The effects of preterm birth on visual development

Trajectories of brain and behaviour development in the womb, at birth and through infancy

Birth is often seen as the starting point for studying effects of the environment on human development, with much research focused on the capacities of young infants. However, recent imaging advances have revealed that the complex behaviours of the fetus and the uterine environment exert influence. Birth is now viewed as a punctuate event along a developmental pathway of increasing autonomy of the child from their mother. Here we highlight (1) increasing physiological autonomy and perceptual sensitivity in the fetus, (2) physiological and neurochemical processes associated with birth that influence future behaviour, (3) the recalibration of motor and sensory systems in the newborn to adapt to the world outside the womb and (4) the effect of the prenatal environment on later infant behaviours and brain function. Taken together, these lines of evidence move us beyond nature-nurture issues to a developmental human lifespan view beginning within the womb.

Self-Reported Findings of the Korean Intermittent Exotropia Multicenter Study Questionnaire

PURPOSE

To determine subjective symptoms and medical history of patients with intermittent exotropia in a large study population.

METHODS

The Korean Intermittent Exotropia Multicenter Study (KIEMS) is a nationwide, observational, cross-sectional, multicenter study conducted by the Korean Association for Pediatric Ophthalmology and Strabismus including 5,385 patients with intermittent exotropia. Subjective symptoms and medical history of patients with intermittent exotropia were extracted by a comprehensive survey based on a self-administered questionnaire according to the study protocol of the KIEMS.

RESULTS

The mean age of symptom onset was 5.5 years. The most common symptom reported in patients with intermittent exotropia was photophobia (52.1%), followed by diplopia at near fixation (7.3%) and distance fixation (6.2%). Preterm birth was found in 8.8%, and 4.1% had perinatal complications. A family history of strabismus was present in 14.9%, and 5.5% of patients had a family member who underwent strabismus surgery.

CONCLUSIONS

The KIEMS is one of the largest clinical studies on intermittent exotropia. Intermittent exotropia frequently caused photophobia and diplopia, and patients with a family history was not uncommon.

Optic atrophy in prematurity: pathophysiology and clinical features

Optic atrophy is an important cause of visual impairment in children, and the aetiological profile has changed over time. Technological advancements led by neuroimaging of the visual pathway and imaging of the optic nerve with optical coherence tomography have accelerated the understanding of this condition. In the new millennium, an increasing prevalence of prematurity as a cause of optic atrophy in children has been highlighted. This new shift has been linked with increasing rates of premature births and improved neonatal survival of preterm infants. The available literature is limited to hospital and registry-based cohorts with modest sample sizes, methodological heterogeneity and selection bias limitations. Larger studies that are better designed are required to better understand the contribution of prematurity to the disease burden. In addition to considering other life-threatening aetiologies, screening for premature birth should be covered as part of a comprehensive history when evaluating a child with paediatric optic atrophy.

A comparative study of stereopsis in term and preterm children with and without retinopathy of prematurity

PURPOSE

To evaluate stereopsis in term-born, preterm, and preterm children with and without retinopathy of prematurity (ROP) and its treatment.

METHODS

The cross-sectional study included 322 children between 3 and 11 years of age born term or preterm, with or without ROP, and with or without treatment for ROP. The ROP treatments were laser therapy, intravitreal injection (IVI) of anti-vascular endothelial growth factor, or their combination. Stereoacuity was measured using the Titmus Stereo Test, and the results among various age groups were analyzed.

RESULTS

Stereopsis was found to improve with increasing age at testing (P < 0.001) across the entire study population. The term group exhibited significantly better stereoacuity than the preterm group (P < 0.001). At 3-5 years and 6-8 years, the preterm children without ROP exhibited significantly better stereoacuity than did those with ROP (P < 0.001 and P = 0.02, respectively); however, at 9-11 years, both groups exhibited similar stereoacuity (P = 0.34). The stereoacuity in the children with untreated ROP was similar to that of the children with treated ROP in all age groups (P > 0.05). No significant differences in stereopsis were identified between children with ROP treated with laser versus with IVI (P > 0.05). From multivariate analysis, younger age at testing (P = 0.001) and younger gestational age (P < 0.001) were associated with poorer stereopsis.

CONCLUSIONS

Stereopsis development gradually improved with age in all groups. The children born preterm exhibited poorer stereoacuity than those born term. Children with ROP treated with laser photocoagulation versus IVI may exhibit similar levels of stereoacuity. Younger age at testing and gestational age were independent risk factors for poorer stereoacuity.

Associations between neonatal nutrition and visual outcomes in 7-year-old children born very preterm

PURPOSE

There is uncertainty about the effect of increased neonatal protein intake on neurodevelopmental outcomes following preterm birth. The aim of this study was to assess the effect of a change in neonatal nutrition protocol at a major tertiary neonatal intensive care unit intended to increase protein intake on ophthalmic and visual development in school-age children born very preterm.

METHODS

The study cohort comprised children (n = 128) with birthweight <1500 g or gestational age < 30 weeks born at Auckland City Hospital before (OldPro group, n = 55) and after (NewPro group, n = 73) a reformulation of parenteral nutrition that resulted in increased total protein intake during the first postnatal week and decreased carbohydrate, total parenteral fluid and sodium intake. Clinical and psychophysical vision assessments were completed at 7 years' corrected age, including visual acuity, global motion perception (a measure of dorsal stream function), stereoacuity, ocular motility and ocular health. Composite measures of favourable overall visual, binocular and functional visual outcomes along with individual vision measures were compared between the groups using logistic and linear regression models.

RESULTS

Favourable overall visual outcome did not differ between the two groups. However, global motion perception was better in the NewPro group (p = 0.04), whereas the OldPro group were more likely to have favourable binocular visual outcomes (60% vs. 36%, p = 0.02) and passing stereoacuity (p = 0.02).

CONCLUSIONS

These results indicate subtle but complex associations between early neonatal nutrition after very preterm birth and visual development at school age.

Comparison of choroidal structural changes between term and preterm children with and without retinopathy of prematurity

PURPOSE

To evaluate the effects of prematurity and retinopathy of prematurity (ROP) treatment on choroidal structure using the image binarization method and compare with term children.

METHODS

Children aged 6-11 years were included in this prospective case-control study. There were 36 (72 eyes) term children and 52 (103 eyes) preterm children included in the study. Subfoveal choroidal thickness (SFCT) and choroidal thickness (CT) at 500, 1500, and 2500 μm temporal and nasal from the fovea were measured. Images were binarized using the Image J program. The choroidal vascularity index (CVI) was calculated by dividing the luminal area by the total subfoveal choroidal area.

RESULTS

There was no significant difference in SCFT between children born at term (290.44±57.617 μm) and preterm (288±69.270 μm) (p = 0.800). CVI was found to be significantly higher in term children (71.90±2.60 %) than in preterm children (69.58±2.72 %) (p<0.001), and the difference was also significant when compared to preterm children without ROP (p = 0.033). In the preterm subgroups, although CVI was higher in preterm children without ROP (70.42±2.24 %) than in those with spontaneous regression (69.34±3.30 %) and those treated with laser photocoagulation (68.91±2.35 %), there was no significant difference (p = 0.330, p = 0.089 respectively). CVI was similar between children with spontaneous regression and those treated with laser photocoagulation (p = 0.909). CVI and logMAR best corrected visual acuity (BCVA) were inversely correlated (r=-0.295 p<0.001).

CONCLUSION

Reduced CVI in preterm children indicates that prematurity is related to the choroid. Choroidal vascularity index appears to be a more reliable marker than CT for evaluating the relationship between choroid and ROP.

Morphine exposure and prematurity affect flash visual evoked potentials in preterm infants

Objective

The present study aimed to explore first the impact of perinatal risk factors on flash-VEP waves and morphology in a group of preterm infants studied at term equivalent age (TEA). Second, to correlate VEP morphology with neurological outcome at 2 years corrected age (CA).

Methods

Infants with a gestational age (GA) at birth <32 weeks, without major brain injury, were enrolled. Multivariate regression analyses were performed, and the models were run separately for each dependent variable N2, P2, N3 latencies and P2 amplitude. Logistic regression was applied to study N4 component (present/absent) and VEP morphology (regular/irregular). The predictors were GA, bronchopulmonary dysplasia (BPD), postmenstrual age at VEP registration, cumulative morphine and fentanyl dose, and painful procedures. Lastly, linear regression models were performed to assess the relation between the Bayley-III cognitive and motor scores at 2 years CA and VEP morphology, in relation to GA, BPD, painful procedures and cumulative morphine dose.

