Using cluster analysis to provide new insights into development of very low birthweight (VLBW) premature infants

Parsing brain-behavior heterogeneity in very preterm born children using integrated similarity networks

Very preterm birth (VPT; ≤32 weeks' gestation) is associated with altered brain development and cognitive and behavioral difficulties across the lifespan. However, heterogeneity in outcomes among individuals born VPT makes it challenging to identify those most vulnerable to neurodevelopmental sequelae. Here, we aimed to stratify VPT children into distinct behavioral subgroups and explore between-subgroup differences in neonatal brain structure and function. 198 VPT children (98 females) previously enrolled in the Evaluation of Preterm Imaging Study (EudraCT 2009-011602-42) underwent Magnetic Resonance Imaging at term-equivalent age and neuropsychological assessments at 4-7 years. Using an integrative clustering approach, we combined neonatal socio-demographic, clinical factors and childhood socio-emotional and executive function outcomes, to identify distinct subgroups of children based on their similarity profiles in a multidimensional space. We characterized resultant subgroups using domain-specific outcomes (temperament, psychopathology, IQ and cognitively stimulating home environment) and explored between-subgroup differences in neonatal brain volumes (voxel-wise Tensor-Based-Morphometry), functional connectivity (voxel-wise degree centrality) and structural connectivity (Tract-Based-Spatial-Statistics). Results showed two- and three-cluster data-driven solutions. The two-cluster solution comprised a 'resilient' subgroup (lower psychopathology and higher IQ, executive function and socio-emotional scores) and an 'at-risk' subgroup (poorer behavioral and cognitive outcomes). No neuroimaging differences between the resilient and at-risk subgroups were found. The three-cluster solution showed an additional third 'intermediate' subgroup, displaying behavioral and cognitive outcomes intermediate between the resilient and at-risk subgroups. The resilient subgroup had the most cognitively stimulating home environment and the at-risk subgroup showed the highest neonatal clinical risk, while the intermediate subgroup showed the lowest clinical, but the highest socio-demographic risk. Compared to the intermediate subgroup, the resilient subgroup displayed larger neonatal insular and orbitofrontal volumes and stronger orbitofrontal functional connectivity, while the at-risk group showed widespread white matter microstructural alterations. These findings suggest that risk stratification following VPT birth is feasible and could be used translationally to guide personalized interventions aimed at promoting children's resilience.

Neurobehavioral Phenotype and Dysexecutive Syndrome of Preterm Children: Comorbidity or Trigger? An Update

Premature birth is a worldwide public health priority. One in ten children is born before 37 weeks of gestational age and, in developed countries, survival rates without major neonatal morbidity are increasing. Although severe sequelae associated with these births have decreased, their neurobehavioral difficulties, often associated in multiple fields, remain stable but still widespread. These neurobehavioral difficulties hamper the normal development of academic achievements and societal integration and intensify the children's needs for rehabilitation during their preschool and academic years. Severe sequelae increase when gestational age decreases. This is even truer if the socio-cultural background is impeded by low income, education and language skills as compared with defined averages. However, moderate and/or minor neurocognitive and/or behavioral difficulties are almost identical for a moderate or a late preterm birth. Obtaining a better clinical description of neurobehavioral characteristics of those pretermly born, once they reach preschool age, is essential to detect behavioral issues as well as early specific cognitive difficulties (working memory, planning, inhibition, language expression and reception, attention and fine motor skills, etc.). Such information would provide a better understanding of the executive functions' role in brain connectivity, neurodevelopment and neuroanatomical correlation with premature encephalopathy.

Are multidisciplinary neurodevelopmental profiles of children born very preterm at age 2 relevant to their long-term development? A preliminary study

To identify distinctive multidisciplinary neurodevelopmental profiles of relatively healthy children born very preterm (VPT) and describe the longitudinal course of these profiles up to age 10. At 2 years of corrected age, 84 children born VPT underwent standardized testing for cognitive, language, speech, motor, behavioral, and auditory nerve function. These data were submitted to factor and cluster analysis. Sixty-one of these children underwent cognitive, language, and behavioral assessment again at age 10. Descriptive statistics were used to analyze longitudinal trajectories for each profile. Four neurodevelopmental profiles were identified at age 2. Profile 1 children (n = 22/26%) had excellent cognitive-language-motor function, normal behavioral and auditory nerve function, but showed an unexpected severe decline up to age 10. Profile 2 children (n = 16/19%) had very low behavioral function, low cognitive-language-motor function, and accelerated auditory nerve function. Their scores remained low up until age 10. Profile 3 children (n = 17/20%) had delayed auditory nerve function, low behavioral function, and slightly lower cognitive-language-motor function. They showed the most increasing trajectory. Profile 4 children (n = 29/35%) had very low cognitive-language-motor function, normal behavioral and auditory nerve function, but showed wide variation in their trajectory. Our preliminary study showed that a multidisciplinary profile-oriented approach may be important in children born VPT to improve counseling and provide targeted treatment for at risk children. High performers at age 2 may not be expected to maintain their favorable development. Behavioral problems might negatively impact language development. Delayed auditory nerve function might represent a slow start and catch-up development.

