The ALIGN Framework: A Parent-Informed Approach to Prognostic Communication for Infants With Neurologic Conditions

Enhancing shared decision-making for infants in the intensive care unit: lessons from parents

BACKGROUND

Understanding parent preferences and experiences of decision-making can guide interventions to improve shared decision-making. We aimed to characterize how parents (1) incorporated values into decision-making, (2) evaluated clinician recommendations, and (3) experienced their decisional role.

METHODS

In this qualitative study, we longitudinally interviewed parents of infants with neurologic conditions about their experiences making decisions for their child. Infants were eligible if they were (1) hospitalized in a critical care unit, (2) < 1 years old, (3) diagnosed with a neurologic condition and (4) expected to have a family conference to discuss goals of care or neurologic prognosis. Data were analyzed using a conventional content analysis approach.

RESULTS

In total, 123 interviews were conducted with 52 parents (n = 37 mothers, n = 15 fathers) of 37 infants. We identified 3 themes: (1) Clarifying and communicating values: Parents characterized challenges weighing multiple decision-relevant values. (2) Evaluating clinician recommendations: Parents appreciated clinician recommendations that incorporated their values. (3) Understanding decision-making roles: Parents typically preferred an active role; poor alignment between preferred and actual decision-making role sometimes precipitated conflict with the team.

CONCLUSION

We identified parent-informed opportunities to support shared decision-making for critically ill infants. Future interventions should target strategies to help parents clarify and communicate values, ensure that clinician recommendations acknowledge parent values, and identify parent-preferred decisional roles.

IMPACT

Existing data suggest gaps in how parents and clinicians partner in making decisions for critically ill infants. In this descriptive qualitative study, we characterized the parent experience of decision-making amidst critical illness. Parents shared challenges associated with weighing and communicating multiple, sometimes competing, decision-relevant values. Parents appreciated when clinicians offered recommendations that acknowledged their values. Parents preferred an active decision-making role; poor alignment between preferred and actual decision-making role sometimes led to conflict with the team. Future decision-making interventions should target strategies to help parents communicate and clarify values, ensure that clinician recommendations integrate parent values, and identify parent-preferred decisional roles.

Parents' perspectives on conversations about prognosis and an assessment of prognostic information available online: A mixed-methods study

BACKGROUND

Conversations about prognosis for genetic neurodevelopmental conditions are becoming more frequent; however, there is a lack of evidence and guidance on how to approach these conversations and frame the information being provided.

OBJECTIVE

(1) To understand how parents perceive prognostic conversations with healthcare professionals and their preferences for these conversations, (2) To investigate the framing of prognostic information found online.

METHODS

This was a mixed-methods study, comprising of (1) a thematic analysis of interviews with parents and (2) a quantification of prognostic information available on the internet that portrayed a negative message. The strategy to classify the framing of prognostic information was defined iteratively, informed by the information found online.

RESULTS

We interviewed 32 parents from across Australia. Parents had a child with a genetic neurodevelopmental condition, such as Fragile X syndrome (28 %), 22q11.2 deletion syndrome (16 %) or Angelman syndrome (16 %). Parents reported their preference to discuss their child's potential strengths as well as challenges regarding prognosis. They reported that conversations about prognosis often focused on the child's possible deficits and that online information they encountered was similarly framed negatively. Our analysis of online information confirmed parents accounts: 95.3 % was coded as negative, while only 4.7 % was positive/neutral.

CONCLUSIONS

Our data provide evidence of an over-emphasis of deficit-framed prognostic information about genetic neurodevelopmental conditions. The initial exposure to negative information may adversely affect parents' psychological well-being and expectations, which future research could address. Health professionals could consider strengths-based framing of prognostic information gained from current and emerging technologies when returning results to families. Findings from this study can help to inform health communication practices as well as online content development.

Communicating neurological prognosis in the prenatal period: a narrative review and practice guidelines

Clinicians may face an array of challenges in conducting fetal neurological consultations including prognostic uncertainty, a lack of training in fetal counseling, and limited opportunity to build rapport with families. In this setting, it is critical to employ high-quality, family-centered care to allow expectant parents to make informed decisions. Despite the challenges and gravity of these consultations, there remains limited data outlining best conduct and communication practices. This narrative review aims to summarize relevant literature around counseling within fetal neurology, focusing on three key themes: (1) discussing neurological prognosis and uncertainty, (2) navigating evolving decision making, (3) recognizing bias and understanding patient context. We provide practical recommendations to clinicians conducting fetal neurological counseling and outline future research priorities. IMPACT: Fetal neurological conditions can have a significant impact on child short- and long-term health outcomes. Prenatal consultations are an important venue to discuss information regarding fetal prognosis and decision making with expectant parents. However, there is limited evidence supporting best communication practices within this setting. This review summarizes current literature around expectant parent prognostic communication preferences and outlines practical recommendations and priorities for future research.

