Functional outcomes in self-care, mobility, communication, and learning in extremely low-birth weight infants

Feasibility and validity of the Health Status Classification System-Preschool (HSCS-PS) in a large community sample: the Generation R study

OBJECTIVES

To evaluate the feasibility, discriminant validity and concurrent validity of the Health Status Classification System-Preschool (HSCS-PS) in children aged 3 years in a large community sample in the Netherlands.

DESIGN/SETTING

A prospective population-based cohort in Rotterdam, the Netherlands.

PARTICIPANTS

A questionnaire was administrated to a sample of parents of 4546 children (36.7±1.5 months).

OUTCOME MEASURES

Health-related quality of life (HRQOL) of children was measured by HSCS-PS. The HSCS-PS consists of 10 original domains. Two single-item measures of 'General health' and 'Behavior' were added. A disability score was calculated by summing up all 10 original domains to describe the overall health status. Feasibility was assessed by the response rate, percentages of missing answers, score distributions and the presence of floor/ceiling effects. Discriminant validity was analysed between subgroups with predefined conditions: low birth weight, preterm birth, wheezing, Ear-Nose-Throat surgical procedures and behaviour problems. In the absence of another HRQOL measure, this study uses the single-items 'General health' and 'Behavior' as a first step to evaluate concurrent validity of the HSCS-PS.

RESULTS

Feasibility: response rate was 69%. Ceiling effects were observed in all domains. Discriminant validity: the disability score discriminated clearly between subgroups of children born with a 'very low birth weight', 'very preterm birth', with 'four or more than four times wheezing', 'at least one ear-nose-throat surgical procedures', 'behaviour problems present' and the 'reference' group. Concurrent validity: HSCS-PS domains correlated better with hypothesised parallel additional domains than with other non-hypothesised original domains.

CONCLUSIONS

This study supports the feasibility and validity of the HSCS-PS among preschoolers in community settings. We recommend developing a utility-based scoring algorithm for the HSCS-PS. Further empirical studies and repeated evaluations in varied populations are recommended.

Educational and rehabilitation service utilization in adolescents born preterm or with a congenital heart defect and at high risk for disability

AIM

This historical cohort study describes the use of educational and rehabilitation services in adolescents born preterm or with a congenital heart defect (CHD).

METHOD

Parents of 76 young people (mean age 15y 8mo [SD 1y 8mo]) with CHD and 125 born ≤29 weeks gestational age (mean age 16y [SD 2y 5mo]) completed a demographics questionnaire including educational and rehabilitation resource utilization within the previous 6 months. Rehabilitation services included occupational therapy, physical therapy, speech language pathology, psychology. Developmental (Leiter Brief IQ, Movement-ABC, Strengths and Difficulties Questionnaire) and functional (Vineland) status of the young people was assessed. Pearson χ² tests were used to perform simple pairwise comparisons of categorical outcomes across the two groups (CHD, preterm). Univariate logistic regression was used to examine predictors of service utilization.

RESULTS

Developmental profiles of the two groups (CHD/preterm) were similar (29.9%/30% IQ<80; 43.5%/50.0% motor difficulties; 23.7%/22.9% behavior problems). One-third received educational supports or attended segregated schools. Only 16% (preterm) and 26.7% (CHD) were receiving rehabilitation services. Services were provided predominantly in the school setting, typically weekly. Few received occupational therapy or physical therapy (1.3-7.6%) despite functional limitations. Leiter Brief IQ<70 was associated with receiving educational supports (CHD: OR 5.53, 95% CI 1.29-23.68; preterm: OR 14.63, 3.10-69.08) and rehabilitation services (CHD: OR 4.46, 1.06-18.88; preterm: OR 5.11, 1.41-18.49). Young people with motor deficits were more likely to require educational (CHD: OR 5.72, 1.99-16.42; preterm: OR 3.11, 1.43-6.77) and rehabilitation services (preterm: OR 3.97, 1.21-13.03).

INTERPRETATION

Although young people with impairments were more likely to receive educational and rehabilitation services, many may not be adequately supported, particularly by rehabilitation specialists. Rehabilitation services at this important transition phase could be beneficial in optimizing adaptive functioning in the home, school, and community.