Results

Eighty infants were enrolled. Morphine was the predictor of N2 (R2 = 0.09, p = 0.006), P2 (R2 = 0.11, p = 0.002), and N3 (R2 = 0.13, p = 0.003) latencies. Younger GA was associated with lower amplitude (R2 = 0.05, p = 0.029). None of the independent variables predicted the presence of N4 component, nor VEP morphology in the logistic analysis. VEP morphology was not associated with cognitive and motor scores at 2 years.

Conclusions

Morphine treatment and prematurity were risk factors for altered VEPs parameters at TEA. In our cohort VEP morphology did not predict neurological outcome.

Significance

Morphine administration should be evaluated according to potential risks and benefits, and dosage individually accustomed, according to pain and comfort scores, considering the possible risk for neurodevelopmental impairment.

Blindness is decreasing among children born preterm during the last four decades in Denmark

PURPOSE

Children born preterm are believed to be at increased risk of visual impairment (VI). The increased survival rate of extremely preterm children may have changed the spectrum of diseases occurring postnatally. The aim of this study was to analyse the prevalence and causes of VI in an ex-preterm Danish population during the last 4 decades.

METHODS

The study was based on the National Register of Blind and Visually Impaired Children (NRVIC). Ex-preterms born at gestational age (GA) <32 weeks and enrolled in NRVIC at any time between 1988 and 2020 were included. The main cause of VI, the severity of VI and systemic comorbidities were analysed for temporal changes.

RESULTS

A total of 335 patients were included. The prevalence of VI decreased from 26/1000 preterm children in the 1980s to 15/1000 in 2000s. Blindness due to preterm birth is almost eliminated affecting 1/1000 today. Sequelae to retinopathy of prematurity (ROP) was the most common cause of VI (51% of cases) in the 1980s but decreased to 34% in 2010s, whereas non-ocular causes of VI increased from 1% to 36%, respectively. More than half of the children (64%) had combined comorbidities and 36% had isolated VI.

CONCLUSION

The improved monitoring in neonatal intensive care units and management of ROP has reduced the prevalence of severe VI due to ROP and almost eliminated blindness over the last decades in Denmark. However, preterm children are still at risk of non-ocular causes of VI and comorbidities following the premature delivery.

Association between Autism Spectrum Disorder (ASD) and vision problems. A systematic review and meta-analysis

AIM

To conduct a systematic review and meta-analysis assessing whether vision and/or eye disorders are associated with Autism Spectrum Disorder (ASD).

METHOD

Based on a pre-registered protocol (PROSPERO: CRD42022328485), we searched PubMed, Web of Knowledge/Science, Ovid Medline, Embase and APA PsycINFO up to 5th February 2022, with no language/type of document restrictions. We included observational studies 1) reporting at least one measure of vision in people of any age with a diagnosis of ASD based on DSM or ICD criteria, or ADOS; or 2) reporting the prevalence of ASD in people with and without vision disorders. Study quality was assessed with the Appraisal tool for Cross-Sectional Studies (AXIS). Random-effects meta-analyses were used for data synthesis.

RESULTS

We included 49 studies in the narrative synthesis and 46 studies in the meta-analyses (15,629,159 individuals distributed across multiple different measures). We found meta-analytic evidence of increased prevalence of strabismus (OR = 4.72 [95% CI: 4.60, 4.85]) in people with versus those without ASD (non-significant heterogeneity: Q = 1.0545, p = 0.7881). We also found evidence of increased accommodation deficits (Hedge's g = 0.68 [CI: 0.28, 1.08]) (non-significant heterogeneity: Q = 6.9331, p = 0.0741), reduced peripheral vision (-0.82 [CI: -1.32, -0.33]) (non-significant heterogeneity: Q = 4.8075, p = 0.4398), reduced stereoacuity (0.73 [CI: -1.14, -0.31]) (non-significant heterogeneity: Q = 0.8974, p = 0.3435), increased color discrimination difficulties (0.69 [CI: 0.27,1.10]) (non-significant heterogeneity: Q = 9.9928, p = 0.1890), reduced contrast sensitivity (0.45 [CI: -0.60, -0.30]) (non-significant heterogeneity: Q = 9.9928, p = 0.1890) and increased retinal thickness (=0.29 [CI: 0.07, 0.51]) (non-significant heterogeneity: Q = 0.8113, p = 0.9918) in ASD.

DISCUSSION

ASD is associated with some self-reported and objectively measured functional vision problems, and structural alterations of the eye, even though we observed several methodological limitations in the individual studies included in our meta-analyses. Further research should clarify the causal relationship, if any, between ASD and problems of vision during early life.

PROSPERO REGISTRATION

CRD42022328485.

The long-term mediation role of cytokines on the causal pathway from maternal gestational age to offspring eye diseases: Lifecourse-Network Mendelian randomization

BACKGROUND

Gestational duration has a significant impact on eye diseases. A large number of evidences suggest that cytokines are associated with gestational duration and eye diseases. However, the causal relationships among cytokines, maternal gestational impairment and offspring eye diseases remain unclear.

METHODS

We performed lifecourse-network Mendelian randomization (MR) to explore the causal relationships between maternal gestational duration (from the Early Growth Genetics (EGG) Consortium and the Lundbeck Foundation Initiative for Integrative Psychiatric Research (iPSYCH) study, N = 84,689), neonatal/adult cytokines (from the NHGRI-EBI Catalog, N = 764/4,618), and adult eye diseases (from FinnGen consotium, N = 309,154) using summary-level data from large genome-wide association studies. Multiplicative random effects inverse variance weighted (IVW) and multivariable-IVW methods were the main analysis methods, and the other 15 pleiotropy-robust methods, weak IV-robust methods, and outliers-robust methods were used as auxiliary methods.

RESULTS

Maternal gestational age (early preterm birth, preterm birth, gestational duration, and post-term birth) had a causal relationship with 42 eye diseases. Four neonatal cytokines, Tumor Necrosis Factor-α(TNF-α), IL10, GROA, and CTACK, as well as four adult cytokines, CTACK, IL10, IL12p70 and IL6 are mediators in the causal relationships between early preterm birth and preterm birth in eight eye diseases. However, after adjusting for these mediators, a null direct causal effect of early preterm birth and preterm birth on eight eye diseases was found. In addition, there was no mediator in the causal relationship between gestational duration and post-term birth to eye diseases.

CONCLUSION

The effects of maternal gestational duration on offspring eye diseases through cytokines are long-term and life-course effects.

[Changes in neonatal care : Implications for ophthalmological care]

BACKGROUND

Preterm infants are at risk of characteristic, sometimes life-threatening diseases and development of deficits related to immaturity. In the field of ophthalmology, retinopathy of prematurity (ROP) and vision impairment reflect structural and functional disturbances in this large group of patients. In high income countries, more and more very immature preterm infants survive into adolescence and adulthood.

OBJECTIVE

To characterize the impact of an increasing number of surviving individuals born preterm on the provision of ophthalmological care in Germany.

MATERIAL AND METHODS

A literature search and analysis of key figures and quality indicators published in national health registers were carried out.

RESULTS

Currently, about 60,000 preterm infants are born in Germany every year. Of these, approximately 3600 extremely immature preterm infants with a gestational age < 28 weeks are treated with a curative approach on neonatal units. The survival rate is around 80%. A rise in the proportion of infants suffering from severe ROP has not been observed in recent years in Germany. The incidences of other structural and functional visual impairments vary between 3% and 25% in high income countries.

CONCLUSION

The incidence of ROP apparently has not increased in Germany. However, specific peculiarities of the structure and function of the visual system of individuals born preterm have to be taken into account. Approximately 70,000 outpatient check-ups of infants and toddlers, who require both, ophthalmological and developmental neurological expertise, are estimated for Germany each year.

Preterm birth accelerates the maturation of spontaneous and resting activity in the visual cortex

Prematurity is among the leading risks for poor neurocognitive outcomes. The brains of preterm infants show alterations in structure and electrical activity, but the underlying circuit mechanisms are unclear. To address this, we performed a cross-species study of the electrophysiological activity in the visual cortices of prematurely born infants and mice. Using electroencephalography (EEG) in a sample of healthy preterm (N = 29) and term (N = 28) infants, we found that the maturation of the aperiodic EEG component was accelerated in the preterm cohort, with a significantly flatter 1/f slope when compared to the term infants. The flatter slope was a result of decreased spectral power in the theta and alpha bands and was correlated with the degree of prematurity. To determine the circuit and cellular changes that potentially mediate the changes in 1/f slope after preterm birth, we used in vivo electrophysiology in preterm mice and found that, similar to infants, preterm birth results in a flattened 1/f slope. We analyzed neuronal activity in the visual cortex of preterm (N = 6) and term (N = 9) mice and found suppressed spontaneous firing of neurons. Using immunohistochemistry, we further found an accelerated maturation of inhibitory circuits. In both preterm mice and infants, the functional maturation of the cortex was accelerated, underscoring birth as a critical checkpoint in cortical maturation. Our study points to a potential mechanism of preterm birth-related changes in resting neural activity, highlighting the utility of a cross-species approach in studying the neural circuit mechanisms of preterm birth-related neurodevelopmental conditions.

