The improving outlook for the small prematurely born infant

Prenatal and perinatal striatal injury: a hypothetical cause of attention-deficit-hyperactivity disorder?

Experimental data indicate a particular vulnerability of striatal neurons in the developing brain, and together with the idea that the striatum is important for context recognition and behavior, these data have led the author to search for subtle striatal lesions, in the form of biochemical changes, in children who have suffered perinatal adverse events. Evidence is presented to demonstrate that the composition of metabolites in the striatum is altered, primarily in the form of an elevated level of lactate, in human neonates who have suffered various perinatal disorders, such as germinal matrix hemorrhage, intrauterine growth retardation, and asphyxia. An elevated level of lactate suggests tissue hypoxia, which may interfere with the formation of frontostriatal circuits and may play a role in the pathogenesis of the behavioral disturbances observed in a proportion of children with a history of perinatal adverse events.

Utility of the Maternal Perinatal Scale (MPS) in distinguishing normal from learning disabled children

This study examined perinatal complications and risk factors as predictors of learning disabilities in schoolaged children. Specifically, the Maternal Perinatal Scale (MPS) was used to distinguish between normal children and those classified as learning disabled (LD) by their school system. One hundred and eight participants, 54 in each classification, were selected from a small Midwestern area. A stepwise discriminant analysis demonstrated that all four factors of the MPS contribute significantly to the prediction. A linear composite of MPS factor scores correctly classified 93.5% of all participants, with only two normal and five LD children being misclassified. Repeating the results with other clinical populations, these results support the use of the MPS in assessing the perinatal history. More importantly, these data are consistent with the notion that perinatal complications increase the likelihood of future impairment. Moreover, the MPS shows promise as a screening device for use in early preventative programs which diminish the negative psychological, sociological, and neuropsychological outcomes for children with neurological disorders.

Short-term memory and language outcomes after extreme prematurity at birth

The performance of 26 children (3;0-4;0 years) who were born before 32 weeks gestation was compared with the performance of 26 full-term children on a range of short-term memory and language measures. The measures tested vocabulary, expressive language, phonological short-term memory, and general nonverbal ability. Preterm children scored more poorly across the full range of measures. The mildly depressed performance of the preterm group on the short-term memory and language measures was attributable to the large deficits on these tests shown by a subgroup of approximately one third of preterm children identified as being "at risk" for persisting language difficulties using the Bus Story Test (Bishop & Edmundson, 1987). The findings indicate that preterm birth and associated hazards may constitute a significant risk factor for specific language impairment in a sizable minority of children.

Characteristics at four months follow-up of infants born small for gestational age: a controlled study

This prospective study compared 65 small-for-gestational-age (SGA) (birth weight < 3rd centile) and 71 control infants at a corrected age of 4 months. It was hypothesised that differences would exist in growth, development, temperament and minor neurological signs and that these would be predicted by type (proportional/disproportional) of growth restriction at birth and maternal mood disturbance at birth or at 4 months. Infants had a Griffith's developmental test and neuromotor assessment. Maternal mood and infant temperament were surveyed. Few differences were found between SGA and control infants. SGA infants showed catch-up growth with 63% being above the third percentile and 43% being above the tenth percentile for weight. SGA infants had lower Griffith's GQ scores (97 vs. 102, P = 0.02) and they were rated in temperament as more manageable than controls. There were no differences in subtle neuromotor signs. Neither type of SGA nor maternal mood disturbance at birth had prognostic significance for infant catch up growth, neuromotor scores, or temperament though level of maternal stress and anxiety at 4 months were related to lower GQ scores in SGA infants.

Severity of medical and neurologic complications as a determinant of neurodevelopmental outcome at 6 and 12 months in very low birth weight infants

Very low birth weight (n = 154) and term infants (n = 119) had neurologic and developmental assessment at 6 and 12 months of age. Preterm infants with severe neonatal complications were considered to be at high risk, and those with milder complications were considered to be at low risk, for neurodevelopmental abnormality. Compared to term infants, high- and low-risk infants had abnormalities at 6 months in total neurologic score, cranial nerves, motor tone, motor coordination, and reflexes (P < .001). At 12 months, all groups had improved. However, high-risk infants had persistent abnormalities in the same subcategories (P < .001), whereas low-risk infants differed from term infants only in motor tone (P < .001). Bayley developmental scores were different for all groups at 6 months (P < .001), but at 12 months only high-risk infants differed from term infants (P < .01). These results demonstrate improvement in neurologic and developmental scores over time in very low birth weight infants. The degree of neurodevelopmental abnormality and improvement over time is related to severity of neonatal complications in preterm infants.

