Clinical and subclinical deficits at 8 years in a geographically defined cohort of low birthweight infants

Prevalence of motor-skill impairment in preterm children who do not develop cerebral palsy: a systematic review

AIM

Motor skill impairment is a common negative outcome in children born preterm who do not develop cerebral palsy (CP). This study aimed to conduct a systematic review of current data to provide an accurate estimate of the prevalence of non-CP motor impairment in preterm children at school age.

METHOD

We searched the Medline, PubMed, and PsycInfo databases and relevant journals to identify all studies published post-1990 that reported the prevalence of motor impairment in school-aged children born preterm (<37 wks' gestation) using standardised motor assessment batteries. We applied a range of exclusionary criteria, with 11 studies included in the final analyses. We identified two levels of motor impairment commonly reported - mild-moderate and moderate - and conducted a random effects meta-analysis to produce a prevalence estimate for each.

RESULTS

The pooled estimate for mild-moderate impairment in preterm children was 40.5/100. and for moderate motor impairment the estimate was 19.0/100. There was also a trend for lower motor impairment levels in samples born before 1990 compared with those born after 1990.

INTERPRETATION

Children born preterm are at increased risk of motor impairment, with prevalence three to four times greater than in the general population. This highlights the need for improved surveillance and intervention strategies in this group of children.

Cerebral blood flow velocity asymmetry, neurobehavioral maturation, and the cognitive development of premature infants across the first two years

OBJECTIVE

Premature infants are at risk of adverse developmental outcomes even with no demonstrable neurological damage. Neonatal physiological measures that can serve as indicators of later development are therefore important for early evaluation and intervention.

METHODS

We followed the development of 51 low birth weight, premature infants across the first 2 years. Mean systolic cerebral blood flow velocity (CBFV) in the left and right middle cerebral arteries was measured at 37 weeks gestational age, neurobehavioral maturation was assessed with the Neonatal Behavior Assessment Scales (NBAS), and cognitive development was evaluated at 6, 12, and 24 months.

RESULTS

Different patterns emerged for CBFV in the right versus left middle cerebral artery. Greater absolute values of right systolic CBFV were related to poorer performance on the habituation and orientation scales of the NBAS, whereas greater left systolic CBFV absolute values were related to better Mental Development Index (MDI) scores at 24 months. Right systolic CBFV asymmetry was related to poor neonatal orientation and low MDI score at 24 months. On the other hand, infants with left systolic CBFV asymmetry showed a more rapid increase in cognitive skills from 12 to 24 months and better cognitive performance at 2 years.

CONCLUSION

Measurement of systolic CBFV in the neonatal period may assist in identifying infants at risk of poor developmental outcome.

Influence of maternal and social factors as predictors of low birth weight in Italy

Background

The purpose of this study is to provide insight into the determinants of low birth weight (LBW) in Italy.

Methods

The study was carried out in a non-teaching hospital in Catanzaro (Italy). All LBW and very LBW newborns (200) were included in the study and a random sample of 400 newborns weighing ≥ 2500 g was selected. Data were collected from the delivery certificates during one year. Smoking activity of mother and familiar and/or social support during pregnancy was gathered through telephone interviews.

Results

Overall annual LBW rate was 11.8%. Among LBW newborn there were 125 preterm and 75 term. Younger mothers, those who smoked during pregnancy, and had fewer prenatal care visits were more likely to deliver a LBW child; moreover, preterm newborns, delivered by caesarean section, and twin or multiple birth were significantly more likely to have a LBW. The comparison of very LBW (<1500 g) to LBW newborns showed that a very LBW was significantly more likely in newborns delivered by less educated mothers, those who work outside the home, live in smaller towns, and had less echographies; moreover, as expected, very LBW newborns were more likely to be preterm.

Conclusion

Several modifiable factors affect the risk of LBW, even when universal access to health care is freely available, but socio-economic status appears to correlate only to very LBW.

Birthweight and cognitive development during childhood

OBJECTIVES

Low birthweight has been reported to be associated with lower IQ at school age. Further, some evidence suggests that the association extends across the range of normal birthweights. This study assessed the relationship of birthweight to cognitive development in the Port Pirie birth cohort.

METHODS

Of 723 singleton live births recruited into a prospective birth cohort study, 601, 548, 494 and 375 children were followed at ages 2, 4, 7 and 11-13 years, respectively. The children's developmental status was assessed using the Bayley Scales of Infant Development at age 2 years, the McCarthy Scales of Children's Abilities at age 4 years, and the revised Wechsler Intelligence Scale for Children at ages 7 and 11-13 years. The association between birthweight and cognitive function was assessed with multiple linear regression, adjusting for a wide range of possible confounders.

RESULTS

The mean birthweight was 3386 g (SD: 517). There was a statistically significant association between birthweight and cognitive performance at age 2 years (adjusted deficit: 0.97 points per 100 g lighter; 95% CI: 0.4-1.5), but the magnitude of this association gradually decreased and became statistically non-significant at later childhood.

CONCLUSIONS

The relationship between birthweight and cognitive development becomes progressively attenuated at increasing age. At older ages, socioenvironmental factors appear to play an increasingly important part in children's cognitive development.

Are there critical periods for brain growth in children born preterm?

BACKGROUND

Children born very preterm who attend mainstream schools have a high prevalence of minor motor, behavioural, and learning disorders. These appear to be associated with reduced postnatal growth, particularly of the head. It is unclear when this poor growth occurs and whether growth restriction during different periods has different effects on later function.

OBJECTIVE

To identify periods during early development, in children born preterm, when impaired head growth may influence minor motor and cognitive function.

POPULATION

A geographically defined cohort of 194 infants born in Merseyside during 1980-81 and weighing less than 1500 g.

METHODS

Measurements of head circumference (occipitofrontal circumference (OFC)) were available at birth, hospital discharge, 4 years, and 15 years of age. Assessments of intelligence (intelligence quotient (IQ)) and minor motor impairment (test of motor impairment (TOMI)) were made at 8 years of age. Clinical, social, and demographic variables were obtained from the clinical record and maternal interviews.

RESULTS

IQ correlated significantly with OFC at 4 and 15 years of age after correction for growth restriction at birth (intrauterine growth restriction (IUGR)) and social class. TOMI scores correlated significantly with OFC at all four times, but especially with OFC at discharge and with change in OFC between birth and discharge. They were not affected by correction for social class or IUGR.

CONCLUSION

Although both IQ and minor motor impairments correlate strongly with each other at school age in very low birthweight children, the factors determining them and their timing of operation are different. Interventions designed to improve IQ in this population would need to reduce IUGR and improve later childhood growth. Those aimed to improve motor ability need to be targeted more at brain protection during the neonatal period.

Psychosocial and academic characteristics of extremely low birth weight (< or =800 g) adolescents who are free of major impairment compared with term-born control subjects

OBJECTIVE

To compare academic and cognitive ability, attention, attitudes, and behavior of extremely low birth weight (ELBW) adolescents who are free of major impairments at 17 years of age with term-born control subjects.

