Influence of perinatal, developmental and environmental factors on cognitive abilities of preterm children without major impairments at 5 years

Multisensory Stimulation Improves Cognition and Behavior in Adult Male Rats Born to LT4-treated Thyroidectomized Dams

Gestational hypothyroidism can impair development, cognition, and mood. Here, we tested whether multisensory stimulation (MS) improves the phenotype of rats born to surgically thyroidectomized (Tx) dams suboptimally treated with LT4. 8-week-old female Tx Wistar rats were kept on daily LT4 (0.7 µg/100 g body weight) dosed by gavage (serum TSH and T4 levels indicated moderate hypothyroidism) and 3 weeks later placed for breeding. MS of the litter started at age 60 days and lasted for 8 weeks. It consisted of twice per week of physical, cognitive, sensorial, and food stimuli. The offspring were assessed before and after MS for standardized tests of locomotor activity, cognition, and mood. Gestational hypothyroidism resulted in reduced litter size and increased offspring mortality. The pups exhibited delayed physical development, impairment of short- and long-term memory, and anxiety- and depressive-like behaviors. Nonetheless, ambulatory activity, social memory, and social preference were not affected by gestational hypothyroidism. MS restored short-term memory and anxiety while improving depressive like-behaviors. MS did not improve long-term memory. MS also did not modify the performance of control litter born to intact dams. We conclude that cognition and mood impairments caused by moderate gestational hypothyroidism were reversed or minimized in rats through MS. Further studies should define the molecular mechanisms involved.

Early vocal contact and music in the NICU: new insights into preventive interventions

It is now clearly established that the environment and the sensory stimuli, particularly during the perinatal period, have an impact on infant's development. During the last trimester of gestation, activity-dependent plasticity shapes the fetal brain, and prematurity has been shown to alter the typical developmental trajectories. In this delicate period, preventive interventions aiming at modulating these developmental trajectories through activity-inducing interventions are currently underway to be tested. The purpose of this review paper is to describe the potentialities of early vocal contact and music on the preterm infant's brain development, and their potential beneficial effect on early development. Scientific evidence supports a behavioral orientation of the newborn to organized sounds, such as those of voice and music, and recent neuroimaging studies further confirm full cerebral processing of music as multisensory stimuli. However, the impact of long-term effects of music exposure and early vocal contact on preterm infants' long-term neurodevelopment needs be further investigated. To conclude, it is necessary to establish the neuroscientific bases of the early perception and the long-term effects of music and early vocal contact on the premature newborns' development. Scientific projects are currently on the way to fill this gap in knowledge.

Impact of peri-intraventricular haemorrhage and periventricular leukomalacia in the neurodevelopment of preterms: A systematic review and meta-analysis

CONTEXT

Whether all degrees of periventricular leukomalacia (PVL) and peri-intraventricular haemorrhage (PIVH) have a negative impact on neurodevelopment.

OBJECTIVE

To determine the impact of PVL and PIVH in the incidence of cerebral palsy, sensorineural impairment and development scores in preterm neonates. Registered in PROSPERO (CRD42017073113).

DATA SOURCES

PubMed, Embase, SciELO, LILACS, and Cochrane databases.

STUDY SELECTION

Prospective cohort studies evaluating neurodevelopment in children born preterm which performed brain imaging in the neonatal period.

DATA EXTRACTION

Two independent researchers extracted data using a predesigned data extraction sheet.

STATISTICAL METHODS

A random-effects model was used, with Mantel-Haenszel approach and a Sidik-Jonkman method for the estimation of variances, combined with Hartung-Knapp-Sidik-Jonkman correction. Heterogeneity was assessed through the I2 statistic and sensitivity analysis were performed when possible. No funnel plots were generated but publication bias was discussed as a possible limitation.

RESULTS

Our analysis concluded premature children with any degree of PIVH are at increased risk for cerebral palsy (CP) when compared to children with no PIVH (3.4, 95% CI 1.60-7.22; 9 studies), a finding that persisted on subgroup analysis for studies with mean birth weight of less than 1000 grams. Similarly, PVL was associated with CP, both in its cystic (19.12, 95% CI 4.57-79.90; 2 studies) and non-cystic form (9.27, 95% CI 5.93-14.50; 2 studies). We also found children with cystic PVL may be at risk for visual and hearing impairment compared to normal children, but evidence is weak.

LIMITATIONS

Major limitations were the lack of data for PVL in general, especially for the outcome of neurodevelopment, the high heterogeneity among methods used to assess neurodevelopment and the small number of studies, which led to meta-analysis with high heterogeneity and wide confidence intervals.

CONCLUSIONS

There was no evidence supporting the hypothesis that PIVH causes impairment in neuropsychomotor development in our meta-analysis, but review of newer studies show an increased risk for lower intelligence scores in children with severe lesions, both PIVH and PVL. There is evidence to support the hypothesis that children with any degree of PIVH, especially those born below 1000 grams and those with severe haemorrhage, are at increased risk of developing CP, as well as children with PVL, both cystic and non-cystic.

Multilingualism was associated with lower cognitive outcomes in children who were born very and extremely preterm

Aim

This study determined whether cognitive outcomes differed between very preterm (VPT) and extremely preterm (EPT) children who were monolingual or multilingual when they reached the corrected ages of two and five years.

Methods

The data were collected at the Emma Children's Hospital, Amsterdam, The Netherlands, as part of our national neonatal follow‐up programme and comprised 325 VPT/EPT children born between January 1, 2007 and January 1, 2012. The study used the Third Editions of the Bayley Scales of Infant and Toddler Development and the Wechsler Preschool and Primary Scale of Intelligence.

Results

We compared 234 monolingual children, 65 multilingual children who spoke Dutch and at least one foreign language at home and 26 multilingual children who didn't speak Dutch at home. The best performers on the cognitive scale at two years of age and the verbal subscales at five years of age were the monolingual children, followed by the children who spoke Dutch and at least one foreign language at home, then the children who only spoke foreign languages at home.

Conclusion

In our study cohort from The Netherlands, multilingualism lowered the cognitive and verbal outcomes of VPT/EPT children at the corrected ages of two and five years.

