No change in neurodevelopment at 11 years after extremely preterm birth

Neurosensory, cognitive and academic outcomes at 8 years in children born 22-23 weeks' gestation compared with more mature births

Despite providing intensive care to more infants born <24 weeks' gestation, data on school-age outcomes, critical for counselling and decision-making, are sparse.

OBJECTIVE

To compare major neurosensory, cognitive and academic impairment among school-aged children born extremely preterm at 22-23 weeks' gestation (EP22-23) with those born 24-25 weeks (EP24-25), 26-27 weeks (EP26-27) and term (≥37 weeks).

DESIGN

Three prospective longitudinal cohorts.

SETTING

Victoria, Australia.

PARTICIPANTS

All EP live births (22-27 weeks) and term-born controls born in 1991-1992, 1997 and 2005.

MAIN OUTCOME MEASURES

At 8 years, major neurosensory disability (any of moderate/severe cerebral palsy, IQ <-2 SD relative to controls, blindness or deafness), motor, cognitive and academic impairment, executive dysfunction and poor health utility. Risk ratios (RRs) and risk differences between EP22-23 (reference) and other gestational age groups were estimated using generalised linear models, adjusted for era of birth, social risk and multiple birth.

RESULTS

The risk of major neurosensory disability was higher for EP22-23 (n=21) than more mature groups (168 EP24-25; 312 EP26-27; 576 term), with increasing magnitude of difference as the gestation increased (adjusted RR (95% CI) compared with EP24-25: 1.39 (0.70 to 2.76), p=0.35; EP26-27: 1.85 (0.95 to 3.61), p=0.07; term: 13.9 (5.75 to 33.7), p<0.001). Similar trends were seen with other outcomes. Two-thirds of EP22-23 survivors were free of major neurosensory disability.

CONCLUSIONS

Although children born EP22-23 experienced higher rates of disability and impairment at 8 years than children born more maturely, many were free of major neurosensory disability. These data support providing active care to infants born EP22-23.

Optimal presence: enhancing parent integration to maximize neurodevelopmental outcomes in preterm infants

Preterm birth disrupts the natural progression of events in the parent-infant relationship and bestows many of the typical parent responsibilities to the clinical care team. In turn, the neonatal intensive care environment (NICU) introduces obstacles to parents that would not otherwise be encountered and forces parents to adapt to this artificial environment as they seek to bond with and care for their newborn. Facilitating parent presence at the bedside and incorporating them into the care of their preterm infant is critical for lessening the immediate burden to both the parent and offspring while also ensuring the best possible outcome for preterm infants. In this review, we explore the impact that parents exert on the neurodevelopmental outcome of preterm infants and identify several barriers and facilitators to parent presence.

Antenatal and neonatal exposure to SARS-CoV-2 and children's development: a systematic review and meta-analysis

OBJECTIVES

To conduct a systematic review of the impact of antenatal and neonatal exposure to SARS-CoV-2 on developmental outcomes in preterm and term-born infants.

METHODS

We searched Embase, Emcare, MEDLINE, PsycINFO, Web of Science and grey literature on May 27, 2022 and updated on May 8, 2023. Studies defining exposure with a positive SARS-CoV-2 protein or genetic material, used a contemporaneous non-exposed cohort, and reported developmental outcomes up to 2 years of age were included.

RESULTS

Four out of 828 screened studies were included. Meta-analysis included 815 infants screened for developmental delay (n = 306 exposed; n = 509 non-exposed) between 3- and 11-months of age. Among term-born infants, we did not find an increased risk of delay in communication (odd's ratio: 0.73 (95% CI: 0.24-2.24)), gross motor (1.50 (0.62, 3.62)), fine motor (2.90 (0.58, 14.43)), problem-solving (1.19 (0.54, 2.66)) or personal-social development (1.93 (0.78, 4.75)) in exposed infants. The number of preterm-born infants in the exposed (n = 37) and comparison cohorts (n = 41) were too few to report meaningful comparisons.

CONCLUSION

Evidence regarding the potential impact of antenatal or neonatal exposure to SARS-CoV-2 infection on developmental outcomes in early infancy is limited and inconsistent. Larger cohorts with outcomes beyond the first year of life are needed.

IMPACT

The current evidence examining associations between SARS-CoV-2 exposure during the neonatal period and developmental outcomes in infancy is limited by there being few studies with extremely small sample sizes. Based on sparse data there was no consistent association between antenatal or neonatal exposure to SARS-CoV-2 infection and an adverse impact on developmental outcomes below 12 months of age for babies born preterm or at term. This study highlights that larger cohorts with outcomes assessed beyond the first year are needed to determine the potential longer-term impact of SARS-CoV-2 infection exposure on child development.

Perinatal Outcomes of Immigrant Mothers and Their Infants Born Very Preterm across Germany

BACKGROUND

In Germany, more than 40% of infants are born to immigrant parents. Increased survival rates of very preterm (below 32 weeks gestation at birth; VP) infants have not resulted in equally improved life chances and quality of life. More information on perinatal variations in outcomes according to social inequalities, migration background, and language barriers is needed. We tested whether mothers' immigrant status and language barriers are associated with perinatal health and short-term neonatal outcomes.

METHODS

The data are from the national multi-centre German Neonatal Network (GNN) cohort, including VP births from 2009 onwards. In total, 3606 (n = 1738 female) children were assessed, and 919 (n = 449 female) of these children had immigrant backgrounds. Immigrant status was operationalised as a binary variable based on the children's mothers' countries of birth (born in Germany vs. foreign-born). Self-reported home language (L1) was used to calculate the average linguistic distance to German as one continuous variable.

RESULTS

Mixed-effects models showed that two out of fourteen effects of interest survived the adjustment for known confounders and accounting for the nestedness of data within birth hospitals. Linguistic distance from mothers' L1s to German was independently associated with diagnoses of preeclampsia (OR = 1.01, 95% CI = [1.00, 1.01]). Infants of foreign-born mothers had higher odds for amniotic infection syndrome (AIS; OR = 1.45 [1.13, 1.86]) than infants of German mothers.

CONCLUSIONS

Our findings from this large multi-centre longitudinal cohort of VP-born children indicate that maternal immigrant status and language barriers have limited impact on perinatal health and severe neonatal outcomes. This suggests that, regardless of background or language skills, there may be few inequalities in the perinatal health of pregnant women and their newborn preterm infants.

Predictability of the neurodevelopmental assessment based on the Kyoto Scale of Psychological Development 2001 at 18-24 months of corrected age and 3 years of age in identifying cognitive impairment at 6 years of age in very preterm infants: A retrospective study at a Japanese tertiary center

BACKGROUND

It is unknown how accurately the current Japanese classification system for neurodevelopmental delay based on the assessment with the Kyoto Scale of Psychological Development (KSPD) at toddlerhood and pre-school periods predicts cognitive impairment at school age.

METHODS

This single-center retrospective cohort study enrolled infants born at 22-29 weeks of gestational age. At 18-24 months of corrected age and 3 years of age, the patients were categorized according to the current Japanese criteria for neurodevelopmental delay based on their overall developmental quotient calculated using the KSPD-2001. Cognitive impairment at 6 years of age was classified according to the calculated or estimated full-scale intelligence quotient. The predictability of the current Japanese classification of neurodevelopmental delay for cognitive impairment at 6 years of age was investigated.

RESULTS

Of 566 eligible patients, 364 (64 %) completed the protocol. The current classification for the neurodevelopmental delay showed significant agreement with the severity of cognitive impairment at 6 years of age. The sensitivity and specificity of the KSPD-2001-based assessment for any cognitive impairment at 6 years of age were 0.64 and 0.74 at 18-24 months of corrected age and 0.83 and 0.70 at 3 years of age. The corresponding sensitivity and specificity for moderate/severe cognitive impairment were 0.51 and 0.96 at 18-24 months of corrected age and 0.68 and 0.95 at 3 years of age.

CONCLUSION

The KSPD-2001 is a useful tool to predict the severity of cognitive impairment at school age.