Association between prenatal exposure to trace elements mixture and visual acuity in infants: A prospective birth cohort study

BACKGROUND

Prenatal environmental factors may affect the development of the offspring and can bring long lasting consequences to the offspring's health. To date, only few studies have reported inconclusive association between prenatal single trace element exposure and visual acuity, and no studies have investigated the association between prenatal exposure to trace elements mixture and visual acuity in infants.

METHODS

In the prospective cohort study, grating acuity in infants (12 ± 1 months) was measured by Teller Acuity Cards II. Concentrations of 20 trace elements in maternal urine samples collected in early-trimester were measured by Inductively Coupled Plasma Mass Spectrometry. Elastic net regression (ENET) was applied to select important trace elements. Nonlinear associations of the trace elements levels with abnormal grating were explored using the restricted cubic spline (RCS) method. The associations between selected individual elements and abnormal grating acuity were further appraised using the logistic regression model. Then Bayesian Kernel Machine Regression (BKMR) was used to estimate the joint effects of mixture and interactions between trace elements combining with NLinteraction.

RESULTS

Of 932 mother-infant pairs, 70 infants had abnormal grating acuity. The ENET model produced 8 trace elements with non-zero coefficients, including cadmium, manganese, molybdenum, nickel, rubidium, antimony, tin and titanium. RCS analyses identified no nonlinear associations of the 8 elements with abnormal grating acuity. The single-exposure analyses using logistic regression revealed that prenatal molybdenum exposure possessed a significantly positive association with abnormal grating acuity (odds ratio [OR]: 1.44 per IQR increase, 95% confidence interval [CI]: 1.05, 1.96; P = 0.023), while prenatal nickel exposure presented with a significantly inverse association with abnormal grating acuity (OR: 0.64 per IQR increase, 95% CI: 0.45, 0.89; P = 0.009). Similar effects were also observed in BKMR models. Moreover, the BKMR models and NLinteraction method identified potential interaction between molybdenum and nickel.

CONCLUSIONS

We established that prenatal exposure to high concentration of molybdenum and low concentration of nickel was associated with the increased risk of abnormal visual acuity. Potential interaction may exist between molybdenum and nickel on abnormal visual acuity.

Preterm birth accelerates the maturation of spontaneous and resting activity in the visual cortex

Prematurity is among the leading risks for poor neurocognitive outcomes. The brains of preterm infants show alterations in structure and electrical activity, but the underlying circuit mechanisms are unclear. To address this, we performed a cross-species study of the electrophysiological activity in the visual cortices of prematurely born infants and mice. Using electroencephalography (EEG) in a sample of healthy preterm (N=29) and term (N=28) infants, we found that the maturation of the aperiodic EEG component was accelerated in the preterm cohort, with a significantly flatter 1/f slope when compared to the term infants. The flatter slope was a result of decreased spectral power in the theta and alpha bands and was correlated with the degree of prematurity. To determine the circuit and cellular changes that potentially mediate the changes in 1/f slope after preterm birth, we used in vivo electrophysiology in preterm mice and found that, similar to infants, preterm birth results in a flattened 1/f slope. We analyzed neuronal activity in the visual cortex of preterm mice (N=6 preterm and 9 term mice) and found suppressed spontaneous firing of neurons. Using immunohistochemistry, we further found an accelerated maturation of inhibitory circuits. In both preterm mice and infants, the functional maturation of the cortex was accelerated, underscoring birth as a critical checkpoint in cortical maturation. Our study points to a potential mechanism of preterm birth-related changes in resting neural activity, highlighting the utility of a cross-species approach in studying the neural circuit mechanisms of preterm birth-related neurodevelopmental conditions.

Visual function correlates with neurodevelopment in a population cohort of school-aged children born extremely preterm

AIM

To investigate visual function and neurodevelopment in a geographically defined population cohort of school-aged children born extremely preterm.

METHODS

All children born extremely preterm in Central Norway between 2006 and 2011 (n=65) were identified, and 36 (median age, min/max: 13, 10/16) were included. Best-corrected visual acuity (BCVA), contrast sensitivity (four spatial frequencies), parent-reported challenges and neuropsychological testing in learning, executive functions, motor skills, perception, reaction time, working and visual memory, processing speed, and pattern separation were measured. Brain MRI (3T) was acquired and read by a neuroradiologist.

RESULTS

Median (min/max) BCVA letter score was 85 (35/91) in the better and 82 (13/89) in the worse eye. ROP participants (n=7) had lower contrast sensitivity in the two highest spatial frequencies (p = 0.024 and p = 0.004). Parent-reported challenges correlated negatively with BCVA (learning: p = 0.014; executive functions: p = 0.002; motor skills: p = 0.000; and perception: p = 0.001), while motor skills correlated negatively with one (p = 0.010) and perception with two (p = 0.003 and p = 0.009) of four spatial frequencies. Neuropsychological tests were reduced relative to norms. None had MRI-verified preterm brain injury.

CONCLUSION

Visual function was subnormal and correlated with parent-reported challenges in a small cohort of extremely preterm school-aged children, indicating that visual function may be a marker of neurodevelopmental outcomes.

Assessment of the perception of vertical subjectivity in children born preterm

Children born preterm have increased rates of paediatric mortality and morbidity. Prematurity has been associated with impaired visual perception and visuo-motor integration. The alteration of the perception of verticality translates into alterations of the vestibular system at central and/or peripheral level, which may manifest itself in symptoms such as imbalance, dizziness or even vertigo. The aim of this study was to compare subjective visual vertical (SVV) test scores in children born preterm with those of children born at term at ages between 7 and 10. One hundred ten children with no neurodevelopmental disorder of 7 to 10 years of age were studied using a mobile application on a smartphone attached to a wall by means of a rotating plate. The SVV test was compared between two groups: a group of 55 preterm children (53 very preterm children born under 32 weeks of gestational age and 2 preterm with very low birth weight) and another group of 55 children born at term (after 37 weeks of gestational age). The SVV results were analysed for comparison with respect to prematurity, sex and age. We found no significant differences in the SVV study in the comparison between preterm and term children. In addition, no significant differences were observed regarding sex or age between 7 and 10 years.  Conclusion: We found no alterations in the perception of vertical subjectivity in children between 7 and 10 years of age, with antecedents of very preterm birth and/or very low birth weight. What is Known: • The different studies published so far suggest the existence of balance disorders in premature children, although in most of these studies the children are examined at an age when the vestibular system is not mature and with non-specific tests for the study of the vestibular system. What is New: • We compared the results of the subjective visual vertical (SVV) test in a group of 55 preterm children (53 very preterm children born under 32 weeks of gestational age and 2 preterm with very low weight at birth) and in a group of 55 children born at term (after 37 weeks of gestational age), at the ages of 7 to 10 years and observed no differences. • We conclude that, if there had been any vestibular alterations due to very premature birth, these must have been compensated by the age of 7.

Prematurity and BPD: what general pediatricians should know

More and more very low birth weight (VLBW) infants around the world survive nowadays, with consequently larger numbers of children developing prematurity-related morbidities, especially bronchopulmonary dysplasia (BPD). BPD is a multifactorial disease and its rising incidence in recent years means that general pediatricians are much more likely to encounter a child born extremely preterm, possibly with BPD, in their clinical practice. Short- and long-term sequelae in VLBW patients may affect not only pulmonary function (principally characterized by an obstructive pattern), but also other aspect including the neurological (neurodevelopmental and neuropsychiatric disorders), the sensorial (earing and visual impairment), the cardiological (systemic and pulmonary hypertension, reduced exercise tolerance and ischemic heart disease in adult age), nutritional (feeding difficulties and nutritional deficits), and auxological (extrauterine growth restriction). For the most premature infants at least, a multidisciplinary follow-up is warranted after discharge from the neonatal intensive care unit in order to optimize their respiratory and neurocognitive potential, and prevent respiratory infections, nutritional deficiencies or cardiovascular impairments.  Conclusion: The aim of this review is to summarize the main characteristics of preterm and BPD infants, providing the general pediatrician with practical information regarding these patients' multidisciplinary complex follow-up. We explore the current evidence on respiratory outcomes and their management that actually does not have a definitive available option. We also discuss the available investigations, treatments, and strategies for prevention and prophylaxis to improve the non-respiratory outcomes and the quality of life for these children and their families, a critical aspect not always considered. This comprehensive approach, added to the increased needs of a VLBW subjects, is obviously related to very high health-related costs that should be beared in mind. What is Known: • Every day, a general pediatrician is more likely to encounter a former very low birth weight infant. • Very low birth weight and prematurity are frequently related not only with worse respiratory outcomes, but also with neurological, sensorial, cardiovascular, renal, and nutritional issues. What is New: • This review provides to the general pediatrician a comprehensive approach for the follow-up of former premature very low birth weight children, with information to improve the quality of life of this special population.

