Five-year follow-up of a clinic-based sleep intervention for paediatric epilepsy: A randomized clinical trial

Sleep disturbances in children with epilepsy are prevalent, and are associated with substantial adverse medical and psychosocial consequences. This study is a 5-year follow-up of a clinic-based sleep intervention study that randomized 100 toddlers and preschool-age children with epilepsy to a usual care group or a sleep intervention group. The intervention group received standard paediatric neurology care plus three education sessions during the child's routine clinic visit. The outcomes measured were: (1) child sleep by actigraphy and parental report; and (2) maternal sleep and depression. We aimed to evaluate the long-term benefits of a clinic-based sleep intervention for paediatric epilepsy. In total, 42 families (42.0%) participated. The average child's age at follow-up was 9.55 years. Thirty-eight (90.5%) children were not obtaining sufficient sleep at baseline, and 40 (95.2%) at the 5-year follow-up. The numbers of children with clinically significant sleep disturbances were 40 (95.2%) at baseline and 36 (85.7%) at the 5-year follow-up. Fourteen mothers (33.3%) had poor sleep quality and high depressive symptoms at both assessment time points. There were no differences (P > 0.05) in the child and maternal outcomes between the two trial arms. Overall, there was no evidence that a clinic-based sleep intervention that effectively improved multiple aspects of sleep in toddlers and preschool-age children with epilepsy had long-lasting beneficial effects. Our findings suggest that sleep interventions for families of children with epilepsy require ongoing reinforcement and monitoring during routine paediatric neurology care to prevent sleep problems from persisting or recurring.

Application of Artificial Intelligence in Infant Movement Classification: A Reliability and Validity Study in Infants Who Were Full-Term and Preterm

OBJECTIVE

Preterm infants are at high risk of neuromotor disorders. Recent advances in digital technology and machine learning algorithms have enabled the tracking and recognition of anatomical key points of the human body. It remains unclear whether the proposed pose estimation model and the skeleton-based action recognition model for adult movement classification are applicable and accurate for infant motor assessment. Therefore, this study aimed to develop and validate an artificial intelligence (AI) model framework for movement recognition in full-term and preterm infants.

METHODS

This observational study prospectively assessed 30 full-term infants and 54 preterm infants using the Alberta Infant Motor Scale (58 movements) from 4 to 18 months of age with their movements recorded by 5 video cameras simultaneously in a standardized clinical setup. The movement videos were annotated for the start/end times and presence of movements by 3 pediatric physical therapists. The annotated videos were used for the development and testing of an AI algorithm that consisted of a 17-point human pose estimation model and a skeleton-based action recognition model.

RESULTS

The infants contributed 153 sessions of Alberta Infant Motor Scale assessment that yielded 13,139 videos of movements for data processing. The intra and interrater reliabilities for movement annotation of videos by the therapists showed high agreements (88%-100%). Thirty-one of the 58 movements were selected for machine learning because of sufficient data samples and developmental significance. Using the annotated results as the standards, the AI algorithm showed satisfactory agreement in classifying the 31 movements (accuracy = 0.91, recall = 0.91, precision = 0.91, and F1 score = 0.91).

CONCLUSION

The AI algorithm was accurate in classifying 31 movements in full-term and preterm infants from 4 to 18 months of age in a standardized clinical setup.

IMPACT

The findings provide the basis for future refinement and validation of the algorithm on home videos to be a remote infant movement assessment.

Cognitive and motor development in preterm children from 6 to 36 months of age: Trajectories, risk factors and predictability

BACKGROUND

Although numerous studies have examined the development of preterm children born very low birth weight (VLBW, birth body weight < 1500 g), variations of developmental progress within individuals have rarely been explored. The aim of this research was to examine the cognitive and motor trajectories in preterm children born VLBW at early ages and to assess the risk factors and predictability of these trajectories.

METHOD

Five hundred and eighty preterm infants born VLBW from three cohort studies (2003 to 2014) were prospectively assessed their mental and motor development using the Bayley Scales at 6, 12, 24, and 36 months, and cognitive, motor and behavioral outcomes using the Movement Assessment Battery for Children and the Child Behavior Checklist for Ages 1.5-5 at 4 years of age.

RESULTS

Preterm children born VLBW manifested three cognitive patterns (stably normal [64.0 %], deteriorating [31.4 %], and persistently delayed [4.6 %]) and four motor patterns (above average [6.3 %], stably normal [60.0 %], deteriorating [28.5 %], and persistently delayed [5.2 %]) during 6-36 months. Low birth body weight, stage III-IV retinopathy of prematurity and low parental socio-economic status were associated with the deteriorating patterns; prolonged hospitalization and major brain damage were additionally associated with the persistently delayed patterns. Furthermore, the cognitive and motor deteriorating pattern was each predictive of cognitive and motor impairment at 4 years of age; whereas, the persistently delayed patterns were predictive of multiple impairments.

CONCLUSION AND IMPLICATIONS

Preterm children born VLBW display heterogeneous trajectories in early cognitive and motor development that predict subsequent developmental and behavioral outcomes.

Collaborative Home-Visit Program for Young Children With Motor Delays in Rural Taiwan: A Pilot Randomized Controlled Trial

BACKGROUND

Caregiver engagement and collaborative team early childhood intervention (ECI) services are international trends; however, relevant evidence of collaborative home-visiting ECI in rural areas is as yet undetermined.

OBJECTIVE

The study aimed to investigate the effectiveness of a collaborative ECI program in a rural area of Taiwan.

DESIGN

The study was a pilot randomized control led trial.

METHODS

Children aged 6 to 33 months experiencing motor delays and their caregivers were enrolled in Taitung, Taiwan. Using stratified randomization, 24 participants were allocated to either experimental or control groups, and both received 5 home visits within 3 months. The experimental group received ECI services based on the International Classification of Functioning, Disability and Health framework and family-centered approaches. The control group received regular home visits by local social workers. Child outcomes included Pediatric Evaluation of Disability Inventory Chinese Version and Peabody Developmental Motor Scale, 2nd edition. Family outcomes included the Disability-Adapted Infant-Toddler version of Home Observation for Measurement, and Chinese versions of the Knowledge of Infant Development Inventory and Parental Stress Index-Short Form. A tester blinded to the study conducted assessments at baseline, postintervention, and 3-month follow-up. Two-way mixed analysis of variance was used with α = .05 (2-tailed).

RESULTS

The experimental group improved scores on the Disability-Adapted Infant-Toddler version of Home Observation for Measurement significantly more than the control group with an effect size of 0.64 at follow-up. In other outcomes, both groups showed no significant differences. The follow-up rate was 69%, and adherence to the ECI program was acceptable.

LIMITATIONS

A limitation of the study was the heterogeneity of the sample.

CONCLUSIONS

This pilot study revealed possible effectiveness in implementing collaborative ECI programs based on family-centered approaches and the International Classification of Functioning, Disability and Health in rural areas. Larger field studies are needed to confirm our findings.

Screen Time Exposure and Altered Sleep in Young Children With Epilepsy

PURPOSE

To examine the association between daily screen time exposure and both sleep patterns (sleep onset, sleep offset, and nighttime, and daily sleep durations) and sleep disturbances among a clinical sample of children with epilepsy.

DESIGN

A cross-sectional actigraphic sleep study.

METHODS

A convenience sample of 141 children with epilepsy (1.5-6 years of age) was recruited from an outpatient pediatric neurology clinic of a university-affiliated children's hospital in northern Taiwan. Participating families completed questionnaires and reported children's screen time use, with children wearing an actigraphy monitor for 7 days to assess sleep patterns. Multivariable linear regression analyses were conducted to examine the association of screen time exposure with the child's sleep patterns and sleep disturbance scores.

FINDINGS

Mean minutes per day of screen time exposure was 89.79 ± 83.94 min, with 62 parents (44.0%) reporting their child having >1 hr of screen time daily. Mean daily sleep duration was 9.26 ± 1.01 hr, with 106 children (93.0%) sleeping <10 hr in a 24-hr period. In multivariate regression models, daily screen time exposure of >1 hour was associated with 23.4-min later sleep onset (b = 0.39, p = .02), 20.4-min later sleep offset (b = 0.34, p = .04), and more severe sleep disturbances (b = 2.42, p = .04).

CONCLUSIONS

In toddlers and preschool-age children with epilepsy, daily screen time exposure is greater and sleep duration is shorter than the recommended amount, with increased screen time exposure associated with disturbed sleep.

CLINICAL RELEVANCE

Parents need to be informed about the possible adverse impact of screen time exposure on children's sleep and health as well as the importance of limiting screen time exposure to <1 hr per day for their toddlers and preschool-age children with epilepsy.

