Does a triplet birth pose a special risk for infant development? Assessing cognitive development in relation to intrauterine growth and mother-infant interaction across the first 2 years

From inner to dyadic connection: the role of mindfulness in mother-infant interaction during the first year of life

Introduction

Mother-infant attunement is fundamental to supporting infant socio-emotional development. Based on the assumption that we connect better with others if we are aware of and connected with our own experience, mindfulness could affect the maternal ability to attune to the infant. However, little is known about this topic in the first year of life. Study 1 aimed to investigate the role of maternal dispositional mindfulness and mindful parenting in mother-infant physiological and behavioral attunement at 3 months of age. Study 2 aimed to explore the effect of a mindfulness-based intervention not specific to parenting experience on mother-infant behavioral and physiological attunement and on maternal wellbeing at 9 months of age.

Methods

In Study 1, mother-infant (n = 67) behavioral and physiological attunement (i.e., co-regulation and RSA) were collected simultaneously each 20 s during face-to-face interaction. Mothers completed questionnaires about their dispositional mindfulness and mindful parenting. In Study 2, mother-infant dyads were randomly divided into a control (n = 20) and an intervention group (n = 29). The intervention group attended a 5-week mindfulness-based intervention. At T1 and T2, the same procedure described in Study 1 was applied and mothers reported about their wellbeing.

Results

Results showed that maternal mindfulness was associated with high physiological and behavioral attunement at 3 months and with more positive maternal behaviors and less stress at 9 months. Analysis evidenced a slight improvement in the intervention group in maternal dispositional mindfulness and a reduction in parenting stress at T2.

Discussion

Findings from both studies suggested that maternal mindfulness could represent a protective factor that could support mothers in fostering better dyadic interactions with their infants. The implementation of mindfulness-based interventions for mothers could have preventive and clinical implications.

Over-reaching with causality language in neurodevelopmental infant research: A methodological literature review

BACKGROUND

A methodological review of 78 empirical articles focusing on the neurodevelopmental outcomes of at-risk infants was conducted.

AIMS

To examine ways language and terminology are used to describe methods, present results, and/or state conclusions in studies published during 1994-2005, a decade reflecting major advances in neurodevelopmental research and in medical intervention. More specifically, to investigate to what extent the design of the study and the language in the results section aligned in regard to causality.

METHODS

A process of search and selection of studies published in pediatric journals was conducted through Google Scholar. Criteria of inclusion and exclusion, following PRISMA, were used. Selected studies reported neurodevelopmental outcomes of infants and young children considered at-risk, and were further categorized accordingly to their study designs. Language use in regard to whether the presentation and interpretation of results may convey causal relationships between birth risk factors and neurodevelopmental outcomes was examined following two analytical steps.

RESULTS

Forty out of 78 studies, (51.28 %) used causality-implying language (e.g., effect, predict, influence) notwithstanding that the study design was non-causal.

CONCLUSIONS

Anticipating the next generation of neurodevelopmental-outcomes research, a framework that aims to raise awareness of the importance of language use and the impact of causality-related terms often used in longitudinal studies is proposed. The objective is to avoid ambiguities and misunderstandings around causal or non-causal connections between birth risk factors and developmental outcomes across diverse audiences, including early intervention practitioners working directly with infants and their families.

Examination of multiple birth as a predictor of autism symptom severity and developmental functioning in an early intervention sample

Multiple birth is one of several perinatal factors associated with increased risk for autism spectrum disorder (ASD); however, complexity in its relationship to ASD symptoms and developmental functioning remains. The present study investigated perinatal risk factors for ASD, primarily focusing on birth status, within a large early intervention sample. In particular, the relationship between ASD, perinatal factors, and the effect of birth status on developmental functioning and ASD symptom severity were examined in youth with and without ASD classification who were born singly or were the product of a multiple birth. Overall, the presence of other perinatal risk factors, including prematurity, low birth weight, and advanced parental age, was primarily related to birth status and not to ASD classification, while severity of ASD symptoms and developmental impairments were primarily related to ASD classification and not to birth status. Study findings and implications for early screening of children with developmental delays are discussed.

Longitudinal effects of breast feeding on parent-reported child behaviour

OBJECTIVE

Shorter breastfeeding duration has been linked to a range of difficulties in children. However, evidence linking shorter breastfeeding duration to child behavioural problems has been inconclusive. Owing to an almost exclusive focus on early childhood in previous research, little is known about breastfeeding effects on behaviour throughout childhood and adolescence. This study examines the longitudinal effect of breast feeding on parent-reported behaviour in children aged 3-14.

DESIGN

Data come from the Millennium Cohort Study, a large, prospective, UK birth cohort study.

PARTICIPANTS

11 148 children, their parents and teachers.

METHODS

This study maps the effect of breastfeeding duration on parent-reported child behaviour longitudinally, using latent growth curve modelling and on teacher-reported child behaviour using multiple regression analyses. Breastfeeding duration was assessed through parent interviews when the child was 9 months old. Children's behavioural development was measured using parent-reported Strengths and Difficulties Questionnaires (SDQ) at 3, 5, 7, 11 and 14 years and teacher-reported SDQs at 7 and 11 years.

RESULTS

Breast feeding was associated with fewer parent-reported behavioural difficulties at all ages even after adjusting for potential confounders (<2 months: B=-0.22, 95% CI -0.39 to -0.04; 2-4 months: B=-0.53, 95% CI -0.75 to -0.32; 4-6 months: B=-1.07, 95% CI -1.33 to -0.81; >6 months: B=-1.24, 95% CI -1.44 to -1.04; B=adjusted mean difference of raw SDQ scores at age 3, reference: never breast fed).

