Cognitive outcomes in school-age children born prematurely

Developmental influence of unconjugated hyperbilirubinemia and neurobehavioral disorders

Bilirubin-induced brain injury in the neonatal period has detrimental effects on neurodevelopment that persist into childhood and adulthood, contributing to childhood developmental disorders. Unconjugated bilirubin is a potent antioxidant that may be useful for protecting against oxidative injuries, but it becomes a potent neurotoxin once it crosses the blood brain barrier. Because bilirubin toxicity involves a myriad of pathological mechanisms, can damage most types of brain cells, and affects brain circuits or loops that influence cognition, learning, behavior, sensory, and language, the clinical effects of bilirubin-induced neurotoxicity are likely to be manifold. One possible effect that several experts have identified is bilirubin-induced neurological dysfunction (subtle kernicterus). However, the underlying biological mechanisms or pathways by which subtle kernicterus could lead to developmental disorders has not been elucidated previously. Our aim in this review is to describe a spectrum of developmental disorders that may reflect subtle kernicterus and outline plausible biological mechanisms for this possible association. We review existing evidence that support or refute the association between unconjugated hyperbilirubinemia and developmental disorders, and limitations associated with these studies.

Eight-Year Developmental Follow-up in Children with Birthweights 1,251–1,500g in KK Women's and Children's Hospital

Background:

Children of very low birth weight (VLBW, birth weight <1,500g) are at risk of developmental disability and learning difficulties. Regular follow-up to a school-going age allows timely diagnosis and intervention.

Methods:

The duration, developmental assessment and service utilisation of 41 VLBW children with birth weights between 1,251–1,500g born in 2001 were retrospectively analysed.

Results:

The median follow-up duration was 5 years 11 months. 56% were followed-up till preschool entry. Gross motor, fine motor and language domains were assessed in more than 95% of children. Information on behavioural and learning problems was only sought for in approximately 50% of children.

Conclusions:

A significant proportion of these high-risk children were either not followed-up long enough or were not adequately assessed for learning and behavioural problems, thus justifying the development of a new standardised follow-up program for larger VLBW children.

Impact of neonatal intensive care on late preterm infants: developmental outcomes at 3 years

BACKGROUND

Late preterm infants (LPIs) (34-36 weeks' gestation) account for up to 75% of preterm births and constitute a significant proportion of all neonatal admissions. This study assessed the impact of neonatal intensive or high-dependency care (IC) on developmental outcomes of LPIs at 3 years of age.

METHODS

This cohort study included 225 children born late preterm in Northern Ireland during 2006. Children born late preterm who received IC were compared with children born late preterm who did not receive IC. Cognitive, motor, and language skills were assessed by using the Bayley Scales of Infant and Toddler Development, Third Edition. Growth was assessed by using anthropometric measures of height and weight.

RESULTS

LPIs who received IC were more often less mature (34 weeks' gestation), with lower birth weight (≤ 2500 g) and Apgar scores (<7 at 5 minutes) compared with the control group. They were more often born by cesarean delivery and more likely to have received resuscitation at birth. At 3 years of age, children born late preterm who received IC demonstrated similar cognitive, motor, and language skills compared with children in the control group. Measurements of growth also did not differ significantly between groups.

CONCLUSIONS

Despite having increased maternal, perinatal, and neonatal risk factors, there were no significant differences in early childhood development between LPIs who received IC and those who did not. LPIs do not receive routine follow-up after IC and this study provides useful and reassuring data for parents and clinicians on the longer-term outcome of this infant group.

Comparison of functional status of 8- to 12-year-old children born prematurely: an integrative review of literature

Prematurity affects one in eight infants in the United States, a rate that reflects an overall increase of 20% between 1990 and 2005 (March of Dimes, 2008). This integrative review presents a synthesis of the current research addressing the functional status of 8- to 12-year-old children born prematurely. Findings from this review support the belief that children born prematurely function differently than their term peers. These children have academic and social delays that may necessitate special service support through middle childhood.

Early childhood development of late-preterm infants: a systematic review

CONTEXT

Late-preterm infants (LPIs) born at 34 to 36 weeks' gestation are increasingly regarded as being at risk for adverse developmental outcomes. To date, the early childhood development of LPIs has not been systematically considered.

OBJECTIVE

To undertake a broad examination of literature relating to early childhood development at the ages of 1 to 7 years of LPIs born at 34 to 36 weeks' gestation.

METHODS

We conducted a systematic review of early childhood outcomes in LPIs by using 9 electronic databases (January 1980 to March 2010). Bibliographies were reviewed. After examination of abstracts, ineligible studies were excluded. A specifically designed data-extraction form was used. The methodologic quality of included studies was assessed by using well-documented quality-appraisal guidelines.

