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

Neurological sequelae of healthcare-associated sepsis in very-low-birthweight infants: Umbrella review and evidence-based outcome tree

Sepsis is a frequent cause of death in very-low-birthweight infants and often results in neurological impairment. Its attributable risk of sequelae has not been systematically assessed. To establish an outcome tree for mapping the burden of neonatal sepsis, we performed systematic literature searches to identify systematic reviews addressing sequelae of neonatal sepsis. We included cohort studies and performed meta-analyses of attributable risks. Evidence quality was assessed using GRADE. Two systematic reviews met inclusion criteria. The first included nine cohort studies with 5,620 participants and five outcomes (neurodevelopmental impairment, cerebral palsy, vision impairment, hearing impairment, death). Pooled risk differences varied between 4% (95% confidence interval (CI):2-10) and 13% (95% CI:5-20). From the second review we analysed four studies with 472 infants. Positive predictive value of neurodevelopmental impairment for later cognitive impairment ranged between 67% (95% CI:22-96) and 83% (95% CI:36-100). Neonatal sepsis increases risk of permanent neurological impairment. Effect size varies by outcome, with evidence quality being low to very low. Data were used to construct an outcome tree for neonatal sepsis. Attributable risk estimates for sequelae following neonatal sepsis are suitable for burden estimation and may serve as outcome parameters in interventional studies.

Predictive value of the Bayley scales of infant development on development of very preterm/very low birth weight children: a meta-analysis

BACKGROUND AND AIMS

The Bayley scales of infant development (BSID) is the most widely used measure to assess neurodevelopment of very preterm (gestational age ≤32 weeks) and very low birth weight (VLBW, ≤1500 g) infants in the first three years of life. This meta-analysis determines the predictive value of the mental developmental index (MDI) and the psychomotor developmental index (PDI)/motor composite, collectively referred to as Bayley motor scale, of the BSID-I, -II and Bayley-III for later cognitive and motor functioning in very preterm/VLBW children.

METHODS

Cochrane Library, PubMed, PsychINFO and CINAHL were searched for English-language peer-reviewed studies published before March 2013. Studies were included if they reported odds ratios or correlations between the MDI or Bayley motor scale scores obtained in the first three years of life, and standardized cognitive or motor assessment obtained later in life in very preterm/VLBW children. Meta-analytic methods were applied to aggregate available data.

RESULTS

A total of 16 studies met inclusion criteria. Across 14 studies (n=1330 children), MDI scores were strongly predictive for later cognitive functioning, r=0.61 (95% CI: 0.57-0.64), explained variance 37%, p<.001. The relationship between MDI scores and later cognitive function was not mediated by birth weight (p=.56), gestational age (p=.70), and time interval between assessments (p=.55). Across five studies (n=555 children), Bayley motor scale scores were moderately predictive for later motor function, r=0.34 (95% CI: 0.26-0.42), explained variance 12%, p<.001.

CONCLUSIONS

In very preterm/VLBW children, MDI scores explain 37% of the variance in later cognitive functioning, whereas Bayley motor scale scores explain 12% of later motor function. Thus a large proportion of the variance remains unexplained, underlining the importance of enhancing prediction of developmental delay in very preterm children.

Effect of breastmilk consumption on neurodevelopmental outcomes at 6 and 12 months of age in VLBW infants

PURPOSE

To determine the influence of breastmilk consumption, as a dose response, in very low-birth-weight (VLBW) infants (< 1,500 g) on neurodevelopmental outcomes at 6 and 12 months corrected age, and to determine the influence of selected sociodemographic and infant variables on neurodevelopmental outcomes.

SUBJECTS

VLBW infants (n = 148) who were fed mother's milk or formula by parental choice.

DESIGN

Prospective cohort with longitudinal follow-up at 6 and 12 months corrected age.

METHODS

Self-administered questionnaires given to mothers at study entry, before discharge, and at 3-, 6-, and 12-month follow-up visits. During hospitalization, mothers recorded the 24-hour volume of expressed milk once per week. At each follow-up visit, the volume of a single feeding was assessed by pre- and postbreastfeeding test weights of infants measured on an electronic scale accurate to 1.0 g. The amount of breastfeeding was also assessed by feeding records and mother's report.

MAIN OUTCOME MEASURES

The Bayley Scales of Infant Development (2nd Edition), the Mental Developmental Index (MDI), and the Psychomotor Developmental Index (PDI).

PRINCIPAL RESULTS

After controlling for specific sociodemographic and infant variables, this study of VLBW infants showed no statistically significant effect of predominantly breastfeeding compared with predominantly formula feeding on neurodevelopmental outcomes to 12 months corrected age. The most significant predictor of MDI scores at 6 and 12 months corrected age was birth weight, in which higher birth weights predicted higher MDI scores.

CONCLUSIONS

Despite the lack of statistically significant differences, the findings suggest a small but consistent advantage in developmental scores in infants who were fed their mother's milk compared with those who were predominantly formula fed. Supporting parents to breastfeed preterm infants may maximize the potential advantages of early nutrition in the neurodevelopmental outcome of VLBW infants.

