Mental Health in Children Born Extremely Preterm Without Severe Neurodevelopmental Disabilities

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Scandinavian perspectives on life support at the border of viability

Advances in neonatal medicine have allowed us to rescue extremely preterm infants. However, both long-term vulnerability and the burden of treatment in the neonatal period increase with decreasing gestational age. This raises questions about the justification of life support when a baby is born at the border of viability, and has led to a so-called "grey zone", where many professionals are unsure whether provision of life support is in the child's best interest. Despite cultural, political and economic similarities, the Scandinavian countries differ in their approach to periviable infants, as seen in their respective national guidelines and practices. In Sweden, guidelines and practice are more rescue-focused at the lower end of the border of viability, Danish guidelines emphasizes the need to involve parental views in the decision-making process, whereas Norway appears to be somewhere in between. In this paper, I will give an overview of national consensus documents and practices in Norway, Sweden and Denmark, and reflect on the ethical justification for the different approaches.

Understanding the course of attention deficit hyperactivity disorder in children born after a threatened preterm labor: a 6-year cohort study

BACKGROUND

Recent research suggests that children born after suspected preterm labor may observe a potential cluster with different attention deficit hyperactivity disorder features, depending on the time of birth. However, the evolution of symptoms and their predictors remain unknown in this population.

OBJECTIVE

This study aimed to examine the trajectories of attention deficit hyperactivity disorder symptoms of children born after suspected preterm labor, between ages 2 and 6 years, considering prematurity condition and comparing with controls. In addition, this study aimed to find potential modifiable predictors of evolution to enhance prognosis.

STUDY DESIGN

In this prospective cohort study, 119 mother-child pairs who experienced suspected preterm labor and 60 controls were included. Patients were divided according to prematurity condition in full term (n=27), late preterm (n=55), and very preterm (n=37). Attention deficit hyperactivity disorder symptoms were assessed at ages 2 and 6 years. The association between potential modifying factors (group, time of assessment, sex, birthweight percentile, maternal history of trauma, maternal anxiety at diagnosis, and maternal anxiety during the children's assessments) and disorder trajectories was assessed by adjusting the Bayesian mixed linear models. All analyses were performed in R (version 4.3.0; R Foundation for Statistical Computing, Vienna, Austria).

RESULTS

An interaction emerged between time and group, with late-preterm neonates born after suspected preterm labor being the only group to improve from ages 2 to 6 years (-2.26 points in Conners scale per percentile decrease and 0.98 probability of effect). Another interaction between time and maternal anxiety at postnatal time assessments intensified over time (0.07 and 0.84). Predictors of symptom severity included lower weight percentile at birth (-0.2 and 0.96), male sex (-2.99 and <0.99), higher maternal anxiety at diagnosis (+0.08 and 0.99), and maternal history of trauma (+0.23 and 0.98).

CONCLUSION

Unlike very-preterm and full-term children, those born late preterm showed an improvement over time, probably because late-preterm children do not carry the sequelae derived from severe prematurity but benefit from close monitoring. As maternal psychopathology emerged as a determinant modifier of course and severity, it is crucial to develop targeted psychological interventions for pregnant individuals and reevaluate monitoring programs for their offspring, regardless of prematurity.

Neurobehavioral symptoms in children born extremely preterm: A Swedish National Study

AIM

To determine the prevalence of neurobehavioral symptoms at 6.5 years in children born extremely preterm (EPT, <27 weeks' gestation).

METHODS

Population-based cohort study of infants born EPT in Sweden from 2004 to 2007. Of 486 survivors 375 were assessed and compared with 369 matched term-born controls. EPT children free from neurosensory and intellectual disabilities (neurodevelopmental disabilities [NDD]-free, n = 236) were compared separately. Standardised questionnaires were used to assess parental ratings of hyperactivity and attention, emotional, peer-relation, conduct and social problems; and deficits in perception, language and memory.

RESULTS

EPT children had more reported problems in all assessed neurobehavioral domains than controls, with more than three times greater odds for most outcomes. Except for conduct problems, increased problems were identified also in NDD-free children. The odds of having neurobehavioral problems in ≥3 co-occurring domains were five (whole EPT group) and three (NDD-free group) times higher than in controls.

CONCLUSION

EPT children with or without NDD have more neurobehavioral problems in multiple domains than term peers. Ongoing assessments of behaviour until school age or beyond should recognise early symptoms of attention, everyday social problems, perceptual, emotional or language difficulties.

Change in neurodevelopmental outcomes for extremely premature infants over time: a systematic review and meta-analysis

OBJECTIVE

Survival rates of extremely premature infants are rising, but changes in neurodevelopmental impairment (NDI) rates are unclear. Our objective was to perform a systematic review of intrainstitutional variability of NDI over time.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Ovid MEDLINE, Embase, PubMed, Cochrane Library and Google Scholar.

STUDY SELECTION

Study eligibility: (1) at least two discrete cohorts of infants born <27 weeks' gestation or <1000 g birth weight, (2) one cohort born after 1990 and at least one subsequent cohort of similar gestational age, (3) all cohorts cared for within the same Neonatal Intensive Care Unit(s) (NICU) and (4) neurodevelopmental outcomes at 18-36 months corrected age.

MAIN OUTCOME

Change in NDI rates. Quality, validity and bias were assessed using Grading of Recommendations, Assessment, Development, and Evaluation and Quality in Prognosis Studies guidelines.

RESULTS

Of 203 publications, 15 were eligible, including 13 229 infants. At the first time point, average NDI rate across study groups weighted by sample size was 41.0% (95% CI 34.0% to 48.0%). The average change in NDI between time points was -3.3% (95% CI -8·8% to 2.2%). For each added week of gestation at birth, the rate of NDI declined by 9.7% (95% CI 6.2% to 13.3%). Most studies exhibited moderate-severe bias in at least one domain, especially attrition rates.

CONCLUSIONS

When comparing discrete same-centre cohorts over time, there was no significant change in NDI rates in infants born <27 weeks' gestation or <1000 g. Higher survival rates unaccompanied by improvement in neurodevelopment highlight urgency for renewed focus on the causes of NDI and evidence-based strategies to reduce brain injury.

