Preterm outcomes research: a critical component of neonatal intensive care

While early preterm outcome studies described the lives of preterm survivors to justify the efforts required to save them, subsequent studies demonstrated their increased incidence of cerebral palsy, mental retardation, sensory impairments, minor neuromotor dysfunction, language delays, visual-perceptual disorders, learning disability and behavior problems compared to fullterm controls. Because infants born at the lower limit of viability require the most resources and have the highest incidence of neurodevelopmental disability, there is concern that resources have gone primarily to neonatal intensive care and are not available for meeting the followup, health, educational and emotional needs of these fragile infants and their families. Despite many methodological concerns, preterm outcome studies have provided insight into risk factors for and causes of CNS injury in preterm infants. Nevertheless, it remains difficult to predict neurodevelopmental outcome for individual preterm infants. Perinatal and neonatal risk factors are inadequate proxies for neurodevelopmental disability. Recent randomized controlled trials with one to five year neurodevelopmental followup have provided valuable information about perinatal and neonatal treatments. Recognizing adverse longterm neurodevelopmental effects of pharmacological doses of postnatal steroids is a sobering reminder of the need for longterm neurodevelopmental followup in all neonatal randomized controlled trials. Ongoing longterm preterm neurodevelopmental studies, analysis of changes in outcomes over time and among centers, and evaluation of the longterm safety, efficacy and effectiveness of many perinatal and neonatal management strategies and proposed neuroprotective agents are all necessary for further medical and technological advances in neonatal intensive care.     

Developmental and medical factors associated with parenting stress in mothers of toddlers born very preterm in a neonatal follow-up clinic

The purpose of this exploratory, cross-sectional study was to identify child-related factors associated with maternal parenting stress in toddlers born very preterm and followed in a neonatal follow-up (NFU) clinic. The study aimed to describe the associations of current medical complications and presence of developmental delays with total parenting stress. Participants were 53 mother–child dyads presenting in a NFU clinic. Mothers completed the Parenting Stress Index-Short Form (PSI-SF), and children were administered the Brigance Early Head Start Screen II. Medical variables were also collected from the child's medical record. Approximately 24% of mothers had at least one elevated subscale score on the PSI-SF. Regression analyses indicated that receipt of early intervention services was associated with increased parenting stress among mothers of toddlers born very preterm, though number of current medical complications was not. Parents of children born very preterm are at increased risk for parenting stress that extends beyond discharge from the neonatal intensive care unit . Clinicians working in NFU clinics are positioned to monitor for increased parenting stress, particularly among families of children with emerging signs of developmental delay.     

Late Preterm Birth: A Review of Medical and Neuropsychological Childhood Outcomes

Late preterm (LP) birth (34 0/7 - 36 6/7 weeks?? gestation) accounts for nearly three-fourths of all preterm births, making this population a sizeable public health concern. The immature fetal development associated with LP delivery increases the risk of mortality and short-term medical complications. Which combination of maternal, fetal, or neonatal risk factors may be most critical has only recently begun to be addressed, and whether LP birth??s disruptive impact on brain development will exert adverse effects on neuropsychological functioning in childhood and adolescence has been understudied. Early data have shown a graded response, with LP children often functioning better than very preterm children but worse than term children, and with subtle intellectual and neuropsychological deficits in LP children compared with healthy children born at term gestational age. Further characterization of the neuropsychological profile is required and would be best accomplished through prospective longitudinal studies. Moreover, since moderate and LP births result in disparate medical and psychological outcomes, the common methodology of combining these participants into a single research cohort to assess risk and outcome should be reconsidered. The rapidly growing LP outcomes literature reinforces a critical principle: fetal development occurs along a dynamic maturational continuum from conception to birth, with each successive gestational day likely to improve overall outcome.     

