Effects of fetal growth restriction on the perinatal neurovascular unit and possible treatment targets

The neurovascular unit (NVU) within the brain is a multicellular unit that synergistically acts to maintain blood-brain barrier function and meet cerebral metabolic demand. Recent studies have indicated disruption to the NVU is associated with neuropathology in the perinatal brain. Infants with fetal growth restriction (FGR) are known to be at increased risk of neurodevelopmental conditions including motor, learning, and behavioural deficits. There are currently no neuroprotective treatments for these conditions. In this review, we analyse large animal studies examining the effects of FGR on the perinatal NVU. These studies show altered vascularity in the FGR brain as well as blood-brain barrier dysfunction due to underlying cellular changes, mediated by neuroinflammation. Neuroinflammation is a key mechanism associated with pathological effects in the FGR brain. Hence, targeting inflammation may be key to preserving the multicellular NVU and providing neuroprotection in FGR. A number of maternal and postnatal therapies with anti-inflammatory components have been investigated in FGR animal models examining targets for amelioration of NVU disruption. Each therapy showed promise by uniquely ameliorating the adverse effects of FGR on multiple aspects of the NVU. The successful implementation of a clinically viable neuroprotective treatment has the potential to improve outcomes for neonates affected by FGR. IMPACT: Disruption to the neurovascular unit is associated with neuropathology in fetal growth restriction. Inflammation is a key mechanism associated with neurovascular unit disruption in the growth-restricted brain. Anti-inflammatory treatments ameliorate adverse effects on the neurovascular unit and may provide neuroprotection.

Diagnostic accuracy of the Hammersmith Neonatal Neurological Examination in predicting motor outcome at 12 months for infants born very preterm

AIM

To evaluate the predictive validity of the Hammersmith Neonatal Neurological Examination (HNNE) performed early (at 32 weeks postmenstrual age) and at term-equivalent age (TEA) for 12-month motor outcomes in infants born very preterm.

METHOD

This was a diagnostic study using data from a prospective birth cohort. A total of 104 infants born preterm at less than 31 weeks gestational age (males n = 61; mean = 28 weeks 1 day [SD 1 week 6 days], range 23 weeks 1 day-30 weeks 6 days) underwent HNNE early and at TEA, which were scored by comparison with term data. Motor outcomes at 12 months corrected age were determined using the Bayley Scales of Infant and Toddler Development, Third Edition (scores ≤85). Cut-off points were determined using receiver operating characteristic curves.

RESULTS

Sixteen (15%) infants born preterm had motor impairment at 12 months corrected age. The HNNE total score cut-off points with the best combination of sensitivity and specificity at early and TEA assessments were 15.2 or lower (sensitivity 77%, 95% confidence interval [CI] = 46%-95%; specificity 74%, 95% CI = 63%-83%) and 23.5 or lower (sensitivity 67%, 95% CI = 38%-88%; specificity 66%, 95% CI = 54%-76%) respectively. The most predictive subscale at the early assessment was reflexes (sensitivity 86%, 95% CI = 57%-98%; specificity 62%, 95% CI = 51%-72%; cut-off point ≤3); at TEA, it was spontaneous movements (sensitivity 73%, 95% CI = 45%-92%; specificity 60%, 95% CI = 48%-70%; cut-off point ≤2).

INTERPRETATION

The HNNE provides moderate predictive accuracy for motor outcome at 12 months corrected age in infants born very preterm. Although modest at both time points, early assessment had stronger predictive ability for motor outcomes than TEA when scored using term data, highlighting the value of performing the HNNE earlier in the neonatal period. Performing HNNE earlier may assist risk stratification when planning follow-up services.

Blood Biomarkers in the Fetally Growth Restricted and Small for Gestational Age Neonate: Associations with Brain Injury

Fetal growth restriction (FGR) and small for gestational age (SGA) infants have increased risk of mortality and morbidity. Although both FGR and SGA infants have low birthweights for gestational age, a diagnosis of FGR also requires assessments of umbilical artery Doppler, physiological determinants, neonatal features of malnutrition, and in utero growth retardation. Both FGR and SGA are associated with adverse neurodevelopmental outcomes ranging from learning and behavioral difficulties to cerebral palsy. Up to 50% of FGR, newborns are not diagnosed until around the time of birth, yet this diagnosis lacks further indication of the risk of brain injury or adverse neurodevelopmental outcomes. Blood biomarkers may be a promising tool. Defining blood biomarkers indicating an infant's risk of brain injury would provide the opportunity for early detection and therefore earlier support. The aim of this review was to summarize the current literature to assist in guiding the future direction for the early detection of adverse brain outcomes in FGR and SGA neonates. The studies investigated potential diagnostic blood biomarkers from cord and neonatal blood or serum from FGR and SGA human neonates. Results were often conflicting with heterogeneity common in the biomarkers examined, timepoints, gestational age, and definitions of FGR and SGA used. Due to these variations, it was difficult to draw strong conclusions from the results. The search for blood biomarkers of brain injury in FGR and SGA neonates should continue as early detection and intervention is critical to improve outcomes for these neonates.

Early detection of developmental delay in infants born very preterm or with very low birthweight

AIM

This study aimed to identify early clinical biomarkers from birth to 16 weeks corrected age to predict typical outcome and developmental delay in infants born very preterm or with very low birthweight.

METHOD

A prospective cohort of infants on the Sunshine Coast, Australia, was assessed using the Premie-Neuro Examination, the General Movement Assessment (GMA), the Alberta Infant Motor Scale, and the Infant Sensory Profile 2. At 24 months corrected age, delay was identified using the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) and Neurosensory Motor Developmental Assessment (NSMDA).

RESULTS

One hundred and four infants were recruited; 79 completed outcome assessments (43 females, 36 males; mean gestational age 30 weeks [SD 1 week 6 days], mean birthweight 1346 g [SD 323]). The incidence of developmental delay (motor or cognitive) was 6.3%. Suboptimal quality of fidgety general movements (temporal organization) at 16 weeks corrected age demonstrated the best predictive accuracy (Bayley-III motor: sensitivity 100% [95% confidence interval {CI} 3-100], specificity 75% [95% CI 63-84], area under the curve [AUC] 0.87); Bayley-III cognitive: sensitivity 100% [95% CI 3-100], specificity 75% [95% CI 64-84], AUC 0.88); NSMDA motor: sensitivity 100% [95% CI 40-100], specificity 81% [95% CI 70-90], AUC 0.91 [95% CI 0.86-0.95]). GMA trajectories that combined abnormal writhing general movements at 4 to 5 weeks corrected age with suboptimal quality of fidgety movement at 16 weeks corrected age were strongly predictive of developmental delay, superior to all other clinical tools, and perinatal and demographic variables investigated (p = 0.01, Akaike information criterion method 18.79 [score corrected for small sample size], accounting for 93% of the cumulative weight).

INTERPRETATION

Only the GMA had sufficient predictive validity to act as a biomarker for both conditions: typical outcome and developmental delay (motor or cognitive). GMA trajectories that assessed both writhing general movements at 4 to 5 weeks corrected age and quality of fidgety movement at 16 weeks corrected age predicted adverse neurodevelopmental outcome, accurately differentiating between infants with typical outcomes and those at increased risk for motor or cognitive delay.

Early brain morphometrics from neonatal MRI predict motor and cognitive outcomes at 2-years corrected age in very preterm infants

Infants born very preterm face a range of neurodevelopmental challenges in cognitive, language, behavioural and/or motor domains. Early accurate identification of those at risk of adverse neurodevelopmental outcomes, through clinical assessment and Magnetic Resonance Imaging (MRI), enables prognostication of outcomes and the initiation of targeted early interventions. This study utilises a prospective cohort of 181 infants born <31 weeks gestation, who had 3T MRIs acquired at 29-35 weeks postmenstrual age and a comprehensive neurodevelopmental evaluation at 2 years corrected age (CA). Cognitive, language and motor outcomes were assessed using the Bayley Scales of Infant and Toddler Development - Third Edition and functional motor outcomes using the Neuro-sensory Motor Developmental Assessment. By leveraging advanced structural MRI pre-processing steps to standardise the data, and the state-of-the-art developing Human Connectome Pipeline, early MRI biomarkers of neurodevelopmental outcomes were identified. Using Least Absolute Shrinkage and Selection Operator (LASSO) regression, significant associations between brain structure on early MRIs with 2-year outcomes were obtained (r = 0.51 and 0.48 for motor and cognitive outcomes respectively) on an independent 25% of the data. Additionally, important brain biomarkers from early MRIs were identified, including cortical grey matter volumes, as well as cortical thickness and sulcal depth across the entire cortex. Adverse outcome on the Bayley-III motor and cognitive composite scores were accurately predicted, with an Area Under the Curve of 0.86 for both scores. These associations between 2-year outcomes and patient prognosis and early neonatal MRI measures demonstrate the utility of imaging prior to term equivalent age for providing earlier commencement of targeted interventions for infants born preterm.

