Preschool language outcomes of children with history of bronchopulmonary dysplasia and very low birth weight

Brain age predicted using graph convolutional neural network explains neurodevelopmental trajectory in preterm neonates

OBJECTIVES

Dramatic brain morphological changes occur throughout the third trimester of gestation. In this study, we investigated whether the predicted brain age (PBA) derived from graph convolutional network (GCN) that accounts for cortical morphometrics in third trimester is associated with postnatal abnormalities and neurodevelopmental outcome.

METHODS

In total, 577 T1 MRI scans of preterm neonates from two different datasets were analyzed; the NEOCIVET pipeline generated cortical surfaces and morphological features, which were then fed to the GCN to predict brain age. The brain age index (BAI; PBA minus chronological age) was used to determine the relationships among preterm birth (i.e., birthweight and birth age), perinatal brain injuries, postnatal events/clinical conditions, BAI at postnatal scan, and neurodevelopmental scores at 30 months.

RESULTS

Brain morphology and GCN-based age prediction of preterm neonates without brain lesions (mean absolute error [MAE]: 0.96 weeks) outperformed conventional machine learning methods using no topological information. Structural equation models (SEM) showed that BAI mediated the influence of preterm birth and postnatal clinical factors, but not perinatal brain injuries, on neurodevelopmental outcome at 30 months of age.

CONCLUSIONS

Brain morphology may be clinically meaningful in measuring brain age, as it relates to postnatal factors, and predicting neurodevelopmental outcome.

CLINICAL RELEVANCE STATEMENT

Understanding the neurodevelopmental trajectory of preterm neonates through the prediction of brain age using a graph convolutional neural network may allow for earlier detection of potential developmental abnormalities and improved interventions, consequently enhancing the prognosis and quality of life in this vulnerable population.

KEY POINTS

•Brain age in preterm neonates predicted using a graph convolutional network with brain morphological changes mediates the pre-scan risk factors and post-scan neurodevelopmental outcomes. •Predicted brain age oriented from conventional deep learning approaches, which indicates the neurodevelopmental status in neonates, shows a lack of sensitivity to perinatal risk factors and predicting neurodevelopmental outcomes. •The new brain age index based on brain morphology and graph convolutional network enhances the accuracy and clinical interpretation of predicted brain age for neonates.

Non-invasive high-frequency ventilation in newborn infants with respiratory distress

BACKGROUND

Respiratory distress occurs in up to 7% of newborns, with respiratory support (RS) provided invasively via an endotracheal (ET) tube or non-invasively via a nasal interface. Invasive ventilation increases the risk of lung injury and chronic lung disease (CLD). Using non-invasive strategies, with or without minimally invasive surfactant, may reduce the need for mechanical ventilation and the risk of lung damage in newborn infants with respiratory distress.

OBJECTIVES

To evaluate the benefits and harms of nasal high-frequency ventilation (nHFV) compared to invasive ventilation via an ET tube or other non-invasive ventilation methods on morbidity and mortality in preterm and term infants with or at risk of respiratory distress.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and three trial registries in April 2023.

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster- or quasi-RCTs of nHFV in newborn infants with respiratory distress compared to invasive or non-invasive ventilation.

DATA COLLECTION AND ANALYSIS

Two authors independently selected the trials for inclusion, extracted data, assessed the risk of bias, and undertook GRADE assessment.

MAIN RESULTS

We identified 33 studies, mostly in low- to middle-income settings, that investigated this therapy in 5068 preterm and 46 term infants. nHFV compared to invasive respiratory therapy for initial RS We are very uncertain whether nHFV reduces mortality before hospital discharge (RR 0.67, 95% CI 0.20 to 2.18; 1 study, 80 infants) or the incidence of CLD (RR 0.38, 95% CI 0.09 to 1.59; 2 studies, 180 infants), both very low-certainty. ET intubation, death or CLD, severe intraventricular haemorrhage (IVH) and neurodevelopmental disability (ND) were not reported. nHFV vs nasal continuous positive airway pressure (nCPAP) used for initial RS We are very uncertain whether nHFV reduces mortality before hospital discharge (RR 1.00, 95% CI 0.41 to 2.41; 4 studies, 531 infants; very low-certainty). nHFV may reduce ET intubation (RR 0.52, 95% CI 0.33 to 0.82; 5 studies, 571 infants), but there may be little or no difference in CLD (RR 1.35, 95% CI 0.80 to 2.27; 4 studies, 481 infants); death or CLD (RR 2.50, 95% CI 0.52 to 12.01; 1 study, 68 participants); or severe IVH (RR 1.17, 95% CI 0.36 to 3.78; 4 studies, 531 infants), all low-certainty evidence. ND was not reported. nHFV vs nasal intermittent positive-pressure ventilation (nIPPV) used for initial RS nHFV may result in little to no difference in mortality before hospital discharge (RR 1.86, 95% CI 0.90 to 3.83; 2 studies, 84 infants; low-certainty). nHFV may have little or no effect in reducing ET intubation (RR 1.33, 95% CI 0.76 to 2.34; 5 studies, 228 infants; low-certainty). There may be a reduction in CLD (RR 0.63, 95% CI 0.42 to 0.95; 5 studies, 307 infants; low-certainty). A single study (36 infants) reported no events for severe IVH. Death or CLD and ND were not reported. nHFV vs high-flow nasal cannula (HFNC) used for initial RS We are very uncertain whether nHFV reduces ET intubation (RR 2.94, 95% CI 0.65 to 13.27; 1 study, 37 infants) or reduces CLD (RR 1.18, 95% CI 0.46 to 2.98; 1 study, 37 participants), both very low-certainty. There were no mortality events before hospital discharge or severe IVH. Other deaths, CLD and ND, were not reported. nHFV vs nCPAP used for RS following planned extubation nHFV probably results in little or no difference in mortality before hospital discharge (RR 0.92, 95% CI 0.52 to 1.64; 6 studies, 1472 infants; moderate-certainty). nHFV may result in a reduction in ET reintubation (RR 0.42, 95% CI 0.35 to 0.51; 11 studies, 1897 infants) and CLD (RR 0.78, 95% CI 0.67 to 0.91; 10 studies, 1829 infants), both low-certainty. nHFV probably has little or no effect on death or CLD (RR 0.90, 95% CI 0.77 to 1.06; 2 studies, 966 infants) and severe IVH (RR 0.80, 95% CI 0.57 to 1.13; 3 studies, 1117 infants), both moderate-certainty. We are very uncertain whether nHFV reduces ND (RR 0.92, 95% CI 0.37 to 2.29; 1 study, 74 infants; very low-certainty). nHFV versus nIPPV used for RS following planned extubation nHFV may have little or no effect on mortality before hospital discharge (RR 1.83, 95% CI 0.70 to 4.79; 2 studies, 984 infants; low-certainty). There is probably a reduction in ET reintubation (RR 0.69, 95% CI 0.54 to 0.89; 6 studies, 1364 infants), but little or no effect on CLD (RR 0.88, 95% CI 0.75 to 1.04; 4 studies, 1236 infants); death or CLD (RR 0.92, 95% CI 0.79 to 1.08; 3 studies, 1070 infants); or severe IVH (RR 0.78, 95% CI 0.55 to 1.10; 4 studies, 1162 infants), all moderate-certainty. One study reported there might be no difference in ND (RR 0.88, 95% CI 0.35 to 2.16; 1 study, 72 infants; low-certainty). nHFV versus nIPPV following initial non-invasive RS failure nHFV may have little or no effect on mortality before hospital discharge (RR 1.44, 95% CI 0.10 to 21.33); or ET intubation (RR 1.23, 95% CI 0.51 to 2.98); or CLD (RR 1.01, 95% CI 0.70 to 1.47); or severe IVH (RR 0.47, 95% CI 0.02 to 10.87); 1 study, 39 participants, all low- or very low-certainty. Other deaths or CLD and ND were not reported.

AUTHORS' CONCLUSIONS

For initial RS, we are very uncertain if using nHFV compared to invasive respiratory therapy affects clinical outcomes. However, nHFV may reduce intubation when compared to nCPAP. For planned extubation, nHFV may reduce the risk of reintubation compared to nCPAP and nIPPV. nHFV may reduce the risk of CLD when compared to nCPAP. Following initial non-invasive respiratory support failure, nHFV when compared to nIPPV may result in little to no difference in intubation. Large trials, particularly in high-income settings, are needed to determine the role of nHFV in initial RS and following the failure of other non-invasive respiratory support. Also, the optimal settings of nHVF require further investigation.