METHODS

Between January 31, 1981, and February 9, 1986, 250 infants of < or =800 g were admitted for intensive care in British Columbia, 98 (39%) of whom survived to late adolescence. Teens with major sensorimotor handicaps and/or IQ <70 were excluded (n = 19). Of the 79 eligible ELBW teens, 53 (67%) were assessed at 17.3 (16.3-19.7) years (birth weight: 720 [520-800 g]; gestation: 26 [23-29] weeks). The test battery screened the following areas: cognitive (Wechsler Intelligence Scale for Adults Third Edition, 3 subtests), academic (Wide Range Achievement Test-3), attention (Connors' Continuous Performance Task), self-report (Harter Self-Perception Profile for Adolescents; Job Search Attitude Inventory), and parent report (Child Behavior Check List). A comparison group of term born control subjects (n = 31) were also assessed (birth weight: 3506 [3068-4196] g; gestation: 40 [39-42] weeks) at age 17.8 (16.5-19.0) years. Multivariate analysis of variance (group x gender) was conducted for each domain (cognitive, academic, self-report, and parent report).

RESULTS

The ELBW group showed lower cognitive scores (vocabulary, block design, and digit symbol) and academic skills (reading and arithmetic) compared with control subjects, with no gender differences. There were no differences in attention between the 2 groups using a repetitive computer task. ELBW teens reported lower scholastic, athletic, job competence, and romantic confidence and viewed themselves as more likely to need help from others in finding a job. In the behavioral domain, parents reported their ELBW teens to display more internalizing, more externalizing, and more total problems than the control teens, with ELBW boys showing more problems. ELBW teens showed a higher percentage of clinically significant behavior problems than control subjects.

CONCLUSIONS

In a provincial cohort of unimpaired survivors of birth weight < or =800 g, psychosocial and educational vulnerabilities persist into late adolescence and may complicate the transition to adult life compared with their peers.

Physical growth and neurodevelopmental outcome of nonhandicapped low-risk children born preterm

BACKGROUND

Outcome studies on the effects of prematurity are increasingly restricted to extremely immature infants with birth weight below 1000 g or gestational age below 26 weeks. In contrast, studies comprising low-risk preterm infants are rare.

AIM

To examine growth and neurodevelopmental outcome, 70 low-risk low birth weight (LBW) children without neurological impairment were followed from birth to 7 years of age. At 7 years of age, LBW children were compared to a matched control group born at term.

METHODS

Postnatal growth was measured at 20 months in the LBW group and at 7 years in LBW and control children. At 20 months, the LBW group was assessed with the Griffiths Scales. At 7 years, LBW and control children were assessed with a neuropsychological test battery comprising tests for language, visual-perceptual, visual-motor, fine and gross motor abilities.

RESULTS

At 7 years of age, the frequency of children with low (3rd-9th percentile) or subnormal (<3rd percentile) growth parameters was increased in the LBW group. The Mean Griffiths Developmental Quotient (DQ) of the preterm group was normal (102.3+/-8.4), and there were only two results below DQ 85. There was no difference between 49 children appropriate for gestational age and 21 small for gestational age (SGA) children. At 7 years of age, reduced mean test results in the range of -0.5 SDS were observed for language and visual-motor abilities in the preterm group. This was due to an increased frequency of LBW children with moderately (SDS -1.0 to -2.0 SDS) subnormal test results. Even for the slightly LBW group (2000 to 2499 g), poorer language abilities were confirmed.

CONCLUSION

All LBW infants, including low-risk populations, should be included in a follow-up program in order to detect deficits early in life and begin treatment before school entry.

Motor skills in adolescents with low birth weight

BACKGROUND

Minor motor problems have been reported in low birthweight children, but few studies have assessed motor skills in adolescents.

OBJECTIVE

To examine the prevalence of motor problems in adolescents with low birth weight.

METHOD

Fifty four very low birthweight (VLBW: birth weight < or = 1500 g), 59 term small for gestational age (SGA: birth weight < 10th centile), and 83 control (birth weight > or = 10th centile at term) children were assessed with the Movement assessment battery for children (Movement ABC) at the age of 14 in a population based study.

RESULTS

One in four VLBW children (odds ratio (OR) 9.3, 95% confidence interval (CI) 2.5 to 34.5) and one in six SGA children (OR 4.7, 95%CI 1.2 to 18.4) had motor problems compared with controls (3.7%). There were no sex differences in motor problems in the VLBW group, and the increased risk was consistent across the continuum of the Movement ABC. For SGA children, the increased risk of motor problems was particularly in manual dexterity in boys.

CONCLUSION

VLBW and SGA adolescents have increased risk of motor problems compared with control children.

The neurodevelopmental progress of infants less than 33 weeks into adolescence

BACKGROUND

Several studies have shown an increased incidence of neurodevelopmental impairment in very preterm survivors at school age compared with controls.

AIM

To compare findings in the same cohort at 8 years and 15 years.

METHODS

A total of 151 of the 224 eligible infants born before 33 weeks of gestation from 1979 to 1982, and who were living in the UK, were assessed at 8 and 15 years. Items common to both assessments were compared to evaluate changes in neurodevelopmental function. The assessment included a structured neurological examination, psychometric tests using the WISC-R (in subjects born in 1981-82), a test of visuomotor integration (Beery), and a school questionnaire.

RESULTS

There was a significant increase in the proportion of subjects classified as impaired with disability from 11% at 8 to 22% at 14-15 years of age. The proportion of subjects classified as impaired without disability increased from 16% at 8 to 26% at 14-15 years of age. Full scale IQ decreased from 104 to 95 from childhood to adolescence, and more adolescents (24%) were requiring extra educational provision than they had at the age of 8 years (15%).

CONCLUSION

Results indicate that between the ages of 8 and 15 years in this cohort of very preterm survivors there is an apparent deterioration in neurodevelopmental outcome category, cognitive function, and extra educational support. It is not clear whether this represents a genuine deterioration in neurocognitive function or whether it represents the expression of pre-existing cerebral pathology in an increasingly complex environment.

Prenatal stress and risk for psychopathology: specific effects or induction of general susceptibility?

This review focuses on prenatal stress as a risk factor for psychopathology. Evidence from animal studies is summarized, and the relevance of prenatal stress models in animals for human studies is discussed. In the offspring of prenatally stressed animals, overactivity and impaired negative feedback regulation of the hypothalamic-pituitary-adrenal axis are consistent findings and may reflect a pathophysiological mechanism involved in the development of psychopathology. Reduced activity of the opioid GABA/benzodiazepine, serotonin, and dopamine systems and increased activity of the sympathico-adrenal system have been found as well. These alterations have been linked to a diverse spectrum of psychopathology. Therefore, the evidence supports the view that exposure to prenatal stress may result in a general susceptibility to psychopathology, rather than exerting a direct effect on a specific form of psychopathology.

Social inequalities in low birth weight in England and Wales: trends and implications for future population health

STUDY OBJECTIVE

To examine social inequalities and trends in low birth weight in England and Wales.

DESIGN

Analysis of routine birth data, comparing (a) couple and sole registered births, and (b) manual and non-manual occupational groups.

SETTING

England and Wales, 1993-2000.

