Early visual assessment in preterm infants with and without brain lesions: correlation with visual and neurodevelopmental outcome at 12 months

Developmental trajectories of visual orienting functions in children born very or extremely preterm

BACKGROUND AND AIMS

Preterm birth increases the risk of neurodevelopmental impairments, such as Cerebral Visual Impairment (CVI), which affects visual processing. Assessing visual functions in young children is challenging with traditional methods that often rely on verbal/motor responses. The aim of the study was to investigate the developmental trajectories of Visual Orienting Functions (VOF) in children born very preterm (<32 weeks gestational age) between 2 and 5 years corrected age (CA) using eye tracking.

METHODS

263 children born preterm underwent eye tracking at 2, 3 and 5 years CA. A subgroup of 49 children underwent all three measurements. Magnetic resonance imaging (MRI) was performed shortly after birth and evaluated for brain damage using a modified Kidokoro scoring protocol. The VOF results to high (cartoon and contrast) and intermediate (form and motion detection) salient visual stimuli of the preterm group were compared to those of term-born age-matched peers.

RESULTS

Approximately 40 % of children born preterm showed normal VOF development to high and intermediate salient stimuli. However, in another 40 % of children born preterm, an increase in delayed visual processing to high-salient stimuli was found at 5 years CA. No significant correlation was found between brain damage on MRI shortly after birth and abnormal VOF at 5 years CA.

CONCLUSION

The data suggest that routine visual screening using high-salient stimuli can identify VOF delays from 2 years CA onwards in children at risk of brain damage. Early detection of visual processing deficits can enable timely interventions and specialized care for pre-schoolers.

The Best Start Trial: A randomised controlled trial of ultra-early parent-administered physiotherapy for infants at high risk of cerebral palsy or motor delay

BACKGROUND

It is unknown whether ultra-early physiotherapy commenced during neonatal intensive care unit admission is of value for optimising developmental outcomes in preterm/term infants at high-risk of cerebral palsy or motor-delay.

AIMS

To determine whether ultra-early parent-administered physiotherapy to preterm/term high- risk infants commenced at earliest from 34-weeks post menstrual age, improves motor outcomes at 16-weeks corrected age (CA) compared to usual care.

METHODS

Single-blind randomised controlled pilot study with 30 infant participants. The primary outcome was the Alberta Infant Motor Scale (AIMS) total score at 16-weeks CA. Secondary outcomes included (i) parent Depression Anxiety and Stress Score and Parent Perceptions Survey at 16-weeks CA; and (ii) Bayley Scales of Infant Development at 12-months CA.

RESULTS

There were no clinically worthwhile effects at 16-weeks CA on the AIMS (mean between-group difference, 95% CI: -0.2, -2.4 to 2.0) or most secondary outcomes. However, the parents' "perception of treatment effectiveness" and "perception of change" favoured the experimental group.

CONCLUSIONS

In this pilot trial, there was no clinically worthwhile effect of ultra-early parent-administered physiotherapy over usual care on the AIMS. However, the intervention was feasible for infants, acceptable to parents and parents perceived a benefit of treatment. Whilst this trial did not demonstrate treatment effectiveness using the AIMS, these findings should be interpreted cautiously because of the small sample size, the low responsivity of the AIMS to change in motor performance and the heterogeneity of the participants. Therefore, the intervention should not be abandoned on the basis of this trial, but rather further evaluated in a larger trial that addresses some of the learnings from this one.

Sensitivity and specificity of the Neonatal Visual Assessment to predict motor and cognitive outcomes in infants born very preterm

BACKGROUND

Very preterm infants are at increased risk of neurodevelopmental impairments. The Neonatal Visual Assessment (NVA) assesses visual function and outcomes and has been used to assess early neurodevelopmental outcomes. This study aimed to compare NVA results of very preterm and term-born infants and to calculate the sensitivity and specificity of the NVA at term equivalent age (TEA) and three months corrected age (CA) to predict motor and cognitive outcomes at 12 months CA in very preterm infants.

METHODS

This prospective observational cohort study recruited infants born before 31 weeks gestation and a healthy term-born control group. The NVA was assessed at TEA and three months CA, and neurodevelopmental outcomes (Bayley Scales of Infant and Toddler Development, Third Edition; Neurosensory Motor Developmental Assessment; Alberta Infant Motor Scale) were performed at 12 months CA. The sensitivity and specificity of the NVA to predict outcomes were calculated based on a previously published optimality score.

RESULTS

248 preterm (54 % male) and 46 term-born infants (48 % male) were analysed. The mean NVA scores of preterm and term-born infants were significantly different at TEA (preterm 3.1±2.1; term-born 1.2±1.7, p < 0.001). The NVA had moderate sensitivity (59-78 %) and low specificity (25-27 %) at TEA, and low sensitivity (21-28 %) and high specificity (86-87 %) at three months CA for the prediction of preterm infants' outcomes at 12 months CA.

CONCLUSION

The NVA at TEA and three months CA was not a strong predictor of motor and cognitive impairments in this contemporary cohort of very preterm infants.

