Severity of neonatal retinopathy of prematurity is predictive of neurodevelopmental functional outcome at age 5.5 years. Behalf of the Cryotherapy for Retinopathy of Prematurity Cooperative Group

Retinopathy of prematurity and neurodevelopmental outcome and quality of life at 10 years of age

Objective

In a cohort of 10-year-old children born extremely preterm, we evaluated the hypothesis that increasing severity of retinopathy of prematurity (ROP) is associated with increasing frequency of unfavorable neurodevelopmental and quality of life outcomes.

Study Design

Study participants were classified according to the severity of ROP. At 10 years of age, their neurocognitive abilities, academic achievement, and gross motor function were assessed, and they were evaluated for autism spectrum disorder, anxiety, depression, and quality of life.

Results

After adjustment for sample attrition and confounders, only the association with lower quality of life persisted. Increasing severity of visual impairment was associated with worse neurodevelopmental outcomes and lower quality of life.

Conclusion

Among extremely preterm children, severity of visual impairment, but not severity of ROP, was associated with adverse neurodevelopmental outcomes at 10 years of age. Both severe ROP and more severe visual impairment were associated with lower quality of life.

Visual impairment burden in retinopathy of prematurity: trends, inequalities, and improvement gaps

Retinopathy of prematurity (ROP) is an important cause of avoidable childhood visual impairment, and the increase in number and survival of premature infants may inflate its burden globally. We aimed to comprehensively assess the trends and inequalities in the burden of ROP-related visual impairment and to identify improvement gaps to facilitate appropriate actions in neonatal care systems. We obtained ROP data from the Global Burden of Disease 2019 study. We employed joinpoint regression analysis to assess the trends of the burden of ROP-related visual impairment, measured by age-standardised prevalence rates, health equity analysis methods to evaluate cross-country burden inequalities, and data envelopment and stochastic frontier analyses to identify improvement gaps based on the development status, i.e., sociodemographic index (SDI). Between 1990 and 2019, the age-standardised prevalence rates of ROP-related visual impairment significantly increased worldwide (average annual percentage change: 0.23 [95% confidence interval, 0.21-0.26] among males and 0.26 [0.25-0.27] among females), primarily in developed regions. Although significant SDI-related cross-country inequalities were identified, these reduced over time (slope index of inequality: -57.74 [-66.22 to -49.25] in 1990 to -29.68 [-38.39 to -20.97] in 2019; health concentration index: -0.11 [-0.13 to -0.09] in 1990 to -0.07 [-0.09 to -0.06] in 2019). Notably, some less-developed countries exhibited superior performance despite limited resources, whereas others with a higher SDI delivered lagging performance.  Conclusion: The global burden of ROP-related visual impairment has steadily increased between 1990 and 2019, with disproportionate burden concentration among less-developed countries, requiring appropriate preventive and intervention measures. What is Known: • Retinopathy of prematurity (ROP) is an important cause of avoidable childhood visual impairment. • The prevalence of ROP is anticipated to increase due to the growing number of extremely premature infants. What is New: • The prevalence of ROP-related visual impairment has increased worldwide, primarily in developed regions, with declining but persisting cross-country inequalities. • The increasing burden of ROP-related visual impairment should be considered as part of global and national health agendas, requiring interventions with proven efficacy.

A meta-analysis of adverse effects of retinopathy of prematurity on neurodevelopment in preterm infants

BACKGROUND

Retinopathy of prematurity (ROP) increases with the survival of late preterm infants, but its relationship with neurodevelopmental outcomes in preterm infants remains controversial. To investigate the relationship between ROP and its severity and adverse neurodevelopmental outcomes in preterm infants.

METHODS

We conducted a meta-analysis. All relevant literature before November 2022 were retrieved from PubMed, Embase, Cochrane Library Web of Science, CNKI, CBM, Wan fang Data, and VIP Database. According to the inclusion criteria and exclusion criteria, eligible literature were included to conduct clinical trial quality assessment, and the Newcastle-Ottawa scale was used to evaluate the quality of evidence. Meta-analysis was performed using RevMan5.3. Data extraction, quality assessment, and meta-analysis were performed independently by 2 people. Mean difference or standardized mean difference of motor, language and cognitive scores (Bayley III or Bayley II) were used as effect sizes for continuous data analysis, all of which were represented by 95% CI. For heterogeneity (I2 ≥ 50% or P < .10), a random effects model was used, otherwise a fixed effects model was used.

RESULTS

A total of 6 literature were included. The results of the ROP group for motor (comprehensive motor, proportional motor, and fine motor), language and cognitive scores were -5.57 (95%CI, -1.43 to 0.04), -0.95 (95%CI, 1.4-0.50), -1.34 (95% CI, 1.77-0.92), -1.75 (95% CI, 2.26-1.24) and -5.56 (95% CI, 9.56-1.57). Additionally, the results of severe ROP group for motor (comprehensive motor, proportional motor, fine motor), language and cognitive scores were -8.32 (95%CI, -8.91 to 7.74), -1.10 (95%CI, -1.83 to -0.36), -1.08 (95%CI, -1.75 to -0.41), -7.03 (95%CI, -7.71 to 6.35), and -7.96 (95%CI, -8.5 to -7.42).

CONCLUSIONS

The Bayley Scale scores of the ROP group were lower than those of the not ROP group, and the scores of the severe ROP were significantly lower than those of the not severe ROP group. These findings suggest that ROP can indeed delay motor, language and cognitive, especially in severe cases.

Relationships between retinopathy of prematurity without ophthalmologic intervention and neurodevelopment and vision at 2 years

BACKGROUND

Severe retinopathy of prematurity (ROP) is associated with adverse outcomes. Relationships between milder ROP and outcomes have not been defined. We hypothesized that children with ROP stage ≤3 who did not receive ophthalmologic intervention would have worse motor, cognitive, and language skills and more vision abnormalities than children without ROP.

METHODS

This was a secondary analysis of a randomized trial evaluating the effects of myo-inositol on ROP in the NICHD Neonatal Research Network. Primary outcomes were Bayley Scales of Infant Development composite scores; secondary outcomes included behavioral difficulties and ophthalmologic measures. Outcomes were compared using adjusted linear or modified Poisson models.

RESULTS

Of 506 children, 173 (34%) had no ROP, 262 (52%) had ROP stage ≤3 without intervention, and 71 (14%) had ROP with intervention. There was no difference in motor, cognitive, or language scores between children with ROP stage ≤3 without intervention and children without ROP. Children with ROP stage ≤3 without intervention had a higher rate of strabismus compared to children without ROP (p = 0.040).

CONCLUSION

Children with ROP stage ≤3 without intervention did not have adverse neurodevelopmental outcomes at 2 years' corrected age compared to children without ROP but did have an increased incidence of strabismus.

IMPACT

This study addresses a gap in the literature regarding the relationship between milder forms of retinopathy of prematurity (ROP) that regress without intervention and neurodevelopment and vision outcomes. Children with a history of ROP stage ≤3 without intervention have similar neurodevelopmental outcomes at 2 years' corrected age as children born extremely preterm without a history of ROP and better outcomes than children with a history of ROP with ophthalmologic intervention. Counseling about likely neurodevelopment and vision outcomes for children born extremely preterm with a history of ROP may be tailored based on the severity of ROP.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov ID: Inositol to Reduce Retinopathy of Prematurity Trial: NCT01954082.

Smartphone application links severity of retinopathy of prematurity to early motor behavior in a cohort of high-risk preterm infants

PURPOSE

To evaluate the General Movement Assessment (GMA) with the Motor Optimality Score-Revised (MOS-R) as a neurodevelopmental marker in infants with retinopathy of prematurity (ROP).

METHODS

Infants screened prospectively for ROP were evaluated at 3 months' post-term age using a smartphone application to complete the GMA and MOS-R. Results were analyzed by ROP severity.

