Are outcomes of extremely preterm infants improving? Impact of Bayley assessment on outcomes

Supervised contrastive learning enhances graph convolutional networks for predicting neurodevelopmental deficits in very preterm infants using brain structural connectome

Very preterm (VPT) infants (born at less than 32 weeks gestational age) are at high risk for various adverse neurodevelopmental deficits. Unfortunately, most of these deficits cannot be accurately diagnosed until the age of 2-5 years old. Given the benefits of early interventions, accurate diagnosis and prediction soon after birth are urgently needed for VPT infants. Previous studies have applied deep learning models to learn the brain structural connectome (SC) to predict neurodevelopmental deficits in the preterm population. However, none of these models are specifically designed for graph-structured data, and thus may potentially miss certain topological information conveyed in the brain SC. In this study, we aim to develop deep learning models to learn the SC acquired at term-equivalent age for early prediction of neurodevelopmental deficits at 2 years corrected age in VPT infants. We directly treated the brain SC as a graph, and applied graph convolutional network (GCN) models to capture complex topological information of the SC. In addition, we applied the supervised contrastive learning (SCL) technique to mitigate the effects of the data scarcity problem, and enable robust training of GCN models. We hypothesize that SCL will enhance GCN models for early prediction of neurodevelopmental deficits in VPT infants using the SC. We used a regional prospective cohort of ∼280 VPT infants who underwent MRI examinations at term-equivalent age from the Cincinnati Infant Neurodevelopment Early Prediction Study (CINEPS). These VPT infants completed neurodevelopmental assessment at 2 years corrected age to evaluate cognition, language, and motor skills. Using the SCL technique, the GCN model achieved mean areas under the receiver operating characteristic curve (AUCs) in the range of 0.72∼0.75 for predicting three neurodevelopmental deficits, outperforming several competing models. Our results support our hypothesis that the SCL technique is able to enhance the GCN model in our prediction tasks.

Prognosis of 22- and 23-Gestational-Week-Old Infants at Our Facility: A Retrospective Cohort Study

OBJECTIVE

 This study aimed to compare inborn infants aged 22 and 23 gestational weeks at our hospital to assess for differences in survival and long-term prognosis.

STUDY DESIGN

 We retrospectively analyzed 22- and 23-gestational-weeks-old infants born in our hospital between January 2011 and December 2018. The prognosis of inborn infants in Japan was also calculated using the Neonatal Research Network of Japan (NRNJ) data during the same period.

RESULTS

 The survival rates at our institution's neonatal intensive care unit discharge, including stillbirth, were 72 and 89% at 22 and 23 gestational weeks, respectively. The mortality rate and neurodevelopmental impairment (NDI) rate at 3 years of age, including stillbirth, were 58 and 32% at 22 and 23 weeks, respectively. Cerebral palsy, mental developmental retardation, visual impairment, and hearing impairment defined NDI. The prognosis at our hospital was better than the average calculated using NRNJ data. Survival rates varied among facilities, and some facilities had survival rates similar to that of our hospital.

CONCLUSION

 The prognosis of 22-gestational-week-old inborn infants was inferior to that of 23 gestational weeks in our institution but was better than previously reported. If aggressive treatment is provided, survival without sequelae can be fully expected even for 22-gestational-week-old infants.

KEY POINTS

· We examined babies of gestation ages 22 and 23 weeks.. · We examined the survival and neurological prognoses.. · We compared our facility with that in entire Japan..

Impact of maternal infection on outcomes in extremely preterm infants

BACKGROUND

Infants born less than 29 weeks, or extremely preterm (EPT), experience increased morbidity and mortality. We hypothesized that exposure to maternal infection might contribute to neurodevelopmental impairment (NDI) or death at 2 years of age.

METHODS

We conducted a retrospective cohort study of EPT infants from January 2010 to December 2020. Maternal data extracted included maternal infections, classified as extrauterine or intrauterine. Placental pathologic and infant data were extracted. The primary outcome was NDI or death at 2 years of age.

RESULTS

548 EPT infants were born to 496 pregnant people: 379 (69%) were not exposed to any documented maternal infection prenatally, 124 (23%) to extrauterine infection, and 45 (8%) to intrauterine infection. Neither diagnosis of maternal extrauterine nor intrauterine infection was associated with NDI or death at 2 years of age (p > 0.05). Acute histologic chorioamnionitis was associated with NDI or death at 2 years of age (p = 0.033).

CONCLUSIONS

Maternal infection was not associated with NDI or death at 2 years of age in EPT infants. However, acute histologic chorioamnionitis was associated with this outcome. Further work should investigate the differential influence of infection and immune response with this pathology as relates to outcomes in EPT infants.

IMPACT

Maternal infection was not associated with neurodevelopmental impairment (NDI) or death at 2 years of age in extremely preterm (EPT) infants. This is reassuring support that mechanisms at the maternal-fetal interface largely protect the EPT infant. However, pathologic findings of acute histologic chorioamnionitis were associated with NDI and death at 2 years of age. Further work should investigate the differential influence of infection and immune response with acute histologic chorioamnionitis on pathology as relates to outcomes in EPT infants.

Association between neurodevelopmental outcomes and concomitant presence of NEC and IVH in extremely low birth weight infants

OBJECTIVE

To quantify the association between necrotizing enterocolitis (NEC) and neurodevelopmental disability (NDI) in extremely low birth weight (ELBW) infants with intraventricular hemorrhage (IVH).

STUDY DESIGN

ELBW survivors born 2011-2017 and evaluated at 16-26 months corrected age in the Vermont Oxford Network (VON) ELBW Follow-Up Project were included. Logistic regression determined the adjusted relative risk (aRR) of severe NDI in medical or surgical NEC compared to no NEC, stratified by severity of IVH.

RESULTS

Follow-up evaluation occurred in 5870 ELBW survivors. Compared to no NEC, medical NEC had no impact on NDI, regardless of IVH status. Surgical NEC increased risk of NDI in patients with no IVH (aRR 1.69; 95% CI 1.36-2.09), mild IVH (aRR 1.36;0.97-1.92), and severe IVH (aRR 1.35;1.13-1.60).

CONCLUSIONS

ELBW infants with surgical NEC carry increased risk of neurodevelopmental disability within each IVH severity stratum. These data describe the additive insult of surgical NEC and IVH on neurodevelopment, informing prognostic discussions and highlighting the need for preventative interventions.

Do Bayley-III Composite Scores at 18-22 Months Corrected Age Predict Full-Scale IQ at 6-7 Years in Children Born Extremely Preterm?

OBJECTIVE

To determine the ability of the Bayley-III cognitive and language composite scores at 18-22 months corrected age to predict WISC-IV Full Scale IQ (FSIQ) at 6-7 years in infants born extremely preterm.

STUDY DESIGN

Children in this study were part of the Neuroimaging and Neurodevelopmental Outcome cohort, a secondary study to the SUPPORT trial and born 240/7-276/7 weeks gestational age. Bayley-III cognitive and language scores and WISC-IV FSIQ were compared with pairwise Pearson correlation coefficients and adjusted for medical and socioeconomic variables using linear mixed effect regression models.

RESULTS

Bayley-III cognitive (r = 0.33) and language scores (r = 0.44) were mildly correlated with WISC-IV FSIQ score. Of the children with Bayley-III cognitive scores of <70, 67% also had FSIQ of <70. There was less consistency for children with Bayley-III scores in the 85-100 range; 43% had an FSIQ of <85 and 10% an FSIQ of <70. Among those with Bayley-III language scores >100, approximately 1 in 5 had an FSIQ of <85. A cut point of 92 for the cognitive composite score resulted in sensitivity (0.60), specificity (0.64). A cut point of 88 for the language composite score produced sensitivity (0.61), specificity (0.70).

CONCLUSIONS

Findings indicate the Bayley-III cognitive and language scores correlate with later IQ, but may fail to predict delay or misclassify children who are not delayed at school age. The Bayley-III can be a useful tool to help identify children born extremely preterm who have below average cognitive scores and may be at the greatest risk for ongoing cognitive difficulties.

TRIAL REGISTRATION

Extended Follow-up at School Age for the SUPPORT Neuroimaging and Neurodevelopmental Outcomes (NEURO) Cohort: NCT00233324.

Use of term reference infants in assessing the developmental outcome of extremely preterm infants: lessons learned in a multicenter study

OBJECTIVE

Extremely preterm (EP) impairment rates are likely underestimated using the Bayley III norm-based thresholds scores and may be better assessed relative to concurrent healthy term reference (TR) infants born in the same hospital.

STUDY DESIGN

Blinded, certified examiners in the Neonatal Research Network (NRN) evaluated EP survivors and a sample of healthy TR infants recruited near the 2-year assessment age.

RESULTS

We assessed 1452 EP infants and 183 TR infants. TR-based thresholds showed higher overall EP impairment than Bayley norm-based thresholds (O.R. = 1.86; [95% CI 1.56-2.23], especially for severe impairment (36% vs. 24%; p ≤ 0.001). Difficulty recruiting TR patients at 2 years extended the study by 14 months and affected their demographics.

CONCLUSION

Impairment rates among EP infants appear to be substantially underestimated from Bayley III norms. These rates may be best assessed by comparison with healthy term infants followed with minimal attrition from birth in the same centers.

CLINICALTRIALS

GOV ID

Term Reference (under the Generic Database Study): NCT00063063.

Developmental consequences of short apneas and periodic breathing in preterm infants

OBJECTIVE

We investigated the relationship between respiratory events experienced before and after hospital discharge and developmental outcomes at 6 months corrected age (CA).