Correlation between Early Visual Functions and Cognitive Outcome in Infants at Risk for Cerebral Palsy or Other Neurodevelopmental Disorders: A Systematic Review

Early key visual skills, such as tracking objects, sustaining gaze, and shifting attention, rapidly develop within the first 6 months of infant life. These abilities play a significant role in the development of cognitive functions but are frequently compromised in infants at risk of developing neurodevelopmental disorders. This systematic review evaluates the potential of early vision function in the prediction of cognition at or above 12 months. Five databases were searched for relevant articles, and their quality was assessed with the Quality Assessment of Diagnostic Accuracy Studies tool. Eight studies were suitable, including 521 preterm-born infants at varying risk of developing Cerebral Palsy (CP). Each study showed a significant correlation between vision and cognitive outcome. Predictive analysis including sensitivity and specificity was possible for three studies. Methodological quality was variable. Sensitivity ranged between 57 and 100% in the vision function assessments items, while specificity ranged from 59 to 100%. In conclusion, early vision showed strong correlation with cognition ≥ 12 months. While no single vision assessment was found to be superior, evaluation of specific functions, namely fixation and following, both at term age and between 3 and 6 months, demonstrated strong predictive validity.

Early Neurodevelopmental Assessments of Neonates Discharged From the Neonatal Intensive Care Unit: A Physiatrist's Perspective

The survival rate of children admitted in the neonatal intensive care unit (NICU) after birth is on the increase; hence, proper evaluation and care of their neurodevelopment has become an important issue. Neurodevelopmental assessments of individual domains regarding motor, language, cognition, and sensory perception are crucial in planning prompt interventions for neonates requiring immediate support and rehabilitation treatment. These assessments are essential for identifying areas of weakness and designing targeted interventions to improve future functional outcomes and the quality of lives for both the infants and their families. However, initial stratification of risk to select those who are in danger of neurodevelopmental disorders is also important in terms of cost-effectiveness. Efficient and robust functional evaluations to recognize early signs of developmental disorders will help NICU graduates receive interventions and enhance functional capabilities if needed. Several age-dependent, domain-specific neurodevelopmental assessment tools are available; therefore, this review summarizes the characteristics of these tools and aims to develop multidimensional, standardized, and regular follow-up plans for NICU graduates in Korea.

Neurodevelopmental Outcomes Associated With Intravitreal Bevacizumab Injections for Retinopathy of Prematurity

BACKGROUND

Retinopathy of prematurity (ROP) is a common disorder among premature infants associated with significant morbidity. The current standard of care includes laser ablation therapy when needed. While intravitreal bevacizumab (IVB) injections have emerged as a new therapy for ROP, so have concerns about the systemic effects of the bevacizumab (Avastin), specifically on neurodevelopmental outcomes.

PURPOSE

To review the current literature on the impact of IVB on neurodevelopmental outcomes in neonates with ROP to inform nurses' knowledge and practice.

METHODS

A literature search was performed in the PubMed, CINAHL, and Embase databases. Eleven primary studies examining neurodevelopmental outcomes related to IVB were identified and reviewed.

RESULTS

Limitations of current studies, including small sample sizes, retrospective analysis subject to selection bias, and confounding factors such as sedation/anesthesia exposure, prevent robust conclusions from being drawn. However, there is not currently any clear evidence of negative neurodevelopmental impacts associated with IVB despite a sound theoretical basis for concern.

IMPLICATIONS FOR PRACTICE

Nurses should include all known and potential risks and benefits when counseling families and developing individualized plans of care for their neonatal patients with ROP.

IMPLICATIONS FOR RESEARCH

Well-designed, prospective studies examining neurodevelopmental outcomes at later time points are needed to conclusively support or disprove results of IVB therapy for ROP in the context of potential adverse effects.

Short- and mid-term multidisciplinary outcomes of newborns exposed to SARS-CoV-2 in utero or during the perinatal period: preliminary findings

The long-term outcomes of newborns exposed to SARS-CoV-2 infection in utero or during the first hours of life are still unknown. We performed a single-center, prospective, observational study of newborns born from mothers with microbiologically confirmed SARS-CoV-2 infection in pregnancy or at time of delivery. Infants were offered a multidisciplinary follow-up consisting of nasopharyngeal Polymerase Chain Reaction test at birth and at 48-72 h of life, auxological growth and neurological development, serologic testing, and audiological and ophthalmological assessments. One-hundred ninety-eight mothers and 199 newborns were enrolled. Of the 199 newborns, 171 underwent nasopharyngeal swab, four (2.3%) and two (1.15%) children tested positive at birth and 48-72 h of life, respectively. None had SARS-CoV-2 related symptoms. Auxologic and neurologic development were normal in all children during follow-up. Nine out of 59 infants had SARS-CoV-2 IgG at 3 months of life, which was associated with a positive nasopharyngeal swab at birth (P = 0.04). Twenty seven out of 143 (18.8%) newborns had pathologic transitory evoked otoacoustic emissions at birth, although 14/27 repeated after 1 month were normal. Audiological evaluation was completed with Auditory Brainstem Response between the third and sixth month of life in 34 children, showing in all normal hearing threshold. The ophthalmological evaluation found retinal vascular anomalies in 3/20 (15%) children, immature visual acuity in 5/20 (25%) children, and reduced distance attention in 6/20 cases (30%).

