Neurodevelopmental outcome and early rehabilitation of premature babies - is it needed in the first 2 years of life?

INTRODUCTION AND OBJECTIVE

The aim of the study was to evaluate the neurodevelopmental outcomes of extremely premature babies at the age of 2 years, and to determine whether rehabilitation was carried out during this period. An additional aim was to determine the relationship between the use of rehabilitation and the degree of prematurity, asphyxia, birth weight, and the result of brain ultrasound.

MATERIAL AND METHODS

The study included 87 premature babies born between 24-31 weeks of pregnancy. A rehabilitation specialist assessed the neurodevelopmental outcomes of the children aged 2 years. Based on the documentation, the frequency of rehabilitation and its dependence on prematurity, asphyxia, birth weight and ultrasound results were analyzed.

RESULTS

Correct neurodevelopmental outcome in children aged 2 years was found in 57 (65%) children, of whom 40 (46%) did not undergo rehabilitation. Incorrect development was observed in a group of 30 children - 12 patients were diagnosed with CP (14%), and 18 (21%) had 'red flags' of development milestones, they underwent rehabilitation. There was no statistically significant relationship between the degree of prematurity, perinatal asphyxia, birth weight and rehabilitation in the first 2 years of life. Abnormal ultrasound results were more common in rehabilitated children (n = 25; 53%) than in children without rehabilitation (n = 10; 25%), p = 0.008.

CONCLUSIONS

Correct neurodevelopmental outcome at the age of 2 reached two-thirds of extreme prematurities, most of which did not need rehabilitation during this period. According to the authors' knowledge, this is the first study to show the percentage of premature babies who in the first 2 years of life did not require rehabilitation and achieved normal development.

Interventions to improve gross motor performance in children with neurodevelopmental disorders: a meta-analysis

BACKGROUND

Gross motor skills are fundamental to childhood development. The effectiveness of current physical therapy options for children with mild to moderate gross motor disorders is unknown. The aim of this study was to systematically review the literature to investigate the effectiveness of conservative interventions to improve gross motor performance in children with a range of neurodevelopmental disorders.

METHODS

A systematic review with meta-analysis was conducted. MEDLINE, EMBASE, AMED, CINAHL, PsycINFO, PEDro, Cochrane Collaboration, Google Scholar databases and clinical trial registries were searched. Published randomised controlled trials including children 3 to ≤18 years with (i) Developmental Coordination Disorder (DCD) or Cerebral Palsy (CP) (Gross Motor Function Classification System Level 1) or Developmental Delay or Minimal Acquired Brain Injury or Prematurity (<30 weeks gestational age) or Fetal Alcohol Spectrum Disorders; and (ii) receiving non-pharmacological or non-surgical interventions from a health professional and (iii) gross motor outcomes obtained using a standardised assessment tool. Meta-analysis was performed to determine the pooled effect of intervention on gross motor function. Methodological quality and strength of meta-analysis recommendations were evaluated using PEDro and the GRADE approach respectively.

RESULTS

Of 2513 papers, 9 met inclusion criteria including children with CP (n = 2) or DCD (n = 7) receiving 11 different interventions. Only two of 9 trials showed an effect for treatment. Using the least conservative trial outcomes a large beneficial effect of intervention was shown (SMD:-0.8; 95% CI:-1.1 to -0.5) with "very low quality" GRADE ratings. Using the most conservative trial outcomes there is no treatment effect (SMD:-0.1; 95% CI:-0.3 to 0.2) with "low quality" GRADE ratings. Study limitations included the small number and poor quality of the available trials.

CONCLUSION

Although we found that some interventions with a task-orientated framework can improve gross motor outcomes in children with DCD or CP, these findings are limited by the very low quality of the available evidence. High quality intervention trials are urgently needed.

Resuscitation intensity at birth is associated with changes in brain metabolic development in preterm neonates

INTRODUCTION

Intensive resuscitation at birth has been linked to intraventricular haemorrhage (IVH) in the preterm neonate. However, the impact of less intensive resuscitation on more subtle alterations in brain metabolic development is largely unknown. Our objective was to determine the relationship between the intensity of neonatal resuscitation following preterm birth on brain metabolic development.

METHODS

One hundred thirty-three very preterm-born neonates (median gestational age [GA] 27 ± 2 weeks) underwent MR spectroscopic imaging early in life (median postmenstrual age 32 weeks) and again at term-equivalent age (median 40 weeks). Severity of white matter injury, IVH and cerebellar haemorrhage on magnetic resonance imaging were scored. Ratios of N-acetylaspartate (NAA) and lactate to choline (Cho) were calculated in eight regions of interest and were assessed in relation to intensiveness of resuscitation strategy (bag and mask, continuous positive airway pressure [CPAP], intubation, cardiopulmonary resuscitation [CPR]).

RESULTS

Within the first hour of life, 14 newborns had no intervention, 3 received bag and mask, 30 had CPAP, 79 were intubated and 7 had CPR. Resuscitated infants were more likely to have IVH (p = 0.02). More intensive resuscitation was associated with decreased NAA/Cho maturation (p < 0.001, adjusting for birth GA). Metabolic development was similar in neonates requiring CPAP in comparison to those receiving no intervention. The change in lactate/Cho did not differ across resuscitation categories (p = 0.8).

CONCLUSIONS

Intensity of resuscitation at birth is related to changes in metabolic brain development from early in life to term-equivalent age. Results suggest that preventing the need for intensive neonatal resuscitation may provide an opportunity to improve brain development in preterm neonates.

