Infant AFAR: Automated facial action recognition in infants

Automated detection of facial action units in infants is challenging. Infant faces have different proportions, less texture, fewer wrinkles and furrows, and unique facial actions relative to adults. For these and related reasons, action unit (AU) detectors that are trained on adult faces may generalize poorly to infant faces. To train and test AU detectors for infant faces, we trained convolutional neural networks (CNN) in adult video databases and fine-tuned these networks in two large, manually annotated, infant video databases that differ in context, head pose, illumination, video resolution, and infant age. AUs were those central to expression of positive and negative emotion. AU detectors trained in infants greatly outperformed ones trained previously in adults. Training AU detectors across infant databases afforded greater robustness to between-database differences than did training database specific AU detectors and outperformed previous state-of-the-art in infant AU detection. The resulting AU detection system, which we refer to as Infant AFAR (Automated Facial Action Recognition), is available to the research community for further testing and applications in infant emotion, social interaction, and related topics.

Behavioral and Social Functioning of Children With and Without Positional Plagiocephaly: Late Infancy to School Age

Positional plagiocephaly and/or brachycephaly (PPB) is associated with cognition, motor, and other developmental outcomes, but little is known about the social-behavioral adjustment of children with PPB. The primary aim of this study was to compare the social-behavioral development of preschool and school-age children with and without PPB and to examine the potential moderating effects of PPB severity on group differences.

Two hundred twenty children with a history of PPB and 164 controls participated in at least one behavioral assessment at 4-11 months, 18 months, 36 months, and 7 years. The frequencies of observed problem behaviors and social competence were estimated using the Child Behavior Checklist Ages 1.5-5 (CBCL/1.5-5), Caregiver-Teacher Report Form(C-TRF), CBCL/6-18, and Teacher Report Form.

Children with PPB were similar to controls on the internalizing, externalizing, or total problems composites. At 7 years, CBCL/6-18 total competence scores were significantly lower in children with histories of PPB than controls. In analyses stratified by PPB severity, we found that children with moderate/severe PPB had slightly higher scores on the C-TRF internalizing scale at 36 months and lower total competence scores at age 7 years. Children who had a history of mild PPB were similar to controls on all outcomes.

This study is the first to examine social and behavioral outcomes in a large cohort of children with and without a history of PPB. We found limited evidence of an association between PPB and parent and teacher-reported social-emotional and behavioral adjustment through early school-age.

Do Infant Motor Skills Mediate the Association Between Positional Plagiocephaly/Brachycephaly and Cognition in School-Aged Children?

OBJECTIVE

Positional plagiocephaly/brachycephaly (PPB) is associated with lower cognitive scores in school-aged children. This study tested the hypothesis that infant motor skills mediate this association.

METHODS

Children with a history of PPB (cases, n = 187) and without PPB (controls, n = 149) were followed from infancy through approximately 9 years of age. Infant motor skills were assessed using the Bayley Scales of Infant and Toddler Development, 3rd edition (Bayley-3), and cognition was assessed using the Differential Ability Scales, 2nd edition (DAS-2). The Bayley-3 motor composite was examined as a mediator of the association between PPB and DAS-2 general cognitive ability (GCA) scores. In secondary analyses, mediation models were examined for the DAS-2 verbal ability, nonverbal ability, and working memory scores; models using the Bayley-3 fine versus gross motor scores also were examined.

RESULTS

Cases scored lower than controls on the DAS-GCA (β = -4.6; 95% CI = -7.2 to -2.0), with an indirect (mediated) effect of β = -1.5 (95% CI = -2.6 to -0.4) and direct effect of β = -3.1 (95% CI = -5.7 to -0.5). Infant motor skills accounted for approximately 33% of the case-control difference in DAS-2 GCA scores. Results were similar for other DAS-2 outcomes. Evidence of mediation was greater for Bayley-3 gross motor versus fine motor scores.

CONCLUSION

Infant motor skills partially mediate the association between PPB and cognition in school-aged children. Monitoring motor development and providing intervention as needed may help offset associated developmental concerns for children with PPB.

IMPACT

To our knowledge, this study is the first longitudinal investigation of the development of children with and without PPB from infancy through the early school years and the first to examine motor skills as a mediator of cognitive outcomes in this population. The findings highlight the importance of early motor skills for other developmental outcomes.

LAY SUMMARY

Infants' motor skills are related to the development of PPB and its association with later cognition. If your child has PPB, physical therapists may have an important role in assessing and providing treatment to promote motor development.

Cognitive, Motor, and Language Development of Preschool Children With Craniofacial Microsomia

OBJECTIVE

To examine neurodevelopment in preschool-aged children with craniofacial microsomia (CFM) relative to unaffected peers.

DESIGN

Multisite, longitudinal cohort study.

SETTING

Tertiary care centers in the United States.

PARTICIPANTS

We included 92 children with CFM ("cases") through craniofacial centers and clinics. Seventy-six children without CFM (controls) were included from pediatric practices and community advertisements. This study reports on outcomes assessed when participants were an average age of 38.4 months (SD = 1.9).

MAIN OUTCOME MEASURES

We assessed cognitive and motor skills using the Bayley Scales of Infant and Toddler Development, third edition (Bayley-III), and language function using subtests from the Clinical Evaluation of Language Fundamentals-Preschool, second edition (CELF-P2).

RESULTS

Case-control differences were negligible for Bayley-III cognitive (effect sizes [ES] = -0.06, P = .72) and motor outcomes (ES = -0.19, P = .25). Cases scored lower than controls on most scales of the CELF-P2 (ES = -0.58 to -0.20, P = .01 to .26). Frequency counts for "developmental delay" (ie, one or more scores > 1 SD below the normative mean) were higher for cases (39%) than controls (15%); however, the adjusted odds ratio = 1.73 (P = 0.21) was not significant. Case-control differences were most evident in children with microtia or other combinations of CFM-related facial features.

CONCLUSIONS

Cognitive and motor scores were similar for preschool-aged children with and without CFM. However, children with CFM scored lower than controls on language measures. We recommend early monitoring of language to identify preschoolers with CFM who could benefit from intervention.

Behavioral Adjustment of Preschool Children With and Without Craniofacial Microsomia

OBJECTIVE

The study aim was to assess behavioral adjustment in preschool children with and without craniofacial microsomia (CFM).

DESIGN

Multisite cohort study of preschoolers with CFM ("cases") or without CFM ("controls").

PARTICIPANTS

Mothers (89%), fathers (9%), and other caregivers (2%) of 161 preschoolers.

OUTCOME MEASURE

Child Behavior Check List (CBCL 1.5-5); linear regressions with standardized effect sizes (ES) adjusted for sociodemographic confounds.

RESULTS

Child Behavior Check Lists for 89 cases and 72 controls (average age 38.3 ± 1.9 months). Children were male (54%), white (69%), and of Latino ethnicity (47%). Cases had microtia with mandibular hypoplasia (52%), microtia only (30%), or other CFM-associated features (18%). Nearly 20% of cases had extracranial anomalies. Composite CBCL scores were in the average range compared to test norms and similar for cases and controls. On the subscales, cases' parents reported higher Anxious/Depressed scores (ES = 0.35, P = .04), Stress Problems (ES = 0.40, P = .04), Anxiety Problems (ES = 0.34, P = .04), and Autism Spectrum Problems (ES = 0.41, P = .02); however, the autism subscale primarily reflected speech concerns. Among cases, more problems were reported for children with extracranial anomalies and certain phenotypic categories with small ES.

CONCLUSIONS

Behavioral adjustment of preschoolers with CFM was comparable to peers. However, parental reports reflected greater concern for internalizing behaviors; thus, anxiety screening and interventions may benefit children with CFM. Among cases, more problems were reported for those with more complex presentations of CFM. Craniofacial microsomia-related speech problems should be distinguished from associated psychosocial symptoms during developmental evaluations.

Prediction of school-age IQ, academic achievement, and motor skills in children with positional plagiocephaly

Introduction

Children with positional plagiocephaly and/or brachycephaly (PPB) are at risk of early developmental delay, but little is known about early life factors associated with school-age neurodevelopment. This study examined associations of demographic characteristics, prenatal risk factors and early neurodevelopment assessment with school-age IQ, academic performance, and motor development in children with PPB.

