Children and young people's experiences of living with rare diseases: An integrative review

PROBLEM

Rare diseases are any disease affecting fewer than five people in 10,000. More than 8000 rare diseases and 50-75% of all rare diseases affect children. The purpose of this review was to critically appraise and synthesize existing literature relating to the impact of rare diseases on children's day-to-day lives.

ELIGIBILITY CRITERIA

An integrative literature review was conducted using the CINAHL Plus, PsycINFO, and PubMed databases. Studies were included if they were a primary source was published between the years 2005 and 2019 and written in the English language.

SAMPLE

Eight primary sources met the inclusion criteria.

RESULTS

Seven main themes emerged from the review as follows: (i) the experience of stigmatisations, (ii) self-consciousness, (iii) restrictions in independent living, (iv) developing resilience/coping strategies, (v) psychological and emotional impact, (vi) social impact vs social connectedness and (vii) transition challenges.

CONCLUSIONS

The experience of having a rare illness differed across different age groups. Children (typically aged 3-10) with rare diseases generally view themselves and their lives the same way like their healthy peers. They were more likely to report being adaptive and resilient than those aged 12 or older. Young people reported being different compared to young children, and they faced numerous challenges related to their illness.

IMPLICATIONS FOR PRACTICE

To provide the best possible level of care for children and families with rare disorders, health services must be informed and equipped to provide the necessary supports specific to the unique needs of children and young people living with rare diseases.

UCL MotionInput: Touchless computing interactions in clinical training, radiology and operating theatres

Coupled with advances to federated on-device computer vision, the convenience of use and ease of access of cameras integrated into existing computers and tablets will increase touchless computing uptake in the form of gesture recognition software in healthcare for both clinicians and patients.

Making the invisible visible: New perspectives on the intersection of human-environment interactions of clinical teams in intensive care

Understanding human behaviour is essential to the successful adoption of new technologies, and for the promotion of safer care. This requires capturing the detail of clinical workflows to inform the design of new human-technology interactions. We are interested particularly in the possibilities for touchless technologies that can decipher human speech, gesture and motion and allow for interactions that are free of contact. Here, we employ a new approach by installing a single 360° camera into a clinical environment to analyse touch patterns and human-environment interactions across a clinical team to recommend design considerations for new technologies with the potential to reduce avoidable touch.

OUP accepted manuscript

The increasing volume and richness of healthcare data collected during routine clinical practice have not yet translated into significant numbers of actionable insights that have systematically improved patient outcomes. An evidence-practice gap continues to exist in healthcare. We contest that this gap can be reduced by assessing the use of nudge theory as part of clinical decision support systems (CDSS). Deploying nudges to modify clinician behaviour and improve adherence to guideline-directed therapy represents an underused tool in bridging the evidence-practice gap. In conjunction with electronic health records (EHRs) and newer devices including artificial intelligence algorithms that are increasingly integrated within learning health systems, nudges such as CDSS alerts should be iteratively tested for all stakeholders involved in health decision-making: clinicians, researchers, and patients alike. Not only could they improve the implementation of known evidence, but the true value of nudging could lie in areas where traditional randomized controlled trials are lacking, and where clinical equipoise and variation dominate. The opportunity to test CDSS nudge alerts and their ability to standardize behaviour in the face of uncertainty may generate novel insights and improve patient outcomes in areas of clinical practice currently without a robust evidence base.

Maple syrup urine disease: Clinical outcomes, metabolic control, and genotypes in a screened population after four decades of newborn bloodspot screening in the Republic of Ireland