Early evolution of glial morphology and inflammatory cytokines following hypoxic-ischemic injury in the newborn piglet brain

Neuroinflammation is a hallmark of hypoxic-ischemic injury and can be characterized by the activation of glial cells and the expression of inflammatory cytokines and chemokines. Interleukin (IL)-1β and tumor necrosis factor (TNF)α are among the best-characterized early response cytokines and are often expressed concurrently. Several types of central nervous system cells secrete IL-1β and TNFα, including microglia, astrocytes, and neurons, and these cytokines convey potent pro-inflammatory actions. Chemokines also play a central role in neuroinflammation by controlling inflammatory cell trafficking. Our aim was to characterise the evolution of early neuroinflammation in the neonatal piglet model of hypoxic-ischemic encephalopathy (HIE). Piglets (< 24 h old) were exposed to HI insult, and recovered to 2, 4, 8, 12 or 24H post-insult. Brain tissue from the frontal cortex and basal ganglia was harvested for assessment of glial cell activation profiles and transcription levels of inflammatory markers in HI piglets with comparison to a control group of newborn piglets. Fluorescence microscopy was used to observe microglia, astrocytes, neurons, degenerating neurons and possibly apoptotic cells, and quantitative polymerase chain reaction was used to measure gene expression of several cytokines and chemokines. HI injury was associated with microglial activation and morphological changes to astrocytes at all time points examined. Gene expression analyses of inflammation-related markers revealed significantly higher expression of pro-inflammatory cytokines tumor necrosis factor-α (TNFα) and interleukin 1 beta (IL-1β), chemokines cxc-chemokine motif ligand (CXCL)8 and CXCL10, and anti-inflammatory cytokine transforming growth factor (TGF)β in every HI group, with some region-specific differences noted. No significant difference was observed in the level of C-X-C chemokine receptor (CCR)5 over time. This high degree of neuroinflammation was associated with a reduction in the number of neurons in piglets at 12H and 24H in the frontal cortex, and the putamen at 12H. This reduction of neurons was not associated with increased numbers of degenerating neurons or potentially apoptotic cells. HI injury triggered a robust early neuroinflammatory response associated with a reduction in neurons in cortical and subcortical regions in our piglet model of HIE. This neuroinflammatory response may be targeted using novel therapeutics to reduce neuropathology in our piglet model of neonatal HIE.

Effect of asthma management with exhaled nitric oxide versus usual care on perinatal outcomes

INTRODUCTION

Asthma exacerbations in pregnancy are associated with adverse perinatal outcomes. We aimed to determine whether fractional exhaled nitric oxide (F _ENO)-based asthma management improves perinatal outcomes compared to usual care.

METHODS

The Breathing for Life Trial was a multicentre, parallel-group, randomised controlled trial conducted in six hospital antenatal clinics, which compared asthma management guided by F _ENO (adjustment of asthma treatment according to exhaled nitric oxide and symptoms each 6-12 weeks) to usual care (no treatment adjustment as part of the trial). The primary outcome was a composite of adverse perinatal events (preterm birth, small for gestational age (SGA), perinatal mortality or neonatal hospitalisation) assessed using hospital records. Secondary outcomes included maternal asthma exacerbations. Concealed random allocation, stratified by study site and self-reported smoking status was used, with blinded outcome assessment and statistical analysis (intention to treat).

RESULTS

Pregnant women with current asthma were recruited; 599 to the control group (608 infants) and 601 to the intervention (615 infants). There were no significant group differences for the primary composite perinatal outcome (152 (25.6%) out of 594 control, 177 (29.4%) out of 603 intervention; OR 1.21, 95% CI 0.94-1.56; p=0.15), preterm birth (OR 1.14, 95% CI 0.78-1.68), SGA (OR 1.06, 95% CI 0.78-1.68), perinatal mortality (OR 3.62, 95% CI 0.80-16.5), neonatal hospitalisation (OR 1.24, 95% CI 0.89-1.72) or maternal asthma exacerbations requiring hospital admission or emergency department presentation (OR 1.19, 95% CI 0.69-2.05).

CONCLUSION

F _ENO-guided asthma pharmacotherapy delivered by a nurse or midwife in the antenatal clinic setting did not improve perinatal outcomes.

Umbilical Cord Blood Cell Clearance Post-Infusion in Immune-Competent Children with Cerebral Palsy

Umbilical cord blood cells have therapeutic potential for neurological disorders, through a paracrine mechanism of action. A greater understanding of the safety and immunological effects of allogeneic donor cord blood cells in the context of a healthy recipient immune system, such as in cerebral palsy, is needed. This study aimed to determine how quickly donor cord blood cells were cleared from the circulation in children with cerebral palsy who received a single intravenous infusion of 12/12 human leucocyte antigen (HLA)-matched sibling cord blood cells. Twelve participants with cerebral palsy aged 2-12 years received cord blood cell infusions as part of a phase I trial of umbilical blood infusion for cerebral palsy. Digital droplet PCR analysis of DNA copy number variants specific to donor and recipient was used to assess donor DNA clearance at five timepoints post-infusion, a surrogate measure of cell clearance. Donor cells were cleared by 3 months post-infusion in 11/12 participants. When detected, donor DNA was at a fraction of 0.01-0.31% of total DNA with no signs of graft-versus-host disease in any participant. The donor DNA clearance times provided by this study have important implications for understanding the safety of allogeneic cord blood cell infusion for cerebral palsy and translational tissue engineering or regenerative medicine research in other disorders.

Neurological examination at 32-weeks postmenstrual age predicts 12-month cognitive outcomes in very preterm-born infants

BACKGROUND

To determine the diagnostic accuracy of Hammersmith Neonatal Neurological Examination (HNNE) at 30-32 weeks postmenstrual age (PMA, 'Early') and term equivalent age (TEA) in infants born <31 weeks PMA to predict cognitive outcomes at 12 months corrected age (CA).

METHODS

Prospective cohort study of 119 infants (73 males; median 28.4 weeks gestational age at birth) who underwent Early and TEA HNNE. At 12 months CA, 104 participants completed Bayley Scales of Infant and Toddler Development, 3rd Edition, (Bayley-III). Optimum cut-off points for each HNNE subscale were determined to establish diagnostic accuracy for predicting adverse cognitive outcomes on the Bayley-III Cognitive Composite Scale (≤85).

RESULTS

The best diagnostic accuracy for HNNE total score at 30-32 weeks PMA predicting cognitive impairment occurred at cut-off ≤16.7 (sensitivity (Se) = 71%, specificity (Sp) = 51%). The Abnormal Signs subscale demonstrated the best balance of sensitivity/specificity combination (Se = 71%, Sp = 71%; cut-off ≤1.5). For HNNE at TEA, the total score at cut-off ≤24.5 had Se = 71% and Sp = 47% for predicting cognitive impairment. The Tone Patterns subscale demonstrated the strongest diagnostic accuracy at TEA (Se = 71%, Sp = 63%; cut-off ≤3).

CONCLUSIONS

Early and TEA HNNE demonstrated moderate diagnostic accuracy for cognitive outcomes at 12-months CA in infants born <31 weeks gestational age.

CLINICAL TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry; Trial Registration Number: ACTRN12613000280707; web address of trial: http://www.ANZCTR.org.au/ACTRN12613000280707.aspx .

IMPACT

Early Hammersmith Neonatal Neurological Examination (HNNE) assessment at 30-32 weeks postmenstrual age has moderate diagnostic accuracy for cognitive outcomes at 12 months corrected age in infants born <31 weeks gestation. Early HNNE at 30-32 weeks has stronger predictive validity than HNNE at term equivalent age. Early HNNE may provide an early marker for risk-stratification to optimise the planning of post-discharge support and follow-up services for infants born preterm.

Infant massage and brain maturation measured using EEG: A randomised controlled trial

BACKGROUND

Very preterm (VPT) infants develop adverse neurological sequelae from early exposure of the immature brain to the extrauterine environment.

AIMS

To determine the effects of infant massage on brain maturation in low-risk VPT infants.

STUDY DESIGN

A randomised controlled trial of VPT infants, who received standard care or daily massage therapy, administered by the mother, from 34 weeks' to 40 weeks' corrected age (CA).

SUBJECTS

VPT infants (born at 28 weeks to 32 + 6 weeks' gestational age, G.A.) and a healthy at term cohort for comparison.

OUTCOME MEASURES

At term equivalent age (39 weeks' to 42 weeks' CA), EEG was recorded to calculate global relative power (GRP), using power spectral analysis.

RESULTS

Sixty infants were recruited, and EEGs of 25 massage and 20 standard care infants were analysable. There was no difference between groups in primary outcome (beta GRP). There was a significantly higher central alpha relative power measured in the intervention group infants, compared to standard care (SC) group (mean difference = 1.42, 95 % confidence interval (CI): 0.12 to 2.73; p = 0.03). A massage dose effect was shown by a positive correlation between, massage dose and beta, alpha and theta GRP (r = 0.42, 95%CI = 0.12 to 0.64, r = 0.45; 95%CI = 0.16 to 0.66, r = 0.39; 95%CI = 0.10 to 0.62 respectively) and a negative correlation between massage dose and delta GRP (r = -0.41, 95%CI = -0.64 to -0.12), suggesting that a higher dose of massage is associated with more favourable brain maturation.

CONCLUSIONS

Central alpha regional relative power was greater in massaged infants compared to SC group infants, suggesting relatively greater brain maturation in this area. A measurable massage dose effect in favour of greater brain maturation, shows promise for verification in a larger clinical trial.

Neonatal EEG seizure detection using a new signal structural complexity measure based on matching pursuit decomposition with nonstationary dictionary

BACKGROUND AND OBJECTIVE

In newborns, it is often difficult to accurately differentiate between seizure and non-seizure based solely on clinical manifestations. This highlights the importance of electroencephalogram (EEG) in the recognition and management of neonatal seizures. This paper proposes an effective algorithm for the detection of neonatal seizure using multichannel EEG.

METHODS

Neonatal EEG changes morphology as it alternates between seizure and non-seizure states. A new signal complexity measure based on matching pursuit (MP) decomposition is proposed and used to detect transitions between these two states. The new measure, referred to as weighted structural complexity (WSC), was used for the detection of seizures in 30 newborn EEG records. Multiple IIR filters and an MP-based filter were designed and used to remove artifacts from the EEG data. Geometrical correlation between the EEG data channels was applied to reduce the number of false detections caused by remnant artifacts. The seizure detector's performance was assessed using several epoch-based (e.g., accuracy) and event-based (GDR = good detection rate and FD/h = false detections per hour) metrics.