RESULTS

Of 105 enrolled infants, 83 completed the study. Of these, 54 (65%) had any ROP, 32 (39%) had severe ROP, and 13 (16%) had type 1 ROP. The proportion with aberrant GMA was significantly higher in infants with severe ROP (14/32 [44%]) compared with infants who had milder ROP (8/51 [16%]; P = 0.006). Of those with severe ROP, there was no significant difference comparing infants with type 1 ROP treated with bevacizumab (7/13 [54%]) to infants with type 2 ROP without treatment (7/19 [37%]; P = 0.47). Although the presence of any ROP, stage of ROP, and severe ROP each predicted lower MOS-R scores on univariate analyses, only severe bronchopulmonary dysplasia and markers of brain injury remained significant in the multivariate analysis.

CONCLUSIONS

The GMA was a convenient, short-term method of data collection with low attrition. Although severe ROP initially appeared linked to poor early motor scores, this association is likely confounded by neurological and respiratory complications, which frequently accompany severe ROP.

Retinopathy of prematurity and neurodevelopmental outcomes in preterm infants: A systematic review and meta-analysis

Background

Retinopathy of prematurity (ROP) and abnormal brain development share similar risk factors and mechanisms. There has been contrasting evidence on the association of ROP with adverse neurodevelopmental outcomes.

Objective

We analysed the association between ROP at levels of severity and treatment with all neurodevelopmental outcomes until adolescence.

Data source

We followed PRISMA guidelines and searched Medline and Embase between 1 August 1990 and 31 March 2022.

Study selection and participants

Randomised or quasi-randomised clinical trials and observational studies on preterm infants (<37 weeks) with ROP [type 1 or severe ROP, type 2 or milder ROP, laser or anti-vascular endothelial growth factor (VEGF) treated] were included.

Data extraction and synthesis

We included studies on ROP and any neurocognitive or neuropsychiatric outcomes.

Outcomes

The primary outcomes were as follows: cognitive composite scores evaluated between the ages of 18 and 48 months by the Bayley Scales of Infant and Toddler Development (BSID) or equivalent; neurodevelopmental impairment (NDI; moderate to severe NDI or severe NDI), cerebral palsy, cognitive impairment; and neuropsychiatric or behavioural problems. The secondary outcomes were as follows: motor and language composite scores evaluated between the ages of 18 and 48 months by BSID or equivalent; motor/language impairment; and moderate/severe NDI as defined by the authors.

Results

In preterm infants, "any ROP" was associated with an increased risk of cognitive impairment or intellectual disability [n = 83,506; odds ratio (OR): 2.56; 95% CI: 1.40-4.69; p = 0.002], cerebral palsy (n = 3,706; OR: 2.26; 95% CI: 1.72-2.96; p < 0.001), behavioural problems (n = 81,439; OR: 2.45; 95% CI: 1.03-5.83; p = 0.04), or NDI as defined by authors (n = 1,930; OR: 3.83; 95% CI: 1.61-9.12; p = 0.002). Type 1 or severe ROP increased the risk of cerebral palsy (OR: 2.19; 95% CI: 1.23-3.88; p = 0.07), cognitive impairment or intellectual disability (n = 5,167; OR: 3.56; 95% CI: 2.6-4.86; p < 0.001), and behavioural problems (n = 5,500; OR: 2.76; 95% CI: 2.11-3.60; p < 0.001) more than type 2 ROP at 18-24 months. Infants treated with anti-VEGF had higher odds of moderate cognitive impairment than the laser surgery group if adjusted data (gestational age, sex severe intraventricular haemorrhage, bronchopulmonary dysplasia, sepsis, surgical necrotising enterocolitis, and maternal education) were analysed [adjusted OR (aOR): 1.93; 95% CI: 1.23-3.03; p = 0.04], but not for cerebral palsy (aOR: 1.29; 95% CI: 0.65-2.56; p = 0.45). All outcomes were adjudged with a "very low" certainty of evidence.

Conclusion and relevance

Infants with "any ROP" had higher risks of cognitive impairment or intellectual disability, cerebral palsy, and behavioural problems. Anti-VEGF treatment increased the risk of moderate cognitive impairment. These results support the association of ROP and anti-VEGF treatment with adverse neurodevelopmental outcomes.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42022326009.

Association Between Retinopathy of Prematurity in Very-Low-Birth-Weight Infants and Neurodevelopmental Impairment

PURPOSE

To evaluate the impact of retinopathy of prematurity (ROP) severity and the treatment of very-low-birth-weight infants (VLBWIs) on neurodevelopmental impairment in early childhood.

DESIGN

Prospective cohort study.

METHOD

This was a prospective cohort study. The data were obtained from the Korean Neonatal Network (KNN), a nationwide registry for VLBWIs. Infants who were born from 2013 to 2015 and underwent ROP evaluation at birth and neurodevelopmental examinations at corrected ages of 18 to 24 months were included in the study. Infants with a history of meningitis or severe congenital anomalies were excluded. The VLBWI patients were grouped into no ROP, no treatment-requiring ROP (non-TR-ROP), and treatment-requiring ROP (TR-ROP) groups. Neurodevelopmental impairment was defined as participants who had at least 1 developmental problem according to the Bayley Scales of Infant and Toddler Development-2nd Edition (Bayley-II; <70), Bayley Scales of Infant and Toddler Development-3rd Edition (Bayley-III; <70), and Korean Developmental Screening Test (K-DST) tests (below -1 SD), and the Korean Ages and Stages Questionnaire (K-ASQ) (below the threshold) and Gross Motor Function Classification System (GMFCS; at level 2 or above). Multivariable logistic regression analysis was performed to evaluate the association between ROP and neurodevelopmental impairment.

RESULT

Among 3132 infants, 1093 (34.9%) had ROP. Among the ROP infants, 644 were not treated for ROP (non-TR-ROP group) and 449 received ROP treatments (TR-ROP group). The patients in the TR-ROP group had an increased risk of developing neurodevelopmental problems compared to those in the no ROP group (odds ratio [OR] = 1.72, 95% CI = 1.33-2.21). The TR-ROP group had a higher risk of all 3 types of neurodevelopmental problems: mental (OR = 1.62, 95% CI = 1.25-2.09), social (OR = 1.62, 95% CI = 1.12-2.09), and motor (OR = 1.69, 95% CI = 1.31-2.18). The risk of neurodevelopmental problems in patients treated with laser therapy did not differ from that in patients treated with anti-vascular endothelial growth factor (anti-VEGF) therapy (OR = 1.17, 95% CI = 0.73-1.88).

CONCLUSION

ROP was independently associated with neurodevelopmental impairment in early childhood. The type of ROP treatment (anti-VEGF or laser treatment) did not affect neurodevelopmental impairment in patients in the TR-ROP group.

Association of prematurity with complications and failure to rescue in neonatal surgery

BACKGROUND

The majority of failure to rescue (FTR), or death after a postoperative complication, in pediatric surgery occurs among infants and neonates. The purpose of this study is to evaluate the association between gestational age (GA) and FTR in infants and neonates.

METHODS

National cohort study of 46,452 patients < 1 year old within the National Surgical Quality Improvement Program-Pediatric database who underwent inpatient surgery. Patients were categorized as preterm neonates, term neonates, or infants. Neonates were stratified based on GA. Surgical procedures were classified as low- (< 1% mortality) or high-risk (≥ 1%). Multivariable logistic regression and cubic splines were used to evaluate the association between GA and FTR.

RESULTS

Preterm neonates had the highest FTR (28%) rates. Among neonates, FTR increased with decreasing GA (≥ 37 weeks, 12%; 33-36 weeks, 15%; 29-32 weeks, 30%; 25-28 weeks 41%; ≤ 24 weeks, 57%). For both low- and high-risk procedures, FTR significantly (trend test, p < 0.01) increased with decreasing GA. When stratifying preterm neonates by GA, all GAs ≤ 28 weeks were associated with significantly higher odds of FTR for low- (OR 2.47, 95% CI [1.38-4.41]) and high-risk (OR 2.27, 95% CI [1.33-3.87]) procedures. A lone inflection point for FTR was identified at 31-32 weeks with cubic spline analysis.

CONCLUSIONS

The dose-dependent relationship between decreasing GA and FTR as well as the FTR inflection point noted at GA 31-32 weeks can be used by stakeholders in designing quality improvement initiatives and directing perioperative care.

LEVEL OF EVIDENCE

Level IV, Retrospective cohort study.