Interaction Between Prematurity and the MAOA Gene on Mental Development in Children: A Longitudinal View

This study aimed to examine the association of dopamine-related genes with mental and motor development and the gene-environment interaction in preterm and term children. A total of 201 preterm and 111 term children were examined for their development at 6, 12, 18, 24, and 36 months and were genotyped for 15 single-nucleotide polymorphisms (SNPs) in dopamine-related genes (DRD2, DRD3, DAT1, COMT, and MAOA). An independent sample of 256 preterm children was used for replication. Since the developmental age trends of preterm children differed from those of term children, the analyses were stratified by prematurity. Among the 8 SNPs on the MAOA gene examined in the whole learning sample, the results of linkage disequilibrium analysis indicated that they were located in one block (all D' > 0.9), and rs2239448 was chosen as the tag (r² > 0.85). In the analysis of individual SNPs in each dopamine-related gene, the tag SNP (rs2239448) in MAOA remained significantly associated with the mental scores of preterm children for the interaction with age trend (p < 0.0001; largest effect size of 0.65 at 24 months) after Bonferroni correction for multiple testing. Similar findings for rs2239448 were replicated in the independent sample (p = 0.026). However, none of the SNPs were associated with the motor scores of preterm children, and none were related to the mental or motor scores of term children. The genetic variants of the MAOA gene exert influence on mental development throughout early childhood for preterm, but not term, children.

Family-Centered Care Enhanced Neonatal Neurophysiological Function in Preterm Infants: Randomized Controlled Trial

BACKGROUND

Family-centered intervention for preterm infants has shown short- to medium-term developmental benefits; however, the neurological effects of intervention have rarely been explored.

OBJECTIVE

The objectives of this study were to examine the effect of a family-centered intervention program (FCIP) on neurophysiological functions in preterm infants with very low birth weight (VLBW; birth weight of < 1500 g) in Taiwan, to compare the effect of the FCIP with that of a usual-care program (UCP), and to explore the FCIP-induced changes in neurobehavioral and neurophysiological functions.

DESIGN

This was a multicenter, single-blind randomized controlled trial.

SETTING

The study took place in 3 medical centers in northern and southern Taiwan.

PARTICIPANTS

Two hundred fifty-one preterm infants with VLBW were included.

INTERVENTION

The FCIP group received a family-centered intervention and the UCP group received standard care during hospitalization.

MEASUREMENTS

Infants were assessed in terms of neurobehavioral performance using the Neonatal Neurobehavioral Examination-Chinese version, and their neurophysiological function was assessed using electroencephalography/event-related potentials during sleep and during an auditory oddball task during the neonatal period.

RESULTS

The FCIP promoted more mature neurophysiological function than the UCP, including greater negative mean amplitudes of mismatch negativities in the left frontal region in the oddball task in all infants, lower intrahemispheric prefrontal-central coherence during sleep in infants who were small for gestational age, and higher interhemispheric frontal coherence during sleep in those who were appropriate for gestational age. Furthermore, interhemispheric coherence was positively associated with the total neurobehavioral score in preterm infants who were appropriate for gestational age (r = 0.20).

LIMITATIONS

The fact that more parental adherence strategies were used in the FCIP group than in the UCP group might have favored the intervention effect in this study.

CONCLUSIONS

Family-centered intervention facilitates short-term neurophysiological maturation in preterm infants with VLBW in Taiwan.

Multidimensional Developments and Free-Play Movement Tracking in 30- to 36-Month-Old Toddlers With Autism Spectrum Disorder Who Were Full Term

BACKGROUND

Few studies have investigated multidimensional developments and free-play movement performance in toddlers with an early diagnosis of autism spectrum disorder (ASD).

OBJECTIVE

This study compared cognitive, motor, and behavioral developments and free-play movement performance in toddlers with ASD who were full term (FT-ASD), toddlers who were full term and are typically developing (FT-TD), and toddlers who were born preterm and had a very low birth weight (VLBW-PT).

DESIGN

This was a prospective cross-sectional study.

METHODS

Forty-five 30- to 36-month-old age-matched toddlers were recruited and divided into FT-ASD, FT-TD, and VLBW-PT groups. Their developments were examined using the Mullen Scales of Early Learning; the Peabody Developmental Motor Scales, Second Edition; the Child Behavior Checklist for Ages 1.5 to 5; and the Repetitive Behavior Scale-Revised. In addition, the toddlers' free-play movements were tracked in laboratory settings using an automatic movement tracking system.

RESULTS

Toddlers with FT-ASD exhibited lower cognitive and motor scores and a higher degree of behavioral problems compared with toddlers with FT-TD or VLBW-PT. Furthermore, the movement tracking data in a free-play setting revealed that toddlers with FT-ASD displayed a higher degree of turning velocity, a higher moving time, and a higher frequency of moving toward the peripheral region compared with toddlers with FT-TD or VLBW-PT. Moreover, several motor developmental and movement-tracking indicators were found to correlate with behavioral problems and cognitive scores in toddlers with FT-ASD.

LIMITATIONS

The study results may have been affected by the small sample size, the cross-sectional design, and tracking only the whole body without subtle movements or segmental motions.

CONCLUSIONS

The findings suggest varied aspects of co-occurring developmental conditions and movement-based problems in toddlers with FT-ASD. Using standardized and sensitive measures for the early assessment of perceptuo-motor impairments is necessary for timely early intervention for such toddlers.

Behavioral-educational sleep interventions for pediatric epilepsy: a randomized controlled trial

Study Objectives

To evaluate the effect of a clinic-based, behavioral-educational sleep intervention on sleep of children with epilepsy, maternal knowledge about childhood sleep, and maternal sleep quality.

Methods

A total of 100 toddlers and preschool-age children with epilepsy (1.5–6 years, 55% boys) and their parents were randomized to receive sleep intervention (n = 50) or usual care with attention (n = 50). Outcomes were assessed at baseline, 3, 6, and 12 months after intervention with the use of objective actigraphy, Children’s Sleep Habits Questionnaire, Parents’ Sleep Knowledge Inventory, and Pittsburgh Sleep Quality Index. Intervention effects were examined using general linear models for repeated measurements to compare the mean change in outcomes from baseline to 12 months post-intervention between the two groups.

Results

Sleep intervention resulted in children having greater sleep efficiency by 2.03% compared with the usual care group (95% CI = 0.20% to 3.86%; p = .03). Children in the intervention group also had significantly longer total nighttime sleep as objectively assessed by actigraphy than did those in the usual care group, with an adjusted mean difference of 16.13 minutes (95% CI = 0.24% to 32.03%; p = .04). No intervention effects were observed for maternal knowledge about childhood sleep, and maternal sleep quality.

Conclusion

Sleep intervention provided during routine neurologic visits results in significant, measurable, and sustained benefits in sleep quality and quantity in children with epilepsy. Future trials are warranted to evaluate whether improvements in sleep could impact health-related quality of life or other aspects of functioning in children with epilepsy.

Clinical Trial

This trial has been registered at www.clinicaltrials.gov (trial name: Sleep Intervention for Pediatric Epilepsy; registration number: NCT02514291).

Postural Control and Interceptive Skills in Children With Autism Spectrum Disorder

BACKGROUND

Increasing evidence shows common motor deficits associated with autism spectrum disorder (ASD) that can relate to impaired planning and control processes of the sensorimotor system. Catching is a fundamental motor skill that requires coordination between vision, posture, and arm movements. Although postural control and ball catching have been shown to be impaired in children with ASD, previous studies have not investigated how these components are integrated.

OBJECTIVE

The objective of this study was to investigate the sensorimotor control of arm movements and postural adjustments during ball catching in children with and without ASD.

DESIGN

This study employed a cross-sectional design.

METHODS

Fifteen children with ASD (mean [SD] age = 8.8 [1.2] years; 12 boys) and 15 age- and sex-matched typically developing children participated in this study. Children were asked to catch a ball rolling down a ramp in 6 test conditions in which visual inputs and ramp direction were manipulated to provide different sensory conditions and postural demands.

RESULTS

Compared with their typically developing peers, children with ASD had increased difficulties catching balls, especially those from lateral directions. They less often used visual information to plan for catching motion, demonstrated fewer and delayed anticipatory postural adjustments, and exhibited increased corrective control.

LIMITATIONS

The sample excluded children with intellectual disability and attention deficit and hyperactivity disorders that might reduce the generalizability to the whole ASD population.

CONCLUSIONS

Our results suggest that motor difficulties present in children with ASD can result from compromised sensorimotor integration in planning and control of movements.

Neonatal respiratory status predicts longitudinal respiratory health outcomes in preterm infants

OBJECTIVES

To examine the relationship between neonatal respiratory status and longitudinal respiratory health outcomes in preterm infants with very low birth weight (VLBW, birth weight <1500 g).

METHODS

A total of 109 VLBW preterm infants were prospectively assessed for respiratory status using the Toce clinical and radiographic scoring method on a postnatal day 28, and severity of bronchopulmonary dysplasia (BPD) at 36-weeks postmenstrual age (PMA), respiratory morbidity within 1 year of corrected age (CA), pulmonary function test, and six-minute walk test at 4 years of age.

