Early developmental intervention programmes provided post hospital discharge to prevent motor and cognitive impairment in preterm infants

The relationship between home environment affordances and motor development and sensory processing skills in premature infants

The availability of stimulating materials in the home environment is of great importance to optimizing an infant's development. This study, which has a cross-sectional study design, was conducted to examine the relationship between home environment conditions and equipment support and the motor development and sensory processing skills of premature infants. Children born premature, aged 10-16 months, were included in the study. Motor development was evaluated with the Peabody Motor Development Scale-2, and sensory processing skills were evaluated with the Test of Sensory Function in Infants. The Affordances in the Home Environment for Motor Development-Infant Scale was used to evaluate the home environment. A total of 51 premature infants were included in the study. It was determined that there was a significant relationship between physical space, stimulus variety and fine motor toys in the home environment and Peabody Motor Development Scale-2 gross motor and fine motor development scores. It was also shown that there was a relationship between the tactile and total scores of the Test of Sensory Function in Infants Scale and the variety of stimuli in the home environment and gross motor toy scores. These findings show that the opportunities provided in the home environment of premature infants may be related to their motor development and sensory processing skills. Consequently, the home environment may be associated with experiencing movements and sensory experiences.

Research gaps in the neurodevelopmental assessment of children with complex congenital heart defects: a scoping review

Background

Children with congenital heart defects (CHD) are at risk for a range of developmental disabilities that challenge cognition, executive functioning, self-regulation, communication, social-emotional functioning, and motor skills. Ongoing developmental surveillance is therefore key to maximizing neurodevelopmental outcome opportunities. It is crucial that the measures used cover the spectrum of neurodevelopmental domains relevant to capturing possible predictors and malleable factors of child development.

Objectives

This work aimed to synthesize the literature on neurodevelopmental measures and the corresponding developmental domains assessed in children aged 1-8 years with complex CHD.

Methods

PubMed was searched for terms relating to psycho-social, cognitive and linguistic-communicative outcomes in children with CHD. 1,380 papers with a focus on complex CHD that reported neurodevelopmental assessments were identified; ultimately, data from 78 articles that used standardized neurodevelopmental assessment tools were extracted.

Results

Thirty-nine (50%) of these excluded children with syndromes, and 9 (12%) excluded children with disorders of intellectual development. 10% of the studies were longitudinal. The neurodevelopmental domains addressed by the methods used were: 53% cognition, 16% psychosocial functioning, 18% language/communication/speech production, and 13% motor development-associated constructs.

Conclusions

Data on social communication, expressive and receptive language, speech motor, and motor function are underrepresented. There is a lack of research into everyday use of language and into measures assessing language and communication early in life. Overall, longitudinal studies are required that include communication measures and their interrelations with other developmental domains.

Early Detection and Intervention for Children with High Risk of Cerebral Palsy: A Survey of Physical Therapists and Occupational Therapists in Brazil

AIMS

The purpose of this study was to assess the current clinical practice of physiotherapists and occupational therapists on early detection and early intervention for children with cerebral palsy (CP) in Brazil.

METHODS

This was a cross-sectional study. A purpose-developed electronic survey was disseminated across the country to physiotherapists and occupational therapists working with young children with or at risk of CP.

RESULTS

A total of 205 anonymous respondents were included. Most participants (64.4%) agree that the diagnosis of CP can be made before 6 months of age. General Movements Assessment (26.8%) and Hammersmith Infant Neurological Examination (37.1%) were used infrequently. Infants at risk for CP receive therapy twice a week or more by 58.5% of therapists, 93.2% identified parents' goals as the most important factor in customizing the early intervention program. The most frequent intervention strategies for this age group were active stimulation of the child (n = 182), family training (n = 161), strategies to optimize the environment (n = 143), and neurodevelopmental treatment/Bobath (n = 99).

CONCLUSIONS

Currently, pediatric physiotherapists and occupational therapists in Brazil do not fully incorporate best practice tools for early identification of children with CP, nor sufficient best evidence-based interventions.

Stability of developmental milestones: Insights from a 44-year analysis

Using standardized test procedures is a reliable way of assessing early childhood development in the pediatric setting. However, normal population's developmental parameters may change over time. The aim of this study was to determine whether a change of developmental percentiles is present in infants in Germany during recent decades. Measured by an established German diagnostic instrument (Münchener Funktionelle Entwicklungsdiagnostik) we cross-sectionally compared developmental data (cognition, expressive language, language comprehension, fine and gross motor skills, social development, daily-living skills) of children aged 0-36 months collected in the 1970s and in 2018. N = 2065 children and their parents were included (1970s sample: N = 1660 and 2018 sample: N = 405). The T-Test of dependent variables showed nonsignificant differences in the developmental scales. We hypothesized an infant Flynn effect, but the results of this study suggest that there are no developmental changes associated with the 50th percentile. Nevertheless, it is critical to emphasize the need for periodic revision and re-norming of developmental test procedures, even in the absence of significant changes in individual items.

Evaluating causal influence of maternal educational attainment on offspring birthweight via observational study and Mendelian randomization analyses

Background

Although extensive discussions on the influence of maternal educational attainment on offspring birthweight, the conclusion remains controversial, and it is challenging to comprehensively assess the causal association between them.

Methods

To estimate effect of maternal educational attainment on the birthweight of first child, we first conducted an individual-level analysis with UK Biobank participants of white ancestry (n = 208,162). We then implemented Mendelian randomization (MR) methods including inverse variance weighted (IVW) MR and multivariable MR to assess the causal relation between maternal education and maternal-specific birthweight. Finally, using the UK Biobank parent-offspring trio data (n = 618), we performed a polygenic score based MR to simultaneously adjust for confounding effects of fetal-specific birthweight and paternal educational attainment. We also conducted simulations for power evaluation and sensitivity analyses for horizontal pleiotropy of instruments.

Results

We observed that birthweight of first child was positively influenced by maternal education, with 7 years of maternal education as the reference, adjusted effect = 44.8 (95%CIs 38.0-51.6, P = 6.15 × 10-38), 54.9 (95%CIs 47.6-62.2, P = 4.21 × 10-128), and 89.4 (95%CIs 82.1-96.7, P = 4.28 × 10-34) for 10, 15 and 20 years of maternal educational attainment, respectively. A causal relation between maternal education and offspring birthweight was revealed by IVW MR (estimated effect = 0.074 for one standard deviation increase in maternal education years, 95%CIs 0.054-0.093, P = 2.56 × 10-13) and by complementary MR methods. This connection was not substantially affected by paternal education or horizontal pleiotropy. Further, we found a positive but insignificant causal association (adjusted effect = 24.0, 95%CIs -150.1-198.1, P = 0.787) between maternal education and offspring birthweight after simultaneously controlling for fetal genome and paternal education; this null causality was largely due to limited power of small sample sizes of parent-offspring trios.

Conclusion

This study offers supportive evidence for a causal association between maternal education and offspring birthweight, highlighting the significance of enhancing maternal education to prevent low birthweight.

Early developmental intervention programmes provided post hospital discharge to prevent motor and cognitive impairment in preterm infants

BACKGROUND

Infants born preterm are at increased risk of cognitive and motor impairments compared with infants born at term. Early developmental interventions for preterm infants are targeted at the infant or the parent-infant relationship, or both, and may focus on different aspects of early development. They aim to improve developmental outcomes for these infants, but the long-term benefits remain unclear. This is an update of a Cochrane review first published in 2007 and updated in 2012 and 2015.

OBJECTIVES

Primary objective To assess the effect of early developmental interventions compared with standard care in prevention of motor or cognitive impairment for preterm infants in infancy (zero to < three years), preschool age (three to < five years), and school age (five to < 18 years). Secondary objective To assess the effect of early developmental interventions compared with standard care on motor or cognitive impairment for subgroups of preterm infants, including groups based on gestational age, birthweight, brain injury, timing or focus of intervention and study quality.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO and trial registries in July 2023. We cross-referenced relevant literature, including identified trials and existing review articles.

SELECTION CRITERIA

Studies included randomised, quasi-randomised controlled trials (RCTs) or cluster-randomised trials of early developmental intervention programmes that began within the first 12 months of life for infants born before 37 weeks' gestational age (GA). Interventions could commence as an inpatient but had to include a post discharge component for inclusion in this review. Outcome measures were not prespecified, other than that they had to assess cognitive outcomes, motor outcomes or both. The control groups in the studies could receive standard care that would normally be provided.

