The Knowledge Translation of Early Cerebral Palsy (KiTE CP) Study: Implementing Screening Among a High-Risk Prospective Cohort of Australian Infants

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Parent screening questionnaires to detect cognitive and language delay at 2 years in high-risk infants: an analysis from the Victorian Infant Collaborative Study 2016-2017 cohort

OBJECTIVE

To determine the accuracy of two developmental screening questionnaires to detect cognitive or language delay, defined using the Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III), in children born extremely preterm (EP: <28 weeks' gestation) or extremely low birth weight (ELBW: <1000 g).

DESIGN

Prospective cohort study.

SETTING

State of Victoria, Australia.

PATIENTS

211 infants born EP/ELBW assessed at 2 years' corrected age (mean 2.2, SD 0.2).

MAIN OUTCOME MEASURES

Cognitive and language delay (<-1 SD) on the Bayley-III. The screening questionnaires were the Parent Report of Children's Abilities-Revised (PARCA-R) and the Ages & Stages Questionnaires Third Edition (ASQ-3).

RESULTS

The PARCA-R performed better than the ASQ-3, but neither questionnaire had substantial agreement with the Bayley-III to detect cognitive delay; kappa (95% CI): PARCA-R 0.43 (0.23, 0.63); ASQ-3 0.15 (-0.05, 0.35); sensitivity (95% CI): PARCA-R 70% (53%, 84%) ASQ-3 62% (47%, 76%); specificity (95% CI): PARCA-R 73% (60%, 84%) ASQ-3 53% (38%, 68%). When both tools were used in combination (below cut-off on at least one assessment), sensitivity increased to 78% (60%, 91%) but specificity fell to 45% (29%, 62%). Similar trends were noted for language delay on the Bayley-III, although kappa values were better than for cognitive delay.

CONCLUSIONS

Neither screening questionnaire identified cognitive delay well, but both were better at identifying language delay. The PARCA-R detects delay on the Bayley-III more accurately than the ASQ-3. Sensitivity for detecting delay is greatest when the PARCA-R and ASQ-3 were used in combination, but resulted in lower specificity.

Automated identification of abnormal infant movements from smart phone videos

Cerebral palsy (CP) is the most common cause of physical disability during childhood, occurring at a rate of 2.1 per 1000 live births. Early diagnosis is key to improving functional outcomes for children with CP. The General Movements (GMs) Assessment has high predictive validity for the detection of CP and is routinely used in high-risk infants but only 50% of infants with CP have overt risk factors when they are born. The implementation of CP screening programs represents an important endeavour, but feasibility is limited by access to trained GMs assessors. To facilitate progress towards this goal, we report a deep-learning framework for automating the GMs Assessment. We acquired 503 videos captured by parents and caregivers at home of infants aged between 12- and 18-weeks term-corrected age using a dedicated smartphone app. Using a deep learning algorithm, we automatically labelled and tracked 18 key body points in each video. We designed a custom pipeline to adjust for camera movement and infant size and trained a second machine learning algorithm to predict GMs classification from body point movement. Our automated body point labelling approach achieved human-level accuracy (mean ± SD error of 3.7 ± 5.2% of infant length) compared to gold-standard human annotation. Using body point tracking data, our prediction model achieved a cross-validated area under the curve (mean ± S.D.) of 0.80 ± 0.08 in unseen test data for predicting expert GMs classification with a sensitivity of 76% ± 15% for abnormal GMs and a negative predictive value of 94% ± 3%. This work highlights the potential for automated GMs screening programs to detect abnormal movements in infants as early as three months term-corrected age using digital technologies.

Postnatal corticosteroids and developmental outcomes in extremely preterm or extremely low birth weight infants: The Victorian Infant Collaborative Study 2016-17 cohort

AIM

Systemic postnatal corticosteroids are used to treat or prevent bronchopulmonary dysplasia (BPD) in extremely preterm (EP) or extremely low birth weight (ELBW) infants but are associated with long-term harm. We aimed to assess the relationship between cumulative postnatal corticosteroid dose and neurodevelopmental outcomes.

METHODS

Longitudinal cohort study of all EP/ELBW livebirths in Victoria, Australia 2016-2017. Perinatal data were collected prospectively. Neurodevelopmental assessment was performed at 2 years' corrected age. Linear and logistic regression were used to determine relationships between cumulative corticosteroid dose and neurodevelopment, adjusted for gestational age, birth weight, sex and major intraventricular haemorrhage.

RESULTS

Seventy-six EP/ELBW infants received postnatal corticosteroids to treat or prevent BPD, 62/65 survivors were seen at 2 years. Median (IQR) cumulative postnatal corticosteroid dose was 1.36 (0.92-3.45) mg/kg dexamethasone equivalent. Higher cumulative corticosteroid dose was associated with increased odds of cerebral palsy, adjusted OR (95% CI) 1.47 (1.04, 2.07). Higher cumulative corticosteroid dose was also associated with lower cognitive and motor developmental scores, however, this weakened after adjustment for confounding variables: cognitive composite score adjusted coefficient (95% CI) -1.3 (-2.7, 0.1) and motor composite score adjusted coefficient (95% CI) -1.3 (-2.8, 0.2).

CONCLUSION

Higher cumulative postnatal corticosteroid dose in EP/ELBW infants is associated with increased odds of cerebral palsy at 2 years' corrected age. Adequately powered studies are needed to assess the independent effects of cumulative steroid dose on neurodevelopmental outcomes.

Mobile Solutions for Clinical Surveillance and Evaluation in Infancy-General Movement Apps

The Prechtl General Movements Assessment (GMA) has become a clinician and researcher toolbox for evaluating neurodevelopment in early infancy. Given that it involves the observation of infant movements from video recordings, utilising smartphone applications to obtain these recordings seems like the natural progression for the field. In this review, we look back on the development of apps for acquiring general movement videos, describe the application and research studies of available apps, and discuss future directions of mobile solutions and their usability in research and clinical practice. We emphasise the importance of understanding the background that has led to these developments while introducing new technologies, including the barriers and facilitators along the pathway. The GMApp and Baby Moves apps were the first ones developed to increase accessibility of the GMA, with two further apps, NeuroMotion and InMotion, designed since. The Baby Moves app has been applied most frequently. For the mobile future of GMA, we advocate collaboration to boost the field's progression and to reduce research waste. We propose future collaborative solutions, including standardisation of cross-site data collection, adaptation to local context and privacy laws, employment of user feedback, and sustainable IT structures enabling continuous software updating.

Impact of current Australian paid parental leave on families of preterm and sick infants

AIM

Parents of preterm or sick infants are at increased risk of mental health problems. The financial stress associated with an infant's prolonged hospital stay can have an additional negative effect on families' wellbeing and child development. This study explores parent use of Australian paid parental leave (PPL) and the financial impact of having an infant requiring neonatal care.

METHODS

Retrospective, cross-sectional, online survey study conducted from November 2020 to February 2021. Participants were parents of babies born from 1 January 2013, admitted to a neonatal intensive care unit or special care nursery in Australia. The survey explored use of Australian Government and private sector PPL, and financial stress. Parent-reported anxiety and depression were measured using the EuroQol Group 5D-5L Anxiety and Stress Subscale.

RESULTS

Two hundred and thirty-one parents responded of which 93% had a preterm infant. Seventy-three percent of infants were hospitalised for more than 1 month, and 34% were readmitted to hospital within the first year following discharge home. Eighty-three percent of parents reported moderate, severe or extreme levels of anxiety or depression. Seventy-six percent reported that having a child in hospital had a moderate-very large financial impact on their family. Parents identified main costs to be travel, food, inability to work and direct medical costs.

CONCLUSIONS

Having an infant born preterm or sick has significant emotional and financial implications for families. The current Australian Government PPL scheme does not adequately support parents of preterm or sick infants, and a change is urgently needed to improve outcomes for this vulnerable population.

Parent-recorded videos of infant spontaneous movement: Comparisons at 3-4 months and relationships with 2-year developmental outcomes in extremely preterm, extremely low birthweight and term-born infants

BACKGROUND

Infants born extremely preterm (EP, <28-week gestational age) or extremely low birthweight (ELBW, <1000 g) are at risk of developmental delay and cerebral palsy (CP). The General Movements Assessment (GMA) and its extension, the Motor Optimality Score, revised (MOS-R) (assesses movement patterns and posture), may help to identify early delays.

OBJECTIVES

To compare differences in the MOS-R scored from parent-recorded videos between infants born EP/ELBW and term-born infants, to determine relationships between the MOS-R and 2-year cognitive, language and motor outcomes and if any relationships differ between birth groups and the association of the GMA (fidgety) with CP.

