An abnormal cerebroplacental ratio (CPR) is predictive of early childhood delayed neurodevelopment in the setting of fetal growth restriction

BACKGROUND

Fetal growth restriction accounts for a significant proportion of perinatal morbidity and death. The cerebroplacental ratio is gaining much interest as a useful tool in differentiating the "at-risk" fetus in both fetal growth restriction and appropriate-for-gestational-age pregnancies. The Prospective Observational Trial to Optimize Pediatric Health in Fetal Growth Restriction group has demonstrated previously that the presence of this "brain-sparing" effect is associated significantly with adverse perinatal outcomes in the fetal growth restriction cohort. However, data about neurodevelopment in children from pregnancies that are complicated by fetal growth restriction are sparse and conflicting.

OBJECTIVE

The aim of the Prospective Observational Trial to Optimize Pediatric Health in Fetal Growth Restriction NeuroDevelopmental Assessment Study was to determine whether children born after fetal growth-restricted pregnancies are at additional risk of adverse early childhood developmental outcomes compared with children born small for gestational age. The objective of this secondary analysis was to describe the role of cerebroplacental ratio in the prediction of adverse early childhood neurodevelopmental outcome.

STUDY DESIGN

Participants were recruited prospectively from the Perinatal Ireland multicenter observational Prospective Observational Trial to Optimize Pediatric Health in Fetal Growth Restriction study cohort. Fetal growth restriction was defined as birthweight <10th percentile with abnormal antenatal umbilical artery Doppler indices. Small for gestational age was defined similarly in the absence of abnormal Doppler indices. Cerebroplacental ratio was calculated with the pulsatility indices of the middle cerebral artery and divided by umbilical artery with an abnormal value <1. Children (n=375) were assessed at 3 years with the use of the Ages and Stages Questionnaire and the Bayley Scales of Infant and Toddler Development, 3rd edition. Small-for-gestational-age pregnancies with normal Doppler indices were compared with (1) fetal growth-restricted cases with abnormal umbilical artery Doppler and normal cerebroplacental ratio or (2) fetal growth restriction cases with both abnormal umbilical artery and cerebroplacental ratio. Statistical analysis was performed with statistical software via 2-sample t-test with Bonferroni adjustment, and a probability value of .00625 was considered significant.

RESULTS

Assessments were performed on 198 small-for-gestational-age children, 136 fetal growth-restricted children with abnormal umbilical artery Doppler images and normal cerebroplacental ratio, and 41 fetal growth-restricted children with both abnormal umbilical artery Doppler and cerebroplacental ratio. At 3 years of age, although there were no differences in head circumference, children who also had an abnormal cerebroplacental ratio had persistently shorter stature (P=.005) and lower weight (P=.18). Children from fetal growth restriction-affected pregnancies demonstrated poorer neurodevelopmental outcome than their small-for-gestational-age counterparts. Fetal growth-restricted pregnancies with an abnormal cerebroplacental ratio had significantly poorer neurologic outcome at 3 years of age across all measured variables.

CONCLUSION

We have demonstrated that growth-restricted pregnancies with a cerebroplacental ratio <1 have a significantly increased risk of delayed neurodevelopment at 3 years of age when compared with pregnancies with abnormal umbilical artery Doppler evidence alone. This study further substantiates the benefit of routine assessment of cerebroplacental ratio in fetal growth-restricted pregnancies and for counseling parents regarding the long-term outcome of affected infants.

Early psychosocial development of small for gestational age and intrauterine growth-restricted children: a systematic review

OBJECTIVE

To examine evidence regarding psychosocial development from one month to four years of age in small for gestational age and intrauterine growth-restricted children.

STUDY DESIGN

Studies were included if participants met criteria for small for gestational age or intrauterine growth restriction, follow-up was from age 1 month to 4 years, methods were described, and appropriate comparison groups were included. Methodological quality of included studies was assessed using quality-appraisal guidelines.

RESULTS

Of 3216 studies reviewed, 24 were included. Poorer psychosocial development was described for small for gestational age children in 15 and for intrauterine growth-restricted children in 3 studies. Only 5 studies measured placental insufficiency using Doppler ultrasound. Study heterogeneity limited synthesis and interpretation.

CONCLUSIONS

Although evidence suggests that small for gestational age children are at risk of poorer early childhood psychosocial outcomes, further research is required to clarify whether placental insufficiency is associated with poorer early psychosocial development.

Pregnancy-specific stress, fetoplacental haemodynamics, and neonatal outcomes in women with small for gestational age pregnancies: a secondary analysis of the multicentre Prospective Observational Trial to Optimise Paediatric Health in Intrauterine Growth Restriction

OBJECTIVES

To examine associations between maternal pregnancy-specific stress and umbilical (UA PI) and middle cerebral artery pulsatility indices (MCA PI), cerebroplacental ratio, absent end diastolic flow (AEDF), birthweight, prematurity, neonatal intensive care unit admission and adverse obstetric outcomes in women with small for gestational age pregnancies. It was hypothesised that maternal pregnancy-specific stress would be associated with fetoplacental haemodynamics and neonatal outcomes.

