White Matter Injury and General Movements in High-Risk Preterm Infants

Gait and sEMG characteristics of lower limbs in children with unilateral spastic cerebral palsy during walking

BACKGROUND

Children with unilateral spastic cerebral palsy (USCP) have muscle hypertonia, balance, and coordination defects that affect gross motor skills, especially walking. Understanding the gait characteristics and lower limb muscle activation patterns of USCP children can provide an objective and quantitative basis for patient assessment and treatment plan formulation.

OBJECTIVE

This study compared the gait and lower limb muscle activation characteristics of children with USCP and with typical development (TD) during walking.

METHODS

We recorded gait and sEMG data of 20 children with USCP, and 20 with typical development. sEMG signals were acquired from the bilateral tibialis anterior (TA) and lateral gastrocnemius muscles (LG) during walking. The root mean square (RMS) value, integrated electromyographic (iEMG) value and co-contraction ratio (CR) were used to evaluate muscle activity. Student's t Test and non-parametric rank sum Test were used to compare the differences between the data groups (significance level of 0.05).

RESULTS

The stance time, step length, speed, single leg support time ratio, ground impact, pre-swing angle, and muscle strength of the affected side were significantly decreased compared to those of the unaffected side in children with USCP (P < 0.05), while the swing phase, muscle tonus of LG were significantly prolonged (P < 0.05). Compared with TD children, children with USCP exhibited reduced bilateral walking ability, particularly noticeable in their smaller pre-swing angle(P < 0.05), diminished muscle strength of the TA and LG, as well as LG spasms(P < 0.05).

SIGNIFICANCE

Children with USCP have decreased ambulatory gait stability. Step length, pull acceleration, pre-swing angle, and CR can be used as sensitive indicators for gait assessment. Strengthening the TA muscle and reducing ankle spasm may help improve gait and postural stability in children with USCP.

Spontaneous movements as prognostic tool of neurodevelopmental outcomes in preterm infants: a narrative review

An estimated 15 million infants are born prematurely each year. Although the survival rate of preterm infants has increased with advances in perinatal and neonatal care, many still experience various complications. Since improving the neurodevelopmental outcomes of preterm births is a crucial topic, accurate evaluations should be performed to detect infants at high risk of cerebral palsy. General movements are spontaneous movements involving the whole body as the expression of neural activity and can be an excellent biomarker of neural dysfunction caused by brain impairment in preterm infants. The predictive value of general movements with respect to cerebral palsy increases with continuous observation. Automated approaches to examining general movements based on machine learning can help overcome the limited utilization of assessment tools owing to their qualitative or semiquantitative nature and high dependence on assessor skills and experience. This review covers each of these topics by summarizing normal and abnormal general movements as well as recent advances in automatic approaches based on infantile spontaneous movements.

Evaluation of white matter microstructural alterations in premature infants with necrotizing enterocolitis

Background

Preterm infants with necrotizing enterocolitis (NEC) are at high risk of adverse neurodevelopmental outcomes. The aim of this study was to explore the value of diffusion tensor imaging (DTI) combined with serum C-reactive protein (CRP) and procalcitonin (PCT) in evaluating alterations of white matter (WM) microstructure in preterm infants with NEC.

Methods

A retrospective cross-sectional study was conducted in which all participants were consecutively enrolled at The Third Affiliated Hospital of Zhengzhou University from June 2017 and October 2021. Data from 30 preterm infants with NEC [mean gestational age at birth 31.41±1.15 weeks; mean age at magnetic resonance imaging (MRI) 37.53±3.08 weeks] and 40 healthy preterm infants with no NEC were recorded (mean gestational age at birth 32.27±2.09 weeks; mean age at MRI 37.15±3.23 weeks). WM was used to obtain the fractional anisotropy (FA) and mean diffusivity (MD) values of the regions of interest (ROIs). Additionally, serum levels of CRP and PCT were determined. Spearman correlation analysis was performed between the WM-derived parameters, CRP level, and the PCT serum index.

Results

Preterm infants with NEC had reduced FA values and elevated MD values in WM regions [posterior limbs of the internal capsule (PLIC), lentiform nucleus (LN), frontal white matter (FWM)] compared to the control group (P<0.05). Additionally, the FA of the PLIC was negatively correlated with serum CRP (r=-0.846; P<0.05) and PCT (r=-0.843; P<0.05). Meanwhile, the MD of PLIC was positively correlated with serum CRP (r=0.743; P<0.05) and PCT (r=0.743; P<0.05, respectively). The area under the curve (AUC) of FA and MD combined with CRP and PCT in the diagnosis of WM microstructure alterations with NEC was 0.968, representing a considerable improvement in predicted efficacy over single indicators, including FA [AUC: 0.938; 95% confidence interval (CI): 0.840-0.950], MD (AUC: 0.807; 95% CI: 0.722-0.838), CRP (AUC: 0.867; 95% CI: 0.822-0.889), and PCT (AUC: 0.706; 95% CI: 0.701-0.758).

Conclusions

WM can noninvasively and quantitatively assess the WM microstructure alterations in preterm infants with NEC. WM combined with serum CRP and PCT demonstrated superior performance in detecting and evaluating WM microstructure alterations in preterm infants with NEC.

Microstructural Brain Development and Neurodevelopmental Outcome of Very Preterm Infants of Mothers with Gestational Diabetes Mellitus

INTRODUCTION

There are data linking gestational diabetes mellitus (GDM) with adverse neurodevelopmental outcome in the offspring. We investigated the effect of GDM on microstructural brain development and neurodevelopmental outcome of very preterm infants.

