Health and school performance of teenagers born before 29 weeks gestation

How back pain influences daily activities and quality of life: Incidence of back pain related to age

Low back pain is a prevalent global musculoskeletal issue, with a lifetime prevalence ranging from 49% to 70% in adults. Traditionally associated with adults, recent field surveys indicate comparable prevalence rates in children and adolescents, challenging earlier assumptions. Non-specific low back pain, where the source cannot be identified through diagnostic imaging, accounts for about 80%-90% of cases. Studies have shown that over 80% of adolescents with low back pain exhibit no underlying pathology. The prevalence of low back pain in younger populations varies widely, influenced by study methodology, age, and pain types. Research suggests that back pain prevalence in adolescents increases with age, with a shift in attitudes considering it is not necessarily indicative of specific issues. Level of evidence: level V.

High-Risk Infant Follow-Up After NICU Discharge: Current Care Models and Future Considerations

Preterm infants are at heightened risk for chronic health problems and developmental delays compared with term-born peers. High-risk infant follow-up programs provide surveillance and support for problems that may emerge during infancy and early childhood. Although considered standard of care, program structure, content, and timing are highly variable. Families face challenges accessing recommended follow-up services. Here, the authors review common models of high-risk infant follow-up, describe novel approaches, and outline considerations for improving the quality, value, and equity of follow-up care.

Subjective Well-Being and Self-Esteem in Preterm Born Adolescents: An Individual Participant Data Meta-Analysis

OBJECTIVE

To study self-reported well-being and self-esteem among adolescents born very preterm (VPT; <32 wk of gestation) and moderate to late preterm (MLPT; 32-36 wk of gestation) compared with those born full-term (FT) in an individual participant data (IPD) meta-analysis.

METHODS

We obtained IPD from the following 4 data sources: The Avon Longitudinal Study of Parents and Children (United Kingdom), the Millennium Cohort Study (United Kingdom), the Basel Study of Preterm Children (Switzerland), and the Bavarian Longitudinal Study (Germany) and conducted two-step random-effects IPD meta-analysis. A total of 986 MLPT, 412 VPT, and 12,719 FT born adolescents reported on subjective well-being and 927 MLPT, 175 VPT, and 13,312 FT born adolescents reported on global self-esteem.

RESULTS

Adolescents born VPT or MLPT were not different from those born FT regarding general subjective well-being; family, school, and physical appearance-related well-being; and global self-esteem. However, adolescents born VPT reported lower well-being in peer relationships than those born FT (β = -0.209, 95% confidence interval = -0.336 to -0.082). There was no main effect of fetal growth restriction (FGR) and no moderation by FGR, sex, parental education, and ethnicity. No significant heterogeneity between cohorts was found, although some heterogeneity estimates were moderate.

CONCLUSION

Adolescents born preterm mostly report no lower well-being and self-esteem than adolescents born FT. However, they perceive their peer relationships as poorer than those born FT.

Special health care needs explains the effect of extremely low birth weight on math but not language achievement

OBJECTIVES

Extremely low birth weight (ELBW; <1kg) adolescents are at risk for special health care needs (SHCN) and poor math achievement compared to normal birth weight (NBW) peers. SHCN are associated with poor academic achievement among NBW children. We hypothesize that SHCN explain the effect of ELBW on math achievement.

METHODS

We compared age 14 Woodcock-Johnson Calculation standard scores between 181 ELBW infants and 115 NBW controls. Persistent SHCN included: 1) prescription medication or equipment use, 2) subspecialty or therapeutic service use, or 3) hospitalization. We used nonlinear marginal effects models to decompose the total effect of ELBW on math into the following 4 components: the effect of ELBW controlling for SHCN, the effect of SHCN controlling for ELBW, effect modification by SHCN, and mediated interaction where SHCN is both causal mediator and effect modifier. Models were adjusted for sociodemographic factors.

RESULTS

ELBW adolescents had lower mean math scores than NBW peers (81.3 vs. 96.4). SHCN were more common among ELBW adolescents (54.1% vs. 27%). The total effect of ELBW on math scores was -15.7 points (95% CI -21.0, -10.5). The effect of birth weight alone was -7.6 points (95% CI -13.7, -1.4); the effect of SHCN alone was negligible. SHCN interaction and mediated interaction effects each accounted for 25% of the total effect.

CONCLUSIONS

Birth weight alone explains only half of the effect of ELBW on math achievement. We found evidence of effect modification and mediation by SHCN. Understanding these explanatory pathways may lead to targeted interventions for improved outcomes.

Associations Between Gestational Age at Birth and Alcohol Use in the Avon Longitudinal Study of Parents and Children

BACKGROUND

The relationship between gestational age at birth (GA) and alcohol use measures in early adulthood was examined in a large U.K. community-based birth cohort (Avon Longitudinal Study of Parents and Children).

METHODS

A series of linear and logistic regression models were used to test for main effects of a continuous measure of GA on a range of alcohol use measures, and moderation of these associations by sex. In addition, mediation analyses assessed the extent to which significant associations between GA and alcohol use operated indirectly, through influences of the parental environment and/or childhood measures of emotional and behavioral health (EBH).

RESULTS

Earlier GA significantly predicted never drinking by age 18, but was not associated with other measures of alcohol use behavior among young adult drinkers (i.e., Self-Rating of the Effects of Alcohol, Alcohol Use Disorders Identification Test, or DSM-IV-TR Criteria for Alcohol Dependence). The association between earlier GA and never drinking by age 18 was moderated by sex, such that females born early were less likely to have ever had a drink by age 18. In the full sample, childhood measures of EBH were found to mediate the association between earlier GA and never drinking by age 18. This association was not mediated by parenting factors.

CONCLUSIONS

Earlier GA is associated with never drinking alcohol in early adulthood, in females. Emotional and behavioral difficulties experienced in early childhood may mediate the relationship between earlier GA and never drinking by age 18.

Emotional and Behavioral Problems of Preterm and Full-Term Children at School Entry

BACKGROUND AND OBJECTIVES

Preterm children, compared with term children, are at increased risk of emotional and behavioral problems (EB-problems). Prevalences of EB-problems seem to vary with degree of prematurity and age at assessment. We therefore assessed individual stability of EB-problems in preterm compared with term children first before school entry and again 1 year after school entry, and variation in stability within the preterm group.

METHODS

We used data of 401 early preterm (25-31 weeks' gestational age), 653 moderately preterm (32-35 weeks' gestational age), and 389 term children from the Longitudinal Preterm Outcome Project cohort study. We classified EB-problems based on the Child Behavior Checklist at ages 4 and 5; this resulted in 4 categories: consistently normal (2 normal scores), emerging (normal score at age 4 and clinical/subclinical score at age 5), resolving, and persistent EB-problems.