Modeling a gross motor curve of typically developing Dutch infants from 3.5 to 15.5 months based on the Alberta Infant Motor Scale

BACKGROUND

Interindividual variability in gross motor development of infants is substantial and challenges the interpretation of motor assessments. Longitudinal research can provide insight into variability in individual gross motor trajectories.

PURPOSE

To model a gross motor growth curve of healthy term-born infants from 3.5 to 15.5 months with the Alberta Infant Motor Scale (AIMS) and to explore groups of infants with different patterns of development.

METHODS

A prospective longitudinal study including six assessments with the AIMS. A Linear Mixed Model analysis (LMM) was applied to model motor growth, controlled for covariates. Cluster analysis was used to explore groups with different pathways. Growth curves for the subgroups were modelled and differences in the covariates between the groups were described and tested.

RESULTS

In total, data of 103 infants was included in the LMM which showed that a cubic function (F(1,571) = 89.68, p < 0.001) fitted the data best. None of the covariates remained in the model. Cluster analysis delineated three clinically relevant groups: 1) Early developers (32%), 2) Gradual developers (46%), and 3) Late bloomers (22%). Significant differences in covariates between the groups were found for birth order, maternal education and maternal employment.

CONCLUSION

The current study contributes to knowledge about gross motor trajectories of healthy term born infants. Cluster analysis identified three groups with different gross motor trajectories. The motor growth curve provides a starting point for future research on motor trajectories of infants at risk and can contribute to accurate screening.

Follow-Up de Nascidos Prematuros: Uma Revisão Sistemática da Literatura

Resumo Objetivou-se mapear estudos científicos sobre follow-up de prematuros na área da psicologia. Buscou-se no portal BVS artigos empíricos publicados até dezembro de 2017 pelos descritores prematur* AND follow up AND child AND psychology. A partir dos critérios adotados, analisou-se 48 artigos, nas categorias: faixa etária em que os prematuros foram avaliados; objetivos do estudo; tipo de avaliação realizada; e resultados encontrados. Destaca-se que a metade realizou o follow-up entre o nascimento e a adolescência, a maioria investigou o desenvolvimento neuropsicológico e encontrou associações entre a prematuridade, déficits cognitivos e psicológicos. Compreende-se que os estudos priorizam as repercussões no desenvolvimento de habilidades e competências, dando pouca atenção aos aspectos psíquicos e às interações criança-pais-ambiente.

A new perspective: Establishing developmental profiles of premature infants based on Bayley-III scores at age 2

Longitudinal and cross-sectional studies in early childhood generally focus on different developmental areas separately. The aim of this study is to identify the most common developmental profiles regarding cognitive, language and motor skills among low birthweight (LBW) children. Our sample included 208 LBW children examined at 24-28 months. We used cluster analysis to identify developmental profiles based on the scores of the Bayley-III Cognitive, Language and Motor scales. We found three consistent profiles (High, Mildly Delayed and Severely Delayed) and three inconsistent, average profiles (with High Expressive Language, with Mildly Delayed Expressive Language and with Severely Delayed Language). Socioeconomic status, maternal education, in vitro fertilization, plurality and chronic morbidities were significantly related to the clusters. Cluster analysis might be an effective method to identify developmental profiles of preterm (and other at-risk) children, which might result in a more complex understanding of cognitive and psychomotor development in early childhood.

Prediction of Delayed Neurodevelopment in Infants Using Brainstem Auditory Evoked Potentials and the Bayley II Scales

