Factors associated with neurodevelopmental outcome at 2 years after very preterm birth: the population-based Nord-Pas-de-Calais EPIPAGE cohort

Impact of an early educational protocol on the oral language of children born preterm exhibiting phonological fragility: a multicenter randomized clinical trial

We conducted a six-center, prospective, randomized, open-label trial to assess whether an early standardized educational protocol provided from 42 to 48 months of age improved the progression of oral language and phonological development in children born preterm. A total of 552 children with phonological fragility were included in this study. The children were randomized to receive the educational protocol (guided arm, n = 87) or not (non-guided arm, n = 78). In the guided arm, the oral language development used a short "say and do" type educational protocol designed to maintain visual attention and train the developmental phonology/lexicon/morphosyntax structural links. In contrast, a conservative approach was used in the non-guided arm. A total of 70 guided and 73 non-guided children completed the study. After 6 months, the educated children showed a non-significant increase in their phonology score (p = 0.37), while the variations in the scores of the expressive lexicon (secondary endpoints) were significantly improved (p = 0.0008). We conclude that the short, standardized stimulation of the sensorimotor aspects of language in children born very preterm increased the expressive lexicon. This protocol improved the language of the premature children, especially those with minimal motor skills, with more significant improvement in the phonological scores.

Clinical trial registration

clinicaltrials.gov, identifier NCT01426659.

Predictors of the Outcome at 2 Years in Neonates With Congenital Cytomegalovirus Infection

BACKGROUND

Approximately 20% of neonates with congenital cytomegalovirus (cCMV) develop long-term sequelae. The ability to accurately predict long-term outcomes as early as the neonatal period would help to provide for appropriate parental counseling and treatment indications. With this study, we aimed to identify neonatal predictive markers of cCMV long-term outcomes.

METHODS

As this study's subjects, we chose neonates diagnosed with cCMV in 13 hospitals throughout France recruited from 2013 to 2017 and evaluated for at least 2 years with thorough clinical, audiology, and imaging evaluations and psychomotor development tests.

RESULTS

A total of 253 neonates were included, and 3 were later excluded because of the identification of a genetic disorder. A total of 227 were followed up for 2 years: 187/227 (82%) and 34/227 (15%) were infected after a maternal primary or nonprimary infection, respectively, 91/227 (40%) were symptomatic at birth, and 44/227 (19%) had cCMV sequelae. Maternal primary infection in the first trimester was the strongest prognosis factor (odds ratio = 38.34 [95% confidence interval, 5.02-293], P < .001). A predictive model of no risk of sequelae at 2 years of age according to normal hearing loss at birth, normal cerebral ultrasound, and normal platelet count had 98% specificity, 69% sensitivity, and 0.89 area under the curve (95% confidence interval, 0.83-0.96).

CONCLUSIONS

In the studied population, children with normal hearing at birth, normal platelet count at birth, and a normal cranial ultrasound had no risk of neurologic sequelae and a low risk of delayed unilateral sensorineural hearing loss. The use of this model based on readily available neonatal markers should help clinicians establish a personalized care pathway for each cCMV neonate.

Impact of selected risk factors on motor performance in the third month of life and motor development in the ninth month

Background

Proper motor development can be influenced by a range of risk factors. The resulting motor performance can be assessed through quantitative and qualitative analysis of posture and movement patterns.

Methods

This study was designed as the cohort follow-up of the motor assessment and aimed to demonstrate, in a mathematical way, the impact of particular risk factors on elements of motor performance in the 3^rd month and the final motor performance in the 9^th month of life. Four hundred nineteen children were assessed (236 male and 183 female), including 129 born preterm. Each child aged 3 month underwent a physiotherapeutic assessment of the quantitative and qualitative development, in the prone and supine positions. The neurologist examined each child aged 9 month, referring to the Denver Development Screening Test II and assessing reflexes, muscle tone and symmetry. The following risk factors were analyzed after the neurological consultation: condition at birth (5^th min Apgar score), week of gestation at birth, intraventricular hemorrhage, respiratory distress syndrome, and the incidence of intrauterine hypotrophy and hyperbilirubinemia determined based on medical records.

Results

A combination of several risk factors affected motor development stronger than any one of them solely, with Apgar score, hyperbilirubinemia, and intraventricular hemorrhage exhibiting the most significant impact.

Conclusions

Premature birth on its own did not cause a substantial delay in motor development. Nonetheless, its co-occurrence with other risk factors, namely intraventricular hemorrhage, respiratory distress syndrome, and hyperbilirubinemia, notably worsened motor development prognosis. Moreover, improper position of the vertebral column, scapulae, shoulders, and pelvis in the third month of life may predict disturbances in further motor development.

Safety of sildenafil in premature infants at risk of bronchopulmonary dysplasia: Rationale and methods of a phase II randomized trial

Bronchopulmonary dysplasia (BPD) is a disease of chronic respiratory insufficiency stemming from premature birth and iatrogenic lung injury leading to alveolar simplification, impaired alveolar-capillary development, interstitial fibrosis, and often pulmonary hypertension. BPD is the most common pulmonary sequela of prematurity and is often fatal; however, there remains no FDA-approved therapies to treat or prevent BPD. Sildenafil is increasingly used off-label in premature infants despite scant safety and efficacy data. Sildenafil reduces lung injury and preserves normal vasculature in preclinical models, and improves outcomes in children with pulmonary hypertension, and thus is a promising candidate for BPD. Following phase I studies, we developed the phase II SIL02 trial to describe the safety, pharmacokinetics and preliminary effectiveness of intravenous and enteral sildenafil in premature infants at risk for BPD. SIL02 is a randomized, double-blind, placebo-controlled, 3-cohort, sequential dose-escalating trial of enteral or intravenous (IV) sildenafil dosed every 8 h for up to 34 days. The target IV doses were 0.125, 0.5 and 1 mg/kg/dose in cohorts 1, 2 and 3, respectively; while the enteral doses will be double the IV doses. Eligible infants must be < 29 weeks' gestation at birth and requiring respiratory support at 7–28 days' postnatal age. Adverse events and preliminary effectiveness will be compared by treatment group. Using the final population PK model, empirical Bayesian estimates will be generated for each patient. Preliminary effectiveness will be measured by the incidence of moderate to severe BPD or death at 36 weeks and change in the BPD risk estimation.

Online clinical tool to estimate risk of bronchopulmonary dysplasia in extremely preterm infants

OBJECTIVE

Develop an online estimator that accurately predicts bronchopulmonary dysplasia (BPD) severity or death using readily-available demographic and clinical data.

DESIGN

Retrospective analysis of data entered into a prospective registry.

SETTING

Infants cared for at centres of the United States Neonatal Research Network between 2011 and 2017.

PATIENTS

Infants 501-1250 g birth weight and 23 0/7-28 6/7 weeks' gestation.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Separate multinomial regression models for postnatal days 1, 3, 7, 14 and 28 were developed to estimate the individual probabilities of death or BPD severity (no BPD, grade 1 BPD, grade 2 BPD, grade 3 BPD) defined according to the mode of respiratory support administered at 36 weeks' postmenstrual age.

RESULTS

Among 9181 included infants, birth weight was most predictive of death or BPD severity on postnatal day 1, while mode of respiratory support was the most predictive factor on days 3, 7, 14 and 28. The predictive accuracy of the models increased at each time period from postnatal day 1 (C-statistic: 0.674) to postnatal day 28 (C-statistic 0.741). We used these results to develop a web-based model that provides predicted estimates for BPD by postnatal day.

CONCLUSION

The probability of BPD or death in extremely preterm infants can be estimated with reasonable accuracy using a limited amount of readily available clinical information. This tool may aid clinical prognostication, future research, and center-specific quality improvement surrounding BPD prevention.

TRIAL REGISTRATION NUMBER

NCT00063063.

Visuospatial functions in preterm schoolchildren without cognitive delay: Using Pascual's Graphomotor test as a screening method

BACKGROUND

Preterm children obtain worse scores in tests that evaluate visuospatial functions. Pascual's graphomotor test (PGMt) assesses maturity in copying drawings in childhood, quickly evaluating the graphomotor aptitude that is a partial aspect of non-verbal intelligence.

AIMS

To evaluate visuospatial functions in preterm children compared to full-term children. To assess the capacity of the Pascual graphomotor test (PGMt) to detect visuospatial disorders more specifically than non-verbal intelligence quotient (IQ).