Since 1972, 18 patients (10 females/8 males) have been detected by newborn bloodspot screening (NBS) with neonatal-onset maple syrup urine disease (MSUD) in Ireland. Patients were stratified into three clusters according to clinical outcome at the time of data collection, including developmental, clinical, and IQ data. A fourth cluster comprised of two early childhood deaths; a third patient died as an adult. We present neuroimaging and electroencephalography together with clinical and biochemical data. Incidence of MSUD (1972-2018) was 1 in 147 975. Overall good clinical outcomes were achieved with 15/18 patients alive and with essentially normal functioning (with only the lowest performing cluster lying beyond a single SD on their full scale intelligence quotient). Molecular genetic analysis revealed genotypes hitherto not reported, including a possible digenic inheritance state for the BCKDHA and DBT genes in one family. Treatment has been based on early implementation of emergency treatment, diet, close monitoring, and even dialysis in the setting of acute metabolic decompensation. A plasma leucine ≥400 μmol/L (outside therapeutic range) was more frequently observed in infancy or during adolescence, possibly due to infections, hormonal changes, or noncompliance. Children require careful management during metabolic decompensations in early childhood, and this represented a key risk period in our cohort. A high level of metabolic control can be achieved through diet with early implementation of a "sick day" regime and, in some cases, dialysis as a rescue therapy. The Irish cohort, despite largely classical phenotypes, achieved good outcomes in the NBS era, underlining the importance of early diagnosis and skilled multidisciplinary team management.

Designing Personas for Expressive Robots

Imbuing robots with personality has been shown to be an effective design approach in HRI, promoting user trust and acceptance. We explore personality design in a non-anthropomorphic voice-assisted home robot. Our design approach developed three distinct robot personas: Butler, Buddy, and Sidekick, intended to differ in proactivity and emotional impact. Persona differences were signaled to users by a combination of humanoid (speech, intonation), and indirect cues (colors and movement). We use Big Five personality theory to evaluate perceived differences between personas in an exploratory Wizard of Oz study. Participants were largely able to recognize underlying personality traits expressed through these cue combinations in ways that were consistent with our design goals. The proactive Buddy persona was judged as more Extravert than the more passive Sidekick persona, and the Butler persona was perceived as more Conscientious and less Neurotic than either Buddy or Butler personas. Users also had clear preferences between different personas; they wanted robots that mimicked but accentuated their own personality. Results suggest that future designs might exploit abstract cues to signal personality traits.

Expanding the genetic and phenotypic spectrum of branched-chain amino acid transferase 2 deficiency

The first step in branched-chain amino acid (BCAA) catabolism is catalyzed by the two BCAA transferase isoenzymes, cytoplasmic branched-chain amino acid transferase (BCAT) 1, and mitochondrial BCAT2. Defects in the second step of BCAA catabolism cause maple syrup urine disease (MSUD), a condition which has been far more extensively investigated. Here, we studied the consequences of BCAT2 deficiency, an ultra-rare condition in humans. We present genetic, clinical, and functional data in five individuals from four different families with homozygous or compound heterozygous BCAT2 mutations which were all detected following abnormal biochemical profile results or familial mutation segregation studies. We demonstrate that BCAT2 deficiency has a recognizable biochemical profile with raised plasma BCAAs and, in contrast with MSUD, low-normal branched-chain keto acids (BCKAs) with undetectable l-allo-isoleucine. Interestingly, unlike in MSUD, none of the individuals with BCAT2 deficiency developed acute encephalopathy even with exceptionally high BCAA levels. We observed wide-ranging clinical phenotypes in individuals with BCAT2 deficiency. While one adult was apparently asymptomatic, three individuals had presented with developmental delay and autistic features. We show that the biochemical characteristics of BCAT2 deficiency may be amenable to protein-restricted diet and that early treatment may improve outcome in affected individuals. BCAT2 deficiency is an inborn error of BCAA catabolism. At present, it is unclear whether developmental delay and autism are parts of the variable phenotypic spectrum of this condition or coincidental. Further studies will be required to explore this.

A blended design approach for pervasive healthcare: bringing together users, experts and technology

Pervasive healthcare is beginning to investigate how novel sensory technologies can be used to measure body movements and provide various forms of feedback. This position paper reflects on a blended design approach that uses a combination of technology inspiration, consultation with experts and user-centred design for the development of a personalized pervasive healthcare system to support stroke rehabilitation.

Outcomes of siblings with classical galactosemia

OBJECTIVES

To determine the long-term outcome of dietary intervention in siblings from 14 Irish families with classical galactosemia (McKusick 230400), an autosomal recessive disorder of carbohydrate metabolism and galactose-1-phosphate uridyltransferase (GALT) deficiency.