A Seat at the Table: Family Conferences for Infants with Neurological Conditions

Objective: We aimed to characterize parents' perspectives on the value of and opportunities to improve conferences between parents of critically ill infants and the health care team. Background: The parent perspective on the value of family conferences in the intensive care unit is not well characterized. Methods: In this descriptive qualitative study, parents of infants with neurological conditions in the intensive care unit at a U.S. academic medical center completed longitudinal semi-structured interviews about their experiences making decisions and communicating with clinicians. Parents were included if they had an upcoming family conference to discuss goals of care or neurological prognosis. This secondary data analysis targets interview content about family conferences. Parent responses were characterized using a conventional content analysis approach. Results: Fifty-two parents of 37 infants completed 123 interviews. Parents described valuing when clinicians (1) provided space to process emotions, (2) prioritized "big picture" discussions about serious decisions, (3) dedicated time to parent questions, and (4) responded to parent concerns and made an effort to foster consensus. Parent-identified opportunities for improvement included: (1) having the team assume responsibility for calling regular meetings, (2) prioritizing attendance of consistent and supportive team members, and (3) summarizing meeting content for parents and documenting discussions for clinicians. Conclusions: These findings demonstrate that parents of infants with neurological conditions value family conferences as an important venue for communicating with the health care team. Future studies should explore the feasibility and impact of regularly scheduled family conferences, attendees dedicated to parent support, and accessible meeting summaries on therapeutic alliance, parent well-being, and communication quality.

Predictors of Death or Severe Impairment in Neonates With Hypoxic-Ischemic Encephalopathy

Importance

Outcomes after hypoxic-ischemic encephalopathy (HIE) are variable. Predicting death or severe neurodevelopmental impairment (NDI) in affected neonates is crucial for guiding management and parent communication.

Objective

To predict death or severe NDI in neonates who receive hypothermia for HIE.

Design, Setting, and Participants

This prognostic study included participants enrolled in a large US clinical trial conducted in US neonatal intensive care units who were born between January 2017 and October 2019 and followed up to age 2 years. Eligible participants were neonates with moderate-severe HIE born at 36 weeks or more gestation and with 2-year outcome data. Data were analyzed June 2023. External validation was performed with a UK cohort.

Exposure

Clinical, electroencephalography (EEG), and magnetic resonance imaging (MRI) variables were curated and examined at 24 hours and following cooling.

Main Outcome and Measures

Death or severe NDI at age 2 years. Severe NDI was defined as Bayley Scales of Infant Toddler Development cognitive score below 70, Gross Motor Function Classification System score of 3 or higher, or quadriparesis. Model performance metrics were derived from training, internal, and external validation datasets.

Results

Among 424 neonates (mean [SD] gestational age, 39.1 [1.4] weeks; 192 female [45.3%]; 28 Asian [6.6%], 50 Black [11.8%], 311 White [73.3%]), 105 (24.7%) had severe encephalopathy at enrollment. Overall, 59 (13.9%) died and 46 (10.8%) had severe NDI. In the 24-hour model, the combined presence of 3 clinical characteristics-(1) severely abnormal EEG, (2) pH level of 7.11 or below, and (3) 5-minute Apgar score of 0-had a specificity of 99.6% (95% CI, 97.5%-100%) and a positive predictive value (PPV) of 95.2% (95% CI, 73.2%-99.3%). Validation model metrics were 97.9% (95% CI, 92.7%-99.8%) for internal specificity, with a PPV of 77.8% (95% CI, 43.4%-94.1%), and 97.6% (95% CI, 95.1%-99.0%) for external specificity, with a PPV of 46.2% (95% CI, 23.3%-70.8%). In the postcooling model, specificity for T1, T2, or diffusion-weighted imaging (DWI) abnormality in at least 2 of 3 deep gray regions (ie, thalamus, caudate, putamen and/or globus pallidus) plus a severely abnormal EEG within the first 24 hours was 99.1% (95% CI, 96.8%-99.9%), with a PPV of 91.7% (95% CI, 72.8%-97.8%). Internal specificity in this model was 98.9% (95% CI, 94.1%-100%), with a PPV of 92.9% (95% CI, 64.2%-99.0%); external specificity was 98.6% (95% CI, 96.5%-99.6%), with a PPV of 83.3% (95% CI, 64.1%-93.4%).