Symptoms and antecedents of autism in children born extremely premature: a national population-based study

The objective of this study is to investigate the prevalence of autism (ASD) symptoms, i.e. , social difficulties, repetitive behaviors, and communicational problems, among children born extremely preterm (EP) compared to a reference group, and to investigate possible antecedents of ASD symptoms among EP children. Method is a national Norwegian cohort of 11 year old EP children, excluding those with intellectual disabilities, non-ambulatory cerebral palsy, blindness, and/or deafness. Parents and teachers reported ASD symptoms using The Autism Spectrum Screening Questionnaire (ASSQ). Social difficulties, repetitive behaviors, communicational problems, and a total ASSQ score were presented. Combined ratings on the ASSQ was defined as parent and/or teacher scoring the child ≥ 98th percentile of the reference group, which was the population-based Bergen Child Study. Of eligible children, 216 (64%) EP and 1882 (61%) reference children participated. EP children had significantly higher mean scores and combined ratings on social difficulties (14.5% vs. 4.1%, OR: 3.2), repetitive behaviors (23.7% vs. 4.0%, OR: 6.4), communicational problems (23.1% vs. 4.8%, OR: 5.4), and the total ASSQ score (18.3% vs. 3.4%, OR: 5.7) compared to reference children. Only no prenatal steroids, IQ 70-84, and mental health problems at 5 years of age were significantly associated with ASD symptoms at 11 years of age. EP children were at increased risk of social difficulties, repetitive behaviors, and communicational problems, and approximately one out of five were reported as high scorers of ASD symptoms. No prenatal steroids use, IQ in the lower range, and mental health problems at 5 years of age were associated with ASD symptoms.

Sex differences in the effects of prematurity and/or low birthweight on neurodevelopmental outcomes: systematic review and meta-analyses

BACKGROUND

Premature birth and/or low birthweight have long-lasting effects on cognition. The purpose of the present systematic review is to examine whether the effects of prematurity and/or low birth weight on neurodevelopmental outcomes differ between males and females.

METHODS

Web of Science, Scopus, and Ovid MEDLINE were searched for studies of humans born premature and/or of low birthweight, where neurodevelopmental phenotypes were measured at 1 year of age or older. Studies must have reported outcomes in such a way that it was possible to assess whether effects were greater in one sex than the other. Risk of bias was assessed using both the Newcastle-Ottawa scale and the National Institutes of Health Quality assessment tool for observational cohort and cross-sectional studies.

RESULTS

Seventy-five studies were included for descriptive synthesis, although only 24 presented data in a way that could be extracted for meta-analyses. Meta-analyses found that severe and moderate prematurity/low birthweight impaired cognitive function, and severe prematurity/low birthweight also increased internalizing problem scores. Moderate, but not severe, prematurity/low birthweight significantly increased externalizing problem scores. In no case did effects of prematurity/low birthweight differ between males and females. Heterogeneity among studies was generally high and significant, although age at assessment was not a significant moderator of effect. Descriptive synthesis did not identify an obvious excess or deficiency of male-biased or female-biased effects for any trait category. Individual study quality was generally good, and we found no evidence of publication bias.

CONCLUSIONS

We found no evidence that the sexes differ in their susceptibility to the effects of severe or moderate prematurity/low birthweight on cognitive function, internalizing traits or externalizing traits. Result heterogeneity tended to be high, but this reflects that one sex is not consistently more affected than the other. Frequently stated generalizations that one sex is more susceptible to prenatal adversity should be re-evaluated.

Latent class analysis to characterize neonatal risk for neurodevelopmental differences

BACKGROUND

Neonatal risk factors, such as preterm birth and low birth weight, have been robustly linked to neurodevelopmental deficits, yet it is still unclear why some infants born preterm and/or low birth weight experience neurodevelopmental difficulties while others do not. The current study investigated this heterogeneity in neurodevelopmental abilities by examining additional neonatal morbidities as risk factors, utilizing latent class analysis to classify neonates into groups based on similar neonatal risk factors, and including neonates from the full spectrum of gestational age.

METHODS

Neonates who received neonatal care at an academic public hospital during an almost 10-year period (n = 19,951) were included in the latent class analysis, and 21 neonatal indicators of health were used. Neonatal class, sex, and the interaction between neonatal class and sex were used to examine differences in neurodevelopment at 18 months of age in a typically developing population.

RESULTS

The best fitting model included five infant classes: healthy, hypoxic, critically ill, minorly ill, and complicated delivery. Scores on the parent-rated neurodevelopmental measure differed by class such that infants in the critically ill, minorly ill, and complicated delivery classes had lower scores. There was no main effect of sex on the neurodevelopmental measure scores, but the interaction between sex and neonatal class was significant for three out of five neurodevelopmental domains.

CONCLUSIONS

The current study extends the understanding of risk factors in neurodevelopment by including several neonatal medical conditions that are often overlooked and by using a person-centered, as opposed to variable-centered, approach. Future work should continue to examine risk factors, such as maternal health during pregnancy and medical interventions for newborns, in relation to neonatal risks and neurodevelopment by using a person-centered approach.

Relative Age and Psychotropic Drug Use in Preterm and Term-Born Children and Young Adults

BACKGROUND AND OBJECTIVES

Being among the youngest within a school class is linked to disadvantages in various educational and mental health domains. This study aimed to investigate whether preterm born infants are particularly vulnerable to relative age effects on mental health, not previously studied.

METHODS

We used registry data on all Norwegians born between 1989 and 1998 to compare prescription status for psychostimulants, antidepressants, hypnotics, anxiolytics, and antipsychotics per year from age 10 to 23 years (2004-2016) between exposure groups with different time of birth in the year (relative age) and different gestational age (preterm versus term).

RESULTS

Of 488 470 individuals, 29 657 (6,1%) were born preterm. For term born in November/December, the adjusted odds ratio (aORs) for psychostimulant prescription compared with peers born in January/February was 1.80 (95% confidence interval [CI], 1.69-1.91) at ages 10 to 14 years, and 1.17 (95% CI, 1.08-1.27) at ages 20 to 23 years. Within preterm born, the corresponding results were 1.39 (95% CI, 1.13-1.69) and 1.34 (95% CI, 1,00-1.78) at ages 10 through 14 and 20 through 23 years, respectively.