RESULTS

A high Toce clinical score on day 28 was associated with the occurrence of respiratory morbidity within 1 year of CA and poor pulmonary function and functional exercise performance at 4 years of age in VLBW preterm infants (all P < 0.05). BPD at 36-weeks PMA was associated with an increased risk of respiratory morbidity within 1 year of CA and its negative impact on pulmonary function and functional exercise performance at 4 years of age was most pronounced in the severe form (all P < 0.05).

CONCLUSIONS

Early assessments of neonatal respiratory status including Toce clinical score and the severity of BPD are valid to identify VLBW preterm infants who are at risk of adverse longitudinal respiratory health outcomes.

Sleep and Behavior Problems in Children With Epilepsy

We designed a cross-sectional study to examine the association between sleep and behavior problems in toddlers and preschool-age children with epilepsy. We found that 71 (78.9%) children slept less than 10 hours in a 24-hour period according to the actigraphy, with 75 (83.3%) children waking for more than an hour during nocturnal sleep. Twenty-five (27.8%) children usually or sometimes had an inconsistent bedtime, and 24 (26.7%) did not sleep the same amount each day. Twenty-nine (32.2%) and 18 (20.0%) children had an internalizing and externalizing problem in clinical range, respectively. Sleep anxiety was significantly (p < .01) associated with increased internalizing and externalizing problems, even after the relevant epilepsy variables were controlled for. Findings from our study suggest that screening of sleep and behavior problems should be part of routine epilepsy care to identify children with problematic sleep and unrecognized sleep disorders and those at risk of behavioral dysfunction.

Validation of the modified checklist for autism in toddlers, revised with follow-up in Taiwanese toddlers

BACKGROUND

The Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F) is a two-stage screening scale for determining the risk of autism spectrum disorder (ASD) in toddlers. However, the validity of the M-CHAT-R/F for Asian populations has not yet been established.

AIMS

This study investigated the psychometric properties of the M-CHAT-R/F, Taiwan version (M-CHAT-R/F-T), among low- and high-risk Taiwanese toddlers aged 16-30 months. The associations among M-CHAT-R/F-T scores, developmental performance at 24 and 30 months, and ASD diagnosis prediction at 36 months were examined.

METHODS AND PROCEDURES

A two-stage screening of the M-CHAT-R/F-T was applied to a study sample comprising 25 toddlers with ASD and 71 atypically developing (ATD) and 221 typically developing (TD) toddlers.

OUTCOMES AND RESULTS

The M-CHAT-R/F-T exhibited acceptable internal consistency and test-retest reliability. The M-CHAT-R/F-T scores were significantly correlated with several syndrome scores of the Child Behavior Checklist for Ages 1.5-5 and were significantly higher among toddlers with ASD than among ATD or TD toddlers. Furthermore, M-CHAT-R/F-T scores were negatively correlated with developmental scores in the Mullen Scales of Early Learning at 24 and 30 months. Moreover, the screening exhibited acceptable predictive validity (sensitivity = 0.86; specificity = 0.96) for ASD diagnosis at 36 months.

CONCLUSIONS AND IMPLICATIONS

The findings indicate that the M-CHAT-R/F-T is a valid and reliable tool for the developmental screening of low- and high-risk Taiwanese toddlers in community and clinical settings.

The sFlt-1/PlGF ratio as a predictor for poor pregnancy and neonatal outcomes

BACKGROUND

Soluble fms-like tyrosine kinase receptor-1 (sFlt-1)/placental growth factor (PlGF) ratio has been studied extensively as a predictive marker for pre-eclampsia. However, its usefulness for predicting neonatal outcomes remains unknown. This study aimed to evaluate the association of sFlt-1/PlGF ratio with pregnancy outcomes, neonatal morbidities and short-term postnatal growth patterns in pregnant women and their babies.

METHODS

sFlt-1 and PlGF were measured in women with fetal intrauterine growth retardation (IUGR) or pre-eclampsia during gestational age (GA) of 16-36 weeks. These women were classified into high- and low-ratio groups with a sFlt-1/PlGF cut-off ratio of 85. The maternal and neonatal outcomes were retrospectively reviewed and compared between the two groups.

RESULTS

A total of 25 pregnant women were recruited. Thirteen of them had a sFlt-1/PlGF ratio over 85 and twelve had a ratio of less than 85. The median duration from elevation of sFlt-1/PlGF to delivery was 4.5 weeks. Women in the high SFlt-1/PlGF ratio group had higher rates of intrauterine fetal demise (2/13 vs. 0/12) and early termination (1/13 vs. 0/12). The surviving offspring in this group had a higher incidence of preterm birth (GA: 31.4 ± 2.9 weeks vs. 37.3 ± 1.3 weeks, p < 0.001), lower birth weight (1142 ± 472 g vs. 2311 ± 236 g, p < 0.001), higher incidence of respiratory distress syndrome (6/10 vs. 0/12, p = 0.002) and bronchopulmonary dysplasia (4/10 vs. 0/12, p = 0.01). However, the percentile of body weight, height and head circumference at 28 days of age, 56 days of age and the corrected age of 6 months were comparable between groups.

CONCLUSIONS

High sFlt-1/PlGF ratio in pregnant women is associated with poor pregnancy and neonatal outcomes. Therefore, the monitoring of sFlt-1/PlGF ratio in pregnant women with fetal IUGR and timely management for placenta-associated diseases are recommended.

Family-centered Care Improved Neonatal Medical and Neurobehavioral Outcomes in Preterm Infants: Randomized Controlled Trial

BACKGROUND

Family-centered care for preterm infants in Western societies has yielded short- to medium-term benefits. However, the intervention effects have rarely been validated in Eastern societies.

OBJECTIVE

The aim of this study was to examine whether a family-centered intervention program (FCIP) could improve the short-term medical and neurobehavioral outcomes in preterm infants with very low birth weight (VLBW; a birth weight of <1,500 g) in Taiwan over the outcomes seen with a usual care program (UCP).

DESIGN

This was a multicenter, single-blind, randomized controlled trial study.

SETTING

Three medical centers in northern and southern Taiwan were the locations for the study.

PARTICIPANTS

The participants were 251 VLBW preterm infants without severe perinatal complications.

INTERVENTION

The infants were randomly assigned to receive the FCIP or the UCP during hospitalization.

MEASUREMENTS

Infant morbidities, feeding, growth, and neurobehavioral performance were evaluated during the neonatal period. Parental adherence to interventions was measured in the FCIP group.

RESULTS

The FCIP promoted earlier full enteral feeding (β = -1.1 weeks; 95% CI = -1.9 to -0.2 weeks) and hospital discharge (β = -0.6 week; 95% CI = -1.1 to -0.1 weeks), greater weight gain (β = 3.3 g/d; 95% CI = 0.1 to 6.6 g/d), and better neurobehavioral performance than the UCP (β = 1.2 points; 95% CI = 0.2 to 2.3 points). Furthermore, a higher degree of parental motivation in interventions, goal attainment, and comprehensiveness of home activities was significantly associated with greater effects in infants' neurobehavioral performance and weight gain (r = .20-.31; all Ps < .05).

LIMITATIONS

The findings may not be generalized to preterm infants with severe perinatal diseases and parents with a low level of interest in interventions.

CONCLUSIONS

Family-centered care facilitated short-term medical and neurobehavioral outcomes in VLBW preterm infants in Taiwan; the effects were likely achieved through parental adherence to interventions. The designated strategies may be considered in a future launch of family-centered care in Taiwan.

Agreement Between Actigraphy and Diary-Recorded Measures of Sleep in Children With Epilepsy

PURPOSE

To describe sleep patterns in young children with epilepsy and to examine levels of agreement between measurements derived from actigraphy and diary recordings.

DESIGN

Cross-sectional study.

METHODS

Eighty-nine toddlers and preschool-aged children with epilepsy wore an actigraph on their wrists for 7 consecutive days. Parents and caregivers maintained a concurrent sleep diary while the child was wearing the monitor. Levels of agreement between actigraphy and diary recordings were examined using the Bland and Altman method separately for all recording days, weekdays, and weekends.

FINDINGS

Discrepancies between actigraphy-derived and diary-documented sleep onset, sleep offset, actual sleep at night, wake after sleep onset, and daytime sleep were ±35, ±15, ±82, ±70, and ±29 min, respectively. Differences between actigraphy and diary-derived sleep variables were consistently greater for weekends than for weekdays. Discrepancies between actigraphy and diary-derived actual sleep at night were significantly greater for children who slept alone than for those who co-slept with a parent.

CONCLUSIONS

Our study demonstrates an acceptable agreement between actigraphy and diary recordings for sleep onset, sleep offset, and daytime sleep, but insufficient agreement for actual sleep at night and wake after sleep onset, with parents of children sleeping alone more likely to misestimate child sleep behaviors. Deviation of weekend sleep from weekdays further decreased the accuracy of parental sleep estimates and increased the discrepancies between actigraphy and diary.

CLINICAL RELEVANCE

Sleep in children with epilepsy assessed using diary recordings alone could be misleading, and actigraphy should be preferred over diaries when resources are available.