STUDY DESIGN

Preterm infants born between 28-32 weeks gestational age (GA) were studied at 32-36 weeks postmenstrual age (PMA), 36-40 weeks PMA, 3- and 6-months CA. Percentage total sleep time (%TST) with respiratory events (isolated apneas, sequential apneas and periodic breathing (PB)) at each study was calculated. Stepwise multiple linear regressions determined significant predictors of developmental outcomes at 6 months.

RESULT

%TST with respiratory events at term were significant predictors of language (R2 = 0.165, β = -0.416) and motor (R2 = 0.180, β = -0.485) composite scores of the Bayley Scales of Infant Development at 6 months, independent of GA, birth weight and sex.

CONCLUSIONS

In clinically stable very preterm infants at term equivalent age, time spent having respiratory events, was related to a reduction in language and motor outcomes at 6 months.

Immuno-epigenetic signature derived in saliva associates with the encephalopathy of prematurity and perinatal inflammatory disorders

BACKGROUND

Preterm birth is closely associated with a phenotype that includes brain dysmaturation and neurocognitive impairment, commonly termed Encephalopathy of Prematurity (EoP), of which systemic inflammation is considered a key driver. DNA methylation (DNAm) signatures of inflammation from peripheral blood associate with poor brain imaging outcomes in adult cohorts. However, the robustness of DNAm inflammatory scores in infancy, their relation to comorbidities of preterm birth characterised by inflammation, neonatal neuroimaging metrics of EoP, and saliva cross-tissue applicability are unknown.

METHODS

Using salivary DNAm from 258 neonates (n = 155 preterm, gestational age at birth 23.28 - 34.84 weeks, n = 103 term, gestational age at birth 37.00 - 42.14 weeks), we investigated the impact of a DNAm surrogate for C-reactive protein (DNAm CRP) on brain structure and other clinically defined inflammatory exposures. We assessed i) if DNAm CRP estimates varied between preterm infants at term equivalent age and term infants, ii) how DNAm CRP related to different types of inflammatory exposure (maternal, fetal and postnatal) and iii) whether elevated DNAm CRP associated with poorer measures of neonatal brain volume and white matter connectivity.

RESULTS

Higher DNAm CRP was linked to preterm status (-0.0107 ± 0.0008, compared with -0.0118 ± 0.0006 among term infants; p < 0.001), as well as perinatal inflammatory diseases, including histologic chorioamnionitis, sepsis, bronchopulmonary dysplasia, and necrotising enterocolitis (OR range |2.00 | to |4.71|, p < 0.01). Preterm infants with higher DNAm CRP scores had lower brain volume in deep grey matter, white matter, and hippocampi and amygdalae (β range |0.185| to |0.218|). No such associations were observed for term infants. Association magnitudes were largest for measures of white matter microstructure among preterms, where elevated epigenetic inflammation associated with poorer global measures of white matter integrity (β range |0.206| to |0.371|), independent of other confounding exposures.

CONCLUSIONS

Inflammatory-related DNAm captures the allostatic load of inflammatory burden in preterm infants. Such DNAm measures complement biological and clinical metrics when investigating the determinants of neurodevelopmental differences.

Emotional and behavioural outcomes at 8 years of age in preterm-born children: A longitudinal study

AIM

To evaluate the predictive value of perinatal factors and neurodevelopmental evaluation in the emotional and behavioural outcomes in preterm-born children at 7-9 years of age.

METHODS

We evaluated the Strengths and Difficulties Questionnaire (SDQ) extended score at 8.2 ± 0.2 years, among 70 preterm-born children (32 early and 38 moderately preterms) with a previous Bayley-III neurodevelopmental evaluation.

RESULTS

Early compared to moderately preterms had a higher total SDQ (12 compared to 8, p = 0.031), and emotional symptoms score (4 compared to 3, p = 0.022); no significant differences were recorded in abnormal/borderline-scored children between the two groups. The total SDQ and emotional symptoms scores were significantly correlated with gestational age, birth weight, perinatal factors and the cognitive and motor Bayley-III scores. Early prematurity was associated with the total SDQ score (beta 2.09, 95% CI 1.32, 3.87), and the score of emotional symptoms (beta 1.70, 95% CI 1.38, 2.19), after adjusting for sex, neonatal sepsis and the existence of an older sibling.

CONCLUSION

Prematurity, birth weight, perinatal factors and the cognitive and motor Bayley-III scores were significantly associated with the total SDQ and the emotional symptoms score, in preterm-born children.

Impact of time to full enteral feeding on long-term neurodevelopment without mediating by postnatal growth failure in very-low-birth-weight-infants

This study aimed to determine if time to achieve full enteral feeding (TFF) directly impacted long-term neurodevelopmental delay (NDD) and whether long-term postnatal growth failure (PGF) was a mediator of this association in very-low-birth-weight (VLBW) infants. Using prospectively collected cohort data from the Korean Neonatal Network, we included eligible VLBW infants who achieved TFF at least once and classified enrolled infants into four groups using exposure severity (P1 to P4 as TFF < 16, 16-30, 31-45, and > 45 postnatal days, respectively). After adjusting for confounding variables, survival without NDD was significantly decreased in P4 infants compared with that in P2 infants. P1 infants had a lower risk of weight and height PGF than P2 infants; however, P4 infants had higher risks of height and head circumference PGF than P2 infants. Weight and height PGF were significantly associated with an increased risk of NDD. In mediation analysis, early and delayed TFF revealed direct positive and negative impacts, respectively, on the risk of NDD without mediation by PGF. TFF impacted survival without NDD, and PGF did not mediate this association in VLBW infants. Additionally, these results can be translated into evidence-based quality improvement practice.

Proportion of Infant Neurodevelopment Trials Reporting a Null Finding: A Systematic Review

CONTEXT

Discovering new interventions to improve neurodevelopmental outcomes is a priority; however, clinical trials are challenging and methodological issues may impact the interpretation of intervention efficacy.

OBJECTIVES

Characterize the proportion of infant neurodevelopment trials reporting a null finding and identify features that may contribute to a null result.

DATA SOURCES

The Cochrane library, Medline, Embase, and CINAHL databases.

STUDY SELECTION

Randomized controlled trials recruiting infants aged <6 months comparing any "infant-directed" intervention against standard care, placebo, or another intervention. Neurodevelopment assessed as the primary outcome between 12 months and 10 years of age using a defined list of tools.

DATA EXTRACTION

Two reviewers independently extracted data and assessed quality of included studies.

RESULTS

Of n = 1283 records screened, 21 studies (from 20 reports) were included. Of 18 superiority studies, >70% reported a null finding. Features were identified that may have contributed to the high proportion of null findings, including selection and timing of the primary outcome measure, anticipated effect size, sample size and power, and statistical analysis methodology and rigor.

LIMITATIONS

Publication bias against null studies means the proportion of null findings is likely underestimated. Studies assessing neurodevelopment as a secondary or within a composite outcome were excluded.

CONCLUSIONS

This review identified a high proportion of infant neurodevelopmental trials that produced a null finding and detected several methodological and design considerations which may have contributed. We make several recommendations for future trials, including more sophisticated approaches to trial design, outcome assessment, and analysis.

Early Developmental Trends in High-Risk Neonates Later Diagnosed With Autism Spectrum Disorder

PURPOSE

We hypothesized that clinical data from a neonatal intensive care unit (NICU) infant developmental follow-up clinic would identify early manifestations of autism spectrum disorder (ASD).

METHODS

One hundred forty-four infants were identified; 72 later diagnosed with ASD and 72 controls. Retrospective chart review provided data from the Test of Infant Motor Performance (TIMP) and the Bayley Scales of Infant and Toddler Development, third edition (Bayley-III), between 8 and 26 months of age.

RESULTS

Between-group comparisons indicated no significant group difference in TIMP scores; however, Bayley-III scaled scores differed between the groups at 2 administration times. The within-group Bayley-III change scores declined significantly more for the ASD group in cognitive and communication subtests.

CONCLUSION

High-risk neonates, due to prematurity or morbidity, later diagnosed with ASD demonstrated statistically significant differences, including a more precipitous drop in Bayley-III scores over time. Early, longitudinal developmental surveillance for neonates at risk of ASD is critical. What this adds to the evidence: Early identification of ASD is critical to optimize developmental outcomes in young children, including infants born prematurely or with neonatal morbidity, who are perceived to have an increased risk for ASD. Despite these findings, minimal research has been conducted to evaluate the utility of commonly administered norm-referenced developmental surveillance instruments to identify possible early signs of ASD in this high-risk population due to prematurity or neonatal morbidity and not familial association. The present study analyzed retrospectively collected clinical data from a NICU developmental follow-up clinic for 144 infants, 72 of which were later diagnosed with ASD and 72 sex- and gestational age-matched controls. Results demonstrated statistically significant poorer Bayley-III outcomes for the ASD group compared with controls at 2 different study time points, including a more precipitous drop in Bayley-III scaled scores over time. This study highlights the importance of early and longitudinal developmental surveillance for high-risk neonates at risk of ASD.

Incidence of and Neurodevelopmental Outcomes After Late-Onset Meningitis Among Children Born Extremely Preterm

Importance

Late-onset meningitis (LOM) has been associated with adverse neurodevelopmental outcomes in children born extremely preterm.

Objective

To report the incidence of LOM during birth hospitalization and neurodevelopmental outcomes at 18 to 26 months' corrected age.

Design, Setting, and Participants

This cohort study is a secondary analysis of a multicenter prospective cohort of children born at 22 to 26 weeks' gestation between 2003 and 2017 with follow-up from 2004 to 2021. The study was conducted at 25 Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network centers.