RESULTS

Compared to the neurologist marking, the proposed detector was able to detect EEG seizures with 94% accuracy, 90.9% GDR, and 0.14 FD/h (95% CI: [0.06, 0.34]).

CONCLUSIONS

The high performance of the MP-based detector may have significant implications for the accurate diagnosis of neonatal seizures and the appropriate use of anticonvulsants and ongoing clinical assessment and care of the newborn.

Watch me grow integrated (WMG-I): protocol for a cluster randomised controlled trial of a web-based surveillance approach for developmental screening in primary care settings

INTRODUCTION

The increasing prevalence of developmental disorders in early childhood poses a significant global health burden. Early detection of developmental problems is vital to ensure timely access to early intervention, and universal developmental surveillance is recommended best practice for identifying issues. Despite this, there is currently considerable variation in developmental surveillance and screening between Australian states and territories and low rates of developmental screening uptake by parents. This study aims to evaluate an innovative web-based developmental surveillance programme and a sustainable approach to referral and care pathways, linking primary care general practice (GP) services that fall under federal policy responsibility and state government-funded child health services.

METHODS AND ANALYSIS

The proposed study describes a longitudinal cluster randomised controlled trial (c-RCT) comparing a 'Watch Me Grow Integrated' (WMG-I) approach for developmental screening, to Surveillance as Usual (SaU) in GPs. Forty practices will be recruited across New South Wales and Queensland, and randomly allocated into either the (1) WMG-I or (2) SaU group. A cohort of 2000 children will be recruited during their 18-month vaccination visit or opportunistic visit to GP. At the end of the c-RCT, a qualitative study using focus groups/interviews will evaluate parent and practitioner views of the WMG-I programme and inform national and state policy recommendations.

ETHICS AND DISSEMINATION

The South Western Sydney Local Health District (2020/ETH01625), UNSW Sydney (2020/ETH01625) and University of Queensland (2021/HE000667) Human Research Ethics Committees independently reviewed and approved this study. Findings will be reported to the funding bodies, study institutes and partners; families and peer-reviewed conferences/publications.

TRIAL REGISTRATION NUMBER

ANZCTR12621000680864.

Early Motor Repertoire of Very Preterm Infants and Relationships with 2-Year Neurodevelopment

The Motor Optimality Score, revised (MOS-R) is an extension of the Prechtl General Movements Assessment. This study aims to determine the relationship between MOS-R and 2-year neurodevelopmental outcomes in a cohort of 169 infants born very preterm (<31 weeks’ gestational age), and to examine the predictive validity of the MOS-R at 3−4 months’ corrected age (CA) above perinatal variables associated with poor outcomes, including Prechtl fidgety movements. Development at 2 years’ CA was assessed using Bayley Scales of Infant and Toddler Development, Third edition (Bayley-III) (motor/cognitive impairment: Bayley-III ≤ 85) and Neurological, Sensory, Motor, Developmental Assessment (NSMDA) (neurosensory motor impairment: NSMDA ≥ 12). Cerebral palsy (CP) was classified at 2 years as definite or clinical. The MOS-R was related to 2-year outcomes: Bayley-III motor (BMOS-R = 1.24 95% confidence interval (0.78, 1.70)), cognitive (BMOS-R = 0.91 (0.48, 1.35)), NSMDA scores (BMOS-R = −0.34 (−0.42, −0.25)), definite CP (odds ratio [OR] 0.67 (0.53, 0.86)), clinical CP (OR 0.74 (0.66, 0.83)) for each 1-point increase in MOS-R. MOS-R ≤ 23 predicted motor (sensitivity 78% (60−91%); specificity 63% (54−72%)) and neurosensory motor impairment (sensitivity 86% (64−97%); specificity 59% (51−68%)). The MOS-R is strongly related to CP and motor and cognitive delay at 2 years and is a good predictor of motor and neurosensory motor impairment.

Brain outcomes in runted piglets: a translational model of fetal growth restriction

etal growth restriction (FGR) is associated with long-term neurodevelopmental disabilities including learning and behavioural disorders, autism, and cerebral palsy. Persistent changes in brain structure and function that are associated with developmental disabilities are demonstrated in FGR neonates. However, the mechanisms underlying these changes remain to be determined. There are currently no therapeutic interventions available to protect the FGR newborn brain. With the wide range of long-term neurodevelopmental disorders associated with FGR, the use of an animal model appropriate to investigating mechanisms of injury in the FGR newborn is crucial for the development of effective and targeted therapies for babies. Piglets are ideal animals to explore how perinatal insults affect brain structure and function. FGR occurs spontaneously in the piglet, unlike other animal models that require surgical or chemical intervention, allowing brain outcomes to be studied without the confounding impacts of experimental interventions. The FGR piglet mimics many of the human pathophysiological outcomes associated with FGR including asymmetrical growth restriction with brain sparing. This review will discuss the similarities observed in brain outcomes between the human FGR and FGR piglet from a magnetic resonance imaging in the living and a histological perspective. FGR piglet studies provide the opportunity to determine and track mechanisms of brain injury in a clinically relevant animal model of FGR. Findings from these FGR piglet studies may provide critical information to rapidly translate neuroprotective interventions to clinic to improve outcomes for newborn babies.

Electroencephalographic studies in growth-restricted and small-for-gestational-age neonates

Foetal growth restriction (FGR) and being born small for gestational age (SGA) are associated with neurodevelopmental delay. Early diagnosis of neurological damage is difficult in FGR and SGA neonates. Electroencephalography (EEG) has the potential as a tool for the assessment of brain development in FGR/SGA neonates. In this review, we analyse the evidence base on the use of EEG for the assessment of neonates with FGR or SGA. We found consistent findings that FGR/SGA is associated with measurable changes in the EEG that present immediately after birth and persist into childhood. Early manifestations of FGR/SGA in the EEG include changes in spectral power, symmetry/synchrony, sleep-wake cycling, and the continuity of EEG amplitude. Later manifestations of FGR/SGA into infancy and early childhood include changes in spectral power, sleep architecture, and EEG amplitude. FGR/SGA infants had poorer neurodevelopmental outcomes than appropriate for gestational age controls. The EEG has the potential to identify FGR/SGA infants and assess the functional correlates of neurological damage. IMPACT: FGR/SGA neonates have significantly different EEG activity compared to AGA neonates. EEG differences persist into childhood and are associated with adverse neurodevelopmental outcomes. EEG has the potential for early identification of brain impairment in FGR/SGA neonates.

Effect of Treatment of Clinical Seizures vs Electrographic Seizures in Full-Term and Near-Term Neonates: A Randomized Clinical Trial

IMPORTANCE

Seizures in the neonatal period are associated with increased mortality and morbidity. Bedside amplitude-integrated electroencephalography (aEEG) has facilitated the detection of electrographic seizures; however, whether these seizures should be treated remains uncertain.

OBJECTIVE

To determine if the active management of electrographic and clinical seizures in encephalopathic term or near-term neonates improves survival free of severe disability at 2 years of age compared with only treating clinically detected seizures.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted in tertiary newborn intensive care units recruited from 2012 to 2016 and followed up until 2 years of age. Participants included neonates with encephalopathy at 35 weeks' gestation or more and younger than 48 hours old. Data analysis was completed in April 2021.

INTERVENTIONS

Randomization was to an electrographic seizure group (ESG) in which seizures detected on aEEG were treated in addition to clinical seizures or a clinical seizure group (CSG) in which only seizures detected clinically were treated.

MAIN OUTCOMES AND MEASURES

Primary outcome was death or severe disability at 2 years, defined as scores in any developmental domain more than 2 SD below the Australian mean assessed with Bayley Scales of Neonate and Toddler Development, 3rd ed (BSID-III), or the presence of cerebral palsy, blindness, or deafness. Secondary outcomes included magnetic resonance imaging brain injury score at 5 to 14 days, time to full suck feeds, and individual domain scores on BSID-III at 2 years.

RESULTS

Of 212 randomized neonates, the mean (SD) gestational age was 39.2 (1.7) weeks and 122 (58%) were male; 152 (72%) had moderate to severe hypoxic-ischemic encephalopathy (HIE) and 147 (84%) had electrographic seizures. A total of 86 neonates were included in the ESG group and 86 were included in the CSG group. Ten of 86 (9%) neonates in the ESG and 4 of 86 (4%) in the CSG died before the 2-year assessment. The odds of the primary outcome were not significantly different in the ESG group compared with the CSG group (ESG, 38 of 86 [44%] vs CSG, 27 of 86 [31%]; odds ratio [OR], 1.83; 95% CI, 0.96 to 3.49; P = .14). There was also no significant difference in those with HIE (OR, 1.77; 95% CI, 0.84 to 3.73; P = .26). There was evidence that cognitive outcomes were worse in the ESG (mean [SD] scores, ESG: 97.4 [17.7] vs CSG: 103.8 [17.3]; mean difference, -6.5 [95% CI, -1.2 to -11.8]; P = .01). There was little evidence of a difference in secondary outcomes, including time to suck feeds, seizure burden, or brain injury score.

CONCLUSIONS AND RELEVANCE

Treating electrographic and clinical seizures with currently used anticonvulsants did not significantly reduce the rate of death or disability at 2 years in a heterogeneous group of neonates with seizures.

TRIAL REGISTRATION

http://anzctr.org.au Identifier: ACTRN12611000327987.