STUDY DESIGN AND SUBJECTS

case and control study.

CASES

preterm children between 5 and 11 years of age without cognitive delay; controls: full-term children with the same characteristics. For each child clinical history, neurological examination, language-free intelligence test Toni 2 (IQ) and Pascual's graphomotor test (PGMt) were carried out.

RESULTS

135 children were enrolled (59 cases vs. 79 controls). The mean age was 7.4 years. 55% were male. The mean gestational age of cases was 30.5 weeks with 34% extremely preterm. Cases obtained worse mean scores in both tests. The mean IQ scores were: cases 117.4, controls 125.0 (p = 0.004). The mean graphomotor quotient (GQ) scores were statistically and clinically significant (cases 76.8; controls 98.3, p = 0.001). Although we have found a positive correlation between IQ and GQ scores (cc = 0.31 p = 0.01), the differences found in the GQ between groups have been maintained regardless of the IQ in the multivariate analysis (GQ: cases 78.3 (SD 14.8), controls 98.3 (SD 12.5), p = 0.04).

CONCLUSIONS

GQ is a useful tool for screening for visuospatial anomalies. GQ more specifically measures the visuoperceptive disorder regardless of non-verbal cognitive level.

Self‐reported sensitivity to pain in early and moderately‐late preterm‐born adolescents: A community‐based cohort study

We aimed to compare ratings of self‐reported and parent‐reported pain sensitivity between early preterm (EP), moderately‐late preterm (MLP), and full‐term (FT) adolescents. For EP adolescents, we aimed to determine whether pain sensitivity was associated with early‐life events. EP (n = 68, response rate 47.4%), MLP (n = 128, response rate 33.0%), and FT (n = 78, response rate 31.1%) adolescents and their parents (n = 277) answered an author‐generated question on pain sensitivity at 14‐15 years of age within a community‐based cohort study. Differences between groups were determined using the chi‐square test for trends. For EP adolescents, we assessed associations of treatment modalities (inotrope treatment, mechanical ventilation, and C‐section) and neonatal morbidities (sepsis/necrotizing enterocolitis, small‐for‐gestational age status, asphyxia, and cerebral pathologies) with adolescent pain sensitivity using logistic regression analyses. Increased pain sensitivity was reported by 18% of EP adolescents, compared with 12% of MLP adolescents, and 7% of FT adolescents (P = 0.033). Parent‐reported pain sensitivity did not differ by gestational age group. For EP adolescents, inotrope treatment was associated with increased pain sensitivity (odds ratio, 5.00, 95% confidence interval, 1.23‐20.4, P = 0.025). No other neonatal treatment modalities or morbidities were associated with pain sensitivity in adolescence. In conclusion, we observed higher proportions of increased pain sensitivity for EP and MLP adolescents. Physicians treating preterm adolescents should be aware of altered pain sensitivity.

Quantifying the Burden of Congenital Cytomegalovirus Infection With Long-term Sequelae in Subsequent Pregnancies of Women Seronegative at Their First Pregnancy

BACKGROUND

In women seronegative before pregnancy, congenital cytomegalovirus (cCMV)-related sequelae are exclusively seen in those infected in the first trimester of pregnancy. Following a maternal primary infection in the first trimester, up to 30% of infected neonates suffer long-term sequelae. Maternal parity is an established risk factor of cCMV in previously seronegative women. Our objective was to quantify, in a population of women seronegative at their first pregnancy, the risk of cCMV and related sequelae following primary infections in the first trimester in subsequent pregnancies.

METHODS

There were 739 women seronegative at their first pregnancy who had at least 1 of 971 subsequent pregnancies and deliveries managed at our institution. All women had CMV immunoglobin (Ig) G and IgM testing at 11-14 weeks of each pregnancy.

RESULTS

Between 2 consecutive pregnancies, 15.6% (115/739) of women seroconverted. Of these seroconversions, 29% (33/115) occurred in the periconceptional period or in the first trimester. The risks for cCMV and related sequelae (neurologic and/or hearing loss) following a maternal infection in the first trimester were, respectively, 24- and 6-fold higher (risk ratios, 24 [95% confidence interval {CI}, 10.8-62.3] and 6 [95% CI 1.5-24], respectively) than in the general pregnant population. Of all primary maternal infections and fetal infections in the first trimester, 88% (29/33) and 92% (11/12), respectively, occurred when the inter-pregnancy interval was ≤2 years.

CONCLUSIONS

Women seronegative at their first pregnancy with a subsequent pregnancy within 2 years have the highest risk of delivering a child with cCMV-related sequelae. These women should be made aware of the risk and given the opportunity of serology screening in the first trimester.

Accuracy of prenatal ultrasound screening to identify fetuses infected by cytomegalovirus which will develop severe long-term sequelae

OBJECTIVES

To compare the ability of detailed routine ultrasound examination, performed without knowledge of maternal serology and fetal status, with that of targeted prenatal imaging performed in prenatal diagnostic units in cases of known fetal infection to identify cytomegalovirus (CMV)-infected fetuses that will develop long-term sequelae.

METHODS

All prenatal imaging reports were collected for 255 children with congenital CMV in a registered cohort between 2013 and 2017 (NCT01923636). All women had undergone detailed routine fetal ultrasound examination at 20-24 and 30-34 weeks as part of routine antenatal care. All cases of known fetal CMV infection had also undergone targeted prenatal ultrasound examination. Postnatal structured follow-up for up to 48 months of age involved clinical, audiological and neurological assessment, including Brunet-Lezine scoring. Long-term sequelae (> 12 months) were considered to be mild in cases with isolated unilateral hearing loss and/or vestibular disorders, and severe in cases with bilateral hearing loss and/or neurological sequelae. All imaging reports were analyzed retrospectively with the knowledge of congenital CMV infection, searching for reference to findings that were, or could have been, related to fetal infection. Findings were analyzed in relation to whether the cases were diagnosed with CMV in utero or only postnatally.

RESULTS

There were 237 children with complete follow-up data (> 12 months), for a median of 24 (range, 12-48) months. Of these, 30% (71/237) were diagnosed with CMV prenatally and 70% (166/237) were diagnosed within 3 weeks after birth. 72.5% (29/40) of children with long-term sequelae, including 74% (14/19) with severe long-term sequelae, were not identified in the prenatal period. Among those diagnosed prenatally, the sensitivity of prenatal imaging for predicting long-term sequelae and severe long-term sequelae was 91% and 100%, respectively, while, in the group diagnosed only postnatally, non-specific infection-related ultrasound findings had been reported without raising suspicion in 48% of cases with long-term sequelae and 64% of those with severe long-term sequelae.

CONCLUSIONS

Routine detailed ultrasound examination in pregnancy is not an appropriate screening tool for congenital CMV infection that leads to long-term sequelae, in contrast with the high performance of targeted prenatal imaging in known cases of fetal infection. The non-specific nature of ultrasound features of CMV and their evolution, and a lack of awareness of caregivers about congenital CMV, are likely explanations. Awareness of the sonologist regarding congenital CMV and knowledge of the maternal serological status in the first trimester seem key to the performance of prenatal ultrasound. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Sequelae of Congenital Cytomegalovirus Following Maternal Primary Infections Are Limited to Those Acquired in the First Trimester of Pregnancy

BACKGROUND

The known relationship between the gestational age at maternal primary infection an the outcome of congenital CMV is based on small, retrospective studies conducted between 1980 and 2011. They reported that 32% and 15% of cases had sequelae following a maternal primary infection in the first and second or the third trimester, respectively. We aimed to revisit this relationship prospectively between 2011 and 2017, using accurate virological tools.

METHODS

We collected data on women with a primary infection and an infected child aged at least 1 year at the time of analysis. An accurate determination of the timing of the primary infection was based upon serial measurements of immunoglobulin (Ig) M and IgG and on IgG avidity in sera collected at each trimester. The case outcome was assessed according to a structured follow-up between birth and 48 months.

RESULTS

We included 255 women and their 260 fetuses/neonates. The dating of the maternal infection was prospective in 86% of cases and retrospective in 14%. At a median follow-up of 24 months, the proportion of sensorineural hearing loss and/or neurologic sequelae were 32.4% (95% confidence interval [CI] 23.72-42.09) after a maternal primary infection in the first trimester, 0 (95% CI 0-6.49) after an infection in the second trimester, and 0 (95% CI 0-11.95) after an infection in the third trimester (P < .0001).