What risk factors for Developmental Language Disorder can tell us about the neurobiological mechanisms of language development

Language is a complex multidimensional cognitive system that is connected to many neurocognitive capacities. The development of language is therefore strongly intertwined with the development of these capacities and their neurobiological substrates. Consequently, language problems, for example those of children with Developmental Language Disorder (DLD), are explained by a variety of etiological pathways and each of these pathways will be associated with specific risk factors. In this review, we attempt to link previously described factors that may interfere with language development to putative underlying neurobiological mechanisms of language development, hoping to uncover openings for future therapeutical approaches or interventions that can help children to optimally develop their language skills.

Effect of biomedical complications on very and extremely preterm children's language

Introduction

Very and extremely preterm children have been found to show delays in the development of language in early years. In some investigations, however, a rigorous control of biomedical complications, such as Periventricular Leukomalacia (PVL), Intraventricular Hemorrhage (IVH) or Bronchopulmonary Dysplasia (BPD), does not always exist. For that reason, a confounding effect of low gestational age and biomedical complications may lead to erroneous conclusions about the effect of gestational age.

Methods

In this investigation we compare language development [use of words, sentence complexity and mean length of the three longest utterances (MLU3)] of three groups of Chilean children at 24 months of age (corrected age for preterm children). The first group was composed of 42 healthy full-term children (Full term group: FT), the second group of 60 preterm children born below 32 gestational weeks without medical complications (low risk preterm group: LRPT), and the third group was composed of 64 children below 32 gestational weeks who had medical complications (High risk preterm group: HRPT). The three groups were similar in terms of gender distribution, maternal education, and socio-economic environment. The instrument used to assess language was the Communicative Development Inventories (CDI). In addition, the Ages and Stages Questionnaire-3 (ASQ-3) was also used to assess other developmental dimensions.

Results

The results indicate that HRPT and LRPT children obtained significantly lower results than the FT group in the three language measures obtained through the CDI. No significant differences were observed between the HRPT and the LRPT groups, although the HRPT obtained the lowest results in the three CDI measures. The results obtained through the administration of the ASQ-3 confirm the delay of both preterm groups in communicative development when compared to the FT group. No significant differences between the FT and the PT groups were observed in gross motor, fine motor and problem solving dimensions of the ASQ-3. The LRPT group obtained results that were significantly higher than those of the FT group and the HRPT group in gross motor development.

Discussion

These results seem to indicate that the area of language development is particularly influenced by very or extremely low gestational age.

Association between brain structural network efficiency at term-equivalent age and early development of cerebral palsy in very preterm infants

Very preterm infants (born at less than 32 weeks gestational age) are at high risk for serious motor impairments, including cerebral palsy (CP). The brain network changes that antecede the early development of CP in infants are not well characterized, and a better understanding may suggest new strategies for risk-stratification at term, which could lead to earlier access to therapies. Graph theoretical methods applied to diffusion MRI-derived brain connectomes may help quantify the organization and information transfer capacity of the preterm brain with greater nuance than overt structural or regional microstructural changes. Our aim was to shed light on the pathophysiology of early CP development, before the occurrence of early intervention therapies and other environmental confounders, to help identify the best early biomarkers of CP risk in VPT infants. In a cohort of 395 very preterm infants, we extracted cortical morphometrics and brain volumes from structural MRI and also applied graph theoretical methods to diffusion MRI connectomes, both acquired at term-equivalent age. Metrics from graph network analysis, especially global efficiency, strength values of the major sensorimotor tracts, and local efficiency of the motor nodes and novel non-motor regions were strongly inversely related to early CP diagnosis. These measures remained significantly associated with CP after correction for common risk factors of motor development, suggesting that metrics of brain network efficiency at term may be sensitive biomarkers for early CP detection. We demonstrate for the first time that in VPT infants, early CP diagnosis is anteceded by decreased brain network segregation in numerous nodes, including motor regions commonly-associated with CP and also novel regions that may partially explain the high rate of cognitive impairments concomitant with CP diagnosis. These advanced MRI biomarkers may help identify the highest risk infants by term-equivalent age, facilitating earlier interventions that are informed by early pathophysiological changes.

Prevalence of Language Delay among Healthy Preterm Children, Language Outcomes and Predictive Factors

Language delay (LD) and its relationship with later language impairment in preterm children is a topic of major concern. Previous studies comparing LD in preterm (PT) and full-term (FT) children were mainly carried out with samples of extremely preterm and very preterm children (sometimes with additional medical problems). Very few of them were longitudinal studies, which is essential to understand developmental relationships between LD and later language impairment. In this study, we compare the prevalence of LD in low-risk preterm children to that of FT children in a longitudinal design ranging from 10 to 60 months of age. We also analyze which variables are related to a higher risk of LD at 22, 30 and 60 months of age. Different language tests were administered to three groups of preterm children of different gestational ages and to one group of full-term children from the ages of 10 to 60 months. ANOVA comparisons between groups and logistic regression analyses to identify possible predictors of language delay at 22, 30 and 60 months of age were performed. The results found indicate that there were practically no differences between gestational age groups. Healthy PT children, therefore, do not have, in general terms, a higher risk of language delay than FT children. Previous language delay and cognitive delay are the strongest and longest-lasting predictors of later language impairment. Other factors, such as a scarce use of gestures at 10 months or male gender, affect early LD at 22 months of age, although their effect disappears as children grow older. Low maternal education appears to have a late effect. Gestational age does not have any significant effect on the appearance of LD.

Family environmental risk factors for developmental speech delay in children in Northern China

Most reported risk factors for developmental speech delay (DSD) remain controversial, and studies on paternal influencing factors are rare. This study investigated family environmental risk factors for DSD in northern China. The medical records of 276 patients diagnosed with DSD at four centres between October 2018 and October 2019 were retrospectively analysed. A questionnaire was designed that contained items such as maternal age at the child’s birth, child sex, child age, birth order, family type and parental personality. Patients whose medical records lacked complete information for this investigation were contacted by e-mail or phone. Additionally, 339 families whose children received routine physical examinations at the four involved centres completed the survey. Data were collected, and potential risk factors were analysed using the t test or chi-square test; the obtained outcomes were subjected to multivariable logistic regression for further analysis. The multivariable regression showed that older maternal age at the child’s birth (OR = 1.312 (1.192–1.444), P < 0.001), introverted paternal personality (OR = 0.023 (0.011–0.048), P < 0.001), low average parental education level (OR = 2.771 (1.226–6.263), P = 0.014), low monthly family income (OR = 4.447 (1.934–10.222), P < 0.001), and rare parent–child communication (OR = 6.445 (3.441–12.072), P < 0.001) were independent risk factors for DSD in children in North China. The study results may provide useful data for broadening and deepening the understanding of family risk factors for DSD.

Neurodevelopmental outcomes in very preterm infants: The role of severity of Bronchopulmonary Dysplasia

OBJECTIVE

Bronchopulmonary dysplasia is a chronic respiratory disease that still affects preterm neonates; its association with neurodevelopmental (ND) impairment is already known. Different studies investigated neurodevelopmental outcomes in infants with BPD, often using the old dichotomous definition (BPD vs Non-BPD). This retrospective study aims to evaluate the role of different BPD severity grades on ND outcomes at 24 months of corrected age (CA).

METHODS

All preterm infants born between 2011 and 2015 in the study hospital with a gestational age (GA) ≤ 30 weeks and discharged from our NICU were included and were divided in infants with and without BPD. Infants with BPD were divided into three severity groups as defined by NICHD/NHLBI Workshop in 2001, and were compared to their Non-BPD peers, matching them according to the same GA and year of birth. At 24 months postmenstrual age, we assessed general outcomes (growth and hospital readmissions) and neurodevelopmental outcomes (motor, developmental and sensory outcomes) with a standardized assessment.

RESULTS

We enrolled 89 patients affected by BPD of different grades of severity and a control group of 89 preterm infants without BPD. Infants with Moderate and Severe BPD showed a significantly higher corrected odds ratio (OR) for cognitive impairment compared to controls. Within the group of infants without severe disability (regarding Griffiths' scales), infants with Moderate and Severe BPD as well as infants with Mild BPD showed a significantly higher risk of a lower total Developmental Quotient (DQ) score, even after correction for confounding factors.

CONCLUSIONS

Our study evidenced that not only Severe BPD infants, but also Moderate ones showed a higher risk of overall cognitive impairment at 24 months CA. Within the group of infants without severe disability, also those with Mild BPD had lower Griffiths DQ scores than those without. This would suggest that infants with BPD, regardless of severity, warrant neurodevelopmental follow-up.