METHODS

A geographical cohort (EP/ELBW and term-control infants) was assessed using the MOS-R inclusive of the GMA at 3- to 4-month corrected age (CA), and the Bayley Scales of Infant and Toddler Development, 3rd edition (Bayley-III) at 2-year CA. Differences in mean total MOS-R between groups, relationships between MOS-R and 2-year outcomes and relationships between GMA (fidgety) and CP in infants born EP/ELBW were estimated using linear/logistic regression.

RESULTS

Three hundred and twelve infants (147 EP/ELBW; 165 term) had complete MOS-R and Bayley-III assessments. Mean MOS-R was lower in infants born EP/ELBW than controls (mean difference -3.2, 95% confidence interval [CI] -4.2, -2.3). MOS-R was positively related to cognitive (β [regression coefficient] = 0.71, 95% CI 0.27, 1.15), language (β = 0.96, 95% CI 0.38, 1.54) and motor outcomes (β = .89, 95% CI 0.45, 1.34). There was little evidence for interaction effects between birth groups for any outcome. Absent/abnormal fidgety movements were related to CP in children born EP/ELBW (risk ratio 5.91, 95% CI 1.48, 23.7).

CONCLUSIONS

Infants born EP/ELBW have lower MOS-R than infants born at term. A higher MOS-R is related to better outcomes for 2-year development, with similar relationships in both birth groups. Absent/abnormal fidgety movements are related to CP in EP/ELBW survivors.

Early motor repertoire and neurodevelopment at 2 years in infants born extremely preterm or extremely-low-birthweight

AIM

To determine the relationship between early motor repertoire and 2-year neurodevelopment in infants born extremely preterm (<28 weeks' gestation) or extremely-low-birthweight (ELBW) (<1000g).

METHOD

This was a geographical prospective cohort of 139 infants born extremely preterm/ELBW (mean gestational age 26.7 weeks, standard deviation [SD] 2.0, 68/139 [49%] male), with parent-recorded videos suitable for scoring the General Movements Assessment (GMA). Motor repertoire was assessed using the Motor Optimality Score-Revised (MOS-R), with and without the fidgety movement subsection, and the GMA alone at 12 to 13⁺⁶  weeks corrected age and 14 to 15⁺⁶  weeks corrected age. At 2 years corrected age, impaired development was defined as Bayley Scales of Infant and Toddler Development, Third Edition motor and cognitive development scores 1SD or less relative to controls born at term; paediatricians diagnosed cerebral palsy (CP).

RESULTS

Greater MOS-R scores at 14 to 15⁺⁶  weeks corrected age were associated with lower odds of CP (odds ratio [OR] per 1-point increase=0.83, 95% confidence interval [CI]=0.71-0.99), and motor (OR=0.93, 95% CI=0.87-0.99), or cognitive impairment (OR=0.94, 95% CI=0.88-0.99). Absent/abnormal GMA at 14 to 15⁺⁶ weeks was associated with CP and motor delay. There was little evidence that MOS-R scores at 12 to 13⁺⁶ weeks were associated with neurodevelopmental outcomes at 2 years.

INTERPRETATION

Poorer MOS-R scores and absent/abnormal GMA, scored from parent-recorded videos at 14 to 15⁺⁶  weeks gestational age, are associated with CP and developmental impairment in 2-year-old infants born extremely preterm/ELBW.

School Readiness in Children Born <30 Weeks' Gestation at Risk for Developmental Coordination Disorder: A Prospective Cohort Study

OBJECTIVE

The objective of this study was to determine whether school readiness differs between children born <30 weeks' gestation who are classified as at risk for developmental coordination disorder (DCD) and those who are not.

METHODS

This study was a prospective cohort study of children born <30 weeks' gestation. Children were classified as at risk for DCD at a corrected age of 4 to 5 years if they scored <16th centile on the Movement Assessment Battery for Children-Second Edition (MABC-2), had a full scale IQ score of ≥80 on the Wechsler Preschool and Primary Scale of Intelligence-Fourth Edition (WPPSI-IV), and had no cerebral palsy. Children were assessed on 4 school readiness domains: (1) health/physical development [Physical Health domain of Pediatric Quality of Life Inventory (PedsQL), Pediatric Evaluation of Disability Inventory Computer Adaptive Test, and Little Developmental Coordination Disorder Questionnaire], (2) social-emotional development (Strengths and Difficulties Questionnaire and PedsQL psychosocial domains), (3) cognitive skills/general knowledge (WPPSI-IV), and (4) language skills (WPPSI-IV).

RESULTS

Of 123 children assessed, 16 were ineligible (IQ < 80 or cerebral palsy: n = 15; incomplete MABC-2: n = 1); 28 of 107 (26%) eligible children were at risk for DCD. Children at risk for DCD had poorer performance on all school readiness domains, with group differences of more than 0.4 SD in health/physical development, social-emotional development, and language skills and up to 0.8 SD for cognitive skills/general knowledge compared with those not at risk of DCD.

CONCLUSION

Being at risk for DCD in children born <30 weeks' gestation is associated with challenges in multiple school readiness domains, not only the health/physical domain.

Instructional guides for filming infant movements at home are effective for the General Movements Assessment

AIM

To determine the effectiveness of two instructional guides to obtain video recordings for the General Movements Assessment (GMA).

METHODS

A cross-sectional study of a community sample of family participants with low-risk term newborn infants recruited via social media and randomly allocated to receive one of two instructional guides (detailed or quick versions) to film their infant's movements at home. Participants returned videos via a secure Research Electronic Database Capture link and videos were scored for quality across 10 criteria, along with scoring the GMA. Participants were surveyed about their perceptions of the instructional guides and electronic file transmission.

RESULTS

Seventy-six parents of infants were enrolled and randomly allocated to receive detailed (n = 38) and quick (n = 38) instructions to film their infant for a GMA. Videos were returned by 87% (95% confidence interval (CI) 72%, 96%) of detailed instruction users and 84% (95% CI 69%, 94%) of quick instruction users. The GMA could be conducted on all returned videos. The mean score for video quality was 9.9/10 (standard deviation 0.4, 95% CI 9.7, 10.0) for detailed instructions and 9.7 (standard deviation 0.6, 95% CI 9.4, 9.9) for quick instructions. Overall, participants felt that either instructional guide was easy to use. Fifteen (20%) participants had difficulties with video file transmission, requiring additional support.

CONCLUSIONS

Parents can successfully use one of two different instructional guides for filming their infant's movements for GMA; however, support should be provided for safe and easy file transmission.

Relationships between early postnatal cranial ultrasonography linear measures and neurobehaviour at term-equivalent age in infants born <30 weeks' gestational age

BACKGROUND

The relationship between early postnatal brain development and neurobehaviour at term-equivalent age (TEA) remains uncertain.

AIM

We aimed to explore relationships between early postnatal cranial ultrasonography (cUS) linear measures of brain size and brain growth with neurobehaviour at TEA in infants born <30 weeks' gestational age (GA).

STUDY DESIGN

Prospective observational cohort study.

SUBJECTS

137 infants born <30 weeks' GA without major brain injury on neonatal cUS.

OUTCOME MEASURES

Neurobehaviour at TEA assessed using the General Movements Assessment (GMA) and Hammersmith Neonatal Neurological Examination (HNNE).

RESULTS

The GMA was administered in 115/137 (84%) infants; 80 (70%) presented with abnormal general movements (GMs) (79 poor repertoire, 1 cramped synchronised). The HNNE was assessed in 106/137 (77%) infants; 52 (49%) had a suboptimal total score. With respect to brain size, larger measures of the corpus callosum length (CCL) and right anterior horn width (AHW) at 1-month were related to lower risk of abnormal GMs, and larger measures of the biparietal diameter at 1-week and 2-months were related to lower risk of a suboptimal HNNE. As for brain growth, increases of the CCL and transcerebellar diameter between birth and 1-month, and left and right AHWs between 1- and 2-months, were related to lower risk of abnormal GMs.

CONCLUSION

Early postnatal brain size and brain growth were related to neurobehaviour at TEA in infants born <30 weeks' GA. This study provides preliminary evidence for the prognostic utility of early postnatal cUS linear measures as potential markers of neurodevelopment in later childhood.

The causal effect of being born extremely preterm or extremely low birthweight on neurodevelopment and social-emotional development at 2 years

AIM

To assess the causal effect of being born extremely preterm (EP; <28 weeks' gestation) or extremely low birthweight (ELBW; <1000 g), compared with being born at term, on neurodevelopment and social-emotional development at 2 years' corrected age.

METHODS

Prospective geographical cohort study of children born EP/ELBW over 12 months in 2016 from Victoria, Australia, and term-born controls. Children were assessed at 2 years' corrected age with the Bayley Scales of Infant and Toddler Development-3rd edition and the Infant-Toddler Social and Emotional Assessment. Delay was defined as <-1 standard deviation relative to the mean of controls. The estimand of interest was the mean difference/odds ratio (OR) between the EP/ELBW and control groups estimated using linear/logistic regression, adjusted for multiple pregnancy and social risk.