Neurosensory Alterations in Retinopathy of Prematurity: A Window to Neurological Impairments Associated to Preterm Birth

Retinopathy of prematurity (ROP) is one of the main blinding diseases affecting preterm newborns and is classically considered a vascular disorder. The premature exposure to the extrauterine environment, which is hyperoxic in respect to the intrauterine environment, triggers a cascade of events leading to retinal ischemia which, in turn, makes the retina hypoxic thus setting off angiogenic processes. However, many children with a history of ROP show persistent vision impairment, and there is evidence of an association between ROP and neurosensory disabilities. This is not surprising given the strict relationship between neuronal function and an adequate blood supply. In the present work, we revised literature data evidencing to what extent ROP can be considered a neurodegenerative disease, also taking advantage from data obtained in preclinical models of ROP. The involvement of different retinal cell populations in triggering the neuronal damage in ROP was described along with the neurological outcomes associated to ROP. The situation of ROP in Italy was assessed as well.

Neurodevelopmental Outcomes Associated With Intravitreal Bevacizumab Injections for Retinopathy of Prematurity

BACKGROUND

Retinopathy of prematurity (ROP) is a common disorder among premature infants associated with significant morbidity. The current standard of care includes laser ablation therapy when needed. While intravitreal bevacizumab (IVB) injections have emerged as a new therapy for ROP, so have concerns about the systemic effects of the bevacizumab (Avastin), specifically on neurodevelopmental outcomes.

PURPOSE

To review the current literature on the impact of IVB on neurodevelopmental outcomes in neonates with ROP to inform nurses' knowledge and practice.

METHODS

A literature search was performed in the PubMed, CINAHL, and Embase databases. Eleven primary studies examining neurodevelopmental outcomes related to IVB were identified and reviewed.

RESULTS

Limitations of current studies, including small sample sizes, retrospective analysis subject to selection bias, and confounding factors such as sedation/anesthesia exposure, prevent robust conclusions from being drawn. However, there is not currently any clear evidence of negative neurodevelopmental impacts associated with IVB despite a sound theoretical basis for concern.

IMPLICATIONS FOR PRACTICE

Nurses should include all known and potential risks and benefits when counseling families and developing individualized plans of care for their neonatal patients with ROP.

IMPLICATIONS FOR RESEARCH

Well-designed, prospective studies examining neurodevelopmental outcomes at later time points are needed to conclusively support or disprove results of IVB therapy for ROP in the context of potential adverse effects.

Neurodevelopmental outcomes in very low birthweight infants with retinopathy of prematurity in a nationwide cohort study

In a nationwide prospective cohort of Korean infants with very low birthweights (VLBW, birth weight < 1500 g) from 70 neonatal intensive care units of the Korean Neonatal Network, we investigated neurodevelopmental outcomes in preterm infants with retinopathy of prematurity (ROP) from 2132 infants with VLBW who had undergone developmental assessments at 18–24 months of corrected age. Motor, cognitive, or language delay was determined using developmental scores that were less than 1 standard deviation from the average. Comparative analyses and multivariate regression analyses were performed to validate the association between ROP or its treatment and developmental delay. Motor (52.8% vs. 36.3%), cognitive (46.8% vs. 31.6%), and language delays (42.5% vs. 28.4%) were noted more frequently in infants with ROP than in those without ROP; this was statistically significant (all P < 0.001). Multivariate analyses showed that motor and cognitive delays were significantly associated with ROP. There were no remarkable differences between the neurodevelopmental outcomes and the treatment modalities (laser photocoagulation, anti-vascular endothelial growth factor injection, or both) for ROP, and both stratification and multivariate regression analyses confirmed no significant association between anti-vascular endothelial growth factor therapy and neurodevelopmental delay. As ROP is significantly associated with poor neurodevelopmental outcomes independent of extreme prematurity, neurodevelopmental functions should be given attention in infants with ROP.

Severe Retinopathy of Prematurity Associated With Neurodevelopmental Disorder in Children

OBJECTIVE

This study aimed to investigate whether severe retinopathy of prematurity (ROP) could be an association factor for neurodevelopmental disorders in premature infants without other risk factors-such as congenital anomalies, birth injuries, and neurological diseases-that may cause developmental delay.

METHODS

We used health claims data recorded between 2007 and 2018 in the Korean National Health Insurance Service (KNHIS) database. We recruited a total of 18,256 premature infant born between 2007 and 2008 without congenital anomaly or birth injury (with ROP 6,995, without ROP 11,261) and divided them into four groups as follows: Group A, 209 extremely premature infants [gestational age (GA) < 28] with mild ROP; Group B, 75 extremely premature infants (GA < 28) with severe ROP; Group C, 6,510 other premature infants (28 ≤ GA <37)with mild ROP; and Group D, 201 other premature infants (28 ≤ GA < 37) with severe ROP. Using regression analysis, we analyzed whether there was a correlation between ROP prevalence, severity, and developmental delay in premature infants without other risk factors.

RESULTS

The prevalence of developmental delay, according to GA and ROP severity, was higher in patients with severe ROP than in the other patients. The prevalence gradually decreased after birth. Among extremely premature infants with ROP, those with severe ROP had a 3.082-fold higher association with neurodevelopmental complications than those with mild ROP (p < 0.001). Compared with other premature infants with ROP, those with severe ROP had a 3.269-fold higher association with neurodevelopmental complications than those with mild ROP.

CONCLUSION

The severity of ROP may be associated with neurodevelopmental disorders in premature infants.

Neurodevelopmental outcomes in preterm infants with retinopathy of prematurity

Over the past decade there has been a paradigm shift in the treatment of retinopathy of prematurity (ROP) with the introduction of antivascular endothelial growth factor (anti-VEGF) treatments. Anti-VEGF agents have the advantages of being easier to administer, requiring less anesthesia, having the potential for improved peripheral vision, and producing less refractive error than laser treatment. On the other hand, it is known that intravitreal administration of anti-VEGF agents lowers VEGF levels in the blood and raises the theoretical concern of intraocular anti-VEGF causing deleterious effects in other organ systems, including the brain. As a result, there has been increased attention recently on neurodevelopmental outcomes in infants treated with anti-VEGF agents. These studies should be put into context with what is known about systemic comorbidities, socioeconomic influences, and the effects of extreme prematurity itself on neurodevelopmental outcomes. We summarize what is known about neurodevelopmental outcomes in extremely preterm infants with ROP, discuss the implications for determining the neurodevelopmental status using neurodevelopmental testing as well as other indicators, and review the existing literature relating to neurodevelopmental outcomes in babies treated for ROP.

Neurodevelopmental outcomes following bevacizumab treatment for retinopathy of prematurity: a systematic review and meta-analysis

OBJECTIVE

To systematically review the studies exploring the association between bevacizumab and neurodevelopmental outcomes.

METHODS

Embase, Medline, CINAHL, and Cochrane Library databases were searched for studies examining neurodevelopmental outcomes of preterm infants treated with bevacizumab compared to laser ablation or cryotherapy for severe retinopathy of prematurity (ROP).

RESULTS

Thirteen studies (clinical trial = 1; cohort studies = 12) were included. Random-effects model meta-analysis showed significant increased odds of cognitive impairment associated with bevacizumab treatment on both unadjusted (unadjusted odds ratio (OR) 1.61; 95% confidence interval (CI) 1.12, 2.30) and adjusted analyses (adjusted OR 1.90; 95% CI 1.22, 2.97). Infants treated with bevacizumab for severe ROP had significantly lower Bayley-III cognitive (mean difference (MD) -1.66; 95% CI -3.21, -0.12), and language composite scores (MD -5.50; 95% CI -8.24, -2.76) compared to infants treated with laser ablation or cryotherapy.

CONCLUSION

Bevacizumab treatment for severe ROP is associated with increased risk of cognitive impairment and lower cognitive and language scores in preterm infants.

Perinatal Risk and Protective Factors in the Development of Diffuse White Matter Abnormality on Term-Equivalent Age Magnetic Resonance Imaging in Infants Born Very Preterm

OBJECTIVE

To identify perinatal clinical diseases and treatments that are associated with the development of objectively diagnosed diffuse white matter abnormality (DWMA) on structural magnetic resonance imaging (MRI) at term-equivalent age in infants born very preterm.

