Extreme prematurity and school outcomes

The association of environmental factors with neurocognitive outcomes in survivors of childhood acute lymphoblastic leukemia (ALL)

PURPOSE

To investigate the association of environmental factors, rehabilitation services during therapy and socioeconomic status (SES - insurance type), with neurocognitive outcomes at the end of therapy for survivors of childhood acute lymphoblastic leukemia (ALL).

METHODS

Survivors (n = 236) treated on the St. Jude Total Therapy Study 16 completed end of therapy testing with performance measures (IQ, attention, processing speed, fine motor skills, academics) and caregiver ratings (attention, executive function, adaptive skills). Environmental factors were abstracted from the medical record.

RESULTS

Distribution of sex (47.3% female, p = 0.399), treatment arm (45.5% low risk, 54.5% standard/high risk p = 0.929), insurance type (47.7% private, 52.3% public/none, p = 0.117), and mean age at diagnosis (7.7 vs. 6.8 years, p = 0.143) were similar for groups with (n = 110; 46.6%) and without (n = 126; 53.6%) rehabilitation services during therapy. Compared to those without rehabilitation, the rehabilitation group (n = 110; 46.4%) had more caregiver reported problems with attention (Z = -0.28 vs. 0.43, p = 0.022), executive function (Z = -0.50 vs. -0.08, p = 0.003), and adaptive skills (Z = -0.41 vs.-0.13, p = 0.031). Among the rehabilitation group, there was no difference in outcomes by insurance status. Among those without rehabilitation, those with public insurance had worse neurocognitive outcomes than those with private insurance in IQ (Z = -0.04 vs. -0.45, p = 0.0115), processing speed (Z = -0.10 vs. -0.75, p = 0.0030), reading (Z = 0.18 vs. -0.59, p < 0.0001), and math (Z = -0.04 vs. -0.50, p = 0.0021).

CONCLUSION

Participation in rehabilitation services during early intensive therapy is associated with end of therapy caregiver-reported neurocognitive outcomes in daily life.

Low Birth Weight and Psychoeducational Outcomes: Investigation of an African American Birth Cohort

African Americans experience more than double the prevalence of low birth weight (LBW)/premature birth compared to their Caucasian counterparts, reflecting a public health crisis and a significant social justice concern. However, there is a paucity of LBW outcome studies in African American samples. There are even fewer that investigate developmental outcomes within the moderately LBW range (i.e., 1500–2500 g), the most prevalent category of LBW births. This study investigates the relationship between LBW and various psychoeducational outcomes in a prospectively designed African American birth cohort. Multivariate logit analyses of the Johns Hopkins University Pathways to Adulthood study compared LBW children with normal birth weight children on a number of outcome measures at seven and 8 years of age. Results revealed that children born within the lowest birth weight category produced the most adverse findings, from both a statistical and clinical standpoint, on measures of cognitive ability, academic achievement, speech, language, auditory processing, and visual–motor integration.

Posttraumatic Stress Disorder Among Low-Income Adolescents Experiencing Family-Neighborhood Income Disparities

Certain neighborhood factors may increase the risk of exposure to trauma, therefore increasing the risk of posttraumatic stress disorder (PTSD). Other aspects of neighborhoods can be protective, such as neighborhood-based social relationships, which provide social support that buffers the risk of developing PTSD. The strength of these social relationships may not be as dependent on neighborhood conditions as much as they are contingent on socioeconomic similarities between neighborhood residents. Using a nationally representative sample of hospital emergency department admissions in the United States (N = 13,669,251), this study hypothesized that an interaction between family-level income and neighborhood-level income would be associated with adolescent PTSD. The results show that female adolescents who resided in the highest income areas were 1.39 times more likely, 95% CI [1.09, 1.77], to be diagnosed with PTSD than those who lived in the lowest income areas. This association was not statistically significant for male adolescents. Additionally, low-income female youth were nearly one-third more likely than their non-low-income counterparts to be diagnosed, odds ratio (OR) = 1.29, 95% CI [1.12, 1.48], whereas low-income male youth were nearly twice as likely than their non-low-income counterparts to be diagnosed, OR = 1.95, 95% CI [1.62, 2.34]. Furthermore, there was an interaction among both male and female adolescents such that lower-income adolescents living in higher-income areas had higher odds of a PTSD diagnosis compared to their higher-income peers in areas that were in the same median household income quartile.

Homicidal Ideation and Forensic Psychopathology: Evidence From the 2016 Nationwide Emergency Department Sample (NEDS)

Homicide is the most serious and costly criminal offense and better forensic and criminological understanding of homicidal ideation as a potential psychobehavioral precursor to homicidal conduct is critical. Using data from the 2016 Nationwide Emergency Department Sample (NEDS) from the Healthcare Cost and Utilization Project (HCUP) distributed by the Agency for Healthcare Research and Quality (AHRQ), we found 64,910 cases of homicidal ideation among a sample of 25.6 + million-a prevalence of 0.25%. Numerous conditions conferred increased substantially the likelihood of homicidal ideation including antisocial personality disorder (2406%), schizoaffective disorder (1821%), borderline personality disorder (1557%), paranoid personality disorder (1,504%), schizophrenia (1,143%), obsessive-compulsive personality disorder (921%), brief psychotic disorder (771%), unspecified psychosis (737%), avoidant personality disorder (596%), and schizoid personality disorder (571%), delusional disorder (546%), and other psychotic disorder (504%). Homicidal ideation is comorbid with serious psychiatric and behavioral problems and has important implications for offender typologies and homicidality.

Sleep problems, behavioural problems and respiratory health in children born extremely preterm: a parental questionnaire study

OBJECTIVE

To explore whether children born extremely preterm (EPT) with different types of sleep problems had more behavioural and respiratory health problems than EPT children without sleep problems.

DESIGN

Prospective, nationwide, questionnaire-based study. At 11 years of age, parents reported on four current sleep problems: difficulty falling asleep or frequent awakenings, snoring, daytime sleepiness and not recommended sleep duration (<9 hours). Behavioural problems were assessed by parents and teachers with the Strengths and Difficulties Questionnaire (SDQ). Parents assessed respiratory symptoms with the International Study of Asthma and Allergies in Childhood questionnaire and described use of asthma medication.

SETTING

Norway.

PATIENTS

EPT children.

MAIN OUTCOME MEASURES

Specified sleep problems, behavioural problems and respiratory health.

RESULTS

Data were obtained from 216 of 372 (58 %) of eligible children. All four specified sleep problems were associated with significantly higher parent-reported SDQ total-score (OR 1.1 for all), and except for not recommended sleep duration, also with higher teacher-reported SDQ total-score (OR 1.1 for all). Daytime sleepiness was strongly associated with wheezing last 12 months (OR 3.4), disturbed sleep due to wheezing (OR 3.9), wheeze during or after exercise (OR 2.9), use of inhaled corticosteroids or oral leukotriene modifiers (OR 3.4) and use of bronchodilators (OR 3.9). Snoring was associated with wheezing during or after exercise (OR 2.8) and current asthma (OR 4.2).