Comparison of functional status of 8- to 12-year-old children born prematurely: an integrative review of literature

Prematurity affects one in eight infants in the United States, a rate that reflects an overall increase of 20% between 1990 and 2005 (March of Dimes, 2008). This integrative review presents a synthesis of the current research addressing the functional status of 8- to 12-year-old children born prematurely. Findings from this review support the belief that children born prematurely function differently than their term peers. These children have academic and social delays that may necessitate special service support through middle childhood.

Developing and validating the Communication Function Classification System for individuals with cerebral palsy

AIM

The purpose of this study was to create and validate the Communication Function Classification System (CFCS) for children with cerebral palsy (CP), for use by a wide variety of individuals who are interested in CP. This paper reports the content validity, interrater reliability, and test-retest reliability of the CFCS for children with CP.

METHOD

An 11-member development team created comprehensive descriptions of the CFCS levels, and four nominal groups comprising 27 participants critiqued these levels. Within a Delphi survey, 112 participants commented on the clarity and usefulness of the CFCS. Interrater reliability was completed by 61 professionals and 68 parents/relatives who classified 69 children with CP aged 2 to 18 years. Test-retest reliability was completed by 48 professionals who allowed at least 2 weeks between classifications. The participants who assessed the CFCS were all relevant stakeholders: adults with CP, parents of children with CP, educators, occupational therapists, physical therapists, physicians, and speech-language pathologists.

RESULTS

The interrater reliability of the CFCS was 0.66 between two professionals and 0.49 between a parent and a professional. Professional interrater reliability improved to 0.77 for classification of children older than 4 years. The test-retest reliability was 0.82.

INTERPRETATION

The CFCS demonstrates content validity and shows very good test-retest reliability, good professional interrater reliability, and moderate parent-professional interrater reliability. Combining the CFCS with the Gross Motor Function Classification System and the Manual Ability Classification System contributes to a functional performance view of daily life for individuals with CP, in accordance with the World Health Organization's International Classification of Functioning, Disability and Health.

Impact at age 11 years of major neonatal morbidities in children born extremely preterm

BACKGROUND

Uncertainty continues regarding the extent to which neonatal morbidities predict poor long-term outcome and functional abilities in extremely preterm infants.

OBJECTIVE

The goal of this study was to determine the impact of bronchopulmonary dysplasia (BPD), ultrasonographic signs of brain injury, and severe retinopathy of prematurity (ROP) on 11-year outcomes in infants born at <26 weeks' gestation.

METHODS

A total of 247 infants were born alive before 26 completed weeks of gestation from 1990 through 1992 in all of Sweden, and 98 (40%) survived to a postmenstrual age of 36 weeks. Main outcome measures were (1) poor outcome, defined as combined end point of death after 36 weeks' postmenstrual age or survival with at least 1 major disability at 11 years, and (2) consequences of chronic conditions in the survivors according to a validated instrument administered to parents.

RESULTS

Brain injury and severe ROP but not BPD correlated independently with poor outcome at 11 years of age. Among children who were free from BPD, brain injury, and severe ROP, 10% had a poor outcome. Corresponding rates with any 1, any 2, and all 3 neonatal morbidities were 19%, 58%, and 80%, respectively. Multivariate analysis revealed that brain injury and severe ROP were associated with high rates of consequences of chronic conditions.

CONCLUSIONS

In infants born extremely preterm who survive to a postmenstrual age of 36 weeks, severe ROP and brain injury separately predict the risk of death or major disability at 11 years of age. Thus, continued research to determine how to prevent these complications of prematurity is critical.

