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Lazarus MF, Marchman VA, Brignoni-Pérez E, Dubner S, Feldman HM, Scala M, Travis KE. Inpatient Skin-to-skin Care Predicts 12-Month Neurodevelopmental Outcomes in Very Preterm Infants. J Pediatr 2024; 274:114190. [PMID: 39004169 DOI: 10.1016/j.jpeds.2024.114190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 06/24/2024] [Accepted: 07/08/2024] [Indexed: 07/16/2024]
Abstract
OBJECTIVE To examine the relationship between inpatient skin-to-skin care rates and neurodevelopmental scores measured at 12 months in very preterm (VPT) infants. STUDY DESIGN From a retrospective review of medical records of 181 VPT infants (<32 weeks gestational age [GA] at birth), we derived skin-to-skin care rate, ie, total minutes of skin-to-skin care each infant received over the number of days of hospital stay. We used scores on the Capute Scales from routine follow-up assessments at 12 months to measure neurodevelopmental outcomes. RESULTS Families averaged approximately 17 minutes/day of skin-to-skin care (2 days/week, 70 minutes/session), although there was substantial variability. Variation in skin-to-skin rate was positively associated with outcomes at 12 months corrected age (r = 0.25, P < .001). Skin-to-skin rate significantly predicted 6.2% unique variance in 12-month neurodevelopmental outcomes, after adjusting for GA, socioeconomic status (SES), health acuity, and visitation frequency. A 20-minute increase in skin-to-skin care per day was associated with a 10-point increase (0.67 SDs) in neurodevelopmental outcomes at 12 months. GA and infant health acuity did not moderate these relations. CONCLUSION VPT infants who experienced more skin-to-skin care during hospitalization demonstrated higher scores on 12-month neurodevelopmental assessments. Results provide evidence that skin-to-skin care confers extended benefits to VPT infants through the first year of life. Skin-to-skin care offers promise as a family-centered intervention designed to promote positive developmental outcomes in at-risk infants.
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Affiliation(s)
- Molly F Lazarus
- Division of Developmental-Behavioral Pediatrics, Department of Pediatrics, Stanford University, Stanford, CA; Department of Pediatrics, Burke-Cornell Medical Research Institute, Weill Medical College, Cornell University, New York, NY
| | - Virginia A Marchman
- Division of Developmental-Behavioral Pediatrics, Department of Pediatrics, Stanford University, Stanford, CA; Department of Psychology, Stanford University, Stanford, CA
| | - Edith Brignoni-Pérez
- Division of Developmental-Behavioral Pediatrics, Department of Pediatrics, Stanford University, Stanford, CA; Department of Psychiatry, Stanford University, Stanford, CA
| | - Sarah Dubner
- Division of Developmental-Behavioral Pediatrics, Department of Pediatrics, Stanford University, Stanford, CA
| | - Heidi M Feldman
- Division of Developmental-Behavioral Pediatrics, Department of Pediatrics, Stanford University, Stanford, CA
| | - Melissa Scala
- Division of Neonatology, Department of Pediatrics, Stanford University, Stanford, CA
| | - Katherine E Travis
- Division of Developmental-Behavioral Pediatrics, Department of Pediatrics, Stanford University, Stanford, CA; Department of Pediatrics, Burke-Cornell Medical Research Institute, Weill Medical College, Cornell University, New York, NY.
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Roberts MY, Sone BJ, Jones MK, Standley M, Conner T, Lee ED, Norton ES, Roman J, Speights M, Young R, Weisleder A. What the Evidence Does (and Does Not) Show for the Centers for Disease Control and Prevention Child Development Milestones: An Illustrative Example Using Expressive Vocabulary. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2023; 66:3622-3632. [PMID: 37536464 DOI: 10.1044/2023_jslhr-23-00020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
PURPOSE Child development milestones are a critical tool for pediatricians and caregivers to use for developmental surveillance. Following review and selection by a panel of subject matter experts, the Centers for Disease Control and Prevention (CDC) published a revised list of milestones across multiple domains of development. Using expressive vocabulary, a key indicator of language development, as an illustrative example, the purpose of this brief review is to evaluate the evidence used to establish the CDC developmental milestones and determine whether the samples used to establish these milestones are representative of U.S. children. METHOD Authors reviewed the methods and evidence cited to determine the CDC milestones. First, authors identified each language/communication milestone that measured expressive vocabulary as number of words, followed by review of the sources cited in support of each extracted milestone. Then, data related to both milestones and sample characteristics were extracted and compiled as well as compared with data from a validated parent report measure of expressive vocabulary, the MacArthur-Bates Communication Development Inventories. RESULTS Results indicated that evidence was conflicting, misaligned, or missing for the selected CDC expressive vocabulary milestones. This review also indicated that the samples used to determine the selected CDC expressive vocabulary milestones are not representative of U.S. children. CONCLUSION The striking paucity of evidence supporting the new CDC milestones for expressive vocabulary illustrates the critical need for future research in this area to establish more accurate milestones for U.S. children, with a focus on culturally inclusive large-scale data.