CONCLUSION

This study provides further evidence supporting links between breastfeeding duration and children's socioemotional behavioural development. Potential implications include intervention strategies encouraging breast feeding.

Social Behavior as a Transdiagnostic Marker of Resilience

The recent shift from psychopathology to resilience and from diagnosis to functioning requires the construction of transdiagnostic markers of adaptation. This review describes a model of resilience that is based on the neurobiology of affiliation and the initial condition of mammals that mature in the context of the mother's body and social behavior. The model proposes three tenets of resilience-plasticity, sociality, and meaning-and argues that coordinated social behavior stands at the core sustaining resilience. Two lines in the maturation of coordinated social behavior are charted, across animal evolution and throughout human development, culminating in the mature human reciprocity of empathy, mutuality, and perspective-taking. Cumulative evidence across ages and clinical conditions and based on our behavioral coding system demonstrates that social reciprocity, defined by plasticity at the individual, dyadic, and group levels, denotes resilience, whereas the two poles of disengagement/avoidance and intrusion/rigidity characterize specific psychopathologies, each with a distinct behavioral signature. Attention to developmentally sensitive markers and to the dimension of meaning in human sociality may open new, behavior-based pathways to resilience.

Impact of stunting on early childhood cognitive development in Benin: evidence from Demographic and Health Survey

Background

Proper nutrition is crucial for enhancing brain function and improving learning. Over time, large evidence has existed to show that childhood undernutrition, marked by stunting, is connected with age-long reduction in cognitive and academic achievement. It is of interest to achieve healthy growth and optimal cognitive development in early childhood. The objective of this study was to examine stunting considered to adversely influence cognitive development among children and therefore of public health importance.

Results

About two thirds (64.3%) of under-five children attained optimal cognition. Stunted children had 7% reduction in optimal cognitive development, compared with not stunted children (RR = 0.93; 95%CI 0.83, 0.98). Among the covariates, geographical region was significantly associated with optimal cognitive development. In addition, children of Islamic, traditional/other religion, and no religion had significant reduction in optimal cognitive development, compared with children of Christianity belief. Children from mothers who had secondary and tertiary education, listened to radio, and watched television had an increase in optimal cognitive development, compared with children from uneducated mothers. Furthermore, children from mothers who are employed had an 8% increase in optimal cognitive development (RR = 1.08; 95%CI: 1.02, 1.14).

Conclusion

Due to the adverse impact of stunting on optimal cognitive development, we suggest that government and stakeholders in child welfare should ensure that development programmes combine health and nutrition services with early learning and rely on families as partners to have children’s cognitive development effectively. Early childhood cognitive development programmes should be implemented through families and caregivers, with special focus on disadvantaged children as a poverty reduction strategy, and ensure that all children are adequately nourished.

Early styles of interaction in mother-twin infant dyads and maternal mental health

Transition to parenthood is considered a critical process for mothers of twins. There are, however, few studies on the subject. This study aims to evaluate the differences between mother-twin infant dyads and mother-singleton infant dyads with regard to maternal depression, anxiety, parenting stress, and the quality of mother-infant interaction. Mothers of twin infants (N = 40) were compared to mothers of singletons (N = 72). At infant 3 months, maternal depression, anxiety, and parenting stress were assessed via a questionnaire and styles of interaction with the Care-Index. The results indicated that mothers of twins (vs mothers of singletons) had significantly higher state anxiety and higher scores on the Difficult Child Scale of the Parenting Stress Index at infant 3 months. No significant differences between the two groups were found with regard to maternal depression. Mothers of twins had significantly lower sensitivity and were more unresponsive than mothers of singletons. Twin infants had significantly more difficult and compliant behaviours than singleton infants. Assisted reproductive treatment (ART) and prematurity had no effect on any of the examined variables. State anxiety was shown to partially mediate the relationship between twin parenthood and maternal sensitivity and to completely mediate the relationship between twin parenthood and infant difficult style. Maternal unresponsiveness was shown to be exclusively linked to being the parent of twins. The study shows that twin parenthood has a significant effect on maternal mental health and on the quality of mother-infant interaction and highlights the importance of early prevention programmes for twin parents.

Impact of mother-infant interaction on development during the first year of life: A systematic review

The objectives of this project were to systematically review the impact of mother-infant interaction on the development of infants 12 months or younger and determine factors that mediate this relationship and early development. We systematically reviewed the literature and identified 21 papers which fulfilled inclusion and exclusion criteria. The majority of the studies found significant association between mother-infant interaction and language, cognition, motor, and social development during the first year of life. Only seven studies assessed motor development and four studies found significant relationship between motor development and mother-infant interaction. Prematurity, infant age, multiples births, maternal anxiety, maternal opioid exposure, history of foster care, and criminal record were the only factors found to mediate the relationship between mother-infant interaction and social, cognitive, and language development. The quality of the interactions between a mother and infant can both positively and negatively influence cognitive, language, and social outcomes during the first year of life. Additional research is needed to determine the influence of mother-infant interaction on motor development. Future research is needed on the efficacy of interventions designed to alter mother-infant interaction with the ultimate goal of achieving positive developmental outcomes during the first year of life.