STUDY DESIGN

Outcomes in siblings on dietary galactose restriction were studied to evaluate whether birth order (ie, time of commencement of diet) and compliance with lactose-restricted diet (galactose intake > or < 20 mg /day), assessed by dietary recall and biochemical monitoring of galactose-1-phosphate [Gal-1-P] and galactitol values, affected outcomes. The outcome variables assessed were IQ, speech, and language assessment scores, neurologic examination results, and magnetic resonance imaging (MRI) of the brain.

RESULTS

There was a high incidence of complications in the overall group, particularly speech and language delay (77%) and low IQ (71%). There was no significant difference in outcome between earlier-treated and later-treated siblings or any correlation with mean Gal-1-P or galactitol values. In most cases, cerebral white matter disease was evident on MRI scanning, with evidence of progressive cerebellar degeneration seen in 2 highly compliant families.

CONCLUSION

The subjects with a higher galactose intake did not exhibit an increased incidence of complications; conversely, those who were very compliant with dietary restrictions did not have more favorable outcomes.

New molecular reporters for rapid protein folding assays

The GFP folding reporter assay [1] uses a C-terminal GFP fusion to report on the folding success of upstream fused polypeptides. The GFP folding assay is widely-used for screening protein variants with improved folding and solubility [2]–[8], but truncation artifacts may arise during evolution, i.e. from de novo internal ribosome entry sites [9]. One way to reduce such artifacts would be to insert target genes within the scaffolding of GFP circular permuted variants. Circular permutants of fluorescent proteins often misfold and are non-fluorescent, and do not readily tolerate fused polypeptides within the fluorescent protein scaffolding [10]–[12]. To overcome these limitations, and to increase the dynamic range for reporting on protein misfolding, we have created eight GFP insertion reporters with different sensitivities to protein misfolding using chimeras of two previously described GFP variants, the GFP folding reporter [1] and the robustly-folding “superfolder” GFP [13]. We applied this technology to engineer soluble variants of Rv0113, a protein from Mycobacterium tuberculosis initially expressed as inclusion bodies in Escherichia coli. Using GFP insertion reporters with increasing stringency for each cycle of mutagenesis and selection led to a variant that produced large amounts of soluble protein at 37°C in Escherichia coli. The new reporter constructs discriminate against truncation artifacts previously isolated during directed evolution of Rv0113 using the original C-terminal GFP folding reporter. Using GFP insertion reporters with variable stringency should prove useful for engineering protein variants with improved folding and solubility, while reducing the number of artifacts arising from internal cryptic ribosome initiation sites.

Neonatal neurodevelopmental outcomes following tocolysis with glycerol trinitrate patches

OBJECTIVE

The object of this study was to determine the effects of maternal tocolysis with glycerol trinitrate (GTN) patches on the neurodevelopment of infants.

STUDY DESIGN

This was a randomized, multicenter, controlled trial comparing the efficacy of GTN patches with standard beta2 agonist as tocolytic therapy. The previously reported outcomes of this study indicated no difference in neonatal mortality or morbidity to hospital discharge. One hundred fifty-six surviving infants from 2 Australian centers were psychometrically assessed using the Griffiths Mental development Scales (revised) at 18 months of age.

RESULTS

There was no difference in psychometric performance between those infants enrolled in either the GTN (81 infants) or beta2 agonist (75 infants) arm of the study.

CONCLUSION

This randomized trial supports no significant difference between GTN patches in comparison with standard beta2 agonist for tocolytic therapy. The results underscore the association between premature labor and adverse infant outcomes.

High dose caffeine citrate for extubation of preterm infants: a randomised controlled trial

OBJECTIVE

To compare two dosing regimens for caffeine citrate in the periextubation period for neonates born at less than 30 weeks gestation in terms of successful extubation and adverse effects.

DESIGN

A multicentre, randomised, double blind, clinical trial.

SETTING

Four tertiary neonatal units within Australia.

PATIENTS

Infants born less than 30 weeks gestation ventilated for more than 48 hours.