Perinatal risk factors as predictors of developmental functioning

This study examined the relationship between perinatal risk factors and developmental functioning for a referred population of 216 children. A canonical correlation analysis indicated that 31% of the variability in developmental information could be predicted from perinatal events. The results were interpreted as lending support to a multivariate link between perinatal complications and developmental functioning for referred children.

Mental and intellectual development of neonatal surgical children in a long-term follow-up

The mental and intellectual development of 75 children aged 6 to 10 years who had undergone operations during their neonatal period was estimated using the WISC-R intelligence test and the Bender-Gestalt test (BGT). WISC-R test results correlated with patients' total surgical stress scores, number of operations, and total duration of hospitalization. A tendency for verbal IQ deficiency was observed in many patients. BGT results correlated with the number of operations and total period of hospitalization. Patients with anorectal anomalies were apparently affected more than those with other diseases. An accumulation of therapeutic stresses relating to operations and hospitalizations during childhood extending through the neonatal period may affect subsequent mental and intellectual development.

Neurodevelopmental and medical status of low-birthweight survivors of bronchopulmonary dysplasia at 10 to 12 years of age

Thirty low-birthweight (less than 1500g) infants (15 with bronchopulmonary dysplasia (BPD), and 15 controls less than or equal to 5 days O2) and 15 fullterm controls were evaluated at 10 to 12 years of age. BPD children weighted less than fullterm children and had smaller head circumferences than either preterm or fullterm controls. They also had significantly more neurological abnormality than both control groups. BPD children and preterm controls had lower WISC-R arithmetic scores and lower Beery VMI scores, as well as greater need of resources and special education compared with fullterm controls. BPD survivors at 10 to 12 years of age continue to manifest sequelae related to their early pulmonary disease.

Language development of very low birth weight infants and fullterm controls at 12 months of age

Twenty-eight very low birth weight (VLBW) and 32 full term infants were prospectively assessed at one year of age for hearing, language development and neurological status. The prevalence of conductive hearing deficits was the same in both groups. Language scores in VLBW infants were significantly lower than in fullterm controls and 39% had significant language delays. VLBW infants exhibited a shorter attention span and were less likely to understand simple questions, to recognize objects or body parts when named, to initiate speech-gesture games, to follow simple commands and to imitate or use words consistently. Language quotients were directly associated with gestational age and five minute Apgar scores and inversely associated with severity of intraventricular hemorrhage, bronchopulmonary dysplasia and length of hospital stay. VLBW small for gestational age infants exhibited more advanced language skills than VLBW appropriate for gestational age infants. Language delays were more prevalent among, but not limited to, infants with mild to moderate neurological abnormalities. The influence of prematurity and VLBW on language development is complex and multifactorial and research is continuing to determine the predictive validity and long term significance of the early language delays described in this study.

Growth outcome and feeding practices of the very low birth weight infant (less than 1500 grams) within the first year of life

Growth outcome for 1 year of corrected age and feeding practices during that first year of life were described for a large population of very low birth weight (VLBW) infants. Growth patterns of weight, length, and occipitofrontal circumference through 12 months of corrected age, and weight/length ratios at 12 months, were determined for 122 VLBW infants less than or equal to 1500 gm and less than or equal to 35 weeks of gestational age at birth; feeding practices were surveyed within a subpopulation of 89 infants. Differences in growth were apparent when infants were grouped according to sex and appropriateness of intrauterine growth. When the mean values of each group were compared, the female infants of appropriate size for gestational age demonstrated growth at higher percentiles (National Center for Health Statistics term-infant norms) for all three measurements (weight, length, and occipitofrontal circumference). Male infants whose size was appropriate for gestational age, and male and female infants who were small for gestational age, all grew similarly, at lower percentiles for weight and length, when compared with the same norms. Growth in occipitofrontal circumference was closest to term infant norms in all subgroups of infants. The majority of the infants, regardless of subgroup, achieved weights and lengths greater than 5th percentile and proportionate growth with a normal weight/length ratio. At 12 months of corrected age, 30% remained at less than 5th percentile in weight, 21% in length, and 14% in occipitofrontal circumference. Eighteen infants (15%) had a marked discrepancy in weight for length, with a weight/length ratio less than 5th percentile. Three prevalent practices that could result in compromised nutrition were identified: (1) cereals were introduced at an early age, (2) 2% and skim cow milk were fed to approximately 50% of the infants within the first year of life, and (3) whole cow milk was introduced to some VLBW infants at an early age. Caretakers apparently viewed their infants in terms of chronologic age rather than age corrected for prematurity when it came to the initiation of solids and cow milk. Whether increased attention to appropriate feeding practices during the first year of life would result in a more favorable growth outcome for VLBW infants is not known.