DESIGN

This is a secondary analysis of data collected for a large-scale prospective observational study.

SETTING

This study was conducted in the seven major obstetric hospitals in Ireland and Northern Ireland.

PARTICIPANTS

Participants included 331 women who participated in the Prospective Observational Trial to Optimise Paediatric Health in Intrauterine Growth Restriction. Women with singleton pregnancies between 24 and 36 weeks gestation, estimated fetal weight <10th percentile and no major structural or chromosomal abnormalities were included.

PRIMARY AND SECONDARY OUTCOME MEASURES

Serial Doppler ultrasound examinations of the umbilical and middle cerebral arteries between 20 and 42 weeks gestation, Pregnancy Distress Questionnaire (PDQ) scores between 23 and 40 weeks gestation and neonatal outcomes.

RESULTS

Concerns about physical symptoms and body image at 35-40 weeks were associated with lower odds of abnormal UAPI (OR 0.826, 95% CI 0.696 to 0.979, p=0.028). PDQ score (OR 1.073, 95% CI 1.012 to 1.137, p=0.017), concerns about birth and the baby (OR 1.143, 95% CI 1.037 to 1.260, p=0.007) and concerns about physical symptoms and body image (OR 1.283, 95% CI 1.070 to 1.538, p=0.007) at 29-34 weeks were associated with higher odds of abnormal MCA PI. Concerns about birth and the baby at 29-34 weeks (OR 1.202, 95% CI 1.018 to 1.421, p=0.030) were associated with higher odds of AEDF. Concerns about physical symptoms and body image at 35-40 weeks were associated with decreased odds of neonatal intensive care unit admission (OR 0.635, 95% CI 0.435 to 0.927, p=0.019).

CONCLUSIONS

These findings suggest that fetoplacental haemodynamics may be a mechanistic link between maternal prenatal stress and fetal and neonatal well-being, but additional research is required.

Impact of an educational DVD on anxiety and glycaemic control in women diagnosed with gestational diabetes mellitus (GDM): A randomised controlled trial

AIMS

The diagnosis of gestational diabetes mellitus (GDM) during pregnancy can lead to anxiety. This study evaluated the impact of an innovative patient-centred educational DVD on anxiety and glycaemic control in women newly diagnosed with GDM.

METHODS

150 multi-ethnic women, aged 19-44years, from three UK hospitals were randomised to either usual care plus DVD (DVD group, n=77) or usual care alone (control group, n=73) at GDM diagnosis. Primary outcomes were anxiety (State-Trait Anxiety Inventory) and mean 1-h postprandial capillary self-monitored blood glucose for all meals, on day prior to follow-up.

RESULTS

No significant difference between the DVD and control group were reported, for anxiety (37.7±11.7 vs 36.2±10.9; mean difference after adjustment for covariates (95% CI) 2.5 (-0.8, 5.9) or for mean 1-h postprandial glucose for all meals (6.9±0.9 vs 7.0±1.2mmol/L; -0.2 (-0.5, 0.2). However, the DVD group had significantly lower postprandial breakfast glucose compared to the control group (6.8±1.2 vs 7.4±1.9mmol/L; -0.5 (-1.1, -<0.1; p=0.04).

CONCLUSIONS

The results in this trial did not highlight any differences between those who received the intervention and those who received usual care. It is possible that women already felt supported by their frequent attendance at specialist clinics for monitoring and advice. Healthcare professional and family support are key elements to empowering women with GDM and require further consideration in future interventions. Nonetheless, educational resources such as this will be beneficial to help support women given the current resource and time implications of the year on year rises in the incidence of gestational diabetes.

Effect of implementation of a preconception counselling resource for women with diabetes: A population based study

AIM

To evaluate the effect of regional implementation of a preconception counselling resource into routine diabetes care on pregnancy planning indicators.

METHODS

A preconception counselling DVD was distributed to women by diabetes care teams and general practices. Subsequently, in a prospective population-based study, pregnancy planning indicators were evaluated. The post-DVD cohort (n=135), including a viewed-DVD subgroup (n=58), were compared with an historical cohort (pre-DVD, n=114). Primary outcome was HbA1c at first diabetes-antenatal visit. Secondary outcomes included preconception folic acid consumption, planned pregnancy and HbA1c recorded in the 6 months preconception.

RESULTS

Mean first visit HbA1c was lower post-DVD vs. pre-DVD: 7.5% vs. 7.8% [58.4 vs. 61.8mmol/mol]; p=0.12), although not statistically significant. 53% and 20% of women with type 1 and 2 diabetes, respectively, viewed the DVD. The viewed-DVD subgroup were significantly more likely to have lower first visit HbA1c: 6.9% vs. 7.8% [52.1 vs. 61.8mmol/mol], P<0.001; planned pregnancy (88% vs. 59%, P<0.001); taken folic acid preconception (81% vs. 43%, P=0.001); and had HbA1c recorded preconception (88% vs. 53%, P<0.001) than the pre-DVD cohort.