'I don't want him to always be so far behind': Parental perceptions of child independence in the context of extreme prematurity; a qualitative study

This study addresses the paucity of research on parents of extremely preterm adolescents (born <27 weeks of gestation) and their experiences within the framework of parental determinism. We conducted semi-structured interviews with twenty-two mothers and one father. Data were analysed thematically, revealing three overarching themes and eight subthemes shaping parental accounts. These themes centred on parental ambitions for their children, their perceptions of their child's abilities, and the parenting behaviours employed to support parental aspirations. Parents' actions were influenced by their ambitions and the belief that they could impact their child's future independence. While some parents adopted 'trusting', non-intensive parenting behaviours, those anticipating challenges for their child's future independence resorted to intensive parenting practices. These findings align with the concept of parental determinism, emphasising the perceived causal link between present parental actions and future child outcomes. In the context of extreme prematurity, a nuanced understanding of parental perceptions regarding their child's future independence aligned with a delicate balance between hope and realistic aspiration is crucial for enhancing parental support and well-being.

The Triple Aim Quality Improvement Gold Standard Illustrated as Extremely Premature Infant Care

OBJECTIVES

The Triple Aim is widely regarded as the quality improvement gold standard that enhances population health, lowers costs, and betters individual care. There have been no large-scale, sustained demonstrations of such improvement in healthcare. Illustrating the Triple Aim using relevant extremely premature infant outcomes might highlight interwoven proficiency and efficiency complexities that impede sustained value progress.

STUDY DESIGN

Ten long-term collaborating neonatal intensive care units (NICU) in the Vermont Oxford Network calculated the Triple Aim in 230/7 to 276/7-week infants using three surrogate measures: (1) population health/x-axis-eight major morbidity rates as a composite, risk-adjusted metric; (2) cost/y-axis-total hospital length of stay; and (3) individual care/z-axis-mortality, then illustrated this relationship as a sphere within a three-dimensional cube.

RESULTS

Three thousand seven hundred six infants born between January 1, 2014 and December 31, 2019, with mean (standard deviation) gestational age of 25.7 (1.4) weeks and birth weight of 803 (208) grams were analyzed. Triple Aim three-axis cube positions varied inconsistently comparing NICUs. Each NICUs' sphere illustrated mixed x- and z-axis movement (clinical proficiency), and y-axis movement (cost efficiency). No NICU demonstrated the theoretically ideal Triple Aim improvement in all three axes. Backward movement in at least one axis occurred in eight NICUs. The whole-group Triple Aim sphere moved forward along the x-axis (better morbidities metric), but moved backward in the y-axis length of stay and z-axis mortality measurements.

CONCLUSION

Illustrating the Triple Aim gold standard as extreme prematurity outcomes reveals complexities inherent to simultaneous attempts at improving interwoven quality and cost outcomes. Lack of progress using relevant Triple Aim parameters from our well-established collaboration highlights the difficulties prioritizing competing outcomes, variable potentially-better-practice applications amongst NICUs, unmeasured biologic interactions, and obscured cultural-environmental contexts that all likely affect care. Triple Aim excellence, if even remotely possible, will necessitate scalable, evidence-based methodologies, pragmatism regarding inevitable trade-offs, and wise constrained-resource decisions.

KEY POINTS

· The Triple Aim gold standard is elusive. There is no demonstration of sustained, large-scale success in healthcare and our quality improvement network has previously published benchmark extreme prematuritymorbidity improvements.. · Extreme prematurity outcomes illustrated as the Triple Aim show uneven results in relevant surrogate parameters and Triple Aim achievement, if even possible, will necessitate evidence-based methodologies that are scalable.. · Pragmatism, inevitable trade-offs, and wise constrained-resource decisions are required for Triple Aim success..

Comparing behavioural outcomes in children born extremely preterm between 2006 and 1995: the EPICure studies

BACKGROUND

Children born extremely preterm (EP) are at increased risk of neurocognitive and behavioural morbidity. Here, we investigate whether behavioural outcomes have changed over time concomitant with increasing survival following EP birth.

METHODS

Comparison of outcomes at 11 years of age for two prospective national cohorts of children born EP in 1995 (EPICure) and 2006 (EPICure2), assessed alongside term-born children. Behavioural outcomes were assessed using the parent-completed Strengths and Difficulties Questionnaire (SDQ), DuPaul Attention-Deficit/Hyperactivity Disorder Rating Scale (ADHD-RS), and Social Communication Questionnaire (SCQ).

RESULTS

In EPICure, 176 EP and 153 term-born children were assessed (mean age: 10.9 years); in EPICure2, 112 EP and 143 term-born children were assessed (mean age: 11.8 years). In both cohorts, EP children had higher mean scores and more clinically significant difficulties than term-born children on almost all measures. Comparing outcomes for EP children in the two cohorts, there were no significant differences in mean scores or in the proportion of children with clinically significant difficulties after adjustment for confounders. Using term-born children as reference, EP children in EPICure2 had significantly higher SDQ total difficulties and ADHD-RS hyperactivity impulsivity z-scores than EP children in EPICure.

CONCLUSIONS

Behavioural outcomes have not improved for EP children born in 2006 compared with those born in 1995. Relative to term-born peers, EP children born in 2006 had worse outcomes than those born in 1995. There is an ongoing need for long-term clinical follow-up and psychological support for children born EP.

Secular trends in physical growth, biological maturation, and intelligence in children and adolescents born between 1978 and 1993

Introduction

Human physical growth, biological maturation, and intelligence have been documented as increasing for over 100 years. Comparing the timing of secular trends in these characteristics could provide insight into what underlies them. However, they have not been examined in parallel in the same cohort during different developmental phases. Thus, the aim of this study was to examine secular trends in body height, weight, and head circumference, biological maturation, and intelligence by assessing these traits concurrently at four points during development: the ages of 4, 9, 14, and 18 years.

Methods

Data derived from growth measures, bone age as an indicator of biological maturation, and full-scale intelligence tests were drawn from 236 participants of the Zurich Longitudinal Studies born between 1978 and 1993. In addition, birth weight was analyzed as an indicator of prenatal conditions.

Results

Secular trends for height and weight at 4 years were positive (0.35 SD increase per decade for height and an insignificant 0.27 SD increase per decade for weight) and remained similar at 9 and 14 years (height: 0.46 SD and 0.38 SD increase per decade; weight: 0.51 SD and 0.51 SD increase per decade, respectively) as well as for weight at age 18 years (0.36 SD increase per decade). In contrast, the secular trend in height was no longer evident at age 18 years (0.09 SD increase per decade). Secular trends for biological maturation at 14 years were similar to those of height and weight (0.54 SD increase per decade). At 18 years, the trend was non-significant (0.38 SD increase per decade). For intelligence, a positive secular trend was found at 4 years (0.54 SD increase per decade). In contrast, negative secular trends were observed at 9 years (0.54 SD decrease per decade) and 14 years (0.60 SD decrease per decade). No secular trend was observed at any of the four ages for head circumference (0.01, 0.24, 0.17, and - 0.04 SD increase per decade, respectively) and birth weight (0.01 SD decrease per decade).

Discussion

The different patterns of changes in physical growth, biological maturation, and intelligence between 1978 and 1993 indicate that distinct mechanisms underlie these secular trends.

Parenting stress and health-related quality of life among parents of extremely preterm born early adolescents in England: a cross-sectional study

OBJECTIVE

To determine whether extremely preterm (EP) birth exerts persisting effects on parents in early adolescence.

DESIGN

Cross-sectional survey conducted between March 2017 and October 2018.

SETTING

Evaluation of a longitudinal population-based birth cohort in England at 11 years of age (EPICure2@11 Study).

PARTICIPANTS

Parents of EP (<27 weeks of gestation) adolescents and control parents of term born (≥37 weeks of gestation) classmates of similar age and sex.

MAIN OUTCOME MEASURES

The Parenting Stress Index Short Form (PSI-4-SF) and the Short Form Health Survey (SF-12v1).