STUDY DESIGN

A prospective cohort of 392 infants born very preterm (≤32 weeks of gestational age) was enrolled from 5 level III/IV neonatal intensive care units between September 2016 and November 2019. MRIs of the brain were collected at 39 to 45 weeks of postmenstrual age to evaluate DWMA volume. A predefined list of pertinent maternal characteristics, pregnancy/delivery data, and neonatal intensive care unit data were collected for enrolled patients to identify antecedents of objectively diagnosed DWMA.

RESULTS

Of the 392 infants in the cohort, 377 (96%) had high-quality MRI data. Their mean (SD) gestational age was 29.3 (2.5) weeks. In multivariable linear regression analyses, pneumothorax (P = .027), severe bronchopulmonary dysplasia (BPD) (P = .009), severe retinopathy of prematurity (P < .001), and male sex (P = .041) were associated with increasing volume of DWMA. The following factors were associated with decreased risk of DWMA: postnatal dexamethasone therapy for severe BPD (P = .004), duration of caffeine therapy for severe BPD (P = .009), and exclusive maternal milk diet at neonatal intensive care unit discharge (P = .049).

CONCLUSIONS

Severe retinopathy of prematurity and BPD exhibited the strongest adverse association with development of DWMA. We also identified treatments and nutritional factors that appear protective against the development of DWMA that also have implications for the clinical care of infants born very preterm.

Analysis of Brain Injury Biomarker Neurofilament Light and Neurodevelopmental Outcomes and Retinopathy of Prematurity Among Preterm Infants

IMPORTANCE

Circulating levels of neurofilament light (NfL) and glial fibrillary acidic protein (GFAP) are important in the course of brain injury in adults, but longitudinal postnatal circulating levels in preterm infants have not been investigated.

OBJECTIVES

To examine postnatal longitudinal serum levels of NfL and GFAP in preterm infants during the first 15 weeks of life and to explore possible associations between these biomarkers, neonatal morbidities, and neurodevelopmental outcomes at 2 years.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from 3 clinical studies, including 221 infants born before 32 weeks gestational age (GA) from 1999 to 2015; neurodevelopmental outcomes were evaluated in 120 infants. Data were collected at tertiary-level neonatal intensive care units in Gothenburg, Lund, and Uppsala, Sweden. Data analysis was conducted from January to October 2020.

EXPOSURE

Preterm birth.

MAIN OUTCOMES AND MEASURES

Serum NfL and GFAP levels, retinopathy of prematurity (ROP), intraventricular hemorrhage, and Bayley Scales of Infant Development II and III at 2 years of age, analyzed by multivariate logistic regression measured by odds ratio (OR), and receiver operating characteristic curve (ROC) analysis. Area under the curve (AUC) was also measured.

RESULTS

The 221 included infants (108 [48.9%] girls) had a mean (SD) GA at birth of 26.5 (2.1) weeks and a mean (SD) birth weight of 896 (301) grams. NfL levels increased after birth, remaining high during the first 4 weeks of life before declining to continuously low levels by postnatal age 12 weeks (median [range] NfL level at birth: 58.8 [11.5-1371.3] ng/L; 1 wk: 83.5 [14.1-952.2] ng/L; 4 wk: 24.4 [7.0-306.0] ng/L; 12 wk: 9.1 [3.7-57.0] ng/L). In a binary logistic regression model adjusted for GA at birth, birth weight SD score, Apgar status at 5 minutes, and mode of delivery, the NfL AUC at weeks 2 to 4 was independently associated with any ROP (OR, 4.79; 95% CI, 2.17-10.56; P < .001). In an exploratory analysis adjusted for GA at birth and sex, NfL AUC at weeks 2 to 4 was independently associated with unfavorable neurodevelopmental outcomes at 2 years corrected age (OR per 10-unit NfL increase, 1.07; 95% CI, 1.02-1.13; P = .01). Longitudinal GFAP levels were not significantly associated with neonatal morbidity or neurodevelopmental outcome.

CONCLUSIONS AND RELEVANCE

In this study, high NfL levels during the first weeks of life were associated with ROP and poor neurodevelopmental outcomes at 2 years of age. Associations between NfL and later neurovascular development in infants born prematurely should be investigated further.

Brain White Matter Maturation and Early Developmental Outcomes in Preterm Infants With Retinopathy of Prematurity

Purpose

To investigate brain white matter pathways using magnetic resonance diffusion tensor imaging (DTI) and correlate the findings with developmental outcomes at 18 months of corrected age in preterm infants with and without retinopathy of prematurity (ROP).

Methods

In this prospective cohort study, probabilistic maps of the 26 white matter pathways associated with motor, cognitive, visual, and limbic/language functions were generated in 84 preterm infants using DTI obtained at term-equivalent age. The mean fractional anisotropy (FA) and mean diffusivity (MD) values were compared between those with and without ROP. Developmental outcomes were assessed using the third edition of Bayley Scales of Infant and Toddler Development (BSID-III) at 18 months of corrected age. Multiple regression analyses were performed to confirm the association among developmental outcomes, white matter pathways, and ROP or severe ROP after adjusting for potential confounders.

Results

The white matter pathways were insignificantly associated with ROP or severe ROP. There were no significant differences in the FA and MD values of the pathways between ROP infants treated with and without bevacizumab therapy. Furthermore, there were no significant differences in BSID-III scores between infants with and without ROP or severe ROP. The BSID-III scores at 18 months of age showed a significant association with FA or MD values in several pathways.

Conclusions

ROP or severe ROP was insignificantly associated with maturation delay of the white matter pathways. Developmental outcomes were similar between preterm infants with and without ROP or severe ROP or between ROP infants with and without intravitreal bevacizumab therapy.

Strategies to Prevent Severe Retinopathy of Prematurity: A 2020 Update and Meta-analysis

The incidence of retinopathy of prematurity (ROP) is showing an increasing trend in the United States. This may be because of increasing survival rates among extremely preterm infants (<25 weeks' gestation) and targeting higher oxygen saturation. Five randomized clinical trials of low versus high oxygen saturation target ranges found increased mortality in the low oxygen saturation target group and an increased incidence of ROP in the high oxygen saturation target group. The American Academy of Pediatrics recommends using an oxygen saturation target range of 90% to 95% in extremely low-birthweight infants. The change of practice to target this higher oxygen saturation range, from admission until discharge, may be contributing to the increasing incidence of ROP in extremely preterm infants. To decrease the incidence of ROP without increasing mortality, 2 new cohort trials suggest gradually increasing oxygen saturation targets as preterm infants mature. There is evidence that human milk, vitamin A, and omega-3 fatty acids can help, in addition to continuous oxygen saturation monitoring, to decrease the risk of ROP. We review this literature and provide a meta-analysis to evaluate the evidence.

Early visual and neuro-development in preterm infants with and without retinopathy

BACKGROUND

Retinopathy of prematurity (ROP) is often associated with visual impairment and multiple developmental disabilities.

AIMS

As most of the previous studies include infants with brain lesions, that can determine visual impairment per se, a cohort of low neurological risk preterm infants without ROP and with various degree of severity of ROP was assessed in order to establish visual and neurodevelopmental outcome.

STUDY DESIGN

Preterm infants born at <31 weeks gestation, without major brain lesions, underwent visual function assessment at 1 year corrected age and neurodevelopmental assessment at 2 years corrected age.

SUBJECTS

One hundred and five infants were included in the study: 42 infants did not develop ROP, 7 reached stage 1 in zone 2 ROP, 37 reached prethreshold (untreated) type 2 ROP. The remaining 19 infants were classified as type 1 ROP.

OUTCOME MEASURES

Visual function (including fixing, tracking, visual acuity, visual field, attention at distance and nystagmus) were assessed at 12 months corrected age and Griffiths Scales at 2 years corrected age.

RESULTS

The severity of ROP was strongly correlated (p < 0.001) with both visual function at 1 year and neurodevelopment at 2 years. Similarly, the presence of nystagmus was also strongly correlated with visual and neurodevelopmental sequelae.