The Effect of Bilingual Exposure on Executive Function Skills in Preterm and Full-Term Preschoolers

OBJECTIVE

To evaluate the effects of bilingual exposure on executive function (EF) skills, measured by parent-rating and performance-based instruments, in preterm and full-term preschoolers.

METHOD

Children age 3 to 5 years (mean 4.4) born preterm (PT; n = 82) and full term (FT; n = 79) had monolingual (PT-M, n = 51; FT-M, n = 53) or bilingual (PT-B, n = 31; FT-B, n = 26) language exposure. Groups were similar in age, gender and race, but PT children had lower socioeconomic status (SES) than FT children. Parents completed a language questionnaire and diary and a standardized parent rating of EF skills. Children completed EF tasks that tap response inhibition, working memory, and cognitive flexibility. ANCOVA and logistic regression examined effects on EF of birth group (PT/FT), language status (M/B), and birth group by language status interaction, controlling for age and SES.

RESULTS

Compared to children born FT, children born PT had significantly higher parent-rated EF scores and poorer performance on all but one EF task, both indicating more EF problems. No main effects of language status and no birth group by language status interactions were significant.

CONCLUSION

PT status was clearly associated with poorer EF skills, similar to many other studies. In this sample, bilingual exposure conferred neither an advantage nor disadvantage in the FT and PT group. This information may prove useful in counseling families of both PT and FT children about the impact of bilingual exposure on their children's cognitive skills.

Screening preschool children for fine motor skills: environmental influence

[Purpose] The aim of this study was to investigate the influence of gender and family factors on performance in the fine motor domain of the Denver II developmental screening test. [Subjects and Methods] Data were obtained from 2038 healthy children, 999 boys (49%) and 1039 girls (51%) in four age groups: 0-24 months (57%), 25-40 months (21.1%), 41-56 months (10.4%), and 57-82 months (11.5%). [Results] Female gender, higher maternal age, especially in children older than 24 months, and higher maternal education were associated with earlier accomplishment of fine motor items. Higher socioeconomic status was correlated with fine motor skills more noticeably at young ages. [Conclusion] The results of this study support the role of environmental factors in the interpretation of fine motor test results and point to target groups for intervention, such as infants in the low socioeconomic group and preschool children of less educated mothers. Studies in different populations may reveal particular patterns that affect child development.

Development of a 12 month screener based on items from the Bayley II Scales of Infant Development for use in Low Middle Income countries

OBJECTIVES

The purpose of the current study was to adapt the Bayley Scales of Infant Development II for use as a screening measure that could be used by health care professionals in Low Middle Income (LMI) countries with 12 month old infants to determine if they needed further assessment and early intervention.

METHODS

The adaptations were made as part of a larger study of children participating in a home-based early intervention program in India, Pakistan, and Zambia. Using Item Response Theory, a brief 12 month screener, with excellent sensitivity and specificity was identified.

RESULTS

The proposed 12 month screener contains 7 mental/cognitive items and 5 motor items. Children who cannot perform more than 3 items on the mental scale (sensitivity 79%, specificity 85%) and/or 3 items on the motor scale (sensitivity 96%, specificity 95%) should be referred for further assessment.

CONCLUSION

This screener can reliably be used to determine if a child needs further developmental assessment.

Neurodevelopmental outcomes at 7 years' corrected age in preterm infants who were fed high-dose docosahexaenoic acid to term equivalent: a follow-up of a randomised controlled trial

OBJECTIVE

To determine if improvements in cognitive outcome detected at 18 months' corrected age (CA) in infants born <33 weeks' gestation receiving a high-docosahexaenoic acid (DHA) compared with standard-DHA diet were sustained in early childhood.

DESIGN

Follow-up of a multicentre randomised controlled trial. Randomisation was stratified for sex, birth weight (<1250 vs ≥1250 g) and hospital.

SETTING

Five Australian tertiary hospitals from 2008 to 2013.

PARTICIPANTS

626 of the 657 participants randomised between 2001 and 2005 were eligible to participate.

INTERVENTIONS

High-DHA (≈1% total fatty acids) enteral feeds compared with standard-DHA (≈0.3% total fatty acids) from age 2-4 days until term CA.

PRIMARY OUTCOME

Full Scale IQ of the Wechsler Abbreviated Scale of Intelligence (WASI) at 7 years CA. Prespecified subgroup analyses based on the randomisation strata (sex, birth weight) were conducted.

RESULTS

604 (92% of the 657 originally randomised) consented to participate (291 high-DHA, 313 standard-DHA). To address missing data in the 604 consenting participants (22 for primary outcome), multiple imputation was performed. The Full Scale IQ was not significantly different between groups (high-DHA 98.3, SD 14.0, standard-DHA 98.5, SD 14.9; mean difference adjusted for sex, birthweight strata and hospital -0.3, 95% CI -2.9 to 2.2; p=0.79). There were no significant differences in any secondary outcomes. In prespecified subgroup analyses, there was a significant sex by treatment interaction on measures of parent-reported executive function and behaviour. Scores were within the normal range but girls receiving the high-DHA diet scored significantly higher (poorer outcome) compared with girls receiving the standard-DHA diet.

CONCLUSIONS

Supplementing the diets of preterm infants with a DHA dose of approximately 1% total fatty acids from days 2-4 until term CA showed no evidence of benefit at 7 years' CA.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry: ACTRN12606000327583.

The effect of socioeconomic status on the language outcome of preterm infants at toddler age

BACKGROUND

Independently, both prematurity and low socioeconomic status (SES) compromise language outcome but less is known regarding the effects of low SES on outcome of prior preterm infants at toddler age.

AIM

To assess SES effects on the language outcome of prior preterm infants at toddler age.

STUDY DESIGN

Retrospective chart review of infants born at ≤32 weeks, matched for gestational age (GA), birth weight (BW), chronic lung disease (CLD), periventricular leukomalacia (PVL), right and left intraventricular hemorrhage (IVH-R, L), and age at Bayley Scales of Infant Development III (BSID-III) testing.

SUBJECTS

Using insurance status as a proxy for SES, 65 children with private insurance (P-Ins) were matched with 65 children with Medicaid-type insurance (M-Ins).

OUTCOME MEASURES

Bayley Scales of Infant Development-III Language Composite.