MAIN RESULTS

Social inequalities in low birth weight were evident throughout 1993-2000: relative to the non-manual group, there is an increased risk for the manual group (range in RR 1.22-1.35) and sole registrations (RR 1.51-1.67). An estimated 6.5% (2979 births) of low birth weight in 2000 could have been avoided if risks associated with the manual group were absent, and 2.8% (1290 births) avoided if risks associated with sole registration were absent. Between 1993 and 2000, the low birthweight rate increased significantly with an estimated overall increase of 11%. Increases were evident in all social groups (15% in manual, 11% in sole registrations and 9% in non-manual); however relative to non-manual the increase in RRs were not statistically significant for manual or sole registrations. When multiple births are excluded, the rate of low birth weight is reduced but there is still a significant increase over time and social differentials are undiminished.

CONCLUSIONS

There are social inequalities in low birth weight in England and Wales that have not narrowed over an eight year period, 1993-2000. These inequalities are likely to affect childhood and adult health inequalities in the future, hence strategies will need to address differences in low birth weight and further monitoring of trends is therefore desirable.

Macropremies: underprivileged newborns

The focus of neonatal intensive care has been on very low birthweight infants, who comprise only 1.4% of neonates. Too little attention is paid to moderately preterm infants that we call macropremies or moderately low birthweight infants (MLBW, with birthweights 1500-2500 grams). Admitting over half MLBW infants to normal nurseries presumes that they have few needs and an excellent prognosis similar to fullterm newborns. It does not take into account the macropremie's vulnerability to complications of prematurity due to immature organ systems. Obstetricians are increasingly willing to deliver these infants prematurely for signs of fetal distress. As many as 25% of children with cerebral palsy referred to a disability clinic in Paris were MLBW, with hypoxic-ischemic-inflammatory associated disorders in one-third. The majority of MLBW infants who required neonatal intensive care at a tertiary care center in Baltimore had complications of prematurity: 47% had respiratory problems, 20% had feeding intolerance and 9% had hypoglycemia. MLBW infants comprise 5-7% of the neonatal population but account for 14% of neonatal deaths, 18-37% of children with cerebral palsy and 7-12% of children with mental retardation. Increasing the level of neonatal care for the macropremie's transition to extrauterine life would be economically feasible if it prevented as few as 30% of cases of major disability. A change in attitude towards this low risk (but not risk free) group of MLBW infants will both reduce morbidity and improve their health and neurodevelopmental outcome. It includes: 1) Providing an intermediate level of neonatal care for a short duration, with close monitoring and prompt intervention as needed, and 2) Neonatal neurodevelopmental screening to allow focused neurodevelopmental followup of MLBW infants with abnormalities.

General Certificate of Secondary Education performance in very low birthweight infants

AIM

To compare children of very low birth weight with matched controls for their performance in the General Certificate of Secondary Education (GCSE).

METHODS

GCSE examination results of 167 children of birth weight < or =1500 g attending mainstream schools and without clinical disability and 167 individually matched classroom controls were analysed.

RESULTS

In 143 instances, both children of a matched pair were entered for examination in one or more GCSE subjects. The total points score obtained was greater in the comparison group than in the index cases (difference between means 4.45: 95% CI 0.95 to 7.94; p = 0.01). The mean point score per examination subject was also significantly greater in the comparison group than in the index cases (mean of differences 0.43: 95% CI 0.12 to 0.73; p < 0.01).

CONCLUSIONS

As the children were closely matched for school and several social variables, factors acting during fetal or early postnatal development of very low birthweight infants probably compromise performance in the GCSE examination to a greater extent than school or childhood social environmental factors.

Oculomotor control in a group of very low birth weight (VLBW) children

VLBW infants are at risk of lesions including intraventricular haemorrhage and periventricular leucomalacia. Those with normal IQ still present with reading difficulties. Oculomotor performance was assessed on 14 VLBWs (IQ > 85) and 15 full-term age-matched controls. Anti-saccade errors were significantly higher for the VLBWs (78%) compared to full terms (62%) (P = 0.02). Smooth pursuit latency was longer for the VLBWs compared to the full terms. Greater anti-saccade errors may be indicative of a lesion affecting the frontal cortex or developmental delay. Oculomotor deficits in VLBW children may be associated with the higher incidence of reading difficulties that have been reported.

Early pain in preterm infants. A model of long-term effects

There are multiple lines of evidence suggesting that in vulnerable prematurely born infants, repeated and prolonged pain exposure may affect the subsequent development of pain systems, as well as potentially contribute to alterations in long-term development and behavior. Multiple factors cumulatively contribute to altered developmental trajectories in such infants. These include characteristics of the developing organism (low tactile threshold, sensitization, rapid brain development), characteristics intrinsic to the infant (gestation, illness severity), characteristics of the experience in the neonatal intensive care unit (pain exposure and cumulative stress), and characteristics of the caregivers within their family and social context. This article provides a model for examining long-term effects of pain in the newborn period embedded in a developmental context framework.

Birth weight, childhood socioeconomic environment, and cognitive development in the 1958 British birth cohort study

OBJECTIVES

To examine the combined effect of social class and weight at birth on cognitive trajectories during school age and the associations between birth weight and educational outcomes through to 33 years.

DESIGN

Longitudinal, population based, birth cohort study.

PARTICIPANTS

10 845 males and females born during 3-9 March 1958 with information on birth weight, social class, and cognitive tests.

MAIN OUTCOME MEASURES

Reading, maths, draw a man, copying designs, verbal and non-verbal ability tests at ages 7, 11, and 16, highest qualifications achieved by 33, and trajectories of maths standardised scores at 7-16 years.

RESULTS

The outcome of all childhood cognitive tests and educational achievements improved significantly with increasing birth weight. Analysis of maths scores at 7 and of highest qualifications achieved by 33 showed that the relations were robust to adjustment for potential confounding factors. For each kilogram increase in birth weight, maths z score increased by 0.17 (adjusted estimate 0.15, 95% confidence interval 0.10 to 0.21) for males and 0.21 (0.20, 0.14 to 0.25) for females. Trajectories of maths z scores between 7 and 16 years diverged for different social class groups: participants from classes I and II increased their relative position on the score with increasing age, whereas classes IV and V showed a relative decline with increasing age. Birth weight explained much less of the variation in cognition than did social class (range 0.5-1.5% v 2.9-12.5%).

CONCLUSIONS

The postnatal environment has an overwhelming influence on cognitive function through to early adulthood, but these strong effects do not explain the weaker but independent association with birth weight.

Neonatal predictors of school-based services used by NICU graduates at school age

BACKGROUND

Ill or premature newborns are at increased risk for ongoing morbidity throughout childhood. Federal legislation now mandates that states provide early intervention, special education, and disability accommodations for children with special needs. Because all children born prematurely do not require all services, targeting services to the children with greatest risk is essential. This study examined whether neonatal characteristics could predict special school-based service use (speech, occupational, physical therapy, special education) in later childhood.

METHODS

Subjects were 53 children, ages 7 to 11 years, graduates of one Midwest Level 3 neonatal intensive care unit (NICU). Neonatal data were used to calculate Neurobiologic Risk Scores (NBRS), a sum of illness factors related to brain damage. Birth weight, length of NICU stay, and NBRS were compared to the children's school performance on standardized tools and to report cards.

