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

Longitudinal relations of prematurity and fetal growth restrictions with hyperactivity/inattention and aggression/delinquency

BACKGROUND

It is the aim of this study to analyze the longitudinal relationship between premature birth and low birth weight and the reciprocal influence between hyperactive/inattentive behavior and aggressive/delinquent behavior problems in children from early to late childhood.

METHODS

This study contains data from the German Erlangen-Nuremberg Development and Prevention Study. It applies prospective longitudinal path analyses on data obtained from postnatal pediatric assessments as well as later psychosocial behavior assessments by teachers and parents on N = 667 children, out of which n = 83 children (12.44%) were born preterm/small for gestational age.

RESULTS

The results show direct effects of birth complications at the beginning of preschool on hyperactivity/inattentiveness (teacher rating: ß = 0.28; p = 0.017; parent rating: ß = 0.32; p = 0.005), but not on aggression/delinquency (teacher rating: ß = 0.002; p = 0.427; parent rating: ß = 0.12; p = 0.324). Reciprocal effects between aggression/delinquency and hyperactivity/inattentiveness were stable at the end of elementary school, but not at the end of preschool across informants.

CONCLUSION

Our results support a differentiated view on the potential development of behavior problems after birth complications and the demand for early prevention measures.

IMPACT STATEMENT

Our results extend to the existing body of research by providing insight into the longitudinal effects of prematurity and fetal growth restrictions on hyperactive and aggressive/delinquent behavioral problems throughout a rather long period of development in childhood. The results show direct effects of birth complications on the development of hyperactivity for boys, but not for girls across informants. No direct effects of birth complications on aggression/delinquency are found. Our findings speak against too simple views on behavioral consequences of birth complications and thus can relieve too anxious parents, however close monitoring of the behavioral development of respective children is indicated.

Screening and determinant of suspected developmental delays among Egyptian preschool-aged children: a cross-sectional national community-based study

Background

Early childhood life is critical for optimal development and is the foundation of future well-being. Genetic, sociocultural, and environmental factors are important determinants of child development.

Aim

The objectives were to screen for suspected developmental delays (DDs) among Egyptian preschool children, and to explore the determinants of these delays based on sociodemographic, epidemiological, maternal, and child perinatal risk factors.

Methods

A national Egyptian cross-sectional developmental screening of a representative sample of preschool children (21,316 children) aged 12 to 71 months. The Revised Denver Prescreening Developmental Questionnaire (R-PDQ) followed by the Denver Developmental Screening Test, 2nd edition (DDST) was used.

Results

Each screened child manifested at least one of six developmental categories. Either typical development, gross motor delay (GM), fine motor adaptive delay (FMA), Language delay (L), Personal-social delay (PS), or multiple DDs. The prevalence of preschool children with at least one DD was 6.4%, while 4.5% had multiple DDs. Developmental language delay was the most prevalent, affecting 4.2% of children. The least affected domain was GM (1.9% of children). Boys were more likely to have DD than girls. Children in urban communities were more likely to have at least one DD than those in rural areas (OR = 1.28, 95%CI: 1.14–1.42), and children of middle social class than of low or high social class (OR = 1.49, 95%CI: 1.30–1.70 & OR = 1.40, 95%CI: 1.23–1.59 respectively). The strong perinatal predictors for at least one DD were children with a history of postnatal convulsions (OR = 2.68, 95%CI: 1.97–3.64), low birth weight (OR = 2.06, 95%CI: 1.69–2.52), or history of postnatal cyanosis (OR = 1.77, 95%CI: 1.26–2.49) and mothers had any health problem during pregnancy (OR = 1.73, 95%CI: 1.44–2.07). Higher paternal and maternal education decreased the odds of having any DD by 43% (OR = 0.57, 95% CI: 0.47–0.68) and 31% (OR = 0.69, 95%CI: 0.58–0.82) respectively.

Conclusion

This study demonstrates a considerable attempt to assess the types and the prevalence of DD among preschool children in Egypt. Perinatal factors are among the most common determinants of DD in preschool children and the majority could be preventable risk factors.