Construção da permanência do objeto em crianças nascidas pré-termo muito baixo peso

OBETIVO: descrever e comparar o processo de construção da permanência do objeto entre crianças com histórico de prematuridade e muito baixo peso e crianças nascidas a termo com desenvolvimento típico. MÉTODOS: participaram deste estudo 22 crianças, sendo 8 crianças nascidas pré-termo e muito baixo peso (grupo pesquisa - GP) e 14 crianças nascidas a termo (grupo controle - GC). Os sujeitos foram submetidos a avaliações mensais de cognição e linguagem, contendo a avaliação da noção de permanência do objeto. Todas as sessões foram registradas em vídeo e transcritas em protocolo específico. As crianças de ambos os grupos foram avaliadas dos 6 aos 12 meses, sendo considerada para o GP, a idade corrigida. Os dados foram analisados de forma quantitativa e qualitativa. RESULTADOS: observou-se diferença estatisticamente significante entre os dois grupos para todas as fases da construção da permanência do objeto, evidenciando o atraso (uma média de 2 a 3 meses de atraso) no desenvolvimento cognitivo, apresentado pelo GP, em relação ao GC, durante o período sensório-motor. CONCLUSÃO: os resultados reforçam a idéia de que as crianças nascidas pré-termo e muito baixo peso apresentam risco para alterações ou atrasos no desenvolvimento cognitivo e de linguagem, justificando a elaboração de programas de intervenção fonoaudiológica junto a essas crianças, já durante o primeiro ano de vida.

Functional performance of preterm children at age 4

Functional performance, a child's ability to perform the tasks of daily living and to fulfill expected social roles, is now recommended in follow-up of preterm children. This study examined neonatal, preschool health, and motor effects on functional performance at age 4. The sample of 155 infants, classified by perinatal morbidity and birth weight, was assessed during a home visit. Neonatal illness, socioeconomic status, preschool health, and motor predictors explained 44% of the variance in functional performance. Functional performance is a useful clinical measure to understand how well preterm children perform age-expected daily activities as well as the family burden of preterm sequelae.

Drug exposure, pregnancy outcome and fetal and childhood development occurring in the offspring of mothers with systemic lupus erythematosus and other chronic autoimmune diseases

Most autoimmune diseases occur more commonly in females and many of these young women wish to become mothers. For pregnancy to proceed successfully immunomodulation and physiological changes preparing the reproductive system need to occur. Pregnancy occurring in a chronically ill mother who requires medications in order to maintain her own health and who may have already incurred significant organ pathology gives rise to several problems and so four questions arise: 1) What will be the effect of the pregnancy on the underlying disease? 2) What will be the effect of the disease on the outcome of pregnancy? 3) How to manage the disease, just prior to, throughout and immediately after the pregnancy? 4) The long term fetal and childhood effects of maternal disease and its management. This paper reviews the current literature pertaining to these questions in patients with systemic lupus erythematosus (SLE) and other chronic rheumatic and autoimmune diseases.

Eye-hand co-ordination skills in very preterm infants <29 weeks gestation at 3 years: Effects of preterm birth and retinopathy of prematurity

INTRODUCTION

Preterm infants are known to have low gross motor and fine motor skills. We questioned whether poor eye-hand coordination skills are associated with moderate to severe stages of Retinopathy of Prematurity (ROP).

AIMS

The aim of this study was to examine development, with specific reference to eye-hand coordination skills, among preterm infants <29 weeks gestation with different stages of ROP at 3 years of age.

METHODS AND MATERIALS

Fifteen preterm infants (<29 weeks gestation) who developed Stage 3 ROP were matched for gestation, birthweight and gender with infants who developed Stage 2 and Stage 1/no ROP. Developmental (Griffiths Mental Development Scales and Peabody Developmental Motor Scales) and ophthalmic assessments in the 3 matched groups of 15 were performed at 3 years of age.

RESULTS

1) Whilst the eye-hand coordination scores and Peabody fine motor scores were lower in the Stage 3 ROP group, they were not significantly lower than the other ROP groups. 2) Locomotor, Peabody gross motor skills and hearing and speech were significantly lower in the infants with Stage 3 ROP. The other developmental domains were not significantly different to the severe ROP group. 3) All 3 groups (of preterm infants) had lower eye-hand coordination and Peabody fine motor scores compared to test norms. 4) There were 8 of 15 infants with Stage 3 ROP who developed moderate visual problems by 3 years of age.

CONCLUSION

In preterm infants, low eye-hand coordination/fine motor scores are likely to be due to their extreme prematurity.

Low prevalence of hearing impairment among very low birthweight infants as detected by universal neonatal hearing screening

OBJECTIVES

To (a) study the prevalence of hearing impairment in a cohort of very low birthweight (VLBW) infants and (b) evaluate the effectiveness of transient evoked otoacoustic emissions (TEOAE) as a first stage in-hospital hearing screening tool in this population.