Automatic fetal movement recognition from multi-channel accelerometry data

BACKGROUND AND OBJECTIVE

Significant health care resources are allocated to monitoring high risk pregnancies to minimize growth compromise, reduce morbidity and prevent stillbirth. Fetal movement has been recognized as an important indicator of fetal health. Studies have shown that 25% of pregnancies with decreased fetal movement in the third trimester led to poor outcomes at birth. The studies have also shown that maternal perception of fetal movement is highly subjective and varies from person to person. A non-invasive system for fetal movement detection that can be used outside hospital would represent an advance in at-home monitoring of at-risk pregnancies. This is a challenging task that requires the use of advanced signal processing techniques to differentiate genuine fetal movements from contaminating artefacts.

METHODS

This manuscript proposes a novel algorithm for automatic fetal movement recognition using data collected from wearable tri-axial accelerometers strategically placed on the maternal abdomen. The novelty of the work resides in the efficient removal of artefacts and in distinctive feature extraction. The proposed algorithm used independent component analysis (ICA) for dimensionality reduction and artefact removal. A supplemental technique based on discrete wavelet transform (DWT) was also used to remove artefacts.

RESULTS

To identify fetal movements, 31 features were extracted from the acceleration data. Based on these features, several classifiers were used to distinguish fetal from non-fetal movements. Robustness of the classifiers was tested for various concentrations of artefacts in the classification data. The best performance was achieved by Bagging classifier algorithm, with random forest as its basis classifier, yielding an accuracy ranging from 87.6% to 95.8% depending on the artefact concentration level.

CONCLUSIONS

A high performance detection of fetal movements can be achieved using accelerometery-based systems suitable for long-term monitoring.

Automating Quantitative Measures of an Established Conventional MRI Scoring System for Preterm-Born Infants Scanned between 29 and 47 Weeks' Postmenstrual Age

BACKGROUND AND PURPOSE

Conventional MR imaging scoring is a valuable tool for risk stratification and prognostication of outcomes, but manual scoring is time-consuming, operator-dependent, and requires high-level expertise. This study aimed to automate the regional measurements of an established brain MR imaging scoring system for preterm neonates scanned between 29 and 47 weeks' postmenstrual age.

MATERIALS AND METHODS

This study used T2WI from the longitudinal Prediction of PREterm Motor Outcomes cohort study and the developing Human Connectome Project. Measures of biparietal width, interhemispheric distance, callosal thickness, transcerebellar diameter, lateral ventricular diameter, and deep gray matter area were extracted manually (Prediction of PREterm Motor Outcomes study only) and automatically. Scans with poor quality, failure of automated analysis, or severe pathology were excluded. Agreement, reliability, and associations between manual and automated measures were assessed and compared against statistics for manual measures. Associations between measures with postmenstrual age, gestational age at birth, and birth weight were examined (Pearson correlation) in both cohorts.

RESULTS

A total of 652 MRIs (86%) were suitable for analysis. Automated measures showed good-to-excellent agreement and good reliability with manual measures, except for interhemispheric distance at early MR imaging (scanned between 29 and 35 weeks, postmenstrual age; in line with poor manual reliability) and callosal thickness measures. All measures were positively associated with postmenstrual age (r = 0.11-0.94; R² = 0.01-0.89). Negative and positive associations were found with gestational age at birth (r = -0.26-0.71; R² = 0.05-0.52) and birth weight (r = -0.25-0.75; R² = 0.06-0.56). Automated measures were successfully extracted for 80%-99% of suitable scans.

CONCLUSIONS

Measures of brain injury and impaired brain growth can be automatically extracted from neonatal MR imaging, which could assist with clinical reporting.

Clinical tools used in young infants born very preterm to predict motor and cognitive delay (not cerebral palsy): a systematic review

AIM

This systematic review evaluates the accuracy of clinical tools used at a corrected age of 6 months or younger to predict motor and cognitive delay (not cerebral palsy) at 24 months' corrected age, in infants born very preterm.

METHOD

Six databases were searched. Quality was evaluated using the Quality Assessment of Diagnostic Accuracy Studies tool. Predictive analysis included calculation of sensitivity and specificity, inspection of summary receiver operating characteristics curves, and bivariate meta-analysis.

RESULTS

Six assessments were identified in 10 studies of 992 infants. Overall prevalence of motor delay was 13.8% and cognitive delay was 11.7%. Methodological quality was variable for patient selection, reference standard, flow, and timing. All studies had a low risk of bias for the index test. General Movement Assessment (GMA) predicted motor and cognitive outcomes with good accuracy for mild, moderate, and severe delays (fidgety age: pooled diagnostic odds ratio=12.3 [5.9-29.8]; hierarchical summary receiver operating characteristics curve=0.733). The Hammersmith Infant Neurological Examination (HINE) demonstrated excellent predictive accuracy for severe motor delay (3mo and 6mo; sensitivity 93% [68-100%], specificity 100% [96-100%]) but showed limited ability to predict milder delays.

INTERPRETATION

In the population of infants born very preterm, few assessment tools used at 6 months or younger corrected age have proven predictive accuracy for cognitive and motor delay at 24 months' corrected age. Only the GMA and HINE demonstrated useful predictive validity.

WHAT THIS PAPER ADDS

General movements have predictive validity for both motor and cognitive dysfunction in infants born very preterm. The Hammersmith Infant Neurological Examination showed the highest predictive accuracy for severe motor delay. The General Movement Assessment was the best tool to predict mild-to-moderate motor and cognitive delays.

Prediction of childhood brain outcomes in infants born preterm using neonatal MRI and concurrent clinical biomarkers (PREBO-6): study protocol for a prospective cohort study

INTRODUCTION

Infants born very preterm are at risk of adverse neurodevelopmental outcomes, including cognitive deficits, motor impairments and cerebral palsy. Earlier identification enables targeted early interventions to be implemented with the aim of improving outcomes.

METHODS AND ANALYSIS

Protocol for 6-year follow-up of two cohorts of infants born <31 weeks gestational age (PPREMO: Prediction of Preterm Motor Outcomes; PREBO: Prediction of Preterm Brain Outcomes) and a small term-born reference sample in Brisbane, Australia. Both preterm cohorts underwent very early MRI and concurrent clinical assessment at 32 and 40 weeks postmenstrual age (PMA) and were followed up at 3, 12 and 24 months corrected age (CA). This study will perform MRI and electroencephalography (EEG). Primary outcomes include the Movement Assessment Battery for Children second edition and Full-Scale IQ score from the Wechsler Intelligence Scale for Children fifth edition (WISC-V). Secondary outcomes include the Gross Motor Function Classification System for children with cerebral palsy; executive function (Behavior Rating Inventory of Executive Function second edition, WISC-V Digit Span and Picture Span, Wisconsin Card Sorting Test 64 Card Version); attention (Test of Everyday Attention for Children second edition); language (Clinical Evaluation of Language Fundamentals fifth edition), academic achievement (Woodcock Johnson IV Tests of Achievement); mental health and quality of life (Development and Well-Being Assessment, Autism Spectrum Quotient-10 Items Child version and Child Health Utility-9D).

AIMS

Examine the ability of early neonatal MRI, EEG and concurrent clinical measures at 32 weeks PMA to predict motor, cognitive, language, academic achievement and mental health outcomes at 6 years CA.Determine if early brain abnormalities persist and are evident on brain MRI at 6 years CA and the relationship to EEG and concurrent motor, cognitive, language, academic achievement and mental health outcomes.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from Human Research Ethics Committees at Children's Health Queensland (HREC/19/QCHQ/49800) and The University of Queensland (2019000426). Study findings will be presented at national and international conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12619000155190p. WEB ADDRESS OF TRIAL: http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12619000155190p.

Automated cot-side tracking of functional brain age in preterm infants

Objective

A major challenge in the care of preterm infants is the early identification of compromised neurological development. While several measures are routinely used to track anatomical growth, there is a striking lack of reliable and objective tools for tracking maturation of early brain function; a cornerstone of lifelong neurological health. We present a cot‐side method for measuring the functional maturity of the newborn brain based on routinely available neurological monitoring with electroencephalography (EEG).

Methods

We used a dataset of 177 EEG recordings from 65 preterm infants to train a multivariable prediction of functional brain age (FBA) from EEG. The FBA was validated on an independent set of 99 EEG recordings from 42 preterm infants. The difference between FBA and postmenstrual age (PMA) was evaluated as a predictor for neurodevelopmental outcome.

Results

The FBA correlated strongly with the PMA of an infant, with a median prediction error of less than 1 week. Moreover, individual babies follow well‐defined individual trajectories. The accuracy of the FBA applied to the validation set was statistically equivalent to the training set accuracy. In a subgroup of infants with repeated EEG recordings, a persistently negative predicted age difference was associated with poor neurodevelopmental outcome.

Interpretation

The FBA enables the tracking of functional neurodevelopment in preterm infants. This establishes proof of principle for growth charts for brain function, a new tool to assist clinical management and identify infants who will benefit most from early intervention.

Predicting motor outcome in preterm infants from very early brain diffusion MRI using a deep learning convolutional neural network (CNN) model

BACKGROUND AND AIMS

Preterm birth imposes a high risk for developing neuromotor delay. Earlier prediction of adverse outcome in preterm infants is crucial for referral to earlier intervention. This study aimed to predict abnormal motor outcome at 2 years from early brain diffusion magnetic resonance imaging (MRI) acquired between 29 and 35 weeks postmenstrual age (PMA) using a deep learning convolutional neural network (CNN) model.