DATA COLLECTION AND ANALYSIS

Data were extracted from the included studies regarding study and participant characteristics, timing and focus of interventions and cognitive and motor outcomes. Meta-analysis using RevMan was carried out to determine the effects of early developmental interventions at each age range: infancy (zero to < three years), preschool age (three to < five years) and school age (five to < 18 years) on cognitive and motor outcomes. Subgroup analyses focused on GA, birthweight, brain injury, time of commencement of the intervention, focus of the intervention and study quality. We used standard methodological procedures expected by Cochrane to collect data and evaluate bias. We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

Forty-four studies met the inclusion criteria (5051 randomly assigned participants). There were 19 new studies identified in this update (600 participants) and a further 17 studies awaiting outcomes. Three previously included studies had new data. There was variability in the focus and intensity of the interventions, participant characteristics, and length of follow-up. All included studies were either single or multicentre trials and the number of participants varied from fewer than 20 to up to 915 in one study. The trials included in this review were mainly undertaken in middle- or high-income countries. The majority of studies commenced in the hospital, with fewer commencing once the infant was home. The focus of the intervention programmes for new included studies was increasingly targeted at both the infant and the parent-infant relationship. The intensity and dosages of interventions varied between studies, which is important when considering the applicability of any programme in a clinical setting. Meta-analysis demonstrated that early developmental intervention may improve cognitive outcomes in infancy (developmental quotient (DQ): standardised mean difference (SMD) 0.27 standard deviations (SDs), 95% confidence interval (CI) 0.15 to 0.40; P < 0.001; 25 studies; 3132 participants, low-certainty evidence), and improves cognitive outcomes at preschool age (intelligence quotient (IQ); SMD 0.39 SD, 95% CI 0.29 to 0.50; P < 0.001; 9 studies; 1524 participants, high-certainty evidence). However, early developmental intervention may not improve cognitive outcomes at school age (IQ: SMD 0.16 SD, 95% CI -0.06 to 0.38; P = 0.15; 6 studies; 1453 participants, low-certainty evidence). Heterogeneity between studies for cognitive outcomes in infancy and preschool age was moderate and at school age was substantial. Regarding motor function, meta-analysis of 23 studies showed that early developmental interventions may improve motor outcomes in infancy (motor scale DQ: SMD 0.12 SD, 95% CI 0.04 to 0.19; P = 0.003; 23 studies; 2737 participants, low-certainty evidence). At preschool age, the intervention probably did not improve motor outcomes (motor scale: SMD 0.08 SD, 95% CI -0.16 to 0.32; P = 0.53; 3 studies; 264 participants, moderate-certainty evidence). The evidence at school age for both continuous (motor scale: SMD -0.06 SD, 95% CI -0.31 to 0.18; P = 0.61; three studies; 265 participants, low-certainty evidence) and dichotomous outcome measures (low score on Movement Assessment Battery for Children (ABC) : RR 1.04, 95% CI 0.82 to 1.32; P = 0.74; 3 studies; 413 participants, low-certainty evidence) suggests that intervention may not improve motor outcome. The main source of bias was performance bias, where there was a lack of blinding of participants and personnel, which was unavoidable in this type of intervention study. Other biases in some studies included attrition bias where the outcome data were incomplete, and inadequate allocation concealment or selection bias. The GRADE assessment identified a lower certainty of evidence in the cognitive and motor outcomes at school age. Cognitive outcomes at preschool age demonstrated a high certainty due to more consistency and a larger treatment effect.

AUTHORS' CONCLUSIONS

Early developmental intervention programmes for preterm infants probably improve cognitive and motor outcomes during infancy (low-certainty evidence) while, at preschool age, intervention is shown to improve cognitive outcomes (high-certainty evidence). Considerable heterogeneity exists between studies due to variations in aspects of the intervention programmes, the population and outcome measures utilised. Further research is needed to determine which types of early developmental interventions are most effective in improving cognitive and motor outcomes, and in particular to discern whether there is a longer-term benefit from these programmes.

Neurodevelopment at age 5.5 years according to Ages & Stages Questionnaire at 2 years' corrected age in children born preterm: the EPIPAGE-2 cohort study

OBJECTIVE

To report neurodevelopment at age 5.5 years according to developmental delay screening with the Ages & Stages Questionnaire (ASQ) in late infancy in preterm-born children.

DESIGN

Population-based cohort study, EPIPAGE-2.

SETTING

France, 2011-2017.

PARTICIPANTS

2504 children born at 24-26, 27-31 and 32-34 weeks, free of cerebral palsy, deafness or blindness at 2 years' corrected age.

MAIN OUTCOME MEASURES

Moderate/severe, mild or no disability at age 5.5 years using gross and fine motor, sensory, cognitive and behavioural evaluations. Results of the ASQ completed between 22 and 26 months' corrected age described as positive screening or not.

RESULTS

Among 2504 participants, 38.3% had ASQ positive screening. The probability of having moderate/severe or mild disability was higher for children with ASQ positive versus negative screening: 14.2% vs 7.0%, adjusted OR 2.5 (95% CI 1.8 to 3.4), and 37.6% vs 29.7%, adjusted OR 1.5 (1.2 to 1.9). For children with ASQ positive screening, the probability of having neurodevelopmental disabilities at age 5.5 years was associated with the number of domain scores below threshold, very low gestational age and severe neonatal morbidities. For children with ASQ negative screening, this probability was increased for boys and children born small-for-gestational age. For both groups, maternal level of education was strongly associated with outcomes.

CONCLUSION

In preterm-born children, ASQ screening at 2 years' corrected age was associated with neurodevelopmental disabilities at age 5.5 years. However, other factors should be considered when interpreting the ASQ data to draw further follow-up.

TRIAL REGISTRATION NUMBER

2016-A00333-48.

Impact of an integrated health, nutrition, and early child stimulation and responsive care intervention package delivered to preterm or term small for gestational age babies during infancy on growth and neurodevelopment: study protocol of an individually randomized controlled trial in India (Small Babies Trial)

BACKGROUND

Preterm and term small for gestational age (SGA) babies are at high risk of experiencing malnutrition and impaired neurodevelopment. Standalone interventions have modest and sometimes inconsistent effects on growth and neurodevelopment in these babies. For greater impact, intervention may be needed in multiple domains-health, nutrition, and psychosocial care and support. Therefore, the combined effects of an integrated intervention package for preterm and term SGA on growth and neurodevelopment are worth investigating.

METHODS

An individually randomized controlled trial is being conducted in urban and peri-urban low to middle-socioeconomic neighborhoods in South Delhi, India. Infants are randomized (1:1) into two strata of 1300 preterm and 1300 term SGA infants each to receive the intervention package or routine care. Infants will be followed until 12 months of age. Outcome data will be collected by an independent outcome ascertainment team at infant ages 1, 3, 6, 9, and 12 months and at 2, 6, and 12 months after delivery for mothers.

DISCUSSION

The findings of this study will indicate whether providing an intervention that addresses factors known to limit growth and neurodevelopment can offer substantial benefits to preterm or term SGA infants. The results from this study will increase our understanding of growth and development and guide the design of public health programs in low- and middle-income settings for vulnerable infants.

TRIAL REGISTRATION

The trial has been registered prospectively in Clinical Trial Registry - India # CTRI/2021/11/037881, Registered on 08 November 2021.

Strategies for addressing the needs of children with or at risk of developmental disabilities in early childhood by 2030: a systematic umbrella review

BACKGROUND

There are over 53million children worldwide under five with developmental disabilities who require effective interventions to support their health and well-being. However, challenges in delivering interventions persist due to various barriers, particularly in low-income and middle-income countries.

METHODS

We conducted a global systematic umbrella review to assess the evidence on prevention, early detection and rehabilitation interventions for child functioning outcomes related to developmental disabilities in children under 5 years. We focused on prevalent disabilities worldwide and identified evidence-based interventions. We searched Medline, Embase, PsychINFO, and Cochrane Library for relevant literature from 1st January 2013 to 14th April 2023. A narrative synthesis approach was used to summarise the findings of the included meta-analyses. The results were presented descriptively, including study characteristics, interventions assessed, and outcomes reported. Further, as part of a secondary analysis, we presented the global prevalence of each disability in 2019 from the Global Burden of Disease study, identified the regions with the highest burden and the top ten affected countries. This study is registered with PROSPERO, number CRD42023420099.

RESULTS

We included 18 reviews from 883 citations, which included 1,273,444 children under five with or at risk of developmental disabilities from 251 studies across 30 countries. The conditions with adequate data were cerebral palsy, hearing loss, cognitive impairment, autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder. ASD was the most prevalent target disability (n = 8 reviews, 44%). Most reviews (n = 12, 67%) evaluated early interventions to support behavioural functioning and motor impairment. Only 33% (n = 10/30) of studies in the reviews were from middle-income countries, with no studies from low-income countries. Regarding quality, half of reviews were scored as high confidence (n = 9/18, 50%), seven as moderate (39%) and two (11%) as low.