RESULTS

Most children studied were not receiving special school services. The NBRS and parent report of child competency were related (p = 0.01). Length of NICU stay correlated with teachers' reports of children's academic performance (p = 0.04), and to use of special school services use (p = 0.03). As the NBRS score increased, report card performance decreased.

CONCLUSIONS

Neonatal characteristics predicted school-age service use. This is important for nurses because predicting which children are most likely to need special services can aid in tracking children at high risk for prompt assessments and referrals. Parents, healthcare providers, educators, advocacy groups, and funding agencies need accurate outcome data to influence health, educational, and social policy decisions.

Birth weight and cognitive function at age 11 years: the Scottish Mental Survey 1932

AIMS

To examine the relation between birth weight and cognitive function at age 11 years, and to examine whether this relation is independent of social class.

METHODS

Retrospective cohort study based on birth records from 1921 and cognitive function measured while at school at age 11 in 1932. Subjects were 985 live singletons born in the Edinburgh Royal Maternity and Simpson Memorial Hospital in 1921. Moray House Test scores from the Scottish Mental Survey 1932 were traced on 449 of these children.

RESULTS

Mean score on Moray House Test increased from 30.6 at a birth weight of <2500 g to 44.7 at 4001-4500 g, after correcting for gestational age, maternal age, parity, social class, and legitimacy of birth. Multiple regression showed that 15.6% of the variance in Moray House Test score is contributed by a combination of social class (6.6%), birth weight (3.8%), child's exact age (2.4%), maternal parity (2.0%), and illegitimacy (1.5%). Structural equation modelling confirmed the independent contribution from each of these variables in predicting cognitive ability. A model in which birth weight acted as a mediator of social class had poor fit statistics.

CONCLUSION

In this 1921 birth cohort, social class and birth weight have independent effects on cognitive function at age 11. Future research will relate these childhood data to health and cognition in old age.

Educational and behavioural problems in babies of 32-35 weeks gestation

AIM

To identify incidence of school and behaviour problems at age 7 years in children born between 32 and 35 weeks gestation, and investigate perinatal risk factors.

METHOD

The study population consisted of all children born at 32-35 weeks gestation to mothers resident in Oxfordshire in 1990. General practitioners, parents, and teachers were asked about health, behaviour, and education by postal questionnaire. Teachers rated children on level of function in six areas using a five point scale. They also completed the Strengths and Difficulties behaviour questionnaire. Perinatal risk factors were identified for children with poor school performance using a univariate and multivariate analysis.

RESULTS

Teacher responses were obtained for 117 (66%) of the 176 children in the cohort. Twenty nine (25%) required support from a non-teaching assistant, five (4%) had required a statement of special educational needs, and three (3%) were at special school. Poor outcome was reported for 32% in writing, 31% in fine motor skills, 29% in mathematics, 19% in speaking, 21% in reading, and 12% in physical education. On the behaviour questionnaire, 19% of the cohort achieved an abnormal hyperactivity score (population norm 10%). Multivariate analysis showed perinatal variables that remained significant, independent of other variables; they were discharge from the special care baby unit > 36 weeks postconceptional age (odds ratio 4.15; 95% confidence interval 1.43 to 12.05) and male sex (odds ratio 3.88; 95% confidence interval 1.42 to 10.6).

CONCLUSION

Up to a third of children born between 32 and 35 weeks gestation may have school problems. As there are larger numbers in this gestational category compared with smaller babies, this finding has implications for educational services.

[Mothers of triplets and their children: course from 4 to 7 years after birth]

OBJECTIVES

To study the psychological health of the mothers and their difficulties seven years after the birth of triplets and to compare these results with those obtained at four years.

DATA AND METHODS

Eleven mothers of triplets were followed up from birth to seven. At four and seven years the psychological status of the mothers and their relationships with the triplets were evaluated using a semi-structured interview and the level of depression was measured using a standardized scale (CES-D). At seven years the scores were compared to those of mothers having a singleton child of the same age.

RESULTS

At seven years three mothers of triplets out of 11 still suffered of depressive symptoms. These symptoms were more frequent than among control mothers but non significantly. One mother of triplets out of two (6/11), twice more than at four years, appreciated the increase of her educative tasks and the decrease of practical problems. In the other half of the sample problems still persisted between adults and children.

CONCLUSION

Although the situation seemed to improve at seven years, the mother's psychological distress and quality of relationship with the children remained preoccupying in one family out of two.

Behavior, pain perception, and the extremely low-birth weight survivor

This article explores the literature concerning responses to pain of both premature and term-born newborn infants, the evidence for short-term and long-term effects of pain, and behavioral sequelae in individuals who have experienced repeated early pain in neonatal life as they mature. There is no doubt that pain causes stress in babies and this in turn may adversely affect long-term neurodevelopmental outcome. Although there are methods for assessing dimensions of acute reactivity to pain in an experimental setting, there are no very good measures available at the present time that can be used clinically. In the clinical setting repeated or chronic pain is more likely the norm rather than infrequent discrete noxious stimuli of the sort that can be readily studied. The wind-up phenomenon suggests that, exposed to a cascade of procedures as happens with clustering of care in the clinical setting in an attempt to provide periods of rest for stressed babies, an infant may in fact perceive procedures that are not normally viewed as noxious, as pain. Pain exposure during lifesaving intensive medical care of ELBW neonates may also affect subsequent reactivity to pain in the neonatal period, but behavioral differences are probably not likely to be clinically significant in the long term. Prolonged and repeated untreated pain in the newborn period, however, may produce a relatively permanent shift in basal autonomic arousal related to prior NICU pain experience, which may have long-term sequelae. In the long run, the most significant clinical effects of early pain exposure may be on neurodevelopment, contributing to later attention, learning, and behavior problems in these vulnerable children. Although there is considerable evidence to support a variety of adverse effects of early pain, there is less information about the long-term effects of opiates and benzodiazepines on the developing central nervous system. Current evidence reviewed suggests that judicious use of morphine for adjustment to mechanical ventilation may ameliorate the altered autonomic response. It may be very important, however, to distinguish stress from pain. Animal evidence suggests that the neonatal brain is affected differently when exposed to morphine administered in the absence of pain than in the presence of pain. Pain control may be important for many reasons but overuse of morphine or benzodiazepines may have undesirable long-term effects. This is a rapidly evolving area of knowledge of clear relevance to clinical management likely to affect long-term outcomes of high-risk children.