The Impacts of Cord Blood Cotinine and Glutathione-S-Transferase Gene Polymorphisms on Birth Outcome

BACKGROUND

This study aimed to investigate the association between cord blood cotinine levels and birth outcome, and to determine whether fetal metabolic gene polymorphisms of glutathione-S-transferase (GST) modulate the effect of environmental tobacco smoke exposure during pregnancy.

METHODS

This study included 328 maternal and neonatal pairs. Maternal and cord blood cotinine levels were measured using high performance liquid chromatography. The GST T1 (GSTT1) and GST M1 (GSTM1) polymorphisms were examined using the polymerase chain reaction method. The birth outcomes included birth weight, length, and head circumference, and the risks of having low birth weight and being small for gestational age (SGA).

RESULTS

Cord cotinine level had a dose-dependent impact on the reduction of birth weight, length, and head circumference in newborns. Elevation of cord blood cotinine concentration increased the rate of SGA and low birth weight. The neonates who had GSTT1 or GSTM1 polymorphism were associated with an increased risk of being SGA. A combination of the GSTT1 and GSTM1 null genotype exacerbated the effect of maternal environmental tobacco smoke exposure on SGA more than the presence of either genotype alone (odds ratio=8.90, 95% confidence interval=1.00-79.5).

CONCLUSION

Cord blood cotinine adversely affects birth outcomes. GSTT1 and GSTM1 null genotype may modify the effect of cord blood cotinine on birth outcomes.

Gross Motor Trajectories During the First Year of Life for Preterm Infants With Very Low Birth Weight

BACKGROUND

Early identification of motor dysfunction in preterm infants with very low birth weight (VLBW) is important in order to provide early intervention.

OBJECTIVE

This study was to examine the motor trajectories of preterm infants with VLBW during their first year of life and to investigate the predictive ability and influencing factors of the trajectories.

DESIGN AND METHODS

A total of 342 preterm infants with VLBW were prospectively assessed for motor development by the Alberta Infant Motor Scales at 4, 6, 9, and 12 months and for developmental outcomes using the Bayley Scales of Infant and Toddler Development, second edition, at 24 months. Perinatal and socio-environmental factors were collected at baseline. Growth mixture modeling was used to explore the patterns of infants' motor trajectories during their first year of life. Logistic regression analyses were applied to examine the influencing factors associated with motor trajectories and their predictability of 24-month developmental outcomes.

RESULTS

Preterm infants with VLBW showed 3 distinct motor trajectories: stably normal (55%), deteriorating (32%), and persistently delayed (13%). Furthermore, the motor trajectories were predictive of 24-month cognitive and motor outcomes. Perinatal factors including lower birth weight, male gender, moderate to severe bronchopulmonary dysplasia, stage III to IV retinopathy of prematurity, and major brain damage were associated with a risk of deteriorating and persistently delayed trajectories (all P < .05). Socio-environmental factors had no association with motor trajectories.

LIMITATIONS

The small sample size of the infants with a persistently delayed trajectory may have limited the assessment of some influencing factors.

CONCLUSION

The identified early motor trajectories, predictive values, and influencing factors provide insightful implications for early detection and prevention of motor -disorders in preterm infants with VLBW.

Urinary Neutrophil Gelatinase-Associated Lipocalin Levels in Neonates

BACKGROUND

Acute kidney injury (AKI) is common in preterm infants and is associated with high mortality and morbidity. New biomarkers for the early detection of AKI have been identified. Specifically, urinary neutrophil gelatinase-associated lipocalin (uNGAL) is a new and powerful biomarker for AKI and sepsis. Our study evaluated the reference range of uNGAL in healthy neonates in Taiwan.

METHODS

This study examined 24 preterm and 38 term infants without clinical complications. Urine samples were collected and the uNGAL values were measured at postnatal age (PNA) 3 days, 7 days, 14 days, and 21 days in the preterm infants and at PNA 3 days in the term infants. The uNGAL values were tested using enzyme-linked immunosorbent assay.

RESULTS

The median uNGAL values in the preterm infants at PNA 3 days, 7 days, 14 days, and 21 days were 41.52 ng/mL, 35.82 ng/mL, 43.79 ng/mL, and 30.85 ng/mL, respectively. The median value at PNA 3 days in the term infants was 88.1 ng/mL. No significant differences associated with gestational age, birth body weight, or PNA were observed among the preterm infants. However, the uNGAL values in the female term infants were higher than those in the male term infants (p = 0.003).

CONCLUSION

This study presents preliminary data on uNGAL levels in neonates in Taiwan. A large-scale study investigating the correlations between uNGAL and with gestational age, birth body weight, sex, and PNA is recommended.

Intervention effects on emotion regulation in preterm infants with very low birth weight: A randomize controlled trial

Preterm infants are at risk for emotional difficulties and behavioral problems. This study was aimed to investigate the effects of a clinic-based intervention program (CBIP) and a home-based intervention program (HBIP) compared with a usual care program (UCP) on emotion regulation to stress in preterm infants with very low birth weight (VLBW, birth weight <1500 g). A total of 178 VLBW preterm infants had been previously randomly assigned to receive one of three interventions (57 in CBIP, 63 in HBIP and 58 in UCP). The CBIP and HBIP contained identical child-, parent- and dyad-focused interventions that were provided to infants during hospitalization and were respectively delivered at clinics and at home at PMA 36-38 and 40 weeks, and 1, 2, 4, 6, 9, 12 months of corrected age. All infants were prospectively observed for behavioral reactivity and regulation in response to experimentally evoke stress evoked by a toy-behind-barrier procedure at 12, 18, and 24 months of corrected age. Their cognitive and language abilities, and mothers' responsiveness were also assessed at 12 months as potential covariates. Compared to the UCP-group infants, the HBIP-group infants exhibited shorter durations of visual orientation to a toy (adjusted difference [95% CI]=-1.60 [-3.07 to -0.13], p=0.03), and the CBIP-group infants exhibited shorter durations of avoidance (adjusted difference [95% CI]=-0.84 [-1.57 to -0.10], p=0.03) from 12 to 24 months of corrected age. The CBIP and HBIP showed no difference in the stress reactivity from the UCP, however. These results suggest that comprehensive interventions incorporating child-, parent- and dyad-focused services enhanced VLBW preterm infants' emotion regulation in response to stress at toddler age.

Operating Room Within the Neonatal Intensive Care Unit--Experience of a Medical Center in Taiwan

BACKGROUND

Most neonates who reside in the neonatal intensive care unit (NICU) and require surgery are transferred to the operating room (OR) or undergo bedside surgery. However, critically ill neonates who are transferred often encounter the risk of complications. An OR in our NICU was therefore launched in 2009. This study was to appraise the surgeries performed in the NICU OR and compare results with the traditional main OR outside the NICU.

METHODS

This was a retrospective study in the NICU of a tertiary center. Retrospective chart review was conducted for all neonates who underwent surgical procedures in the NICU OR and the main OR. The information regarding baseline characteristics, surgical procedures and duration, ventilator use, hypothermia, hyperglycemia, instrument dislocations, surgically related infection or complications, and outcomes was obtained.

RESULTS

There were a total of 65 patients in this study, 37 in the NCIU OR group and 28 in the main OR group. The presurgical mean airway pressure and the fraction of inspired oxygen (FiO2) were comparable between the two groups, but the postsurgical FiO2 was significantly lower in the NICU OR group (31.0%) than in the main OR group (40.9%; p = 0.027). Furthermore, the NICU OR group required a significantly shorter preoperation waiting time (34.4 minutes vs. 63.6 minutes, p = 0.001) and had a lower incidence of hypothermia than the main OR group (8.1% vs. 39.3%, p = 0.008). However, surgically related complications were similar between groups.

CONCLUSION

The OR within the NICU may reduce the risk of complications during transportation and provide continuity of care to critically ill neonates. It also decreases the disturbance to other NICU patients during operation.

Mercury, APOE, and child behavior

Methylmercury (MeHg) is a neurotoxicant and may have an adverse impact on child behavior. However, this impact was found to be inconsistent in fish-eating populations. Although the positive effects of the nutrients provided by a fish diet may overcome the effect of MeHg, the possibility of genetic variants influencing an individual's response to MeHg has also been discussed. The role of the Apolipoprotein E (APOE) epsilon 4 allele (ε4) on MeHg related neurotoxicity is still unclear. In the present study, we investigated the role of APOE variants in the relationship between cord blood mercury (Hg) and child behavior. A total of 166 subjects were recruited at delivery, and their cord blood was collected for laboratory analyses of Hg and the APOE genotype. The Child Behavior Checklist (CBCL) was administered to the subjects when they reached the age of two years. An increase in cord blood Hg concentrations in APOE ε4 carriers was consistently associated with an increased score for all CBCL syndromes. After controlling for potential confounding factors, the group of ε4 carriers with an elevated cord blood Hg concentration had significantly higher scores in the syndrome categories of general internalizing, emotionally reactive, and anxiety/depression as well as CBCL total scores. Furthermore, general externalizing and aggressive syndromes were borderline significantly higher in this group. In conclusion, we suggest that APOE may modify the toxicity of MeHg. APOE ε4 carriers may be more vulnerable to the effects of MeHg on child behavior at the age of two years.