STUDY DESIGN

The study group was a cohort of 346 VLBW infants born in 1998-2000 at The Sheba Medical Center. The prevalence of hearing impairment in the study group was compared with that of all other newborn infants participating in a universal newborn hearing screening programme during the same period. To evaluate the effectiveness of TEOAE, a control group of 1205 healthy newborns who had no known risk factors for hearing impairment was selected. The results and follow up of hearing screening for these infants were examined retrospectively.

RESULTS

Only one VLBW infant (0.3%) was diagnosed with bilateral sensory-neural hearing loss. In addition, nine infants (2.7%) were diagnosed with conductive hearing loss. Bronchopulmonary dysplasia and low Apgar score were the most significant factors for predicting the occurrence of conductive hearing loss. The percentage of VLBW infants who successfully passed the in-hospital TEOAE screening was 87.2, compared with 92.2% in the full term control group. No false negative cases were detected on follow up.

CONCLUSIONS

The study shows a low incidence of sensory-neural hearing loss in a cohort of VLBW infants and a relatively high incidence of conductive hearing loss. TEOAE screening was found to be an effective first stage in-hospital hearing screening tool in this population.

Neurodevelopmental outcomes of premature infants treated with inhaled nitric oxide

BACKGROUND

Chronic lung disease and severe intraventricular hemorrhage or periventricular leukomalacia in premature infants are associated with abnormal neurodevelopmental outcomes. In a previous randomized, controlled, single-center trial of premature infants with the respiratory distress syndrome, inhaled nitric oxide decreased the risk of death or chronic lung disease as well as severe intraventricular hemorrhage and periventricular leukomalacia. We hypothesized that infants treated with inhaled nitric oxide would also have improved neurodevelopmental outcomes.

METHODS

We conducted a prospective, longitudinal follow-up study of premature infants who had received inhaled nitric oxide or placebo to investigate neurodevelopmental outcomes at two years of corrected age. Neurologic examination, neurodevelopmental assessment, and anthropometric measurements were made by examiners who were unaware of the children's original treatment assignment.

RESULTS

A total of 138 children (82 percent of survivors) were evaluated. In the group given inhaled nitric oxide, 17 of 70 children (24 percent) had abnormal neurodevelopmental outcomes, defined as either disability (cerebral palsy, bilateral blindness, or bilateral hearing loss) or delay (no disability, but one score of less than 70 on the Bayley Scales of Infant Development II), as compared with 31 of 68 children (46 percent) in the placebo group (relative risk, 0.53; 95 percent confidence interval, 0.33 to 0.87; P=0.01). This effect persisted after adjustment for birth weight and sex, as well as for the presence or absence of chronic lung disease and severe intraventricular hemorrhage or periventricular leukomalacia. The improvement in neurodevelopmental outcome in the group given inhaled nitric oxide was primarily due to a 47 percent decrease in the risk of cognitive impairment (defined by a score of less than 70 on the Bayley Mental Developmental Index) (P=0.03).

CONCLUSIONS

Premature infants treated with inhaled nitric oxide have improved neurodevelopmental outcomes at two years of age.

Spectrum of gross motor function in extremely low birth weight children with cerebral palsy at 18 months of age

OBJECTIVE

The purpose of this study was to evaluate the relationship between cerebral palsy (CP) diagnoses as measured by the topographic distribution of the tone abnormality with level of function on the Gross Motor Function Classification System (GMFCS) and developmental performance on the Bayley Scales of Infant Development II (BSID-II). It was hypothesized that (1) the greater the number of limbs involved, the higher the GMFCS and the lower the BSID-II Motor Scores and (2) there would be a spectrum of function and skill achievement on the GMFCS and BSID-II Motor Scores for children in each of the CP categories.

METHODS

A multicenter, longitudinal cohort study was conducted of 1860 extremely low birth weight (ELBW) infants who were born between August 1, 1995 and February 1, 1998, and evaluated at 18 to 22 months' corrected age. Children were categorized into impairment groups on the basis of the typography of neurologic findings: spastic quadriplegia, triplegia, diplegia, hemiplegia, monoplegia, hypotonic and/or athetotic CP, other abnormal neurologic findings, and normal. The neurologic category then was compared with GMFCS level and BSID-II Motor Scores.

