The Knowledge Translation of Early Cerebral Palsy (KiTE CP) study: Implementing Screening among a High-risk Prospective Cohort of Australian Infants

OBJECTIVE

To describe the implementation of the international guidelines for the early diagnosis of cerebral palsy (CP) and engagement in the screening process in an Australian cohort of infants with neonatal risk factors for CP.

STUDY DESIGN

Prospective cohort study of infants with neonatal risk factors recruited at <6 months corrected age from 11 sites in the states of Victoria, New South Wales, and Queensland, Australia. First, we implemented a multimodal knowledge translation strategy including barrier identification, technology integration, and special interest groups. Screening was implemented as follows: infants with clinical indications for neuroimaging underwent magnetic resonance imaging and/or cranial ultrasound. The Prechtl General Movements Assessment (GMA) was recorded clinically or using an app (Baby Moves). Infants with absent or abnormal fidgety movements on GMA videos were offered further assessment using the Hammersmith Infant Neurological Examination (HINE). Infants with atypical findings on 2/3 assessments met criteria for high risk of CP.

RESULTS

Of the 597 infants (56% male) recruited, 95% (n = 565) received neuroimaging, 90% (n = 537) had scorable GMA videos (2% unscorable/8% no video), and 25% (n = 149) HINE. Overall, 19% of the cohort (n = 114/597) met criteria for high risk of CP, 57% (340/597) had at least 2 normal assessments (of neuroimaging, GMA or HINE), and 24% (n = 143/597) had insufficient assessments.

CONCLUSIONS

Early CP screening was implemented across participating sites using a multimodal knowledge translation strategy. Although the COVID-19 pandemic affected recruitment rates, there was high engagement in the screening process. Reasons for engagement in early screening from parents and clinicians warrant further contextualization and investigation.

Long-term neurodevelopmental outcome in preterm infants with intraventricular haemorrhage

BACKGROUND

Intraventricular haemorrhage (IVH) is one of the key risks for long-term neurodevelopmental issues. There remains controversy over the impact low-grade IVH has on the long-term outcome of premature infants. This study describes the long-term neurodevelopmental impact of Grade I and II IVH in former preterm infants in the early school years.

METHODS

This is a retrospective cohort analysis from one tertiary neonatal intensive care unit (NICU) in Australia including all infants born at <30 weeks' gestation and admitted to the NICU between 2006 and 2013 with complete ultrasound reports and follow-up results. Results of standardised tests for neurodevelopmental outcomes at 5 and 8 years were compared between infants who suffered mild IVH and infants who had normal head ultrasounds.

RESULTS

During the study period, 491 infants <30 weeks gestation were admitted; 275 patients had full follow-up data available. We found no significant difference in examined outcomes at 5- and 8-year follow-up.

CONCLUSION

Mild IVH does not affect cognitive, motor and academic outcomes at school age.

Neurodevelopmental Outcomes of Premature Infants Treated for Patent Ductus Arteriosus: A Population-Based Cohort Study

OBJECTIVE

To compare neurodevelopmental outcomes of extremely preterm infants diagnosed with patent ductus arteriosus (PDA) who were treated medically or surgically and those who were not diagnosed with PDA or who did not undergo treatment for PDA.

STUDY DESIGN

This retrospective population-based cohort study used data from a geographically defined area in New South Wales and the Australian Capital Territory served by a network of 10 neonatal intensive care units. Patients included all preterm infants born at <29 completed weeks of gestation between 1998 and 2004. Moderate/severe functional disability at 2-3 years corrected age was defined as developmental delay, cerebral palsy requiring aids, sensorineural or conductive deafness (requiring bilateral hearing aids or cochlear implant), or bilateral blindness (best visual acuity of <6/60).

RESULTS

Follow-up information at age 2-3 years was available for 1473 infants (74.8%). Compared with infants not diagnosed with a PDA or who did not receive PDA treatment for PDA, those with medically treated PDA (aOR, 1.622; 95% CI, 1.199-2.196) and those with surgically treated PDA (aOR, 2.001; 95% CI, 1.126-3.556) were at significantly greater risk for adverse neurodevelopmental outcomes at age 2-3 years.