Factors associated with treatment mode and termination among preschoolers with ADHD in Taiwan

OBJECTIVES

This study examined the extent to which characteristics of family and health care providers predict treatment initiation, treatment mode, and treatment termination among preschool children with newly diagnosed ADHD.

METHODS

A cohort of 3,583 preschoolers with ADHD was identified from the National Health Insurance Research Database of Taiwan. Individual characteristics and health care records, including medication and nonmedication treatment, were documented. Logistic regression and time-dependent survival analyses were used to evaluate association estimates.

RESULTS

Over 80% of the children with newly diagnosed ADHD received initial treatment within a month of diagnosis, with 41% starting with combined treatment. Only one-quarter remained in treatment by the end of 12 months. In the first year, the termination rate was lowest for those who received rehabilitation treatment only (log-rank test, p<.001). Predictors of termination varied by treatment mode. For combined treatment, factors that marginally increased the likelihood of treatment termination were coming from a family in poverty (adjusted hazard ratio [AHR]=1.72) or from a rural region (AHR=1.40). Receiving initial treatment from a psychiatrist was associated with an increased likelihood of treatment termination for children receiving psychosocial treatment (AHR=1.80, 95% confidence interval [CI]=1.46-2.22) and combined treatment (AHR=1.38, CI=1.20-1.60).

CONCLUSIONS

Family and service provider characteristics appeared to have differential effects on initial receipt and mode of treatment and on one-year treatment termination among preschoolers with ADHD in Taiwan's universal health insurance program. Future efforts should aim at reducing access barriers to comprehensive and continuous health care for very young children with mental or developmental disorders.

A randomized controlled trial of clinic-based and home-based interventions in comparison with usual care for preterm infants: effects and mediators

This study examined the effects and mediators of a clinic-based intervention program (CBIP) and a home-based intervention program (HBIP) compared with usual care in very-low-birth-weight (VLBW) preterm infants on developmental and behavioral outcomes at 24 months of age (corrected for prematurity). In this randomized controlled trial, VLBW preterm infants received either CBIP (n=57), HBIP (n=63), or usual care (n=58) from hospitalization to 12 months. At 12 months, infant emotional regulation was assessed using the toy-behind-barrier procedure and dyadic interaction was observed during free play. At 24 months, infant developmental and behavioral outcomes were assessed using the Bayley Scales of Infant and Toddler Development- 3rd edition and the Child Behavior Checklist for Ages 1.5-5, respectively. Compared with infants under usual care, the CBIP-group infants showed higher cognitive composite scores (difference, 95% confidence interval (CI)=4.4, 0.8-7.9) and a lower rate of motor delay (odds ratio (OR), 95% CI=0.29, 0.08-0.99); the HBIP-group infants had lower sleep problem scores (difference, 95% CI=-1.4, -2.5 to -0.3) and a lower rate of internalizing problems at 24 months (OR, 95% CI=0.51, 0.28-0.93) (all p<.05). The CBIP's effect on cognitive outcome was attenuated when maternal or dyadic interactive behavior was considered; whereas the HBIP's effect on sleep and internalizing behavior was attenuated when duration of orientation to a toy or object was considered. In conclusions, interventions enhanced the cognitive, motor, and behavioral outcomes of VLBW preterm infants. The effects on cognitive and behavioral outcomes might be mediated by early-improved mother-infant interaction and infant emotional regulation, respectively.

Modulated expression of human peripheral blood microRNAs from infancy to adulthood and its role in aging

Accumulating evidence suggests a role for microRNAs (miRNAs) in regulating various processes of mammalian postnatal development and aging. To investigate the changes in blood-based miRNA expression from preterm infants to adulthood, we compared 365 miRNA expression profiles in a screening set of preterm infants and adults. Approximately one-third of the miRNAs were constantly expressed from postnatal development to adulthood, another one-third were differentially expressed between preterm infants and adults, and the remaining one-third were not detectable in these two groups. Based on their expression in infants and adults, the miRNAs were categorized into five classes, and six of the seven miRNAs chosen from each class except one with age-constant expression were confirmed in a validation set containing infants, children, and adults. Comparing the chromosomal locations of the different miRNA classes revealed two hot spots: the miRNA cluster on 14q32.31 exhibited age-constant expression, and the one on 9q22.21 exhibited up-regulation in adults. Furthermore, six miRNAs detectable in adults were down-regulated in older adults, and four chosen for individual quantification were verified in the validation set. Analysis of the network functions revealed that differentially regulated miRNAs between infants and adults and miRNAs that decreased during aging shared two network functions: inflammatory disease and inflammatory response. Four expression patterns existed in the 11 miRNAs from infancy to adulthood, with a significant transition in ages 9–20 years. Our results provide an overview on the regulation pattern of blood miRNAs throughout life and the possible biological functions performed by different classes of miRNAs.

A psychometric study of the Bayley Scales of Infant and Toddler Development - 3rd Edition for term and preterm Taiwanese infants

The Bayley Scales of Infant and Toddler Development - 3rd Edition (Bayley-III) was updated to enhance its usefulness for contemporary child developmental assessment. However, recent data in Western countries have implicated the overestimation of child development by the new instrument. This study aimed to investigate the psychometric features of the Bayley-III for term and preterm infants in Taiwan. Forty-seven term infants and 167 preterm infants were prospectively examined with the Bayley Scales of Infant Development - 2nd Edition (BSID-II) and the Bayley-III at 6, 12, 18, and 24 months of age (corrected for prematurity). The psychometric properties examined included reliability, construct validity, and known-group validity. The intra- and inter-rater reliabilities of the Bayley-III were good to excellent. The correlations between the BSID-II and Bayley-III raw scores were good to excellent for the cognitive and motor items and low to excellent for the language items. Term infants achieved higher composite scores than preterm infants on all of the Bayley-III scales (p<0.05). However, their rates of developmental delay were lower than the previously established prevalence estimates. The Bayley-III cut-off composite score was adjusted 10-20, 1-13, and 12-24 points higher than 70 for optimal prediction of cognitive, language, and motor delay, respectively, as defined by the BSID-II index score<70. The Bayley-III is a reliable instrument that extends its previous edition, especially in early language assessment. However, the upward adjustment of its cut-off score is recommended for the accurate identification of developmental delay in term and preterm Taiwanese infants.

Relationship of neonatal cerebral blood flow velocity asymmetry with early motor, cognitive and language development in term infants

The objective of this study was to examine the relationships of Doppler cerebral blood flow velocity (CBFV) asymmetry measures with developmental outcomes in term infants. Doppler CBFV parameters (peak systolic velocity [PSV] and mean velocity [MV]) of the bilateral middle cerebral arteries of 52 healthy term infants were prospectively examined on postnatal days 1-5, and then their motor, cognitive and language development was evaluated with the Bayley Scales of Infant and Toddler Development, Third Edition, at 6, 12, 18 and 24 months of age. The left CBFV asymmetry measure (PSV or MV) was calculated by subtracting the right-side value from the left-side value. Left CBFV asymmetry measures were significantly positively related to motor scores at 6 (r = 0.3-0.32, p < 0.05) and 12 (r = 0.35, p < 0.05) months of age, but were not related to cognitive or language outcome. Thus, the leftward hemodynamic status of the middle cerebral arteries, as measured by cranial Doppler ultrasound in the neonatal period, predicts early motor outcome in term infants.

In utero exposure to environmental lead and manganese and neurodevelopment at 2 years of age

BACKGROUND AND OBJECTIVE

Manganese, lead, arsenic and mercury are common neurotoxic metals in the environment. Nonetheless, the relationship between prenatal exposure to low doses of neurotoxic metals and neurodevelopment in children is not clear. The objective of this study was to explore the relationship between in utero exposure to environmental neurotoxic metals and neurodevelopment at 2 years of age.

METHODS

The population of this study came from the Taiwan Birth Panel Study. We included 230 pairs of non-smoking mothers without any occupational exposure and their singleton full-term children. The information about exposure during pregnancy was obtained using a structured questionnaire, and the manganese, lead, arsenic and mercury levels in umbilical cord blood samples were analyzed using inductively coupled plasma mass spectrometry. We used the Comprehensive Developmental Inventory for Infants and Toddlers (CDIIT) to evaluate the developmental status of each child at 2 years of age, and we examined the association of in utero exposure to environmental metals and neurodevelopment using linear regression models.