Intervention in the first weeks of life for infants born late preterm: a case series

Infants born late preterm (34-36 weeks of gestation) account for 350 000 US births per year, are at risk for developmental delays, and are rarely included in intervention studies.

PURPOSE

To describe a novel parent-delivered movement intervention program for very young infants and outcomes following intervention and to evaluate the feasibility of using a comprehensive set of outcome measures.

SUMMARY OF KEY POINTS

Two infants born late preterm received intervention from 0.5 to 2.0 months of adjusted age. Development, postural control, reaching, and object exploration assessments were completed at 3 time points. The intervention was well tolerated by the family. Improvements in developmental outcomes, postural control, and object exploration are presented.

STATEMENT OF CONCLUSION

Very early movement experience provided daily by parents may improve development. In combination, norm-referenced and behavioral measures appear sensitive to changes in infant behaviors.

Outcomes of preterm infants: morbidity replaces mortality

Over the last 50 years in the United States a rising preterm birth rate, a progressive decrease in preterm mortality, and a lowering of the limit of viability have made preterm birth a significant public health problem. Neuromaturation, the functional development of the central nervous system (CNS), is a dynamic process that promotes and shapes CNS structural development. This article reviews preterm outcomes, recognizing that multiple factors influence neuromaturation and lead to a range of neurodevelopmental disabilities, dysfunctions, and altered CNS processing. Ways to protect preterm infants and support their growth and development in and beyond intensive care are examined.

Risk factors associated with children lost to care in a state early childhood intervention program

A retrospective cohort study was conducted to identify risk factors associated with children lost to care, and their families, compared to those not lost to care within the California Early Start Program. The cohort included data on 8987 children enrolled in the Early Start Program in 1998. This cohort consisted of 2443 children lost to care, 6363 children not lost to care, and 187 children that were lost to follow-up due to death or moving outside the state of California. Premature birth was the only medical risk factor in this study related to an increased risk of loss. Family risk factors exert a significant effect on loss to care. Risk factors that are predictive of loss to care include mother's age and educational level, Medi-Cal ineligibility, and lack of transportation. By identifying and examining risk factors for loss to care, interventions may be strengthened to promote continued family participation in early intervention services.

[The Outpatient Health Care Package for the very premature infant: application of the program to follow-up services for the Neonatal Intensive Care, Pediatrics Department, Università "La Sapienza" I Facoltà, Roma (June 2008-March 2010)]

Fifty-nine children were enrolled in the Outpatient Health Care Package (OHCP) from 01/06/2008 to 31/03/2010. All children, except two, attended entirely the follow-up appointments; a satisfactory result, considering also that 30% of family were living outside the urban area and more than a third of the families was originated in a foreign country. At 3 months corrected age(CA) Haemoglobin mean values of 47 infants, all in iron treatment, were: 12.26 (10.1-14-1) g/dL; 25% had values between 10.1 and 12 g/dL. Mean values for Calcium were 10.75 (9.50-15.26) mg/dL Mean values for ALP were 393 (179-1075) UI/L, values >1000 UI/L were found in two infants who suspended Vitamin D treatment. At 3 months CA 50 infants performed ABR, 12 of these showing abnormalities. To date 9 infants repeated ABR at 6-9 months CA, 4 of these showed again abnormal results. Overall were found 4 ABR abnormalities among 47 children (8.5%). Outcome of 23 children at 12 months CA: no moderate or severe neurologic abnormalities were found, 4 children (17.4%) presented mild abnormalities, 2 were referred for rehabilitation. No QSM <80% was found (mean QSM 93.7%) in 10 children evaluated. One child presented growth retardation <5 degrees; 2 underwent laser treatment for ROP with normal vision, 7 (30.4%)had sistolic BP > or = 95 degrees; 6 (26%) were rehospitalized. This experience was positive: OHCP promoted a better compliance and standardization of follow-up. It would be desirable to prolong OHCP until school-age, including renal and cardiac functions monitoring.

[Home care for the high-risk newborn infant]

With increased survival of extremely low birth weigh (ELBW) and very ill infants, a lot of them are discharged with unresolved medical issues that complicate their subsequent care. Infants born preterm with low birth weight who require neonatal intensive care experience a much higher rate of hospital readmission and death during the first year after birth compared with healthy term infants. Despite initial hospital care which is one of the most expensive of all kind of hospitalization, home care services are sometimes still sparse though the high risk of this group for failure to thrive, respiratory problems, developmental delays, parenting problems. In addition, societal and economic forces have come to bear on the timing and process of discharge and home care. Moreover it takes time for the family of a high-risk infant to prepare to care for their infant in a home setting and to obtain the necessary support services and mobilize community resources. Careful preparation for discharge, good follow-up and medical home after discharge may reduce these risks.

Neonatal hearing screening in Albania: Results from an ongoing universal screening program

The paper describes the outcomes of an ongoing universal hearing screening program in Tirana, Albania. The main objectives of the project were the evaluation of the feasibility of a neonatal hearing screening program in Albania, and an evaluation of the prevalence of risk factors in the NICU environment. One thousand five hundred and sixty-one (1561) infants from both the WB and NICU were screened with transient evoked otoacoustic emissions (TEOAE). A detailed history of risk factors was collected in each case, thus it was possible to evaluate the main factors influencing the output of the screening program. It was concluded that the program had the capacity to identify infants with congenital hearing loss provided that an informative component is well-structured and delivered. Also, although the prevalence of risk factors appeared high, the reduction of 'case leakage' would allow the precise estimation of the incidence of hearing loss in the Albanian population.