Conclusions and Relevance

In this prognostic study of neonates with moderate or severe HIE who were treated with therapeutic hypothermia, simple models using readily available clinical, EEG, and MRI results during the hospital admission had high specificity and PPV for death or severe NDI at age 2 years.

Pediatric Perspectives on Palliative Care in the Neurocritical Care Unit

Pediatric neurocritical care teams care for patients and families facing the potential for significant neurologic impairment and high mortality. Such admissions are often marked by significant prognostic uncertainty, high levels of parental emotional overload, and multiple potentially life-altering decision points. In addition to clinical acumen, families desire clear and consistent communication, supported decision-making, a multidisciplinary approach to psychosocial supports throughout an admission, and comprehensive bereavement support after a death. Distinct from their adult counterparts, pediatric providers care for a broader set of rare diagnoses with limited prognostic information. Decision-making requires its own ethical framework, with substitutive judgment giving way to the best interest standard as well as "good parent" narratives. When a child dies, bereavement support is often needed for the broader community. There will always be a role for specialist palliative care consultation in the pediatric neurocritical care unit, but the care of every patient and family will be well served by improving these primary palliative care skills.

Psychosocial experiences of clinicians providing care for children with severe neurological impairment

AIM

To investigate clinicians' psychosocial experiences navigating interdisciplinary care for children with severe neurological impairment (SNI), for example children with a developmental epileptic encephalopathy; secondarily, to identify preferences for future interventions to support clinicians caring for children with SNI.

METHOD

We conducted a qualitative descriptive study with interdisciplinary clinicians by using a purposeful sampling recruitment strategy. Twenty-four participants with expertise caring for children with SNI completed in-depth, semi-structured interviews. We transcribed the interviews, de-identified them, and performed inductive thematic analysis.

RESULTS

Thematic analysis elicited interrelated themes. Clinicians experienced immense professional barriers providing patient-centred care across fragmented healthcare contexts. Physical, emotional, and psychological impacts were attributed to inadequate reflective practice training and a paucity of integrated resources to support clinicians over time. Multipronged strategies were prioritized by clinicians, incorporating psychoeducation, interdisciplinary peer mentorship, and psychological resources to build reflective practice skills for clinicians providing complex care in an advancing era of medicine.

INTERPRETATION

This study provides novel and in-depth insight into clinicians' experiences navigating care for children with SNI. The results will be used to inform future integrated and multipronged co-developed resources tailored for clinicians, on the basis of their recommendations.

Providing pediatric neurocritical education across the ages: Bridging of neonatal neurocritical care into pediatric neurocritical care training

Pediatric neurocritical care is a field dedicated to providing specialized assessment and care of critically-ill children with neurologic disease or at risk of neurologic compromise. Fellowship programs for providers interested in specializing in pediatric neurocritical care are growing and developing to meet the needs of trainees and the patient populations that they serve. Fetal and neonatal neurocritical care fellowship remains a separate opportunity for training; however, inclusion of fetal and neonatal neurology education into pediatric neurocritical care broadens understanding of normal and pathologic anatomy and physiology, diagnostic interpretation of the developing brain, targeted management interventions, family counseling and prognostication, and long-term optimization of outcomes. For instance, the care of neurologic injury in congenital heart disease emphasizes the incorporation of medical education across the lifespan. Additionally, neonates requiring NICU admission and care are more likely to require future PICU care and be served by neurocritical care providers. Furthermore, neonates with neurologic injury or at risk for neurologic injury are not exclusively admitted to neonatal units. Education across the age-spectrum inclusive of fetal and neonatal neurology is valuable for trainees in understanding underlying disease processes, management, and sequelae and promotes the growth of the field of pediatric neurocritical care.