RESULTS

The median concentrations of manganese, lead, arsenic and mercury in the cord blood samples in this study were 47.90 µg/L (range, 17.88-106.85 µg/L), 11.41 µg/L (range 0.16-43.22 µg/L), 4.05 µg/L (range, 1.50-12.88 µg/L) and 12.17 µg/L (range, 1.53-64.87 µg/L), respectively. After adjusting for maternal age, infant gender, environmental tobacco smoke during pregnancy and after delivery, Home Observation for Measurement of the Environment Inventory results, and arsenic and mercury levels in cord blood, we found that manganese and lead levels above the 75th percentile had a significant adverse association with the overall (β=-7.03, SE=2.65, P=0.0085), cognitive (β=-8.19, SE=3.17, P=0.0105), and language quotients (β=-6.81, SE=2.73, P=0.0133) of the CDIIT.

CONCLUSIONS

In utero exposure to environmental manganese and lead may have an adverse association with neurodevelopment at 2 years of age, and there is an interaction effect between the manganese and lead levels in the cord blood that could aggravate the effect.

The effect of in-hospital developmental care on neonatal morbidity, growth and development of preterm Taiwanese infants: a randomized controlled trial

INTRODUCTION

Intervention studies of developmental care for preterm infants in Western societies have shown early but unsustainable effects on child outcomes, however only a limited of studies have examined if developmental care interventions produce similar effects in Eastern cultural contexts.

AIMS

To examine the effectiveness of in-hospital developmental care on neonatal morbidity, growth and development of preterm infants with very low birth weight (VLBW; birth weight<1500 g) in Taiwan.

METHODS

One hundred and seventy-eight VLBW preterm infants were randomly assigned to the clinical trial during hospitalization at three hospitals in Taiwan; the control group received five sessions of standard child-focused developmental care and the intervention group received five sessions of child- and parent-focused developmental care. Sixty-two normal term infants were also included as a comparison group. Infants were examined for morbidity, growth and developmental outcomes at term age.

RESULTS

At study entry, more infants in the intervention group were twins or multiples than those in the control group (29% vs. 16%, p=0.05). After adjusting for birth set, the intervention group had lower incidences of stage II-III retinopathy (odds ratio [OR]=0.34 [95% confidence interval (CI): 0.15-0.79]; p=0.01) and feeding desaturation (OR=0.32 [95% CI: 0.10-1.00]; p=0.05) and had greater daily weight gains (difference=2.0 g/day [95% CI: 0-4.0 g/day]; p=0.05) as compared with the control group. However, the intervention and control groups did not differ in any of the neurodevelopmental measures.

CONCLUSIONS

In-hospital developmental care has short-term benefits for Taiwanese VLBW preterm infants in reducing the risk of retinopathy and feeding desaturation as well as in enhancing weight gains at term age.

Maternal-reported behavioral and emotional problems in Taiwanese preschool children

There has been limited epidemiologic information concerning preschoolers' behavioral and emotional problems in Eastern societies. This study was therefore aimed to investigate behavioral and emotional problems in a large sample of Taiwanese preschoolers using the Child Behavior Checklist for Ages 1.5-5 (CBCL/1.5-5). The CBCL/1.5-5 was scored by mothers of 645 Taiwanese preschoolers aged 24-71 months. Psychometric features of the scale as well as the raw scores and prevalence rates of behavioral problems of Taiwanese preschoolers were compared with those of American counterparts. Several demographic variables with the Total Problems and syndromes scores were also examined. The CBCL/1.5-5 was found to have good to excellent levels of reliability (internal consistency, test-retest reliability and inter-parent agreement) and an acceptable model fit of seven-syndrome factor structure (root mean square error of approximation=0.055) when used with Taiwanese preschoolers. The prevalence rate of Total Problems, Internalizing syndrome and Externalizing syndrome score in the clinical range was 25.1%, 11.2% and 25.4%, respectively. Cross-cultural comparisons showed that Taiwanese preschoolers had higher scores in six narrow-band syndromes (effect size d=0.17-0.43, all p's<0.005) and prevalence rates of four Internalizing-related syndromes and Sleep Problems than American sample (odds ratio=2.4-4.9, all p's<0.005). Analyses of behavioral correlates revealed associations of first birth order with higher Internalizing, Externalizing and Total Problems scores (all p's<0.05). Furthermore, younger ages (24-47 months) and male gender were associated with higher Externalizing and Total Problems scores (all p's<0.05). Our data have provided important epidemiologic information to assist in clinical assessment and management of preschoolers' behavioral and emotional problems in an Eastern society.

A nationwide survey of risk factors for stillbirth in Taiwan, 2001-2004

OBJECTIVE

The purpose of this study was to evaluate the nationwide stillbirth rate and explore the potential risk factors associated with stillbirths.

PATIENTS AND METHODS

Data from vital registrations during the time period from January 1, 2001 through to December 31, 2004 in Taiwan were used. Stillbirth was defined as fetal death with more than 20 completed weeks' gestational age (GA) or with birth weight more than 500 g if the GA was not known.

RESULTS

There were a total of 8481 stillbirths identified nationwide between January 1, 2001 and December 31, 2004. The stillbirth rate was nine per 1000 total births in the study period, and the proportionate decline was nearly 48.8% in the most recent decade. There was a significant increase in average maternal age during this period. Advanced maternal age and teenage pregnancy were independent significant risk factors for stillbirths even after accounting for the effects of medical conditions that were more likely to occur among these particular age groups. Those fetuses that had been exposed to cord prolapse, maternal cervical incompetence and oligohydramnios/polyhydramnios were especially vulnerable. By contrast, women who had foreign nationality, fetal ultrasound surveys, fetal heart beat monitoring and hastened parturition were less likely to have stillbirth.

CONCLUSION

The stillbirth rate in Taiwan has remained high despite advancements in medical care. Prenatal evaluation of high risk women may decrease the adverse fetal outcomes.

Maternal psychosocial factors around delivery, and the behavior of 2-year-old children

BACKGROUND

The objectives of the present study were to explore whether maternal psychosocial factors, mental health and work stress around delivery, are related to the behavior of 2-year-old children.

METHODS

In a prospective cohort study design, pregnant women attending the National Taiwan University Hospital for delivery and post-partum care from April 2004 to January 2005 were recruited and their children were observed at 24 months. A total of 186 mother-term-born child dyads completed the measurement. The five-item Mental Health Index (MHI-5) self-report data of maternal psychosocial factors were selected from the Taiwanese version of the short form 36 (SF-36). The Child Behavior Checklist for age 1½-5 (CBCL/1½-5) was completed by the parents when the child was 2 years old.

RESULTS

The mean score of mental health around delivery was 68.11. The proportion of mothers with work stress seldom and always was 61.8% and 24.7%, respectively. The mean of the total CBCL score, and internalizing, externalizing behavior and sleep problems scores was 45.95, 11.89, 15.59 and 4.23, respectively. After adjusting for the potential confounders, maternal work stress around delivery was found to have a significant effect on the total CBCL and externalizing, attention and aggressive, behavioral problems of 2-year old children. Maternal mental health around delivery, however, did not show significant effects on child behavior.

CONCLUSIONS

Work stress around delivery seems to aggravate children's externalizing behavior problems at 2 years old. It is therefore important to improve the psychosocial health and reduce the stress of pregnant women.

Reliability of the assessment of mother-infant sensitivity-chinese version for preterm and term taiwanese mother-infant dyads

PURPOSE

The objectives of this study were to translate and modify the Assessment of Mother-Infant Sensitivity scale into a Chinese version (modified AMIS-C) and to examine its reliability with preterm and term Taiwanese mother-infant dyads.

METHOD

A total of 241 mother-infant pairs (179 preterm dyads and 62 term dyads) were prospectively recorded and their behaviour in feeding assessed using the modified AMIS-C when infants were at 4 and 6 months corrected age. A subset of the sample was used for interrater reliability testing, and the whole sample was used for assessment of internal consistency.

RESULTS

Interrater reliability was high for the modified AMIS-C section and total scores (intra-class correlation coefficients=0.91-0.99). Internal consistency was good to excellent for the maternal section and total score (α=0.71-0.86) and was fair to good for the infant and dyadic section score (α=0.44-0.75).

CONCLUSIONS

The modified AMIS-C scale is a clinically feasible and reliable instrument for assessing mother-infant interaction of preterm and term dyads during early infancy.

International comparisons of behavioral and emotional problems in preschool children: parents' reports from 24 societies

International comparisons were conducted of preschool children's behavioral and emotional problems as reported on the Child Behavior Checklist for Ages 1½-5 by parents in 24 societies (N = 19,850). Item ratings were aggregated into scores on syndromes; Diagnostic and Statistical Manual of Mental Disorders-oriented scales; a Stress Problems scale; and Internalizing, Externalizing, and Total Problems scales. Effect sizes for scale score differences among the 24 societies ranged from small to medium (3-12%). Although societies differed greatly in language, culture, and other characteristics, Total Problems scores for 18 of the 24 societies were within 7.1 points of the omnicultural mean of 33.3 (on a scale of 0-198). Gender and age differences, as well as gender and age interactions with society, were all very small (effect sizes < 1%). Across all pairs of societies, correlations between mean item ratings averaged .78, and correlations between internal consistency alphas for the scales averaged .92, indicating that the rank orders of mean item ratings and internal consistencies of scales were very similar across diverse societies.

