Self-reported health status and health-related quality of life of teenagers who were born before 29 weeks' gestational age

Psychometric Performance of Generic Childhood Multi-Attribute Utility Instruments in Preterm and Low Birthweight Populations: A Systematic Review

BACKGROUND

Individuals born preterm (gestational age < 37 weeks) and/or at low birthweight (<2500 g) are at increased risk of health impairments from birth to adulthood. This review aimed to evaluate the psychometric performance of generic childhood-specific or childhood-compatible multi-attribute utility instruments (MAUIs) in preterm and/or low birthweight (PLB) populations.

METHODS

Searches covered seven databases, including studies that targeted childhood (aged < 18 years) and/or adult (≥18 years) PLB populations; provided psychometric evidence for generic childhood-specific or compatible MAUI(s) (any language version); and published in English. Eighteen psychometric properties were evaluated using a four-part criteria rating system. Data syntheses identified psychometric evidence gaps and summarised the psychometric assessment methods/results.

RESULTS

A total of 42 studies were included, generating 178 criteria rating outputs across four MAUIs: 17D, CHSCS-PS, HUI2, and HUI3. Moreover, 64.0% of outputs concerned the HUI3 MAUI, and 38.2% related to known-group validity. There was no evidence for five psychometric properties. Only 6.7% of outputs concerned reliability and proxy-child agreement. No MAUI outperformed others across all properties. The frequently applied HUI2 and HUI3 lacked content validity evidence.

CONCLUSIONS

This psychometric evidence catalogue should inform the selection of MAUI(s) suited to the specific aims of applications targeting PLB populations. Further psychometric research is warranted to address the gaps in psychometric evidence.

Health-related quality of life in adults born extremely preterm or with extremely low birth weight in the postsurfactant era: a longitudinal cohort study

OBJECTIVES

To compare health-related quality of life (HRQoL) at 25 and 18 years in individuals born extremely preterm (EP, <28 weeks' gestation) or with extremely low birth weight (ELBW, birth weight <1000 g) with term-born (≥37 weeks) controls. Within the EP/ELBW cohort, to determine whether HRQoL differed between those with lower and higher IQs.

METHODS

HRQoL was self-reported using the Health Utilities Index Mark 3 (HUI3) at 18 and 25 years by 297 EP/ELBW and 251 controls born in 1991-1992 in Victoria, Australia. Median differences (MDs) between groups were estimated using multiple imputation to handle missing data.

RESULTS

Adults born EP/ELBW had lower HRQoL (median utility 0.89) at 25 years than controls (median utility 0.93, MD -0.040), but with substantial uncertainty in the estimate (95% CI -0.088 to 0.008) and a smaller reduction at 18 years (MD -0.016, 95% CI -0.061 to 0.029). On individual HUI3 items, there was suboptimal performance on speech (OR 9.28, 95% CI 3.09 to 27.93) and dexterity (OR 5.44, 95% CI 1.04 to 28.45) in the EP/ELBW cohort. Within the EP/ELBW cohort, individuals with lower IQ had lower HRQoL compared with those with higher IQ at 25 (MD -0.031, 95% CI -0.126 to 0.064) and 18 years (MD -0.034, 95% CI -0.107 to 0.040), but again with substantial uncertainty in the estimates.

CONCLUSIONS

Compared with term-born controls, young adults born EP/ELBW reported poorer HRQoL, as did those with lower IQ compared with those with higher IQ in the EP/ELBW cohort. Given the uncertainties, our findings need corroboration.

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

OBJECTIVE

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

DESIGN

Prospective cohort studies.

SETTING

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

PARTICIPANTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION NUMBER

ISRCTN86323684.

Health-Related Quality of Life from Adolescence to Adulthood Following Extremely Preterm Birth

OBJECTIVE

To examine self-reported and parent-reported health-related quality of life (HRQL) in adults born extremely preterm compared with control participants born at term and to evaluate trajectories of health status from adolescence to early adulthood.

STUDY DESIGN

The EPICure study comprises all births <26 weeks of gestation in the United Kingdom and Ireland in 1995 and control participants born at term recruited at age 6 years. In total, 129 participants born extremely preterm and 65 control participants were followed up at the 19-year assessment. HRQL was measured by the Health Utilities Index Mark 3 multiattribute utility (MAU) scores. Only parent-reported HRQL was available at 11 years of age.

RESULTS

Participants born extremely preterm without neurodevelopmental impairment had significantly lower MAU scores at 19 years than controls (median [IQR]: 0.91 [0.79, 0.97] vs 0.97 [0.87, 1.00], P = .008); those with impairment had the lowest scores (0.74 [0.49, 0.90]). A 0.03-0.05 difference is considered clinically significant. Parent-reported findings were similar. Participants born extremely preterm with impairment rated their health significantly better than their parents did (0.74 vs 0.58, P = .01), in contrast to those without impairment and controls. Between 11 and 19 years, median parent-reported MAU scores decreased from 0.87 to 0.77 for participants born extremely preterm (P = .01) and from 1.00 to 0.97 for control participants (P = .02).

CONCLUSIONS

Among young adults born extremely preterm, both participants and parents rated their health status less favorably than control participants born at term. The decline in MAU scores from adolescence to early adulthood following extremely preterm birth indicates continuing health issues in young adult life.

Three biomarker tests to help diagnose preterm labour: a systematic review and economic evaluation

BACKGROUND

Preterm birth may result in short- and long-term health problems for the child. Accurate diagnoses of preterm births could prevent unnecessary (or ensure appropriate) admissions into hospitals or transfers to specialist units.