Vision function in children 10 years after grade 3 or 4 intraventricular haemorrhage with ventricular dilation: A masked prospective study

AIM

We examined children 10 to 11 years after grade 3 or 4 intraventricular haemorrhage and ventricular dilation (IVHVD) and investigated whether the grade of IVHVD affected their visual outcome. We explored associations between visual outcomes with cognitive outcomes and extra support at school.

METHOD

The visual examinations were part of a 10-year follow-up study for children in a randomized trial. Testers followed a protocol and were masked to whether the child had experienced grade 3 or grade 4 IVHVD and all other data.

RESULTS

Thirty-two children were tested: 24 were male and mean (standard deviation) age was 10 years 5 months (1 year 2 months); range 8 years 9 months to 12 years 9 months. All had at least one visual impairment. The median (interquartile range) number of impairments per child was six (six to nine) for children who experienced a grade 4 IVHVD compared with three (two to four) for children who experienced a grade 3 IVHVD (p = 0.003). Each extra vision impairment per child was associated with increased educational support at school, after adjustment for developmental age equivalence (odds ratio = 1.7 [95% confidence interval 1.1-2.6], p = 0.015).

INTERPRETATION

Children who experience grade 3 or 4 IVHVD have a high level of visual morbidity at age 10 to 11 years. These children may have unmet visual needs and their outcomes might improve if these needs could be addressed.

WHAT THIS PAPER ADDS

Parent-reported questionnaire responses underestimated directly assessed visual morbidity. Grade 4 intraventricular haemorrhage and ventricular dilatation (IVHVD) was followed by more vision impairments than grade 3 IVHVD. Simple tests of visual perceptual skills correlated with the neuropsychology tests. Children with supranuclear eye movement disorders were more likely to be receiving extra help at school. Each additional visual impairment increased the likelihood of extra educational support.

Association between ADHD and vision problems. A systematic review and meta-analysis

AIM

To conduct the first systematic review and meta-analysis assessing whether attention-deficit/hyperactivity disorder (ADHD) is associated with disorders of the eye, and/or altered measures of visual function.

METHOD

Based on a pre-registered protocol (PROSPERO: CRD42021256352), we searched PubMed, Web of Knowledge/Science, Ovid Medline, Embase and APA PsycINFO up to 16th November 2021, with no language/type of document restrictions. We included observational studies reporting at least one measure of vision in people of any age meeting DSM/ICD criteria for ADHD and in people without ADHD; or the prevalence of ADHD in people with and without vision disorders. Study quality was assessed with the Appraisal tool for Cross-Sectional Studies (AXIS). Random effects meta-analyses were used for data synthesis.

RESULTS

We included 42 studies in the narrative synthesis and 35 studies in the meta-analyses (3,250,905 participants). We found meta-analytic evidence of increased risk of astigmatism (OR = 1.79 [CI: 1.50, 2.14]), hyperopia and hypermetropia (OR = 1.79 [CI: 1.66, 1.94]), strabismus (OR = 1.93 [CI: 1.75, 2.12]), unspecified vision problems (OR = 1.94 [CI: 1.38, 2.73]) and reduced near point of convergence (OR = 5.02 [CI: 1.78, 14.11]); increased lag (Hedge's g = 0.63 [CI: 0.30, 0.96]) and variability (Hedge's g = 0.40 [CI: 0.17, 0.64]) of the accommodative response; and increased self-reported vision problems (Hedge's g = 0.63 [CI: 0.44, 0.82]) in people with ADHD compared to those without ADHD (with no significant heterogeneity). We also found meta-analytic evidence of no differences between people with and without ADHD on retinal nerve fiber layer thickness (Hedge's g = -0.19 [CI: -0.41, 0.02]) and refractive error (Hedge's g = 0.08 [CI: -0.26, 0.42]) (with no significant heterogeneity).

DISCUSSION

ADHD is associated with some self-reported and objectively ascertained functional vision problems, but not with structural alterations of the eye. Further studies should clarify the causal relationship, if any, between ADHD and problems of vision.

TRIAL REGISTRATION

PROSPERO registration: CRD42021256352.

Intrauterine Inflammation Leads to Select Sex- and Age-Specific Behavior and Molecular Differences in Mice

Sex-specific differences in behavior have been observed in anxiety and learning in children exposed to prenatal inflammation; however, whether these behaviors manifest differently by age is unknown. This study assesses possible behavioral changes due to in utero inflammation as a function of age in neonatal, juvenile, and adult animals and presents potential molecular targets for observed differences. CD-1 timed pregnant dams were injected in utero with lipopolysaccharide (LPS, 50 μg/animal) or saline at embryonic day 15. No differences in stress responses were measured by neonatal ultrasonic vocalizations between LPS- and saline-exposed groups of either sex. By contrast, prenatal inflammation caused a male-specific increase in anxiety in mature but not juvenile animals. Juvenile LPS-exposed females had decreased movement in open field testing that was not present in adult animals. We additionally observed improved memory retrieval after in utero LPS in the juvenile animals of both sexes, which in males may be related to a perseverative phenotype. However, there was an impairment of long-term memory in only adult LPS-exposed females. Finally, gene expression analyses revealed that LPS induced sex-specific changes in genes involved in hippocampal neurogenesis. In conclusion, intrauterine inflammation has age- and sex-specific effects on anxiety and learning that may correlate to sex-specific disruption of gene expression associated with neurogenesis in the hippocampus.

The impact of early intervention on a child with vision loss in infancy - A parental perspective

Purpose

: To assess the impact of early intervention services provided to children with visual loss and to report how parents perceive them in terms of a child's development and the family dynamics.

Methods

: A qualitative descriptive study was conducted on a purposively selected sample of 15 children with severe visual impairment, availing early intervention services at a tertiary care facility in Pune, Maharashtra. Data were collected by conducting in-depth interviews of the parents with the help of a semi-structured interview topic guide. Participants were asked in detail about how and whether various components of the early intervention program (EIP) had an impact on their child. The interviews were audio-recorded, transcribed, and translated into English, and the resultant textual data were analyzed using the qualitative research software NVIVO 12 to identify themes and sub-themes under each domain.

Results

: A total of 15 children were included in the study, with ages ranging from 13 months to 5 years. All the children included in the study suffered from severe visual impairment in infancy (Vision 3/60 - PL). In the course of this EIP, the majority of the children showed consistent progress in various aspects of child development. According to the parents, the most beneficial components of EIP were visual stimulation exercises, an improvised teaching methodology, and counseling services.

Conclusion

: Almost all the parents included in the study reported a positive change in the behavior and development of the child as well as improved family dynamics after implementation of EIP.

Neuroprotective Role of Lactoferrin during Early Brain Development and Injury through Lifespan

Early adverse fetal environments can significantly disturb central nervous system (CNS) development and subsequently alter brain maturation. Nutritional status is a major variable to be considered during development and increasing evidence links neonate and preterm infant impaired brain growth with neurological and psychiatric diseases in adulthood. Breastfeeding is one of the main components required for healthy newborn development due to the many "constitutive" elements breastmilk contains. Maternal intake of specific nutrients during lactation may alter milk composition, thus affecting newborn nutrition and, potentially, brain development. Lactoferrin (Lf) is a major protein present in colostrum and the main protein in human milk, which plays an important role in the benefits of breastfeeding during postnatal development. It has been demonstrated that Lf has antimicrobial, as well as anti-inflammatory properties, and is potentially able to reduce the incidence of sepsis and necrotizing enterocolitis (NEC), which are particularly frequent in premature births. The anti-inflammatory effects of Lf can reduce birth-related pathologies by decreasing the release of pro-inflammatory factors and inhibiting premature cervix maturation (also related to commensal microbiome abnormalities) that could contribute to disrupting brain development. Pre-clinical evidence shows that Lf protects the developing brain from neuronal injury, enhances brain connectivity and neurotrophin production, and decreases inflammation in models of perinatal inflammatory challenge, intrauterine growth restriction (IUGR) and neonatal hypoxia-ischemia (HI). In this context, Lf can provide nutritional support for brain development and cognition and prevent the origin of neuropsychiatric diseases later in life. In this narrative review, we consider the role of certain nutrients during neurodevelopment linking to the latest research on lactoferrin with respect to neonatology. We also discuss new evidence indicating that early neuroprotective pathways modulated by Lf could prevent neurodegeneration through anti-inflammatory and immunomodulatory processes.

