Intelligence and Academic Achievement With Asymptomatic Congenital Cytomegalovirus Infection

OBJECTIVES

To examine intelligence, language, and academic achievement through 18 years of age among children with congenital cytomegalovirus infection identified through hospital-based newborn screening who were asymptomatic at birth compared with uninfected infants.

METHODS

We used growth curve modeling to analyze trends in IQ (full-scale, verbal, and nonverbal intelligence), receptive and expressive vocabulary, and academic achievement in math and reading. Separate models were fit for each outcome, modeling the change in overall scores with increasing age for patients with normal hearing (n = 78) or with sensorineural hearing loss (SNHL) diagnosed by 2 years of age (n = 11) and controls (n = 40).

RESULTS

Patients with SNHL had full-scale intelligence and receptive vocabulary scores that were 7.0 and 13.1 points lower, respectively, compared with controls, but no significant differences were noted in these scores among patients with normal hearing and controls. No significant differences were noted in scores for verbal and nonverbal intelligence, expressive vocabulary, and academic achievement in math and reading among patients with normal hearing or with SNHL and controls.

CONCLUSIONS

Infants with asymptomatic congenital cytomegalovirus infection identified through newborn screening with normal hearing by age 2 years do not appear to have differences in IQ, vocabulary or academic achievement scores during childhood, or adolescence compared with uninfected children.

Early predictors of neurodevelopmental outcome in symptomatic congenital cytomegalovirus infection

OBJECTIVE

To determine the ability of neonatal clinical, audiologic, and computed tomography (CT) findings to predict long-term neurodevelopmental outcome in children with symptomatic congenital cytomegalovirus (CMV) infection.

METHODS

Longitudinal cohort study of children (n = 41) with symptomatic congenital CMV infection evaluated at birth and followed up with serial age-appropriate neurodevelopmental testing. The performance of birth characteristics as predictors of long-term outcome were determined, and clinical and CT scoring systems were developed and correlated with intellectual outcome.

RESULTS

Microcephaly was the most specific predictor of mental retardation (100%; 95% CI 84.5-100) and major motor disability (92.3%; 95% CI 74.8-99). An abnormality detected by CT was the most sensitive predictor for mental retardation (100%; 95% CI 82.3-100) and motor disability (100%; 95% CI 78.2-100). A highly significant (P <.001) positive correlation was found between head size at birth and the intelligence/developmental quotient (IQ/DQ). Approximately 29% of children had an IQ/DQ >90. There was no association between sensorineural hearing loss at birth and cognitive outcome. However, children with sensorineural hearing loss on follow-up (congenital and late-onset) had a lower IQ/DQ (P =.006) than those with normal hearing.

CONCLUSIONS

The presence of microcephaly at birth was the most specific predictor of poor cognitive outcome in children with symptomatic congenital CMV infection, whereas children with normal findings on head CT and head circumference proportional to weight exhibited a good cognitive outcome.

Cytomegalovirus urinary excretion and long term outcome in children with congenital cytomegalovirus infection. Congenital CMV Longitudinal Study Group

BACKGROUND

Cytomegalovirus (CMV) is the most frequent cause of congenital infection, and both symptomatic and asymptomatic infants may have long term sequelae. Children with congenital CMV infection are chronically infected and excrete CMV in the urine for prolonged periods. However, the effect of prolonged viral replication on the long term outcome of these children is unknown.

OBJECTIVE

To determine whether duration of CMV excretion is associated with outcome at 6 years of life in symptomatic and asymptomatic congenitally infected children.

METHODS

Longitudinal cohort study. Children congenitally infected with CMV were identified at birth and followed prospectively in a study of long term effects of congenital CMV infection. The relationship between duration of CMV urinary excretion and growth, neurodevelopment and presence and progression of sensorineural hearing loss (SNHL) at 6 years of age was determined.

RESULTS

There was no significant difference in the duration of viral urinary excretion between children born with asymptomatic (median, 4.55 years) and symptomatic (median, 2.97 years) congenital CMV infection (P = 0.11). Furthermore there was no association between long term growth or cognitive outcome and duration of viral excretion. However, a significantly greater proportion of children who excreted CMV for <4 years had SNHL and progressive SNHL compared with children with CMV excretion >4 years (P = 0.019, P = 0.009, respectively).

