Early intervention and environmental factors: optimizing the development of infants born preterm

Factors Associated with Outpatient Therapy Utilization in Extremely Preterm Infants

OBJECTIVE

Factors influencing utilization of outpatient interventional therapies for extremely low gestational age newborns (ELGANs) after discharge remain poorly characterized, despite a significant risk of neurodevelopmental impairment. We sought to assess the effects of maternal, infant, and environmental characteristics on outpatient therapy utilization in the first 2 years after discharge using data from the Preterm Erythropoietin Neuroprotection (PENUT) Trial.

STUDY DESIGN

This is a secondary analysis of 818, 24 to 27 weeks gestation infants enrolled in the PENUT trial who survived through discharge and completed at least one follow-up call or in-person visit between 4 and 24 months of age. Utilization of a state early intervention (EI) program, physical therapy (PT), occupational therapy (OT), and speech therapy (ST) was recorded. Odds ratios and cumulative frequency curves for resource utilization were calculated for patient characteristics adjusting for gestational age, treatment group, and birth weight.

RESULTS

EI was not accessed by 37% of infants, and 18% did not use any service (PT/OT/ST/EI). Infants diagnosed with severe morbidities (intraventricular hemorrhage, retinopathy of prematurity, bronchopulmonary dysplasia, necrotizing enterocolitis), discharged with home oxygen, or with gastrostomy placement experienced increased utilization of PT, OT, and ST compared with peers. However, substantial variation in service utilization occurred by the state of enrollment and selected maternal characteristics.

CONCLUSIONS

ELGANs with severe medical comorbidities are more likely to utilize services after discharge. Therapy utilization may be impacted by maternal characteristics and state of enrollment. Outpatient therapy services remain significantly underutilized in this high-risk cohort. Further research is required to characterize and optimize the utilization of therapy services following NICU discharge of ELGANs.

KEY POINTS

· Outpatient therapy is underutilized in ELGANs.. · Medical comorbidities may impact therapy use.. · Maternal characteristics may impact therapy use.. · State of enrollment may impact therapy use..

Multiscale entropy as a metric of brain maturation in a large cohort of typically developing children born preterm using longitudinal high-density EEG in the first two years of life

Objective.We aimed to analyze whether complexity of brain electrical activity (EEG) measured by multiscale entropy (MSE) increases with brain maturation during the first two years of life. We also aimed to investigate whether this complexity shows regional differences across the brain, and whether changes in complexity are influenced by extrauterine life experience duration.Approach.We measured MSE of EEG signals recorded longitudinally using a high-density setup (64 or 128 electrodes) in 84 typically developing infants born preterm (<32 weeks' gestation) from term age to two years. We analyzed the complexity index and maximum value of MSE over increasing age, across brain regions, and in function of extrauterine life duration, and used correlation matrices as a metric of functional connectivity of the cerebral cortex.Main results.We found an increase of strong inter-channel correlation of MSE (R > 0.8) with increasing age. Regional analysis showed significantly increased MSE between 3 and 24 months of corrected age in the posterior and middle regions with respect to the anterior region. We found a weak relationship (adjusted R²= 0.135) between MSE and extrauterine life duration.Significance.These findings suggest that brain functional connectivity increases with maturation during the first two years of life. EEG complexity shows regional differences with earlier maturation of the visual cortex and brain regions involved in joint attention than of regions involved in cognitive analysis, abstract thought, and social behavior regulation. Finally, our MSE analysis suggested only a weak influence of early extrauterine life experiences (prior to term age) on EEG complexity.

Persistence of Effects of VLBW/PT Birth Status and Maternal Emotional Availability (EA) on Child EA Trajectories

Few studies have examined the longitudinal impact of birth status on the infant-mother relationship and on children's socio-emotional development. In the present study we investigated developmental patterns of such relationships [using the Emotional Availability (EA) Scales] in fullterm and VLBW/PT infants from infancy to emerging school age. Our objectives were to: (a) model the developmental trajectories of EA dimensions (maternal sensitivity, structuring, non-hostility; child responsiveness, involvement) in a VLBW/PT and fullterm sample, (b) identify potential effects of VLBW/PT status on these trajectories, and (c) determine whether the effects of VLBW/PT status on children's socio-emotional development (child EA) remained after accounting for the effect of maternal EA. Child-mother dyads (n = 109) were observed in home-based interactions (face-to-face and free play) when children were 6, 12, 18, and 57-months-old in fullterm (37-41 weeks, >2500 g; n = 48) and healthy VLBW/PT (26-32 weeks gestation, birth weight 800-1500 g, corrected for gestational age; n = 61) children. Developmental trajectories of maternal and child EA were assessed using multilevel growth modeling in Mplus. Results indicated that, even after controlling for maternal EA, there was a persistent negative effect of VLBW/PT birth status on child EA trajectories. Both initially and over time, VLBW/PT infants lagged behind their fullterm counterparts on levels of responsiveness and involvement with mothers. There was also a persistent positive effect of maternal EA (sensitivity and structuring) on child EA trajectories. Higher average levels of maternal sensitivity and structuring across time were also associated with higher and persistent levels of child responsiveness and involvement of their mothers. Importantly, results held after modeling both effects together, and after controlling for maternal education and child gender. Our results have implications for VLBW/PT children's development, the parent-child relationship, and integrating family level factors and relationship dimensions in early prevention and intervention programs.