RESULTS

All preterm children had higher rates than term children of persistent (7.2% vs 3.6%), emerging (4.3% vs 2.3%), and resolving (7.5% vs 3.6%) EB-problems. Early preterm children had the highest rates of persistent (8.2%) and emerging (5.2%) problems, and moderately preterm children had the highest rates of resolving problems (8.7%). In both preterm and term children, predictive values of normal scores at age 4 for normal scores at age 5 were ∼96%, and of clinical/subclinical scores at age 4 for clinical/subclinical scores at age 5 were ∼50%, except for early preterm children (60%).

CONCLUSIONS

Compared with term children, all preterm children are at risk for persistent and changing EB-problems at school entry; individual stability, however, is difficult to predict based solely on the factor of preterm-birth.

Bullying of preterm children and emotional problems at school age: cross-culturally invariant effects

OBJECTIVE

To investigate whether adolescents who were born extremely preterm (<26 weeks gestation), very preterm (<32 weeks gestation), or with very low birth weight (<1500 g) are more often bullied, and whether this contributes to higher emotional problem scores.

STUDY DESIGN

We used 2 whole population samples: the German Bavarian Longitudinal Study (BLS) (287 very preterm/very low birth weight and 293 term comparison children) and the UK EPICure Study (183 extremely preterm and 102 term comparison children). Peer bullying was assessed by parent report in both cohorts at school years 2 and 6/7. The primary outcome was emotional problems in year 6/7. The effects of prematurity and bullying on emotional problems were investigated with regression analysis and controlled for sex, socioeconomic status, disability, and preexisting emotional problems.

RESULTS

Preterm-born children were more often bullied in both cohorts than term comparisons (BLS: relative risk, 1.27; 95% CI, 1.07-1.50; EPICure: relative risk, 1.69; 95% CI, 1.19-2.41). Both preterm birth and being bullied predicted emotional problems, but after controlling for confounders, only being bullied at both ages remained a significant predictor of emotional problem scores in both cohorts (BLS: B, 0.78; 95% CI, 0.28-1.27; P < .01; EPICure: B, 1.55; 95% CI, 0.79-2.30; P < .001). In the EPICure sample, being born preterm and being bullied at just a single time point also predicted emotional problems.

CONCLUSION

Preterm-born children are more vulnerable to being bullied by peers. Those children who experience bullying over years are more likely to develop emotional problems. Health professionals should routinely ask about peer relationships.

The impact of preterm birth on participation in childhood occupation

Outcome studies of premature babies have focused their assessments predominately on neurodevelopmental impairments without relating these deficits to the impact they have on a child's everyday life. This study aims to determine whether very 'preterm birth alone' impacts on a child's ability to participate in and carry out childhood activities. Forty-four former premature infants between 6 months and 5 years 6 months, born in Galway University Hospital, Ireland, without physical or intellectual disability, were compared with 51 age-matched term-born infants. Study infants had an average gestation of 29 weeks and birth weight of 1,145 g. Functional skills were assessed using the Adaptive Behavior Assessment Scale-II and the Assessment of Preschool Children's Participation. Premature infants had significantly lower mean scores in overall adaptive behaviour compared to term infants, regardless of whether chronological (difference = 13.6, 95% (CI) = [8.2, 19.1]) or corrected (difference = 6.6, 95% CI = [1.4, 11.8]) age was used. Premature infants had lower mean scores in conceptual, social and practical skills, but no difference was found between the groups in intensity or diversity of participation.

CONCLUSION

Premature infants had significantly lower scores in adaptive behaviour than term infants. This measurable effect of preterm birth on 'childhood occupations' merits further investigation.

Participation and enjoyment of leisure activities in adolescents born at ≤ 29 week gestation

BACKGROUND AND OBJECTIVES

Motor, cognitive, social and behavioral problems have been found to persist in adolescents born extremely preterm. Leisure participation has been associated with health benefits; however, few studies have explored leisure participation in this population. The aim of this study was to describe leisure participation in adolescents born at ≤29week gestation. Secondary aims were to identify potential differences in participation related to sex, age, motor competence, and cognitive ability, and between adolescents born preterm and their siblings born at term.

METHODS

This cross-sectional study included 128 adolescents (mean age: 16.0years; 67 females) with a mean gestational age of 26.5weeks. All participants, as well as 22 siblings born at term, completed the Children's Assessment of Participation and Enjoyment.

RESULTS

Participation levels were highest in social and recreational activities, and lowest in active-physical and skill-based activities. Boys participated in more active-physical activities (p=0.01) and more often (p<0.001) than girls, whereas girls had higher participation levels in social and self-improvement activities (p<0.05) than boys. Older adolescents engaged in more social activities (p=0.01) and more frequently (p=0.002) than younger adolescents. Overall, participants with poor motor and cognitive skills had lower participation levels in active-physical and social activities. Adolescents born preterm participated in fewer recreational activities compared to term-born siblings (p=0.013).

CONCLUSIONS

Engagement in active-physical and skill-based leisure activities needs to be promoted in boys, and especially in girls with a history of prematurity. Activities should be adapted to sex and individual skill level in order to promote participation.

Self and parent perspectives on health-related quality of life of adolescents born very preterm

OBJECTIVES

To test whether health-related quality of life (HRQL) based on societal standards differs between very low birth weight/very preterm (VLBW/VP) and full-term (FT) adolescents using self and parent proxy reports. Also, to examine whether self and parent reported HRQL is explained by indicators of objective functioning in childhood.

STUDY DESIGN

This prospective cohort study followed 260 VLBW/VP adolescents, 12 VLBW/VP adolescents with disability, and 282 FT adolescents. Objective functioning was assessed at 8.5 years; HRQL was assessed at 13 years with the Health Utilities Index Mark 3 (HUI3).

RESULTS

Adolescents reported more functional impairment than their parents especially in the psychological aspects of health. The mean difference in HUI3 multi-attribute utility scores between FT and VLBW/VP adolescents was small (parents: 0.91 [95% CI, 0.90, 0.92] vs 0.88 [95% CI, 0.86, 0.90]; adolescents: 0.87 [95% CI, 0.85, 0.89] vs 0.84 [95% CI, 0.82, 0.86]), but high for VLBW/VP adolescents with disabilities (0.18, 95% CI, -0.04, 0.40). Objective function did not predict HRQL in FT adolescents but contributed to prediction of HRQL in VLBW/VP adolescents without disabilities. Different indicators of objective functioning were important for adolescent vs parent reports. More variation in HUI3 scores was explained by objective function in VLBW/VP parent reports compared with adolescent reports (25% vs 18%).

CONCLUSIONS

VLBW/VP adolescents reported poorer HRQL than their FT peers in early adolescence. Improvement in HRQL as VLBW/VP children grow up is, at least partly, explained by exclusion of the most disabled in self reports by VLBW/VP adolescents and the use of different reference points by adolescents compared with parents.