MATERIALS AND METHODS

Preterm infants <32 gestational weeks of mothers with GDM obtained cerebral magnetic resonance imaging (MRI) including diffusion-tensor imaging at term-equivalent age. For every infant, two gestational age-, sex-, and MRI scanner type-matched controls were included. Brain injury was assessed and fractional anisotropy (FA) and apparent diffusion coefficient (ADC) measured in 14 defined cerebral regions. Neurodevelopmental outcome was quantified at the corrected age of 24 months using the Bayley Scales of Infant Development.

RESULTS

We included 47 infants of mothers with GDM and 94 controls. There were no differences in neonatal morbidity between the groups, nor in any type of brain injury. The GDM group showed significantly higher FA values in the centrum semiovale, the posterior limb of the internal capsule and the pons bilaterally, in the corpus callosum and the right occipital white matter, as well as lower ADC values in the right centrum semiovale, the right occipital white matter and the corpus callosum. Neurodevelopmental outcome did not differ between the groups.

CONCLUSION

We found no impairment of brain development in GDM-exposed infants compared to matched controls, but differences in white matter microstructure in specific regions indicating an enhanced maturation. However, neurodevelopmental outcome was equal in both groups. Further studies are needed to better understand brain maturation in preterm infants exposed to GDM.

Early markers of neurodevelopmental disorders based on general movements for very preterm infants: study protocol for a multicentre prospective cohort study in a clinical setting in China

INTRODUCTION

Very preterm (VPT) infants may experience varying degrees of neurodevelopmental challenges. Lack of early markers for neurodevelopmental disorders may delay referral to early interventions. The detailed General Movements Assessment (GMA) could help us to identify early markers for VPT infants at risk of atypical neurodevelopmental clinical phenotype in the very early stage of life as soon as possible. Preterm infants with high risk of atypical neurodevelopmental outcomes will have the best possible start to life if early precise intervention in critical developmental windows is allowed.

METHODS AND ANALYSIS

This is a nationwide, multicentric prospective cohort study that will recruit 577 infants born <32 weeks of age. This study will determine the diagnostic value of the developmental trajectory of general movements (GMs) at writhing and fidgety age with qualitative assessment for different atypical developmental outcomes at 2 years evaluated by the Griffiths Development Scales-Chinese. The difference in the General Movement Optimality Score (GMOS) will be used to distinguish normal (N), poor repertoire (PR) and cramped sychronised (CS) GMs. We plan to build the percentile rank of GMOS (median, 10th, 25th, 75th and 90th percentile rank) in N, PR and CS of each global GM category and analyse the relationship between GMOS in writhing movements and Motor Optimality Score (MOS) in fidgety movements based on the detailed GMA. We explore the subcategories of the GMOS list, and MOS list that may identify specific early markers that help us to identify and predict different clinical phenotypes and functional outcomes in VPT infants.

ETHICS AND DISSEMINATION

The central ethical approval has been confirmed from the Research Ethical Board of Children's Hospital of Fudan University (ref approval no. 2022(029)) and the local ethical approval has been also obtained by the corresponding ethics committees of the recruitment sites. Critical analysis of the study results will contribute to providing a basis for hierarchical management and precise intervention for preterm infants in very early life.

TRIAL REGISTRATION NUMBER

ChiCTR2200064521.

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.

The Early Motor Repertoire in Preterm Infancy and Cognition in Young Adulthood: Preliminary Findings

OBJECTIVE

Preterm birth poses a risk to cognition during childhood. The resulting cognitive problems may persist into young adulthood. The early motor repertoire in infancy is predictive of neurocognitive development in childhood. Our present aim was to investigate whether it also predicts neurocognitive status in young adulthood.

METHOD

We conducted an explorative observational follow-up study in 37 young adults born at a gestational age of less than 35 weeks and/or with a birth weight below 1200 g. Between 1992 and 1997, these individuals were videotaped up until 3 months' corrected age to assess the quality of their early motor repertoire according to Prechtl. The assessment includes general movements, fidgety movements (FMs), and a motor optimality score (MOS). In young adulthood, the following cognitive domains were assessed: memory, speed of information processing, language, attention, and executive function.

RESULTS

Participants in whom FMs were absent in infancy obtained lower scores on memory, speed of information processing, and attention than those with normal FMs. Participants with aberrant FMs, that is, absent or abnormal, obtained poorer scores on memory, speed of information processing speed, attention, and executive function compared to peers who had normal FMs. A higher MOS was associated with better executive function.

CONCLUSIONS

The quality of the early motor repertoire is associated with performance in various cognitive domains in young adulthood. This knowledge may be applied to enable the timely recognition of preterm-born individuals at risk of cognitive dysfunctions.

Effect of a NICU to Home Physical Therapy Intervention on White Matter Trajectories, Motor Skills, and Problem-Solving Skills of Infants Born Very Preterm: A Case Series

Infants born very preterm (VPT; ≤29 weeks of gestation) are at high risk of developmental disabilities and abnormalities in neural white matter characteristics. Early physical therapy interventions such as Supporting Play Exploration and Early Development Intervention (SPEEDI2) are associated with improvements in developmental outcomes. Six VPT infants were enrolled in a randomised clinical trial of SPEEDI2 during the transition from the neonatal intensive care unit to home over four time points. Magnetic resonance imaging scans and fixel-based analysis were performed, and fibre density (FD), fibre cross-section (FC), and fibre density and cross-section values (FDC) were computed. Changes in white matter microstructure and macrostructure were positively correlated with cognitive, motor, and motor-based problem solving over time on developmental assessments. In all infants, the greatest increase in FD, FC, and FDC occurred between Visit 1 and 2 (mean chronological age: 2.68-6.22 months), suggesting that this is a potential window of time to optimally support adaptive development. Results warrant further studies with larger groups to formally compare the impact of intervention and disparity on neurodevelopmental outcomes in infants born VPT.