Neurosensory Alterations in Retinopathy of Prematurity: A Window to Neurological Impairments Associated to Preterm Birth

Retinopathy of prematurity (ROP) is one of the main blinding diseases affecting preterm newborns and is classically considered a vascular disorder. The premature exposure to the extrauterine environment, which is hyperoxic in respect to the intrauterine environment, triggers a cascade of events leading to retinal ischemia which, in turn, makes the retina hypoxic thus setting off angiogenic processes. However, many children with a history of ROP show persistent vision impairment, and there is evidence of an association between ROP and neurosensory disabilities. This is not surprising given the strict relationship between neuronal function and an adequate blood supply. In the present work, we revised literature data evidencing to what extent ROP can be considered a neurodegenerative disease, also taking advantage from data obtained in preclinical models of ROP. The involvement of different retinal cell populations in triggering the neuronal damage in ROP was described along with the neurological outcomes associated to ROP. The situation of ROP in Italy was assessed as well.

Brain microstructural antecedents of visual difficulties in infants born very preterm

Infants born very preterm (VPT) are at risk of later visual problems. Although neonatal screening can identify ophthalmologic abnormalities, subtle perinatal brain injury and/or delayed brain maturation may be significant contributors to complex visual-behavioral problems. Our aim was to assess the micro and macrostructural antecedents of early visual-behavioral difficulties in VPT infants by using diffusion MRI (dMRI) at term-equivalent age. We prospectively recruited a cohort of 262 VPT infants (≤32 weeks gestational age [GA]) from five neonatal intensive care units. We obtained structural and diffusion MRI at term-equivalent age and administered the Preverbal Visual Assessment (PreViAs) questionnaire to parents at 3-4 months corrected age. We used constrained spherical deconvolution to reconstruct nine white matter tracts of the visual pathways with high reliability and performed fixel-based analysis to derive fiber density (FD), fiber-bundle cross-section (FC), and combined fiber density and cross-section (FDC). In multiple logistic regression analyses, we related these tract metrics to visual-behavioral function. Of 262 infants, 191 had both high-quality dMRI and completed PreViAs, constituting the final cohort: mean (SD) GA was 29.3 (2.4) weeks, 90 (47.1%) were males, and postmenstrual age (PMA) at MRI was 42.8 (1.3) weeks. FD and FC of several tracts were altered in infants with (N = 59) versus those without retinopathy of prematurity (N = 132). FDC of the left posterior thalamic radiations (PTR), left inferior longitudinal fasciculus (ILF), right superior longitudinal fasciculus (SLF), and left inferior fronto-occipital fasciculus (IFOF) were significantly associated with visual attention scores, prior to adjusting for confounders. After adjustment for PMA at MRI, GA, severe retinopathy of prematurity, and total brain volume, FDC of the left PTR, left ILF, and left IFOF remained significantly associated with visual attention. Early visual-behavioral difficulties in VPT infants are preceded by micro and macrostructural abnormalities in several major visual pathways at term-equivalent age.

The Association between Gestational Age and Risk for Long Term Ophthalmic Morbidities among Offspring Delivered in Different Preterm Subgroups

Objective: To investigate whether there is a linear association between the degree of prematurity and the risk for long-term ophthalmic morbidity among preterm infants. Study design: A population-based, retrospective cohort study, which included all singleton deliveries occurring between 1991 and 2014 at a single tertiary medical center. All infants were divided into four groups according to gestational age categories: extremely preterm births, very preterm births, moderate to late preterm births and term deliveries (reference group). Hospitalizations of offspring up to 18 years of age involving ophthalmic morbidity were evaluated. Survival curves compared cumulative hospitalizations and regression models controlled for confounding variables. Results: During the study period, 243,363 deliveries met the inclusion criteria. Ophthalmic-related hospitalization rates were lower among children born at term (0.9%) as compared with extremely preterm (3.6%), very preterm (2%), and moderate to late preterm (1.4%) born offspring (p < 0.01; using the chi-square test for trends). The survival curve demonstrated significantly different hospitalization rates between the gestational ages (p < 0.001). The regression demonstrated an independent risk for ophthalmic morbidity among extremely preterm born offspring (adjusted hazard ratio 3.8, confidence interval 1.6−9.2, p < 0.01), as well as very preterm and moderate to late preterm (adjusted hazard ratio 2.2 and 1.5, respectively) as compared with term deliveries. Conclusions: The risk for long-term ophthalmic-related hospitalization of preterm offspring gradually decreases as the gestational age increases.

PM2.5 exposure increases the risk of preterm birth in pre-pregnancy impaired fasting glucose women: A cohort study in a Southern province of China

Previous studies have indicated maternal exposure to particles with aerodynamic diameter <2.5 μm (PM_2.5) is associated with preterm birth (PTB). However, no study has investigated this effect in pre-pregnancy impaired fasting glucose (IFG) women. This study aimed to differentiate the effects of maternal PM_2.5 exposure on PTB between pre-pregnancy IFG and normoglycemia women, and to further identify the susceptible window. This cohort study was conducted between January 2014 and December 2017 in 21 Chinese cities. All the recruited women received pre-pregnancy fasting serum glucose (FSG) tests and were followed up for their delivery outcomes. The PM_2.5 exposures were estimated by the daily air pollution concentrations of the nearby monitors. Women with FSG below 7.0 mmol/L were included in the analysis. We employed the Cox proportional hazards models to examine whether PM_2.5 exposure was associated with PTB. 237957 women were included and 7055 (3.0%) of them were pre-pregnancy IFG. During the entire pregnancy, we found 24.1% (HR = 1.241; 95% CI: 1.069, 1.439), 61.8% (HR = 1.618; 95% CI: 1.311, 1.997) and 18.6% (HR = 1.186; 95% CI: 1.004, 1.402) of increases in risk for all PTB, early PTB (20-33 gestational weeks) and late PTB (34-36 gestational weeks) among the pre-pregnancy IFG women, and 15.9% (HR = 1.159; 95% CI: 1.127, 1.192), 33.9% (HR = 1.339; 95% CI: 1.255, 1.430) and 13.2% (HR = 1.132; 95% CI: 1.098, 1.168) of increases in risk for all PTB, early PTB and late PTB among the normoglycemia women, with each 10 μg/m³ increment of PM_2.5 exposure, respectively. Furthermore, PM_2.5 exposure had the strongest effect on all PTB during trimester 1 (0-12 gestational weeks) among the pre-pregnancy IFG women, compared with the less strong effect during trimester 1 among the normoglycemia women. In conclusion, pre-pregnancy IFG increases the risk of PTB attributed to PM_2.5, especially during trimester 1. Moreover, the effects of PM_2.5 are greater on early PTB than late PTB for both pre-pregnancy IFG and normoglycemia women.

Immature brain structures were associated with poorer eye movement performance at 8 years of age in preterm born children

AIM

Eye movements have rarely been explored in preterm born children. The aim of this study was to compare horizontal eye movements in children born preterm and full term when they reached 8 years of age.

METHODS

Eye movements were recorded in 24 preterm born children (18 boys) and 26 matched controls (19 boys), recruited by a French hospital, using an eye tracker. This identified different types of visually guided saccades, namely step, gap, overlap and antisaccades and pursuit eye movements. The saccades task measured the latency and the percentage of anticipatory and express saccades and errors. The pursuit task measured the gain and percentage of intrusive saccades.

RESULTS

This study confirmed that children born at 24-28 weeks of gestation demonstrated a global deficit in inhibitory processes compared to children born full term. The saccades were less precise in the preterm group, anticipatory and express saccades were elevated and there was a high occurrence of intrusive saccades during pursuit movements.

CONCLUSION

These findings suggest that preterm born children have immature brain structures, particularly the parietal and frontal cortexes that are responsible for both saccade and pursuit performance. These could have been the cause of the abnormal inhibitory control measured in this study.