A Meta-Analysis of Stressors from the Total Environment Associated with Children's General Cognitive Ability

General cognitive ability, often referred to as ‘general intelligence’, comprises a variety of correlated abilities. Childhood general cognitive ability is a well-studied area of research and can be used to predict social outcomes and perceived success. Early life stage (e.g., prenatal, postnatal, toddler) exposures to stressors (i.e., chemical and non-chemical stressors from the total (built, natural, social) environment) can impact the development of childhood cognitive ability. Building from our systematic scoping review (Ruiz et al., 2016), we conducted a meta-analysis to evaluate more than 100 stressors related to cognitive development. Our meta-analysis identified 23 stressors with a significant increase in their likelihood to influence childhood cognitive ability by 10% or more, and 80 stressors were observed to have a statistically significant effect on cognitive ability. Stressors most impactful to cognition during the prenatal period were related to maternal health and the mother’s ability to access information relevant to a healthy pregnancy (e.g., diet, lifestyle). Stressors most impactful to cognition during the early childhood period were dietary nutrients (infancy), quality of social interaction (toddler), and exposure to toxic substances (throughout early childhood). In conducting this analysis, we examined the relative impact of real-world exposures on cognitive development to attempt to understand the inter-relationships between exposures to both chemical and non-chemical stressors and early developmental life stages. Our findings suggest that the stressors observed to be the most influential to childhood cognitive ability are not permanent and can be broadly categorized as activities/behaviors which can be modified to improve childhood cognition. This meta-analysis supports the idea that there are complex relationships between a child’s total environment and early cognitive development.

Neurocognitive function of 10-year-old multiples born less than 28 weeks of gestational age

INTRODUCTION

Few studies have examined the relationship between birth plurality and neurocognitive function among children born extremely preterm.

STUDY DESIGN

We compared rates of Z-scores ≤-2 on 18 tests of neurocognitive function and academic achievement at age 10 years in 245 children arising from twin pregnancies, 55 from triplet pregnancies, and 6 from a septuplet pregnancy to that of 568 singletons, all of whom were born before the 28th week of gestation.

RESULTS

In total, 874 children were evaluated at the age of 10 years. After adjusting for confounders, children of multifetal pregnancies performed significantly better on one of six subtests of executive function than their singleton peers. Performance was similar on all other assessments of intelligence, language, academic achievement, processing speed, visual perception, and fine motor skills.

CONCLUSION

We found no evidence that children born of multifetal pregnancies had worse scores than their singleton peers on assessments of neurocognitive and academic function.

The impact of maternal anxiety disorder on mother-infant interaction in the postpartum period

Background

This study investigated whether postpartum anxiety disorder is associated to altered patterns of infant as well as maternal engagement in a Face-to-Face-Still-Face interaction (FFSF).

Sampling and methods

n = 39 women with postpartum DSM-IV anxiety disorder and n = 48 healthy mothers were videotaped during a FFSF with their infant (M = 4.1 months).

Results

Infants of the clinical group showed significantly less positive engagement during the play episode than infants of controls. This result depended on infant sex: male controls demonstrated more positive interaction than males of anxious mothers. There was no such effect for female infants who engaged significantly less positively during the play episode than males and did not change their positive engagement during the FFSF. These findings imply pronounced interactive positivity and early vulnerability to maternal anxiety symptoms in male infants. Only the infants of the controls showed the still-face effect. They also protested significantly more during the still-face, while the clinical infants’ protest increased significantly during the reunion. Women of both groups did not differ in their interaction. Maternal intrusiveness was associated to infant protest in the course of the FFSF.

Conclusions

Results suggest that mother-infant intervention should consider affect regulation and infant sex-specific characteristics in anxious mother-infant dyads.

Maternal Psychological Distress and Mother-Infant Relationship: Multiple-Birth Versus Singleton Preterm Infants

PURPOSE

Multiple preterm birth is associated with more maternal psychological distress and less positive mother-infant interactions than singleton preterm birth. This study's purpose was to compare psychological distress and the relationship with their infants in mothers of multiples and mothers of singletons.

DESIGN

An exploratory secondary analysis of longitudinal data.

SAMPLE

236 mothers and their preterm infants.

MAIN OUTCOME VARIABLES

Maternal psychological distress (depressive symptoms, anxiety, posttraumatic stress [PTS], parenting stress), the mother-infant relationship (worry; child vulnerability; maternal positive involvement and developmental stimulation; and child developmental maturity, irritability, and social behaviors), and the home environment.

RESULTS

Mothers of multiples had greater PTS symptoms at baseline, anxiety at discharge, and depressive symptoms at six months than mothers of singletons. Mothers of multiples also had more positive home environments at six months. Multiple birth was a risk factor for psychological distress but not for less positive mother-infant interactions.

Cacophonies of discord, moments of harmony: Managing multiple needs in short-term music therapy with triplets and their mother

This article explores some of the issues arising from short-term music therapy with a family of triplets, one of whom had special needs. Starved of nutrition in the womb by her two siblings, Emma was born with restricted growth and medical complications. She spent her first year in hospital, while her brother and sister grew up at home. Emma was referred to music therapy at the age of 2; however, it proved difficult to see her without her siblings. It quickly became apparent that there were many needs within the family: those of Emma, the two siblings and of their mother. Emma’s needs could easily be side-lined by her more dominant siblings. Her mother was struggling to cope with all three children together, and concerned that she had not fully bonded with Emma. Various strategies were used in the family music therapy to contain these multiple needs and attempt to meet some of them.

"GET-UP" study rationale and protocol: a cluster randomised controlled trial to evaluate the effects of reduced sitting on toddlers' cognitive development

BACKGROUND

The educational and cognitive differences associated with low socioeconomic status begin early in life and tend to persist throughout life. Coupled with the finding that levels of sedentary time are negatively associated with cognitive development, and time spent active tends to be lower in disadvantaged circumstances, this highlights the need for interventions that reduce the amount of time children spend sitting and sedentary during childcare. The proposed study aims to assess the effects of reducing sitting time during Early Childhood Education and Care (ECEC) services on cognitive development in toddlers from low socio-economic families.