Disrupted or delayed? Stress discrimination among preterm as compared to full-term infants during the first year of life

BACKGROUND

Several papers pointed out that the language disorders are the most commonly reported cognitive deficits of the preterm (PT) infants. However, neither the exact interpretation (disrupted or delayed) of their language development nor the most powerful perinatal risk factors have been specified yet.

AIMS

We aimed to determine whether postnatal development of prosodic processing of PT infants is disrupted or delayed in the first year of life? We also tested the role of Birth Weight (BW) and Gestational Age (GA) regarding the PT and full-term (FT) infants' language perception.

METHOD

We registered the mismatch responses (MMR) of 34 PT (at 6 and 12 month of ages) and 33 FT infants (at 4 and 10 month of age) elicited by bisyllabic pseudo-words in two oddball conditions.

RESULT

Contrary to their FT peers, younger PT group detected stress changes of the legal stress form only. Analogously, a positive MMR (P-MMR) was found for the legal form discrimination exclusively in PT12 group. Furthermore, the lack of sensitivity to the standard vs. deviant difference was identified in the PT infants. In PT infants, BW explained 21 % of the total variance of the P-MMR.

CONCLUSION

Consequently, we argue that the stress sensitivity of the PT infants is unimpaired, but their stress processing seems to be disrupted from the 6th month on. We suggest for further studies to take BW into account in studies using MMR paradigms in PT infants.

Neonatal white matter tract microstructure and 2-year language outcomes after preterm birth

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Preterm infant white matter tracts uniquely predict later toddler language.

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Neonatal medical history moderates posterior corpus callosum–language relations.

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Different associations by tract may relate to brain maturation and medical history.

Aim

To determine whether variability in diffusion MRI (dMRI) white matter tract metrics, obtained in a cohort of preterm infants prior to neonatal hospital discharge, would be associated with language outcomes at age 2 years, after consideration of age at scan and number of major neonatal complications.

Method

30 children, gestational age 28.9 (2.4) weeks, underwent dMRI at mean post menstrual age 36.4 (1.4) weeks and language assessment with the Bayley Scales of Infant Development–III at mean age 22.2 (1.7) months chronological age. Mean fractional anisotropy (FA) and mean diffusivity (MD) were calculated for 5 white matter tracts. Hierarchical linear regression assessed associations between tract FA, moderating variables, and language outcomes.

Results

FA of the left inferior longitudinal fasciculus accounted for 17% (p = 0.03) of the variance in composite language and FA of the posterior corpus callosum accounted for 19% (p = 0.02) of the variance in composite language, beyond that accounted for by post-menstrual age at scan and neonatal medical complications. The number of neonatal medical complications moderated the relationship between language and posterior corpus callosum FA but did not moderate the association in the other tract.

Conclusion

Language at age 2 is associated with white matter metrics in early infancy in preterm children. The different pattern of associations by fiber group may relate to the stage of brain maturation and/or the nature and timing of medical complications related to preterm birth. Future studies should replicate these findings with a larger sample size to assure reliability of the findings.

Speech and language development of children born following assisted reproductive technologies

OBJECTIVES

Studies which targeted communication skills of children born following assisted reproductive technologies have reported contradictory results. Concerning the increasing rates of children born in these technologies and the importance of some factors as risk factors like birth weight, gestational age, and the number of children per birth in these procedures, studying speech and language skills is critical. So, the current study aimed to investigate the speech and language capabilities of Persian speaking children born following these procedures.

METHODS

A descriptive and cross-sectional study was carried out in Babol city in 2016-2017 to investigate the receptive and expressive language and speech of Persian speaking children born in assisted reproductive technologies in the age range of 6-72 months. Parents of 78 children completed the Newsha Developmental Scale to assess language and speech skills. Then, the language and speech performance of the participants were compared in terms of gestational age, birth weight, number of children per birth, and sex in the current research and they are categorized as normal or having delay in language and speech development.

RESULTS

The participants had statistically significant difference for the receptive language in terms of gestational age (χ² (1) = 5.76, p = 0.01) and birth weight (χ² (1) = 8.22, p = 0.004) but in terms of the number of children per birth (χ² (1) = 7.11, p = 0.009) and sex (χ² (1) = 0.037, p = 0.84) did not have statistically significant difference. The children did not show significant difference for the expressive language in terms of gestational age (χ² (1) = 1.09, p = 0.29), birth weight (χ² (1) = 0.34, p = 0.55), the number of children per birth (χ² (1) = 1.58, p = 0.2), and sex (χ2 (1) = 0.037, p = 0.84). The participants of the present study did not have statistically significant difference in speech in terms of gestational age (χ² (1) = 2.82, p = 0.09), the number of children per birth (χ² (1) = 3.57, p = 0.06), and sex (χ2 (1) = 0.06, p = 0.79). They had significant difference in speech only in terms of birth weight (χ² (1) = 4.13, p = 0.04).

CONCLUSION

Based on the results of the administration of the Newsha Developmental Scale as a screening tool, it seems that some factors like sex and number of children per birth do not affect speech and language performance of children born following ART. Another factor including gestational age and birth weight had effects on some domains. It is essential to design longitudinal studies to follow the speech and language performance of this population.

Retinopathy of Prematurity and Bronchopulmonary Dysplasia are Independent Antecedents of Cortical Maturational Abnormalities in Very Preterm Infants

Very preterm (VPT) infants are at high-risk for neurodevelopmental impairments, however there are few validated biomarkers at term-equivalent age that accurately measure abnormal brain development and predict future impairments. Our objectives were to quantify and contrast cortical features between full-term and VPT infants at term and to associate two key antecedent risk factors, bronchopulmonary dysplasia (BPD) and retinopathy of prematurity (ROP), with cortical maturational changes in VPT infants. We prospectively enrolled a population-based cohort of 110 VPT infants (gestational age ≤31 weeks) and 51 healthy full-term infants (gestational age 38-42 weeks). Structural brain MRI was performed at term. 94 VPT infants and 46 full-term infants with high-quality T2-weighted MRI were analyzed. As compared to full-term infants, VPT infants exhibited significant global cortical maturational abnormalities, including reduced surface area (-5.9%) and gyrification (-6.7%) and increased curvature (5.9%). In multivariable regression controlled for important covariates, BPD was significantly negatively correlated with lobar and global cortical surface area and ROP was significantly negatively correlated with lobar and global sulcal depth in VPT infants. Our cohort of VPT infants exhibited widespread cortical maturation abnormalities by term-equivalent age that were in part anteceded by two of the most potent neonatal diseases, BPD and ROP.

Language Skills in Children Born Preterm (<30 Wks' Gestation) Throughout Childhood: Associations With Biological and Socioenvironmental Factors

OBJECTIVE

To examine the individual and collective contribution of biological and socioenvironmental factors associated with language function at 2, 5, 7, and 13 years in children born preterm (<30 weeks' gestation or <1250 g birth weight).

METHODS

Language function was assessed as part of a prospective longitudinal study of 224 children born preterm at 2, 5, 7, and 13 years using age-appropriate tools. Language Z-scores were generated based on a contemporaneous term-born control group. A selection of biological factors (sex, small for gestational age, bronchopulmonary dysplasia, infection, and qualitatively defined brain injury) and early socioenvironmental factors at age 2 years (primary income earner employment status and type, primary caregiver education level, English as a second language, parental mental health history, parent sensitivity and facilitation, and parent-child synchrony) was chosen a priori. Associations were assessed using univariable and multivariable linear regression models applied to outcomes at each time point.

RESULTS

Higher primary caregiver education level, greater parent-child synchrony, and parent sensitivity were independently associated with better language function across childhood. Socioenvironmental factors together explained an increasing percentage of the variance (9%-18%) in language function from 2 to 13 years of age. In comparison, there was little evidence for associations between biological factors and language function, even during early childhood years.

CONCLUSION

This study highlights the importance of socioenvironmental factors over biological factors for language development throughout childhood. Some of these socioenvironmental factors are potentially modifiable, and parent-based interventions addressing parenting practices and education may benefit preterm children's language development.