CONCLUSIONS

Being relatively young within the school group was associated with increased psychostimulant prescription in the preterm as well as the term population. In contrast to term peers, the relative age effect for psychostimulant prescription seemed to persist to young adulthood for the preterm population. The results suggest that preterm individuals are vulnerable to long-term effects of relative immaturity and that they require careful consideration from both health care professionals and the school system.

Evaluation of the InterRAI Early Years for Degree of Preterm Birth and Gross Motor Delay

Background

The interRAI 0–3 Early Years was recently developed to support intervention efforts based on the needs of young children and their families. One aspect of child development assessed by the Early Years instrument are motor skills, which are integral for the maturity of cognition, language, social-emotional and other developmental outcomes. Gross motor development, however, is negatively impacted by pre-term birth and low birth weight. For the purpose of known-groups validation, an at-risk sample of preterm children using the interRAI 0–3 Early Years was included to examine correlates of preterm risk and the degree of gross motor delay.

Methods

Participant data included children and families (n = 591) from 17 health agencies in Ontario, Canada. Data were collected as part of a pilot study using the full interRAI 0–3 Early Years assessment. Correlational analyses were used to determine relationships between prenatal risk and preterm birth and bivariate analyses examined successful and failed performance of at-risk children on gross motor items. A Kruskal-Wallis test was used to determine the mean difference in gross motor scores for children born at various weeks gestation.

Results

Correlational analysis indicated that prenatal and perinatal factors such as maternal nicotine use during pregnancy did not have significant influence over gross motor achievement for the full sample, however, gross motor scores were lower for children born pre-term or low birth weight based on bivariate analysis. Gross motor scores decreased from 40 weeks’ gestation (mean rank = 310.77), to moderate to late preterm (mean rank = 258.96), and to very preterm (mean rank = 234.54), however extremely preterm (mean rank = 236.28) performed comparably to very preterm.

Interpretation

The interRAI 0–3 was evaluated to determine its efficacy and report findings which confirm the literature regarding delay in gross motor performance for preterm children. Findings confirm that pre-term and low birth weight children are at greater risk for motor delay via the interRAI 0–3 Early Years gross motor domain.

Development and reliability of the coding system evaluating maternal sensitivity to social interactions with 34- to 36-week postmenstrual age preterm infants

Maternal sensitivity (MS), the ability to perceive and synchronously respond to the social signals (SSs), is affected by prematurity. The development of early supportive psychotherapy to foster MS, before discharge of the infant from the neonatal intensive care unit (NICU) is a major challenge in the prevention of subsequent developmental and mental disorders in the child. There are currently no reliable methods for evaluating MS to social interactions with very to moderate preterm infants. We investigated the reliability of a newly developed procedure for assessing MS in interactions between the mother and her 34- to 36-week postmenstrual age (PMA) preterm infant: the Preterm Infant Coding System for Maternal Sensitivity (PRICOSMAS).

METHOD

This study encompassed three steps: testing of the capacity to videorecord SSs in very to moderate preterm infants, selection, by an expert committee, of the recordable and relevant SSs, and investigation of the internal consistency and interrater reliability. The synchronicity between infant and mother's SSs was determined on a 1 s period basis, using ELAN software. Preterm infants born after 25-weeks gestational age (GA) were included while being between 34- and 36-weeks PMA. A perinatal risk inventory score > 10 for the infant precluded from inclusion. Interrater reliabilities were assessed independently by two raters blind to the clinical situation of the mother and infant.

RESULTS

The resulting PRICOSMAS encompassed two four-item SS sections, one covering the preterm infant's SSs and the other, the mother's SSs. Reliability was assessed on a sample of 26 videorecorded observations for 13 mother-preterm infant dyads. Infants' mean age at birth was 30.4 ± 3.1-weeks GA (range: 26.4-35) and PMA at the time of the test was 34.7-weeks (±0.8). Internal consistency ranged from 0.81 to 0.89. Interrater reliability ranged from substantial to almost perfect (0.73-0.88).

CONCLUSION

This study shows that the infants' SSs and MS can be reliably scored in preterm infants as young as 34- to 36-weeks PMA. Our findings suggest that the PRICOSMAS is sufficiently reliable for use, including in NICU, by healthcare professionals or researchers for coding early parent-infant interactions with 34- to 36-week PMA preterm infants.

Effectiveness of Bedside Clinical Screening Tools in Predicting Short-Term Neurodevelopmental Delay Among Very-Low-Birth-Weight Pre-terms: A Prospective Observational Study

Background: Pre-term births are associated with increased risk of various morbidities, especially neurological. Early detection and early intervention to prevent these morbidities will have immediate and long-term benefits to the individuals and society at large. However, the screening and assessment tools, including both clinical and radiological, are not uniformly available in resource-poor settings. The present study was carried out to evaluate the validity of the clinical screening tools for detecting neurodevelopmental delay among very-low-birth-weight (VLBW) pre-term babies.

Methods: This prospective observational study was undertaken in the child development unit of a tertiary care hospital from July 2015 to October 2017. All pre-term VLBW neonates admitted in level III Neonatal Intensive Care within the first 24 hours of life were included in the study. They were subjected to Hammersmith Neonatal Neurological Examination (HNNE) and magnetic resonance imaging (MRI) of brain at term-equivalent age. Subsequently, the same group was followed up with Amiel-Tison (AT) angles, Child Development Centre (CDC) grading for sitting developed at Trivandrum, Kerala, India, and Denver Development Screening Test (DDST-II gross motor) at eight months corrected age, and their outcomes were analyzed.

Results: 17.9% of the ex-preterm were abnormal as per HNNE evaluation at term-corrected age. At short-term follow-up screening, 13.8% were found to be abnormal based on AT angles, while 35.2% were found to be abnormal as per CDC grading and 30.4% were found to have risk for delay as per DDST-II (gross motor). A high level of sensitivity (93.6%) and positive predictive value (91.2%) was observed for HNNE at term equivalent with MRI brain assessment considered as gold standard. Among the follow-up screening tools, CDC grading for sitting, AT angles, and DDST-II had high sensitivity (>85%).

Conclusion: The combination of HNNE along with radiological assessment at term-corrected age can be considered as appropriate for predicting long-term neurodevelopmental outcome in VLBW pre-term infants. During follow-up, simple tools like CDC grading for motor milestones, AT angles, and DDST-II may be utilized if facilities for standard assessment are not available as in resource-poor settings.