CONCLUSION

Our results demonstrate that treatment for PDA may be associated with a greater risk of adverse neurodevelopmental outcome at age 2-3 years. This was particularly so among infants born at <25 weeks gestation. These results may support permissive tolerance of PDAs; however, reasons for this association remain to be elucidated through carefully designed prospective trials.

Treatment of Primary Fetal Hydrothorax with OK-432 (Picibanil): Outcome in 14 Fetuses and a Review of the Literature

Background: Primary fetal hydrothorax (PFHT) is an uncommon condition with an estimated prevalence of 1 in 10,000/15,000 pregnancies. Therapeutic interventions include thoracocentesis, thoraco-amniotic shunting (TAS), and pleurodesis using OK-432. Methods: A review of the literature was performed to identify all cases of PFHT treated with TAS and OK-432. All cases of PFHT referred to the Fetal Maternal Unit at Royal Prince Alfred Hospital between 2002 and 2012 were retrospectively reviewed. In the cohort of fetuses treated with OK-432, the main perinatal outcomes evaluated were termination of pregnancy, live birth, neonatal death, and fetal death in utero. Secondary outcomes included gestational age (GA) at diagnosis, GA at treatment, GA at resolution, birth weight, and GA at birth. The development of the children was screened using the Ages and Stages Questionnaires, Version 3 (ASQ-3, 2009). Results: Primary hydrothorax was diagnosed in 31 fetuses, of which 14 had treatment with OK-432. One pregnancy terminated after treatment with OK-432. Survival was 85% (11/13): 100% in fetuses treated with OK-432 without hydrops, and 78% in those treated with hydrops. This compares well to the cases of TAS in the literature with an average survival of 63%: 85% in fetuses without hydrops and 55% with hydrops. The mean GA at birth was 36+4 weeks and mean birth weight 3,007 g. Eight of the 9 children screened with ASQ-3 scored well within the normal range. Conclusion: OK-432 appears to be a valid treatment option in fetuses with PFHT, particularly in those diagnosed at early GAs.

Long term follow up of high risk children: who, why and how?

BACKGROUND

Most babies are born healthy and grow and develop normally through childhood. There are, however, clearly identifiable high-risk groups of survivors, such as those born preterm or with ill-health, who are destined to have higher than expected rates of health or developmental problems, and for whom more structured and specialised follow-up programs are warranted.

DISCUSSION

This paper presents the results of a two-day workshop held in Melbourne, Australia, to discuss neonatal populations in need of more structured follow-up and why, in addition to how, such a follow-up programme might be structured. Issues discussed included the ages of follow-up, and the personnel and assessment tools that might be required. Challenges for translating results into both clinical practice and research were identified. Further issues covered included information sharing, best practice for families and research gaps.

SUMMARY

A substantial minority of high-risk children has long-term medical, developmental and psychological adverse outcomes and will consume extensive health and education services as they grow older. Early intervention to prevent adverse outcomes and the effective integration of services once problems are identified may reduce the prevalence and severity of certain outcomes, and will contribute to an efficient and effective use of health resources. The shared long-term goal for families and professionals is to work toward ensuring that high risk children maximise their potential and become productive and valued members of society.

Predicting the outcome of specific language impairment at five years of age through early developmental assessment in preterm infants

BACKGROUND

Very preterm infants (<30 weeks of gestation) are at increased risk of specific language impairment and systematic developmental follow-up is essential for the provision of targeted early intervention.

AIMS

To define the predictive value of early language testing and stability of language development, and perinatal and demographic risk factors for the diagnosis of SLI at 5 years, in a cohort of preterm infants.

STUDY DESIGN

We used a retrospective hospital based cohort study.

SUBJECTS

Preterm infants <30 weeks of gestation, were cared for in NICU at RPAH, between 2004 and 2007, and prospectively enrolled in developmental follow-up. Standardised developmental assessment was done at 3 years utilising the Bayley Scales of Infant and Toddler Development-III and the Wechsler Preschool and Primary Scale of Intelligence-III was done at 5 years.

OUTCOME MEASURES

Predictive value and stability of early language testing were assessed with respect to SLI at 5 years, using measures of diagnostic accuracy and kappa values. Multivariate logistic regression was performed during the distribution of perinatal and demographic risk factors for SLI.