RESULTS

A total of 205 EP/ELBW and 201 controls were assessed at 2 years. Delay/concerns were more common in the EP/ELBW group compared with controls, for cognitive (OR 3.7 [95% confidence interval 2.3, 6.0]), language (5.3 [3.1, 9.0]) and motor (3.9 [2.3, 6.3]) development, and social-emotional competence (4.1 [1.6, 10.2]).

CONCLUSION

Being born EP/ELBW has an adverse effect on cognitive, language and motor development, and social-emotional competence at 2 years' corrected age. Close developmental surveillance, including social-emotional development, is recommended.

Predictors of long-term neurodevelopmental outcomes of children born extremely preterm

Children born extremely preterm (<28 weeks' gestation) are at high risk of a range of adverse neurodevelopmental outcomes in later childhood compared with their peers born at term, including cognitive, motor, and behavioral difficulties. These difficulties can be associated with poorer academic achievement and health outcomes at school age. In this review, we discuss several predictors in the newborn period of early childhood neurodevelopmental outcomes including perinatal risk factors, neuroimaging findings and neurobehavioral assessments, along with social and environmental influences for children born extremely preterm. Given the complexity of predicting long-term outcomes in children born extremely preterm, we recommend multi-disciplinary teams in clinical practice to assist in determining an individual child's risk for adverse long-term outcomes and need for referral to targeted intervention, based upon their risk.

Temporal Trends in Neurodevelopmental Outcomes to 2 Years After Extremely Preterm Birth

Importance

Survival of infants born extremely preterm (EP) (<28 weeks' gestation) has increased since the early 1990s. It is necessary to know whether increased survival is accompanied by increased neurodevelopmental disability.

Objective

To examine changes in major (ie, moderate or severe) neurodevelopmental disability and survival free of major neurodevelopmental disability at 2 years in infants born EP.

Design, Setting, and Participants

Four prospective longitudinal cohort studies comprising all EP live births at 22 to 27 weeks' gestation from April 1, 2016, to March 31, 2017, and earlier eras (1991-1992, 1997, and 2005), and contemporaneous term-born controls in the state of Victoria, Australia. Among 1208 live births during the periods studied, data were available for analysis of 2-year outcomes in 1152 children: 422 (1991-1992), 215 (1997), 263 (2005), and 252 (2016-2017). Data analysis was performed from September 17, 2020, to April 15, 2021.

Exposures

Extreme preterm live birth.

Main Outcomes and Measures

Survival, blindness, deafness, cerebral palsy, developmental delay, and neurodevelopmental disability at 2 years' corrected age. Developmental delay comprised a developmental quotient less than -1 SD relative to the control group means on the Bayley Scales for each era. Major neurodevelopmental disability comprised blindness, deafness, moderate to severe cerebral palsy, or a developmental quotient less than -2 SDs. Individual neurodevelopmental outcomes in each era were contrasted relative to the 2016-2017 cohort using logistic regression adjusted for gestational age, sex, birth weight z score, and sociodemographic variables. Changes in survival free of major neurodevelopmental disability over time were also assessed using logistic regression.

Results

Survival to 2 years was highest in 2016-2017 (73% [215 of 293]) compared with earlier eras (1991-1992: 53% [225 of 428]; 1997: 70% [151 of 217]; 2005: 63% [170 of 270]). Blindness and deafness were uncommon (<3%). Cerebral palsy was less common in 2016-2017 (6%) than in earlier eras (1991-1992: 11%; 1997: 12%; 2005: 10%). There were no obvious changes in the rates of developmental quotient less than -2 SDs across eras (1991-1992: 18%; 1997: 22%; 2005: 7%; 2016-2017: 15%) or in rates of major neurodevelopmental disability (1991-1992: 20%; 1997: 26%; 2005: 15%; 2016-2017: 15%). Rates of survival free of major neurodevelopmental disability increased steadily over time: 42% (1991-1992), 51% (1997), 53% (2005), and 62% (2016-2017) (odds ratio, 1.30; 95% CI, 1.15-1.48 per decade; P < .001).

Conclusions and Relevance

These findings suggest that survival free of major disability at age 2 years in children born EP has increased by an absolute 20% since the early 1990s. Increased survival has not been associated with increased neurodevelopmental disability.

Translating antenatal magnesium sulphate neuroprotection for infants born <28 weeks' gestation into practice: A geographical cohort study

BACKGROUND

Magnesium sulphate was introduced for fetal neuroprotection in Australia in 2010. The aim of this study was to determine how often antenatal magnesium sulphate is used currently and its association with cerebral palsy in children born <28 weeks' gestation.

MATERIALS AND METHODS

Participants comprised all survivors born <28 weeks' gestational age in the state of Victoria in 2016-17, and earlier, in 1991-92, 1997, 2005. Rates of cerebral palsy, diagnosed at two years for the 2016-17 cohort, and at eight years in the earlier cohorts, were compared across eras. Within 2016-17, the proportions of children exposed to antenatal magnesium sulphate were determined, and rates of cerebral palsy were compared between those with and without exposure to magnesium sulphate.

RESULTS

Overall, cerebral palsy was present in 6% (11/171) of survivors born in 2016-17, compared with 12% (62/499) of survivors born in the three earlier eras (odds ratio (OR) 0.48, 95% confidence interval (CI) 0.25-0.94; P = 0.032). Data were available for 213/215 (99%) survivors born in 2016-17, of whom 147 (69%) received magnesium sulphate. Data on cerebral palsy at two years were available for 171 (80%) survivors with magnesium data. Cerebral palsy was present in 5/125 (4%) children exposed to magnesium sulphate and in 6/46 (13%) of those not exposed (OR 0.28, 95% CI 0.08-0.96; P = 0.043).

CONCLUSIONS

Antenatal magnesium sulphate is being translated into clinical practice for infants born <28 weeks' gestation, but there is room for improvement. It is associated with lower rates of cerebral palsy in survivors.

Changing consumption of resources for respiratory support and short-term outcomes in four consecutive geographical cohorts of infants born extremely preterm over 25 years since the early 1990s

OBJECTIVES

It is unclear how newer methods of respiratory support for infants born extremely preterm (EP; 22-27 weeks gestation) have affected in-hospital sequelae. We aimed to determine changes in respiratory support, survival and morbidity in EP infants since the early 1990s.

DESIGN

Prospective longitudinal cohort study.

SETTING

The State of Victoria, Australia.

PARTICIPANTS

All EP births offered intensive care in four discrete eras (1991-1992 (24 months): n=332, 1997 (12 months): n=190, 2005 (12 months): n=229, and April 2016-March 2017 (12 months): n=250).

OUTCOME MEASURES

Consumption of respiratory support, survival and morbidity to discharge home. Cost-effectiveness ratios describing the average additional days of respiratory support associated per additional survivor were calculated.

RESULTS

Median duration of any respiratory support increased from 22 days (1991-1992) to 66 days (2016-2017). The increase occurred in non-invasive respiratory support (2 days (1991-1992) to 51 days (2016-2017)), with high-flow nasal cannulae, unavailable in earlier cohorts, comprising almost one-half of the duration in 2016-2017. Survival to discharge home increased (68% (1991-1992) to 87% (2016-2017)). Cystic periventricular leukomalacia decreased (6.3% (1991-1992) to 1.2% (2016-2017)), whereas retinopathy of prematurity requiring treatment increased (4.0% (1991-1992) to 10.0% (2016-2017)). The average additional costs associated with one additional infant surviving in 2016-2017 were 200 (95% CI 150 to 297) days, 326 (183 to 1127) days and 130 (70 to 267) days compared with 1991-1992, 1997 and 2005, respectively.

CONCLUSIONS

Consumption of resources for respiratory support has escalated with improved survival over time. Cystic periventricular leukomalacia reduced in incidence but retinopathy of prematurity requiring treatment increased. How these changes translate into long-term respiratory or neurological function remains to be determined.

Early general movements are associated with developmental outcomes at 4.5-5 years

BACKGROUND

Prechtl's general movements assessment (GMA) post-term has high predictive validity for cerebral palsy, but less is known about whether earlier GMA, including before term, are associated with other developmental problems.

AIMS

To examine the relationships between GMA prior to term and at term-equivalent, with developmental outcomes at 4.5-5 years' corrected age.

STUDY DESIGN

Prospective cohort study.

SUBJECTS

122 very preterm infants born <30 weeks' gestation and 91 healthy term controls.