CONCLUSIONS

Our study showed that the neonatal and mid-term multidisciplinary outcomes of newborns exposed to SARS-CoV-2 infection in utero or during the first hours of life are mostly positive, with the exception of ophthalmologic findings which, in a preliminary cohort, were abnormal in about 15% of cases. Further prospective, longitudinal studies are needed to better understand the clinical outcomes of children exposed to SARS-CoV-2 in utero and in the early postnatal life.

WHAT IS KNOWN

• In utero mother-to-child transmission of SARS-CoV-2 has been documented by several independent studies. • Neonatal COVID-19 is a systemic disease that can be severe, although rarely.

WHAT IS NEW

• Newborns exposed in utero to SARS-CoV-2 have mostly a normal auxological, audiological, and neurological development during the first months of life. • Fundus fluorescein angiography revealed that up to 5% of newborns exposed in utero to SARS-CoV2 can show retinal and choroidal abnormalities, including peripheral hypofluorescence of the choroid and increased vascular tortuosity.

Early clinical and MRI biomarkers of cognitive and motor outcomes in very preterm born infants

BACKGROUND

This study aimed to identify which MRI and clinical assessments, alone or in combination, from (i) early (32 weeks postmenstrual age, PMA), (ii) term equivalent age (TEA) and (iii) 3 months corrected age (CA) are associated with motor or cognitive outcomes at 2 years CA in infants born <31 weeks gestation.

METHODS

Prospective cohort study of 98 infants who underwent early and TEA MRI (n = 59 males; median birth gestational age 28 + 5 weeks). Hammersmith Neonatal Neurological Examination (HNNE), NICU Neonatal Neurobehavioural Scale and General Movements Assessment (GMs) were performed early and at TEA. Premie-Neuro was performed early and GMs, Test of Infant Motor Performance and visual assessment were performed at TEA and 3 months CA. Neurodevelopmental outcomes were determined using Bayley Scales of Infant and Toddler Development 3rd edition.

RESULTS

The best combined motor outcome model included 3-month GMs (β = -11.41; 95% CI = -17.34, -5.49), TEA MRI deep grey matter score (β = -6.23; 95% CI = -9.47, -2.99) and early HNNE reflexes (β = 3.51; 95% CI = 0.86, 6.16). Combined cognitive model included 3-month GMs (β = -10.01; 95% CI = -15.90, -4.12) and TEA HNNE score (β = 1.33; 95% CI = 0.57, 2.08).

CONCLUSION

Early neonatal neurological assessment improves associations with motor outcomes when combined with term MRI and 3-month GMs. Term neurological assessment combined with 3-month GMs improves associations with cognitive outcomes.

IMPACT

We present associations between 32- and 40-week MRI, comprehensive clinical assessments and later 2-year motor and cognitive outcomes for children born <31 weeks gestation. MRI and clinical assessment of motor, neurological and neurobehavioural function earlier than term equivalent age in very preterm infants is safe and becoming more available in clinical settings. Most of these children are discharged from hospital before term age and so completing assessments prior to discharge can assist with follow up. MRI and neurological assessment prior to term equivalent age while the child is still in hospital can provide earlier identification of children at highest risk of adverse outcomes and guide follow-up screening and intervention services.

Early visuospatial attention and processing and related neurodevelopmental outcome at 2 years in children born very preterm

BACKGROUND

The ability to perceive and process visuospatial information is a condition for broader neurodevelopment. We examined the association of early visuospatial attention and processing with later neurodevelopmental outcome in very preterm infants.

METHODS

Visuospatial attention and processing was assessed in 209 children (<30 weeks gestation) using an easy applicable eye tracking-based paradigm at 1 and 2 years. Average reaction times to fixation (RTF) on specific visual stimuli were calculated, representing time needed for overall attention (Cartoon stimuli) and processing (Motion and Form stimuli). Associations between RTFs and various measures of development at 2 years including cognitive and motor development (Bayley Scales of Infant and Toddler Development-Third edition; Bayley-III), language (Lexi test) and behavior (Child Behavior Checklist) were examined.

RESULTS

At 1 year, 100 ms slower Cartoon and Motion RTFs were associated with lower cognitive Bayley-III scores (-4.4 points, 95%CI: -7.4; -1.5 and -1.0 points, -1.8; -0.2, respectively). A 100 ms slower Cartoon RTF was associated with a 3.5 (-6.6; -0.5) point decrease in motor Bayley-III score.

CONCLUSIONS

Visuospatial attention and motion processing at 1 year is predictive of overall cognitive and motor development 1 year later. The nonverbal eye tracking-based test can assist in early detection of preterm children at risk of adverse neurodevelopment.

IMPACT

Visuospatial attention and processing at 1 year corrected age is predictive for overall cognitive and motor development 1 year later in preterm infants. First study to relate early visuospatial attention and processing with later neurodevelopmental outcome in preterm children. Early detection of preterm children at risk of adverse neurodevelopment, which allows for more timely interventions.