RESULTS

One-in-five met diagnostic criteria for SLI (19%, n=24). Limited diagnostic accuracy was found with early expressive language and the stability of language scores demonstrated only fair agreement (Cohen's κ .383). Multilingual status and extreme gestational age at 24-25 weeks were associated with a six-fold increased risk of SLI (OR 6.09, 95% CI 1.89-19.56; OR 6.09, 95% CI 1.28-29.0).

CONCLUSION

We defined a high incidence of SLI among our cohort, but only a limited diagnostic accuracy of early language testing. Multilingual status and extreme prematurity were independent risk factors for SLI. It remains imperative to perform continued developmental assessments beyond pre-school age to identify language impairment with greater accuracy.

Antioxidant efficacy on human skin in vivo investigated by UVA-induced chemiluminescence decay analysis via induced chemiluminescence of human skin

BACKGROUND/AIMS

Exogenous factors (e.g. physical: UV irradiation; or chemical: hydrogen peroxide) and endogenous metabolic processes (e.g. cellular respiration, oxidative burst, etc.) generate oxidative stress in living tissues which are in balance with enzymatic antioxidative systems and ingested antioxidants under normal conditions. These complex biological reactions are accompanied by chemiluminescence (ultraweak photon emission). However, knowledge about the chemiluminescence decay characteristics of human skin and the modulatory influence of topically applied antioxidants is still scarce.

METHODS

Using ICL-S (induced chemiluminescence of human skin), a highly sensitive in vivo method, the decay characteristics of UVA-induced photon emission caused by different UVA doses were investigated in detail. In addition, modulatory properties of topical antioxidant pretreatment were examined for 2 weeks.

RESULTS

UVA-induced chemiluminescence signals were generally characterized by two distinct decay phases: an initial burst (0-5 s), contributing approximately 80% of the complete signal with an inverse dose-response relationship (UVA dose vs. chemiluminescence intensity), followed by a second decay phase (delayed chemiluminescence, 5-200 s) showing a direct correlation. Antioxidant pretreatment caused a reduction in signal intensity of approximately 50%, which was calculated by signal integration and confirmed using the modulation of the intersection point of decay curves resulting from irradiation with different UVA doses at constant intensity with and without treatment.

CONCLUSION

In addition to the established UVA filter testing (independent from UVB filter content) on human skin in vivo, ICL-S is also a valuable tool for the efficacy testing of topically applied antioxidants under in vivo conditions in humans. The first rapid, but short, decay phase not only provides approximately 80% of the complete chemiluminescence signal, but is also essential for the investigation of antioxidant-mediated effects. Chemiluminescence signal modulations induced by UVA intensity reduction (e.g. UV filters in daily care products) can be clearly distinguished from antioxidant-mediated signal modulations. The probe head dimensions permit comprehensive in vivo testing in humans on practically every skin area (e.g. arms, legs, back, abdomen and face).

Motor impairment and low achievement in very preterm children at eight years of age

AIM

To examine the concurrence of motor impairment and academic underachievement in a group of very preterm children at 8 years of age.

METHODS

All surviving children with a gestational age less than 30 weeks, admitted to the neonatal intensive care unit between 1987 and 1997, were prospectively enrolled in developmental follow-up. Children with a neurosensory disability or a low intelligence score (FSIQ < or = 75 points) were excluded. At 8 years of age the Bruininks Oseretsky Test of Motor Proficiency and standardised tests of academic achievement were administered to a sample of 323 very preterm children.

RESULTS

One hundred and one (31.3%) of these very preterm children were identified as having Developmental Coordination Disorder (DCD). Of the children with DCD, 54.4% also had underachievement in literacy and/or numeracy. As the severity of motor impairment increased so too did the severity and complexity of underachievement. Significantly fewer children with motor impairments participated in after-school sporting activities. Children with DCD required more mechanical ventilation support during their hospital admission.

CONCLUSIONS

This study demonstrated that a significant proportion of children born very preterm find both motor and academic skills difficult in early school years.

Low superior vena cava flow and effect of inotropes on neurodevelopment to 3 years in preterm infants

OBJECTIVE

The goal was to report the 1- and 3-year outcomes of preterm infants with low systemic blood flow in the first day and the effect of dobutamine versus dopamine for treatment of low systemic blood flow.

