the effect sizes. Mathematics and reading performance, parent ratings of internalizing problems, teacher ratings of externalizing behavior, and attention problems, showed strong and positive correlations with mean birth weight and mean gestational age (all r values > 0.51).

CONCLUSIONS

Very preterm and/or VLBW children have moderate-to-severe deficits in academic achievement, attention problems, and internalizing behavioral problems and poor EF, which are adverse outcomes that were strongly correlated to their immaturity at birth. During transition to young adulthood these children continue to lag behind term-born peers.

Strong families, tidy houses, and children’s values in adult life: Are “chaotic”, “crowded” and “unstable” homes really so bad?

Chaotic home systems have been linked with children’s adverse psychological and academic outcomes. But, as they represent a departure from the suburban ideal of space, order, and family cohesiveness and stability, they should also be linked with low support for survival values. Using longitudinal data from the 1970 British Cohort Study (BCS70) this study tested this by examining long-term links between chaotic home systems (assessed when cohort members were aged 0—10 years), and support for survival values (racism and authoritarianism) at age 30. A chaotic home system was operationalized in this study as family disruption, low family cohesiveness, overcrowding, untidiness, and residential mobility. The study showed that, after adjustment for controls (mother’s liberalism, authoritarian parenting and educational attainment, family’s social class and material disadvantage, and child’s ethnicity, gender, general ability and adult educational attainment), residential mobility and untidiness were negatively related to authoritarianism and to support for racism, and family cohesiveness was positively and overcrowding negatively related to authoritarianism.

Risk factors affecting school readiness in premature infants with respiratory distress syndrome

OBJECTIVE

With advances in neonatal care, more children born prematurely are successfully reaching school age. It is unknown how many will be ready for school and what factors affect school readiness. Our objective was to assess readiness of children born prematurely for entry into public school, and determine risk factors associated with lack of school readiness in this population.

METHODS

This was a single-center prospective cohort study. Follow- up data were collected for 135 of 167 (81%) surviving premature infants with RDS requiring surfactant-replacement therapy. The children were seen between July 2005 and September 2006 (average age: 5.7 +/- 1.0 years) and underwent standardized neurodevelopmental and health assessments and socioeconomic status classification. A 4-level school-readiness score was constructed by using each child's standardized scores on assessments of basic concepts (Bracken School-Readiness Assessment), perceptual skills (Visual-Motor Integration Test), receptive vocabulary (Peabody Picture Vocabulary Test, Third Edition), daily living functional skills (Pediatric Functional Independence Measure), and presence of sensory impairments or autism. Proportional odds models were used to identify risk factors predicting lower school-readiness levels.

RESULTS

Mean birth weight was 1016 +/- 391 g, and mean gestational age was 27.5 +/- 2.6 weeks. Ninety-one (67%) children were school-ready. Using multivariate analysis, male gender, chronic lung disease, and severe intraventricular hemorrhage or periventricular leukomalacia were associated with lower school-readiness levels. However, the most powerful factor determining school-readiness level was low socioeconomic status.

CONCLUSION

Interventions targeting neonatal morbidities may be much less effective at improving overall performance at school age compared with the effect of the impoverished social environment.

Early interventions involving parents to improve neurodevelopmental outcomes of premature infants: a meta-analysis

OBJECTIVE

To determine in a systematic review, whether interventions for infant development that involve parents, improve neurodevelopment at 12 months corrected age or older.

STUDY DESIGN

Randomized trials were identified where an infant intervention was aimed to improve development and involved parents of preterms; and long-term neurodevelopment using standardized tests at 12 months (or longer) was reported.

RESULT

Identified studies (n=25) used a variety of interventions including parent education, infant stimulation, home visits or individualized developmental care. Meta-analysis at 12 months (N=2198 infants) found significantly higher mental (N=2198) and physical (N=1319) performance scores favoring the intervention group. At 24 months, the mental (N=1490) performance scores were improved, but physical (N=1025) performance scores were not statistically significant. The improvement in neurodevelopmental outcome was not sustained at 36 months (N=961) and 5 years (N=1017).

CONCLUSION

Positive clinically meaningful effects (>5 points) are seen to an age of 36 months, but are no longer present at 5 years.

Intrauterine, early neonatal, and postdischarge growth and neurodevelopmental outcome at 5.4 years in extremely preterm infants after intensive neonatal nutritional support

OBJECTIVE

Extremely preterm infants are at risk for poor growth and impaired neurodevelopment. The objective of this study was to determine whether intrauterine, early neonatal, or postdischarge growth is associated with neurocognitive and motor-developmental outcome in extremely preterm infants.

METHODS

Surviving children who were born between July 1996 and June 1999 at <30 weeks' gestation and with a birth weight <1500 g were evaluated at the age of school entry by application of (1) a standardized neurologic evaluation, (2) the Kaufmann Assessment Battery for Children, and (3) the Gross Motor Function Classification Scale. Growth was assessed on the basis of SD scores of weight and head circumference measured at birth, at discharge, and at the time of the follow-up examination. All infants had received intensive early nutritional support.

RESULTS

A total of 219 (83%) of 263 long-term survivors were evaluated at a median corrected age of 5.4 years. Increasing SD scores for weight and head circumference from birth to discharge were associated with a reduced risk for an abnormal neurologic examination. Catch-up growth of head circumference from birth to discharge was also associated with a reduced risk for impaired mobility. Weight SD score at birth, an increase of weight SD score from birth to discharge, and an increase of head circumference SD score from discharge to follow-up had an effect on the mental processing composite score. The effects of growth on neurodevelopment were by far exceeded by the consequences of intraventricular and periventricular hemorrhage.