Fitness limitations in non-disabled extremely low birthweight adolescents

AIM

This study aims to compare non-disabled otherwise healthy extremely low birthweight (ELBW) (<1000 g) children and term-born peers in an investigation of relationship between cardiorespiratory endurance and parent report of competence.

METHODS

Forty-eight of 105 eligible ELBW 11- to 13-year-old children (27 male) and 55 term-born school peers (28 male) completed a 20-m shuttle run, anthropometric measures, respiratory function tests and the Motor Assessment Battery for Children. Parents completed the Child Behavior Checklist (CBCL).

RESULTS

The ELBW group had poorer cardiorespiratory endurance (P = 0.002), growth (P = 0.002), respiratory function (P = 0.003) and motor ability (P < 0.001) than term-born peers. Parents reported the ELBW children to be less competent than term-born peers: CBCL total T score mean difference -9, 95% confidence interval -14, -5 (P < 0.001). Cardiorespiratory endurance predicted competence (regression coefficient 0.865; 95% confidence interval 0.352, 1.378; P = 0.001) independent of prematurity, growth, respiratory function, motor score, gender and socio-economic status. Cardiorespiratory endurance had association with social competence for all participating children, but was related to CBCL Activities Competence only for the ELBW children who were the significantly less fit group.

CONCLUSIONS

The poor cardiorespiratory endurance prevalent in non-disabled otherwise healthy ELBW children is associated with general competence independent of prematurity and of the impact of other mild physical deficits, gender or socio-economic status. The relationship demonstrated between cardiorespiratory endurance and competence to engage in general activities of daily living, seen only in the less fit ELBW children, identifies the fitness levels in non-disabled ELBW children as a barrier to participation.

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Quality of life of former premature infants during adolescence and beyond

Interest in determining the quality of life of children and adults is now considered a priority. This is a result of a shift in thinking with greater transparency in finding out not only the health outcomes, but also the personal burden of illness and life satisfaction for the individual. However, there is still no consensus on the definition of quality of life or the appropriate tools to measure the same. In the last three decades there has been an exponential increase in the number of publications measuring quality of life, particularly in former premature infants. Most studies show that despite disabilities, children rate their quality of life almost equivalent to that of children born at term, and higher than that predicted by health professionals. This review will focus on the conceptual framework and measurement of self-reported quality of life in the context of former premature infants at adolescence and young adulthood.

The long-term predictive validity of early motor development in "apparently normal" ELBW survivors

BACKGROUND

Within the able majority of ELBW survivors, there is a lack of identified predictors of which children will require extra support despite having escaped significant disability.

AIMS

Investigate the predictive validity of early motor scores, compared to that of perinatal descriptors or early growth, on long-term motor impairment in non-disabled ELBW (<1000g) children.

STUDY DESIGN

Prospective longitudinal study.

OUTCOME MEASURES

48 non-disabled ELBW children (27 male) completed the Neurosensory Motor Developmental Assessment (NSMDA) at 8 months, 2 years and 4 years post term and The Motor Assessment Battery for Children (MABC) at 11-13 years of age. Other possible predictors of long-term outcomes (gestational age, birthweight, multiple birth, head circumference measures and gender) were retrieved from the records.

RESULTS

Early motor assessment (NSMDA score) independently predicted the MABC total score at 11-13 years of age with a positive predictive value of 87% by 4 years post term. There was increased risk of long-term motor impairment associated with male gender but the degree of prematurity, multiple birth status or early growth measures did not predict motor outcome. Postural control and sensory motor scores at 4 years post term, rather than neurological score, were associated with long-term motor outcomes for the ELBW children at 11-13 years of age.

CONCLUSIONS

Early motor scores are valid markers of long-term motor outcomes for "apparently normal" ELBW children. Early postural competence and sensory motor function are discriminating in regards to long-term motor function in neurologically normal ELBW children.

Preterm birth and leisure participation: a synthesis of the literature

Leisure participation has been associated with happiness and well-being in children. Individuals born preterm are at greater risk for motor, cognitive and behavioral difficulties which may contribute to difficulties participating in leisure activities. This systematic review examined the current knowledge on participation in leisure activities in individuals born preterm throughout the lifespan as compared to term born controls. An electronic search of eight databases for articles published up to October 2011 was conducted. The quality of each study was assessed using a standardized checklist. Thirteen studies met the selection criteria. In school-age children, no significant differences were found in activity levels between children born prematurely and term born controls. In adolescents, leisure scores in social activities, hobbies and sports were statistically significantly lower compared to controls. In young adults, differences in frequency and intensity of physical activity were reported compared to term controls. Promoting participation in leisure activities should be encouraged at a young age and continued to adulthood by minimizing the gaps between capabilities and the demands of the tasks and the environment.

Quality of life of adolescents and young adults born at high risk

Research on quality of life (QoL) of adolescents and young adults born preterm and those with congenital heart disease (CHD) was systematically reviewed, and factors associated with QoL were identified. Forty-five studies met the inclusion criteria for review. Although the majority of studies found that self-reported QoL of adolescents and young adults born preterm did not differ from term controls, several studies reported lower QoL among individuals born preterm, especially those who had additional impairments. Most studies on adolescents and young adults with CHD reported lower QoL compared with healthy peers, which may be in part due to real or perceived physical activity limitations of individuals with CHD. Overall, parents reported that their adolescents born at high risk had a less favorable QoL compared with those who served as controls. Encouraging age-appropriate, safe, and enjoyable physical activity and avoiding unnecessary restrictions and overprotection are considerations for optimizing QoL.

Psychopathology in young adults born at extremely low birth weight

BACKGROUND

Little is known about the long-term mental health of extremely low birth weight (ELBW) (<1000 g) survivors. We test whether young adults aged 22 to 26 years born at ELBW differ from normal birth weight (NBW) controls in self-reported levels of psychopathology.

METHOD

Participants included 142 ELBW survivors (86% response) born between 1977 and 1982 to residents of central-west Ontario, Canada and 133 NBW control subjects (92% response). The Young Adult Self-Report measure was used to create five DSM-IV oriented scales aggregated to form internalizing (depressive problems, anxiety problems, avoidant personality problems) and externalizing (attention deficit-hyperactivity disorder problems and antisocial personality problems) scales.

RESULTS

After adjusting for family background characteristics, mean scores for ELBW survivors were 3.02 [95% confidence interval (CI) 0.78-5.26] points higher for internalizing problems and no different, i.e. 0.00 (95% CI -1.17 to 1.17), for externalizing problems. There was a sex × group statistical interaction such that being male muted the risk for externalizing problems among those born at ELBW: -2.11 (95% CI -4.21 to -0.01). Stratifying ELBW adults as born small for gestational age (SGA) versus appropriate weight for gestational age (AGA) revealed a significant gradient of risk for levels of internalizing problems that was largest for SGA, i.e. 4.75 (95% CI 1.24-8.26), and next largest for AGA, 2.49 (95% CI 0.11-4.87), compared with NBW controls.