Exposures

Culture-confirmed LOM.

Main Outcomes and Measures

Incidence and microbiology of LOM (2003-2017); lumbar puncture (LP) performance in late-onset sepsis (LOS) evaluations (2011-2017); composite outcome of death or neurodevelopmental impairment (NDI; 2004-2021).

Results

Among 13 372 infants (median [IQR] gestational age, 25.4 [24.4-26.1] weeks; 6864 [51%] boys), LOM was diagnosed in 167 (1%); LOS without LOM in 4564 (34%); and neither LOS nor LOM in 8641 (65%). The observed incidence of LOM decreased from 2% (95% CI, 1%-3%) in 2003 to 0.4% (95% CI, 0.7%-1.0%) in 2017 (P < .001). LP performance in LOS evaluations decreased from 36% (95% CI, 33%-40%) in 2011 to 24% (95% CI, 21%-27%) in 2017 (P < .001). Among infants with culture-confirmed LOS, LP performance decreased from 58% (95% CI, 51%-65%) to 45% (95% CI, 38%-51%; P = .008). LP performance varied by center among all LOS evaluations (10%-59%, P < .001) and among those with culture-confirmed LOS (23%-79%, P < .001). LOM occurred in the absence of concurrent LOS in 27 of 167 cases (16%). The most common LOM isolates were coagulase-negative Staphylococcus (98 [59%]), Candida albicans (38 [23%]), and Escherichia coli (27 [16%]). Death or NDI occurred in 22 of 46 children (48%) with LOM due to coagulase-negative Staphylococcus, 43 of 67 (64%) due to all other bacterial pathogens, and 26 of 33 (79%) due to fungal pathogens. The adjusted relative risk of death or NDI was increased among children with LOM (aOR, 1.53; 95% CI, 1.04-2.25) and among those with LOS without LOM (aOR, 1.41; 95% CI, 1.29-1.54) compared with children with neither infection.

Conclusions and Relevance

In this cohort study, LP was performed with decreasing frequency, and the observed incidence of LOM also decreased. Both LOM and LOS were associated with increased risk of death or NDI; risk varied by LOM pathogen. The full association of LOM with outcomes of children born extremely preterm may be underestimated by current diagnostic practices.

Enhancing the Follow-up Assessment of Very Preterm Children with Regard to 5-Year IQ Considering Socioeconomic Status

BACKGROUND

Specifying peri- and postnatal factors in children born very preterm (VPT) that affect later outcome helps to improve long-term treatment.

AIM

To enhance the predictability of 5-year cognitive outcome by perinatal, 2-year developmental and socio-economic data.

SUBJECTS AND OUTCOME MEASURES

92 VPT infants, born 2007-2009, gestational age<32 weeks and/or birthweight of 1500 g, were assessed longitudinally including basic neonatal, socio-economic (SES), 2-year Mental Developmental Index (MDI, Bayley Scales II), 5-year Mental Processing Composite (MPC, Kaufman-Assessment Battery for Children), and Language Screening for Preschoolers data. 5-year infants born VPT were compared to 34 term controls.

RESULTS

The IQ of 5-year infants born VPT was 10 points lower than that of term controls and influenced independently by preterm birth and SES. MDI, SES, birth weight and birth complications explained 48% of the variance of the MPC. The MDI proved highly predictive (r=0.6, R2=36%) for MPC but tended to underestimate the cognitive outcome. A total of 61% of the 2-year infants born VPT were already correctly classified (specificity of .93, sensitivity of .54). CHAID decision tree technique identified SES as decisive for the outcome for infants born VPT with medium MDI results (76-91): They benefit from effects associated to a higher SES, while those with a poor MDI outcome and a birth weight≤890 g do not.

CONCLUSION

Developmental follow-up of preterm children enhances the quality of prognosis and later outcome when differentially considering perinatal risks and SES.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Early neurodevelopmental follow-up in the NICHD neonatal research network: Advancing neonatal care and outcomes, opportunities for the future

At the inception of the Eunice Kennedy Shriver National Institute of Child Health and Development Neonatal Research Network (NRN), provision of care for extremely preterm (EPT) infants was considered experimental. The NRN Follow-up Study Group, initiated in 1993, developed infrastructure with certification processes and standards, allowing the NRN to assess 2-year outcomes for EPT and to provide important metrics for randomized clinical trials. This chapter will review the NRN Follow-up Study Group's contributions to understanding factors related to improved neurodevelopmental, behavioral, and social-emotional outcomes of EPT infants. We will also discuss follow up challenges, including reassessing which outcomes are most meaningful for parents and investigators. Finally, we will explore how outcome studies have informed clinical decisions and ethical considerations, given limitations of prediction of complex later childhood outcomes from early neurodevelopmental findings.

Brain Development and Maternal Behavior in Relation to Cognitive and Language Outcomes in Preterm-Born Children

BACKGROUND

Children born very preterm (≤32 weeks gestational age) show poorer cognitive and language development compared with their term-born peers. The importance of supportive maternal responses to the child's cues for promoting neurodevelopment is well established. However, little is known about whether supportive maternal behavior can buffer the association of early brain dysmaturation with cognitive and language performance.

METHODS

Infants born very preterm (N = 226) were recruited from the neonatal intensive care unit for a prospective, observational cohort study. Chart review (e.g., size at birth, postnatal infection) was conducted from birth to discharge. Magnetic resonance imaging, including diffusion tensor imaging, was acquired at approximately 32 weeks postmenstrual age and again at term-equivalent age. Fractional anisotropy, a quantitative measure of brain maturation, was obtained from 11 bilateral regions of interest in the cortical gray matter. At 3 years (n = 187), neurodevelopmental testing (Bayley Scales of Infant and Toddler Development-III) was administered, and parent-child interaction was filmed. Maternal behavior was scored using the Emotional Availability Scale-IV. A total of 146 infants with neonatal brain imaging and follow-up data were included for analysis. Generalized estimating equations were used to examine whether maternal support interacted with mean fractional anisotropy values to predict Cognitive and Language scores at 3 years, accounting for confounding neonatal and maternal factors.

RESULTS

Higher maternal support significantly moderated cortical fractional anisotropy values at term-equivalent age to predict higher Cognitive (interaction term β = 2.01, p = .05) and Language (interaction term β = 1.85, p = .04) scores.

CONCLUSIONS

Findings suggest that supportive maternal behavior following early brain dysmaturation may provide an opportunity to promote optimal neurodevelopment in children born very preterm.

Development of neonatal high-risk preterm infants in comparison to full-term counterparts

Studies on preterm infants usually exclude high-risk neonatal infants with neurological problems. However, it is important to study high-risk preterm infants to better understand later developmental problems. Therefore, this cross-sectional study aimed to compare the cognitive, motor, language, and social-emotional development of high-risk preterm (PT) infants with infants born full-term (FT) with no biological vulnerabilities during early development (up to the first 15 months of age). The sample comprised 133 infants (54 born PT and 79 born FT) assessed in independent subsamples at 6-8 and 12-15 months of age, considering the corrected age for prematurity in the PT infants. Infant development (cognitive, motor, language, and social-emotional) was evaluated using the Bayley-III Scales. Medical charts were reviewed to obtain the clinical history. A multivariate analysis of variance and analysis of variance tests were performed to examine the differences between groups related to infant developmental indicators, controlling for age and socioeconomic variables. Although the PT infants performed significantly more poorly than their FT counterparts, the scores of the PT group were still within the normal range on all Bayley-III domains (cognitive, language, motor, and social-emotional) than their FT counterparts. The findings of the present study provide a better understanding of the developmental prognosis of high-risk PT infants and extend support for preventive intervention programs to improve early childhood development.

A self-training deep neural network for early prediction of cognitive deficits in very preterm infants using brain functional connectome data

BACKGROUND

Deep learning has been employed using brain functional connectome data for evaluating the risk of cognitive deficits in very preterm infants. Although promising, training these deep learning models typically requires a large amount of labeled data, and labeled medical data are often very difficult and expensive to obtain.

OBJECTIVE

This study aimed to develop a self-training deep neural network (DNN) model for early prediction of cognitive deficits at 2 years of corrected age in very preterm infants (gestational age ≤32 weeks) using both labeled and unlabeled brain functional connectome data.

MATERIALS AND METHODS

We collected brain functional connectome data from 343 very preterm infants at a mean (standard deviation) postmenstrual age of 42.7 (2.5) weeks, among whom 103 children had a cognitive assessment at 2 years (i.e. labeled data), and the remaining 240 children had not received 2-year assessments at the time this study was conducted (i.e. unlabeled data). To develop a self-training DNN model, we built an initial student model using labeled brain functional connectome data. Then, we applied the trained model as a teacher model to generate pseudo-labels for unlabeled brain functional connectome data. Next, we combined labeled and pseudo-labeled data to train a new student model. We iterated this procedure to obtain the best student model for the early prediction task in very preterm infants.

RESULTS

In our cross-validation experiments, the proposed self-training DNN model achieved an accuracy of 71.0%, a specificity of 71.5%, a sensitivity of 70.4% and an area under the curve of 0.75, significantly outperforming transfer learning models through pre-training approaches.

CONCLUSION

We report the first self-training prognostic study in very preterm infants, efficiently utilizing a small amount of labeled data with a larger share of unlabeled data to aid the model training. The proposed technique is expected to facilitate deep learning with insufficient training data.