RESULTS

The 163 EP and 125 comparison respondents were most commonly mothers in their mid-40s. EP parents reported higher total parenting stress scores compared with controls, overall (adjusted difference in means: 14 (95% CI 9 to 20)) and after exclusion of moderate and severe child disability and multiples (9 (95% CI 3 to 15). Average physical and mental health-related quality of life scores were similar in the two groups (adjusted difference in means physical health: -2 (95% CI -4 to 1) and mental health: -1 (95% CI -4 to 1)). Among EP parents, 12% (20/164) reported the combination of high parenting stress and low mental health scores. With increasing child age, parenting stress scores for preterm parents were lower in contrast to controls who reported increasing parenting stress.

CONCLUSIONS

In early adolescence, compared with parents of term-born children, EP parents experience increased levels of parenting stress that are particularly high among a proportion of parents and associated with lower mental health-related quality of life. Practitioner awareness of this continuing risk throughout childhood is important to support parental abilities and well-being.

Emotional problems and peer victimization in adolescents born very preterm and full-term: Role of self-control skills in childhood

The aim of the current study was to examine whether self-control skills in childhood moderate the association between very preterm birth (<32 weeks of gestational age) and emotional problems and peer victimization in adolescence. We used data from four prospective cohort studies, which included 29,378 participants in total (N = 645 very preterm; N = 28,733 full-term). Self-control was mother-reported in childhood at 5-11 years whereas emotional problems and peer victimization were both self- and mother-reported at 12-17 years of age. Findings of individual participant data meta-analysis showed that self-control skills in childhood do not moderate the association between very preterm birth and adolescence emotional problems and peer victimization. It was shown that higher self-control skills in childhood predict lower emotional problems and peer victimization in adolescence similarly in very preterm and full-term borns.

Preschool Mathematics and Literacy Skills and Educational Attainment in Adolescents Born Preterm and Full Term

OBJECTIVES

To test whether preschool academic skills were associated with educational attainment in adolescence and whether associations differed between individuals born preterm and at full term.

STUDY DESIGN

This prospective cohort study comprised 6924 individuals, including n = 444 (6.4%) adolescents born preterm (<37 weeks of gestation) from the Avon Longitudinal Study of Parents and Children. Preschool academic (mathematics and literacy) skills were rated by teachers at 4-5 years. Educational attainment at 16 years was informed by attaining a General Certificate of Secondary Education (GCSE) in key subjects mathematics and English. Logistic regressions assessed the association between preterm birth, preschool mathematics, and GCSE Mathematics and between preterm birth, preschool literacy, and GCSE English.

RESULTS

Similar numbers of adolescents born preterm and at term achieved a GCSE in mathematics and English (53.6 % vs 57.4% and 59.5% vs 63.9%, respectively; P values > .05). Higher preschool academic skill scores in mathematics were associated with greater odds of attaining GCSE Mathematics and preschool literacy skills were associated with GCSE English. Adolescents born preterm with higher preschool mathematics (OR: 1.51, CI: 1.14, 2.00) and literacy skills (OR: 1.57, CI: 1.10, 2.25) were more likely to attain GCSEs in the respective subject than their term-born counterparts with equal levels of preschool skills.

CONCLUSIONS

Preschool academic skills in mathematics and literacy are associated with educational attainment of preterm and term-born individuals in adolescence. Children born prematurely may benefit more from preschool mathematics and literacy skills for academic and educational success into adolescence than term-born individuals.

A unit's experience with hybrid NICU design: description of care model and implications for patients, families, and professionals

As the first extra-uterine setting for hospitalized infants, the neonatal intensive care unit (NICU) environment can make a lasting impact on their long-term neurodevelopment. This impact is likely mediated through both specific characteristics of the physical design of the care environment, as well as the experiences that occur within this environment. Recent studies document many established benefits of single-family rooms (SFRs). However, there is concern that infants who spend a prolonged time in SFRs without their parents being intimately involved in their care have reduced opportunities for meaningful experiences, with possible adverse consequences. The purpose of this report is to share an example of an application of the family-centered developmental care model through a hybrid NICU design, inclusive of both SFRs and semi-private bays. In this paper, we empirically describe the physical and operational considerations of a hybrid model, outline the strengths and challenges of this approach, and discuss implications for patients, families, and professionals.

Executive functions assessment in very preterm children at school age: A pilot study about a clinical and experimental approach

While the survival rate of very preterm (VPT) infants has increased in the last decades, they are still at risk of developing long-term neurodevelopmental impairments, especially regarding self-regulatory abilities, and goal-directed behaviors. These skills rely on executive functions (EFs), an umbrella term encompassing the core capacities for inhibition, shifting, and working memory. Existing comprehensive tests are time-consuming and therefore not suitable for all pediatric neuropsychological assessments. The Flanker task is an experimental computer game having the advantage to last less than ten minutes while giving multiple EFs measures. Here, we tested the potency of this task in thirty-one VPT children aged 8-10 years during their clinical assessment. First, we found that VPT children performed in the norm for most clinical tests (i.e., WISC-V, BRIEF, and NEPSY) except for the CPT-3 where they were slower with more omission errors, which could indicate inattentiveness. Second, some Flanker task scores were correlated with standardized clinical testing without resisting to multiple comparisons correction. Finally, compared to full-term children, VPT children showed poorer performance in global EFs measure and lower accuracy in the Flanker task. These findings suggest that this child-friendly version of the Flanker task demonstrated a reasonable sensitivity in capturing EFs with good discrimination between VPT and term children despite VPT children's mild difficulties. It may represent a promising tool for neuropsychological assessments and be suitable as a screening test, providing further validating larger studies. Moreover, while VPT schoolchildren globally display normal intelligence, subtle difficulties that seem to relate to EFs are observed.

Reduced structural connectivity in non-motor networks in children born preterm and the influence of early postnatal human cytomegalovirus infection

Introduction

Preterm birth is increasingly recognized to cause lifelong functional deficits, which often show no correlate in conventional MRI. In addition, early postnatal infection with human cytomegalovirus (hCMV) is being discussed as a possible cause for further impairments. In the present work, we used fixel-based analysis of diffusion-weighted MRI to assess long-term white matter alterations associated with preterm birth and/or early postnatal hCMV infection.

Materials and methods

36 former preterms (PT, median age 14.8 years, median gestational age 28 weeks) and 18 healthy term-born controls (HC, median age 11.1 years) underwent high angular resolution DWI scans (1.5 T, b = 2 000 s/mm2, 60 directions) as well as clinical assessment. All subjects showed normal conventional MRI and normal motor function. Early postnatal hCMV infection status (CMV+ and CMV-) had been determined from repeated screening, ruling out congenital infections. Whole-brain analysis was performed, yielding fixel-wise metrics for fiber density (FD), fiber cross-section (FC), and fiber density and cross-section (FDC). Group differences were identified in a whole-brain analysis, followed by an analysis of tract-averaged metrics within a priori selected tracts associated with cognitive function. Both analyses were repeated while differentiating for postnatal hCMV infection status.

Results

PT showed significant reductions of fixel metrics bilaterally in the cingulum, the genu corporis callosum and forceps minor, the capsula externa, and cerebellar and pontine structures. After including intracranial volume as a covariate, reductions remained significant in the cingulum. The tract-specific investigation revealed further reductions bilaterally in the superior longitudinal fasciculus and the uncinate fasciculus. When differentiating for hCMV infection status, no significant differences were found between CMV+ and CMV-. However, comparing CMV+ against HC, fixel metric reductions were of higher magnitude and of larger spatial extent than in CMV- against HC.

Conclusion

Preterm birth can lead to long-lasting alterations of WM micro- and macrostructure, not visible on conventional MRI. Alterations are located predominantly in WM structures associated with cognitive function, likely underlying the cognitive deficits observed in our cohort. These observed structural alterations were more pronounced in preterms who suffered from early postnatal hCMV infection, in line with previous studies suggesting an additive effect.

Impact of developmental coordination disorder in childhood on educational outcomes in adulthood among neonatal intensive care recipients: a register-based longitudinal cohort study

OBJECTIVES

Developmental coordination disorder (DCD) is related to poorer educational outcomes among children and adolescents. Evidence on this association into adulthood is lacking. Therefore, we aimed to investigate whether probable DCD (pDCD) in childhood affected educational outcomes among adults, and whether this was affected by sex or a co-occurring attention deficit in childhood.