Methods

The study sample consisted of 235 school-age children with PPB followed since infancy. Outcome measures included IQ using the Differential Ability Scales-Second Edition, academic achievement as measured by the Wechsler Individualized Achievement Tests-Third Edition), and motor function using the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition. Linear regression was used to examine the incremental improvement of model fit of demographics, prenatal and early life characteristics, severity of PPB, and neurodevelopment at ages 7, 18, and 36 months as measured by the Bayley-3 on school-age scores.

Results

Mean age at school-age assessment was 9.0 years. Adjusted r² for demographic, prenatal, and early life risk factors ranged from 0.10 to 0.22. Addition of PPB severity and Bayley-3 measures at ages 7 and 18 months did not meaningfully change model fit. Adjusted r² after inclusion of Bayley-3 at 36 months ranged from 0.35 to 0.41.

Conclusion

This study suggests that PPB severity and very early life neurodevelopment have little association with school-age neurodevelopment above and beyond demographic and early life risk factors. However, preschool-age neurodevelopmental assessment may still be useful in identifying children with PPB at risk for delay and who may benefit from early intervention.

Motor Function in School-Aged Children With Positional Plagiocephaly or Brachycephaly

OBJECTIVE

To determine whether children with a history of positional plagiocephaly/brachycephaly (PPB) show persistent deficits in motor development.

METHODS

In a longitudinal cohort study, we completed follow-up assessments with 187 school-aged children with PPB and 149 participants without PPB who were originally enrolled in infancy. Primary outcomes were the Bruininks-Oseretsky Test of Motor Proficiency-Second Edition (BOT-2) composite scores.

RESULTS

Children with PPB scored lower than controls on the BOT-2. Stratified analyses indicated that differences were restricted to children who had moderate-severe PPB. No consistent differences were observed in children who had mild PPB.

CONCLUSION

Children who had moderate-severe PPB in infancy show persistent differences in motor function. We suggest close developmental monitoring and early intervention to address motor deficits.

Speech, Language, and Communication Skills of Adolescents With Craniofacial Microsomia

Purpose Youth with craniofacial microsomia (CFM) have anomalies and comorbidities that increase their risk for speech, language, and communication deficits. We examined these outcomes in youth with and without CFM and explored differences as a function of CFM phenotype and hearing status. Method Participants included youth ages 11-17 years with CFM (n = 107) and demographically similar controls (n = 306). We assessed speech intelligibility, articulation, receptive and expressive language, and parent and teacher report measures of communication. Hearing status was also screened at the study visit. Group differences were estimated using linear regression analyses with standardized effect sizes (ES) adjusted for demographic characteristics (adjusted ES) or negative binomial regression. Results Youth with CFM scored lower than unaffected peers on most measures of intelligibility, articulation, expressive language, and parent- and-teacher-rated communication. Differences were most pronounced among participants with CFM who had mandibular hypoplasia plus microtia (adjusted ES = -1.15 to -0.18). Group differences were larger in youth with CFM who failed the hearing screen (adjusted ES = -0.73 to 0.07) than in those who passed the hearing screen (adjusted ES = -0.34 to 0.27). Conclusions Youth with CFM, particularly those with mandibular hypoplasia plus microtia and/or hearing loss, should be closely monitored for speech and language concerns. Further research is needed to identify the specific needs of youth with CFM as well as to document the course of speech and language development in children with CFM.

Evaluation of prenatal diabetes mellitus and other risk factors for craniofacial microsomia

OBJECTIVES

Craniofacial microsomia (CFM) is a congenital condition that typically involves hypoplasia of the ear and jaw. It is often associated with adverse effects such as hearing loss and sleep-disordered breathing. There is little research on its etiology.

METHODS

We conducted a case-control study from maternal interview data collected from mothers of infants with and without CFM. The study included 108 children with and 84 children without CFM. Logistic regression with adjustment for demographic factors was used to evaluate associations between maternal exposures of interest and risk for CFM overall, as well as for different phenotypic sub-groups of children on the CFM spectrum.

RESULTS

We found a statistically significant association between diabetes mellitus (DM) and CFM (OR 4.01, 95% CI 1.6-10.5). The association was slightly attenuated after adjustment for BMI. Higher parity was also associated with increased risk for CFM (OR 2.0, 95% CI 1.0-4.0). Vitamin A consumption and/or liver consumption was associated with a 70% lower risk compared with non-users (OR 0.3, 95% 0.1-0.8). Maternal age at the time of pregnancy was not associated with CFM.

CONCLUSIONS

These analyses contribute evidence linking maternal DM with an elevated risk of having an infant with CFM, which is consistent with previous research and adds to the body of knowledge about the strength of this association. Further study is warranted to understand the potential mechanisms underlying the effect of DM in the developing embryo.

Cognitive Outcomes and Positional Plagiocephaly

: media-1vid110.1542/5972296741001PEDS-VA_2018-2373Video Abstract BACKGROUND: Studies have revealed an association between positional plagiocephaly and/or brachycephaly (PPB) and development, although little is known about long-term outcomes. We examined cognition and academic achievement in children with and without PPB, testing the hypothesis that children who had PPB as infants would score lower than controls.

METHODS

We enrolled 187 school-aged children with a history of PPB and 149 controls. Exposures were the presence or absence and severity of infancy PPB (mild, moderate to severe). Cognitive and academic outcomes were assessed by using the Differential Ability Scales, Second Edition and Wechsler Individual Achievement Test, Third Edition, respectively.

RESULTS

Children with PPB scored lower than controls on most scales of the Differential Ability Scales, Second Edition (standardized effect sizes [ESs] = -0.38 to -0.20) and the Wechsler Individual Achievement Test, Third Edition (ESs = -0.22 to -0.17). Analyses by PPB severity revealed meaningful differences among children with moderate to severe PPB (ESs = -0.47 to -0.23 for 8 of 9 outcomes), but few differences in children with mild PPB (ESs = -0.28 to 0.14).

CONCLUSIONS

School-aged children with moderate to severe PPB scored lower than controls on cognitive and academic measures; associations were negligible among children with mild PPB. The findings do not necessarily imply that these associations are causal; rather, PPB may serve as a marker of developmental risk. Our findings suggest a role for assessing PPB severity in clinical practice: providing developmental assessment and intervention for infants with more severe deformation and reassurance and anticipatory guidance for patients with mild deformation.

Methods and Challenges in a Cohort Study of Infants and Toddlers With Craniofacial Microsomia: The Clock Study

OBJECTIVE

The Craniofacial microsomia: Longitudinal Outcomes in Children pre-Kindergarten (CLOCK) study is a longitudinal cohort study of neurobehavioral outcomes in infants and toddlers with craniofacial microsomia (CFM). In this article, we review the data collection and methods used to characterize this complex condition and describe the demographic and clinical characteristics of the cohort.

SETTING

Craniofacial and otolaryngology clinics at 5 study sites.

PARTICIPANTS

Infants with CFM and unaffected infants (controls) ages 12 to 24 months were recruited from the same geographical regions and followed to age 36 to 48 months.

METHODS

Phenotypic, neurodevelopmental, and facial expression assessments were completed during the first and third waves of data collection (time 1 and time 3, respectively). Medical history data were taken at both of these time points and during an intermediate parent phone interview (time 2).

RESULTS

Our cohort includes 108 cases and 84 controls. Most cases and controls identified as white and 55% of cases and 37% of controls identified as Hispanic. Nearly all cases had microtia (95%) and 59% had mandibular hypoplasia. Cases received extensive clinical care in infancy, with 59% receiving care in a craniofacial clinic and 28% experiencing at least one surgery. Study visits were completed at a study site (92%) or at the participant's home (8%).

CONCLUSIONS

The CLOCK study represents an effort to overcome the challenges of characterizing the phenotypic and neurodevelopmental outcomes of CFM in a large, demographically and geographically diverse cohort.

Infant/toddler motor skills as predictors of cognition and language in children with and without positional skull deformation

PURPOSE

To estimate associations between early motor abilities (at two age points, 7 and 18 months on average) and cognitive/language outcomes at age 3. To determine whether these associations are similar for children with and without positional plagiocephaly and/or brachycephaly (PPB).