Effect of developmental care for very premature infants on neurodevelopmental outcome at 2 years of age

BackgroundTo determine the effect of developmental care on neurodevelopmental outcome in formerly preterm infants at a corrected age of 2 years.MethodsA prospective phase-lag study was performed at an Austrian neonatal intensive care unit (NICU). From January 2003 to December 2005 (study period of conventional care) and January 2007 to December 2009 (study period of developmental care), we enrolled all infants born in Tyrol at less than 32 weeks of gestation. During this period a total of 261 of 359 preterm infants (participation rate 72.7%) completed the follow-up visit at 2 years of age; there were 124 children in the conventional and 137 in the developmental care group. The association between developmental care and delayed motor or mental development (Bayley Scales of Infant Development II; psychomotor or mental developmental index <85) was analyzed by means of logistic regression analysis at a corrected age of 24 months.ResultsChildren in the developmental care group showed less psychomotor delay than did those in the control group (developmental care group: 16.1%, conventional care group 27.4%; adjusted odds ratio 0.37 [95% confidence interval: 0.19–0.74], P = 0.005). Not smoking in pregnancy and higher gestational age were also significant predictors for a better psychomotor outcome at 2 years of age. Regarding cognitive outcome, no significant difference was observed between these two groups.ConclusionOur data implicate that developmental care may result in an improved 2-year psychomotor outcome in formerly preterm infants.     

Executive Functions in Preschool Children Born Preterm: Application of Cognitive Neuroscience Paradigms

Although children born preterm are at risk for neuropsychological impairments at school age and adolescence, including difficulties with visual motor integration, spatial/constructional skills, attention, arithmetic, and nonverbal executive functions, specific neuropsychological outcome has not been investigated adequately in preschoolers. Application of cognitive neuroscience tasks offers the opportunity to characterize early executive functions in young children born preterm. In a preliminary sample of 29 preschool children born preterm (M birth gestational age = 32.4 weeks), executive function outcome was compared to that of fullterm controls by contrasting performance on two prototypic delayed-response-type paradigms, Delayed Alternation and Spatial Reversal. Preschoolers born preterm correctly retrieved the reward on fewer trials on Delayed Alternation than did matched controls. Furthermore, preschool children born preterm used problem-solving strategies that included more perseverative errors than controls. These preliminary findings highlight the utility of cognitive neuroscience paradigms to understand neuropsychological outcome in preschool children born preterm and suggest areas of developmental vulnerability that may include dorsolateral prefrontal circuits.     

Executive functions in preschool children born preterm: application of cognitive neuroscience paradigms.

Although children born preterm are at risk for neuropsychological impairments at school age and adolescence, including difficulties with visual motor integration, spatial/constructional skills, attention, arithmetic, and nonverbal executive functions, specific neuropsychological outcome has not been investigated adequately in preschoolers. Application of cognitive neuroscience tasks offers the opportunity to characterize early executive functions in young children born preterm. In a preliminary sample of 29 preschool children born preterm (M birth gestational age = 32.4 weeks), executive function outcome was compared to that of fullterm controls by contrasting performance on two prototypic delayed-response-type paradigms, Delayed Alternation and Spatial Reversal. Preschoolers born preterm correctly retrieved the reward on fewer trials on Delayed Alternation than did matched controls. Furthermore, preschool children born preterm used problem-solving strategies that included more perseverative errors than controls. These preliminary findings highlight the utility of cognitive neuroscience paradigms to understand neuropsychological outcome in preschool children born preterm and suggest areas of developmental vulnerability that may include dorsolateral prefrontal circuits.     

Are Newborns Morally Different from Older Children?

Policies and position statements regarding decision-making for extremely premature babies exist in many countries and are often directive, focusing on parental choice and expected outcomes. These recommendations often state survival and handicap as reasons for optional intervention. The fact that such outcome statistics would not justify such approaches in other populations suggests that some other powerful factors are at work. The value of neonatal intensive care has been scrutinized far more than intensive care for older patients and suggests that neonatal care is held to a higher standard of justification. The relative value placed on the life of newborns, in particular the preterm, is less than expected by any objective medical data or any prevailing moral frameworks about the value of individual lives. Why do we feel less obligated to treat the premature baby? Do we put newborns in a special and lesser moral category? We explore this question from a legal and ethical perspective and offer several hypotheses pertaining to personhood, reproductive choices, “precious children,” and probable evolutionary and anthropological factors.     

Visual and auditory orienting responses in preterm infants: a comparison of three cohorts over time.