Interaction of Impulsivity, Attention, and Intelligence in Early Adolescents Born Preterm without Sequelae

There is insufficient evidence on the intellectual and attentional profile of adolescents born prematurely. Aim: to identify maladjustment in intellectual and attention skills at the beginning of secondary school. Method: 69 premature 12-year-old adolescents were evaluated with the WISC, d2 Test of Attention, and Test of Perception of Differences-Revised (CARAS-R). Results: adolescents present intellectual and attention abilities in the normal range. However, all premature adolescents show difficulties in impulse control and female adolescents are better in processing speed. Depending on the category of prematurity, differences in attention skills are evident. Conclusion: adolescents born prematurely without associated sequelae have significantly lower performance in the same areas than the normative group. This could affect the cognitive control of their behavior and academic performance in the medium and long term. Great prematurity could interfere with attention skills and self-control even at the age of 12, especially in males.

Longitudinal Study of Music Therapy's Effectiveness for Premature Infants and Their Caregivers (LongSTEP): Feasibility Study With a Norwegian Cohort

Premature infants and their parents experience significant stress during the perinatal period. Music therapy (MT) may support maternal-infant bonding during this critical period, but studies measuring impact across the infant's first year are lacking. This nonrandomized feasibility study used quantitative and qualitative methods within a critical realist perspective to evaluate the feasibility, acceptability, and suitability of the treatment arm of the Longitudinal Study of music Therapy's Effectiveness for Premature infants and their caregivers (LongSTEP) (NCT03564184) trial with a Norwegian cohort (N = 3). Families were offered MT emphasizing parent-led infant-directed singing during neonatal intensive care unit (NICU) hospitalization and across 3 months post-discharge. We used inductive thematic analysis of semi-structured interviews with parents at discharge from NICU and at 3 months and analyzed quantitative variables descriptively. Findings indicate that: (1) parents of premature infants are willing to participate in MT research where parental voice is a main means of musical interaction; (2) parents are generally willing to engage in MT in NICU and post-discharge phases, finding it particularly interesting to note infant responsiveness and interaction over time; (3) parents seek information about the aims and specific processes involved in MT; (4) the selected self-reports are reasonable to complete; and (5) the Postpartum Bonding Questionnaire appears to be a suitable measure of impaired maternal-infant bonding. Parents reported that they were able to transfer resources honed during MT to parent-infant interactions outside MT and recognized parental voice as a central means of building relation with their infants. Results inform the implementation of a subsequent multinational trial that will address an important gap in knowledge.

Sex influences on the neurocognitive outcome of preterm children

This article presents a revision of the literature regarding the influence of sex differences on the recovery and long-term behavioral and cognitive outcomes of preterm children. After initial discussion of some methodological concerns, the literature regarding the concept of "male disadvantage," which is often used when talking about early neurological and psychomotor outcomes in preterm children, is presented. Subsequently, the literature data on sex-related differences in preterm children are discussed, focusing on their influence on the developmental pathways of cognition, language, executive function, behavior and affect, and response to rehabilitation therapies. Finally, evidence about brain structural and connectivity correlates of sex differences in the brain of preterm survivors is taken into account. Although visuo-spatial and visuo-perceptual functioning is widely studied in the preterm child and is strongly sex specific, little to no data are available regarding male-female differences in preterm children and the interaction effect between sex and preterm birth. For this reason, original data analyses of male-female differences in visuo-spatial performance from a small sample of preterm children are also presented.

Association of Preterm Birth With Prescription of Psychotropic Drugs in Adolescence and Young Adulthood

IMPORTANCE

Individuals born preterm have increased risk of mental health impairment compared with individuals born at term. The associations between preterm birth and attention-deficit/hyperactivity disorder and autism are well established; for depression, anxiety, psychotic and bipolar disorder, studies show divergent results.

OBJECTIVE

To compare the prescription of psychotropic drugs in adolescence and young adulthood between those born preterm and those born at term.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used registry data to identify all Norwegians born after 23 weeks of completed gestation between 1989 and 1998. Included individuals were those without registered birth defects, alive at age 10 years, and with available maternal data. Individuals were followed up from 2004 to 2016. Psychotropic drug prescriptions received from age 10 to 23 years were compared between preterm groups and peers born at term. Individuals were compared with their siblings to control for shared family confounding. Data analyses were performed from August 2018 through February 2020.

EXPOSURES

Gestational age at birth (GA) was categorized in 4 groups: extremely preterm (GA, 23 weeks and 0 days to 27 weeks and 6 days), very preterm (GA, 28 weeks and 0 days to 31 weeks and 6 days), moderately or late preterm (GA, 32 weeks and 0 days to 36 weeks and 6 days), and full term (GA, 37 weeks and 0 days to 44 weeks and 6 days).

MAIN OUTCOMES AND MEASURES

Prescriptions of psychotropic drugs (ie, prescriptions specifically of psychostimulants, antidepressants, anxiolytics, hypnotics or sedatives, or antipsychotics or prescriptions of any of these 5 drugs) among preterm groups were compared with prescriptions among peers born at term and among siblings.

RESULTS

Among 505 030 individuals (259 545 [51.4%] males; mean [SD] birth weight, 3533 [580] g), 762 individuals (0.2%) were extremely preterm, 2907 individuals (0.6%) were very preterm, 25 988 individuals (5.1%) were moderately or late preterm, and 475 373 individuals (94.1%) were full term. Individuals born preterm had increased risk of psychotropic drug prescription, with a dose-response association between GA and prescription. The extremely preterm group had higher rates of prescription for all drug types compared with peers born at term, with odds ratios from 1.7 (95% CI, 1.4-2.1) for antidepressants to 2.7 (95% CI, 2.1-3.4) for psychostimulants. The elevated odds of prescription of all types were less pronounced in the moderately to late preterm group, including odds ratios of 1.1 (95% CI, 1.0-1.1) for antidepressants and 1.2 (95% CI, 1.1-1.2) for psychostimulants. The increases in odds were smaller in the sibling comparison, and increases were not significant for several groups. For example, the OR for any prescription in the sibling analysis was 1.8 (95% CI, 1.2-2.8) in the very preterm group and 1.0 (95% CI, 0.9-1.1) in the moderately or late preterm group.