Developmental coordination disorder at 8 years of age in a regional cohort of extremely-low-birthweight or very preterm infants

The aims of this study were to determine the motor outcome of extremely-low-birthweight (ELBW; <1000g) or very preterm (<28wks) children compared with normal birthweight (NBW) children, to establish the perinatal associations of developmental coordination disorder (DCD) and its cognitive and behavioural consequences. Participants were consecutive surviving ELBW or very preterm children and randomly selected NBW(>2499g) children born in the state of Victoria, Australia, in 1991 or 1992. Main outcomes were: (1) results of the Movement Assessment Battery for Children (MABC) at 8 years of age; (2) cognitive function; (3) academic progress; and (4) behaviour. Of 298 consecutive ELBW/very preterm survivors, 255 (85.6%; 117 males, 138 females) had the MABC at a mean age of 8 years 8 months. More ELBW/very preterm children (9.5%) had DCD than the NBW group (2%, p=0.001). Only male sex increased the likelihood of DCD in ELBW/very preterm children (p=0.017). ELBW/very preterm children with DCD had worse cognitive function and academic test scores (up to 1SD below those without DCD); they also had more adaptive behaviour and externalizing problems, but not internalizing problems. DCD is more common in ELBW/very preterm children, has few perinatal correlates, and is associated with poor cognitive and academic performance as well as increased behaviour problems.

Long-Term Outcome After Neonatal Parenchymatous Brain Lesions

BACKGROUND

Although considered of high prognostic impact, knowledge on the long-term outcome after neonatal parenchymatous brain lesions (PBL) is limited.

PATIENTS

29 children with either unilateral (n = 19) or bilateral (n = 10) hemorrhagic/ischemic PBL.

METHODS

The patients were reinvestigated at 9 9/12 +/- 3 4/12 years of age, using a standardized clinical investigation, the Beery-Buktenica Scales of Visuomotor Integration (VMI) and the Bruininks-Oseretzky Test of Motor Proficiency (BOT). The parents were questioned by means of a standardized questionnaire and the Child Behavior Checklist (CBCL).

RESULTS

90 % of the children showed cerebral palsy (including 12 with hemi- and 8 with tetraplegia). Only 11 % showed normal results on BOT and 39 % on VMI testing. 50 % were bed wetters. Six had required ventriculoperitoneal shunting and 11 were on long-term antiepileptic therapy. Herewith bilateral versus unilateral lesions and low 5-minute APGAR scores were associated with poorer outcome (Cox model and Kaplan-Meier analysis). During follow-up the impact of different disabilities changed. Despite the high rate of cerebral palsy, 71 % learned to walk unaided and 86 % to communicate with words. The last patient learned to walk at 7 years of age. Only one showed poor seizure control. No severe shunt-related complications occurred after 5 years of age. Social, cognitive and behavioral problems increased with age. Only 34 % could attend mainstream schools or kindergartens, and only 50 % displayed normal behavior according to CBCL data, with attention deficiency and social problems being the most important domains. In consequence, nearly all children required 24-hour supervision.

CONCLUSIONS

After birth, organic problems such as delayed motor development, epilepsy and ventriculoperitoneal shunting are of major importance for children with PBL. Although delayed, basic skills such as verbal communication are achieved by the majority of patients. In later childhood and adolescence, social, behavioral and cognitive problems increase. In the future, vast resources will be required to provide adequate education and carers as substitutes for elderly parents.

Treadmill training for an infant born preterm with a grade III intraventricular hemorrhage

BACKGROUND AND PURPOSE

Research has documented the feasibility and benefit of treadmill training in children with cerebral palsy and Down syndrome. The purposes of this case report are: (1) to determine the feasibility of treadmill training in an infant at high risk for neuromotor dysfunction and (2) to describe the child's treadmill stepping patterns following treadmill training.

CASE DESCRIPTION

The male infant, who had a grade III intraventricular hemorrhage following premature birth, began physical therapy and treadmill training at 51/4 months corrected age. Treadmill training was conducted 3 times weekly and videotaped weekly. Videotape analysis determined number of steps, step type, and foot position.

OUTCOMES

Except for foot position, trends in treadmill stepping were similar to those of studies with infants not at high risk for neuromotor disabilities.

DISCUSSION

This case report shows that treadmill training is feasible for an infant at high risk for neuromotor disabilities and may be associated with more mature stepping characteristics. Future research should evaluate optimum treadmill training parameters and long-term developmental outcomes.

Morbidity and mortality after RSV-associated hospitalizations among premature Canadian infants

OBJECTIVE

To evaluate the impact of respiratory syncytial virus (RSV) infections on subsequent health care resource utilization in preterm infants.

STUDY DESIGN

Analysis of data from 2415 preterm infants (32 to 35 weeks gestational age [GA]) hospitalized for proven or probable RSV and matched to 20,254 control infants.