CONCLUSIONS

Depression, anxiety and avoidant personality problems (internalizing problems) are elevated in young adulthood among ELBW survivors. This effect is relatively small overall but noticeably larger among ELBW survivors born SGA.

Special care and school difficulties in 8-year-old very preterm children: the Epipage cohort study

OBJECTIVES

To investigate school difficulties, special care and behavioral problems in 8 year-old very preterm (VPT) children.

PATIENT AND METHODS

Longitudinal population-based cohort in nine regions of France of VPT children and a reference group born at 39-40 weeks of gestation (WG). The main outcome measures were information about school, special care and behavioral problems using Strengths and Difficulties Questionnaire from a questionnaire to parents.

RESULTS

Among the 1439 VPT children, 5% (75/1439) were in a specialised school or class, 18% (259/1439) had repeated a grade in a mainstream class and 77% (1105/1439) were in the appropriate grade-level in mainstream class; these figures were 1% (3/327) , 5% (16/327) and 94% (308/327) , respectively, for the reference group. Also, 15% (221/1435) of VPT children in a mainstream class received support at school versus 5% (16/326) of reference group. More VPT children between the ages of five and eight years received special care (55% (794/1436)) than children born at term (38% (124/325)); more VPT children (21% (292/1387)) had behavioral difficulties than the reference group (11% (35/319)). School difficulties, support at school, special care and behavioral difficulties in VPT children without neuromotor or sensory deficits varied with gestational age, socioeconomic status, and cognitive score at the age of five.

CONCLUSIONS

Most 8-year-old VPT children are in mainstream schools. However, they have a high risk of difficulty in school, with more than half requiring additional support at school and/or special care. Referral to special services has increased between the ages of 5 and 8 years, but remained insufficient for those with borderline cognitive scores.

The quality of life of young children and infants with chronic medical problems: review of the literature

The question "what makes a good quality of life?" is a philosophical one which could be thought immune to scientific investigations. However, over the last few decades there has been great progress in developing tools to quantify quality of life (QoL) to make comparisons between different health states, evaluate the effectiveness of medical interventions, and describe the life trajectories of individuals or groups. Using a series of vignettes, we explore and review the biomedical literature to demonstrate how QoL is affected by chronic health conditions in childhood, and how it evolves as individuals pass into adulthood. Individuals experiencing serious chronic illnesses generally have reduced health-related QoL: their health status has significant repercussions of their everyday life, but scores are usually much better than healthy individuals expect, and better than physicians predict. Global QoL is more than a health status concept. QoL is a complex relationship between objectivity and subjectivity; it requires substantial and valid facts, and it defines itself by an interpretation of health within different schemes of values: societal, medical, and those of the subject themselves. QoL is dynamic; purely physical influences diminish as individuals age, and psychosocial factors become much more important. Resilience frequently allows adaptation to adverse health states, leading to acceptable QoL for most children with disabilities.

Executive and memory function in adolescents born very preterm

BACKGROUND

Many preterm children display school difficulties, which may be mediated by impairment in executive function and memory.

OBJECTIVE

To evaluate executive and memory function among adolescents born preterm compared with term controls at 16 years.

METHODS

A total of 337 of 437 (77%) adolescents born in 1989 to 1992 with a birth weight < 1250 g and 102 term controls were assessed with a battery of executive function and memory tasks. Multiple regression analyses were used to compare groups and to identify associations between selected factors and outcomes among preterm subjects.

RESULTS

Adolescents born preterm, compared with term controls, showed deficits in executive function in the order of 0.4 to 0.6 SD on tasks of verbal fluency, inhibition, cognitive flexibility, planning/organization, and working memory as well as verbal and visuospatial memory. After exclusion of adolescents with neurosensory disabilities and full-scale IQ < 70, significant group differences persisted on most tests. Preterm subjects, compared with term controls, were at increased risk of exhibiting problems related to executive dysfunction, as measured with the Behavior Rating Inventory of Executive Function, on the Metacognition Index (odds ratio [OR]: 2.5 [95% confidence interval (CI): 1.2-5.1]) and the Global Executive Composite (OR: 4.2 [95% CI: 1.6-10.9]), but not on the Behavioral Regulation index (OR: 1.5 [95% CI: 0.7-3.5]). Among adolescents born preterm, severe brain injury on neonatal ultrasound and lower maternal education were the most consistent factors associated with poor outcomes.

CONCLUSIONS

Even after exclusion of preterm subjects with significant disabilities, adolescents born preterm in the early 1990s were at increased risk of deficits in executive function and memory.

Gestational age and basic school achievements: a national follow-up study in Denmark

OBJECTIVE

Children born at <32 weeks' gestation are at increased risk of intellectual impairment. Few studies have focused on the majority of preterm children born at 32 to 36 weeks' gestation. We aimed to investigate the association between the full range of gestational ages at birth and the risk of not completing basic school.

METHODS

This longitudinal, register-based study included all live-born infants in Denmark from 1988 to 1989. Data were obtained from national registers. School achievements were evaluated by using the examination marks. The association between gestational age and not completing basic school was estimated, taking into account the effect of their parents' educational level, being small for gestational age, plurality, and cerebral palsy.

RESULTS

The cohort constituted 120,585 infants, of whom 118,281 (98.6%) were alive in 2007. Of these infants, 5.01% (n = 5.928) were born before 37 weeks' gestation. Of the subjects born before 37 weeks' gestation, 11.5% (95% confidence interval: 10.7-12.4) did not complete basic school compared with 7.5% (95% confidence interval: 7.3-7.6) of those born at term. The percentage of subjects who did not complete basic school increased with decreasing gestational age. The increase was steeper at <31 weeks (4.2% per week) than at 31 to 36 weeks' gestation (0.5% per week).

CONCLUSIONS

The risk of not completing basic school increased with decreasing gestational age. The risk was moderate at ≥31 weeks' gestation and increased steeply at <31 weeks' gestation. The increase at <31 weeks' gestation was only partly explained by cerebral palsy.

Health related quality of life after extremely preterm birth: a matched controlled cohort study

BACKGROUND

The majority of infants born before the last trimester now grow up. However, knowledge on subsequent health related quality of life (HRQoL) is scarce. We therefore aimed to compare HRQoL in children born extremely preterm with control children born at term. Furthermore, we assessed HRQoL in relation to perinatal and neonatal morbidity and to current clinical and sociodemographic characteristics.