CONCLUSIONS

Infants with no or milder retinopathy showed normal visual function at 1 year and neurodevelopment at 2 years. Infants who underwent treatment more frequently showed abnormal results on several aspects of visual function. Presence of nystagmus appeared to increase the risk for abnormal visual function and neurodevelopmental outcome.

Neurodevelopmental Outcomes Comparing Bevacizumab to Laser for Type 1 ROP

BACKGROUND AND OBJECTIVE

To evaluate neurodevelopmental outcomes among infants treated for retinopathy of prematurity (ROP) at the authors' institution.

PATIENTS AND METHODS

Before-and-after retrospective chart reviews identified 40 infants treated with laser and 46 treated with primary intravitreal bevacizumab (IVB). Primary outcomes were death, hearing loss, bilateral visual impairment (BVI), and cerebral palsy (CP); odds ratios (ORs) were calculated to determine factors associated with CP. Secondary outcomes were mean Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III) scores.

RESULTS

Overall, there were no significant differences in primary outcome measures by treatment group. However, adjusted odds of BVI were significantly higher with laser compared to IVB (OR = 13.1; P = .038). Although IVB was not associated with CP, both hydrocephalus and BVI were strongly correlated with CP. Mean Bayley-III scores were similar when comparing nine laser-treated infants to 13 IVB-treated infants.

CONCLUSIONS

Visual outcomes are an important aspect of neurodevelopment. IVB was not associated with severe developmental disabilities and may protect against vision loss in this analysis. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:337-343.].

Retinopathy of prematurity, visual and neurodevelopmental outcome, and imaging of the central nervous system

Recent findings indicate that retinopathy of prematurity (ROP), presently classified by clinical examinations of retinal vascular tissue, is associated with structural alterations of the central nervous system. Such alterations may be the correlate of the association between ROP and impaired long-term neurocognitive and visual development. The advent of imaging techniques such as structural and diffusion tensor magnetic resonance imaging of the brain, and optical coherence tomography of the retina, will allow the complete visual system to be characterized in greater detail. It has been suggested that ROP may be not only a vascular, but a neurovascular disease, being part of a spectrum that includes pathological development in both the retinal and cerebral neurovascular interphase. We review the present knowledge in the field and point to future directions for research to tackle these questions.

Assessment of public oral healthcare services in Curitiba, Brazil: a cross-sectional study using the Primary Care Assessment Tool (PCATool)

OBJECTIVES

To compare two different models of public oral health in primary care services, a so-called family health strategy (FHS), as opposed to non-FHS services designated as 'conventional' healthcare (CHC), regarding the presence and extent of the attributes of 'good' primary healthcare (PHC). The null hypothesis of this study is that the attributes do not differ between the FHS and CHC.

DESIGN

Cross-sectional.

SETTING

Public PHC services in Curitiba, the state capital of Paraná.

PARTICIPANTS

PHC users of the public oral health network (n=900) and dentists active in this municipal network (n=203).

PRIMARY AND SECONDARY OUTCOME MEASURES

The Primary Care Assessment Tool (PCATool)-Dentists and PCATool-Users were used to analyse the primary outcomes ('essential' attributes) and secondary outcomes ('derived' attributes) in the PHC.

RESULTS

Overall, the primary care services in oral health were well evaluated, both by users and by dentists, with mean scores ascribed to PHC attributes mostly above the cut-off point (6.6). The exception for users were affiliation (6.36; 95% CI 6.11 to 6.60) and accessibility (5.83; 95% CI 5.78 to 5.89); and for dentists the accessibility (5.80; 95% CI 5.63 to 5.96). When comparing FHS and CHC, there was a superiority of the FHS model, which reached a general mean score of 7.53 (95% CI 7.48 to 7.58) among users and 7.56 (95% CI 7.45 to 7.67) among dentists; on the other hand, the CHC general mean score was of 6.61 (95% CI 6.49 to 6.73) and 6.68 (95% CI 6.56 to 6.80) respectively for users and dentists.

CONCLUSIONS

The results reveal a reasonable level of attainment of PHC attributes in the services investigated. Nevertheless, public health managers should make efforts to reduce the difficulties faced by users in accessing dental care. The more positive results achieved by FHS services indicate that the provision of oral healthcare under this strategy should be expanded.

Impact of major neonatal morbidities on adolescents born at 23-25 weeks of gestation

AIM

More infants born extremely preterm (EPT) are surviving, but major neonatal morbidities are consistently high. This study examined the impact of bronchopulmonary dysplasia (BPD), brain injuries and severe retinopathy of prematurity (ROP) on adolescents who were born EPT.

METHODS

We focused on EPT infants born at 23-25 weeks at the Swedish university hospitals in Uppsala and Umeå from January 1992 to December 1998. The poor outcome data covered 140 of 142 who survived to 36 weeks, and the chronic conditions data reported by parents covered 132 of 134 still alive at 10-15 years.

RESULTS

Of the 140 survivors at 36 weeks, 29 (21%) had poor outcomes: eight of 140 (6%) died, and 21 of 132 (16%) adolescent survivors had severe neurodevelopmental disabilities (NDD). BPD, severe ROP and/or brain injuries correlated independently with poor outcome. Of those adolescents who were free from BPD, brain injury and severe ROP, 6% had a severe NDD. The corresponding rates with any one, any two or all three neonatal morbidities were 21, 33 and 67%, respectively. BPD and brain injuries were associated with high rates of chronic conditions at 10-15 years of age resulting in functional limitations.

CONCLUSION

In adolescent EPT survivors, BPD and brain injuries were associated with high rates of chronic conditions and special healthcare needs.

Neurobehavioral Outcomes 11 Years After Neonatal Caffeine Therapy for Apnea of Prematurity

BACKGROUND AND OBJECTIVES

Caffeine is effective in the treatment of apnea of prematurity. Although caffeine therapy has a benefit on gross motor skills in school-aged children, effects on neurobehavioral outcomes are not fully understood. We aimed to investigate effects of neonatal caffeine therapy in very low birth weight (500-1250 g) infants on neurobehavioral outcomes in 11-year-old participants of the Caffeine for Apnea of Prematurity trial.

METHODS

Thirteen academic hospitals in Canada, Australia, Great Britain, and Sweden participated in this part of the 11-year follow-up of the double-blind, randomized, placebo-controlled trial. Measures of general intelligence, attention, executive function, visuomotor integration and perception, and behavior were obtained in up to 870 children. The effects of caffeine therapy were assessed by using regression models.

RESULTS

Neurobehavioral outcomes were generally similar for both the caffeine and placebo group. The caffeine group performed better than the placebo group in fine motor coordination (mean difference [MD] = 2.9; 95% confidence interval [CI]: 0.7 to 5.1; P = .01), visuomotor integration (MD = 1.8; 95% CI: 0.0 to 3.7; P < .05), visual perception (MD = 2.0; 95% CI: 0.3 to 3.8; P = .02), and visuospatial organization (MD = 1.2; 95% CI: 0.4 to 2.0; P = .003).

CONCLUSIONS

Neonatal caffeine therapy for apnea of prematurity improved visuomotor, visuoperceptual, and visuospatial abilities at age 11 years. General intelligence, attention, and behavior were not adversely affected by caffeine, which highlights the long-term safety of caffeine therapy for apnea of prematurity in very low birth weight neonates.

Association between cognition and the retinal microvasculature in 11-year old children born preterm or at term

BACKGROUND

Retinal microvessels can be visualized non-invasively and mirror the status of the cerebral microvasculature.

AIMS

To investigate whether in young children born prematurely or at term cognitive performance is related to retinal microvascular traits.

STUDY DESIGN, SUBJECTS

In 93 prematurely born infants (birth weight < 1000 g) and 87 controls born at term, we measured head circumference (HC) and determined intelligence quotient (IQ) by combining matrix reasoning and spatial span (Wechsler Non-Verbal test, Dutch version) and post-processed retinal photographs using Singapore I Vessel Assessment software (version 3.6).