RESULTS

M-Ins vs. P-Ins were similar in GA, BW, and age at BSID-III testing (mean 22.6 months adjusted), as well as other matched characteristics (all p ≥ 0.16). BSID-III Language Composite scores were lower in M-Ins than P-Ins (87.9 ± 11.3 vs. 101.9 ± 13.6) with a clinically significant effect size of 0.93 (p < 0.001). Overall, 45% of M-Ins exhibited mild to moderate language delay compared to 8% of P-Ins. Receptive and Expressive subscale scores also were lower in M-Ins than in P-Ins (both p < 0.001).

CONCLUSIONS

In this preterm cohort, by toddler age, M-Ins was associated with lower scores on measures of overall language as well as receptive and expressive language skills. Our findings, showing such an early influence of SES on language outcome in a cohort matched for biomedical risk, suggest that very early language interventions may be especially important for low SES preterm toddlers.

Severe bronchiolitis in infants born very preterm and neurodevelopmental outcome at 2 years

Preterm infants are at greater risk of bronchopulmonary dysplasia, which is associated with neurodevelopmental impairment. These infants are also more likely to develop severe bronchiolitis, which can contribute to neurodevelopmental impairment. The aim of this study was to determine whether severe bronchiolitis in very preterm infants (born before 33 weeks of gestation) was associated with an increased risk of neurodevelopmental impairment at 2 years of age. We analyzed a population-based cohort of infants (the Loire Infant Follow-up Team cohort) born between 1 January 2003 and 31 December 2009. Severe bronchiolitis was defined as hospitalization due to bronchiolitis during the first year of life. Neurodevelopmental outcome was assessed at 2 years of corrected age. A total of 2,405 infants were included in this analysis and categorized based on neonatal respiratory status: 1,308 (54.4 %) received no respiratory assistance, 864(35.9 %) received oxygen for <28 days, and 167 (6.9 %) had mild and 66 (2.7) moderate or severe bronchopulmonary dysplasia. At 2 years, 502 children displayed non-optimal neurodevelopmental outcome (20.9 %). Moderate or severe bronchopulmonary dysplasia was significantly associated with non-optimal neurodevelopmental outcome at 2 years (adjusted odds ratios (OR) = 2.3 [95 % confidence interval (CI): 1.3-3.9], p = 0.003). In the first year, 318 infants acquired severe bronchiolitis (13.2 %), which was not associated with non-optimal neurodevelopmental outcome (adjusted OR = 1.0 [95 % CI: 0.8-1.4]; p = 0.88). In conclusion, respiratory status in the neonatal period was significantly associated with non-optimal neurodevelopmental outcome at 2 years, while severe bronchiolitis was not.

Parental bilingualism is associated with slower cognitive development in very low birth weight infants

BACKGROUND

Speech development is frequently impaired in very low birth weight (VLBW) infants. Few and controversial data have been published on concepts regarding the influence of bilingual education.

AIMS

The objectives of the current study were to assess the influence of parental bilingualism on speech development and neurodevelopmental outcome in low risk VLBW infants.

STUDY DESIGN

Monocentric prospective controlled cohort study with standardized follow-up.

SUBJECTS

We recruited 50 singleton VLBW infants each from monolingual and bilingual families as well as 90 term control infants. The infants were free of disease and congenital malformation.

OUTCOME MEASURES

Griffiths scales of infant development at the corrected ages of 6 and 12 months, Bayley Scales of Infant Development II (BSID II) with 22 months.

RESULTS

In general, both bilingual and monolingual VLBW infants achieved age-specific milestones at the corrected age of 6, 12 and 22 months. However, bilingual VLBW infants achieved significantly lower scores than their monolingual peers in all cognitive subscales. The influence of maternal education on the neurodevelopmental outcome of the preterm infants was not significant; the subscales' correlation with socioeconomic or biological parameters was poor. However, a clear differentiation between social status and bilingual environment importance for speech development was not possible.

CONCLUSIONS

In the setting of the present investigation, parental bilingualism is associated with slower neurodevelopment in VLBW infants during the first 2 years of life.

Impaired executive functioning in young adults born very preterm

Individuals born very preterm (VPT) are at increased risk of perinatal brain injury and long-term cognitive and behavioral problems. Executive functioning, in particular, has been shown to be impaired in VPT children and adolescents. This study prospectively assessed executive function in young adults who were born VPT (<33 weeks of gestation) [n = 61; mean age, 22.25 (+/-1.07) years; range, 20.62-24.78 years] and controls [n = 64; mean age, 23.20 (+/-1.48) years; range, 19.97-25.46 years]. Tests used comprised the Wechsler Abbreviated Scale of Intelligence (WASI), the Hayling Sentence Completion Test (HSCT), the Controlled Oral Word Association Test (COWAT), the Animal and Object test, the Trail-Making Test (TMT), and the Test of Attentional Performance (TAP). VPT participants showed specific executive function impairments in tasks involving response inhibition and mental flexibility, even when adjusting for IQ, gender, and age. No significant associations were observed between executive function test scores and perinatal variables or neonatal ultrasound classification. The results suggest that, although free from major physical disability, VPT young adults perform worse than controls on tasks involving selective aspects of executive processing, such as mental flexibility and response inhibition.

Long-term outcome of preterm infants treated with nasal continuous positive airway pressure

This study's aim was to assess neurodevelopmental and growth outcome until the age of 4 years of premature infants placed on early nCPAP, in the setting of the neonatal intensive care unit (NICU) and follow-up program of the Division of Neonatology of the Department of Pediatrics of the University Hospital, Lausanne, Switzerland. All consecutive inborn infants weighing <1500 g or <32 weeks of gestational age admitted to the NICU during two periods of 12 months-7.1996-6.1997 and 7.1998-6.1999-were compared before and after the systematic application of early nCPAP. Of 172 infants admitted to the NICU, 150 (87%) survived. 126 (84%) were tested at 6 months' corrected age, 121 (81%) at 18 months' corrected age, and 117 (78%) at the age of 4 years. Detailed perinatal data were collected. Follow-up included neurological examination, developmental testing and measurement of growth parameters. Statistical analyses were performed. Early application of nCPAP and avoidance of mechanical ventilation showed no adverse effects on neurodevelopment and growth. A significantly higher developmental quotient was found in the nCPAP group at 18 months' corrected age. Several trends were also noted in the nCPAP group with a decrease of intraventricular hemorrhage and in "abnormal neurodevelopment" at 6 months corrected age, a bigger head circumference at all different tested ages and a greater height at 6 and 18 months corrected ages. In conclusion, our study of developmental outcome documents the absence of any harmful effect of early application of nCPAP to treat respiratory failure in very low birthweight infants.