OBJECTIVES

The purpose of this report is to assess the test accuracy, clinical effectiveness and cost-effectiveness of the diagnostic tests PartoSure™ (Parsagen Diagnostics Inc., Boston, MA, USA), Actim^® Partus (Medix Biochemica, Espoo, Finland) and the Rapid Fetal Fibronectin (fFN)^® 10Q Cassette Kit (Hologic, Inc., Marlborough, MA, USA) at thresholds ≠50 ng/ml [quantitative fFN (qfFN)] for women presenting with signs and symptoms of preterm labour relative to fFN at 50 ng/ml.

METHODS

Systematic reviews of the published literature were conducted for diagnostic test accuracy (DTA) studies of PartoSure, Actim Partus and qfFN for predicting preterm birth, the clinical effectiveness following treatment decisions informed by test results and economic evaluations of the tests. A model-based economic evaluation was also conducted to extrapolate long-term outcomes from the results of the diagnostic tests. The model followed the structure of the model that informed the 2015 National Institute for Health and Care Excellence guidelines on preterm labour diagnosis and treatment, but with antenatal steroids use, as opposed to tocolysis, driving health outcomes.

RESULTS

Twenty studies were identified evaluating DTA against the reference standard of delivery within 7 days and seven studies were identified evaluating DTA against the reference standard of delivery within 48 hours. Two studies assessed two of the index tests within the same population. One study demonstrated that depending on the threshold used, qfFN was more or less accurate than Actim Partus, whereas the other indicated little difference between PartoSure and Actim Partus. No study assessing qfFN and PartoSure in the same population was identified. The test accuracy results from the other included studies revealed a high level of uncertainty, primarily attributable to substantial methodological, clinical and statistical heterogeneity between studies. No study compared all three tests simultaneously. No clinical effectiveness studies evaluating any of the three biomarker tests were identified. One partial economic evaluation was identified for predicting preterm birth. It assessed the number needed to treat to prevent a respiratory distress syndrome case with a 'treat-all' strategy, relative to testing with qualitative fFN. Because of the lack of data, our de novo model involved the assumption that management of pregnant women fully adhered to the results of the tests. In the base-case analysis for a woman at 30 weeks' gestation, Actim Partus had lower health-care costs and fewer quality-adjusted life-years (QALYs) than qfFN at 50 ng/ml, reducing costs at a rate of £56,030 per QALY lost compared with qfFN at 50 ng/ml. PartoSure is less costly than Actim Partus while being equally effective, but this is based on diagnostic accuracy data from a small study. Treatment with qfFN at 200 ng/ml and 500 ng/ml resulted in lower cost savings per QALY lost relative to fFN at 50 ng/ml than treatment with Actim Partus. In contrast, qfFN at 10 ng/ml increased QALYs, by 0.002, and had a cost per QALY gained of £140,267 relative to fFN at 50 ng/ml. Similar qualitative results were obtained for women presenting at different gestational ages.

CONCLUSION

There is a high degree of uncertainty surrounding the test accuracy and cost-effectiveness results. We are aware of four ongoing UK trials, two of which plan to enrol > 1000 participants. The results of these trials may significantly alter the findings presented here.

STUDY REGISTRATION

The study is registered as PROSPERO CRD42017072696.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Preference-Based Health-Related Quality of Life Outcomes Associated with Preterm Birth: A Systematic Review and Meta-analysis

OBJECTIVES

Assessments of health-related quality of life outcomes associated with preterm birth provide valuable complementary data to the objective biomedical assessments that have traditionally been reported. The objective of this study was to perform a systematic review and meta-analysis of health utility values associated with preterm birth generated using preference-based approaches to health-related quality of life measurement.

METHODS

Systematic searches of MEDLINE, Web of Science, EconLit, EMBASE, CINAHL, PsycINFO, the Cochrane Library and SCOPUS were performed, covering the literature from inception of the search engines to 26 June 2018. Studies reporting health utility values estimated using either direct or indirect utility elicitation methods and published in the English language were included. Central descriptive statistics and measures of variability surrounding health utility values for each study and control group, and differences between comparator groups, are reported for each included article. The effect of preterm birth on health utility values was estimated using a hierarchical linear model in a linear mixed-effects meta-regression.

RESULTS

Of 2139 unique articles retrieved, 20 articles met the inclusion criteria. All but one study used the Health Utilities Index (HUI) Mark 2 (HUI2) or Mark 3 (HUI3) measures as their primary health utility assessment method. All studies reporting health utility values for individuals born preterm or at low birthweight and a control group of individuals born at full term or normal birthweight reported lower utility values in the study groups, regardless of age at assessment, respondent type or valuation method. The meta-regression revealed that preterm birth was associated with a mean utility decrement of 0.066 (95% confidence interval [CI] 0.035-0.098; p < 0.001) after controlling for valuation method, respondent type, administration mode, year of publication, geographical region of study, study setting and age at assessment.

CONCLUSION

Evidence identified by this review can act as data inputs into future economic evaluations of preventive or treatment interventions for preterm birth. Future research should focus particularly on estimating health utility values during the various stages of adulthood, and incorporating the effects of preterm birth on the preference-based health-related quality of life outcomes of parents and other family members.