DESIGN

Register-based longitudinal cohort study.

SETTING

Neonatal intensive care (NIC) recipients born at Uppsala University Children's Hospital, Uppsala, Sweden, from 1986 to 1989 until they reached the age of 28.

PARTICIPANTS

185 NIC recipients.

PRIMARY AND SECONDARY OUTCOME MEASURES

At the age of 6.5, 46 (24.6%) of the NIC recipients were diagnosed with pDCD. Using register-based longitudinal data, we compared participants with and without pDCD in terms of: (1) age at Upper Secondary School (USS) graduation, and (2) highest level of education achieved by age 28.

RESULTS

The median age at USS graduation was 19 years, with similar graduation ages and ranges between those with or without pDCD. However, a higher proportion of participants without pDCD had graduated from USS at ages 19 and 24. By age 29, most participants had completed USS. At age 28, 33% of participants had attained a bachelor's or master's degree. Although there was no significant difference between the groups, the proportion that had attained a degree was higher among those without pDCD and women without pDCD had achieved the highest level of education. Educational outcomes remained similar for those with pDCD, regardless of childhood attention deficit.

CONCLUSIONS

pDCD during childhood may have a lasting impact on educational outcomes, particularly among women. Raising awareness of DCD among parents, health and educational professionals is vital for early identification and the provision of appropriate support and interventions in schools, mitigating the potential negative consequences associated with DCD and promoting positive educational outcomes.

Novel metrics to characterize temporal lobe of very preterm infants on term-equivalent brain MRI

BACKGROUND

Preterm birth adversely impacts brain development and contributes to neurodevelopmental impairment; the temporal lobe may be particularly vulnerable to the impact of very preterm (VP) birth. Yet, no prior magnetic resonance imaging (MRI) scoring system incorporated a method to quantify temporal lobe size in VP infants.

METHODS

We developed and applied three metrics (temporal lobe length, extra-axial space, and temporal horn width) to quantify temporal lobe structure on term-equivalent brain MRIs obtained from 74 VP and 16 term infants. We compared metrics between VP and term infants and explored associations of each metric with perinatal risk factors.

RESULTS

All metrics had excellent reliability (intra-class correlation coefficient 0.62-0.98). VP infants had lower mean temporal lobe length (76.8 mm versus 79.2 mm, p = 0.02); however, the difference attenuated after correction for postmenstrual age. VP infants had larger temporal horn widths compared with term infants (2.6 mm versus 1.8 mm, p < 0.001). Temporal lobe length was positively associated with gestational age, birth weight, and male sex, and negatively associated with the duration of parenteral nutrition.

CONCLUSIONS

The proposed metrics are reliable and sensitive in distinguishing differences in temporal lobe development between VP and full-term infants.

IMPACT

We developed a novel method for quantifying temporal lobe size among very preterm infants at term equivalent using simple metrics performed on brain MRI. Temporal lobe metrics were reliable, correlated with brain volume from volumetric analysis, and were sensitive in identifying differences in temporal lobe development among preterm compared with term infants, specifically larger temporal horn size in preterm infants. This temporal lobe metric system will enable future work to delineate the perinatal and postnatal factors that impact temporal lobe growth, and better understand the relationship between temporal lobe disturbance and neurodevelopment in very preterm infants.

Changes in In-Hospital Survival and Long-Term Neurodevelopmental Outcomes of Extremely Preterm Infants: A Retrospective Study of a Japanese Tertiary Center

OBJECTIVES

The objective of this study was to elucidate whether the survival and long-term neurodevelopmental outcomes of extremely preterm infants have improved in a Japanese tertiary center with an active treatment policy for infants born at 22-23 weeks of gestation.

STUDY DESIGN

This single-centered retrospective cohort study enrolled extremely preterm infants treated at Saitama Medical Center, Saitama Medical University, from 2003 to 2014. Patients with major congenital abnormalities were excluded. Primary outcomes were in-hospital survival and severe neurodevelopmental impairment (NDI) at 6 years of age, which was defined as having severe cerebral palsy, severe cognitive impairment, severe visual impairment, or deafness. We assessed the changes in primary outcomes between the first (period 1; 2003-2008) and the second half (period 2; 2009-2014) of the study period and evaluated the association between birth-year and primary outcomes using multivariate logistic regression models.

RESULTS

Of the 403 eligible patients, 340 (84%) survived to discharge. Among 248 patients available at 6 years of age, 43 (14%) were classified as having severe NDI. Between the 2 periods, in-hospital survival improved from 155 of 198 (78%) to 185 of 205 (90%), but severe NDI increased from 11 of 108 (10%) to 32 of 140 (23%). In multivariate logistic regression models adjusted for gestational age, birthweight, sex, singleton birth, and antenatal corticosteroids, the aOR (95% CI) of birth-year for in-hospital survival and severe NDI was 1.2 (1.1-1.3) and 1.1 (1.0-1.3), respectively.

CONCLUSION

Mortality among extremely preterm infants has improved over the past 12 years; nevertheless, no significant improvement was observed in the long-term neurodevelopmental outcomes.

Attitudes About Extremely Preterm Birth Among Obstetric and Neonatal Health Care Professionals in England: A Qualitative Study

IMPORTANCE

Variation in attitudes between health care professionals involved in the counseling of parents facing extremely preterm birth (<24 wk gestational age) may lead to parental confusion and professional misalignment.

OBJECTIVE

To explore the attitudes of health care professionals involved in the counseling of parents facing preterm birth on the treatment of extremely preterm infants.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study used Q methods to explore the attitudes of neonatal nurses, neonatologists, midwives, and obstetricians involved in the care of extremely preterm infants in 4 UK National Health Service perinatal centers between February 10, 2020, and April 30, 2021. Each participating center had a tertiary level neonatal unit and maternity center. Individuals volunteered participation through choosing to complete the study following a presentation by researchers at each center. A link to the online Q study was emailed to all potential participants by local principal investigators. Participants ranked 53 statements about the treatment of extremely preterm infants in an online quasi-normal distribution grid from strongly agree (6) to strongly disagree (-6).

MAIN OUTCOMES AND MEASURES

Distinguishing factors per professional group (representing different attitudes) identified through by-person factor analysis of Q sort-data were the primary outcome. Areas of shared agreement (consensus) between professional groups were also explored. Q sorts achieving a factor loading of greater than 0.46 (P < .01) on a given factor were included.

RESULTS

In total, 155 health care professionals volunteered participation (128 [82.6%] women; mean [SD] age, 41.6 [10.2] years, mean [SD] experience, 14.1 [9.6] years). Four distinguishing factors were identified between neonatal nurses, 3 for midwives, 5 for neonatologists, and 4 for obstetricians. Analysis of factors within and between professional groups highlighted significant variation in attitudes of professionals toward parental engagement in decision-making, the perceived importance of potential disability in decision-making, and the use of medical technology. Areas of consensus highlighted that most professionals disagreed with statements suggesting disability equates to reduced quality of life. The statement suggesting the parents' decision was considered the most important when considering neonatal resuscitation was placed in the neutral (middistribution) position by all professionals.

CONCLUSIONS AND RELEVANCE

The findings of this qualitative study suggest that parental counseling at extremely low gestations is a complex scenario further complicated by the differences in attitudes within and between professional disciplines toward treatment approaches. The development of multidisciplinary training encompassing all professional groups may facilitate a more consistent and individualized approach toward parental engagement in decision-making.

Impact of Early Nutrient Intake and First Year Growth on Neurodevelopment of Very Low Birth Weight Newborns

Optimal nutrient intake ensuring better neurodevelopment for very low birth weight (VLBW) infants remains unknown. The aim of this study was to assess the relationship between early (first 28 days) nutritional intake, first year growth, and neurodevelopment. In total, 120 VLBW infants were included into the study. A group of 95 infants completed follow-up to 12 months of corrected gestational age (CGA). Nutrient intake was assessed, and weight, length, and head circumference (HC) were measured weekly until discharge and at 3, 6, 9, and 12 months of CGA. Neurodevelopment was assessed at 12 months of CGA. Two groups—extremely preterm (EP) and very/moderately preterm (VP)—were compared. Growth before discharge was slower in the EP group than the VP group. At 12 months, there was no difference in anthropometric characteristics or neurodevelopmental scores between the groups. Higher carbohydrate intake during the first 28 days was the single significant predictor for better cognitive scores only in the EP group (βs = 0.60, p = 0.017). Other nutrients and growth before discharge were not significant for cognitive and motor scores in either group in multivariable models, whereas post-discharge HC growth was associated with both cognitive and motor scores in the VP group. Monitoring intake of all nutrients and both pre-discharge and post-discharge growth is essential for gaining knowledge about individualized nutrition for optimal neurodevelopment.