[Modern possibilities of diagnosing lesions of the visual analyzer in perinatal lesions of the central nervous system in full-term and premature infants]

The article provides an overview of current neuro-ophthalmological diagnostic capabilities in patients with perinatal lesions. The main attention is paid to the diagnosis of patients with periventricular leukomalacia and peri- and intraventricular hemorrhages. The most relevant methods of neuro-ophthalmological diagnosis in hypoxic-ischemic CNS lesions are covered. The functions and peculiarities of blood supply of the germinal matrix are described. The importance of the use of optical coherence tomography and visual evoked potential recording in full-term and premature infants with visual pathway and/or visual cortex lesions in brain lesions is discussed. The conclusion emphasizes the need for an interdisciplinary approach in the examination of children with perinatal CNS lesions.

Visuopathy of prematurity: is retinopathy just the tip of the iceberg?

Research on retinopathy of prematurity (ROP) focuses mainly on the abnormal vascularization patterns that are directly visible for ophthalmologists. However, recent findings indicate that children born prematurely also exhibit changes in the retinal cellular architecture and along the dorsal visual stream, such as structural changes between and within cortical areas. Moreover, perinatal sustained systemic inflammation (SSI) is associated with an increased risk for ROP and the visual deficits that follow. In this paper, we propose that ROP might just be the tip of an iceberg we call visuopathy of prematurity (VOP). The VOP paradigm comprises abnormal vascularization of the retina, alterations in retinal cellular architecture, choroidal degeneration, and abnormalities in the visual pathway, including cortical areas. Furthermore, VOP itself might influence the developmental trajectories of cerebral structures and functions deemed responsible for visual processing, thereby explaining visual deficits among children born preterm.

Visual development of healthy full-term infants under 24 months of age using the Preverbal Visual Assessment (PreViAs) questionnaire

As visual perception development proceeds rapidly after birth, early detection of developmental maturity is required. Healthy infants do not have many opportunities for visual perception evaluation, so a reliable evaluation method is necessary. This retrospective study included 276 healthy full-term infants less than 24 months of age using the Preverbal Visual Assessment (PreViAs) questionnaire, which measures scores of subdivided age groups for the global scores and four domains: visual attention (VA), visual communication (VC), visual-motor coordination (VMC) and visual processing (VP). Through this study, reference values and cut-off scores of the PreViAs questionnaire were presented, reliability was secured, and potential influencing factors of the PreViAs scores were analyzed. Using Cronbach's α coefficient, the global scores were 0.938, 0.781 for VA, 0.660 for VC, 0.874 for VMC, and 0.942 for VP. The internal consistency of the questionnaire was high in the global scores and three domains (VA, VMC, VP). In infants under 12 months, the global scores and the VA, VMC, and VP domains showed positive association with gestational age, whereas the VC domain positively correlated with sex: which was found to be greater for females (P<0.05). In those 12 month and above, no clinical factors were significantly associated with the PreViAs scores in all domains. The PreViAs questionnaire is a useful tool for visual assessment of healthy full-term infants under 24 months of age, suggesting reference values and cut-off scores according to age, and estimating the maturation age for visual perception development of each domain.

Iatrogenic factors contributed to the high rate of preterm birth in a community hospital

BACKGROUND

Preterm birth (PTB) rates have been increased significantly in recent years, mostly due to obstetric intervention. This study presents the incidence of PTB in community hospitals by assessing the association between pregnancy complications and iatrogenic PTB.

METHODS

A total of 6,693 pregnancies were enrolled in the Wuxi Maternity and Child Health Care Hospital of Nanjing Medical University. They were divided into two groups (<35 and ≥35 years of age) to examine the effect of maternal age on PTB. Binary logistic and multiple linear regression analyses were used to assess the relationship between PTB and pregnancy complications.

RESULTS

This study provided the incidence of PTB and found that PP, PROM, and ICP increased the risk of PTB, indicating that pregnancy complications have led to the iatrogenic PTB and contributed to the high rate of PTB, especially in the group of advanced-age pregnant women. The prevalence of PTB was 9.53%. Placenta previa (PP), premature rupture of membranes (PROM), and intrahepatic cholestasis of pregnancy (ICP) were significantly associated with PTB. Among all the risk factors, hypertension, disease in pregnancy, premature PROM, and PP were observed as independent key factors for iatrogenic PTBs. In the advanced-age group, PP and pPROM increased the risk of PTB.

CONCLUSIONS

It is often necessary to terminate a pregnancy in community hospitals to balance the safety of the fetus and the maternal comorbid symptoms, which has led to nosocomial premature delivery. Therefore, high-risk pregnancies should be carefully evaluated and comprehensively treated with caution to balance the preterm rate and the safety of the pregnant woman and fetus, and the pros and cons of the outcomes, which has brought a challenge to an obstetrician to reduce the proportion of iatrogenic PTB.

Cortical Visual Impairment in Childhood: 'Blindsight' and the Sprague Effect Revisited

The paper discusses and provides support for diverse processes of brain plasticity in visual function after damage in infancy and childhood in comparison with injury that occurs in the adult brain. We provide support and description of neuroplastic mechanisms in childhood that do not seemingly exist in the same way in the adult brain. Examples include the ability to foster the development of thalamocortical connectivities that can circumvent the lesion and reach their cortical destination in the occipital cortex as the developing brain is more efficient in building new connections. Supporting this claim is the fact that in those with central visual field defects we can note that the extrastriatal visual connectivities are greater when a lesion occurs earlier in life as opposed to in the neurologically mature adult. The result is a significantly more optimized system of visual and spatial exploration within the ‘blind’ field of view. The discussion is provided within the context of “blindsight” and the “Sprague Effect”.

Early-term deliveries and long-term pediatric ophthalmic morbidity of the offspring. Int J Gynaecol Obstet 2021;157:640-646. [PMID: 34383310 DOI: 10.1002/ijgo.13875]

OBJECTIVE

To examine whether early-term delivery impacts on the long-term ophthalmic health of offspring.

METHODS

A retrospective population-based cohort study was conducted, including all singleton deliveries (1991-2014) occurring at a tertiary medical center. Gestational age was divided into: early prematurity, late prematurity, and early, full, late, and post term. Hospitalizations of offspring up to 18 years of age involving ophthalmic morbidity were evaluated. Survival curves compared cumulative hospitalizations and regression models controlled for confounders.

RESULTS

During the study period, 243 363 deliveries met the inclusion criteria. Ophthalmic-related hospitalization rates were lower among early-term born children (1.0%) as compared with early- (2.2%) and late-preterm (1.3%) born children, but higher than those in full- (0.9%), late- (0.8%), and post-term (0.8%) born offspring (P < 0.001). The survival curve demonstrated significantly different hospitalization rates in the different gestational ages (P < 0.001). The regression demonstrated an independent risk for ophthalmic morbidity among early-term born offspring (adjusted hazard ratio 1.14, confidence interval 1.03-1.27, P = 0.009), whereas late- and post-term deliveries were associated with a lower risk (adjusted hazard ratio 0.83 and 0.74, respectively) as compared with full-term deliveries.

CONCLUSION

The risk for long-term ophthalmic-related hospitalizations of offspring gradually declines as gestational age advances.

Adults Born Preterm: Long-Term Health Risks of Former Very Low Birth Weight Infants

BACKGROUND

Advances in neonatology now enable increasing numbers of very low birth weight neonates (<1500 g) to survive into early adulthood and beyond. What are the implications for their long-term care?

METHODS

Selective literature search on the outcome of very low birth weight neonates in adulthood ("adults born preterm").

RESULTS

Robust data are available on the pulmonary, metabolic, cardiovascular, renal, neurocognitive, sensory-visual, social-emotional, mental, reproductive, and musculoskeletal long-term risks. On the somatic level, elevated rates have been documented for asthma (odds Ratio [OR] 2.37), diabetes mellitus (OR 1.54), and chronic renal disease (hazard ratio [HR] 3.01), along with the cardiovascular and cerebrovascular sequelae of a tendency toward arterial hypertension. On the psychosocial level, the main findings are deficits in romantic partnerships (OR 0.72) and a lower reproduction rate (relative risk [RR] male/female 0.24/0.33). The affected women also have an elevated risk of preterm delivery.

CONCLUSION

A risk profile with both somatic and psychosocial aspects can be discerned for adults who were born prematurely, even if some of these risks are present in low absolute numbers. As the ability to compensate for latent deficits declines with age, such adults may suffer from "premature aging as the late price of premature birth." A holistic approach to care with personalized prevention strategies-which for most of them was discontinued at discharge from pediatric follow-up-therefore seems appropriate in adulthood as well.