METHODS

A cohort of 128 infants born at <30 weeks of gestation underwent echocardiographic measurement of superior vena cava flow at 3, 10, and 24 hours of age. Forty-two infants with low superior vena cava flow (<41 mL/kg per minute) were assigned randomly to dobutamine or dopamine. Surviving infants underwent blinded neurodevelopmental assessments at corrected ages of 1 and 3 years.

RESULTS

Seventy-six of 87 surviving infants were seen at 1 year and 67 at 3 years. Forty-four infants had low superior vena cava flow. At 3 years, with adjustment for perinatal risk factors, death was predicted by low superior vena cava flow, lower gestational age, and low 5-minute Apgar score. Substantial reductions in the Griffiths General Quotient were associated with low superior vena cava flow and birth weight of <10th percentile. Infants with low flow had significant reductions in personal-social, hearing and speech, and performance subscales. Death or disability at 3 years was predicted by low superior vena cava flow and lower gestational age. For infants treated with inotropes, no significant differences were found in clinical outcomes, except for reduced rates of late severe periventricular/intraventricular hemorrhage in the dobutamine group. At 3 years, infants in the dopamine group had significantly more disability and a lower Griffiths General Quotient. At the latest time measured, however, combined rates of death or disability were similar.

CONCLUSIONS

Early low superior vena cava flow was associated with substantial rates of death, morbidity, and developmental impairments. No difference was found in combined rates of death and disability for infants assigned randomly to dopamine or dobutamine.

Phonology, rapid naming and academic achievement in very preterm children at eight years of age

AIM

To examine the impact and additive effect of phonology and rapid naming deficits on reading, spelling and mathematics achievement in a group of very preterm children at 8 years of age.

METHODS

All surviving children with a gestational age less than 30 weeks, admitted to the neonatal intensive care unit at Royal Prince Alfred Hospital, in 1994 and 1995, were prospectively enrolled in developmental follow-up. Children with a neurosensory disability or a low intelligence score (FSIQ<or=85 points) were excluded. At 8 years of age standardised psychometric measures of cognition, linguistic ability and academic achievement were administered to a sample of 63 children.

RESULTS

Twenty-four (38.1%) children showed low achievement in reading, spelling or mathematics. Of these, 18 (75%) children showed low achievement in reading. Reading achievement was significantly correlated to phonological awareness, rapid naming and expressive vocabulary. Children with phonological awareness and rapid naming deficits showed significantly more delay in reading than children without such deficits. Children who had rapid naming deficits were more likely to show multiple skill delays. Rapid naming showed significant, though modest correlations with immaturity and illness variables. Maternal education was significantly associated with achievement.

CONCLUSIONS

Phonological awareness does predict reading performance in very preterm children. Rapid naming appears to be related to complex multiple academic delays, and may reflect a neurological timing or efficiency factor with effects independent of intelligence and significantly influenced by immaturity and illness.

Educational and therapeutic resource dependency at early school-age in children who were born very preterm

AIM

To examine the incidence of educational and therapeutic resource dependency in a group of very preterm children at 8 years of age.

METHODS

All children with a gestational age less than 30 weeks, who survived to discharge from the neonatal intensive care unit at Royal Prince Alfred Hospital, between 1987 and 1994, were prospectively enrolled in developmental follow-up. At 8 years of age, information regarding resource dependency was obtained from parents and teachers using interviews and questionnaires. Standardized psychometric measures of cognition and academic achievement were administered.

RESULTS

Information was obtained for 365 (73.3%) of surviving 8-year-old children; 65 (17.8%) had a neurosensory disability and 24 (36.9%) children in this group were in full-time special education. In those without neurosensory disability (n=300), seven (2.3%) children were already in full-time special education for an intellectual deficit. Among children in mainstream education, 154/293 (52.5%) had received or were still receiving additional assistance in some form (part-time special education, grade retention, therapeutic intervention or private tutoring). Difficulty in literacy was the most commonly reported problem. Resource dependency was not related to gestation nor predicted by intelligence in children without neurosensory disability, but was related to maternal education. Children who had had or were continuing to receive part-time assistance showed delays in academic skills at assessment.

CONCLUSIONS

A high level of on-going resource dependency exists in this group in an attempt to maintain grade appropriate achievement. Resource dependency is not related to gestation in neurologically normal children. General cognitive measures of intelligence do not predict these problems in the majority of children.