Reading, Mathematics and Fine Motor Skills at 5 Years of Age in US Children who were Extremely Premature at Birth

Objectives The prevalence of extreme prematurity at birth has increased, but little research has examined its impact on developmental outcomes in large representative samples within the United States. This study examined the association of extreme prematurity with kindergarteners' reading skills, mathematics skills and fine motor skills. Methods The early childhood longitudinal study-birth cohort, a representative sample of the US children born in 2001 was analyzed for this study. Early reading and mathematics skills and fine motor skills were compared among 200 extremely premature children (EPC) (gestational age <28 wks or birthweight <1000 g), 500 premature children (PC), and 4300 term children (TC) (≥37wks or ≥2500 g). Generalized linear regression analyses included sampling weights, children's age, race, sex, and general health status, and parental marital status and education among singleton children. Results At age 5 years, EPC were 2.6(95 % CI 1.7-3.8) times more likely to fail build a gate and were 3.1(95 % CI 1.6-5.8) times more likely to fail all four drawing tasks compared to TC (p values <0.001). Fine motor performance of PC (failed to build a gate, 1.3[95 % CI 1.0-1.7]; failed to draw all four shapes, 1.1[95 % CI 0.8-1.6]) was not significantly different from TC. Mean early reading scale score (36.8[SE:1.3]) of EPC was 4.0 points lower than TC (p value < 0.0001) while mean reading score (39.9[SE:1.4]) of PC was not significantly different from TC (40.8[SE:1.1]). Mean mathematics scale score were significantly lower for both EPC (35.5[SE:1.0], p value < 0.001) and PC (39.8[SE:0.8], p value = 0.023) compared to TC (41.0[SE:0.6]). Conclusions for Practice Extreme prematurity at birth was associated with cognitive and fine motor delays at age 5 years. This suggests that based on a nationally representative sample of infants, the biological risk of extreme prematurity persists after adjusting for other factors related to development.

Health-Related Quality of Life Trajectories of Extremely Low Birth Weight Survivors into Adulthood

OBJECTIVES

To compare the health-related quality of life (HRQL) trajectories of a regional cohort of extremely low birth weight (ELBW, <1000 g) survivors (births from 1977 to 1982) and a group of normal birth weight (NBW) controls, at 3 ages: 12-16 years, 22-26 years, and 29-36 years, spanning over 20 years. We hypothesized that the HRQL of the ELBW cohort would be significantly compromised compared with their NBW peers, and that neurosensory impairments (NSI) would have an additional negative effect.

STUDY DESIGN

We used the Health Utilities Index Mark 3, in which health status was self-assessed and utility scores were derived from community preferences; multilevel modeling was used to delineate trajectories of HRQL among ELBW survivors with (n = 37) and without NSI (n = 116), and NBW controls (n = 137).

RESULTS

Adjusting for participant sex and socioeconomic status at age 8 years, ELBW survivors with NSI had consistently lower HRQL compared with both ELBW survivors without NSI and NBW controls, from adolescence through to adulthood (β = -0.264; P < .001). ELBW survivors without NSI also had significantly lower HRQL compared with NBW controls (β = -0.092; P < .01). At all ages, differences seen in the Health Utilities Index Mark 3 scores between ELBW participants and NBW controls were clinically important, though there was no differential rate of decline between the 2 groups.

CONCLUSIONS

ELBW survivors manifest meaningfully poorer HRQL from their early teens through their mid-30s. Individuals with NSI appear to represent a distinct group of ELBW survivors with substantially lower HRQL at all ages. Information on HRQL can be helpful in prioritizing research and intervention strategies.

Health-Related Quality of Life Into Adulthood After Very Preterm Birth

BACKGROUND

This study investigated change of health-related quality of life (HRQL) in very preterm/very low birth weight (VP/VLBW; born at <32 weeks' gestation and/or <1500 g birth weight) individuals from adolescence to adulthood. Are perceptions similar by different informants (self, parents) and is HRQL related to economic and social functioning?

METHODS

In a prospective whole-population sample in South Germany, 260 VP/VLBW and 229 term born individuals were assessed from birth to adulthood. HRQL was evaluated by self and parent report at age 13 and 26 years with the Health Utilities Index Mark 3 (HUI3), and economic and social functioning from interview and standard assessments at 26 years.

RESULTS

At both time points, HUI3 scores of VP/VLBW were reported to be lower compared with term born controls by participants and parents. Except for adolescent self-reports (P = .13) these differences were all significant (P < .05). In contrast to participants themselves, parents reported VP/VLBW individuals' HRQL to be worsening over time (change of mean HUI3 scores: 0.88-0.86, P = .03). Parents, particularly, reported negative changes in emotion and pain for VP/VLBW individuals over time. Participant and parent-perceived HRQL was negatively related to economic and social functioning outcomes such as receiving social benefits, unemployment, dating romantic partner or having friends.

CONCLUSIONS

VP/VLBW individuals and their parents perceive HRQL to be lower compared with term controls in adolescence and in adulthood. Lower HRQL was related to economic and social functioning problems in adulthood. No evidence for improvement of HRQL into adulthood was found in this geographical sample in Germany.

Quality of life of individuals born preterm: a systematic review of assessment approaches

PURPOSE

To review the existing literature regarding factors associated with quality of life (QoL) of individuals who were born preterm. The review focuses on assessment approaches and information sources.

METHODS

A systematic review of empirical studies published in PubMed, PsycARTICLES, PsycINFO, LILACS, and SciELO databases between 2007 and 2015. Search terms were chosen that relate preterm birth to QoL.

RESULTS

Twenty-two articles were included. Of these, ten investigated QoL in children, six investigated adolescents, and six investigated adults. All studies used generic instruments to assess QoL. There was a high rate of parental report to assess QoL in studies of children. Adolescent and adult studies most often assessed QoL through self-report. Parents of children who were born preterm reported worse QoL for their children compared with parents of children born full term. Teenagers and adults who were born preterm self-reported more positive outcomes in their QoL. The main risk factors associated with worse QoL in children who were born preterm were congenital malformations, mechanical ventilation during the neonatal phase, cognitive impairments, behavioral problems, physical disabilities, low family income, and black race.