OUTCOME MEASURES, RESULTS

Compared with controls, cases had smaller HC (51.7 vs 53.4 cm; p < 0.001), lower IQ (93.9 vs 109.2; p < 0.001), smaller retinal arteriolar (CRAE; 162.7 vs 174.0 μm; p < 0.001) and venular (CRVE; 234.9 vs 242.8 μm; p = 0.003) diameters and CRAE/CRVE ratio (0.69 vs 0.72; p = 0.001). A 1-SD decrease in CRAE was associated with smaller HC (-0.53 cm; p < 0.001) and lower total IQ (-3.74; p < 0.001), matrix reasoning (-1.77; p = 0.004) and spatial span (-2.03; p = 0.002). These associations persisted after adjustment for sex and age and risk factors for cognitive impairment, including blood pressure, body mass index and parental educational attainment.

CONCLUSIONS

HC, total IQ, matrix reasoning and spatial span decrease with smaller retinal arteriolar diameter. Our findings suggest that maldevelopment of the cerebral microcirculation, as mirrored by the retinal microvasculature, has lasting effects on the growth of the brain and cognitive performance of prematurely born children.

Bevacizumab or laser for aggressive posterior retinopathy of prematurity

PURPOSE

The purpose of this study was to report the rate of reactivation and structural outcome, after the laser or bevacizumab treatment for aggressive posterior retinopathy of prematurity (APROP).

METHODS

Retrospective chart review was conducted on consecutive infants with APROP treated with (1) laser or (2) bevacizumab, followed by fluorescein angiography and prophylactic laser to the persistent avascular retina.

RESULTS

Thirty-six eyes of 19 patients were included in this study. The mean gestational age was 24.5 weeks with a mean birth weight of 632 g in the bevacizumab group and 24.7 weeks and 777 g in the laser group. Unfavorable outcome occurred in 1 of 22 eyes treated with bevacizumab and in 5 of 14 eyes in the laser group (P = 0.002). Reactivation requiring treatment was common in both groups, 9/22 after bevacizumab and 6/14 after laser (ns).

CONCLUSION

Regardless of the initial treatment reactivation requiring retreatment is common in eyes with APROP. The unfavorable structural outcome was significantly more common after initial laser treatment than after initial bevacizumab treatment.

Relation of Retinopathy of Prematurity to Brain Volumes at Term Equivalent Age and Developmental Outcome at 2 Years of Corrected Age in Very Preterm Infants

BACKGROUND

Retinopathy of prematurity (ROP) is a major complication of preterm birth and has been associated with later visual and nonvisual impairments.

OBJECTIVES

To evaluate relationships between any stage of ROP, brain volumes, and developmental outcomes.

METHODS

This study included 52 very preterm infants (gestational age [mean ± SD]: 26.4 ± 1.9 weeks). Total brain, gray matter, unmyelinated white matter (UWMV), and cerebellar volumes were estimated in 51 out of 52 infants by magnetic resonance imaging at term-equivalent age. Bayley Scales of Infant Development were used to assess developmental outcomes in 49 out of 52 infants at a mean corrected age of 24.6 months.

RESULTS

Nineteen out of 52 infants developed any stage of ROP. Infants with ROP had a lower median (IQR) UWMV (173 [156-181] vs. 204 [186-216] mL, p < 0.001) and cerebellar volume (18.3 [16.5-20] vs. 22.3 [20.3-24.7] mL, p < 0.001) than infants without ROP. They also had a lower median (IQR) mental developmental index (72 [56-83] vs. 100 [88-104], p < 0.001) and a lower psychomotor developmental index (80 [60-85] vs. 92 [81-103], p = 0.002). Brain volumes and developmental outcomes did not differ among infants with different stages of ROP.

CONCLUSION

Any stage of ROP in preterm infants was associated with a reduced brain volume and an impaired developmental outcome. These results suggest that common pathways may lead to impaired neural and neurovascular development in the brain and retina and that all stages of ROP may be considered in future studies on ROP and development.

Systemic Inflammation-Associated Proteins and Retinopathy of Prematurity in Infants Born Before the 28th Week of Gestation

Purpose

To assess the association between systemic levels of inflammation-associated proteins and severe retinopathy of prematurity (ROP) in extremely preterm infants.

Methods

We collected whole blood on filter paper on postnatal days 1, 7, 14, 21, and 28 from 1205 infants born before the 28th week of gestation, and measured the concentrations of 27 inflammation-associated, angiogenic, and neurotrophic proteins. We calculated odds ratios with 95% confidence intervals for the association between top quartile concentrations of each protein and prethreshold ROP.

Results

During the first three weeks after birth, high concentrations of VEGF-R1, myeloperoxidase (MPO), IL-8, intercellular adhesion molecule (ICAM)-1, matrix metalloproteinase 9, erythropoietin, TNF-α, and basic fibroblast growth factor were associated with an increased risk for prethreshold ROP. On day 28, high levels of serum amyloid A, MPO, IL-6, TNF-α, TNF-R1/-R2, IL-8, and ICAM-1 were associated with an increased risk. Top quartile concentrations of the proinflammatory cytokines TNF-α and IL-6 were associated with increased risks of ROP when levels of neuroprotective proteins and growth factors, including BDNF, insulin-like growth factor 1, IGFBP-1, VEGFR-1 and -2, ANG-1 and PlGF, were not in the top quartile. In contrast, high concentrations of NT-4 and BDNF appeared protective only in infants without elevated inflammatory mediators.

Conclusions

Systemic inflammation during the first postnatal month was associated with an increased risk of prethreshold ROP. Elevated concentrations of growth factors, angiogenic proteins, and neurotrophins appeared to modulate this risk, and were capable of reducing the risk even in the absence of systemic inflammation.

Retinopathy of prematurity: inflammation, choroidal degeneration, and novel promising therapeutic strategies

Retinopathy of prematurity (ROP) is an important cause of childhood blindness globally, and the incidence is rising. The disease is characterized by initial arrested retinal vascularization followed by neovascularization and ensuing retinal detachment causing permanent visual loss. Although neovascularization can be effectively treated via retinal laser ablation, it is unknown which children are at risk of entering this vision-threatening phase of the disease. Laser ablation may itself induce visual field deficits, and there is therefore a need to identify targets for novel and less destructive treatments of ROP. Inflammation is considered a key contributor to the pathogenesis of ROP. A large proportion of preterm infants with ROP will have residual visual loss linked to loss of photoreceptor (PR) and the integrity of the retinal pigment epithelium (RPE) in the macular region. Recent studies using animal models of ROP suggest that choroidal degeneration may be associated with a loss of integrity of the outer retina, a phenomenon so far largely undescribed in ROP pathogenesis. In this review, we highlight inflammatory and neuron-derived factors related to ROP progression, as well, potential targets for new treatment strategies. We also introduce choroidal degeneration as a significant cause of residual visual loss following ROP. We propose that ROP should no longer be considered an inner retinal vasculopathy only, but also a disease of choroidal degeneration affecting both retinal pigment epithelium and photoreceptor integrity.

Functional Independence Measure for Children: A Comparison of Chinese and Japanese Children

The Functional Independence Measure for Children (WeeFIM) is a simple-to-administer scale for assessing functional independence across 3 domains (self-care, mobility, cognition) in children. There are normative data from America and Japan. In 2001 to 2002, the authors created a normative Chinese WeeFIM profile and compared this with the American one. In this study, they aimed to compare their Chinese normative data with the Japanese one. Methods. A random sampling of 445 normal Chinese children from different social classes in Hong Kong was conducted in the community. It was conducted via face-to-face interviews with the mother, and a normative database was created. Results. Similar to the Japanese children, the WeeFIM total score and 3 main domain subscores (self-care, mobility, and cognition) increased progressively with age. In the self-care domain, Chinese children achieved modified independence or level 6 earlier in all items except toileting. For the mobility domain, the item chair transfer was achieved earlier in the Chinese children, whereas toilet transfer, stair, tub transfer, and locomotion were achieved later in Chinese children. As for cognition domain, the item problem solving was achieved earlier but comprehension, social interaction, and memory were achieved later in the Chinese children. The authors’ results showed the same pattern of increasing WeeFIM score with increasing chronological age, which is similar to the Japanese children. There are 3 patterns of WeeFIM score achievement in this Chinese cohort. As for the Japanese children, the 3 patterns of WeeFIM score achievement from independent to dependent are 1) rapid change, 2) gradual change, and 3) linear change. Conclusions. WeeFIM is a validated standardized tool for assessing the outcome of rehabilitation programs. It should be widely used to assess rehabilitative achievement in children from different ethnic origins. The authors’ previous study and this current study demonstrated that the authors’ normative WeeFIM profile showed similar results to the American and Japanese children. However, there are minor differences in the WeeFIM scoring in the 3 main domains, which might be due to cultural differences between ethnic groups. Thus, usage of the WeeFIM with a different age criteria in achieving independence according to local culture should be adopted.