CONCLUSION

EPT children with different types of sleep problems had more behavioural and respiratory health problems than EPT children without sleep problems.

Weak functional connectivity in the human fetal brain prior to preterm birth

It has been suggested that neurological problems more frequent in those born preterm are expressed prior to birth, but owing to technical limitations, this has been difficult to test in humans. We applied novel fetal resting-state functional MRI to measure brain function in 32 human fetuses in utero and found that systems-level neural functional connectivity was diminished in fetuses that would subsequently be born preterm. Neural connectivity was reduced in a left-hemisphere pre-language region, and the degree to which connectivity of this left language region extended to right-hemisphere homologs was positively associated with the time elapsed between fMRI assessment and delivery. These results provide the first evidence that altered functional connectivity in the preterm brain is identifiable before birth. They suggest that neurodevelopmental disorders associated with preterm birth may result from neurological insults that begin in utero.

Estimating community-level costs of preterm birth

OBJECTIVES

To develop generalizable methods for estimating the economic impact of preterm birth at the community level on initial hospital expenditures, educational attainment and lost earnings as well as to estimate potential savings associated with reductions in preterm birth.

STUDY DESIGN

The retrospective, population-based analysis used vital statistics and population demographics from Hamilton County, Ohio, USA, in 2012.

METHODS

We adjusted previously reported, mean initial hospital cost estimates (stratified by each week of gestation) to 2012 dollars using national cost-to-charge ratios. Next, we calculated excess costs attributable to prematurity and potential hospital cost savings, which could be realized by prolonging each preterm pregnancy by a single week of gestation. Using reported associations among preterm birth, educational attainment and adult earnings, we developed generalizable formulas to calculate lost academic degrees and lost income estimates attributable to preterm birth. The formulas generated estimates based on local population demographics.

RESULTS

The annual initial hospital cost associated with 1444 preterm infants was estimated at $93 million. In addition, over 9000 fewer college degrees and over $300 million in lost annual earnings were attributed to local adults who were born preterm. Prolonging each preterm birth by 1 week could potentially reduce initial hospital expenditures by over $25 million. Additional potential savings could be realized as healthier infants attain higher levels of education and earnings as adults.

CONCLUSIONS

The generalizable methods developed for estimating the economic impact of preterm birth at the community level can be used by any community in which vital statistics and population demographics are available. Cost estimates can serve to rally support for local stakeholder investment in developing strategies for preterm birth intervention leading to improved pregnancy outcomes.

Effect of socioeconomic status disparity on child language and neural outcome: how early is early?

It is not news that poverty adversely affects child outcome. The literature is replete with reports of deleterious effects on developmental outcome, cognitive function, and school performance in children and youth. Causative factors include poor nutrition, exposure to toxins, inadequate parenting, lack of cognitive stimulation, unstable social support, genetics, and toxic environments. Less is known regarding how early in life adverse effects may be detected. This review proposes to elucidate "how early is early" through discussion of seminal articles related to the effect of socioeconomic status on language outcome and a discussion of the emerging literature on effects of socioeconomic status disparity on brain structure in very young children. Given the young ages at which such outcomes are detected, the critical need for early targeted interventions for our youngest is underscored. Further, the fiscal reasonableness of initiating quality interventions supports these initiatives. As early life adversity produces lasting and deleterious effects on developmental outcome and brain structure, increased focus on programs and policies directed to reducing the impact of socioeconomic disparities is essential.

Monolingual and bilingual preschoolers' use of gestures to interpret ambiguous pronouns

Young children typically do not use order-of-mention to resolve ambiguous pronouns, but may do so if given additional cues, such as gestures. Additionally, this ability to utilize gestures may be enhanced in bilingual children, who may be more sensitive to such cues due to their unique language experience. We asked monolingual and bilingual four-year-olds and adults to determine referents of ambiguous pronouns given order-of-mention and co-referential localizing gestures. Results showed that bilingual children, like adults, but not monolingual children, used order-of-mention with gestures to resolve ambiguous pronouns. This highlights a wider implication of bilingualism for socio-cognitive development in children.

Perinatal, neonatal, and family social factors predicting poor school outcome of low-birth-weight survivors: an integrative review

PURPOSE

To examine the relationship of perinatal factors, neonatal factors, and family characteristics with school outcomes of low-birth-weight (LBW) children.

DESIGN AND METHODS

An integrative review of the literature was performed using electronic databases focusing on key words, including school outcome, school performance, educational outcome, academic outcome/academic achievement, and LBW.

RESULTS

The in utero or neonatal risk factors for poor school outcome included in this review were perinatal brain injury, brain structural abnormality, motor deficits, and neonatal conditions. Social risk factors found to contribute to poorer school outcomes were family structure, family stability, parental education, poverty, male sex, nonwhite race, and acculturation level.

CONCLUSIONS

Long-term school outcomes of LBW children are influenced by a number of factors related to the characteristics of both children and their families. These factors need to be considered when designing preventive interventions.

Economical Analysis of Different Clinical Approaches in Pre-Viability Amniorrhexis-A Case Series

Prolonged oligohydramnios following extreme preterm prelabour rupture of membranes (EPPROM) is traditionally associated with a high morbidity and mortality to both the mother and the baby. The clinical maternal evaluation and fetal ultrasound assessment may provide important prognostic information for the clinicians and should be taken into account when counselling the patients so as to provide them with enough information to make decision of continuing or interrupting the pregnancy. Current financial constraints on the National Healthcare Service (NHS) resources make it imperative for clinical decision-makers and budgetary planners to make the right decision of continuing or terminating a second trimester pre-viability amniorrhexis for desperate parents. To assess the economic consequences following EPPROM, the risk of infection to both baby and mother, psychological impact on the parents and associated complications and further disability after delivery on this fragile group of patients to the NHS resources. We review the clinical course, outcome, and the challenges to parents and health care professionals on three pregnancies complicated by EPPROM, occurring before 24 weeks’ gestation with a membrane rupture to delivery interval (latent period) of 14 days or more. The anticipated birth of an extremely premature infant poses many challenges for parents and health care professionals. As parents are faced with difficult decisions that can have a long-term impact on the infant, family and country’s resources, it is critical to provide the type of information and support that is needed by them. Taking all these into consideration with the period of ventilation and respiratory assistance in Neonatal Intensive Care Unit (NICU) is essential to provide maximum chances for survival, minimizing the risk for long term sequelae of the neonate and provides the parents enough time to decide on making the right decision with the associated guidance of the healthcare provider.

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

BACKGROUND

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

AIM

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

STUDY DESIGN

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

SUBJECTS

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

OUTCOME MEASURES

Bayley Scales of Infant Development-III Language Composite.

RESULTS

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

CONCLUSIONS

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

Bullying of extremely low birth weight children: associated risk factors during adolescence

BACKGROUND

Preterm children have many risk factors which may increase their susceptibility to being bullied.