Mass Incarceration and Children's Health: A State-Level Analysis of Adverse Birth Outcomes and Infant, Child, and Teen Mortality

Children's health indicators such as mortality and adverse birth outcomes are poorer in the United States than in comparable nations. These measures also show racial inequities within the United States, with Black children experiencing the highest levels. Mass incarceration may partially explain these findings. High incarceration rates can disrupt community functioning, influencing behavior and health. The purpose of the current study was to conduct a macro (state)-level analysis examining whether yearly state incarceration rates predict health outcomes including infant, child, and teen mortality as well as preterm birth and low birth weight. It was hypothesized that prior year incarceration rates would show positive relationships with all outcomes and that relationships would be stronger for Black than for white children. Yearly state-level panel data were gathered from 1990 to 2017. Weighted least squares regression used states' prior year incarceration rates to predict child health outcomes, using controls for overall state effects and year-to-year effects. Time-varying covariates such as state unemployment rate were also included to address the possibility of spurious relationships. Results indicated that as hypothesized, incarceration rates positively predicted infant mortality, child mortality (for Black children only), preterm births, and low-weight births. Relationships tended to be stronger for Black than for white children.

Therapeutic Effects of Mesenchymal Stromal Cell-Derived Small Extracellular Vesicles in Oxygen-Induced Multi-Organ Disease: A Developmental Perspective

Despite major advances in neonatal intensive care, infants born at extremely low birth weight still face an increased risk for chronic illness that may persist into adulthood. Pulmonary, retinal, and neurocognitive morbidities associated with preterm birth remain widespread despite interventions designed to minimize organ dysfunction. The design of therapeutic applications for preterm pathologies sharing common underlying triggers, such as fluctuations in oxygen supply or in the inflammatory state, requires alternative strategies that promote anti-inflammatory, pro-angiogenic, and trophic activities—ideally as a unitary treatment. Mesenchymal stem/stromal cell-derived extracellular vesicles (MEx) possess such inherent advantages, and they represent a most promising treatment candidate, as they have been shown to contribute to immunomodulation, homeostasis, and tissue regeneration. Current pre-clinical studies into the MEx mechanism of action are focusing on their restorative capability in the context of preterm birth-related pathologies, albeit not always with a multisystemic focus. This perspective will discuss the pathogenic mechanisms underlying the multisystemic lesions resulting from early-life disruption of normal physiology triggered by high oxygen exposures and pro-inflammatory conditions and introduce the application of MEx as immunomodulators and growth-promoting mediators for multisystem therapy.

Functional Magnetic Resonance Imaging during Visual Perception Tasks in Adolescents Born Prematurely

OBJECTIVES

Impairments in visual perception are among the most common developmental difficulties related to being born prematurely, and they are often accompanied by problems in other developmental domains. Neural activation in participants born prematurely and full-term during tasks that assess several areas of visual perception has not been studied. To better understand the neural substrates of the visual perceptual impairments, we compared behavioral performance and brain activations during visual perception tasks in adolescents born very preterm (birth weight ≤1500 g or gestational age <32 weeks) and full-term.

METHODS

Tasks assessing visual closure, discrimination of a deviating figure, and discrimination of figure and ground from the Motor-Free Visual Perception Test, Third Edition were performed by participants born very preterm (n = 37) and full-term (n = 34) at 12 years of age during functional magnetic resonance imaging.

RESULTS

Behavioral performance in the visual perception tasks did not differ between the groups. However, during the visual closure task, brain activation was significantly stronger in the group born very preterm in a number of areas including the frontal, anterior cingulate, temporal, and posterior medial parietal/cingulate cortices, as well as in parts of the cerebellum, thalamus, and caudate nucleus.

CONCLUSIONS

Differing activations during the visual closure task potentially reflect a compensatory neural process related to premature birth or lesser neural efficiency or may be a result of the use of compensatory behavioral strategies in the study group born very preterm.

Prenatal Tobacco Exposure and Childhood Neurodevelopment among Infants Born Prematurely

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

KEY POINTS

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

Visual assessment of preterm and full-term infants under the age of 12 months using the Preverbal Visual Assessment questionnaire

BACKGROUND

Infants develop many complex visual competences within the first 12 months of life. Premature infants are at high risk for abnormal visual and neurological development. Clinical medical history or neurologic evaluation do not give enough information on visual maturation in infants under 12 months of age.

AIMS

To compare visual maturation between preterm and full-term infants aged under 12 months, using the Preverbal Visual Assessment questionnaire (PreViAs).

STUDY DESIGN

Retrospective cross-sectional analysis.

SUBJECTS

Infants aged under 12 months, who visited our rehabilitation department for early intervention. Infants were categorized as either preterm or full-term, and assigned to one of three subgroups (0-4 months, 4-8 months, 8-12 months) according to corrected or chronological age.

OUTCOME MEASURES

PreViAs scores.

RESULTS

There were 200 preterm and 225 full-term infants analyzed. The mean global PreViAs scores among preterm infants were significantly lower than among full-term infants in all age groups (0-4 months: p = 0.033, 4-8 months: p = 0.005, and 8-12 months: p = 0.008). The mean global scores and four subdomain scores of the PreViAs were significantly lower (p < 0.001) in very preterm (under 32-weeks gestational age) and very low birth weight (under 1500 g birth weight) than in moderate-to-late preterm infants (between 32- to 37- weeks gestational age) and infants with birth weight above 1500 g. Patent ductus arteriosus, retinopathy of prematurity, and birth weight (percent) showed significant correlation with PreViAs global scores.

CONCLUSION

PreViAs is a useful tool for visual assessment of infants under 12 months, especially in high-risk infants.

Gestational Hormone Concentrations Are Associated With Timing of Delivery in a Fetal Sex-Dependent Manner

BACKGROUND

Early delivery remains a significant public health problem that has long-lasting impacts on mother and child. Understanding biological mechanisms underlying timing of labor, including endocrine disruption, can inform prevention efforts.

METHODS

Gestational hormones were measured among 976 women in PROTECT, a longitudinal birth cohort in Puerto Rico. We evaluated associations between hormone concentrations at 18 and 26 weeks gestation and gestational age at birth, while assessing effect modification by fetal sex. Exploratory analyses assessed binary outcomes of overall preterm birth (PTB, <37 weeks gestation) and the spontaneous PTB subtype, defined as preterm premature rupture of membranes, spontaneous preterm labor, or both. Multivariable logistic and linear regressions were fit using visit-specific hormone concentrations, and fetal sex-specific effects were estimated using interaction terms. Main outcome models were adjusted for maternal age, education, marital status, alcohol consumption, environmental tobacco smoke exposure, and pre-pregnancy body mass index (BMI). Exploratory models adjusted for maternal age and education.

RESULTS

We observed reduced gestational age at birth with higher circulating CRH (β: -2.73 days, 95% CI: -4.97, -0.42), progesterone (β: -4.90 days, 95% CI: -7.07, -2.73), and fT4 concentrations (β: -2.73 days, 95% CI: -4.76, -0.70) at 18 weeks specifically among male fetuses. Greater odds of overall and spontaneous PTB were observed among males with higher CRH, estriol, progesterone, total triiodothyronine (T3), and free thyroxine (fT4) concentrations. Greater odds of PTB among females was observed with higher testosterone concentrations.

CONCLUSIONS

Various associations between hormones and timing of delivery were modified by fetal sex and timing of hormone measurement. Future studies are needed to understand differential mechanisms involved with timing of labor between fetal sexes.

Visual Perception, Fine Motor, and Visual-Motor Skills in Very Preterm and Term-Born Children before School Entry-Observational Cohort Study

Very preterm children (<32 weeks gestation at birth; VP) are at risk of developmental difficulties. Specific functional difficulties and delays in visual perception, fine motor, and visual-motor skills have received little research attention, although they are critical for daily life and school readiness. Our aim was to assess these skills in a contemporary cohort of 60 VP and 60 matched term-born children before school entry. We administered the Movement Assessment Battery for Children (M-ABC-2) and the Developmental Test of Visual Perception (DTVP-2). Linear and logistic regressions were run to test group differences in performance and rates of developmental delay in visual perception, fine motor, and visual-motor skills. Very preterm children had lower scores than term-born children in visual perception (β = -0.25; p = 0.006), fine motor (β = -0.44; p < 0.001), and visual-motor tasks (β = -0.46; p < 0.001). The rate of developmental delay (<-1 SD) was higher among VP in visual perception (odds ratio (OR) = 3.4; 95% confidence interval (CI 1.1-10.6)), fine motor (OR = 6.2 (2.4-16.0)), and visual-motor skills (OR = 13.4 (4.1-43.9)) than in term-born controls. VP children are at increased risk for clinically relevant developmental delays in visual perception, fine motor, and visual-motor skills. Following up VP children until preschool age may facilitate early identification and timely intervention.