Premorbid IQ in patients with functional psychosis and their first-degree relatives

Numerous studies have found deficits in premorbid IQ in schizophrenic patients, but it is not clear whether this deficit is shared by (a) patients with other functional psychoses, and (b) relatives of these patients. Ninety-one schizophrenic patients, 66 affective psychotic patients (29 schizoaffective and 37 manic or depressed), and 50 normal control subjects were administered the National Adult Reading Test (NART) which provides an estimate of premorbid IQ. The NART was also completed by 85 first-degree relatives of schizophrenic patients and by 65 first-degree relatives of affective psychotic patients. After adjustments were made for sex, social class, ethnicity and years of education, schizophrenic patients had significantly lower premorbid IQ than their relatives, the affective psychotic patients and controls. Manic and depressed patients had significantly lower NART scores than their first-degree relatives, but schizoaffective patients did not, and neither group differed significantly from controls. There was no significant difference in premorbid IQ between patients who had experienced obstetric complications (OC+) and those who had not (OC-). Both OC+ and OC- schizophrenic patients differed significantly from their relatives, but the disparity was greatest between OC+ patients and their relatives. Relatives of OC+ schizophrenic patients had significantly higher IQ than relatives of OC- schizophrenic patients.

School difficulties at adolescence in a regional cohort of children who were extremely low birth weight

OBJECTIVES

To compare measures of psychometric assessment and school difficulties in a cohort of extremely low birth weight (ELBW) teenagers and term controls, and to determine whether there is stability in psychometric measures between age 8 and the teen years.

STUDY DESIGN

Longitudinal follow-up; geographically defined region.

PARTICIPANTS

150 of 169 (89%) ELBW survivors born between 1977 and 1982 and 124 of 145 (86%) sociodemographically matched term controls between 12 and 16 years of age. Psychometric measures: Wechsler Intelligence Scale for Children-Revised, Wide Range Achievement Test-Revised, and a validated parent questionnaire.

RESULTS

Neurosensory impairments were present in 28% of ELBW and 1% of controls. The mean Wechsler Intelligence Scale for Children-Revised scores were ELBW: 89 +/- 19 and controls: 102 +/- 13. ELBW children did less well on Wide Range Achievement Test-Revised Reading, Spelling, and Arithmetic measures with mean scores in the range from 75 to 85. ELBW children <750 g were more disadvantaged, compared with those >/=750 g. A significantly higher proportion of ELBW children were receiving special educational assistance and/or had repeated a grade (ELBW: 58%; controls: 13%; odds ratio: 9.0). Paired analysis of within-cohort data at age 8 and teen years showed that for both cohorts Arithmetic scores declined, but there were small improvements in other measures, predominantly in the term children.

CONCLUSIONS

Differences of 13 to 18 points in psychometric measures in ELBW teens compared with controls are both statistically significant and clinically relevant. Decreasing birth weight was associated with increased risk on all measures. The high utilization of special educational resources has economic implications, and the incremental cost attributable to being extremely premature needs to be determined.

A prospective study of limiting longstanding illness in early adulthood

BACKGROUND

Chronic illness and disability are of increasing public health importance but little is known about the lifetime influences involved in their onset and progression. We aim to (i) establish whether an individual's rating of limiting illness is stable over a 10-year period from age 23 to 33; (ii) assess the relationship between childhood and adult disability; and (iii) identify lifecourse influences on limiting illness in early adulthood.

METHODS

Data were from the 1958 British birth cohort, including the original birth survey and follow-ups at ages 7, 11, 16, 23 and 33 years. Limiting longstanding illness was the outcome at both ages 23 and 33. Potential predictors included childhood health and physical development, socioeconomic conditions in early life and adulthood, and behavioural factors. We estimated the effect of potential explanatory factors using logistic regression, in both univariate and multivariate analyses, separately for limiting illness at 23 and 33 years.

RESULTS

Prevalence of limiting illness increased from 5.1% (men) and 4.1% (women) at age 23 to 6% for both sexes at age 33. Risk of limiting illness at age 33 was greater for those reporting an illness at age 23 (29.4%, compared with 4.7% of those without illness), though the majority (66%) of 33-year limiting illnesses had no previous record at age 23 or for childhood. Multivariate analysis of limiting illness at age 23 confirmed the high risk for those with childhood disability and also established two further major predictors, namely, injury (adjusted odds ratio [OR] = 1.42, 95% CI: 1.09-1.86) and intermediate socio-emotional status (adjusted OR = 1.73, 95% CI: 1.29-2.31). Additional risks were identified for limiting illness at age 33, including: (i) injury in the preceding 10 years (adjusted OR = 1.55, 95% CI : 1.18-2.04); (ii) body mass index (BMI), for which the relationship was non-linear, with elevated risks for the underweight (adjusted OR = 1.53, 95% CI: 1.03-2.26) and overweight (OR = 1.28, 95% CI: 0.87-1.89); (iii) childhood disadvantage at either or both ages 7 and 11 (adjusted OR = 1.53, 95% CI : 1.07-2.17); and (iv) height at age 7, with a significant non-linear relationship (the adjusted OR for height less than 15th percentile was 1.43 and for height more than the 85th percentile, 1.30).

CONCLUSIONS

Both childhood and adult factors predict limiting illness in early adulthood. Childhood is important because some adult illnesses originate in early life, and also because childhood environment influences the risk of adult limiting illness several years later. Our findings suggest that studies seeking to understand the causes of limiting illness, that currently tend to focus exclusively on contemporary factors, need also to consider the contribution of environment in early life.

The impact of low birth weight, perinatal conditions, and sociodemographic factors on educational outcome in kindergarten

OBJECTIVE

To assess the relative effects and the impact of perinatal and sociodemographic risk factors on long-term morbidity within a total birth population in Florida.

METHODS

School records for 339 171 children entering kindergarten in Florida public schools in the 1992-1993, 1993-1994, or 1994-1995 academic years were matched with Florida birth records from 1985 to 1990. Effects on long-term morbidity were assessed through a multivariate analysis of an educational outcome variable, defined as placement into 9 mutually exclusive categories in kindergarten. Of those categories, 7 were special education (SE) classifications determined by statewide standardized eligibility criteria, 1 was academic problems, and the reference category was regular classroom. Generalized logistic regression was used to simultaneously estimate the odds of placement in SE and academic problems. The impact of all risk factors was assessed via estimated attributable excess/deficit numbers, based on the multivariate analysis.

RESULTS

Educational outcome was significantly influenced by both perinatal and sociodemographic factors. Perinatal factors had greater adverse effects on the most severe SE types, with birth weight <1000 g having the greatest effect. Sociodemographic predictors had greater effects on the mild educational disabilities. Because of their greater prevalence, the impact attributable to each of the factors (poverty, male gender, low maternal education, or non-white race) was between 5 and 10 times greater than that of low birth weight and >10 times greater than that of very low birth weight, presence of a congenital anomaly, or prenatal care.

CONCLUSIONS

Results are consistent with the hypothesis that adverse perinatal conditions result in severe educational disabilities, whereas less severe outcomes are influenced by sociodemographic factors. Overall, sociodemographic factors have a greater total impact on adverse educational outcomes than perinatal factors.

School performance and behaviour in extremely preterm growth-retarded infants

OBJECTIVE

To describe school performance and behaviour of extremely preterm, growth-retarded infants.