High-Risk Neighborhoods and Neurodevelopmental Outcomes in Infants Born Preterm

OBJECTIVE

To study the association between neighborhood risk and moderate to severe neurodevelopmental impairment (NDI) at 22-26 months corrected age in children born at <34 weeks of gestation. We hypothesized that infants born preterm living in high-risk neighborhoods would have a greater risk of NDI and cognitive, motor, and language delays.

STUDY DESIGN

We studied a retrospective cohort of 1291 infants born preterm between 2005 and 2016, excluding infants with congenital anomalies. NDI was defined as any one of the following: a Bayley Scales of Infant and Toddler Development-III Cognitive or Motor composite score <85, bilateral blindness, bilateral hearing impairment, or moderate-severe cerebral palsy. Maternal addresses were geocoded to identify census block groups and create high-risk versus low-risk neighborhood groups. Bivariate and regression analyses were run to assess the impact of neighborhood risk on outcomes.

RESULTS

Infants from high-risk (n = 538; 42%) and low-risk (n = 753; 58%) neighborhoods were compared. In bivariate analyses, the risk of NDI and cognitive, motor, and language delays was greater in high-risk neighborhoods. In adjusted regression models, the risks of NDI (OR, 1.43; 95% CI, 1.04-1.98), cognitive delay (OR, 1.62; 95% CI, 1.15-2.28), and language delay (OR, 1.58; 95% CI, 1.15-2.16) were greater in high-risk neighborhoods. Breast milk at discharge was more common in low-risk neighborhoods and was protective of NDI in regression analysis.

CONCLUSIONS

High neighborhood risk provides an independent contribution to preterm adverse NDI, cognitive, and language outcomes. In addition, breast milk at discharge was protective. Knowledge of neighborhood risk may inform the targeted implementation of programs for socially disadvantaged infants.

Treatment of Posthemorrhagic Hydrocephalus

The incidence of intraventricular hemorrhage (IVH) has overall declined to 15% to 20% of preterm infants with birth weight less than 1500 g. One of the major complications of severe IVH is posthemorrhagic ventricular dilation (PHVD). Nearly 10% of all infants with IVH and 20% of infants with severe IVH will develop progressive PHVD requiring surgical intervention to prevent parenchymal damage in the developing brain. This review focuses on the controversies regarding posthemorrhagic hydrocephalus interventions with a focus on how to interpret recent data from trials that some have seen as heralding a call toward more aggressive intervention.

Cognitive Outcomes Following Intravitreal Bevacizumab for Retinopathy of Prematurity: 4- to 6-Year Outcomes in a Prospective Cohort

PURPOSE

To determine the long-term cognitive outcomes in children who underwent intravitreal bevacizumab (IVB) for retinopathy of prematurity (ROP).

DESIGN

Prospective cohort study.

METHODS

This single-center study enrolled 186 children between 3 and 6 years of age and included 101 children in the final analysis: premature without ROP (group 1), ROP not needing treatment (group 2), IVB monotherapy (group 3), IVB plus laser therapy (group 4), and laser monotherapy (group 5). The Full-Scale Intelligence Quotient (FSIQ) was evaluated by the Wechsler Preschool and Primary Scale of Intelligence Test at baseline and then annually for 1-2 years and compared among groups.

RESULTS

The age at cognitive evaluation was 4.5-4.9 years at baseline and 6.1-7.0 years at the last follow-up. The FSIQ was comparable among the groups at both time points (P = .08 and .50, respectively). Severe cognitive impairment (FSIQ < 70) was more common in group 4 at baseline (4%, 22%, 13%, 33%, and 0% in groups 1-5, respectively; P = .03) but did not differ among the groups at the last follow-up (6%, 0%, 4%, 22%, and 0%; P = .22). After adjusting for sex, Apgar score, neonatal adverse events, and days on mechanical ventilation, IVB was not associated with FSIQ either at baseline or at the last follow-up.

CONCLUSIONS

At 4.5 to beyond 6 years of age, children who underwent IVB monotherapy had comparable cognitive outcomes compared to the other premature children without prior IVB. Children who underwent IVB plus laser showed higher severe cognitive impairment at 4.5 years of age.

Quantitative Diffusion and Spectroscopic Neuroimaging Combined with a Novel Early-Developmental Assessment Improves Models for 1-Year Developmental Outcomes

BACKGROUND AND PURPOSE

Preterm infants are at risk for overt and silent CNS injury, with developmental consequences that are difficult to predict. The novel Specific Test of Early Infant Motor Performance, administered in preterm infants at term age, is indicative of later developmental gross motor and cognitive scores at 12 months. Here, we assessed whether functional performance on this early assessment correlates with CNS integrity via MR spectroscopy or diffusional kurtosis imaging and whether these quantitative neuroimaging methods improve predictions for future 12-month developmental scores.

MATERIALS AND METHODS

MR spectroscopy and quantitative diffusion MR imaging data were acquired in preterm infants (n = 16) at term. Testing was performed at term and 3 months using the Specific Test of Early Infant Motor Performance and the Bayley Scales of Infant and Toddler Development, Third Edition, at 12 months. We modeled the relationship of MR spectroscopy and diffusion MR imaging data with both test scores via multiple linear regression.

RESULTS

MR spectroscopy NAA ratios at a TE of 270 ms in the frontal WM and basal ganglia and kurtosis metrics in major WM tracts correlated strongly with total Specific Test of Early Infant Motor Performance scores. The addition of MR spectroscopy and diffusion separately improved the functional predictions of 12-month outcomes.

CONCLUSIONS

Microstructural integrity of the major WM tracts and metabolism in the basal ganglia and frontal WM strongly correlate with early developmental performance, suggesting that the Specific Test of Early Infant Motor Performance reflects CNS integrity after preterm birth. This study demonstrates that combining quantitative neuroimaging and early functional movement improves the prediction of 12-month outcomes in premature infants.

Serial plasma biomarkers of brain injury in infants with neonatal encephalopathy treated with therapeutic hypothermia

BACKGROUND

Neonatal encephalopathy (NE) is a major cause of long-term neurodevelopmental disability in neonates. We evaluated the ability of serially measured biomarkers of brain injury to predict adverse neurological outcomes in this population.

METHODS

Circulating brain injury biomarkers including BDNF, IL-6, IL-8, IL-10, VEGF, Tau, GFAP, and NRGN were measured at 0, 12, 24, 48, 72, and 96 h of cooling from 103 infants with NE undergoing TH. The biomarkers' individual and combinative ability to predict death or severe brain injury and adverse neurodevelopmental outcomes beyond 1 year of age was assessed.

RESULTS

Early measurements of inflammatory cytokines IL-6, 8, and 10 within 24 HOL (AUC = 0.826) and late measurements of Tau from 72 to 96 HOL (AUC = 0.883, OR 4.37) were accurate in predicting severe brain injury seen on MRI. Late measurements of Tau were predictive of adverse neurodevelopmental outcomes (AUC = 0.81, OR 2.59).

CONCLUSIONS

Tau was consistently a predictive marker for brain injury in neonates with NE. However, in the first 24 HOL, IL-6, 8, and 10 in combination were most predictive of death or severe brain injury. The results of this study support the use of a serial biomarker panel to assess brain injury over the time course of disease in NE.

IMPACT

While recent studies have evaluated candidate brain injury biomarkers, no biomarker is in current clinical use. This study supports the use of a serial biomarker panel for ongoing assessment of brain injury neonates with NE. In combination, IL6, IL8, and IL10 in the first 24 h of cooling were more predictive of brain injury by MRI than each cytokine alone. Individually, Tau was overall most consistently predictive of adverse neurological outcomes, particularly when measured at or after rewarming.

Maternal, perinatal and childhood outcomes of the PPROMEXIL-III cohort: Pregnancies complicated by previable prelabor rupture of membranes

OBJECTIVE

Perinatal mortality after previable prelabor rupture of membranes (previable PROM) might be underestimated as most studies exclude patients with poor prognosis, or solely include patients in tertiary-care centers. We aimed to report perinatal, neonatal and long-term outcomes in a consecutive series of women with pregnancies complicated by previable PROM.

STUDY DESIGN

We conducted a prospective cohort study including women with singleton pregnancies and previable PROM ≤ 23⁺⁶ weeks gestational age (GA) from one tertiary hospital and eight affiliated secondary hospitals in the region of Amsterdam, the Netherlands (June 2012 until January 2016, PPROMEXIL-III cohort). Exclusion criteria were signs of active labor before onset of PROM or fetal structural anomalies visible at ultrasound. We assessed perinatal mortality. Furthermore, outcomes were maternal, perinatal, neonatal and long-term child characteristics.

RESULTS

We included 98 pregnancies with previable PROM. Twelve women (12.2%) opted for termination of pregnancy, resulting in 86 pregnancies included in further analyses. Median GA at PROM was 20⁺² weeks (interquartile range (IQR) 17⁺⁶-22⁺⁰). Median GA at delivery was 22⁺⁶ weeks (IQR 20⁺¹-26⁺⁴). Delivery within 1 week occurred in 38.4% of women and 60.4% delivered before 24 weeks GA (viability). Perinatal mortality occurred in 73.3% of pregnancies. 23/33 (69.7%) live-born neonates survived to discharge, representing 26.7% of total. None of the children died after discharge. Developmental data at two and/or five years of age was available for 13/23 children (i.e. all children born before 32 weeks of gestation), with 69.2% of children reporting a normal neurodevelopment. However, more than half of children reported respiratory problems.

CONCLUSION

In women with previable PROM perinatal mortality was 73.3%, with a normal neurodevelopment in 69.2% of surviving children with follow-up data. Due to broad inclusion criteria, this cohort represents a population more generalizable to daily practice as compared to previous studies.