CONCLUSIONS

These results suggest that a cytomegalovirus infection can be severe only when the virus hits the fetus in the embryonic or early fetal period. Recent guidelines recommend auditory follow-ups for at least 5 years for all infected children. This raises parental anxiety and generates significant costs. We suggest that auditory and specialized neurologic follow-ups may be recommended only in cases of a maternal infection in the first trimester.

Relative contributions of prenatal complications, perinatal characteristics, neonatal morbidities and socio-economic conditions of preterm infants on the occurrence of developmental disorders up to 7 years of age

BACKGROUND

To investigate the relative contributions of prenatal complications, perinatal characteristics, neonatal morbidities and socio-economic conditions on the occurrence of motor, sensory, cognitive, language and psychological disorders in a large longitudinal preterm infant population during the first 7 years after birth.

METHODS

The study population comprised 4122 infants born at <35 weeks of gestation who were followed for an average of 74.0 months after birth. Developmental disorders, including motor, sensory, cognitive, language and psychological, were assessed at each follow-up visit from 18 months to 7 years of age. The investigated determinants included prenatal complications (prolonged rupture of membranes >24 hours, intrauterine growth restriction, preterm labour and maternal hypertension), perinatal characteristics (gender, multiple pregnancies, gestational age, birth weight, APGAR score and intubation or ventilation in the delivery room), neonatal complications (low weight gain during hospitalization, respiratory assistance, severe neurological anomalies, nosocomial infections) and socio-economic characteristics (socio-economic level, parental separation, urbanicity). Based on hazard ratios determined using a propensity score matching approach, population-attributable fractions (PAF) were calculated for each of the four types of determinants and for each developmental disorder.

RESULTS

The percentages of motor, sensory, cognitive, language and psychological disorders were 17.0, 13.4, 29.1, 25.9 and 26.1%, respectively. The PAF for the perinatal characteristics were the highest and they were similar for the different developmental disorders considered (around 60%). For the neonatal and socio-economic determinants, the PAF varied according to the disorder, with contributions of up to 17% for motor and 27% for language disorders, respectively. Finally, prenatal complications had the lowest contributions (between 6 and 13%).

CONCLUSIONS

This study illustrates the heterogeneity of risk factors on the risk of developmental disorder in preterm infants. These results suggest the importance of considering both medical and psycho-social follow-ups of preterm infants and their families.

Long-term outcomes of very low birth weight infants with spontaneous intestinal perforation: A retrospective case-matched cohort study

BACKGROUND

Spontaneous intestinal perforation (SIP) is an intestinal complication that occurs in very ill preterms. We investigated whether SIP survivors have worse neurodevelopmental and gastrointestinal outcomes and a poorer quality of life than controls.

METHODS

A retrospective case-matched cohort study was performed involving infants treated for SIP in a NICU between August 1994 and April 2014. Controls and SIP patients were matched to gestational age, gender, and birth period. Medical records were reviewed. Telephone surveys were conducted to evaluate the medical condition, quality of life (PedsQL™ 4.0), neuropsychiatric and gastrointestinal outcome. McNemar's and Wilcoxon tests were performed, and generalized linear models were computed.

RESULTS

Forty-nine SIP patients were included. The percentages of children with multiple disabilities (40% vs. 17%, OR = 3.3) and requiring physiotherapy (86% vs. 60%, OR = 4.77) were higher in the SIP group than in the control group. Intraventricular hemorrhage (IVH) led to a worse neurodevelopmental outcome regardless of SIP (OR = 8.79 for disability), and female gender was a protective factor against disability (OR = 0.06). Reported quality of life and gastrointestinal comorbidities did not differ between the two groups.

CONCLUSION

SIP survivors tend to be at risk of multiple disabilities. IVH and female gender influence the neurodevelopmental outcome regardless of SIP.

LEVELS OF EVIDENCE

Level III: case-control study.

Poorer outcomes of all low birth weight groups at age 10: Missouri statewide case-control study

BACKGROUND

In 1989-1991, a population-based cohort of every Missouri birth weighing < 1500 g was identified over a 16-month period. Infants born moderately low birth weight (MLBW, 1500-2499 g) and normal birth weight (NBW, ≥ 2500 g), were matched to < 1500 g infants by delivery date, race, maternal age, and residence.

AIMS

To compare outcomes of extremely low birth weight (ELBW, < 1000 g), very low birth weight (VLBW, 1000-1499 g), and MLBW, to NBW infants at age 10.

STUDY DESIGN

A population-based cohort and matched case-control study OUTCOME MEASURES: A Child Health and Development Questionnaire developed for this study collected social, medical, educational and special services history. The Conners' Parent Rating Scale-Revised was also completed by parents/caregivers.

RESULTS

As birth weight declined, the prevalence of adverse outcomes increased. Children in all LBW groups were more likely than NBW children to have problems in speech and language, vision, fine and gross motor tasks, illnesses, attention, school performance, and increased requirements for therapy and accommodation. Repetition of a grade was three times higher for MLBW children and over three times higher for the other LBW groups.

CONCLUSION

In this statewide population-based study, controlling for child's sex, mother's age, race, residence, education, marital status, Medicaid assistance, and smoking or alcohol use during pregnancy, failed to eliminate the strong effect of decreasing birth weight. Problems were most frequent in ELBW, however, VLBW and MLBW also had many significantly greater problems than NBW children. All LBW groups of children experienced greater adverse health and developmental outcomes resulting in significant habilitation and educational challenges.

Prenatal parental involvement in decision for delivery room management at 22-26 weeks of gestation in France - The EPIPAGE-2 Cohort Study

OBJECTIVE

Our main objective was to examine if parental prenatal preferences predict delivery-room management of extremely preterm periviable infants. The secondary objectives were to describe parental involvement and the content of prenatal counseling given to parents for this prenatal decision.

DESIGN

Prospective study of neonates liveborn between 22 and 26 weeks of gestation in France in 2011 among the neonates included in the EPIPAGE-2 study.

SETTING

18 centers participating in the "Extreme Prematurity Group" substudy of the EPIPAGE-2 study.

PATIENTS

302 neonates liveborn between 22-26 weeks among which 113 with known parental preferences while parental preferences were unknown or unavailable for 186 and delivery room management was missing for 3.

RESULTS

Data on prenatal counseling and parental preferences were collected by a questionnaire completed by professionals who cared for the baby at birth; delivery room (DR) management, classified as stabilization or initiation of resuscitation (SIR) vs comfort care (CC). The 113 neonates studied had a mean (SD) gestational age of 24 (0.1) weeks. Parents of neonates in the CC group preferred SIR less frequently than those with neonates in the SIR group (16% vs 88%, p < .001). After multivariate analysis, preference for SIR was an independent factor associated with this management. Professionals qualified decisions as shared (81%), exclusively medical (16%) or parental (3%). Information was described as medical with no personal opinion (71%), complete (75%) and generally pessimistic (54%).

CONCLUSION

Parental involvement in prenatal decision-making did not reach satisfying rates in the studied setting. When available, prenatal parental preference was a determining factor for DR management of extremely preterm neonates. Potential biases in the content of prenatal counselling given to parents need to be evaluated.

Furosemide Exposure and Prevention of Bronchopulmonary Dysplasia in Premature Infants

OBJECTIVE

To evaluate the association between furosemide exposure and risk of bronchopulmonary dysplasia (BPD).

STUDY DESIGN

This retrospective cohort study included infants (2004-2015) born at 23-29 weeks gestational age and 501-1249 g birth weight. We compared the demographic and clinical characteristics of infants exposed and not exposed to furosemide between postnatal day 7 and 36 weeks postmenstrual age. We examined the association between furosemide exposure and 2 outcomes: BPD and BPD or death. We performed multivariable probit regression models that included demographic and clinical variables in addition to 2 instrumental variables: furosemide exposure by discharge year, and furosemide exposure by site.

RESULTS

Of 37 693 included infants, 19 235 (51%) were exposed to furosemide; these infants were more premature and had higher respiratory support. Of 33 760 infants who survived to BPD evaluation, 15 954 (47%) had BPD. An increase in the proportion of furosemide exposure days by 10 percentage points was associated with a decrease in both the incidence of BPD (4.6 percentage points; P = .001), and BPD or death (3.7 percentage points; P = .01).