CONCLUSIONS

Implementation of a preconception counselling resource was associated with improved pregnancy planning indicators. Women with type 2 diabetes are difficult to reach. Greater awareness within primary care of the importance of preconception counselling among this population is needed.

Prenatal stress and hemodynamics in pregnancy: a systematic review

Maternal prenatal stress is associated with preterm birth, intrauterine growth restriction, and developmental delay. However, the impact of prenatal stress on hemodynamics during pregnancy remains unclear. This systematic review was conducted in order to assess the quality of the evidence available to date regarding the relationship between prenatal stress and maternal-fetal hemodynamics. The PubMed/Medline, EMBASE, PsycINFO, Maternity and Infant Care, Trip, Cochrane Library, and CINAHL databases were searched using the search terms pregnancy; stress; fetus; blood; Doppler; ultrasound. Studies were eligible for inclusion if prenatal stress was assessed with standardized measures, hemodynamics was measured with Doppler ultrasound, and methods were adequately described. A specifically designed data extraction form was used. The methodological quality of included studies was assessed using well-accepted quality appraisal guidelines. Of 2532 studies reviewed, 12 met the criteria for inclusion. Six reported that prenatal stress significantly affects maternal or fetal hemodynamics; six found no significant association between maternal stress and circulation. Significant relationships between prenatal stress and uterine artery resistance (RI) and pulsatility (PI) indices, umbilical artery RI, PI, and systolic/diastolic ratio, fetal middle cerebral artery PI, cerebroplacental ratio, and umbilical vein volume blood flow were found. To date, there is limited evidence that prenatal stress is associated with changes in circulation. More carefully designed studies with larger sample sizes, repeated assessments across gestation, tighter control for confounding factors, and measures of pregnancy-specific stress will clarify this relationship.

Exploring the needs, concerns and knowledge of women diagnosed with gestational diabetes: A qualitative study

OBJECTIVE

to explore the concerns, needs and knowledge of women diagnosed with Gestational Diabetes Mellitus (GDM).

DESIGN

a qualitative study of women with GDM or a history of GDM.

METHODS

nineteen women who were both pregnant and recently diagnosed with GDM or post- natal with a recent history of GDM were recruited from outpatient diabetes care clinics. This qualitative study utilised focus groups. Participants were asked a series of open-ended questions to explore (1) current knowledge of GDM; (2) anxiety when diagnosed with GDM, and whether this changed overtime; (3) understanding and managing GDM and (4) the future impact of GDM. The data were analysed using a conventional content analysis approach.

FINDINGS

women experienced a steep learning curve when initially diagnosed and eventually became skilled at managing their disease effectively. The use of insulin was associated with fear and guilt. Diet advice was sometimes complex and not culturally appropriate. Women appeared not to be fully aware of the short or long-term consequences of a diagnosis of GDM.

CONCLUSIONS

midwives and other Health Care Professionals need to be cognisant of the impact of a diagnosis of GDM and give individual and culturally appropriate advice (especially with regards to diet). High quality, evidence based information resources need to be made available to this group of women. Future health risks and lifestyle changes need to be discussed at diagnosis to ensure women have the opportunity to improve their health.

Preferences for a third-trimester ultrasound scan in a low-risk obstetric population: a discrete choice experiment

OBJECTIVE

Establish maternal preferences for a third-trimester ultrasound scan in a healthy, low-risk pregnant population.

DESIGN

Cross-sectional study incorporating a discrete choice experiment.

SETTING

A large, urban maternity hospital in Northern Ireland.

PARTICIPANTS

One hundred and forty-six women in their second trimester of pregnancy.

METHODS

A discrete choice experiment was designed to elicit preferences for four attributes of a third-trimester ultrasound scan: health-care professional conducting the scan, detection rate for abnormal foetal growth, provision of non-medical information, cost. Additional data collected included age, marital status, socio-economic status, obstetric history, pregnancy-specific stress levels, perceived health and whether pregnancy was planned. Analysis was undertaken using a mixed logit model with interaction effects.

MAIN OUTCOME MEASURES

Women's preferences for, and trade-offs between, the attributes of a hypothetical scan and indirect willingness-to-pay estimates.

RESULTS

Women had significant positive preference for higher rate of detection, lower cost and provision of non-medical information, with no significant value placed on scan operator. Interaction effects revealed subgroups that valued the scan most: women experiencing their first pregnancy, women reporting higher levels of stress, an adverse obstetric history and older women.

CONCLUSIONS

Women were able to trade on aspects of care and place relative importance on clinical, non-clinical outcomes and processes of service delivery, thus highlighting the potential of using health utilities in the development of services from a clinical, economic and social perspective. Specifically, maternal preferences exhibited provide valuable information for designing a randomized trial of effectiveness and insight for clinical and policy decision makers to inform woman-centred care.