Global prevalence of long-term neurodevelopmental impairment following extremely preterm birth: a systematic literature review

Objective

Neurodevelopmental impairment (NDI) is a major complication of extreme prematurity. This systematic review was conducted to summarize the worldwide long-term prevalence of NDI associated with extreme prematurity.

Methods

Embase and MEDLINE databases were searched for epidemiologic and observational/real-world studies, published in English between 2011 and 2016, reporting long-term prevalence of NDI (occurring from 1 year) among extremely preterm infants born at gestational age (GA) ≤28 weeks.

Results

Of 2406 articles identified through searches, 69 met the protocol NDI definition (24 North America, 25 Europe, 20 Rest of World). Prevalence of any severity NDI in North America was 8%–59% at 18 months to 2 years, and 11%–37% at 2–5 years; prevalence of moderate NDI in Europe was 10%–13% at 18 months to 2 years, 3% at 2–5 years, and 9%–19% at ≥5 years; prevalence of any NDI in Rest of World was 15%–61% at 18 months to 2 years, and 42% at 2–5 years (no North America/Rest of World studies reported any NDI at ≥5 years). A trend toward higher prevalence of NDI with lower GA at birth was observed.

Conclusions

Extreme prematurity has a significant long-term worldwide impact on neurodevelopmental outcomes.

Extra-uterine growth restriction in preterm infants: Neurodevelopmental outcomes according to different definitions

AIM

Extra-uterine Growth Restriction (EUGR) is common among preterm infants. Two types of EUGR definitions are still now available: cross-sectional definitions and longitudinal ones. In a cohort of very preterm infants, we aimed to evaluate which definition could better predict neurodevelopmental outcomes at 2 years of corrected age. We used Italian Neonatal Study Charts (INeS) growth charts and INTERGROWTH-21st (IG-21) standard charts and compared results.

METHOD

We restrospectively collected data from clinical charts of 324 preterm newborns with a gestational age ≤30 weeks born from 2012 to 2017. Then we compared forty-eight definitions (24 cross-sectional and 24 longitudinal) of EUGR, in term of neurodevelopmental outcomes at 2 years of corrected age.

RESULTS

We included in the study 254 preterm infants, whose clinical information met the enrolment criteria. Nineteen out of 48 definitions of EUGR were significantly predictive both for Griffith's Development Quotient (GDQ) and Neurodevelopment Impairment (NDI). Among these, longitudinal definitions appeared to have a higher negative predictive value for NDI than cross-sectional ones. Furthermore, infants with EUGR appeared to have a lower cognitive score than their peers without EUGR.

INTERPRETATION

A loss of Zs > 1 SDS in weight and head circumference, calculated from when physiological weight loss is over and identified as soon as possible rather than at discharge, better predicts neurodevelopmental outcomes of preterm infants.

Comparison of two markers of iron sufficiency and neurodevelopmental outcomes

BACKGROUND

Iron deficiency during critical windows of brain development is associated with suboptimal neurodevelopmental outcomes. Identifying markers of neonatal iron status that best correlate with neurodevelopmental outcome is critical for optimal management of iron supplementation of neonates.

AIMS

We aimed to evaluate two markers of iron sufficiency, ferritin and zinc protoporphyrin-to-heme ratios (ZnPP/H), with neurodevelopmental outcomes.

STUDY DESIGN

This is a retrospective cohort study.

SUBJECTS

All infants with concurrent ferritin and ZnPP/H measurements obtained between October 2014 and April 2017 and Bayley Scales of Infant Development, 3rd Edition (BSID-III) evaluated at 24 months corrected age were included.

OUTCOME MEASURES

Associations between iron markers (minimum, maximum and median ferritin and ZnPP/H) and BSID-III score at 24 months were assessed.

RESULTS

223 lab measurements from 62 infants were assessed. Mean gestational age was 28.1 weeks (SD = 2.6) with a mean birth weight of 1.1 kg (SD = 0.4). Significant associations between maximum and median ZnPP/H and motor score, and between median ZnPP/H and cognitive score were observed. Trends were also seen with higher minimum, median and maximum ZnPP/H associated with lower BSID-III scores, but did not reach statistical significance (p > 0.05). The associations between ferritin values and BSID scores were less consistent.

CONCLUSIONS

A positive association was seen between ZnPP/H values and BSID-III scores. Trends between ferritin and BSID values were less consistent, potentially because ferritin is more affected by inflammation. Consideration should be given to using ZnPP/H preferentially to adjust iron supplementation in the NICU to improve neurodevelopmental outcomes.

Small for Gestational Age Moderate to Late Preterm Children: A Neuropsychological Follow-up

Determine whether SGA constitutes a neurodevelopmental risk-factor of MLP, exploring if potential developmental difficulties at toddlerhood persist and are related to school-age performance. 109 SGA and 109 adequate for gestational age MLP children were evaluated at 2 and at 6.5 y.o. SGA children obtained poorer results in several areas at both timepoints; and their development at toddlerhood strongly correlated with only some results at school-age. SGA confers vulnerability to MLP, evolving from global/unspecific difficulties in toddlerhood to a domain-specific profile (attentional/dysexecutive) at 6.5. Findings claim the need for neuropsychological follow-up in MLP to identify emerging difficulties.

Music Is Life-Follow-Up Qualitative Study on Parental Experiences of Creative Music Therapy in the Neonatal Period

Developmental problems in extremely preterm (EP) infants and the associated longitudinal burden for their families are major health issues worldwide. Approaches to social-emotional support such as family-integrating Creative Music Therapy (CMT) are warranted. We aimed: (1) to explore parental perspectives on the use of CMT with EP infants in the neonatal hospitalization period and (2) to examine the possible longitudinal influence of CMT. A qualitative design was used to examine the perspective of six families from various backgrounds. Semi-structured interviews were carried out when the infants reached school age. We used an inductive-deductive thematic analysis to identify three main themes, each with three sub-themes: (1) the positive impact of CMT on the infants, the parents, and bonding; (2) the attitude toward CMT, from being open-minded to recommending it as complementary therapy; and (3) the experience of overall healthy infant development despite unique developmental delay issues. The findings elucidate the positive and formative impact of CMT on both infants and parents in the stressful NICU setting and beyond. CMT may empower positive transformation in the parents through individualized early nurturing musical interactions, capacity building, and positive reinforcement. Further research may help to identify and implement potentially modifiable factors for improving health care in this vulnerable group through early family-integrating, resource-based approaches such as CMT.

Autism spectrum disorders in extremely preterm infants and placental pathology findings: a matched case-control study

BACKGROUND

The prevalence of autism spectrum disorders (ASD) is 5-fold higher in preterm (PT) infants born ≤28 weeks gestational age (GA) as compared to the general population. The relationship between placental pathologic lesions and ASD in PT infants has not been studied.

OBJECTIVES

The objective of this study was to determine the association of placental pathology with the occurrence of ASD in PT infants born ≤28 weeks GA.

STUDY DESIGN

A matched case-control study to identify confirmed ASD cases (n = 16) and matched controls (n = 48) born at Parkland Hospital between January 2012 and December 2015. Patients were matched using known variables associated with increased risk of ASD in PT infants. Placental histology from all births was reviewed.

RESULTS

Children with ASD had 2-fold greater incidence of multiple placental pathologic lesions vs. matched controls [11/16 (69%) vs.16/48 (33%), respectively; P = 0.01]. In contrast, single placental pathologic lesions were not associated with ASD [5/16 (31%) vs. 21/48 (43%), respectively; P = 0.1].

CONCLUSIONS

In this study, we have demonstrated an association between the increasing complexity of histologic placental lesions and the later risk for ASD in infants born ≤28 weeks GA. Thus, placental pathology findings may be valuable in further understanding the prenatal pathologic processes underlying ASD in PT infants.

IMPACT

PT infants with ASD have a 2-fold greater incidence of multiple placental pathologies. This is the first study to report an association between the complexity of histologic placental lesions and later risk of ASD in infant born extremely PT (i.e., ≤28 weeks GA). This study reiterates the importance of examining placental pathologic lesions, since placental evidence of antenatal insults correlates with postnatal morbidities and mortality in PT infants.

Is It Correct to Correct for Prematurity? Theoretic Analysis of the Bayley-4 Normative Data

OBJECTIVE

To determine whether correction for prematurity is appropriate for cognitive, language, and motor function at varying degrees of prematurity and at different baseline functional levels.

METHODS

The newly published Bayley-4 normative data on 1700 normal children were used. Raw scores for baseline levels of function (-2 SD, -1 SD, and M) were identified at 6, 12, 24, and 36 months for receptive communication, expressive communication, fine motor, and gross motor scaled scores and cognitive, language, and motor composite scores. Differences between the baseline and uncorrected scores at 4, 3, 2, and 1 months of prematurity were evaluated at each age.

RESULTS

Using a cutoff of 3 points (1/5 SD), correction is needed for cognitive composite scores at all gestational ages for the first 2 years and in those born 4 months premature at 3 years of age; language and motor composite scores should be corrected to 3 years at all degrees of prematurity.

CONCLUSION

Not correcting for prematurity in cognitive, language, and motor function at 3 years and younger places preterm infants at a distinct disadvantage when compared to peers with few exceptions, suggesting that such correction should be routine.

Intrapartum opioid analgesia and childhood neurodevelopmental outcomes among infants born preterm

BACKGROUND

There are concerns regarding neurobehavioral changes in infants exposed to parenteral opioids during labor; however, long-term neurodevelopment remains unstudied.