METHODS

The Bayley Scales of Infant/Toddler Development 3 were given at all age points to 235 children with PPB and 167 without PPB. Linear regressions assessed longitudinal associations between fine and gross motor scales and cognition/language. Item analyses examined the contributions of specific motor skills.

RESULTS

Associations between 7-month motor skills and cognition/language were modest overall (effect sizes [ES] = - 0.08 to 0.10, p = .13 to .95). At 18 months, both fine and gross motor skills were associated with outcomes for children with PPB (ES = 0.21 to 0.41, p < .001 to .01), but among those without PPB, only fine motor skills were associated with outcomes (ES = 0.21 to 0.27, p < .001 to .001).

CONCLUSIONS

Toddlers' motor skills were associated with cognition and language at 3 years, particularly among children with PPB. Interventions targeting early motor development in infants and toddlers with PPB may have downstream benefits for other outcomes.

Neurodevelopment of Infants with and without Craniofacial Microsomia

OBJECTIVES

To determine whether infant cases with craniofacial microsomia (CFM) evidence poorer neurodevelopmental status than demographically similar infants without craniofacial diagnoses ("controls"), and to examine cases' neurodevelopmental outcomes by facial phenotype and hearing status.

STUDY DESIGN

Multicenter, observational study of 108 cases and 84 controls aged 12-24 months. Participants were assessed by the Bayley Scales of Infant and Toddler Development-Third Edition and the Preschool Language Scales-Fifth Edition (PLS-5). Facial features were classified with the Phenotypic Assessment Tool for Craniofacial Microsomia.

RESULTS

After adjustment for demographic variables, there was little difference in Bayley Scales of Infant and Toddler Development-Third Edition or Preschool Language Scales-Fifth Edition outcomes between cases and controls. Estimates of mean differences ranged from -0.23 to 1.79 corresponding to standardized effect sizes of -.02 to 0.12 (P values from .30 to .88). Outcomes were better among females and those with higher socioeconomic status. Among cases, facial phenotype and hearing status showed little to no association with outcomes. Analysis of individual test scores indicated that 21% of cases and 16% of controls were developmentally delayed (OR  0.68, 95% CI 0.29-1.61).

CONCLUSIONS

Although learning problems have been observed in older children with CFM, we found no evidence of developmental or language delay among infants. Variation in outcomes across prior studies may reflect differences in ascertainment methods and CFM diagnostic criteria.

Facial Expressiveness in Infants With and Without Craniofacial Microsomia: Preliminary Findings

OBJECTIVE

To compare facial expressiveness (FE) of infants with and without craniofacial macrosomia (cases and controls, respectively) and to compare phenotypic variation among cases in relation to FE.

DESIGN

Positive and negative affect was elicited in response to standardized emotion inductions, video recorded, and manually coded from video using the Facial Action Coding System for Infants and Young Children.

SETTING

Five craniofacial centers: Children's Hospital of Los Angeles, Children's Hospital of Philadelphia, Seattle Children's Hospital, University of Illinois-Chicago, and University of North Carolina-Chapel Hill.

PARTICIPANTS

Eighty ethnically diverse 12- to 14-month-old infants.

MAIN OUTCOME MEASURES

FE was measured on a frame-by-frame basis as the sum of 9 observed facial action units (AUs) representative of positive and negative affect.

RESULTS

FE differed between conditions intended to elicit positive and negative affect (95% confidence interval = 0.09-0.66, P = .01). FE failed to differ between cases and controls (ES = -0.16 to -0.02, P = .47 to .92). Among cases, those with and without mandibular hypoplasia showed similar levels of FE (ES = -0.38 to 0.54, P = .10 to .66).

CONCLUSIONS

FE varied between positive and negative affect, and cases and controls responded similarly. Null findings for case/control differences may be attributable to a lower than anticipated prevalence of nerve palsy among cases, the selection of AUs, or the use of manual coding. In future research, we will reexamine group differences using an automated, computer vision approach that can cover a broader range of facial movements and their dynamics.

Head shape at age 36 months among children with and without a history of positional skull deformation

OBJECTIVE In this study, the authors examined head shape through age 36 months for children with and without a history of positional plagiocephaly and/or brachycephaly (PPB). METHODS Infants with PPB (cases) were identified through a craniofacial clinic at the time of diagnosis. Infants without diagnosed PPB were identified through a participant registry. Clinician ratings of 3D cranial images were used to confirm the presence or absence of PPB. The cohort included 235 case infants (diagnosed PPB, confirmed with 3D imaging), 167 unaffected controls (no diagnosed PPB, no deformation detected), and 70 affected controls (no diagnosed PPB, discernible skull deformation). Participants were seen in infancy (age 7 months, on average) and again at ages 18 and 36 months. At each visit, automated 3D measures of skull deformation quantified posterior flattening and generated an absolute asymmetry score. The authors also used automated 2D measures to approximate overall asymmetry (approximate oblique cranial length ratio) and calculate the cephalic index. They used linear regression to compare cases to unaffected controls and to compare affected versus unaffected controls on all measures. They also calculated the proportion of children in each group with "persistent PPB," defined as one or more head shape measures above the 95th percentile relative to unaffected controls at 36 months. RESULTS Head shape became more rounded and symmetric for children with and without PPB, particularly between infancy and age 18 months. However, children with PPB continued to show greater skull deformation and asymmetry than unaffected controls at age 36 months. These differences were large in magnitude, ranging from 1 to 2 standard deviations (SDs), and in most (85.6%) of the cases, there was evidence of persistent PPB at 36 months. Similarly, although differences were more modest (i.e., 0.26-0.94 SD), affected controls continued to exhibit skull deformation on most measures relative to unaffected controls and approximately 30% had persistent PPB. Within the case group, head shape at 36 months was similar for untreated patients with PPB and for those who received helmet treatment and for patients with and without a history of torticollis. CONCLUSIONS Although head shape continues to improve, children with a history of skull deformation in infancy continue to exhibit measureable cranial flattening and asymmetry through age 36 months.

Behavioral-Social Adjustment of Adolescents with Craniofacial Microsomia

OBJECTIVE

The objective was to assess differences in psychosocial adjustment between adolescents with and without craniofacial microsomia (CFM).

DESIGN

This is a case-control follow-up study in adolescents with and without CFM.

SETTING

Participants were originally recruited as infants from 26 cities across the United States and Canada.

PARTICIPANTS

Participants included 142 adolescents with CFM (cases) and 316 peers without CFM (controls), their caregivers, and their teachers.

MAIN OUTCOME MEASURES

Social and behavior measures from the Achenbach System of Empirically Based Assessments (ASEBA), the PedsQL: Core Version, and the Children's Communication Checklist-2nd edition (CCC-2) were used. Linear regression was used to estimate case-control differences and corresponding standardized effect sizes (ES) and 95% confidence intervals after adjustment for sociodemographic confounds. We also examined case-control differences by facial phenotype and hearing status.

RESULTS

The magnitude and direction of case-control differences varied across assessment and respondent, but were generally modest (ES = -0.4 to 0.02, P values ranged from .003 to .85). There was little evidence for variation in case-control differences across different facial phenotypes or as a function of hearing status.

CONCLUSIONS

Our results suggest that in spite of multiple risk factors, adolescents with CFM exhibit behavior problems no more frequently than their peers without CFM. Future studies of individuals with CFM should focus on resilience and social coping mechanisms, in addition to maladjustment.

Multisite Study of Infants with Single-Suture Craniosynostosis: Preliminary Report of Presurgery Development

Objective

To evaluate the cognitive and language development of untreated infants with a single suture craniosynostosis at time of diagnosis.

Design and Participants

The study presents time 1 assessments on the first 100 infants with a single suture craniosynostosis (sagittal, metopic, unilateral coronal, and lambdoid) referred to the Infant Learning Project, a prospective, multisite, longitudinal study evaluating neurocognitive development.