Parent ratings of child cognition and language compared with Bayley-III in preterm 3-year-olds

BACKGROUND

Parent ratings on questionnaires may provide valid and cost-effective tools for screening cognitive development of children at risk of developmental delay.

AIMS

In this study, we examined the convergent validity of combining parent-based reports of non-verbal cognitive abilities (PARCA3) and verbal abilities (CDI-III) in relation to the Bayley-III cognitive scale in 3-year-olds born late pre-term.

METHODS

Mothers of 185 late-preterm children were asked to complete the PARCA3 and the CDI-III shortly before children reached age three; children were then assessed using the Bayley-III close to their third birthday.

RESULTS

The two maternal questionnaires were significantly and moderately correlated with the Bayley-III cognitive scores. Together the maternal ratings accounted for 15% of the variance in the Bayley-III cognitive scores, after controlling for other covariates in regression analysis. In particular, the PARCA3 contributed significantly to explain variance in the Bayley-III cognitive scores when controlling for the CDI-III. However, the CDI-III was also independently associated with the Bayley-III cognitive scores.

CONCLUSIONS

Parent ratings of child cognition and language together may provide cost-effective screening of development in "at risk" preschoolers.

Early childhood neurodevelopment after intrauterine growth restriction: a systematic review

BACKGROUND AND OBJECTIVE

Children who experienced intrauterine growth restriction (IUGR) may be at increased risk for adverse developmental outcomes in early childhood. The objective of this study was to carry out a systematic review of neurodevelopmental outcomes from 6 months to 3 years after IUGR.

METHODS

PubMed, Embase, PsycINFO, Maternity and Infant Care, and CINAHL databases were searched by using the search terms intrauterine, fetal, growth restriction, child development, neurodevelopment, early childhood, cognitive, motor, speech, language. Studies were eligible for inclusion if participants met specified criteria for growth restriction, follow-up was conducted within 6 months to 3 years, methods were adequately described, non-IUGR comparison groups were included, and full English text of the article was available. A specifically designed data extraction form was used. The methodological quality of included studies was assessed using well-documented quality-appraisal guidelines.

RESULTS

Of 731 studies reviewed, 16 were included. Poorer neurodevelopmental outcomes after IUGR were described in 11. Ten found motor, 8 cognitive, and 7 language delays. Other delays included social development, attention, and adaptive behavior. Only 8 included abnormal Doppler parameters in their definitions of IUGR.

CONCLUSIONS

Evidence suggests that children are at risk for poorer neurodevelopmental outcomes following IUGR from 6 months to 3 years of age. The heterogeneity of primary outcomes, assessment measures, adjustment for confounding variables, and definitions of IUGR limits synthesis and interpretation. Sample sizes in most studies were small, and some examined preterm IUGR children without including term IUGR or AGA comparison groups, limiting the value of extant studies.

Behavioural outcomes at 3 years of age among late preterm infants admitted to neonatal intensive care: a cohort study

OBJECTIVE

Examine the behavioural outcomes at age 3 years of late preterm infants (LPIs) who were admitted to neonatal intensive care (NIC) in comparison with LPIs who were not admitted.

METHOD

This cohort study prospectively recruited 225 children born late preterm (34-36(+6) weeks gestation) in 2006 in Northern Ireland, now aged 3 years. Two groups were compared: LPIs who received NIC (study; n=103) and LPIs who did not receive NIC (control; n=122). Parents/guardians completed the Child Behaviour Checklist/1½-5. Descriptive maternal and infant data were also collected.

RESULTS

As expected LPI children admitted to NIC had higher medical risk than the non-admitted comparison group (increased caesarean section, born at earlier gestation, lower birth weight and an episode of resuscitation at birth). LPIs admitted to NIC scored higher on the Child Behaviour Checklist/1½-5 compared with those who were not admitted indicating more behavioural problems; this was statistically significant for the Aggressive Behaviour Subscale (z=-2.36) and the Externalising Problems Scale (z=-2.42). The group difference on the Externalising Problems Scale was no longer significant after controlling for gender, gestational age and deprivation score.

CONCLUSIONS

This study provides valuable data on the behaviour at age 3 years of LPIs admitted to NIC compared with LPIs not admitted to NIC. Further research would be beneficial to explore medical and psychosocial explanations for observed differences between groups using large prospective cohort studies.

Neonatal intensive care and late preterm infants: health and family functioning at three years

BACKGROUND

Late preterm infants (LPIs), born at 34+0 to 36+6 weeks of gestation contribute a significant proportion of all neonatal intensive care (NIC) admissions and are regarded as being at risk of adverse outcomes compared to term-born infants.

AIM

To explore the health outcomes and family functioning of LPIs who required neonatal intensive care, at three years of age.

STUDY DESIGN AND SUBJECTS

This cohort study included 225 children born late preterm, between 1 January and 31 December 2006 in Northern Ireland. Children admitted for NIC (study group, n=103) were compared with children who did not require NIC or who required special care only for up to three days (comparison group, n=122).

OUTCOME MEASURES

Health outcomes were measured using the Health Status Questionnaire, health service usage by parent report and family functioning using the PedsQL™ Family Impact Module.