RESULTS

A total of 282 (15.2%) of the 1860 children evaluated had CP. Children with more limbs involved had more abnormal GMFCS levels and lower BSID-II scores, reflecting more severe functional limitations. However, for each CP diagnostic category, there was a spectrum of gross motor functional levels and BSID-II scores. Although more than 1 (26.6%) in 4 of the children with CP had moderate to severe gross motor functional impairment, 1 (27.6%) in 4 had motor functional skills that allowed for ambulation.

CONCLUSIONS

Given the range of gross motor skill outcomes for specific types of CP, the GMFCS is a better indicator of gross motor functional impairment than the traditional categorization of CP that specifies the number of limbs with neurologic impairment. The neurodevelopmental assessment of young children is optimized by combining a standard neurologic examination with measures of gross and fine motor function (GMFCS and Bayley Psychomotor Developmental Index). Additional studies to examine longer term functional motor and adaptive-functional developmental skills are required to devise strategies that delineate therapies to optimize functional performance.

Self-perceived quality of life of children and adolescents with physical disabilities in Hong Kong

Although illnesses and diseases are thought to adversely affect quality of life (QoL), whether children who have physical disabilities (PD) from a young age adapt to the effect of developmental disabilities has rarely been investigated. This study attempted to assess the subjective wellbeing, and examine the correlation between objective and subjective QoL, of children with PD. Using a self-reported non-disease-specific questionnaire, the QoL of 72 young persons (13.5+/-2.0 years) with PD was contrasted with those who do not have disabilities (n = 510; age-matched). MANOVA analyses revealed that the PD group had lower objective QoL score (63.0+/-7.4 vs. 66.8+/-5.7, p < 0.001) but the two groups were not significantly different in subjective QoL score (70.9+/-11.4 vs. 69.6+/-13.6, p = 0.466). No correlation was found between objective and subjective QoL in the PD group (r ranged from 0.06 to 0.19), while weak to medium correlations (r ranged from 0.03 to 0.41) were observed for the controls. The apparent detachment of subjective feeling and objective circumstances in the PD group may reflect adjustment to developmental disabilities.

The role of a language scale for infant and preschool assessment

The PLS-4 (Preschool Language Scale, 4th edition) is a psychometrically sound instrument constructed to assess language skills in children from birth to 6 years 11 months. It is a useful diagnostic and research tool that can be used to identify current comprehension and expressive language skills and can measure changes in language skills over time. The test is individually administered and includes tasks that assess skills in the areas of preverbal behaviors, as well as linguistic skills in the areas of semantics, morphology, syntax, integrative language skills, and preliteracy skills. Extensive reliability and validity evidence are presented. The test has been used extensively in research examining language development of young children from different home environments, children with identified medical conditions, and children participating in a variety of habilitation and intervention programs. Both the previous edition (PLS-3) and the new PLS-4 English and Spanish editions are used extensively in clinical, medical, and research settings to examine developmental language patterns of infants, toddlers, and preschoolers.

The effects of an early physical therapy intervention for very preterm, very low birth weight infants: a randomized controlled clinical trial

PURPOSE

A randomized controlled clinical trial was used to investigate effects of physical therapy (PT) intervention on motor outcome of infants born very preterm with very low birth weight (VLBW).

METHODS

Seventy-two infants born very preterm with VLBW were randomly assigned to a nontreatment (NT) (n = 38) or treatment (T) (n = 34) group. The T group received developmental PT from birth until four months corrected age (CA) weekdays during the infant's neonatal stay and on a needs- and problem-orientated basis thereafter. The NT group received no intervention. Both groups were assessed at four months CA using the Alberta Infant Motor Scale (AIMS) as was a control group of 14 infants born full term. Parental compliance was measured using a parent questionnaire.

RESULTS

PT intervention had no significant effect on the T group's motor performance. However, no T group subjects had abnormal motor development at four months CA when compared to the NT group (16%) and the control group (14%) (p = 0.09). The T group subjects with high levels of parental compliance had better scores on the AIMS than those with lower parental compliance (p = 0.05).