METHODS/DESIGN

We will implement a 12-months 2-arm parallel group cluster randomised controlled trial (RCT) with Australian toddlers, aged 12 to 26 months at baseline. Educators from the ECEC services allocated to the intervention group will receive professional development on how to reduce sitting time while children attend ECEC. Participants' cognitive development will be assessed as a primary outcome, at baseline and post-intervention, using the cognitive sub-test from the Bayley Scales of Infant and Toddler Development.

DISCUSSION

This trial has the potential to inform programs and policies designed to optimize developmental and health outcomes in toddlers, specifically in those from disadvantaged backgrounds.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12616000471482 , 11/04/2016, retrospectively registered.

Contributions of a Child's Built, Natural, and Social Environments to Their General Cognitive Ability: A Systematic Scoping Review

The etiology of a child’s cognitive ability is complex, with research suggesting that it is not attributed to a single determinant or even a defined period of exposure. Rather, cognitive development is the product of cumulative interactions with the environment, both negative and positive, over the life course. The aim of this systematic scoping review was to collate evidence associated with children’s cognitive health, including inherent factors as well as chemical and non-chemical stressors from the built, natural, and social environments. Three databases were used to identify recent epidemiological studies (2003–2013) that examined exposure factors associated with general cognitive ability in children. Over 100 factors were evaluated from 258 eligible studies. We found that recent literature mainly assessed the hypothesized negative effects of either inherent factors or chemical exposures present in the physical environment. Prenatal growth, sleep health, lead and water pollutants showed consistent negative effects. Of the few studies that examined social stressors, results consistently showed cognitive development to be influenced by both positive and negative social interactions at home, in school or the community. Among behavioral factors related to diet and lifestyle choices of the mother, breastfeeding was the most studied, showing consistent positive associations with cognitive ability. There were mostly inconsistent results for both chemical and non-chemical stressors. The majority of studies utilized traditional exposure assessments, evaluating chemical and non-chemical stressors separately. Collective evidence from a limited number of studies revealed that cumulative exposure assessment that incorporates multiple chemical and non-chemical stressors over the life course may unravel the variability in effect on cognitive development and help explain the inconsistencies across studies. Future research examining the interactions of multiple stressors within a child’s total environment, depicting a more real-world exposure, will aid in understanding the cumulative effects associated with a child’s ability to learn.

Efficacy of a Crisis Intervention in Improving Mother-Child Interaction and Children's Play Functioning

OBJECTIVE

We examined the efficacy of a crisis-based intervention in improving mother-child interaction and children's play functioning for families who had experienced domestic violence.

METHOD

Using a pretest-posttest two-group control study design, we assigned the intervention group (n=20 mother-child dyads) to the Family Intervention for Improving Occupational Performance (FI-OP) program and the control group (n=17 dyads) to a playroom program. Both programs consisted of eight 30-min sessions. We videotaped dyads during free play and used standardized tools to assess interactions, play skills, and playfulness.

RESULTS

After the intervention, mother-child interaction was significantly better in the FI-OP group than in the playroom group. The children in the FI-OP group also demonstrated significantly greater improvement in play skills, but not in playfulness.

CONCLUSION

FI-OP is a promising program for improving aspects of mother-child interaction and children's play functioning among survivors of domestic violence.

Playfulness and Interaction: An Exploratory Study of Past and Current Exposure to Domestic Violence

Violence against women affects mother-child interactions, which may in turn affect their children's playfulness. We examined the effect of a history of violence against mothers on mother-child interactions and children's playfulness. This cross-sectional pilot study consisted of 36 mother-child dyads residing in family crisis shelters due to serious violence from an intimate partner. One subgroup had experienced violence during childhood, another had posttraumatic stress disorder (PTSD). Instruments included Posttraumatic Diagnostic Scale, Test of Playfulness, and Coding Interactive Behavior System. Mann-Whitney test and Spearman's rank correlation coefficients were calculated. Results indicated that children of mothers without PTSD were more playful than children of mothers with PTSD. Mothers who had not reported of childhood exposure to violence and who did not have PTSD had better interactions with more playful children.

Perinatal Dyadic Psychotherapy for postpartum depression: a randomized controlled pilot trial

An integrated approach addressing maternal depression and associated mother-infant relationship dysfunction may improve outcomes. This study tested Perinatal Dyadic Psychotherapy (PDP), a dual-focused mother-infant intervention to prevent/decrease maternal postpartum depression and improve aspects of the mother-infant relationship related to child development. Women recruited from hospital postpartum units were screened using a three-stage process. Forty-two depressed first-time mothers and their 6-week-old infants were enrolled and randomized to receive the PDP intervention or usual care plus depression monitoring by phone. The intervention consisted of eight home-based, nurse-delivered mother-infant sessions consisting of (a) supportive, relationship-based, mother-infant psychotherapy, and (b) a developmentally based infant-oriented component focused on promoting positive mother-infant interactions. Data collected at baseline, post-intervention, and three-month follow-up included measures of maternal depression, anxiety, maternal self-esteem, parenting stress, and mother-infant interaction. Depression and anxiety symptoms and diagnoses decreased significantly, and maternal self-esteem increased significantly across the study time frame with no between-group differences. There were no significant differences between groups on parenting stress or mother-infant interaction at post-intervention and follow-up. No participants developed onset of postpartum depression during the course of the study. PDP holds potential for treating depression in the context of the mother-infant relationship; however, usual care plus depression monitoring showed equal benefit. Further research is needed to explore using low-intensity interventions as a first step in a stepped care approach and to determine what subset of at-risk or depressed postpartum mothers might benefit most from the PDP intervention.