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Affiliation(s)
- Megan Y Roberts
- Department of Communication Sciences and Disorders, Northwestern University, Evanston, IL
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Bailey J Sone
- Department of Communication Sciences and Disorders, Northwestern University, Evanston, IL
| | - Maranda K Jones
- Department of Communication Sciences and Disorders, Northwestern University, Evanston, IL
| | - Murielle Standley
- Department of Communication Sciences and Disorders, Northwestern University, Evanston, IL
| | - Tracy Conner
- Department of Communication Sciences and Disorders, Northwestern University, Evanston, IL
| | - E Debbie Lee
- Department of Communication Sciences and Disorders, Northwestern University, Evanston, IL
| | - Elizabeth S Norton
- Department of Communication Sciences and Disorders, Northwestern University, Evanston, IL
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Judith Roman
- Department of Communication Sciences and Disorders, Northwestern University, Evanston, IL
| | - Marisha Speights
- Department of Communication Sciences and Disorders, Northwestern University, Evanston, IL
| | - Rylie Young
- Department of Communication Sciences and Disorders, Northwestern University, Evanston, IL
| | - Adriana Weisleder
- Department of Communication Sciences and Disorders, Northwestern University, Evanston, IL
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Srivastava S, Macke EL, Swanson LC, Coulter D, Klee EW, Mullegama SV, Xie Y, Lanpher BC, Bedoukian EC, Skraban CM, Villard L, Milh M, Leppert MLO, Cohen JS. Expansion of the Genotypic and Phenotypic Spectrum of WASF1-Related Neurodevelopmental Disorder. Brain Sci 2021; 11:brainsci11070931. [PMID: 34356165 PMCID: PMC8307306 DOI: 10.3390/brainsci11070931] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 07/05/2021] [Indexed: 11/18/2022] Open
Abstract
In humans, de novo truncating variants in WASF1 (Wiskott–Aldrich syndrome protein family member 1) have been linked to presentations of moderate-to-profound intellectual disability (ID), autistic features, and epilepsy. Apart from one case series, there is limited information on the phenotypic spectrum and genetic landscape of WASF1-related neurodevelopmental disorder (NDD). In this report, we describe detailed clinical characteristics of six individuals with WASF1-related NDD. We demonstrate a broader spectrum of neurodevelopmental impairment including more mildly affected individuals. Further, we report new variant types, including a copy number variant (CNV), resulting in the partial deletion of WASF1 in monozygotic twins, and three missense variants, two of which alter the same residue, p.W161. This report adds further evidence that de novo variants in WASF1 cause an autosomal dominant NDD.
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Affiliation(s)
- Siddharth Srivastava
- Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA; (S.S.); (L.C.S.); (D.C.)
| | - Erica L. Macke
- Center for Individualized Medicine, Mayo Clinic, Rochester, MN 55902, USA; (E.L.M.); (E.W.K.); (B.C.L.)
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN 55902, USA
| | - Lindsay C. Swanson
- Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA; (S.S.); (L.C.S.); (D.C.)
| | - David Coulter
- Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA; (S.S.); (L.C.S.); (D.C.)
| | - Eric W. Klee
- Center for Individualized Medicine, Mayo Clinic, Rochester, MN 55902, USA; (E.L.M.); (E.W.K.); (B.C.L.)
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN 55902, USA
| | | | - Yili Xie
- GeneDx Inc., Gaithersburg, MD 20877, USA; (S.V.M.); (Y.X.)
| | - Brendan C. Lanpher
- Center for Individualized Medicine, Mayo Clinic, Rochester, MN 55902, USA; (E.L.M.); (E.W.K.); (B.C.L.)
- Department of Clinical Genomics, Mayo Clinic, Rochester, MN 55902, USA
| | - Emma C. Bedoukian
- Roberts Individualized Medical Genetics Center, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (E.C.B.); (C.M.S.)
- Division of Human Genetics, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Cara M. Skraban
- Roberts Individualized Medical Genetics Center, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (E.C.B.); (C.M.S.)