OBJECTIVE

We aimed to examine the association between parenteral opioids used as labor analgesia and perinatal outcomes and childhood neurodevelopment until 2 years of age among infants born prematurely. We hypothesized that intrapartum exposure to parenteral opioids is associated with impaired neurodevelopment and adverse perinatal outcomes.

STUDY DESIGN

This was a secondary analysis of a multicenter, randomized controlled trial assessing magnesium for the prevention of cerebral palsy in infants at risk for preterm birth. Women delivering a singleton, nonanomalous, live infant before 37 weeks' gestation were considered for inclusion. Women were excluded if they had missing exposure or primary outcome data, were exposed to general anesthesia, or reported use of heroin or unspecified illicit drugs. Women reporting use of nonopioid illicit drugs such as cocaine and marijuana were not excluded. Groups were compared based on exposure or nonexposure to parenteral opioids (intravenous or intramuscular) used as labor analgesia. The primary outcome was any psychomotor or mental developmental delay at 24 months according to the Bayley Scales of Infant Development II. Secondary outcomes were the Bayley Scales of Infant Development II subdomains and adverse perinatal outcomes. Multivariable logistic regression models were performed and adjusted odds ratios with 95% confidence intervals were estimated.

RESULTS

Of the 1404 women included, 535 (38%) received parenteral opioids as labor analgesia. Women receiving parenteral opioids were more likely to be younger, Hispanic, and present with cervical dilation ≥4 cm. Parenteral opioid recipients had lower rates of illicit nonopioid drug or tobacco use, a lower rate of cesarean delivery, lower educational level and were less likely to be undergoing induction. Women receiving parenteral opioids who underwent cesarean delivery were less likely to do so because of a nonreassuring fetal status. In the unadjusted and adjusted analyses, there were no significant differences in the primary outcomes of psychomotor or mental developmental delay at 2 years of age (adjusted odds ratio, 0.96; confidence interval, 0.76-1.20). The only significant difference in secondary outcomes was a shorter O₂ requirement duration in the parenteral opioid group (2 vs 4 days; P=.002).

CONCLUSION

Among a population of preterm infants vulnerable to neurologic impairment, intrapartum exposure to parenteral opioids was not associated with an increased risk for neurodevelopmental delay up to 2 years of age, nor did these infants have worse perinatal outcomes.

Development of Gross Motor Evaluation for Children Aged 18 to 42 Months

PURPOSE

To test the reliability and validity of the gross motor items making up a new instrument, Hong Kong Comprehensive Assessment Scales for Toddlers (HKCAS-T) for quantifying gross motor development among children aged 18 to 42 months.

METHODS

The 37 items were administered to 330 children, including 258 typically developing children and 72 children with gross motor delay.

RESULTS

Rasch analyzes indicated that the fit statistics of the 37 items were within the acceptable range. The assessment was found able to differentiate between typically developing children and those with gross motor delay and among children of different ages. The raw score reliability (KR-20) was 0.94.

CONCLUSION

The new instrument is a promising alternative for assessing young children's gross motor development.

Proactive neonatal treatment at 22 weeks of gestation: a systematic review and meta-analysis

OBJECTIVE

The objective of this study was to provide a systematic review and meta-analysis to quantify prognosis and identify factors associated with variations in reported mortality estimates among infants who were born at 22 weeks of gestation and provided proactive treatment (resuscitation and intensive care).

DATA SOURCES

PubMed, Scopus, and Web of Science databases, with no language restrictions, were searched for articles published from January 2000 to February 2020.

STUDY ELIGIBILITY CRITERIA

Reports on live-born infants who were delivered at 22 weeks of gestation and provided proactive care were included. The primary outcome was survival to hospital discharge; secondary outcomes included survival without major morbidity and survival without neurodevelopmental impairment. Because we expected differences across studies in the definitions for various morbidities, multiple definitions for composite outcomes of major morbidities were prespecified. Neurodevelopmental impairment was based on Bayley Scales of Infant Development II or III. Data extractions were performed independently, and outcomes agreed on a priori.

STUDY APPRAISAL AND SYNTHESIS METHODS

Methodological quality was assessed using the Quality in Prognostic Studies tool. An adapted version of the Grading of Recommendations Assessment, Development and Evaluation approach for prognostic studies was used to evaluate confidence in overall estimates. Outcomes were assessed as prevalence and 95% confidence intervals. Variabilities across studies attributable to heterogeneity were estimated with the I² statistic; publication bias was assessed with the Luis Furuya-Kanamori index. Data were pooled using the inverse variance heterogeneity model.

RESULTS

Literature searches returned 21,952 articles, with 2034 considered in full; 31 studies of 2226 infants who were delivered at 22 weeks of gestation and provided proactive neonatal treatment were included. No articles were excluded for study design or risk of bias. The pooled prevalence of survival was 29.0% (95% confidence interval, 17.2-41.6; 31 studies, 2226 infants; I²=79.4%; Luis Furuya-Kanamori index=0.04). Survival among infants born to mothers receiving antenatal corticosteroids was twice the survival of infants born to mothers not receiving antenatal corticosteroids (39.0% vs 19.5%; P<.01). The overall prevalence of survival without major morbidity, using a definition that includes any bronchopulmonary dysplasia, was 11.0% (95% confidence interval, 8.0-14.3; 10 studies, 374 infants; I²=0%; Luis Furuya-Kanamori index=3.02). The overall rate of survival without moderate or severe impairment was 37.0% (95% confidence interval, 14.6-61.5; 5 studies, 39 infants; I²=45%; Luis Furuya-Kanamori index=-0.15). Based on the year of publication, survival rates increased between 2000 and 2020 (slope of the regression line=0.09; standard error=0.03; P<.01). Studies were highly diverse with regard to interventions and outcomes reported.

CONCLUSION

The reported survival rates varied greatly among studies and were likely influenced by combining observational data from disparate sources, lack of individual patient-level data, and bias in the component studies from which the data were drawn. Therefore, pooled results should be interpreted with caution. To answer fundamental questions beyond the breadth of available data, multicenter, multidisciplinary collaborations, including alignment of important outcomes by stakeholders, are needed.

Prenatal Tobacco Exposure and Childhood Neurodevelopment among Infants Born Prematurely

OBJECTIVE

Nicotine is an established neuroteratogen, and prenatal tobacco exposure alters the structure of the developing nervous system. An association between prenatal tobacco exposure and impaired neurologic function is less well established. We examine the association between prenatal tobacco exposure and childhood neurodevelopment among infants born preterm.

STUDY DESIGN

Secondary analysis of a multicenter randomized controlled trial assessing the benefits of magnesium sulfate for the prevention of cerebral palsy in preterm infants. Women were included if they delivered a singleton and nonanomalous infant before 37 weeks. Exposure was any self-reported prenatal tobacco use. Primary outcome was the original trial composite outcome of moderate or severe cerebral palsy at 2 years of age, or stillbirth, or infant death by 1 year of age. Secondary outcomes included components of the composite and mild cerebral palsy at 2 years, Bayley Scales of Infant Development II motor and mental scores, death before two years, and use of auditory aids or corrective lenses. Multivariable logistic regression models were performed to estimate adjusted odds ratios (aOR) with 95% confidence intervals.

RESULTS

Of 1,826 women included, 503 (27.5%) used tobacco. Tobacco users were more likely to be older, unmarried, and white; have a prior preterm birth; have received no prenatal care; and to use illicit drugs or alcohol. Gestational age at delivery, betamethasone exposure, and magnesium exposure were not different between groups. There were no differences in the composite primary outcome or in rates of cerebral palsy by tobacco use. Moderate developmental delay was more common among tobacco exposed in bivariate but not adjusted analysis (20.5 vs. 15.9%, p = 0.035). In adjusted analysis, tobacco exposure was associated with increased use of corrective lenses (5.0 vs. 2.9%, aOR: 2.28, 95% confidence interval: 1.28-4.07).

CONCLUSION

Prenatal tobacco exposure is not associated with neurodevelopmental impairment in infants born preterm. However, tobacco exposure may be associated with impaired vision.

KEY POINTS

· Tobacco exposure is not associated with impaired neurodevelopment in this preterm population.. · Prenatal tobacco exposure is associated with increased need for corrective lenses.. · Tobacco use in pregnancy may be a risk factor for poorer visual acuity in children..

Neurologic Outcomes After Prenatal Treatment of Twin-Twin Transfusion Syndrome

Monochorionic twin gestations possess disproportionately higher risk for perinatal morbidity and mortality when compared with dichorionic twin pregnancies due to their potential to develop specific complications attributable to a shared placenta and intertwin placental circulation. Since the advent of fetoscopic laser surgery, outcomes of pregnancies affected by twin-twin transfusion syndrome (TTTS) have improved, with reduced rates of mortality and morbidity when compared with amnioreduction or expectant management. The focus of this article is to review the literature regarding neurologic outcomes among pediatric survivors of fetal intervention for TTTS.