Sensitive periods in human social development: New insights from research on oxytocin, synchrony, and high-risk parenting

Sensitive periods (SP) in behavioral development appeared in the biological sciences during the first decade of the 20th century, and research in animal models beginning in the 1950s provide terminology and evidence for SP effects. This paper proposes a rigorous program for human SP research and argues that the complexity of the human brain and variability of the human ecology necessitate that SP effects must be studied in humans, employ longitudinal designs starting at birth, test mechanism-based hypotheses based on animal studies that manipulate early environments, and utilize high-risk conditions as “natural experiments.” In light of research on the molecular basis of critical periods and their sequential cascades, it is proposed that the oxytocin (OT) system, an ancient and integrative system that cross-talks with the stress, reward, immune, and brain stem mediated homeostatic systems and supports mammalian sociality, plays a unique role in experience-dependent plasticity that buttresses SP effects due to its (a) dendritic mode of release leading to autoregulated functioning primed by early experience, (b) pulsatile pattern of activity, and (c) special role in neural plasticity at the molecular and network assembly levels. Synchrony, the coordination of biology and behavior during social contact, is suggested as a mechanism by which SP exert their effect on OT functionality, the social brain, and adult sociality. Findings from four high-risk birth cohorts, each followed repeatedly from birth to 10 years, provide unique “natural experiments” for human SP research based on specific programs in animal models. These include prematurity (maternal proximity), multiple birth (peer rearing), postpartum depression (low licking and grooming), and chronic unpredictable trauma (maternal rotation, variable foraging demands). In each cohort, hypotheses are based on the missing environmental component during SP, and findings on social synchrony, OT functionality, stress response, emotion regulation, and mental health accord with the multilevel and dynamic principles of developmental psychopathology. The results on the potential for reparation versus chronicity following early deprivation highlight a flexible conceptualization of resilience based on human SP research. Consideration of SP effects at the molecular, endocrine, brain, and behavioral levels and in relation to the neural plasticity and multifinality of human social functions may assist in fine-tuning early detection and the construction of targeted individualized interventions.

Weighing physical activity: the impact of a family-based group lifestyle intervention for pediatric obesity on participants' physical activity

OBJECTIVES

To examine differences in self-reported physical activity (PA) between participants enrolled in the treatment versus active control condition of a pediatric obesity intervention, and to test associations between parent and child PA.

METHODS

Participants (N = 93) included children aged 7-17 years and their parent. Analyses tested whether participants in the treatment condition reported greater PA at postintervention and 12-month follow-up compared with the control condition. Further, researchers examined change in PA across time and whether change in parent PA was associated with change in child PA.

RESULTS

Children in the treatment condition reported greater PA at 12-month follow-up. Parents in the treatment group reported a significant increase in PA between baseline and postintervention. Change in parent PA was associated with changes in child PA across multiple periods.

CONCLUSIONS

Family-based obesity interventions may promote long-term change in self-reported PA among youths, and change in parent PA may be a contributing factor.

Discordance in neonatal risk factors and early childhood outcomes of very low birth weight (<1.5 kg) twins

OBJECTIVE

To examine the rates of discordance in neonatal risk factors and neurodevelopmental outcomes within very low birth weight twin pairs and the factors associated with discordant outcomes.

STUDY DESIGN

Rates of neonatal risk factors and neurodevelopmental outcomes, and discordance in outcomes were examined for 88 very low birth weight twin pairs born between 1990 and 2005 and followed through 20 months' corrected age.

RESULT

Discordance rates ranged from 17 to 42% for neonatal risk factors and from 18 to 31% for neurodevelopmental outcomes. In regression analysis, affected co-twins were significantly more likely to have had an abnormal cerebral ultrasound than their unaffected co-twins in pairs discordant for cerebral palsy (odds ratio (OR): 13.00, 95% confidence interval (CI): 2.22 to 76.03)) and in pairs discordant for neurodevelopmental impairment (OR: 4.00, 95% CI: 1.13 to 14.18). Outcomes and discordance in outcomes were similar for monochorionic and dichorionic pairs.

CONCLUSION

Despite shared genetics and risk factors, twins may have discordant outcomes. Information on discordant neonatal and neurodevelopmental outcomes is important for counseling families of twins.

Preterm twin and triplet pregnancies are at increased risk for the development of cystic periventricular leukomalacia

BACKGROUND

An increased risk of cerebral palsy in multiples has been reported.

AIMS

To determine the risk for the development of periventricular leukomalacia (PVL) of twin and triplet pregnancy.

STUDY DESIGN

Retrospective single-centre study at a tertiary care university hospital.

SUBJECTS

Infants ≤ 35 weeks gestational age born between 1988 and 2008.

OUTCOME MEASURES

Risk of twin and triplet compared to singleton pregnancy regarding development of PVL in one offspring.

RESULTS

Of 6195 infants 117 singletons and 39 multiples were diagnosed as having cystic PVL. Perinatal data did not differ as did not ultrasonographic findings and neurologic outcome. The relative risk (RR) of a twin pregnancy resulting in at least one infant with PVL when born prior to 36 weeks was 2.181 (CI 95% 1.474-3.228, p < .0001), and 6.793 (CI 95% 2.470-13.108, p < .0001) of a triplet pregnancy. In-vitro fertilisation was present in 3% of affected twins compared to 100% in triplets (p < .001).

CONCLUSION

We found an increased risk for PVL in preterm twin and triplet pregnancies.

Health-related quality of life and behavior of triplets at adolescent age

OBJECTIVES

To assess health-related quality of life (HRQoL) and behavior of triplets compared with matched singletons at adolescent age and to identify medical and sociodemographic predictors of outcome.

STUDY DESIGN

Fifty-four triplets (19 sets, mean [SD] gestational age 32.0 [2.4] weeks, birth weight 1580 [450] g) and 51 gestational age-, birth weight-, and sex-matched singleton controls self-rated their HRQoL at age 14.5 (0.3) years. Proxy reports about HRQoL and behavior were obtained by parents and teachers. HRQoL was measured with the Kidscreen-52 questionnaire child and parent form, and behavior with the Achenbach Child Behavior Checklist.