Motor Optimality Scores are significantly lower in a population of high-risk infants than in infants born moderate-late preterm

BACKGROUND

The Motor Optimality Score-Revised (MOS-R) is a detailed scoring of the General Movement Assessment (GMA), measuring the spontaneous behaviors of infants. Infants born moderate-late preterm are not traditionally followed in high-risk clinics, but have increased risk of neurodevelopmental disability.

AIMS

Compare MOS-R at 3 months corrected age (CA) in high-risk (HR; very preterm or abnormal neuroimaging) infants to infants born moderate-late preterm (MLP).

STUDY DESIGN

In this prospective cohort study, parents of enrolled infants created video recordings using an app at 3 months CA. Videos were scored with the General Movement Assessment (GMA) and MOS-R. MOS-R scores were divided into "higher-risk" (≤19) and "lower-risk" (≥20).

SUBJECTS

181 infants born MLP or categorized as HR.

RESULTS

Among enrolled infants, 68 (38 %) were in the MLP group, and 113 infants were in the HR group. The HR group had 3.8 increased odds of having an aberrant GMA score compared to the MLP group (p < 0.01, 95 % CI 1.38-10.52). The HR group had significantly lower MOS-R scores (mean 20) than the MLP group (mean 24; p < 0.001; 95%CI 3.3-7.3). The HR group had 11.2 increased odds of having a higher-risk MOS-R score (95%CI 2.5-47.6, p < 0.001) than MLP group. Infants were most likely to have a lower MOS-R score if they had any of the following: VP shunt placement, periventricular leukomalacia, or bronchopulmonary dysplasia.

CONCLUSIONS

Aberrant GMA and higher-risk MOS-R scores were more common in infants at high-risk, reflecting history of brain lesions and younger gestational age at birth.

Association between General Movements Assessment and Later Motor Delay (excluding Cerebral Palsy) in Low-Birth-Weight Infants

The general movements (GMs) assessment is useful for the prediction of cerebral palsy (CP) and other developmental disorders. Developmental coordination disorder (DCD) is highly prevalent in low-birth-weight (LBW) infants. We investigated the association between aberrant GMs during early infancy and later motor development in LBW infants. The study included infants who fulfilled the following criteria: GMs assessed at 9–20 weeks post-term age; developmental quotient (DQ) assessed at 3 years of age using the Kyoto Scale; intelligence quotient (IQ) assessed at 6 years of age. Participants with normal IQs at 6 years of age without a diagnosis of CP (14 males and 37 females, 23–36 weeks gestation with birth weights of 492–1498 g) were categorized into normal (n = 39) and aberrant (n = 12) groups based on GMs assessment; DQ was compared between the groups. We investigated the items in the DQ assessment and found that the infants in the aberrant group were more frequently unable to perform. Infants in the aberrant group showed a significantly lower DQ in the ‘postural-motor domain’, and were more frequently unable to ‘climb the stairs with alternating legs’ and ‘Jump from a 15–20 cm platform’. This study highlights that GMs aberrancy in early infancy is associated with a delayed gross motor development, even in children with a typical development. The GMs assessment may be useful for the prediction of DCD.

Spontaneous movements, motor milestones, and temperament of preterm-born infants: Associations with mother-infant attunement

Preterm-born infants and their mothers are at higher risk of showing less attuned interactions. We sought to identify characteristics of preterm-born infants associated with the attunement of mother-infant interactions at the corrected ages of 3-4 months, looking specifically at motor behaviors. We focused on infants' spontaneous movements, achievement of motor milestones, and temperament, which at this young age is often manifested via movement. Sixty preterm-born infants (Mdn_{gestation age in weeks}  = 33, 57.38% male, corrected age Mdn = 14 weeks, interquartile range = 13-16) and their mothers participated. Independent observers rated mother-infant attunement, infants' spontaneous movements, and infants' achievement of motor milestones. Mothers reported infant temperament. We found infants' smooth and fluent movement character and continual fidgety movements were associated with better attunement in terms of higher maternal sensitivity and non-intrusiveness and higher infant responsiveness and involvement. Unexpectedly, infants' achievement of motor milestones was not significantly associated with mother-infant attunement, and maternal reports of infants' higher soothability were associated with lower maternal sensitivity. The study illustrates the value of including the assessment of infants' spontaneous movements, designed for early detection of neurological deficiencies, in research and in clinical practice with parents and preterm-born infants.

Inter-observer reliability using the General Movement Assessment is influenced by rater experience

OBJECTIVE

To describe the inter-observer reliability of the General Movement Assessment (GMA) among a sample of infants at high-risk of cerebral palsy (CP) among raters with various levels of experience.

METHODS

Video assessments of 150 high-risk infants at 10-15 weeks corrected age were rated by three Prechtl GMA-certified observers with varied experience using the assessment. Videos were scored based on temporal organization of fidgety movements (FMs), presence of abnormal FMs, or absence of FMs. Inter-observer agreements were analyzed with Gwet's AC1 statistic.