Pulmonary Function and Systolic Blood Pressure in Very Low Birth Weight Infants at 34 - 36 Weeks of Corrected Age

Purpose

Preterm infants are at increased risk of systemic hypertension compared to term infants. Bronchopulmonary dysplasia (BPD) has been shown to be associated with hypertension in preterm infants albeit with no causation reported. BPD is characterized by abnormal pulmonary function tests (PFTs), specifically elevated passive respiratory resistance (Rrs), decreased passive respiratory compliance (Crs) and decreased functional residual capacity (FRC). There have been no studies comparing PFTs in very low birth weight (VLBW) infants with and without hypertension. We hypothesized that stable VLBW infants with hypertension will have altered PFTs.

Patients and Methods

Retrospective cohort study of infants < 1500 grams at birth (VLBW) who had PFTs performed near 34-36 weeks of corrected gestational age (CGA). We excluded infants with congenital anomalies, known hypertensive disorders or those at risk of medication-induced hypertension. Data obtained included PFT parameters (Rrs, Crs, FRC) and mean systolic blood pressure (SBP).

Results

59 VLBW infants were identified for analysis, 14 with and 45 without hypertension. Hypertensive and normotensive patients were similar in terms of mean gestational age (26.6 vs 27.4 weeks), mean CGA at PFTs (36.1 vs 34.6 weeks) and proportion of BPD (36% vs 36%). The Rrs was significantly higher in hypertensive versus normotensive patients [median Rrs of 0.080 (0.069, 0.090) versus 0.066 (0.054, 0.083) cmH₂O/mL/sec; p = 0.04]. There was no difference in systolic blood pressure in the infants with and without BPD.

Conclusion

In this cohort of contemporary VLBW infants, those with hypertension had increased Rrs. This finding warrants a prospective study with a larger sample size and long-term follow-up.

Language in 2-year-old children born preterm and term: a cohort study

PURPOSE

Language skills are critical. Children born very preterm are vulnerable to language problems, but further work is needed to determine characteristics and specific predictors of language problems in this population. We aimed to compare language outcomes between 2-year-old children born <30 weeks and their term-born peers; and to explore risk factors for language difficulties in this cohort.

DESIGN

Language at 2 years was examined in 134 children born <30 weeks and 133 children born at term using the Bayley Scales of Infant and Toddler Development - 3rd Edition (Bayley-3) and the Communication and Symbolic Behaviour Scale: Developmental Profile (Infant Toddler Checklist) (CSBS:DP). Outcomes were compared between groups. Factors hypothesised to predict language outcome were examined in the preterm group: gestational age at birth, birth weight z-score, sex, hearing loss, multilingualism, maternal education, brain abnormality on MRI, medical risk and oromotor concerns at 12 months.

RESULTS

Children born <30 weeks performed more poorly on the CSBS:DP (particularly the social and symbolic composites) and the language scale of the Bayley-3 at 2 years than term-born peers. Lower gestational age at birth, male sex, hearing loss and multilingualism predicted poorer language scores.

CONCLUSIONS

Despite improvements in medical management, children born very preterm exhibit language delays at 2 years of age, with specific deficits in social communication and symbolic skills. Significant predictors of poorer language outcomes were similar to those in the general population (male sex, hearing loss, multilingualism), suggesting that further work is needed to establish which specific factors place preterm-born children at heightened risk.

Expressive Language in Preschoolers Born Preterm: Results of Language Sample Analysis and Standardized Assessment

Purpose Preschoolers born preterm are at an increased risk for the development of language impairments. The primary objective of this study was to document the expressive language skills of preschoolers born preterm through 2 assessment procedures, language sample analysis, and standardized assessment. A secondary objective was to investigate the role of nonlinguistic factors in standardized assessment scores. Method The language skills of 29 children born preterm (mean gestational age of 31 weeks) were compared to a group of 29 preschoolers born full term. Language samples were collected during free play and objective measures of semantic and grammatical skills were calculated. Likewise, grammatical and semantic measures of language were obtained from a standardized assessment. Information on nonlinguistic factors, including attention, hyperactivity, and nonverbal intelligence quotient, was also collected. Results The results of analyses of variance indicated that the children in the PT group had significantly poorer performance than the children born full term on all of the measures of language skill obtained from the language sample analysis. Group differences were found for only 1 measure of language skill obtained from the standardized assessments. Nonverbal factors were not found to account for group differences in assessment scores. Conclusions Generally, the children born preterm performed more poorly when language skill was measured via language sample analysis than standardized assessment. These findings underscore the importance of using language sample analysis in conjunction with standardized assessment in the evaluation of children's developing language skills.

Predictors of early vocabulary growth in children born preterm and full term: A study of processing speed and medical complications

Delays in expressive vocabulary may be harbingers of long-term language difficulties. In toddlers born full term (FT), individual differences in language processing speed are associated with variation in expressive vocabulary growth. Children born preterm (PT) are at increased risk for persistent language deficits. Here, we evaluate predictors of early vocabulary growth in PT toddlers in relation to two sources of variability: language processing speed and medical complications of prematurity. Vocabulary growth from 16 to 30 months (adjusted for degree of prematurity) was modeled longitudinally using parent reports in English-speaking FT (n = 63; ≥37 weeks, ≥2495 g) and PT (n = 69; ≤32 weeks, <1800 g) children, matched on sex and socioeconomic status. Children were tested in the "looking-while-listening task" at 18 months to derive a measure of language processing speed. Each PT child was assessed for number of medical complications (13 maximum), based on medical chart reviews. PT and FT children displayed similar vocabulary trajectories; however, birth group disparities began to emerge by 30 months. PT children were slower in language processing speed than FT children. Critically, language processing speed predicted expressive vocabulary size at 30 months; interactions with birth group were not significant (all p > .20). In PT children, faster language processing speed predicted stronger outcomes regardless of number of medical complications; slower processing speed and more medical complications predicted poorer outcomes. Faster processing speed reflected favorable neuropsychological processes associated with faster expressive vocabulary growth that overrode the impact of medical complications on language outcomes in PT children.

The influence of preterm birth on expressive vocabulary at the age of 36 to 41 months

Children born preterm (PT) have a higher risk of language delays than children born full-term (FT). Expressive vocabulary plays a central role in language development, as later grammar ability can be predicted from earlier vocabulary size.To determine the effects of preterm birth on expressive vocabulary at the age of 36 to 41 months.Cross-sectional study of 27 PT (children with a gestational age of ≤ 32 + 0 weeks and/or a birth weight ≤ 1500 g) and 26 FT children (from several kindergartens in Vienna, Austria). The groups were matched regarding age, sex, and monolingual Austrian German speech. They were all examined using the active vocabulary test (AWST-R) and the development test, Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III).The AWST-R revealed significantly lower scores (46% vs 52%, P = .027) for PT children. The Bayley-III revealed significantly lower scores in language development (mean 96.3 ± 11.81 vs 105.1 ± 6.24, P = .002) and the expressive communication subscale (8.78 ± 2.01 vs 10.69 ± 1.49, P < .001) for PT children, but no differences in cognitive development (98.5 ± 11.08 vs 100.8 ± 6.43, P = .369) or on the receptive communication subscale (10.15 ± 2.23 vs 11.08 ± 1.09, P = .060).Preterm children tested had less expressive vocabulary (AWST-R and Bayley-III) than those born full-term, while test results in their cognitive development and receptive communication (Bayley-III) did not differ.

Cognitive skills in preterm infants with bronchopulmonary dysplasia at 1 year adjusted and 2 years chronological age

Objective: The objective of this study was to evaluate for decline in cognitive scores from 12 to 24 months of age for preterm infants ≤32 weeks gestational age for those with and without bronchopulmonary dysplasia.Study design: In an observational retrospective study, detailed medical data was collected from the electronic medical records of preterm infants born between January 2009 and December 2015 who had cognitive evaluations using Bayley Scales of Infant Development, 3rd ed (BISD-3) at 12 months corrected gestational age and 24 months chronological age. Infants were divided into three groups, bronchopulmonary dysplasia (BPD), prolonged oxygen requirement that did not meet BPD criteria, or pulmonary insufficiency (PI), and respiratory distress only (RDS). Decline in cognitive functions was based on the BISD-3 standard deviation of 15 points, no decline ≤3.5 point, moderate, > 3.5 to <7.5 points, significant >7.5 points.Results: The sample included 165 preterm infants divided into three groups, BPD, n = 39, PI, n = 79, RDS only, n = 47. The groups did not differ on gender, ethnicity, birthweight or gestational age. The groups did not differ in percent of infants who showed no, moderate or significant decline. In all groups, the percentage of infants showing a cognitive decline of >7.5 points varied from 67% to 76%Conclusion: There was no significant difference in cognitive decline for those with and without BPD. Of note is that a large percentage of infants in each group showed at least one-half standard deviation of cognitive decline across the 12 and 24 months evaluations. Our concern is that correcting for gestational age at 12 months may delay early intervention when significant delays are found at 24 months.