RESULTS

Self- and parent-reported HRQoL values was similar in both groups except for the dimensions "mood and emotions" and "autonomy," which were better (P = .001, P = .03) in triplets. Parents reported significantly less behavioral problems in triplets compared with controls. Compared with community norms, both HRQoL and behavior measures in triplets were in the normal range. Parent-reported HRQoL was predicted by dichorionicity.

CONCLUSIONS

HRQoL and behavioral outcome in adolescent triplets was good in our study and was, in some aspects, better than in matched singleton controls. Dichorionicity is an important outcome determinant.

Breastfeeding and educational achievement at age 5

Our aim was to investigate whether the duration of breastfeeding, at all or exclusively, is associated with educational achievement at age 5. We used data from a prospective, population-based UK cohort study, the Millennium Cohort Study (MCS). 5489 children from White ethnic background born at term in 2000-2001, attending school in England in 2006, were included in our analyses. Educational achievement was measured using the Foundation Stage Profile (FSP), a statutory assessment undertaken by teachers at the end of the child's first school year. Breastfeeding duration was ascertained from interviews with the mother when the child was 9 months old. We used modified Poisson's regression to model the association of breastfeeding duration with having reached a good level of achievement overall (≥78 overall points and ≥6 in 'personal, social and emotional development' and 'communication, language and literacy' points) and in specific areas (≥6 points) of development. Children who had been breastfed for up to 2 months were more likely to have reached a good level of overall achievement [adjusted rate ratio (RR): 1.09, 95% confidence interval (CI): 1.01, 1.19] than never breastfed children. This association was more marked in children breastfed for 2-4 months (adjusted RR: 1.17, 95% CI: 1.07, 1.29) and in those breastfed for longer than 4 months (adjusted RR: 1.16, 95% CI: 1.07, 1.26). The associations of exclusive breastfeeding with the educational achievement were similar. Our findings suggest that longer duration of breastfeeding, at all or exclusively, is associated with better educational achievement at age 5.

The role of birthweight discordance in the intellectual and motor outcome for triplets at early school age

AIM

We assessed motor and intellectual outcome in triplets at school age and investigated the predictive value of perinatal and demographic factors.

METHODS

Seventy-one live-born newborn infants (24 triplet pregnancies) were prospectively enrolled at birth. At the age of 6 years, 58 children (31 males, 27 females; mean gestational age 31.2 wks [SD 2.2 wks]; mean birthweight 1622 g [SD 440 g]) returned for a neurodevelopmental examination. A comparison group for triplets born before 32 gestational weeks comprising 26 gestational age-, birthweight-, and sex-matched singletons was also recruited (mean gestational age 30.1 wk [SD 1.5 wk]; mean birthweight 1142 g [SD 210 g]; 12 males, 14 females). The Zurich Neuromotor Assessment was used to examine motor performance, and intellectual abilities were assessed with the Kaufman Assessment Battery for Children (K-ABC).

RESULTS

Motor performance and movement quality in these individuals was significantly reduced compared with the test norms for all motor tasks (p<0.001) other than static balance. The mean values on the Mental Processing Composite (95.3, SD 8.4) and the Achievement Scale (90.1, SD 13.8) of the K-ABC were also lower than those in the test reference (p<0.05 and p<0.01 respectively). Triplets born at less than 32 weeks' gestation showed poorer pure motor and adaptive gross motor performance (both p<0.05) than, but similar intellectual performance to, the gestational age-, birthweight- and sex-matched singletons. Poor outcome was predicted by low socio-economic status and by intertriplet birthweight discordance (both p<0.01).

INTERPRETATION

Triplets were at an increased risk of mild motor and intellectual impairments. This finding is important for tailoring therapeutic interventions for these children and for parental counselling. Very preterm triplets showed similar outcomes to the singleton comparison children, except that they had poorer motor performance. Low socio-economic status was a major risk factor for impaired intellectual development. In addition, birthweight discordance may also be considered a predictor for poor long-term motor and intellectual outcome in triplets.

Follow-up issues with multiples

The rate of multiple pregnancy has increased in developed countries, a finding usually attributed to more widespread use of assisted reproductive technologies. Multiple pregnancies are associated with a greater risk of pregnancy complications, including intrauterine growth restriction of one or more of the fetuses, vascular communications within a shared monochorionic placenta and premature delivery. Surviving infants are at significantly greater risk of developing cerebral palsy due to a combination of a higher proportion of them being preterm or of low birth weight, and complications associated with chorionicity. These infants are also at greater risk for abnormal cognitive development and learning disabilities for the same reasons. Parenting styles and family dynamics may also differ with multiples compared with singletons, which may affect long-term behaviour and development.Thus, infants of multiple pregnancies should receive careful neurodevelopmental follow-up. For larger, lower risk infants, this follow-up may be provided by general paediatricians within the community. However, for infants with birth weights of less than 1000 g or with a complicated antenatal or neonatal course, follow-up should be in a high-risk neonatal follow-up clinic with appropriate multidisciplinary support.

Birth weight in a large series of triplets

BACKGROUND

Triplets are often born premature and with a low birth weight. Because the incidence of triplet births is rare, there are relatively few studies describing triplet birth weight characteristics. Earlier studies are often characterized by small sample sizes and lack information on important background variables such as zygosity. The objective of this study is to examine factors associated with birth weight in a large, population-based sample of triplets registered with the Netherlands Twin Register (NTR).