The correlation between placental pathology and intraventricular hemorrhage in the preterm infant. The Developmental Epidemiology Network Investigators

The aim of this study is to better understand the relationship between placental pathology and risk of intraventricular hemorrhage (IVH). We address two specific hypotheses. 1) Morphologic correlates of pregnancy-induced hypertension (PIH) are associated with a decreased risk of IVH. 2) Morphologic correlates of amniotic sac inflammation (ASI) are associated with an increased risk of IVH. Maternal, neonatal, and placental data were analyzed by univariate and multivariate methods in this prospective cohort study of 1095 very low birth weight infants. A cluster analysis model was used to categorize the placental pathologic features into clusters, the two main ones being PIH and ASI. Deliveries were subdivided by the interval between membrane rupture and delivery as an index of preexisting infection (<1 h) and ascending infection (> or =1 h). Univariate analysis supports both hypotheses. However, in multivariate models that adjusted for such potential confounders as gestational age, labor, and route of delivery, the only associations that persisted were the increased risk of IVH associated with the presence of chorionic or umbilical vasculitis in infants born within 1 h of membrane rupture. Placental correlates of PIH do not provide additional information about IVH risk independent of the presence of other components of the PIH and ASI clusters, and confounders such as gestational age, labor, and route of delivery. Placental correlates of ASI, specifically the fetal responses of chorionic and umbilical vasculitis to preexisting infection, are associated with an increased risk of IVH independent of confounders. Cytokines may provide the link between placental inflammation and fetal/neonatal brain hemorrhage.

Using the clinical linguistic and auditory milestone scale for developmental screening in high-risk preterm infants

Eighty-one preterm infants (mean gestational age 29 weeks, range 24-36 weeks) discharged from The Johns Hopkins Hospital Neonatal Intensive Care Unit were followed up sequentially from birth to 2 years of age by use of the Clinical Linguistic and Auditory Milestone Scale (CLAMS) to evaluate language development. Children were studied during three time intervals: Interval 1: 3-5 months chronologic age (CA); Interval 2: 9-14 months (CA); and Interval 3: 18-24 months (CA). Psychometric test scores were compared with CLAMS Language Quotients (LQ) by use of full, partial (75%, 50%, 25%), and no "correction" for weeks of prematurity to determine whether "correcting" for prematurity would yield a more accurate estimate of eventual cognitive outcome. CLAMS LQ at Interval 1 was highly correlated with CLAMS LQ at Interval 2 and CLAMS LQ at Interval 2 correlated well with CLAMS LQ at Interval 3 (r = 0.57 and 0.64, respectively, P = 0.0001). Correlations indicated that there was an orderly, sequential development of language in the preterm infant. CLAMS evaluations correlated significantly with psychometric test results during Interval 2 and Interval 3 (r = 0.34, P < 0.02 and r = 0.75, P = 0.0001, respectively). The CLAMS proved to be a useful instrument for monitoring preterm language development in the primary pediatric care setting.

Fetal drug therapy

As prenatal diagnosis has become more sophisticated, avenues for a variety of intrauterine therapies have been opened. Considerable experience has been gained with surgical and pharmacologic approaches. This article provides a review of intrauterine drug therapy aimed at preventing fetal and neonatal disease and treating existing fetal conditions. The future awaits the exciting applications of intrauterine hematopoietic transplants and genetic therapy.

Infants with bronchopulmonary dysplasia: a developmental perspective

Infants with bronchopulmonary dysplasia (BPD) are medically fragile and developmentally at risk for neuromotor and sensory delays. long-term neurodevelopmental outcomes can be positively impacted by an organized and purposeful program of developmental follow-up and early intervention. Nurses play an integral role in provision and coordination of the multifaceted health care required by these medically fragile infants.

Correlates of left-handedness in a large sample of schizophrenic patients

Questionnaire data concerning hand preference from the parents of 686 schizophrenic patients were used to test predictions relevant to neurodevelopmental models of schizophrenia. In line with predictions, left-handed patients (n = 94) had a more frequent history of difficult birth, more childhood cognitive and behavioural abnormalities and more persistent auditory hallucinations than did right-handed patients.

Development of prospective control of catching moving objects in preterm at-risk infants

Healthy term infants and infants classified as neurologically at-risk because of low birthweight and preterm birth were tested longitudinally between 20 and 48 weeks on the ability to use visual information predictively. Reaching for an object moving at different speeds was assessed; the object was occluded from view by a screen during the last part of its approach. At each infant's first reaching session, gaze anticipated the reappearance of the moving toy; however, onset of reaching and prospective control of gaze and hand varied considerably between the normal and at-risk groups. In addition, some at-risk infants geared their actions not to the time but to the distance that the toy was from the catching place, causing problems with faster-moving toys. The two children who anticipated least well were the only two of the at-risk group who were later diagnosed as having cerebral palsy.