RESULTS

We found fair to moderate agreement when subcategories of normal FMs (continuous and intermittent) were included (AC₁ = 0.32-0.57) and moderate to near perfect agreement when normal categories of FMs were combined (AC₁ = 0.60-0.95). Reliability was higher among observers with more experience using the GMA (AC₁ = 0.57-0.98) than the observer with less experience (AC₁ = 0.32-0.61).

CONCLUSIONS

Caution may be warranted when the GMA is used to differentiate "continuous and intermittent" FMs temporal organization. The GMA is highly reliable among experienced raters when comparing normal FMs to other FMs categorizations.

Preterm and writhing movements: is it possible to predict fidgety movements in preterm infants?

BACKGROUND

Preterm infants who do not have fidgety movements at 3 months of corrected age have up to ten times greater risk of developing cerebral palsy or other alterations in motor development, compared to infants who exhibit such movements. The General Movements Assessment (GMA) is a validated tool that may predict the fidgety movement period.

OBJECTIVE

This study aimed to describe the trajectory of the General Movements Assessment (GMA) during the preterm and writhing movements periods in preterm infants and determine the best time point to predict the fidgety movements period.

STUDY DESIGN

Fifty-two preterm newborns were evaluated by the GMA method.

RESULTS

GMA assessment at the age of 5 weeks post term was found the most predictive of neuromotor development disorders in at-risk newborns, with a sensitivity and specificity of 86% and 58%, respectively, and a high negative predictive value (92%) and increased hit ratio (69% accuracy).

CONCLUSION

Preterm infants with ≤34 weeks of gestational age have a high prevalence of poor repertoire classifications on the GMA and one single assessment with GMA near the time of NICU discharge seems to be the best time to determine infants who need to be followed more carefully, but the best time point to predict the fidgety movements period was 5 weeks post term.

Associations Between Early Structural Magnetic Resonance Imaging, Hammersmith Infant Neurological Examination, and General Movements Assessment in Infants Born Very Preterm

OBJECTIVE

To evaluate the prevalence and associations between structural magnetic resonance imaging (sMRI) injury/abnormality at term-equivalent age and absent fidgety General Movements Assessment (GMA) and abnormal Hammersmith Infant Neurological Examination (HINE) scores among infants born very preterm at 3-4 months of corrected age.

STUDY DESIGN

This prospective cohort study enrolled 392 infants born ≤2 weeks of gestation from 5 neonatal intensive care units in the greater Cincinnati area between September 2016 and October 2019. Infants completed sMRI at term-equivalent age and GMA and HINE at 3-4 months of corrected age. All assessors were blinded.

RESULTS

Of 392 infants, 375 (96%) had complete data. Of these, 44 (12%) exhibited moderate or severe brain abnormalities, 17 (4.5%) had abnormal GMA, and 77 (20.3%) had abnormal HINE. Global and regional abnormality scores on sMRI were significantly correlated with GMA (R2 range 0.05-0.17) and HINE at 3-4 months of corrected age (R2 range 0.01-0.17). These associations remained significant in multivariable analyses after adjusting for gestational age and sex. There was a significant but low correlation (R2 0.14) between GMA and HINE.

CONCLUSIONS

We observed a low prevalence of moderate or severe brain abnormalities in survivors born very preterm in this geographically defined cohort. The much greater prevalence of abnormal motor examination on the HINE compared with GMA and their low correlation suggests that these tests evaluate different constructs and, thus, should be used in combination with sMRI rather than interchangeably.

Clinical tools used in young infants born very preterm to predict motor and cognitive delay (not cerebral palsy): a systematic review

AIM

This systematic review evaluates the accuracy of clinical tools used at a corrected age of 6 months or younger to predict motor and cognitive delay (not cerebral palsy) at 24 months' corrected age, in infants born very preterm.

METHOD

Six databases were searched. Quality was evaluated using the Quality Assessment of Diagnostic Accuracy Studies tool. Predictive analysis included calculation of sensitivity and specificity, inspection of summary receiver operating characteristics curves, and bivariate meta-analysis.

RESULTS

Six assessments were identified in 10 studies of 992 infants. Overall prevalence of motor delay was 13.8% and cognitive delay was 11.7%. Methodological quality was variable for patient selection, reference standard, flow, and timing. All studies had a low risk of bias for the index test. General Movement Assessment (GMA) predicted motor and cognitive outcomes with good accuracy for mild, moderate, and severe delays (fidgety age: pooled diagnostic odds ratio=12.3 [5.9-29.8]; hierarchical summary receiver operating characteristics curve=0.733). The Hammersmith Infant Neurological Examination (HINE) demonstrated excellent predictive accuracy for severe motor delay (3mo and 6mo; sensitivity 93% [68-100%], specificity 100% [96-100%]) but showed limited ability to predict milder delays.

INTERPRETATION

In the population of infants born very preterm, few assessment tools used at 6 months or younger corrected age have proven predictive accuracy for cognitive and motor delay at 24 months' corrected age. Only the GMA and HINE demonstrated useful predictive validity.

WHAT THIS PAPER ADDS

General movements have predictive validity for both motor and cognitive dysfunction in infants born very preterm. The Hammersmith Infant Neurological Examination showed the highest predictive accuracy for severe motor delay. The General Movement Assessment was the best tool to predict mild-to-moderate motor and cognitive delays.