METHOD

The Child Health Questionnaire (CHQ-PF50) and a general questionnaire were applied in a population based cohort of 10 year old children born at gestational age < or = 28 weeks or with birth weight < or = 1000 grams in Western Norway in 1991-92 and in term-born controls, individually matched for gender and time of birth. The McNemar test and paired t-tests were used to explore group differences between preterms and matched controls. Paired regression models and analyses of interaction (SPSS mixed linear model) were used to explore potential effects of sociodemographic and clinical characteristics on HRQoL in the two groups.

RESULTS

All 35 eligible preterm children participated. None had major impairments. Learning and/or attention problems were present in 71% of preterms and 20% of controls (odds ratio (OR): 7.0; 95% confidence interval (CI): 2.2 to 27.6). Insufficient professional support was described by 36% of preterm vs. 3% of control parents (OR: infinite; CI: 2.7 to infinite). Preterms scored lower on eight CHQ-PF50 sub-scales and the two summary scores, boys accounting for most of the deficits in areas of behavior, psychosocial functioning and parental burden. HRQoL was associated with learning and/or attention problems in both preterm and control children, significantly more so in preterms in areas related to health and parental burden. Within the preterm group, HRQoL was mostly unrelated to perinatal and neonatal morbidity.

CONCLUSIONS

HRQoL for children born extremely preterm, and particularly for boys, was described by parents to be inferior to that of children born at term, and sufficiently poor to affect the daily life of the children and their families. Learning and/or attention problems were reported for a majority of preterms, strongly influencing their HRQoL.

Prediction of neurodevelopmental outcome after preterm birth

Prediction of outcome after preterm birth is critical, but remains difficult, particularly in the early postnatal period. The ability to predict outcome improves parental counseling and selection of infants for early therapeutic strategies aiming at preventing or ameliorating cerebral injury. This review gives an overview of the spectrum and severity of neurodevelopmental, behavioral, and psychosocial outcomes, with discussion of predictors of outcome and, in particular, the clinical, electrophysiological, and imaging predictors. A detailed neurologic examination of infants is a valuable predictive tool in terms of later moderate to severe neurodevelopmental impairments; however, it may be limited in the immediate newborn period. Electrophysiological, neuroimaging, and clinical risk factors for adverse neurodevelopmental outcome have been identified. Good prediction is usually achieved for major functional disabilities in early childhood, but is poorer for moderate or mild long-term outcome. Future research should focus on the long-term quality of life, academic achievement, and the influence of the sociocultural environment. More emphasis should be placed on genetic diversity as a modifying factor for the large variability in outcome.

Lasting effects of preterm birth and neonatal brain hemorrhage at 12 years of age

OBJECTIVES

Our goals were to compare cognitive, language, behavioral, and educational outcomes of preterm children to term controls and to evaluate the impact of neonatal brain injury, indomethacin, and environmental risk factors on intellectual function at 12 years of age.

METHODS

A total of 375 children born in 1989-1992 with birth weights of 600 to 1250 g enrolled in the Indomethacin Intraventricular Hemorrhage Prevention Trial and 111 controls were evaluated. Neuropsychometric testing, neurologic examination, and interviews on educational needs were completed. Severe brain injury was defined as the presence of grade 3 to 4 indomethacin intraventricular hemorrhage, periventricular leukomalacia, or severe ventriculomegaly on cranial ultrasound.

RESULTS

On the Wechsler Scales of Intelligence for Children, the preterm cohort obtained a full-scale IQ of 87.9 +/- 18.3, verbal IQ of 90.8 +/- 18.9, and performance IQ of 86.8 +/- 17.9. Preterm children obtained scores 6 to 14 points lower than term controls on all psychometric tests after adjustment for sociodemographic factors. On the Clinical Evaluation of Language Fundamentals (test of basic language skills), 22% to 24% of preterm children scored in the abnormal ranges (<70) as opposed to 2% to 4% of controls. Preterm children with and without brain injury required more school services (76% and 44% vs 16%), and support in reading (44% and 28% vs 9%), writing (44% and 20% vs 4%), and mathematics (47% and 30% vs 6%) compared with controls. Preterm children also displayed more behavior problems than their term counterparts. Severe neonatal brain injury was the strongest predictor of poor intelligence. Antenatal steroids, higher maternal education, and 2-parent family were associated with better cognition, whereas minority status incurred a disadvantage. Indomethacin did not affect intellectual function among preterm children.

CONCLUSIONS

Preterm children born in the early 1990s, especially those with severe brain injury, demonstrate serious deficits in their neuropsychological profile, which translates into increased use of school services at 12 years.

The role of transient hypothyroxinemia of prematurity in development of visual abilities

Preterm birth is associated with an increased risk of visual impairment. However, not all visual deficits can be fully explained by the typical prematurity morbidity factors. In addition, children born preterm often exhibit transient hypothroxinemia of prematurity (THOP) due to premature severing of the maternal supply of thyroid hormones. Because thyroid hormone is critically needed for multiple facets of early brain development, including the structures needed for visual processing, and because the maternal thyroid supply is essential throughout pregnancy, it is possible that THOP contributes to the visual impairments seen in preterm children. To test this hypothesis, we used both clinical tests and visual-evoked potential techniques to assess visual abilities in two cohorts of preterm infants whose thyroid hormone levels were measured in the perinatal period. In the first cohort born 30 to 35 weeks gestation, we found associations between low thyroid hormone levels and reduced visual attention at 3 months corrected age (Study 1) and poor visuomotor abilities at 12 and 18 months corrected age (Study 2). In the second cohort born 23 to 35 weeks gestation, THOP severity was negatively correlated with attention at 3 months corrected age (Study 3) and contrast sensitivity and color vision at 6 months corrected age (Study 4). These findings therefore suggest that thyroid hormone is necessary for the development of early visual abilities and that THOP may partially explain the visual deficits of preterm infants.

Perinatal factors reported by mothers: do they agree with medical records?

As perinatal events have been linked with diseases of later onset, epidemiological studies on child development and adult health require information on the perinatal period. When national neonatal registers do not exist, review of medical records may be impractical. However, neonatal information could be obtained by asking mothers to complete a postal questionnaire using data from the Personal Child Health Record (PCHR). We assessed agreement between medical records and mothers' reports for information on delivery and the newborn's condition at birth, based on the PCHR, a short time after delivery. Of 711 women giving birth in 3 French hospitals and invited to participate in the study, 580 (82%) completed a postal questionnaire 6 weeks after delivery, copying the data recorded in the PCHR when available. Information on pregnancy, delivery and the newborn's health at birth was independently extracted from medical records by physicians of the maternity departments. Agreement between medical records and maternal reports for a range of perinatal factors was assessed in 580 newborn-mother dyads using kappa coefficients. Agreement was excellent for first and second stages of delivery, gestational age, birth weight, birth size and head circumference (kappa coefficients 0.80-1.00) and good for hospitalization during pregnancy, but poor for Apgar scores. With this exception, mothers' reports appeared reliable when compared with medical records. As PCHRs exist in most developed countries, this approach could be used in epidemiological studies on child development to increase the reliability of mothers' reports of their newborn's condition at birth.