CONCLUSIONS AND RELEVANCE

This cohort study found higher rates of prescription of psychotropic drugs throughout adolescence and young adulthood among individuals with all degrees of preterm birth compared with those born at term. These results provide further evidence for an increased risk of mental health impairment among individuals born preterm and suggest that this is not restricted to the most preterm groups.

Intellectual Disability in KATP Channel Neonatal Diabetes

OBJECTIVE

Neonatal diabetes has been shown to be associated with high neuropsychiatric morbidity in a genotype-phenotype-dependent manner. However, the specific impact of different mutations on intellectual functioning is still insufficiently characterized. Specifically, only a small number of subjects with developmental delay have been comprehensively assessed, creating a knowledge gap about patients carrying the heaviest burden.

RESEARCH DESIGN AND METHODS

We assessed the intellectual functioning and mental health of the complete Norwegian population with K_ATP channel neonatal diabetes. Eight sulfonylurea-treated children (five with the p.V59M genotype [KCNJ11]) were assessed using age-matched control subjects with type 1 diabetes. The investigations included a physical and motor developmental examination, cerebral MRI, psychometrical examination, and questionnaires assessing intellectual capabilities and psychiatric morbidity.

RESULTS

A strong genotype-phenotype correlation was found, revealing the p.V59M genotype as highly associated with substantial intellectual disability, with no significant correlation with the time of sulfonylurea initiation. Consistent with previous studies, other genotypes were associated with minor cognitive impairment. Cerebral MRI verified normal brain anatomy in all but one child.

CONCLUSIONS

We here presented a comprehensive assessment of intellectual functioning in the largest cohort of p.V59M subjects to date. The level of intellectual disability revealed not only changes the interpretation of other psychological measures but downplays a strong protective effect of sulfonylurea. Within the scope of this study, we could not find evidence supporting an early treatment start to be beneficial, although a weaker effect cannot be ruled out.

Unisensory and Multisensory Responses in Fetal Alcohol Spectrum Disorders (FASD): Effects of Spatial Congruence

While it is generally accepted that structural and functional brain deficits underlie the behavioral deficits associated with Fetal Alcohol Spectrum Disorders (FASD), the degree to which these problems are expressed in sensory pathology is unknown. Electrophysiological measures indicate that neural processing is delayed in visual and auditory domains. Furthermore, multiple reports of white matter deficits due to prenatal alcohol exposure indicate altered cortical connectivity in individuals with FASD. Multisensory integration requires close coordination between disparate cortical areas leading us to hypothesize that individuals with FASD will have impaired multisensory integration relative to healthy control (HC) participants. Participants' neurophysiological responses were recorded using magnetoencephalography (MEG) during passive unisensory or simultaneous, spatially congruent or incongruent multisensory auditory and somatosensory stimuli. Source timecourses from evoked responses were estimated using multi-dipole spatiotemporal modeling. Auditory M100 response latency was faster for the multisensory relative to the unisensory condition but no group differences were observed. M200 auditory latency to congruent stimuli was earlier and congruent amplitude was larger in participants with FASD relative to controls. Somatosensory M100 response latency was faster in right hemisphere for multisensory relative to unisensory stimulation in both groups. FASD participants' somatosensory M200 responses were delayed by 13 ms, but only for the unisensory presentation of the somatosensory stimulus. M200 results indicate that unisensory and multisensory processing is altered in FASD; it remains to be seen if the multisensory response represents a normalization of the unisensory deficits.

The Golden Hour: a quality improvement initiative for extremely premature infants in the neonatal intensive care unit

BACKGROUND

Following delivery, extremely premature infants are vulnerable to rapid development of hypothermia and hypoglycemia. To reduce local rates of these morbidities, a multidisciplinary team developed a protocol standardizing evidence-based care practices during the first hour after birth.

METHODS

Using quality improvement methodology, the Golden Hour protocol was implemented for all inborn infants <27 weeks' gestation. Data were collected (2012-2017) over three phases; pre-protocol (n = 80), Phase I (n = 42), and Phase II (n = 92).

RESULTS

There were no significant differences in infant characteristics. Improvements in hypothermia (59% vs 26% vs 38%; p = 0.001), hypoglycemia (18% vs 7% vs 4%; p = 0.012), and minutes to completion of stabilization [median (Q1,Q3) 110 (89,138) vs 111 (94,135) vs 92 (74,129); p = 0.0035] were observed.

CONCLUSIONS

Implementation of an evidence-based, Golden Hour protocol is an effective intervention for reducing hypothermia and hypoglycemia in extremely premature infants.

Risk for Behavioral Problems Independent of Cognitive Functioning in Children Born at Low Gestational Ages

This study aimed to investigate cognitive and behavioral outcomes in relation to gestational age (GA) in school-aged children born preterm (PT). Results from the Wechsler Intelligence Scale for Children, 4th edition (WISC-IV), and the Child Behavior Checklist (CBCL) were analyzed in 51 children (mean age: 7.8 years [range: 7.0-8.7]) born PT (mean GA: 31 weeks [range: 23-35]; birth weight, mean: 1,637 g [range: 404-2,962]) with the majority (96%) having no diagnosed cognitive, sensory, or motor impairments. The control group included 57 age-matched typically developing children (mean age: 7.9 years [range: 6.2-8.7]) born full-term (FT). Children born PT, extremely PT (GA < 28) in particular, showed significantly lower cognitive performance and higher behavioral problem scores compared with children born FT. GA was found to predict aspects of both cognitive functioning and behavioral problems within the PT group, with lower GA being related to both poorer cognitive outcomes and elevated affective and attention-deficit/hyperactivity problems. Global cognitive functioning did not independently predict aspects of behavioral outcomes. Findings demonstrate that, even in children born PT without severe perinatal and/or postnatal complications and receiving active perinatal care, a short gestation is an evident risk factor for long-term negative effects on mental health independent of cognitive functioning. Additional findings suggest that both reduced growth and lower parental educational level may contribute to increased risk for poorer cognitive and behavioral functioning in children born PT.