CONCLUSIONS

More days of furosemide exposure between postnatal day 7 and 36 weeks was associated with decreased risk of BPD and a combined outcome of BPD or death.

Autonomic maturation from birth to 2 years: normative values

Background

While heart rate variability (HRV) constitutes a relevant non-invasive tool to assess the autonomic nervous system (ANS) function with recognized diagnostic or therapeutic implications, there is still a lack of established data on maturation of autonomic control of heart rate during the first months of life. The Autonomic Baby Evaluation (AuBE) cohort was built to establish, the normal autonomic maturation profile from birth up to 2 years, in a healthy population of full-term newborns.

Methods

Heart rate variability analysis was carried out in 271 full-term newborns (mean gestational age 39 wGA + 5 days) from reliable polysomnographic recordings at 0 (n = 270) and 6 (n = 221) months and from a 24-hour ambulatory electrocardiogram (ECG) at 12 (n = 210), 18 (n = 197), and 24 (n = 190) months. Indices of HRV analysis were calculated through the ANSLabTools software.

Results

Indices are dissociated according a temporal, geometrical, frequency, Poincaré, empirical mode decomposition, fractal, Chaos and DC/AC and entropy analysis. Each index is presented for five different periods of time, 0, 6, 12, 18 and 24 months and with smoothed values in the 3rd, 10th, 50th, 90th and 97th percentiles. Data are also presented for the full cohort and individualized by sex to account for gender variability.

Discussion & conclusion

The physiological autonomic maturation profile from birth to 2 years in a healthy population of term neonates results in a fine-tuning autonomic maturation underlying progressively a new equilibrium and privileging the parasympathetic activity over the sympathetic activity.

Agreement of an echocardiogram-based diagnosis of pulmonary hypertension in infants at risk for bronchopulmonary dysplasia among masked reviewers

OBJECTIVE

To evaluate the agreement of an echocardiogram-based pulmonary hypertension diagnosis in premature infants at risk for bronchopulmonary dysplasia (BPD).

STUDY DESIGN

Echocardiograms from infants born ≤28 weeks post menstrual age were retrospectively reviewed with a standardized reading protocol by three pediatric cardiologists masked to patient's clinical history to determine the presence of pulmonary hypertension.

RESULTS

A total of 483 echocardiograms from 49 unique patients were each reviewed by three pediatric cardiologists. Overall there was an 82.9% agreement on the presence of pulmonary hypertension among the three readers (95% CI: 78.4%, 85.4%) with a modified Fleiss' kappa of 0.759 (95% CI: 0.711, 0.801). Percent agreement between rereads was 92.4%, and modified Fleiss' kappa was 0.847 (95% CI: 0.750, 0.931).

CONCLUSIONS

Using a standardized reading protocol and echocardiogram-based definition of pulmonary hypertension, there is high inter- and intra-rater agreement for the diagnosis of pulmonary hypertension in at-risk premature infants, suggesting echocardiography can be successfully used for clinical and research monitoring of pulmonary hypertension in infants.

Human Milk: An Ideal Food for Nutrition of Preterm Newborn

Human milk is the best food for newborn nutrition. There is no ideal composition of human milk and also no easy way to control the complexity of its nutritional quality and the quantity received by breastfed infants. Pediatricians and nutritionists use charts of infant growth (weight, size, head circumference) and neurodevelopment criteria that reflect the food that these infants receive. These charts reflect first the infant physiology and likely reflect the composition of human milk when infants are breastfed. In a situation of preterm birth, mother physiology impacts partly breast milk composition and this explains how this is more difficult to correlate infant growth or neurodevelopment with milk composition. Some biomarkers (lipids, oligosaccharides) have been identified in breast milk but their function is not always yet known. A better knowledge on how human milk could act on infant development to the mid- and long-term participating thus to nutritional programming is a challenging question for a better management of infants' nutrition, especially for preterm infants who are most fragile.

Sex differences in psychomotor development during the preschool period: A longitudinal study of the effects of environmental factors and of emotional, behavioral, and social functioning

We sought to determine the extent to which sex differences in psychomotor development during the preschool period can be explained by differential exposure to environmental factors and/or differences in emotional, behavioral, or social functioning. Children from the EDEN mother-child cohort were assessed for language, gross motor, and fine motor skills at 2, 3, and 5-6 years of age using parental questionnaires and neuropsychological tests. Structural equation models examining the associations between sex and language, gross motor, and fine motor skills at 2, 3, and 5-6 years were performed while adjusting for a broad range of pre- and postnatal environmental factors as well as emotional, behavioral and socialization difficulties. Girls (n = 492) showed better fine motor skills than boys (n = 563) at 2 years (Cohen's d = 0.67 in the fully adjusted models), at 3 years (d = 0.72), and to a lesser extent at 5-6 years (d = 0.29). Girls also showed better language skills at 2 years (d = 0.36) and 3 years (d = 0.37) but not at 5-6 years (d = 0.04). We found no significant differences between girls and boys in gross motor skills at 2, 3, or 5-6 years. Similar results were found in the models unadjusted and adjusted for pre- and postnatal environmental factors as well as emotional, behavioral, and socialization difficulties. Our findings are consistent with the idea that sex differences in fine motor and language skills at 2 and 3 years of age are not explained by differential exposure to environmental factors or by sex differences in emotional, behavioral, or social functioning.

Infant psychomotor development in cases of maternal postpartum depression: Observation of a mother and baby unit

Studies of the first year of infant psychomotor development in cases of maternal postpartum depression are lacking. The mother and baby unit (MBU) is a healthcare system available to infants and their mothers during the postpartum period in a psychiatric hospital, which provides support and preserves the parent’s role in the child’s daily care. The aim of the paper is to describe the developmental profile of babies of mothers with severe postpartum depression treated in an MBU through the developmental quotients. Using the Brunet-Lézine scale, we studied six-month-old infants whose mothers were hospitalized. The study population consisted of 15 infants. The mean global developmental quotient score was 96.7. A developmental quotient lower than 80 was not observed for any of the children. We found no global psychomotor developmental delays. Despite this, the posture subscore was the area in which we observed the most difficulties. It is possible that the tonic dialogue between the mother and infant is disrupted by maternal depression.

Perinatal stress moderates the link between early and later emotional skills in very preterm-born children: An 11-year-long longitudinal study

BACKGROUND

Very preterm (VPT) birth refers to an early stressful event putting children at heightened risk for emotional difficulties. However, there is an important individual variability, leaving unexplained why some VPT children do not develop emotional difficulties, while others develop such difficulties in the early years or later in life.

AIM

In this study, we examined whether perinatal stress is a risk factor explaining heterogeneities in emotional problems in VPT children.

METHODS

Thirty-six VPT children and 22 full-term born (FT) children participated in an 11 year-long study. Risk for perinatal stress was assessed at birth with the Perinatal Risk Inventory. Mothers reported children's emotional difficulties at 18 months of child age on the Symptom Checklist and at 11 years on the Child Behavior Checklist.

RESULTS

Results indicated significant differences in emotional scores at 11 years not only between VPT and FT children but also between the low and high perinatal stress groups. More importantly, emotional scores at 18 months influenced variability in internalizing scores at 11 years only in VPT children with high perinatal stress.

CONCLUSION

Although prematurity affects the emotional abilities of preadolescents, the link between emotional skills in early and later childhood is moderated by the severity of perinatal stress. In particular, VPT children who are born with more complications, and as such experience a more stressful perinatal environment, are more likely to show emotional difficulties at preadolescence.

Severe Neurodevelopmental Impairment in Neonates Born Preterm: Impact of Varying Definitions in a Canadian Cohort

OBJECTIVE

To assess the impact of variations in the definition of severe neurodevelopmental impairment (NDI) on the incidence of severe NDI and the association with risk factors using the Canadian Neonatal Follow-Up Network cohort.

STUDY DESIGN

Literature review of severe NDI definitions and application of these definitions were performed in this database cohort study. Infants born at 23-28 completed weeks of gestation between 2009 and 2011 (n = 2187) admitted to a Canadian Neonatal Network neonatal intensive care unit and assessed at 21 months' corrected age were included. The incidence of severe NDI, aORs, and 95% CIs were calculated to express the relationship between risk factors and severe NDI using the definitions with the highest and the lowest incidence rates of severe NDI.