RESULTS

Mean (SD) age at the index admission was 7.7 (5.5) months; 46% of the infants were male. Mean (SD) subsequent health services, excluding the index event, for the RSV cohort and control infants, respectively, were hospitalization, 2.96 (2.81) versus 1.28 (1.42); special care unit visits, 0.67 (1.70) versus 0.40 (0.33); respiratory therapy visits, 0:31 (0.70) versus 0.13 (0.37); physician consults, 3.61 (4.54) versus 0.89 (1.12); in-hospital procedures, 1.05 (4.02) versus 0.81 (1.51); outpatient visits, 18.4 (10.58) versus 7.54 (4.31); and mean (SD) inpatient days, 14.71 (18.69) versus 5.04 (7.09). All differences were statistically significant (P<.001). Diagnoses for the RSV and control cohorts were respiratory conditions (64% versus 13%), fever (2.7% versus 0.7%), anorexia (2.2% versus 0.6%), lack of normal physiological development (2.8% versus 1.1%; P<.05), overall deaths (8.1% versus 1.6%; P<.001), and sudden death (6.1% versus 0.3%; P<.001).

CONCLUSIONS

RSV hospitalization in healthy premature infants is associated with a significant increase in subsequent health care resource utilization and mortality. Results support prophylaxis of premature infants against RSV hospitalization.

Managing preemie stomas: more than just the pouch

This article provides a review of diseases affecting preterm neonates that may result in fecal diversion and types of stomas created during surgical intervention. Characteristics influencing ostomy management in this population, particularly skin barrier properties, are examined. Finally, ostomy equipment and pouching techniques are discussed to provide health professionals with clinically-based guidelines and practical strategies for managing premature ostomates.

Perinatal morbidity, mild motor delay, and later school outcomes

Four dimensions of motor competence were evaluated in 4-year-old term and preterm children and were related to academic achievement and use of school services at age 8 years. The objective of the study was to evaluate a graduated 'stair-step' effect between perinatal morbidity, mild motor delay, and later school outcomes in 168 children (88 females, 80 males) stratified into four study groups: 134 healthy term infants > or = 37 weeks' gestation, birthweight > or = 2500g); 134 preterm infants < or = 37 weeks' gestation divided into healthy preterm (n=41), clinically ill preterms (n=59), and preterm infants with neurological illness (n=34). Significant differences were found in total, fine and gross motor performance, and visual-motor integration at age 4 years. Scores for the preterm groups decreased with increasing morbidity. At age 4 years, mild motor delay was found in all preterm groups. Children with mild motor delay had lower academic achievement scores (Wide Range Achievement Test-3) and higher rates of school service use at age 8 years. Perinatal morbidity and compromised motor performance are important precursors of educational underachievement.

[Cerebral palsy in childhood: 250 cases report]

OBJECTIVE

To know the etiological factors of cerebral palsy (CP) incident during pregnancy and neonatal/perinatal periods. To know evolution of a child with a CP diagnosis.

PATIENTS, MATERIAL AND METHODS

Bibliographical review of paediatric and rehabilitation texts and databases in Internet. Elaboration of a data collecting questionnaire for reviewing clinical records of patients treated in Paediatric Rehabilitation between 1996 and 2000.

RESULTS

250 patients records reviewed. Most frequent illnesses during pregnancy: first twelve weeks haemorrhages: 17.9% and diabetes 8.4%. Child birth: preterm births 32%, cephalic presentation 78.8%, caesarean operations 32%. Mean birth weight 2,714 g, low birth weight babies 27.2%. Needed hospitalary treatment 48%. Mean time in incubator: 46 days among preterm and 26.6 among full term. Mean time in intensive care units: 44.4 days among preterm and 22.7 among full term. Associated diagnoses: CRP 8%, birth asphyxia 24%, neonatal jaundice 27.2%, neonatal respiratory distress 24%, neonatal sepsis 10%, congenital cardiological illnesses 2.4%, dismorphia 2.4%, epilepsy in 40%. Diagnostic imaging: atrophy 38.8%, hydrocephalus 29.4%, ischemia 14.9%, haemorrhage 11.6%. No findings in 23.8%. Children were sent to Paediatric Rehabilitation at mean age of 8 months. Most frequent disorders: spastic quadriplegia (36.1%) spastic diplegia (26.5%) and hemiplegia (17%). Mental retardation 55%. School attendance 81.2%. CP postnatal in 5.2%.

CONCLUSIONS

Incidence of CP (2.5/1,000 alive new born) hardly avoidable for persistent rates of prematurity and complications in child births. Good quality of life and survival until adult ages.

Early physiotherapy intervention in premature infants

Preterm infants are more likely to have disabling cerebral palsy (CP) than term infants. It has been reported that early therapeutic approaches may be appropriate for infants at risk of neuromotor dysfunction, to minimize the degree of future handicaps. Two hundred and twenty-nine infants born at less than 34 weeks' gestation, with birth weight < or = 2,000 g, cared for in the neonatal intensive care unit of Hacettepe University Hospital between January 1997-June 1999 were included in this study. Of the 229 infants initially included, 39 (17%) were dropped from the study within the first 12 months' assessment, due to lack of participation from the families. Thirty of the remaining 190 infants were found to have perinatal hypoxia or abnormal neurosonography, and were taken as the group at risk of development of CP, thus receiving early intervention therapy; these are listed as "premature at risk". The study group consisted of 160 infants not considered at risk. These were randomly paired into two groups of 80 infants, one that was given early interventional therapy, and the control group that received no program. Eleven of the 30 infants at risk, 2 of the 80 infants from the intervention group, and 4 of the 80 from the control group were diagnosed as having CP within the first six months of life. There was no difference in the age of loss or acquisition of reflexes and general abilities between the intervention and control groups. There was no difference in the prevalence of CP between the intervention and control groups. In conclusion this study showed no effect of early intervention in premature babies without risk of CP other than prematurity.