Longitudinal Study of music Therapy's Effectiveness for Premature infants and their caregivers (LongSTEP): protocol for an international randomised trial

INTRODUCTION

Preterm birth has major medical, psychological and socioeconomic consequences worldwide. Music therapy (MT) has positive effects on physiological measures of preterm infants and maternal anxiety, but rigorous studies including long-term follow-up are missing. Drawing on caregivers' inherent resources, this study emphasises caregiver involvement in MT to promote attuned, developmentally appropriate musical interactions that may be of mutual benefit to infant and parent. This study will determine whether MT, as delivered by a qualified music therapist during neonatal intensive care unit (NICU) hospitalisation and/or in home/municipal settings following discharge, is superior to standard care in improving bonding between primary caregivers and preterm infants, parent well-being and infant development. METHODS AND ANALYSIS: Design: international multicentre, assessor-blind, 2×2 factorial, pragmatic randomised controlled trial; informed by a completed feasibility study. Participants: 250 preterm infants and their parents. Intervention: MT focusing on parental singing specifically tailored to infant responses, will be delivered during NICU and/or during a postdischarge 6-month period. Primary outcome: changes in mother-infant bonding at 6-month corrected age (CA), as measured by the Postpartum Bonding Questionnaire. Secondary outcomes: mother-infant bonding at discharge and at 12-month CA; child development over 24 months; and parental depression, anxiety and stress, and infant rehospitalisation, all over 12 months.

ETHICS AND DISSEMINATION

The Regional Committees for Medical and Health Research Ethics approved the study (2018/994/REK Nord, 03 July 2018). Service users were involved in development of the study and will be involved in implementation and dissemination. Dissemination of findings will apply to local, national and international levels.

TRIAL REGISTRATION NUMBER

NCT03564184.

Development and predictors of childhood mental health problems in former extremely preterm infants

OBJECTIVE

To investigate development and predictors of mental health problems from five to eleven years of age in children born extremely preterm (EP).

METHOD

In a national Norwegian cohort of children born before a gestational age of 28 weeks or with a birthweight <1000 g mental health was assessed by parents at five and eleven years of age using The Strengths and Difficulties Questionnaire. A Total Difficulties Score ≥ 90th percentile (TDS90) for a reference group was used as a measure of a mental health problem. Of 338 eligible EP children, 162 (48%) attended at both ages.

RESULTS

The rate of TDS90 was 52 (32%) at five and 37 (23%) at eleven years of age (p = 0.025). Of the 52 children with TDS90 at five years, 25 had TDS90 at eleven years of age, and of 37 children with TDS90 at eleven, 25 had TDS90 at five years of age. Mental health problems and an IQ of 70-84 at five years were independent predictors of TDS90 at eleven years of age.

CONCLUSION

The rate of mental health problems decreased from five to eleven years, but individual stability was moderate. Mental health problems and intellectual function in the lower normal range at preschool age were independent predictors of later mental health problems.

Survival and Impairment of Extremely Premature Infants: A Meta-analysis

CONTEXT

Survival of infants born at the limit of viability varies between high-income countries.

OBJECTIVE

To summarize the prognosis of survival and risk of impairment for infants born at 22 + 0/7 weeks' to 27 + 6/7 weeks' gestational age (GA) in high-income countries.

DATA SOURCES

We searched 9 databases for cohort studies published between 2000 and 2017 in which researchers reported on survival or neurodevelopmental outcomes.

STUDY SELECTION

GA was based on ultrasound results, the last menstrual period, or a combination of both, and neurodevelopmental outcomes were measured by using the Bayley Scales of Infant Development II or III at 18 to 36 months of age.

DATA EXTRACTION

Two reviewers independently extracted data and assessed the risk of bias and quality of evidence.

RESULTS

Sixty-five studies were included. Mean survival rates increased from near 0% of all births, 7.3% of live births, and 24.1% of infants admitted to intensive care at 22 weeks' GA to 82.1%, 90.1%, and 90.2% at 27 weeks' GA, respectively. For the survivors, the rates of severe impairment decreased from 36.3% to 19.1% for 22 to 24 weeks' GA and from 14.0% to 4.2% for 25 to 27 weeks' GA. The mean chance of survival without impairment for infants born alive increased from 1.2% to 9.3% for 22 to 24 weeks' GA and from 40.6% to 64.2% for 25 to 27 weeks' GA.

LIMITATIONS

The confidence in these estimates ranged from high to very low.

CONCLUSIONS

Survival without impairment was substantially lower for children born at <25 weeks' GA than for those born later.

[Identification of behavioural and emotional problems in premature children in the primary care setting]

Objetivos

Evidenciar la utilidad, para su uso por el pediatra de atención primaria, del cuestionario BASC (Behavior Assessment System for Children) para la detección precoz de los problemas psicológicos y comportamentales en los prematuros.

Diseño

Estudio transversal y descriptivo.

Emplazamiento

Centro de atención primaria (Área Sanitaria IV del Principado de Asturias) y centro hospitalario (Hospital Universitario Central de Asturias), España.

Participantes

Padres de 87 niños prematuros con peso menor de 1.500 g al nacimiento y de 43 controles nacidos a término, ambos grupos con edad de 5 a 7 años.

Mediciones principales

Se aplicó el cuestionario BASC (versión para padres).

Resultados

Los niños prematuros presentan diferencias respecto a los controles, muestran mayores niveles de inatención (Z = −4,125; p < 0,001), ansiedad (Z = −2,801; p = 0,005) e interiorización de conductas (Z = −2,148; p = 0,032), conductas que son más evidentes a los 5 años. Los niños prematuros presentan mayores niveles de hiperactividad (Z = −2,082; p = 0,037) y problemas de conducta (Z = −2.354; p = 0,019) que las niñas, que destacan en problemas de atención (Z = −2.345; p = 0,019).

Conclusiones

El BASC permite la detección y diagnóstico precoz en atención primaria de los problemas de conducta y emocionales de los niños prematuros.