Cognitive and motor development in preterm children from 6 to 36 months of age: Trajectories, risk factors and predictability

BACKGROUND

Although numerous studies have examined the development of preterm children born very low birth weight (VLBW, birth body weight < 1500 g), variations of developmental progress within individuals have rarely been explored. The aim of this research was to examine the cognitive and motor trajectories in preterm children born VLBW at early ages and to assess the risk factors and predictability of these trajectories.

METHOD

Five hundred and eighty preterm infants born VLBW from three cohort studies (2003 to 2014) were prospectively assessed their mental and motor development using the Bayley Scales at 6, 12, 24, and 36 months, and cognitive, motor and behavioral outcomes using the Movement Assessment Battery for Children and the Child Behavior Checklist for Ages 1.5-5 at 4 years of age.

RESULTS

Preterm children born VLBW manifested three cognitive patterns (stably normal [64.0 %], deteriorating [31.4 %], and persistently delayed [4.6 %]) and four motor patterns (above average [6.3 %], stably normal [60.0 %], deteriorating [28.5 %], and persistently delayed [5.2 %]) during 6-36 months. Low birth body weight, stage III-IV retinopathy of prematurity and low parental socio-economic status were associated with the deteriorating patterns; prolonged hospitalization and major brain damage were additionally associated with the persistently delayed patterns. Furthermore, the cognitive and motor deteriorating pattern was each predictive of cognitive and motor impairment at 4 years of age; whereas, the persistently delayed patterns were predictive of multiple impairments.

CONCLUSION AND IMPLICATIONS

Preterm children born VLBW display heterogeneous trajectories in early cognitive and motor development that predict subsequent developmental and behavioral outcomes.

Economic costs and health utility values associated with extremely preterm birth: Evidence from the EPICure2 cohort study

BACKGROUND

Preterm birth is associated with adverse health and developmental sequelae that impose a burden on finite resources and significant challenges for individuals, families and societies.

OBJECTIVES

To estimate economic outcomes at age 11 associated with extremely preterm birth using evidence from a whole population study (EPICure2 study).

METHODS

The study population comprised a sample of children born at ≤26 completed weeks of gestation during 2006 in England (n = 200) and a comparison group of classmates born at term (n = 143). Societal costs were estimated using parent and teacher reports of service utilisation, and valuations of work losses and additional care costs to families. Utility scores for the Health Utilities Index Mark 2 (HUI2) and Mark 3 (HUI3) were generated using UK and Canadian value sets. Generalised linear regression was used to estimate the impact of extremely preterm birth on societal costs and utility scores.

RESULTS

Unadjusted mean societal costs that excluded provision of special educational support in mainstream schools during the 11th year after birth were £6536 for the extremely preterm group and £3275 for their classmates, generating a difference of £3262 (95% confidence interval [CI] £1912, £5543). The mean adjusted cost difference was £2916 (95% CI £1609, £4224), including special educational needs provision in mainstream schools increased the adjusted cost difference to £4772 (95% CI £3166, £6378). Compared with birth at term, extremely preterm birth generated mean-adjusted utility decrements ranging from 0.13 (95% CI 0.09, 0.18) based on the UK HUI2 statistical inference tariff to 0.28 (95% CI 0.18, 0.37) based on the Canadian HUI3 tariff.

CONCLUSIONS

The adverse economic impact of extremely preterm birth persists into late childhood. Further longitudinal studies conducted from multiple perspectives are needed to understand the magnitude, trajectory and underpinning mechanisms of economic outcomes following extremely preterm birth.

Reduced health-related quality of life in children born extremely preterm in 2006 compared with 1995: the EPICure Studies

OBJECTIVE

To compare health-related quality of life (HRQL) in childhood for extremely preterm (EP) births before 26 weeks of gestation in England in two eras: 1995 and 2006.

DESIGN

Prospective cohort studies.

SETTING

School or home-based assessments at 11 years of age.

PARTICIPANTS

Available data for 88 EP children born before 26 weeks of gestation in 2006 (EPICure2) were compared with those of 140 born in England during 1995 (EPICure). To account for social secular trends, the comparison between eras was also made for term-born controls as reference.

MAIN OUTCOME MEASURES

HRQL was measured using the parent-completed Health Utilities Index (HUI) questionnaire with utility scores calculated using the HUI3 classification system. Eight attributes were assessed: vision, hearing, speech, ambulation, dexterity, emotion, cognition and pain.

RESULTS

At 11 years, mean utility scores were significantly lower in EPICure2 (2006) than in EPICure (1995; Δ -0.12, 95% CI -0.20 to -0.04). The difference increased (Δ -0.27, 95% CI -0.41 to -0.12) after adjusting for significant perinatal and demographic differences between cohorts. Rates of suboptimal function were increased in EPICure2 for all eight attributes, but statistically significant differences were only found in speech (p=0.004) and dexterity (p=0.020). After excluding children with severe neurodevelopmental impairment, the adjusted difference between cohorts remained significant but attenuated (-0.14 (-0.26 to -0.01)). Mean utility scores for controls were similar between cohorts (Δ -0.01 (-0.04 to 0.02)).

CONCLUSIONS

Using parent report, there was a clinically significant decline in HRQL ratings for EP children over time. Areas contributing the most to the decline were speech and dexterity.

TRIAL REGISTRATION NUMBER

ISRCTN86323684.

Sensory-based interventions in the NICU: systematic review of effects on preterm brain development

BACKGROUND

Infants born preterm are known to be at risk for abnormal brain development and adverse neurobehavioral outcomes. To improve early neurodevelopment, several non-pharmacological interventions have been developed and implemented in the neonatal intensive care unit (NICU). Sensory-based interventions seem to improve short-term neurodevelopmental outcomes in the inherently stressful NICU environment. However, how this type of intervention affects brain development in the preterm population remains unclear.

METHODS

A systematic review of the literature was conducted for published studies in the past 20 years reporting the effects of early, non-pharmacological, sensory-based interventions on the neonatal brain after preterm birth.

RESULTS

Twelve randomized controlled trials (RCT) reporting short-term effects of auditory, tactile, and multisensory interventions were included after the screening of 1202 articles. Large heterogeneity was identified among studies in relation to both types of intervention and outcomes. Three areas of focus for sensory interventions were identified: auditory-based, tactile-based, and multisensory interventions.

CONCLUSIONS

Diversity in interventions and outcome measures challenges the possibility to perform an integrative synthesis of results and to translate these for evidence-based clinical practice. This review identifies gaps in the literature and methodological challenges for the implementation of RCTs of sensory interventions in the NICU.

IMPACT

This paper represents the first systematic review to investigate the effect of non-pharmacological, sensory-based interventions in the NICU on neonatal brain development. Although reviewed RCTs present evidence on the impact of such interventions on the neonatal brain following preterm birth, it is not yet possible to formulate clear guidelines for clinical practice. This review integrates existing literature on the effect of sensory-based interventions on the brain after preterm birth and identifies methodological challenges for the conduction of high-quality RCTs.

Neurodevelopmental disorders and somatic diagnoses in a national cohort of children born before 24 weeks of gestation

AIM

This study investigated childhood diagnoses in children born extremely preterm before 24 weeks of gestation.

METHODS

Diagnoses of neurodevelopmental disorders and selected somatic diagnoses were retrospectively retrieved from national Swedish registries for children born before 24 weeks from 2007 to 2018. Their individual medical files were also examined.