Visual and auditory orienting responses were compared in three cohorts of preterm infants (N = 351) born between 1977 and 1987. The infants were divided into one group born between 25 and 34 weeks gestational age (n = 140) and one group born between 35 and 37 weeks gestational age (n = 211). Ratings were made of the infants' best orienting responses to a bull's-eye, rattle, bell, voice, and face plus voice combined. Analyses of covariance were computed to adjust for changes in perinatal variables between 1977 and 1987. For both groups, there were significant differences between cohorts on orienting to the bull's-eye, with a trend for the 25- to 34-week group on orienting to the rattle. Behavioral outcome for preterm infants has improved with changes in neonatal intensive care.     

Stability of developmental status and risk of impairment at 24 and 36 months in late preterm infants

BackgroundFew studies investigated whether late preterm infants might have developmental delays in several domains in early life and how stable the lag in developmental status might be.AimWe aimed to examine the stability of potential delays across developmental domains at 24 and 36 months of age in late preterm (34°-36⁶ weeks) and term (≥37 weeks) children and whether the risk of delays remained high at 36 months.Study design, subjects, and outcome measureWe conducted a prospective cohort analysis of the children of pregnant women participating in the Vitamin Antenatal Asthma Reduction Trial (VDAART). 652 children who were prospectively followed up and had parent-completed Ages Stages Questionnaires (ASQ-3) questionnaires at both 24 and 36 months were analyzed to assess their domain-specific developmental status.Results6.61 % (42/635) of children had a late preterm birth. Developmental delays were stable between 24 and 36 months on all 5 domains for the children born preterm and on 4/5 domains for those born at term. The developmental domains with the status stability at 24 and 36 months in both late preterm and term children were the gross motor, communication, personal-social skills, and problem-solving. Late preterm children compared with term children remained at higher risk of delays at 36 months for gross motor, communication, and problem-solving skills (aOR = 4.54, 95 %CI: 1.81−10.79; aOR = 8.60, 95 %CI: 3.10−23.28 and aOR = 3.80, 95 %CI: 1.58−8.73, respectively).ConclusionLate preterm birth is associated with suboptimal development and stability in several domains at both 24 and 36 months and compared with term birth, requiring early monitoring and assessment of the developmental lag to avoid potential long-term implications.     

Health and educational outcomes of children who experienced severe neonatal medical complications.

To determine the long-term developmental and educational outcomes of a sample of low birthweight infants with intraventricular hemorrhage (IVH), the authors conducted developmental assessments and interviews 8 years after the initiation of an early intervention project. At the time of the follow-up, 62% of the children were experiencing some developmental or behavior problems, with visual impairments, cerebral palsy, and attention deficits occurring most frequently. Grade of IVH and the number of days spent in the neonatal intensive care unit were the best predictors of later developmental delays. The sample also scored below average on school achievement; approximately 30% of those in school were eligible for special education services. These findings corroborate results from investigations with similar populations whose birth characteristics put them at risk for subsequent developmental delay.     

Withholding Hydration and Nutrition in Newborns

In the twenty-first century, decisions to withhold or withdraw life-supporting measures commonly precede death in the neonatal intensive care unit without major ethical controversy. However, caregivers often feel much greater turmoil with regard to stopping medical hydration and nutrition than they do when considering discontinuation of mechanical ventilation or circulatory support. Nevertheless, forgoing medical fluids and food represents a morally acceptable option as part of a carefully developed palliative care plan considering the infant’s prognosis and the burdens of continued treatment. Decisions to stop any form of life support should focus on the clinical circumstances, not the means used to sustain life.     

Cognitive development in 7- to 24-month-old extremely/very-to-moderately/late preterm and full-term born infants: The mediating role of focused attention

The present study analyzed the links between prematurity, attention, and global cognitive performance in infancy and early childhood. At 7 months, focused attention (FA) was examined with an object examination task in 93 preterm infants (39 of them born extremely/very preterm, 54 born moderately/late preterm, and 38 infants born full-term). Global cognition was assessed at 7 and 24 months with the Bayley-II cognitive scale. Groups did not differ with respect to global cognitive performance but FA of infants born extremely/very preterm was significantly lower than in infants born moderately/late preterm. FA correlated significantly with both prematurity and cognitive performance at 7 months of age but not with global cognition in childhood. Findings point to a subtle adverse effect of prematurity on early attention and reveal evidence for the mediating role of FA on the effect of prematurity on cognition.     