Background: Brainstem auditory evoked potentials (BAEP) provide an objective analysis of central nervous system function and development in infants. This study proposed to examine the relationship between infant BAEP values at age 6 months, and their neurodevelopment at age 2 years assessed by the mental development indices (MDI), a form of Bayley Scales of Infant Development. We hypothesized that in infants with BAEP values outside normal range, there may be neurodevelopmental delays, as shown by their MDI scores. Methods: An exploratory investigation was conducted using preterm (28-36 weeks gestation; 95 cases) and term infants (≥37 weeks gestation; 100 cases) who were born with specific perinatal conditions. BAEP values were recorded in these infants from 1 to 8 months of age, and compared with MDI scores in these infants at age 2 years. A multivariate linear regressions model was performed to test the associations between all variables and MDI scores. Stratified linear regression was used to test the interactions between gestational age and BAEP values with MDI scores. Significance was determined at a p < 0.05. Results: We found that BAEP values were inversely associated with MDI scores in premature infants (β = -1.89; 95% confidence interval = -3.42 to -0.36), and that the effect of gestational age and BAEP values on the MDI scores is decreased by 1.89 points due to the interaction between these two variables. In premature babies, the lower the BAEP value below the mean, the greater the decrease in MDI score at age 2 years. Asphyxia and lower socioeconomic status in the family were also covariates associated with lower MDI scores at age 2 years. Conclusion: The data provided evidence that BAEP values outside the normal range in premature infants at age 6 months may predict developmental delays in cognitive and motor skills, as shown by MDI scores. We propose that BAEP assessment may be utilized as a potential indicator for neurodevelopment, and suggest that early intellectual and public health interventions should be encouraged to enrich neurodevelopment in premature babies with BAEP values outside the normal range.

Supporting caregivers of children born prematurely in the development of language: A scoping review

Background

Infants born prematurely can display impairments that negatively impact the early years of their development. Compared to their peers born at term, preterm children have higher risks of cerebral palsy, sensory deficits, learning disabilities, cognitive and language deficits, as well as difficulties related to attention and behaviour. Following discharge, parents of preterm children are often supported through neonatal follow-up programs or by community health care practitioners. Through assessment and consultation, professionals foster parental resilience by teaching them about their child's development. Research shows a large volume of literature on improving outcomes for preterm infants, but less attention has been given to the impact and potential importance of education of parents regarding the care they provide from the home.

Objective

A scoping review was completed to determine the best practices for early intervention in premature children regarding the development of language skills during the preschool years.

Methods

The review followed the guidelines for the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA).

Results

Four general themes emerged from the review and included the importance of providing (1) parental training in the care of an infant born prematurely during neonatal intensive care unit stay; (2) education on the development of language and the importance of parental responsiveness; (3) provision of activities to support child language learning; and (4) overall and ongoing monitoring and support by qualified health professionals.

Conclusions

The conclusions drawn will provide guidance to health care professionals regarding the education of parents on best practices for stimulating language development in their child.

Neuromotor Development of Children Aged 6 and 7 Years Born before the 30th Week Gestation

Introduction

The aim of this study was to evaluate and compare the level of neuromotor function and somatic development in 6- and 7-year-old children born before the 30th week gestation with that in full-term children at the same age, as well as the correlation between prematurity and motor development.

Material and Methods

The study group consisted of prematurely born 40 children. Their mean gestational age at birth was 27.8 ± 1.6 weeks (range 24–30 weeks). The control group consisted of 40 healthy children born with normal birth weight (>2500 g). The neuromotor function was assessed using Touwen neurological examination criteria. During the examination, the attention was focused on the hand preference, laterality, synkinesis, and asymmetry. In addition, children's weight, height, and BMI index were measured.

Results

Premature children showed much worse results than full-term ones in hand function (p < 0,001). They obtained the best results in paper tearing while crossing the body midline turned out to be the most difficult. Considering the quality of walking, the biggest difficulty for the premature children was to walk backwards along the straight line while during normal walking they showed the best results. The results for the muscle tone subcategory in the study group were also significantly worse than those in control group (p < 0,001), as well as the total outcome for the movement coordination and diadochokinesis subcategories (p < 0,001).

Conclusion

The nondisabled, prematurely born children have significantly lower average outcomes regarding hand function, quality of walking, muscle tone, coordination, and diadochokinesis at age of six to seven, compared to the full-term peers.

Do Infants Born Very Premature and Who Have Very Low Birth Weight Catch Up With Their Full Term Peers in Their Language Abilities by Early School Age?

PURPOSE

This study examined the extent to which children born preterm (< 37 weeks) and/or who have low birth weight (< 2,500 g) catch up with their full term peers in terms of their language abilities at early school age (≥ 5 to < 9 years).

METHOD

A systematic literature search identified empirical studies that fit the inclusion criteria. Data from the tests/questionnaires used for meta-analysis spanned the following language categories: total language score, expressive language, receptive language, pragmatics, phonological awareness, and grammar. The means (standard deviations) were extracted from the studies and were converted to mean difference and 95% confidence intervals to test for overall effect.