Preterm brain Injury: White matter injury

Despite the advances in neonatal intensive care, the preterm brain remains vulnerable to white matter injury (WMI) and disruption of normal brain development (i.e., dysmaturation). Compared to severe cystic WMI encountered in the past decades, contemporary cohorts of preterm neonates experience milder WMIs. More than destructive lesions, disruption of the normal developmental trajectory of cellular elements of the white and the gray matter occurs. In the acute phase, in response to hypoxia-ischemia and/or infection and inflammation, multifocal areas of necrosis within the periventricular white matter involve all cellular elements. Later, chronic WMI is characterized by diffuse WMI with aberrant regeneration of oligodendrocytes, which fail to mature to myelinating oligodendrocytes, leading to myelination disturbances. Complete neuronal degeneration classically accompanies necrotic white matter lesions, while altered neurogenesis, represented by a reduction of the dendritic arbor and synapse formation, is observed in response to diffuse WMI. Neuroimaging studies now provide more insight in assessing both injury and dysmaturation of both gray and white matter. Preterm brain injury remains an important cause of neurodevelopmental disabilities, which are still observed in up to 50% of the preterm survivors and take the form of a complex combination of motor, cognitive, and behavioral concerns.

Behavioral and Socioemotional Development in Preterm Children

Prematurity is a significant risk factor for impaired neurodevelopmental outcomes. These include motor, cognitive, language, behavioral, and socioemotional competence. Long-term overall function depends on healthy socioemotional functioning. The vulnerability of the preterm brain during critical periods of development contributes to behavioral and socioemotional problems in preterm children. Attention deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) clinical features are more frequent in preterm children compared with their full-term counterparts; however, true rates of ASD and ADHD vary across studies. Early detection of behavioral and socioemotional problems in preterm children would enable timely early intervention to improve long-term functional outcomes.

Biological and Social Influences on the Neurodevelopmental Outcomes of Preterm Infants

Although very preterm birth and very low birthweight are recognized risk factors for longer term developmental difficulties, there is a wide spectrum of outcomes for children and adolescents born preterm. Biological and social variables have the potential to explain this variability. Although current understanding of these influences and how they interact is incomplete, perinatal factors are related to permanent neurosensory impairments such as cerebral palsy, blindness, and deafness. Cognitive and academic outcomes are variably associated with biological and social variables across development, and the most robust correlates of behavior and mental health difficulties include early behavioral problems and family influences.

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.

Network-based decoupling of local gyrification in obsessive-compulsive disorder

Gyrification is associated with cortical maturation and closely linked to neurodevelopmental processes. Obsessive-compulsive disorder has previously been associated with neurodevelopmental risk factors. Using graph theoretical modeling we examined structural covariance patterns to assess potential disruptions in processes associated with neurodevelopment in OCD. In total 97 patients and 92 healthy controls underwent magnetic resonance imaging. Structural covariance networks based on local gyrification indices were constructed using an atlas-based parcellation scheme. Network properties were assessed using the network-based statistic as well as global and local graph theoretical measures. Correlations between gyrification and symptom severity as well as age of disease onset were examined. Network-based statistic analysis revealed one cluster with significantly decreased structural covariance in patients comprising mainly ventral brain regions (p = .041). Normalized characteristic path length was found to be impaired in patients (p = .051). On a nodal level, left middle frontal sulcus displayed a significantly decreased local clustering coefficient (p < .001). Finally, gyrification in several inferior frontal nodes significantly correlated with age of onset but not symptom severity. The decrease in a gyrification-based covariance network in OCD appears to be mostly confined to ventral areas in which gyrification starts the latest during development. This pattern may indicate that alterations taking place during development are potentially time locked to specific periods. Correlations between gyrification in inferio-frontal nodes and age of onset potentially indicate a structural trait rather than state marker for OCD. Finally, a trend in impaired global integration capabilities may point towards potentially widespread global alterations during neurodevelopment in patients.

Attention deficit hyperactivity disorder and autism spectrum disorder symptoms in school-age children born very preterm

BACKGROUND

Very preterm (VP) children face a broad range of neurodevelopmental sequelae, including behavioral problems.

AIM

To investigate prevalence, pervasiveness and co-occurrence of symptoms of attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) in school-age children born very preterm.

METHODS

Using questionnaire and diagnostic interview data, parent and teacher reported symptoms of ADHD and ASD of 57 VP-children (mean age = 9.2 years) were compared with 57 gender and age matched full-term children using t-tests. Intra-class correlation coefficients quantified parent-teacher agreement. Correlation analysis investigated co-occurrence of ADHD/ASD symptoms. ADHD/ASD measures were aggregated using principal component analysis. Regression analyses investigated the contribution of perinatal risk factors, sex and SES to ADHD/ASD symptoms.

RESULTS

VP-children showed higher levels of parent and teacher reported attention problems, social impairment and compromised communication skills. Fair to strong agreement was found between parent and teacher reported ADHD and ASD symptoms, indicating pervasiveness of observed difficulties. Co-occurrence of ADHD and ASD symptoms in VP-children was found. Lower gestational age was associated with higher ADHD and ASD symptom levels, male sex with higher ADHD symptom levels and lower SES with higher ASD symptom levels.

CONCLUSION

School-age VP-children show higher levels of ADHD and ASD symptoms, and attention, socialization and communication difficulties in particular. Routinely screening for these problems is recommended in follow-up care.

Prenatal and Neonatal Factors Predicting Sleep Problems in Children Born Extremely Preterm or With Extremely Low Birthweight

Objective: Prematurely born children have been reported to have more sleep problems throughout childhood than children born at term. The aim of this study was to explore if prenatal or neonatal factors can predict sleep problems at age 11 years in children born extremely preterm (EPT). Method: A prospective observational study of all infants who were born EPT in Norway in 1999 and 2000. Prenatal and neonatal data were collected by all Norwegian obstetric and pediatric departments. Parental questionnaire mapped sleep problems and sleep habits at the age of 11 years. Results: Of the 372 eligible children, 221 participated. Of those, 28.1% snored, 27.5% had difficulty falling asleep or frequent awakenings and 17.2% suffered from daytime sleepiness. The mean sleep duration was 9.4 h (range 4.3-11.0 h). Smoking in pregnancy predicted snoring (odds ratio 4.3). Neonatal cerebral hemorrhage and being born small for gestational age predicted difficulty falling asleep or frequent awakenings (odds ratio 2.2 and 2.3). Other morbidities during pregnancy or the newborn period, gestational age or the burden of treatment in the neonatal intensive care unit did not predict sleep problems. None of the studied prenatal or neonatal factors predicted daytime sleepiness or sleep duration <9 h. Conclusion: Of numerous prenatal and neonatal factors, only smoking during pregnancy, being born small for gestational age and cerebral hemorrhage predicted sleep problems at 11 years of age among these children born EPT.