METHODS

Seventy-seven very preterm infants (born <31 weeks gestational age (GA)) in a prospective longitudinal cohort underwent diffusion MR imaging (3T Siemens Trio; 64 directions, b ​= ​2000 ​s/mm²). Motor outcome at 2 years corrected age (CA) was measured by Neuro-Sensory Motor Developmental Assessment (NSMDA). Scores were dichotomised into normal (functional score: 0, normal; n ​= ​48) and abnormal scores (functional score: 1-5, mild-profound; n ​= ​29). MRIs were pre-processed to reduce artefacts, upsampled to 1.25 ​mm isotropic resolution and maps of fractional anisotropy (FA) were estimated. Patches extracted from each image were used as inputs to train a CNN, wherein each image patch predicted either normal or abnormal outcome. In a postprocessing step, an image was classified as predicting abnormal outcome if at least 27% (determined by a grid search to maximise the model performance) of its patches predicted abnormal outcome. Otherwise, it was considered as normal. Ten-fold cross-validation was used to estimate performance. Finally, heatmaps of model predictions for patches in abnormal scans were generated to explore the locations associated with abnormal outcome.

RESULTS

For the identification of infants with abnormal motor outcome based on the FA data from early MRI, we achieved mean sensitivity 70% (standard deviation SD 19%), mean specificity 74% (SD 39%), mean AUC (area under the receiver operating characteristic curve) 72% (SD 14%), mean F1 score of 68% (SD 13%) and mean accuracy 73% (SD 19%) on an unseen test data set. Patch-based prediction heatmaps showed that the patches around the motor cortex and somatosensory regions were most frequently identified by the model with high precision (74%) as a location associated with abnormal outcome. Part of the cerebellum, and occipital and frontal lobes were also highly associated with abnormal NSMDA/motor outcome.

DISCUSSION/CONCLUSION

This study established the potential of an early brain MRI-based deep learning CNN model to identify preterm infants at risk of a later motor impairment and to identify brain regions predictive of adverse outcome. Results suggest that predictions can be made from FA maps of diffusion MRIs well before term equivalent age (TEA) without any prior knowledge of which MRI features to extract and associated feature extraction steps. This method, therefore, is suitable for any case of brain condition/abnormality. Future studies should be conducted on a larger cohort to re-validate the robustness and effectiveness of these models.

Single group multisite safety trial of sibling cord blood cell infusion to children with cerebral palsy: study protocol and rationale

INTRODUCTION

Cerebral palsy (CP) is the most common physical disability of childhood but has no cure. Stem cells have the potential to improve brain injury and are proposed as a therapy for CP. However, many questions remain unanswered about the most appropriate cell type, timing of infusions, dose required and associated risks. Therefore, human safety and efficacy trials are necessary to progress knowledge in the field.

METHODS AND ANALYSIS

This is a single group study with sample size n=12 to investigate safety of single-dose intravenous 12/12 human leucocyte antigen-matched sibling cord blood cell infusion to children with CP aged 1-16 years without immune suppression. The study is similar to a 3+3 design, where the first two groups of participants have severe CP, and the final six participants include children with all motor severities. Children will be monitored for adverse events and the duration that donor cells are detected. Assessments at baseline, 3 and 12 months will investigate safety and preliminary evidence of change in gross motor, fine motor, cognitive and quality of life outcomes.

ETHICS AND DISSEMINATION

Full approval was obtained from The Royal Children's Hospital Human Research Ethics Committee, and a clinical trial notification was accepted by Australia's Therapeutic Goods Administration. Participant guardian informed consent will be obtained before any study procedures. The main results of this study will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ACTRN12616000403437, NCT03087110.

A Randomized Trial of Baby Triple P for Preterm Infants: Child Outcomes at 2 Years of Corrected Age

OBJECTIVE

To determine the efficacy of a hospital-based intervention that transitions into existing community support, in enhancing developmental outcomes at 2 years of corrected age in infants born at less than 32 weeks.

STUDY DESIGN

In total, 323 families of 384 infants born <32 weeks were randomized to receive intervention or care-as-usual. The intervention teaches parents coping skills, partner support, and effective parenting strategies over 4 hospital-based and 4 home-phone sessions. At 2 years of corrected age maternally reported child behavior was assessed by the Infant and Toddler Social Emotional Adjustment Scale. Observed child behavior was coded with the Revised Family Observation Schedule. Cognitive, language, and motor skills were assessed with the Bayley Scales of Infant and Toddler Development III.

RESULTS

Mean gestational age of infants was 28.5 weeks (SD = 2.1), and mothers' mean age was 30.6 years (SD = 5.8). A total of 162 families (n = 196 infants) were allocated to intervention and 161 families (n = 188 infants) received care-as-usual. There was no significant adjusted difference between treatment groups on dysregulation (0.2; 95% CI -2.5 to 3.0, P = .9) externalizing (0.3; 95% CI -1.6 to 2.2, P = .8), internalizing (-1.5; 95% CI -4.3 to 1.3, P = .3), observed aversive (0.00; -0.04 to 0.04, P = .9), or nonaversive behavior (-0.01; 95% CI -0.05 to 0.03, P = .7). Intervention children scored significantly higher on cognition (3.5; 95% CI 0.2-6.8, P = .04) and motor skill (5.5; 95% CI 2.5-8.4, P < .001), and approached significance on language (3.8; 95% CI -0.3 to 7.9, P = .07).

CONCLUSIONS

Baby Triple P for Preterm Infants increases cognitive and motor skills but does not impact behavior. The results are evidence that hospital-based interventions can improve some developmental outcomes for infants <32 weeks.

TRIAL REGISTRATION

ACTRN 12612000194864.

Docosahexaenoic acid supplementation of preterm infants and parent-reported symptoms of allergic disease at 7 years corrected age: follow-up of a randomized controlled trial

BACKGROUND

Docosahexaenoic acid (DHA, 22:6n-3) supplementation in the prenatal period is associated with a reduction in the incidence of some symptoms of allergic disease. Infants born preterm are at increased risk of allergic disease, but it is unknown if DHA supplementation reduces the risk of childhood allergies.

OBJECTIVES

The aim of this study was to determine if supplementation of infants born at <33 wk gestation with high-DHA compared with standard-DHA enteral feeds decreases the incidence and severity of parent-reported allergic disease symptoms at a corrected age (CA) of 7 y.

METHODS

This study was a follow-up of an Australian multicenter randomized controlled trial. Infants were given high-DHA (∼1% total fatty acids) or standard-DHA (∼0.3% total fatty acids) enteral feeds from 2-4 d of postnatal age until 40 wk postmenstrual age. Parent-reported incidence of respiratory allergic disease symptoms including wheeze and rhinitis at 7 y CA were the main outcomes. Other outcomes included the incidence of eczema symptoms; severity of any symptoms; and the incidence of wheeze, rhinitis, rhinoconjunctivitis, and eczema from birth to 7 y CA.

RESULTS

Data were available for 569 of 657 (87%) children originally randomized. Symptoms of wheeze or rhinitis at 7 y CA did not differ between high- and standard-DHA groups [wheeze: RR: 1.10; 95% CI: 0.73, 1.65; P = 0.66; rhinitis: RR: 1.09; 95% CI: 0.81, 1.46; P = 0.59]. There was no difference in other allergic disease symptoms at 7 y CA or in the severity of symptoms. Parent-reported symptoms of wheeze, rhinitis, rhinoconjunctivitis, or eczema from birth to 7 y CA did not differ between the groups.

CONCLUSIONS

High-dose DHA supplementation of infants born at <33 wk gestation did not alter allergic disease symptoms or severity at 7 y CA, or from birth to 7 y CA compared with standard-dose DHA. This trial was registered with the Australian New Zealand Clinical Trials Registry as ANZCTR 12606000327583 (http://www.anzctr.org.au).

Ibuprofen Treatment Reduces the Neuroinflammatory Response and Associated Neuronal and White Matter Impairment in the Growth Restricted Newborn

Intrauterine growth restriction (IUGR) is a condition where the fetus does not achieve optimal growth, commonly caused by placental insufficiency. The chronic decrease in blood flow restricts oxygen and nutrient supply to the fetus, which can damage numerous organ systems, with the fetal brain being particularly vulnerable. Although white matter and neuronal injury are evident in IUGR infants, the specific mechanisms underlying these changes are poorly understood. Inflammation is considered to be a main driver in exacerbating brain injury. Using a spontaneous piglet model of IUGR, we aim to determine whether administration of the anti-inflammatory drug ibuprofen will decrease inflammation at postnatal day 4 (P4). The treatment group received ibuprofen (20 mg/kg/day on day 1 and 10 mg/kg/day on days 2 and 3) in piglet formula during the morning feed each day and brains examined on P4. Markers of inflammation, apoptosis, cell proliferation, neuronal injury, and white matter injury were examined. Ibuprofen treatment ameliorated the increase in numbers of microglia and astrocytes in the parietal cortex and white matter tracts of the IUGR piglet brain on P4 as well as decreasing proinflammatory cytokines. Ibuprofen treatment prevented the reduction in apoptosis, neuronal cell counts, and myelin index in the IUGR piglets. Our findings demonstrate ibuprofen reduces the inflammatory response in the IUGR neonatal brain and concurrently reduces neuronal and white matter impairment.

Fat trajectory after birth in very preterm infants mimics healthy term infants

BACKGROUND

Infants born very preterm experience poor postnatal growth relative to intrauterine growth, but at term equivalent age, they have increased percentage body fat compared with infants born at term.

OBJECTIVES

The aim of this study was to assess body composition in very preterm infants born before 32 weeks postmenstrual age and to compare this with infants born at 32-36 weeks of gestation.

METHODS

Percentage fat, fat mass and fat-free mass were measured in 87 very preterm infants born <32 weeks of gestation and studied at 32-36 weeks and in 88 control infants born at 32-36 weeks of gestation and measured on days 2-5 postnatally.

RESULTS

At 32-36 weeks, very preterm infants were lighter and shorter, had significantly greater percentage fat and absolute fat mass and had a significantly lower absolute fat-free mass than the control group. The trajectory in percentage fat over increasing postnatal age in very preterm infants was closely aligned to that in term infants.