CONCLUSIONS

Growth from birth to discharge seemed to be associated with long-term motor development. Cognitive development was associated with intrauterine growth measured as weight at birth, early neonatal weight gain, and postdischarge head circumference growth. Improving particularly early neonatal growth may improve long-term outcome in extremely preterm infants, but the effects of improved growth may only be small.

[Following the high-risk newborn: Why? How? Conducting an early medical-psychosocial consultation during hospitalization]

The usual follow-up of high-risk children concentrates on screening for sequelae of perinatal pathology, required by emergency pediatricians and neonatologists to assess their practices. The objective is to manage pathologies by intervening as early as possible. However, is this classical medical model, i.e., the diagnosis of something pathological and a schedule of consultations planned at specific dates, adapted to the needs of high-risk children and their parents? Beyond screening, the child development consultation at the Rozanoff Early Medico-Social Action Center, set up at the A. Trousseau Hospital in 1985, proposes a consultation in which a neuropediatrician, a physical therapist, a pediatric psychiatrist-psychoanalyst, and a social worker closely collaborate. The care begun during neonatal hospitalization concentrates on the needs of the child and parents, with a primary objective of lending support to child-parent interaction. The observation of a child born at 26 GW presenting gaze avoidance concurrent with symptoms of depression in the mother exemplifies the importance of this visit. Why are there still so few of this type of consultation taking into account the medical, psychological, and social risks in a single visit? Why is the attention given to neurologic problems, for which there is currently no cure, so disproportionate to the lack of awareness of the psychological and social risks for which effective prevention and treatment possibilities do exist?

Postdischarge growth and development in a predominantly Hispanic, very low birth weight population

OBJECTIVES

The goals were to assess postdischarge growth and developmental progress of very low birth weight (birth weight: <1500 g) premature infants in a predominantly Hispanic population and to identify predictors for neurodevelopmental impairment at 3 years of age.

METHODS

A cohort of 135 very low birth weight infants (gestational age: 23 to 35 weeks) were monitored to 3 years of age. Maternal and neonatal characteristics, anthropometric z scores, and developmental performance (using corrected age until 24 months) were analyzed collectively and according to gestational age groups. Specific criteria for failure to thrive and microcephaly were used.

RESULTS

A characteristic pattern of poor weight gain in the first 12 months was followed by accelerated weight gain starting at 18 months, whereas head growth decreased at 18 months, with recovery beginning at 30 months of age. Infants born at gestational age of <or=26 weeks remained growth-impaired at 3 years of age, whereas infants born at gestational age of >or=27 weeks achieved catch-up growth by 30 months of age. Mean developmental scores also decreased in infancy, with improvements in motor development emerging at 18 months and cognitive skills at 30 months. Growth z scores, particularly for head growth, correlated with developmental scores. Infants born at gestational age of <or=26 weeks were most likely to have neonatal morbidities, failure to thrive, and neurodevelopmental impairment. With adjustment for gestational age and neonatal morbidities, Hispanic acculturation, failure to thrive, and microcephaly were predictive of neurodevelopmental impairment.

CONCLUSIONS

Very low birth weight infants exhibited growth patterns that coincided with developmental progress in the first 3 years of life. Birth at gestational age of <or=26 weeks was associated with greatest risk for developmental impairment, whereas failure to thrive and microcephaly increased neurodevelopmental impairment risk regardless of gestational age.

Health-related quality of life for extremely low birth weight adolescents in Canada, Germany, and the Netherlands

OBJECTIVE

The goal was to compare health-related quality of life of 12- to 16-year-old adolescents born at an extremely low birth weight in regional cohorts from Ontario (Canada), Bavaria (Germany), and the Netherlands.

METHODS

Patients were extremely low birth weight survivors from Canada, Germany, and the Netherlands. Health-related quality of life was assessed with Health Utilities Index 3. Missing data were substituted by proxy reports. Differences in mean Health Utilities Index 3 scores were tested by using analysis of variance. Differences in the numbers of children with affected attributes were tested by using logistic regression analyses.

RESULTS

Survival rates were similar; response rates varied between 71% and 90%. Significant differences in health-related quality of life were found between the cohorts, with Dutch children scoring highest on Health Utilities Index 3 and German children scoring lowest, independent of birth weight, gestational age, and cerebral palsy. Differences in mean utility scores were mainly attributable to differences in the cognition health attribute. Most of the results were corroborated by logistic regression analyses.

CONCLUSIONS

There were significant differences between the 3 cohorts in health-related quality of life, not related to differences in birth weight, gestational age, or cerebral palsy. Survival and response rates alone cannot explain these differences.

Parenting preemies: a unique program for family support and education after NICU discharge

Research supports the importance of family-centered care in the neonatal intensive care unit (NICU). The significance of continuity in family-centered care beyond the NICU has recently gained attention. Parenting Preemies is a unique and easily replicated postdischarge program designed to ease the transition from hospital to home for NICU graduates and their families. The comprehensive program provides an effective means to demonstrate ongoing, family-centered, and cost-effective outreach after discharge. The specific target population includes premature, low birth-weight, and special needs infants, and their parents. A multidisciplinary team utilizes evidenced-based principles to facilitate an education and support group, in conjunction with home visits, as the foundation for promotion of optimal outcomes for preemies and their parents. Participant satisfaction is consistently positive.