RESULTS

The incidence of severe NDI ranged from 3.5% to 14.9% (highest vs lowest rate ratio 4.29; 95% CI 3.37-5.47). The associations between risk factors and severe NDI varied depending on the definition used. Maternal ethnicity, employment status, antenatal corticosteroid treatment, and gestational age were not associated consistently with severe NDI. Although maternal substance use, sex, score of neonatal acute physiology >20, late-onset sepsis, bronchopulmonary dysplasia, and brain injury were consistently associated with severe NDI irrespective of definition, the strength of the associations varied.

CONCLUSIONS

The definition of severe NDI significantly influences the incidence and the associations between risk factors and severe NDI. A standardized definition would facilitate site comparisons and scientific communication.

Do Infants Born Very Premature and Who Have Very Low Birth Weight Catch Up With Their Full Term Peers in Their Language Abilities by Early School Age?

PURPOSE

This study examined the extent to which children born preterm (< 37 weeks) and/or who have low birth weight (< 2,500 g) catch up with their full term peers in terms of their language abilities at early school age (≥ 5 to < 9 years).

METHOD

A systematic literature search identified empirical studies that fit the inclusion criteria. Data from the tests/questionnaires used for meta-analysis spanned the following language categories: total language score, expressive language, receptive language, pragmatics, phonological awareness, and grammar. The means (standard deviations) were extracted from the studies and were converted to mean difference and 95% confidence intervals to test for overall effect.

RESULTS

Sixteen studies met the inclusionary criteria, for a total of 2,739 participants, of which 1,224 were born full term and 1,515 were born preterm. It is important to note that the preterm cohort represented very preterm infants who have a very low birth weight. The meta-analysis found that preterm infants scored significantly worse on total language (p < .001), receptive language (p < .001), expressive language (p < .001), phonological awareness (p < .001), and grammar (p = .03) than their full term peers. However, preterm infants did not score significantly worse than their peers on their pragmatics (p = .19).

CONCLUSIONS

Children born VPT and who have VLBW perform worse than their peers on their total language, receptive language, expressive language, phonological awareness, and grammar abilities by early school age. This information is important for speech-language pathologists to consider as children born prematurely reach school age.

To which extent social withdrawal at the age of 1 year is associated with IQ at 5-6 years old? Results of the EDEN mother-child cohort

The present study aims to determine to which extent social withdrawal at 1 year is associated with the child's IQ at the end of the preschool period. Children (N = 1045) from the EDEN mother-child cohort were assessed for social withdrawal behaviours at 1 year by trained midwives using the Alarm Distress BaBy (ADBB) scale. Midwives also examined infants' language and motor development at 1 year. At the age 5-6 years, IQ scores were based on the WPPSI-III. Linear regression models were used to determine the association between IQ and ADBB, adjusted for a broad range of pre- and postnatal environmental factors and for language and motor skills scores at 1 year. After adjusting for environmental factors, children with social withdrawal at 1 years (ADBB ≥5; N = 195) had significantly lower IQ scores at 5-6 years (-2.81 IQ points; p value 0.007) compared to children without social withdrawal (ADBB <5; N = 847). When motor and language skills at 1 year were included in the previous model, no association between social withdrawal and IQ at 5-6 years was found. Being socially withdrawn at 1 year is associated with lower IQ scores at 5-6 years. The potential influence of these developmental aspects on each other (withdrawal behaviour and language/motor skills) may occur early in development. Our results improve our understanding of the outcomes of early social withdrawal behaviour and call for early detection of delay in acquisition of language/motor skills among socially withdrawn young children.

Eight principles for patient-centred and family-centred care for newborns in the neonatal intensive care unit

Despite the recent improvements in perinatal medical care leading to an increase in survival rates, adverse neurodevelopmental outcomes occur more frequently in preterm and/or high-risk infants. Medical risk factors for neurodevelopmental delays like male gender or intrauterine growth restriction and family sociocultural characteristics have been identified. Significant data have provided evidence of the detrimental impact of overhelming environmental sensory inputs, such as pain and stress, on the developing human brain and strategies aimed at preventing this impact. These strategies, such as free parental access or sleep protection, could be considered 'principles of care'. Implementation of these principles do not require additional research due to the body of evidence. We review the scientific evidence for these principles here.

Risk Factor Models for Neurodevelopmental Outcomes in Children Born Very Preterm or With Very Low Birth Weight: A Systematic Review of Methodology and Reporting

The prediction of long-term outcomes in surviving infants born very preterm (VPT) or with very low birth weight (VLBW) is necessary to guide clinical management, provide information to parents, and help target and evaluate interventions. There is a large body of literature describing risk factor models for neurodevelopmental outcomes in VPT/VLBW children, yet few, if any, have been developed for use in routine clinical practice or adopted for use in research studies or policy evaluation. We sought to systematically review the methods and reporting of studies that have developed a multivariable risk factor model for neurodevelopment in surviving VPT/VLBW children. We searched the MEDLINE, Embase, and PsycINFO databases from January 1, 1990, to June 1, 2014, and identified 78 studies reporting 222 risk factor models. Most studies presented risk factor analyses that were not intended to be used for prediction, confirming that there is a dearth of specifically designed prognostic modeling studies for long-term outcomes in surviving VPT/VLBW children. We highlight the strengths and weaknesses of the research methodology and reporting to date, and provide recommendations for the design and analysis of future studies seeking to analyze risk prediction or develop prognostic models for VPT/VLBW children.

Do developmental milestones at 4, 8, 12 and 24 months predict IQ at 5-6 years old? Results of the EDEN mother-child cohort

RATIONALE

The present study aims: (i) to determine how well developmental milestones at 4, 8, 12 and 24 months may predict IQ at 5-6 years old, (ii) to identify cognitive domains during the first two years that best predict later IQ and (iii) to determine whether children with IQ in the normal range at 5-6 years old may differ from disabled (IQ < 70) and gifted children (IQ > 130) with regard to their early cognitive development.

METHOD

The main developmental milestones were collected through self-administered questionnaires rated by parents at 4, 8, 12 and 24 months and through parental questionnaires administered by a trained interviewer and questionnaires completed following a medical examination at 12 months. These questionnaires were derived from the Brunet-Lézine Psychomotor Development Scale and they addressed several cognitive domains (gross and fine motor skills, language and socialization).

RESULTS

(i) Developmental milestones predict a substantial part of the later IQ variance from 24 months (R² ∼ 20%). (ii) Early language skills more strongly predict later IQ than the other cognitive domains. (iii) Several cognitive domains, but particularly language skills, predict disabled children at 5-6 years old (from the age of 8 months) and gifted children (from the age of 12 months).

DISCUSSION

The present study provides valuable information for early developmental assessment and could contribute to a better understanding of intellectual development.

Impact of fetal growth restriction on neurodevelopmental outcome at 2 years for extremely preterm infants: a single institution study

AIM

We evaluated the impact of fetal growth restriction on neurodevelopmental outcomes at 2 years corrected age for infants born before 27 weeks gestational age.

METHOD

Data on infants born before 27 weeks gestational age between 1999 and 2008 (n=463), admitted to a tertiary neonatal unit in Paris, were used to compare neurological outcomes at 2 years for infants with birthweight lower than the 10th centile and birthweight of at least the 10th centile, using intrauterine reference curves. Outcomes were cerebral palsy (CP) and the Brunet-Lézine assessment of cognitive development, which provides age-corrected overall and domain-specific (global and fine motor skills, language and social interaction) developmental quotients. Models were adjusted for perinatal and social factors.

RESULTS

Seventy-two percent of infants were discharged alive. Eighty-three percent (n=268) were evaluated at 2 years. Six percent had CP. Fetal growth restriction was not associated with the risk of CP. After adjustment, children with a birthweight lower than the 10th centile had a global developmental quotient 4.7 points lower than those with birthweight of at least the 10th centile (p<0.001); differences were greatest for fine motor and social skills (-4.7, p=0.053 and -7.3, p<0.001 respectively).

INTERPRETATION

In extremely preterm children, fetal growth restriction was associated with poorer neurodevelopmental outcomes at 2 years, but not with CP.

Changing definitions of long-term follow-up: Should "long term" be even longer?