AIMS

To examine the prevalence of bullying among extremely low birth weight (ELBW, <1 kg) and normal birth weight (NBW) adolescents and the associated sociodemographic, physical, and psychosocial risk factors and correlates among the ELBW children.

METHODS

Cohort study of self-reports of bullying among 172 ELBW adolescents born 1992-1995 compared to 115 NBW adolescents of similar age, sex and sociodemographic status. Reports of being bullied were documented using the KIDSCREEN-52 Questionnaire which includes three Likert type questions concerning social acceptance and bullying. Multiple linear regression analyses adjusting for sociodemographic factors were used to examine the correlates of bullying among the ELBW children.

RESULTS

Group differences revealed a non-significant trend of higher mean bullying scores among ELBW vs. NBW children (1.56 vs. 1.16, p=0.057). ELBW boys had significantly higher bullying scores than NBW boys (1.94 vs. 0.91, p<0.01), whereas ELBW and NBW girls did not differ (1.34 vs. 1.30, p=0.58). Bullying of ELBW children was significantly associated with subnormal IQ, functional limitations, anxiety and ADHD, poor school connectedness, less peer connectedness, less satisfaction with health and comfort, and less risk avoidance.

CONCLUSION

ELBW boys, but not girls, are more likely to be victims of bullying than NBW boys. School and health professionals need to be aware of the risk of bullying among ELBW male adolescents.

ART and health: clinical outcomes and insights on molecular mechanisms from rodent studies

Since the birth of the first IVF-conceived child in 1978, the use of assisted reproductive technologies (ART) has grown dramatically, contributing to the successful birth of 5 million individuals worldwide. However, there are several reported associations of ART with pregnancy complications, such as low birthweight (LBW), preterm birth, birth defects, epigenetic disorders, cancer and poor metabolic health. Whether this is attributed to ART procedures or to the subset of the population seeking ART remains a controversy, but the most relevant question today concerns the potential long-term implications of assisted conception. Recent evidence has emerged suggesting that ART-conceived children have distinct metabolic profiles that may predispose to cardiovascular pathologies in adulthood. Because the eldest IVF individuals are still too young to exhibit components of chronic middle-aged syndromes, the use of animal models has become particularly useful in describing the effects of unusual or stressful preimplantation experiences on adult fitness. Elucidating the molecular mechanisms by which embryos integrate environmental signals into development and metabolic gene expression programs will be essential for optimizing ART procedures such as in vitro culture conditions, embryo selection and transfer. In the future, additional animal studies to identify mechanisms underlying unfavorable ART outcomes, as well as more epidemiological reviews to monitor the long-term health of ART children are required, given that ART procedures have become routine medical practice.

Unexpected: an interpretive description of parental traumas' associated with preterm birth

BACKGROUND

Preterm birth (PTB) places a considerable emotional, psychological, and financial burden on parents, families, health care resources, and society as a whole. Efforts to estimate these costs have typically considered the direct medical costs of the initial hospital and outpatient follow-up care but have not considered non-financial costs associated with PTB such as adverse psychosocial and emotional effects, family disruption, strain on relationships, alterations in self-esteem, and deterioration in physical and mental health. The aim of this inquiry is to understand parents' experience of PTB to inform the design of subsequent studies of the direct and indirect cost of PTB. The study highlights the traumatic nature of having a child born preterm and discusses implications for clinical care and further research.

METHOD

Through interviews and focus groups, this interpretive descriptive study explored parents' experiences of PTB. The interviews were audiotaped, transcribed, and analyzed for themes. Analysis was ongoing throughout the study and in subsequent interviews, parents were asked to reflect and elaborate on the emerging themes as they were identified.

RESULTS

PTB is a traumatic event that shattered parents' taken-for-granted expectations of parenthood. For parents in our study, the trauma they experienced was not related to infant characteristics (e.g., gestational age, birth weight, Apgar scores, or length of stay in the NICU), but rather to prolonged uncertainty, lack of agency, disruptions in meaning systems, and alterations in parental role expectations. Our findings help to explain why things like breast feeding, kangaroo care, and family centered practices are so meaningful to parents in the NICU. As well as helping to (re)construct their role as parents, these activities afford parents a sense of agency, thereby moderating their own helplessness.

CONCLUSION

These findings underscore the traumatic nature and resultant psychological distress related to PTB. Obstetrical and neonatal healthcare providers need to be educated about the symptoms of Acute Stress Disorder (ASD) and Posttraumatic Stress Disorder (PTSD) to better understand and support parents' efforts to adapt and to make appropriate referrals if problems develop. Longitudinal economic studies must consider the psychosocial implications of PTB to in order to determine the total related costs.

Preimplantation stress and development

The developmental origins of health and disease hypothesis holds that inappropriate environmental cues in utero, a period marked by tremendous developmental sensitivity, facilitate cellular reprogramming to ultimately predispose disease in adulthood. In this review, we analyze if stress during early stages of development can affect future health. This has wide clinical importance, given that 5 million children have been conceived with assisted reproductive technologies (ART). Because the primary outcome of assisted reproduction procedures is delivery at term of a live, healthy baby, the postnatal effects occurring outside ofthe neonatal period are often overlooked. To this end, the long-term outcome of ART is appropriately the most relevant concern of the field today. Evidence of adverse consequences is controversial. The majority of studies have concluded no obvious problems in IVF-conceived children, although a number of isolated cases of imprinted diseases, cancers, or malformations have been reported. Given that animal studies suggest alteration of metabolic pathways following preimplantation stress, it will be of great importance to follow-up ART individuals as they enter later stages of adult life.

Preterm delivery and low birth weight in singleton pregnancies conceived by women with and without a history of infertility

OBJECTIVE

To determine predictors of low birth weight (LBW) and preterm delivery (PTD) in singleton pregnancies conceived by women with and without a history of infertility.

DESIGN

Retrospective cohort study.

SETTING

Eleven infertility clinics in northern California.

PATIENT(S)

Three groups of women who carried singleton pregnancies to ≥20 weeks' gestation: 542 infertile women who conceived after treatment, 441 infertile women who conceived spontaneously, and 1,008 fertile women for comparison.

INTERVENTION(S)

Chart review.

MAIN OUTCOME MEASURE(S)

Association of LBW or PTD with infertility treatment, maternal age, parity, obesity, or development of gestational diabetes.

RESULT(S)

Infertile women who conceived with treatment were more likely to be obese, develop gestational diabetes, and have ovarian, ovulatory, or male factor infertility than infertile women who conceived spontaneously. Infertile women who conceived after treatment had 1.61 times greater odds of having an LBW infant. Nulliparity was an independent predictor of LBW and PTD in all three groups after controlling for maternal age, history of infertility, infertility treatment, obesity, and gestational diabetes.

CONCLUSION(S)

Nulliparous women and women with a history of infertility who conceive a singleton after treatment may be at increased odds for having an LBW infant. Infertile women do not appear to be at increased odds for PTD.