CONCLUSIONS

Children congenitally infected with CMV are chronically infected for years, but the duration of CMV urinary excretion is not associated with abnormalities of growth, or neurodevelopmental deficits. However, SNHL and progressive SNHL were associated with a shorter duration of CMV excretion.

The longitudinal assessment of congenitally infected infants

Infants with congenital infections are at high risk for developmental disabilities. Because of this increased-risk status, they require comprehensive, longitudinal follow-up that should begin in the neonatal period with sensory, developmental, and neuromotor assessments as well as neuroradiological imaging. Reassessments of general development, sensory function, neuromotor abilities, and emerging language should be done during the early years, with cognitive, preacademic, and phonologic-awareness skills assessed during the preschool years. Serial evaluations of cognitive, academic, language, attention, neuromotor and sensory functions are needed through adolescence. Such surveillance of children with congenital infections is required to identify specific disabilities, to determine educational/intervention needs, and to investigate the total effects of congenital infection.

Polymerase chain reaction to detect cytomegalovirus DNA in the cerebrospinal fluid of neonates with congenital infection

To determine if cytomegalovirus (CMV) DNA could be detected in the cerebrospinal fluid (CSF) of infants with congenital infection with CMV, polymerase chain reaction (PCR) was done on CSF samples from 13 infants (10 with confirmed, 1 with possible, and 2 with asymptomatic congenital CMV infection) and on CSF samples from 100 control patients with alternative diagnoses. By use of two sets of primers that targeted different areas of the CMV genome, CMV DNA was amplified in the CSF of 6 of 10 symptomatic infants, 0 of 3 infants with asymptomatic CMV infection or possible congenital CMV disease, and 2 control patients (one primer set only). A positive CSF PCR result at birth correlated with a poor neurodevelopmental outcome (P = .048; two-tailed Fisher's exact test).

Progressive hearing loss in infants with asymptomatic congenital cytomegalovirus infection

Congenital cytomegalovirus (CMV) infection is a major public health problem because 30,000 to 40,000 neonates with the infection are born each year in the United States. Although 90% of the congenitally infected infants are asymptomatic at birth, evidence is accumulating that these infants are at risk for audiologic, neurologic, and developmental sequelae. The current study describes the audiologic outcome of 59 infants with asymptomatic congenital CMV infection compared with 26 control infants. Eight of 59 infected infants had congenital sensorineural hearing loss (SNHL) but none of the control subjects did. Longitudinal audiologic assessments revealed that 5 of the 8 infants had further deterioration of their SNHL; a ninth infant with initially normal hearing experienced a unilateral SNHL during the first year of life, with further deterioration subsequently. The frequency of SNHL was similar for infected infants born to mothers with recurrent CMV infections during pregnancy (2 of 9) and for those born to mothers who experienced primary CMV infections (5 of 26). There was a significant difference between the occurrence of hearing loss in infected infants with normal computed tomographic scans (2 of 40) compared with those with either periventricular radiolucencies (4 of 13) or calcifications (1 of 3). Children with SNHL often have no identified cause of the loss; thus, it is likely that many of these children had asymptomatic congenital CMV infection. Given the progressive nature of SNHL associated with asymptomatic congenital CMV infection, longitudinal audiologic assessments are mandatory.

Evaluation of higher-level auditory function in children with asymptomatic congenital cytomegalovirus infection

Higher-level auditory/cognitive functions were evaluated in 16 children: eight with asymptomatic congenital cytomegalovirus (CMV) infections and eight children documented not to have asymptomatic congenital CMV infections. Hearing sensitivity was within normal limits in all subjects. Results in both groups were within the normal range on the screening measures of verbal abilities, visual perception, social behavior, and memory span. In contrast, results of the auditory measures revealed abnormal dichotic speech perception, delayed latencies on auditory brainstem evoked responses, and disproportionately slow reaction times in a difficult listening condition (Stroop task). With the exception of dichotic speech perception, however, the pattern of auditory results suggested subtle disorders that were difficult to discern unequivocally with the small subject sample. Further studies are encouraged to determine the status of higher-level auditory/cognitive functions in children with asymptomatic congenital CMV infections.