CONCLUSION

PT intervention does not significantly affect motor performance of infants born very preterm with VLBW at four months CA. Parental compliance and intervention frequency may have influenced the outcome. Preliminary evidence suggests that neonatal and early PT may reduce the incidence of motor delay among infants born very preterm with VLBW. Follow-up of this group is recommended to ascertain the long-term benefits of this type of early PT.

The lingering academic deficits of low birth weight children

OBJECTIVE

To estimate the influence of low birth weight (LBW; < or =2500 g) on academic achievement in reading and mathematics in 12th grade in 2 socioeconomically and racially disparate, geographically defined communities.

METHODS

Representative samples of LBW and normal birth weight (NBW) children who were born in 1983-1985 and were from the inner city of Detroit and nearby middle class suburbs were assessed longitudinally. Woodcock-Johnson Psycho-Educational Battery-Revised standardized tests of reading and mathematics were used at ages 11 and 17 (n = 773). Multiple regression analysis applying generalized estimating equations was used to assess the independent effects of LBW on test scores.

RESULTS

Compared with NBW children, LBW children manifested deficits of 3 to 5 points in age-standardized tests of academic achievement at age 17 that had persisted with little change from age 11. LBW-related deficits were similar in urban and suburban communities and were independent of family factors. At age 17, LBW children were approximately 50% more likely than NBW children to score below the standardized population mean in both reading and mathematics. The LBW-related deficits in academic achievement in adolescence were largely accounted for by LBW-related deficits in general cognitive abilities, measured by IQ tests at age 6.

CONCLUSIONS

Interventions to address the lingering effects of LBW on the acquisition of core academic skills during the school years should focus on preschool LBW children in both inner city and suburban communities.

Educational and social competencies at 8 years in children with threshold retinopathy of prematurity in the CRYO-ROP multicenter study

OBJECTIVE

To describe the educational status and special education services at 8 years among children who had threshold retinopathy of prematurity (ROP).

METHODS

A prospective study was conducted of a cohort of children who had birth weight of <1251 g and threshold ROP in the Cryotherapy for Retinopathy of Prematurity multicenter study. At age 5.5 years, visual status, functional skills, and social information were obtained. At 8 years, special education classes, developmental disabilities, rehabilitation therapies, and academic and social competencies were determined by questionnaire. Visual status was considered favorable/unfavorable on the basis of the better eye.

RESULTS

Of 255 survivors, 216 (85%) were evaluated at both 5.5 and 8 years. Major impairments were significantly more prevalent in children with unfavorable versus favorable visual status: cerebral palsy (39% vs 16%), developmental disability (57% vs 22%), autism (9% vs 1%), and epilepsy (23% vs 3%). Special education services (63% vs 27%), below-grade-level academic performance (84% vs 48%), and school-based rehabilitation services were significantly less common in children with favorable visual status. Favorable visual status, favorable functional ratings at 5.5 years, markers of higher socioeconomic status, and nonblack race were associated with significantly lower rates of both special education placement and below-grade-level academic performance at age 8. On multivariate logistic regression, only favorable visual status and functional status remained significant predictors for decreasing special education placement.

CONCLUSION

Threshold ROP is associated with high rates of developmental, educational, and social challenges in middle childhood; preserved vision was associated with a clear advantage, with more than half of the children with favorable visual status performing at grade level.

Is retinopathy of prematurity increasing among infants less than 1250 g birth weight?

OBJECTIVE

Retinopathy of prematurity (ROP) is a complication seen in many very low birth weight infants. Severe ROP has been called a "marker" for severe disability. The purpose of this study was to evaluate the occurrence and severity of ROP among infants < or =1250 g birth weight treated in the Special Care Nursery at Women & Infants' Hospital over a period of 7 years from 1994 to 2000.

STUDY DESIGN

This was a retrospective review of ROP data combined with neonatal follow-up data. Of the 1002 infants born with birth weights <1250 g, ophthalmologic data were available for 739 of 839 survivors. Analysis of variance and chi2 along with logistic regression were used to analyze outcomes.