[Etiologies of cerebral palsy and classical treatment possibilities]

Cerebral palsy is a non-progressive disorder of the developing brain with different etiologies in the pre-, peri- or postnatal period. The most important of these diseases is cystic periventricular leukomalacia (PVL), followed by intra- and periventricular hemorrhage, hypoxic-ischemic encephalopathy, vascular disorders, infections or brain malformations. The underlying cause is always a damage of the first motor neuron. Prevalence of cerebral palsy in Europe is 2-3 per 1000 live births with a broad spectrum in different birth weight groups. Our own data concerning only pre-term infants in the NICU with birth weight below 1500 g (VLBW) are between 10%-20%. Established classical treatment methods include physiotherapy (Bobath, Vojta, Hippotherapy), methods of speech and occupational therapists (Castillo-Morales, Sensory Integration) and other therapeutical concepts (Petö, Affolter, Frostig).

Rates of hospitalization for respiratory syncytial virus infection among children in medicaid

OBJECTIVE

To determine rates of hospitalization associated with respiratory syncytial virus (RSV) infection among children with and without specific medical conditions.

STUDY DESIGN

Retrospective cohort study of all children <3 years old enrolled in the Tennessee Medicaid program from July 1989 through June 1993 (248,652 child-years).

RESULTS

During the first year of life, the estimated number of RSV hospitalizations per 1000 children was 388 for those with bronchopulmonary dysplasia, 92 for those with congenital heart disease, 70 for children born at < or = 28 weeks' gestation, 66 for those born at 29 to <33 weeks, 57 for those born at 33 to <36 weeks, and 30 for children born at term with no underlying medical condition. In the second year of life, children with bronchopulmonary dysplasia had an estimated 73 RSV hospitalizations per 1000 children, whereas those with congenital heart disease had 18 and those with prematurity 16 per 1000. Overall, 53% of RSV hospitalizations occurred in healthy children born at term.

CONCLUSIONS

Children with bronchopulmonary dysplasia have high rates of RSV hospitalization until 24 months of age. In contrast, after the first year of life, children with congenital heart disease or prematurity have rates no higher than that of children at low risk who are <12 months old.

"What can I do to enhance the development of a premature infant with chronic lung disease?"

CASE. Timmy was born at 32 weeks of gestation after an uncomplicated pregnancy until there was a spontaneous rupture of the membranes and preterm labor associated with chorioamnionitis. A 2-month hospitalization in the neonatal intensive care unit (NICU) was associated with pneumonia, a Grade II intraventricular hemorrhage, chronic lung disease, and a slow weight gain in the nursery. He was discharged to home with plans for ongoing care by his pediatrician. The primary care pediatrician attended a multidisciplinary conference with the NICU staff and Timmy's parents. At the time of discharge from the nursery, at 38 weeks postconceptual age, Timmy still required oral diuretics and supplemental oxygen, as well as other medications such as iron. Timmy's respiratory rates were between 40 and 60 breaths per minute at rest, with mild intercostal retractions. He was discharged with a cardiorespiratory monitor. The discharge examination revealed mild to moderate symmetrical hypotonia with intact deep tendon reflexes, shoulder girdle weakness, and a mild head lag. Timmy would regard a human face and a bright object and would follow them briefly. He became active and would thrash his extremities with minimal tactile, bright light, or auditory stimulation. Typically, he settled slowly with swaddling and a pacifier. Nursing was slow to develop; he was currently receiving one half of his calories at the breast and the remainder of his calories from bottle-feeding of fortified expressed breast milk. As she prepared for the first office visit with Timmy and his parents, the pediatrician asked herself, "What can I do to enhance the developmental outcome for this child?"

Auditory neuropathy with preserved cochlear microphonics and secondary loss of otoacoustic emissions

Auditory neuropathy is defined as absent or severely distorted auditory brainstem responses with preserved otoacoustic emissions and cochlear microphonics. This entity can be found in various circumstances including pre-lingual children. An almost universal characteristic reported from adult patients is the ineffectiveness of traditional hearing aids. Adequate management of pre-lingual cases therefore remains an open problem. This paper describes two pre-lingual children whose follow-up data demonstrated a selective loss of the otoacoustic emissions, whereas the cochlear microphonics remained preserved. In one of the patients, hearing aid fitting as soon as she lost her otoacoustic emissions proved successful. These findings have important implications for the operational definition of the condition, since one must be prepared to encounter cases with absent otoacoustic emissions. The present data also demonstrate that conventional amplification can benefit pre-lingual auditory neuropathy cases, at least once they have lost their otoacoustic emissions.

Confidential enquiry into deaths due to prematurity

The aim of this study was to audit the management of neonatal respiratory distress syndrome (RDS) in a geographically defined population using a retrospective peer review of case notes. The subjects were 49 infants of 24-36 wk gestation with a birthweight >499 g, and dying as a consequence of prematurity at <1 y of age in Wales during 1996. Forty-four infants (90%) were delivered in a unit with staff experienced in the management of preterm birth. Of the 30 infants <30 weeks' gestation, 29 (97%) received neonatal intensive care on a (sub)regional unit. Predelivery corticosteroids were indicated in 34 cases and administered in 31 (91%). Resuscitation at birth was indicated in 47 infants and conducted satisfactorily in 42 (89%). Temperature on admission to the neonatal unit was not recorded in 7 infants; in the other 42 it was >35.5 degrees C in 21 (50%). Early surfactant therapy was administered to 31/34 (91%) infants still intubated 120 min after birth, but was given within 30 min to only 8 (24%). Mechanical ventilation was assessed in 41 infants and considered to be good in 23 (56%). Cardiovascular therapy was evaluated in 40 infants requiring active support and considered to be good in 31 (78%). We concluded that neonatal RDS was generally well managed, thermal care during resuscitation was poor, surfactant should be administered more promptly, and deficiencies in the management of ventilation were common and related mainly to poor anticipation and a slow response to problems.