Children of battered women: developmental and learning profiles

Children in battered women's shelters have been shown to have more behavior problems than their peers but limited information is available about their development. A pilot survey was undertaken to determine the prevalence of developmental or academic problems in children of residents of a battered women's shelter. Demographic data, medical and school histories and responses to standardized developmental or behavioral surveys were obtained from 39 mothers of 76 children. Two-thirds of the children were victims of abuse. On the Minnesota Child Development Inventory, the mean General Developmental Quotient (DQ) of 28 preschool children was 98; however, 39% had developmental delays by test criteria. Of 46 school-aged children, 21 (46%) had evidence of academic problems, including grade repetition, failing grades and need for special educational services. On the Louisville Behavior Checklist, 75% of 48 children had behavior problems. Children in a battered women's shelter are likely to experience academic and behavioral problems; however, further study is needed to elucidate etiological factors.

Asymptomatic congenital cytomegalovirus infection. Audiologic, neuroradiologic, and neurodevelopmental abnormalities during the first year

Twenty-eight infants with asymptomatic congenital cytomegalovirus infection and 13 control infants were followed up prospectively. Congenital sensorineural hearing loss was documented by auditory brain-stem responses in four infected infants (two had mild bilateral loss, one had mild unilateral loss, and one had extreme unilateral loss) but in no controls. Four infected infants had diffuse periventricular radiolucencies on computed tomographic scan; none had calcifications or ventriculomegaly. No differences between groups were noted on neurologic examination results or on the Bayley Mental Developmental Index; however, one infected infant had a severely delayed Bayley Psychomotor Developmental Index score. In addition, the mean Mental Developmental Index score of the four infected infants with diffuse periventricular radiolucencies was significantly below that of the remaining infected infants (93 +/- 8 vs 109 +/- 13). These data suggest that asymptomatic congenital cytomegalovirus infection may be associated with a broad range of audiologic, subtle neuroradiologic, and neurodevelopmental differences in early infancy.

An exploratory study of the structure and validity of pediatric examination of educational readiness (PEER) factors

The Pediatric Examination of Educational Readiness (PEER) is an assessment instrument specifically designed for use by pediatricians in assessing the development of preschool children. The present study investigated the psychometric properties of the PEER. Specifically, factor analyses of items from the Developmental Attainment and Associated Observation components of the test were performed. The PEER was administered to 69 preschool children. Three major factors were identified as making up the Developmental Attainment portion of the test: perceptual-motor, verbal-cognitive, and gross motor. The Associated Observations component was found to be composed of only one factor, attention. Children's performance on only two of these four factors was associated with their performance on the McCarthy Scales, the Woodcock-Johnson skills cluster, and the Minnesota Child Development Inventory. Discussion focused on the validity and utility of the PEER.

Nonhandicapped very-low-birth-weight infants at one year of age: developmental profile

The developmental profile of 61 very-low-birth-weight infants without major cognitive, motor, or sensory deficits was compared with that of 28 term infants at 1 year chronologic age. The groups significantly differed in two ways on the Revised Gesell Developmental Schedules. First, very-low-birth-weight infants were more likely than term infants to have significant discrepancies between either their fine motor or language abilities and their early problem-solving skills as measured by the Adaptive scale of the Gesell. Second, across all fields of behavior (adaptive, gross motor, fine motor, language, and personal/social), very-low-birth-weight infants scored significantly below term infants. The very-low-birth-weight infant's motor performance significantly correlated with bronchopulmonary dysplasia, intracranial hemorrhage, and number of days spent in the hospital. Language performance significantly correlated with intracranial hemorrhage, birth weight, and sex. These findings underscore the limitations of global developmental scores to describe adequately the developmental performance of very-low-birth-weight infants. Instead, a comprehensive assessment of all fields of behavior is necessary to provide an accurate profile of this high-risk group.