Minor neurological dysfunction, cognitive development and somatic development at the age of 3 to 11 years in very-low-birthweight infants with transient periventricular echodensities

AIM

To determine, using strict exclusion criteria, whether transient periventricular echodensities (TPE) in very-low-birthweight infants lead to minor neurological dysfunction and problems in cognitive and somatic development in children without major neurological impairments.

METHODS

23 children with TPE were matched to 23 children without TPE. Exclusion criteria were small for gestational age, microcephaly at birth, diplegia, asphyxia, psychomotor retardation, intraventricular haemorrhage grade III/IV, major surgical interventions and malformations. The Kaufman Assessment Battery for Children, Draw-a-Man Test and neuropaediatric examination were used for evaluation.

RESULTS

There were no differences in demographic data, growth and socio-economic status. Significant differences with lower results in the TPE group were found in fine motor skills and in the Draw-a-Man Test. In the Kaufman Assessment Battery for Children, all subscales were below average in the TPE group, except the sequential processing scale. In the control group, all subscales were within the average range.

CONCLUSION

By using strict exclusion criteria to eliminate other risk factors for minimal neurological dysfunction and poor cognitive development, we were able to focus on the effect of TPE. TPE seem to affect cognitive development and cause minor neurological dysfunction.

Infant position in neonates receiving mechanical ventilation

BACKGROUND

Several body positions other than standard supine position have been used in patients undergoing intensive care for reducing the incidence of pressure ulcers of the skin, contractures or ankylosis and for improving the patient's well being. In patients from different age groups undergoing mechanical ventilation (MV), it has been observed that particular positions, such as prone position, may improve some respiratory parameters. Benefits from these positions have not been clearly defined in critically ill newborns who may require mechanical ventilation for extended periods of time.

OBJECTIVES

To assess the effects of different positioning of newborn infants receiving MV on short term respiratory outcomes and complications of prematurity.

SEARCH STRATEGY

Databases searched (up to May 2006) were the Oxford Database of Perinatal Trials, CINAHL, MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2006). Hand searches of proceedings of the Society for Pediatric Research from 1990 to May 2006 were used to identify unpublished studies.

SELECTION CRITERIA

Randomised or quasi randomised clinical trials comparing different positions in newborns receiving mechanical ventilation.

DATA COLLECTION AND ANALYSIS

Three independent and unblinded reviewers assessed the trials for inclusion in the review and extracted the data. Data were double-checked and entered into the Review Manager software.

MAIN RESULTS

Eleven trials involving 206 infants were included in this review. Several positions were compared: prone vs. supine, prone vs. lateral right, lateral right vs. supine, lateral left vs. supine, lateral right vs. lateral left and good lung dependent vs. good lung uppermost. Apart from one of the two studies that compared lateral right vs. lateral left positions, and one comparing prone vs. supine position, all the included studies had a crossover design. Comparing prone vs. supine position, an increase in arterial P02 in the prone position of between 2.75 and 9.72 mm Hg (95% CI) was observed (one trial). When % hemoglobin oxygen saturation was measured with pulse oximetry, improvement in the prone position was from 1.18 to 4.36% (typical effect based on four trials). In addition, there was a slight improvement in the number of episodes of desaturation. It was not possible to establish whether this effect remained once the intervention was stopped. Negative effects from the interventions were not described, although this issue was not studied in sufficient detail. Effects of position on other outcomes were not statistically significant; however, either positive nor negative effects cannot be excluded considering the small numbers that were studied.

AUTHORS' CONCLUSIONS

The prone position was found to slightly improve the oxygenation in neonates undergoing mechanical ventilation. However, we found no evidence concerning whether particular body positions during mechanical ventilation of the neonate are effective in producing sustained and clinically relevant improvements.

Birthweight and cognitive development during childhood

OBJECTIVES

Low birthweight has been reported to be associated with lower IQ at school age. Further, some evidence suggests that the association extends across the range of normal birthweights. This study assessed the relationship of birthweight to cognitive development in the Port Pirie birth cohort.

METHODS

Of 723 singleton live births recruited into a prospective birth cohort study, 601, 548, 494 and 375 children were followed at ages 2, 4, 7 and 11-13 years, respectively. The children's developmental status was assessed using the Bayley Scales of Infant Development at age 2 years, the McCarthy Scales of Children's Abilities at age 4 years, and the revised Wechsler Intelligence Scale for Children at ages 7 and 11-13 years. The association between birthweight and cognitive function was assessed with multiple linear regression, adjusting for a wide range of possible confounders.

RESULTS

The mean birthweight was 3386 g (SD: 517). There was a statistically significant association between birthweight and cognitive performance at age 2 years (adjusted deficit: 0.97 points per 100 g lighter; 95% CI: 0.4-1.5), but the magnitude of this association gradually decreased and became statistically non-significant at later childhood.

CONCLUSIONS

The relationship between birthweight and cognitive development becomes progressively attenuated at increasing age. At older ages, socioenvironmental factors appear to play an increasingly important part in children's cognitive development.

Intrauterine growth restriction and absent or reverse end-diastolic blood flow in umbilical artery (Doppler class II or III): A retrospective study of short- and long-term fetal morbidity and mortality

OBJECTIVE

Absent or reverse end-diastolic flow (Doppler II/III) in umbilical artery is correlated with poor perinatal outcome, particularly in intrauterine growth restricted (IUGR) fetuses. The optimal timing of delivery is still controversial. We studied the short- and long-term morbidity and mortality among these children associated with our defined management.

STUDY DESIGN

Sixty-nine IUGR fetuses with umbilical Doppler II/III were divided into three groups; Group 1, severe early IUGR, no therapeutic intervention (n = 7); Group 2, fetuses with pathological biophysical profile, immediate delivery (n = 35); Group 3, fetuses for which expectant management had been decided (n = 27).