- Division of Human Genetics, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Laurent Villard
- Department of Medical Genetics, AP-HM, La Timone Children’s Hospital, 13385 Marseille, France;
- Inserm, Marseille Medical Genetics Center, Faculté de Médecine de Marseille, Aix Marseille University, 13385 Marseille, France;
| | - Mathieu Milh
- Inserm, Marseille Medical Genetics Center, Faculté de Médecine de Marseille, Aix Marseille University, 13385 Marseille, France;
- Department of Pediatric Neurology, AP-HM, La Timone Children’s Hospital, 13385 Marseille, France
| | - Mary L. O. Leppert
- Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD 21205, USA;
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Julie S. Cohen
- Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD 21205, USA;
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Correspondence:
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Refetoff S, Pappa T, Williams MK, Matheus MG, Liao XH, Hansen K, Nicol L, Pierce M, Blasco PA, Wiebers Jensen M, Bernal J, Weiss RE, Dumitrescu AM, LaFranchi S. Prenatal Treatment of Thyroid Hormone Cell Membrane Transport Defect Caused by MCT8 Gene Mutation. Thyroid 2021; 31:713-720. [PMID: 32746752 PMCID: PMC8110025 DOI: 10.1089/thy.2020.0306] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background: Mutations of the thyroid hormone (TH)-specific cell membrane transporter, monocarboxylate transporter 8 (MCT8), produce an X-chromosome-linked syndrome of TH deficiency in the brain and excess in peripheral tissues. The clinical consequences include brain hypothyroidism causing severe psychoneuromotor abnormalities (no speech, truncal hypotonia, and spastic quadriplegia) and hypermetabolism (poor weight gain, tachycardia, and increased metabolism, associated with high serum levels of the active TH, T3). Treatment in infancy and childhood with TH analogues that reduce serum triiodothyronine (T3) corrects hypermetabolism, but has no effect on the psychoneuromotor deficits. Studies of brain from a 30-week-old MCT8-deficient embryo indicated that brain abnormalities were already present during fetal life. Methods: A carrier woman with an affected male child (MCT8 A252fs268*), pregnant with a second affected male embryo, elected to carry the pregnancy to term. We treated the fetus with weekly 500 μg intra-amniotic instillation of levothyroxine (LT4) from 18 weeks of gestation until birth at 35 weeks. Thyroxine (T4), T3, and thyrotropin (TSH) were measured in the amniotic fluid and maternal serum. Treatment after birth was continued with LT4 and propylthiouracil. Follow-up included brain magnetic resonance imaging (MRI) and neurodevelopmental evaluation, both compared with the untreated brother. Results: During intrauterine life, T4 and T3 in the amniotic fluid were maintained above threefold to twofold the baseline and TSH was suppressed by 80%, while maternal serum levels remained unchanged. At birth, the infant serum T4 was 14.5 μg/dL and TSH <0.01 mU/L compared with the average in untreated MCT8-deficient infants of 5.1 μg/ and >8 mU/L, respectively. MRI at six months of age showed near-normal brain myelination compared with much reduced in the untreated brother. Neurodevelopmental assessment showed developmental quotients in receptive language and problem-solving, and gross motor and fine motor function ranged from 12 to 25 at 31 months in the treated boy and from 1 to 7 at 58 months in the untreated brother. Conclusions: This is the first demonstration that prenatal treatment improved the neuromotor and neurocognitive function in MCT8 deficiency. Earlier treatment with TH analogues that concentrate in the fetus when given to the mother may further rescue the phenotype.
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Affiliation(s)
- Samuel Refetoff
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
- Department of Pediatrics, The University of Chicago, Chicago, Illinois, USA
- Committees on Genetics, and The University of Chicago, Chicago, Illinois, USA
- Address correspondence to: Samuel Refetoff, MD, Department of Medicine, The University of Chicago, MC3090, 5841 South Maryland Avenue, Chicago, IL 60637, USA
| | - Theodora Pappa
- Department of Molecular Metabolism and Nutrition, The University of Chicago, Chicago, Illinois, USA
| | | | - M. Gisele Matheus
- Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Xiao-Hui Liao
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Karen Hansen
- Northwest Perinatal Center, Portland, Oregon, USA
| | - Lindsey Nicol
- Department of Pediatrics–Endocrinology and Oregon Health & Science University, Portland, Oregon, USA
| | - Melinda Pierce
- Department of Pediatrics–Endocrinology and Oregon Health & Science University, Portland, Oregon, USA
| | - Peter A. Blasco
- Neurodevelopmental Disabilities Doernbacher Children's Hospital, Oregon Health & Science University, Portland, Oregon, USA
| | - Mandie Wiebers Jensen
- Neurodevelopmental Disabilities Doernbacher Children's Hospital, Oregon Health & Science University, Portland, Oregon, USA
| | - Juan Bernal
- Instituto de Investigaciones Biomedicas, Consejo Superior de Investigaciones Cientificas, Universidad Autonoma de Madrid and Center for Biomedical Research on Rare Diseases, Madrid, Spain
| | - Roy E. Weiss
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Alexandra M. Dumitrescu
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
- Department of Molecular Metabolism and Nutrition, The University of Chicago, Chicago, Illinois, USA
| | - Stephen LaFranchi
- Department of Pediatrics–Endocrinology and Oregon Health & Science University, Portland, Oregon, USA