Low superior vena cava flow and neurodevelopment at 3 years in very preterm infants

OBJECTIVES

Low superior vena cava (SVC) flow is common in the first hours after very preterm birth and has a strong association with subsequent periventricular/intraventricular hemorrhage. We report the neurodevelopmental outcome at 3 years of age of very preterm babies who had serial echocardiographic studies, including measures of SVC flow, during the first 48 hours after birth.

STUDY DESIGN

A prospective observational study was performed on a cohort of 126 babies (<30 weeks), 103 of whom survived to discharge. Neurodevelopmental follow-up data, which included abnormal developmental quotient, abnormal motor score, and cerebral palsy, were available for 93% of this cohort at 3 years of age. Relations between 3-year outcome and early hemodynamic measures and clinical parameters were explored.

RESULTS

After controlling for confounding variables, average SVC flow over the first 24 hours of life was significantly associated with the primary outcome of death or survival with any disability (P=.004) and with the secondary outcome of abnormal developmental quotient (P = .006). A greater number of low SVC flow readings during the first 24 hours was significantly related to death and adverse developmental outcome, but the individual lowest SVC flow was not, suggesting the importance of duration of low SVC flow. After adjustment, there was no significant association between average mean blood pressure over the first 24 hours and abnormal developmental outcome, whereas the proportion of mean blood pressure readings less than the gestational age showed a trend toward an association with death and any disability.

CONCLUSIONS

Low early postnatal blood flow to the upper body and brain may be one factor in the causal pathway of impaired preterm neurodevelopmental outcome.

Assessment of neurological status in preterm infants in neonatal intensive care and prediction of cerebral palsy

The purpose of this study was to determine the diagnostic accuracy of a neurological assessment performed before discharge from the nursery to predict cerebral palsy at three years of age in preterm infants. Infants born < 31 weeks gestation between 1992 and 1996 were assessed using the Lacey Assessment of the Preterm Infant (LAPI) prior to discharge. Infants were classified as having no abnormality, possible abnormality, or definite abnormality. At three years of age, the infants had a neurological examination. Infants were stratified into those assessed at < or = 33 weeks postmenstrual age and those assessed at least once > 33 weeks postmenstrual age. Of the 203 infants, 36 were diagnosed with cerebral palsy at three years. Seven were assessed < or = 33 postmenstrual age and 29 were assessed > 33 weeks postmenstrual age. For infants assessed < or = 33 weeks and classified as having any abnormality (possible or definite), the LAPI had 86% sensitivity, 83% specificity, and 96% negative predictive value for subsequent cerebral palsy. The LAPI was less accurate when applied to infants < 33 weeks postmenstrual age. The LAPI is an accurate diagnostic tool in the preterm period for the prediction of normal motor development or cerebral palsy at three years of age. This information may be used to target intervention.

Very preterm children who do not cooperate with assessments at three years of age: skill differences at five years

This study examined skill differences at 5 years of age for very preterm children who were or were not cooperative with developmental testing at 3 years of age. All children born between 1986 and 1991 who were less than 30 weeks of gestation were followed prospectively. Two hundred one children were seen at both the 3- and 5-year assessments. Of the 201 children, 24 (11.9%) who had been uncooperative in the assessment at 3 years were seen at 5 years. Uncooperative children were matched to a group of cooperative children for sex, gestation, and/or birth weight. Nonparametric analyses revealed that scores on the Binet Pattern Analysis (p < .01) and the Bead Memory (p < .01) subtests were significantly different between the groups. The uncooperative children scored significantly more often in the at-risk range for tests of minor neurological dysfunction (MND; p < .01) compared with cooperative matched controls. The authors speculate that in very preterm children, uncooperative behavior shown at 3 years of age associated with poor visual/spatial skills and a high level of MND at 5 years of age may reveal children at risk for the development of nonverbal learning disabilities.

Short- and long-term neurological outcomes following neonatal chest physiotherapy

OBJECTIVE

To test the hypothesis that chest physiotherapy in extremely premature infants is associated with abnormal neurological outcomes.

METHODS

All babies born during the years 1992-1994 at gestations of 24-29 weeks who survived to 28 days were included in the study cohort (n=213). Chest physiotherapy was provided by trained physiotherapists for babies with secretions causing obstruction to the airway or for babies with evidence of collapse and/or consolidation. The relationship between chest physiotherapy and cystic brain lesions at discharge, or cerebral palsy (CP) and developmental quotient (DQ) at 1 year corrected age, were then explored.