Early visual and neuro-development in preterm infants with and without retinopathy

BACKGROUND

Retinopathy of prematurity (ROP) is often associated with visual impairment and multiple developmental disabilities.

AIMS

As most of the previous studies include infants with brain lesions, that can determine visual impairment per se, a cohort of low neurological risk preterm infants without ROP and with various degree of severity of ROP was assessed in order to establish visual and neurodevelopmental outcome.

STUDY DESIGN

Preterm infants born at <31 weeks gestation, without major brain lesions, underwent visual function assessment at 1 year corrected age and neurodevelopmental assessment at 2 years corrected age.

SUBJECTS

One hundred and five infants were included in the study: 42 infants did not develop ROP, 7 reached stage 1 in zone 2 ROP, 37 reached prethreshold (untreated) type 2 ROP. The remaining 19 infants were classified as type 1 ROP.

OUTCOME MEASURES

Visual function (including fixing, tracking, visual acuity, visual field, attention at distance and nystagmus) were assessed at 12 months corrected age and Griffiths Scales at 2 years corrected age.

RESULTS

The severity of ROP was strongly correlated (p < 0.001) with both visual function at 1 year and neurodevelopment at 2 years. Similarly, the presence of nystagmus was also strongly correlated with visual and neurodevelopmental sequelae.

CONCLUSIONS

Infants with no or milder retinopathy showed normal visual function at 1 year and neurodevelopment at 2 years. Infants who underwent treatment more frequently showed abnormal results on several aspects of visual function. Presence of nystagmus appeared to increase the risk for abnormal visual function and neurodevelopmental outcome.

The development of vision between nature and nurture: clinical implications from visual neuroscience

BACKGROUND

Vision is an adaptive function and should be considered a prerequisite for neurodevelopment because it permits the organization and the comprehension of the sensory data collected by the visual system during daily life. For this reason, the influence of visual functions on neuromotor, cognitive, and emotional development has been investigated by several studies that have highlighted how visual functions can drive the organization and maturation of human behavior. Recent studies on animals and human models have indicated that visual functions mature gradually during post-natal life, and its development is closely linked to environment and experience.

DISCUSSION

The role of vision in early brain development and some of the neuroplasticity mechanisms that have been described in the presence of cerebral damage during childhood are analyzed in this review, according to a neurorehabilitation prospective.

Are early visual behavior impairments involved in the onset of autism spectrum disorders? Insights for early diagnosis and intervention

A correct use of the visual behavior (VB), and its integration with motor function, represents the earliest mean used by infants to explore and act on the social and non-social surrounding environment. The aim of this mini review is to present influential evidence of abnormalities in the VB domain in ASD individuals and to discuss the implication of these findings for early identification and intervention. We analyzed the possible anomalies in oculomotor abilities, visual attention, and visual-motor integration, as parts of a wider visual behavior defect, that could affect children with autism spectrum disorders (ASD) since the early stages of development.Conclusion: According to the literature, difficulties in these three areas have been often reported in children with ASD, and the visual-perception deficit could have cascading effects on learning processes and on social development. Despite this evidence of atypical VB in ASD, their investigation is not yet included into diagnostic processes, and they are not yet considered a specific treatment target.What is Known:•Atypical social use of visual behavior is one the first symptoms in children with autism spectrum disorders•Individuals with autism spectrum disorders often show unusual visual exploration of the surrounding environmentWhat is New:•It is possible to hypothesize that early visual behavior abnormalities may affect experiences that permit learning processes and social and communicative development in infants•An early assessment of visual behavior, as a core symptom of ASD, might improve the diagnostic processes and might help to developing more individualized treatments.

Effects of Early Intervention on Visual Function in Preterm Infants: A Randomized Controlled Trial

Objectives: To determine the effectiveness of an early intervention program in enhancing visual function in very preterm infants. Methods: We conducted a RCT. We included preterm infants born between 25⁺⁰ and 29⁺⁶ weeks of gestational age (GA), without severe morbidities, and their families. Infants were randomized to either receive Standard Care (SC) or Early Intervention (EI). SC, according to NICU protocols, included Kangaroo Mother Care and minimal handling. EI included, in addition to routine care, parental training according to the PremieStart program, and multisensory stimulation (infant massage and visual interaction) performed by parents. Visual function was assessed at term equivalent age (TEA) using a prevalidated battery evaluating ocular spontaneous motility, ability to fix and follow a target, reaction to color, stripes discrimination and visual attention at distance. Results: Seventy preterm (EI n = 34, SC n = 36) infants were enrolled. Thirteen were excluded according to protocol. Fifty-seven infants (EI = 27, SC = 30) were assessed at TEA. The two groups were comparable for parental and infant characteristics. In total, 59% of infants in the EI group achieved the highest score in all the nine assessed items compared to 17% in the SC group (p = 0.001): all infants in both groups showed complete maturation in four items, but EI infants showed more mature findings in the other five items (ocular motility both spontaneous and with target, tracking arc, stripes discrimination and attention at distance). Conclusions: Our results suggest that EI has a positive effect on visual function maturation in preterm infants at TEA. Trial Registration: clinicalTrial.gov (NCT02983513).