There have been amazing changes in outcomes of preterm (PT) infants in the past decades. Whereas early studies reported only survival rates, Dr. Julius Hess published the first outcome study of PT infants in Chicago in 1953. Dr. Lubchenco then published the 10-year follow-up of premature infants born in 1947-1953 and identified a 68% handicap rate. As a result of these early studies, the importance of evaluating NICU graduates both for surveillance and as an outcome of trials was recognized. During the 1970s, there was a gradual expansion in the number of follow-up programs in the United States (US) with an increasing number of follow-up studies published. In the 1980s, the importance of multicenter clinical research networks was recognized and the NICHD Neonatal Research Network (NRN) was initiated in 1986. Follow-up protocols, definitions, and outcomes have evolved over the last 30 years and will be reviewed with a focus on NICHD NRN studies.

A Comparison of the Birth Characteristics of Idiopathic Toe Walking and Toe Walking Gait Due to Medical Reasons

OBJECTIVE

To determine and compare the birth history or postnatal complications of idiopathic toe walking (ITW) and toe walking known to be associated with a medical condition.

STUDY DESIGN

This was a retrospective chart review of parent-reported birth histories of children who presented to a dedicated toe-walking clinic between 2010 and 2014. This cohort comprised children diagnosed with ITW and children with a medical reason for their toe-walking gait. Data were compared with Australian Perinatal statistical normative data.

RESULTS

Ninety-five children (60 males, 63%) were diagnosed with ITW, with a mean (SD) age of 5.8 (2.9) years. Children with an ITW gait were found to have greater rates of prematurity (OR 2.4; 95% CI 1.43-4.03), greater rates of admission to a special care nursery or neonatal intensive care unit (OR 1.98; 95% CI 1.23-3.18), and lower birth weights (OR 6.6; 95% CI 3.48-12.5) than the normative population. Children with a medical reason for toe walking (n = 28, 68% males) also had greater rates of prematurity (OR 2.4; 95% CI 0.94-6.09) than the normative population and more instrumented births than the ITW cohort (OR 1.56; 95% CI 0.64-3.77). No association was found between assisted-birth intervention and the ITW cohort compared with the normative population or group with a medical cause for toe walking.

CONCLUSIONS

ITW gait was associated with greater rates of complications during and after delivery. Such complications have been associated previously as risk factors for neurologic insult affecting motor development.

Outcome comparison of very preterm infants cared for in the neonatal intensive care units in Australia and New Zealand and in Canada

AIM

To compare risk-adjusted neonatal intensive care unit outcomes between regions of similar population demography and health-care systems in Australia-New Zealand and Canada to generate meaningful hypothesis for outcome improvements.

METHODS

Retrospective study of data from preterm infants (<32 weeks gestational age) cared for in 29 ANZNN (Australian and New Zealand Neonatal Network) and 26 Canadian Neonatal Network (CNN) intensive care unit admitted between 2005 and 2007. Moribund infants or those with major congenital malformation were excluded.

RESULTS

The 9995 ANZNN infants had a higher gestational age (29 vs. 28 weeks, P < 0.0001), lower rate of outborn status (13.2% vs. 19.1%, P < 0.0001) and Apgar score <7 at 5 min (14.8% vs. 21.6%, P < 0.0001) than their 7141 CNN counterparts. After adjustment, ANZNN and CNN infants had a similar likelihood of survival (adjusted odds ratio (AOR) 1.01 (0.88, 1.16)), but ANZNN infants were at lower risk of severe retinopathy (AOR 0.71 (0.61, 0.83)), severe ultrasound neurological injury (AOR 0.68 (0.59, 0.78)), necrotising enterocolitis (AOR 0.65 (0.56, 0.76)), chronic lung disease (AOR 0.67 (0.62, 0.73)) and late-onset sepsis (AOR 0.83 (0.76, 0.91)). ANZNN infants were at a higher risk of pulmonary air leak (AOR 1.20 (1.01, 1.42)), early-onset sepsis (AOR 1.33 (1.02, 1.74)). More ANZNN infants received any respiratory support (AOR 1.27 (1.14, 1.41)) and continuous positive airway pressure as sole respiratory support (AOR 2.50 (2.27, 2.70)).

CONCLUSIONS

Despite similarities in settings, ANZNN infants fared better in most measures. Outcome disparities may be related to differences in tertiary service provision, referral and clinical practices.

Effects of Antenatal Maternal Depression and Anxiety on Children's Early Cognitive Development: A Prospective Cohort Study

Introduction

Studies have shown that depression or anxiety occur in 10–20% of pregnant women. These disorders are often undertreated and may affect mothers and children’s health. This study investigates the relation between antenatal maternal depression, anxiety and children’s early cognitive development among 1380 two-year-old children and 1227 three-year-old children.

Methods

In the French EDEN Mother-Child Cohort Study, language ability was assessed with the Communicative Development Inventory at 2 years of age and overall development with the Ages and Stages Questionnaire at 3 years of age. Multiple regressions and structural equation modeling were used to examine links between depression, anxiety during pregnancy and child cognitive development.

Results

We found strong significant associations between maternal antenatal anxiety and poorer children’s cognitive development at 2 and 3 years. Antenatal maternal depression was not associated with child development, except when antenatal maternal anxiety was also present. Both postnatal maternal depression and parental stimulation appeared to play mediating roles in the relation between antenatal maternal anxiety and children’s cognitive development. At 3 years, parental stimulation mediated 13.2% of the effect of antenatal maternal anxiety while postnatal maternal depression mediated 26.5%.

Discussion

The partial nature of these effects suggests that other mediators may play a role. Implications for theory and research on child development are discussed.

Psychiatric diagnoses, emotional-behavioral symptoms and functional outcomes in adolescents born preterm with very low birth weights

Children born preterm with very low birth weight (VLBW; birth weight ≤1,500 g) run risks of neurodevelopmental disorders. Studies of adolescent outcome are relatively few. In this follow-up survey, we examined the emotional-behavioral symptoms, psychiatric diagnoses and functional status in a geographically-based birth cohort of VLBW adolescents (average 13.4 years) as registered in a level III center of a recently developed Asian country. Psychiatric interviews were conducted. Parents were asked to fill out the Child Behavioral Checklist and the Current Status Survey. Results revealed that neonatal survival rate was 75.7% (112/148). In the follow-up, 26.2% of the adolescents required individualized educational plan; 52.5% were with at least one neuropsychiatric diagnosis (e.g. cerebral palsy 24.6%, intellectual disabilities 21.3%, attention deficit/hyperactivity disorder 19.7%), and 32.8% of the participants were disabled. Logistic regression found that neonatal sepsis and grade III/IV intraventricular hemorrhage were most predictive of a disabled status in adolescence.

Spectrum of neurodevelopmental disabilities: a cohort study in hungary

The spectrum of neurodevelopmental disabilities was studied in a cohort of patients in Hungary. A search for etiologies and assessment of the degree of intellectual disability were carried out. The study included 241 (131 boys) patients. Disability occurred without any prenatal, perinatal, and/or neonatal adverse events in 167 patients. They were classified into the following subgroups: genetic syndromes with recognized etiology, global developmental delay/intellectual disability in association with dysmorphic features but unknown etiology, global developmental delay/intellectual disability without dysmorphic features and recognized etiology, brain malformations, inborn errors of metabolism, leukoencephalopathies, epileptic syndromes, developmental language impairment, and neuromuscular disorders. Adverse events occurred in 74 children classified into subgroups such as cerebral palsy after delivery preterm or at term, and disabilities without cerebral palsy. The etiology was identified in 66.4%, and genetic diagnosis was found in 19.5%. Classification of neurodevelopmental disorders contribute to etiological diagnosis, proper rehabilitation, and genetic counseling.