The effects of a people-centred model on longitudinality of care and utilization pattern of healthcare services--Brazilian evidence

Brazil is experiencing a time of change in pattern of care: from ‘traditional’ to Family Health Strategy (FHS), a model guided by the principles of people, family and community-centred medicine. The heterogeneity in care currently offered affects the primary care impact. This study aims to evaluate the longitudinality of care and correlate this primary care principle to the utilization pattern of care among patients hospitalized due to preventable conditions, comparing the two care models currently offered in Brazil. It is a cross-sectional, analytical and descriptive study with a quantitative approach. The sample consisted of 501 patients from 0 to 14 years old. Data was collected in 2011 and the Primary Care Assessment Tool (PCATool-Brazil) child version was used. Bivariate and multivariate analyses were performed including patient-related variables (age, maternal education, income and type of diagnosis) and care model. From the hospitalizations occurred during the period, 65.2% were Ambulatory Care Sensitive Conditions. Patients evaluated ‘longitudinality’ as regular. Both the care continuity dimension and the utilization pattern of care services showed a link with the care model offered. Findings suggest that the FHS care model, based on the assumptions of people-centred medicine, was associated with better ratings of care continuity, which was reflected in a more appropriate utilization pattern of care services.

Optical coherence tomography of the preterm eye: from retinopathy of prematurity to brain development

Preterm infants with retinopathy of prematurity are at increased risk of poor neurodevelopmental outcomes. Because the neurosensory retina is an extension of the central nervous system, anatomic abnormalities in the anterior visual pathway often relate to system and central nervous system health. We describe optical coherence tomography as a powerful imaging modality that has recently been adapted to the infant population and provides noninvasive, high-resolution, cross-sectional imaging of the infant eye at the bedside. Optical coherence tomography has increased understanding of normal eye development and has identified several potential biomarkers of brain abnormalities and poorer neurodevelopment.

FUNCTIONAL OUTCOMES OF YOUNG INFANTS WITH AND WITHOUT MACULAR EDEMA

PURPOSE

The authors relate posterior segment microanatomy from perinatal spectral domain optical coherence tomography to visual acuity, brain abnormalities, and neurodevelopment.

METHODS

Thirteen infants (11 preterm and 2 term birth), imaged in the nursery with portable spectral domain optical coherence tomography, had visual acuity and sensorimotor testing at age 9 months to 15 months (grating acuity) or 4 years to 5 years (optotype), and medical records reviewed for brain magnetic resonance imaging reports and Bayley scales testing at age 18 months to 24 months.

RESULTS

Eight children with age-appropriate macular microanatomy without edema on perinatal spectral domain optical coherence tomography had optimal (≥ 20/40) or within normal limits (grating acuity) visual acuity. Five children with perinatal macular edema had suboptimal visual acuity (in 9/10 eyes) and sensorimotor deficits, magnetic resonance imaging abnormalities, or poor neurodevelopment. Macular edema persisted in 1 infant through 9-month corrected age.

CONCLUSION

Maturation of the visual system and evolution of retinal anomalies can be monitored with posterior segment spectral domain optical coherence tomography. Retinal microanatomy observed in infancy might relate to subsequent vision and other central nervous system events, but additional studies are needed to determine the range of normal microanatomy in infants and how this relates to vision and neurodevelopment.

Neurodevelopmental Outcomes Following Bevacizumab Injections for Retinopathy of Prematurity

BACKGROUND AND OBJECTIVE

Bevacizumab intravitreal injection, a vascular endothelial growth factor inhibitor, is used to treat retinopathy of prematurity (ROP). However, concerns have been raised regarding its systemic absorption and effect on developing tissues including brain. This study compared neurodevelopment at 18 months' corrected age in preterm infants of <29 weeks' gestation treated with bevacizumab versus laser ablation.

METHODS

Data from the Canadian Neonatal Network and the Canadian Neonatal Follow-Up Network databases were retrospectively reviewed. Infants born at <29 weeks' in 2010-2011 with treated ROP were studied. Neurodevelopmental outcome at 18 months was assessed by using neurologic examination and the Bayley Scales of Infant and Toddler Development Third Edition. Regression analyses were performed.

RESULTS

Of 125 treated infants, 27 received bevacizumab and 98 laser. The bevacizumab group, compared with laser, obtained a median Bayley Scales of Infant and Toddler Development Third Edition motor composite score of 81 (interquartile range, 70-91) versus 88 (79-97), a language composite score of 79 (65-97) versus 89 (74-97), and a cognitive score of 90 (80-100) versus 90 (85-100). Difference was detected on the motor score only (P = .02). Odds of severe neurodevelopmental disabilities (Bayley scores <70, severe cerebral palsy, hearing aids, or bilateral blindness) was 3.1 times higher (95% confidence interval: 1.2-8.4) in infants treated with bevacizumab versus laser after adjusting for gestational age, gender, maternal education, Score for Neonatal Acute Physiology-II score, bronchopulmonary dysplasia, sepsis, and severe brain injury.

CONCLUSIONS

Preterm infants treated with bevacizumab versus laser had higher odds of severe neurodevelopmental disabilities. Further investigation on the long-term safety of antivascular endothelial growth factor treatment of ROP is needed.

Prediction of Late Death or Disability at Age 5 Years Using a Count of 3 Neonatal Morbidities in Very Low Birth Weight Infants

OBJECTIVE

To evaluate bronchopulmonary dysplasia (BPD), serious brain injury, and severe retinopathy of prematurity (ROP) as predictors of poor long-term outcome in very low birth weight infants.

STUDY DESIGN

We examined the associations between counts of the 3 morbidities and long-term outcomes in 1514 of 1791 (85%) infants with birth weights of 500-1250 g who were enrolled in the Caffeine for Apnea of Prematurity trial from October 1999, to October 2004, had complete morbidity data, and were alive at 36 weeks postmenstrual age (PMA). BPD was defined as use of supplemental oxygen at 36 weeks PMA. Serious brain injury on cranial ultrasound included grade 3 and 4 hemorrhage, cystic periventricular leucomalacia, porencephalic cysts, or ventriculomegaly of any cause. Poor long-term outcome was death after 36 weeks PMA or survival to 5 years with 1 or more of the following disabilities: motor impairment, cognitive impairment, behavior problems, poor general health, deafness, and blindness.

RESULTS

BPD, serious brain injury, and severe ROP occurred in 43%, 13%, and 6% of the infants, respectively. Each of the 3 morbidities was similarly and independently correlated with poor 5-year outcome. Rates of death or disability (95% CI) in children with none, any 1, any 2, and all 3 morbidities were 11.2% (9.0%-13.7%), 22.9% (19.6%-26.5%), 43.9% (35.5%-52.6%), and 61.5% (40.6%-79.8%), respectively.

CONCLUSIONS

In very low birth weight infants who survive to 36 weeks PMA, a count of BPD, serious brain injury, and severe ROP predicts the risk of a late death or survival with disability at 5 years.

Retinopathy of prematurity and neurodevelopmental disabilities in premature infants

Prematurity is a major global health issue leading to high mortality and morbidity among the survivors. Neurodevelopmental disability (NDD) and retinopathy of prematurity (ROP) are the most common complications of prematurity. In fact, ROP is the second leading cause of childhood blindness in the world. Although there is much information regarding the occurrence of ROP and of NDD in premature infants, there have been few studies on ROP and its association with NDD. The objectives of this article are to review the current literature on the subject and to publish our own findings concerning the association between ROP and NDD in premature infants. The review suggests that although NDDs are related to degree of prematurity, NDD could also be the result of visual impairments resulting from ROP. Our own study shows a close association between NDD and zonal involvement of ROP: higher NDD if zone 1 is involved and less if zone 3 is involved.