RESULTS

Of 4581 studies, 10 (3 prospective and 7 retrospective cohort) were included. Studies were heterogeneous, and poorer outcomes were reported among LPIs in relation to neurodevelopmental disabilities, educational ability, early-intervention requirements, medical disabilities, and physical growth in comparison to term-born children. No identified study used healthy nonadmitted LPIs as a comparison group for admitted LPIs.

CONCLUSIONS

Evidence suggests that LPIs are at increased risk of adverse developmental outcomes and academic difficulties up to 7 years of age in comparison to term infants. An infant control group matched for gestational age has not been used; thus, for LPIs, the effect of neonatal admission on longer-term outcomes has not been fully explored. Systematic measurement of early childhood outcomes is lacking, and focused long-term follow-up studies are needed to investigate early childhood development after late-preterm birth.

The role of systemic hemodynamic disturbances in prematurity-related brain injury

Premature infants who experience cerebrovascular injury frequently have acute and long-term neurologic complications. In this article, we explore the relationship between systemic hemodynamic insults and brain injury in this patient population and the mechanisms that might be at play.

Epidemiology and burden of malaria in pregnancy

We reviewed evidence of the clinical implications and burden of malaria in pregnancy. Most studies come from sub-Saharan Africa, where approximately 25 million pregnant women are at risk of Plasmodium falciparum infection every year, and one in four women have evidence of placental infection at the time of delivery. P falciparum infections during pregnancy in Africa rarely result in fever and therefore remain undetected and untreated. Meta-analyses of intervention trials suggest that successful prevention of these infections reduces the risk of severe maternal anaemia by 38%, low birthweight by 43%, and perinatal mortality by 27% among paucigravidae. Low birthweight associated with malaria in pregnancy is estimated to result in 100,000 infant deaths in Africa each year. Although paucigravidae are most affected by malaria, the consequences for infants born to multigravid women in Africa may be greater than previously appreciated. This is because HIV increases the risk of malaria and its adverse effects, particularly in multigravidae, and recent observational studies show that placental infection almost doubles the risk of malaria infection and morbidity in infants born to multigravidae. Outside Africa, malaria infection rates in pregnant women are much lower but are more likely to cause severe disease, preterm births, and fetal loss. Plasmodium vivax is common in Asia and the Americas and, unlike P falciparum, does not cytoadhere in the placenta, yet, is associated with maternal anaemia and low birthweight. The effect of infection in the first trimester, and the longer term effects of malaria beyond infancy, are largely unknown and may be substantial. Better estimates are also needed of the effects of malaria in pregnancy outside Africa, and on maternal morbidity and mortality in Africa. Global risk maps will allow better estimation of potential impact of successful control of malaria in pregnancy.

Preventing Low Birth Weight in Illinois: Outcomes of the Family Case Management Program

OBJECTIVES

In the mid 1980's the federal government passed legislation allowing states to expand their Medicaid programs for pregnant women. States were also offered matching funds for "enhanced" prenatal care services. The Illinois Family Case Management (FCM) Program targets low-income women and aims to reduce barriers to prenatal care and infant healthcare utilization and also provides health education. We evaluated the outcome of the Illinois Family Case Management Program (FCM) in preventing low birth weight in Winnebago County.

METHODS

A total of 6,440 participants were included in this study. Logistic regression was used to test whether number of visits or total hours of visitation were significant protective factors against low birth weight.

RESULTS

While participating in the FCM Program resulted in a lower rate of low birth weight delivery, neither increasing time with a family case manager nor increasing number of visits showed statistically significant additional protection against low birth weight delivery after adjustment for potential confounding factors.

CONCLUSION

In order to further improve program outcomes, efforts need to include improving quality of interventions or developing new interventions rather than simply increasing the amount of current intervention for each participant. The cost effectiveness of shifting FCM Program efforts away from infants (aged 0-1 year) towards improved prenatal interventions should be evaluated.

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

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

Designing the neonatal intensive care unit for optimal family involvement

The design of a new neonatal intensive care unit provides an opportunity to ensure that the new facility best meets the needs of the infants and families whom the unit serves. In design planning,administrators, staff, family members, and the architect must work together in a self-education process that entails examining current design standards, exploring exemplary facilities at other institutions,defining the priorities and needs of infants, families, and staff, and deciding how to respond to them. The involvement of family members in this important work can help ensure that the facility is responsive to families and supports the family as the primary caregiver and decision maker for the infant. Such an environment will lead to improved health and developmental outcomes for infants and greater family and staff satisfaction.