RESULTS

We studied 383 children born at a median of 23.3 (range 21.9-23.9) weeks, with a median birthweight of 565 (range 340-874) grams. Three-quarters (75%) had neurodevelopmental disorders, including speech disorders (52%), intellectual disabilities (40%), attention deficit hyperactivity disorder (30%), autism spectrum disorders (24%), visual impairment (22%), cerebral palsy (17%), epilepsy (10%) and hearing impairment (5%). More boys than girls born at 23 weeks had intellectual disabilities (45% vs. 27%, p < 0.01) and visual impairment (25% vs. 14%, p < 0.01). Just over half of the cohort (55%) received habilitation care. The majority (88%) had somatic diagnoses, including asthma (63%) and failure to thrive/short stature (39%).

CONCLUSION

Most children born before 24 weeks had neurodevelopmental disorders and/or additional somatic diagnoses in childhood and were referred to habilitation services. Clinicians should be aware of the multiple health and developmental problems affecting these children. Resources are needed to identify their long-term support needs at an early stage.

The extremely preterm young adult - State of the art

Recently several studies have reported adult outcomes for individuals born at extremely low gestations, although they tend to be included as part of slightly more mature populations. The growth in collaborative studies allows greater confidence in the identification of persisting risk and allows us to have confidence in the likely outcomes in more contemporary cohorts. This review shows the persistence of adverse outcomes through to adult life and includes a range of outcomes including all body systems evaluated. Nonetheless adult outcomes demonstrate that most survivors appear to be free of major disabling conditions and demonstrate good participation in society. Several studies have reported outcomes in the third decade, but subsequent ageing trajectories have not yet been defined. The stability of many of the outcomes evaluated over childhood into adult life and the lack of improvement in prevalence of childhood impairments found in contemporary cohorts indicates persisting levels of risk.

Tracking of lung function from 10 to 35 years after being born extremely preterm or with extremely low birth weight

Background

Lifelong pulmonary consequences of being born extremely preterm or with extremely low birth weight remain unknown. We aimed to describe lung function trajectories from 10 to 35 years of age for individuals born extremely preterm, and address potential cohort effects over a period that encompassed major changes in perinatal care.

Methods

We performed repeated spirometry in three population-based cohorts born at gestational age ≤28 weeks or with birth weight ≤1000 g during 1982–85, 1991–92 and 1999–2000, referred to as extremely preterm-born, and in term-born controls matched for age and gender. Examinations were performed at 10, 18, 25 and 35 years. Longitudinal data were analysed using mixed models regression, with the extremely preterm-born stratified by bronchopulmonary dysplasia (BPD).

Results

We recruited 148/174 (85%) eligible extremely preterm-born and 138 term-born. Compared with term-born, the extremely preterm-born had lower z-scores for forced expiratory volume in 1 s (FEV₁) at most assessments, the main exceptions were in the groups without BPD in the two youngest cohorts. FEV₁ trajectories were largely parallel for the extremely preterm- and term-born, also during the period 25–35 years that includes the onset of the age-related decline in lung function. Extremely preterm-born had lower peak lung function than term-born, but z-FEV₁ values improved for each consecutive decade of birth (p=0.009). More extremely preterm—than term-born fulfilled the spirometry criteria for chronic obstructive pulmonary disease, 44/148 (30%) vs 7/138 (5%), p<0.001.

Conclusions

Lung function after extremely preterm birth tracked in parallel, but significantly below the trajectories of term-born from 10 to 35 years, including the incipient age-related decline from 25 to 35 years. The deficits versus term-born decreased with each decade of birth from 1980 to 2000.

Mathematical performance in childhood and early adult outcomes after very preterm birth: an individual participant data meta-analysis

AIM

To investigate the strength of the independent associations of mathematics performance in children born very preterm (<32wks' gestation or <1500g birthweight) with attending postsecondary education and their current employment status in young adulthood.

METHOD

We harmonized data from six very preterm birth cohorts from five different countries and carried out one-stage individual participant data meta-analyses (n=954, 52% female) using mixed effects logistic regression models. Mathematics scores at 8 to 11 years of age were z-standardized using contemporary cohort-specific controls. Outcomes included any postsecondary education, and employment/education status in young adulthood. All models were adjusted for year of birth, gestational age, sex, maternal education, and IQ in childhood.

RESULTS

Higher mathematics performance in childhood was independently associated with having attended any postsecondary education (odds ratio [OR] per SD increase in mathematics z-score: 1.36 [95% confidence interval {CI}: 1.03, 1.79]) but not with current employment/education status (OR 1.14 per SD increase [95% CI: 0.87, 1.48]).

INTERPRETATION

Among populations born very preterm, childhood mathematics performance is important for adult educational attainment, but not for employment status.

Growth in extremely preterm children born in England in 1995 and 2006: the EPICure studies

OBJECTIVES

To determine growth outcomes at 11 years of age in children born <27 weeks of gestation in England in 2006 (EPICure2) and to compare growth from birth to 11 years of age for births<26 weeks with those in England in 1995 (EPICure).

METHODS

200 EPICure2 children assessed at 11 years alongside 143 term-born controls. Growth measures from birth to 11 years were compared for births<26 weeks between EPICure2 (n=112) and EPICure (n=176). Growth parameter z-scores were derived from 1990 UK standards.

RESULTS

Among EPICure2 children, mean z-scores for height and weight were close to the population standards (0.08 and 0.18 SD, respectively) but significantly below those of controls: difference in mean (Δ) z-scores for weight -0.42 SD (95% CI -0.68 to -0.17), for height -0.45 SD (-0.70 to -0.20) and for head circumference (HC) -1.05 SD (-1.35 to -0.75); mean body mass index (BMI) z-score in EPICure2 children was 0.18 SD, not significantly different from controls (0.43 SD, p=0.065). Compared with EPICure, EPICure2 children born <26 weeks at 11 years had higher z-scores for weight (Δ 0.72 (0.47, 0.96)), height (Δ 0.55 (0.29, 0.81)) and BMI (Δ 0.56 (0.24, 0.87)), which were not fully explained by perinatal/demographic differences between eras. Weight catch-up was greater from term-age to 2.5/3 years in EPICure2 than in EPICure (1.25 SD vs 0.53 SD; p<0.001). Poor HC growth was observed in EPICure2, unchanged from EPICure.

CONCLUSIONS

Since 1995, childhood growth in weight, height and BMI have improved for births <26 weeks of gestation, but there was no improvement in head growth.

Refining regional organization of services in the UK to improve outcomes of pregnancies delivering at extremely low gestational age

Care for pregnant women and their infants at extremely low gestational ages challenges clinical teams. The continuing rise in survival at gestational ages below 25 weeks has prompted re-evaluation of practice guidelines within the UK and other countries. This paper describes the background data that have guided our practice, the approach that has been taken to deliver optimal outcomes for pregnancies delivering at extremely low gestational age in the UK, mainly through centralising care, and discusses the research and audit data that support our practice. In particular, we emphasize the importance of a coordinated perinatal approach to both mother and infant, and careful assessment of the risks to both, to ensure that we develop the highest quality personalized care for each family, supported by national quality improvement and research evidence.

Extreme prematurity: Risk and resiliency

Individuals born extremely preterm (before 28 weeks of gestation) comprise only about 0.7% of births in the United States and an even lower proportion in other high resource countries. However, these individuals account for a disproportionate number of children with cerebral palsy, intellectual deficit, autism spectrum disorder, attention deficit hyperactivity disorder, and epilepsy. This review describes two large multiple center cohorts comprised of individuals born extremely preterm: the EPICURE cohort, recruited 1995 in the United Kingdom and the Republic of Ireland, and the Extremely Low Gestational Age Newborn (ELGAN), recruited 2002-2004 in five states in the United States. The primary focus of these studies has been neurodevelopmental disorders, but also of interest are growth, respiratory illness, and parent- and self-reported global health and well-being. Both of these studies indicate that among individuals born extremely preterm the risks of most neurodevelopmental disorders are increased. Early life factors that contribute to this risk include perinatal brain damage, some of which can be identified using neonatal head ultrasound, bronchopulmonary dysplasia, and neonatal systemic inflammation. Prenatal factors, particularly the family's socioeconomic position, also appear to contribute to risk. For most adverse outcomes, the risk is higher in males. Young adults born extremely preterm who have neurodevelopmental impairment, as compared to those without such impairment, rate their quality of life lower. However, young adults born extremely preterm who do not have neurodevelopmental impairments rate their quality of life as being similar to that of young adults born at term. Finally, we summarize the current state of interventions designed to improve the life course of extremely premature infants, with particular focus on efforts to prevent premature birth and on postnatal efforts to prevent adverse neurodevelopmental outcomes.