Neonatal intensive care: is it worth it? Developmental sequelae of very low birthweight

A significant portion of the health care dollar has been spent on neonatal intensive care since the early 1970s when technologic developments permitted salvage of very small premature infants. The wisdom of allocating so much for so few has been challenged, especially if the result is an increase in the number of severely mentally and motorically disabled children. Studies from around the world of the secular trends in mortality and morbidity for very and extremely low-birthweight babies uniformly indicate that there have been dramatic decreases in mortality and morbidity in the past 20 years. The relative proportion of moderate to severe disability has remained stable during this period of increasing survival potential. Thus, although the absolute numbers of children with disabilities caused by complications of very low birthweight may have increased slightly, they constitute a small minority of the overall number of children with disabilities requiring special educational and other services. Most surviving children with birthweights less than 1500 g remain free of significant functional impairments. It is often difficult for the clinician to identify early or even midway through the neonatal course which infants will have severe, life-long disabilities. By the time identification is feasible, heroic decisions about life supports are no longer called for. Thus, the ethical issues discussed earlier regarding decision-making based on anticipated quality of life become less relevant as the child's condition stabilizes. Given the generally favorable prognosis for even the smallest premature infant, the clinician is probably best advised to give the individual patient the benefit of the doubt. Undoubtedly, there will be exceptions. The more subtle effects of very low birthweight on learning and behavior are just becoming clear as long-term follow-up studies appear in the literature. Very low-birthweight infants who do not manifest severe disability do seem to be at risk for learning problems, although overall cognitive function is in the normal range. There are other effects of preterm birth. On average, stature appears to remain lower, although there may be catch-up growth later in childhood. Having a very low-birthweight infant places considerable stress on the family, but it is unclear whether this has a long-term impact. Studies have failed to show a consistent influence of preterm birth on long-term behavior. Behavior is likely affected more by the social-emotional milieu in which the child is reared than prematurity itself. The environment seems to take over in importance in affecting cognitive functioning after the first several years of life.(ABSTRACT TRUNCATED AT 400 WORDS)

Current developments in the understanding of mental retardation. Part I: Biological and phenomenological perspectives

During the past decade, noteworthy advances have taken place within the field of mental retardation. The application of advanced biological techniques in such areas as molecular genetics and neuroimaging has substantially improved our ability to identify the biological factors that underlie the origin and pathogenesis of an increasing number of mental retardation syndromes. Refined genetic and psychosocial assessments have highlighted the impressive degree of heterogeneity that is present within and across many mental retardation syndromes, stimulating increasing interest and study. This, the first of a two-part review, will focus on recent developments in biological and phenomenological aspects of mental retardation.

Large postnatally acquired porencephalic cysts: unexpected developmental outcomes

To determine the neurodevelopmental outcome for infants with posthemorrhagic intraparenchymal cysts, we reviewed retrospectively clinical, ultrasonographic, and developmental features in 16 affected children. At a mean follow-up age of 33 months, five subjects had normal cognitive outcomes (developmental quotient [DQ] or IQ greater than 83), nine had borderline to mild deficits (DQ or IQ, 52 to 83), but only three had moderate to severe deficits (DQ or IQ less than 52). Spastic cerebral palsy was present in 13 (81%); only one child (6%) had a chronic seizure disorder requiring medication. Cognitively normal children were less likely to have had neonatal seizures (P less than .05) and tended to have more localized cysts. Otherwise, we found no relationship between outcome and neonatal clinical or laboratory findings. Overall, these results suggest that although motor deficits are common in infants with severe intraventricular hemorrhage and porencephalic cysts, cognitive outcomes may be more favorable than has been suspected previously.

Very-low-birth-weight, preterm infants with or without intracranial hemorrhage. Neurologic, cognitive and cranial MRI correlations at 4-8-year follow-up

Fourteen very-low-birth-weight (VLBW) preterm infants with and without intracranial hemorrhage (ICH) were prospectively followed from birth to 4 to 8 years for the purpose of determining neurologic and cognitive sequelae associated with ICH severity and to correlate outcomes with brain morphology as determined by Magnetic Resonance Imaging (MRI). Intracranial hemorrhage was documented by cranial ultrasonography performed in early life. Follow-up assessments included neurologic and psychometric examinations and cranial MRI scans. Of six children with no ICH, five had normal results on all three follow-up measures. Three children with Grade I-II ICH had mild to moderate neurologic and cognitive sequelae with focal white matter MRI abnormalities. Five children with Grade III-IV ICH had severe neurologic, cognitive, and MRI deficits, including MRI regional and diffuse white matter abnormalities and/or cortical atrophy. Focal and diffuse neurologic deficits correlated with the extent of MRI morphologic abnormalities. Results of this study indicate that ICH severity correlated with outcomes in children at follow-up; the more severe the ICH, the more adverse the neurologic, cognitive, and MRI results. MRI white matter abnormalities were present in all children with any degree ICH, while ventriculomegaly was seen only in severe ICH (Grade III-IV ICH). Neurologic deficits correlated with MRI structural abnormalities.