RESULTS

In Group 1, stillbirth was observed after a mean delay of 6.3 days. Group 2 delivered at an average of 31.6 weeks and two died in the neonatal period (6%). In Group 3 after a mean delay of 8 days, average gestational age at delivery was 31.7 weeks; two intra uterine and four perinatal deaths were observed (22%). Long-term follow-up revealed no sequelae in 25/31 (81%) and 15/18 (83%), and major handicap occurred in 1 (3%) and 2 patients (11%), respectively, for Groups 2 and 3.

CONCLUSION

Fetal mortality was observed in 22% of this high risk group. After a mean period of follow-up of 5 years, 82% of infants showed no sequelae. According to our management, IUGR associated with umbilical Doppler II or III does not show any benefit from an expectant management in term of long-term morbidity.

Adverse neurodevelopmental outcomes among extremely low birth weight infants with a normal head ultrasound: prevalence and antecedents

OBJECTIVE

Severe abnormalities of the head ultrasound (HUS) are important predictors of cerebral palsy (CP) and mental retardation, and a normal HUS usually ensures the absence of major impairments. With the increasing survival of extremely low birth weight (ELBW) infants (birth weight <1000 g), the prognostic significance of a normal HUS may differ. This study examined the prevalence of and risk factors for CP and impaired mental development among ELBW infants with a normal HUS.

METHODS

Study infants were ELBW infants who were cared for in Neonatal Research Network centers in the years 1995-1999, had a normal early and late HUS, survived to discharge, and returned for follow-up assessments at 18 to 22 months' corrected age. The outcomes of interest were a score <70 on the Bayley Scales of Infant Development-II Mental Developmental Index (MDI) and CP. Risk factors included maternal demographics; infant characteristics; and interventions or morbidities related to the lung, infection, and nutrition. Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). A time-oriented approach was used to select variables for inclusion in logistic models.

RESULTS

Of 1749 infants with a normal early and late HUS (performed at a mean age of 6 and 47 days, respectively), 1473 (84%) returned for follow-up assessment. Infants had a birth weight of 792 +/- 134 g (mean +/- SD) and gestational age of 26 +/- 2 weeks. Rates of CP and MDI <70 were 9.4% and 25.3%, respectively, and 29.2% of infants had either CP or MDI <70. In multivariate analyses, factors associated with CP were male gender (OR: 1.8; 95% CI: 1.2-2.6), multiple birth, (OR: 1.6; 95% CI: 1.1-2.5), decreasing birth weight (OR: 1.3 for each 100-g decrease; 95% CI: 1.1-1.5), pneumothorax (OR: 2.3; 95% CI: 1.2-4.4), and days of conventional ventilation (OR: 1.2 for each additional 10 days; 95% CI: 1.1-1.3). With the exception of pneumothorax, these same factors were associated with MDI <70, in addition to less maternal education (OR: 1.4; 95% CI: 1.0-1.9) and Medicaid or lack of coverage for maternal insurance (OR: 1.7; 95% CI: 1.2-2.4).

CONCLUSIONS

Nearly 30% of ELBW infants with a normal HUS had either CP or a low MDI. Risk factors that are associated with this high rate of adverse outcomes include pneumothorax, prolonged exposure to mechanical ventilation, and educational and economic disadvantage. Improvements in pulmonary care to reduce duration of ventilation and avoid air leaks might improve neurodevelopmental outcome for ELBW infants.

The EPICure study: associations and antecedents of neurological and developmental disability at 30 months of age following extremely preterm birth

AIMS

To describe perinatal factors associated with later morbidity among extremely preterm children at 30 months of age corrected for prematurity.

POPULATION

Of 308 surviving children born at <or=25 weeks gestation in the United Kingdom and Ireland from March to December 1995, 283 (92%) were evaluated at 30 months of age corrected for prematurity.

METHODS

Cerebral palsy, severe motor disability, and Bayley scores were used as dependent variables in sequential multiple regression analyses to identify factors associated with adverse outcomes.

RESULTS

Adverse outcomes were consistently more common in boys. Factors related to perinatal illness, ultrasound evidence of brain injury, and treatment (particularly postnatal steroids) were associated with adverse motor outcomes (cerebral palsy, disability or Bayley psychomotor development index). Increasing duration of postnatal steroid treatment was associated with poor motor outcomes. A score was developed for severe motor disability with good negative predictive value. In contrast, mental development was associated with a broader range of factors: ethnic group, maternal educational level, the use of antenatal steroids, and prolonged rupture of membranes in addition to chronic lung disease.

CONCLUSION

Male sex is a pervasive risk factor for poor outcome at extremely low gestations. Avoidable or effective treatment factors are identified, which may indicate the potential for improving outcome.

Impact of motor skills on cognitive test results in very-low-birthweight children

Standardized tests that are frequently used to evaluate the cognitive development of very-low-birthweight children often appear to measure motor ability as well as cognitive skills. To estimate the impact of motor skills on individual test performance among very-low-birthweight children of kindergarten age, we employed factor analysis in a sample of 298 very-low-birthweight children that included severely disabled children. Using a test battery designed to measure concentration, language skills, overall cognitive development, visuomotor abilities, and memory, we identified two factors in each of three diagnostic subgroups: unimpaired children (n = 184), clumsy children (n = 56), and children with cerebral palsy (n = 33). Based on the pattern of factor loadings, we interpret the first factor as capturing language and overall cognitive abilities, whereas the second factor appears to capture motor abilities. Language skills explained 49% and motor abilities accounted for 16% of the overall variance of the individual test results. Among children with attention deficit (n = 25), a third factor emerged. In these children, we interpret the first factor as capturing language or cognitive skills, the second as representing visuomotor skills, and the third as a quantifier of the ability to concentrate. The test battery tested the same abilities in impaired and unimpaired children; however, these were not always the abilities that the battery aimed to test. Future studies need to evaluate whether factor scores only for cognitive but not motor abilities might be useful outcome variables.