Outcome of vaginal progesterone as a tocolytic agent: randomized clinical trial

Vaginal progesterone has a potential beneficial effect in postponing of preterm labor by suppression of prostaglandins cascades. Although different studies evaluated the use of progesterone for preterm birth, the exact effect of which on prolongation of pregnancy remains unclear. Seventy two women who underwent preterm labor were managed by magnesium sulfate. Then they were randomly assigned to continue pregnancy either by applying vaginal progesterone (400 mg) until delivery or without using any drug. Gestational age mean at the time of delivery (P = 0.039) and postponing delivery mean time (P = 0.048) were significantly higher in progesterone group. Comparison of neonatal outcomes between two groups of patients showed meaningful benefits of progesterone in increasing of neonatal weight, reduction of low birth weight babies, and lowing neonate admitted in NICU.

Prevention of preterm delivery in twin gestations (PREDICT): a multicenter, randomized, placebo-controlled trial on the effect of vaginal micronized progesterone

OBJECTIVE

Studies on high-risk singleton gestations have shown a preventive effect of progesterone treatment on preterm delivery. This study was conducted to investigate the preventive effect of vaginal micronized progesterone in a large population of twin gestations.

METHODS

This was a double-blind, placebo-controlled randomized trial performed in 17 centers in Denmark and Austria. Women with twin gestations were randomized to daily treatment with progesterone pessaries or apparently identical placebo pessaries, starting from 20-24 weeks until 34 weeks' gestation. Primary outcome was incidence of delivery before 34 weeks' gestation. Secondary outcomes were maternal and neonatal complications and long-term infant follow-up, by Ages and Stages Questionnaire (ASQ), 6 months and 18 months after the expected date of delivery. We also updated a published meta-analysis to include our data and those of another recently published twin trial.

RESULTS

A total of 677 women were randomized to the two treatments. Two women in the placebo group were lost to follow-up. Baseline characteristics for the groups were similar. Incidence of delivery before 34 weeks was 15.3% in the progesterone group vs 18.5% in the placebo group (odds ratio, 0.8 (95% CI, 0.5-1.2)). Risks of maternal and neonatal complications were comparable for the two groups. Mean ASQ scores at 6 months and 18 months were not significantly different between the two groups (215 for infants in the progesterone group and 218 for infants in the placebo group at 6 months (P = 0.45) and 193 and 194, respectively, at 18 months (P = 0.89)). The meta-analysis gave a pooled odds ratio of 1.06 (95% CI, 0.86-1.31).

CONCLUSION

Progesterone treatment did not prevent preterm delivery in twin gestations. There were no harmful effects to fetuses and infants of maternal progesterone treatment.

Vaginal micronized progesterone and risk of preterm delivery in high-risk twin pregnancies: secondary analysis of a placebo-controlled randomized trial and meta-analysis

OBJECTIVES

Progesterone treatment reduces the risk of preterm delivery in high-risk singleton pregnancies. Our aim was to evaluate the preventive effect of vaginal progesterone in high-risk twins.

METHODS

This was a subanalysis of a Danish-Austrian, double-blind, placebo-controlled, randomized trial (PREDICT study), in which women with twin pregnancies were randomized to daily treatment with progesterone or placebo pessaries from 20-24 weeks until 34 weeks' gestation. This subpopulation consisted of high-risk pregnancies, defined by the finding of cervical length ≤ 10th centile at 20-24 weeks' gestation or history of either spontaneous delivery before 34 weeks or miscarriage after 12 weeks. Primary outcome was delivery before 34 weeks. Secondary outcomes were complications for infants including long-term follow-up by Ages and Stages Questionnaire (ASQ) at 6 and 18 months of age.

RESULTS

In 72 (10.6%) of the 677 women participating in the PREDICT study, the pregnancy was considered to be high-risk, including 47 with cervical length ≤ 10th centile, 28 with a history of preterm delivery or late miscarriage and three fulfilling both criteria. Baseline characteristics for progesterone and placebo groups were similar. Mean gestational age at delivery did not differ significantly between the two groups either in patients with a short cervix (34.3 ± 4.1 vs. 34.5 ± 3.0 weeks, P = 0.87) or in those with a history of preterm delivery or late miscarriage (34.6 ± 4.2 vs. 35.2 ± 2.7 weeks, P = 0.62). Similarly, there were no significant differences between the treatment groups in maternal or neonatal complications and mean ASQ score at 6 and 18 months of age.

CONCLUSION

In high-risk twin pregnancies, progesterone treatment does not significantly improve outcome.

Pattern visual evoked potential performance in preterm preschoolers with average intelligence quotients

BACKGROUND

Preterm infants are more likely to develop visual perceptual and visual-motor impairments. Visual perceptual deficiencies may contribute to significant difficulties in daily life, but few reports are available relating electrophysiological assessment of the visual system to spatial information problems in premature preschoolers with average intelligence quotients.

AIM

This study was designed to investigate preterm preschoolers' responses to various spatial frequencies of pattern reversal visual evoked potential (PRVEP) and compare them to normal children.

DESIGN

Participants were 20 very low birth weight (VLBW), 41 low birth weight (LBW) and 41 normal children who were 4 to 6 years old and were free from major disability and developmentally appropriate for gestational age at birth. They were evaluated using the Chinese population adaptation of the Wechsler Preschool and Primary Scale of Intelligence (WPPSI) and recorded PRVEP at five levels of spatial frequency (checkerboard pattern (check) sizes of 108', 54', 27', 13' and 7') using a VikingQuest-IV neuroelectrophysiological device (Nicolet, Madison, WI, USA).

RESULTS

Compared with normal children, the LBW and VLBW groups had significantly lower level in the tests of verbal, performance and overall intelligence quotients, particularly in performance, although the levels were within the average range. The PRVEP P100 wave latencies were significantly prolonged at all five degrees of spatial frequency in the VLBW group compared with the controls, while showing delay in the LBW with 13' and 7' check size. In the meanwhile, the amplitudes of P100 at all five spatial frequencies were significantly smaller in the VLBW and LBW groups than in the normal children. And VLBW group had even lower P100 amplitudes than the LBW group.

CONCLUSIONS

Preterm preschoolers with average cognition capability are at risk of defect in visual-spatial perception, especially when they are confronted with more complicated information. PRVEP may provide an objective and convenient measurement in detecting the problem of visual perception in children.

Implicit and explicit learning: applications from basic research to sports for individuals with impaired movement dynamics

PURPOSE

Motor skills can be learned in an explicit or an implicit manner. Explicit learning places high demands on working memory capacity, but engagement of working memory is largely circumvented when skills are learned implicitly. We propose that individuals with impaired movement dynamics may benefit from implicit learning methods when acquiring sports-related motor skills.

METHOD

We discuss converging evidence that individuals with cerebral palsy and children born prematurely have compromised working memory capacity. This may in part explain the difficulties they encounter when learning motor and other skills. We also review tentative evidence that older people, whose movement dynamics deteriorate, can implicitly learn sports-related motor skills and that this results in more durable performance gains than explicit learning.