Main Outcome Measures

Infants were assessed with the mental (Mental Development Index [MDI]) and motor scales (Psychomotor Developmental Index [PDI]) of the Bayley Scales of Infant Development and the Preschool Language Scale receptive (PLS-AC) and expressive (PLS-EC) language scales. Mothers completed the Parenting Stress Inventory, a brief measure of intelligence (maternal IQ [MAT-IQ]), and provided information regarding family socioeconomic status (SES).

Results

As a group, infants scored significantly lower than the normative data on the MDI (91.9), PDI (83.5), PLS-AC (90.4), and PLS-EC (95.8), and the distribution of scores differed significantly from the expected distribution. MAT-IQ and SES were significantly correlated (.47, p < .01) with mothers of higher IQ coming from higher SES groups. Both MAT-IQ and SES were significantly negatively correlated with life stress events; however, neither MAT-IQ nor SES was correlated with any of the infant development scores.

Conclusions

There may be a greater developmental risk for infants with a single suture craniosynostosis than previously believed. However, control group data will be necessary to confirm findings.

Sleep Outcomes in Children With Single-Suture Craniosynostosis Compared With Unaffected Controls

OBJECTIVE

To compare risk for sleep-disordered breathing between children with and without single-suture craniosynostosis.

PARTICIPANTS

A total of 184 children with single-suture craniosynostosis and 184 controls.

MAIN OUTCOME MEASURES

Parent reported sleep-disordered breathing-related symptoms.

RESULTS

Current sleep problems were reported in 19% of patients with single-suture craniosynostosis and 14% of controls (adjusted odds ratio = 1.6; 95% CI, 0.9 to 2.8). Ever having sleep problems was reported in 25% and 23% of cases and controls, respectively (adjusted odds ratio = 1.2; 95% CI, 0.7 to 1.9). Overall, snoring was statistically associated with single-suture craniosynostosis (P = .01) and was more often reported as 2+ nights per week (versus never) in patients with single-suture craniosynostosis (13%) than in controls (4%) (adjusted odds ratio = 3.5; 95% CI, 1.5 to 8.2).

CONCLUSIONS

Though preliminary, increased presence of snoring during sleep in children with single-suture craniosynostosis compared with controls suggests that children with isolated single-suture craniosynostosis may be at increased risk for sleep-disordered breathing. Further study using standardized assessments of sleep-disordered breathing is needed.

Automatic Action Unit Detection in Infants Using Convolutional Neural Network

Action unit detection in infants relative to adults presents unique challenges. Jaw contour is less distinct, facial texture is reduced, and rapid and unusual facial movements are common. To detect facial action units in spontaneous behavior of infants, we propose a multi-label Convolutional Neural Network (CNN). Eighty-six infants were recorded during tasks intended to elicit enjoyment and frustration. Using an extension of FACS for infants (Baby FACS), over 230,000 frames were manually coded for ground truth. To control for chance agreement, inter-observer agreement between Baby-FACS coders was quantified using free-margin kappa. Kappa coefficients ranged from 0.79 to 0.93, which represents high agreement. The multi-label CNN achieved comparable agreement with manual coding. Kappa ranged from 0.69 to 0.93. Importantly, the CNN-based AU detection revealed the same change in findings with respect to infant expressiveness between tasks. While further research is needed, these findings suggest that automatic AU detection in infants is a viable alternative to manual coding of infant facial expression.

Structural brain differences in school-age children with and without single-suture craniosynostosis

OBJECTIVE Single-suture craniosynostosis (SSC), the premature fusion of a cranial suture, is characterized by dysmorphology of the craniofacial skeleton. Evidence to suggest that children with SSC are at an elevated risk of mild to moderate developmental delays and neurocognitive deficits is mounting, but the associations among premature suture fusion, neuroanatomy, and neurocognition are unexplained. The goals of this study were to determine 1) whether differences in the brain are present in young children with the 2 most common forms of SSC (sagittal and metopic) several years following surgical correction, and 2) whether the pattern of differences varies by affected suture (sagittal or metopic). Examination of differences in the brains of children with SSC several years after surgery may illuminate the growth trajectory of the brain after the potential constraint of the dysmorphic cranium has been relieved. METHODS The authors compared quantitative measures of the brain acquired from MR images obtained from children with sagittal or metopic craniosynostosis (n = 36) at 7 years of age to those obtained from a group of unaffected controls (n = 27) at the same age. The authors measured the volumes of the whole brain, cerebral cortex, cerebral white matter, cerebral cortex by lobe, and ventricles. Additionally, they measured the midsagittal area of the corpus callosum and its segments and of the cerebellar vermis and its component lobules. Measurements obtained from children with SSC and controls were compared using linear regression models. RESULTS No volume measures of the cerebrum or of the whole brain differed significantly between patients with SSC and controls (p > 0.05). However, ventricle volume was significantly increased in patients with SSC (p = 0.001), particularly in those with sagittal craniosynostosis (p < 0.001). In contrast, the area of the corpus callosum was significantly reduced in patients with metopic synostosis (p = 0.04), particularly in the posterior segments (p = 0.004). Similarly, the area of lobules VI-VII of the cerebellar vermis was reduced in patients with SSC (p = 0.03), with those with metopic craniosynostosis showing the greatest reduction (p = 0.01). CONCLUSIONS The lack of differences in overall brain size or regional differences in the size of the lobes of the cerebrum in children with metopic and sagittal synostosis suggests that the elevated risk of neurodevelopmental deficits is not likely to be associated with differences in the cerebral cortex. Instead, this study showed localized differences between sagittal and metopic craniosynostosis cases as compared with controls in the ventricles and in the midsagittal structures of the corpus callosum and the cerebellum. It remains to be tested whether these structural differences are associated with the increased risk for developmental delay and neurocognitive deficits in children with SSC.

Attention and executive function in children with and without single-suture craniosynostosis

Children with single-suture craniosynostosis (SSC) have higher rates of learning disabilities and related neurocognitive problems than unaffected peers. Executive function (EF) and attention are thought to be areas of particular vulnerability, though studies to date have been limited by small sample sizes and a lack of control groups. We evaluated 179 school-aged children with SSC (cases) and 183 unaffected controls at an average age of 7 years using clinician-administered and parent and teacher report measures of EF and attention. Among children with SSC, we examined differences as a function of suture location (sagittal, metopic, unicoronal, or lambdoid) and age of corrective surgery. We used linear regression analyses, adjusted for potential confounders, to compare the two groups on all outcome measures. Cases scored lower than controls on most measures, though the magnitude of these differences was small and most were statistically insignificant. The largest relative deficit was on a measure of inhibitory control. Results changed little in sensitivity analyses adjusting for potential attrition bias and for the effects of developmental and academic interventions. Among cases, there were few differences in relation to the location of suture fusion or timing of surgery. Overall, we found limited evidence of broad deficits in EF or attention in children with SSC relative to unaffected controls. Neurocognitive development for children with SSC appears to be variable, across affected children and outcomes assessed. Further research is needed to understand the potential sources of this variability.

Upper respiratory infection during pregnancy and neurodevelopmental outcomes among offspring

Objective

Maternal infection during pregnancy is associated with psychiatric disorders among offspring. The aim of this study was to investigate associations between upper respiratory infection (URI) in pregnancy and measures of cognitive and behavioral outcomes in child offspring.

Materials and methods

A longitudinal study of 534 mother-child pairs with information regarding prenatal exposures collected through an interview conducted on average one year after delivery and subsequent participation in a childhood cognitive and psychosocial assessment between the ages 5–12 years. Childhood cognition was measured using the Peabody Picture Vocabulary Test (PPVT-III) and the Beery-Buktenica Test of Visual Motor Integration-Fifth Edition (VMI-5) and behavioral function measured using the Child Behavior Checklist (CBCL) and teacher-report using the Teacher Report Form (TRF). Adjusted mean differences (adjMD) in outcome measures were calculated between mothers reporting the presence or absence of a URI during pregnancy.

Results

URI during pregnancy was not associated with the two measures of cognition given to offspring, but was associated with modest increases in total behavioral problems reported by mothers (adjMD: 3.72; CI: 1.91–5.54) and teachers (adjMD: 2.74; CI: 0.97–4.50). We observed differences in CBCL and TRF scores based on timing of URI: infections in mid-pregnancy (lunar months 4–5) were associated with poorer scores than were infections in early pregnancy (lunar months 2–3).