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Dorner RA, Allen MC, Robinson S, Soares BP, Perin J, Ramos E, Gerner G, Burton VJ. Early neurodevelopmental outcome in preterm posthemorrhagic ventricular dilatation and hydrocephalus: Neonatal ICU Network Neurobehavioral Scale and imaging predict 3-6-month motor quotients and Capute Scales. J Neurosurg Pediatr 2020; 25:217-227. [PMID: 31860810 PMCID: PMC7305038 DOI: 10.3171/2019.9.peds19438] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 09/16/2019] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Brain injury remains a serious complication of prematurity. Almost half of infants with severe intraventricular hemorrhage (IVH) develop posthemorrhagic ventricular dilatation (PHVD) and 20% need surgery for posthemorrhagic hydrocephalus (PHH). This population is associated with an increased risk of later neurodevelopmental disability, but there is uncertainty about which radiological and examination features predict later disability. In this study the authors sought to devise and describe a novel combination of neurobehavioral examination and imaging for prediction of neurodevelopmental disability among preterm infants with PHVD and PHH. METHODS The study patients were preterm infants (< 36 weeks gestation) with IVH and PHVD, with or without PHH. Ventricular index (VI), anterior horn width (AHW), thalamooccipital distance (TOD), ventricle/brain (V/B) ratio, and resistive indices (RIs) were recorded on the head ultrasound (HUS) just prior to surgery, or the HUS capturing the worst PHVD when surgery was not indicated. The posterior fossa was assessed with MRI. Neonatal ICU Network Neurobehavioral Scale (NNNS) examinations were performed at term age equivalent for each infant. A neurodevelopmental assessment using the Capute Scales (Capute Cognitive Adaptive Test [CAT] scores and Capute Clinical Linguistic Auditory Milestone Scale [CLAMS] scores) and a motor quotient (MQ) assessment were performed between 3 and 6 months of age corrected for degree of prematurity (corrected age). MQs < 50 reflect moderate to severe delays in early motor milestone attainment, CAT scores < 85 reflect delays in early visual and problem-solving abilities, and CLAMS scores < 85 reflect delays in early language. RESULTS Twenty-one infants underwent assessments that included imaging and NNNS examinations, Capute Scales assessments, and MQs. NNNS nonoptimal reflexes (NOR) and hypertonicity subscores and AHW were associated with MQs < 50: NOR subscore OR 2.46 (95% CI 1.15-37.6, p = 0.034), hypertonicity subscore OR 1.68 (95% CI 1.04-3.78, p = 0.037), and AHW OR 1.13 (95% CI 1.01-1.39, p = 0.041). PVHI, cystic changes, and neurosurgical intervention were associated with CAT scores < 85: PVHI OR 9.2 (95% CI 1.2-73.2, p = 0.037); cystic changes OR 12.0 (95% CI 1.0-141.3, p = 0.048), and neurosurgical intervention OR 11.2 (95% CI 1.0-120.4, p = 0.046). Every 1-SD increase in the NOR subscore was associated with an increase in odds of a CAT score < 85, OR 4.0 (95% CI 1.0-15.0, p = 0.044). Worse NNNS NOR subscores were associated with early language delay: for a 1-SD increase in NOR subscore, there was an increase in the odds of a CLAMS score < 85, OR 19.5 (95% CI 1.3-303, p = 0.034). CONCLUSIONS In former preterm children with severe IVH and PHVD, neonatal neurological examination findings and imaging features are associated with delays at 3-6 months in motor milestones, visual and problem-solving abilities, and language.
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Affiliation(s)
- Rebecca A. Dorner
- Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine
- Neurosciences Intensive Care Nursery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Marilee C. Allen
- Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins University School of Medicine
- Neurosciences Intensive Care Nursery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Shenandoah Robinson
- Neurosciences Intensive Care Nursery, Johns Hopkins Hospital, Baltimore, Maryland
- Pediatric Neurosurgery, Johns Hopkins University School of Medicine
| | - Bruno P. Soares
- Radiology, University of Vermont Medical Center, Burlington, Vermont
| | - Jamie Perin
- Bloomberg School of Public Health, Biostatistics, Epidemiology, and Data Management Core, Johns Hopkins University, Baltimore, Maryland
| | - Ezequiel Ramos
- Medical Doctorate Program, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Vera Joanna Burton
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, Maryland
- Department of Neurology, Johns Hopkins University School of Medicine
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6
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Rojnueangnit K, Khaosamlee P, Chunsuwan I, Vorravanpreecha N, Lertboonnum T, Rodjanadit R, Sriplienchan P. Quality of life and comprehensive health supervision for children with Down syndrome in Thailand. J Community Genet 2020; 11:351-358. [PMID: 32088880 DOI: 10.1007/s12687-020-00458-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 02/17/2020] [Indexed: 11/29/2022] Open
Abstract
Children with Down syndrome often require several specialty doctors and multidisciplinary teams for their associated anomalies. This may impact their quality of life and creates gaps in treatment monitoring. No studies have yet been conducted in Thailand to measure their quality of life and level of comprehensive health supervision. Therefore, we aimed to study the quality of life among children with Down syndrome and determine if they receive comprehensive health supervision for their condition. In this descriptive research, data were collected from a medical record review of children with Down syndrome during a 1-year period in our Pediatric Outpatient Clinic; 50 children and 39 caregivers participated. Mean total quality of life score of the children was 67.9/100 points. The children had the highest scores (73.6 ± 12.8) in emotional functioning and the lowest (57.2 ± 25.6) in cognitive functioning. It appears that the quality of life may be lower in Down syndrome patients than in Thai children without it. Regarding health supervision, all 50 were screened for thyroid function, and 48 received cardiac evaluations. However, only 17 (34%) received "complete basic assessment" of 5 screening combinations with developmental evaluations and growth monitoring. Furthermore, none received "comprehensive" evaluations for all recommended conditions. While these findings show a need for health supervision improvement for children with Down syndrome within our hospital, they may also be indicative for most care facilities throughout Thailand.