Visual assessment in Down Syndrome: The relevance of early visual functions

BACKGROUND

Children with Down Syndrome (DS) have a high prevalence of ocular disorders, and even when ophthalmological deficits (i.e. refractive errors or strabismus) are corrected, visual acuity seems to have a different developmental trend compared to typical children. Unfortunately, there is no consensus about the age at which it is fundamental to perform a first comprehensive visual assessment in this population.

AIMS

We analyzed early visual functions in a sample of 42 Italian children with DS, in order to achieve new insights for early surveillance and intervention.

MATERIAL AND METHODS

DS children were evaluated with the Early Neurovisual Assessment, including Teller Acuity Cards (at 6, 12 and 18 months of age) and the Pediatric Ophthalmological Examination (within the 36th months of age).

RESULTS

Visual acuity in our sample was lower than findings reported in the literature on healthy Italian children, but the values were within the confidence interval reported in previous studies on DS children. Moderate or severe refractive errors (> 3diopters) were present in five children (four had hyperopia and one myopia). Abnormalities in ocular motility were observed in 15 children and pathological findings for fundus oculi or lens were found in another eight. Furthermore, ophthalmological findings correlated with visual acuity at 18 months of age.

CONCLUSION

According to our results, the Early Neurovisual Assessment at 18 months of life is a reliable tool for early detection of visual disorders in children with DS and it is useful for programming early intervention to promote their neurodevelopment.

High-risk follow-up: Early intervention and rehabilitation

Early detection of childhood disability is possible using clinically available tools and procedures. Early detection of disability enables early intervention that maximizes the child's outcome, prevents the onset of complications, and supports parents. In this chapter, first we summarize the best-available tools for accurately predicting major childhood disabilities early, including autism spectrum disorder, cerebral palsy, developmental coordination disorder, fetal alcohol spectrum disorder, intellectual disability, hearing impairment, and visual impairment. Second, we provide an overview of the preclinical and clinical evidence for inducing neuroplasticity following brain injury. Third, we describe and appraise the evidence base for: (a) training-based interventions that induce neuroplasticity, (b) rehabilitation interventions not focused on inducing neuroplasticity, (c) complementary and alternative interventions, (d) environmental enrichment interventions in the neonatal intensive care and community settings, and (e) parent-child interaction interventions in the neonatal intensive care and community settings. Fourth, we explore emergent treatment options at clinical trial, designed to induce brain repair following injury. In conclusion, early diagnosis enables early intervention, which improves child and parent outcomes. We now know which interventions provide the biggest gains and the information can be used to help inform parental decision making when designing treatment plans for their children.

Relationship between very early brain structure and neuromotor, neurological and neurobehavioral function in infants born <31 weeks gestational age

AIM

This study aimed to examine associations between structural MRI and concurrent motor, neurological and neurobehavioral measures at 30-32 weeks postmenstrual age (PMA; 'Early'), and at term equivalent age ('Term').

METHOD

In this prospective cohort study, infants underwent Early MRI (n = 119; 73 male; median 32 weeks 1 day PMA) and Term MRI (n = 102; 61 male; median 40 weeks 4 days PMA) at 3 T. Structural images were scored generating white matter (WM), cortical gray matter, deep gray matter, cerebellar and global brain abnormality scores. Clinical measures were General Movements Assessment (GMs), Hammersmith Neonatal Neurological Examination (HNNE) and NICU Neonatal Neurobehavioral Scale (NNNS). The Premie-Neuro was administered Early and the Test of Infant Motor Performance (TIMP) and a visual assessment at Term.

RESULTS

Early MRI cerebellar scores were strongly associated with neurological components of HNNE (reflexes), NNNS (Hypertonicity), the Premie-Neuro neurological subscale (regression coefficient β = -0.06; 95% confidence interval CI = -0.09, -0.04; p < .001) and cramped-synchronized GMs (β = 1.10; 95%CI = 0.57, 1.63; p < .001). Term MRI WM and global scores were strongly associated with the TIMP (WM β = -1.02; 95%CI = -1.67, -0.36; p = .002; global β = -1.59; 95%CI = -2.62, -0.56; p = .001).

INTERPRETATION

Brain structure on Early and Term MRI was associated with concurrent motor, neurological and neurobehavioral function in very preterm infants.

Vision Assessments and Interventions for Infants 0-2 Years at High Risk for Cerebral Palsy: A Systematic Review

We performed a systematic review and evaluated the level of evidence of vision interventions and assessments for infants at high risk for or with a diagnosis of cerebral palsy from zero to two years of age. Articles were evaluated based on the level of methodologic quality, evidence, and clinical utilization. Thirty publications with vision assessments and five with vision interventions met criteria for inclusion. Assessments included standard care neuroimaging, electrophysiology, and neuro-ophthalmologic examination techniques that are utilized clinically with any preverbal or nonverbal pediatric patient. The overall level of evidence of interventions was strong for neuroprotective interventions such as caffeine and hypothermia but weak for surgery, visual training, or developmental programs. There are few evidence-based interventions and assessments that address cerebral/cortical visual impairment-related needs of infants and toddlers at high risk for or with cerebral palsy. Recommendation guidelines include the use of three types of standard care methodologies and two types of protective interventions.