Conclusions

In general, URI in pregnancy was not associated with decrements in childhood cognition, but may be associated with behavior problems.

•

URI in early pregnancy was not associated with childhood cognitive outcomes.

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URI in pregnancy was associated with increases in behavior problems among offspring.

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Associations with behavior were varied by the timing and duration of reported URI.

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Both treated and untreated URI were associated with increases in behavior problems.

Observed child and parent toothbrushing behaviors and child oral health

BACKGROUND

Parent-led toothbrushing effectively reduces early childhood caries. Research on the strategies that parents use to promote this behavior is, however, lacking.

AIM

To examine associations between parent-child toothbrushing interactions and child oral health using a newly developed measure, the Toothbrushing Observation System (TBOS).

DESIGN

One hundred children ages 18-60 months and their parents were video-recorded during toothbrushing interactions. Using these recordings, six raters coded parent and child behaviors and the duration of toothbrushing. We examined the reliability of the coding system and associations between observed parent and child behaviors and three indices of oral health: caries, gingival health, and history of dental procedures requiring general anesthesia.

RESULTS

Reliabilities were moderate to strong for TBOS child and parent scores. Parent TBOS scores and longer duration of parent-led toothbrushing were associated with fewer decayed, missing or filled tooth surfaces and lower incidence of gingivitis and procedures requiring general anesthesia. Associations between child TBOS scores and dental outcomes were modest, suggesting the relative importance of parent versus child behaviors at this early age.

CONCLUSIONS

Parents' child behavior management skills and the duration of parent-led toothbrushing were associated with better child oral health. These findings suggest that parenting skills are an important target for future behavioral oral health interventions.

Language, learning, and memory in children with and without single-suture craniosynostosis

OBJECTIVE The language and memory functions of children with and without single-suture craniosynostosis (SSC) were compared at school age (mean 7.45 years, standard deviation [SD] 0.54 years). The children in this cohort were originally recruited in infancy and prior to cranial surgery for those with SSC. METHODS Individual evaluations of 179 school-aged children with SSC and 183 controls were conducted (70% of the original cohort) using standardized measures of language, learning, and memory. Parents participated in an interview about specialized education interventions and school progress. Parents and teachers completed questionnaires about language development. RESULTS Children with SSC (cases) obtained lower scores than controls on all measures. The adjusted differences in language, learning, and memory scores were modest, with SD ranging from 0.0 to -0.4 (p values ranged from 0.001 to 0.99). Censored normal regression was used to account for intervention services received prior to the school-age evaluation; this increased case-control differences (SD range 0.1 to -0.5, p value range 0.001 to 0.50). Mean scores for cases in each SSC diagnostic group were lower than those for controls, with the greatest differences observed among children with unilateral coronal craniosynostosis. CONCLUSIONS Children with SSC continue to show poorer performance than controls on language, learning, and memory tasks at early elementary school age, even when controlling for known confounders, although mean differences are small. Multidisciplinary care, including direct psychological assessment, for children with SSC should extend through school age with a specific focus on language and conceptual learning, as these are areas of potential risk. Future research is needed to investigate language, memory, and learning for this population during the middle to high school years.

Sex differences in the neurodevelopment of school-age children with and without single-suture craniosynostosis

PURPOSE

Previous studies have indicated that infants and school-age children with single-suture craniosynostosis (SSC, cases) score modestly but consistently lower than unaffected children (controls) on neurodevelopmental tests. However, sex differences in these functions rarely have been examined, and it is unknown whether potential sex differences vary by case status (cases vs. controls) or location of suture fusion.

METHODS

We tested 182 cases and 183 demographically matched controls at a mean age of 7.4 years. We measured intellectual abilities with the Wechsler Scale of Intelligence for Children-Fourth Edition. We assessed reading, spelling, and math with a combination of the Wide Range Assessment Test-Fourth Edition, the Test of Word Reading Efficiency, and the Comprehensive Test of Phonological Processing.

RESULTS

Among both cases and controls, males scored lower on all measures than females with standard score differences ranging from -1.2 to -7.8 for controls (p values from <0.001 to 0.55) and -2.3 to -8.5 for cases (p values from <0.001 to 0.33). For all but one measure, sex differences were slightly larger for cases than controls. Among cases, males were more likely than females to have learning problems (50 vs. 30%, respectively), with the highest level observed among males with unicoronal synostosis (86%).

CONCLUSIONS

Sex differences in neurodevelopmental abilities among children with SSC are substantial, but not a unique correlate of this disorder as similar differences were observed among controls. Girls and those with sagittal synostosis have the lowest risk for academic problems. Boys with unicoronal synostosis warrant close developmental surveillance.

Intellectual and academic functioning of school-age children with single-suture craniosynostosis

OBJECTIVE

We compared the developmental status of school-age children with single-suture craniosynostosis (case group) and unaffected children (control group). Within the case group we compared the performance of children distinguished by location of suture fusion (sagittal, metopic, unicoronal, lambdoid).

METHODS

We administered standardized tests of intelligence, reading, spelling, and math to 182 case participants and 183 control participants. This sample represented 70% of those tested during infancy before case participants had corrective surgery.

RESULTS

After adjustment for demographics, case participants' average scores were lower than those of control participants on all measures. The largest observed differences were in Full-Scale IQ and math computation, where case participants' adjusted mean scores were 2.5 to 4 points lower than those of control participants (Ps ranged from .002 to .09). Adjusted mean case-control differences on other measures of achievement were modest, although case deficits became more pronounced after adjustment for participation in developmental interventions. Among case participants, 58% had no discernible learning problem (score <25th percentile on a standardized achievement test). Children with metopic, unicoronal, and lambdoid synostosis tended to score lower on most measures than did children with sagittal fusions (Ps ranged from <.001 to .82).

CONCLUSIONS

The developmental delays observed among infants with single-suture craniosynostosis are partially evident at school age, as manifested by lower average scores than those of control participants on measures of IQ and math. However, case participants' average scores were only slightly lower than those of control participants on reading and spelling measures, and the frequency of specific learning problems was comparable. Among case participants, those with unicoronal and lambdoid fusions appear to be the most neurodevelopmentally vulnerable.

Longitudinal Analysis of Parenting Stress in Mothers and Fathers of Infants with and without Single-Suture Craniosynostosis

Objective

To examine longitudinal differences in reported stress between parents of children with and without single-suture craniosynostosis and to compare the stress reports of mothers and fathers.

Design

Multi-site, nonrandomized prospective study.

Setting/Participants

Children with single-suture craniosynostosis (cases) were identified via referral of the treating surgeon or physician at the time of diagnosis, and those without single-suture craniosynostosis (controls) were recruited from pediatric practices, birthing centers, and announcements in print media. When children were aged 6, 18, and 36 months (on average), mothers and fathers of children with and without single-suture craniosynostosis completed the Parenting Stress Index. For cases, 247 mothers and 211 fathers completed the Parenting Stress Index at the first visit; corresponding numbers for controls were 254 and 220, respectively.

Main Outcome Measures

The Parenting Stress Index Parent and Child Domains and subscales scores.

Results

We found few differences between parents of infants with and without single-suture craniosynostosis, regardless of parent gender. Irrespective of case status, mothers consistently reported higher stress than fathers on the Parent Domain. Within the Parent Domain, mothers reported more stress than fathers on the Role Restriction and Spousal Support subscales.

Conclusions

The parents of children with single-suture craniosynostosis reported levels of stress similar to those reported by parents of same-aged, unaffected children. Mothers reported greater stress than fathers, and these differences remained remarkably stable over time. This may reflect widely held perceptions of gender differences in parenting roles.

Nausea and vomiting during pregnancy and neurodevelopmental outcomes in offspring

BACKGROUND

Nausea and vomiting during pregnancy (NVP) is the most common complication of pregnancy. NVP has been associated with improved fetal outcomes, but its association with childhood neurodevelopmental outcomes has rarely been studied.