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Affiliation(s)
- Kitiwan Rojnueangnit
- Department of Pediatrics, Faculty of Medicine, Thammasat University, 99 Moo 18 Phahonyothin Road, Khlong Luang, Pathumthani, 12120, Thailand.
| | - Penrawee Khaosamlee
- Department of Pediatrics, Faculty of Medicine, Thammasat University, 99 Moo 18 Phahonyothin Road, Khlong Luang, Pathumthani, 12120, Thailand.,Department of Pediatrics, Amnatcharoen Hospital, Amnat Charoen, Thailand
| | - Issarapa Chunsuwan
- Department of Pediatrics, Faculty of Medicine, Thammasat University, 99 Moo 18 Phahonyothin Road, Khlong Luang, Pathumthani, 12120, Thailand
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7
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Cognitive, Language, and Visuomotor Abilities of Very Low Birthweight Infants at Corrected Age of Two Years. Indian Pediatr 2020. [DOI: 10.1007/s13312-020-1778-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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8
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Kim SW, Kim JY, Lee SY, Jeon HR. The Comparison of M-B CDI-K Short Form and K-ASQ as Screening Test for Language Development. Ann Rehabil Med 2016; 40:1108-1113. [PMID: 28119842 PMCID: PMC5256322 DOI: 10.5535/arm.2016.40.6.1108] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 05/09/2016] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To investigate the usefulness of the communication domain in the Korean version of Ages and Stages Questionnaire (K-ASQ), and short form of the Korean version of MacArthur-Bates Communicative Development Inventories (M-B CDI-K), as screening tests for language developmental delay. METHODS Data was collected between April 2010 and December 2013, from children who visited either the Department of Physical Medicine and Rehabilitation or the Developmental Delay Clinic, presenting with language development delay as their chief complaint. All the children took the short form of M-B CDI-K and K-ASQ as screening tests, and received diagnostic language assessments including Sequenced Language Scale for Infants (SELSI) or Preschool Receptive-Expressive Language Scale (PRES). RESULTS A total of 206 children, mean age 29.7 months, were enrolled. The final diagnoses were developmental language disorder, global developmental delay, autism spectrum disorder, cerebral palsy, etc. The M-B CDI-K short form and the communication domain of the K-ASQ had 95.9% and 76.7% sensitivity, and 82.4% and 85.3% specificity, with regards to diagnostic language assessments. The M-B CDI-K short form showed higher negative predictive value and better accuracy than the communication domain of the K-ASQ. CONCLUSION The screening ability of K-ASQ was not sufficient for children with language development delay, and the M-B CDI-K short form should be implemented for additional screening.