Screening and determinant of suspected developmental delays among Egyptian preschool-aged children: a cross-sectional national community-based study

BACKGROUND

Early childhood life is critical for optimal development and is the foundation of future well-being. Genetic, sociocultural, and environmental factors are important determinants of child development.

AIM

The objectives were to screen for suspected developmental delays (DDs) among Egyptian preschool children, and to explore the determinants of these delays based on sociodemographic, epidemiological, maternal, and child perinatal risk factors.

METHODS

A national Egyptian cross-sectional developmental screening of a representative sample of preschool children (21,316 children) aged 12 to 71 months. The Revised Denver Prescreening Developmental Questionnaire (R-PDQ) followed by the Denver Developmental Screening Test, 2nd edition (DDST) was used.

RESULTS

Each screened child manifested at least one of six developmental categories. Either typical development, gross motor delay (GM), fine motor adaptive delay (FMA), Language delay (L), Personal-social delay (PS), or multiple DDs. The prevalence of preschool children with at least one DD was 6.4%, while 4.5% had multiple DDs. Developmental language delay was the most prevalent, affecting 4.2% of children. The least affected domain was GM (1.9% of children). Boys were more likely to have DD than girls. Children in urban communities were more likely to have at least one DD than those in rural areas (OR = 1.28, 95%CI: 1.14-1.42), and children of middle social class than of low or high social class (OR = 1.49, 95%CI: 1.30-1.70 & OR = 1.40, 95%CI: 1.23-1.59 respectively). The strong perinatal predictors for at least one DD were children with a history of postnatal convulsions (OR = 2.68, 95%CI: 1.97-3.64), low birth weight (OR = 2.06, 95%CI: 1.69-2.52), or history of postnatal cyanosis (OR = 1.77, 95%CI: 1.26-2.49) and mothers had any health problem during pregnancy (OR = 1.73, 95%CI: 1.44-2.07). Higher paternal and maternal education decreased the odds of having any DD by 43% (OR = 0.57, 95% CI: 0.47-0.68) and 31% (OR = 0.69, 95%CI: 0.58-0.82) respectively.

CONCLUSION

This study demonstrates a considerable attempt to assess the types and the prevalence of DD among preschool children in Egypt. Perinatal factors are among the most common determinants of DD in preschool children and the majority could be preventable risk factors.

Intelligence Quotient (IQ) in school-aged preterm infants: A systematic review

Preterm birth (before 37 weeks of gestational age) is associated with certain risks to child development. The aim of this systematic review was to summarize available and updated empirical evidence on prematurity as a risk factor for cognitive development in school age. Thus, we attempted to identify similarities and differences with the full-term population and to point out possible risk or protective factors among the biological, psychosocial and family variables. The conceptualization and methodology of this review followed the PRISMA recommendations. The search was carried out in Web of Science, Scopus, PsycInfo, and Dialnet databases, in May 2022. The search was limited to journal articles, published between 2012 and 2022, in English and Spanish. Research articles selected were those focused on the intelligence quotient (IQ) of preterm children aged 6-12 years. The review included studies with cross-sectional or longitudinal cohorts, compared to a control group of children born at term or to standardized scales. The quality of evidence of the selected studies was verified with the Mixed Methods Appraisal Tool (MMAT). The initial search identified 1,040 articles. Forty articles met the inclusion criteria and were finally included in this review. These studies involved 5,396 preterm children from 37 different cohorts. Despite the diversity found among the results, in general, total IQ scores were within the normative mean for premature children; however, compared to their full-term peers, these scores were lower. The most studied variables in relation to IQ are perinatal (e.g., gestational age and birth weight) and family (e.g., socioeconomic level and education level of the mother). Recent studies corroborate that premature birth affects cognitive development in school age, and identify associated perinatal and family variables.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=337371; identifier: CRD42022337371.