RESULTS

LPIs who required NIC revealed similar health outcomes at three years in comparison to those who did not. Despite this, more parents of LPIs who required NIC reported visiting their GP and medical specialists during their child's third year of life. Differences in family functioning were also observed with mothers of LPIs who required NIC reporting, significantly lower levels of social and physical functioning, increased difficulties with communication and increased levels of worry.

CONCLUSIONS

LPIs were observed to have similar health outcomes at three years of age regardless of NIC requirement. The increase in GP and medical specialist visits and family functioning difficulties observed among those infants who required NIC merits further investigation.

Tea tree oil (5%) body wash versus standard care (Johnson's Baby Softwash) to prevent colonization with methicillin-resistant Staphylococcus aureus in critically ill adults: a randomized controlled trial

OBJECTIVES

To determine whether the daily use of 5% tea tree oil (TTO) body wash (Novabac 5% Skin Wash) compared with standard care [Johnson's Baby Softwash (JBS)] had a lower incidence of methicillin-resistant Staphylococcus aureus (MRSA) colonization.

PATIENTS

The study setting was two intensive care units (ICUs; mixed medical, surgical and trauma) in Northern Ireland between October 2007 and July 2009. The study population comprised 391 patients who were randomized to JBS or TTO body wash.

METHODS

This was a Phase 2/3, prospective, open-label, randomized, controlled trial.

TRIAL REGISTRATION

ISRCTN65190967. The primary outcome was new MRSA colonization during ICU stay. Secondary outcomes included the incidence of MRSA bacteraemia and maximum increase in sequential organ failure assessment score.

RESULTS

A total of 445 patients were randomized to the study. After randomization, 54 patients were withdrawn; 30 because of a positive MRSA screen at study entry, 11 due to lack of consent, 11 were inappropriately randomized and 2 had adverse reactions. Thirty-nine (10%) patients developed new MRSA colonization (JBS n = 22, 11.2%; TTO body wash n = 17, 8.7%). The difference in percentage colonized (2.5%, 95% CI - 8.95 to 3.94; P = 0.50) was not significant. The mean maximum increase in sequential organ failure assessment score was not significant (JBS 1.44, SD 1.92; TTO body wash 1.28, SD 1.79; P = 0.85) and no study patients developed MRSA bacteraemia.

CONCLUSIONS

Compared with JBS, TTO body wash cannot be recommended as an effective means of reducing MRSA colonization.

Impact of neonatal intensive care on late preterm infants: developmental outcomes at 3 years

BACKGROUND

Late preterm infants (LPIs) (34-36 weeks' gestation) account for up to 75% of preterm births and constitute a significant proportion of all neonatal admissions. This study assessed the impact of neonatal intensive or high-dependency care (IC) on developmental outcomes of LPIs at 3 years of age.

METHODS

This cohort study included 225 children born late preterm in Northern Ireland during 2006. Children born late preterm who received IC were compared with children born late preterm who did not receive IC. Cognitive, motor, and language skills were assessed by using the Bayley Scales of Infant and Toddler Development, Third Edition. Growth was assessed by using anthropometric measures of height and weight.

RESULTS

LPIs who received IC were more often less mature (34 weeks' gestation), with lower birth weight (≤ 2500 g) and Apgar scores (<7 at 5 minutes) compared with the control group. They were more often born by cesarean delivery and more likely to have received resuscitation at birth. At 3 years of age, children born late preterm who received IC demonstrated similar cognitive, motor, and language skills compared with children in the control group. Measurements of growth also did not differ significantly between groups.

CONCLUSIONS

Despite having increased maternal, perinatal, and neonatal risk factors, there were no significant differences in early childhood development between LPIs who received IC and those who did not. LPIs do not receive routine follow-up after IC and this study provides useful and reassuring data for parents and clinicians on the longer-term outcome of this infant group.

Evaluation of a DVD for women with diabetes: impact on knowledge and attitudes to preconception care

AIMS

To determine if an educational DVD increases knowledge and changes attitudes of women with diabetes towards preconception care.

METHODS

Ninety-seven women with diabetes (Type 1, n = 89; Type 2, n = 8), aged 18-40 years, completed a pre-DVD and post-DVD intervention study by postal questionnaire. Beliefs and attitudes associated with preventing an unplanned pregnancy and seeking preconception care were assessed using a validated questionnaire; scales included benefits, barriers, personal attitudes and self-efficacy. Knowledge of pregnancy planning and pregnancy-related risks were assessed by a 22-item questionnaire.

RESULTS

After viewing the DVD there was significant positive change in women's perceived benefits of, and their personal attitudes to, receiving preconception care and using contraception: change in score post-DVD viewing 0.7 (95% confidence interval 0.3, 1.2), P = 0.003, and 0.8 (0.3, 1.2), P = 0.001, respectively. The DVD significantly improved self-efficacy, that is, self-confidence to use contraception for prevention of an unplanned pregnancy and to access preconception care [3.3 (1.9, 4.7), P < 0.001], and significantly reduced perceived barriers to preconception care [-0.7 (-1.2, -0.2), P = 0.01]. Knowledge of pregnancy planning and pregnancy-related risks increased significantly after viewing the DVD: mean increase was 37.6 ± 20.0%, P < 0.001, and 16.9 ± 21.2%, P < 0.001, respectively.