CONCLUSIONS

Agreement between parents and children about QoL in preterm individuals was lower in younger age groups compared with older age groups. The differences in QoL throughout the different age groups may have arisen because of developmental changes or differences in the source of information used (i.e., parent report or self-report). We recommend that QoL assessments in children born preterm should consider both parent report and self-report.

A Review of the Development and Application of Generic Multi-Attribute Utility Instruments for Paediatric Populations

Multi-attribute utility instruments (MAUIs) are increasingly being used as a means of quantifying utility for the calculation of quality-adjusted life-years within the context of cost utility analysis. Traditionally, MAUIs have been developed and applied in adult populations. However, increasingly, researchers in health economics and other disciplines are recognising the importance of the measurement and valuation of health in both children and adolescents. Presently, there are nine generic MAUIs available internationally that have been used in paediatric populations: the Quality of Well-Being Scale (QWB), the Health Utility Index Mark 2 (HUI2), the HUI3, the Sixteen-dimensional measure of health-related quality of life (HRQoL) (16D), the Seventeen-dimensional measure of HRQoL (17D), the Assessment of Quality of Life 6-Dimension (AQoL-6D) Adolescent, the Child Health Utility 9D (CHU9D), the EQ-5D Youth version (EQ-5D-Y) and the Adolescent Health Utility Measure (AHUM). This paper critically reviews the development and application of the above nine MAUIs and discusses the specific challenges of health utility measurement in children and adolescents. Areas for further research relating to the development and application of generic MAUIs in paediatric populations are highlighted.

Persisting behavior problems in extremely low birth weight adolescents

OBJECTIVE

To describe behavior problems in extremely low birth weight (ELBW, <1000 g) adolescents born 1992 through 1995 based on parent ratings and adolescent self-ratings at age 14 years and to examine changes in parent ratings from ages 8-14.

METHOD

Parent ratings of behavior problems and adolescent self-ratings were obtained for 169 ELBW adolescents (mean birth weight 815 g, gestational age 26 wk) and 115 normal birth weight (NBW) controls at 14 years. Parent ratings of behavior at age 8 years were also available. Behavior outcomes were assessed using symptom severity scores and rates of scores above DSM-IV symptom cutoffs for clinical disorder.

RESULTS

The ELBW group had higher symptom severity scores on parent ratings at age 14 years than NBW controls for inattentive attention-deficit hyperactivity disorder (ADHD), anxiety, and social problems (all p's < .01). Rates of parent ratings meeting DSM-IV symptom criteria for inattentive ADHD were also higher for the ELBW group (12% vs. 1%, p < .01). In contrast, the ELBW group had lower symptom severity scores on self-ratings than controls for several scales. Group differences in parent ratings decreased over time for ADHD, especially among females, but were stable for anxiety and social problems.

CONCLUSIONS

Extremely low birth weight adolescents continue to have behavior problems similar to those evident at a younger age, but these problems are not evident in behavioral self-ratings. The findings suggest that parent ratings provide contrasting perspectives on behavior problems in ELBW youth and support the need to identify and treat these problems early in childhood.

Independent living and romantic relations among young adults born preterm

BACKGROUND

Young adults born preterm at very low birth weight start families later. Whether less severe immaturity affects adult social outcomes is poorly known.

METHODS

The study "Preterm birth and early life programming of adult health and disease" (ESTER, 2009-2011) identified adults born early preterm (<34 weeks' gestation, N = 149), late preterm (≥ 34 to <37 weeks' gestation, N = 248), and at term (≥ 37 weeks' gestation, N = 356) from the Northern Finland Birth Cohort 1986 and the Finnish Medical Birth Register (1987-1989), with perinatal data, medical and family history, socioeconomic status, and lifestyle from routine visits or questionnaires. Cox, logistic, and ordinal regressions estimated the hazard and odds ratios (HR and OR) with 95% confidence intervals of outcomes related to preterm birth.

RESULTS

Compared with term-born subjects, those born early and late preterm were less likely to have cohabited with a romantic partner (HR, 0.79; [0.61-1.03] and HR, 0.80; [0.65-0.99], respectively) or experienced sexual intercourse (HR, 0.83; [0.66-1.05] and HR, 0.76; [0.63-0.92], respectively) by young adulthood. They also had higher odds of obtaining a 1-point lower score in a visual analog scale of self-perceived sexual attractiveness (OR, 1.45; [1.09-1.98] and OR, 1.44; [1.06-1.97] for early and late preterm birth, respectively). No difference was observed in the likelihood of departing from childhood home and number of individuals having their own families.

CONCLUSIONS

Young adults born preterm experience more social challenges, which may affect their romantic relationships and future family planning.

Self and parent perspectives on health-related quality of life of adolescents born very preterm

OBJECTIVES

To test whether health-related quality of life (HRQL) based on societal standards differs between very low birth weight/very preterm (VLBW/VP) and full-term (FT) adolescents using self and parent proxy reports. Also, to examine whether self and parent reported HRQL is explained by indicators of objective functioning in childhood.

STUDY DESIGN

This prospective cohort study followed 260 VLBW/VP adolescents, 12 VLBW/VP adolescents with disability, and 282 FT adolescents. Objective functioning was assessed at 8.5 years; HRQL was assessed at 13 years with the Health Utilities Index Mark 3 (HUI3).

RESULTS

Adolescents reported more functional impairment than their parents especially in the psychological aspects of health. The mean difference in HUI3 multi-attribute utility scores between FT and VLBW/VP adolescents was small (parents: 0.91 [95% CI, 0.90, 0.92] vs 0.88 [95% CI, 0.86, 0.90]; adolescents: 0.87 [95% CI, 0.85, 0.89] vs 0.84 [95% CI, 0.82, 0.86]), but high for VLBW/VP adolescents with disabilities (0.18, 95% CI, -0.04, 0.40). Objective function did not predict HRQL in FT adolescents but contributed to prediction of HRQL in VLBW/VP adolescents without disabilities. Different indicators of objective functioning were important for adolescent vs parent reports. More variation in HUI3 scores was explained by objective function in VLBW/VP parent reports compared with adolescent reports (25% vs 18%).