Neonatologists' Resuscitation Decisions at Birth for Extremely Premature Infants. A Belgian Qualitative Study

OBJECTIVE

Deciding whether initiating or withholding resuscitation at birth for extremely preterm infants (EPIs) can be difficult due to uncertainty on outcomes. Clinical uncertainty generates ethical uncertainty. Thus, physicians' attitudes and perspectives on resuscitation of EPIs might influence resuscitation decisions. We aimed at understanding how neonatologists make clinical-ethical decisions for EPI resuscitation and how they perceive these decisions.

METHODS

We performed a qualitative study using a constructivist account of grounded theory. Face-to-face, semi-structured in-depth interviews with neonatologists comprised data collection. For data analysis, we used the Qualitative Analysis Guide of Leuven.

RESULTS

We interviewed 20 neonatologists working in 10 hospitals in Belgium. Participants' decision-making can be described as consensus-based, gestational age-based, contextualized, progressive, and shared. All participants agreed on the importance of using the consensus expressed in guidelines as a guidance for the decision-making, i.e., consensus-based. Consequently, all 20 participants use GA thresholds indicated in the guidelines, i.e., GA-based. However, they use these thresholds differently in their decisions. Few participants rigidly follow established thresholds. The vast majority reported using additional contextual factors as birthweight or parents' wishes in the decision-making, rather than only the EPIs' GA, i.e., contextualized. All participants agreed on the importance of involving the parents in the decision-making, i.e., shared, and indeed parents' wishes were among the most valued factors considered in the decision-making. However, the extent to which parents were involved in the decision-making depended on the infant's GA. Participants described a gray zone in which parents' were viewed as the main decision-makers due to the high clinical uncertainty. This mean that participants tend to follow parents' request even when they disagree with it. Outside the gray zone, physicians were viewed as the main decision-makers. This mean that, although parents' wishes were still considered, counseling was more directive and the final decision was made by the physician.

CONCLUSION

Although an EPI's GA remains the main factor guiding neonatologists' resuscitation decisions, other factors are seriously considered in the decision-making process. All neonatologist participants agreed on the importance of involving parents in the decision-making. However, they involve parents differently depending on the EPI's GA.

Gestational Age, Parent Education, and Education in Adulthood

BACKGROUND

Adults born preterm (<37 weeks) have lower educational attainment than those born term. Whether this relationship is modified by family factors such as socioeconomic background is, however, less well known. We investigated whether the relationship between gestational age and educational attainment in adulthood differed according to parents' educational level in 4 Nordic countries.

METHODS

This register-based cohort study included singletons born alive from 1987 up to 1992 in Denmark, Finland, Norway, and Sweden. In each study population, we investigated effect modification by parents' educational level (low, intermediate, high) on the association between gestational age at birth (25-44 completed weeks) and low educational attainment at 25 years (not having completed upper secondary education) using general estimation equations logistic regressions.

RESULTS

A total of 4.3%, 4.0%, 4.8%, and 5.0% singletons were born preterm in the Danish (n = 331 448), Finnish (n = 220 095), Norwegian (n = 292 840), and Swedish (n = 513 975) populations, respectively. In all countries, both lower gestational age and lower parental educational level contributed additively to low educational attainment. For example, in Denmark, the relative risk of low educational attainment was 1.84 (95% confidence interval 1.44 to 2.26) in adults born at 28 to 31 weeks whose parents had high educational level and 5.25 (95% confidence interval 4.53 to 6.02) in adults born at 28 to 31 weeks whose parents had low educational level, compared with a reference group born at 39 to 41 weeks with high parental educational level.

CONCLUSIONS

Although higher parental education level was associated with higher educational attainment for all gestational ages, parental education did not mitigate the educational disadvantages of shorter gestational age.

Neonatologists' decision-making for resuscitation and non-resuscitation of extremely preterm infants: ethical principles, challenges, and strategies-a qualitative study

Background

Deciding whether to resuscitate extremely preterm infants (EPIs) is clinically and ethically problematic. The aim of the study was to understand neonatologists’ clinical–ethical decision-making for resuscitation of EPIs.

Methods

We conducted a qualitative study in Belgium, following a constructivist account of the Grounded Theory. We conducted 20 in-depth, face-to-face, semi-structured interviews with neonatologists. Data analysis followed the qualitative analysis guide of Leuven.

Results

The main principles guiding participants’ decision-making were EPIs’ best interest and respect for parents’ autonomy. Participants agreed that justice as resource allocation should not be considered in resuscitation decision-making. The main ethical challenge for participants was dealing with the conflict between EPIs’ best interest and respect for parents’ autonomy. This conflict was most prominent when parents and clinicians disagreed about births within the gray zone (24–25 weeks). Participants’ coping strategies included setting limits on extent of EPI care provided and rigidly following established guidelines. However, these strategies were not always feasible or successful. Although rare, these situations often led to long-lasting moral distress.

Conclusions

Participants’ clinical–ethical reasoning for resuscitation of EPIs can be mainly characterized as an attempt to balance EPIs’ best interest and respect for parents’ autonomy. This approach could explain why neonatologists considered conflicts between these principles as their main ethical challenge and why lack of resolution increases the risk of moral distress. Therefore, more research is needed to better understand moral distress in EPI resuscitation decisions.

Clinical Trial Registration: The study received ethical approval from the ethics committee of UZ/KU Leuven (S62867). Confidentiality of personal information and anonymity was guaranteed in accordance with the General Data Protection Regulation of 25 May 2018.

Consequences of using chronological age versus corrected age when testing cognitive and motor development in infancy and intelligence quotient at school age for children born preterm

BACKGROUND

Children born preterm (<37 weeks' gestation) have an increased risk of poor neurodevelopment, including lower intelligence quotient (IQ) scores compared with their term-born counterparts.

OBJECTIVE

To explore the differences in psychometric scores for cognition and motor skills when they are age-standardized according to chronological age instead of corrected age for children born preterm.

METHODS

We assessed = 554 children born <33 weeks' gestation with the Bayley Scales of Infant Development, 2nd edition (mental and motor scores) at 18 months and the Weschler Abbreviated Scale of Intelligence (IQ score) at seven years of age. Scores were standardized according to chronological age and corrected age and differences between mean chronological and corrected scores were compared, along with the proportion of children whose scores could be classified as impaired.

RESULTS

When scores were standardized according to chronological age instead of corrected age there was a large significant difference of 17.3 points on the mental scale (79.5 vs. 96.8, respectively) and 11.8 points on the motor scale (84.8 vs. 96.6, respectively) at 18 months. By seven years, the difference in IQ scores remained, although of a smaller magnitude at 1.9 points between mean chronological and corrected age scoring (97.2 vs. 99.1, respectively).

CONCLUSION

Consistent with previous literature, outcome assessments for preterm infants consistently differed according to use of chronological or corrected age to standardized scores. Cognitive scores were impacted more severely than motor scores, and differences were more substantial in early childhood than later in childhood. For clinical purposes, correction for preterm birth is only likely to have an impact during early childhood, however assessments for research purposes should continue to correct into childhood to account for the persistent bias due to preterm birth.

Association of Very Preterm Birth or Very Low Birth Weight With Intelligence in Adulthood: An Individual Participant Data Meta-analysis

IMPORTANCE

Birth before 32 weeks' gestation (very preterm [VPT]) and birth weight below 1500 g (very low birth weight [VLBW]) have been associated with lower cognitive performance in childhood. However, there are few investigations of the association of neonatal morbidities and maternal educational levels with the adult cognitive performance of individuals born VPT or VLBW (VPT/VLBW).