METHODS

In a sample of 1230 triplets from 410 families, the effects of assisted reproductive techniques, zygosity, birth order, gestational age, sex, maternal smoking and alcohol consumption during pregnancy on birth weight were assessed. The resemblance among triplets for birth weight was estimated as a function of zygosity. Birth weight discordance within families was studied by the pair-wise difference between triplets, expressed as a percentage of the birth weight of the heaviest child. We compare data from triplets registered with the NTR with data from population records, which include live births, stillbirths and children that have deceased within days after birth.

RESULTS

There was no effect of assisted reproductive techniques on triplet birth weight. At gestational age 24 to 40 weeks triplets gained on average 130 grams per week; boys weighed 110 grams more than girls and triplets of smoking mothers weighted 104 grams less than children of non-smoking mothers. Monozygotic triplets had lower birth weights than di- and trizygotic triplets and birth weight discordance was smaller in monozygotic triplets than in di- and trizygotic triplets. The correlation in birth weight among monozygotic and dizygotic triplets was 0.42 and 0.32, respectively. In nearly two-thirds of the families, the heaviest and the lightest triplet had a birth weight discordance over 15%. The NTR sample is representative for the Dutch triplet population that is still alive 28 days after birth.

CONCLUSION

Birth weight is an important determinant of childhood development. Triplet status, gestational age, sex, zygosity and maternal smoking affect birth weight. The combined effects amount to a difference of 364 grams between monozygotic girl triplets of smoking mothers compared to dizygotic boy triplets of non-smoking mothers of the same gestational age. Birth weight in triplets is also influenced by genetic factors, as indicated by a larger correlation in monozygotic than in di- and trizygotic triplets.

Motor development of triplets: a Japanese prospective cohort study

We analyzed whether motor development in early life is different between singletons and triplets in Japan. The motor development was reported by mothers by postal questionnaire for 1,121 triplet children and in regular health check-ups for 13,906 singleton children. Children who were suspected of having neurological abnormality or disability were excluded from the analysis. The ages of milestone achievements were significantly higher in triplets for each outcome compared to singletons. Further, after adjustment for gestational age, birthweight, and birth length, the differences were significant for maintaining head, sitting alone and standing holding on. In children with birthweight of 2 kg or more, the ages of milestone achievements were significantly higher in triplets for each outcome compared to singletons, except walking holding on. Moreover, after adjustment for the confounding factors, the differences were significant for sitting alone and walking independently. On the contrary, singletons attained motor development facilitating crawling, walking holding on, and walking independently slower than triplets among those children with birthweight of 2 kg or less after adjustment for gestational age. In conclusion, triplets are overall at higher risk for the delay of gross motor milestones as compared to singletons independently of birth-related factors. In contrast, among children with a birthweight of less than 2 kg, singletons showed slower motor development than triplets after adjusting for gestational age. There is an obvious need to apply developmental standards that consider at least both multiple birth status (singleton, twin or triplet) and birthweight.

Triplets across the first 5 years: the discordant infant at birth remains at developmental risk

OBJECTIVES

To examine whether the risk posed to infant development by triplet birth persists into childhood and whether growth-discordant triplets are at a particularly high developmental risk.

METHODS

Twenty-one sets of triplets were matched with 21 sets of twins and 21 singletons (N = 126) for medical and demographic conditions and were followed from birth to 5 years. At 6, 12, and 24 months, cognitive development was assessed and mother-infant interactions were coded for maternal sensitivity and child social engagement. At 5 years, the children's cognitive development and neuropsychological skills were tested, social engagement was coded from mother-child interactions, and behavior problems were examined. Maternal adjustment was assessed during interviews at 1 and 5 years.

RESULTS

Although triplets showed lower cognitive performance at 6, 12, and 24 months as compared with singletons and twins, differences were attenuated by 5 years in both global IQ and executive functions. Similarly, the lower social engagement observed across infancy and the higher internalizing symptoms reported at 2 years for those in the triplet group were no longer found at 5 years. Difficulties in maternal adjustment among mothers of triplets decreased from 1 to 5 years. However, in 65.2% of the initial sample there was a weight discordance of >15% at birth, and the discordant triplets showed poorer cognitive and social development as compared with their siblings across infancy. At 5 years, the discordant children demonstrated lower cognitive and executive functions performance, decreased social engagement, and higher internalizing symptoms as compared with both siblings and peers.

CONCLUSIONS

Whereas most triplets catch up after an early developmental delay, the risk for discordant triplets seems to persist into childhood. Such infants, who are at both biological and environmental risk, should receive special and consistent professional care.

Multiple births are a risk factor for postpartum maternal depressive symptoms

OBJECTIVE

The purpose of the study was to assess the relationship between multiple births and maternal depressive symptoms measured 9 months after delivery.

METHODS

Data were derived from the Early Childhood Longitudinal Study-Birth Cohort, a longitudinal study of a nationally representative sample of children born in 2001. Depressive symptoms were measured at 9 months by using an abbreviated version of the Center for Epidemiologic Studies Depression Scale. Logistic regression analyses were conducted to study the association between multiple births and maternal depressive symptoms, with adjustment for demographic and household socioeconomic characteristics and maternal history of mental health problems. A total of 8069 mothers were included for analyses.

RESULTS

The prevalence of moderate/severe depressive symptoms at 9 months after delivery was estimated to be 16.0% and 19.0% among mothers of singletons and multiple births, respectively. Only 27.0% of women who had moderate/severe depressive symptoms reported talking about emotional or psychological problems with a mental health specialist or a general medical provider within the 12 months before the interview. The proportions of women with depressive symptoms who were receiving mental health services did not vary according to plurality status.

CONCLUSIONS

Mothers of multiple births had 43% greater odds of having moderate/severe, 9-month postpartum, depressive symptoms, compared with mothers of singletons. Greater attention is needed in pediatric settings to address maternal depression in families with multiple births.