Assessment of gestational age and neuromaturation

Neuromaturation is the functional development of the central nervous system (CNS). It is by its very nature a dynamic process, a continuous interaction between the genome and first the intrauterine environment, then the extrauterine environment. Understanding neuromaturation and being able to measure it is fundamental to infant neurodevelopmental assessment. Fetal and preterm neuromaturation has become easier to observe with the advent of prenatal ultrasonography and neonatal intensive care units. A number of measures of degree of fetal maturation have been developed and used to estimate gestational age (GA) at birth. The most reliable measures of GA are prenatal measures, especially from the first trimester. Postnatal GA measurements tend to be least accurate at the extremes of gestation, that is, in extremely preterm and post-term infants. Observations of measures of neuromaturation in infants born to mothers with pregnancy complications, including intrauterine growth restriction, multiple gestation, and chronic hypertension, have led to the discovery that stressed pregnancies may accelerate fetal pulmonary and CNS maturation. This acceleration of neuromaturation does not occur before 30 weeks' gestation and has a cost with respect to cognitive limitations manifested in childhood. The ability to measure fetal and preterm neuromaturation provides an assessment of neurodevelopmental progress that can be used to reassure parents or identify at risk infants who would benefit from limited comprehensive follow-up and early intervention services. In addition, measures of neuromaturation have the potential to provide insight into mechanisms of CNS injury and recovery, much-needed early feedback in intervention or treatment trials and a measure of early CNS function for research into the relationships between CNS structure and function.     

Is level of prematurity a risk/plasticity factor at three years of age?

Children born preterm have poorer outcomes than children born full-term, but the caregiving environment can ameliorate some of these differences. Recent research has proposed that preterm birth may be a plasticity factor, leading to better outcomes for preterm than full-term infants in higher quality environments. This analysis uses data from two waves of an Irish study of children (at 9 months and 3 years of age, n = 11,134 children) and their caregivers (n = 11,132 mothers, n = 9998 fathers) to investigate differences in how caregiving affects social, cognitive, and motor skills between full-term, late preterm, and very preterm children. Results indicate that parental emotional distress and quality of attachment are important for child outcomes. Both being born very preterm and late preterm continue to be risk factors for poorer outcomes at 3 years of age. Only fathers’ emotional distress significantly moderated the effect of prematurity on infants’ cognitive and social outcomes—no other interactions between prematurity and environment were significant. These interactions were somewhat in line with diathesis stress, but the effect sizes were too small to provide strong support for this model. There is no evidence that preterm birth is a plasticity factor.     

Executive Function in Very Preterm Children at Early School Age

We examined whether very preterm (≤30 weeks gestation) children at early school age have impairments in executive function (EF) independent of IQ and processing speed, and whether demographic and neonatal risk factors were associated with EF impairments. A consecutive sample of 50 children (27 boys and 23 girls) born very preterm (mean age = 5.9 years, SD = 0.4, mean gestational age = 28.0 weeks, SD = 1.4) was compared to a sample of 50 age-matched full-term controls (23 girls and 27 boys, mean age = 6.0 years, SD = 0.6) with respect to performance on a comprehensive EF battery, assessing the domains of inhibition, working memory, switching, verbal fluency, and concept generation. The very preterm group demonstrated poor performance compared to the controls on all EF domains, even after partialing out the effects of IQ. Processing speed was marginally related to EF. Analyses with demographic and neonatal risk factors showed maternal education and gestational age to be related to EF. This study adds to the emerging body of literature showing that very preterm birth is associated with EF impairments.     

Relations between neonatal states and 8-month developmental outcome in preterm infants

This study investigated longitudinal relations between measures of neonatal state behavior and developmental outcome in a sample of preterm infants (N = 16). Results indicate that irritability/reactivity in the neonatal period is positively associated with Bayley scores and exploratory play at 8 months. Conversely, neonatal alertness was not associated with these developmental measures. These preliminary findings, based on a small sample, are discussed in the context of preterm function.     