Parental post-traumatic reactions after premature birth: implications for sleeping and eating problems in the infant

BACKGROUND

Progress in perinatal medicine has made it possible to increase the survival of very or extremely low birthweight infants. Developmental outcomes of surviving preterm infants have been analysed at the paediatric, neurological, cognitive, and behavioural levels, and a series of perinatal and environmental risk factors have been identified. The threat to the child's survival and invasive medical procedures can be very traumatic for the parents. Few empirical reports have considered post-traumatic stress reactions of the parents as a possible variable affecting a child's outcome. Some studies have described sleeping and eating problems as related to prematurity; these problems are especially critical for the parents.

OBJECTIVE

To examine the effects of post-traumatic reactions of the parents on sleeping and eating problems of the children.

DESIGN

Fifty families with a premature infant (25-33 gestation weeks) and a control group of 25 families with a full term infant participated in the study. Perinatal risks were evaluated during the hospital stay. Mothers and fathers were interviewed when their children were 18 months old about the child's problems and filled in a perinatal post-traumatic stress disorder questionnaire (PPQ).

RESULTS

The severity of the perinatal risks only partly predicts a child's problems. Independently of the perinatal risks, the intensity of the post-traumatic reactions of the parents is an important predictor of these problems.

CONCLUSIONS

These findings suggest that the parental response to premature birth mediates the risks of later adverse outcomes. Preventive intervention should be promoted.

[A comparative study of the perceptual and motor performance at school age of preterm and full term children]

The objective of this study was to compare the perceptualmotor performance in school age children who were born preterm and full term. Two groups of children, ages 5 to 7, participated in this study. Group I had 35 children, from low-income families, born up to the 34 week of gestation and/or weight bellow 1500 g. Group II had 35 full-term children, matched by age, gender and socioeconomic status to the children in Group I. Children were tested on the Bender gestalt, the motor accuracy test and on balance and postural responses measures. The preterm group obtained significantly lower scores in the majority of the tests. These besides reinforcing the importance of the follow-up of preterm children up to school age, also indicate the need to stimulate the fine motor and postural control Devment, even among preterm children who do not show evidence of neurological impairment.

Cognitive outcomes in school-age children born prematurely

The purpose of this article is to discuss findings in the literature regarding long-term developmental outcomes of infants born prematurely, to examine potential causes of individual differences in these outcomes, and to explore directions for future research. An extensive table summarizes recent (1996-2002) international studies of developmental outcomes among children of school age and older who were born with low birth weight, especially as the studies relate to cognitive development and academic performance. The discussion then examines how characteristics of the child and the environment may interact to produce individual differences in outcomes. Processes of attention regulation within the context of the psychosocial environment are examined as an important possible direction for future research. When designing and implementing interventions aimed at improving outcomes in this and other groups of children at risk for delays and deficits, it is important to consider how various factors affect development.

Infant position in neonates receiving mechanical ventilation

BACKGROUND

Several body positions other than standard supine position have been used in patients undergoing intensive care for reducing the incidence of pressure ulcers of the skin, contractures or ankylosis and for improving the patient's well being. In patients from different age groups undergoing mechanical ventilation (MV), it has been observed that particular positions such as prone position may improve some respiratory parameters. Benefits from these positions have not been clearly defined in Neonatology, a field where it is common that patients require mechanical ventilation sometimes during extended time periods.

OBJECTIVES

To assess the effects on both short and long-term outcomes of different positioning of newborn infants receiving MV.

SEARCH STRATEGY

Databases searched (up to January 2002) were the Oxford Database of Perinatal Trials, CINAHL, MEDLINE, EMBASE and Cochrane Controlled Trials Register (The Cochrane Library, Issue 1, 2002). Hand searches of proceedings of the Society for Pediatric Research from 1990 to January 2002 were used to identify unpublished studies.

SELECTION CRITERIA

Randomised or quasi randomised clinical trials comparing different positions in newborns receiving mechanical ventilation.

DATA COLLECTION AND ANALYSIS

Three independent and unblinded reviewers assessed the trials for inclusion in the review and extracted the data. Data were double-checked and entered into the Review Manager software.

MAIN RESULTS

Ten trials involving 164 infants were included in this review. Several positions were compared: prone vs. supine, prone vs. lateral right, lateral right vs. supine, lateral left vs. supine, lateral right vs. lateral left and good lung dependent vs. good lung uppermost. Apart from one of the two studies that compared lateral right vs. lateral left positions, all the included studies had a crossover design. Comparing prone vs. supine position, an increase in arterial P02 in the prone position of between 2.75 and 9.72 mm Hg (95%CI) was observed (one trial). When % hemoglobin oxygen saturation was measured with pulse oximetry, improvement in the prone position was from 1.17 to 4.36% (typical effect based on four trials). It was not possible to establish whether this effect remained once the intervention was stopped. Negative effects from the interventions were not described, although this issue was not studied enough. Effects of position on other outcomes were not statistically significant; however, these cannot be excluded considering the small numbers that were studied.

REVIEWER'S CONCLUSIONS

The prone position was found to slightly improve the oxygenation in neonates undergoing mechanical ventilation. However, we found no evidence concerning whether particular body positions during mechanical ventilation of the neonate are effective in producing sustained and clinically relevant improvements.

Social inequality in educational achievement and psychosocial adjustment throughout childhood: magnitude and mechanisms

The paper examines the hypothesis that social inequalities in children's developmental resources level off during adolescence against an alternative hypothesis that they continue to exert their influence throughout all of childhood. Using data from the National Child Development Study, the study applies two models. Both are premised on the understanding that the social and physical environments in which children are raised affects their resources in the domains of educational achievement and psychosocial adjustment. A 'class inequalities' model seeks to determine the extent of social class inequalities at three key stages in children's development: the transition from infant to junior schooling at age 7, from primary to secondary education at age 11 and from compulsory education to further education or work at age 16. The second model is a contextual-systems model which seeks to expand our understanding of the pathways from family social class to children's educational achievement and psychosocial adjustment through some more proximal determinants of these resources: material deprivation, school composition, parental involvement and aspirations. Social class inequalities in educational achievement were found to be greater than inequalities in psychosocial adjustment. The same developmental pattern was observed for both outcomes: inequalities increased from age 7 to age 11 and then remained at the same level at 16 yr. The contextual-systems models showed that when social inequalities are interpreted more broadly than a narrow class based definition, they continue to widen in adolescence. In particular, family influences, indicated by parental involvement become less important and social contexts beyond the family, reflected in material conditions and school composition, become more important. At age 16, material deprivation was the strongest determinant of psychosocial adjustment while school composition was most strongly related to educational achievement. The contextual-systems model provides a more complete account of social inequalities in children's educational achievement and psychosocial adjustment than simple estimates of social class effects.