RESULTS

An increase in the overall occurrence of ROP was identified (40% to 54% linear trend, p=0.007). The occurrence of threshold ROP ranged from 2% to 5% (NS). Infants at greatest risk of ROP were those micropremies with birth weights <750 g (p<0.001).

CONCLUSION

Severe ROP continues to be a significant morbidity among infants <750 g.

Management decisions in extremely premature infants

Survival rates in excess of 25% at 23 weeks' gestation and in excess of 50% at 24 weeks' gestation have been reported among live births in the 1990s within tertiary perinatal care centres in the USA and Australia. Decisions about medical management at these gestational ages can no longer be based merely on whether survival is possible. Relevant moral considerations include the primacy of the newborn's best interests, parental autonomy, physicians' duties of beneficence and non-maleficence, and distributive justice. There is significant variability between developed nations in the survival of extremely premature infants among cohorts born within perinatal tertiary care centres. This is, at least to some degree, the result of differences in the aggressiveness of obstetrical and neonatal management at these gestational ages. There is also great variability in the prevalence of major neurodevelopmental disability among survivors. Moreover, the prevalence of major disabilities does not inform quality-of-life considerations adequately. Despite similar gestational age ranges over which the benefit:burden ratio of aggressive obstetric and neonatal care is questioned in developed countries, there is marked variation in the frequency with which it is provided within these ranges. This is understandable given the relevant moral values and the different ways in which competing values will be balanced by different individuals, cultures and societies; the increasing survival of extremely premature infants, but the persistence of high (but widely variable) prevalences of major disabilities reported among survivors and even higher prevalences of mild-to-moderate neurodevelopmental sequelae; our imperfect ability to estimate an individual extremely premature infant's prognosis; and the complexities of estimating the quality of life from the individual's own perspective.

Quality of life of 6-year-old survivors from a regional neonatal unit

OBJECTIVE

Quality of life (QOL) of children who required treatment in a national neonatal intensive care unit (NICU) during the first week of life was determined at 6 years of age.

METHOD

QOL was assessed using a standardized questionnaire employing a multi-attribute scoring system including the functions: hearing, vision, speech, mobility, emotion, learning, self-care and pain. After excluding those with congenital neurodevelopmental disorders, questionnaire returns were analyzed from 177 children treated in the NICU in 1990 and a comparative age-matched group of 230 children who did not require neonatal care. Of these, returns were obtained from 143 (81%) cases and 171 (74%) of the non-treated group.

RESULTS

There was no difference in overall ability between the two groups, with 95 (66%) of cases and 126 (74%) of the comparison group reporting normal scores in all functions. Children treated in the NICU had decreased scores in individual functions including speech (p = 0.04), mobility (p = 0.009) and self-care (p = 0.006). For the study population, males had lower function in speech (p = 0.04) and learning (p = 0.001), with significantly worse function overall (p = 0.02) when compared with female cases. When compared with same-gender children who did not require NICU care, overall function was also significantly worse for male but not female cases (p = 0.0002), and this was largely contributed to by impairment in speech (p = 0.03), mobility (p = 0.04), learning abilities (p = 0.02) and self-care (p = 0.03). Eleven (7.7%) cases compared with just two (1.2%) children who were not treated in the NICU required assistance at school (p = 0.009). No difference was observed when QOL was assessed according to gestational age and birth weight.

CONCLUSION

Using a simple scoring system this study has shown that, for survivors who required early neonatal intensive care, the QOL at 6 years compared favorably with that of children not treated in the NICU, especially for girls.

Measuring functional outcomes after prematurity: developmental impact of very low birth weight and extremely low birth weight status on childhood disability