Pediatric Neuropalliative Medicine

Neurological disease in childhood has significant impacts on not only physical well-being, but also on the social, environmental, and emotional health of the child, their family, and the larger community. Pediatric neuropalliative medicine is a recently developed area of subspecialty practice that supports families affected by serious neurological illness in navigating uncertain illness trajectories, refractory symptoms, and the myriad medical decisions that arise over the life of the child. Despite their medical needs, children with neurological diseases live full, joyful, and connected lives with their families, many of whom also experience personal growth and find meaning in their caregiving. Patients and families under the care of neurologists also face many systemic and interpersonal biases, both within the health care system and in the community, and encounter frequent gaps in their home and community-based supports. This chapter summarizes what is known about pediatric neuropalliative medicine and highlights the future research, educational, and clinical innovations that are needed to build more comprehensive and well-prepared systems to address unmet needs. Particularly in the modern era of child neurology practice where disease-modifying treatments are becoming increasingly available, pediatric neuropalliative medicine is an essential area of subspecialty practice that helps to support the personhood and quality of life of the individuals affected by serious illness and their families. As medicine helps more and more children with neurological impairment survive, medical treatment must include not only treatment for the physical body, but also care and support for the complexity of human experience of living with serious illness.

Communicating with Parents About Therapeutic Hypothermia and Hypoxic Ischemic Encephalopathy: Integrating a Palliative Care Approach into Practice

Parents of newborns with hypoxic ischemic encephalopathy (HIE) can face communication challenges in the neonatal intensive care unit. Both specialty palliative care and primary palliative care trained clinicians can assist parents as they navigate traumatic experiences and uncertain prognoses. Using evidence-based frameworks, the authors provide samples of how to communicate with parents and promote parent well-being across the care trajectory. The authors demonstrate how to involve parents in a shared decision-making process and give special consideration to the complexities of hospital discharge and the transition home. Sustained investment to guide the development of effective communication skills is crucial to support families of infants with HIE.

Understanding the multidimensional neurodevelopmental outcomes in children after congenital Zika virus exposure

Since 2016, international research groups have focused on assessing outcomes of children with in utero Zika virus (ZIKV) exposure. While the more severe outcomes of congenital Zika syndrome (CZS) occur in up to 10% of children with antenatal exposure, early findings among ZIKV-exposed children without CZS ages 0-5 years suggest that they may also have differences in multiple domains of neurodevelopment. Thus, longitudinal follow-up of all children with antenatal ZIKV exposure has been recommended. This review presents a summary of neurodevelopmental phenotypes of infants and children following antenatal ZIKV exposure. We present a multidimensional framework to understand child neurodevelopment from an interdisciplinary and whole-child perspective (International Classification of Functioning, Disability and Health model) and multi-domain ZIKV Outcome Toolboxes. The toolboxes are for clinicians, researchers, child educators, and others to implement longitudinal multi-domain neurodevelopmental assessments between ages 0-12 years. Recent innovations in telehealth and neuroimaging can help evaluate outcomes in ZIKV exposed children. The objective is to describe the multiple facets of neurodevelopmental focused care that can support the health, function, and well-being of children with antenatal ZIKV exposure. The research and clinical follow-up strategies are applicable to ZIKV and other congenital infectious or environmental exposures that can impact child neurodevelopment. IMPACT: International longitudinal cohort studies have revealed a range of differences in neurodevelopment among children with antenatal Zika virus (ZIKV) exposure. A multidimensional and whole-child framework is necessary to understand the neurodevelopment of children with antenatal ZIKV exposure in relation to family life, community participation, and environment. Multi-domain toolboxes that utilize parent questionnaires and child evaluations are presented. These toolboxes can be used internationally alongside telehealth, brain imaging, and other innovations to improve understanding of child outcomes.

Parental impact during and after neonatal intensive care admission

Parents play a pivotal role in neurodevelopmental outcomes of their children in the neonatal intensive care unit (NICU) and beyond. Integration of parents in clinical care and research is synergistic. Engaged parents yield more comprehensive clinical care and more robust and meaningful research products. Subsequently, successful clinical and research efforts improve outcomes for children. We review strategies for parental integration into NICU clinical care and research, including parental involvement in therapeutic interventions and neurodevelopmental care, and effective communication strategies for clinicians and researchers. We discuss challenges in neonatal trials and emphasize the need for building a culture of research, collaborative partnerships with patient advocacy organizations, and ongoing support beyond the NICU. Overall, we call for recognizing and fostering the impactful role of parents as teammates with clinicians and researchers in optimizing neurodevelopmental outcomes in the NICU and beyond.