Linguistic skills in relation to neurological findings at 8 years of age in children born preterm

The linguistic skills of 8-year-old children born preterm (n = 42) with birthweight < 1750 grams from a 1-year birth cohort for 1985-86 in northern Finland were studied with three different language tests, namely the Illinois Test of Psycholinguistic Abilities (ITPA), the Token Test for Children (TTC) and the Morphological Test (MT) for Finnish children. Full-term control children (n = 42) with birthweight > or = 2500 grams from the same birth cohort were matched individually with their preterm pairs for age, sex, twinship, mother's education, place of residence, birth order and family type. The preterm children's language abilities were studied in relation to their neurological status and to the periventricular leukomalacia (PVL) findings of magnetic resonance imaging (MRI). The preterm children with minor neurodevelopmental dysfunctions (MND) scored worst and differed significantly from their matched controls in TTC. They also differed significantly from other preterm subgroups, namely healthy preterm and preterm children with cerebral palsy (CP), in verbal comprehension measured by TTC. PVL findings were not associated with performance in the language ability tests. A closer and regular follow-up of language development in the MND-disabled group among the low-birthweight preterm children is recommended.

Childhood neglect and cognitive development in extremely low birth weight infants: a prospective study

OBJECTIVE

To examine the relationship between child maltreatment and cognitive development in extremely low birth weight infants, adjusting for perinatal and parental risk factors.

METHODS

A total of 352 infants with birth weight of <1000 g were followed prospectively for 4 years. The data were analyzed with regard to perinatal and parental risk factors and referrals for suspected child maltreatment to government agencies. Perinatal risk factors included birth weight, gestation, gender, periventricular hemorrhage, ventricular dilation, home oxygen requirement, and necrotizing enterocolitis. Parental risk factors included maternal age, race, marital status, education, and hospital insurance status. Cognitive z scores were calculated at 1, 2, and 4 years, and head circumference z scores were calculated at birth, 2 years, and 4 years.

RESULTS

Fifteen percent of infants were referred to child protective services for suspected child maltreatment. The adjusted general cognitive index at 4 years was significantly reduced in infants who were referred for neglect (-17.6; 95% confidence interval: -3.3, -31.9). Infants whose neglect was substantiated had a progressive decline in their cognitive function over time (cognitive z scores: -0.97, -1.37, and -2.05 standard deviations at 1, 2, and 4 years, respectively), compared with non-neglected infants (z scores: -0.04 to -0.36). They had a significantly smaller head circumference at 2 and 4 years but not at birth (adjusted z score at 4 years: -0.812; 95% confidence interval: -0.167, -1.458). Perinatal risk factors and physical disability were not related to maltreatment referral; only parental factors were independent predictors.

CONCLUSIONS

Childhood neglect is associated significantly with delayed cognitive development and head growth. Addressing risk factors antenatally and in early childhood may improve outcomes.

Correlação entre a função motora e cognitiva de pacientes com Paralisia Cerebral

Este trabalho é uma revisão da literatura sobre a correlação entre a função motora e cognitiva em pacientes com Paralisia Cerebral (PC). Os estudos encontrados correlacionam as alterações motoras em crianças com PC com as alterações de quociente de inteligência (QI), linguagem, percepção visual, auditiva, somatossensorial, e funções executivas. Foi visto que quanto maior o comprometimento motor, maior o comprometimento cognitivo. Entretanto, crianças com quadros motores mais graves podem ter funções cognitivas como percepção auditiva, somatossensorial e de raciocínio dentro do padrão de normalidade se forem expostas a um ambiente enriquecido e à interação social intensa. Algumas crianças com PC podem ainda ter um desempenho superior em habilidades de auto-cuidado quando comparadas com crianças normais, devido a constante estimulação pela equipe multiprofissional e cuidadores

Cognitive development, temperament and behavior at 2 years as indicative of language development at 4 years in pre-term infants

This study focuses on the early temperamental (TTQ = toddler temperament questionnaire), behavioral (IBR = infant behavior record), and cognitive precursors of impaired language functioning in preschool-age pre-terms infants. The study group consisted of 63 pre-term infants with a mean birth weight of 1246 +/- 437 g born in 1989-1991 in the University Central Hospital of Helsinki. Children with major disabilities (CP or mental retardation) were excluded. At the age of 4 years, 22% showed impaired language function. Logistic regression analysis showed that the Bayley MDI score was the best predictor in identifying an increased risk for language impairment. Behavioral characteristics were more strongly associated with subsequent language impairment than temperament.

Birth weight and cognitive function in the British 1946 birth cohort: longitudinal population based study

OBJECTIVE

To examine the association between birth weight and cognitive function in the normal population.

DESIGN

A longitudinal, population based, birth cohort study.

PARTICIPANTS

3900 males and females born in 1946.

MAIN OUTCOME MEASURES

Cognitive function from childhood to middle life (measured at ages 8, 11, 15, 26, and 43 years).

RESULTS

Birth weight was significantly and positively associated with cognitive ability at age 8 (with an estimated standard deviation score of 0.44 (95% confidence interval 0.28 to 0.59)) between the lowest and highest birthweight categories after sex, father's social class, mother's education, and birth order were controlled for. This association was evident across the normal birthweight range (>2.5 kg) and so was not accounted for exclusively by low birth weight. The association was also observed at ages 11, 15, and 26, and weakly at age 43, although these associations were dependent on the association at age 8. Birth weight was also associated with education, with those of higher birth weight more likely to have achieved higher qualifications, and this effect was accounted for partly by cognitive function at age 8.

CONCLUSIONS

Birth weight was associated with cognitive ability at age 8 in the general population, and in the normal birthweight range. The effect at this age largely explains associations between birth weight and cognitive function at subsequent ages. Similarly, the association between birth weight and education was accounted for partly by earlier cognitive scores.

Health status development in a cohort of preterm children

OBJECTIVE

To determine the impact of preterm birth on health status (HS) development at the ages of 5 and 10 years in a cohort of children born before term.