OUTCOME MEASURES

GMA (categorised as 'normal' or 'abnormal') were assessed at <32, 32-33 and 34-36 weeks' postmenstrual age for the preterm infants, and at term-equivalent for both groups. Children were assessed at 4.5-5 years' corrected age using the Movement Assessment Battery for Children-2nd edition (MABC-2), Pediatric Evaluation of Disability Inventory-Computer Adaptive Test (PEDI-CAT), Pediatric Quality of Life Inventory (PedsQL), Little Developmental Coordination Disorder Questionnaire (Little DCD-Q) and Wechsler Preschool and Primary Scale of Intelligence-IV (WPPSI-IV).

RESULTS

Prior to term, abnormal GMA at the first two timepoints were associated with lower scores on the Little DCD-Q, and abnormal GMA at the second and third timepoints with lower quality of life scores and PEDI-CAT mobility domain scores. Abnormal GMA at term-equivalent were associated with lower MABC-2, mobility and quality of life scores for preterm infants, and worse social/cognitive domain scores for both groups.

CONCLUSIONS

Abnormal GMA prior to term and at term-equivalent are associated with worse motor, functional and cognitive outcomes at 4.5-5 years' corrected age, and may be useful to identify infants for developmental surveillance/early intervention.

Effect of ampicillin, cephalexin, ceftiofur and tetracycline treatment on selection of resistant coliforms in a swine faecal microcosmos

AIMS

To analyse and compare the effect of selection power for antimicrobial resistance (AMR) in coliforms of two kinds of β-lactams-aminopenicillins; ampicillin (Amp) and cephalosporins; cephalexin (Cpn) and ceftiofur (Cef)-and tetracycline (Tet) using an approach based on a swine faecal microcosmos.

METHODS AND RESULTS

Sixteen faecal samples from 32 pigs (mixed two by two) were treated with Amp, Cpn, Cef and Tet for 6 h (T6h) at concentrations expected to reach the animals gut when using in vivo standard doses. Controls (no drug added) were also tested. Next, samples were 1 : 100 diluted and left under the same conditions (no antimicrobial added) for further 20 h (T20h). The proportion of resistant coliform bacteria (R coliforms) to each antimicrobial was analysed just before starting the treatment (T0), at T6h and at T20h. Coselection was also studied by replica plating. Treatment for 6 h yielded significant increase in proportion of R coliforms, regardless of the drug and lack of selection pressure showed different effects at T20h depending on the antimicrobial used. Selective pressure was associated with the type of the β-lactam with Amp selecting for significantly higher numbers of R coliforms than cephalosporins.

CONCLUSIONS

AMR development was observed following short treatment, and for Amp and Tet treatment, resistance persisted 20 h beyond the interruption of treatment. An association between kind of β-lactam and power of selection was found.

SIGNIFICANCE AND IMPACT OF THE STUDY

AMR represents a threat to human health globally and antimicrobial treatment of livestock has a direct impact on this problem. Through our approach based on a swine faecal microcosmos, we demonstrated the effect on AMR development of several drugs commonly used in livestock. Cephalosporins, representing last-line antimicrobials in human medicine, exerted lower selective pressure than Amp under the conditions used and yielded higher proportion of multidrug-R strains.

Evaluation of novel multiplex qPCR assays for diagnosis of pathogens associated with the bovine respiratory disease complex

Bovine respiratory disease complex is the most common disease requiring the use of antimicrobials in industrial calf production worldwide. Pathogenic bacteria (Mannheimia haemolytica (Mh), Pasteurella multocida (Pm), Histophilus somni (Hs), and Mycoplasma bovis) and a range of viruses (bovine respiratory syncytial virus, bovine coronavirus, bovine parainfluenza virus type 3, bovine viral diarrhea virus and bovine herpesvirus type 1) are associated with this complex. As most of these pathogens can be present in healthy and diseased calves, simple detection of their presence in diseased calves carries low predictive value. In other multi-agent diseases of livestock, quantification of pathogens has added substantially to the predictive value of microbiological diagnosis. The aim of this study was to evaluate the ability of two recently developed quantitative PCR (qPCR) kits (Pneumo4B and Pneumo4V) to detect and quantify these bacterial and viral pathogens, respectively. Test efficiencies of the qPCR assays, based on nucleic acid dilution series of target bacteria and viruses, were 93-106% and 91-104%, respectively, with assay detection limits of 10-50 copies of nucleic acids. All 44 strains of target bacteria were correctly identified, with no false positive reactions in 135strains of non-target bacterial species. Based on standard curves of log₁₀ CFU versus cycle threshold (Ct) values, quantification was possible over a 5-log range of bacteria. In 92 tracheal aspirate samples, the kappa values for agreement between Pneumo4B and bacterial culture were 0.64-0.84 for Mh, Pm and Hs. In an additional 84 tracheal aspirates, agreement between Pneumo4B or Pneumo 4V and certified diagnostic qPCR assays was moderate (0.57) for M. bovis and high (0.71-0.90) for viral pathogens. Thus Pneumo4 kits specifically detected and quantified the relevant pathogens.

Occurrence of and temporal trends in fidgety general movements in infants born extremely preterm/extremely low birthweight and term-born controls

BACKGROUND

Fidgety general movements have high predictive validity for later cerebral palsy (CP) but their temporal organisation requires further understanding for assessment accuracy.

AIMS

To describe the occurrence of and temporal trends in fidgety movements, and whether they differ between infants born preterm and at term.

STUDY DESIGN

Cohort study.

SUBJECTS

We assessed 155 EP/ELBW infants and 185 term-born infants born extremely preterm (EP; <28 weeks' gestation) and/or extremely low birthweight (ELBW; <1000 g birthweight) or at term (37-42 weeks' gestation) in the state of Victoria, Australia.

OUTCOME MEASURES

Parents of infants submitted up to two videos at 12-13⁺⁶ and/or 14-16⁺⁶ weeks' corrected age of infants' general movements. Videos were scored using the Prechtl General Movements Assessment (GMA) (fidgety) and classified as normal or absent/abnormal. Infants with at least one normal GMA were classified as normal. Individual GMA trajectories were analysed over time using logistic regression.

RESULTS

Overall, infants born EP/ELBW were more likely to have absent/abnormal fidgety movements than term-born infants (23% versus 3%, odds ratio [OR] 8.50 (95% confidence interval (CI) 3.48-20.8, p < 0.001). Fewer EP/ELBW and term-born infants showed absent/abnormal fidgety movements with each week of increasing age (EP/ELBW OR 0.46, 95% CI 0.25-0.84, p = 0.01; term-born OR 0.35, 95% CI 0.16-0.8, p = 0.01; interaction, p = 0.53).

CONCLUSIONS

Absent/abnormal fidgety movements are more prevalent in infants born EP/ELBW than at term. Fidgety movements normalise with older age in both infants born EP/ELBW and at term between 12 and 16⁺⁶ weeks' corrected age.

Brain structure and neurological and behavioural functioning in infants born preterm

AIM

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

METHOD

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

RESULTS

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

INTERPRETATION

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

WHAT THIS PAPER ADDS

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

The Baby Moves smartphone app for General Movements Assessment: Engagement amongst extremely preterm and term-born infants in a state-wide geographical study

AIM

The Baby Moves smartphone application is designed for parents to video their infants' spontaneous movement for remote General Movements Assessment (GMA). We aimed to assess the engagement with Baby Moves amongst high- and low-risk infants' families and the socio-demographic variables related to engagement.

METHODS

Families of extremely preterm (EP; <28 weeks' gestational age) or extremely low-birthweight (ELBW; <1000 g) infants and term-born controls from a state-wide geographical cohort study were asked to download Baby Moves. Baby Moves provided reminders and instructions to capture videos of their infants' general movements. Parents were surveyed about Baby Moves' usability.

RESULTS

The parents of 451 infants (226 EP/ELBW; 225 control) were recruited; 416 (204 EP/ELBW; 212 control) downloaded Baby Moves, and 346 (158 EP/ELBW; 188 control) returned at least one scorable video for remote GMA. Fewer EP/ELBW families submitted a scorable video than controls (70 vs. 83%, respectively; odds ratio (OR) 0.48, 95% confidence interval (CI) 0.3-0.79, P = 0.003), but the difference diminished when adjusted for socio-demographic variables (OR 1.09, 95% CI 0.59-2.0, P = 0.79). Families who received government financial support (OR 0.28, 95% CI 0.1-0.78, P = 0.015), who spoke limited English at home (OR 0.39, 95% CI 0.22-0.69, P = 0.001) or with lower maternal education (OR 0.38, 95% CI 0.21-0.68, P = 0.001) were less likely to return a scorable video. Surveyed parents responded mostly positively to Baby Moves' usability.

CONCLUSIONS

Most parents in this study successfully used Baby Moves to capture infant movements for remote GMA. Families of lower socio-demographic status used Baby Moves less.