METHODS

Subjects were children aged 5-12 years (n = 560) who were controls in a previously conducted case-control study of prenatal risk factors for craniofacial malformations. Information on NVP, including trimester, duration, and treatment, was collected through a maternal interview conducted within 3 years of delivery. Neurocognition was assessed using the Peabody Picture Vocabulary Test (PPVT-III) and the Beery-Buktenica Test of Visual Motor Integration-Fifth Edition (VMI-5). Psychosocial outcomes, including internalising and externalising behaviour problems, were measured by maternal report, using the Child Behavior Checklist (CBCL), and teacher report, using the Teacher Report Form. Linear regression models were used to calculate adjusted mean (adjMD -3.04, 95% confidence interval (CI) -5.02, -1.06) differences (adjMD) and 95% confidence intervals [CI] on test scores for children exposed and unexposed to NVP in utero. Differences based on trimester, duration, and treatment were assessed.

RESULTS

NVP was reported among 63% of women and was most common in early pregnancy. Children exposed to NVP performed worse on the VMI-5 [-3.04, 95% CI: -5.02, -1.06] but exhibited few other differences from unexposed children. Durations of NVP ≥4 months were associated with poorer scores on PPVT-III (adjMD -2.52), VMI-5 (adjMD -5.41), and CBCL [adjMD 3.38 (internalising) and adjMD 4.19 (externalising)].

CONCLUSIONS

Overall, there were few differences between children exposed and unexposed to NVP. NVP was associated with slightly worse visual motor performance, and prolonged NVP and NVP extending late into pregnancy were associated with poorer scores on several neurodevelopmental measures.

Academic achievement in children with oral clefts versus unaffected siblings

OBJECTIVE

To compare academic achievement in children with oral-facial clefts (OFC) with their unaffected siblings.

METHODS

256 children with OFC were identified from the Iowa Registry for Congenital and Inherited Disorders, and 387 unaffected siblings were identified from birth certificates. These data were linked to Iowa Testing Programs achievement data. We compared academic achievement in children with OFC with their unaffected siblings using linear regression models, adjusted for potential confounders. In post hoc analyses, we explored modifiers of siblings' academic performance.

RESULTS

Achievement scores were similar between children with OFC and their siblings. Children with cleft palate only were significantly more likely to use special education than their unaffected siblings. Siblings' academic achievement was inversely related to distance in birth order and age from the affected child.

CONCLUSION

Children with OFC and their siblings received similar achievement scores. Younger siblings, in particular, may share a vulnerability to poor academic outcomes.

Three-dimensional head shape quantification for infants with and without deformational plagiocephaly

OBJECTIVE

The authors developed and tested three-dimensional (3D) indices for quantifying the severity of deformational plagiocephaly (DP).

DESIGN

The authors evaluated the extent to which infants with and without DP (as determined by clinic referral and two experts' ratings) could be correctly classified.

PARTICIPANTS

Infants aged 4 to 11 months, including 154 with diagnosed DP and 100 infants without a history of DP or other craniofacial condition. After excluding participants with discrepant expert ratings, data from 90 infants with DP and 50 infants without DP were retained.

MEASUREMENTS

Two-dimensional (2D) histograms of surface normal vector angles were extracted from 3D mesh data and used to compute the severity scores.

OUTCOME MEASURES

Left posterior flattening score (LPFS), right posterior flattening score (RPFS), asymmetry score (AS), absolute asymmetry score (AAS), and an approximation of a previously described 2D measure, the oblique cranial length ratio (aOCLR). Two-dimensional histograms localized the posterior flatness for each participant.

ANALYSIS

The authors fit receiver operating characteristic curves and calculated the area under the curves (AUC) to evaluate the relative accuracy of DP classification using the above measures.

RESULTS

The AUC statistics were AAS = 91%, LPFS = 97%, RPFS = 91%, AS = 99%, and aOCLR = 79%.

CONCLUSION

Novel 3D-based plagiocephaly posterior severity scores provided better sensitivity and specificity in the discrimination of plagiocephalic and typical head shapes than the 2D measurements provided by a close approximation of OCLR. These indices will allow for more precise quantification of the DP phenotype in future studies on the prevalence of this condition, which may lead to improved clinical care.

Psychosocial outcomes in children with and without non-syndromic craniosynostosis: findings from two studies

Objective : To evaluate the hypothesis that children with craniosynostosis and their parents have differences in psychosocial outcomes, as compared with an unaffected control group. Design : Two studies were conducted, both which followed children born with and without craniosynostosis. Study 1 ascertained affected children from clinics, and study 2 ascertained affected children from a population-based study of birth defects. Participants : Study 1 included 22 children with single-suture craniosynostosis and 18 controls, ages 4 to 5 years. Study 2 included 24 children with nonsyndromic craniosynostosis and 124 unaffected controls, ages 5 to 9 years. Main Outcome Measures : Outcome measures included the Child Behavior Checklist, Social Competence Scale, Pediatric Quality of Life Inventory, and Parenting Stress Index. Results : We observed lower scores on measures of health-related quality of life in cases versus controls, with adjusted effect sizes ranging from -0.72 to -0.44 (p < .05) on summary measures. Small but statistically nonsignificant increases in behavioral problems were observed in cases versus controls, with no apparent differences in social competence or parenting stress. Conclusions : Results provide preliminary evidence suggesting that children with nonsyndromic craniosynostosis may have elevated risk for psychosocial difficulties, particularly health-related quality of life. Continued follow-up through preadolescence and adolescence is warranted.

Development at age 36 months in children with deformational plagiocephaly

OBJECTIVES

Infants and toddlers with deformational plagiocephaly (DP) have been shown to score lower on developmental measures than unaffected children. To determine whether these differences persist, we examined development in 36-month-old children with and without a history of DP.

METHODS

Participants included 224 children with DP and 231 children without diagnosed DP, all of who had been followed in a longitudinal study since infancy. To confirm the presence or absence of DP, pediatricians blinded to children's case status rated 3-dimensional cranial images taken when children were 7 months old on average. The Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III) was administered as a measure of child development.

RESULTS

Children with DP scored lower on all scales of the BSID-III than children without DP. Differences were largest in cognition, language, and parent-reported adaptive behavior (adjusted differences = -2.9 to -4.4 standard score points) and smallest in motor development (adjusted difference = -2.7). Children in the control group who did not have previously diagnosed DP but who were later rated by pediatricians to have at least mild cranial deformation also scored lower on the BSID-III than unaffected controls.

CONCLUSIONS

Preschool-aged children with a history of DP continue to receive lower developmental scores than unaffected controls. These findings do not imply that DP causes developmental problems, but DP may nonetheless serve as a marker of developmental risk. We encourage clinicians to screen children with DP for developmental concerns to facilitate early identification and intervention.

Duration of exposure to cranial vault surgery: associations with neurodevelopment among children with single-suture craniosynostosis

OBJECTIVE

To evaluate associations between neurodevelopment and exposure to surgery and anesthetic agents in children with single-suture craniosynostosis (SSC).

BACKGROUND

Young children with SSC have unexplained neurodevelopmental delays. The possible contributions of factors related to cranial vault surgery - including anesthesia - have not been previously examined.

METHODS/MATERIALS

Two anesthesiologists reviewed the surgical records of 89 infants (70 had complete data). Primary exposures were duration of surgery and anesthesia and total duration of inhaled anesthesia (at age 6 months on average). Outcomes were the cognitive and motor scores from the Bayley Scales of Infant Development-II and language scores from the Preschool Language Scale, 3rd edition, given at age 36 months. Linear regression using robust standard error estimates was performed, adjusting for age at surgery and suture site.

RESULTS

Anesthesia duration ranged from 155 to 547 min. For every 30-min increase in anesthesia duration, the estimated average decrease in developmental test scores ranged from 1.1 to 2.9 (P ranged from <0.001 to 0.30). Similar, but weaker findings were observed with surgery duration and total duration of inhaled anesthesia. Inverse relations between exposure amounts and neurodevelopment were stronger in children with nonsagittal synostosis.

CONCLUSIONS

Average neurodevelopmental scores were lower among children experiencing longer surgeries and higher exposures to inhaled anesthesia. These associations may be due to anesthesia exposure, nonspecific effects of surgery, or unmeasured variables that correlate with surgery duration. Further study of potential causal mechanisms is warranted.