DESIGN

Cohort study at two tertiary care centres. Included were all surviving, singleton infants (N= 127) with fetal growth retardation due to placental insufficiency. All were delivered by caesarean section because of signs of fetal distress before the beginning of labour at a gestational age of 26 to 32 weeks during the years 1984-1989. Main outcome measures were special education, mainstream education below the appropriate age level and behaviour according to attention-deficit hyperactivity criteria at school age (4 1/2-10 1/2 yrs). The children were divided into two subgroups according to age at follow-up (> or =7 1/2 and <7 1/2 yr). A logistic regression analysis was performed with special school or repeating a grade and behavioural disturbance as dependent variables and gestational age, birth weight, sex of the infant, neonatal complications (intra cerebral haemorrhage, respiratory distress syndrome, bronchopulmonary dysplasia or sepsis), age category at follow-up and sociodemographic factors as independent variables.

RESULTS

114 (90%) had a complete follow-up. Special education was found in 14% of the assessed children. More children in the older age group than in the younger age group were placed in special school (20% versus 10%). Behavioural problems were scored in 39% of the assessed children attending mainstream education. Special education was related to neonatal complications (bronchopulmonary dysplasia), behavioural problems to the absence of either parent.

CONCLUSION

This specific group of growth-retarded children is at serious disadvantage for adequate performance in school, although the incidence of special education and behavioural problems was comparable to other preterm infants. Both special education and behavioural problems were not related to obstetric variables as gestational age and/or birth weight.

Neuromotor ability in 5- to 7-year-old children with very low or extremely low birthweight

This study was intended to determine the effects of extremely low birthweight (ELBW, 500 to 999 g) and very low birthweight (VLBW, 1000 to 1499 g) on neuromotor ability in 5- to 7-year-old children. Fourteen ELBW and 20 VLBW children were compared with 24 term control children of normal birthweight (NBW, >2500 g). Using quantitative assessment instruments, the following data were collected: maximal cycling speed during 30 seconds of cycling at 'zero' resistance, simple reaction time of the legs, and performance on components of a whole-body coordination test. The main findings were a slower reaction time, lower maximal cycling speed, and lower coordination scores in the ELBW group compared with the NBW group and, for some variables, with the VLBW group. The reduced motor performance in these children appears for the most part to be a reflection of impaired neuromotor control and motor development, rather than merely a smaller body or muscle size.

Cognitive and educational outcome of very-low-birthweight children in early adolescence

A cohort of 138 very-low-birthweight (VLBW) 12-year-old children and matched control children were assessed on objective cognitive and educational measures. School performance was rated by teachers and by the children themselves. VLBW children were shown to have lower IQ scores, and poorer scores on all objective educational measures compared with control children. Controlling for IQ differences, mathematics and reading-comprehension scores remained significantly lower for VLBW children. Teachers rated VLBW children lower in all curriculum areas. Significantly more VLBW children were found to be 'failing' in one or more subject and an increased proportion compared with the control children had received remedial education. The VLBW group showed no evidence of 'catch up' between 6 and 12 years of age. Multiple regression analyses were used to identify predictors of cognitive and educational outcome. The duration of mechanical ventilation in the neonatal period was inversely related to outcome. Full-Scale IQ at 6 years, motor-skills score at 6 years, and head circumference at 12 years all predicted outcome at 12 years, as did maternal education, family income and size. Individually, many VLBW children perform satisfactorily, but as a group VLBW children appear to be at a long-term disadvantage to peers in the areas of cognitive and educational performance.

Psychological findings in preterm children related to neurologic status and magnetic resonance imaging

OBJECTIVE

Preterm children experience learning disabilities more often than full-term children, but detailed information on their neuropsychological and neurologic determinants is lacking. We therefore examined these problems more closely and also studied if clinical neurologic examination and/or magnetic resonance imaging (MRI) can be used as tools to screen the preterm children at risk for these problems.

METHODS

In a population-based study, the psychological performance of 42 preterm children with a birth weight <1750 g and of their matched controls was assessed at 8 years of age and the findings were then related to clinical neurologic examination and MRI. Learning disabilities of these children, reported by the teachers, were also studied.

RESULTS

The cognitive ability of the preterm children, although in the normal range, was significantly lower than that of the control children. They performed particularly poorly in tasks requiring spatial and visuoperceptual abilities, which were associated with the finding of periventricular leukomalacia in MRI, especially with posterior ventricular enlargement. The preterm children with minor neurodevelopmental dysfunction (MND) had the most problems in neuropsychological tests, whereas the clinically healthy preterm children and those with cerebral palsy had fewer problems. The problems of MND children emerged in the domain of attention. They also experienced the most problems at school.

CONCLUSIONS

Visuospatial problems were associated with periventricular leukomalacia in MRI, but learning disabilities were most frequent among the preterm children with minor neurologic abnormalities. We recommend closer follow-up of preterm children with MND.

Cognitive, educational, and behavioural outcomes at 7 to 8 years in a national very low birthweight cohort

AIMS

To examine cognitive, behavioural, and educational outcomes in middle childhood among a birth cohort of very low birthweight children.

METHODS

Two hundred and ninety eight survivors from a national birth cohort of 413 New Zealand very low birthweight (VLBW) children born in 1986 were assessed at 7 to 8 years of age on measures of behaviour, cognitive ability, school performance and the need for special education. These outcomes were compared with the same measures in a general population sample of over 1000 children studied at a similar age.

RESULTS

The VLBW children had significantly higher rates of problems and poorer levels of functioning across all outcome measures than the general child sample. These differences persisted even after control for variability in social, family, and other characteristics of the two samples and for the degree of sensorineural disability. There was evidence of a gradient of risk with birthweight, with extremely low birthweight children having generally higher rates of problems and difficulties than other VLBW children after covariate control.

CONCLUSIONS

The findings are consistent with a growing body of research evidence which suggests that premature and VLBW infants are at increased risk of longer term morbidity and functional impairment in middle childhood.

Eye movements, prematurity and developmental co-ordination disorder

Horizontal pursuit eye movements were investigated in two separate groups of children: One group exhibited developmental co-ordination disorder (n = 8) whilst another group of children were born prematurely (n = 8). Both studies found a reduced gain in pursuit eye movements when the respective populations were compared with control groups (n = 32). A difference was also found in the ability of some children to temporally synchronize their tracking response to the stimulus, which was indicative of poor predictive control rather than lags in the control system. We suggest that horizontal eye movements may be a sensitive indicator of more general motor deficits during childhood development.

Neurodevelopmental consequences associated with the premature neonate

Changes in neonatal care have resulted in an increased survival rate among low birth weight infants. Because their neurologic system is immature, these infants are vulnerable to neurologic injury. Major and minor neurodevelopmental consequences can result. Most preterm infants survive without serious difficulties; however, the lower the birth weight, the higher the likelihood that problems will occur. Numerous factors can increase a preterm infant's risk for disease and impairment, and the neonatal nurse can perform a significant role in minimizing this risk.

[Neuro-intellectual prognosis at school age for 62 children born with a gestational age of under 32 weeks]

AIM

The aim of this study was to detail the incidence of cerebral palsy in children born before 32 weeks of gestation and to evaluate the scholastic and intellectual performance in non-handicapped children.