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Affiliation(s)
- Seong Woo Kim
- Department of Physical Medicine and Rehabilitation, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Ji Yong Kim
- Department of Physical Medicine and Rehabilitation, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Sang Yoon Lee
- Department of Physical Medicine and Rehabilitation, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Ha Ra Jeon
- Department of Physical Medicine and Rehabilitation, National Health Insurance Service Ilsan Hospital, Goyang, Korea
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9
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Burton VJ, Gerner G, Cristofalo E, Chung SE, Jennings JM, Parkinson C, Koehler RC, Chavez-Valdez R, Johnston MV, Northington FJ, Lee JK. A pilot cohort study of cerebral autoregulation and 2-year neurodevelopmental outcomes in neonates with hypoxic-ischemic encephalopathy who received therapeutic hypothermia. BMC Neurol 2015; 15:209. [PMID: 26486728 PMCID: PMC4618147 DOI: 10.1186/s12883-015-0464-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 10/06/2015] [Indexed: 11/17/2022] Open
Abstract
Background Neurodevelopmental disabilities persist in survivors of neonatal hypoxic-ischemic encephalopathy (HIE) despite treatment with therapeutic hypothermia. Cerebrovascular autoregulation, the mechanism that maintains cerebral perfusion during changes in blood pressure, may influence outcomes. Our objective was to describe the relationship between acute autoregulatory vasoreactivity during treatment and neurodevelopmental outcomes at 2 years of age. Methods In a pilot study of 28 neonates with HIE, we measured cerebral autoregulatory vasoreactivity with the hemoglobin volume index (HVx) during therapeutic hypothermia, rewarming, and the first 6 h of normothermia. The HVx, which is derived from near-infrared spectroscopy, was used to identify the individual optimal mean arterial blood pressure (MAPOPT) at which autoregulatory vasoreactivity is greatest. Cognitive and motor neurodevelopmental evaluations were completed in 19 children at 21–32 months of age. MAPOPT, blood pressure in relation to MAPOPT, blood pressure below gestational age + 5 (ga + 5), and regional cerebral oximetry (rSO2) were compared to the neurodevelopmental outcomes. Results Nineteen children who had HIE and were treated with therapeutic hypothermia performed in the average range on cognitive and motor evaluations at 21–32 months of age, although the mean performance was lower than that of published normative samples. Children with impairments at the 2-year evaluation had higher MAPOPT values, spent more time with blood pressure below MAPOPT, and had greater blood pressure deviation below MAPOPT during rewarming in the neonatal period than those without impairments. Greater blood pressure deviation above MAPOPT during rewarming was associated with less disability and higher cognitive scores. No association was observed between rSO2 or blood pressure below ga + 5 and neurodevelopmental outcomes. Conclusion In this pilot cohort, motor and cognitive impairments at 21–32 months of age were associated with greater blood pressure deviation below MAPOPT during rewarming following therapeutic hypothermia, but not with rSO2 or blood pressure below ga + 5. This suggests that identifying individual neonates’ MAPOPT is superior to using hemodynamic goals based on gestational age or rSO2 in the acute management of neonatal HIE. Electronic supplementary material The online version of this article (doi:10.1186/s12883-015-0464-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Vera Joanna Burton
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA. .,Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Johns Hopkins School of Medicine, 801 N Broadway, Baltimore, MD, 21205, USA.
| | - Gwendolyn Gerner
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, MD, USA.
| | - Elizabeth Cristofalo
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA. .,Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Shang-en Chung
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Jacky M Jennings
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Charlamaine Parkinson
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Raymond C Koehler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Raul Chavez-Valdez
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Michael V Johnston
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA. .,Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Hugo Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD, USA.
| | - Frances J Northington
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Jennifer K Lee
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
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10
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Burton VJ, Gerner G, Cristofalo E, Chung SE, Jennings JM, Parkinson C, Koehler RC, Chavez-Valdez R, Johnston MV, Northington FJ, Lee JK. A pilot cohort study of cerebral autoregulation and 2-year neurodevelopmental outcomes in neonates with hypoxic-ischemic encephalopathy who received therapeutic hypothermia. BMC Neurol 2015. [PMID: 26486728 DOI: 10.1186/s12883‐015‐0464‐4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Neurodevelopmental disabilities persist in survivors of neonatal hypoxic-ischemic encephalopathy (HIE) despite treatment with therapeutic hypothermia. Cerebrovascular autoregulation, the mechanism that maintains cerebral perfusion during changes in blood pressure, may influence outcomes. Our objective was to describe the relationship between acute autoregulatory vasoreactivity during treatment and neurodevelopmental outcomes at 2 years of age. METHODS In a pilot study of 28 neonates with HIE, we measured cerebral autoregulatory vasoreactivity with the hemoglobin volume index (HVx) during therapeutic hypothermia, rewarming, and the first 6 h of normothermia. The HVx, which is derived from near-infrared spectroscopy, was used to identify the individual optimal mean arterial blood pressure (MAPOPT) at which autoregulatory vasoreactivity is greatest. Cognitive and motor neurodevelopmental evaluations were completed in 19 children at 21-32 months of age. MAPOPT, blood pressure in relation to MAPOPT, blood pressure below gestational age + 5 (ga + 5), and regional cerebral oximetry (rSO2) were compared to the neurodevelopmental outcomes. RESULTS Nineteen children who had HIE and were treated with therapeutic hypothermia performed in the average range on cognitive and motor evaluations at 21-32 months of age, although the mean performance was lower than that of published normative samples. Children with impairments at the 2-year evaluation had higher MAPOPT values, spent more time with blood pressure below MAPOPT, and had greater blood pressure deviation below MAPOPT during rewarming in the neonatal period than those without impairments. Greater blood pressure deviation above MAPOPT during rewarming was associated with less disability and higher cognitive scores. No association was observed between rSO2 or blood pressure below ga + 5 and neurodevelopmental outcomes. CONCLUSION In this pilot cohort, motor and cognitive impairments at 21-32 months of age were associated with greater blood pressure deviation below MAPOPT during rewarming following therapeutic hypothermia, but not with rSO2 or blood pressure below ga + 5. This suggests that identifying individual neonates' MAPOPT is superior to using hemodynamic goals based on gestational age or rSO2 in the acute management of neonatal HIE.