GSTM1 modifies the effect of maternal exposure to environmental tobacco smoke on neonatal primitive reflexes

OBJECTIVE

The aim of this study was to examine whether infant metabolic gene polymorphisms modify the effect of maternal environmental tobacco smoke (ETS) on neonatal neurobehavior.

METHODS

We conducted a birth cohort study of 87 nonsmoking women who delivered single births of normal birth weight. We enrolled the women before delivery, interviewed them using a structured questionnaire, and collected umbilical cord blood. Umbilical cord cotinine, a blood indicator of prenatal ETS exposure, was analyzed. The Neonatal Neurobehavioral Examination-Chinese Version (NNE-C) was administrated within 5 days after delivery to examine neonatal neurobehavior. Four infant metabolic genes, CYP1A1 MspI, CYP1A1 Ile462Val, GSTT1, and GSTM1, were identified.

RESULTS

Maternal ETS exposure during pregnancy was not related to neonatal neurobehavior when infant genetic polymorphisms were not considered. However, maternal ETS exposure did cause adverse effects in neonates with the absent type of GSTM1. Adverse effects were seen on the total NNE-C (β = -2.55; p = .02) and on primitive reflexes (β = -1.70; p = .004), especially in grasp reflexes (β = -.36; p = .011) and tonic neck reflexes (β = -.36; p = .049). In addition, there was a significant interaction between maternal ETS exposure and infant GSTM1 genotype on neonate grasp reflexes (p for interaction = .019).

CONCLUSIONS

These data indicate that weaker responses in neonatal primitive reflexes in infants with the absent type GSTM1 were related to maternal ETS exposure during pregnancy.

The Taiwan Birth Panel Study: a prospective cohort study for environmentally- related child health

BACKGROUND

The Taiwan Birth Panel Study (TBPS) is a prospective follow-up study to investigate the development of child health and disease in relation to in-utero and/or early childhood environmental exposures. The rationale behind the establishment of such a cohort includes the magnitude of potential environmental exposures, the timing of exposure window, fatal and children's susceptibility to toxicants, early exposure delayed effects, and low-level or unknown neurodevelopmental toxicants.

METHODS

A total of 486 mother-infant paired was enrolled from April 2004 to January 2005 in this study. Maternal blood before delivery, placenta and umbilical cord blood at birth, and mothers' urine after delivery were collected. The follow-up was scheduled at birth, 4, 6 months, and 1, 2, 3 and 5 years. The children's blood, urine, hair, and saliva were collected at 2 years of age and children's urine was collected at 5 years of age as well. The study has been approved by the ethical committee of National Taiwan University Hospital. All the subjects signed the inform consent on entering the study and each of the follow up.

RESULTS

Through this prospective birth cohort, the main health outcomes were focused on child growth, neurodevelopment, behaviour problem and atopic diseases. We investigated the main prenatal and postnatal factors including smoking, heavy metals, perfluorinated chemicals, and non-persistent pesticides under the consideration of interaction of the environment and genes.

CONCLUSIONS

This cohort study bridges knowledge gaps and answers unsolved issues in the low-level, prenatal or postnatal, and multiple exposures, genetic effect modification, and the initiation and progression of "environmentally-related childhood diseases."

Serial measurements of serum alkaline phosphatase for early prediction of osteopaenia in preterm infants

AIM

Osteopaenia commonly occurs in preterm infants; however, its diagnosis is often delayed when based on radiological findings. The aim of this study was to examine whether serial measurements of bone turnover markers are useful for early prediction of osteopaenia in preterm infants.

METHODS

Premature infants of ≤ 34 weeks gestation were enrolled. Serum alkaline phosphatase (ALP), bone form ALP (BALP), calcium and inorganic phosphate were concurrently measured biweekly from 3 weeks post-natal age until 40 weeks post-conceptional age. Radiographic examination of the forearm was performed at term age. Osteopaenia was defined as positive radiographic findings according to Koo's criteria.

RESULTS

Of the 46 premature infants completing the follow-up study at term age, 18 showed osteopaenia in radiographic examination. Serum ALP was highly correlated with BALP (R(2) = 0.93, P < 0.001). Infants who had osteopaenia showed a higher level of ALP and BALP after 3 weeks post-natal age than those who had no osteopaenia. ALP concentration exceeding 700 IU/L at 3 weeks post-natal age was predictive of osteopaenia at term age (sensitivity 73% and specificity 73%) and so did for the predictive value of BALP concentration exceeding 95 ug/L (sensitivity 73% and specificity 80%). BALP measures provided no greater benefit of diagnostic performance than ALP in early detection of osteopaenia. Furthermore, premature infants with osteopaenia showed similar levels of calcium and inorganic phosphatase concentration compared with those without.

CONCLUSION

Serum ALP concentration exceeding 700 IU/L at 3 weeks post-natal age can predict the risk of osteopaenia in preterm infants.

Maternal psychosocial factors around delivery on development of 2-year-old children: A prospective cohort study

AIM

To explore whether maternal psychosocial factors around delivery are related to development of 2-year-old children.

METHODS

Pregnant women going to the hospital for delivery were recruited, and their children were observed at 24 months. A total of 186 mother-child dyads completed the measurement. Self-report data of maternal psychosocial factors around delivery were selected from the Taiwanese version of the short-form 36. The Comprehensive Developmental Inventory for Infants and Toddlers was completed by interviewers and the main care givers for the child at 2 years old.

RESULTS

Using the multiple linear regression analysis and adjusting for potential confounders, maternal vitality around delivery was found to have a significantly positive relationship with the whole Comprehensive Developmental Inventory for Infants and Toddlers (P = 0.005) and self-help development (P = 0.001), but work stress had a significantly negative relationship with motor development (seldom, P = 0.050; always, P = 0.048).

CONCLUSIONS

Maternal vitality around delivery was beneficial to a child's self-help development, while work stress seemed to be an adverse effect on child's motor development in later life. It is important to improve the psychosocial health of pregnant women.

Preschool psychopathology reported by parents in 23 societies: testing the seven-syndrome model of the child behavior checklist for ages 1.5-5

OBJECTIVE

To test the fit of a seven-syndrome model to ratings of preschoolers' problems by parents in very diverse societies.

METHOD

Parents of 19,106 children 18 to 71 months of age from 23 societies in Asia, Australasia, Europe, the Middle East, and South America completed the Child Behavior Checklist for Ages 1.5-5 (CBCL/1.5-5). Confirmatory factor analyses were used to test the seven-syndrome model separately for each society.

RESULTS

The primary model fit index, the root mean square error of approximation (RMSEA), indicated acceptable to good fit for each society. Although a six-syndrome model combining the Emotionally Reactive and Anxious/Depressed syndromes also fit the data for nine societies, it fit less well than the seven-syndrome model for seven of the nine societies. Other fit indices yielded less consistent results than the RMSEA.

CONCLUSIONS

The seven-syndrome model provides one way to capture patterns of children's problems that are manifested in ratings by parents from many societies. Clinicians working with preschoolers from these societies can thus assess and describe parents' ratings of behavioral, emotional, and social problems in terms of the seven syndromes. The results illustrate possibilities for culture-general taxonomic constructs of preschool psychopathology. Problems not captured by the CBCL/1.5-5 may form additional syndromes, and other syndrome models may also fit the data.

CYP1A1 modifies the effect of maternal exposure to environmental tobacco smoke on child behavior

INTRODUCTION

Maternal environmental tobacco smoke (ETS) has been identified as a key risk factor for problem behavior in children, but the role of genetic susceptibility is not clear. The purpose of this study was to examine the metabolic genetic modification effect of exposure to ETS in nonsmoking mothers on child behavior at 2 years of age.

METHODS

A prospective cohort study was conducted among 191 mothers who gave births between 2004 and 2005 and their infants in Taiwan. The mothers completed a questionnaire before delivery in which they provided information on exposure to ETS during pregnancy. Four metabolic genes, CYP1A1 MspI, CYP1A1 Ile462Val, GSTT1, and GSTM1 were isolated from both maternal and infant DNA samples. Children's behavior problems at 2 years of age were reported by their mothers using the Child Behavior Checklist/1.5-5. Multiple linear models were used to estimate the effects of ETS and genotype on child behavior.

RESULTS

Maternal ETS exposure was associated with the anxious score. The ETS-exposed group with both the CYP1A1 MspI and the CYP1A1 Ile462Val variants had higher scores, as reflected in total CBCL score as well as scores on the internalizing scale and its emotional subdomain, the anxious scale, and the externalizing scale and its aggressive subdomain.

CONCLUSIONS

Child behavioral problems may be associated with prenatal ETS exposure, and this effect may be modified by infant CYP1A1 MspI and CYP1A1 Ile462Val genes.