POPULATION AND METHODS

The population included 63 survivors hospitalized in 1984-85 (gestational age: 30.06 +/- 1.21 weeks; birth weight: 1386 +/- 267 g; inborn 60%; male: 38.7%; small for gestational age: 4.8%; hyaline membrane disease: 32%; European: 98.4%). Neurodevelopmental assessment was performed by pediatricians and psychologists using Wisc-R, visual screening by Monoyer scale, hearing by audiometry realized by oto-rhinolaryngologists.

RESULTS

There were 62 survivors (one child dead by sudden infant death syndrome). Fifty children evaluated at a mean age of 9.3 +/- 0.7 years and written data available for another eight. Twelve children presented with cerebral palsy. Risk factors were ultrasound abnormalities of parenchymal brain and male gender. In children without cerebral palsy, we observed 12 visual and two hearing impairment. Three were in special education, 32 were in an age-appropriate level, nine with one year below. Neonatal events were not associated with the Wisc-R results except for ultrasound abnormalities of parenchymal brain. Wisc-R was strongly correlated with familial economic and education level.

CONCLUSION

School performances in non-handicapped children born before 32 weeks is satisfying. Intellectual performance is mainly correlated with familial economic and education level.

Influence of obstetric management on outcome of extremely preterm growth retarded infants

AIM

To describe the long term outcome of extremely preterm growth retarded infants in relation to obstetric management and various perinatal events.

METHODS

A cohort study was undertaken in two tertiary care centres with different obstetric management. All infants with fetal growth retardation due to placental insufficiency and resulting in fetal distress at 26 to 32 weeks of gestation, were included for the years 1984-89. Main outcome measures were impairment, disability, or handicap at 2 years corrected age and at school age (4 1/2 to 10 1/2 years).

RESULTS

One hundred and twenty five (98%) were followed up until 2 years corrected age in the outpatient department; 114 (90%) were assessed at school age. Impairments were found in 37% and disabilities or handicaps in 9% of the assessed infants, with no difference between centres. All disabled or handicapped children had already been identified by 2 years corrected age.

CONCLUSIONS

Disability or handicap were related to neonatal complications (intracerebral haemorrhage or bronchopulmonary dysplasia) and not to obstetric variables, thus making antenatal prediction impossible. The incidence of disability or handicap in these growth retarded infants was comparable with that of other preterm infants.

Birth weight and physical ability in 5- to 8-yr-old healthy children born prematurely

Recent advances in perinatal care have resulted in increased survival rates of extremely small and immature newborns. This has resulted in some neurodevelopmental impairment. The purpose of this study was to quantitatively evaluate and compare neuromuscular performance in children born prematurely at various levels of subnormal birth weight (BW). Subjects were 5- to 8-yr-old children born prematurely at different levels of subnormal BW (535-1760 g, N = 22, PM), and age-matched controls born at full term (> 2500 g, N = 15, CON). None of the subjects had any clinically defined neuromuscular disabilities. Body mass (BM) of PM was lower than that of CON (18.3 +/- 2.7 vs 21.7 +/- 3.8 kg) with no difference in height or sum of 4 skinfolds. Peak mechanical power output determined with a 15-s modified Wingate Anaerobic Test and corrected for BM was lower (P = 0.07) in PM than in CON (5.11 +/- 1.07 vs 5.94 +/- 1.00 W.kg-1). This was especially noticeable in children born at extremely low BW (ELBW, < 1000 g, 4.49 +/- 1.04 W.kg-1, P < 0.01). Peak power, determined in a force-plate vertical jump, corrected for BM was lower in PM vs CON (25.5 +/- 5.4 vs 30.8 +/- 5.2 W.kg-1, respectively P = 0.01), especially in the ELBW group (20.0 +/- 5.5 W.kg-1). Similarly, the elapsed time between peak velocity and actual jump take-off was longer in PM than in CON (41.2 +/- 9.4 vs 35.8 +/- 5.8 ms, respectively, P = 0.04). No differences were observed in peak force. The results suggest that performance deficiencies of prematurely-born children may be a result of inferior inter-muscular coordination. The precise neuromotor factors responsible for this should be identified by future research.

School age outcome in low birth weight preterm infants

Very low birth weight (VLBW) children at school age show variability in their outcome, compared with normal birth weight children, although many early physical and health differences are equalized by middle childhood. Studies of nonhandicapped VLBW children have found a higher rate of school retention and school problems in this population. Differences in intelligence have been reported, although these are often confounded by socioeconomic factors such as educational level of the parent. Few studies today of children born in the late 1970s and early 1980s have related school age outcome to central nervous system (CNS) status, yet for learning disabilities or other neuropsychological deficits, this may be highly relevant. Better understanding of medical risk factors, however, will not affect the decisive influence of social factors on their expression in the school age child.

Neurophysiological assessment of brain function and maturation: I. A measure of brain adaptation in high risk infants

Neurophysiologic assessments using EEG/polysomnographic studies permit the clinician to recognize expected patterns of brain maturation in the healthy neonate. By comparison, one can detect encephalopathic behaviors of newborns who are medically at risk. Severe physiologic expressions of encephalopathy are associated with neuropathologic lesions on postmortem examinations, brain lesions documented on neuroimaging studies, and major neurodevelopmental sequelae of survivors. However, such patterns are observed for only a minority of high risk neonates; less severe encephalopathies occur more frequently in neonates without evidence of brain lesions on imaging studies who either recover from medical illness or who manifest no findings of neurological dysfunction. These subtle and persistent brain disorders are obviously more difficult to detect and grade. This is specifically relevant for preterm infants in whom various degrees of encephalopathy may exist, but whose physiologic behaviors must be distinguished form expected behavioral and neurophysiologic patterns of prematurity. Neonates may express brain dysfunction as altered rates of brain maturation, as compared with expected patterns for a given conceptional age. Neurophysiologic expressions of brain dysmaturity, either from prenatal and/or postnatal stresses, may actually occur in a substantially larger segment of the high risk neonatal population than has been anticipated. EEG-sleep studies can serve as a noninvasive neurophysiologic probe of brain organization and maturation to extend clinical observations to assess the severity and persistence of brain dysfunction in a neonate who may be at risk for later neurodevelopmental compromise.

Effect of neonatal circumcision on pain response during subsequent routine vaccination

BACKGROUND

Preliminary studies suggested that pain experienced by infants in the neonatal period may have long-lasting effects on future infant behaviour. The objectives of this study were to find out whether neonatal circumcision altered pain response at 4-month or 6-month vaccination compared with the response in uncircumcised infants, and whether pretreatment of circumcision pain with lidocaine-prilocaine cream (Emla) affects the subsequent vaccination response.

METHODS

We used a prospective cohort design to study 87 infants. The infants formed three groups--uncircumcised infants, and infants who had been randomly assigned Emla or placebo in a previous clinical trial to assess the efficacy of Emla cream as pretreatment for pain in neonatal circumcision. Infants were videotaped during vaccination done at the primary care physician's clinic. Videotapes were scored without knowledge of circumcision or treatment status by a research assistant who had been trained to measure infant facial action, cry duration, and visual analogue scale pain scores.