CONCLUSIONS

This study demonstrates the effectiveness of a DVD in increasing knowledge and enhancing attitudes of women with diabetes to preconception care. This DVD could be used as a prepregnancy counselling resource to prepare women with diabetes for pregnancy.

Early childhood development of late-preterm infants: a systematic review

CONTEXT

Late-preterm infants (LPIs) born at 34 to 36 weeks' gestation are increasingly regarded as being at risk for adverse developmental outcomes. To date, the early childhood development of LPIs has not been systematically considered.

OBJECTIVE

To undertake a broad examination of literature relating to early childhood development at the ages of 1 to 7 years of LPIs born at 34 to 36 weeks' gestation.

METHODS

We conducted a systematic review of early childhood outcomes in LPIs by using 9 electronic databases (January 1980 to March 2010). Bibliographies were reviewed. After examination of abstracts, ineligible studies were excluded. A specifically designed data-extraction form was used. The methodologic quality of included studies was assessed by using well-documented quality-appraisal guidelines.

RESULTS

Of 4581 studies, 10 (3 prospective and 7 retrospective cohort) were included. Studies were heterogeneous, and poorer outcomes were reported among LPIs in relation to neurodevelopmental disabilities, educational ability, early-intervention requirements, medical disabilities, and physical growth in comparison to term-born children. No identified study used healthy nonadmitted LPIs as a comparison group for admitted LPIs.

CONCLUSIONS

Evidence suggests that LPIs are at increased risk of adverse developmental outcomes and academic difficulties up to 7 years of age in comparison to term infants. An infant control group matched for gestational age has not been used; thus, for LPIs, the effect of neonatal admission on longer-term outcomes has not been fully explored. Systematic measurement of early childhood outcomes is lacking, and focused long-term follow-up studies are needed to investigate early childhood development after late-preterm birth.

An exploration of knowledge and attitudes related to pre-pregnancy care in women with diabetes

AIMS

Pre-pregnancy care optimizes pregnancy outcome in women with pre-gestational diabetes, yet most women enter pregnancy unprepared. We sought to determine knowledge and attitudes of women with Type 1 and Type 2 diabetes of childbearing age towards pre-pregnancy care.

METHODS

Twenty-four women (18 with Type 1 diabetes and six with Type 2 diabetes) aged 17-40 years took part in one of four focus group sessions: young nulliparous women with Type 1 diabetes (Group A), older nulliparous women with Type 1 diabetes (Group B), parous women with Type 1 diabetes (Group C) and women with Type 2 diabetes of mixed parity (Group D).

RESULTS

Content analysis of transcribed focus groups revealed that, while women were well informed about the need to plan pregnancy, awareness of the rationale for planning was only evident in parous women or those who had actively sought pre-pregnancy advice. Within each group, there was uncertainty about what pre-pregnancy advice entailed. Despite many women reporting positive healthcare experiences, frequently cited barriers to discussing issues around family planning included unsupportive staff, busy clinics and perceived social stereotypes held by health professionals.

CONCLUSIONS

Knowledge and attitudes reported in this study highlight the need for women with diabetes, regardless of age, marital status or type of diabetes, to receive guidance about planning pregnancy in a motivating, positive and supportive manner. The important patient viewpoints expressed in this study may help health professionals determine how best to encourage women to avail of pre-pregnancy care.

Interventions to prevent hypothermia at birth in preterm and/or low birthweight infants

BACKGROUND

Hypothermia incurred during routine postnatal resuscitation is a world-wide issue (across all climates), associated with morbidity and mortality. Keeping vulnerable preterm infants warm is problematic even when recommended routine thermal care guidelines are followed in the delivery suite.

OBJECTIVES

To assess efficacy and safety of interventions designed for prevention of hypothermia in preterm and/or low birthweight infants applied within ten minutes after birth in the delivery suite compared with routine thermal care.

SEARCH STRATEGY

The standard search strategy of The Cochrane Collaboration was followed. Electronic databases were searched: MEDLINE (1966 to July Week 4 2007 ), CINAHL (1982 to July Week 4 2007), EMBASE (1974 to 01/08/2007), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2007), Database of Abstracts of Reviews of Effects (DARE 1994 to July 2007), conference/symposia proceedings using ZETOC (1993 to 17/08/2007), ISI proceedings (1990 to 17/08/2007) and OCLC WorldCat (July 2007). Identified articles were cross-referenced. No language restrictions were imposed.

SELECTION CRITERIA

All trials using randomised or quasi-randomised allocations to test a specific intervention designed to prevent hypothermia, (apart from 'routine' thermal care) applied within 10 minutes after birth in the delivery suite to infants of < 37 weeks' gestational age or birthweight </=2500 g.