Comparison of the Efficiency of the Botulinum Toxin for the Treatment of Esotropia in Children with and without Neurological Disease and/or Prematurity

OBJECTIVE

To compare the effect of botulinum toxin injection for the management of esotropia in patients with and without neurological disease and/or prematurity.

METHODS

A single-center, retrospective, nonrandomized controlled study was performed on botulinum toxin in 87 children divided into two groups: study group of esotropia in 56 children with neurological disease and/or prematurity and, control group of 31 healthy children with infantile esotropia. All patients were followed for at least 24 months after injection. Success was defined as motor alignment with 10^Δ of orthotropia after single bilateral botulinum injection.

RESULTS

Mean age at treatment was similar in both groups (15.5 vs 14.8 months; p = .555). Mean pretreatment deviation was similar in both groups (50.8^Δ vs 50^Δ; p = .855). The success rate was better in the control group (61.2% vs 51.7%, p = .265) at 24 months after injection, but the change in the mean angle of deviation was not statistically significant between the groups at 12 and 24 months after injection (p = .264 and p = .547, respectively). Multivariate regression analysis showed that pretreatment angle of deviation and presence of retinopathy of prematurity were significant predictors at 12 months after injection (p = .0001 and p = .004, respectively), while pretreatment angle of deviation was found to be a predictor at 24 months after injection (p = .0001).

CONCLUSIONS

Decreased angle of deviation and absence of retinopathy of prematurity were associated with a better result. There was no difference in motor alignment of esotropia in children with and without neurological disease and/or prematurity. In these patients, botulinum injection may be used as an alternative to surgery.

Evidence for Attentional Phenotypes in Infancy and Their Role in Visual Cognitive Performance

Infant visual attention rapidly develops during the first year of life, playing a pivotal role in the way infants process, learn, and respond to their visual world. It is possible that individual differences in eye movement patterns shape early experience and thus subsequent cognitive development. If this is the case, then it may be possible to identify sub-optimal attentional behaviors in infancy, before the emergence of cognitive deficit. In Experiment 1, a latent profile analysis was conducted on scores derived from the Infant Orienting with Attention (IOWA) task, a cued-attention task that measures individual differences in spatial attention and orienting proficiency. This analysis identified three profiles that varied substantially in terms of attentional efficiency. The largest of these profiles (“high flexible”, 55%) demonstrated functionally optimal patterns of attentional functioning with relatively rapid, selective, and adaptive orienting responses. The next largest group (“low reactive”, 39.6%) demonstrated low attentional sensitivity with slow, insensitive orienting responses. The smallest group (“high reactive”, 5.4%) demonstrated attentional over-sensitivity, with rapid, unselective and inaccurate orienting responses. A linear mixed effect model and growth curve analysis conducted on 5- to 11-month-old eye tracking data revealed significant stable differences in growth trajectory for each phenotype group. Results from Experiment 2 demonstrated the ability of attentional phenotypes to explain individual differences in general cognitive functioning, revealing significant between-phenotype group differences in performance on a visual short-term memory task. Taken together, results presented here demonstrate that attentional phenotypes are present early in life and predict unique patterns of growth from 5 to 11 months, and may be useful in understanding the origin of individual differences in general visuo-cognitive functioning.

Visual Perceptual Skills in Very Preterm Children: Developmental Course and Associations With Neural Activation

BACKGROUND

The objective of this study was to examine how nonverbal skills at age five years relate to visual perception and brain activation during visual perception tasks at age 12 years in very preterm subjects without visual or other neurodevelopmental impairments or major brain pathologies.

METHODS

At age five years, 36 prematurely born (birth weight ≤1500 g or gestational age less than 32 weeks) and 31 term-born control children were assessed with the nonverbal subtests of the Wechsler Preschool and Primary Scale of Intelligence-Revised and the NEPSY-Second Edition. At age 12 years the same children were re-assessed with tasks from the Motor-Free Visual Perception Test, Third Edition, during functional magnetic resonance imaging.

RESULTS

Test performance at age five years was significantly poorer in the very preterm group than the control subjects, but at age 12 years performance was similar in both groups. In the very preterm group, better nonverbal skills at age five years were significantly associated with stronger neural activation during the visual perception task at age 12 years. No associations between nonverbal skills at age five years and brain activation at age 12 years appeared in the control group.

CONCLUSIONS

The associations between better nonverbal skills and stronger neural activation during visual perception task only observed in the very preterm group may reflect delayed development of the visual perception network and/or prematurity-related neural plasticity. The developmental follow-up of very preterm children should include psychological assessment of nonverbal skills at least until age five years.

Flash VEP in clinically stable pre-term and full-term infants

PURPOSE

Pre-term infants are at risk of abnormal visual development that can range from subtle to severe. The aim of this study was to compare flash VEPs in clinically stable pre-term and full-term infants at 6 months of age.

METHODS

Twenty-five pre-term and 25 full-term infants underwent flash VEP testing at the age of 6 months. Monocular VEPs were recorded using flash goggles on a RETIscan system under normal sleeping conditions. Amplitude and peak time responses of the P2 component in the two eyes were averaged and compared between the two groups. Multiple regression analyses were performed to assess the relationship of the P2 responses with birth weight (BW) and gestational age (GA).

RESULTS

At 6 months corrected age, pre-term infants had significantly delayed P2 peak times than full-term infants (mean difference: 10.88 [95% CI 4.00-17.76] ms, p = 0.005). Pre-term infants also showed significantly reduced P2 amplitudes as compared to full-term infants (mean difference: 2.36 [0.83-3.89] µV, p = 0.003). Although the regression model with GA and BW as fixed factors explained 20% of the variance in the P2 peak time (F_2,47 = 5.98, p = .0045), only GA showed a significant negative relationship (β = -2.66, p = .003). Neither GA (β = 0.21, p = .28) nor BW (β = 0.001, p = .32) showed any relationship with P2 amplitude.

CONCLUSIONS

Our results demonstrate that, compared with full-term infants, clinically stable pre-term infants exhibit abnormal flash VEPs, with a delay in P2 peak time and a reduction in P2 amplitude. These findings support a potential dysfunction of the visual pathway in clinically stable pre-term infants as compared to full-term infants.

Use of complex visual stimuli allows controlled recruitment of cortical networks in infants

OBJECTIVE

To characterize cortical networks activated by patterned visual stimuli in infants, and to evaluate their potential for assessment of visual processing and their associations with neurocognitive development.

METHODS

Three visual stimuli, orientation reversal (OR), global form (GF), and global motion (GM), were presented to cohort of five-month-old infants (N = 26). Eye tracker was used to guide the stimulation and to choose epochs for analysis. Visual responses were recorded with electroencephalography and analysed in source space using weighted phase lag index as the connectivity measure. The networks were quantified using several metrics that were compared between stimuli and correlated to cognitive outcomes.

RESULTS

Responses to OR/GF/GM stimuli were observed in nearly all (96/100/100%) recordings. All stimuli recruited cortical networks that were partly condition-specific in their characteristics. The more complex GF and GM conditions recruited wider global networks than OR. Additionally, strength of the GF network showed positive association with later cognitive performance.

CONCLUSIONS

Network analysis suggests that visual stimulation recruits large-scale cortical networks that extend far beyond the conventional visual streams and that differ between stimulation conditions.

SIGNIFICANCE

The method allows controlled recruitment of wide cortical networks, which holds promise for the early assessment of visual processing and its related higher-order cognitive processes.

Alteration in the time and/or mode of delivery differentially modulates early development in mice

Delivery is a complex biological process involving hormonal and mechanical stimuli that together condition the survival and development of the fetus out of the womb. Accordingly, changes in the time or way of being born are associated with an alteration of fundamental biological functions and hypothesized to promote the emergence of neurodevelopmental disorders. Hence, the steadily rise in preterm birth and cesarean section (CS) delivery rates over the past years has become a worldwide health concern. In our previous work, we reported that even though no long-term autistic-like deficits were observed, mice born preterm by CS presented early transient neuronal and communicative defects. However, understanding if these alterations were due to an early birth combined with CS delivery, or if prematurity solely could lead to a similar outcome remained to be evaluated. Using mice born either at term or preterm by vaginal or CS delivery, we assessed early life ultrasonic vocalizations and the onset of eye opening. We report that alterations in communicative behaviors are finely attuned and specifically affected either by preterm birth or by the association between CS delivery and preterm birth in mice, while delayed onset of eye opening is due to prematurity. Moreover, our work further underlies a gender-dependent vulnerability to changes in the time and/or way of being born with distinct outcomes observed in males and females. Thus, our results shed light on the intricacy of birth alterations and might further explain the disparities reported in epidemiological studies.