Attributes of primary care in community health centres in China and implications for equitable care: a cross-sectional measurement of patients' experiences

BACKGROUND

China has been undergoing a health-care reform, and community health centres (CHCs) are being established as primary care provider across urban areas.

AIM

To evaluate primary care attributes in CHCs by measuring patients' experiences.

DESIGN

Cross-sectional surveys of 3360 adult service users with multistage cluster sampling.

METHODS

We developed a short assessment tool consisting of 33 items derived from the short version of the original Primary Care Assessment Tool-Adult Edition (PCAT-AE). The reliability and validity of the instrument were evaluated. Score distributions were assessed using descriptive statistics with 95% confidence interval (CI). The overall PCAT scores were categorized into three quantile groups (lower score, medium score and optimal score). Ordinal logistic regression analysis was performed to explore patient characteristics associated with optimal score after controlling for demographic, socio-economic, health conditions and health-care utilization characteristics.

RESULTS

One-third (33.4%, 95% CI: 31.0-35.9%) of subjects had optimal overall PCAT scores, while the majority (83.4%) reported medium-to-lower score in the community orientation scale. Patients' characteristics with respect to health-care utilization had major effects on PCAT scores. Subjects with the presence of social medical insurance had higher odds of having greater experience in most primary care attributes and tended to report optimal primary care experience (aOR 2.30, 95% CI: 1.92-2.75) compared with those without social medical insurance.

CONCLUSIONS

Equitable primary care is yet to be strengthened with regard to the community orientation attribute, and particularly among patients without social medical insurance, as they tend to have inferior experiences in the primary care sector.

Antecedents and correlates of visual field deficits in children born extremely preterm

AIM

We sought to identify the antecedents and correlates of visual field deficits (VFDs) at age 2 years among infants born before the 28th week of gestation.

METHODS

The visual fields of 1023 infants were assessed by confrontation at age 2 years. We compared the ante-and postnatal characteristics and exposures of the 65 infants with a VFD to their peers who did not have a VFD. We used time-oriented logistic regression risk models to assess the associations of potential antecedents and correlates with a VFD.

RESULTS

In the final regression model, VFD was associated with maternal consumption of aspirin during the current pregnancy, recurring/persistent acidemia during the first 3 postnatal days, cerebral ventriculomegaly seen on neonatal ultrasound, prethreshold retinopathy of prematurity (ROP), and supplemental oxygen and ventilator dependence at 36 weeks post-menstrual age. Birth before the 27th week was also associated with increased risk, but its significance was diminished by the addition of postnatal variables.

CONCLUSION

In this sample of extremely preterm born infants, antenatal as well as early and late postnatal characteristics and exposures are associated with an increased risk of having a VFD. Our study adds to our knowledge about the complex etiology of visual deficits of prematurity, and supports a multifactorial cause of these deficits.

Poorer neurodevelopmental outcomes associated with cystoid macular edema identified in preterm infants in the intensive care nursery

PURPOSE

To evaluate the association between cystoid macular edema (CME) observed in very preterm infants and developmental outcomes at 18 to 24 months corrected age.

DESIGN

Cohort study.

PARTICIPANTS

Infants born at or less than 1500 g or at or less than 30 weeks postmenstrual age who underwent screening for retinopathy of prematurity (ROP) in an intensive care nursery.

METHODS

Bedside handheld spectral-domain optical coherence tomography (SD OCT; Envisu, Bioptigen, Inc, Research Triangle Park, NC) imaging was obtained from preterm infants who were being screened for ROP and graded for presence of CME, central foveal thickness (CFT), inner nuclear layer thickness, and foveal-to-parafoveal thickness ratio. At 18 to 24 months corrected age, the children were assessed with the Bayley Scales of Infant and Toddler Development, Third Edition.

MAIN OUTCOME MEASURES

Scores on the Bayley cognitive, language, and motor subscales.

RESULTS

Among 77 children with SD OCT imaging, 53 were evaluated with the Bayley Scales. Compared with children who did not have CME as infants (n=22), the mean score for children who had CME (n=31) was 7.3 points (95% confidence interval [CI], -15.5 to 0.9; P=0.08) lower on the cognitive subscale, 14.1 points (95% CI, -22.7 to -5.5; P=0.002) lower for the language subscale, and 11.5 points (95% CI, -21.6 to -1.3; P=0.03) lower for the motor subscale. Differences were maintained after adjusting for gestational age and birth weight. Severity of CME, as assessed by foveal-to-parafoveal thickness ratio, within the CME group correlated with poorer cognitive (R2=0.16, P=0.03) and motor (R2=0.15, P=0.03) development.

CONCLUSIONS

Cystoid macular edema observed on SD OCT in very preterm infants screened for ROP is associated with poorer language and motor skills at 18 to 24 months corrected age. Evaluation of the retina with SD-OCT may serve as an indicator of neurodevelopmental health for very preterm infants in the intensive care nursery.

Retinopathy of prematurity and brain damage in the very preterm newborn

PURPOSE

To explain why very preterm newborns who develop retinopathy of prematurity (ROP) appear to be at increased risk of abnormalities of both brain structure and function.

METHODS

A total of 1,085 children born at <28 weeks' gestation had clinically indicated retinal examinations and had a developmental assessment at 2 years corrected age. Relationships between ROP categories and brain abnormalities were explored using logistic regression models with adjustment for potential confounders.

RESULTS

The 173 children who had severe ROP, defined as prethreshold ROP (n = 146) or worse (n = 27) were somewhat more likely than their peers without ROP to have brain ultrasound lesions or cerebral palsy. They were approximately twice as likely to have very low Bayley Scales scores. After adjusting for risk factors common to both ROP and brain disorders, infants who developed severe ROP were at increased risk of low Bayley Scales only. Among children with prethreshold ROP, exposure to anesthesia was not associated with low Bayley Scales.

CONCLUSIONS

Some but not all of the association of ROP with brain disorders can be explained by common risk factors. Most of the increased risks of very low Bayley Scales associated with ROP are probably not a consequence of exposure to anesthetic agents.

Brain development after neonatal intermittent hyperoxia-hypoxia in the rat studied by longitudinal MRI and immunohistochemistry

BACKGROUND

Neonatal intermittent hyperoxia-hypoxia (IHH) is involved in the pathogenesis of retinopathy of prematurity. Whether similar oxygen fluctuations will create pathological changes in the grey and white matter of the brain is unknown.

METHODS

From birth until postnatal day 14 (P14), two litters (total n = 22) were reared in IHH: hyperoxia (50% O2) interrupted by three consecutive two-minute episodes of hypoxia (12% O2) every sixth hour. Controls (n = 8) were reared in room-air (20.9% O2). Longitudinal MRI (Diffusion Tensor Imaging and T2-mapping) was performed on P14 and P28 and retinal and brain tissue were examined for histopathological changes. Long-term neurodevelopment was assessed on P20 and P27.

RESULTS

Mean, radial and axial diffusivity were higher in white matter of IHH versus controls at P14 (p < 0.04), while fractional anisotropy (FA) was lower in the hippocampal fimbria and tended to be lower in corpus callosum (p = 0.08) and external capsule (p = 0.05). White matter diffusivity in IHH was similar to controls at P28. Higher cortical vessel density (p = 0.005) was observed at P14. Cortical and thalamic T2-relaxation time and mean diffusivity were higher in the IHH group at P14 (p ≤ 0.03), and albumin leakage was present at P28. Rats in the IHH group ran for a longer time on a Rotarod than the control group (p ≤ 0.005). Pups with lower bodyweight had more severe MRI alterations and albumin leakage.

CONCLUSION

IHH led to subtle reversible changes in brain white matter diffusivity, grey matter water content and vascular density. However, alterations in blood-brain barrier permeability may point to long-term effects. The changes seen after IHH exposure were more severe in animals with lower bodyweight and future studies should aim at exploring possible interactions between IHH and growth restriction.