Early intervention for low birthweight, premature infants: participation and intellectual development

The Infant Health and Development Program was an eight-site randomized controlled trial of comprehensive early intervention for low birthweight, premature infants during the first 3 years of life in which intellectual development was an outcome of major importance. At 24 and 36 months, but not at 12 months, higher Mental Development Index and IQ were associated with higher levels of participation in the intervention. In a longitudinal analysis of these data, we found that the intellectual development of children in the intervention group was associated with each of the three intervention modalities (the number of home visits received, days attended at child centers, and the number of parent meetings attended) but not with children's background characteristics (i.e., maternal education, birthweight). We suggest that these findings represent a dose-response relation between intervention and outcome.

Long-term developmental outcomes of low birth weight infants

Advances in neonatal medicine have resulted in the increased survival of infants at lower and lower birth weight. While these medical success stories highlight the power of medical technology to save many of the tiniest infants at birth, serious questions remain about how these infants will develop and whether they will have normal, productive lives. Low birth weight children can be born at term or before term and have varying degrees of social and medical risk. Because low birth weight children are not a homogeneous group, they have a broad spectrum of growth, health, and developmental outcomes. While the vast majority of low birth weight children have normal outcomes, as a group they generally have higher rates of subnormal growth, illnesses, and neurodevelopmental problems. These problems increase as the child's birth weight decreases. With the exception of a small minority of low birth weight children with mental retardation and/or cerebral palsy, the developmental sequelae for most low birth weight infants include mild problems in cognition, attention, and neuromotor functioning. Long-term follow-up studies conducted on children born in the 1960s indicated that the adverse consequences of being born low birth weight were still apparent in adolescence. Adverse sociodemographic factors negatively affect developmental outcomes across the continuum of low birth weight and appear to have far greater effects on long-term cognitive outcomes than most of the biological risk factors. In addition, the cognitive defects associated with social or environmental risks become more pronounced as the child ages. Enrichment programs for low birth weight children seem to be most effective for the moderately low birth weight child who comes from a lower socioeconomic group. Continued research and attempts to decrease the rate of low birth weight and associated perinatal medical sequelae are of primary importance. Ongoing documentation of the long-term outcome of low birth weight children needs to be mandated, as does the implementation of environmental enrichment programs to help ameliorate the long-term consequences for infants who are born low birth weight.

The influence of neonatal intensive care unit caregiving practices on motor functioning of preterm infants

OBJECTIVES

Experimental design intervention studies have demonstrated that a model of individualized developmental care based on specific behavioral observation improves medical and behavioral outcome for very small preterm infants. It is proposed that infants who were not directly involved in an experimental intervention study per se, but were patients in a neonatal intensive care unit (NICU) where such studies took place and the model was adopted as the standard of care, demonstrate some of the same benefits as the infants in the experimental study.

METHOD

The study was a retrospective descriptive analysis of an existing data set. The functioning of two cohorts of infants, comparable medically and demographically and cared for in an NICU where developmental care research was conducted and subsequently adopted as the standard of care, was measured after discharge with the Assessment of Preterm Infants' Behavior (APIB). Cohort I was cared for before the first study of individualized developmental care in the NICU; Cohort II was cared for after the individualized developmental care approach was adopted as the standard of care for the NICU.

RESULTS

Cohort II infants demonstrated better scores than Cohort I infants on 8 out of 23 summary variables, 6 of which reflect improved motor functioning. They also showed significantly better scores on 7 of the 17 specific motor variables of the APIB.

CONCLUSION

Infants cared for in an NICU with an individualized developmental care approach showed improved motor system functioning compared to infants cared for in the same NICU before the approach was adopted. It is speculated that the individualized developmental approach to care based in the synactive theory of development contributed to the documented improvements. This finding would indicate that functioning of preterm infants, particularly in terms of their motor systems, can be influenced by modification in caregiving.

Medical considerations and practice guidelines for the neonatal occupational therapist

Provision of safe and effective occupational therapy in neonatal intensive care units requires an understanding of neonatal medical conditions and treatment modalities. This article explains basic medical concepts and technology with terminology frequently encountered in neonatal intensive care. Discussions of neonatal thermoregulation, respiratory care, hemodynamic monitoring, and metabolic support are presented as general areas of focus. Equipment usage and precautions are included. Several case studies illustrate the incorporation of medical knowledge into neonatal occupational therapy practice.

Parent and occupational therapist collaboration in the neonatal intensive care unit

Medical care of infants in the neonatal intensive care unit (NICU) is so complex that professionals have been almost exclusively responsible for providing care to the infants and information to their families. Although federal law now mandates early intervention programs and service providers to include families in decision making and treatment implementation for their children, family-centered care has generally not been implemented in the NICU. This article offers suggestions for occupational therapists from members of the Parent Connection, an NICU parent support group. They state that a therapist can have the greatest effect on an infant's development by helping the parents develop skills to nurture their infant the way that they choose.