Single blind randomised controlled trial of GAME (Goals - Activity - Motor Enrichment) in infants at high risk of cerebral palsy

BACKGROUND

Cerebral palsy (CP) is caused by a lesion in the developing infant brain. Recent neuroplasticity literature suggests that intensive, task-specific intervention ought to commence early, during the critical period of neural development.

AIMS

To determine whether "GAME" (Goals - Activity - Motor Enrichment), a motor learning, environmental enrichment intervention, is effective for improving motor skills in infants at high risk of CP.

METHODS AND PROCEDURES

Single blind randomised controlled trial of GAME versus standard care. Primary outcome was motor skills on the Peabody Developmental Motor Scales-2 (PDMS-2). Secondary outcomes included Canadian Occupational Performance Measure (COPM), Bayley Scales of Infant and Toddler Development (BSID-III) and Gross Motor Function Measure-66 (GMFM-66). Outcome assessors were masked to group allocation and data analyzed with multiple regression.

OUTCOMES AND RESULTS

All n=30 infants enrolled received the assigned intervention until 16 weeks post enrolment. At 12 months of age, n=26 completed assessments. Significant between group differences were found in raw scores on the PDMS-2 in favour of GAME (B=20.71, 95%CI 1.66-39.76, p=0. 03) and at 12 months on the total motor quotient (B=8.29, 95%CI 0.13-16.45,p =0.05). Significant between group differences favored GAME participants at 12 months on the cognitive scale of the BSID-III and satisfaction scores on the COPM.

CONCLUSION

GAME intervention resulted in advanced motor and cognitive outcomes when compared with standard care.

Visual tracking in very preterm infants at 4 mo predicts neurodevelopment at 3 y of age

BACKGROUND

Typically developing infants track moving objects with eye and head movements in a smooth and predictive way at 4 mo of age, but this ability is delayed in very preterm infants. We hypothesized that visual tracking ability in very preterm infants predicts later neurodevelopment.

METHOD

In 67 very preterm infants (gestational age<32 wk), eye and head movements were assessed at 4 mo corrected age while the infant tracked a moving object. Gaze gain, smooth pursuit, head movements, and timing of gaze relative the object were analyzed off line. Results of the five subscales included in the Bayley Scales of Infant Development (BSID-III) at 3 y of age were evaluated in relation to the visual tracking data and to perinatal risk factors.

RESULTS

Significant correlations were obtained between gaze gain and cognition, receptive and expressive language, and fine motor function, respectively, also after controlling for gestational age, severe brain damage, retinopathy of prematurity, and bronchopulmonary dysplasia.

CONCLUSION

This is the first study demonstrating that the basic ability to visually track a moving object at 4 mo robustly predicts neurodevelopment at 3 y of age in children born very preterm.

Visuo-manual coordination in preterm infants without neurological impairments

The extent of and reasons for visuo-manual coordination deficits in moderate and late preterm born infants without neurological impairments are not well known. This paper presents a longitudinal study on the visuo-manual development of twelve preterm infants, born after 33-36 weeks of gestation without neurological complications, between the ages of 6 and 12 months. Visuo-manual integration and grasping were assessed using the Peabody Developmental Motor Scales, along with bimanual coordination and handedness tests. Visual function was examined once prior to the beginning of the study. Gross motor development was also evaluated every month. Preterm infants were compared to a control group of ten full-term infants according to corrected age. Compared to full-terms, the visual perception of preterm infants was close to normal, with only a measure of visual fixation lower than in full-terms. In contrast, preterm infants had delayed development of visuo-manual integration, grasping, bimanual coordination, and handedness even when compared using corrected age. Tonicity and gestational age at birth were the main variables associated to the delays. These results are discussed in terms of the possible factors underlying such delays. They need to be confirmed on a larger sample of preterm born children, and to be correlated with later development. This would allow developing markers of future neuropsychological impairments during childhood.

Long-term effect of high-dose supplementation with DHA on visual function at school age in children born at <33 wk gestational age: results from a follow-up of a randomized controlled trial

BACKGROUND

Children born preterm are at risk of visual-processing impairments. Several lines of evidence have contributed to the rationale that docosahexaenoic acid (DHA) supplementation of preterm infants may improve outcomes in visual processing.

OBJECTIVE

The aim was to determine whether at 7 y of age children who were born very preterm and who received a high-DHA diet have better visual-processing outcomes than do infants fed a standard-DHA diet.

DESIGN

This was a follow-up study in a subgroup of children from a randomized controlled trial. Infants were randomly assigned to milk containing a higher concentration of DHA (1% of total fatty acids; high-DHA group) or a standard amount of DHA (0.2-0.3% of total fatty acids as DHA; control group). The randomization schedule was stratified by sex and birth weights of <1250 or ≥1250 g. A total of 104 (49 in the high-DHA group and 55 in the standard-DHA group) children aged 7 y were assessed on a range of visual-processing measures, including visual acuity, contrast sensitivity, vernier acuity, binocular stereopsis, and visual perception.