CONCLUSIONS

We identified geographical and disability-related inequities. There is a lack of evidence from outside high-income settings. The study underscores gaps in evidence concerning prevention, identification and intervention, revealing a stark mismatch between the available evidence base and the regions experiencing the highest prevalence rates of developmental disabilities.

The emergence of the multisensory brain: From the womb to the first steps

The becoming of the human being is a multisensory process that starts in the womb. By integrating spontaneous neuronal activity with inputs from the external world, the developing brain learns to make sense of itself through multiple sensory experiences. Over the past ten years, advances in neuroimaging and electrophysiological techniques have allowed the exploration of the neural correlates of multisensory processing in the newborn and infant brain, thus adding an important piece of information to behavioral evidence of early sensitivity to multisensory events. Here, we review recent behavioral and neuroimaging findings to document the origins and early development of multisensory processing, particularly showing that the human brain appears naturally tuned to multisensory events at birth, which requires multisensory experience to fully mature. We conclude the review by highlighting the potential uses and benefits of multisensory interventions in promoting healthy development by discussing emerging studies in preterm infants.

Factors influencing caregiver buy-in to early intervention physical therapy

PURPOSE

The family-centered care framework of Early Intervention (EI) has shifted the focus toward caregiver engagement, but the underlying processes that build this are unknown. The aims of this study were 1) to describe the process of caregiver engagement in therapy and (2) to identify factors perceived to influence caregiver buy-in, confidence, and engagement in EI.

METHODS

This preliminary descriptive study utilized quantitative questionnaires and qualitative semi-structured interviews of EI participants (23 caregivers and four physical therapists). Interviews were transcribed and theme coded until saturation was achieved and a concept map was developed.

RESULTS

All caregivers believed that their children benefited from EI, that they were empowered and confident in caring for their children, and their quality of life improved based on the quantitative data. The qualitative data revealed that building a rapport and therapeutic relationship is the foundation to developing buy-in. Reciprocal communication is critical to the relationship and the buy-in. Caregiver knowledge and awareness of progress foster caregiver buy-in and confidence once the relationship is established.

CONCLUSION

Improved understanding of the factors influencing the development of buy-in will provide a framework for the clinician to enhance caregiver buy-in. Enhanced buy-in may promote parental engagement and improved outcomes for the child and family.

Unconditional cash transfers for preterm neonates: evidence, policy implications, and next steps for research

To address socioeconomic disparities in the health outcomes of preterm infants, we must move beyond describing these disparities and focus on the development and implementation of interventions that disrupt the factors contributing to them. Unconditional cash transfers (UCTs), which provide unrestricted payments to individuals or households, can help mitigate income disparities and improve health outcomes. While UCTs have been utilized for other vulnerable populations, their full potential has yet to be realized for low-income families with preterm infants, who face significant financial strain. In this perspective, we review evidence supporting UCTs as an intervention for children in the U.S. (including those born term and preterm), discuss the potential benefits of recurring UCTs to low-income families of preterm infants, and propose a conceptual model through which UCTs may improve outcomes for preterm infants. We conclude with potential policy levers for implementing UCTs and key unanswered questions for researchers.

Impact of the COVID-19 pandemic on early intervention utilization and need for referral after NICU discharge in VLBW infants

OBJECTIVE

To examine the impact of COVID-19 pandemic on early intervention (EI) services in VLBW infants.

STUDY DESIGN

208 VLBW infants seen in NICU follow-up (FU) pre-COVID-19 were compared to 132 infants seen during COVID-19 at 4, 8 and 20 months corrected age (CA) in terms of enrollment in Child and Family Connections (CFC; intake agency for EI), EI therapies, need for CFC referral and Bayley scores.

RESULTS

Infants seen during COVID-19 at 4, 8 and 20 months CA were 3.4 (OR, 95% CI 1.64, 6.98), 4.0 (1.77, 8.95) and 4.8 (2.10, 11.08) times more likely to need CFC referral at FU based on severity of developmental delay. Infants followed during COVID-19 had significantly lower mean Bayley cognitive and language scores at 20 months CA.

CONCLUSIONS

VLBW infants seen during COVID-19 had significantly higher odds of needing EI and significantly lower cognitive and language scores at 20 months CA.

Time-motion observations to characterize the developmental environment in a paediatric post-acute care hospital

BACKGROUND

Chronically hospitalized children are at risk for neurodevelopmental delay, compounded by restricted social interactions, movement and environmental stimulation. We measured patients' movements and interactions to characterize developmentally relevant aspects of our inpatient environment and identify opportunities for developmental enrichment.

METHODS

As part of a quality improvement initiative to inform neurodevelopmental programming for children with medical complexity at our paediatric post-acute care specialty hospital, we conducted >232 hours of time-motion observations. Trained observers followed 0- to 5-year-old inpatients from 7 am to 7 pm on weekdays, categorizing observations within five domains: Where, With, Position, State and Environment. Observations were collected continuously utilizing REDCap on iPads. A change in any domain initiated a new observation.

RESULTS

Patients were median 1 year and 8 months of age (range 2 months to 3 years 9 months) with a median length of hospitalization of 514 days (range 66-1298). In total, 2636 unique observations (or median 134 observations per patient-day [range 95-210]) were collected. Patients left their rooms up to 4 times per day for median 1 h and 34 min (range 41 min to 4 h:30 min). Patients spent 4 h:6 min (2 h:57 min to 6 h:30 min) interacting with someone and 3 h:51 min (57 min to 6 h:36 min) out of bed each day. Patients were simultaneously out of their beds, interacting with someone and awake for 2 h:21 min (51 min to 4 h:19 min) each day.

CONCLUSIONS

Despite a care model prioritizing time out of bed and social interaction, time-motion observations indicate patients spent many of their waking hours in bed and alone. Quantifying our inpatients developmental opportunities will inform neurodevelopmental programming initiatives.

Corpus callosum abnormalities at term-equivalent age are associated with language development at two years corrected age in infants born very preterm

We studied the impact of microstructural abnormalities in the corpus callosum on language development in 348 infants born very prematurely. We discovered that the fractional anisotropy of the corpus callosum anterior midbody was a significant predictor of standardized language scores at two years, independent of clinical and social risk factors.

Early developmental support for preterm infants based on exploratory behaviors: A parallel randomized controlled study

INTRODUCTION

Preterm infants are at high risk for developmental disabilities, and their parents are at increased risk for high stress. Early intervention programs are applied to reduce these adverse outcomes. The primary aim is to compare the efficacy of the novel Explorer Baby early intervention program for the holistic development of preterm infants. The second objective was to compare the stress levels of their mothers.

METHODS

Randomized clinical trial with 38 weeks-6 months corrected age preterm infants at low risk for cerebral palsy, randomly assigned to experimental (Explorer Baby) or active control neurodevelopmental therapy (NDT) groups. Fifty-seven infants were enrolled in the study, and 51 (26 Explorer Baby, 25 NDT) completed it. Bayley III was used as a primary outcome before, during, and after the intervention.

RESULTS

When we compared the changes between the groups before and after therapy, no significant differences were found in any of the primary or secondary outcomes (between-group comparisons). When comparing the changes in both groups before and after therapy (in-group comparison), the Explorer Baby group demonstrated significant improvements in cognitive (Hedges' g = .83) and explorative language skills (Hedges' g = .65), whereas the NDT group showed improved parent-child dysfunctional interaction (Hedges' g = 2.66) between T0-T1 and T0-T2.

CONCLUSIONS

The Explorer Baby early intervention program may be a preferred option to support premature infants without brain injury, as it shows greater skill acquisition than NDT, although not statistically significant. Both methods are safe as they support premature babies without negatively affecting mothers' overall stress levels.

Early Intensive Bimanual Stimulation Program (BB-Bim) for Infants at Risk of Unilateral Cerebral Palsy: A Randomized, Multiple-Baseline, Single-Case Study

IMPORTANCE

Clinical practice guidelines for infants at high risk of cerebral palsy (CP) emphasize the importance of very early and intensive intervention.

OBJECTIVE

To determine the feasibility of a new, home-based, early intensive bimanual stimulation program (BB-Bim) and its impact on hand function in infants at risk of unilateral CP.

DESIGN

Single case experimental design, multiple baseline across subjects, lasting from 12 to 15 wk, including a 4- to 7-wk randomized baseline, followed by 8 wk of BB-Bim.

SETTING

Home.

PARTICIPANTS

Infants (ages 3-12 mo) with suspected unilateral CP, whose parents agreed to participate in the stimulation program.

INTERVENTION

Parent-provided bimanual stimulation 20 min/day, 6×/wk, with weekly occupational therapist coaching visits.