Mental health assessed by the Strengths and Difficulties Questionnaire for children born extremely preterm without severe disabilities at 11 years of age: a Norwegian, national population-based study

The aims were to investigate mental health problems with the Strength and Difficulties Questionnaire (SDQ) in children born extremely preterm/extremely low birth weight (EP/ELBW) without severe disabilities compared to controls, and to identify peri-, or neonatal factors possibly predicting later mental health problems. A national Norwegian cohort of 11-year-old EP/ELBW children, excluding those with intellectual disabilities, non-ambulatory cerebral palsy, blindness and/or deafness, was assessed. Parents and teachers completed the SDQ. Mean scores and scores ≥90th percentile for the control group, combined (parent and/or teacher reporting the child ≥90th percentile), and pervasive ratings (both parent and teacher reporting the child ≥90th percentile) were presented. The controls consisted of an unselected population of all 11-year-old children born in 1995 who attended public or private schools in Bergen. Of the eligible children, 216 (64%) EP/ELBW and 1882 (61%) control children participated. The EP/ELBW children had significantly higher scores and/or increased risk of parent, teacher, combined, and pervasive rated hyperactivity/inattention, emotional-, and peer problems (OR 2.1-6.3). Only parents reported the EP/ELBW children to be at an increased risk of conduct problems (OR 1.6, 95% CI 1.1-2.6). Only low maternal education at birth was significantly associated with mental health problems at 11 years of age (OR 2.5, 95% CI 1.2-5.4). EP/ELBW children without severe disabilities had increased risk of symptoms of hyperactivity/inattention, emotional-, and peer problems. None of the peri- or neonatal factors were significantly associated with later mental health problems, except for low maternal education.

Children born extremely preterm had different sleeping habits at 11 years of age and more childhood sleep problems than term-born children

AIM

This study explored whether extremely preterm (EPT) children had different sleep characteristics in childhood than children born at term and how neurodevelopmental disabilities (NDD) affected sleep in children born EPT.

METHODS

A Norwegian national cohort of 231 children born EPT from 1999 to 2000 and separate study data on 556 children born at term in 2001 were compared. Parental questionnaires mapped the children's current sleep habits at 11 years of age, namely the prevalence of sleep problems throughout childhood until this age and five categories of sleep problems. In addition, the EPT children were clinically assessed at five years of age.

RESULTS

The EPT children had different sleep habits than the controls, for example they went to bed earlier. EPT children had a higher prevalence of sleep problems than the controls throughout childhood (26% versus 14%, p < 0.001) and this was also higher for the 93 EPT children with no NDD (20%) than for the controls (14%) and increased with increasing NDD to 67% (p = 0.015) for the six children with severe NDD.

CONCLUSION

EPT children had different sleep habits to term-born controls at 11 years of age, including those with no NDD. The prevalence of sleep problems increased with increasing NDD.

Behavioral Patterns in Adolescents Born at 23 to 25 Weeks of Gestation

BACKGROUND

This study examined mental health outcomes in extremely preterm children (EPT) born at 23 to 25 weeks of gestation between 1992 and 1998 at 2 Swedish tertiary care centers that offered regional and active perinatal care to all live-born EPT infants.

METHODS

We assessed 132 (98%) of the 134 EPT survivors at 10 to 15 years of age alongside term-born controls. Behavioral and emotional problems were evaluated by using Achenbach's Child Behavior Checklist and Teacher Report Form and Conners' Parent and Teacher scales for attention-deficit/hyperactivity disorder.

RESULTS

Parents and teachers reported significantly more problems with internalizing behaviors as well as attention, social, and thought problems in EPT children than in controls, even when those with major neurodevelopmental disabilities (NDDs) were excluded. Multivariate analysis of covariance of the behavioral problems reported by parents and teachers revealed no interactions, but significant main effects emerged for group status (EPT versus control) and sex, with all effect sizes being medium to large and accounting for 8% to 14% of the variance. Compared with the controls, EPT children without NDDs had significantly increased rates of ≥90th percentile for total Conners' attention-deficit/hyperactivity disorder problem scores (parents: 40% vs 15%, odds ratio: 3.7, P < .001) (teachers: 24% vs 9%, odds ratio: 3.3, P = .005). The corresponding rates were higher in the total population.

CONCLUSIONS

EPT children with or without NDDs had behavioral problems characterized by a higher risk for anxiety and attention, social, and thought problems. These findings further strengthen the proposition that a preterm behavioral phenotype is recognizable in adolescents born EPT.

Prenatal stress alters amygdala functional connectivity in preterm neonates

Exposure to prenatal and early-life stress results in alterations in neural connectivity and an increased risk for neuropsychiatric disorders. In particular, alterations in amygdala connectivity have emerged as a common effect across several recent studies. However, the impact of prenatal stress exposure on the functional organization of the amygdala has yet to be explored in the prematurely-born, a population at high risk for neuropsychiatric disorders. We test the hypothesis that preterm birth and prenatal exposure to maternal stress alter functional connectivity of the amygdala using two independent cohorts. The first cohort is used to establish the effects of preterm birth and consists of 12 very preterm neonates and 25 term controls, all without prenatal stress exposure. The second is analyzed to establish the effects of prenatal stress exposure and consists of 16 extremely preterm neonates with prenatal stress exposure and 10 extremely preterm neonates with no known prenatal stress exposure. Standard resting-state functional magnetic resonance imaging and seed connectivity methods are used. When compared to term controls, very preterm neonates show significantly reduced connectivity between the amygdala and the thalamus, the hypothalamus, the brainstem, and the insula (p < 0.05). Similarly, when compared to extremely preterm neonates without exposure to prenatal stress, extremely preterm neonates with exposure to prenatal stress show significantly less connectivity between the left amygdala and the thalamus, the hypothalamus, and the peristriate cortex (p < 0.05). Exploratory analysis of the combined cohorts suggests additive effects of prenatal stress on alterations in amygdala connectivity associated with preterm birth. Functional connectivity from the amygdala to other subcortical regions is decreased in preterm neonates compared to term controls. In addition, these data, for the first time, suggest that prenatal stress exposure amplifies these decreases.