INTERVENTIONS

Two dosing regimens of caffeine citrate (20 v 5 mg/kg/day) for periextubation management. Treatment started 24 hours before a planned extubation or within six hours of an unplanned extubation.

MAIN OUTCOME MEASURE

Failure to extubate within 48 hours of caffeine loading or reintubation and ventilation or doxapram within seven days of caffeine loading.

RESULTS

A total of 234 neonates were enrolled. A significant reduction in failure to extubate was shown for the 20 mg/kg/day dosing group (15.0% v 29.8%; relative risk 0.51; 95% confidence interval (CI) 0.31 to 0.85; number needed to treat 7 (95% CI 4 to 24)). A significant difference in duration of mechanical ventilation was shown for infants of less than 28 weeks gestation receiving the high dose of caffeine (mean (SD) days 14.4 (11.1) v 22.1 (17.1); p = 0.01). No difference in adverse effects was detected in terms of mortality, major neonatal morbidity, death, or severe disability or general quotient at 12 months.

CONCLUSIONS

This trial shows short term benefits for a 20 mg/kg/day dosing regimen of caffeine citrate for neonates born at less than 30 weeks gestation in the periextubation period, without evidence of harm in the first year of life.

Movement and motor development in ELBW infants at 1 year is related to cognitive and motor abilities at 4 years

A relationship between motor ability and cognitive performance has been previously reported. This study aimed to investigate the association between movement and cognitive performance at 1 and 4 years corrected age of children born less than 1000 g, and whether developmental testing of movement at 1 year is predictive of cognitive performance at 4 years. Motor development was assessed at both ages using the neurosensory motor developmental assessment (NSMDA) and motor development was classified as normal, or minimal, mild, moderate-severe dysfunction. Cognitive performance was assessed on the Griffith Mental Developmental Scale at 1 year and McCarthy Scales of Children's Abilities at 4 years. Subjects included 198 children of birthweight less than 1000 g. Of these 132 children returned for follow-up at the corrected ages of both 1 and 4 years. The 66 children not included had a slight increase in gestational age, while the mothers were younger and had a lower level of education. A significant association was found between NSMDA group classification at 1 year and cognitive performance at both 1 and 4 years (p<0.001; p<0.0001) and between the subscales of each test (1 year, p<0.0001; 4 years, p<0.001). Group classification of motor development at 1 year was predictive of cognitive performance at 4 years (p<0.0001) and this was independent of biological and social factors and presence of cerebral palsy (CP). The findings support a close link between motor and cognitive development in children born <1000 g and emphasise the advantage of detailed assessment of movement at 1 year.

A parent-completed developmental questionnaire: follow up of ex-premature infants

OBJECTIVE

Premature infants are at increased risk of developmental disability. Early identification of problems allows intervention to ameliorate or attenuate problems. A reliable screening tool allows triage of children in this high-risk population by identifying those unlikely to need full developmental assessment. To explore the test characteristics of an established parent-completed developmental assessment questionnaire 'Ages and Stages Questionnaire' (ASQ) in follow up of an Australian population of premature infants.

METHODOLOGY

One hundred and sixty-seven children born prematurely with corrected ages 12- to 48-months attending the Growth and Development Clinic at the Mater Children's Hospital in Brisbane, Queensland, Australia; 136 questionnaires 'ASQ' were returned completed (81%) and were compared to formal psychometric assessment (Griffith Mental Development Scales for 12- and 24-months, Bayley Mental Development Intelligence Scale for 18-months, McCarthy General Cognitive Intelligence Scale for 48-months). Developmental delay was considered to be present if any of the above psychometric assessments fell below 1.0 standard deviations (SD). The ASQ cut-off used was 2.0 SD (US data derived means and SD).

RESULTS

Aggregate results for all age groups comparing ASQ to psychometric assessments as 'gold standards' found the ASQ to have the following test characteristics: sensitivity (90%); specificity (77%); positive predictive value (40%); negative predictive value (98%); % over-referred (20%); % under-referred (1%); % agreement (79%). Likelihood ratio for children failing the ASQ was 3.8 and for passing the ASQ was 0.13. Twenty-one children with known disabilities were included in the study and in 14 of these, the ASQ overall score agreed with the psychometric assessment (67%).