Die Bedeutung fötaler und neonataler Motorik für die kindliche Entwicklung und die Früherkennung von Entwicklungsstörungen

Zusammenfassung. Theoretischer Hintergrund: Die von Central Pattern Generators (CPGs) generierten Bewegungen des Neugeborenen und jungen Säuglings haben eine lange pränatale Vorgeschichte. Fragestellung: Welche Bedeutung hat die Analyse der CPG-Aktivität, besonders der General Movements (GMs) in der entwicklungsneurologischen Diagnostik? Methode: Unsere Übersichtsarbeit bezieht sich auf Prechtl’s General Movement Assessment (GMA), das ab dem Frühgeborenenalter bis zum Ende des 5. Monats nach einer Termingeburt anwendbar ist. Ergebnisse: Das GMA ermöglicht die Vorhersage einer Zerebralparese mit einer Sensitivität von 98 % und einer Spezifität von 91 %. Abnormale cramped-synchronized GMs sind ein früher Marker für spastische Zerebralparesen. Das Fehlen von Fidgety Movements (im 3.–5. Monat) weist auf alle Formen der Zerebralparese hin und kann auch bei bestimmten genetischen Erkrankungen auftreten. Zwei von drei Säuglingen mit einer späteren Diagnose Autismus haben atypische GMs und fallen vor allem durch ihre Monotonie in den Bewegungen auf. Diskussion und Schlussfolgerung: Mittels GMA lassen sich mit großer Treffsicherheit typische Entwicklungsverläufe vorhersagen oder aber ein Risiko für einen atypischen Verlauf erkennen und somit frühzeitige Interventionen einleiten.

Diffusion tensor imaging in hyperthyroidism: assessment of microstructural white matter abnormality with a tract-based spatial statistical analysis

BACKGROUND

Metabolic, morphological, and functional brain changes associated with a neurological deficit in hyperthyroidism have been observed. However, changes in microstructural white matter (WM), which can explain the underlying pathophysiology of brain dysfunctions, have not been researched.

PURPOSE

To assess microstructural WM abnormality in patients with untreated or newly diagnosed hyperthyroidism using tract-based spatial statistics (TBSS).

MATERIAL AND METHODS

Eighteen patients with hyperthyroidism and 14 age- and sex-matched healthy controls were included in this study. TBSS were used in this diffusion tensor imaging study for a whole-brain voxel-wise analysis of fractional anisotropy, mean diffusivity, axial diffusivity (AD), and radial diffusivity (RD) of WM.

RESULTS

When compared to the control group, TBSS showed a significant increase in the RD of the corpus callosum, anterior and posterior corona radiata, posterior thalamic radiation, cingulum, superior longitudinal fasciculus, and the retrolenticular region of the internal capsule in patients with hyperthyroidism (P < 0.05), as well as a significant decrease in AD in the anterior corona radiata and the genu of corpus callosum (P < 0.05).

CONCLUSION

This study showed that more regions are affected by the RD increase than the AD decrease in the WM tracts of patients with hyperthyroidism. These preliminary results suggest that demyelination is the main mechanism of microstructural alterations in the WM of hyperthyroid patients.

Early intervention and its short-term effect on the temporal organization of fidgety movements

BACKGROUND

The Prechtl General Movement Assessment (GMA) predicts various neurological and developmental disorders while also documenting therapeutic effects.

AIMS

To describe the temporal organization of fidgety general movements in infants with mild to moderate postural asymmetries and/or tonus regulation problems, and to analyze to what extent the temporal organization of fidgety movements will change after physiotherapy.

STUDY DESIGN

Repeated measure design.

PARTICIPANTS

Twelve infants (five females) with mild to moderate postural asymmetries and/or tonus regulation problems were admitted for an early intervention program. The gestational age ranged from 27 to 40 weeks (Median, 36 weeks; nine infants born preterm) with birth weights ranging from 740 g to 3500 g (Median, 2590 g).

MEASURES

Fidgety movements and their temporal organization were measured using the Prechtl GMA at 9 to 19 weeks post term age (Median, 14 weeks) before and after an early motor training procedure. The movements of one of the infants were analysed using a computer-based approach, measuring the mean and standard deviation of quantity of motion, height of motion and width of motion.

RESULTS

Seven infants had sporadic fidgety movements, and five had intermittent fidgety movements. None had continual fidgety movements before the intervention was initiated. After intervention, the temporal organization of fidgety movements increased in all infants. The observations of these movements were supported by computer-based analysis.

CONCLUSION

The study indicates that early intervention increases the temporal organization of fidgety movements in infants with postural asymmetries and/or tonus regulation problems. The clinical significance of this finding needs to be further evaluated.

Microstructural white matter abnormalities in hypothyroidism evaluation with diffusion tensor imaging tract-based spatial statistical analysis

PURPOSE

Hypothyroidism is presented in a wide range from neuropsychiatric problems including depression, memory and cognitive disorders to poor motor coordination. Against the background of morphologic, functional and molecular changes on the white and grey matter of the brain, we aimed to investigate the effects of hypothyroidism on white matter (WM) integrity using tract-based spatial statistics (TBSS).

METHODS

Eighteen patients with hyperthyroidism and 14 age-sex-matched healthy control subjects were included in this study. TBSS was used in the diffusion tensor imaging study for whole-brain voxel wise analysis of fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD) and radial diffusivity (RD) of WM.