CONCLUSIONS

Infants born very preterm accumulate fat rapidly after birth and have a deficit in fat-free mass. Fat accumulation may be triggered by birth or associated events. If this rapid fat accretion is not taken into account, assessment of growth based on weight alone will underestimate the deficit in fat-free mass.

Neuropathology in intrauterine growth restricted newborn piglets is associated with glial activation and proinflammatory status in the brain

BACKGROUND

The fetal brain is particularly vulnerable to intrauterine growth restriction (IUGR) conditions evidenced by neuronal and white matter abnormalities and altered neurodevelopment in the IUGR infant. To further our understanding of neurodevelopment in the newborn IUGR brain, clinically relevant models of IUGR are required. This information is critical for the design and implementation of successful therapeutic interventions to reduce aberrant brain development in the IUGR newborn. We utilise the piglet as a model of IUGR as growth restriction occurs spontaneously in the pig as a result of placental insufficiency, making it a highly relevant model of human IUGR. The purpose of this study was to characterise neuropathology and neuroinflammation in the neonatal IUGR piglet brain.

METHODS

Newborn IUGR (< 5th centile) and normally grown (NG) piglets were euthanased on postnatal day 1 (P1; < 18 h) or P4. Immunohistochemistry was utilised to examine neuronal, white matter and inflammatory responses, and PCR for cytokine analysis in parietal cortex of IUGR and NG piglets.

RESULTS

The IUGR piglet brain displayed less NeuN-positive cells and reduced myelination at both P1 and P4 in the parietal cortex, indicating neuronal and white matter disruption. A concurrent decrease in Ki67-positive proliferative cells and increase in cell death (caspase-3) in the IUGR piglet brain was also apparent on P4. We observed significant increases in the number of both Iba-1-positive microglia and GFAP-positive astrocytes in the white matter in IUGR piglet brain on both P1 and P4 compared with NG piglets. These increases were associated with a change in activation state, as noted by altered glial morphology. This inflammatory state was further evident with increased expression levels of proinflammatory cytokines (interleukin-1β, tumour necrosis factor-α) and decreased levels of anti-inflammatory cytokines (interleukin-4 and -10) observed in the IUGR piglet brains.

CONCLUSIONS

These findings suggest that the piglet model of IUGR displays the characteristic neuropathological outcomes of neuronal and white matter impairment similar to those reported in the IUGR human brain. The activated glial morphology and elevated proinflammatory cytokines is indicative of an inflammatory response that may be associated with neuronal damage and white matter disruption. These findings support the use of the piglet as a pre-clinical model for studying mechanisms of altered neurodevelopment in the IUGR newborn.

Effect of Delayed Cord Clamping on Cerebral Oxygenation in Very Preterm Infants

BACKGROUND AND OBJECTIVE

The mechanism of reported benefits of delayed cord clamping (DCC) are unclear. We aimed to determine whether DCC compared to immediate cord clamping (ICC) in very preterm infants improves cerebral oxygenation in the first 24 h.

STUDY DESIGN

This is a prospective study of a subset of infants at < 30 weeks of gestation who were randomised to DCC (≥60 s) or ICC (< 10 s) and required an indwelling arterial catheter. Regional cerebral oxygenation (rScO2), blood pressure, PI, and peripheral saturation were measured and cerebral fractional tissue oxygen extraction (cFTOE) calculated for the following 3 time intervals: 3-6, 6-12, and 12-28 h of age. Functional ultrasound measures including superior vena cava flow, right ventricular output, ductus arteriosus size and shunt and anterior cerebral artery resistive index were determined.

RESULTS

The mean (±SD) gestation and birth weight of the 51 study infants were 27 ± 1 weeks and 1,046 ± 241 g respectively. Twenty infants received DCC and 31 received ICC. Baseline demographics were similar between the 2 groups. Comparing DCC and ICC infants, there was no difference in rScO2 or cFTOE at any time point. Three out of 20 infants did not receive DCC due to clinical concerns. A sensitivity analysis revealed that cord clamping ≥30 s was significantly associated with increased rScO2 and decreased cFTOE at all 3 time points after adjusting for gestation.

CONCLUSION

Although DCC was not associated with changes in cerebral oxygenation overall, sensitivity analysis suggested a possible effect of an increased rScO2 and a decreased cFTOE with ≥30 s of DCC.

Background EEG features and prediction of cognitive outcomes in very preterm infants: A systematic review

OBJECTIVES

Very preterm infants are at risk of cognitive impairment, but current capacity to predict at-risk infants is sub-optimal. Electroencephalography (EEG) has been used to assess brain function in development. This review investigates the relationship between EEG and cognitive outcomes in very preterm infants.

METHODS

Two reviewers independently conducted a literature search in April 2018 using PubMed, CINAHL, PsycINFO, Cochrane Library, Embase and Web of Science. Studies included very preterm infants (born ≤34 weeks gestational age, GA) who were assessed with EEG at ≤43 weeks postmenstrual age (PMA) and had cognitive outcomes assessed ≥3 months of age. Data on the subjects, EEG, cognitive assessment, and main findings were extracted. Meta-analysis was undertaken to calculate pooled sensitivity and specificity.

RESULTS

31 studies (n = 4712 very preterm infants) met the inclusion criteria. The age of EEG, length of EEG recording, EEG features analysed, age at follow-up, and follow-up assessments were diverse. The included studies were then divided into categories based on their analysed EEG feature(s) for meta-analysis. Only one category had an adequate number of studies for meta-analysis: four papers (n = 255 very preterm infants) reporting dysmature/disorganised EEG patterns were meta-analysed and the pooled sensitivity and specificity for predicting cognitive outcomes were 0.63 (95% CI: 0.53-0.72) and 0.83 (95% CI: 0.74-0.89) respectively.

CONCLUSIONS

There is preliminary evidence that background EEG features can predict cognitive outcomes in very preterm infants. Reported findings were however too heterogeneous to determine which EEG features are best at predicting cognitive outcome.

PREDICTING ATTENDANCE OF A PREVENTIVE PARENTING INTERVENTION FOR VERY PRETERM INFANTS

Preventive parenting interventions can experience challenges in maximizing dosage, or the amount of intervention received by parents. This study examined the associations of baseline mother, father, and very preterm infant (VPT; <32 weeks) characteristics with satisfactory intervention attendance of the family within a randomized controlled trial of Baby Triple P for Preterm Infants (Colditz et al., 2015). Mothers (n = 160) and fathers (n = 115) completed questionnaires prior to the randomization of family units (n = 160) to receive the intervention. Satisfactory session attendance (seven or eight sessions of eight in total) was achieved by 114 families (71.25%). In the logistic model for mothers, satisfactory attendance of the family was more likely when infants were extremely low birth weight (ELBW), odds ratio (OR) = 2.81, 95% confidence interval (CI) [1.16, 6.80], when the mother had a university, OR = 11.38, 95% CI [4.03, 32.19], or trade-certificate-level education, OR = 4.97, 95% CI [1.93, 12.84], or when she was not under financial stress, OR = 3.53, 95% CI [1.34, 9.28]. A similar pattern of results was found in the model for fathers. Session attendance of preventive parenting interventions for VPT infants may be improved by increasing the engagement of parents with infants not born ELBW, who have lower education, or are experiencing financial stress.

Depression, posttraumatic stress and relationship distress in parents of very preterm infants

To determine the prevalence, associated factors, and relationships between symptoms of depression, symptoms of posttraumatic stress (PTS), and relationship distress in mothers and fathers of very preterm (VPT) infants (< 32 weeks). Mothers (n = 323) and fathers (n = 237) completed self-report measures on demographic and outcome variables at 38 days (SD = 23.1, range 9-116) postpartum while their infants were still hospitalised. Of mothers, 46.7% had a moderate to high likelihood of depression, 38.1% had moderate to severe symptoms of PTS, and 25.1% were in higher than average relationship distress. The corresponding percentages in fathers were 16.9, 23.7, and 27%. Depression was positively associated with having previous children (p = 0.01), speaking little or no English at home (p = 0.01), financial stress (p = 0.03), and recently accessing mental health services (p = 0.003) for mothers, and financial stress (p = 0.005) and not being the primary income earner (p = 0.04) for fathers. Similar associations were found for symptoms of PTS and relationship distress. Being in higher relationship distress increased the risk of depression in both mothers (p < .001) and fathers (p = 0.03), and PTS symptoms in mothers (p = 0.001). For both mothers and fathers, depression was associated with more severe PTS symptoms (p < .001). Fathers of VPT infants should be screened for mental health problems alongside mothers, and postpartum parent support programs for VPT infants should include strategies to improve the couple relationship.

Reduced blood volume decreases cerebral blood flow in preterm piglets

KEY POINTS

Preterm infants often have poor cardiovascular function that is associated with adverse neurodevelopmental outcomes. Preterm infants may be vulnerable to hypovolaemia due to excessive vasodilatation and leaky capillaries. Following reduction in blood volume, cardiac output and mean arterial pressure were reduced to the same extent in term and preterm piglets. Cerebral blood flow was maintained following blood volume reduction in term but not in preterm piglets. Effective detection and treatment of functional hypovolaemia may reduce the risk of brain injury in preterm infants.

ABSTRACT

Preterm infants often have impaired cardiovascular function that may contribute to poor neurodevelopmental outcomes. The study aimed to determine the effects of reduced blood volume on cardiovascular function, including cerebral blood flow, in preterm and term piglets. In preterm (97/115 days) and term piglets, up to 10% of the estimated blood volume was removed. Removal of blood was stopped if MAP dropped below 20 mmHg. Heart rate, cardiac contractility and relaxation, cardiac output, mean arterial pressure (MAP), and cerebral blood flow were measured at baseline and again after blood volume reduction. The volume of blood removed was less in preterm piglets than in term piglets (5.1 ± 1.8 vs. 7.7 ± 0.9 mL kg^-1 , mean ± SD, P < 0.001). Cardiac output and MAP decreased to the same extent in term and preterm piglets. Cerebral blood flow decreased in preterm but not term piglets and cerebral vascular conductance increased in term piglets only. Compensatory responses to maintain cerebral blood flow after blood volume reduction are active in term piglets but not in preterm piglets. As a result, even a small reduction in blood volume, or an increase in the capacity of the circulatory system leading to functional hypovolaemia, may lead to a significant reduction in cerebral blood flow and contribute to brain injury in preterm neonates.