Visually impaired infants in the 1980s. A survey of etiologic factors and additional handicapping conditions in a school population

To identify etiologic factors and ophthalmologic diagnoses related to visual impairment in young infants, a survey was carried out within the 22 school districts providing educational services to all visually impaired infants, birth to 3 years of age, in Harris County, Texas. Review of 102 records revealed that 51 percent had impaired vision associated with prenatal factors, and 31 percent were associated with perinatal events. The most frequent ophthalmologic diagnoses were lesions of the optic nerve, optic pathway, and visual centers of the brain (cortical blindness). A majority of the infants had multiple handicaps: 17 percent had hearing loss, 48 percent had cerebral palsy, 46 percent had seizures, and 78 percent had severe developmental delay. The high incidence of multiple handicaps and significant medical problems indicates the necessity for interface between physicians and educators who serve the visually impaired infant.

Neurodevelopmental status of low birth weight infants with bronchopulmonary dysplasia requiring prolonged oxygen supplementation

Fifty infants weighing 1,500 g or less at birth with a diagnosis of bronchopulmonary dysplasia (BPD) were followed to a mean age of 25 months to determine their clinical course and short-term neurodevelopmental outcome after discharge from the Neonatal Intensive Care Unit, and to identify possible predictive factors for outcome. Because study participation was voluntary, the subjects may not have represented the total population of BPD survivors. Occurrences of abnormalities were high: 11 hearing impaired, 10 legally blind, 14 cerebral palsy, and 23 abnormal development scores. Twenty-one subjects had feeding problems and weight was below the fifth percentile in 26. Home-oxygen therapy was required by 50 per cent of the subjects. Although severity of illness, duration of oxygen therapy and feeding problems were greater among those sent home on oxygen, their neurodevelopmental status did not differ from that of infants breathing room air by discharge. Factors associated with neurodevelopmental outcome were intracranial hemorrhage, pulmonary air leak, and length of hospital stay.

Congenital cytomegalovirus infection and maternal systemic lupus erythematosus: a case report

We describe an infant with symptomatic congenital cytomegalovirus infection, who was born to a mother with active systemic lupus erythematosus. Infection in the child resulted from reactivation of maternal cytomegalovirus infection. The mother's use of prednisone may have contributed to the reactivation. The role of maternal immunosuppression in the acquisition of congenital viral infection by the neonate is discussed.

Estimates of heritabilities and correlations of traits associated with pelvic area in beef cattle

Pelvic measurements, cow weights and cow ages were obtained on 703 Angus- and Hereford-sired cows from five Louisiana Agricultural Experiment Station herds. Cows were either purebred or crossbred, ranging in age from 1 to 14 yr, and sired by 52 Angus and 63 Hereford bulls. All pelvic measurements were obtained via the rectum by the same technician. Paternal half-sib heritability estimates and genetic (rG) and phenotypic (rP) correlations were computed for pelvic height (PH), pelvic width (PW), pelvic area (PA-I; the product of PH X PW), the ratio of PH to PW and cow weight (CW). Pelvic area was also calculated as an ellipse using the formula PA-II = pi (PH/2)(PW/2). Mean PA-I was 298.5 cm2 while PA-II averaged 234.4 cm2. The pooled heritability estimate for PA-I was .68 +/- .34, indicating that pelvic area is a highly heritable trait and should respond to selection. The estimate for PA-II was similar (.66 +/- .34). The heritability of PW was higher than for PH or PA-I. The heritability of CW was .57 +/- .34 and CW was positively correlated (rG2 = .47 and rP = .40) with PA-I. Direct selection for PA-I was estimated to yield a response of 12.2 cm2 in one generation with a correlated response for CW of 12.5 kg. If change in CW was held at zero using a restricted selection index, about 90% as much increase in PA-I was estimated compared with ignoring CW in the index. Therefore, selection for increased pelvic area can be accomplished without causing large increases in cow size. This should aid in reducing calving difficulty.