Rapid eye movement (REM) in premature neonates and developmental outcome at 6 months

Different aspects of early sleep organization have been associated with subsequent development in premature infants. The aim of the present study was to assess the relations between rapid eye movement (REM) activity in premature neonates and infants' developmental outcomes at 6 months. Participants were 81 premature infants (47 males). Sleep-wake states and REM were observed across 4 consecutive evening hours (7-11 PM) in 10-s frames when infants were between 32 and 36 weeks post-menstrual age. Developmental outcome was assessed at 6 months with the mental development index (MDI) of the Bayley II. Infants with low-REM activity spent more time in less growth-promoting states, including crying and unfocused alert states in the neonatal period and had lower MDI scores at 6 months corrected age compared to infants with high-REM. Differences between the high- and low-REM groups were independent of neonatal medical risk. Low-REM activity may serve as an indicator of developmental risk among premature neonates.

Neonatal state organization, neuromaturation, mother-infant interaction, and cognitive development in small-for-gestational-age premature infants

OBJECTIVE

The purpose of this work was to examine the relations among neuromaturation, mother-infant relationship, and cognitive development in small-for-gestational-age premature infants and to assess the interactive effects of birth weight and intrauterine growth restriction on developmental outcomes.

METHODS

We studied 120 singleton premature infants (birth weight: 530-1790 g; gestational age: 25-35 weeks). In group 1, 40 small-for-gestational-age infants (22 girls) were case-matched with group 2 (n = 40) for birth weight (appropriate for gestational age matched for birth weight) and group 3 (n = 40) matched for gestational age (appropriate for gestational age matched for gestational age). Exclusion criteria included intraventricular hemorrhage grade 4, perinatal asphyxia, central nervous system infections, and genetic conditions. Infants were further divided into those born below and above 1000-g subgroups. Neonatal state organization was observed for 4 consecutive hours. Neuromaturation was assessed with the Neonatal Behavioral Assessment Scale. At 3 and 24 months' corrected age, mother-infant interaction was evaluated. At 1 and 2 years' corrected age, the infants' cognitive development was tested with the Bayley Scale of Infant Development, 2nd edition.

RESULTS

Small-for-gestational-age infants showed less organized state and less mature neurobehavioral profiles, particularly in the orientation and motor domains. Mother-infant interactions were characterized by maternal intrusiveness and miscoordination and negative infant engagement. Cognitive outcomes at 1 and 2 years were lower for the small-for-gestational-age group. Small-for-gestational-age infants born < 1000 g showed the poorest neurodevelopmental, social, and cognitive development of all of the groups. Cognitive outcomes at 2 years were predicted by small-for-gestational-age status, the interaction of actual birth weight and small-for-gestational-age status, neonatal state organization, and maternal intrusive behavior.

CONCLUSION

Small-for-gestational-age premature infants are at higher risk for developmental and cognitive delays, as well as difficulties in the mother-infant relationship across infancy. Those born at extremely low birth weight are at a double risk. This group should receive special clinical attention and care.

Follow-up of twins: health, behaviour, speech, language outcomes and implications for parents

The introduction of assisted reproduction has resulted in a growing number of multiple births. These infants and their parents experience increased, and sometimes unique, medical and psychological risks when compared to singletons. Rates of maternal morbidity, fetal and infant mortality are increased in multiple pregnancies. Twins have a death rate four times higher than singletons and this figure is six times higher for triplets. The main reason is preterm and very preterm birth in multiples, resulting in low and very low birth weight children. Perinatal mortality and morbidity are also more elevated in monozygotic (MZ) twins as compared to dizygotic (DZ) twins. In addition to an increased risk of mortality, multiples have higher rates of morbidity, specifically cerebral palsy and mental subnormality. Language and speech delays are more pronounced in multiples, as are cognitive delays, motor development, behavioural problems and difficulties in parent-child interactions. Depression among parents of multiples is reported to be higher than those of singletons. This paper aims to critically appraise the literature regarding the aforementioned topics, including a comparison between the outcomes for iatrogenic and spontaneously conceived twins and to suggest areas for further research.

The development of siblings of children with autism at 4 and 14 months: social engagement, communication, and cognition

AIMS

To compare siblings of children with autism (SIBS-A) and siblings of children with typical development (SIBS-TD) at 4 and 14 months of age.

METHODS

At 4 months, mother-infant interactional synchrony during free play, infant gaze and affect during the still-face paradigm, and infant responsiveness to a name-calling paradigm were examined (n = 21 in each group). At 14 months, verbal and nonverbal communication skills were examined as well as cognition (30 SIBS-A and 31 SIBS-TD).

RESULTS

Most SIBS-A were functioning as well as the SIBS-TD at 4 and 14 months of age. However, some differences in early social engagement and later communicative and cognitive skills emerged. Synchrony was weaker in the SIBS-A dyads, but only for infant-led interactions. Infant SIBS-A revealed more neutral affect during the still-face procedure and were less upset by it than was true for the SIBS-TD. A surprising result was that significantly more SIBS-A responded to their name being called by their mothers compared to SIBS-TD. At 14 months, SIBS-A made fewer nonverbal requesting gestures and achieved lower language scores on the Bayley Scale. Six SIBS-A revealed a language delay of 5 months and were responsible for some of the significant differences between SIBS-A and SIBS-TD. Furthermore, infant SIBS-A who showed more neutral affect to the still face and were less able to respond to their name being called by their mothers initiated fewer nonverbal joint attention and requesting behaviors at 14 months, respectively.

DISCUSSION

Focused on the genetic liability for the broad phenotype of autism as well as the possible influence of having a sibling with autism.