RESULTS

Individuals with altered movement dynamics and compromised working memory can benefit from implicit motor learning.

CONCLUSION

We conclude with an appeal for more extensive evaluation of the merits of implicit motor learning in individuals with impaired movement dynamics.

The role of progesterone in prevention of preterm birth

Preterm birth continues to provide an enormous challenge in the delivery of perinatal health care, and is associated with considerable short and long-term health consequences for surviving infants. Progesterone has a role in maintaining pregnancy, by suppression of the calcium-calmodulin-myosin light chain kinase system. Additionally, progesterone has recognized anti-inflammatory properties, raising a possible link between inflammatory processes, alterations in progesterone receptor expression and the onset of preterm labor. Systematic reviews of randomized controlled trials evaluating the use of intramuscular and vaginal progesterone in women considered to be at increased risk of preterm birth have been published, with primary outcomes of perinatal death, preterm birth <34 weeks, and neurodevelopmental handicap in childhood. Eleven randomized controlled trials were included in the systematic review, involving 2714 women and 3452 infants, with results presented according to the reason women were considered to be at increased risk of preterm birth. While there is a potential beneficial effect in the use of progesterone for some women considered to be at increased risk of preterm birth, primarily in the reduction in the risk of preterm birth before 34 weeks gestation, it remains unclear if the observed prolongation of pregnancy translates into improved health outcomes for the infant.

Emerging tocolytics: challenges in designing and testing drugs to delay preterm delivery and prolong pregnancy

The global rate of preterm delivery (before 37 completed weeks of pregnancy) is increasing and there are no effective means available to prevent this rise. Prematurity is the principal cause of neonatal mortality and a major cause of pediatric morbidity and long-term disability. Current strategies to prolong pregnancy are based on inhibiting the mechanisms that effect uterine smooth muscle (myometrium) contractions in women who are in preterm labor. Most drugs in this group were developed for other purposes. Newer strategies are designed to maintain a state of uterine quiescence and pregnancy, preventing the myometrium from initiating contractions and entering preterm labor. Again, it may be possible to use existing drugs for pregnancy maintenance. Several financial and practical barriers exist for developing completely new drugs to delay labor. Designing clinical trials to test tocolytics is complicated, as the health of two patients must be considered and the nature of preterm birth and its outcomes are different at early preterm labor (< 28 weeks) and late preterm labor (34 - 36 weeks).

Community supports after surviving extremely low-birth-weight, extremely preterm birth: special outpatient services in early childhood

OBJECTIVE

To determine special outpatient services (SOS) use, need, associated factors, and neurodevelopmental and functional outcomes among extremely preterm infants at 18 to 22 months' corrected age.

DESIGN

Retrospective analysis.

SETTING

National Institute of Child Health and Human Development (NICHD) Neonatal Research Network.

PARTICIPANTS

Infants younger than 28 weeks' gestational age who had been born weighing less than 1000 g at an NICHD Neonatal Research Network center from January 1, 1997, to December 31, 2000, and who were receiving follow-up at 18 to 22 months' corrected age.

INTERVENTIONS

Questionnaires were administered at the 18- to 22-month follow-up visit regarding SOS use since hospital discharge and the current need for SOS (social work, visiting nurse, medical specialty, early intervention, speech and language services, occupational therapy and physical therapy, and neurodevelopmental and behavioral services).

MAIN OUTCOME MEASURES

The use of and need for SOS were analyzed by gestational age. Logistic regression analysis identified factors independently associated with the use of more than 5 services and with the need for any services.

RESULTS

Of 2315 infants, 54.7% used more than 3 SOS by 18 to 22 months, and 19.1% used 6 to 7 SOS. The need for any SOS was reported by approximately 37%. The following variables that were commonly associated with adverse neurodevelopmental outcomes were also associated with the use of more than 5 SOS: sepsis, birth weight, postnatal corticosteroid use, bronchopulmonary dysplasia, and cystic periventricular leukomalacia or grade 3 or 4 intraventricular hemorrhage. Male sex was associated with the need for any SOS. Although high SOS use was more likely among children with adverse neurodevelopmental outcomes, a reported need for SOS was common even among those with mild developmental impairment (39.7%) and mild cerebral palsy (42.2%).

CONCLUSIONS

High SOS use is common, has identifiable neonatal risk factors, and is associated with neurodevelopmental impairment. Extremely preterm survivors have substantial need for community supports regardless of their impairment level. Efforts to improve comprehensive delivery of family-centered community-based services are urgently needed.

Young adults with very low birth weight: leaving the parental home and sexual relationships--Helsinki Study of Very Low Birth Weight Adults

OBJECTIVE

Although most children and adults who are born very preterm live healthy lives, they have, on average, lower cognitive scores, more internalizing behaviors, and deficits in social skills. This could well affect their transition to adulthood. We studied the tempo of first leaving the parental home and starting cohabitation with an intimate partner and sexual experience of young adults with very low birth weight (<1500 g).

METHODS

In conjunction with the Helsinki Study of Very Low Birth Weight Adults, 162 very low birth weight individuals and 188 individuals who were born at term (mean age: 22.3 years [range: 18.5-27.1]) and did not have any major disability filled out a questionnaire. For analysis of their ages at events which had not occurred in all subjects, we used survival analysis (Cox regression), adjusted for gender, current height, parents' ages at the birth, maternal smoking during pregnancy, parental educational attainment, number of siblings, and parental divorce/death.

RESULTS

During their late teens and early adulthood, these very low birth weight adults were less likely to leave the parental home and to start cohabiting with an intimate partner. In gender-stratified analyses, these hazard ratios were similar between genders, but the latter was statistically significant for women only. These very low birth weight adults were also less likely to experience sexual intercourse. This relationship was statistically significant for women but not for men; however, very low birth weight women and men both reported a smaller lifetime number of sex partners than did control subjects.

CONCLUSIONS

Healthy young adults with very low birth weight show a delay in leaving the parental home and starting sexual activity and partnerships.

Association of birth outcomes and maternal, school, and neighborhood characteristics with subsequent numeracy achievement

This study investigated the relation between birth characteristics and numeracy attainment at age 8 years. Using a multilevel approach, the authors analyzed all non-Aboriginal singletons born in Western Australia who attended government schools and participated in a Western Australia-wide numeracy test in grade 3 between 1999 and 2005. Appropriateness of intrauterine growth was expressed as the proportion of optimal growth parameters for gestational duration, infant sex, and maternal height and parity, which was derived from a total population of births without risk factors for growth restriction. After the authors controlled for sociodemographic factors, term birth and proportion of optimal head circumference at birth were associated with higher numeracy scores. Increasing proportion of optimal birth length and being firstborn were associated with relatively higher numeracy scores among children born to mothers residing in the most educationally deprived area. The relative advantage of being born first was also higher for children born to single mothers. In contrast, higher Apgar scores and greater proportion of optimal birth weight were associated with a lower relative advantage for children born to single mothers. In summary, term birth and increased growth in head circumference and length are key birth characteristics associated with higher numeracy scores, especially among disadvantaged children.