Outcome for preschoolers of very low birthweight: sociocultural and environmental influences

The impact of the environment on the outcome of children of very low birthweight at preschool age was assessed. Embracing an ecologic perspective, the study incorporated several family and sociocultural variables. The role of the environment was significant in explaining the cognitive, language, and temperamental status of these children at age 3 years. Although the high-risk cohort performed less well than a matched comparison group, maternal IQ and family sociocultural status essentially obscured differences on two of the three outcome measures. In addition, all three high-risk groups--children of very low birthweight with and without concomitant medical complications, and full-term children with perinatal asphyxia--obtained scores on all outcome measures within one standard deviation of the mean of the scores of the comparison group. Favorable early environmental circumstances appear to compensate frequently for difficult prenatal and perinatal insults. Biologic and environmental factors interact and appear differentially to influence emerging cognitive, language, and behavioral functions.

Catch up growth in preterm infants

Seventy-one surviving infants were followed up from birth to 24 weeks of postnatal age. Their mean gestational age was 32 weeks with a range of 26-36 weeks and a standard deviation of 2.1 weeks. Their mean birth weight was 1,805 kg with a range of 0.675-2.5 kg and a standard deviation of 0.408 kg. Their weights, lengths and head circumferences were measured at birth, 6, 12 and 24 weeks. Curves for the mean weight, length and head circumference were produced and superimposed on the available intrauterine and extrauterine growth charts. The growth curves of the preterm infants did not show the flattening noted in the intrauterine curves towards term. The curve of the mean weight of the preterm infants started at the 50th centile for Gairdner & Pearson (1971) at birth to drop below that shortly after birth. At 40 weeks of postconceptional age the mean weight curve of preterm infants crossed the 50th centile and continued above it to reach the 90th centile at 60 weeks. The curves of mean length and head circumference started below the 50th centile at birth and crossed it at 40 weeks and continued above it to approach the 90th centile at 60 weeks. Growth velocity was calculated as a relative gradient using the straight line equation (y = a + bx), where y is the weight, length or head circumference, and x is the independent variable and here it is the group mean of the parameter at the corresponding ages. Catch up growth is taken as a relative gradient significantly greater than one. The first 24 weeks of postnatal life are defined as a period of catch up growth with the first 8 weeks as an interval of maximum head velocity.

Controlled study of intelligence and school performance of very low-birthweight children from a defined geographical area

The authors studied the intellectual outcome of 45 of the 47 schoolchildren who had been born with very low birthweights (less than 1501 g) in Wolverhampton between 1975 and 1978 and were free of major handicap. Their outcome was compared with that of a control group matched for age, sex, race and social class. The very low-birthweight children had lower IQs, were more likely to be performing poorly or below average at school and were more likely to show emotional disturbance. Those who had had a major neonatal illness were most likely to be performing below average at school. These results may be representative of the outcome for very low-birthweight babies born in the United Kingdom during the late 1970s.

Continuing care for the preterm infant after dismissal from the neonatal intensive care unit

As more low-birth-weight babies survive, primary-care physicians are facing the responsibility of providing continuing care for those who have been dismissed from neonatal intensive-care units. Premature infants often require outpatient care for bronchopulmonary dysplasia, apnea, retinopathy of prematurity, intraventricular hemorrhage, hearing loss, hypothyroxinemia, anemia, neurodevelopmental sequelae, assessment of growth and nutrition, immunizations, and psychosocial stress. In this review, we present guidelines for the primary-care physician for the management of these conditions in preterm infants.