Early Diagnosis and Treatment of Cerebral Palsy in Children with a History of Preterm Birth

Infants born preterm are at increased risk of cerebral palsy (CP), with the risk increasing with decreasing gestational age. Although preterm children are at increased risk of CP compared with their term-born peers, most preterm children do not have CP and thus, it is important to have a standardized process for detecting those children at high risk of CP early. A combination of clinical history, neuroimaging, and physical examination is recommended to ensure early, accurate diagnosis. Early detection of CP is essential for timely early intervention to optimize outcomes for children and their families.

NICU Graduates: The Role of the Allied Health Team in Follow-Up

Infants who graduate from the neonatal intensive care unit, including those infants born preterm and/or with brain injury, are at increased risk of long-term neurodevelopmental impairments. The developmental allied health team, consisting of physical therapy, occupational therapy, and speech pathology, is crucial in early evaluation of gross motor, fine motor, feeding, and language development. Surveillance of neurodevelopment in the first year of life is essential to ensure early detection of specific developmental delays and impairments, and to ensure timely referral for early intervention. Early intervention is not only important in optimizing long-term outcomes for the child, but it also plays an important role in enhancing the parent-child relationship and parental well-being. In this review, we discuss the role of the developmental allied health team in the follow-up of high-risk infants, identify key assessment tools used in early neurodevelopmental surveillance, and provide recommendations regarding referral to intervention programs to optimize child and family outcomes. [Pediatr Ann. 2018;47(4):e165-e171.].

Preterm and term-equivalent age general movements and 1-year neurodevelopmental outcomes for infants born before 30 weeks' gestation

AIM

To examine the associations between Prechtl's General Movements Assessment (GMA), conducted from birth to term-equivalent age, and neurodevelopmental outcomes at 12 months corrected age, in infants born very preterm.

METHOD

One hundred and thirty-seven infants born before 30 weeks' gestation had serial GMA (categorized as 'normal' or 'abnormal') before term and at term-equivalent age. At 12 months corrected age, neurodevelopment was assessed using the Alberta Infant Motor Scale (AIMS); Neurological, Sensory, Motor, Developmental Assessment (NSMDA); and Touwen Infant Neurological Examination (TINE). The relationships between GMA at four time points and 12-month neurodevelopmental assessments were examined using regression models.

RESULTS

Abnormal GMA at all time points were associated with worse continuous scores on the AIMS, NSMDA, and TINE (p<0.05). Abnormal GMA before term and at term-equivalent age were associated with increased odds of mild-severe dysfunction on the NSMDA (odds ratio [OR] 4.26, 95% confidence interval [CI] 1.55-11.71, p<0.01; and OR 4.16, 95% CI 1.55-11.17, p<0.01 respectively) and abnormal GMA before term with increased odds of suboptimal-abnormal motor function on the TINE (OR 2.75, 95% CI 1.10-6.85, p=0.03).

INTERPRETATION

Abnormal GMA before term and at term-equivalent age were associated with worse neurodevelopment at 12 months corrected age in children born very preterm.

WHAT THIS PAPER ADDS

Abnormal general movements before term predict developmental deficits at 1 year in infants born very preterm. General Movements Assessment before term identifies at-risk infants born very preterm.

Continuum of neurobehaviour and its associations with brain MRI in infants born preterm

BACKGROUND

Infants born very preterm (VPT) and moderate-to-late preterm (MLPT) are at increased risk of long-term neurodevelopmental deficits, but how these deficits relate to early neurobehaviour in MLPT children is unclear. The aims of this study were to compare the neurobehavioural performance of infants born across three different gestational age groups: preterm <30 weeks' gestational age (PT<30); MLPT (32-36 weeks' gestational age) and term age (≥37 weeks' gestational age), and explore the relationships between MRI brain abnormalities and neurobehaviour at term-equivalent age.

METHODS

Neurobehaviour was assessed at term-equivalent age in 149 PT<30, 200 MLPT and 200 term-born infants using the Neonatal Intensive Care UnitNetwork Neurobehavioral Scale (NNNS), the Hammersmith Neonatal Neurological Examination (HNNE) and Prechtl's Qualitative Assessment of General Movements (GMA). A subset of 110 PT<30 and 198 MLPT infants had concurrent brain MRI.

RESULTS

Proportions with abnormal neurobehaviour on the NNNS and the HNNE, and abnormal GMA all increased with decreasing gestational age. Higher brain MRI abnormality scores in some regions were associated with suboptimal neurobehaviour on the NNNS and HNNE. The relationships between brain MRI abnormality scores and suboptimal neurobehaviour were similar in both PT<30 and MLPT infants. The relationship between brain MRI abnormality scores and abnormal GMA was stronger in PT<30 infants.

CONCLUSIONS

There was a continuum of neurobehaviour across gestational ages. The relationships between brain abnormality scores and suboptimal neurobehaviour provide evidence that neurobehavioural assessments offer insight into the integrity of the developing brain, and may be useful in earlier identification of the highest-risk infants.

Neuropredictors of oromotor feeding impairment in 12month-old children

BACKGROUND

Feeding impairment is prevalent in children with neurodevelopmental issues. Neuroimaging and neurobehavioral outcomes at term are predictive of later neuromotor impairment, but it is unknown whether they predict feeding impairment.

AIMS

To determine whether neurobehavior and brain magnetic resonance imaging (MRI) at term predict oromotor feeding at 12 months in preterm and term-born children.

STUDY DESIGN

Prospective cohort study.

SUBJECTS

248 infants (97 born <30 weeks and 151 born at term) recruited at birth.

OUTCOME MEASURES

Neurobehavioral assessments (General Movements (GMA), Hammersmith Neonatal Neurological Examination (HNNE), Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS)); and brain MRI were administered at term-equivalent age. Oromotor feeding was assessed at 12 months corrected age using the Schedule for Oral Motor Assessment.

RESULTS

49/227 children had oromotor feeding impairment. Neurobehavior associated with later feeding impairment was: suboptimal NNNS stress (odds ratio [OR] 2.68; 95% confidence interval [CI] 1.20–6.01), non-optimal reflexes (OR 3.33; 95% CI 1.37–8.11) and arousal scales (OR 2.54; 95% CI 1.03–6.27); suboptimal HNNE total (OR 4.69; 95% CI 2.20–10.00), reflexes (OR 2.62; 95% CI 1.06–6.49), and tone scores (OR 3.87; 95% CI 1.45–10.35); and abnormal GMA (OR 2.60; 95% CI 1.21–5.57). Smaller biparietal diameter also predicted feeding impairment (OR 0.88; 95% CI 0.79–0.97). There was little evidence that relationships differed between birth groups.

CONCLUSIONS

Neurobehavior and biparietal diameter at term are associated with oromotor feeding at 12 months. These results may identify children at greatest risk of oromotor feeding impairment.

Association Between Moderate and Late Preterm Birth and Neurodevelopment and Social-Emotional Development at Age 2 Years

IMPORTANCE

Moderate and late preterm (MLPT) births comprise most preterm infants. Therefore, long-term developmental concerns in this population potentially have a large public health influence. While there are increasing reports of developmental problems in MLPT children, detail is lacking on the precise domains that are affected.

OBJECTIVE

To compare neurodevelopment and social-emotional development between MLPT infants and term-born control infants at age 2 years.

DESIGN, SETTING, AND PARTICIPANTS

This investigation was a prospective longitudinal cohort study at a single tertiary hospital. Participants were MLPT infants (32-36 weeks' completed gestation) and healthy full-term controls (≥37 weeks' gestation) recruited at birth. During a 3-year period between December 7, 2009, and November 7, 2012, MLPT infants were recruited at birth from the neonatal unit and postnatal wards of the Royal Women's Hospital, Melbourne, Australia. The term control recruitment extended to March 26, 2014. The dates of the data developmental assessments were February 23, 2012, to April 8, 2016.

EXPOSURE

Moderate and late preterm birth.

MAIN OUTCOMES AND MEASURES

Cerebral palsy, blindness, and deafness assessed by a pediatrician; cognitive, language, and motor development assessed using the Bayley Scales of Infant Development-Third Edition (developmental delay was defined as less than -1 SD relative to the mean in controls in any domain of the scales); and social-emotional and behavioral problems assessed by a parent questionnaire (Infant Toddler Social Emotional Assessment). Outcomes were compared between birth groups using linear and logistic regression, adjusted for social risk.