Is there evidence that long-term outcomes have improved with intensive care?

Advances in perinatal interventions over the past three decades, such as antenatal steroid therapy, ventilator techniques, surfactant therapy, and enhanced nutrition have resulted in a dramatic improvement in the survival of very low birth weight (VLBW) infants. Simultaneously, other advances in reproductive technology procedures have resulted in greater numbers of preterm and multiple births. These extremely premature births account for the vast majority of infant mortality and morbidity in the developed world. Despite the innovative interventions, VLBW infants remain at substantial risk for a wide spectrum of long-term morbidity including cerebral palsy (CP), mental retardation, developmental delay, school problems, behavioral issues, growth failure, and overall poor health status. Recently, ethical concerns have been expressed that improved survival rates for the most immature infants may result in increased rates of disability with substantial resource utilization and declining quality of life for the survivors. This chapter critically evaluates the available neurodevelopmental and health outcomes of very premature infants from the developed world in an attempt to determine if there is evidence that long-term outcomes have improved with neonatal intensive care. Studies on the rates of neurodevelopmental impairment including CP, early childhood and school age functional problems, and special health care issues are surveyed in order to evaluate changes over time and provide an assessment of the success of neonatal intensive care over the past three decades.

Attention problems in very low birth weight preschoolers: are new screening measures needed for this special population?

PROBLEM

Children born prematurely have been shown to have a range of problems that often result in delayed academic achievement.

METHODS

The current study assessed both attention problem scores (Child Behavior Checklist) and actual performance on tasks tapping three attention networks in a sample of children (n = 94) born with very low birth weights (VLBW; < or = 1500 grams).

FINDINGS

Attention problem scores were extremely low and did not predict children's actual attention performance.

CONCLUSIONS

A body of research is developing that suggests VLBW children may have specific, yet subtle, attention problems that may differ from those of other children.

Self-reported health status and health-related quality of life of teenagers who were born before 29 weeks' gestational age

OBJECTIVE

The objective of this study was to describe the self-reported health status and health-related quality of life of British teenagers who are in mainstream schooling and were born before 29 weeks' gestational age compared with British teenagers who were born at term.

METHODS

All surviving children who were born at <29 weeks' gestation in the former Northern Region of England in 1983 and in the former Oxford Region of England and in Scotland in 1984 were eligible. A comparison group of teenagers who were born at term were also recruited. Children's responses to the Health Utilities Index Mark III were compared.

RESULTS

A total of 218 of the original 535 children who were born in the 3 regions during the study period were alive at 15 to 16 years of age. A complete Health Utilities Index Mark III record was available for 140 children in mainstream schools and for 108 control subjects. In 7 of the 8 attributes (vision, hearing, speech, emotion, pain, ambulation, and dexterity), there were no statistically significant differences in any functional impairment between the comparator groups. However, the preterm group did report a higher level of functional impairment in the cognition attribute (40.7% vs 25.0%). Although there was no difference in the median Health Utilities Index Mark III utility score between the 2 groups (0.93), there was a broader range of utility scores for the preterm group (0.07-1.0 vs 0.45-1.0 for the control group).

CONCLUSIONS

Despite objective evidence that children and teenagers who were born preterm have poorer health on average than term-born control subjects, this is not reflected in their own ratings of their health status and health-related quality of life at 15 to 16 years of age. The reasons for these differences need to be further explored.

Grade failure and special education placement in sexual offenders' educational histories

A sample of 701 adult men underwent assessment following illegal or clinically significant sexual behaviors or interests. Patients were categorized on the basis of phallometric (penile) responses in the laboratory to erotic stimuli depicting adults, pubescent children, and prepubescent children; histories of sexual offenses; and self-reported sexual interests. Comprising the categories were men sexually interested in prepubescent children (pedophiles; n = 114), men sexually interested in pubescent children (hebephiles; n = 377), men sexually interested in adults and who had committed a sexual offense against an adult (teleiophilic offenders; n = 139), and men sexually interested in adults and who had no known history of any sexual offenses (teleiophilic nonoffenders; n = 71). Patients' assessments included IQ testing and self-reported academic history, which included any grade failures and assignment to special education classes. Relative to the teleiophilic offenders, both the pedophilic and the hebephilic groups showed approximately double the odds of failing a grade or being enrolled in special education, both before and after covarying IQ. No significant differences were detected between the teleiophilic offenders and the teleiophilic nonoffenders. These data are consistent with the hypothesis that an erotic age preference for children sometimes results from a perturbation of neurodevelopment occurring early in life.

Gestational age and birth weight in relation to school performance of 10-year-old children: a follow-up study of children born after 32 completed weeks

BACKGROUND

Children born extremely premature (<28 weeks) or with a very low birth weight (<1500 g) have a poorer school performance than children born at term with a normal birth weight. Much less is known about children of higher gestational ages and birth weights. We studied gestational age after 32 completed weeks and birth weight in relation to the child's school performance at the age of 10 years.

METHODS

We performed a follow-up study of 5319 children born between January 1990 and June 1992. We got the information on birth weight and gestational age from birth registration forms; when the children were between 9 and 11 years of age, we gathered information about their school performance (reading, spelling, and arithmetic) from questionnaires completed by the parents and the children's primary school teachers.

RESULTS

The association between birth weight and reading, as well as spelling and arithmetic disabilities, showed a graded relationship, with children who weighed <2500 g having the highest risks. Even children who weighed between 3000 and 3499 g had an increased risk of all 3 learning disabilities compared with children who weighed between 3500 and 4000 g. This association persisted after adjustment for potential cofounders and when the analyses were restricted to children born at term (39-40 weeks of gestation), suggesting that the association could not be explained by a low gestational age. Compared with children born at term, reading and spelling difficulties were more often found among children born at gestational age 33 to 36 weeks and 37 to 38 weeks, whereas there was no relation between gestational age and arithmetic difficulties.

CONCLUSIONS

Gestational age and birth weight were associated with school performance in the 10-year-old child and the association extended into the reference range of both birth weight and gestational age.

Inflammation, brain damage and visual dysfunction in preterm infants

Antenatal intrauterine infection and the fetal inflammatory response appear to be important pathogenetic factors in preterm birth and subsequent neonatal disorders of the lung and brain. In this paper, we expand this concept to include visual dysfunction. Although present data tend to support our notion, we suggest that more experimental and epidemiological research is needed to elucidate mechanisms of infection/inflammation-induced damage to the eye and visual brain pathways of preterm infants.

Outcome of extreme prematurity: as information increases so do the dilemmas

Application of technology in neonatal intensive care has been very successful in reducing mortality, particularly in extremely low birthweight infants. As survival has improved, the need for accurate studies of long term outcome has increased. This need has been met by studies that are larger, more inclusive, and address a wider variety of later outcomes. Rather than a comprehensive quantitative review of these studies, this article uses a smaller number of studies that focus on infants of borderline viability, to illustrate current dilemmas and challenges in interpretation, and the actions, both individual and societal, that may be prompted by these interpretations.