MEASURES

Weekly repeated measures were the Hand Assessment in Infants (HAI) and Goal Attainment Scaling (GAS). Feasibility and relevance were assessed with a logbook and a parental report, including 10 continuous 0-10 scaled questions.

RESULTS

Six infants were included (2 with left and 4 with right brain lesions). Parents provided a mean 3.4 to 6.2 stimulation sessions/wk. Feasibility and relevance were highly rated (Ms = 8.2-9.6, SDs = 0.2-1.3). Stimulation significantly improved HAI bimanual and total scores for all infants, with no impact on HAI unilateral scores. GAS scores improved with stimulation (significant for 3 infants).

CONCLUSIONS AND RELEVANCE

BB-Bim was feasible and tended to improve bimanual function in infants at risk of unilateral CP. What This Article Adds: Parent-provided daily bimanual stimulation at home is feasible when parents are coached weekly by an occupational therapist. Bimanual stimulation seems to improve functional interactions between the hands among infants at high risk of unilateral CP.

Utility of the 21-month neurodevelopmental outcome for predicting neurodevelopmental impairment at 36 months for preterm infants <29 weeks gestation

OBJECTIVE

To determine the sensitivity and specificity of the 21-month neurodevelopmental outcome for predicting the presence of neurodevelopmental impairment at 36 months corrected age in a population of preterm infants under 29 weeks gestation.

STUDY DESIGN

This is a retrospective observational cohort study. Preterm infants born under 29 weeks gestation who were followed up at both 18-21 months and 36 months corrected age with outcome data available were enrolled.

RESULTS

Overall, 713 preterm infants <29 weeks gestation and were included in the final analysis. The specificity of the 21-month assessment for predicting neurodevelopmental impairment at 36 months corrected age was 66% (95% confidence interval[CI] 62-71%) with a positive predictive value of 61% (95% CI 56-66%).

CONCLUSION

In preterm neonates born <29 weeks gestation, the 18-21 months corrected neurodevelopmental outcome had low specificity and positive predictive value for predicting the presence of neurodevelopmental impairment at 36 months corrected age.

A Feasibility Study of a Physical and Occupational Therapy-Led and Parent-Administered Program to Improve Parent Mental Health and Infant Development

AIMS

Extremely premature birth puts infants at high risk for developmental delay and results in parent anxiety and depression. The primary objective of this study was to characterize feasibility and acceptability of a therapist-led, parent-administered therapy and massage program designed to support parent mental health and infant development.

METHODS

A single cohort of 25 dyads - parents (24 mothers, 1 father) and extremely preterm (<28 wk gestation) infants - participated in the intervention. During hospitalization, parents attended weekly hands-on education sessions with a primary therapist. Parents received bi-weekly developmental support emails for 12 months post-discharge and were scheduled for 2 outpatient follow up visits. We collected measures of parent anxiety, depression, and competence at baseline, hospital discharge, and <4 and 12 months post-discharge.

RESULTS

All feasibility targets were met or exceeded at baseline and discharge (≥70%). Dyads participated in an average of 11 therapy sessions (range, 5-20) during hospitalization. Lower rates of data collection adherence were observed over successive follow ups (range, 40-76%). Parent-rated feasibility and acceptability scores were high at all time points.

CONCLUSIONS

Results support parent-rated feasibility and acceptability of the TEMPO intervention for extremely preterm infants and their parents in the Neonatal Intensive Care Unit.

Postnatal growth restriction and neurodevelopment at 5 years of age: a European extremely preterm birth cohort study

OBJECTIVE

To investigate whether extrauterine growth restriction (EUGR) during the neonatal hospitalisation by sex among extremely preterm (EPT) infants is associated with cerebral palsy (CP) and cognitive and motor abilities at 5 years of age.

STUDY DESIGN

Population-based cohort of births <28 weeks of gestation with data from obstetric and neonatal records and parental questionnaires and clinical assessments at 5 years of age.

SETTING

11 European countries.

PATIENTS

957 EPT infants born in 2011-2012.

MAIN OUTCOMES

EUGR at discharge from the neonatal unit was defined as (1) the difference between Z-scores at birth and discharge with <-2 SD as severe, -2 to -1 SD as moderate using Fenton's growth charts (Fenton) and (2) average weight-gain velocity using Patel's formula in grams (g) per kilogram per day (Patel) with <11.2 g (first quartile) as severe, 11.2-12.5 g (median) as moderate. Five-year outcomes were: a CP diagnosis, intelligence quotient (IQ) using the Wechsler Preschool and Primary Scales of Intelligence tests and motor function using the Movement Assessment Battery for Children, second edition.

RESULTS

40.1% and 33.9% children were classified as having moderate and severe EUGR, respectively, by Fenton and 23.8% and 26.3% by Patel. Among children without CP, those with severe EUGR had lower IQ than children without EUGR (-3.9 points, 95% Confidence Interval (CI)=-7.2 to -0.6 for Fenton and -5.0 points, 95% CI=-8.2 to -1.8 for Patel), with no interaction by sex. No significant associations were observed between motor function and CP.

CONCLUSIONS

Severe EUGR among EPT infants was associated with decreased IQ at 5 years of age.

Prediction of movement difficulties at 5 years from parent report at 2 years in children born extremely preterm

AIM

To assess the predictive validity of parent-reported gross motor impairment (GMI) at age 2 years to detect significant movement difficulties at age 5 years in children born extremely preterm.

METHOD

Data were from 556 children (270 males, 286 females) born at less than 28 weeks' gestation in 2011 to 2012 in 10 European countries. Parent report of moderate/severe GMI was defined as walking unsteadily or unable to walk unassisted at 2 years corrected age. Examiners assessed significant movement difficulties (score ≤ 5th centile on the Movement Assessment Battery for Children, Second Edition) and diagnoses of cerebral palsy (CP) were collected by parent report at 5 years chronological age.

RESULTS

At 2 years, 66 (11.9%) children had moderate/severe GMI. At 5 years, 212 (38.1%) had significant movement difficulties. Parent reports of GMI at age 2 years accurately classified CP at age 5 years in 91.0% to 93.2% of children. Classification of moderate/severe GMI at age 2 years had high specificity (96.2%; 95% confidence interval 93.6-98.0) and positive predictive value (80.3%; 68.7-89.1) for significant movement difficulties at age 5 years. However, 74.5% of children with significant movement difficulties at 5 years were not identified with moderate/severe GMI at age 2 years, resulting in low sensitivity (25.1%; 19.4-31.5).

INTERPRETATION

This questionnaire may be used to identify children born extremely preterm who at age 2 years have a diagnosis of CP or movement difficulties that are likely to have a significant impact on their functional outcomes at age 5 years.

A systematic review of early motor interventions for infants with congenital heart disease and open-heart surgery

BACKGROUND

Motor development delay is the first neurodevelopmental impairment that becomes apparent in infants with congenital heart disease (CHD). Early interventions have addressed high-risk groups like infants born preterm, but little is known about interventions to improve motor outcome in CHD infants at risk of motor delay. The purpose of this review was to systematically review the literature on type and effect of motor intervention applied during the first year of life in infants with CHD following open-heart surgery.

METHODS

Scoping searches were performed in May 2020 and April 2023 via MEDLINE, Embase, CINAHL, Cochrane, PsycINFO, PEDro, and Scopus. The review included studies published in English from 2015 to 2022. Primary outcome was infants' motor development measured by standardized and non-standardized motor assessments, and if available, infants' language and cognitive development, and any parental quality-of-life assessments as secondary outcomes. The studies' quality was evaluated with a modified Newcastle-Ottawa scale.

RESULTS

Four papers with low to high methodological quality met inclusion criteria. All studies investigated the influence of early physiotherapy. Four studies involved parents, and three studies used standardized tools to assess motor outcomes. No conclusion can be drawn about any positive effect of early motor interventions.

CONCLUSIONS

Early motor intervention in CHD infants may improve motor development; however, the few existing studies do not provide clear evidence. Thus, more prospective early intervention studies are needed.

TRIAL REGISTRATION

PROSPERO CRD42020200981.

Advocacy in neonatology: current issues and introduction to the series

Advocacy is an increasingly important skill for neonatologists. As social factors play a greater influence on short & long-term newborn outcomes, neonatal physicians must be attentive to policy factors and work to ensure they benefit the health of both patients and the specialty. In this article, we review advocacy issues of current relevance to neonatal practice, including the "Born Alive Executive Order," the "Newborn Screening Saves Lives Act," subspecialty loan repayment and legislation related to donor human milk, as well as introduce topics further discussed as part of the American Academy of Pediatrics Section on Neonatal-Perinatal Medicine Advocacy Series.