An update on pulmonary and neurodevelopmental outcomes of bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) is a common complication of extreme prematurity, and its rate is not improving, despite advances in perinatal intensive care. Children with BPD diagnosed in the neonatal period have higher risks for hospitalizations for respiratory problems over the first few years of life, and they have more asthma in later childhood. Neonates diagnosed with BPD have substantial airway obstruction on lung function testing in later childhood and early adulthood, and many are destined to develop adult chronic obstructive pulmonary disease. Survivors with neonatal BPD have more adverse motor function, worse cognitive development and poorer academic progress than those without BPD. Long-term outcomes for children born extremely preterm will improve if the rate of BPD can be substantially reduced.

Language Trajectories of Children Born Very Preterm and Full Term from Early to Late Childhood

OBJECTIVE

To identify distinct language trajectories of children born very preterm and full term from 2 to 13 years of age and examine predictors for the identified trajectories.

STUDY DESIGN

A cohort of 224 children born very preterm and 77 full term controls recruited at birth were followed up at ages 2, 5, 7, and 13 years. The number of distinct language trajectories was examined using latent growth mixture modeling allowing for linear and quadratic time trends. Potential predictors in the neonatal period (eg, birth group, sex, and medical risk) and at 2 years (ie, social risk and use of allied health services) for the language trajectories were tested using multinomial logistic regression.

RESULTS

Five distinct language trajectories were identified across childhood: stable normal (32% of study cohort), resilient development showing catch-up (36%), precocious language skills (7%), stable low (17%), and high-risk (5%) development. The very preterm group was 8 times more likely to have a language trajectory that represented poorer language development compared with full term controls (very preterm, 40%; full term, 6%). Greater social risk and use of allied health services were associated with poorer language development.

CONCLUSIONS

Variable language trajectories were observed, with a substantial proportion of children born very preterm exhibiting adverse language development. These findings highlight the need for monitoring language skills in children born very preterm before school entry and across middle childhood.

Early Neurodevelopmental Outcome of Very Low Birthweight Neonates with Culture-positive Blood Stream Infection: A Prospective Cohort Study

Aim

Our study aimed to evaluate the early neurodevelopmental outcomes of very low birthweight (VLBW) neonates with culture-proven sepsis compared with VLBW neonates without sepsis.

Materials and methods

Our study included 80 VLBW neonates with blood culture-proven sepsis and 80 VLBW neonates without sepsis. For each neonate with sepsis, a control neonate of matching gender and gestational age was selected. We evaluated weight, length, and head circumference and conducted Hammersmith neonatal neurological examinations for each participant. We also conducted Developmental Assessment Screening II and vision and hearing impairment screening during a follow-up evaluation.

Results

We noted a developmental delay in 11 (23.4%) neonates with sepsis and two (3%) without sepsis at six months of age. The median developmental quotient, motor quotient, and mental quotients were significantly lower in the neonates with sepsis compared to those without sepsis.

Conclusions

Our findings suggest that sepsis significantly affects mortality and neurodevelopmental outcomes at six months in VLBW neonates. Therefore, preventive measures for sepsis in VLBW neonates is crucial, and those with culture-positive sepsis will require close monitoring and follow-up evaluations.

The changing relationship between bronchopulmonary dysplasia and cognition in very preterm infants

AIM

To characterise the relationship between bronchopulmonary dysplasia (BPD) severity and cognition in the post-surfactant era.

METHODS

This was a single-centre retrospective analysis of a cohort of infants born 2009-2012. Inclusion criteria were as follows: admission within 48 hours of birth, gestational age 22-0/7-31-6/7 weeks, birthweight 400-1500 g and Bayley Scales of Infant and Toddler Development-III testing at 18-26 months corrected age. Infants (n = 151) were classified by BPD severity with the NIH Workshop definition. Generalised linear modelling and multivariate logistic regression were performed.

RESULTS

Bayley cognitive score was not associated with BPD severity in univariate (p = 0.053) or multivariate (p = 0.503) analysis. About 27% of infants with no/mild BPD, 33% of infants with moderate BPD and 40% of infants with severe BPD had a cognitive score <85. There was no difference in the odds of cognitive score <85 based on BPD severity in univariate (p = 0.485) or multivariate analysis (p = 0.225). All infants with cognitive score <70 had severe BPD, although the association between cognitive score <70 and BPD severity was not significant.

CONCLUSION

We found no independent effect of BPD severity level on cognition. The likelihood of a cognitive score <85 was not associated with BPD severity.

Why do children with severe bronchopulmonary dysplasia not attend neonatal follow-up care? Parental views of barriers

AIM

To assess in children with severe bronchopulmonary dysplasia at a corrected age of 18-36 months: (i) Neonatal follow-up clinic attendance rates; (ii) Parent-identified reasons for difficulty attending neonatal follow-up.

METHODS

Mixed methods study utilising semi-structured phone interviews with parents of infants eligible for follow-up with severe bronchopulmonary dysplasia (defined as gestational age <32 weeks and requiring ≥30% FiO₂ and/or >2 L nasal cannula at 36 weeks post-menstrual age) at 18-36 months corrected age. Questions addressed barriers to neonatal follow-up attendance. Enrolment continued to saturation (no new themes emerging).

RESULTS

A total of 58 infants (69% male) were enrolled. Infants were 26 ± 2.1 weeks gestational age and birth weight 794 ± 262 g. At 28 ± 5.8 months corrected age, 26% had never attended neonatal follow-up clinic, 16% stopped attending before discharge, 5% were discharged, and 53% were still followed. Longer travel distance from home to follow-up clinic was associated with poorer attendance. Parent-generated items related to neonatal follow-up barriers were coded into four themes: Logistics, Time, Perceptions and Emotional Stress.

CONCLUSION

Despite high risk of developmental delay in infants with severe bronchopulmonary dysplasia, neonatal follow-up rates are suboptimal. Careful review of parent-identified barriers could be utilised to develop targeted strategies to improve neonatal follow-up attendance in this high-risk population.

Sleep disordered breathing in bronchopulmonary dysplasia

BACKGROUND

There are limited data on the effect of bronchopulmonary dysplasia (BPD) on sleep disordered breathing (SDB). We hypothesized that both the severity of prematurity and BPD would increase the likelihood of SDB in early childhood. Our secondary aim was to evaluate the association of demographic factors on the development of SDB.

METHODS

This is a retrospective study of patient factors and overnight polysomnogram (PSG) data of children enrolled in our BPD registry between 2008 and 2015. Association between PSG results and studied variables was assessed using multiple linear regression analysis.

RESULTS

One-hundred-forty children underwent at least one sleep study on room air. The mean respiratory disturbance index (RDI) was elevated at 9.9 events/hr (SD: 10.1). The mean obstructive apnea-hypopnea index (OAHI) was 6.5 (9.1) events/hr and the mean central event rate of 3.0 (3.7) events/hr. RDI had decreased by 22% or 1.5 events/hour (95%CI: 0.6, 1.9) with each year of age (P = 0.005). Subjects with more severe respiratory disease had 38% more central events (P = 0.02). Infants exposed to secondhand smoke had 2.4% lower (P = 0.04) oxygen saturation nadirs and a pattern for more desaturation events. Non-white subjects were found to have 33% higher OAHI (P = 0.05), while white subjects had a 61% higher rate of central events (P < 0.001).

CONCLUSIONS

RDI was elevated in a selected BPD population compared to norms for non-preterm children. BPD severity, smoke exposure, and race may augment the severity of SDB. RDI improved with age but was still elevated by age 4, suggesting that this population is at risk for the sequelae of SDB.

Caregiver Talk and Medical Risk as Predictors of Language Outcomes in Full Term and Preterm Toddlers

This study examined associations between caregiver talk and language skills in full term (FT) and preterm (PT) children (n = 97). All-day recordings of caregiver-child interactions revealed striking similarities in amount of caregiver talk heard by FT and PT children. Children who heard more caregiver talk at 16 months demonstrated better knowledge- and processing-based language skills at 18 months. The unique contributions of caregiver talk were tempered by medical risk in PT children, especially for processing speed. However, there was no evidence that birth status or medical risk moderated the effects of caregiver talk. These findings highlight the role of caregiver talk in shaping language outcomes in FT and PT children and offer insights into links between neurodevelopmental risk and caregiver-child engagement.