RESULTS

In total, 198 MLPT infants (98.5% of 201 recruited) and 183 term-born controls (91.0% of 201 recruited) were assessed at 2 years' corrected age. Compared with controls, MLPT children had worse cognitive, language, and motor development at age 2 years, with adjusted composite score mean differences of -5.3 (95% CI, -8.2 to -2.4) for cognitive development, -11.4 (95% CI, -15.3 to -7.5) for language development, and -7.3 (95% CI, -10.6 to -3.9) for motor development. The odds of developmental delay were higher in the MLPT group compared with controls, with adjusted odds ratios of 1.8 (95% CI, 1.1-3.0) for cognitive delay, 3.1 (95% CI, 1.8-5.2) for language delay, and 2.4 (95% CI, 1.3-4.5) for motor delay. Overall social-emotional competence was worse in MLPT children compared with controls (t statistic mean difference, -3.6 (95% CI, -5.8 to -1.4), but other behavioral domains were similar. The odds of being at risk for social-emotional competence were 3.9 (95% CI, 1.4-10.9) for MLPT children compared with controls.

CONCLUSIONS AND RELEVANCE

Moderate and late preterm children exhibited developmental delay compared with their term-born peers, most marked in the language domain. This knowledge of developmental needs in MLPT infants will assist in targeting surveillance and intervention.

Neurobehaviour at term-equivalent age and neurodevelopmental outcomes at 2 years in infants born moderate-to-late preterm

AIM

To examine the association between newborn neurobehavioural assessments and neurodevelopmental outcomes at 2 years in infants born moderate-to-late preterm (MLPT).

METHOD

Two-hundred and one infants born MLPT (born 32-36⁺⁶ wks' gestation) were assessed with the Hammersmith Neonatal Neurological Examination (HNNE) and NICU Network Neurobehavioral Scale (NNNS), with suboptimal performance defined as scores lower than the 10th centile. Development was assessed at 2 years corrected age with the Bayley Scales of Infant and Toddler Development 3rd Edition, with delay defined as scores less than 1 standard deviation (SD) below the mean. The relationships between neurobehaviour at term and Bayley-III cognitive, language, and motor scales at 2 years were examined using linear regression.

RESULTS

Increased odds for cognitive delay were associated with suboptimal HNNE total scores (odds ratio [OR] 2.66; 95% confidence interval [CI] 1.14-6.23, p=0.020) and suboptimal NNNS excitability (OR 3.01; 95% CI 1.33-6.82, p=0.008) and lethargy (OR 4.05; 95% CI 1.75-9.31, p=0.001) scores. Suboptimal lethargy scores on the NNNS were associated with increased odds of language (OR 5.64; 95% CI 1.33-23.85, p=0.019) and motor delay (OR: 6.86; 95% CI 1.64-28.71, p=0.08).

INTERPRETATION

Suboptimal performance on specific aspects of newborn neurobehavioural assessments is associated with neurodevelopmental delay at 2 years in children born MLPT.

Reliability of Neurobehavioral Assessments from Birth to Term Equivalent Age in Preterm and Term Born Infants

Neurobehavioral assessments provide insight into the functional integrity of the developing brain and help guide early intervention for preterm (<37 weeks' gestation) infants. In the context of shorter hospital stays, clinicians often need to assess preterm infants prior to term equivalent age. Few neurobehavioral assessments used in the preterm period have established interrater reliability.

AIM

To evaluate the interrater reliability of the Hammersmith Neonatal Neurological Examination (HNNE) and the NICU Network Neurobehavioral Scale (NNNS), when used both preterm and at term (>36 weeks).

METHODS

Thirty-five preterm infants and 11 term controls were recruited. Five assessors double-scored the HNNE and NNNS administered either preterm or at term. A one-way random effects, absolute, single-measures interclass correlation coefficient (ICC) was calculated to determine interrater reliability.

RESULTS

Interrater reliability for the HNNE was excellent (ICC > 0.74) for optimality scores, and good (ICC 0.60-0.74) to excellent for subtotal scores, except for 'Tone Patterns' (ICC 0.54). On the NNNS, interrater reliability was predominantly excellent for all items. Interrater agreement was generally excellent at both time points.

CONCLUSIONS

Overall, the HNNE and NNNS neurobehavioral assessments demonstrated mostly excellent interrater reliability when used prior to term and at term.

Motor trajectories from birth to 5 years of children born at less than 30 weeks' gestation: early predictors and functional implications. Protocol for a prospective cohort study

INTRODUCTION

Motor impairments are one of the most frequently reported adverse neurodevelopmental consequences in children born < 30 weeks' gestation. Up to 15% of children born at < 30 weeks have cerebral palsy and an additional 50% have mild to severe motor impairment at school age. The first 5 years of life are critical for the development of fundamental motor skills. These skills form the basis for more complex skills that are required to competently and confidently participate in schooling, sporting and recreational activities. In children born at < 30 weeks' gestation, the trajectory of motor development from birth to 5 years is not fully understood. The neural alterations that underpin motor impairments in these children are also unclear. It is essential to determine if early clinical evaluations and neuroimaging biomarkers can predict later motor impairment and associated functional problems at 5 years of age. This will help to identify children who will benefit the most from early intervention and improve functional outcomes at school age.

RESEARCH AIMS

The primary aim of this study is to compare the prevalence of motor impairment from birth to 5 years of age between children born at < 30 weeks and term-born controls, and to determine whether persistent abnormal motor assessments in the newborn period in those born at < 30 weeks predict abnormal motor functioning at 5 years of age. Secondary aims for children born at < 30 weeks and term-born children are: 1) to determine whether novel early magnetic resonance imaging-based structural or functional biomarkers that can predict motor impairments at 5 years are detectable in the neonatal period; 2) to investigate the association between motor impairments and concurrent deficits in body structure and function at 5 years of age; and 3) to explore how motor impairments at 5 years (including abnormalities of gait, postural control and strength) are associated with concurrent functional outcomes, including physical activity, cognitive ability, learning ability, and behavioural and emotional problems.

DESIGN

Prospective longitudinal cohort study.

PARTICIPANTS AND SETTING

150 preterm children (born at < 30 weeks' gestation) and 151 term-born children (born at > 36 completed weeks' gestation and weighing > 2499g) admitted to the Royal Women's Hospital, Melbourne, were recruited at birth and will be invited to participate in a 5-year follow-up study.

PROCEDURE

This study will examine previously collected data (from birth to 2 years) that comprise detailed motor assessments, and structural and functional brain MRI images. At 5 years, preterm and term, children will be examined using comprehensive motor assessments, including: the Movement Assessment Battery for Children (2nd edition) and measures of gait function through spatiotemporal (assessed with the GAITRite® Walkway) and dynamic postural control (assessed with Microsoft Kinect) variables; and hand grip strength (assessed with a dynamometer); and measures of physical activity (assessed using accelerometry), cognitive development (assessed with Wechsler Preschool and Primary Scale of Intelligence), and emotional and behavioural status (assessed with the Strengths and Difficulties Questionnaire and the Developmental and Wellbeing Assessment). At the 5-year assessment, parents/caregivers will be asked to complete questionnaires on demographics, physical activity, activities of daily living, behaviour, additional therapy (eg, physiotherapy and occupational therapy), and motor function (assessed with Pediatric Evaluation of Disability Inventory, Pediatric Quality of Life Questionnaire, the Little Developmental Co-ordination Questionnaire and an activity diary).

ANALYSIS

For the primary aim, the prevalence of motor impairment from birth to 5 years will be compared between children born at < 30 weeks and at term, using the proportion of children classified as abnormal at each of the time points (term age, 1, 2 and 5 years). Persistent motor impairments during the neonatal period will be assessed as a predictor of severity of motor impairment at 5 years of age in children born < 30 weeks using linear regression. Models will be fitted using generalised estimating equations to allow for the clustering of multiple births. Analysis will be repeated with adjustment for predictors of motor outcome, including additional therapy, sex, brain injury and chronic lung disease.

DISCUSSION/SIGNIFICANCE

Understanding the developmental precursors of motor impairment in children born before 30 weeks is essential for limiting disruption to skill development, and potential secondary impacts on physical activity, participation, academic achievement, self-esteem and associated outcomes (such as obesity, poor physical fitness and social isolation). An improved understanding of motor skill development will enable targeting of interventions and streamlining of services to children at highest risk of motor impairments.

Early general movements and brain magnetic resonance imaging at term-equivalent age in infants born <30weeks' gestation

BACKGROUND

Neurodevelopmental assessments and brain magnetic resonance imaging (MRI) at term-equivalent age (TEA) predict developmental outcomes in preterm infants. However, the relationship between neurodevelopment prior to term and cerebral structure is currently unknown.

AIMS

To examine the relationships between General Movements (GMs) assessed from birth to TEA and brain MRI at TEA in infants born <30weeks' gestation.

STUDY DESIGN

Prospective cohort study. GMs (categorised as 'normal' or 'abnormal') were recorded weekly from birth to 32weeks, and at 34 and 36weeks' postmenstrual age. At TEA, GMs were assessed concurrently with brain MRI (using a validated scoring system).