Thalamic alterations in preterm neonates and their relation to ventral striatum disturbances revealed by a combined shape and pose analysis

Finding the neuroanatomical correlates of prematurity is vital to understanding which structures are affected, and to designing efficient prevention and treatment strategies. Converging results reveal that thalamic abnormalities are important indicators of prematurity. However, little is known about the localization of the abnormalities within the subnuclei of the thalamus, or on the association of altered thalamic development with other deep gray matter disturbances. Here, we aim to investigate the effect of prematurity on the thalamus and the putamen in the neonatal brain, and further investigate the associated abnormalities between these two structures. Using brain structural magnetic resonance imaging, we perform a novel combined shape and pose analysis of the thalamus and putamen between 17 preterm (41.12 ± 5.08 weeks) and 19 term-born (45.51 ± 5.40 weeks) neonates at term equivalent age. We also perform a set of correlation analyses between the thalamus and the putamen, based on the surface and pose results. We locate significant alterations on specific surface regions such as the anterior and ventral anterior (VA) thalamic nuclei, and significant relative pose changes of the left thalamus and the right putamen. In addition, we detect significant association between the thalamus and the putamen for both surface and pose parameters. The regions that are significantly associated include the VA, and the anterior and inferior putamen. We detect statistically significant surface deformations and pose changes on the thalamus and putamen, and for the first time, demonstrate the feasibility of using relative pose parameters as indicators for prematurity in neonates. Our methods show that regional abnormalities of the thalamus are associated with alterations of the putamen, possibly due to disturbed development of shared pre-frontal connectivity. More specifically, the significantly correlated regions in these two structures point to frontal-subcortical pathways including the dorsolateral prefrontal-subcortical circuit, the lateral orbitofrontal-subcortical circuit, the motor circuit, and the oculomotor circuit. These findings reveal new insight into potential subcortical structural covariates for poor neurodevelopmental outcomes in the preterm population.

Population study of neurodevelopmental outcomes of extremely premature infants admitted after office hours

AIM

The aim of the study was to compare neurodevelopmental outcomes of extremely preterm infants admitted during (OH) and after (AH) office hours.

METHODS

A retrospective review of the New South Wales and Australian Capital Territory Neonatal Intensive Care Units' (NICUs) Data Collection of all infants <29 weeks gestation admitted to New South Wales and Australian Capital Territory NICUs between January 1998 and December 2004 was conducted. The primary outcome was moderate/severe functional disability (FD) at 2-3 years follow-up defined as developmental delay (Griffiths Mental Developmental Scales general quotient or Bayley Scales of Infant Development-II mental developmental index >2 standard deviations below the mean), cerebral palsy (unable to walk without aids), deafness (requiring bilateral hearing aids) or blindness (visual acuity <6/60 in the better eye).

RESULTS

Mortality and age at follow-up were comparable between the AH and OH groups. Developmental outcome was evaluated in 972 (74.9%) infants admitted during AH and 501 (74.6%) admitted during OH. FD was not significantly different between the AH and OH groups (17.1% vs. 14.8%, adjusted odds ratio 1.131, 95% confidence interval 1.131 (0.839-1.523), P = 0.420). There were no significant differences between AH and OH infants with cerebral palsy (9.6% vs. 7.6%), developmental delay (5.4% vs. 5.0%) or any other component of FD.

CONCLUSION

There is little circadian variation in mortality and adverse neurodevelopmental outcomes in an NICU network with the current model of after hours staffing and support, and sharing of NICU workload within a network.

Correlation of quantitative texture analysis of cranial ultrasound with later neurobehavior in preterm infants

The purpose of the study was to evaluate the association between a quantitative texture analysis of early neonatal brain ultrasound images and later neurobehavior in preterm infants. A prospective cohort study including 120 preterm (<33 wk of gestational age) infants was performed. Cranial ultrasound images taken early after birth were analyzed in six regions of interest using software based on texture analysis. The resulting texture scores were correlated with the Neonatal Behavioural Assessment Scale (NBAS) at term-equivalent age. The ability of texture scores, in combination with clinical data and standard ultrasound findings, to predict the NBAS results was evaluated. Texture scores were significantly associated with all but one NBAS domain and better predicted NBAS results than clinical data and standard ultrasound findings. The best predictive value was obtained by combining texture scores with clinical information and ultrasound standard findings (area under the curve = 0.94). We conclude that texture analysis of neonatal cranial ultrasound-extracted quantitative features that correlate with later neurobehavior has a higher predictive value than the combination of clinical data with abnormalities in conventional cranial ultrasound.

Neurocognitive outcome of children exposed to perinatal mother-to-child Chikungunya virus infection: the CHIMERE cohort study on Reunion Island

BACKGROUND

Little is known about the neurocognitive outcome in children exposed to perinatal mother-to-child Chikungunya virus (p-CHIKV) infection.

METHODS

The CHIMERE ambispective cohort study compared the neurocognitive function of 33 p-CHIKV-infected children (all but one enrolled retrospectively) at around two years of age with 135 uninfected peers (all enrolled prospectively). Psychomotor development was assessed using the revised Brunet-Lezine scale, examiners blinded to infectious status. Development quotients (DQ) with subscores covering movement/posture, coordination, language, sociability skills were calculated. Predictors of global neurodevelopmental delay (GND, DQ ≤ 85), were investigated using multivariate Poisson regression modeling. Neuroradiologic follow-up using magnetic resonance imaging (MRI) scans was proposed for most of the children with severe forms.

RESULTS

The mean DQ score was 86.3 (95%CI: 81.0-91.5) in infected children compared to 100.2 (95%CI: 98.0-102.5) in uninfected peers (P<0.001). Fifty-one percent (n = 17) of infected children had a GND compared to 15% (n = 21) of uninfected children (P<0.001). Specific neurocognitive delays in p-CHIKV-infected children were as follows: coordination and language (57%), sociability (36%), movement/posture (27%). After adjustment for maternal social situation, small for gestational age, and head circumference, p-CHIKV infection was found associated with GND (incidence rate ratio: 2.79, 95%CI: 1.45-5.34). Further adjustments on gestational age or breastfeeding did not change the independent effect of CHIKV infection on neurocognitive outcome. The mean DQ of p-CHIKV-infected children was lower in severe encephalopathic children than in non-severe children (77.6 versus 91.2, P<0.001). Of the 12 cases of CHIKV neonatal encephalopathy, five developed a microcephaly (head circumference <-2 standard deviations) and four matched the definition of cerebral palsy. MRI scans showed severe restrictions of white matter areas, predominant in the frontal lobes in these children.

CONCLUSIONS

The neurocognitive outcome of children exposed to perinatal mother-to-child CHIKV infection is poor. Severe CHIKV neonatal encephalopathy is associated with an even poorer outcome.

Determinants of body composition in preterm infants at the time of hospital discharge

BACKGROUND

Preterm infants have a higher fat mass (FM) percentage and a lower fat-free mass (FFM) than do term infants at the time of hospital discharge.

OBJECTIVE

We determined perinatal and nutritional factors that affect the body composition of preterm infants at discharge.

DESIGN

A total of 141 preterm infants born at <35 wk of gestation and admitted to Nantes University Hospital Neonatology Unit over a period of 2 y were enrolled. Nutritional intake and growth were monitored during hospitalization. Body composition was assessed by using air-displacement plethysmography at discharge. FFM was compared with reference data in term infants according to sex and gestational age.

RESULTS

Linear regression produced an excellent model to predict absolute FFM from perinatal characteristics and nutrition (R(2) = 0.82) but not the FM percentage (R(2) = 0.24). Gestational and postnatal ages played an equal role in absolute FFM accretion, as did the initial growth (between birth and day 5) and growth between day 5 and discharge. Antenatal corticosteroid treatment slightly reduced FFM accretion. As concerns nutritional intake, a higher protein:energy ratio at days 10 and 21 was significantly associated with decreased risk of an FFM deficit when preterm infants were compared with reference values for term infants. Boys had higher risk of an FFM deficit than did girls.

CONCLUSION

The initial growth and quality of nutrition were significantly associated with absolute FFM accretion during a hospital stay in preterm infants. This trial was registered at clinicaltrials.gov as NCT01450436.

Outcomes of extremely preterm infants following severe intracranial hemorrhage

OBJECTIVE

Severe intracranial hemorrhage (ICH) is an important prognostic variable in extremely preterm (EPT) infants. We examined imaging and clinical variables that predict outcomes in EPT infants with severe ICH.

STUDY DESIGN

Retrospective analysis of 353 EPT infants with severe ICH. Outcomes were compared by examining: (i) unilateral vs bilateral ICH; and (ii) presence vs absence of hemorrhagic parenchymal infarction (HPI). Regression analyses identified variables associated with death or neurodevelopmental impairment (NDI).