Multicenter study of neurodevelopment in 3-year-old children with and without single-suture craniosynostosis

OBJECTIVE

To evaluate the hypothesis that 3-year-old children with single-suture craniosynostosis would receive lower neurodevelopmental scores than a comparable group of children born with patent sutures.

DESIGN

Longitudinal comparison study.

SETTING

Five tertiary care craniofacial centers.

PARTICIPANTS

Patients with craniosynostosis (cases) and a comparison group of children without craniosynostosis(controls). Patients diagnosed with single-suture craniosynostosis from 2002 to 2006 were eligible as cases.Controls were frequency-matched to cases on age, sex, race, socioeconomic status, and study site.

MAIN EXPOSURE

Craniosynostosis.

MAIN OUTCOME MEASURES

We administered the Bayley Scales of Infant Development, Second Edition, mental and motor development indices and the Preschool Language Scales, Third Edition, receptive and expressive communication scales. Children were evaluated at baseline (before surgery in cases and at a similar age in controls)and at 18 and 36 months of age. We compared the groups' performances at 36 months by fitting adjusted linear and logistic regression models. We also estimated adjusted associations between age at surgery and neurodevelopmental scores.

RESULTS

Adjusted mean case deficits ranged from 3 to 6 points (P≤ .008 for all comparisons). Compared with controls, the odds of cases being delayed ranged from 1.5 to 2.0, depending on the neurodevelopmental scale (P values ranged from .03 to .09). Cases' ages at craniosynostosis repair were not strongly related to neurodevelopmental performance.

CONCLUSIONS

In this large, carefully controlled, multicenter study, we observed consistently lower mean neurodevelopmental scores in children with single-suture craniosynostosis compared with controls. These results provide further support for neurodevelopmental screening in young children with single-suture craniosynostosis.

Psychosocial Functioning in Children with and without Orofacial Clefts and Their Parents

Objective

To determine whether psychosocial functioning in children with orofacial clefts and their parents differs from that in unaffected controls.

Design

The study used a nonrandomized, case-control design.

Participants

Outcomes were evaluated in 93 cases with orofacial clefts and 124 controls, aged 5 to 9 years, who were part of the Massachusetts Center for Birth Defects Research and Prevention registry.

Main Outcome Measures

Measures included the Child Behavior Checklist, the PedsQL 4.0, the Social Competence Scale, and the Parenting Stress Inventory.

Results

Group differences were negligible for all measures, and findings changed little with the application of inverse probability weighting to adjust for response bias. Stratified analyses revealed differences according to both sex and age, with worse outcomes observed in male cases and cases aged 7 to 9 years.

Conclusions

In contrast to previous studies, we found minimal differences in psychosocial functioning among children with orofacial clefts and their parents compared with unaffected controls. This may reflect ascertainment factors, and psychosocial differences may be less apparent in population-based versus clinic-based samples. Alternatively, social-emotional deficits may become apparent in older school-aged children, making the preschool and early elementary school years an optimal time for preventive interventions.

Longitudinal, three-dimensional analysis of head shape in children with and without deformational plagiocephaly or brachycephaly

OBJECTIVES

To assess 3-dimensional (3D) changes in head shape in infancy and at age 18 months in children with and without plagiocephaly or brachycephaly.

STUDY DESIGN

Using a longitudinal design, we evaluated head shape using 3D surface imaging. We compared the head shapes of children with (1) diagnosed deformational plagiocephaly or brachycephaly (cases; n=233); (2) unaffected controls, with no evidence of dysmorphology (n=167); and (3) affected controls, who despite having no previous diagnosis demonstrated skull dysmorphology on 3D surface imaging (n=70).

RESULTS

Cases had greater skull flattening and asymmetry than unaffected controls at both time points, as did controls with skull dysmorphology. In all groups, head shapes became less flat and more symmetric over time. Among cases, symmetry improved slightly more for those who received orthotic treatment.

CONCLUSIONS

Although head shape improves over time for children with deformational plagiocephaly or brachycephaly, skull dysmorphology persists relative to unaffected controls. Further research is needed to clarify the extent to which these differences are detectable to clinicians and lay observers.

Development in toddlers with and without deformational plagiocephaly

OBJECTIVE

To determine whether the heightened risk of developmental delays seen in infancy in patients with deformational plagiocephaly (DP) continues into the toddler years.

DESIGN

Longitudinal study comparing the development of children with and without DP, with assessments in infancy (mean age, 7 months) and at age 18 months.

SETTING

Infants with DP were recruited from a large craniofacial center, and unaffected infants were recruited from a research registry.

PARTICIPANTS

The study included 227 children with DP and 232 children without previously diagnosed DP.

MAIN EXPOSURE

Diagnosis of DP by a craniofacial specialist.

MAIN OUTCOME MEASURES

Bayley Scales of Infant and Toddler Development, Third Edition, scores.

RESULTS

Toddlers with DP scored lower than did unaffected children on all the scales of the Bayley Scales of Infant and Toddler Development, Third Edition. Motor score differences were smaller and cognitive and language score differences were greater than those observed in infancy.

CONCLUSIONS

Toddlers with DP continue to exhibit evidence of developmental delays relative to toddlers without DP. These findings do not necessarily imply a causal relationship between DP and development because children with delays may be more likely to develop DP. Nonetheless, it seems that increased developmental surveillance is warranted in this population.

IGF1R variants associated with isolated single suture craniosynostosis

The genetic contribution to the pathogenesis of isolated single suture craniosynostosis is poorly understood. The role of mutations in genes known to be associated with syndromic synostosis appears to be limited. We present our findings of a candidate gene resequencing approach to identify rare variants associated with the most common forms of isolated craniosynostosis. Resequencing of the coding regions, splice junction sites, and 5' and 3' untranslated regions of 27 candidate genes in 186 cases of isolated non-syndromic single suture synostosis revealed three novel and two rare sequence variants (R406H, R595H, N857S, P190S, M446V) in insulin-like growth factor I receptor (IGF1R) that are enriched relative to control samples. Mapping the resultant amino acid changes to the modeled homodimer protein structure suggests a structural basis for segregation between these and other disease-associated mutations found in IGF1R. These data suggest that IGF1R mutations may contribute to the risk and in some cases cause single suture craniosynostosis.

Neurodevelopmental outcomes in children with hemifacial microsomia

OBJECTIVE

To determine whether preadolescent children with hemifacial microsomia (HFM) have higher risk of neurodevelopmental delays than unaffected control individuals.

DESIGN

Case-control follow-up study of neurodevelopment in children with and without HFM.

SETTING

Case individuals were originally recruited from 26 craniofacial centers across the United States and Canada, and controls were recruited through community pediatricians.

PARTICIPANTS

One hundred thirty-six children with HFM (cases) and 568 unaffected children (controls). Main Exposure  History of HFM.

MAIN OUTCOME MEASURES

The Peabody Picture Vocabulary Test-Third Edition, the Beery-Buktenica Developmental Test of Visual Motor Integration-Fifth Edition, and the Academic Competence scales from the Child Behavior Checklist and the Teacher Report Form.

RESULTS

Children with HFM scored lower than controls on all measures (effect size = -0.27 to -0.45; P < .001 to P = .008). Compared with controls, cases were 2 to 3 times as likely to score in the at-risk range. Relative to controls, outcomes were worse for male cases and those whose mothers were 25 years or younger at the time of their birth. Cases with HFM plus other malformations had poorer outcomes, as did cases with hearing, vision, or speech impairments.

CONCLUSIONS

This is the first study, to our knowledge, to show that children with HFM have poorer neurodevelopmental outcomes than unaffected children, but further study using more detailed assessments is indicated. Clinically, the findings suggest that early neurodevelopmental screening is warranted for all children with HFM.

Psychosocial outcomes in children with hemifacial microsomia

OBJECTIVE

To determine whether children with hemifacial microsomia (HFM) have higher risk for psychosocial problems than children without HFM.

METHODS

One hundred and thirty-six children with HFM (64% male, mean age = 6.9 years) were compared to 568 matched controls (50% male, mean age = 7.0 years) on parent and teacher measures of behavior problems and social competence, and teacher rankings of peer acceptance.