RESULTS

There was no evidence of differences between the high-DHA and standard-DHA groups in any of the visual-processing measures. In the majority (12 of 13) of variables assessed, the direction of effect favored the control group. The study was large enough to detect a moderate treatment effect, if one truly existed.

CONCLUSION

Supplementing human milk with DHA at a dose of ∼1% of total fatty acids given in the first months of life to very preterm infants does not appear to confer any long-term benefit for visual processing at school age. This trial was registered at anzctr.org/au as ACTRN12606000327583.

PPREMO: a prospective cohort study of preterm infant brain structure and function to predict neurodevelopmental outcome

BACKGROUND

More than 50 percent of all infants born very preterm will experience significant motor and cognitive impairment. Provision of early intervention is dependent upon accurate, early identification of infants at risk of adverse outcomes. Magnetic resonance imaging at term equivalent age combined with General Movements assessment at 12 weeks corrected age is currently the most accurate method for early prediction of cerebral palsy at 12 months corrected age. To date no studies have compared the use of earlier magnetic resonance imaging combined with neuromotor and neurobehavioural assessments (at 30 weeks postmenstrual age) to predict later motor and neurodevelopmental outcomes including cerebral palsy (at 12-24 months corrected age). This study aims to investigate i) the relationship between earlier brain imaging and neuromotor/neurobehavioural assessments at 30 and 40 weeks postmenstrual age, and ii) their ability to predict motor and neurodevelopmental outcomes at 3 and 12 months corrected age.

METHODS/DESIGN

This prospective cohort study will recruit 80 preterm infants born ≤ 30 week's gestation and a reference group of 20 healthy term born infants from the Royal Brisbane & Women's Hospital in Brisbane, Australia. Infants will undergo brain magnetic resonance imaging at approximately 30 and 40 weeks postmenstrual age to develop our understanding of very early brain structure at 30 weeks and maturation that occurs between 30 and 40 weeks postmenstrual age. A combination of neurological (Hammersmith Neonatal Neurologic Examination), neuromotor (General Movements, Test of Infant Motor Performance), neurobehavioural (NICU Network Neurobehavioural Scale, Premie-Neuro) and visual assessments will be performed at 30 and 40 weeks postmenstrual age to improve our understanding of the relationship between brain structure and function. These data will be compared to motor assessments at 12 weeks corrected age and motor and neurodevelopmental outcomes at 12 months corrected age (neurological assessment by paediatrician, Bayley scales of Infant and Toddler Development, Alberta Infant Motor Scale, Neurosensory Motor Developmental Assessment) to differentiate atypical development (including cerebral palsy and/or motor delay).

DISCUSSION

Earlier identification of those very preterm infants at risk of adverse neurodevelopmental and motor outcomes provides an additional period for intervention to optimise outcomes.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12613000280707. Registered 8 March 2013.

Visual fixation in human newborns correlates with extensive white matter networks and predicts long-term neurocognitive development

Infants are well known to seek eye contact, and they prefer to fixate on developmentally meaningful objects, such as the human face. It is also known, that visual abilities are important for the developmental cascades of cognition from later infancy to childhood. It is less understood, however, whether newborn visual abilities relate to later cognitive development, and whether newborn ability for visual fixation can be assigned to early microstructural maturation. Here, we investigate relationship between newborn visual fixation (VF) and gaze behavior (GB) to performance in visuomotor and visual reasoning tasks in two cohorts with cognitive follow-up at 2 (n = 57) and 5 (n = 1410) years of age. We also analyzed brain microstructural correlates to VF (n = 45) by voxel-based analysis of fractional anisotropy (FA) in newborn diffusion tensor imaging. Our results show that newborn VF is significantly related to visual-motor performance at both 2 and 5 years, as well as to visual reasoning at 5 years of age. Moreover, good newborn VF relates to widely increased FA levels across the white matter. Comparison to motor performance indicated that early VF is preferentially related to visuocognitive development, and that early motor performance relates neither to white matter integrity nor to visuocognitive development. The present findings suggest that newborn VF is supported by brainwide subcortical networks and it represents an early building block for the developmental cascades of cognition.

Effect of early multisensory massage intervention on visual functions in infants with Down syndrome

BACKGROUND

Down syndrome is a frequent cause of intellectual disability, with severe impact on the quality of life of affected individuals and their families, and high social costs. Intervention programs should start soon after birth but no consensus exists on specific types and timing of early interventions in this population.

AIM

This pilot study explores the effects of an early multi-sensory intervention, based on body massage, on the development of visual function in infants with Down syndrome.

METHOD

Infants were randomly allocated to either a massage or a control group. Intervention consisted of only standard care (Control Group) or standard care plus infant massage (Massaged Group). Visual acuity was assessed by Teller Acuity Cards and stereopsis by the Frisby Stereopsis Screening Test at 5, 6, 9 and 12 months.

RESULTS

Massaged Group Infants showed a significantly higher visual acuity at 6 months of age and an accelerated development up to at least 12 months; compared to Controls, stereopsis had an earlier onset in the Massaged Group followed by a faster maturation.