A systematic synthesis of qualitative studies on parents' experiences of participating in early intervention programs with their infant born preterm

Early intervention programs involving both the parent and the infant born preterm have demonstrated positive effects on developmental outcomes for the children. However, studies have also shown that parental engagement and adherence when implementing intervention programs can be challenging. The aim of this review was to provide a comprehensive description and new insights into key messages gleaned from the parent reports on participating in early intervention with their infant born preterm; knowledge vital to facilitate implementation of early interventions into clinical practice when using a model of direct parent involvement. Early intervention is broadly defined as a multi-interdisciplinary field provided to children from birth to five years of age to foster child health, wellbeing, development, adapting parenting and family function. For this systematic synthesis we define early intervention as programs with specific activities completed with the infant during the first year after birth. We assembled qualitative interview studies on parents' experiences with participation in early intervention and applied Malterud's qualitative systematic meta-synthesis to synthesize and translate the original findings across studies. In the analysis we applied enactive concepts of embodiment, autonomy, participatory sensemaking, and agency. 10 qualitative studies were identified and included. The systematic synthesis reveals how parents' successful and meaningful participation in early intervention programs were facilitated by their "active embodied doing." The "embodied doing" appeared as the basis for the parents' sense-making processes, development of confidence, and the ability for parents to see new possibilities for actions within themselves, with and in the child. In that respect, a perception of mutuality in the interaction between parent, infant and interventionist was central. Consequently, an important consideration when implementing early intervention into clinical practice is to promote embodied parent-infant interactions as well as trust between the parent and the interventionist.

Language outcomes at 4 years of linguistically diverse children born very preterm: an Australian retrospective single-centre study

BACKGROUND

Very preterm children are at increased risk of language delays. Concerns have been raised about the utility of standardised English language tools to diagnose language delay in linguistically diverse children. Our study investigated the incidence of language delay at 4 years in linguistically diverse very preterm children.

METHODS

Very preterm children born in South Western Sydney, Australia, between 2012 and 2016, were assessed with the Clinical Evaluation of Language Fundamentals Preschool-2 (CELF-P2) tool at 4 years of age. We sought to determine the incidence of language delay in this cohort using language scores from the CELF-P2 assessment tool, and explore potential predictors associated with language delay.

RESULTS

One hundred and sixty very preterm children attended the 4-year assessment out of the included 270 long-term survivors. At 4 years, 76 (52%) very preterm children had language delay diagnosed using the CELF-P2 assessment tool. Children who preferred a language other than English had lower average core language scores on the CELF-P2 assessment tool (75.1±14.4) compared with children that preferred English (86.5±17.9); p=0.002. Very preterm children growing up in households that preferenced a language other than English and those who were born from multiple births had higher odds of language delay at 4 years (AOR 10.30 (95% CI 2.82 to 38.28); p<0.001 and AOR 2.93 (95% CI 1.20 to 7.14); p=0.018, respectively). Assessing these children using an English language tool may have affected language scores at 4 years.

CONCLUSIONS

In this metropolitan setting, very preterm children from linguistically diverse backgrounds were found to be vulnerable to language delays at 4 years. Further large-scale studies evaluating the language outcomes of linguistically diverse preterm children with more culturally appropriate tools are warranted. We question the utility of standardised English language tools to assess language outcomes of linguistically diverse populations.

Mean 3D Dispersion for Automatic General Movement Assessment of Preterm Infants

The General Movement assessment (GMA) is a validated assessment of brain maturation primarily based on the qualitative analysis of the complexity and the variation of spontaneous motor activity. The GMA can identify preterm infants presenting an early abnormal developmental trajectory before term-equivalent age, which permits a personalized early developmental intervention. However, GMA is time-consuming and relies on a qualitative analysis; these limitations restrict the implementation of GMA in clinical practice. In this study based on a validated dataset of 183 videos from 92 premature infants (54 males, 38 females) born <33 weeks of gestational age (GA) and acquired between 32 and 40 weeks of GA, we introduce the mean 3D dispersion (M3D) for objective quantification and classification of normal and abnormal GMA. Moreover, we have created a new 3D representation of skeleton joints which allows an objective comparison of spontaneous movements of infants of different ages and sizes. Preterm infants with normal versus abnormal GMA had a distinct M3D distribution (p <0.001). The M3D has shown a good classification performance for GMA (AUC=0.7723) and presented an accuracy of 74.1%, a sensitivity of 75.8%, and a specificity of 70.1% when using an M3D of 0.29 as a classification threshold.Clinical relevance- Our study paves the way for the development of quantitative analysis of GMA within the Neonatal Unit.

Early surgery in very preterm infants is associated with brain abnormalities on term MRI: a propensity score analysis

OBJECTIVE

To investigate the association between exposure to surgery under general anesthesia and brain abnormalities and neurodevelopmental outcomes in very preterm infants.

STUDY DESIGN

This prospective observational study includes 392 infants born at or below 32 weeks' gestational age. Participants completed brain MRI at term-equivalent age and Bayley-III assessment at 2 years corrected age. We evaluated the independent effects of surgery on brain MRI abnormalities and neurodevelopmental outcomes after propensity score matching.

RESULTS

All infants completed brain MRI, and 341 (87%) completed neurodevelopmental testing. Forty-five received surgery. Surgery was associated with worse MRI abnormalities (p < 0.0001) but with none of the developmental outcomes after propensity score matching. The global brain abnormality score was associated with the Bayley Cognitive (p = 0.005) and Motor (p = 0.028) composite scores.

CONCLUSIONS

Very preterm infants exposed to surgery under general anesthesia were at higher risk of brain abnormalities on MRI at term.

Multidisciplinary bronchopulmonary dysplasia care

INTRODUCTION

Bronchopulmonary dysplasia (BPD) is a chronic respiratory disease in neonates and infants, which often presents with multisystem organ involvement, co-morbidities, and prolonged hospital stays. Therefore, a multidisciplinary chronic care approach is needed in the severest forms of BPD to optimize outcomes. However, this approach can be challenging to implement. The objective of this article is to review and synthesize the available literature regarding multidisciplinary care in infants and children with established BPD, and to provide a framework that can guide clinical practice and future research.

AREAS COVERED

A literature search was conducted using Ovid MEDLINE, CINAHL, and Embase and several components of multidisciplinary management of BPD were identified and reviewed, including chronic care, team development, team members, discharge planning, and outpatient care.

EXPERT OPINION

Establishing a core multidisciplinary group familiar with the chronicity of established BPD is recommended as best practice for this population. Acknowledging this is not feasible for all individual centers, it is important for clinical practice and future research to focus on the development and incorporation of national consulting services, telemedicine, and educational resources.

Preterm Neurodevelopmental Trajectories from 18 Months to 4.5 Years

OBJECTIVE

To assess the longitudinal trajectory of cognitive, language, and motor outcomes from 18 months to 4.5 years of age in children born very preterm.

STUDY DESIGN

This was a prospective cohort study of 163 infants born very preterm (born 24-32 weeks of gestation) followed longitudinally and assessed with neurodevelopmental scales and magnetic resonance imaging of the brain. Outcomes at 18 months and 3 years were assessed with the Bayley Scales of Infant and Toddler Development, 3rd Edition, and at 4.5 years with the Wechsler Preschool and Primary Scale of Intelligence-III and the Movement Assessment Battery for Children. Cognitive, language, and motor outcomes were categorized as below-average, average, and above-average, and compared across time. Clinical data were analyzed using ANOVA, χ2 tests, and linear regression.

RESULTS

Cognitive and language trajectories were stable from 18 months to 4.5 years for all outcome groups. Motor impairment increased over time, with a greater proportion of children having motor deficits at 4.5 years. Children with below-average cognitive and language outcomes at 4.5 years had more clinical risk factors, greater white matter injury, and lower maternal education. Children with severe motor impairment at 4.5 years were born earlier, had more clinical risk factors, and demonstrated greater white matter injury.

CONCLUSIONS

Children born preterm have stable cognitive and language trajectories, while motor impairment increased at 4.5 years. These results highlight the importance of continued developmental surveillance for children born preterm into preschool age.

Stimulating the motor development of very premature infants: effects of early crawling training on a mini-skateboard

Aim

To examine the effects of an early home-based 8-week crawling intervention performed by trained therapists on the motor and general development of very premature infants during the first year of life.

Methods

At term-equivalent age, immediately following discharge from the Neonatal Intensive Care Unit (NICU), we randomly allocated 44 premature infants born before 32 weeks' gestation without major brain damage to one of three conditions in our intervention study: crawling on a mini-skateboard, the Crawliskate (Crawli), prone positioning control (Mattress), or standard care (Control). The Crawli and Mattress groups received 5 min daily at-home training administered by trained therapists for 8 consecutive weeks upon discharge from the NICU. The outcomes of greatest interest included gross motor development (Bayley-III) at 2, 6, 9, and 12 months (primary outcome) corrected age (CA), mature crawling at 9 months CA and general development at 9 and 12 months CA [Ages and Stages Questionnaires-3 (ASQ-3)]. The study was registered at www.clinicaltrials.gov; registration number: NCT05278286.