Does temperament influence language development? Evidence from preterm and full-term children

The aims of this study are: (1) to describe language and temperament characteristics of one group of low risk preterm (PR) children and a group of full-term (FT) children and (2) to identify those factors which can predict language outcomes at 30 months of age, with special attention on temperament. There is evidence of differences between very or extremely PR and FT children in relation to characteristics of temperament and language development. However, not many studies have been carried out with healthy PR children. The participants were 142 low risk PR children (mean gestational age (GA): 32.60 weeks) and 49 FT children (mean GA 39.84 weeks). The temperament of the children was assessed at 10 months of age through the Infant Behavior Questionnaire-Revised (IBQ-R). At 22 months of age the cognitive development of the children was assessed through the Spanish adaptation of the Batelle Developmental Inventory (BDI). In order to assess the children's language development the Galician adaptation of the MacArthur-Bates CDI was applied at 30 months of age. In addition, socio-demographic information about the children and their families was gathered at birth. The results indicate that there were no significant differences in the language measures of interest (word production, MLU3, and sentence complexity) between groups. The only differences found between the PR and the FT children in the IBQ-R were restricted to the smiling and laughter and the fear subscales. Hierarchical regression analyses performed indicate that GA did not have any predictive effect on language measures taken at 30 months. Cognitive scores were an important predictor of language measures, although certain temperament subscales contributed in a significant way to the variance of language measures, particularly low intensity pleasure, approach, high intensity pleasure, sadness, and vocal reactivity. Therefore, extroverted (positive affectivity) temperament seems to be beneficial for language development.

Screening for Speech and Language Delay in Children 5 Years Old and Younger: A Systematic Review

BACKGROUND AND OBJECTIVES

No recommendation exists for or against routine use of brief, formal screening instruments in primary care to detect speech and language delay in children through 5 years of age. This review aimed to update the evidence on screening and treating children for speech and language since the 2006 US Preventive Services Task Force systematic review.

METHODS

Medline, the Cochrane Library, PsycInfo, Cumulative Index to Nursing and Allied Health Literature, ClinicalTrials.gov, and reference lists. We included studies reporting diagnostic accuracy of screening tools and randomized controlled trials reporting benefits and harms of treatment of speech and language. Two independent reviewers extracted data, checked accuracy, and assigned quality ratings using predefined criteria.

RESULTS

We found no evidence for the impact of screening on speech and language outcomes. In 23 studies evaluating the accuracy of screening tools, sensitivity ranged between 50% and 94%, and specificity ranged between 45% and 96%. Twelve treatment studies improved various outcomes in language, articulation, and stuttering; little evidence emerged for interventions improving other outcomes or for adverse effects of treatment. Risk factors associated with speech and language delay were male gender, family history, and low parental education. A limitation of this review is the lack of well-designed, well-conducted studies addressing whether screening for speech and language delay or disorders improves outcomes.

CONCLUSIONS

Several screening tools can accurately identify children for diagnostic evaluations and interventions, but evidence is inadequate regarding applicability in primary care settings. Some treatments for young children identified with speech and language delays and disorders may be effective.

Language outcomes among ELBW infants in early childhood

BACKGROUND

Limited data are available evaluating language outcomes of preterm infants in early childhood. Furthermore, the relationship between language outcomes, medical morbidities and developmental trajectory in early infancy is unclear.

AIMS

The goal of this study was to evaluate language outcomes among extremely low birth weight (ELBW) infants at 30months adjusted age (AA).

STUDY DESIGN

The Bayley Scales of Infant Development II and the Peabody Picture Vocabulary Test or Expressive One Word Picture Vocabulary Test/Receptive One Word Picture Vocabulary Test were administered at 30months AA to a prospective cohort of ELBW infants who participated in the NICHD Neonatal Network Glutamine Trial and Neurodevelopmental Follow-Up Study. A standardized history and physical examination and query regarding feeding behaviors were performed at 18months AA and 30months AA.

RESULTS

Of the 467 infants evaluated, 55% had receptive language delay at 30months with 23% having severe delays. Fewer (26%) had expressive language delays, with 16% of those being severe delays. Non-English speaking infants had poorer performance on all language measures compared to English-speaking infants. Forty-seven percent of the cohort required assistance with feeds at 18months. These children were more likely to have language delay at the 30month assessment compared to infants who could feed themselves.

CONCLUSIONS

ELBW infants are at risk of language delay in early childhood. Additional research is needed to further explore the relationship between early predictors of language delay and the use of monolingual language assessments in non-English speaking patients with a history of prematurity.

Extremely preterm birth affects boys more and socio-economic and neonatal variables pose sex-specific risks

AIM

The early identification of at-risk extremely preterm (EPT) children could improve long-term outcomes. This study sought to investigate sex differences in developmental outcomes and to identify sex-specific predictors at two and a half years of age.

METHODS

We assessed 217 boys and 181 girls born before 27-week gestation using the Bayley Scales of Infant and Toddler Development, third edition (Bayley-III), as a part of the Extremely Preterm Infants in Sweden Study. Sex-specific differences were calculated. Socio-economic, birth and neonatal factors were calculated separately for boys and girls using regression models.

RESULTS

Girls scored significantly higher than boys on all Bayley-III indices. In both sexes, brain injury, long-term ventilator treatment and foreign-born mothers predicted lower scores. Receiving breast milk by hospital discharge predicted higher scores. Severe retinopathy of prematurity was the strongest predictor of cognitive and language deficits in boys. High parental education predicted higher cognitive and language scores in girls, whereas severe bronchopulmonary dysplasia was the strongest predictor of motor deficits.

CONCLUSION

Extreme prematurity seems to affect boys more than girls. Socio-economic and neonatal factors confer similar risks or protections on both sexes, but some variables pose sex-specific risks. An awareness of risk factors may provide the basis for treatment and follow-up guidelines.

Language development of low risk preterm infants up to the age of 30 months

PURPOSE

To compare the lexical and grammatical development of a group of low risk preterm children with a group of full-term children at 10, 22, and 30 months of corrected age. In addition, the effect of possible determinant factors on linguistic development was investigated.

METHOD

An initial group of 150 low-risk PR children (mean GA: 32.62) and 49 FT children (mean GA: 39.70) recruited at birth were assessed at 10, 22, and 30 months of age. Communicative and linguistic abilities were measured at these three points in time through the CDI. Cognitive development and quality of family environment of the children, among other variables, were also assessed at 22 months of age. Hierarchical regression analyses were performed in order to test those factors which may contribute to prediction of language outcomes.

RESULTS

There was no significant delay in communicative, lexical or grammatical development of PR children. Even when comparisons were performed between fullterm and very preterm children, differences were not significant. Regression analyses indicate that gestures and early word comprehension predict very early word production development, but their effect disappears with time. The most important factors which predict language development at 30 months of age are previous cognitive scores and word production at 22 months of age. The results coming from group comparisons and from hierarchical regression analyses indicate that GA does not significantly affect language development from 10 to 30 months of age.

CONCLUSIONS

Low risk preterm toddlers do not seem to be delayed in their linguistic development.

Impact of prematurity on language skills at school age

PURPOSE

The existing literature on language outcomes in children born prematurely focuses almost exclusively on standardized test scores rather than discourse-level abilities. The authors of this study looked longitudinally at school-age language outcomes and potential moderating variables for a group of twins born prematurely versus a control group of twins born at full term, analyzing both standardized test results and language sample data from the population-based Western Reserve Reading Project (WRRP; Petrill, Deater-Deckard, Thompson, DeThorne, & Schatschneider, 2006).

METHOD

Fifty-seven children born prematurely, at ≤32 weeks or <1,500 g, were compared with 57 children born at full term and were matched for age, gender, race, and parental education. Data included discourse-level language samples and standardized test results, collected at average ages 7, 8, and 10 years. The language samples were analyzed to yield a number of semantic and syntactic measures that were consolidated via factor analysis.

RESULTS

Regression models showed significant differences between the 2 groups for standardized test results, although the mean score for both groups fell in the normal range. For the discourse-level language measures, however, differences never reached statistical significance. Parental education was significantly associated with improved standardized test scores.

CONCLUSIONS

These findings suggest that in the absence of frank neurological impairment, sophisticated semantic and syntactic skills may be relatively intact in the discourse-level language of children born prematurely. Implications for assessment, particularly the potential role of attention and executive function in standardized testing tasks, are reviewed.