Relationship between two-year behaviour and neurodevelopmental outcome at five years of very low-birthweight survivors

A prospective five-year follow-up of survivors of very low birthweight (less than or equal to 1500 g) born in 1979 was carried out at the Queen Victoria Medical Centre, Melbourne, between 1980 and 1985. Of the 57 children reported here, 23 had been identified during psychological testing at two years as having an attention deficit disorder (ADD). Although the number with ADD at five years had decreased to 18, the two-year diagnosis was retained to test its predictive value for outcome at school-age. Children with ADD at two years differed significantly from their peers at five years in verbal, performance and full-scale IQ and had significantly more minor physical disabilities. They also had poorer visual acuity, more tremor, poorer balance, and more deviations with arms extended in pronation. The ADD children had more minor, though chronic, physical illnesses such as tonsillitis and serous otitis media. Their mothers expressed greater concern than the other mothers about hearing and behaviour. The ADD children were rated as significantly more aggressive, difficult to manage and less able to cope with frustration. As a predictor of five-year IQ, behaviour at two years was more powerful than social class. ADD discriminated a subgroup of very low-birthweight children whose lower IQ and multiple physical, neurological and behavioural difficulties place them at very high risk of learning disabilities.

Neurodevelopmental outcome of preschool children born preterm with and without intracranial hemorrhage

Thirty-five children who had been born preterm with and without intracranial hemorrhage and weighing less than or equal to 1500 g were followed prospectively to assess neurodevelopmental outcome. The 13 children with hemorrhage were inferior to the 22 without hemorrhage in terms of birthweight, Apgar scores, health complications at and after birth, neurological integrity at age five and several scales of the McCarthy Scales of Children's Abilities. The hemorrhage group performed significantly below the standardized mean on each of the McCarthy scales, whereas the group without hemorrhage performed below the mean only in Quantitative and Memory scores. The Bayley scales at one year were not clinically sensitive to hemorrhage, but were predictive of McCarthy General Cognitive Index scores at age five. A greater proportion of children with hemorrhage have had educational difficulties and have been included in alternative school programs. Preterm, very low-birthweight children, and particularly those with intracranial hemorrhage, are at high risk for motor, perceptual and cognitive defects which underlie learning difficulties.

Neurodevelopmental outcome and school performance of very-low-birth-weight infants at 8 years of age

The neurodevelopmental outcome and school performance of 50 appropriate for gestational age (AGA) and 33 small for gestational age (SGA) very-low-birth-weight (VLBW) infants, compared to a control group (41 Term infants) were assessed at 8 years of age. The incidence of major handicaps among AGA and SGA/VLBW infants respectively, was 16% and 6%. No major handicap was found in the control group. The incidence of neurodevelopmental abnormalities (NDA) among AGA's (40%) and SGA's (57.6%) compared with the control group (31.7%) was found to be significantly higher. School failure occurred more frequently among VLBW infants (22.9%) and was related in children with NDA--and more particularly among AGA's--to the presence of language disorders or associated NDA. Evaluation of the consequences of NDA and school problems for later academic and professional achievement now requires further follow-up studies.

Sequelae of growth failure in appropriate for gestational age, very low-birthweight infants

The pattern of growth of 235 very low-birthweight children, whose weights were appropriate for gestational age, was characterised by a significant decline in weight, length and head circumference from birth to discharge from hospital, followed by partial recovery in all three measures of growth by two years corrected age. 29 per cent of the children were below the 10th percentile for weight at two years, and this group had a significantly higher incidence of major disabilities, poorer muscular development, more hypotonia and lowered performance on the psychomotor index of the Bayley Scales of Infant Development than their heavier peers. These children's mothers more often perceived them as actively disliking close physical contact, and they were reported by their mothers to have had more infections, minor surgery and chronic otitis media. Taken together, the suboptimal weight-gain, delayed gross motor development and increased maternal perceptions of 'sickliness' and lack of 'cuddliness' in these children are reminiscent of non-organic failure to thrive.