CONCLUSION

The high negative predictive value of the ASQ supports its use as a screening tool for cognitive and motor delays in the follow up of ex-premature infants. This would need to be combined with other strategies as part of a comprehensive follow up program for ex-premature infants.

Head circumference in ELBW babies is associated with learning difficulties and cognition but not ADHD in the school-aged child

This study examines whether a small head circumference (HC) and low head-circumference growth velocity (HGV) during the first year of life predict consequences at school age in learning, cognition, and concentration. A total of 124 extremely-low-birthweight (ELBW) infants (birthweight 500 to 999 g) born between 1977 and 1986 were eligible for follow-up at the corrected ages of 4, 8, and 12 months and 2, 4, and 6 years. Infants were categorized as having a small HC (< 3% or 3 to 10%) on the basis of the 1990 British growth data which allowed standardized z-scores to be calculated for HC, independent of gestation and corrected age. HGV measurements were calculated using differences in the HC z-scores. In 1995, parents of 87 children agreed to participate in a study of learning and attention at school age. Attention-deficit-hyperactivity disorder (ADHD) was assessed using the Du Paul Rating Scale. Academic performances were based on a teacher questionnaire dealing with aspects of reading, writing, mathematics, and spelling. A child was considered to have a learning difficulty if academic problems were present in at least one of these four areas. Intellectual ability was assessed using the McCarthy Scale at 6 years. HC < 3% and 3 to 10% at 8 months' corrected age was strongly associated with school-aged learning problems (P=0.004), with a moderate specificity (70%), positive predictive value (PPV) (67%), and sensitivity (67%). HGV < or = 10% from birth to 4 months was also associated with learning problems at school age (P=0.01) with a higher specificity (98%) and PPV (88%) but lower sensitivity (20%). A logistic regression analysis was performed with the risk for learning difficulties at 8 months as the dependent variable. Sex, gestation, birthweight, multiple births, and a history of intraventricular hemorrhage did not substantially alter the unadjusted odds ratio (4.7; 95% CI 1.9 to 13.6). Maternal age and education did not confound the relation. No association was found between HC or HGV and ADHD. HC < 3% at 4 months (P<0.02), 8 months (P=0.02), and 12 months (P=0.04), and HGV between birth and 4 months (P<0.01) were significantly associated with low cognitive ability at 6 years.

Enamel hypoplasia and dental caries in very-low birthweight children: a case-controlled, longitudinal study

This longitudinal study investigated the sequelae of enamel defects in a group of 25 white, very-low birthweight (VLBW), preterm children (mean birthweight 969 +/- 218 g, mean gestational age 27 +/- 1.9 weeks). Twenty-five race-, age-, and sex-matched, full-term normal birthweight (NBW) control children born at the same hospital, were selected randomly from hospital records. The children were examined at approximate ages of 30, 44, and 52 months. At all examinations, VLBW children had significantly higher prevalence of enamel hypoplasia than did the NBW children. At the last recall examination, 96% of VLBW group, and 45% of the NBW group had at least one tooth with enamel defect, with a mean of 7.6 +/- 4.9 affected teeth per VLBW child, and only 1.0 +/- 1.3 affected teeth per control child (P < 0.001). A significant association of enamel defects with dental caries was observed only in the VLBW group on the second and third examinations (P < 0.001). The defect identified to be most significantly associated with dental caries was a variant showing both enamel hypoplasia and opacity. In spite of a high prevalence of enamel defects, the overall prevalence of dental caries in the VLBW children was not significantly different from that of NBW controls at all three examinations (P < 0.1). Other caries risk factors such as levels of Streptococcus mutans infection, fluoride supplementation, plaque scores, toothbrushing frequency, and daily sugar exposures were examined but none was found to be related significantly to development of dental caries.