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Affiliation(s)
- Vera Joanna Burton
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA. .,Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Johns Hopkins School of Medicine, 801 N Broadway, Baltimore, MD, 21205, USA.
| | - Gwendolyn Gerner
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, MD, USA.
| | - Elizabeth Cristofalo
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA. .,Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Shang-en Chung
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Jacky M Jennings
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Charlamaine Parkinson
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Raymond C Koehler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Raul Chavez-Valdez
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Michael V Johnston
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA. .,Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Hugo Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD, USA.
| | - Frances J Northington
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Jennifer K Lee
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
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11
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Early prediction of the neurological result at 12 months in newborns at neurological risk. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2015. [DOI: 10.1016/j.anpede.2015.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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12
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Herbón F, Garibotti G, Moguilevsky J. [Early prediction of the neurological result at 12 months in newborns at neurological risk]. An Pediatr (Barc) 2014; 83:123-9. [PMID: 25455915 DOI: 10.1016/j.anpedi.2014.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Revised: 10/05/2014] [Accepted: 10/09/2014] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION The aim of this study was to evaluate the Amiel-Tison neurological examination (AT) and cranial ultrasound at term for predicting the neurological result at 12 months in newborns with neurological risk. PATIENTS AND METHODS The study included 89 newborns with high risk of neurological damage, who were discharged from the Neonatal Intensive Care of the Hospital Zonal Bariloche, Argentina. The assessment consisted of a neurological examination and cranial ultrasound at term, and neurological examination and evaluation of development at 12 months. The sensitivity, specificity, positive and negative predictor value was calculated. The relationship between perinatal factors and neurodevelopment at 12 month of age was also calculated using logistic regression models. RESULTS Seventy children completed the follow-up. At 12 months of age, 14% had an abnormal neurological examination, and 17% abnormal development. The neurological examination and the cranial ultrasound at term had low sensitivity to predict abnormal neurodevelopment. At 12 months, 93% of newborns with normal AT showed normal neurological results, and 86% normal development. Among newborns with normal cranial ultrasound the percentages were 90 and 81%, respectively. Among children with three or more perinatal risk factors, the frequency of abnormalities in the neurological response was 5.4 times higher than among those with fewer risk factors, and abnormal development was 3.5 times more frequent. CONCLUSIONS The neurological examination and cranial ultrasound at term had low sensitivity but high negative predictive value for the neurodevelopment at 12 months. Three or more perinatal risk factors were associated with neurodevelopment abnormalities at 12 months of age.
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Affiliation(s)
- F Herbón
- Servicio de Neonatología, Hospital Zonal Bariloche, Bariloche, Argentina.
| | - G Garibotti
- Centro Regional Universitario Bariloche, Universidad Nacional del Comahue, Bariloche, Argentina
| | - J Moguilevsky
- Servicio de Imágenes, Hospital Zonal Bariloche, Bariloche, Argentina
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Lee RWY, Bodurtha J, Cohen J, Fatemi A, Batista D. Deletion 12p12 involving SOX5 in two children with developmental delay and dysmorphic features. Pediatr Neurol 2013; 48:317-20. [PMID: 23498568 DOI: 10.1016/j.pediatrneurol.2012.12.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2012] [Accepted: 12/17/2012] [Indexed: 02/08/2023]
Abstract
The SOX5 gene encodes a transcription factor involved in the regulation of nervous system development and chondrogenesis. This article reports on two cases of 12p12.1 deletion involving SOX5 presenting with global developmental delay, intellectual disability, expressive language delay, mild motor impairment, distinct features, and multiorgan involvement. The first case involves a 32-month-old boy with de novo 53-kilobase interstitial deletion at 12p12.1, representing the smallest deletion reported, and presents with severe symptomatology. The second case is a 31-month-old girl with 3.2-megabase deletion at 12p12.2 p12.1 with severe neurodevelopmental disability and minimal organ involvement. These patients bear many of the characteristics previously reported in patients with SOX5 mutations. We propose a neurodevelopmental approach to a novel syndrome with dose- and location-sensitive SOX5 gene expression.
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Affiliation(s)
- Ryan W Y Lee
- Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, Maryland, USA.