RESULTS

When compared to the control group, the whole brain TBSS revealed extensive reductions of FA in the supratentorial WM including corticospinal tract, posterior limb of the internal capsule (PLIC), uncinate fasciculus, inferior longitudinal fasciculus (p < 0.005). The ROI analyses showed RD increment of superior longitudinal fasciculus, AD decrement of cingulum (CIN), external capsule, PLIC and corpus callosum (CC) in patients with hypothyroidism (p < 0.005). Autoimmune and non-autoimmune hypothyroidism patient subgroups showed a significant difference in terms of hippocampus FA, CIN MD, CC MD, CC AD, CIN RD, SLF RD, CC RD (p < 0.005). CIN FA values showed a negative correlation with the Beck Depression Inventory (p = 0.007, r = - 852).

CONCLUSIONS

These preliminary results of TBSS analyses represented FA and AD decrement, and RD increment in several WM tracts and indicates the demyelination process underlying pathophysiology of clinical aspects of hypothyroidism.

General Movement Assessment from videos of computed 3D infant body models is equally effective compared to conventional RGB video rating

BACKGROUND

General Movement Assessment (GMA) is a powerful tool to predict Cerebral Palsy (CP). Yet, GMA requires substantial training challenging its broad implementation in clinical routine. This inspired a world-wide quest for automated GMA.

AIMS

To test whether a low-cost, marker-less system for three-dimensional motion capture from RGB depth sequences using a whole body infant model may serve as the basis for automated GMA.

STUDY DESIGN

Clinical case study at an academic neurodevelopmental outpatient clinic.

SUBJECTS

Twenty-nine high risk infants were assessed at their clinical follow-up at 2-4 month corrected age (CA). Their neurodevelopmental outcome was assessed regularly up to 12-31 months CA.

OUTCOME MEASURES

GMA according to Hadders-Algra by a masked GMA-expert of conventional and computed 3D body model ("SMIL motion") videos of the same GMs. Agreement between both GMAs was tested using dichotomous and graded scaling with Kappa and intraclass correlations, respectively. Sensitivity and specificity to predict CP at ≥12 months CA were assessed.

RESULTS

Agreement of the two GMA ratings was moderate-good for GM-complexity (κ = 0.58; ICC = 0.874 [95%CI 0.730; 0.941]) and substantial-good for fidgety movements (FMs; Kappa = 0.78, ICC = 0.926 [95%CI 0.843; 0.965]). Five children were diagnosed with CP (four bilateral, one unilateral CP). The GMs of the child with unilateral CP were twice rated as mildly abnormal with FMs. GM-complexity and somewhat less FMs, of both conventional and SMIL motion videos predicted bilateral CP comparably to published literature.

CONCLUSIONS

Our computed infant 3D full body model is an attractive starting point for automated GMA in infants at risk of CP.

Diffusion tensor imaging is associated with motor outcomes of very preterm born children at 11 years of age

AIM

Very preterm children born <32 weeks of gestation are at risk for motor difficulties such as cerebral palsy and developmental coordination disorder. This study explores the association between diffusion tensor imaging metrics at term and motor outcomes at 11 years of age.

METHODS

A cohort of 37 very preterm infants (mean gestational age 29 4/7, SD 2 0/7) born in 2004-2006 in Turku University Hospital underwent diffusion tensor imaging at term. A region of interest analysis of fractional anisotropy and mean diffusivity was performed. Motor outcomes at 11 years of age were measured with the Movement Assessment Battery for Children - Second Edition.

RESULTS

The diffusion metrics of the corpus callosum (genu P = .005, splenium P = .049), the left corona radiata (P = .035) and the right optic radiation (P = .017) were related to later motor performance. Mean diffusivity decreased and fractional anisotropy increased in proportion to the improving performance.

CONCLUSION

The diffusion metrics of the genu and splenium of the corpus callosum, the left corona radiata and the right optic radiation at term were associated with motor skills at 11 years of age. Diffusion tensor imaging should be further studied as a potential tool in recognising children at risk for motor impairment.

Correlates of Normal and Abnormal General Movements in Infancy and Long-Term Neurodevelopment of Preterm Infants: Insights from Functional Connectivity Studies at Term Equivalence

Preterm infants born before 32 weeks gestation have increased risks for neurodevelopmental impairment at two years of age. How brain function differs between preterm infants with normal or impaired development is unknown. However, abnormal spontaneous motor behavior at 12-15 weeks post-term age is associated with neurodevelopmental impairment. We imaged brain blood oxygen level-dependent signals at term-equivalent age in 62 infants born at <32 weeks gestation and explored whether resting state functional connectivity (rsFC) differed with performances on the General Movement Assessment (GMA) at 12-15 weeks, and Bayley III scores at two years of corrected age. Infants with aberrant general movements exhibited decreased rsFC between the basal ganglia and regions in parietal and frontotemporal lobes. Infants with normal Bayley III cognitive scores exhibited increased rsFC between the basal ganglia and association cortices in parietal and occipital lobes compared with cognitively impaired children. Infants with normal motor scores exhibited increased rsFC between the basal ganglia and visual cortices, compared with children with motor impairment. Thus, the presence of abnormal general movements is associated with region-specific differences in rsFC at term. The association of abnormal long-term neurodevelopmental outcomes with decreased rsFC between basal ganglia and sub-score specific cortical regions may provide biomarkers of neurodevelopmental trajectory and 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.].