Extremely low birth weight and control infants at 2 years corrected age: a comparison of intellectual abilities, motor performance, growth and health

A 2-year cohort of 63 surviving extremely low birth weight (ELBW) infants was prospectively studied and 60 of these infants, together with 44 normal birth weight control infants, were assessed at 2 years of age for intellectual abilities, motor skills, growth and health. The total ELBW group differed significantly from controls on overall Griffiths developmental quotient (99.3 vs. 103.8 P = 0.02) and in the personal/social subscale (100.7 vs. 106.7 P = 0.01). A subset of 43 of the ELBW infants was identified as low risk at discharge. No statistically significant differences were present between the low risk ELBW subset and controls in intellectual abilities though both the total ELBW group and the low risk ELBW subset differed from controls in fine and gross motor abilities, and in weight at 2 years. The total ELBW group also experienced more frequent ill health and hospital readmission.

Distributed Cognition: An Alternative Framework for Analysing and Explaining Collaborative Working

This paper examines the theoretical and practical problems that arise from attempts to develop formal characterizations and explanations of many work activities, in particular, collaborative activities. We argue that even seemingly discrete individual activities occur in, and frequently draw upon a complex network of factors: individual, social and organizational. Similarly, organizational and social constraints and practices impact upon individual cognitive processes and the realization of these in specific tasks. Any adequate characterization of work activities therefore requires the analysis and synthesis of information from these traditionally separate sources. We argue that existing frameworks, emanating separately from the respective disciplines (cognitive, social and organizational) do not present an adequate means of studying the dynamics of collaborative activity in situ. An alternative framework, advocated in this paper, is distributed cognition. Its theoretical basis is outlined together with examples of applied studies of computer-mediated work activities in different organizational settings.

Are infants with bronchopulmonary dysplasia at risk for sudden infant death syndrome?

OBJECTIVE

To compare the incidence of sudden infant death syndrome (SIDS) and apparent life-threatening event (ALTE) in infants with bronchopulmonary dysplasia (BPD) and birth weight-matched control infants in view of the changing pattern of chronic lung disease of prematurity.

METHODS

The study population consisted of 78 preterm infants of 26 to 33 weeks gestation who were diagnosed as having BPD and discharged. The 78 control infants were matched with the study infants for birth weight categories. Infants unable to maintain adequate oxygenation without supplemental oxygen when they were feeding well and thriving were discharged on home oxygen. All infants were at least 8 months of age at follow-up and information concerning the occurrence of any ALTE was obtained by direct parent interview.

RESULTS

No infant died during the period of follow-up. Seven (8.9%) of the study group compared with eight (10.5%) of the control infants had an ALTE. Three infants (one study, two control infants) were hospitalized for further investigation. No infant discharged on the home oxygen program had an ALTE.

CONCLUSIONS

The data from this study suggest that preterm infants with BPD are not at increased risk from SIDS compared with preterm infants without this condition. This may be related to close monitoring of the infants' oxygenation status and the provision of home oxygen when appropriate, which should eliminate episodes of unrecognized and untreated hypoxemia. Home monitoring for infants with BPD may not be warranted.

Handedness in extremely low birth weight infants: aetiology and relationship to intellectual abilities, motor performance and behaviour at four and six years

Hand preference was measured in a total group of 71 ELBW children to determine patterns of hand preference at 4 and 6 years, possible aetiological factors leading to handedness, and whether left or non right hand preference were markers for intellectual, motor, temperament or behavioural differences. At both 4 and 6 years the prevalence of left handedness was increased, though this prevalence changed over the period of the study. Results supported brain injury as one mechanism leading to increased left hand preference, though this process did not adequately explain this increase. Possible reasons for this and the apparent change in prevalence with time are examined. Mixed handedness at 4 years was associated with lower intellectual abilities though otherwise children were similar in motor skills, temperament and behaviour independent of hand preference category.