RESULTS

Sixteen studies met the inclusionary criteria, for a total of 2,739 participants, of which 1,224 were born full term and 1,515 were born preterm. It is important to note that the preterm cohort represented very preterm infants who have a very low birth weight. The meta-analysis found that preterm infants scored significantly worse on total language (p < .001), receptive language (p < .001), expressive language (p < .001), phonological awareness (p < .001), and grammar (p = .03) than their full term peers. However, preterm infants did not score significantly worse than their peers on their pragmatics (p = .19).

CONCLUSIONS

Children born VPT and who have VLBW perform worse than their peers on their total language, receptive language, expressive language, phonological awareness, and grammar abilities by early school age. This information is important for speech-language pathologists to consider as children born prematurely reach school age.

Health of VLBW infants in Germany at five years of age: What do parents describe?

BACKGROUND

There are only few data on medical problems and utilization of health services of former very low birth weight (VLBW) children at preschool age.

STUDY DESIGN

At five years of age parents of a cohort of VLBW children (N=862) received questionnaires, a medical interview and examination. The results were compared to the KIGGS cohort (Deutscher-Kinder-und Jugendgesundheitssurvey, N=777).

RESULTS

Parents of the VLBW and KIGGS cohort reported a very good or good health in 95% in their children. When compared to the KIGGS cohort, families in the VLBW cohort had a lower social economic status. The VLBW cohort suffered more frequently from disabilities (9.6% vs. 1.4%), from chronic bronchitis (45% vs. 17%) and from recurrent pain (headaches (20% vs. 7%), ear (16% vs. 6%), throat (23% vs. 8%), tooth (10% vs. 3%)). The VLBW cohort received more specialized care (ophthalmologist, ENT, orthopaedics, paediatric neurologist).

CONCLUSION

Families of VLBW children report a good health status in their children, but they utilized more specialized care. Higher rates of pain are reported in the VLBW cohort. Chronic bronchitis and various upper respiratory infections cause an increased morbidity in former VLBW children. Follow up programs are needed to develop optimal treatment and prevention strategies for these problems.

Development skills of children born premature with low and very low birth weight

Purpose

To compare the performance of children born premature with low birth weight (LBW) and very low birth-weight (VLBW) with that of children born at term, within the age range of one to three years, regarding child development in the gross motor, fine motor-adaptive, personal-social and language domains.

Methods

This is a cross-sectional study in a cohort of 150 infants born premature (experimental group) and at term (control group) divided into eight groups with respect to weight (low birth weight: <2500 grams and very low birth weight: <1500 grams) and age range (aged 12 to 24 and 25 to 36 months). The control groups were paired with the experimental groups as for gender, chronological age, and socioeconomic level. Assessment comprised the application of anamnesis protocol, socioeconomic classification, and Denver Developmental Screening Test (DDST-II). Corrected age was calculated for premature children up to 24 months of age. Descriptive statistical analysis and the Student's t-test were used.

Results

No statistically significant difference was found in the comparison between the groups of infants born premature and at term for all domains evaluated.

Conclusion

The performance of infants born premature was lower than that of infants born at term regarding the gross motor, fine motor-adaptive, personal-social and language domains. In this study, the preterm groups presented different performances, i.e., normative, average, and below average performances were observed within the same group.

Analysis of multi-dimensional contemporaneous EHR data to refine delirium assessments

Delirium is a potentially lethal condition of altered mental status, attention, and level of consciousness with an acute onset and fluctuating course. Its causes are multi-factorial, and its pathophysiology is not well understood; therefore clinical focus has been on prevention strategies and early detection. One patient evaluation technique in routine use is the Confusion Assessment Method (CAM): a relatively simple test resulting in 'positive', 'negative' or 'unable-to-assess' (UTA) ratings. Hartford Hospital nursing staff use the CAM regularly on all non-critical care units, and a high frequency of UTA was observed after reviewing several years of records. In addition, patients with UTA ratings displayed poor outcomes such as in-hospital mortality, longer lengths of stay, and discharge to acute and long term care facilities. We sought to better understand the use of UTA, especially outside of critical care environments, in order to improve delirium detection throughout the hospital. An unsupervised clustering approach was used with additional, concurrent assessment data available in the EHR to categorize patient visits with UTA CAMs. The results yielded insights into the most common situations in which the UTA rating was used (e.g. impaired verbal communication, dementia), suggesting potentially inappropriate ratings that could be refined with further evaluation and remedied with updated clinical training. Analysis of the patient clusters also suggested that unrecognized delirium may contribute to the poor outcomes associated with the use of UTA. This method of using temporally related high dimensional EHR data to illuminate a dynamic medical condition could have wider applicability.