Automatic Posture and Movement Tracking of Infants with Wearable Movement Sensors

Infants’ spontaneous and voluntary movements mirror developmental integrity of brain networks since they require coordinated activation of multiple sites in the central nervous system. Accordingly, early detection of infants with atypical motor development holds promise for recognizing those infants who are at risk for a wide range of neurodevelopmental disorders (e.g., cerebral palsy, autism spectrum disorders). Previously, novel wearable technology has shown promise for offering efficient, scalable and automated methods for movement assessment in adults. Here, we describe the development of an infant wearable, a multi-sensor smart jumpsuit that allows mobile accelerometer and gyroscope data collection during movements. Using this suit, we first recorded play sessions of 22 typically developing infants of approximately 7 months of age. These data were manually annotated for infant posture and movement based on video recordings of the sessions, and using a novel annotation scheme specifically designed to assess the overall movement pattern of infants in the given age group. A machine learning algorithm, based on deep convolutional neural networks (CNNs) was then trained for automatic detection of posture and movement classes using the data and annotations. Our experiments show that the setup can be used for quantitative tracking of infant movement activities with a human equivalent accuracy, i.e., it meets the human inter-rater agreement levels in infant posture and movement classification. We also quantify the ambiguity of human observers in analyzing infant movements, and propose a method for utilizing this uncertainty for performance improvements in training of the automated classifier. Comparison of different sensor configurations also shows that four-limb recording leads to the best performance in posture and movement classification.

Olfactory Bulb Microstructural Changes in Patients With Nasal Septum Deviation

OBJECTIVE

The aim of this study is to assess the microstructural changes to the olfactory bulb (OB) in patients with nasal septum deviation (NSD) using diffusion tensor imaging and to research the association between these changes and the degree of NSD.

METHODS

Ninety-six patients with NSD (46 males, 50 females) who received diffusion tensor imaging were assessed by 2 independent readers. The patients were separated into 3 groups according to the NSD angle. The fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values of the ipsilateral and contralateral OB were measured in all NSD patients by region of interest.

RESULTS

According to deviation side, there was significant difference between the right (R) and left (L) OB FA and ADC values across the 3 groups. In patients with left- and right- sided NSD, FA and ADC values for the left and right OB were significantly different between groups 1 and 3, and groups 2 and 3. There was negative correlation between L-FA (r = -0.481, P = 0.001; r = -0.496, P = 0.001) and R-FA (r = -0.705, P = 0.001; r = -0.286, P = 0.02) versus age and deviation angle. However, there was positive correlation between L-ADC versus age and deviation angle (r = 0.493, P = 0.001; r = 0.482, P = 0.001), as well as positive correlation between R-ADC versus age (r = 0.646, P = 0.001).

CONCLUSION

This is the first study showing ADC increase and FA decrease associated with axonal damage and microstructural integrity loss based on the side of deviation in NSD patients. It has also shown that this abnormality is directly proportional with NSD degree.

Brain structure and neurological and behavioural functioning in infants born preterm

AIM

To examine: (1) relationships between brain structure, and concurrently assessed neurological and behavioural functioning, in infants born preterm at term-equivalent age (TEA; approximately 38-44wks); and (2) whether brain structure-function relationships differ between infants born very (24-29wks) and moderate-late (32-36wks) preterm.

METHOD

A total of 257 infants (91 very preterm, 166 moderate-late preterm; 120 males, 137 females) had structural magnetic resonance imaging (MRI) and neurological and behavioural assessments (Prechtl's general movements assessment, Neonatal Intensive Care Unit Network Neurobehavioral Scale [NNNS] and Hammersmith Neonatal Neurological Examination [HNNE]). Two hundred and sixty-three infants (90 very preterm, 173 moderate-late preterm; 131 males, 132 females) had diffusion MRI and assessments. Associations were investigated between assessment scores and global brain volumes using linear regressions, regional brain volumes using Voxel-Based Morphometry, and white matter microstructure using Tract-Based Spatial Statistics.

RESULTS

Suboptimal scores on some assessments were associated with lower fractional anisotropy and/or higher axial, radial, and mean diffusivities in some tracts: NNNS attention and reflexes, and HNNE total score and tone, were associated with the corpus callosum and optic radiation; NNNS quality of movement with the corona radiata; HNNE abnormal signs with several major tracts. Brain structure-function associations generally did not differ between the very and moderate-late preterm groups.

INTERPRETATION

White matter microstructural alterations may be associated with suboptimal neurological and behavioural performance in some domains at TEA in infants born preterm. Brain structure-function relationships are similar for infants born very preterm and moderate-late preterm.

WHAT THIS PAPER ADDS

Brain volume is not related to neurological/behavioural function in infants born preterm at term. White matter microstructure is related to some neurological/behavioural domains at term. Brain-behaviour relationships are generally similar for infants born very preterm and moderate-late preterm.

The Test of Infant Motor Performance at 3 months predicts language, cognitive, and motor outcomes in infants born preterm at 2 years of age

AIM

To determine the relationship between the Test of Infant Motor Performance (TIMP) at 3 months and cognitive, language, and motor outcomes on the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) at 2 years of age in high-risk infants born preterm.

METHOD

One hundred and six infants (47 females, 59 males) born at earlier than 31 weeks gestational age were prospectively tested with the TIMP at 10 to 15 weeks after term age and were assessed again with the Bayley-III at 2 years corrected age. Sensitivity and specificity were calculated for various cut points of the TIMP z-score and Bayley-III composite scores of no more than 85.