SUBJECTS

149 infants born <30weeks' gestation were recruited from a tertiary hospital.

RESULTS

103 infants had MRI at TEA and GMs recorded. Abnormal GMs prior to term were associated with cortical grey matter abnormality (p<0.03), deep grey matter abnormality (p=0.02) and increased interhemispheric distance (p<0.02). Abnormal GMs at TEA (n=55/90) were associated with more global brain abnormality (p<0.01) and cortical grey matter abnormality (p=0.01), and decreased transcerebellar diameter (p=0.04) on concurrent brain MRI.

CONCLUSIONS

Abnormal GMs both prior to term and at TEA were associated with more marked brain abnormality, and smaller brains at TEA. Abnormal GMs are an early marker of brain abnormalities in very preterm infants.

Neurobehaviour and neurological development in the first month after birth for infants born between 32-42 weeks' gestation

AIMS

The objective of this study was to generate reference values for infants born moderate preterm (MPT), late preterm (LPT) and full term (FT) for three newborn neurobehavioural/neurological examinations in the first weeks after birth.

STUDY DESIGN

Prospective cohort study to examine the expected range of values for MPT (born 32(+0) to 33(+6)), LPT (34(+0) to 36(+6)) and FT (born 37 to 42weeks' gestation) infants' performance on the Hammersmith Neonatal Neurological Examination (HNNE), the Neonatal Intensive Care Unit Network Neurobehavioural Scale (NNNS) and Prechtl's General Movements Assessment (GMA) in the first weeks after birth. Further, to determine the effects of sex, gestational age at birth, and postmenstrual age at assessment on the 3 different assessments within the gestational age groups.

SUBJECTS

80 MPT, 129 LPT and 201 FT infants were recruited shortly after birth from a tertiary hospital.

RESULTS

The means, standard deviations and 5th, 10th, 25th, 50th, 75th, 90th and 95th centiles are presented for the HNNE and NNNS for each of the three gestational age groups. Overall, FT infants performed better than MPT and LPT infants. The rate of normal GMA within the first few weeks after birth was 25% for MPT, 32% for LPT, and 90% for FT infants. The effects of sex, gestational age at birth, and postmenstrual age at assessment varied between test and gestational age groups.

CONCLUSIONS

This study provides normative data for the HNNE, NNNS, and GMA administered within the first weeks after birth in a sample of MPT, LPT and healthy FT infants.

Trajectories of general movements from birth to term-equivalent age in infants born <30 weeks' gestation

BACKGROUND

General movements (GMs) is an assessment with good predictive validity for neurodevelopmental outcomes in preterm infants. However, there is limited information describing the early GMs of very preterm infants, particularly prior to term.

AIMS

To describe the early GMs trajectory of very preterm infants (born <30weeks' gestation) from birth to term-equivalent age, and to assess the influence of known perinatal risk factors on GMs.

STUDY DESIGN

Prospective cohort study.

SUBJECTS

149 very preterm infants born <30weeks' gestation.

OUTCOME MEASURES

GMs were recorded weekly from birth until 32weeks' postmenstrual age, and then fortnightly until 38weeks' postmenstrual age. GMs were also assessed at term-equivalent age. Detailed perinatal data were collected.

RESULTS

Of 669 GMs assessed, 551 were preterm and 118 were at term-equivalent age. Prior to term, 15% (n=82) of GMs were normal and 85% (n=469) were abnormal, with the proportion of abnormal GMs decreasing with increasing postmenstrual age (p for trend <0.001). By term-equivalent 30% (n=35) of GMs were normal. On univariable analysis, lower gestational age (p<0.001), postnatal infection (p<0.001) and bronchopulmonary dysplasia (p=0.001) were associated with abnormal GMs. Postnatal infection was the only independent perinatal association with abnormal GMs on multivariable analysis. All four infants with grade III/IV intraventricular haemorrhage (IVH) had persistently abnormal GMs.

CONCLUSIONS

GMs were predominantly abnormal in very preterm infants, with a higher proportion of normal GMs at term-equivalent age than prior to term. Abnormal GMs were associated with postnatal infection and IVH.

Genetic relatedness of commensal Escherichia coli from nursery pigs in intensive pig production in Denmark and molecular characterization of genetically different strains

AIMS

To determine the genetic relatedness and the presence of virulence and antibiotic resistance genes in commensal Escherichia coli from nursery pigs in Danish intensive production.

METHODS AND RESULTS

The genetic diversity of 1000 E. coli strains randomly picked (N = 50 isolates) from cultured faecal samples (N = 4 pigs) from five intensive Danish pigs farms was analysed by repetitive extragenic palindromic-PCR (REP-PCR) and 42 unique REP-profiles were detected (similarity <92%). One profile was dominant (67.2% of strains) but farms differed significantly in the diversity of commensal E. coli: between eight and 21 different profiles per farm were detected. One to three strains representing each REP-profile were characterized by multilocus typing scheme-typing, as well as for presence of antimicrobial and virulence genes and serogrouping through microarray analysis. The 42 REP-profiles were classified into 22 different sequence types (ST) with ST10 being the most common, encompassing 10 REP-profiles. Resistance and virulence genes were detected in most of the isolates. Genes encoding AmpC-β-lactamases and quinolone resistance were found in one and three isolates, respectively. Toxin-producing genes were observed in 20 isolates.

CONCLUSIONS

A low genetic diversity was found in commensal gut E. coli from nursery pigs in Denmark. No correlation was observed between REP-profiles, ST-types and resistance/virulence patterns.

SIGNIFICANCE AND IMPACT OF THE STUDY

This is the first study analysing in depth the genetic variability of commensal E. coli from pigs in Danish intensive pig production. A tendency for higher diversity was observed with in nursery pigs that were treated with zinc oxide only, in absence of other antimicrobials. Strains with potential to disseminate virulence and antibiotic resistance genes to pathogenic subgroups of E. coli were found to be wide-spread.

UV-B and temperature enhancement affect spring and autumn phenology in Populus tremula

Perennial plants growing at high latitudes synchronize growth and dormancy to appropriate seasons by sensing environmental cues. Autumnal growth cessation, bud set and dormancy induction are commonly driven by the length of photoperiod and light quality, and the responses are modified by temperature. However, although ultraviolet (UV)-B radiation is well known to affect plant growth and development, information on the effects on bud phenology is scarce. We examined the separate and combined effects of enhanced temperature and UV-B on autumnal bud set and spring bud break in female and male clones of Populus tremula in an outdoor experiment in Joensuu, Eastern Finland. Enhancements of UV-B and temperature were modulated to +30% and +2 °C, respectively, from June to October 2012. Enhanced UV-B accelerated bud set, while increased temperature delayed it. For both UV-B and temperature, we found sex-related differences in responsiveness. Temperature increase had a stronger delaying effect on bud maturation in male compared with female clones. Also, male clones were more responsive to UV-B increase than female clones. Increasing autumnal temperature enhanced bud break in spring for both sexes, while UV-B enhanced bud break in male clones. In conclusion, we found that UV-B affected phenological shifts in P. tremula, and that temperature and UV-B affected genders differently.

Antimicrobial resistance in faecal samples from buffalo, wildebeest and zebra grazing together with and without cattle in Tanzania

AIM

The aim of this study was to determine whether the practice of co-grazing with cattle and wild life constitutes a risk of transmission of antibiotic resistant bacteria to wild ungulates.

METHODS AND RESULTS

Faecal samples were collected from buffalo (n = 35), wildebeest (n = 40), zebra (n = 40) and cattle (N = 20) from Mikumi National Park, Tanzania (MNP), where cattle is prohibited and from Ngorongoro Conservation Area (NCA) where co-grazing is practiced. The number of coliforms and enterococci resistant to selected antibiotics was determined. Wild life generally harboured higher number of resistant Escherichia coli and Enterococci than cattle, but with no general influence in wild life of co-grazing with cattle. Vancomycin-resistant Enterococci were detected in wild life samples, and E. coli resistant to cefotaxime and enrofloxacin were observed among isolates from all wild life, but not from cattle. Culture independent estimates of the number of sulII gene copies obtained by qPCR did not differ between wild life from the two sample sites, while tetW was significantly higher in samples from MPN than from NCA.

CONCLUSIONS

Antibiotic resistant bacteria were not more frequently found in ungulates grazing together with cattle than ungulates without this interaction.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study did not indicate that transmission of antibiotic resistant bacteria is a frequent event following co-grazing of wild life and cattle.