Cerebellar hemorrhage in the term neonate: developmental and neurologic outcome

To elucidate the effects of cerebellar hemorrhage on the term neonate, neurodevelopmental assessments were conducted at a mean age of 32 months on six children. In addition to cerebellar hemorrhage, ventriculomegaly was present on each subject's initial computed tomographic scan. All were managed without surgical evacuation. Two patients required shunts for progressive ventriculomegaly. Five patients had follow-up computed tomography indicating mild atrophy of the superior anterior vermis of the cerebellum; however, none had abnormal ventricular size or abnormalities of the cerebrum. On detailed examination conducted between the ages of 18 and 48 months, five had hypotonia, truncal ataxia, and intention tremor; two had nystagmus. Only one patient walked independently. Intellectual performance of four patients was within the retarded range and two had mildly delayed development. Two patients had markedly disordered expressive language. These data suggest that term neonates surviving cerebellar hemorrhage have neurologic deficits related to the site of hemorrhage, and cognitive deficits related to more generalized cerebral insult.

Evaluation of crossbred Brahman and continental European beef cattle in a subtropical environment for birth and weaning traits

A total of 528 birth and 475 weaning records collected over a 3-yr period were analyzed to evaluate the productivity of several beef cattle breed crosses. The calves were produced by artificial insemination using 17 Brahman, 15 Chianina, 15 Maine Anjou and 16 Simmental sires bred to Angus and Hereford dams varying in age from 3 to 11 yr. Breed-of-sire effects were important (P less than .05 to P less than .001) for gestation length, birth weight, conformation score and condition score, but were not observed for birth weight adjusted for gestation length, percentage calving assistance, survival rate or weaning weight. Brahman crosses had the longest gestation lengths, being 4.7 d longer than Simmental crosses, which were the shortest in length. Chianina crosses were the heaviest at birth and experienced the most calving difficulty. Simmental crosses had the highest survival rate. Although breed-of-sire differences were observed in conformation score, the difference was less than one-third of a grade between the highest-scoring Simmental crosses and the lowest-scoring Brahman and Chianina crosses. Brahman crosses had the highest condition scores, being approximately one-third of a grade higher than the lowest-ranking Chianina crosses. Differences among the sire breeds for weaning weight were surprisingly small, varying only 3 kg from the heaviest to lightest breed-of-sire groups. Angus dams had shorter gestation lengths (P less than .001) and produced calves that weighed more at weaning (P less than .001) and scored higher for conformation (P less than .001) and condition (P less than .001) score than Hereford dams.(ABSTRACT TRUNCATED AT 250 WORDS)

Survival of low-birth-weight infants with neonatal intraventricular hemorrhage. Outcome in the preschool years

Twenty-nine low-birth-weight infants who survived neonatal intraventricular hemorrhage (IVH) were followed up prospectively and were last examined at a mean age of 3 1/2 years. The mean gestational age (+/- SD) of the group was 28.9 weeks (+/- 2.4 weeks), and the mean birth weight (+/- SD) was 1,167 g (+/- 292 g). Ten patients (34%) had normal neurologic outcome, and four (14%) had minimal abnormalities. Nine children (31%) were categorized as moderately abnormal, and six (21%) had severe abnormalities on neurologic examination. Intellectual performance was normal for 14 patients (48%), mildly delayed for seven (24%), and in the retarded range for eight (28%). Twelve children (41%), at 3 years of age, had handicapping conditions severe enough to warrant admission to special education programs in the public school. The grade of IVH was related significantly to neurologic outcome; both grade of hemorrhage and birth weight were correlated significantly with need for special education. Intellectual performance was related not only to grade of hemorrhage and birth weight, but also to paternal social class.

Symptomatic congenital cytomegalovirus. Disorders of language, learning, and hearing

Seventeen patients with symptomatic congenital cytomegalovirus (CMV) were studied longitudinally, with emphasis given to disorders of language, learning, and hearing. At a mean age of 5.5 years (range, 1 go 10 years), nine children (53%) performed in the retarded range. Eleven (65%) experienced sensorineural hearing loss, in three of whom it was progressive. Developmental verbal dyspraxia was documented in two children and suspected in a third. Disabilities in several areas of the learning process exhibited by four children with normal intelligence and hearing loss. Although the effects of congenital CMV were diverse, all of the children had developmental disorders that necessitated special education. Such patients require longitudinal follow-up that includes more than tests of intelligence and hearing. All areas of development must be evaluated to appreciate the full effect of CMV encephalitis in utero.