SAMPLE

Six hundred eighty-eight children, born in 1983 with a gestational age of <32 weeks and a birth weight of <1500 g.

DESIGN

Prospectively collected HS variables, obtained from the parents, were analyzed in a longitudinal perspective by using principal component analyses.

RESULTS

One third of the sample had minor to severe HS problems at both ages of measurement. One third had problems on one assessment only. The remainder of the sample had no HS problems at either age. The analyses grouped the HS variables into 3 combinations. Problems in basic functioning, such as mobility or speech, decreased with age. Negative moods substantially increased, and concentration problems increased slightly. Specifically at risk were preterm born children with handicaps, boys, and children who were small for gestational age.

CONCLUSION

According to the parents, one third of the cohort had no HS problems at either age. The pattern of HS problems of the preterm born children changed between 5 and 10 years of age.

Prognostic factors for walking attainment in very low-birthweight preterm infants

The purpose of this study was to compare the age of walking attainment between very low-birthweight (VLBW) preterm infants and normal term infants, and to determine the variables that affect the walking attainment in VLBW infants. Ninety-six VLBW preterm infants and 82 normal term infants were prospectively followed to determine their age of walking attainment and to monitor gross motor development with sequential clinic visits at 6, 9, 12 and 18 months corrected age. Perinatal and sociodemographic data were collected through review of medical records. The VLBW infants were significantly older at attainment of walking (median 14 months) than the term infants (median 12 months) after correction for prematurity. By the age of 18 months, all term infants had attained walking ability; while 11% of VLBW infants were still unable to walk. Multivariate proportional hazards regression analysis revealed that low gestational age was significantly associated with late attainment of walking in VLBW infants. With the adjustment for gestational age, prolonged ventilation (or oxygen therapy) and severe retinopathy of prematurity were significant predictors of late walking attainment. Our findings indicate that VLBW preterm infants have an increased risk of delayed attainment of walking. Furthermore, the contribution of low gestational age to the delayed walking attainment in VLBW infants may occur via the plausible pathways of neonatal respiratory distress and severe retinopathy of prematurity.

Visual-motor function of very low birth weight and full-term children at 3 1/2 to 4 years of age

Improvements in perinatal and neonatal management have not only led to a higher survival rate of very low birth weight infants (VLBW; < or = 1,500 g or < 32 weeks gestational age), but also to a better outcome of these children. However the percentage of VLBW children who need special education because of later school problems remains high even in children considered neurologically normal during infancy. We assessed 40 VLBW children and 83 healthy full-term children at age 3 to 4 years by means of a simple and short test for visual-motor deficits. The test included the copying and cutting-out of geometric shapes, the building of models, the recognition of colours and the observation of the concentration and cooperation during the test. All VLBW children had had a good perinatal outcome and had been considered neurologically normal at one year of age. Most VLBW children scored within 1 standard deviation (S.D.) of the test mean, but on average the VLBW children scored significantly lower than the full-term infants in the copying of figures, the cutting-out of geometric forms, the building of models and in the overall concentration and cooperation during the test. Children who attended a nursery school achieved significantly better test results. Girls tended to have better results, but this was not statistically significant. Social factors and age had a significantly greater impact on results than perinatal factors. In summary, VLBW children scored significantly less in almost every test item compared to their term peers. Our test battery could serve as a short introductory test to screen for deficits in visual-motor skills, especially in VLBW children.

West syndrome with periventricular leukomalacia: a morphometric MRI study

A morphometric magnetic resonance imaging study was performed, and the results were compared among three groups (group 1, periventricular leukomalacia patients with West syndrome; group 2, periventricular leukomalacia patients without West syndrome; and group 3, control patients) to clarify the characteristics and cause of West syndrome. This study included 21 infants (11 males and 10 females, 7 months to 2 years 8 months old) born at 24-32 weeks of gestation and weighing 625-1,908 gm. The Evans ratio, ratio of the posterior horns, Cella media index, width of the third ventricle, and the areas of the midbrain, pons, and medulla oblongata were measured and compared among the three groups. There were no differences of gestation or birth weight among the three groups. The Evans ratio, ratio of the posterior horns, Cella media index, and width of the third ventricle were larger in group 1 than in groups 2 and 3. The ratio of the posterior horns and Cella media index were larger in group 2 than in group 3, although the width of the third ventricle was not. Myelination was delayed in all patients in group 1 and in two patients in group 2. In group 1 the areas of the midbrain and pons were smaller than in groups 2 and 3 and the medulla oblongata was smaller than in group 3, although there were no differences in midbrain, pons, and medulla oblongata between groups 2 and 3. Although the infants with periventricular leukomalacia and West syndrome frequently demonstrated marked ventricular dilatation and delayed myelination, the atrophy of midbrain and pons was the most characteristic, and the damage may cause West syndrome.

Psychological findings in preterm children related to neurologic status and magnetic resonance imaging

OBJECTIVE

Preterm children experience learning disabilities more often than full-term children, but detailed information on their neuropsychological and neurologic determinants is lacking. We therefore examined these problems more closely and also studied if clinical neurologic examination and/or magnetic resonance imaging (MRI) can be used as tools to screen the preterm children at risk for these problems.

METHODS

In a population-based study, the psychological performance of 42 preterm children with a birth weight <1750 g and of their matched controls was assessed at 8 years of age and the findings were then related to clinical neurologic examination and MRI. Learning disabilities of these children, reported by the teachers, were also studied.

RESULTS

The cognitive ability of the preterm children, although in the normal range, was significantly lower than that of the control children. They performed particularly poorly in tasks requiring spatial and visuoperceptual abilities, which were associated with the finding of periventricular leukomalacia in MRI, especially with posterior ventricular enlargement. The preterm children with minor neurodevelopmental dysfunction (MND) had the most problems in neuropsychological tests, whereas the clinically healthy preterm children and those with cerebral palsy had fewer problems. The problems of MND children emerged in the domain of attention. They also experienced the most problems at school.

CONCLUSIONS

Visuospatial problems were associated with periventricular leukomalacia in MRI, but learning disabilities were most frequent among the preterm children with minor neurologic abnormalities. We recommend closer follow-up of preterm children with MND.