Interaction and development in the first year. I. The effects of prematurity

Six month infant-mother interaction patterns were observed and 10 month Bayley MDI scores were obtained in 10 fullterm and 14 healthy preterm (less than 37 weeks) infants. Relationships among interaction parameters and intellectual performance are compared with those among earlier interaction patterns and development. At 6 months preterm dyads were more synchronised and had higher levels of interaction than fullterm dyads; preterm mothers demonstrated lower levels of affection. Fullterm variables reflecting unfocussed infant vocalising at 2, 3 and 6 months were negatively related to later development while those maternal variables indicating general and specific stimulation were positively related. Preterm infant vocalising levels at 3 and 6 months were positively related while 3 and particularly 6 month variables indicating maternal stimulation and high levels of dyadic interaction were negatively related to later development. In both groups early maternal state differentiation in responses was positively related to 10 month intellectual performance. Ten month MDI scores for the preterm group were lower than for the fullterm group. The results are discussed with respect to information processing abilities, optimal patterns of interaction for each kind of infant, and their differential paths of development in the first year.

Nine-year follow-up of infants weighing 1 500 g or less at birth

A nine-year follow-up of 116 children born consecutively in 1971-74 with a birthweight of 1 500 g or less showed that 59 had died. Of those who were alive, four had severe motor and/or mental handicaps and three were blind because of retrolental fibroplasia. The low birthweight children without severe handicaps were found to have impaired motor function, speech defects and impaired school achievement more often than the controls. There was a significant correlation between the test results at the age of five and nine years, which indicates that children with school failure can be recognized and early remedial treatment started before school or on starting school.

Differential maturation of cortical auditory evoked potentials to speech sounds in normal fullterm and very low-birthweight infants

Cortical auditory evoked potentials (AEP) to the consonant-vowel syllables/da/and/ta/and 800Hz tone were recorded at 40 weeks post-conceptional age and at one, two and three months after term in normal fullterm and very low-birthweight infants. As a group, the very low-birthweight infants exhibited significantly less mature AEPs to consonant-vowel syllables than the normal-birthweight infants at 40 weeks post-conceptional age. Consistent but statistically non-significant differences also were found for tones at 40 weeks post-conceptional age, and for all stimuli at one and two months after term. By three months, all the infants exhibited mature AEP morphology and topography.

Determinants of developmental performance of very low-birthweight survivors at one and two years of age

The developmental outcome of 61 very low-birthweight infants was studied prospectively by means of the Bayley Scales of Infant Development at one and two years of age, corrected for prematurity. Preliminary analysis revealed that the mean scores for mental and psychomotor development were within the normal limits at both testing occasions. However, further analysis showed that there was a significant decrease in mental development scores from one to two years of age, due primarily to an increase in the numbers of low-scoring children with 'hyperactive' behaviour at two years. Separate subgroups of children with suboptimal mental and psychomotor development scores were characterised at both testing occasions by the presence of 'hyperactive' behaviour and disability, usually of a minor degree. The presence of hyperactivity, disability and lowered mental performance may help in the early identification of children at increased developmental risk.

Hypoxic-ischemic cerebral necrosis in midgestational sheep fetuses: physiopathologic correlations

Thirty-eight midgestational sheep fetuses were exposed 120 min to marked hypoxia. The brains in eight that reduced their mean arterial blood pressure to less than 30 mm Hg were markedly damaged. In these same fetuses the serum lactic acid concentrations were elevated during exposure to hypoxia to excessively high values (greater than 15 mM) and remained elevated for a prolonged period during recovery. Twenty-one fetuses exposed to the same magnitude of hypoxia that maintained their blood pressure unchanged showed less marked elevations of serum lactate concentrations and remained brain-intact. Greater quantities of pentobarbital administered to the ewes during hypoxia seemed to protect the brain from hypoxia and this effect was dose-dependent. Exposure of midgestational sheep fetuses to marked hypoxia associated with reductions in cerebral blood flow due to decreased blood pressure and impaired cerebral autoregulation caused major focal cerebral necrosis.

Pulmonary sequelae of neonatal respiratory distress in very low birthweight infants: a clinical and physiological study

Twenty infants, mechanically ventilated in the neonatal period for respiratory distress syndrome, were compared with 15 healthy controls, matched for birthweight(less than 1501 g) but greater in mean gestational age. Clinical features and lung mechanics (by whole body plethysmography) were recorded at 6-monthly intervals until about one year. THe neonatal course of the mechanically ventilated infants was commonly complicated by tracheobronchial hypersecretion and the later course by a fairly high incidence of lower respiratory tract illness. In this group, thoracic gas volume, dynamic compliance, pulmonary and airways conductance were all abnormal during the middle 4 months of the first year and reverted towards normal towards the end of the first year. The control group had normal lung mechanics. Early lung function tests were of limited value in predicting later lower respiratory tract illness, which was more common in boys, after neonatal mechanical ventilation for longer than 24 hours or raised ambient oxygen for longer than 5 days. There were few predictive physical signs. In this group of very low birthweight infants, respiratory distress syndrome of sufficient severity to require mechanical ventilation led to significant physiological and clinical disturbances of lung function which lasted into the second 6 months of life and which were particularly severe in those who had recurrent lower respiratory tract illness.