DATA COLLECTION AND ANALYSIS

Methodological quality was assessed and data were extracted for important clinical outcomes including adverse effects of the intervention by at least three independent review authors. Authors were contacted for missing data. Data were analysed using RevMan 4.2.5. Relative risk (RR), risk difference (RD) and number needed to treat (NNT) with 95% confidence limits were calculated for each dichotomous outcome and mean differences (MD) with 95% confidence limits for continuous outcomes.

MAIN RESULTS

Six studies giving a total of 304 infants randomised and 295 completing the studies were included. Four comparisons to 'routine care' were undertaken within two categories:1) barriers to heat loss (four studies): plastic wrap or bag (three), stockinet caps (one) and2) external heat sources (two studies): skin-to-skin (one), transwarmer mattress (one). Plastic barriers were effective in reducing heat losses in infants < 28 weeks' gestation (three studies, n = 159; WMD 0.76 degrees C; 95% CI 0.49, 1.03), but not in infants between 28 to 31 week's gestation. There was insufficient evidence to suggest that plastic wrap reduces the risk of death within hospital stay (three studies, n = 161; typical RR 0.63; 95% CI 0.32, 1.22; typical RD -0.09; 95% CI -0.20, 0.03). There was no evidence of a significant difference in major brain injury, mean duration of oxygen therapy or hospitalisation for infants < 29 weeks' gestation. Stockinet caps were not effective (borderline significant for infants < 2000 g birthweight) in reducing heat losses.Skin-to-skin care was shown to be effective in reducing the risk of hypothermia when compared to conventional incubator care for infants 1200 to 2199 g birthweight (one study, n = 31; RR 0.09; 95% CI 0.01, 0.64; NNT 2; 2 to 4). The transwarmer mattress kept infants </=1500 g significantly warmer and reduced the incidence of hypothermia on admission to NICU(one study, n = 24; RR 0.30; 95% CI 0.11, 0.83; NNT 2 range 2 to 4).

AUTHORS' CONCLUSIONS

Plastic wraps or bags, skin-to-skin care and transwarmer mattresses all keep preterm infants warmer, leading to higher temperatures on admission to neonatal units and less hypothermia. Given the low NNT, consideration should be given to using these interventions in the delivery suite. However, the small numbers of infants and studies and the absence of long-term follow-up mean that firm recommendations for clinical practice cannot be given. There is a need to conduct large, high quality randomised controlled trials looking at long-term outcomes.

Does intrauterine growth restriction affect quality of life in adulthood?

OBJECTIVE

To compare health-related quality of life in 50-year-old adults who were born at term (> or =37 to 42 weeks' gestation) with intrauterine growth restriction (IUGR; birth weight <10th centile) and a group born at term without IUGR (> or =10th centile).

DESIGN

Case control study.

SETTING

A large regional maternity hospital in Northern Ireland.

SUBJECTS

235 adults who were born between 1954 and 1956 in the Royal Maternity Hospital, Belfast. 111 subjects born with IUGR and 124 controls with normal birth weight for gestation were compared.

MAIN OUTCOME MEASURE

Health-related quality of life in adulthood was assessed using the Short Form-36 Health Survey (SF-36).

RESULTS

The two groups reported similar health-related quality of life on each of the eight dimensions of the SF-36 and there were no significant differences between them. Adjusting for potential confounding variables did not alter this conclusion.

CONCLUSIONS

The similarity of SF-36 scores indicated that those born with IUGR did not perceive this to adversely influence health-related quality of life at 50 years of age compared with those with normal birth weight.

A retrospective cohort study exploring the relationship between antenatal reflexology and intranatal outcomes

The integration of reflexology into midwifery care has become more common in recent years as a result of a developing interest in alternative and complementary therapies and also due to the integration of new skills into midwifery practice. The objective of this study was to investigate the association of antenatal reflexology with different outcomes in the intranatal period. The key variables of interest were onset of labour, duration of labour, analgesia used and mode of delivery. The findings showed there was no significant difference in the onset of labour or duration of labour between the two groups. The group who had four or more reflexology treatments had a reduced length of labour but this was not statistically significant. There was a significant difference in the use of Entonox between the two groups with the reflexology group having a lower uptake. Fewer women in the reflexology group had a normal labour with a higher percentage of women having a forceps delivery. In conclusion the only statistically significant difference between groups was less use of Entonox in the reflexology group. Further research requires standardized treatment and outcome measurement using prospective randomized designs with large samples.

Interventions to prevent hypothermia at birth in preterm and/or low birthweight babies

BACKGROUND

Hypothermia incurred during routine postnatal resuscitation is a world-wide issue (across all climates), with associated morbidity and mortality. Keeping vulnerable preterm infants warm is problematic even when recommended routine thermal care guidelines are followed in the delivery suite.

OBJECTIVES

To assess efficacy and safety of interventions, designed for prevention of hypothermia in preterm and/or low birthweight infants, applied within 10 minutes after birth in the delivery suite compared with routine thermal care.