Therapeutic potential to reduce brain injury in growth restricted newborns

Brain injury in intrauterine growth restricted (IUGR) infants is a major contributing factor to morbidity and mortality worldwide. Adverse outcomes range from mild learning difficulties, to attention difficulties, neurobehavioral issues, cerebral palsy, epilepsy, and other cognitive and psychiatric disorders. While the use of medication to ameliorate neurological deficits in IUGR neonates has been identified as warranting urgent research for several years, few trials have been reported. This review summarises clinical trials focusing on brain protection in the IUGR newborn as well as therapeutic interventions trialled in animal models of IUGR. Therapeutically targeting mechanisms of brain injury in the IUGR neonate is fundamental to improving long-term neurodevelopmental outcomes. Inflammation is a key mechanism in neonatal brain injury; and therefore an appealing target. Ibuprofen, an anti-inflammatory drug currently used in the preterm neonate, may be a potential therapeutic candidate to treat brain injury in the IUGR neonate. To better understand the potential of ibuprofen and other therapeutic agents to be neuroprotective in the IUGR neonate, long-term follow-up information of neurodevelopmental outcomes must be studied. Where agents such as ibuprofen are shown to be effective, have a good safety profile and are relatively inexpensive, they can be widely adopted and lead to improved outcomes.

Diagnostic accuracy of early magnetic resonance imaging to determine motor outcomes in infants born preterm: a systematic review and meta-analysis

AIM

To examine the diagnostic ability of early magnetic resonance imaging (MRI; <36wks postmenstrual age) to detect later adverse motor outcomes or cerebral palsy (CP) in infants born preterm.

METHOD

Studies of infants born preterm with MRI earlier than 36 weeks postmenstrual age and quantitative motor data or a diagnosis of CP at or beyond 1 year corrected age were identified. Study details were extracted and meta-analyses performed where possible. Quality of included studies was evaluated with the QUADAS-2 (a revised tool for the quality assessment of diagnostic accuracy studies).

RESULTS

Thirty-one articles met the inclusion criteria, five of which reported diagnostic accuracy and five reported data sufficient for calculation of diagnostic accuracy. Early structural MRI global scores detected a later diagnosis of CP with a pooled sensitivity of 100% (95% confidence interval [CI] 86-100) and a specificity of 93% (95% CI 59-100). Global structural MRI scores determined adverse motor outcomes with a pooled sensitivity of 89% (95% CI 44-100) and a specificity of 98% (95% CI 90-100). White matter scores determined adverse motor outcomes with a pooled sensitivity of 33% (95% CI 20-48) and a specificity of 83% (95% CI 78-88).

INTERPRETATION

Early structural MRI has reasonable sensitivity and specificity to determine adverse motor outcomes and CP in infants born preterm. Greater reporting of diagnostic accuracy in studies examining relationships with motor outcomes and CP is required to facilitate clinical utility of early MRI.

WHAT THIS PAPER ADDS

Early magnetic resonance imaging (MRI) has reasonable sensitivity and specificity to determine later adverse motor outcomes and cerebral palsy (CP). Detection of infants who progressed to CP was stronger than motor outcomes. Global MRI scores determined adverse motor outcomes more accurately than white matter scores. Few studies report diagnostic accuracy of early MRI findings. Diagnostic accuracy is required to draw clinically meaningful conclusions from early MRI studies.

Fixel-based analysis reveals alterations is brain microstructure and macrostructure of preterm-born infants at term equivalent age

Preterm birth causes significant disruption in ongoing brain development, frequently resulting in adverse neurodevelopmental outcomes. Brain imaging using diffusion MRI may provide valuable insight into microstructural properties of the developing brain. The aim of this study was to establish whether the recently introduced fixel-based analysis method, with its associated measures of fibre density (FD), fibre bundle cross-section (FC), and fibre density and bundle cross-section (FDC), is suitable for the investigation of the preterm infant brain at term equivalent age. High-angular resolution diffusion weighted images (HARDI) of 55 preterm-born infants and 20 term-born infants, scanned around term-equivalent age, were included in this study (3 T, 64 directions, b = 2000 s/mm²). Postmenstrual age at the time of MRI, and intracranial volume (FC and FDC only), were identified as confounding variables. Gestational age at birth was correlated with all fixel measures in the splenium of the corpus callosum. Compared to term-born infants, preterm infants showed reduced FD, FC, and FDC in a number of regions, including the corpus callosum, anterior commissure, cortico-spinal tract, optic radiations, and cingulum. Preterm infants with minimal macroscopic brain abnormality showed more extensive reductions than preterm infants without any macroscopic brain abnormality; however, little differences were observed between preterm infants with no and with minimal brain abnormality. FC showed significant reductions in preterm versus term infants outside regions identified with FD and FDC, highlighting the complementary role of these measures. Fixel-based analysis identified both microstructural and macrostructural abnormalities in preterm born infants, providing a more complete picture of early brain development than previous diffusion tensor imaging (DTI) based approaches.

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Gestational age at birth associated with measurements in corpus callosum splenium.

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Preterms without macroscopic brain abnormality show differences to term infants.

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No differences between preterms with minimal versus without abnormality detected.

Identification and expression of a unique neonatal variant of the GABAA receptor α3 subunit

The GABA_A receptor provides the majority of inhibitory neurotransmission in the adult central nervous system but in immature brain is responsible for much of the excitatory drive, a requirement for normal brain development. It is well established that GABA_A receptor subunit expression changes across the course of brain development. In the present study, we have identified a splice variant of the GABA_A receptor α₃ subunit which appears unique to the developing brain, referred to here as the GABA_A receptor α₃ subunit neonatal variant (GABA_A receptor α_3N). RT-PCR and sequence analysis revealed splicing of exon 8 of the α₃ subunit. Western blot analysis showed expression of GABA_A receptor α_3N in the cortex of several neonatal species and significantly reduced expression of this splice variant in the corresponding adult brains. Expression was evident in multiple brain regions and decreased across development in the pig. Fractionation revealed differential cellular localisation in the parietal cortex, hippocampus and thalamus of the full-length GABA_A receptor α₃ and GABA_A receptor α_3N. Immunoprecipitation showed direct interaction with the GABA_A receptor subunits α₁ and γ₂ but not with gephyrin.

Validation of an MRI Brain Injury and Growth Scoring System in Very Preterm Infants Scanned at 29- to 35-Week Postmenstrual Age

BACKGROUND AND PURPOSE

The diagnostic and prognostic potential of brain MR imaging before term-equivalent age is limited until valid MR imaging scoring systems are available. This study aimed to validate an MR imaging scoring system of brain injury and impaired growth for use at 29 to 35 weeks postmenstrual age in infants born at <31 weeks gestational age.

MATERIALS AND METHODS

Eighty-three infants in a prospective cohort study underwent early 3T MR imaging between 29 and 35 weeks' postmenstrual age (mean, 32⁺² ± 1⁺³ weeks; 49 males, born at median gestation of 28⁺⁴ weeks; range, 23⁺⁶-30⁺⁶ weeks; mean birthweight, 1068 ± 312 g). Seventy-seven infants had a second MR scan at term-equivalent age (mean, 40⁺⁶ ± 1⁺³ weeks). Structural images were scored using a modified scoring system which generated WM, cortical gray matter, deep gray matter, cerebellar, and global scores. Outcome at 12-months corrected age (mean, 12 months 4 days ± 1⁺² weeks) consisted of the Bayley Scales of Infant and Toddler Development, 3rd ed. (Bayley III), and the Neuro-Sensory Motor Developmental Assessment.

RESULTS

Early MR imaging global, WM, and deep gray matter scores were negatively associated with Bayley III motor (regression coefficient for global score β = -1.31; 95% CI, -2.39 to -0.23; P = .02), cognitive (β = -1.52; 95% CI, -2.39 to -0.65; P < .01) and the Neuro-Sensory Motor Developmental Assessment outcomes (β = -1.73; 95% CI, -3.19 to -0.28; P = .02). Early MR imaging cerebellar scores were negatively associated with the Neuro-Sensory Motor Developmental Assessment (β = -5.99; 95% CI, -11.82 to -0.16; P = .04). Results were reconfirmed at term-equivalent-age MR imaging.

CONCLUSIONS

This clinically accessible MR imaging scoring system is valid for use at 29 to 35 weeks postmenstrual age in infants born very preterm. It enables identification of infants at risk of adverse outcomes before the current standard of term-equivalent age.