Results

A 3 (Condition) × 4 (Age) repeated measures ANOVA revealed that Crawli group infants had significantly higher Bayley-III gross motor development scores than Mattress and Control group infants. Crawli group infants also scored significantly higher on groups of Bayley-III items related to specific motor skills than infants in the other groups, including crawling at 9 months CA. We found significant differences in favor of the Crawli group in separate one-way ANOVAs at each of the ages we examined. A 3 (Condition) × 2 (Age) repeated measures ANOVA revealed that the Crawli group scored significantly higher than the Control group for the ASQ-3 total score and communication score and significantly higher for the fine motor score than the Control and Mattress groups. We found additional significant differences in favor of the Crawli group for other dimensions of the ASQ-3 in separate one-way ANOVAs at 9 and 12 months CA.

Interpretation

Early crawling training on a Crawliskate provides an effective way to promote motor and general development in very premature infants. The findings also provide clear evidence for a link between newborn crawling and more mature crawling later in development.

The association between parental risks and childhood development: findings from a community-based survey in East China

BACKGROUND

Nurturing care is necessary for optimal early childhood development. This study aimed to investigate the prevalence of parental risks in rural East China and assess their impacts on early development in children younger than three years old.

METHODS

This community-based cross-sectional survey was conducted among 3852 caregiver-child pairs in Zhejiang Province from December 2019 to January 2020. Children aged 0 to 3 years were recruited from China's Early Childhood Development Program (ECD). Local child health care providers conducted face-to-face interviews with the primary caregivers. Demographic information of the participants was collected by questionnaire. Each child was screened for parental risk through the Parental Risk Checklist designed by the ECD program. The Ages and Stages Questionnaire (ASQ) was used to identify children with potential developmental delays. Multinomial logistic regression model and linear trend test were applied to assess the association between parental risks and suspected developmental delays.

RESULTS

Among the 3852 children included in the analyses, 46.70% had at least one parental risk and 9.01% presented suspected developmental delays in any domain of ASQ. Parental risk was statistically associated with the overall suspected developmental delay in young children (Relative Risk Ratio (RRR): 1.36; 95% confidence interval (CI): 1.08, 1.72; P = 0.010) after adjusting potential confounders. Compared with children with no parental risk, children exposed to 3 or more parental risks had 2.59, 5.76, 3.95, and 2.84 times higher risk of the suspected developmental delay in overall ASQ, communication, problem-solving, and personal-social domain, respectively (P values < 0.05). The linear trend tests found that the more parental risks, the higher possibility of developmental delay (P values < 0.05).

CONCLUSIONS

Parental risks are prevalent among children under three years in rural East China, which may increase the risk of developmental delays in children. Meanwhile, parental risk screening can be used to recognize poor nurturing care in primary health care settings. Targeted interventions are warranted to improve nurturing care for optimal early childhood development.

Association between combined spinal-epidural analgesia and neurodevelopment at 3 years old: The Japan Environment and Children's Study

AIM

To investigate the association between maternal combined spinal-epidural analgesia during vaginal delivery and neurodevelopment in 3-year-old children.

METHODS

Using data from the Japan Environment and Children's Study, a birth cohort study on pregnant women and their offspring, we described the background, perinatal outcomes, and neurodevelopmental outcomes of participants with a singleton pregnancy who received combined spinal-epidural analgesia during vaginal delivery and those who did not. The association between maternal combined spinal-epidural analgesia and abnormalities in five domains of the Ages and Stages Questionnaire, Third Edition, was analyzed using univariable and multivariable logistic regression analyses. Crude and adjusted odds ratios with 95% confidence intervals (95% CI) were calculated.

RESULTS

Among 59 379 participants, 82 (0.1%) children (exposed group) were born to mothers who received combined spinal-epidural analgesia during vaginal delivery. In the exposed versus control groups, 1.2% versus 3.7% had communication abnormalities (adjusted odds ratio [95% CI]: 0.30 [0.04-2.19]), 6.1% versus 4.1% exhibited gross-motor abnormalities (1.36 [95% CI: 0.55-3.36]), 10.9% vs. 7.1% had fine-motor abnormalities (1.46 [95% CI: 0.72-2.96]), 6.1% vs. 6.9% showed difficulties with problem-solving (0.81 [95% CI: 0.33-2.01]), and 2.4% vs. 3.0% had personal-social problems (0.70 [95% CI: 0.17-2.85]).

CONCLUSIONS

Exposure to combined spinal-epidural analgesia during vaginal delivery was not associated with the risk of neurodevelopmental abnormalities; however, the sample size of our study might not be appropriate for the study design.

Predictive value of Bayley-III Motor Index for later motor difficulties in children born extremely preterm

AIM

To investigate the predictive ability of the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) Motor Index, in children born extremely preterm (<27 gestational weeks) without cerebral palsy.

METHODS

Children from the EXPRESS study (all extremely preterm births in Sweden, 2004-2007) without neurosensory impairments assessed with Bayley-III at 2.5 years corrected age and Movement Assessment Battery for Children, Second Edition (MABC-2), at 6.5 years comprised the eligible study population (n = 282). Motor difficulty was defined as MABC-2 ≤5th percentile.

RESULTS

Motor difficulties were found in 57 of 282 children (20.2%) at 6.5 years. The Bayley-III explained 18.0% of the variance in the MABC-2 (p < 0.001). The area under the receiver operating curve was 0.71 (95% confidence interval 0.64-0.79, p < 0.001). At a Bayley-III cut-off value of 85, sensitivity, specificity and positive and negative predictive values for motor difficulties were 26.3% (15.5-39.7), 92.9% (88.1-95.9), 48.4% (33.0-64.0) and 83.3% (80.9-85.4). Likelihood ratios were inconclusive.

CONCLUSION

The Bayley-III at 2.5 years corrected age was a modest predictor of motor outcome in children born extremely preterm at 6.5 years, and underestimated the rate of motor difficulties. Children require follow-up beyond preschool age.

Neurodevelopmental Outcomes at Two Years' Corrected Age of Very Preterm Infants After Implementation of a Post-discharge Responsive Parenting Intervention Program (TOP program)

OBJECTIVE

To compare neurodevelopmental outcomes at two years corrected age (CA) between infants born very preterm (VP) who did or did not receive a post-discharge responsive parenting intervention (TOP program) between discharge home and 12 months CA.

STUDY DESIGN

The Systemic Hydrocortisone to Prevent Bronchopulmonary Dysplasia (SToP-BPD) study showed no differences between treatment groups in motor and cognitive development using the Dutch Bayley Scales of Infant Development, and behavior using the Child Behavior Check List at two years CA. During its study period, the TOP program was gradually scaled up nationwide in the same population, providing an opportunity to evaluate the effect of this program on neurodevelopmental outcome, after adjusting for baseline differences.

RESULTS

Among 262 surviving VP infants in the SToP-BPD study, 35% received the TOP program. Infants in the TOP group had a significantly lower incidence of a cognitive score <85 (20.3% vs. 35.2%; adjusted absolute risk reduction -14.1% [95% CI -27.2 to -1.1]; p=0.03), and a significantly higher mean cognitive score (96.7 ±13.8), compared with the non-TOP group (92.0 ±17.5; crude mean difference 4.7 [95% CI 0.3 to 9.2]; p=0.03). No significant differences were found on motor scores. For behavior problems, a small but statistically significant effect for anxious/depressive problems was found in the TOP group (50.5 vs. 51.2; p=0.02).

CONCLUSIONS

VP infants supported by the TOP program from discharge until 12 months CA had better cognitive function at two years CA. This study demonstrates a sustained positive effect of the TOP program in VP infants.

Prelinguistic intersubjective and socio-communicative skills in infants with neurodevelopmental disabilities aged 0-36 months: A new assessment and parent support tool

Background

Although children with neurodevelopmental disability (NDD) present with several deficits, they partially share developmental impairments in prelinguistic intersubjective and socio-communicative skills, which are not easily assessed by conventional tests during the first years of life.

Aim

The current paper presents a new procedure to assess the prelinguistic intersubjective and socio-communicative skills of NDD children aged 0-36 months. A specific observation form template, called the Observation of Prelinguistic Intersubjective and Socio-Communicative Skills (OPISCoS) form, has been designed to systematically detect infant skills during daily routines (e.g., mealtime, playtime, desk activities). The OPISCoS form helps speech therapists to provide parents support to better perceive and understand early communicative signals from their children, avoiding the risk of excessive or reduced social stimulation.