RESULTS

The TIMP z-scores at 10 to 15 weeks of age were significantly associated with all three subscales on the Bayley-III at 2 years of age (p<0.001). Using a TIMP z-score cutoff of -0.5, specificity was relatively high for cognitive (87%), language (88%), and motor (89%) outcomes, but sensitivity was low (cognitive 41%, language 49%, motor 57%).

INTERPRETATION

This study demonstrates that the TIMP is related to cognitive, language, and motor outcomes on the Bayley-III at 2 years of age in high-risk infants born preterm.

WHAT THIS PAPER ADDS

The Test of Infant Motor Performance (TIMP) predicts Bayley Scales of Infant and Toddler Development, Third Edition outcomes at 2 years of age. The TIMP is relatively good at discriminating between children who will and will not have typical development.

Developmental outcome in a group of twins: Relation to perinatal factors and general movements

BACKGROUND

The quality of general movements (GMs) has proven to have predictive value for the developmental outcome, but this has not yet been studied in twins.

AIMS

Our aim was to analyse the quality of GMs and neurological and developmental outcome in relation to the gestational age (GA), mode of conception and other perinatal risk factors in a group of twins.

STUDY DESIGN

The documentation of twins referred for follow-up in the period from 1998 to 2016 was studied retrospectively. Data concerning the quality of GMs, perinatal risk factors and developmental outcome were analysed.

SUBJECTS

Eighty-nine twin pairs, GA from 24 to 38 weeks (median 35.0; IQR 3), birth weight 670 g-3820 g (median 2323; IQR 645) were included.

OUTCOME MEASURES

Results of neurological, psychological and speech/language development and school outcome were analysed.

RESULTS

GMs at term age and at three to four months postterm age did not differ with regard to the mode of conception. Preterm birth was significantly related to GMs at three to four months postterm age. At term age, GMs were significantly related to neurological outcome, while at three to four months postterm age, GMs were related to both the neurological and psychological outcome. Difficulties in speech/language development were diagnosed in almost half of the children, more frequently in boys and children with lower Apgar scores.

CONCLUSION

The study highlights the value of GMs for predicting the developmental outcome in twins and indicates the importance of developmental, especially speech/language, follow-up in twins.

General Movements: A Behavioral Biomarker of Later Motor and Cognitive Dysfunction in NICU Graduates

Infants who have graduated from a neonatal intensive care unit require close follow-up because they have a greater chance of experiencing later motor and cognitive difficulties; however, these difficulties are often challenging to identify at an early age. The General Movement Assessment is a low-cost and highly reliable tool that can indicate abnormal neurological development in young high-risk infants, but it has not yet been widely implemented in the United States. In this review, we discuss the literature about the use of the General Movement Assessment in high-risk infants and how to implement the tool in a clinical setting. [Pediatr Ann. 2018;47(4):e159-e164.].

Neural substrate and clinical significance of general movements: an update

General movements are present from early fetal life to 3 to 5 months corrected age. Atypical general movements, especially in the last, so-called fidgety general movement phase, are predictive of cerebral palsy (CP). This review updates knowledge on the neural substrate and clinical significance of typical and atypical general movements. Typical general movements are primarily characterized by complexity and variation. Presumably these core characteristics are initially induced by modulating activity of the cortical subplate. When the subplate gradually dissolves between 3 months before term and 3 months corrected age the cortical plate takes over. This coincides with the fidgety general movement phase. Conceivably, fidgety activity reflects 'sparsification', i.e. fragmentation of cortical network activity. The quintessential feature of atypical general movements is reduced complexity and variation. This is attributed to impaired integrity of extensive cortical-subcortical networks, in which the subplate and periventricular white matter play a prominent role. The most serious forms of network impairment are associated with absent fidgety movements.

WHAT THIS PAPER ADDS

The emergence of fidgety movements reflects a developmental transition from widespread to fragmented cortical network activity. Atypical general movements characterized by reduced complexity and variation are attributed to impaired integrity of extensive cortical-subcortical networks.

Combined fetal inflammation and postnatal hypoxia causes myelin deficits and autism-like behavior in a rat model of diffuse white matter injury

Diffuse white matter injury (WMI) is a serious problem in extremely preterm infants, and is associated with adverse neurodevelopmental outcome, including cognitive impairments and an increased risk of autism-spectrum disorders. Important risk factors include fetal or perinatal inflammatory insults and fluctuating cerebral oxygenation. However, the exact mechanisms underlying diffuse WMI are not fully understood and no treatment options are currently available. The use of clinically relevant animal models is crucial to advance knowledge on the pathophysiology of diffuse WMI, allowing the definition of novel therapeutic targets. In the present study, we developed a multiple-hit animal model of diffuse WMI by combining fetal inflammation and postnatal hypoxia in rats. We characterized the effects on white matter development and functional outcome by immunohistochemistry, MRI and behavioral paradigms. Combined fetal inflammation and postnatal hypoxia resulted in delayed cortical myelination, microglia activation and astrogliosis at P18, together with long-term changes in oligodendrocyte maturation as observed in 10 week old animals. Furthermore, rats with WMI showed impaired motor performance, increased anxiety and signs of autism-like behavior, i.e. reduced social play behavior and increased repetitive grooming. In conclusion, the combination of fetal inflammation and postnatal hypoxia in rats induces a pattern of brain injury and functional impairments that closely resembles the clinical situation of diffuse WMI. This animal model provides the opportunity to elucidate pathophysiological mechanisms underlying WMI, and can be used to develop novel treatment options for diffuse WMI in preterm infants.