FINDINGS

Birth characteristics and infant characteristics at the time of vaccination, including age and temperament scores, did not differ significantly among groups. Multivariate ANOVA revealed a significant group effect (p < 0.001) in difference (vaccination minus baseline) values for percentage facial action, percentage cry time, and visual analogue scale pain scores. Univariate ANOVAs were significant for all outcome measures (p < 0.05): infants circumcised with placebo had higher difference scores than uncircumcised infants for percentage facial action (136.9 vs 77.5%), percentage cry duration (53.8 vs 24.7%), and visual analogue scale pain scores (5.1 vs 3.1 cm). There was a significant linear trend on all outcome measures, showing increasing pain scores from uncircumcised infants, to those circumcised with Emla, to those circumcised with placebo.

INTERPRETATION

Circumcised infants showed a stronger pain response to subsequent routine vaccination than uncircumcised infants. Among the circumcised group, preoperative treatment with Emla attenuated the pain response to vaccination. We recommend treatment to prevent neonatal circumcision pain.

Prospective study of New Zealand very low birthweight infants: outcome at 7-8 years

OBJECTIVE

To determine the survival and sensorineural outcome at 7-8 years in very low birthweight (VLBW) infants born in New Zealand in 1986.

METHODOLOGY

In 1986 all VLBW New Zealand infants admitted to neonatal units were enrolled in a prospective study of acute retinopathy of prematurity. Surviving infants were traced and were assessed at a home visit. Parents were asked a comprehensive questionnaire, and children underwent a visual assessment including photorefraction and were tested with the Revised Wechsler Intelligence Scale for Children (WISC-R).

RESULTS

Four hundred and thirteen VLBW infants were admitted to neonatal units in 1986, 338 (81.8%) surviving to discharge, 12 children died after discharge, 17 were traced to overseas, seven declined to participate and four were untraced, leaving 298 (96% survivors resident in New Zealand) who were assessed at a mean age of 7.6 (+/- 0.4 years, 15 children (5.0%) had severe disability, 14 (4.7%) moderate disability, and 46 (15.4%) mild disability. Blindness (vision worse than 6/60) occurred in eight children (2.7%), deafness requiring aids in four (1.3%), any form of cerebral palsy in 17 (5.7%), and an JQ score on the WISC-R > 1 SD below the mean in 62 (20.8%). There was no significant difference in outcome for children with birthweight < 1000 g and 1000-1499 g.

CONCLUSIONS

Long-term (7-8 year) survival and disability rates in this national cohort of VLBW infants is comparable with that reported from other populations. Although a majority of children have no disability a sizeable proportion do perform poorly on the WISC-R. This may relate in part to problems such as a short attention span and poor visual-motor integration.

Recurrent abdominal pain and Helicobacter pylori in a community-based sample of London children

Helicobacter pylori is accepted as an important factor in the pathogenesis of peptic ulcer disease. Infection is probably most commonly acquired in early life but there is still limited information on the prevalence or symptomatology of H. pylori infection in childhood. The aim of the present study was to establish the prevalence of H. pylori infection in a large sample of urban school children and to determine its relationship, if any, to a history of recurrent abdominal pain. Using a commercial ELISA significant levels of anti-H. pylori IgG antibody were detected in 107/640 (16.7%) of school children (M, 383; F, 257; mean age 9.15 years, range 4-13). No relationship was demonstrated between H. pylori seropositivity and a personal or family history of recurrent abdominal pain or the nature of the pain.

Neurodevelopmental outcome at age two years amongst very low birth weight infants: results from a district general hospital

STUDY OBJECTIVES

To describe the survival and neurodevelopmental outcome at age 2 years of very low birth weight infants from routinely collected information in a district general hospital setting.

DESIGN

Case note review and child health surveillance information was collected on all liveborn < 1,501 g infants born in our district general hospital over 4 years, 1989-1992. Main outcome measures were (a) death before discharge, (b) normal neurodevelopment at age 2 years, (c) minor impairment at age 2 years, (d) major impairment at age 2 years. Comparability with other published work was examined.

SETTING

Rotherham District General Hospital, a maternity unit with neonatal intensive care facilities. Selected infants were transferred for continuing neonatal intensive care to a tertiary unit. Most infants were followed up to age 2 years in a dedicated clinic.

SUBJECTS

Liveborn very low birth weight infants.

MAIN RESULTS

Over the 4 year period there were 125 liveborn infants < 1,501 g; 93 (74%) survived to discharge home. Defined neurodevelopmental outcome measures were easily retrievable in 92 children at age 2 years from hospital case notes or child health surveillance records. Sixty-four children (70%) were neurodevelopmentally normal, 10 children (11%) had a major impairment (mostly cerebral palsy) and 18 (19%) had an isolated minor impairment.

CONCLUSIONS

The incidence of major impairment amongst very low birth weight infants in our district general unit is broadly comparable with other published series. Outcome measures of neurodevelopmental status are available from routinely collected clinical information. The use of such measures to make detailed comparisons between units is problematical because of a wide range of confounding variables.

Cost of care for a geographically determined population of low birthweight infants to age 8-9 years. I. Children without disability

AIM

To determine the extra cost of healthcare associated with low birthweight, in a cohort study of a geographically defined population in five health districts that comprise Merseyside.

METHODS

The study comprised all children of birthweight < or = 1500 g and a 10% random sample of those weighing 1501-2000 g, without clinical disability, born in 1980 and 1981 to mothers resident in Merseyside, and their controls, matched by age, sex, and school class, followed up to age 8-9 years.

RESULTS

The cost of care associated with the initial admission to the neonatal special/intensive care unit and subsequent use of hospital and family practitioner services was assessed. There were 641 survivors without disability and 227 non-survivors who weighed < or = 2000 g at birth. The mean cost of neonatal care per low birthweight child was 13 times greater than for a control child. For children weighing < or = 1000 g at birth, neonatal costs were 55 times greater than for the control children. Low birthweight children continue to use hospital and family practitioner services more intensively than controls to age 8-9 years.

CONCLUSION

Low birthweight children used hospital and family practitioner services more intensively throughout the follow up period. Whether the increased use of health services persists into adolescence and adulthood is yet to be determined.

Cost of care for a geographically determined population of low birthweight infants to age 8-9 years. II. Children with disability

AIM

To determine the cost of health and educational service provision for low birthweight children with a clinical disability.

METHODS

Cohort study of a geographically defined population in five health districts that comprise the County of Merseyside was undertaken. All children with a clinical disability born in 1980 and 1981 to mothers resident in the County of Merseyside were followed up to age 8-9 years. The cost of care associated with the initial admission to the neonatal special/intensive care unit and subsequent use of hospital, family practitioner, and special education services was assessed.

RESULTS

There were 52 children with a disability; the disability rate in children of birthweight < or = 2000 g was estimated at 7.7%. Of the total expenditure to age 8-9 years, special education was the largest category (52%) and neonatal care accounted for 35%. The disabled children accounted for 38% of the cost of the whole cohort of 693 disabled and non-disabled children who weighed < or = 2000 g at birth.

CONCLUSION

In a cohort of low birthweight children, those who are disabled account for a disproportionate amount of the total expenditure to age 8-9. The cost of long term care for disabled young persons and adults will increasingly dominate the cost of care for the whole cohort of low birthweight children.