Developmental Changes in Expression of GABAA Receptor Subunits α1, α2, and α3 in the Pig Brain

GABA is a major neurotransmitter in the mammalian brain. In the mature brain GABA exerts inhibitory actions via the GABAA receptor (GABAAR); however, in the immature brain GABA provides much of the excitatory drive. We examined the expression of 3 predominant GABAA α-subunit proteins in the pig brain at various pre- and postnatal ages. Brain tissue was collected from piglets born via caesarean section at preterm ages 91, 97, 100, and 104 days' gestational age (GA), at term equivalent (114 days' GA, caesarean section) and at term, postnatal day 0 (P0) (spontaneous delivery, term = 115 days). Tissue was obtained from piglets at P4 and P7. Adult tissue from sows was collected postmortem after caesarean section. In all cortical regions and basal ganglia (1) α3 exhibited a significant increase in protein expression at 100 days' GA, (2) α3 expression decreased with age after 100 days' GA, (3) α1 increased with age, with peak expression at P7 in cortices, hippocampus, and thalamus, and (4) α2 protein expression remained relatively constant across the ages examined. The subunit expression of α3 was most abundant at preterm ages, with α1 the predominant subunit expressed postnatally. Immunofluorescent labelling revealed α1 expression on the somatic membranes of pyramidal cells in the cortex and hippocampus, and in the cerebellar Purkinje cells. Positive α3 labelling was apparent on interneurones in the cortex and hippocampus. The switch between dominant α-subunits may coincide with the functional change in GABAergic neurotransmission from excitation to inhibition. Brain growth in the pig closely reflects that in the term human, making the pig a valuable non-primate model for studying development and the effects of insults on the perinatal brain.

Comparison of In-Hospital Maternal Mortality Between Hospital Systems in Queensland, Australia and Louisiana, United States

BACKGROUND

It is well documented that the American maternal mortality ratio has increased during the years 2000-2015. The Australian maternal mortality ratio, in contrast, has decreased during the same time period, a trend common among most Western countries.

METHODS

This study was a retrospective cohort study of cases of in-hospital maternal deaths in the Ochsner Health System (Louisiana, United States) and the Queensland Health System (Australia) from 1995 to 2013. The aim was to determine if American and Australian women have a similar rate of preventable maternal death and if the deaths were attributable to the same factors. A multidisciplinary team assessed medical records to determine preventability.

RESULTS

Sixteen eligible medical records were identified in the Ochsner Health System and 15 in the Queensland Health System. In the American cohort, deaths in the private insurance group (n=5) were least likely to be preventable (P=0.003). Australian maternal deaths were less likely to occur among women with late or no prenatal care than American maternal deaths; the risk difference was 44.5% for all deaths (95% confidence interval [CI]=9.7%, 79.4%; P=0.03) and 50.0% for potentially preventable deaths (95% CI=9.3%, 90.6%; P=0.04).

CONCLUSION

Women from Louisiana, United States and Queensland, Australia have similar rates of preventable maternal death. No statistically significant factors explained trends in Australian maternal death; American maternal mortality was significantly associated with point of entry into prenatal care, likely influenced by insurance status. Furthermore, the majority of deaths in this group were complicated by hospital systems-based factors.

Review: Neuroinflammation in intrauterine growth restriction

Disruption to the maternal environment during pregnancy from events such as hypoxia, stress, toxins, inflammation, and reduced placental blood flow can affect fetal development. Intrauterine growth restriction (IUGR) is commonly caused by chronic placental insufficiency, interrupting supply of oxygen and nutrients to the fetus resulting in abnormal fetal growth. IUGR is a major cause of perinatal morbidity and mortality, occurring in approximately 5-10% of pregnancies. The fetal brain is particularly vulnerable in IUGR and there is an increased risk of long-term neurological disorders including cerebral palsy, epilepsy, learning difficulties, behavioural difficulties and psychiatric diagnoses. Few studies have focused on how growth restriction interferes with normal brain development in the IUGR neonate but recent studies in growth restricted animal models demonstrate increased neuroinflammation. This review describes the role of neuroinflammation in the progression of brain injury in growth restricted neonates. Identifying the mediators responsible for alterations in brain development in the IUGR infant is key to prevention and treatment of brain injury in these infants.

Neonatal seizures are associated with redistribution and loss of GABAA α-subunits in the hypoxic-ischaemic pig

Seizures are a common manifestation of hypoxic-ischaemic brain injury in the neonate. In status epilepticus models alterations to GABA_A R subunit expression have been suggested to contribute to (i) abnormal development of the GABAergic system, (ii) why seizures become self-sustaining and (iii) the development of pharmacoresistance. Detailed investigation of GABA_A R subunit protein expression after neonatal hypoxia-ischaemia (HI) is currently insufficient. Using our pig model of HI and subsequent spontaneous neonatal seizures, we investigated changes in protein expression of the three predominant α-subunits of the GABA_A R; α₁ , α₂ and α₃ . Anaesthetized, ventilated newborn pigs (< 24 h old) were subjected to 30 min HI and subsequently recovered to 24 or 72 h. Amplitude-integrated electroencephalography was used to monitor brain activity and identify seizure activity. Brain tissue was collected post-mortem and GABA_A R α-subunit protein expression was analysed using western blot and immunohistochemistry. GABA_A R α₁ and α₃ protein expression was significantly reduced in animals that developed seizures after HI; HI animals that did not develop seizures did not exhibit the same reductions. Immunohistochemistry revealed decreased α₁ and α₃ expression, and α₁ redistribution from the cell membrane to the cytosol, in the hippocampus of seizure animals. Multivariate analyses, controlling for HI severity and neuronal injury, revealed that seizures were independently associated with significant GABA_A R α₃ reduction. This is the first study to show loss and redistribution of GABA_A R α-subunits in a neonatal brain experiencing seizures. Our findings are similar to those reported in models of SE and in chronic epilepsy.

The Breathing for Life Trial: a randomised controlled trial of fractional exhaled nitric oxide (FENO)-based management of asthma during pregnancy and its impact on perinatal outcomes and infant and childhood respiratory health

BACKGROUND

Asthma exacerbations are common during pregnancy and associated with an increased risk of adverse perinatal outcomes. Adjusting asthma treatment based on airway inflammation rather than symptoms reduces the exacerbation rate by 50 %. The Breathing for Life Trial (BLT) will test whether this approach also improves perinatal outcomes.

METHODS/DESIGN

BLT is a multicentre, parallel group, randomised controlled trial of asthma management guided by fractional exhaled nitric oxide (FENO, a marker of eosinophilic airway inflammation) compared to usual care, with prospective infant follow-up. Women with physician-diagnosed asthma, asthma symptoms and/or medication use in the previous 12 months, who are 12-22 weeks gestation, will be eligible for inclusion. Women randomised to the control group will have one clinical assessment of their asthma, including self-management education. Any treatment changes will be made by their general practitioner. Women randomised to the intervention group will have clinical assessments every 3-6 weeks during pregnancy, and asthma treatments will be adjusted every second visit based on an algorithm which uses FENO to adjust inhaled corticosteroid (ICS) dose (increase in dose when FENO >29 parts per billion (ppb), decrease in dose when FENO <19 ppb, and no change when FENO is between 19 and 29 ppb). A long acting beta agonist (LABA) will be added when symptoms remain uncontrolled. Both the control and intervention groups will report on exacerbations at a postpartum phone interview. The primary outcome is adverse perinatal outcome (a composite measure including preterm birth, intrauterine growth restriction, neonatal hospitalisation at birth or perinatal mortality), assessed from hospital records. Secondary outcomes will be each component of the primary outcome, maternal exacerbations requiring medical intervention during pregnancy (both smokers and non-smokers), and hospitalisation and emergency department presentation for wheeze, bronchiolitis or croup in the first 12 months of infancy. Outcome assessment and statistical analysis of the primary outcome will be blinded. To detect a reduction in adverse perinatal outcomes from 35 % to 26 %, 600 pregnant women with asthma per group are required.

DISCUSSION

This trial will provide evidence for the effectiveness of a FENO-based management strategy in improving perinatal outcomes in pregnant women with asthma. If successful, this would improve the management of pregnant women with asthma worldwide.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12613000202763 .

PPREMO: a prospective cohort study of preterm infant brain structure and function to predict neurodevelopmental outcome

BACKGROUND

More than 50 percent of all infants born very preterm will experience significant motor and cognitive impairment. Provision of early intervention is dependent upon accurate, early identification of infants at risk of adverse outcomes. Magnetic resonance imaging at term equivalent age combined with General Movements assessment at 12 weeks corrected age is currently the most accurate method for early prediction of cerebral palsy at 12 months corrected age. To date no studies have compared the use of earlier magnetic resonance imaging combined with neuromotor and neurobehavioural assessments (at 30 weeks postmenstrual age) to predict later motor and neurodevelopmental outcomes including cerebral palsy (at 12-24 months corrected age). This study aims to investigate i) the relationship between earlier brain imaging and neuromotor/neurobehavioural assessments at 30 and 40 weeks postmenstrual age, and ii) their ability to predict motor and neurodevelopmental outcomes at 3 and 12 months corrected age.

METHODS/DESIGN

This prospective cohort study will recruit 80 preterm infants born ≤ 30 week's gestation and a reference group of 20 healthy term born infants from the Royal Brisbane & Women's Hospital in Brisbane, Australia. Infants will undergo brain magnetic resonance imaging at approximately 30 and 40 weeks postmenstrual age to develop our understanding of very early brain structure at 30 weeks and maturation that occurs between 30 and 40 weeks postmenstrual age. A combination of neurological (Hammersmith Neonatal Neurologic Examination), neuromotor (General Movements, Test of Infant Motor Performance), neurobehavioural (NICU Network Neurobehavioural Scale, Premie-Neuro) and visual assessments will be performed at 30 and 40 weeks postmenstrual age to improve our understanding of the relationship between brain structure and function. These data will be compared to motor assessments at 12 weeks corrected age and motor and neurodevelopmental outcomes at 12 months corrected age (neurological assessment by paediatrician, Bayley scales of Infant and Toddler Development, Alberta Infant Motor Scale, Neurosensory Motor Developmental Assessment) to differentiate atypical development (including cerebral palsy and/or motor delay).

DISCUSSION

Earlier identification of those very preterm infants at risk of adverse neurodevelopmental and motor outcomes provides an additional period for intervention to optimise outcomes.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12613000280707. Registered 8 March 2013.