Management of congenital cystic adenomatoid malformation and bronchopulmonary sequestration in newborns

BACKGROUND

Congenital cystic adenomatoid malformation (CCAM) and bronchopulmonary sequestration (BPS) are major embryonic pulmonary developmental anomalies. Early surgical excision is becoming an increasingly common option. We investigated the clinical features and management of patients with CCAM and BPS at the National Taiwan University Hospital.

METHODS

We conducted a retrospective review of neonates diagnosed with CCAM and/or BPS at the Hospital from July 1995 to January 2008. Prenatal examination, postnatal presentation, management and patient outcome were analyzed. We also propose a concise algorithm for the practical management of these conditions.

RESULTS

Sixteen patients were recruited including eight (50%) with CCAM, five (31%) with BPS and three (19%) with mixed-type lesions (CCAM with BPS). Thirteen (81%) patients were diagnosed antenatally at a median gestational age of 20 weeks. Eleven (69%) patients underwent surgical resection before 6 months of age because of respiratory distress or repeated pulmonary infection. There were no surgery-related complications among the seven patients who underwent early surgery within 1 month of age. Five (31%) patients remained asymptomatic and did not undergo surgery. All patients survived with no limitations to daily activity during follow-up periods of 1-8 years.

CONCLUSION

The high proportion of mixed-type lesions suggests that CCAM and BPS may share the same developmental ancestry. Early surgical resection within 1 month of age is safe in symptomatic patients.

Severity of bronchopulmonary dysplasia and increased risk of feeding desaturation and growth delay in very low birth weight preterm infants

Oral feeding has been reported to compromise breathing among preterm infants with bronchopulmonary dysplasia (BPD) during hospitalization or shortly after discharge. However, limited information was available concerning whether preterm infants with BPD remain vulnerable to feeding and growth insufficiency after a longer term of follow-up. The purpose of this study was therefore to examine the effect of severity of BPD on pulse oxygen saturation (SpO(2)) during feeding and growth in very low birth weight (VLBW) preterm infants during infancy. Seventy-two preterm infants with VLBW and 15 term infants were prospectively examined their growth and SpO(2) during feeding at 2, 4, and 6 months of corrected age. The severity of BPD was graded in VLBW infants according to the American National Institutes of Health consensus definition. In comparison to VLBW infants with mild BPD and term infants, VLBW infants with severe BPD showed significantly lower mean levels of SpO(2) during feeding at 2-6 months corrected age (P < 0.05). Those with severe BPD further exhibited higher rates of growth delay (weight < 10th percentile) throughout the study period. Among VLBW infants, severe BPD had an adverse relation with subsequent weight measures after adjustment for medical and demographic confounding variables (beta = -904 g, P = 0.03). The consensus BPD definition is useful to identify those preterm infants who are at greater risk of feeding desaturation and growth delay during infancy and close monitoring of SpO(2) during feeding should be advised.

Neonatal and pregnancy outcome in primary antiphospholipid syndrome: a 10-year experience in one medical center

BACKGROUND

Antiphospholipid syndrome (APS) in pregnancy is characterized by the presence of maternal autoantibodies in association with recurrent fetal loss and severe obstetric complications such as prematurity, intrauterine growth retardation, or placental insufficiency. This study aimed to assess the perinatal outcomes in neonates born to mothers with APS.

METHODS

The medical records of pregnant women with APS and their offspring were retrospectively collected between January 1997 and July 2007. Maternal and perinatal histories including demographic data, medications, obstetric histories, and neonatal clinical manifestations and laboratory data were analyzed.

RESULTS

Eleven women with a diagnosis of primary APS were included. Eight of these patients had experienced frequent spontaneous abortions (72.7%), and four had unexplained fetal deaths (36.3%). None of them had vascular thrombosis. Specific autoimmune antibodies were detected, including anticardiolipin antibody (n=6), anti-beta2 glycoprotein I (n=3), and antiphospholipid antibody (n=7). Among the pregnancies, five had preterm births (45.4%), two had intrauterine growth retardation (18.1%), and one had intrauterine fetal demise (9.1%). Thrombocytopenia was noted in three babies, all of whose mothers had lower platelet counts. One patient with neonatal thrombocytopenia developed intracranial hemorrhage, seen on brain images.

CONCLUSIONS

This limited study suggests that neonates born to mothers with primary APS are at risk of prematurity, being small for gestational age, and having thrombocytopenia. Further large, prospective studies are required to better define the perinatal outcomes.

Impact of delivery mode and gestational age on haematological parameters in Taiwanese preterm infants

AIM

Reference ranges of haematological parameters in preterm infants are limited. The aim of this study is to determine the reference values of haematological parameters in preterm infants in Taiwan, and to assess the impact of gestational age and mode of delivery on these parameters.

METHOD

Medical records were retrospectively reviewed in preterm infants admitted to National Taiwan University Hospital from January 2001 to December 2004. The inclusion criteria included infants with <37 weeks of gestation who had blood sampling within 24 h of birth. The exclusion criteria included those with maternal history of antepartum haemorrhage, chorioamnionitis, fever, sepsis, preeclampsia and hypertension; and perinatal history of twin-to-twin transfusion syndrome, feto-maternal transfusion, injury and infection.

RESULTS

Of 568 preterm infants with blood cell counts, 337 were available for analysis. There were trends of increase in red blood cell counts, haemoglobin levels and haematocrit values as gestation increased up to 34 weeks. In contrast, a trend of decrease was noted in mean corpuscular volume values. There was an initial trend of decrease in white blood cell counts and then increased after 31 weeks gestation. The platelet counts were essentially unchanged. Infants born by vaginal delivery generally had higher haematological parameters than those born by Caesarean section at different gestational ages except for mean corpuscular volume values.

CONCLUSIONS

We established the reference ranges of haematological parameters in Taiwanese preterm infants. Health-care professionals must be cautious in clinical application of the haematological values because of varying antenatal and perinatal risk factors.

Spontaneous multiseptated cystic pneumomediastinum in a term newborn

Pneumomediastinum usually occurs after assisted ventilation. Spontaneous pneumomediastinum without preceding assisted ventilation, and presenting as a huge cystic mass in a term newborn infant has rarely been reported. We report a term baby who developed respiratory distress at 2 days of age. A huge cystic tumor of the thymus or a congenital mediastinal cystic tumor was initially suggested by chest radiography and computed tomography. Follow-up chest film revealed a "spinnaker sail sign" which is a typical radiographic presentation of pneumomediastinum.

Neonatal listeriosis in Taiwan, 1990-2007

OBJECTIVES

Listeria monocytogenes is an important pathogen in neonates in Western countries, with a fatality rate of 20-30%. There is limited information on neonatal listeriosis in Eastern countries. The purpose of this study was to delineate the occurrence and clinical picture of neonatal listeriosis in Taiwan.

METHODS

A questionnaire-based survey of all of the 17 medical centers in Taiwan was performed, and a literature review of neonatal listeriosis as reported in Taiwan from 1990 to 2007 was made.

RESULTS

A total of 14 cases (10 male, four female) of neonatal listeriosis were identified, including 11 found from the survey of four medical centers and another three collected from the literature review. Three were found to have occurred prior to 2000 and 11 were found to have occurred after 2000. The age of onset was less than 3 days in all cases. L. monocytogenes was identified from blood in 13, cerebrospinal fluid in four, and gastric aspirate in two. Half of the cases (7/14) had involvement of the central nervous system with pleocytosis and hypoglycorrhachia in cerebrospinal fluid, and three of them even developed hydrocephalus. The mortality rate was 29%.

CONCLUSIONS

Our findings suggest that listeriosis may emerge as an important health threat among newborn infants in Taiwan.

High perinatal seroprevalence of cytomegalovirus in northern Taiwan

AIM

The living style, health-care system and socio-economic environments have changed substantially in Taiwan over past 20 years. This study was aimed to estimate the current perinatal cytomegalovirus (CMV) seroprevalence in northern Taiwan.

METHODS

In a Taiwan Birth Panel Study, 483 pairs of mothers and neonates were prospectively recruited from one tertiary medical center, one local hospital, and two obstetric clinics located in northern Taiwan from April 2004 through January 2005. Sera of their paired maternal and cord blood were tested by an enzyme-linked immunosorbent assay method for CMV IgG and IgM antibodies. Additional data were collected for health measures and epidemiological characteristics through trained interviewers utilising structured questionnaires.

RESULTS

Among 483 mothers studied, 93% were Taiwanese, 6.4% were immigrants from the south-eastern Asia and Mainland China, and 0.6% was aborigines. The seropositive rate of CMV IgG and IgM among the mothers was 91.1% and 3.5%, respectively. The immigrant mothers and the mothers younger than 20 years of age had a higher IgM seroprevalence (P < 0.05). Furthermore, 90.8% of the offspring had CMV IgG seropositivity and yet none of the neonates were CMV IgM positive.

CONCLUSION

The seroprevalence of CMV among childbearing women is high in northern Taiwan. The immigrant mothers and the teenage mothers appear to have higher seropositivity of CMV IgM.