Neurodevelopmental Outcome in Extremely Low Birth Weight Infants at 2-3 Years of Age

Background and objectives: The aims of this study were to examine the relationship between neurological outcomes at 3- and 6-months corrected age with the neurodevelopmental outcome at 3 years of age; to identify the perinatal/neonatal risk factors for poor neurodevelopmental outcomes at 3 years of age. Materials and methods: In our single-centre longitudinal cohort study, of the 73 consecutive infants admitted to our Neonatal Intensive Care Unit (NICU), 49 infants (80%) received both Hammersmith Infant Neurological Examination (HINE) at 3- and 6-months corrected age and Bayley–III neurodevelopmental assessment at 2–3 years chronological age. At 3 months follow up, 8.2% had suboptimal scores (below 10th percentile) on the HINE. At 6 months follow up, 4.1% had suboptimal scores (below 10th percentile) on the HINE. The means(±SD) for Bayley-III cognitive, language, and motor subscales were (96.3 ± 9.8), (99.9 ± 11.9), (93.2 ± 9.9). Results: At 3 months corrected age, higher total HINE scores and subscores for function of cranial nerves, posture, tone, were associated with better cognitive scores while poorer scores for function of cranial nerves, posture, movements, tone, and total HINE score were associated with lower motor scores. Infants with a HINE subscore of function of cranial nerves in the suboptimal range have three times higher odds of having a motor delay. Infants with a HINE subscore of function of cranial nerves in the suboptimal range have more than two times higher odds of having a language delay. At 6 months corrected age, poorer scores for function of cranial nerves, movements, tone, reflexes, and total HINE score were associated with worse Bayley-III motor scores whilst infants who have a total HINE score and a subscore of reflexes in the suboptimal range have four and seven times, respectively, higher odds of having a motor delay. Conclusions: Early identification of infants at risk for adverse long-term outcomes is essential in introducing early intervention therapies for optimizing neurodevelopmental outcomes.

Predictive Value of the BSID-II and the Bayley-III for Early School Age Cognitive Function in Very Preterm Infants

Objective

To compare the predictive validity of the Bayley Scales of Infant Development, Second Edition (BSID-II) and the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) for cognitive function at early school age in very preterm infants.

Methods

Seventy-seven former preterm infants (born <32 weeks gestation and ≤2000 g) completed both the BSID-II and the Bayley-III at 2 years corrected age. Children enrolled at hospitals that perform follow-up beyond 2 years had cognitive assessments with the Wechsler Preschool and Primary Scale of Intelligence Fourth Edition (WPPSI-IV). Associations between Bayley and WPPSI scores were assessed using correlation coefficients, linear regression, and Bland-Altman plots.

Results

Thirty-one of 45 eligible children were tested with the WPPSI-IV at 47 ± 11 months. Average BSID-II Mental Development Index (MDI) was 86 ± 19, Bayley-III Cognitive composite score was 101 ± 12 and WPPSI Full Scale IQ (FSIQ) was 96 ± 12. Correlation between MDI and FSIQ was 0.54 (P < .001); correlation between Bayley-III cognitive composite score and FSIQ was 0.31 (P = .03). Bayley-III language composite had a modestly stronger correlation with FSIQ than cognitive composite (correlation coefficient 0.39; P = .005). Linear regression models also demonstrated that BSID-II was more closely correlated with FSIQ than Bayley-III. This bias was consistent across the full range of scores.

Conclusion

The BSID-II underestimated FSIQ and the Bayley-III overestimated FSIQ. Children at risk for impairment might be missed with the Bayley-III. As the Bayley-4 is introduced, clinicians and researchers should be cautious about interpretation of scores until performance of this new measure is fully understood.

Neuromotor Development Evaluation of Preterm Babies Less than 34 Weeks of Gestation with Bayley III at 18-24 Months

Objectives

To assess and evaluate the risk factors affecting the neuromotor development of preterm babies at corrected age 18 to 24 months.

Methods

Preterm babies ≤ 34 weeks of gestational age (GA) who were born in our hospital between 2011 and 2014 were prospectively included in the study. Prenatal, perinatal, and postnatal features of the babies were recorded. Bayley Scales of Infants and Toddler Development, Third Edition (Bayley-III), was applied at corrected age 18 to 24 months.

Results

All data of 96 babies were obtained during the study, mean birth weight was 1542 ± 518 g, and mean corrected age was 20.9 ± 4.7 months. Cerebral palsy was found in 11 babies (11.5%). According to Bayley III scores, 13.5% cognitive delay, 19.8% language delay, and 33.3% motor delay rations were detected. A positive correlation was found between GA and motor composite scores (p = 0.011). The mean motor composite score was lower in babies with the Apgar score less than 7 at 1st and 5th minutes (p = 0.007 and p = 0.003) and applied resuscitation in the delivery room (p = 0.033). The mean language composite score was found to be higher in babies with antenatal steroid administration (p = 0.003). A negative correlation was found between the motor composite score and the oxygen treatment time and mechanical ventilation support time (p = 0.001 and p = 0.007).

Conclusion

In preterm babies less than 34 weeks, the birth weight, GA, Apgar score, oxygen treatment time, mechanical ventilation support time, and resuscitation in a delivery room were determined to affect the Bayley III motor score. Language development was found better in babies with antenatal steroid administration.

Developmental trajectories of infants born at less than 30 weeks' gestation on the Bayley-III Scales

OBJECTIVE

To describe the cognitive, language and motor developmental trajectories of children born very preterm and to identify perinatal factors that predict the trajectories.

DESIGN

Data from a cohort of 1142 infants born at <30 weeks' gestation who were prospectively assessed on the Bayley Scales of Infant and Toddler Development, third edition (Bayley-III) at 3, 6, 12 and 24 months corrected age, were analysed using the Super Imposition by Translation and Rotation (SITAR) growth curve analysis model.

MAIN OUTCOME MEASURES

Developmental trajectory SITAR models for Bayley-III cognitive, language (receptive and expressive communication subscales) and motor (fine and gross motor subscales) scores.

RESULTS

The successfully fitted SITAR models explained 62% of variance in cognitive development, 68% in receptive communication, 53% in fine motor and 68% in the gross motor development. There was too much variation in the expressive communication subscale to fit a SITAR model. The rate of development (gradient of the curve) best explains the variation in trajectories of development in all domains. Lower gestational age, lower birth weight and male sex significantly predicted a slower rate of development.

CONCLUSION

The rate of development, rather than single time point developmental assessment, best predicts the very preterm infant's developmental trajectory and should be the focus for monitoring and early intervention.

General anesthesia for cesarean delivery and childhood neurodevelopmental and perinatal outcomes: a secondary analysis of a randomized controlled trial

BACKGROUND

In 2016, the U.S. Food and Drug Administration expressed concern that neurodevelopment may be negatively affected by anesthesia or sedation exposure in pregnancy or before three years of age. We examined the association between general anesthesia at the time of cesarean delivery and early childhood neurodevelopment.

METHODS

A secondary analysis of a multicenter randomized controlled trial assessing magnesium for prevention of cerebral palsy in infants at risk for preterm delivery. Exposure was general compared to neuraxial anesthesia. The primary outcome was motor or mental delay at two years of age, assessed by Bayley Scales of Infant Development II (BSIDII). Secondary outcomes included BSIDII subdomains and perinatal outcomes. Multivariable logistic regression models were performed to control for confounders.

RESULTS

Of 557 women undergoing cesarean delivery, 119 (21%) received general anesthesia. There were no differences in the primary composite outcome of developmental delay (aOR 0.93, 95% CI 0.61 to 1.43) or the BSIDII subdomains of mild, moderate, or severe mental delay, or mild or moderate motor delay. Severe motor delay was more common among infants exposed to general anesthesia (aOR 1.98, 95% CI 1.06 to 3.69). Infants exposed to general anesthesia had longer neonatal intensive care stays (51 vs 37 days, P=0.010).

CONCLUSIONS

General anesthesia for cesarean delivery was not associated with overall neurodevelopmental delay at two years of age, except for greater odds of severe motor delay. Future studies should evaluate this finding, as well as the impact on neurodevelopment of longer or multiple anesthetic exposures across all gestational ages.

Which Bayley-III cut-off values should be used in different developmental levels?

Background/aim

Latest version of Bayley Scales (Bayley-III) and its predecessor (BSID-II) are the most widely used standardized developmental tools in infancy and early childhood. Recent studies showed that Bayley-III scores were higher than BSID-II in 18–24 month-old and mostly premature infants. We aimed to evaluate the generalization of inflated scores of Bayley-III to children aged 6–42 months with different disease groups, and to find out which cut-off points should be used in Bayley-III to detect mild, moderate, and severe developmental delay according to BSID-II standard cut-off points.

Materials and methods

Two hundred and fifty-five children aged 6–42 months with different diseases and developmental levels were administered both the Bayley-III and BSID-II in the same session between 15 November 2017 and 15 April 2018.

Results

The mean Bayley-III Cognitive Composite (CC) and Cognitive Language Composite (CLC) scores were respectively 13.1 ± 9.1 and 8.6 ± 8 points higher than BSID-II Mental Development Index (MDI) scores (P < 0.001). The mean Bayley-III Motor Composite (MC) scores were 14.4 ± 10.5 points higher than BSID-II Psychomotor Developmental Index (PDI) scores (P < 0.001). Cognitive delay was found in 126 (49.4%) and 59 (23.1%) children according to BSID-II MDI and Bayley-III CC scores, respectively. Motor delay was found in 174 (69.3%) and 86 (34.3%) children according to the BSID-II PDI and Bayley-III MC scores, respectively. Children had less cognitive (48.6%) and motor delay (54.5%) according to Bayley-III scores. Bayley-III scores were significantly higher than BSID-II scores for all ages (P < 0.001). According to ROC analysis the cut-off scores for mild, moderate, and severe delay were 92.5, 83.2, and 71.2 for Bayley-III CLC; and 98.5, 86.5, and 74.5 for Bayley-III MC, respectively.

Conclusion

Bayley-III scores should be interpreted carefully for all age ranges and different diagnosis. The risk for underestimation of developmental delays by Bayley-III should be kept in mind. Different Bayley-III cut-off scores should be used to define developmental delay levels.