School performance of adolescents born preterm: neuropsychological and background correlates

In this longitudinal study the development of preterm and control children was followed from infancy until adolescence. School performance at the age of 16 in subjects born very preterm with a gestational age (GA) of <or= 32 weeks was compared with the performance of adolescents born full-term. None of the subjects had major disabilities. The study groups performed similarly in most school subjects, including mathematics, the second foreign language and the native language (Finnish). Subjects in the preterm group achieved significantly higher grade points in the first foreign language than control subjects. In particular, the difference was evident between the preterm and control boys. The extremely preterm group with a GA <or= 29 weeks did not differ from the more mature group with a GA between 30 and 32 weeks in terms of the school grade points. Verbal and performance scale IQs as assessed at the age of 9 were of primary importance in predicting school success in adolescence. The results suggest a good outcome, measured by school grade scores at 16 years of age, of the subjects born very preterm.

Quality of life of formerly preterm and very low birth weight infants from preschool age to adulthood: a systematic review

OBJECTIVE

The goal of this systematic review was to synthesize studies that examined the health-related quality of life of preschool- and school-aged children, adolescents, and young adults who were born preterm and/or at very low birth weight.

METHODS

We searched 7 databases up to September 2006 (Medline, PubMed, Embase, EBM Reviews, Cumulative Index of Nursing and Allied Health Literature, PsycINFO, and the Educational Resource Information Center) as well as gray literature sources. We independently screened studies and included them only if a quality-of-life outcome measure was used and findings compared preterm, very low birth weight, or extremely low birth weight infants with term or normal birth weight peers. We independently assessed the methodologic quality of each study by using criteria adapted from the Centre for Reviews and Dissemination.

RESULTS

Fifteen cohort or cross-sectional studies met the review criteria. In 6 studies of preschool-aged children, differences were found between study and control groups, suggesting that many preschool children born preterm or at very low birth weight perform more poorly than their peers in physical, emotional, and/or social functioning. Extremely low birth weight school-aged children had lower health utility scores compared with their peers, and similar results were found for adolescents. Parents of preterm and very low birth weight teens noted significantly poorer performance in their child's global health, behavior, and physical functioning, whereas the teenagers themselves did not. In young adulthood, differences in physical functioning remained, but subjective quality of life was similar to normal birth weight peers.

CONCLUSIONS

The effects of preterm birth/very low birth weight on health-related quality of life seem to diminish over time, which possibly reflects issues related to a child's report versus a parent-proxy report, differing definitions of health-related quality of life, and adaptation of individuals over time, versus true change in health-related quality of life.

Behaviour and quality of life at school age of children who had bronchopulmonary dysplasia

BACKGROUND

There is little information available concerning behavioural and functional health problems in children who had bronchopulmonary dysplasia (BPD).

AIM

To compare behavioural problems and quality of life in a cohort of children at school age who had BPD with preterm and term controls.

METHODS

The cohort of 78 BPD children of 26 to 33 weeks' gestation was matched for birth weight with preterm controls. At school age follow-up, information was available for 66 BPD children and 60 preterm controls. (Three children with severe cerebral palsy were excluded). Parents completed the Child Behaviour Checklist (CBCL) and the Child Health Questionnaire (CHQ). The child's teacher completed the Teacher Report Form (TRF) of the CBCL, with the teachers of the BPD children completing a TRF on a classroom control. Parents completed a questionnaire on their levels of anxiety and depression.

RESULTS

The mean total problem score on the CBCL for the BPD children was similar to the controls, with the BPD children displaying more internalising behaviours. Little variation was seen between the BPD and preterm children on the TRF. Significant differences between classroom controls and the BPD children were found for the total problem scores (p=0.001), internalising behaviours (p=0.01) and social (p=0.047), attention (p=0.0001) and thought problems (0.047). Results from the CHQ showed no difference between the groups in their physical health or the impact of health problems on family life.

CONCLUSION

BPD children at school age display more internalising behaviour than preterm controls, with marked differences on comparison with classroom controls. Quality of life, however, does not seem to be adversely affected compared to the preterm controls.

What matters in the long term: reflections on the context of adult outcomes versus detailed measures in childhood

The primary goals of modern perinatal intensive care are to improve survival and neurodevelopmental outcomes of high-risk infants. The detailed assessments at follow-up in the early years provide us with valuable information on the performance of the children at a given point in time. With increasing age of the subjects, the investigation into their outcome has evolved from a narrow focus of neurodevelopmental status to broader considerations of their overall morbidity, accomplishments and self-perception of their health and quality of life. In this chapter, we will reflect on the importance of the detailed measures in the early years, the impact of moderating background variables on predictability of outcomes, implications for the future and what really matters at young adulthood for infants born prematurely. We will explore the perspectives of different respondents and the need to look beyond the traditional measures to obtain complementary information.

Parental protection of extremely low birth weight children at age 8 years

OBJECTIVE

To examine parent protection and its correlates among 8-year-old ELBW children compared with normal birth weight (NBW) controls.

METHODS

The population included 217 eight-year-old ELBW children born 1992-1995 (92% of the surviving birth cohort; mean birth weight, 811 g; mean gestational age, 26.4 weeks) and 176 NBW controls. The primary outcome measure, the Parent Protection Scale (PPS), included a total score and four domains including Supervision, Separation, Dependence, and Control. Multivariate analyses were performed to examine the predictors of parental protection and overprotection.

RESULTS

After adjusting for socioeconomic status (SES), race, sex, and age of the child, parents of ELBW children reported significantly higher mean total Parent Protection Scale scores (31.1 vs 29.7, p = .03) than parents of NBW children and higher scores on the subscale of Parent Control (8.0 vs 7.5, p = .04). These differences were not significant when the 36 children with neurosensory impairments were excluded. Parents of ELBW children also reported higher rates of overprotection than controls (10% vs 2%, p = .001), findings that remained significant even after excluding children with neurosensory impairments (8% vs 2%, p = .011). Multivariate analyses revealed lower SES to be associated with higher total Parent Protection Scale scores in both the ELBW (p < .001) and NBW (p < .05) groups. Additional correlates included neurosensory impairment (p < .05) and functional limitations (p < .001) in the ELBW group and black race (p < .05) and maternal depression (p < .01) in the NBW group. Lower child IQ was significantly associated with higher PPS scores only in the neurosensory impaired subgroup of ELBW children.

CONCLUSIONS

Longer term follow-up will be necessary to examine the effects of the increased parent protection on the development of autonomy and interpersonal relationships as the children enter adolescence.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparison of current health, functional limitations, and health care use of young adults who were born with extremely low birth weight and normal birth weight

OBJECTIVE

The objective of this study was to compare the current health status, physical ability, functional limitations, and health care use of extremely low birth weight and normal birth weight young adults.