The prevalence and origins of left hand preference in high risk infants, and its implications for intellectual, motor and behavioural performance at four and six years

This study investigates the origins of hand preference at 4 years in a cohort of 115 high risk and premature infants; the relationship between patterns of hand preference and intellectual, motor, temperament and behavioural status at 4 and 6 years; and evidence for brain injury in mediating the relationship between hand preference and development disorder. Increased left hand preference was independently associated with extreme prematurity, high neonatal risk, increased numbers of minor physical anomalies, lowered intellectual and motor abilities, and more difficult temperament. These findings supported the presence of intrauterine and neonatal pathological mechanisms leading to left hand preference in a small number of children. Neither poor function of the non dominant hand nor absence of a family history of left handedness could further define this pathological subgroup. Support for pathological mechanisms producing left handedness was found predominatly in the infants of high birth weight, whereas prevalence of left handedness was increased mainly among the extremely low birth weight infants. In this latter group the prevalence of left handedness was also increased among children of normal intelligence, suggesting that mechanisms other than brain damage lead to left hand preference in very premature infants.

Speech and language outcomes in preschool-aged survivors of neonatal intensive care

This paper reports on the second stage of a longitudinal follow-up of the speech and language outcomes in a cohort of children who required neonatal intensive care. From 3 years of age, when the first stage was completed, to preschool age, the rate for major overall communication problems rose from 13% to 17%. However, when children with frank neurological or intellectual problems were excluded, this figure dropped to 8%. The impact of perinatal, medical and environmental variables on speech and language outcomes was again investigated. Differences were found between those that were important at 3 years of age and those that were important at preschool age. New variables emerged as contributing to language expression, including gender and the perinatal variables, gestational age and respiratory distress syndrome. Maternal education level was even more important to language comprehension at preschool age than at 3 years of age. Factors that might explain improvement, or lack of improvement, in speech and language skills are discussed.

Speech and language outcomes 3 years after neonatal intensive care

Although major handicap rates have been documented in children who required neonatal intensive care, minor handicap rates, including speech and language problems, have received less attention. This paper reports the first stage of a longitudinal study of 118 children, which investigated the speech and language outcomes at 3 years of age. Differences from the normal population were found for the articulation measure, but not for the language comprehension and expression measures used. A major overall communication problem was determined to exist in 13% of the children. The impact of perinatal, medical and environmental variables was investigated. Variables such as low birthweight, short gestational age and mechanical ventilation, found to be important in other studies, had no significant impact on the speech and language outcomes of this cohort of 3 years old. However, for children who had experienced respiratory distress syndrome, there was an effect on articulation and language expression. Paediatric complications and maternal education level had the largest effects on language comprehension and expression, suggesting they were the persistent variables which most contributed to speech and language outcomes at 3 years of age.

Audiological evaluation of very low birthweight infants

A population of consecutively surviving very low birthweight (VLBW) infants comprising 41 infants (24 female) birthweight less than 1000 g and 108 infants (63 female) birthweight 1000-1500 g received detailed audiological evaluation. The audiological test battery comprised auditory brainstem evoked response (ABR) prior to hospital discharge, behavioural audiometry and tympanometry at 8-12 months and monitoring as necessary. The ABR results were interpreted with reference to a normative group of 36 full-term infants (birthweight 2.4-4.5 kg). Of the 142 VLBW infants completing audiological evaluation, one (0.7%) had evidence of moderate-severe high frequency sensorineural hearing loss, 83 (58.5%) evidence of conductive dysfunction (18 severe, 42 moderate and 23 mild) and only 58 (40.8%) normal hearing. The 19 infants with severe auditory impairment were more likely to have suffered moderate-severe apnoea, greater than or equal to two courses of mechanical ventilation, prolonged oxygen therapy and recurrent upper respiratory tract infections in the first year of life than infants without severe impairment (P less than 0.05). Because of the incidence of conductive pathology, difficulties occurred when attempting to compare ABR status at 36-42 weeks postmenstrual age with peripheral hearing status at 8-12 months as assessed by visual reinforcement orientation audiometry (VROA) and impedance audiometry. The most useful ABR test parameters as screening measures of peripheral auditory status were Wave I-III-V morphology, wave V threshold levels and wave V absolute latency values when used in combination as a test battery.(ABSTRACT TRUNCATED AT 250 WORDS)

Neonatal cranial ultrasonography as predictor of 2 year outcome of very low birthweight infants