Racial/Ethnic Disparities Among Extremely Preterm Infants in the United States From 2002 to 2016

IMPORTANCE

Racial/ethnic disparities in quality of care among extremely preterm infants are associated with adverse outcomes.

OBJECTIVE

To assess whether racial/ethnic disparities in major outcomes and key care practices were changing over time among extremely preterm infants.

DESIGN, SETTING, AND PARTICIPANTS

This observational cohort study used prospectively collected data from 25 US academic medical centers. Participants included 20 092 infants of 22 to 27 weeks' gestation with a birth weight of 401 to 1500 g born at centers participating in the National Institute of Child Health and Human Development Neonatal Research Network from 2002 to 2016. Of these infants, 9316 born from 2006 to 2014 were eligible for follow-up at 18 to 26 months' postmenstrual age (excluding 5871 infants born before 2006, 2594 infants born after 2014, and 2311 ineligible infants including 64 with birth weight >1000 g and 2247 infants with gestational age >26 6/7 weeks), of whom 745 (8.0%) did not have known follow-up outcomes at 18 to 26 months.

MAIN OUTCOMES AND MEASURES

Rates of mortality, major morbidities, and care practice use over time were evaluated using models adjusted for baseline characteristics, center, and birth year. Data analyses were conducted from 2018 to 2019.

RESULTS

In total, 20 092 infants with a mean (SD) gestational age of 25.1 (1.5) weeks met the inclusion criteria and were available for the primary outcome: 8331 (41.5%) black infants, 3701 (18.4%) Hispanic infants, and 8060 (40.1%) white infants. Hospital mortality decreased over time in all groups. The rate of improvement in hospital mortality over time did not differ among black and Hispanic infants compared with white infants (black infants went from 35% to 24%, Hispanic infants went from 32% to 27%, and white infants went from 30% to 22%; P = .59 for race × year interaction). The rates of late-onset sepsis among black infants (went from 37% to 24%) and Hispanic infants (went from 45% to 23%) were initially higher than for white infants (went from 36% to 25%) but decreased more rapidly and converged during the most recent years (P = .02 for race × year interaction). Changes in rates of other major morbidities did not differ by race/ethnicity. Death before follow-up decreased over time (from 2006 to 2014: black infants, 14%; Hispanic infants, 39%, white infants, 15%), but moderate-severe neurodevelopmental impairment increased over time in all racial/ethnic groups (increase from 2006 to 2014: black infants, 70%; Hispanic infants, 123%; white infants, 130%). Rates of antenatal corticosteroid exposure (black infants went from 72% to 90%, Hispanic infants went from 73% to 83%, and white infants went from 86% to 90%; P = .01 for race × year interaction) and of cesarean delivery (black infants went from 45% to 59%, Hispanic infants went from 49% to 59%, and white infants went from 62% to 63%; P = .03 for race × year interaction) were initially lower among black and Hispanic infants compared with white infants, but these differences decreased over time.

CONCLUSIONS AND RELEVANCE

Among extremely preterm infants, improvements in adjusted rates of mortality and most major morbidities did not differ by race/ethnicity, but rates of neurodevelopmental impairment increased in all groups. There were narrowing racial/ethnic disparities in important care practices, including the use of antenatal corticosteroids and cesarean delivery.

Tracheostomy in Infants in the Neonatal Intensive Care Unit

Approximately half of all pediatric tracheostomies are performed in infants younger than 1 year. Most tracheostomies in patients in the NICU are performed in cases of chronic respiratory failure requiring prolonged mechanical ventilation or upper airway obstruction. With improvements in ventilation and management of long-term intubation, indications for tracheostomy and perioperative management in this population continue to evolve. Evidence-based protocols to guide routine postoperative care, prevent and manage tracheostomy emergencies including accidental decannulation and tube obstruction, and attempt elective decannulation are sparse. Clinician awareness of safe tracheostomy practices and larger, prospective studies in infants are needed to improve clinical care of this vulnerable population.

Predicting motor outcome in preterm infants from very early brain diffusion MRI using a deep learning convolutional neural network (CNN) model

BACKGROUND AND AIMS

Preterm birth imposes a high risk for developing neuromotor delay. Earlier prediction of adverse outcome in preterm infants is crucial for referral to earlier intervention. This study aimed to predict abnormal motor outcome at 2 years from early brain diffusion magnetic resonance imaging (MRI) acquired between 29 and 35 weeks postmenstrual age (PMA) using a deep learning convolutional neural network (CNN) model.

METHODS

Seventy-seven very preterm infants (born <31 weeks gestational age (GA)) in a prospective longitudinal cohort underwent diffusion MR imaging (3T Siemens Trio; 64 directions, b ​= ​2000 ​s/mm²). Motor outcome at 2 years corrected age (CA) was measured by Neuro-Sensory Motor Developmental Assessment (NSMDA). Scores were dichotomised into normal (functional score: 0, normal; n ​= ​48) and abnormal scores (functional score: 1-5, mild-profound; n ​= ​29). MRIs were pre-processed to reduce artefacts, upsampled to 1.25 ​mm isotropic resolution and maps of fractional anisotropy (FA) were estimated. Patches extracted from each image were used as inputs to train a CNN, wherein each image patch predicted either normal or abnormal outcome. In a postprocessing step, an image was classified as predicting abnormal outcome if at least 27% (determined by a grid search to maximise the model performance) of its patches predicted abnormal outcome. Otherwise, it was considered as normal. Ten-fold cross-validation was used to estimate performance. Finally, heatmaps of model predictions for patches in abnormal scans were generated to explore the locations associated with abnormal outcome.

RESULTS

For the identification of infants with abnormal motor outcome based on the FA data from early MRI, we achieved mean sensitivity 70% (standard deviation SD 19%), mean specificity 74% (SD 39%), mean AUC (area under the receiver operating characteristic curve) 72% (SD 14%), mean F1 score of 68% (SD 13%) and mean accuracy 73% (SD 19%) on an unseen test data set. Patch-based prediction heatmaps showed that the patches around the motor cortex and somatosensory regions were most frequently identified by the model with high precision (74%) as a location associated with abnormal outcome. Part of the cerebellum, and occipital and frontal lobes were also highly associated with abnormal NSMDA/motor outcome.

DISCUSSION/CONCLUSION

This study established the potential of an early brain MRI-based deep learning CNN model to identify preterm infants at risk of a later motor impairment and to identify brain regions predictive of adverse outcome. Results suggest that predictions can be made from FA maps of diffusion MRIs well before term equivalent age (TEA) without any prior knowledge of which MRI features to extract and associated feature extraction steps. This method, therefore, is suitable for any case of brain condition/abnormality. Future studies should be conducted on a larger cohort to re-validate the robustness and effectiveness of these models.

Timing of postnatal steroids for bronchopulmonary dysplasia: association with pulmonary and neurodevelopmental outcomes

OBJECTIVE

To determine the associations between age at first postnatal corticosteroids (PNS) exposure and risk for severe bronchopulmonary dysplasia (BPD) and neurodevelopmental impairment (NDI).

STUDY DESIGN

Cohort study of 951 infants born <27 weeks gestational age at NICHD Neonatal Research Network sites who received PNS between 8 days of life (DOL) and 36 weeks' postmenstrual age was used to produce adjusted odds ratios (aOR).

RESULTS

Compared with infants in the reference group (22-28 DOL-lowest rate), aOR for severe BPD was similar for children given PNS between DOL 8 and 49 but higher among infants treated at DOL 50-63 (aOR 1.77, 95% CI 1.03-3.06), and at DOL ≥64 (aOR 3.06, 95% CI 1.44-6.48). The aOR for NDI did not vary significantly by age of PNS exposure.

CONCLUSION

For infants at high risk of BPD, initial PNS should be considered prior to 50 DOL for the lowest associated odds of severe BPD.

Mortality and Neurodevelopmental Outcomes in the Heart Rate Characteristics Monitoring Randomized Controlled Trial

OBJECTIVE

To test whether the composite outcome of death or neurodevelopmental impairment (NDI) at 18-22 months corrected age for infants ≤1000 g at birth is decreased by continuous monitoring of heart rate characteristics during neonatal intensive care.

STUDY DESIGN

We studied a subset of participants enrolled in a multicenter randomized trial of heart rate characteristics monitoring. Survivors were evaluated at 18-22 months corrected age with a standardized neurologic examination and the Bayley Scales of Infant Development-III (BSID-III). NDI was defined as Gross Motor Function Classification System of >2 (moderate or severe cerebral palsy), BSID-III language or cognitive scores of <70, severe bilateral hearing impairment, and/or bilateral blindness.

RESULTS

The composite outcome, death or NDI, was obtained for 628 of 884 study infants (72%). The prevalence of this outcome was 44.4% (136/306) among controls (infants randomized to heart rate characteristics monitored but not displayed) and 38.9% (125/322) among infants randomized to heart rate characteristics monitoring displayed (relative risk, 0.87; 95% CI, 0.73-1.05; P = .17). Mortality was reduced from 32.0% (99/307) among controls to 24.8% (81/326) among monitoring displayed infants (relative risk, 0.75; 95% CI, 0.59 to 0.97; P = .028). The composite outcomes of death or severe CP and death or mildly low Bayley cognitive score occurred less frequently in the displayed group (P < .05).

CONCLUSIONS

We found no difference in the composite outcome of death or NDI for extremely preterm infants whose heart rate characteristics were and were not displayed during neonatal intensive care. Two outcomes that included mortality or a specific NDI were less frequent in the displayed group.