The effect of oral support on sucking efficiency in preterm infants

OBJECTIVE

The purpose of this study was to determine the effectiveness of oral support on feeding efficiency in preterm infants who were identified by the medical team as poor feeders.

METHOD

Thirteen premature infants between 34 and 40 weeks' postconceptional age were selected from a group of infants at Children's Hospital and Medical Center in Seattle, Washington. They were fed twice within a 26-hr period, once with oral support and once without. The order of occurrence of these two conditions was randomly selected without replacement to assure that an equal number of both conditions occurred during the first feed. Only the first 2 min of the feed were used in data analysis.

RESULTS

A statistically significant difference (z = -2.62, p < .01, two-tailed) in volume intake occurred between the oral support condition (M = 10.9 cc) and the no oral support condition (M = 4.8 cc).

CONCLUSION

This study validates the use of oral support as an effective treatment technique to enhance sucking efficiency in preterm infants.

A global perspective on feeding assessment in the neonatal intensive care unit

A comprehensive assessment of feeding performance of infants in the neonatal intensive care unit (NICU) includes not only the traditional approaches of evaluating oral motor control and sensory responses but also evaluation of other factors. Infant feeding is a highly complex and integrated process involving numerous body systems. A global assessment would determine the infant's feeding function in the key areas of state and behavior, tactile responses, motoric control, oral motor function, physiologic control, and coordination of sucking, swallowing, and breathing. Information is obtained through skilled clinical observation as well as from technological monitors or medical tests and procedures. This article provides an overview of a comprehensive assessment that occupational therapists may use when providing service to infants in the NICU.

Neurobehavioral assessment of high-risk infants in the neonatal intensive care unit

Neurobehavioral organization describes infants' abilities to organize themselves within their central nervous system maturation and environment. As part of infants' environment, caregivers can structure the environment to support infants' development. Care of the high-risk infant emphasizes support of infants' emerging neurobehavioral organization. This article describes the theoretical rationale of neurobehavioral organization, effect on the infant and family, and assessments available to the neonatal occupational therapist for use with high-risk infants. Information gained via neurobehavioral assessment can be used to engage parents in better understanding their infant's behaviors and interact at a level appropriate with their infant.

Developing competency in the neonatal intensive care unit: a hospital training program

There are few specialized programs available to train occupational therapists and physical therapists to treat competently in a neonatal intensive care unit (NICU), yet hospitals are trying to fill such positions, and the need for advanced training is essential. A hospital-based program that provides clinical NICU training to therapists from other hospitals is presented. The program is short-term and highly individualized and emphasizes learning pertinent medical information, nonintrusive evaluation skills, and therapeutic intervention with advanced clinical judgment.

Infant mental health in occupational therapy practice in the neonatal intensive care unit

The work of supporting an infant's emotional development and mental health begins in the neonatal intensive care unit (NICU). It depends on understanding the family and uses the parallel processes involved in relationship building to maximize the environment for the optimal development of the infant in the NICU. Occupational therapy service provision is discussed in light of knowledge about the developmental work of the full-term neonates and their parents and the corresponding work of infants in the NICU and their families. A brief vignette of occupational therapy services provided in the context of a relationship-focused infant mental health model is included.

Prediction of preschool sensory and motor performance by 18-month neurologic scores among children born prematurely

OBJECTIVES

Premature birth places a child at risk for a number of academic and behavioral deficits. The challenge currently facing interventionists is to identify at an early age those preterm children who will develop such deficits. Identified children can then be targeted for intervention to forestall deficits at school age.

METHOD

This study examined the use of a neurologic assessment, administered at 18 months of age, to identify children who will have difficulties at preschool age. Premature children identified as neurologically normal or neurologically suspicious at the age of 18 months were tested with the Miller Assessment for Preschoolers.

RESULTS

Although there was some variability in performance, as a group the children classified as neurologically suspicious at 18 months continued to fall into a risk category at 4 years of age.

CONCLUSION

Because such categorization may predict inadequate performance during the school-age years, monitoring of the child's development is warranted.

To PEEP or not to PEEP?

It is well recognised that reducing positive end expiratory pressure (PEEP) leads to an increase in the tidal volume and minute volume in ventilated neonates. The magnitude of this effect is perhaps not commonly appreciated, however. Effectively, PEEP is four times as potent as peak inflation pressure (PIP) in bringing about changes in tidal volume. The influence of changes in PEEP and PIP on tidal volume and the relative magnitude of each are considered. Twenty one preterm infants were studied on 38 separate occasions. All were sedated, paralysed, and ventilated, 19 for hyaline membrane disease. A 1 cm H2O reduction in PEEP was twice as potent as a 2 cm H2O increase in PIP in achieving an increase in tidal volume (14 v 7%). Similarly, increasing PEEP by 1 cm H2O was twice as effective as a 2 cm H2O decrease in PIP in reducing tidal volume (13 v 6%). Small (0.5-1 cm H2O) changes in PEEP can often be used to improve ventilation and carbon dioxide elimination. Levels of PEEP of 4-5 cm H2O may, at times, impair gas exchange and contribute to overdistension.