Interdisciplinary fetal-neonatal neurology training improves brain health across the lifespan

Integrated fetal, neonatal, and pediatric training constitute an interdisciplinary fetal-neonatal neurology (FNN) program. A dynamic neural exposome concept strengthens curriculum content. Trainees participate in mentoring committee selection for guidance during a proposed two-year program. Prenatal to postnatal clinical learning re-enforces early toxic stressor interplay that influences gene-environment interactions. Maternal-placental-fetal triad, neonatal, or childhood diseases require diagnostic and therapeutic decisions during the first 1,000 days when 80 % of neural connections contribute to life-course phenotypic expression. Pediatric follow-up through 3 years adjusts to gestational ages of preterm survivors. Cumulative reproductive, pregnancy, pediatric and adult exposome effects require educational experiences that emphasize a principle-to-practice approach to a brain capital strategy across the lifespan. More rigorous training during fetal, neonatal, and pediatric rotations will be offered to full time trainees. Adult neurology residents, medical students, and trainees from diverse disciplines will learn essential topics during time-limited rotations. Curriculum content will require periodic re-assessments using educational science standards that maintain competence while promoting creative and collaborative problem-solving. Continued career-long learning by FNN graduates will strengthen shared healthcare decisions by all stakeholders. Recognition of adaptive or maladaptive neuroplasticity mechanisms requires analytic skills that identify phenotypes associated with disease pathways. Developmental origins and life-course concepts emphasize brain health across the developmental-aging continuum, applicable to interdisciplinary research collaborations. Social determinants of health recognize diversity, equity, and inclusion priorities with each neurological intervention, particularly for those challenged with disparities. Diagnostic and therapeutic strategies must address resource challenges particularly throughout the Global South to effectively lower the worldwide burden of neurologic disease. Sustainable development goals proposed by the World Health Organization offer universally applicable guidelines in response to ongoing global and regional polycrises. Gender, race, ethnicity, and socio-economic equality promote effective preventive, rescue and reparative neuroprotective interventions. Global synergistic efforts can be enhanced by establishing leadership within academic teaching hubs in FNN training to assist with structure and guidance for smaller healthcare facilities in each community that will improve practice, education and research objectives. Reduced mortality with an improved quality of life must prioritize maternal-pediatric health and well-being to sustain brain health across each lifespan with transgenerational benefits.

Training in neonatal neurocritical care: A case-based interdisciplinary approach

Interdisciplinary fetal-neonatal neurology (FNN) training strengthens neonatal neurocritical care (NNCC) clinical decisions. Neonatal neurological phenotypes require immediate followed by sustained neuroprotective care path choices through discharge. Serial assessments during neonatal intensive care unit (NICU) rounds are supplemented by family conferences and didactic interactions. These encounters collectively contribute to optimal interventions yielding more accurate outcome predictions. Maternal-placental-fetal (MPF) triad disease pathways influence postnatal medical complications which potentially reduce effective interventions and negatively impact outcome. The science of uncertainty regarding each neonate's clinical status must consider timing and etiologies that are responsible for fetal and neonatal brain disorders. Shared clinical decisions among all stakeholders' balance "fast" (heuristic) and "slow" (analytic) thinking as more information is assessed regarding etiopathogenetic effects that impair the developmental neuroplasticity process. Two case vignettes stress the importance of FNN perspectives during NNCC that integrates this dual cognitive approach. Clinical care paths evaluations are discussed for an encephalopathic extremely preterm and full-term newborn. Recognition of cognitive errors followed by debiasing strategies can improve clinical decisions during NICU care. Re-evaluations with serial assessments of examination, imaging, placental-cord, and metabolic-genetic information improve clinical decisions that maintain accuracy for interventions and outcome predictions. Discharge planning includes shared decisions among all stakeholders when coordinating primary care, pediatric subspecialty, and early intervention participation. Prioritizing social determinants of healthcare during FNN training strengthens equitable career long NNCC clinical practice, education, and research goals. These perspectives contribute to a life course brain health capital strategy that will benefit all persons across each and successive lifespans.