Methods

The OPISCoS form is composed of three sections, namely, "Pragmatics and Communication," "Decoding," and "Expression," which are useful to delineate the communication abilities of children with NDD and are not tapped by traditional batteries. Vignettes from clinical practice illustrate and provide exemplifications for using the OPISCoS form with NDD infants and their parents.

Results

The OPISCoS form was reported for two children and showed potential in detecting disrupted communicative behaviors and planning specific early interventions. Further, we observed an improvement not only in children's communicative abilities improve but also in their interactions with parents. From a clinical point of view, the OPISCoS form (1) offers an observational perspective of prelinguistic intersubjective and socio-communicative skills in infants with NDD and (2) may be useful to practitioners to enhance parents' sensitivity to their infants' communicative behavior.

Conclusion

The OPISCoS form was developed in clinical practice and is based on a very preliminary description of a new observational procedure as integration for the assessment of NDD children. The OPISCoS form appears to be a useful tool for the clinical assessment of prelinguistic intersubjective and socio-communicative skills in NDD infants as well as for promoting the quality of early parenting.

Risk factors for cerebral palsy and movement difficulties in 5-year-old children born extremely preterm

BACKGROUND

Motor impairment is common after extremely preterm (EPT, <28 weeks' gestational age (GA)) birth, with cerebral palsy (CP) affecting about 10% of children and non-CP movement difficulties (MD) up to 50%. This study investigated the sociodemographic, perinatal and neonatal risk factors for CP and non-CP MD.

METHODS

Data come from a European population-based cohort of children born EPT in 2011-2012 in 11 countries. We used multinomial logistic regression to assess risk factors for CP and non-CP MD (Movement Assessment Battery for Children - 2nd edition ≤5th percentile) compared to no MD (>15th percentile) among 5-year-old children.

RESULTS

Compared to children without MD (n = 366), young maternal age, male sex and bronchopulmonary dysplasia were similarly associated with CP (n = 100) and non-CP MD (n = 224) with relative risk ratios (RRR) ranging from 2.3 to 3.6. CP was strongly related to severe brain lesions (RRR >10), other neonatal morbidities, congenital anomalies and low Apgar score (RRR: 2.4-3.3), while non-CP MD was associated with primiparity, maternal education, small for GA (RRR: 1.6-2.6) and severe brain lesions, but at a much lower order of magnitude.

CONCLUSION

CP and non-CP MD have different risk factor profiles, with fewer clinical but more sociodemographic risk factors for non-CP MD.

IMPACT

Young maternal age, male sex and bronchopulmonary dysplasia similarly increased risks of both cerebral palsy and non-cerebral palsy movement difficulties. Cerebral palsy was strongly related to clinical risk factors including severe brain lesions and other neonatal morbidities, while non-cerebral palsy movement difficulties were more associated with sociodemographic risk factors. These results on the similarities and differences in risk profiles of children with cerebral palsy and non-cerebral palsy movement difficulties raise questions for etiological research and provide a basis for improving the identification of children who may benefit from follow-up and early intervention.

The Effect of a Parent-Directed Program to Improve Infants' Motor Skills

Poor motor skills are associated with several factors that might delay children's development. Therefore, early programs to promote a child's motor development are essential. Within the first year of life, parents have a critical role in promoting their infant's motor development. However, little research has explored parent-directed programs that promote infant development in a Scandinavian context. This study aimed to evaluate the effectiveness of a parent-directed program to improve infant motor development.

METHODS

Parents of infants received a parent-directed program that included guidance from health visitors on ways to promote motor development, videos with motor development activities and a bag with related materials. Two municipalities in Denmark took part in the study (one intervention, one control). Health visitors in both municipalities measured the infants' age-appropriate motor skills once when the infants were between 9-11 months of age. A logistic regression model was used to analyze the data.

RESULTS

No difference was detected in motor development over time in the two municipalities regarding the proportion of children with age-appropriate motor skills.

CONCLUSIONS

A parent-directed program in which parents were guided to play and encourage motor development with their infant showed no effect on infants' age-appropriate motor skills at 9-11 months.

Measuring the impact of deprivation on learning difficulties and behaviour among infants born preterm: A cohort study

BACKGROUND

Preterm birth and social deprivation are known risk factors for learning difficulties. However there has been little work looking into the interaction between these two risks. We aimed to identify if children born preterm to families with higher levels of social deprivation are disproportionately more likely to have learning difficulties than those with lower levels of social deprivation.

METHODS

Data from the RANOPS (Respiratory And Neurological Outcomes in children born Preterm Study) was used to assess prevalence of learning difficulties. The effects of preterm birth and deprivation were reviewed. Multi-level logistic regression models were used to examine if gestational age and deprivation impacts interacted after adjustment for possible confounders. Primary outcome measure was parent-reported learning difficulties. Secondary outcome measures were parent-reported behavioural problems and a statement of special educational need.

RESULTS

We investigated the developmental outcomes of 6,691 infants with a median age of 5 years at time of survey (IQR 5). Deprivation decile (OR 1.08 (1.03,1.12)) and preterm birth (OR 2.67 (2.02,3.53)) were both associated with increased risk of learning difficulties. There was little evidence for any interaction between preterm birth and deprivation (p = 0.298) and the risk of learning difficulties.

CONCLUSIONS

Deprivation and preterm birth have significant associations with learning difficulties. While deprivation does not appear to have potentiated the impact of preterm birth, preterm infants in the most deprived areas have the highest risk of learning difficulties with almost 1 in 3 extremely premature infants with a learning difficulty in the most deprived areas.

Biomedical and Psychosocial Determinants of Early Neurodevelopment After Preterm Birth

Prematurity and them related conditions are subject of scientific discussion. From the point of view optimization of postpartum processes, timely assessment of individual biomedical and psychosocial conditions and management of preventive intervention is very important, because of its linkage to issues of preterm infants and their families in long-term perspectives. The goal of the literature review is to bring together existing body of knowledge on biomedical, psychological, and social issues of premature infants related to early neurodevelopment in order to achieve better systemic vision. For this goal scientific articles related to neurological development delay of premature children and the possibilities of their timely identification were processed using electronic scientific search systems. Diagnostic tools to identify at-risk children and early intervention programs discussed in the article, significantly improve the chances of premature child development. In the article Introduced materials are to support: Clinicians to make correct decisions regarding important components of premature infants; Healthcare policy makers to plan targeted programs and activities; Public to better understand prematurity issues, especially in case of prematurely-born family members.

The potential of COPCA's coaching for families with infants with special needs in low- and middle-income countries

Infants at high biological risk of or with a neurodevelopmental disorder run a high risk of delayed school readiness. This is especially true for infants in low- and middle-income countries (LMICs). This perspective paper first summarizes evidence on intervention elements that are effective in promoting family well-being and child development in infants at high biological risk in high income countries. Crucial elements are family centeredness, goal orientation, a home setting, focus on activity and participation, and challenging the infant to explore the world and the own body by means of self-produced movements. The studies revealed that coaching as applied in COPCA (COPing and CAring for infants with special needs) is a pivotal element determining the success of intervention.The paper continues by describing COPCA and its coaching. Next, we report on two pilot studies addressing COPCA's implementation in Brazil. Finally, we discuss why COPCA is a promising early intervention program for infants at high biological risk of neurodisability in LMICs: COPCA is adapted to the families' strengths and needs, it empowers families and promotes child development therewith facilitating school readiness. Moreover, it may be delivered by tele-coaching therewith eliminating families' burden to travel to distant intervention clinics.

Management challenges in the treatment of severe hyperbilirubinemia in low- and middle-income countries: Encouraging advancements, remaining gaps, and future opportunities

Neonatal jaundice (NJ) is common in newborn infants. Severe NJ (SNJ) has potentially negative neurological sequelae that are largely preventable in high resource settings if timely diagnosis and treatment are provided. Advancements in NJ care in low- and middle-income countries (LMIC) have been made over recent years, especially with respect to an emphasis on parental education about the disease and technological advancements for improved diagnosis and treatment. Challenges remain, however, due to lack of routine screening for SNJ risk factors, fragmented medical infrastructure, and lack of culturally appropriate and regionally specific treatment guidelines. This article highlights both encouraging advancements in NJ care as well as remaining gaps. Opportunities are identified for future work in eliminating the gaps in NJ care and preventing death and disability related to SNJ around the globe.

Short stature and language development in the United Kingdom: a longitudinal analysis of children from the Millennium Cohort Study

BACKGROUND

In low- and middle-income countries, poverty and impaired growth prevent children from meeting their cognitive developmental potential. There are few studies investigating these relationships in high-income settings.