School achievement in a regional cohort of children born very low birthweight

Children born very low birthweight (VLBW, <=1500 g) have historically had lower average school achievement than their normal birthweight peers. However, perinatal care and survival have changed dramatically since prior cohorts accrued, prompting reassessment. Surfactant therapy became generally available 8/1/1990, and the use of ante- and postnatal steroids increased substantially around this time. Standardized test scores and teacher ratings in math, reading, science, and social studies were obtained at age 10 for a cohort of children admitted to six regional NICUs in Wisconsin and Iowa, 8/1/1988 - 6/30/1991. We compared achievement between the VLBW cohort and controls from the same school districts. Among VLBW children, we determined neonatal and early childhood factors associated with achievement on standardized tests (ordinal logistic regression) and teacher ratings (linear regression) and evaluated whether achievement differed by birth year. Compared to population controls, VLBW children's greatest deficits occurred in mathematics. Scores on the standardized math exam and teacher ratings of overall achievement were positively associated with birthweight, social function measured at age five, and socioeconomic status. VLBW children born in the post-surfactant era (after 8/1/1990) had lower achievement on the standardized math exam than children born during the pre-surfactant era of the prior two years. Lower achievement in the post-surfactant era may be due to greater survival among less healthy neonates or increased exposure to postnatal steroids. VLBW children more likely to struggle academically could be identified by early childhood measures, allowing for targeted interventions to mitigate their difficulties.

The association between early minor motor difficulties in extreme low birth weight infants and school age attentional difficulties

INTRODUCTION

Extremely premature infants of normal intellectual ability have an increased prevalence of motor and attentional difficulties. Knowledge of the relationship between early motor difficulties and measures of attention at school age would enhance understanding of these developmental pathways, their interrelationship and opportunities for intervention.

OBJECTIVE

This study examines whether an association exists between early findings of minor motor difficulties and school age clinical and psychometric measures of attention.

METHODOLOGY

45/60 eligible ELBW(1000 g) or preterm (< 27/40 gestation) infants born at the Mater Mother's Hospital were assessed at 12 and 24 months for minor motor deficits (using NSMDA) and at 7-9 years for attention, using clinical (Conners and Du Paul Rating Scales) and psychometric (assessing attention span, selective and divided attention) measures.

RESULTS

NSMDA at 12 months was only associated with the psychometric measures of verbal attention span. It was not associated with later clinical measures of attention. NSMDA at 24 months was strongly associated with specific clinical measures of attention at school age, independent of biological and social factors. It was not associated with psychometric measures of attention.

CONCLUSION

The major finding of this study is that motor difficulties in ELBW infants at 2 years are associated with later clinical measures of attention. Possible mechanisms underlying this relationship are considered.

Visual perceptual skills in children born with very low birth weights

INTRODUCTION

A disproportionate number of very low birth weight (VLBW; < or =1500 g) children require special education services and have school-related problems even when they are free from major disabilities and have average intelligence quotient scores. Visual-perceptual problems have been suggested as contributors to deficits in academic performance, but few data are available describing specific visual-perceptual problems. This study was designed to identify specific visual-perceptual skills in VLBW children.

METHOD

Participants were 92 VLBW children aged 4 through 5 years who were free from major disability and appropriate for gestational age at birth. The Test of Visual-Perceptual Skills (non-motor)-Revised was used.

RESULTS

Despite intelligent quotient scores in the average range, the majority (63% to 78.3%) of the children performed below age level on all seven subscales of a normed assessment of visual perceptual skills.

DISCUSSION

Results suggest that visual perceptual screening should be considered as a part of routine evaluations of preschool-aged children born prematurely. Early identification of specific deficits could lead to interventions to improve achievement trajectories for these high-risk children.

Systemic prenatal insults disrupt telencephalon development: implications for potential interventions

Infants born prematurely are prone to chronic neurologic deficits including cerebral palsy, epilepsy, cognitive delay, behavioral problems, and neurosensory impairments. In affected children, imaging and neuropathological findings demonstrate significant damage to white matter. The extent of cortical damage has been less obvious. Advances in the understanding of telencephalon development provide insights into how systemic intrauterine insults affect the developing white matter, subplate, and cortex, and lead to multiple neurologic impairments. In addition to white matter oligodendrocytes and axons, other elements at risk for perinatal brain injury include subplate neurons, GABAergic neurons migrating through white matter and subplate, and afferents of maturing neurotransmitter systems. Common insults including hypoxia-ischemia and infection often affect the developing brain differently than the mature brain, and insults precipitate a cascade of damage to multiple neural lineages. Insights from development can identify potential targets for therapies to repair the damaged neonatal brain before it has matured.

The economic consequences of preterm birth during the first 10 years of life

OBJECTIVE

To examine the association between gestational age at the time of birth and long-term use and cost of hospital inpatient services.

DESIGN

Multi-level modelling of the hospital service utilisation and cost profile of each child born in hospital during 1978-1988 in two areas covered by the Oxford Record Linkage Study.

SETTING

Oxfordshire and West Berkshire.

POPULATION

117,212 children divided into four subgroups by gestational age at birth: <28 weeks, 28-31 weeks, 32-36 weeks, 37 weeks or greater.

MAIN OUTCOME MEASURES

Number and duration of hospital admissions during the first 10 years of life. Costs, expressed in pound sterling and valued at 1998-1999 prices, of hospital inpatient services.

RESULTS

The cumulative cost of hospital inpatient admissions incurred during the first 10 years of life, including the initial birth admission, averaged 17,819.94 [22,322.87 UK pounds] for children born at <28 weeks gestation, 17,751.00 [19,055.53 UK pounds] for children born at 28-31 weeks gestation, 5,376.39 [7,393.78 UK pounds] for children born at 32-36 weeks gestation, and 1,658.63 [3,409.14 UK pounds] for children born at 37 weeks gestation or greater. The adjusted number of hospital inpatient admissions, inpatient days and costs, respectively, over the first 10 years of life was 130%, 77% and 443% higher for children born at <28 weeks gestation than for children born at term.

CONCLUSION

The adverse sequelae of preterm birth are likely to have considerable long-term economic consequences for the health services and for society as a whole.

Learning disabilities in children with very low birthweight: prevalence, neuropsychological correlates, and educational interventions

This study examined achievement, neuropsychological, and intervention outcomes at a mean age of 11 years in children with very low birthweight (VLBW, <1500 g) compared with a term-born control group. To assess the prevalence and correlates of specific learning disabilities (LD), the sample was limited to children without neurosensory disorders who had at least low average IQ. Participants included 31 children with <750 g birthweight, 41 with 750-1499 g birthweight, and 52 controls. The <750 g group obtained lower scores in math, IQ, and perceptual-organizational skills than the term-born group. The < 750 g group also had higher rates of past and present LD than the controls. Despite these differences, the groups did not differ significantly in rates of special education or tutorial/remedial assistance. These findings suggest that children with extremely low birthweight without gross physical or intellectual impairments are at higher risk for LD and cognitive deficiencies than their term-born peers and that further efforts are needed to improve identification and treatment of these learning problems.