RESULT

Bilateral ICH and HPI had higher rates of adverse outcomes and were independently associated with death/NDI. HPI was the most important variable for infants of lower birth weight, and bilateral ICH for larger infants. For infants surviving to 36 weeks, shunt placement was most associated with death/NDI.

CONCLUSION

Bilateral ICH and the presence of HPI in EPT infants with severe ICH are associated with death/NDI, though the importance depends on birth weight and survival to 36 weeks.

Critical serum creatinine values in very preterm newborns

Background

Renal failure in neonates is associated with an increased risk of mortality and morbidity. But critical values are not known.

Objective

To define critical values for serum creatinine levels by gestational age in preterm infants, as a predictive factor for mortality and morbidity.

Study Design

This was a retrospective study of all preterm infants born before 33 weeks of gestational age, hospitalized in Nantes University Hospital NICU between 2003 and 2009, with serum creatinine levels measured between postnatal days 3 to 30. Children were retrospectively randomized into either training or validation set. Critical creatinine values were defined within the training set as the 90^th percentile values of highest serum creatinine (HSCr) in infants with optimal neurodevelopmental at two years of age. The relationship between these critical creatinine values and neonatal mortality, and non-optimal neural development at two years, was then assessed in the validation set.

Results and Conclusion

The analysis involved a total of 1,461 infants (gestational ages of 24-27 weeks (n=322), 28-29 weeks (n=336), and 30-32 weeks (803)), and 14,721 creatinine assessments. The critical values determined in the training set (n=485) were 1.6, 1.1 and 1.0 mg/dL for each gestational age group, respectively. In the validation set (n=976), a serum creatinine level above the critical value was significantly associated with neonatal mortality (Odds ratio: 8.55 (95% confidence interval: 4.23-17.28); p<0.01) after adjusting for known renal failure risk factors, and with non-optimal neurodevelopmental outcome at two years (odds ratio: 2.06 (95% confidence interval: 1.26-3.36); p=0.004) before adjustment. Creatinine values greater than 1.6, 1.1 and 1.0 mg/dL respectively at 24-27, 28-29, 30-32 weeks of gestation were associated with mortality before and after adjustment for risk factors, and with non-optimal neurodevelopmental outcome, before adjustment.

Feeding and drinking skills in preterm and low birth weight infants compared to full term infants at a corrected age of nine months

Feeding and drinking skills were registered in 47 preterm (<32 weeks) and/or low birth weight (<1500 g) infants and compared to 52 healthy full term infants at a (corrected) age of nine months. In the preterm and/or SGA infants a delay was found for sufficient postural balance, drinking independently from a bottle, eating skills and accepting teeth brushing at a corrected age of nine months compared to healthy controls. For tongue position and movement, and choking during drinking no difference was found between both groups.

[Outcome at two years corrected age of a cohort of very low birth weight infants from hospitals within the neonatal SEN1500 network]

OBJECTIVE

To describe growth and neurodevelopmental status of 4,944 children who completed a follow-up at two years of corrected age out of the 10,456 newborns with weight ≤1500g born between the years 2002-2007 and discharged from hospitals within the network SEN1500. A total of 522 newborns were excluded as they had some type of malformation. The total number of children assessed represents the 49.76% of children discharged alive and without malformations.

METHODS

A retrospective review was conducted using prospectively collected data in the SEN1500 database. We compared growth data at two years of corrected age according to birth weight and sex. Motor impairment, incidence of cerebral palsy, visual and hearing disabilities, and abnormal neurodevelopment for gestational age were analysed between groups. We studied the associations between cerebral palsy (CP) and perinatal factors.

RESULTS

At 2 years of age 44.2% of children had a weight <2 SD for corrected age. Children with birth weight ≤1000g showed worse outcomes in growth. Some type of motor impairment was observed in 6.96% of the infants, and 4.56% of them were diagnosed with CP. The incidence was higher among males with birth weight ≤1000g. There was an incidence of 5.21% of visual disability, with 0.5% of children being blind in one or both eyes. Cerebral palsy was associated with retinopathy of prematurity, severe intraventricular haemorrhage, and periventricular leukomalacia, in particular cystic periventricular leukomalacia.

Severe bronchiolitis in infants born very preterm and neurodevelopmental outcome at 2 years

Preterm infants are at greater risk of bronchopulmonary dysplasia, which is associated with neurodevelopmental impairment. These infants are also more likely to develop severe bronchiolitis, which can contribute to neurodevelopmental impairment. The aim of this study was to determine whether severe bronchiolitis in very preterm infants (born before 33 weeks of gestation) was associated with an increased risk of neurodevelopmental impairment at 2 years of age. We analyzed a population-based cohort of infants (the Loire Infant Follow-up Team cohort) born between 1 January 2003 and 31 December 2009. Severe bronchiolitis was defined as hospitalization due to bronchiolitis during the first year of life. Neurodevelopmental outcome was assessed at 2 years of corrected age. A total of 2,405 infants were included in this analysis and categorized based on neonatal respiratory status: 1,308 (54.4 %) received no respiratory assistance, 864(35.9 %) received oxygen for <28 days, and 167 (6.9 %) had mild and 66 (2.7) moderate or severe bronchopulmonary dysplasia. At 2 years, 502 children displayed non-optimal neurodevelopmental outcome (20.9 %). Moderate or severe bronchopulmonary dysplasia was significantly associated with non-optimal neurodevelopmental outcome at 2 years (adjusted odds ratios (OR) = 2.3 [95 % confidence interval (CI): 1.3-3.9], p = 0.003). In the first year, 318 infants acquired severe bronchiolitis (13.2 %), which was not associated with non-optimal neurodevelopmental outcome (adjusted OR = 1.0 [95 % CI: 0.8-1.4]; p = 0.88). In conclusion, respiratory status in the neonatal period was significantly associated with non-optimal neurodevelopmental outcome at 2 years, while severe bronchiolitis was not.

Impaired language abilities and white matter abnormalities in children born very preterm and/or very low birth weight

OBJECTIVES

To investigate language abilities in children born very preterm (VPT; <32 weeks' gestational age) or very low birth weight (VLBW; <1500 g) at 7 years of age and compare their performances with children born at term, and to determine whether group differences could be explained by cerebral white matter abnormality on neonatal magnetic resonance imaging.

STUDY DESIGN

A cohort of 198 children born <30 weeks' gestational age and/or <1250 g, and 70 term controls were examined. White matter abnormalities were rated quantitatively on brain magnetic resonance imaging at term-equivalent age. Language was assessed at age 7 years using standardized language tests. Differences between groups were tested in the 5 language subdomains of phonological awareness, semantics, grammar, discourse, and pragmatics. A mediation effect was tested between birth group, white matter abnormality, and language subdomains.

RESULTS

The VPT/VLBW group performed significantly worse than controls on all language subdomains (all P < .001). White matter abnormality mediated the effect of group differences on phonological awareness, and partly mediated this effect for semantics, grammar, and discourse. White matter abnormality was not significantly associated with pragmatics (P = .13).

CONCLUSIONS

Language is an important area of concern in children born VPT/VLBW. Neonatal white matter abnormality is an important predictor of outcome; however, different language abilities are differentially associated with neonatal white matter abnormality.

Follow-up study of 2-year-olds born at very low gestational age in Estonia

AIM

To study very low gestational age (VLGA, <32 weeks) infants at 2 years of age and to identify the predictors of adverse outcomes.

METHODS

A population-based cohort of 155 surviving VLGA infants born in Estonia in 2007 was followed up and compared with a matched full-term (FT) control group. A logistic regression model was used to test associations between risk factors and adverse outcomes.

RESULTS

No impairment was found in 60% of the VLGA infants. Neurodevelopmental impairment was noted in 12% of VLGA infants, with 8% of the infants affected by cerebral palsy without independent walking, 5% with cognitive delay, 10% with language delay and 1% with hearing impairment. The differences between preterm and FT infants in terms of the mean Cognitive, Language, and Motor Composite Scores assessed using the Bayley-III scales were in excess of 0.5 SD. Somatic growth delay was a significant problem among preterm infants. The existence of severe neonatal cerebral lesions was the most significant predictor of adverse outcomes.

CONCLUSION

In all domains studied, adverse conditions were more prevalent among VLGA infants than among the FT control group. Efforts to reduce neonatal morbidity in preterm infants should be a key priority for health care in Estonia.