CONCLUSIONS

VLBW/VP adolescents reported poorer HRQL than their FT peers in early adolescence. Improvement in HRQL as VLBW/VP children grow up is, at least partly, explained by exclusion of the most disabled in self reports by VLBW/VP adolescents and the use of different reference points by adolescents compared with parents.

Counselling and management for anticipated extremely preterm birth

Extremely preterm birth (birth between 22(0/7) and 25(6/7) weeks' gestational age [GA]) often requires parents to make complex choices about the care of their infant. Health professionals have a significant role in providing information, guidance and support. Parents facing the birth of an extremely preterm infant should have the chance to meet with both obstetrical and paediatric/neonatal care providers to receive accurate information about their infant's prognosis, provided with clarity and compassion. Decision making between parents and health professionals should be an informed and shared process, with documentation of all management decisions. Consultation with and transfer to tertiary perinatal centres are important for the care of both mother and fetus. As the survival of infants born before or at 22 completed weeks' GA remains uncommon, a noninterventional approach is recommended, whereas at 23, 24 and 25 weeks' GA, counselling about outcomes and decision making should be individualized for each infant and family, using factors which influence prognosis. All extremely preterm infants who are not resuscitated, or for whom resuscitation is not successful, must receive compassionate palliative care.

Quality of life at age 18 years after extremely preterm birth in the post-surfactant era

OBJECTIVES

To assess the self-reported quality of life, health status, self-esteem, and functional outcomes at age 18 years of extremely preterm (EP; <28 weeks gestation) or extremely low birth weight (ELBW; birth weight <1000 g) adolescents born in 1991-1992 compared with normal birth weight (birth weight >2499 g) controls, and, within the EP/ELBW cohort, to assess whether these outcomes are related to gestational age or birth weight.

STUDY DESIGN

Self-reported measures of quality of life, health status, self-esteem, and functional outcomes were obtained at age 18 years from a geographic cohort of all survivors born EP/ELBW in 1991-1992 in the state of Victoria, Australia, along with matched normal birth weight controls.

RESULTS

Data were available from 194 EP/ELBW and 148 control adolescents. EP/ELBW adolescents reported similar overall quality of life, health status, and self-esteem as controls (P > .05). Birth at younger gestational age or lower birth weight were not related to poorer quality of life within the EP/ELBW cohort (P > .05). EP/ELBW adolescents reported less physical activity (OR, 0.5; 95% CI, 0.3-0.8; P < .01), sexual activity (OR, 0.6; 95% CI, 0.4-0.9; P = .01), and alcohol intake (OR, 0.5; 95% CI, 0.3-0.8; P = .01) compared with controls. Other aspects of risk-taking behavior were similar in the 2 groups (P > .05).

CONCLUSION

EP/ELBW individuals born after the introduction of exogenous surfactant are transitioning well into young adulthood, despite the fact that more of the tiniest and most immature infants survive than ever before. They report similar quality of life, self-esteem, and social and risk-taking behaviors as controls.

Quality of life of former premature infants during adolescence and beyond

Interest in determining the quality of life of children and adults is now considered a priority. This is a result of a shift in thinking with greater transparency in finding out not only the health outcomes, but also the personal burden of illness and life satisfaction for the individual. However, there is still no consensus on the definition of quality of life or the appropriate tools to measure the same. In the last three decades there has been an exponential increase in the number of publications measuring quality of life, particularly in former premature infants. Most studies show that despite disabilities, children rate their quality of life almost equivalent to that of children born at term, and higher than that predicted by health professionals. This review will focus on the conceptual framework and measurement of self-reported quality of life in the context of former premature infants at adolescence and young adulthood.

Preterm children quality of life evaluation: a qualitative study to approach physicians' perception

BACKGROUND

While data for preterm children health-related quality of life are available, there are little data on the perception of health-related quality of life evaluation by physicians who manage preterm children, or its use in real life and decision making. The aim of this qualitative study is to highlight among physicians, themes of reflection about health-related quality of life in extremely preterm children (less than 28 weeks' gestation).

METHODS

Focus groups at a French University Hospital with physicians who manage extremely preterm children: obstetricians, intensive care physicians, neonatal physicians and paediatric neurologists. The focus groups allowed the participants to discuss (drawing on their personal experience), three principal topics regarding the health-related quality of life of preterm children: representation, expectations in daily practice and evaluation method.

RESULTS

We included fourteen participants in the three focus groups. Many themes emerged from the focus groups: approaches for defining health-related quality of life and difficulties of utilization, the role that health-related quality of life should have in the system of care, the problem of standards and evidence-based decision making. Physicians had difficulties with taking positions regarding this concept. There were no differences by gender, age or seniority, but points of view varied by specialty and type of practice. Physicians who had longer specialized care for extremely preterm children were more sensitive to the impact of preterm complications on health-related quality of life.

CONCLUSIONS

This study provides preliminary results about physicians' perspective on the health-related quality of life of extremely preterm children. The themes emerged from the focus groups are classically described in other domains but not all in so clear a way (definition, interests and limits, ethical reflection). This approach was never developed in the field of prematurity with well-knowed consequences on quality of life. These results require to be confirmed on a larger representative sample. The themes and questions of this broad opinion survey will rest on the information issued from our preliminary interviews.