Interdisciplinary fetal neurology care: Current practice, challenges, and future directions

As the field of fetal-neonatal neurology has expanded over the past 2 decades with increasingly complex diagnoses, multidisciplinary collaboration with many subspecialties including genetics, neonatology, obstetrics, maternal fetal medicine, surgical sub-specialties, cardiology, radiology, palliative care, and ethics has needed to evolve to strive to offer optimal patient care. While comprehensive care delivery with an inter-disciplinary approach is preferred, there are often barriers based on numerous health disparities especially in resource limited settings. Even in the context of comprehensive care, diagnostic and prognostic uncertainty lead to challenges for providers during fetal neurology consultations. We present a case that highlights advantages of a comprehensive multi-disciplinary team in caring for the medical and social challenges of patients faced with a fetal neurologic diagnosis. Inter-disciplinary training focusing on maternal, fetal, neonatal, and childhood neurodevelopmental course and collaboration among the numerous stakeholders that contribute to fetal neurology practice is needed to provide optimal counseling and care for families faced with a fetal neurological diagnosis.

The science of uncertainty guides fetal-neonatal neurology principles and practice: diagnostic-prognostic opportunities and challenges

Fetal-neonatal neurologists (FNNs) consider diagnostic, therapeutic, and prognostic decisions strengthened by interdisciplinary collaborations. Bio-social perspectives of the woman's health influence evaluations of maternal-placental-fetal (MPF) triad, neonate, and child. A dual cognitive process integrates "fast thinking-slow thinking" to reach shared decisions that minimize bias and maintain trust. Assessing the science of uncertainty with uncertainties in science improves diagnostic choices across the developmental-aging continuum. Three case vignettes highlight challenges that illustrate this approach. The first maternal-fetal dyad involved a woman who had been recommended to terminate her pregnancy based on an incorrect diagnosis of an encephalocele. A meningocele was subsequently identified when she sought a second opinion with normal outcome for her child. The second vignette involved two pregnancies during which fetal cardiac rhabdomyoma was identified, suggesting tuberous sclerosis complex (TSC). One woman sought an out-of-state termination without confirmation using fetal brain MRI or postmortem examination. The second woman requested pregnancy care with postnatal evaluations. Her adult child experiences challenges associated with TSC sequelae. The third vignette involved a prenatal diagnosis of an open neural tube defect with arthrogryposis multiplex congenita. The family requested prenatal surgical closure of the defect at another institution at their personal expense despite receiving a grave prognosis. The subsequent Management of Myelomeningocele Study (MOMS) would not have recommended this procedure. Their adult child requires medical care for global developmental delay, intractable epilepsy, and autism. These three evaluations involved uncertainties requiring shared clinical decisions among all stakeholders. Falsely negative or misleading positive interpretation of results reduced chances for optimal outcomes. FNN diagnostic skills require an understanding of dynamic gene-environment interactions affecting reproductive followed by pregnancy exposomes that influence the MPF triad health with fetal neuroplasticity consequences. Toxic stressor interplay can impair the neural exposome, expressed as anomalous and/or destructive fetal brain lesions. Functional improvements or permanent sequelae may be expressed across the lifespan. Equitable and compassionate healthcare for women and families require shared decisions that preserve pregnancy health, guided by person-specific racial-ethnic, religious, and bio-social perspectives. Applying developmental origins theory to neurologic principles and practice supports a brain health capital strategy for all persons across each generation.

Family Reflections on a Lifecourse Journey after Neonatal Intensive Care: Neurodiversity, Enablement and Hope

In 1969, my sister Christianne was born late preterm with a genetic disorder and given a very pessimistic prognosis. I will describe, from a family perspective, some lifecourse lessons about neurodiversity using the World Health Organization International Classification Model of Functioning (WHO-ICF). This model emphasizes that, in communicating about the complexity of outcomes of disability, attention must be paid to facilitators and barriers for optimizing health, functioning in daily life, and participation in the community. I will describe several developmental lifecourse lessons learned in negotiating fragmented systems of health, education, and community care. I will suggest ways to improve physician-parent communication, focusing on enablement to decrease a family's sense of isolation and despair. I have benefitted from my parents' archives, discussions with all my seven sisters (including Christianne), and discussions with my brother and sister-in law. They all have provided invaluable feedback from a family perspective during Christianne's lived lifecourse journey with neurodiversity.