Need for supplemental oxygen at discharge in infants with bronchopulmonary dysplasia is not associated with worse neurodevelopmental outcomes at 3 years corrected age

OBJECTIVES

To determine if chronic oxygen dependency (discharge home on supplemental oxygen) in children with bronchopulmonary dysplasia (BPD; defined as requirement for supplemental O2 at 36 weeks postmenstrual age) predicts neurodevelopmental disability rates and growth outcomes at 36 months corrected age (CA).

STUDY DESIGN

Longitudinal cohort study.

SETTING

Southern Alberta regional center located at high altitude.

PARTICIPANTS

Preterm infants weighing ≤1250 grams with no BPD, BPD, and BPD with chronic oxygen dependency.

MAIN OUTCOME MEASURES

Neurodevelopmental and growth outcomes.

RESULTS

Of 1563 preterm infants admitted from 1995-2007, 1212 survived. Complete follow-up data were available for 1030 (85%) children. Children in BPD and BPD with chronic oxygen dependency groups had significantly lower birth weights, gestational ages, prolonged mechanical ventilation and oxygen supplementation and received more postnatal steroids, compared to those without BPD. Children with BPD and BPD with chronic oxygen dependency were more likely to be below the 5th centile in weight and height compared to those without BPD but there was little difference between the BPD and BPD with chronic oxygen dependency groups. After controlling for confounding variables, children who had BPD and BPD with chronic oxygen dependency had higher odds of neurodevelopmental disability compared to those without BPD [OR (odds ratio) 1.9 (95%CI 1.1 to 3.5) and OR 1.8 (1.1 to 2.9), respectively], with no significant difference between BPD and BPD with chronic oxygen dependency [OR 0.9 (95% CI 0.6 to 1.5)].

CONCLUSIONS

BPD and BPD with chronic oxygen dependency in children predicts abnormal neurodevelopmental outcomes at 36 months CA. However, the neurodevelopmental disability rates were not significantly higher in BPD with chronic oxygen dependency children compared to children with BPD only. Compared to those without BPD, growth is impaired in children with BPD and BPD with chronic oxygen dependency, but no difference between the latter two groups.

Neurobehavioral development of preterm and full term children: biomedical and environmental influences

BACKGROUND

Previous studies indicate that VLBW preterm children obtain significantly lower scores than full-term children in all the NBAS clusters. However the samples studied usually presented additional medical complications.

AIMS

The present study aims to compare the results obtained by low-risk preterm and full term children in the NBAS, and relate possible differences to biological and contextual factors.

METHOD

Early neurobehavioral development of 150 preterm (PR) children is compared to that of 49 full term children (FT). The children were assessed at the age of 15 days (corrected age for preterm children) with the NBAS. Biological and environmental variables were collected through an extended interview with the mothers as well as medical data.

RESULTS

Significant differences were found between preterm and full term children in the following areas: motor, range of state, and regulation of state. Differences were also found in relation to birth weight in these same three areas, following a parallel pattern. These differences between the two groups were not, however, necessarily more favorable for the FT group; the PR group had higher results in the motor and range of state areas, and lower results in the regulation of state area. The mothers' smoking habit had a negative effect on infants' regulation and orientation.

CONCLUSIONS

No general maturation delay in this particular sample of preterm children was found.

The impact of extrinsic demographic factors on Cantonese speech acquisition

This study modeled the associations between extrinsic demographic factors and children's speech acquisition in Hong Kong Cantonese. The speech of 937 Cantonese-speaking children aged 2;4 to 6;7 in Hong Kong was assessed using a standardized speech test. Demographic information regarding household income, paternal education, maternal education, presence of siblings and having a domestic helper as the main caregiver was collected via parent questionnaires. After controlling for age and sex, higher maternal education and higher household income were significantly associated with better speech skills; however, these variables explained a negligible amount of variance. Paternal education, number of siblings and having a foreign domestic helper did not associate with a child's speech acquisition. Extrinsic factors only exerted minimal influence on children's speech acquisition. A large amount of unexplained variance in speech ability still warrants further research.

Bronchopulmonary dysplasia and neurodevelopmental outcome in extremely preterm neonates

We tested the hypothesis that the use of supplemental oxygen (sO2) at discharge from the NICU in extremely preterm neonates is associated with a greater risk of neurodevelopmental impairment (NDI) at 18 months corrected gestational age (CGA) than the risk of NDI of those neonates discharged in room air. Four hundred twenty-four charts were retrospectively reviewed from infants born at <27 weeks and transferred to Nationwide Children's Hospital from December 1, 2004 to June 14, 2010. Use of sO2 was evaluated on day of life (dol) 28, at 36 weeks post-menstrual age (PMA), and at discharge. Logistic regression was used to identify postnatal risk factors associated with sO2 at discharge and NDI. At dol 28, 96 % of surviving patients received sO2, and therefore had bronchopulmonary dysplasia (BPD) by definition from a National Institutes of Child Health and Human Development workshop. At 36 weeks PMA, 89 % continued on sO2 (moderate/severe BPD), and at discharge, 74 % continued on sO2. When factors associated with NDI were examined, the need for mechanical ventilation ≥28 days (adjOR = 3.21, p = 0.01), grade III-IV intraventricular hemorrhage (IVH) (adjOR = 4.61, p < 0.01), and discharge at >43 weeks PMA (adjOR = 2.12, p = 0.04) were the strongest predictors of NDI at 18 months CGA. There was no difference in Bayley Scales of Infant Development, third edition composite scores between patients with no/mild BPD and patients with moderate/severe BPD (cognitive p = 0.60, communication p = 0.53, motor p = 0.19) or those scores between patients on and off oxygen at discharge (cognitive p = 0.58, communication p = 0.70, motor p = 0.62).

CONCLUSIONS

The need for sO2 at discharge is not associated with an increased risk of NDI in these patients. The strongest predictors of poor neurodevelopmental outcome in this population were prolonged positive pressure support, grade III-IV IVH, and discharge at >43 weeks PMA.

Outcomes of extremely low birth weight infants with bronchopulmonary dysplasia: impact of the physiologic definition

AIMS

We compared neurodevelopmental outcomes of extremely low birth weight (ELBW) infants with and without bronchopulmonary dysplasia (BPD), using the physiologic definition.

STUDY DESIGN

ELBW (birth weights<1000 g) infants admitted to the Neonatal Research Network centers and hospitalized at 36 weeks postmenstrual age (n=1189) were classified using the physiologic definition of BPD. Infants underwent Bayley III assessment at 18-22 months corrected age. Multivariable logistic regression was used to determine the association between physiologic BPD and cognitive impairment (score<70).

RESULTS

BPD by the physiologic definition was diagnosed in 603 (52%) infants, 537 of whom were mechanically ventilated or on FiO(2)>30% and 66 who failed the room air challenge. Infants on room air (n=505) and those who passed the room air challenge (n=51) were classified as "no BPD" (n=556). At follow up, infants with BPD had significantly lower mean weight and head circumference. Moderate to severe cerebral palsy (7 vs. 2.1%) and spastic diplegia (7.8 vs. 4.1%) and quadriplegia (3.9 vs. 0.9%) phenotypes as well as cognitive (12.8 vs. 4.6%) and language scores<70 (24.2 vs. 12.3%) were significantly more frequent in those with BPD compared to those without BPD. BPD was independently associated (adjusted OR 2.4; 95% CI 1.40-4.13) with cognitive impairment.

CONCLUSIONS

Rates of adverse neurodevelopmental outcomes in early childhood were significantly higher in those with BPD. BPD by the physiologic definition was independently associated with cognitive impairment using Bayley Scales III. These findings have implications for targeted post-discharge surveillance and early intervention.

Biological and environmental factors as predictors of language skills in very preterm children at 5 years of age

OBJECTIVE

Language problems are thought to occur more frequently in very preterm children compared with healthy term born children. The primary aim of this study was to examine the contributions of biological and environmental risk factors to language outcomes in very preterm children at 5 years of age.

METHODS

A cohort of 227 very preterm infants (birth weight <1250 g or gestational age <30 weeks) were recruited at birth and followed up at 2 and 5 years of age (corrected for prematurity) in a prospective, longitudinal study in Melbourne, Australia. Outcomes at 5 years of age were the Expressive and Receptive Language Scales from the Kaufman Survey of Early Academic and Language Skills. A range of hypothesized biological and environmental factors identified from past research were examined as predictors of language outcomes at 5 years of age using linear regression models.

RESULTS

Lower maternal education and poorer communication skills in the child at 2 years of age were predictive of poorer expressive and poorer receptive language outcomes at 5 years of age. Lower expressive language scores were also associated with the presence of moderate-severe white matter abnormalities on neonatal magnetic resonance imaging.