RESULTS

Parents of cases and controls reported similar levels of behavior problems and social competence. Teachers reported higher frequencies of internalizing problems, lower social competence and less peer acceptance for cases. Relative to controls, teacher-rated outcomes were worse for female cases, those with younger mothers at the time of birth, those with eye anomalies, and those with one or more malformations in addition to the core features of HFM.

CONCLUSIONS

This study provides the first evidence of relatively poor psychosocial outcomes among children with HFM.

Little evidence of association between severity of trigonocephaly and cognitive development in infants with single-suture metopic synostosis

OBJECTIVES

To measure severity of trigonocephaly among infants with single-suture metopic craniosynostosis by using a novel shape descriptor, the trigonocephaly severity index (TSI), and to evaluate whether degree of trigonocephaly correlates with their neurodevelopmental test scores.

METHODS

We conducted a multicenter cross-sectional and longitudinal study, identifying and recruiting 65 infants with metopic synostosis before their corrective surgery. We obtained computed tomography images for 49 infants and measured the presurgical TSI, a 3-dimensional outline-based cranial shape descriptor. We evaluated neurodevelopment by administering the Bayley Scales of Infant Development, Second Edition, and the Preschool Language Scale, Third Edition, before surgery and at 18 and 36 months of age. We fit linear regression models to estimate associations between test scores and TSI values adjusted for age at testing and race/ethnicity. We fit logistic regression models to estimate whether the odds of developmental delay were increased among children with more severe trigonocephaly.

RESULTS

We observed little adjusted association between neurodevelopmental test scores and TSI values, and no associations that persisted at 3 years. Trigonocephaly was less severe among children referred at older ages.

CONCLUSION

We observed little evidence of an association between the severity of trigonocephaly among metopic synostosis patients and their neurodevelopmental test scores. Detecting such a relationship with precision may require larger sample sizes or alternative phenotypic quantifiers. Until studies are conducted to explore these possibilities, it appears that although associated with the presence of metopic synostosis, the risk of developmental delays in young children is unrelated to further variation in trigonocephalic shape.

Language and early reading among children with orofacial clefts

OBJECTIVE

To test the hypothesis that children with orofacial clefts score lower than controls on measures of language and reading and to examine predictors of these outcomes.

DESIGN

Longitudinal study tracking the development of children with and without orofacial clefts from infancy through age 7 years.

SUBJECTS

Children with isolated cleft lip and palate (n = 29) and cleft palate only (n = 28) were recruited from the craniofacial program in an urban medical center. Seventy-seven demographically similar, unaffected controls were recruited via advertisements placed in area pediatric clinics and community centers.

MEASURES

Infant measures assessed child development and mother-child interactions during feeding and teaching tasks. At ages 5 and 7 years, measures of language functioning and academic achievement were completed along with an interview to collect school placement data and information on speech services received.

RESULTS

There were no significant group differences in language at ages 5 and 7 years. Children with clefts scored significantly higher than controls on measures of early reading at age 7 years. Outcomes were predicted by demographic factors, the quality of mother-child interactions during teaching and feeding tasks, and cognitive development scores at age 24 months.

CONCLUSIONS

Findings do not support the hypothesis that children with clefts score lower than controls on neurocognitive and academic achievement measures. Predictive analyses revealed several dimensions that may be used in clinical practice to identify children at risk for learning and developmental concerns.

Copy number variation analysis in single-suture craniosynostosis: multiple rare variants including RUNX2 duplication in two cousins with metopic craniosynostosis

Little is known about genes that underlie isolated single-suture craniosynostosis. In this study, we hypothesize that rare copy number variants (CNV) in patients with isolated single-suture craniosynostosis contain genes important for cranial development. Using whole genome array comparative genomic hybridization (CGH), we evaluated DNA from 186 individuals with single-suture craniosynostosis for submicroscopic deletions and duplications. We identified a 1.1 Mb duplication encompassing RUNX2 in two affected cousins with metopic synostosis and hypodontia. Given that RUNX2 is required as a master switch for osteoblast differentiation and interacts with TWIST1, mutations in which also cause craniosynostosis, we conclude that the duplication in this family is pathogenic, albeit with reduced penetrance. In addition, we find that a total of 7.5% of individuals with single-suture synostosis in our series have at least one rare deletion or duplication that contains genes and that has not been previously reported in unaffected individuals. The genes within and disrupted by CNVs in this cohort are potential novel candidate genes for craniosynostosis. © 2010 Wiley-Liss, Inc.

Mothers' and fathers' reports of stress in families of infants with and without single-suture craniosynostosis

OBJECTIVE

To compare relative levels of stress reported by mothers and fathers in families containing infants with and without single-suture craniosynostosis.

DESIGN

Case-control study.

PARTICIPANTS

Mothers and fathers of 246 infants with recently diagnosed single-suture craniosynostosis and 253 frequency-matched control infants completed the Parenting Stress Index just prior to their infant's cranioplastic surgery. Family demographic information and mothers' ratings of the severity of their child's single-suture craniosynostosis were obtained.

RESULTS

Average Parent Domain scores for parents of infants with single-suture craniosynostosis differed little from those reported by parents of control infants; however, Child Domain scores among parents of infants with single-suture craniosynostosis were higher on some subscales, primarily related to unexpected infant health and appearance issues. In both groups, fathers reported higher Child Domain stress than mothers, and mothers reported higher Parent Domain stress than fathers. Case mothers reported greater stress if they perceived their child's condition as more noticeable to others.

CONCLUSIONS

Prior to cases' cranioplastic surgery, parents of children with and without single-suture craniosynostosis reported similar levels of stress in relation to their parenting roles and the behavioral characteristics of their infants. Visibility of condition should be considered a risk for increased stress for mothers of infants with single-suture craniosynostosis. Stress differences between mothers and fathers were far more discernible than those associated with the presence or absence of single-suture craniosynostosis.

Case-control study of neurodevelopment in deformational plagiocephaly

OBJECTIVE

We assessed the neurodevelopment of infants with and without deformational plagiocephaly (DP), at an average age of 6 months.

METHODS

The Bayley Scales of Infant Development III (BSID-III) were administered to 235 case subjects and 237 demographically similar, control participants. Three-dimensional head photographs were randomized and rated for severity of deformation by 2 craniofacial dysmorphologists who were blinded to case status.

RESULTS

We excluded 2 case subjects with no photographic evidence of DP and 70 control subjects who were judged to have some degree of DP. With control for age, gender, and socioeconomic status, case subjects performed worse than control subjects on all BSID-III scales and subscales. Case subjects' average scores on the motor composite scale were approximately 10 points lower than control subjects' average scores (P < .001). Differences for the cognitive and language composite scales were approximately 5 points, on average (P < .001 for both scales). In subscale analyses, case subjects' gross-motor deficits were greater than their fine-motor deficits. Among case subjects, there was no association between BSID-III performance and the presence of torticollis or infant age at diagnosis.

CONCLUSIONS

DP seems to be associated with early neurodevelopmental disadvantage, which is most evident in motor functions. After follow-up evaluations of this cohort at 18 and 36 months, we will assess the stability of this finding. These data do not necessarily imply that DP causes neurodevelopmental delay; they indicate only that DP is a marker of elevated risk for delays. Pediatricians should monitor closely the development of infants with this condition.

Reading in children with orofacial clefts versus controls

OBJECTIVE

To examine reading and related skills in children with and without orofacial clefts.

METHODS

Forty-two children with orofacial clefts were recruited from an urban craniofacial center. A demographically similar sample of 43 children without clefts was recruited using community advertisements and a research registry. Participants completed assessments of basic reading, phonological awareness, phonological memory, reading fluency, and rapid naming. Parents completed a semi-structured interview regarding educational and medical history.

RESULTS

Children with clefts scored significantly lower than controls on measures of basic reading, phonological memory, and reading fluency.

CONCLUSIONS

This is one of the first studies of reading in children with orofacial clefts to include a control sample. The findings suggest that children with clefts are less adept readers than demographically matched peers without clefts, supporting the need to monitor academic achievement in this population.