Neurological 'soft' signs in low-birthweight children

Sixty-six longitudinally studied prematurely born children who had weighed between 1000 and 1750g at birth were examined neurologically at eight years of age. 13 of these children had localizing neurological findings and another 20 were found to have two or more non-localizing ('soft') signs of CNS dysfunction. These 33 children were significantly more likely to have sustained perinatal complications than were children whose neurological examinations were normal. However, a history of prenatal complications was significantly more frequent among children who subsequently developed 'soft' signs, while children with localizing findings were significantly more likely to have experienced postnatal complications. No significant differences in IQ or reading and arithmetic achievement test-score levels were found between children with 'soft' signs and those who were neurologically normal. Nevertheless, children with 'soft' signs were significantly more likely to have received special education and to have been referred for psychiatric consultation than were children who were neurologically normal.

Mortality of low birthweight infants in England and Wales 1953 to 1979

National trends in the survival of low birthweight infants for the years 1953 to 1979 were examined. While stillbirth and day 1-28 mortality rates improved steadily throughout this period, day 0 mortality did not start to fall until the mid-1960s and then it improved in all birthweight groups. This suggests that special and intensive baby care units introduced progressively since about 1961 are exerting an appreciable effect on mortality. There is a serious lack of representative data on rates of handicap in the survivors.

Estimating the cots required for neonatal intensive care

Estimates of the number of cots required for neonatal intensive care have been based on recommendations made in 1971 in the Sheldon report, and there is concern that the recommendations are now out of date. Therefore changes in the use of neonatal care within one health region (North-east Thames) during the years 1972, 1974, and 1976 have been examined. It was found that new developments in the sophisticated care of very small and sick babies have placed greater demands on cots and other resources. More babies of very low birthweights are now being cared for in the two units in the region and the average length of stay in hospital is increasing. Criteria have been refined and brought up to date to estimate the likely requirements for neonatal intensive care cots, taking into account recent developments in the care of small babies.

Outcome for survivors of mechanical ventilation weighing less than 1,250 gm at birth

We investigated the outcome in 28 survivors of mechanical ventilation weighing less than 1,250 gm at birth. Fifteen infants (54%) had neurodevelopmental sequelae, of whom eight had major handicaps. These eight infants differed significantly from the rest of the infants studied in the following manner: lower mean birth weight and gestational age, delay in transportation to our Neonatal Intensive Care Unit, and high incidence of bacterial sepsis. The remaining seven infants with NDS were functionally normal or minimally impaired at the time of the study, although significant problems may yet emerge with continued follow-up. Retrolental fibroplasia was diagnosed in 11 infants (39%) and resolved in two. The development of RLF was associated with prolonged oxygen exposure and the presence of bacterial sepsis. However, since major handicap, RLF, and sepsis were all problems observed in the smallest infants, a cause-and-effect relationship between sepsis and these sequelae remains speculative.

Behavioral development of premature infants: an ethological approach

This study examines the motor and social development of 21 very small preterm infants up to 34 weeks post-conceptional age. Seven infants were born at 26 to 27 weeks gestation, seven at 28 to 30 weeks and seven at 31 to 32 weeks. They were all physically healthy, as were their mothers. All the infants were observed for 40 minutes twice weekly, using a continuous recording technique. 12 types of infant behavior were recorded. The results indicate that the mean percentage and mean duration of both gross motor movements and 'social' behavior of these small infants do not vary between 26 and 34 weeks post-conceptional age. Moreover, infants born at 26 and 27 weeks gestation showed the same distribution of behaivor during their hospital stay as those born at 28 to 30 or 31 to 32 weeks. There was little individual stability over the weeks in the level of motor activity and social behaivor displayed by the infants, which implies that the behavior of these infants is generally variable as long as they remain physically healthy.