OBJECTIVE

To assess differences in adult IQ between VPT/VLBW and term-born individuals and to examine the association of adult IQ with cohort factors, neonatal morbidities, and maternal educational level among VPT/VLBW participants.

DATA SOURCES

Systematic review of published data from PubMed and meta-analysis of individual participant data (IPD) of cohorts from 2 consortia (Research on European Children and Adults Born Preterm [RECAP] and Adults Born Preterm International Collaboration [APIC]).

STUDY SELECTION

The meta-analysis included prospective longitudinal cohort studies that assessed the full-scale IQ of adults born VPT or VLBW and respective control groups comprising term-born adults.

DATA EXTRACTION AND SYNTHESIS

The study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline for analyses of individual participant data and identified 8 studies that provided data from 2135 adults (1068 VPT/VLBW and 1067 term-born participants) born between 1978 and 1995. Meta-analyses of IPD were performed using a 1-stage approach, treating VPT birth or VLBW and cohort as random effects.

MAIN OUTCOMES AND MEASURES

Full-scale IQ scores were converted to z scores within each cohort using the combined SD of VPT/VLBW participants and a control group of term-born participants, with scores centered on the mean of the control group.

RESULTS

A total of 426 records were identified and screened. After exclusions, 13 studies were included in the aggregate meta-analysis. The IPD meta-analysis included 8 of the 9 RECAP and APIC cohorts with adult IQ data. The mean (SD) age among the 8 IPD cohorts was 24.6 (4.3) years, and 1163 participants (54.5%) were women. In unadjusted analyses, VPT/VLBW participants had mean adult IQ scores that were 0.78 SD (95% CI, -0.90 to -0.66 SD) lower than term-born participants, equivalent to a difference of 12 IQ points. Among VPT/VLBW participants, lower gestational age (score difference per week of gestation, 0.11; 95% CI, 0.07-0.14), lower birth weight z scores (score difference per 1.0 SD, 0.21; 95% CI, 0.14-0.28), the presence of neonatal bronchopulmonary dysplasia (score difference, -0.16; 95% CI, -0.30 to -0.02) or any grade of intraventricular hemorrhage (score difference, -0.19; 95% CI, -0.33 to -0.05), and lower maternal educational level (score difference, 0.26; 95% CI, 0.17-0.35) were all significantly associated with lower IQ scores in adulthood.

CONCLUSIONS AND RELEVANCE

In this IPD meta-analysis, lower gestational age, lower weight for gestational age, neonatal morbidities, and lower maternal educational levels were all important risk factors associated with lower IQ among young adults born VPT or VLBW.

Disturbed sleep in children born extremely preterm is associated with behavioural and emotional symptoms

AIM

To determine whether children born extremely preterm are at increased risk for sleep disturbances and to explore relationships between extremely preterm birth, sleep and attention-deficit/hyperactivity disorder (ADHD) symptoms and emotional symptoms.

METHOD

EPICure2 cohort study. Parents of 165 children born ≤26 weeks' gestation (53% male) and 121 children born at term (43% male) completed the Children's Sleep Habits Questionnaire, sleep disordered breathing subscale of the Pediatric Sleep Questionnaire, the emotional problems scale of the Strengths and Difficulties Questionnaire and the ADHD Rating Scale-5 at 11 years of age.

RESULTS

Extremely preterm children had greater habitual snoring (adjusted odds ratio 6.8; 95% confidence interval 2.3, 20.3), less frequently fell asleep within 20 minutes (Cohen's d 0.33), higher night wakings (d 0.44) and daytime sleepiness scores (d 0.40) than term-born children; there was no between-group difference in sleep duration scores. Among children without severe disability, night wakings scores partially mediated the relationship between preterm birth and inattention (additional 5% of variance explained), hyperactivity/impulsivity (13%) and emotional problems (9%). Snoring partially mediated the relationship between preterm birth, hyperactivity/impulsivity and inattention (additional 1-5% of variance).

CONCLUSION

Children born extremely preterm are at increased risk of disturbed sleep compared to term-born children. As night wakings partially mediated the relationship between preterm birth and ADHD symptoms and emotional problems, reducing sleep disturbance may improve sleep and reduce attention and emotional problems in this population.

Changes in emotional problems, hyperactivity and conduct problems in moderate to late preterm children and adolescents born between 1958 and 2002 in the United Kingdom

Background

Preterm birth is a risk factor for the development of emotional and behavioural problems in childhood and adolescence. Given the substantial improvements in neonatal care across decades, it has been expected that the difference in emotional problems, hyperactivity, and conduct problems between moderate to late preterm (MLPT) and full term (FT) children and adolescents have declined in recent years.

Methods

Data from four UK population-based studies were used: The National Child Development Study (NCDS; 1958), the British Cohort Study (BCS70; 1970), the Avon Longitudinal Study of Parents and Children (ALSPAC, 1991-1992) and the Millennium Cohort Study (MCS; 2000-2002). Emotional problems, hyperactivity and conduct problems were assessed with mother-reports in early childhood (5-7 years), late childhood (10-11 years) and adolescence (14-16 years). Furthermore, emotional problems were self-reported in adolescence in BCS70, ALSPAC and MCS.

Results

In the most recent cohort, the MLPT group had higher mother-reported emotional problems than those born FT in late childhood and adolescence, whereas there were no differences in self-reported emotional problems in adolescence. Regarding mother-reported hyperactivity symptoms, the MLPT group had higher scores than the FT group in the two most recent cohorts in late childhood and in the most recent cohort in adolescence. Regarding mother-reported conduct problems, MLPT children had significantly higher scores than the FT children in the oldest and in the most recent cohort in late childhood. On the other hand, in adolescence, MLPT children had significantly lower scores in conduct problems in comparison to FT children in the cohort born in 1991-1992.

Conclusions

Mother-reported emotional problems and hyperactivity symptoms of those born MLPT have increased from the birth years 1958 to 2000-2002 during late childhood and adolescence, whereas self-reported emotional problems were similar in MLPT and FT groups during adolescence from 1970 to 2000-2002. Findings are less consistent regarding conduct problems. The current findings highlight the importance of raising the awareness of teachers about the association between MLPT birth and behavioural and emotional problems in late childhood and adolescence to prevent the long-term negative outcomes associated with the sequalae of MLPT birth.

Developmental Trajectories in Very Preterm Born Children Up to 8 Years: A Longitudinal Cohort Study

Aim: Long-term outcome data in preterm children is often limited to cross-sectional measurement of neurodevelopmental impairment (NDI) at the corrected age of 24-36 months. However, impairments may only become overt during childhood or resolve with time, and individual trajectories in outcome over time may vary. The primary aim of this study was to describe NDI in very preterm born children at three subsequent ages of 2, 5, and 8 years of age. As a secondary aim, a longitudinal analysis was performed on the individual longitudinal trajectories in NDI from 2 to 8 years of age. Methods: Single-center prospective cohort study including children born between 1990 and 2011 below 30 weeks' gestation and followed into 2019. The outcome measurement was NDI assessed at 2, 5, and 8 years of age. NDI is a composite score that includes cognitive, neurological, visual, and auditory functions, in which problems were categorized as none, mild, moderate, or severe. Cognitive function measured as total DQ/IQ score was assessed by standardized psychometric tests. Neurological, visual, and auditory functions were assessed by the neonatologist. Results: In total, 921 children were eligible for follow-up, of whom 726 (79%) children were assessed. No NDI was seen in 54, 54, and 62%, mild NDI was seen in 31, 36, and 30%, and moderate-to-severe NDI was seen in 15, 9.2, and 8.6% of the children at 2, 5, and 8 years, respectively. From 2 to 8 years, 63% of the children remained in the same NDI category, 20% of the children improved to a better NDI category, and 17% deteriorated toward a worse NDI category. No differences were found in baseline characteristics of infants that improved or deteriorated. Extreme prematurity, male gender and low parental education were associated with worse NDI status at all time points. Although we observed considerable individual variation over time in NDI status, the course of the trajectories in NDI were not associated with gestation, gender, and parental education. Conclusions: Continued follow-up until school life is essential in order to provide optimal and individually focused referrals and care when needed.