Les troubles du développement des enfants grands prématurés mesurés à l’âge scolaire

Advances in perinatal care have lead to the survival of an increasing number of children born very premature. The purpose of this review is to discuss findings in the literature regarding long term developmental outcome of infants born prematurely especially for studies with children at least 5 years old, born in the 80's or after, in a context of care with increased use of antenatal corticoids, in utero transfer, and surfactant therapy. Developmental sequelae, which are seen in children older than those presenting severe deficiencies, concerns a greater number of very premature children. They have poorer outcomes than term children or normal birth weight controls for cognitive-neuropsychological skills, school performances and behavior. Long term follow up of these children shows that consequences are still present for adolescents or young adults. There is a gradient of developmental sequelae in children that is inversely related to decreasing gestational age or birth weight. Developmental sequelae are related to neonatal medical complications and social risks factors. Research should be conducted in order to better understand etiology and neuropathological basis of sequelae, and the long term developmental implication of being born very premature and the type of care or intervention which could improve their development. An early and regular follow up by a team specialized in child development should be proposed in order to detect developmental sequelae and propose early intervention.

"Womb" literacy: reading to infants in the NICU

PROMOTING LITERACY IS NOT generally one of the top priorities in the care of high-risk infants in the NICU. Basic survival and tending to medical needs are obviously the most pressing concerns. However, we know from various studies that high-risk infants are at greater risk for less-than-optimal cognitive outcomes.1–3 For example, preterm infants are at greater risk than term infants for lower overall IQ scores, repeating a grade, and failing to graduate from high school.1,2 Interventions to improve the academic achievement of children are most effective when begun in the preschool years.4

Bias in reported neurodevelopmental outcomes among extremely low birth weight survivors

OBJECTIVES

The purpose of this study was to investigate possible bias in the evaluation of neurodevelopment and somatic growth at 18 to 22 months' postmenstrual age among extremely low birth weight (ELBW) survivors (401-1000 g at birth).

METHODS

Data from a cohort of 1483 ELBW infant survivors who were born January 1993 through December 1994 and cared for at centers in the Neonatal Research Network of the National Institute of Child Health and Human Development were examined retrospectively. Children who were compliant with an 18- to 22-month follow-up visit, who visited but were not measured, or who made no visit were compared regarding 4 outcomes: 1) Bayley Scales of Infant Development, 2nd edition, Mental Developmental Index (MDI) <70 and 2) Psychomotor Developmental Index (PDI) <70, 3) presence or absence of cerebral palsy, and 4) weight <10th percentile for age. Logistic regression models were used to predict likelihood of these outcomes for children with no follow-up evaluation, and predicted probability distributions were compared across the groups.

RESULTS

Compared with children who were lost to follow-up, those who were compliant with follow-up were more likely to have been 1 of a multiple birth, to have received postnatal glucocorticoids, and to have had chronic lung disease. These factors were significantly associated with MDI and PDI <70 in the compliant group. Chronic lung disease was associated with increased risk of cerebral palsy (CP). MDI and PDI scores <70 were found in 37% and 29% of children who were evaluated at follow-up, respectively. Prediction models revealed that 34% and 26% of infants in the no-visit group would have had MDI and PDI scores <70. Compliant children tended to have greater incidence of MDI <70 compared with those predicted in the no-visit group but not PDI <70. CP was identified in 17% of the compliant group and predicted for 18% of the no-visit group. Predicted probabilities of having CP were marginally higher among the no-visit infants compared with those who were compliant with follow-up. There were no statistically significant somatic growth differences among the compliant, visit but not measured, and no-visit groups.

CONCLUSION

ELBW infant survivors who weighed 401 to 1000 g at birth and who are compliant with follow-up evaluations may have worse Bayley Scales of Infant Development, 2nd edition, MDI scores than infants with no visit. Thus, follow-up studies based on infants who are compliant with follow-up care may lead to an overestimation of adverse outcomes in ELBW survivors.

Accuracy of absence of fetal breathing movements in predicting preterm birth: a systematic review

OBJECTIVE

To determine the accuracy with which the absence of fetal breathing movements on ultrasound examination predicts spontaneous preterm birth in women with threatened preterm labor.

METHODS

Data sources included Medline, Embase, Pascal, Biosis, Cochrane Library, Medion, National Research Register, SciSearch, conference papers, and manual searching of bibliographies of known primary and review articles. A study was selected if it used absence of fetal breathing movements on ultrasound to predict spontaneous preterm birth in women with threatened preterm labor but before advanced cervical dilatation. Two reviewers independently selected studies and extracted data on their characteristics, quality and accuracy. Accuracy data were used to form 2 x 2 contingency tables with birth within 48 h and within 7 days of testing as the reference standards. Likelihood ratios for a positive test (LR+) and negative test (LR-) were calculated as a measure of accuracy.

RESULTS

There were eight studies, which included a total of 328 women, evaluating the accuracy of absence of fetal breathing movements in predicting spontaneous preterm birth in women with threatened preterm labor. There were differences in the methodological quality among the included studies. All were lacking in one or more item that make up an ideal test accuracy study. For women presenting with threatened preterm labor, meta-analysis showed a summary LR+ of 14.80 (95% CI, 6.30-34.79) with a corresponding summary LR- of 0.46 (95% CI, 0.36-0.58) for predicting preterm birth within 7 days, and summary LR+ of 7.84 (95% CI, 1.12-54.99) and summary LR- of 0.25 (95% CI, 0.13-0.48) for predicting preterm birth within 48 h of testing.

CONCLUSION

Absence of fetal breathing movements has the potential to be a useful test in predicting preterm birth both within 7 days and within 48 h of testing. However, the available studies were deficient in their sample size and quality of methodology. Future research should be undertaken to evaluate this technology and to address the methodological deficiencies.

Parent-child interaction and attention regulation in children born prematurely

ISSUES AND PURPOSE

The goal of this pilot study was to understand attention behaviors in extremely low-birth-weight (ELBW) children within the context of parent-child interactions and their relation to the child's independent performance.

DESIGN AND METHODS

Parent-child and child-alone puzzle matching tasks, demographics, and IQ were measured in a sample of 15 4-year-olds who weighed <1000 g at birth and were free from major disability.

RESULTS

A self-regulated and efficient strategy during the parent-child puzzle was related to using an efficient strategy when working alone. Attention regulation during the parent-child puzzle was related to accuracy in the child-alone task. Parents appeared to be regulating attention appropriately.

PRACTICE IMPLICATIONS

Understanding the mechanisms of attention regulation in ELBW children could lead to specific interventions to support parents in strengthening their children's self-regulatory functioning.

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.