METHODS

Participants were 12,536 children born between 2000 and 2002 in the UK and participating in the Millennium Cohort Study (MCS). Short stature was defined as having a height-for-age 2 or more standard deviations below the median (≤ - 2 SDS) at age 3 years. Standardized British Abilities Scales II (BAS II) language measures, used to assess language development at ages 3, 5, 7 and 11 years, were the main outcome assessed.

RESULTS

Children with short stature at age 3 years (4.1%) had language development scores that were consistently lower from ages 3 to 11 years (- 0.26 standard deviations (SD) (95% CI - 0.37, - 0.15)). This effect was attenuated but remained significant after adjustment for covariates. Trajectory analysis produced four distinct patterns of language development scores (low-declining, low-improving, average and high). Multinomial logistic regression models showed that children with short stature had a higher risk of being in the low-declining group, relative to the average group (relative risk ratio (RRR) = 2.11 (95% CI 1.51, 2.95)). They were also less likely to be in the high-scoring group (RRR = 0.65 (0.52, 0.82)). Children with short stature at age 3 years who had 'caught up' by age 5 years (height-for-age ≥ 2 SDS) did not have significantly different scores from children with persistent short stature, but had a higher probability of being in the high-performing group than children without catch-up growth (RRR = 1.84 (1.11, 3.07)).

CONCLUSIONS

Short stature at age 3 years was associated with lower language development scores at ages 3 to 11 years in UK children. These associations remained significant after adjustment for socioeconomic, child and parental factors.

Can web-based implementation interventions improve physician early diagnosis of cerebral palsy? Protocol for a 3-arm parallel superiority randomised controlled trial and cost-consequence analysis comparing adaptive and non-adaptive virtual patient instructional designs with control to evaluate effectiveness on physician behaviour, diagnostic skills and patient outcomes

INTRODUCTION

Cerebral palsy (CP) is the most common childhood physical disability. Accurate diagnosis before 6 months is possible using predictive tools and decision-making skills. Yet diagnosis is typically made at 12-24 months of age, hindering access to early interventions that improve functional outcomes. Change in practice is required for physicians in key diagnostic behaviours. This study aims to close the identified research-practice gap and increase accurate CP diagnosis before 6 months of age through tailored web-based implementation interventions. This trial will determine whether adaptive e-learning using virtual patients, targeting CP diagnostic behaviours and clinical decision-making skills, effectively changes physician behaviour and practice compared with non-adaptive e-learning instructional design or control.

METHODS AND ANALYSIS

This study is a 3-arm parallel superiority randomised controlled trial of two tailored e-learning interventions developed to expedite physician CP diagnosis. The trial will compare adaptive (arm 1) and non-adaptive (arm 2) instructional designs with waitlist control (arm 3) to evaluate change in physician behaviour, skills and diagnostic practice. A sample size of 275 paediatric physicians enables detection of small magnitude effects (0.2) of primary outcomes between intervention comparators with 90% power (α=0.05), allowing for 30% attrition. Barrier analysis, Delphi survey, Behaviour Change Wheel and learning theory frameworks guided the intervention designs. Adaptive and non-adaptive video and navigation sequences utilising virtual patients and clinical practice guideline content were developed, integrating formative key features assessment targeting clinical decision-making skills relative to CP diagnosis.Physician outcomes will be evaluated based on postintervention key feature examination scores plus preintervention/postintervention behavioural intentions and practice measures. Associations with CP population registers will evaluate real-world diagnostic patient outcomes. Intervention costs will be reported in a cost-consequence analysis from funders' and societal perspectives.

ETHICS AND DISSEMINATION

Ethics approved from The University of Sydney (Project number 2021/386). Results will be disseminated through peer-reviewed journals and scientific conferences.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry: ACTRN 12622000184774.

Identification of risk factors in pre-term infants with abnormal general movements

INTRODUCTION

This study aimed to investigate the relationship between prenatal, perinatal, and postnatal risk factors for neurodevelopmental impairment (NDI) with the outcomes of General Movement (GM) Assessment (GMA) in pre-term infants at 3-5 months of age. We sought to identify the risk factors associated with the predictors of psychomotor development in pre-term newborns, such as normal fidgety movements (FMs), absent FMs, or abnormal FMs, assessed during the fidgety period of motor development.

METHODS

The SYNAGIS program (prophylactic of Respiratory Syncytial Virus Infection) was used to identify risk factors for the development of neuromotor deficits in 164 pre-term infants who were at high risk of developing these deficits. Based on the GMA, all participants were divided into three groups of infants who presented: (1) normal FMs; (2) absent FMs; and (3) abnormal FMs.

RESULTS

The results of the current study suggest that abnormal GMs not only indicate commonly known factors like birth asphyxia (BA), respiratory distress syndrome (RDS), periventricular leukomalacia (PVL), intraventricular hemorrhage (IVH) grades 3-4, but also predict the development of motor impairments. In the present study, several specific risk factors including bronchopulmonary dysplasia (BPD), infertility treatments, maternal acute viral/bacterial infections during pregnancy, and elevated bilirubin levels were identified as attributes of an atypical fidgety movement pattern.

CONCLUSIONS

Additional clinical data, such as risk factors for NDI associated with early predictors of psychomotor development in pre-term newborns, i.e., absent or abnormal FMs, may be helpful in predicting neurological outcomes in pre-term infants with developmental concerns in the 1st month of life.

Early Intervention Involving Specific Task-Environment-Participation (STEP) Protocol for Infants at Risk: A Feasibility Study

Aims: To verify the feasibility and preliminary effects of the STEP protocol, an intervention based on specific motor skills, environmental factors and participation, in infants at biological risk.Methods: Twenty-eight at-risk infants (STEP Protocol = 14; Standard Intervention = 14), aged 3-9 months and at risk for developmental delay. The following outcomes were assessed: motor skills (Alberta Infant Motor Scale-AIMS); frequency and involvement of participation (Young Children's Participation and Environment Measure-YC-PEM), and home environment opportunities (Affordances in the Home Environment for Motor Development-AHEMD-IS). For both groups, interventions were provided by parents. The intervention for group was based on the following principles: (1) standard intervention: stimulation of motor skills; (2) STEP: stimulation of motor skills, participation, mother-infant interaction, environmental enrichment. A mean comparison test was applied to verify difference between groups after the intervention.Results: The protocol showed good retention and recruitment rates. The STEP group had significantly higher outcomes after intervention on the AIMS (p = 0.014); frequency (p = 0.02) and engagement (p = 0.03) in participation, when compared to standard intervention.Conclusions: The results showed that the STEP protocol is feasible, and presents better results compared to the standard intervention, which reinforces the importance of promoting participation, specific motor skills and family involvement.

Le suivi de l'extrême prématuré après le congé des soins intensifs néonatals

La survie des extrêmes prématurés (moins de 28 semaines d'âge gestationnel) s'est améliorée au fil du temps. Bon nombre s'en sortent bien et ont une bonne qualité de vie. Ils demeurent toutefois vulnérables à des problèmes de santé, y compris des difficultés neurosensorielles et neurodéveloppementales, que les médecins de première ligne, les pédiatres et les cliniques spécialisées doivent surveiller. Le présent document de principes passe en revue les conséquences médicales et neurodéveloppementales potentielles pour les extrêmes prématurés dans les deux ans suivant leur congé et fournit des stratégies de counseling, de dépistage précoce et d'intervention. Parce qu'ils sont tous liés à l'extrême prématurité, la dysplasie bronchopulmonaire ou les troubles respiratoires, les problèmes d'alimentation et de croissance, le développement neurosensoriel (vision et audition), la paralysie cérébrale et le trouble du spectre de l'autisme doivent faire rapidement l'objet d'une évaluation. Pour évaluer la croissance et le développement, il faut corriger l'âge chronologique en fonction de l'âge gestationnel jusqu'à 36 mois de vie. Par ailleurs, l'attention au bien-être émotionnel des parents et des proches fait partie intégrante des soins de qualité de l'extrême prématuré.

Follow-up care of the extremely preterm infant after discharge from the neonatal intensive care unit

The survival of babies born extremely preterm (EP, <28 weeks gestation) has improved over time, and many have good outcomes and quality of life. They remain at risk for health issues, including neurosensory and neurodevelopmental difficulties requiring monitoring by primary physicians, paediatricians, and specialty clinics. This statement reviews potential medical and neurodevelopmental consequences for EP infants in the first 2 years after discharge and provides strategies for counselling, early detection, and intervention. EP-related conditions to assess for early include bronchopulmonary dysplasia or respiratory morbidity, feeding and growth concerns, neurosensory development (vision and hearing), cerebral palsy, and autism spectrum disorder. Correction for gestational age should be used for growth and development until 36 months of age. Integral to quality care of the child born EP is attention to the emotional well-being of parents and caregivers.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL TRIAL REGISTRATION

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

IMPACT

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