Demonstration of persistent contamination of a cooked egg product production facility with Salmonella enterica serovar Tennessee and characterization of the persistent strain

AIMS

The aim of this study was to investigate whether continuous contamination of light pasteurized egg products with Salmonella enterica serovar Tennessee (S. Tennessee) at a large European producer of industrial egg products was caused by persistent contamination of the production facility and to characterize the persistent strains.

METHODS AND RESULTS

Seventy-three S. Tennessee isolates collected from products over a 3-year period with intermittent contamination, and 15 control strains were compared by pulsed field gel electrophoresis (PFGE) using two enzymes. Forty-five case isolates distributed throughout the full period were shown to belong to one profile type. Isolates representing different PFGE profiles were all assigned to ST 319 by multilocus sequence typing (MLST). The case isolates did not show a higher ability to form biofilm on a plastic surface than noncase isolates. Characteristically, members of the persistent clone were weak producers of H2 S in laboratory medium. S. Tennessee isolated from the case was able to grow better in pasteurized egg product compared with other serovars investigated.

CONCLUSIONS

It was concluded that the contamination was caused by a persistent strain in the production facility and that this strain apparently had adapted to grow in the relevant egg product.

SIGNIFICANCE AND IMPACT OF THE STUDY

S. Tennessee has previously been associated with persistence in hatching facilities. This is the first report of persistent contamination of an egg production facility with this serovar.

Molecular epidemiology of Salmonella gallinarum in chickens in Tanzania

A molecular epidemiological investigation of Salmonella gallinarum infection in scavenging local chickens and commercial layers in Tanzania was conducted between August 1997 and April 1998. A total of 1152 chickens were randomly selected from 10 villages and seven commercial farms. For serological and cultural prevalence studies, 1152 blood samples and 912 cloacal swabs were collected. In scavenging local chickens, the individual serological and cultural prevalences were 6.3 and 0%, while the prevalences were significantly higher in commercial layers at 18.4 and 2.6% (P < 0.001), respectively. The risk of infection in flocks of scavenging local chickens that had contact with commercial chickens was six times greater than the risk of infection in flocks of scavenging local chickens that had no contact with commercial chickens. Thirty-four S. gallinarum isolated from commercial chickens in this study, together with 29 Tanzanian historical isolates, were characterized using plasmid profiling and ribotyping. Fifty-one isolates contained both 85 and 2.5kb plasmids, five isolates contained only one plasmid of 85kb, and seven isolates had no plasmids. Ribotyping using HindIII restriction endonuclease demonstrated seven different ribotypes. Forty-seven isolates had similar results in both typing systems, suggesting they belonged to one clone. It is concluded that S. gallinarum infection in chickens in Tanzania is more prevalent in commercial layers than in scavenging local chickens. One strain of S. gallinarum from chickens first isolated in a Dar es Salaam hatchery was found to be common throughout the country.

A new real-time PCR method for the identification of Salmonella Dublin

AIMS

Development of a real-time PCR method for the specific detection of Salmonella Dublin.

METHODS AND RESULTS

The method was directed towards a Salm. Dublin-specific sequence of the vagC gene on the Salmonella virulence plasmid (pSDV) and towards Salmonella genus-specific sequence of the invA gene, serving as an internal amplification control. The method showed 100% inclusivity and exclusivity when tested on a strain collection containing 50 serotyped S . Dublin strains, 20 strains of other Salmonella serotypes and 10 non- Salmonella strains. The method also showed 100% inclusivity and 99% exclusivity in a collaborative study comprising eight laboratories, where each laboratory received ten different S . Dublin strains and 10 other Salmonella serotypes.

CONCLUSIONS

The method showed excellent performance both when validated in the laboratory and in the collaborative study.

SIGNIFICANCE AND IMPACT OF THE STUDY

Application of the present method in food control, for example at slaughterhouses, can improve the contamination control of this veterinary and clinically important Salmonella serotype.

The importance of motility and chemotaxis for extra-animal survival of Salmonella enterica serovar Typhimurium and Dublin

AIMS

This study investigated the importance of flagella and motility of Salmonella enterica serovar Typhimurium and Dublin in models of extra-animal survival.

METHODS AND RESULTS

The study was performed using transposon mutants in flagella genes fliC and fljB and in chemotaxis genes cheA, cheB and cheR. Flagella and chemotaxis were found to be of minor importance for attachment to plant leaves, survival in liquid manure and interaction with the nematode C. elegans, while differences were observed between the fliC mutant and the wild-type strain of S. Dublin in interactions with amoebae.

CONCLUSIONS

The study shows that flagella and chemotaxis play a minor role in extra-animal survival of these two serovars of Salmonella under the conditions tested.

SIGNIFICANCE AND IMPACT OF THE STUDY

Extra-animal survival is important in the full infection cycle for zoonotic salmonellae. Such serovars are motile. Even though the current study was only based on the characterization of two serovars, it strongly suggests that motility and chemotaxis are of minor importance during the spread of Salmonella from one animal to the next through the external environment.

Time-course investigation of infection with a low virulent Pasteurella multocida strain in normal and immune-suppressed 12-week-old free-range chickens

Twelve-week-old indigenous chickens, either immune-suppressed using dexamethasone (IS) or non-immune-suppressed (NIS), were challenged with a low virulent strain, Pasteurella multocida strain NCTC 10322(T), and developed clinical signs and pathological lesions typical of chronic fowl cholera. NIS birds demonstrated much more severe signs of fowl cholera than IS birds. With few exceptions, signs recorded in IS and NIS birds were of the same types, but significantly milder in the IS birds, indicating that immune suppression does not change the course of infection but rather the severity of signs in fowl cholera. P. multocida signals by fluorescent in situ hybridization (FISH) were observed between 1 h and 14 days in the lungs, trachea, air sacs, liver, spleen, bursa of Fabricius and caecal tonsils, while signals from other organs mostly were observed after 24 h. More organs had FISH signals in NIS birds than in IS birds and at higher frequency per organ. Many organs were positive by FISH even 14 days post infection, and it is suggested that these organs may be likely places for long-term carriage of P. multocida following infection. The present study has demonstrated the spread of P. multocida in different tissues in chickens and distribution of lesions associated with chronic fowl cholera, and pointed to a decrease of pathology in IS birds. Since dexamethasone mostly affects heterophils, the study suggests that these cells play a role in the development of lesions associated with chronic fowl cholera in chickens.

Survival of Salmonella on cuts of beef carcasses subjected to dry aging

AIMS

The aim of this study was to determine the survival of 15 different strains of Salmonella of selected serotypes during prolonged cold storage of beef.

METHODS AND RESULTS

Fifteen strains of eight different serotypes of Salmonella were spiked onto fresh cuts beef portions, and the survival was followed during storage in a laboratory cooling system. Over a 14-day period, all strains were reduced significantly in numbers; however, strains of Salmonella Typhimurium DT104 and Salmonella Enteritidis PT4 and PT8 survived significantly longer than strains of the serovars Dublin, Derby, Infantis and Newport. For five selected strains, the observations were verified in a pilot plant cooling facility mimicking industrial cooling. No significant differences in reduction were found between the two cooling methods.

CONCLUSIONS

A significant reduction in Salmonella can be obtained by dry aging of beef during cold storage but the survival is strain dependent.

SIGNIFICANCE AND IMPACT OF THE STUDY

From a hygienic point of view, cold storage of unpacked beef, which is still performed in small slaughterhouses, is a good alternative to vacuum packaging.

Ribotypes of Salmonella enterica serovar Gallinarum biovars gallinarum and pullorum

Ninety-four isolates of Salmonella enterica serovar Gallinarum biovar pullorum and forty-one isolates of biovar gallinarum were ribotyped using the enzymes, HindIII, EcoRI and SmaI, and a digoxigenin-labelled E. coli-derived rRNA probe. Using HindIII, 13 profile types were observed within biovar gallinarum and 12 within biovar pullorum. The most common types accounted for 39% of biovar pullorum isolates and 47% for biovar gallinarum. EcoRI digests revealed two profile types within biovar pullorum, one accounting for 96% of the isolates, and three EcoRI profiles within biovar gallinarum, with 81% of the isolates belonging to the dominant type. Using SmaI, biovar pullorum showed two profile types with 94% of the isolates belonging to the dominant one, while SmaI digestion revealed only one ribotype within biovar gallinarum. The SmaI ribotype of biovar gallinarum was identical to the less common of the two SmaI types in biovar pullorum. Two of the HindIII profile types were seen in both biovars. The two biovars did not share any of the EcoRI profiles. Numerical analysis based on the ribotypes revealed a 94% similarity between the two biovars, but they clustered separately in a similarity dendrogram, underlining the existence of two different biovars. The results indicate that ribotyping, especially using EcoRI, may be useful in separating biovars gallinarum and pullorum. The ribotypes obtained with isolates from different countries indicated that different clones of biovar gallinarum might exist in different regions.