Psychosocial interventions for very low birthweight infants: their scope and efficacy

With the burgeoning of infant psychiatry, and the increasing survival and development of cohorts of very low birthweight (VLBW) infants, psychiatrists are becoming increasingly involved with other professionals in designing and implementing early intervention programs. Psychosocial interventions for VLBW infants generally report positive results regardless of the orientation of the practitioners, or the stated goal of the intervention: however, they have often taken place independently of longitudinal research, and sometimes without grounding in theories of infant and family development. This paper first reviews the current state of research and findings related to infant-focussed, parent-directed, and interactional programs. Second, it addresses a number of basic questions to be considered by psychiatrists involved in consulting to neonatal intensive care units, who have to appraise, design or implement intervention programs with this group. Throughout this discussion, it is proposed that the notion of infants at developmental risk needs to be supplemented by that of caregivers at risk, and that the professional boundaries which these distinctions represent need to be overcome.

A validity study of the posture and fine motor assessment of infants

This study investigated the concurrent and construct validity of the Posture and Fine Motor Assessment of Infants (PFMAI) (Case-Smith, 1991). The subjects were 90 infants, 65 of whom were healthy and full-term and 25 of whom were premature and had medical risk factors. Concurrent validity was investigated through administration of the Peabody Developmental Motor Scales (Folio & Fewell, 1983) and the PFMAI (n = 25). Strong positive correlations resulted between the Peabody Gross Motor scale and PFMAI Posture scale and between the Peabody Fine Motor scale and PFMAI Fine Motor scale. Concurrent validity was also measured through correlation scores on the Bayley Scales of Infant Development (Bayley, 1969) with scores on the PFMAI. The correlations between the Bayley Motor scale and the PFMAI Posture scale and between the Bayley Mental scale and the PFMAI Fine Motor scale were high. Construct validity was estimated through an evaluation of how accurately the PFMAI discriminated between the premature subjects and the full-term subjects. A discriminant analysis indicated that the PFMAI accurately classified 78% of the subjects as being either premature or full-term (i.e., 80% of the full-term subjects and 72% of the premature subjects). When the premature subjects were categorized as low-risk or high-risk according to their medical histories, the PFMAI accurately classified 66.7% of the total subject population as full-term, low-risk premature, or high-risk premature. These results indicate that the PFMAI has the adequate reliability and validity necessary for use as a clinical and a research instrument.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparing the effects of neonatal intensive care unit intervention on premature infants at different weights

This study investigated the efficacy of an intervention program in the neonatal intensive care unit (NICU) on the development of premature infants from low socioeconomic status (SES) backgrounds. Sixty premature infants born at a county hospital over an 8-month period and their mothers were the focus of this study. The infants were assigned to either a control group or an experimental group. The experimental group received teaching and reinforcement about their babies' behavior from a child development specialist when they visited the NICU. Of the initial 60 infants, 49 completed the study at 8 months, but because data from only the first born of twin pairs were used, 41 infants were included in the final analysis. Infants were divided into two weight groups: one below and one above 1500 g. There was a significant effect of the intervention on the infants' mental and motor scores at 4 and 8 months. Significant differences on the total Home Observation for Measurement of the Environment (HOME) were noted between the groups. There were some significant differences between intervention and control groups on the interaction of the mother with the infant at 4 months but not in the play situation at 8 months. The lighter premature infants had a greater boost from the intervention than did the heavier premature infants. The intervention had no effect on the mother's perception of her infant's temperament or on her confidence skills. In line with other research findings, the infants who weighed less than 1500 g seemed to have benefited most from the intervention, and the effect of the intervention was most notable at 4 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Leg movements in the supine position of infants with spastic diplegia

Leg movements in the supine position of 49 infants with spastic diplegia (three to 11 months corrected age) were examined. Only simultaneous flexion and extension of the hips and knees were seen, with exceptional isolated hip movements; the simultaneous movements had synergic features. When the knees were flexed, the hips were flexed, abducted and externally rotated, and the ankles were dorsiflexed. When the knees were extended, the hips were extended, adducted and internally rotated and the ankles were plantar-flexed. Hip flexion combined with knee extension (leg elevation) and isolated knee movements were not seen in diplegic infants, but were seen in all control preterm infants with a good prognosis, after five and six months corrected age, respectively. The absence of these movements is a useful diagnostic item for spastic diplegia.

Influence of medical history on assessment of at-risk infants

The influence of knowledge of their medical history on the assessment of at-risk infants was examined. Two at-risk infants, one with a high-risk medical history and one with a low-risk history, were assessed and videotaped using the Movement Assessment of Infants. 41 physical therapists were randomly assigned to assess the videotaped examinations in four groups with different knowledge of the infants' histories (high-risk infant with actual or low-risk history; low-risk infant with actual or high-risk history). The clinical significance of the difference in total risk scores between knowledge conditions of a high-risk history and a low-risk history was greater for the low-risk infant. The higher mean total risk score for the low-risk infant assessed with a high-risk history suggests that false positive results could occur which may alter parents' perceptions and interactions with the infants and consequently influence their development.

[Compensatory potentials of the central nervous system in premature newborn infants]

Compensatory potentials of the central nervous system (CNS) in preterm infants with a history of hypoxic-ischemic encephalopathy have been discussed with an emphasis on a need for revision of traditional perceptions. The use of new methods of evaluation of the developing brain indicates the phenomenon of its neurologic adaptability. It is suggested by a high incidence of CNS functional recovery in surviving preterm infants. The recovery process is phasic and bears most promise if rehabilitative interventions are individualized for every child.