METHODS

A longitudinal study was conducted of a population-based cohort of 166 extremely low birth weight survivors (501-1000 g birth weight; 1977-1982 births) and a group of 145 sociodemographically comparable normal birth weight individuals. Current health status, history of illnesses, hospitalizations, use of health resources, and physical self-efficacy were assessed through questionnaires that were administered to the young adults by masked interviewers.

RESULTS

Individuals completed the assessments at a mean age of 23 years. Neurosensory impairments were identified in 27% of extremely low birth weight and 2% of normal birth weight individuals. No differences were reported in the current health status for physical or mental summary scores. Extremely low birth weight young adults reported a higher prevalence of chronic health conditions in the past 6 months. A significantly higher proportion of extremely low birth weight individuals had functional limitations in seeing, hearing, and dexterity and experienced clumsiness and learning difficulties. Except for prescription glasses, medications for depression, and home-care services for extremely low birth weight individuals, there were no significant differences between groups in use of health care resources. Extremely low birth weight individuals had significantly weaker hand grip strength and lower scores for physical self-efficacy, perceived physical ability, and physical self-confidence.

CONCLUSIONS

Extremely low birth weight young adults seem to enjoy similar current health status to their normal birth weight peers. However, they continue to have significantly poorer physical abilities and a higher prevalence of chronic health conditions and functional limitations. Contrary to expectations, they do not pose a significant burden to the health care system at young adulthood.

Chronic conditions, functional limitations, and special health care needs in 10- to 12-year-old children born at 23 to 25 weeks' gestation in the 1990s: a Swedish national prospective follow-up study

BACKGROUND

Children born extremely immature (gestational age < 26 weeks' gestation) increasingly reach school age. Information on their overall functioning and special health care needs is necessary to plan for their medical and educational services. This study was undertaken to examine neurosensory, medical, and developmental conditions together with functional limitations and special health care needs of extremely immature children compared with control subjects born at term.

METHODS

We studied 11-year-old children born before 26 completed weeks of gestation in all of Sweden from 1990 through 1992. All had been evaluated at 36 months' corrected age. Identification of children with chronic conditions lasting > or = 12 months was based on a questionnaire administered to parents. Neurosensory impairments were identified by reviewing health records. Information regarding other specific medical diagnoses and developmental disabilities was obtained by standard parent and teacher questionnaires.

RESULTS

Of 89 eligible children, 86 (97%) were studied at a mean age of 11 years. An equal number of children born at term served as controls. Logistic-regression analyses adjusting for social risk factors and gender showed that significantly more extremely immature children than controls had chronic conditions, including functional limitations (64% vs 11%, respectively), compensatory dependency needs (59% vs 25%), and services above those routinely required by children (67% vs 22%). Specific diagnoses or disabilities with higher rates in extremely immature children than in controls included neurosensory impairment (15% vs 2%), asthma (20% vs 6%), poor motor skills of > 2 SDs above the mean (26% vs 3%), poor visual perception of > 2 SDs above the mean (21% vs 4%), poor learning skills of > 2 SDs above the mean (27% vs 3%), poor adaptive functioning with T scores of < 40 (42% vs 9%), and poor academic performance with T score < 40 (49% vs 7%).

CONCLUSIONS

Children born extremely immature have significantly greater health problems and special health care needs at 11 years of age. However, few children have severe impairments that curtail major activities of daily living.

Adverse perinatal conditions in hearing-impaired children in a developing country

Prevailing adverse perinatal conditions in developing countries have been associated with substantial mortality, but little evidence exists on their impact on permanent childhood disabilities and morbidity due to limitations in clinical investigations and medical records. This study aims to identify the possible association between parent-reported adverse perinatal conditions and permanent hearing loss, in order to establish service needs within current maternal and child health programmes. Structured questionnaires were administered to 363 parents of deaf children and 309 parents of normal-hearing children in an inner city area of Lagos, Nigeria. The parents were from all social classes. After a multivariable logistic regression analysis, birth asphyxia [OR 20.45; 95% CI 6.26, 66.85], difficult delivery [OR 8.09; 95% CI 2.76, 23.68], neonatal jaundice [OR 2.45; 95% CI 1.25, 4.79] and neonatal seizures [OR 2.30; 95% CI 1.09, 4.85] were associated with permanent hearing loss. Consanguineous marriages [OR 6.69; 95% CI 2.72, 16.46] and family history of deafness [OR 6.27; 95% CI 2.07, 18.97] also emerged as additional risk factors for permanent hearing loss. In addition, parents of children in state-owned schools for the deaf were significantly more likely to belong to higher social classes compared with normal-hearing children in mainstream state-owned schools. There is a need to incorporate services for the early detection of permanent hearing loss into current maternal and child healthcare programmes in developing countries.

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

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

Neurodevelopmental follow-up after preterm birth: follow up after two years

Marked differences are seen in neurological and health status, intellectual functioning, school performance and behaviour between children born prematurely and those born at term. Assessment in later childhood has identified more subtle problems than the severe disability or sensory deficits readily identifiable at two years. These problems include learning disabilities, specific neuropsychological deficits in executive function, difficulties in visual-motor integration and perception, selective language impairment, motor coordination disorders, behaviour problems, attention deficit hyperactivity disorder (ADHD), and reduced educational achievement. Follow-up to school entry and beyond is thus required to determine the true prevalence and nature of the neurodevelopmental problems arising from preterm birth. Consensus about the assessment used, definitions of disability and health status, age of assessment and who undertakes it are necessary and should allow comparison across populations; this may help to maximise outcomes for children clearly at biological risk. Assessment of outcome for children born preterm beyond two years is required for counselling parents, planning health and education provision, for evaluation of services and to facilitate understanding of the longer term effects of preterm birth on brain development.

Randomised trial of parental support for families with very preterm children: outcome at 5 years

AIMS

To test the effectiveness of a home based developmental education intervention in improving outcome at 5 years for very preterm infants.

METHODS

The Avon Premature Infant Project (APIP) is a randomised controlled trial in which the parents of 284 babies born <33 weeks gestational age received a developmental education programme, a social support intervention, or standard care. A term reference population was also recruited. This study reports outcomes at 5 years (mean age 58 months 15 days) for 187 (66%) of these children without disability. Outcomes were assessed using the British Ability Scales II for cognitive development, the Movement ABC for motor impairment, and the Child Behavior Checklist for behavioural problems.