Hearing loss, auditory neuropathy, and neurological co-morbidity in children with birthweight <750 g

BACKGROUND AND AIMS

The current literature considers a birthweight <1,500 g as a risk factor for sensorineural hearing loss (SNHL, hearing threshold >25 decibels), auditory neuropathy (AN), and several neurological sequelae. The aim of the study was to determine the frequency and risk factors associated with SNHL, AN, and neurological morbidity in a group of children with birthweights of <750 g treated at a neonatal care unit and recruited into a long-term follow-up program.

METHODS

A case-control study was carried out. Inclusion criteria were birthweight <750 g and born between the years 2000 and 2010. We performed brainstem auditory-evoked potentials (BAEP), evoked otoacoustic emissions (EOAE) and free-field audiometry (FFA) in this population. Neonatal variables and procedures were compared between children with SNHL and children with normal bilateral hearing (NBH).

RESULTS

A total of 93 children with a mean age of 4 years were included in the follow-up. Six children (6.4%) had SNHL and 87 had NBH. We were unable to identify AN in the sample. Mean weight for this sample was 673 ± 68 g and gestational age 27.5 ± 2 weeks. Variables reflecting differences between groups included days under mechanical ventilation, furosemide treatment, and bronchopulmonary dysplasia. In the SNHL group, three patients had periventricular leukomalacia, two had hydrocephalus, and one patient had cerebral palsy.

CONCLUSIONS

Frequency of SNHL in children with birthweights <750 g was higher than in other premature infants and was related with mechanical ventilation, furosemide application, and bronchopulmonary dysplasia. Association with other neurological morbidities was frequent. Early diagnosis and intervention are required.

Self-reported adolescent health status of extremely low birth weight children born 1992-1995

OBJECTIVES

To compare the self-reported health of extremely low birth weight (ELBW, <1 kg) adolescents with that of normal birth weight (NBW) controls and the children's assessments of their general health at ages 8 versus 14 years.

METHODS

One hundred sixty-eight ELBW children and 115 NBW controls of similar gender and sociodemographic status completed the Child Health and Illness Profile-Adolescent Edition at age 14 years. It includes 6 domains: Satisfaction, Comfort, Resilience, Risk Avoidance, Achievement, and Disorders. At age 8 years, the children had completed the Child Health and Illness Profile-Child Edition. Results were compared between ELBW and NBW subjects adjusting for gender and sociodemographic status.

RESULTS

ELBW adolescents rated their health similar to that of NBW adolescents in the domains of Satisfaction, Comfort, Resilience, Achievement and Disorders but reported more Risk Avoidance (effect size [ES] 0.6, P < .001). In the subdomain of Resilience, they also noted less physical activity (ES -0.58, P < .001), and in the subdomain of Disorders, more long-term surgical (ES -0.49) and psychosocial disorders (ES -0.49; both P < .01). Both ELBW and NBW children reported a decrease in general health between ages 8 and 14 years, which did not differ significantly between groups.

CONCLUSIONS

ELBW adolescents report similar health and well-being compared with NBW controls but greater risk avoidance. Both ELBW and NBW children rate their general health to be poorer at age 14 than at age 8 years, possibly due to age-related developmental changes.

Health status and health-related quality of life in a pediatric palliative care program

BACKGROUND

Children with life-threatening illnesses have unique physical and psychosocial needs that pediatric palliative care programs can address. Integrated programs strive to address these needs from the point of diagnosis through death, if needed, at the same time that curative care is provided. To better understand the variation in these needs, we assessed the health status and health-related quality of life (HRQOL) of children enrolled in an integrated pediatric palliative care program.

METHODS

A telephone survey was conducted with 98 parents whose children were enrolled in an integrated pediatric palliative care program in Florida. The Health Utilities Index (HUI) system was used to assess health status and HRQOL.

RESULTS

HUI2 attribute levels show that children have the greatest impairment with moderate-to-severe burdens related to self-care, mobility, and sensation, and the least impairment with emotion. HUI3 attribute levels show that children have the greatest impairment with moderate-to-severe burdens related to ambulation and cognition and the least impairment with hearing and emotional functioning. Mean overall HUI2 and HUI3 utility scores are 0.37 and 0.15, respectively.

CONCLUSION

Children with life-threatening illnesses in our sample had a high level of morbidity compared with those found in other HUI studies of children with acute or chronic health conditions. Not only do our results highlight severely impaired HRQOL, they also demonstrate the wide variety of health states and needs for children in integrated palliative care programs. This information can help develop strategies to encourage more providers to participate in integrated pediatric palliative care programs.

Quality of life of early school-age French children born preterm: a cohort study

OBJECTIVES

To describe the health-related quality of life (HRQL) of a cohort of children aged 6-10 years who were born preterm; and to determine whether sociodemographic factors, neonatal features and neurocognitive status were affecting their HRQL.

STUDY DESIGN

All singleton infants born between 24 and 32 weeks of gestation between January 1997 and December 2001 at the study hospital, who were still alive in 2007 (age 6-10 years), and who had undergone complete clinical paediatric follow-up were included in the study. Maternal and perinatal data were obtained by chart review and regular clinical examination. The 'Battery for Rapid Evaluation of Cognitive Functions' (BREV) was used for cognitive evaluation when children were aged 4-8 years. HRQL data were collected in 2007 using the 'Vécu et Santé Perçue de l'Adolescent et de l'Enfant' (VSP-A) questionnaire (parent version). The HRQL of the preterm children was compared with that of a French reference population.