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14
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Greiner MV, Lawrence AP, Horn P, Newmeyer AJ, Makoroff KL. Early clinical indicators of developmental outcome in abusive head trauma. Childs Nerv Syst 2012; 28:889-96. [PMID: 22367916 DOI: 10.1007/s00381-012-1714-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Accepted: 01/31/2012] [Indexed: 01/07/2023]
Abstract
PURPOSE The purpose of the study was to determine the developmental prognostic significance of early clinical indicators in abusive head trauma. METHODS Seventy-one children were diagnosed with abusive head trauma and followed in a post-injury growth and development clinic. A retrospective chart review was completed to gather clinical features at the time of injury, including presence or absence of early post-traumatic seizures, presence or absence of intubation, and presence or absence of pediatric intensive care unit admission. Children then underwent developmental testing with use of the Capute Scales of the Cognitive Adaptive Test (CAT) and the Clinical Linguistic and Auditory Milestone Scale (CLAMS) during follow-up clinic visits. Clinical features at initial injury were compared to developmental outcome. RESULTS Thirty-four of 71 patients with seizures during their admission hospitalization scored significantly lower on follow-up developmental testing than patients who did not have seizures. Twenty-one of 71 patients who required intubation scored lower on developmental testing than patients who did not require intubation. Thirty-five of 71 patients who required pediatric intensive care unit admission scored lower on developmental testing than patients who did not require pediatric intensive care unit admission. CONCLUSIONS This study demonstrates that clinical factors at the time of injury, such as early post-traumatic seizures and intubation requirement, are associated with poorer developmental outcome. This study also suggests that close developmental follow-up should be obtained for all children with abusive head trauma, regardless of whether or not the child was admitted to the PICU.
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Affiliation(s)
- Mary V Greiner
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA.
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16
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Tur BS, Küçükdeveci AA, Kutlay S, Yavuzer G, Elhan AH, Tennant A. Psychometric properties of the WeeFIM in children with cerebral palsy in Turkey. Dev Med Child Neurol 2009; 51:732-8. [PMID: 19207295 DOI: 10.1111/j.1469-8749.2008.03255.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The Functional Independence Measure for Children (WeeFIM) instrument has recently been adapted and validated for non-disabled children in Turkey. The aim of this study was to validate the instrument in children with cerebral palsy (CP). One hundred and thirty-four children with CP were assessed using the WeeFIM. Reliability was tested by internal consistency, intraclass and interrater correlation coefficients (ICCs), internal construct validity by Rasch analysis, and external construct validity by correlation with the Denver II Development Test (Denver II). Mean age of the participants (70 females, 64 males) was 4y 6mo (SD 3y 8mo, range 6mo-16y). CP type was: diplegia in 37.3%, hemiplegia in 20.2%, quadriplegia in 8.2%, 'baby at risk' (i.e. infants who show neuromotor delay but cannot be classified in a CP type) in 29.9%, and other in 4.5%. Reliability of the WeeFIM was excellent with high Cronbach's alpha and ICC values ranging between 0.91 and 0.98 for the motor and cognitive scales. After collapsing response categories, both motor and cognitive scales met Rasch model expectations. Unidimensionality of the motor scale was confirmed after adjustment for local dependency of items. There was no substantive differential item functioning and strict unidimensionality for both scales was shown by analysis of the residuals. External construct validity was supported by expected high correlations with developmental ages determined by the social, fine motor function, language, and gross motor function domains of the Denver II. We conclude that the WeeFIM is a reliable and valid instrument for evaluating the functional status of Turkish children with CP.
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Affiliation(s)
- Birkan Sonel Tur
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Ankara University, Turkey
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Steele RG, Nelson TD, Cole BP. Use of developmental milestones in pediatric residency training and practice: time to rethink the meaning of the mean. J Dev Behav Pediatr 2007; 28:58-69. [PMID: 17353739 PMCID: PMC2707752 DOI: 10.1097/dbp.0b013e31803084c6] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Pediatricians frequently report the use of developmental milestones in monitoring young children's development, despite evidence that use of screening tools improves detection of developmental delays. METHODS Core texts in the field of pediatrics and developmental-behavioral pediatrics were reviewed for content and presentation on child development. Most texts included and many focused on developmental milestones, many with an emphasis on 50th percentile milestone data. Problems and limitations in the use of 50th percentile milestones to monitor young children's development and to identify children whose development is suspicious for delay, include questionable utility in clinical decision making and the potential to increase parental anxiety. RESULTS The recommendation is made to reconsider a focus on 50th percentile milestone data in pediatric training and practice, in favor of measures that have better clinical utility and are more psychometrically sound. CONCLUSION A conceptual approach to the presentation of developmental milestones differentiates the use of the 10th, 50th, and 90th percentiles of age of achievement of skills, based on the clinical purpose of surveillance.
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Affiliation(s)
- Ric G Steele
- Clinical Child Psychology Program, Dole Human Development Center, University of Kansas, Lawrence, KS 66045-7555, USA.
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