RESULTS

Ninety-seven babies (45% of the cohort) received physiotherapy. No baby had a brain lesion similar to that described as encephaloclastic porencephaly. Babies receiving physiotherapy had significantly lower birthweights and gestational ages. Of the 13 babies found to have either periventricular leucomalacia or porencephalic cysts, seven (7%) were in the physiotherapy group, and six (5%) were in the nonphysiotherapy group. Of the babies surviving to 1 year corrected age, 189 (92%) had multidisciplinary follow-up. Eleven (13%) of the babies who received physiotherapy had suspected CP, and 14 (13%) of those not receiving physiotherapy had CP. The DQ of those who received physiotherapy was 96.0+/-16.6, and 101.6+/-16.6 for those who did not. Following adjustment for gestational age and other unequal risk factors using logistic regression, none of the above outcomes was significantly associated with the number of physiotherapy treatments.

CONCLUSION

We could find no evidence that chest physiotherapy, as given in our unit, was associated with abnormal neurological outcomes in extremely preterm infants.

Developmental outcome at 12 months corrected age for infants born less than 30 weeks gestation: influence of reduced intrauterine and postnatal growth

Infants born at less than 30 weeks gestation were prospectively followed to examine the consequences of size at birth and subsequent growth on development in the first year of life. A total of 438 infants were admitted to the intensive care nursery; 53 (12.1%) infants were small for gestational age (SGA). A total of 315 infants survived to discharge; 19 (6%) were SGA. SGA infants were matched with appropriate for gestational age (AGA) infants for sex, GA, incidence of chronic lung disease and head ultrasound at discharge. The high death rate amongst SGA infants was attributable to a combination of extreme prematurity and inappropriate intrauterine growth. There was no difference between SGA and AGA groups for major developmental disability at 1-year corrected age. The effect of subsequent growth on development was examined by comparing children in the cohort above (Appropriate) and below (Small) the 10th percentile for weight at 1 year. Children small at 1 year had a significantly higher rate of major developmental disability at 1 year. Perinatal variables demonstrate that those infants small at 1 year had been of significantly younger GA, lighter BW, had received more ventilator and oxygen therapy. They also had a higher incidence of chronic lung disease. Thus, being born SGA at less than 30 weeks is not of itself associated with increased disability at 1 year when other confounding factors are taken into account. While a causal link has not been established, poor growth in the first year of life does appear to be associated with poorer outcome at 1 year, irrespective of birth status.

Serum analyte pattern characteristic of fulminant hepatic failure

Fulminant hepatic failure (FHF) is a poorly understood condition in which total liver failure occurs and is thought to be caused by a variety of conditions including Reye's syndrome, hepatitis, drug overdoses, and vascular insufficiency. While this condition is an uncommon one, it carries with it a high fatality rate and must therefore be diagnosed as rapidly as possible. Six patients have been observed over a two-year period with biopsy and/or autopsy-confirmed FHF: one with acute hepatitis B-delta; three with histories of alcoholism, two of them with cirrhosis; one with acute tylenol overdose; and one with hepatic vascular insufficiency. All of these patients, except one, exhibited a rapid, fatal downhill course after onset of symptoms. In all of these patients, a consistent elevation was observed in serum levels of aspartate aminotransferase (AST) or serum glutamate oxaloacetate transaminase (SGOT) and alanine aminotransferase (ALT) or serum glutamate pyruvate transaminase (SGPT) such that the ratio of AST to ALT was significantly greater than 1 and in serum levels of ammonia. Other liver function tests were found to be abnormal but not in so consistent a pattern, although total protein and albumin were found to be significantly decreased in all of these patients. The stereotypical elevation of the transaminases with high AST-to-ALT ratios and the rise in ammonia appear to characterize this life-threatening illness most reliably.

Sleep disorders in children

Everyone who cares for families with young children will be familiar with the pale sleepless look on a mother's face, the bags under her eyes and the extra rouge worn to camouflage her fatigue if she is trying to cope with a child with a sleep disorder. An explanation of simple behavioural techniques can markedly improve the situation and help parents regain confidence in their parenting skills.