CONCLUSIONS

Results support the role of both biological and environmental factors in the evolution of language difficulties and highlight the need to consider these factors in the follow-up of preterm infants.

Precursors to language in preterm infants: speech perception abilities in the first year of life

Language development in infants born very preterm is often compromised. Poor language skills have been described in preschoolers and differences between preterms and full terms, relative to early vocabulary size and morphosyntactical complexity, have also been identified. However, very few data are available concerning early speech perception abilities and their predictive value for later language outcomes. An overview of the results obtained in a prospective study exploring the link between early speech perception abilities and lexical development in the second year of life in a population of very preterm infants (≤32 gestation weeks) is presented. Specifically, behavioral measures relative to (a) native-language recognition and discrimination from a rhythmically distant and a rhythmically close nonfamiliar languages, and (b) monosyllabic word-form segmentation, were obtained and compared to data from full-term infants. Expressive vocabulary at two test ages (12 and 18 months, corrected age for gestation) was measured using the MacArthur Communicative Development Inventory. Behavioral results indicated that differences between preterm and control groups were present, but only evident when task demands were high in terms of language processing, selective attention to relevant information and memory load. When responses could be based on acquired knowledge from accumulated linguistic experience, between-group differences were no longer observed. Critically, while preterm infants responded satisfactorily to the native-language recognition and discrimination tasks, they clearly differed from full-term infants in the more challenging activity of extracting and retaining word-form units from fluent speech, a fundamental ability for starting to building a lexicon. Correlations between results from the language discrimination tasks and expressive vocabulary measures could not be systematically established. However, attention time to novel words in the word segmentation task yielded a significant correlation with vocabulary at both test ages. The predictive value of the behavioral measures in this research for an early identification of language delays in the preterm population was, thus, limited. However, early evidence of preterms' difficulties in speech and language processing tasks involving complex materials reveals a weakness in their initial approach to the language acquisition process that may constrain their future language skills well beyond the prelexical stage.

Does preterm birth increase a child's risk for language impairment?

BACKGROUND

Although premature birth is associated with lags in language acquisition, it is unclear whether preterms exhibit an elevated risk for language impairment (LI). This study determined whether preterms, without frank cerebral damage, at 2;6 and 3;6 exhibited a higher rate of risk for LI as compared to full-terms, and also sought to identify predictors of risk.

METHOD

Sixty-four Italian very immature preterms were assessed longitudinally at 2;6 and 3;6; age-matched full-terms served as controls at 2;6 (n=22) and 3;6 (n=40). Each completed individualized assessments of cognition and language ability. At each time point, using cut-offs specific to each of the language measures, children were differentiated into two groups (at risk for LI, not at risk).

RESULTS

The percentage of full-terms at risk for LI at 2;6 (9.1% to 13.6%) and 3;6 (7.5%) was consistent with prior estimates of LI at these ages. The percentage of preterms at risk for LI at 2;6 (16.1% to 24.1%) and 3;6 (34.4%) was higher at both ages and statistically significant at 3;6 (difference=26.8%, 95% CI=12.3% to 41.4%). The best model predicting risk status at 3;6 was preterms' mean length of utterance (MLU) at 2;6, (sensitivity 72.73%, specificity 85%) when adjusting for maternal education.

CONCLUSION

Preterms exhibit a heightened risk for LI in the preschool years, since about one in four preterms at 2;6 and one in three preterms at 3;6 experiences significant lags in language acquisition. Findings argue the importance of early identification of language difficulties among preterms coupled with implementation of systematic language-focused interventions for these youngsters.

Conductive hearing loss in children with bronchopulmonary dysplasia: a longitudinal follow-up study in children aged between 6 and 24 months

AIMS

To determine the occurrence of isolated and recurrent episodes of conductive hearing loss (CHL) during the first two years of life in very low birth weight (VLBW) infants with and without bronchopulmonary dysplasia (BPD). STUDY DESIGN, SUBJECTS AND OUTCOME MEASURES: In a longitudinal clinical study, 187 children were evaluated at 6, 9, 12, 15 18 and 24 months of age by visual reinforcement audiometry, tympanometry and auditory brain response system.

RESULTS

Of the children with BPD, 54.5% presented with episodes of CHL, as opposed to 34.7% of the children without BPD. This difference was found to be statistically significant. The recurrent or persistent episodes were more frequent among children with BPD (25.7%) than among those without BPD (8.3%). The independent variables that contributed to this finding were small for gestational age and a 5 min Apgar score.

CONCLUSIONS

Recurrent CHL episodes are more frequent among VLBW infants with BPD than among VLBW infants without BPD.

Risk and protective factors associated with speech and language impairment in a nationally representative sample of 4- to 5-year-old children

PURPOSE

To determine risk and protective factors for speech and language impairment in early childhood.

METHOD

Data are presented for a nationally representative sample of 4,983 children participating in the Longitudinal Study of Australian Children (described in McLeod & Harrison, 2009). Thirty-one child, parent, family, and community factors previously reported as being predictors of speech and language impairment were tested as predictors of (a) parent-rated expressive speech/language concern and (b) receptive language concern, (c) use of speech-language pathology services, and (d) low receptive vocabulary.

RESULTS

Bivariate logistic regression analyses confirmed 29 of the identified factors. However, when tested concurrently with other predictors in multivariate analyses, only 19 remained significant: 9 for 2-4 outcomes and 10 for 1 outcome. Consistent risk factors were being male, having ongoing hearing problems, and having a more reactive temperament. Protective factors were having a more persistent and sociable temperament and higher levels of maternal well-being. Results differed by outcome for having an older sibling, parents speaking a language other than English, and parental support for children's learning at home.

CONCLUSION

Identification of children requiring speech and language assessment requires consideration of the context of family life as well as biological and psychosocial factors intrinsic to the child.

Long-term outcomes of bronchopulmonary dysplasia

As more very preterm infants survive, more survivors will have bronchopulmonary dysplasia (BPD). Children with BPD have higher rates of cognitive, educational and behavioural impairments, and also reduced lung function, through childhood and into early life than would normally be expected. The importance of these neurological and respiratory problems later into adult life needs to be determined.

Chronic lung disease and developmental delay at 2 years of age in children born before 28 weeks' gestation

INTRODUCTION

Extremely low gestational age newborns (ELGANs) are at increased risk of chronic lung disease (CLD) and of developmental delay. Some studies have suggested that CLD contributes to developmental delay.

PATIENTS AND METHODS

We examined data collected prospectively on 915 infants born before the 28th week of gestation in 2002-2004 who were assessed at 24 months of age with the Bayley Scales of Infant Development-2nd Edition or the Vineland Adaptive Behavior Scales. We excluded infants who were not able to walk independently (Gross Motor Function Classification System score < 1) and, therefore, more likely to have functionally important fine motor impairments. We defined CLD as receipt of oxygen at 36 weeks' postmenstrual age and classified infants as either not receiving mechanical ventilation (MV) (CLD without MV) or receiving MV (CLD with MV).

RESULTS

Forty-nine percent of ELGANs had CLD; of these, 14% were receiving MV at 36 weeks' postmenstrual age. ELGANs without CLD had the lowest risk of a Mental Developmental Index (MDI) or a Psychomotor Developmental Index (PDI) of <55, followed by ELGANs with CLD not receiving MV, and ELGANs with CLD receiving MV (9%, 12%, and 18% for the MDI and 7%, 10%, and 20% for the PDI, respectively). In time-oriented multivariate models, the risk of an MDI of <55 was associated with the following variables: gestational age of <25 weeks; single mother; late bacteremia; pneumothorax; and necrotizing enterocolitis. The risk of a PDI of <55 was associated with variables such as single mother, a complete course of antenatal corticosteroids, early and persistent pulmonary dysfunction, pulmonary deterioration during the second postnatal week, pneumothorax, and pulmonary interstitial emphysema. CLD, without or with MV, was not associated with the risk of either a low MDI or a low PDI. However, CLD with MV approached, but did not achieve, nominal statistical significance (odds ratio: 1.9 [95% confidence interval: 0.97-3.9]) for the association with a PDI of <55.

CONCLUSIONS

Among children without severe gross motor delays, risk factors for CLD account for the association between CLD and developmental delay. Once those factors are considered in time-oriented risk models, CLD does not seem to increase the risk of either a low MDI or a low PDI. However, severe CLD might increase the risk of a low PDI.