Interdisciplinary fetal-neonatal neurology training applies neural exposome perspectives to neurology principles and practice

An interdisciplinary fetal-neonatal neurology (FNN) program over the first 1,000 days teaches perspectives of the neural exposome that are applicable across the life span. This curriculum strengthens neonatal neurocritical care, pediatric, and adult neurology training objectives. Teaching at maternal-pediatric hospital centers optimally merges reproductive, pregnancy, and pediatric approaches to healthcare. Phenotype-genotype expressions of health or disease pathways represent a dynamic neural exposome over developmental time. The science of uncertainty applied to FNN training re-enforces the importance of shared clinical decisions that minimize bias and reduce cognitive errors. Trainees select mentoring committee participants that will maximize their learning experiences. Standardized questions and oral presentations monitor educational progress. Master or doctoral defense preparation and competitive research funding can be goals for specific individuals. FNN principles applied to practice offer an understanding of gene-environment interactions that recognizes the effects of reproductive health on the maternal-placental-fetal triad, neonate, child, and adult. Pre-conception and prenatal adversities potentially diminish life-course brain health. Endogenous and exogenous toxic stressor interplay (TSI) alters the neural exposome through maladaptive developmental neuroplasticity. Developmental disorders and epilepsy are primarily expressed during the first 1,000 days. Communicable and noncommunicable illnesses continue to interact with the neural exposome to express diverse neurologic disorders across the lifespan, particularly during the critical/sensitive time periods of adolescence and reproductive senescence. Anomalous or destructive fetal neuropathologic lesions change clinical expressions across this developmental-aging continuum. An integrated understanding of reproductive, pregnancy, placental, neonatal, childhood, and adult exposome effects offers a life-course perspective of the neural exposome. Exosome research promises improved disease monitoring and drug delivery starting during pregnancy. Developmental origins of health and disease principles applied to FNN practice anticipate neurologic diagnoses with interventions that can benefit successive generations. Addressing health care disparities in the Global South and high-income country medical deserts require constructive dialogue among stakeholders to achieve medical equity. Population health policies require a brain capital strategy that reduces the global burden of neurologic diseases by applying FNN principles and practice. This integrative neurologic care approach will prolong survival with an improved quality of life for persons across the lifespan confronted with neurological disorders.

Prognostic Discordance Among Parents and Physicians Caring for Infants with Neurologic Conditions

OBJECTIVE

To determine the frequency, degree, and nature of prognostic discordance between parents and physicians caring for infants with neurologic conditions.

STUDY DESIGN

In this observational cohort study, we enrolled parents and physicians caring for infants with neurologic conditions in advance of a family conference. Parent-physician dyads completed a postconference survey targeting expected neurologic outcomes across 3 domains (motor, speech, and cognition) using a 6-point scale. Prognostic discordance was defined as a difference of ≥2 response options and was considered moderate (difference of 2-3 response options) or high (difference of 4-5 response options). Responses were categorized as differences in belief and/or differences in understanding using an existing paradigm.

RESULTS

Forty parent-physician dyads of 28 infants completed surveys. Parent-physician discordance about prognosis occurred in ≥1 domain in the majority of dyads (n = 28/40, 70%). Discordance was generally moderate in degree (n = 23/28, 82%) and occurred with similar frequency across all domains. Of parent-physician dyads with discordance, the majority contained a difference in understanding in at least 1 domain (n = 25/28, 89%), while a minority contained a difference of belief (n = 6/28, 21%). When discordance was present, parents were typically more optimistic in their predictions compared with physicians (n = 25/28, 89%).

CONCLUSIONS

Differing perceptions about the prognosis of critically ill infants are common and due to differences in both understanding and belief. These findings can be used to develop targeted interventions to improve prognostic communication.

Neurocognitive Dysfunction After Treatment for Pediatric Brain Tumors: Subtype-Specific Findings and Proposal for Brain Network-Informed Evaluations

The increasing number of long-term survivors of pediatric brain tumors requires us to incorporate the most recent knowledge derived from cognitive neuroscience into their oncological treatment. As the lesion itself, as well as each treatment, can cause specific neural damage, the long-term neurocognitive outcomes are highly complex and challenging to assess. The number of neurocognitive studies in this population grows exponentially worldwide, motivating modern neuroscience to provide guidance in follow-up before, during and after treatment. In this review, we provide an overview of structural and functional brain connectomes and their role in the neuropsychological outcomes of specific brain tumor types. Based on this information, we propose a theoretical neuroscientific framework to apply appropriate neuropsychological and imaging follow-up for future clinical care and rehabilitation trials.