CONCLUSION

Environmental enrichment, in the tested form of infant massage, seems to affect maturation of visual functions in human infants, also in the presence of a genetic disability, when applied during a period of high brain plasticity.

Visual function in preterm infants: visualizing the brain to improve prognosis

Considerable development of the visual system occurs in the third trimester of life, a time when very preterm-born infants are in a neonatal intensive care unit (NICU). Their very early birth during a period of rapid and marked neurodevelopment and their clinical course makes them a very high-risk population. A range of different events impacts brain development and the visual system, leading to significant long-term visual dysfunction. Improved neuroimaging techniques provide an important window on the early brain and visual system development of these vulnerable infants. Greater understanding of the etiology of visual impairment subsequent to preterm birth and the timing of critical processes will allow early recognition and the earlier implementations of interventions. In the longer term, this will help clinicians optimize NICU practice to reduce the incidence of visual dysfunction in these children.

Visual performance in preterm infants with brain injuries compared with low-risk preterm infants

BACKGROUND

Neonatal brain injuries are the main cause of visual deficit produced by damage to posterior visual pathways. While there are several studies of visual function in low-risk preterm infants or older children with brain injuries, research in children of early age is lacking.

AIM

To assess several aspects of visual function in preterm infants with brain injuries and to compare them with another group of low-risk preterm infants of the same age.

STUDY DESIGN AND SUBJECTS

Forty-eight preterm infants with brain injuries and 56 low-risk preterm infants.

OUTCOME MEASURES

The ML Leonhardt Battery of Optotypes was used to assess visual functions. This test was previously validated at a post-menstrual age of 40 weeks in newborns and at 30-plus weeks in preterm infants.

RESULTS

The group of preterm infants with brain lesions showed a delayed pattern of visual functions in alertness, fixation, visual attention and tracking behavior compared to infants in the healthy preterm group. The differences between both groups, in the visual behaviors analyzed were around 30%. These visual functions could be identified from the first weeks of life.

CONCLUSION

Our results confirm the importance of using a straightforward screening test with preterm infants in order to assess altered visual function, especially in infants with brain injuries. The findings also highlight the need to provide visual stimulation very early on in life.

Visual function assessment in late-preterm newborns

AIM

To describe the development of visual functions in a population of low-risk late preterm infants.

SUBJECTS AND METHODS

Eighty low-risk late preterm with a gestational age between 34.0 and 36.9 weeks were assessed at birth and at term equivalent age (TEA) using a structured visual assessment battery. The results were compared to those previously obtained in term born infants using the same battery.

RESULTS

For 5 items (spontaneous ocular motility, ocular motility with target, fixation, horizontal tracking and color tracking) the results were similar both at birth and TEA; for the other 4 (vertical and arc tracking, ability to discriminate striped black/white targets and attention at distance) visual findings at TEA were more mature than at birth. Comparing the responses in late preterm at TEA and term-born infants at 48 h of life, only 2 items (attention at distance, ability to discriminate black/white stripes) were different, with more mature findings in late preterm infants.

CONCLUSIONS

Our results show that in late preterm some aspects of visual functions have a progressive maturation infants between birth and TEA, confirming that the time between birth and term age appears to be crucial for the development of these abilities.

Neurological and visual assessments in very and late low-risk preterm infants

In this review, we report our experience on early neurological and visual developments in preterm infants assessed during the neonatal period using the Dubowitz neonatal neurological assessment and a new battery for visual assessment. The assessments were performed in both very and late low-risk preterm infants and in healthy term-born infants. We report the findings in the three cohorts, evaluating the influence of gestational age and extrauterine exposure on both neurological and visual developments.

Visual cortical function in very low birth weight infants without retinal or cerebral pathology

PURPOSE

Preterm infants are at high risk of visual and neural developmental deficits. However, the development of visual cortical function in preterm infants with no retinal or neurologic morbidity has not been well defined. To determine whether premature birth itself alters visual cortical function, swept parameter visual evoked potential (sVEP) responses of healthy preterm infants were compared with those of term infants.

METHODS

Fifty-two term infants and 58 very low birth weight (VLBW) infants without significant retinopathy of prematurity or neurologic morbidities were enrolled. Recruited VLBW infants were between 26 and 33 weeks of gestational age, with birth weights of less than 1500 g. Spatial frequency, contrast, and vernier offset sweep VEP tuning functions were measured at 5 to 7 months' corrected age. Acuity and contrast thresholds were derived by extrapolating the tuning functions to 0 amplitude. These thresholds and suprathreshold response amplitudes were compared between groups.

RESULTS

Preterm infants showed increased thresholds (indicating decreased sensitivity to visual stimuli) and reductions in amplitudes for all three measures. These changes in cortical responsiveness were larger in the <30 weeks ' gestational age subgroup than in the ≥30 weeks' gestational age subgroup.

CONCLUSIONS

Preterm infants with VLBW had measurable and significant changes in cortical responsiveness that were correlated with gestational age. These results suggest that premature birth in the absence of identifiable retinal or neurologic abnormalities has a significant effect on visual cortical sensitivity at 5 to 7 months' of corrected age and that gestational age is an important factor in visual development.