A test of differential susceptibility in behavior trajectories of preterm infants from preschool to adulthood

Preterm birth predisposes children to internalizing and externalizing behaviors that may persist into adolescence resulting in adult mental health conditions. Social and caregiving contexts, particularly for vulnerable infants born preterm, influence long-term outcomes, but mechanisms are not clearly understood. Healthcare teams caring for those born preterm face difficulty predicting who will be most affected by risk, who will most benefit, and the optimal timing of intervention. Differential susceptibility theory offers an alternative to the traditional risk-only assessments and theories by positing that individuals may be more, or less, susceptible to environmental influences. A sample of preterm- and term-born infants were followed from birth to 23 years of age. Mixed model repeated measures analyses of internalizing and externalizing behaviors were utilized for the comparison groups (N = 214; observations = 1070). Environmental contexts were indexed as proximal protection (low, moderate, high) and medical risk (low, moderate, high). Personal characteristic covariates of sex, race, socioeconomic status, and cognition were modeled. Internalizing behavior trajectories varied significantly over time. Early proximal protective environments conferred a sustained positive influence on behaviors. There is partial support for differential susceptibility theory suggesting that prematurity, as a malleability characteristic enables absorption of both the positive and negative influences of the environment, with greater intensity that those without malleability. The current analyses suggest lasting effects of the preschool age proximal environment on internalizing and externalizing behaviors in young adulthood for those born preterm. Understanding these nuances may aid healthcare professionals in the promotion and timing of interventions to support the child and family. The current manuscript reflects ongoing analyses of longitudinal data. No patient or public contribution to the analyses were required for testing the differential susceptibility theory. The authors would solicit patient or public contribution when implementing practice or policy changes based on the results.

Postponed Withholding: Balanced Decision-Making at the Margins of Viability

Advances in neonatology have led to improved survival for periviable infants. Immaturity still carries a high risk of short- and long-term harms, and uncertainty turns provision of life support into an ethical dilemma. Shared decision-making with parents has gained ground. However, the need to start immediate life support and the ensuing difficulty of withdrawing treatment stands in tension with the possibility of a fair decision-making process. Both the parental "instinct of saving" and "withdrawal resistance" involved can preclude shared decision-making. To help health care personnel and empower parents, we propose a novel approach labeled "postponed withholding." In the absence of a prenatal advance directive, life support is started at birth, followed by planned redirection to palliative care after one week, unless parents, after a thorough counseling process, actively ask for continued life support. Despite the emotional challenges, this approach can facilitate ethically balanced decision-making processes in the gray zone.

Neonatal sepsis is associated with behavioral abnormalities in very low birthweight infants at preschool age

OBJECTIVE

This study aimed to investigate neonatal sepsis as potential risk factor for adverse behavioral outcome in very low birth weight infants (VLBWI) at preschool age. Regardless of improvements in the obstetric and neonatal intensive care, preterm infants are still at high risk for behavioral problems later in life. The spectrum, origin and potential risk factors of these behavioral problems have not been well-defined.

METHODS

In this retrospective observational study, the influence of culture-proven neonatal sepsis on the behavioral outcome of VLBWI born at a gestational age <32 weeks was analyzed at 5 years of age in a multivariable regression model. Behavior was assessed with the Child Behavior Checklist (CBCL). Neonatal morbidities, socioeconomic status and neurodevelopmental outcome served as covariates in the analysis.

RESULTS

312 VLBWI entered the final analysis, of whom 11% had experienced neonatal sepsis. Neonatal sepsis appeared to be a relevant risk factor for both internalizing, i.e., emotional reactivity and anxiety/depression, as well as externalizing behavioral problems, i.e., oppositional and aggressive behavior in this cohort of VLBWI. Low socioeconomic status and male gender were additional statistically significant risk factors for both internalizing and externalizing behavioral problems. No difference in neurocognitive development was observed between the groups.

CONCLUSION

The study supports the fact that VLBWI are vulnerable to multiple behavioral disorders independent of their cognitive development. In contrast to former assumptions, the results of the study emphasize that not only post-natal environment but also neonatal morbidities, especially neonatal sepsis, have an impact on behavioral outcome of VLBWI at preschool age.