RESULTS

Of 202 children who fulfilled the inclusion criteria, 82 children participated in the study. Their mean age was 7.9 years [standard deviation (SD) 1.4], mean birth weight was 1130.0 g (SD 361.4), 23 children were born before 28 weeks of gestation, 46 were female and 11 had major neurocognitive disorders. These data were not significantly different for the non-respondents (n=120). Parents of preterm children reported a significantly lower perception of HRQL of their child compared with parents of children in the reference population, as reflected by VSP-A global index scores and scores for the 'body image', 'vitality', 'psychological well-being' and 'school performance' dimensions. In multivariate analyses, three factors were found to be significantly associated with at least one dimension in the VSP-A scale in the preterm children: presence of major neurocognitive disorders, negatively correlated with 'vitality', 'relationships with friends', 'physical well-being' and 'school performance' dimensions; maternal parity, positively correlated with the 'psychological well-being' dimension; and socio-economic status of family, positively correlated with the 'relationships with friends' dimension. The maximum R(2) was 15%.

CONCLUSION

In addition to neurocognitive disorders, other variables such as socio-economic status of the family have a significant impact on the HRQL of preterm children at 6-10 years of age. Given the low proportion of variability in HRQL explained by the models, there is a need to explore other factors (e.g. environmental).

Quality of life of adolescents and young adults born at high risk

Research on quality of life (QoL) of adolescents and young adults born preterm and those with congenital heart disease (CHD) was systematically reviewed, and factors associated with QoL were identified. Forty-five studies met the inclusion criteria for review. Although the majority of studies found that self-reported QoL of adolescents and young adults born preterm did not differ from term controls, several studies reported lower QoL among individuals born preterm, especially those who had additional impairments. Most studies on adolescents and young adults with CHD reported lower QoL compared with healthy peers, which may be in part due to real or perceived physical activity limitations of individuals with CHD. Overall, parents reported that their adolescents born at high risk had a less favorable QoL compared with those who served as controls. Encouraging age-appropriate, safe, and enjoyable physical activity and avoiding unnecessary restrictions and overprotection are considerations for optimizing QoL.

Health status of extremely low-birth-weight children at 8 years of age: child and parent perspective

OBJECTIVES

To compare the self-reported health of extremely low-birth-weight (ELBW; <1 kg) preterm children with that of normal-birth-weight (NBW) control children and the children's perspective with that of their parents.

DESIGN

We administered questionnaires to the ELBW and NBW children and their parents from March 1, 2000, through February 2003.

SETTING

A children's hospital.

PARTICIPANTS

Two hundred two ELBW children and 176 NBW children aged 8 years of similar sociodemographic status.

MAIN EXPOSURE

Birth weight of less than 1 kg.

MAIN OUTCOME MEASURES

The Child Health and Illness Profile-Child Edition child and parent reports.

RESULTS

There was poor agreement between the parent and child ratings of health for the ELBW and NBW cohorts. The ELBW children rated their health as similar to that of NBW children. In contrast, parents of ELBW children reported significantly poorer health for their children than parents of NBW controls, including poorer satisfaction with health, comfort, and achievement and less risk avoidance.

CONCLUSIONS

There is poor agreement between child and parent reports of health. At 8 years of age, ELBW children rate their health as similar to that of NBW controls. Their parents, however, report significantly poorer health. Both perspectives need to be considered when making health care decisions.

Mapping analyses to estimate health utilities based on responses to the OM8-30 Otitis Media Questionnaire

PURPOSE

To investigate the statistical relationship between the OM8-30 health-related quality of life measure for children with otitis media with effusion (OME) and measures of health utility (Health Utilities Index [HUI] Mark 3 and Mark 2) and to develop models to estimate HUI3 and HUI2 health utilities from OM8-30 scores.

METHODS

A placebo-controlled, randomised trial (GNOME) evaluating intranasal mometasone in 217 children with OME provided concurrent responses to OM8-30 and HUI at three time points. Ordinary least squares (OLS), generalised linear models and two-step regression analyses were used to predict HUI3 and HUI2 utilities based on OM8-30 facet and domain scores.

RESULTS

OLS models including all nine OM8-30 facets with or without predicted hearing level (HL) produced the best predictions of HUI3 utilities (mean absolute error: 0.134 with HL and 0.132 without; R(2): 0.63 with HL and 0.596 without). An OLS model predicting HUI3 utilities based on the two OM8-30 domain scores, reported hearing difficulties, predicted HL, age and sex also produced accurate predictions.

CONCLUSION

Regression equations predicting HUI3 and HUI2 utilities based on OM8-30 facet and domain scores have been developed. These provide an empirical basis for estimating quality-adjusted life years (QALYs) for interventions in children with OME.

Costs and health utilities associated with extremely preterm birth: evidence from the EPICure study

OBJECTIVE

To estimate costs and health utilities associated with extremely preterm birth at approximately 11 years of age using evidence from a whole population study (the EPICure study).

METHODS

The study population comprised surviving children born at 20 through 25 completed weeks of gestation in all 276 maternity units in the United Kingdom and Republic of Ireland from March through December 1995 and a control group of classmates born at full term, matched for age, sex, and ethnic group. Estimates of utilization of health, social, and education services were combined with unit costs derived from primary and secondary sources. Generalized liner regression was used to estimate the impact of extremely preterm birth on public sector costs during the 11th year of life. Suboptimal levels of function for each of the eight attributes of the Health Utilities Index Mark III (cognition, vision, hearing, speech, ambulation, dexterity, emotion, and pain) and multiplicative multi-attribute utility scores were compared between the extremely preterm children and their classmates. Tobit regressions were performed to explore the effects of gestational age at birth on the Health Utilities Index Mark III multiattribute utility score.