RESULTS

Preterm infants showed poorer cognitive performance than their term peers. Mean (SD) general conceptual ability (GCA) scores were: Portage 99.2 (15.7); parent adviser 100.3 (14.8); preterm control 101.1 (15.0); term reference 107.2 (13.4). There were no significant differences between preterm groups in GCA scores indicating no effect of either intervention. Similarly, there was no significant effect of intervention on behavioural or motor outcomes. Further analyses, in which outcome data were adjusted for social factors, did not reveal any differences between the three preterm groups or by subgroups classified by a range of perinatal variables.

CONCLUSION

The small advantage shown at 2 years of age is no longer detectable at 5 years. These results question the effectiveness of early intervention in enhancing cognitive, behavioural, and motor function at 5 years.

Randomized, controlled trial of dexamethasone in neonatal chronic lung disease: 13- to 17-year follow-up study: I. Neurologic, psychological, and educational outcomes

OBJECTIVES

To study neurologic, educational, and psychological status in adolescence of neonates enrolled in a double-blind, randomized, controlled trial of dexamethasone therapy for chronic lung disease.

PARTICIPANTS

A total of 287 infants who were chronically dependent on supplementary oxygen and were 2 to 12 weeks of age were recruited from 31 centers in 6 countries to a randomized, controlled trial of dexamethasone base (0.5 mg/kg per day for 1 week); 95% of survivors were reviewed at 3 years. Survivors from the 25 British and Irish centers were retraced at 13 to 17 years of age.

OUTCOME MEASURES

Nonverbal reasoning, British Picture Vocabulary Scale, Goodman Strengths and Difficulties Questionnaire behavior scores, school national test results, teacher ability ratings, and parental and general practitioner questionnaires.

RESULTS

A total of 195 children were eligible for the follow-up study. Information was available for 150 children (77%), with 142 (73%) being assessed in home visits. No baseline differences were detected between the children included in the follow-up study and those not included. There was a slight excess of cerebral palsy in the steroid group, which was not statistically significant (relative risk: 1.58; 95% confidence interval: 0.81-3.07). Overall disability rates in both groups were high (21% moderate and 14% severe), but with no difference between the 2 groups (for severe disability, relative risk: 0.84; 95% confidence interval: 0.37-1.86).

CONCLUSIONS

Information was obtained for 150 adolescents randomized to receive dexamethasone or placebo for neonatal chronic lung disease. Rates of disabilities and educational difficulties were high, but with no significant differences between the 2 groups. Some use of open-label steroids in the placebo group plus losses to long-term follow-up monitoring reduced the power of this study to detect clinically important differences, and this study cannot rule out a real increase in cerebral palsy, as reported by others.

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.

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

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

Behavioral and emotional adjustment of teenagers in mainstream school who were born before 29 weeks' gestation

OBJECTIVES

To investigate behavioral and emotional problems and positive adjustment of 15-to 16-year-olds who were born at extremely low gestational age (ELGA), from the perspective of parents, teachers, and teenagers.

METHODS

Prospective follow-up was conducted of birth cohorts, with classroom control subjects. All infants who were born before 29 weeks in 1983-1984 (mean gestational age: 27 weeks) to mothers who resided in 3 regions of the United Kingdom were studied. A total of 82% (179 of 218) of survivors were traced at age 15 to 16. The 150 in mainstream school were compared with age- and gender-matched classroom control subjects (n = 108). Behavioral and emotional problems, delinquency, peer relations, self-esteem, and hobbies, were assessed by standardized, well-validated instruments, including the Strengths and Difficulties Questionnaire, administered by mail to parents, teenagers, and teachers.

RESULTS

Parents were more likely to rate ELGA teenagers than control subjects as in the "abnormal" range for hyperactivity (8% vs 1%; difference: 7%; (95% confidence interval [CI]: 2-12), peer relationship problems (19% vs 5%; difference: 14%; 95% CI: 6-21), and emotional problems (18% vs 7%; difference: 11%; 95% CI: 3-19), but not conduct problems (10% vs 5%; difference: 5%; 95% CI: -1 to 12)). Teachers reported a similar pattern. In contrast, compared with control subjects, ELGA teenagers did not rate themselves as having more problems with peers, hyperactivity, conduct, depression, or low self-esteem. They reported more emotional problems but less delinquency, alcohol, cannabis, and other drug use.

CONCLUSIONS

Compared with mainstream classmates, children who are born extremely early continue to have higher levels of parent- and teacher-reported emotional, attentional, and peer problems well into their teens. However, despite these problems, they do not show signs of more serious conduct disorders, delinquency, drug use, or depression.

Larger corpus callosum size with better motor performance in prematurely born children

The objective of this study is to determine the relation between the size of the corpus callosum (CC) and motor performance in a population-based cohort of preterm children. Preterm born children (n = 221) with a gestational age less than or equal to 32 weeks and/or a birth weight below 1500 g were eligible for this study. At the age of 7 or 8 years, frontal, middle, posterior, and total areas (mm2) of the corpus callosum were measured on true midsagittal MRI. Due to anxiety of 10 children and motion artifacts in 7 other children, 204 MRIs could be assessed in the preterm group (mean GA 29.4 weeks, sd 2.0,mean BW 1200 g, sd 323). The preterm group consisted of 15 children with cerebral palsy (CP) and 189 children without CP. Motor function was established by using the Movement Assessment Battery for Children, and the Developmental Test of Visual Motor Integration was obtained. The same examinations were performed in 21 term born children. The mean total cross-sectional CC area was significantly smaller in preterm born infants compared with their term born controls (338 mm2 versus 422 mm2, P < 0.0001). The preterm children with CP had significantly smaller mean CC areas compared with the preterms who did not develop CP (P < 0.0001-P < 0.002). However, the preterms born without CP also had significantly smaller body, posterior, and total CC areas compared with term born controls (P < 0.0001-P < 0.002). Only the difference in frontal area measurements dilrc) -3.3 mm2/score point (95% CI -4.5, -2.1). The association existed in all parts of the CC but increased in the direction of the posterior part: frontal: lrc -0.8 mm2/score point (-1.2, -0.4), middle: lrc -1.1 mm2/score point (-1.7, -0.5) and posterior: lrc -1.4 mm2/score point (-1.8, -0.9). An association between CC area and its subareas and the standard scores of the VMI was also found. A larger CC was strongly related t o better scores onthe VMI test total area CC: lrc 0.05 score/mm2 (95% CI 0.03, 0.07), frontal: lrc 0.12 score/mm2 (0.05,0.19), middle: lrc 0.10 score/mm2 (0.05, 0.15) and posterior: lrc 0.12 score/mm2 (0.06, 0.18). After adjustment for gestational age, birth weight, and total cerebral area, these associations were still significant. There is a strong association between the size of the corpus callosum (total midsagittal cross area as well as frontal, middle, and posterior area) and motor function in preterm children, investigated at school age. A poorer score on the Movement ABC was related to a smaller CC. A larger CC was strongly associated with better VMI standard scores.