Our purpose was to describe functional outcomes in essential activities in preschool, school-age, and adolescent children who were born very (<32 weeks gestation) and extremely (<28 weeks gestation) prematurely. Very low birth weight (VLBW; 1000-1499 g), or extremely low birth weight (ELBW;<1000 g) populations are the focus of our analysis. We describe models of disablement and enablement for specifying the complexity of childhood outcomes using a framework of pathophysiology, impairment, functional limitation and functional strengths, disability in social roles and social participation, societal limitations and environmental facilitators. Representative early childhood, preschool, school-age, and adolescent studies were examined in terms of describing children's functional strengths and challenges after VLBW and ELBW survival. In early childhood, disability was assessed by diagnosing neurosensory impairments and delays on developmental testing. Instruments for measuring functional status in essential activities of self-care, mobility, communication and learning are described. Rates of neurosensory disability in the first three years among recent ELBW survivors ranged from 9-26% for cerebral palsy, 1-15% for blindness, 0-9% for deafness, and 6-42% for evolving cognitive disability (MDI <70). Rates of preschool functional limitation were 5-27% motor, 5-30% self-care, and 5-22% communicative. Rates of school-age functional educational disabilities exceeded 50%. Rates of adolescent activity limitation were 13-32% and vocational limitations were 27-71%. By examining the functional strengths and challenges of children with major neurodevelopmental impairments after very or extremely preterm birth, we can examine causal pathways that lessen the risk of severe functional disability. Among children with mild to moderate disability, we can enhance functional outcomes, optimize community participation, and provide quality family supports. In order to assess the changing outcomes of this vulnerable population of survivors, combinations of clinical and survey based methodologies are required.

Functional status of school-aged children with Down syndrome

OBJECTIVE

To field test, in questionnaire format, the Functional Independence Measure for Children (WeeFIM, a schedule usually administered by interview) on parents of a cohort of school-aged children with Down syndrome.

METHODS

The parents of 211 Western Australian children with Down syndrome participated in the present study, representing 79.9% of all children with Down syndrome in the State. Subjects were identified using two sources: (i) the Birth Defects Registry; and (ii) the Disability Services Commission.

RESULTS

The total WeeFIM score was 106.2 +/- 17.0 (mean +/- SD) out of a possible 126. Girls scored higher than boys (108.6 vs 103.6; P = 0.05). Scores increased across all age groups (P < 0.0001), even relative to normative data. Performance was strongest in the transfer and locomotion domains and weakest in social cognition.

CONCLUSION

We found that severe functional limitations are rare in school-aged children with Down syndrome. Some support and supervision are required for complex self-care, communication and social skill tasks. This study demonstrates the feasibility of using the WeeFIM for collecting population survey data in children with developmental disability. This may be useful for the longitudinal tracking of such populations, as well as the monitoring of response to interventions.

The outcome of extreme prematurity

Significant advances in perinatology and neonatology in the last decade have resulted in increased survival of extremely premature infants. Survival rates for infants born in tertiary perinatal and neonatal care centers in the United States in the 1990s increase with each week of gestational age from 22 through 26 weeks. Reported survival rates at 22 weeks range from 0% to 21% in the few reporting studies. Reported survival rates at 23 and 24 weeks range from 5% to 46% and from 40% to 59%, respectively. These may not be the maximum survival rates possible because at these gestational ages information is either insufficient to determine that obstetric and neonatal intensive care strategies to maximize neonatal survival were used or it is specified that such strategies were not used. Reported survival rates at 25 and 26 weeks range from 60% to 82% and from from 75% to 93%, respectively. The literature regarding the prevalence of major neurodevelopmental disabilities among extremely premature survivors in the last 25 years is heteogeneous, and the reported prevalances of major disability vary much more than do survival rates. However, the majority of extremely premature infants who survive will be free of major disability. Overall, approximately one fifth to one quarter of survivors have at least one major disability-impaired mental development, cerebral palsy, blindness, or deafness. Impaired mental development is the most prevalent disability (17%-21% [95% CI] of survivors affected), followed by cerebral palsy (12%-15% of survivors affected). Blindness and deafness are less common (5% to 8% and 3% to 5% of survivors affected, respectively). Approximately one half of disabled survivors have more than one major disability. Based on studies of infants less than 750 to 1,000 grams birth weight, it can be anticipated that approximately another half of all extremely premature survivors will have one or more subtle neurodevelopmental disabilities in the school and teenage years. There is little evidence to suggest that long-term neurodevelopmental outcome has changed from the late 1970s to the early 1990s or with increasing survival. Survival of individual extremely premature infants cannot be accurately predicted in the immediate perinatal period. Major disability cannot be accurately predicted for individual survivors during the course in the newborn intensive care unit.