RESULTS

Mean (standard deviation [SD]) public sector costs over the 12-month period were 6484 UK pounds (5548 pounds) for the combined extremely preterm group and 4007 pounds (2537 pounds) for their classmates, generating a mean cost difference of 2477 UK pounds(bootstrap 95% confidence interval [CI] 1605 pounds, 3360 pounds) that was statistically significant (P < 0.001). The generalized linear models revealed that compared to birth at term, birth at < or =23 completed weeks, 24(+0)-24(+6) weeks and 25(+0)-25(+6) weeks gestation increased public sector costs by an average of 2417 UK pounds (95% CI 60 pounds, 4774 pounds; P = 0.044), 1528 UK pounds (95% CI 129 pounds, 2927 pounds; P = 0.032) and 1501 UK pounds (95% CI 428 pounds, 2574 pounds; P = 0.006), respectively. In all eight attributes of the Health Utilities Index Mark III, there were significantly higher proportions of suboptimal levels of function among the extremely preterm children (P < or = 0.05). The mean (SD) multiattribute utility score for the extremely preterm children as a cohort was 0.789 (0.264), compared to 0.956 (0.102) for the classmates born at term, a mean difference in utility score of 0.167 (95% CI 0.124, 0.209) that was statistically significant (P < 0.001). The Tobit regressions revealed that, compared to birth at term, birth at < or =23 completed weeks, 24(+0)-24(+6) weeks and 25(+0)-25(+6) weeks gestation reduced the Health Utilities Index Mark III multi-attribute utility score by an average of 0.312 (95% CI 0.169, 0.455; P < 0.001), 0.337 (95% CI 0.235, 0.439; P < 0.001) and 0.243 (95% CI 0.159, 0.327; P < 0.001), respectively.

CONCLUSIONS

The results of this study should be used to inform the development of future economic evaluations of interventions aimed at preventing extremely preterm birth or alleviating its effects.

Health-related quality of life in 5-year-old very low birth weight infants

OBJECTIVE

To investigate the effect of preterm birth, the time of birth, and birth hospital level and district on health-related quality of life (HRQoL) and quality-adjusted life years (QALYs).

STUDY DESIGN

This national study included all very low birth weight infants (VLBWIs; birth weight <or= 1500 g or gestational age < 32 weeks) born in Finland between 2000 and 2003 (n = 1169; live-born, n = 900) and full-term controls (n = 368). Register data and parental questionnaires were used. The relationships among HRQoL and QALYs at age 5 years and preterm birth, time of birth, and the level and district of the birth hospital were studied.

RESULTS

HRQoL at age 5 years was lower and 1.3 QALYs were lost in VLBWIs compared with controls. Regional differences in the QALYs of VLBWIs were found among the 5 university hospital districts. Birth hospital level or birth outside office hours had no effect on the QALYs of live-born VLBWIs. The adjusted HRQoL total score was not affected by birth outside office hours or by the birth hospital level or district.

CONCLUSIONS

Differences in QALYs related to hospital district suggest variation in the care of VLBWIs that needs to be addressed.

Clinical report--Antenatal counseling regarding resuscitation at an extremely low gestational age

The anticipated delivery of an extremely low gestational age infant raises difficult questions for all involved, including whether to initiate resuscitation after delivery. Each institution caring for women at risk of delivering extremely preterm infants should provide comprehensive and consistent guidelines for antenatal counseling. Parents should be provided the most accurate prognosis possible on the basis of all the factors known to affect outcome for a particular case. Although it is not feasible to have specific criteria for when the initiation of resuscitation should or should not be offered, the following general guidelines are suggested. If the physicians involved believe there is no chance for survival, resuscitation is not indicated and should not be initiated. When a good outcome is considered very unlikely, the parents should be given the choice of whether resuscitation should be initiated, and clinicians should respect their preference. Finally, if a good outcome is considered reasonably likely, clinicians should initiate resuscitation and, together with the parents, continually reevaluate whether intensive care should be continued. Whenever resuscitation is considered an option, a qualified individual, preferably a neonatologist, should be involved and should be present in the delivery room to manage this complex situation. Comfort care should be provided for all infants for whom resuscitation is not initiated or is not successful.

PedsQL relates to function and behavior in very low and normal birth weight 2- and 3-year-olds from a regional cohort

STUDY OBJECTIVE

To compare PedsQL scores in young children who were very low (< or =1,500 g) or normal birth weight (>2,500 g) and to examine the relationship of the PedsQL score to behavioral and functional scores.

METHODS

The PedsQL, Achenbach Child Behavior Checklist and the PEDI functional scales were telephone administered to parents of a regional cohort of 672 very low birth weight and 455 normal birth weight children, 2- and 3-years old. PedsQL scales were regressed on behavior, function and health conditions.

RESULTS

Mean (SD) overall PedsQL score was 91 (8.4) for normal birth weight and 87 (12) for very low birth weight children, and changed little when standardized to the race/ethnicity and maternal education of corresponding Wisconsin births. Mobility function and the CBCL explained 58% of the variance in PedsQL, but the relationship was curvilinear.

CONCLUSION

The PedsQL is sensitive to health problems of very low birth weight in young children. The PedsQL is quite strongly related to mobility and behavior problems, but scales these differently than do standard instruments. Parents either do not think of subtle issues with child function and behavior without specific prompting or do not perceive them as problems affecting quality of life.

Measurement of quality of life of survivors of neonatal intensive care: critique and implications

In recent years, an increasing number of studies on the quality of life (QoL) of adults and children have been published, mostly describing outcomes of various medical conditions. Yet, despite the wide interest, there is no universal consensus even on the very definition of what constitutes QoL, particularly for children. Herein, we discuss the conceptual framework and operational definitions of QoL and health-related quality of life (HRQL), address some methodological issues, and review the literature on QoL studies among premature infants. We also describe areas of research that are likely to be fruitful in advancing the consideration of QoL in future studies and in clinical practice.