Real time ultrasound scans using an ATL 300C sector scanner with 5-7.5 MHz transducer were performed on days 1, 4, 7 and thereafter as clinically necessary on 153 consecutively discharged very low birthweight (VLBW) infants. One hundred and forty-six long-term survivors were assessed fully at 2 years. The prevalence of cerebroventricular haemorrhage (CVH) in these survivors was 34.2% (grade 1-21.2%; grade 2-4.8%; grade 3-3.4%; grade 4-4.8%), ventricular dilatation 19.9% (including 4.1% with ventriculoperitoneal shunt), and ischaemia 9%. Impairments at 2 years were classified as nil, mild, moderate, severe or multiply severe, based on the criteria of Kitchen et al. Overall, 120 infants (82.2%) were unimpaired and 6.2% had mild, 3.4% had moderate, 4.1% had severe and 4.1% had multiply severe impairment. The major factors associated with impairment were gestational age less than 28 weeks, birthweight less than 1000 g, vaginal delivery, respiratory distress syndrome, mechanical ventilation, pulmonary air leaks and CVH. When these factors were reanalysed in a logistic regression model for odds ratios, only CVH (P less than 0.005) and birth by spontaneous vaginal delivery (P less than 0.05) were significant. The prevalence of impairment was 11.4% with no CVH, 6.5% grade 1, 71% grade 2, 20.0% grade 3 and 100.0% grade 4 CVH. The sensitivity of CVH of grade 2 or greater as a screening test was 64.7% for impairment, 78.6% for cerebral palsy and 70% for severe intellectual handicap. The mean general quotient (GQ) (Griffiths) at 2 years for infants with CVH was 89.1, and 97.5 for those without CVH (P less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical spectrum of neonatal apnoea in very low birthweight infants

This study quantifies apnoea and assesses the response to xanthine derivatives amongst 172 consecutively born, surviving very low birth weight (VLBW) infants, 136 appropriate weight for gestational age (AGA), 36 small for gestational age (SGA). All babies had electronic monitoring of heart and respiratory rates and nursing staff recorded episodes of apnoea (greater than 10 s), bradycardia (less than 100) and cyanosis. Only 42 (24.2%) babies had no episodes recorded. (25 AGA, 17 SGA). Sixty-four (37.2%) received active resuscitation on at least one occasion with six babies ventilated by bag and mask on more than 10 occasions. Apnoea had commenced by day 10 of life in all the babies who had apnoea and persisted beyond day 50 in only six; however four of these infants were still requiring active resuscitation. Apnoea had ceased by 37 weeks post-conceptual age in 88% and by 40 weeks in all but three babies. Risk factor analysis revealed a strong correlation (P less than 0.005) with lower gestational ages and birth weights, respiratory distress syndrome (RDS) and the problems associated with it, such as mechanical ventilation, patency of the ductus arteriosus (PDA) and chronic neonatal lung disease. A single, reversible cause for apnoea was rarely demonstrated. Care must be exercised with feeding, physiotherapy and suctioning the pharynx and trachea of 'at risk' infants. Xanthine derivatives were highly effective in decreasing the frequency of recurrent apnoea from a mean of 10.08 episodes one day before, to 1.83 two days after commencement of treatment.

Interactions of alcohol and caffeine on human reaction time

Eight naive subjects (4 males and 4 females) took part in an experiment to investigate the direction of the interactive effects of alcohol and caffeine on reaction time. Subjects were tested under each of four conditions on separate occasions: no alcohol + no caffeine; no alcohol + caffeine; alcohol + no caffeine; and alcohol + caffeine. Alcohol was given in the form of 65.5 degrees proof vodka in the quantity of 2.2 ml/kg body weight; caffeine was given in the form of crushed 150-mg tablets in decaffeinated coffee. Under these conditions the experiment demonstrated that caffeine has a synergistic interaction with alcohol. Furthermore, using Sternberg's (37) additive-factor method, it was shown that the effects of both alcohol and alcohol + caffeine occur mainly at the peripheral stages of information processing (i.e. at the stimulus input and response output) rather than centrally.