SEARCH STRATEGY

The standard search strategy of The Cochrane Collaboration was followed. Electronic databases were searched: MEDLINE (1966 to May Week 4 2004 ), CINAHL (1982 to May Week 4 2004), EMBASE (1974 to 09/07/04), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2004), Database of Abstracts of Reviews of Effects (DARE 1994 to July 2004), conference/symposia proceedings using ZETOC (1993 to July 2004), ISI proceedings (1990 to 09/07/2004) and OCLC WorldCat (July 2004). Identified articles were cross-referenced. No language restrictions were imposed.

SELECTION CRITERIA

All trials using randomised or quasi-randomised allocations to test a specific intervention designed to prevent hypothermia, (apart from 'routine' thermal care) applied within 10 minutes after birth in the delivery suite to infants of < 37 weeks' gestational age or birthweight </=2500 g.

DATA COLLECTION AND ANALYSIS

Methodological quality was assessed and data were extracted for important clinical outcomes including adverse effects of the intervention by at least three independent reviewers. Authors were contacted for missing data. Data were analysed using RevMan 4.2.5. Relative risk (RR), risk difference (RD) and number needed to treat (NNT) with 95% confidence limits were calculated for each dichotomous outcome and mean differences (MD) with 95% confidence limits for continuous outcomes.

MAIN RESULTS

Six studies giving a total of 304 infants randomised and 295 completing the studies were included. Four comparisons to 'routine care' were undertaken within two categories: 1) barriers to heat loss (four studies): plastic wrap or bag (three), stockinet caps (one) and 2) external heat sources (two studies): skin-to-skin (one), transwarmer mattress (one). Plastic barriers were effective in reducing heat losses in infants < 28 weeks' gestation (three studies, n = 159; WMD 0.76 degrees C; 95% CI 0.49, 1.03) but not in the 28 to 31 week group. There was insufficient evidence to suggest that plastic wrap reduces the risk of death within hospital stay (three studies, n = 161; typical RR 0.63; 95% CI 0.32, 1.22; typical RD -0.09; 95% CI -0.20, 0.03). There was no evidence of a significant difference in major brain injury, mean duration of oxygen therapy or hospitalisation for infants < 29 weeks' gestation. Stockinet caps were not effective (borderline significant for infants < 2000 g birthweight) in reducing heat losses.Skin-to-skin care was shown to be effective in reducing the risk of hypothermia when compared to conventional incubator care for infants 1200 to 2199 g birthweight (one study, n = 31; RR 0.09; 95% CI 0.01, 0.64; NNT 2; 2 to 4). The transwarmer mattress significantly kept infants </=1500 g warmer and reduced the incidence of hypothermia on admission to NICU (one study, n = 24; RR 0.30; 95% CI 0.11, 0.83; NNT 2 range 2 to 4).

AUTHORS' CONCLUSIONS

Plastic wraps or bags, skin-to-skin care and transwarmer mattresses all keep preterm infants warmer, leading to higher temperatures on admission to neonatal units and less hypothermia. Given the low NNT, consideration should be given to using these interventions in the delivery suite. However, the small numbers of infants and studies and the absence of long term follow-up mean that firm recommendations for clinical practice cannot be given. There is a need to conduct large, high quality randomised controlled trials looking at long-term outcomes.

Identification of subtypes of problem drinkers based on neuropsychological performance

The key issue addressed in this paper is: Can specific subtypes of drinkers be identified on the basis of their neuropsychological performance? A multivariate model of neuropsychological deficits related to alcohol abuse was proposed and cluster analysis was used to see if subtypes could be identified which matched those indicated in the multivariate model. A neuropsychological cognitive assessment battery was given to a wide variety of drinkers (N = 88). Factor analysis yielded scores on four factors which formed the basis for the cluster analysis. Seven stable clusters were identified based on cognitive performance alone. Additionally, clusters were significantly differentiated by age, IQ, education, number of units of alcohol consumed on a heavy drinking day, nutritional status, stress and the Eysenck Personality Questionnaire Lie score. The seven clusters were eventually profiled as healthy males, healthy females, males with stress-related deficits, females with stress-related deficits, mildly impaired males, deficits related to liver dysfunction and mild alcoholic Korsakoff syndrome. The clusters successfully mapped onto the proposed model reinforcing the need for a multivariate approach to the study of neuropsychological deficits in problem drinkers.

The effect of alcohol consumption on recency discrimination ability: an early screening test for alcohol-induced cognitive impairment

In this short study the relationship between recency discrimination ability and a measure of alcohol intake was examined using a series of regression analyses. Semi-partial correlations were extracted in order to evaluate which variables (level of alcohol consumption, age and IQ) best predicted recency discrimination performance on both verbal and non-verbal tasks. Results showed that while IQ best predicted performance on the verbal task both IQ and alcohol intake were significant predictors on the non-verbal task. The results are discussed in relation to current findings and the continuity hypothesis.