The very low birth weight infant after discharge from intensive care: anticipatory health care and developmental course

Despite intensive research, the data available on the long-term effects of prematurity on development of the child have not led to clearcut conclusions, particularly when the investigations are based on infant or perinatal factors alone. Previous research does indicate that the infant is "at risk" through school age and that the parents' perception of the child and the harmony between the child and his environment are powerful determinants of outcome. The implications for medical care, however, are clear. The developing low birth weight infant is best served by close medical supervision, particularly during the turbulent early years. Health care should be planned to include ongoing developmental assessment and screening at least through school entrance so that emerging vulnerabilities or deficits may be addressed as early as possible, thus impeding developmental progress minimally. An optimal care plan includes active partnership with the parents in detection of weaknesses, reinforcement of strengths, and formulation of recommendations for behavioral and educational management. For the physician this will require clinical acumen, an understanding of the child within the context of his environment, an attitude of supportive realism and a long view.

Neurobehavioral performance of low-birthweight infants at 40 weeks conceptional age: comparison with normal fullterm infants

This study compares the neurobehavioral status of 118 low-birthweight infants tested at 40 weeks conceptional age with that of 76 normal fullterm infants. A neonatal neurobehavioral examination comprising 21 test and four summary items was used. The most striking differences between the groups were found in visual and auditory orienting, with approximately two-thirds of the low-birthweight infants falling below the range of performance of the fullterm group. Items testing motor performance showed a lower incidence of deviant performance among the low-birthweight infants. Of the 21 test items, 19 could be assigned cut-off scores, below which infants can be considered deviant on the specific items.

Infants of very low birthweight. A 15-year analysis

357 babies weighing 501--1500 g were born alive at Hammersmith Hospital in 1961--75. 58.5% died in the neonatal period and 1.4% at 4--25 months of age. 1.4% of the total are untraced, 5.3% have major handicap, 5.6% have minor handicap, and 27.8% are apparently normal. There was no significant improvement in neonatal mortality in three 5-year periods, 1961--65, 1966--70, and 1971--75, except that more small-for-gestational-age babies survived in the last period than in the first. More of these babies survived than did babies whose birthweight was appropriate for gestational age. There was no significant improvement in the proportion of handicapped children among the very-low-weight liveborn babies throughout the 15-year period, despite increasing complexity of care.

Obstetric factors influencing outcome in infants weighing from 1,001 to 1,500 grams

The neonatal mortality rate has dramatically improved in recent years. Occurrence of these losses is concentrated in low-birth-weight infants. At Los Angeles County-University of Southern California Medical Center, the infants weighing less than 1,500 grams contribute two thirds of neonatal deaths, although they may represent only 1.5 per cent of total births. Such observations have led to the evaluation of obstetric factors as they relate to the outcome in the low-birth-weight infants weighing from 1,001 to 1,500 grams. Retrospective evaluation of 201 low-birth-weight-infants' charts demonstrated a tendency by the obstetrician to clinically underestimate fetal weight. In cases where fetal estimated weight and measured birth weight correlated, the mortality rate was 20 per cent; in cases of underestimation, the mortality rate rose to 50 per cent. Other obstetric factors evaluated were the use of FHR monitoring, the method of delivery, and the significance of the Apgar score.

Follow-up of preschool age survivors of neonatal intensive care

High risk birth status is related to a number of subsequent deficits in development. Factors such as maternal education and economic status of the family are hypothesized to affect the development of high risk children. In this study preschool aged survivors (n = 18) of a neonatal intensive care nursery were compared to a randomly selected control sample (n = 18) on measures of intelligence, receptive language, and visual motor integration. No significant effects were found for birth status alone. A significant interaction between level of maternal education and birth status was found on the measure of intelligence.

The very low birthweight infant: impact on parents during the pre-school years

This paper presents follow-up data on 75 families who had children born between 1970 and 1971 at birthweights under 1501 g (very low birthweight: VLBW) and a comparison group of 55 families who had children born at the same time but at birthweights over 2500 g. An interview done when the children were 3--5 yr old revealed that parents with a VLBW child gave a less favourable evaluation of their child in 2 of 7 areas considered: development and play. These differences of evaluation were caused by a subgroup of 22 VLBW children with neurological and/or intellectual defects. No evidence came forth to indicate that the experience of having a VLBW child had significant or continuing impact on the family. An absence of serious social problems such as child abuse or the child's failure to thrive were noted.