Prem Baby Triple P a new parenting intervention for parents of infants born very preterm: acceptability and barriers

Over 10% of preterm infants develop major disabilities, 50% develop behavioural problems and 40% need special education ( [Huddy et al., 2001] and [0185] ). Prem Baby Triple P is a new variant of the Positive Parenting Program (Triple P) adapted specifically for parents of very preterm infants. The aim of this study is to assess the acceptability of Prem Baby Triple P to parents of infants born preterm and to test whether parental attributions and parental perception of infant health/developmental status are barriers to intervention acceptability. One hundred and twenty-three parents of preterm infants participated, 83 parents of very preterm infants and 40 parents of preterm infants. In addition, 32 parents of term infants participated as a comparison group. The acceptability of Prem Baby Triple P was moderately high and did not differ significantly across the three groups. Parental attributions were not found to be barriers to intervention acceptability and parental perceptions that their infant is less healthy/developmentally delayed facilitated Prem Baby Triple P acceptance in parents of infants born very preterm. This suggests that the planned Prem Baby Triple P content is acceptable to parents of infants born very preterm and sensitised to medical and developmental issues. These findings, as social validation data, will contribute towards the further development of Prem Baby Triple P and a future randomised controlled trial.     

Public health issues related to infection in pregnancy and cerebral palsy

Cerebral palsy is the most common neuromotor developmental disability of childhood, affecting as many as 8,000 to 12,000 children born in the U.S. each year (corresponding to a prevalence rate of between 2 and 3 per 1000 children). Recent improvements in neonatal care have not resulted in a decline in the overall prevalence of cerebral palsy and, in fact, greater numbers of very preterm/very low birth weight infants are surviving with cerebral palsy and other developmental problems. Infection in pregnancy may be an important cause of the disorder. In preterm infants, there appears to be about a 2-fold increased risk for cerebral palsy from chorioamnionitis, and in term infants the estimated increased risk is about 4-fold. Provisionally, chorioamnionitis might account for 12% of spastic cerebral palsy in term infants and 28% of cerebral palsy in preterm infants. Studies of biochemical markers of fetal inflammation typically associated with infection also suggest that an inflammatory response may be an important independent etiologic factor. If a substantial proportion of cerebral palsy is attributable to acute amnionitis infection and/or neonatal sepsis, cerebral palsy should have decreased in the United States after administration of intrapartum antibiotics became widespread in response to publication of public health consensus guidelines for Group B streptococcus in 1996. However, failure to detect declines could have a number of explanations and these explanations illustrate the many public health challenges related to intrauterine infection and cerebral palsy. Given the gaps in our current knowledge about intrauterine infection and cerebral palsy, public health recommendations for timely and specific prevention activities are limited at this time.     

Mental Illness and Mental Health: The Two Continua Model Across the Lifespan

Mental health has long been defined as the absence of psychopathologies, such as depression and anxiety. The absence of mental illness, however, is a minimal outcome from a psychological perspective on lifespan development. This article therefore focuses on mental illness as well as on three core components of positive mental health: feelings of happiness and satisfaction with life (emotional well-being), positive individual functioning in terms of self-realization (psychological well-being), and positive societal functioning in terms of being of social value (social well-being). The two continua model holds that mental illness and mental health are related but distinct dimensions. This model was studied on the basis of a cross-sectional representative internet survey of Dutch adults (N = 1,340; 18–87 years). Mental illness was measured with the Brief Symptom Inventory and mental health with the Mental Health Continuum Short Form. It was found that older adults, except for the oldest-old, scored lower on psychopathological symptoms and were less likely to be mentally ill than younger adults. Although there were fewer age differences for mental health, older adults experienced more emotional, similar social and slightly lower psychological well-being. In sum, today’s older adults have fewer mental illness problems, but they are not in a better positive mental health than today’s younger adults. These findings support the validity of the two continua model in adult development.     

Interaction between mother and pre-term infant at 34 weeks post-conceptional age

The impact of premature birth and perinatal medical status on early mother–infant interaction was assessed in 75 dyads with pre-term infants divided into three groups. Infants' gestational age at birth and need for neonatal intensive care intervention differentiated the groups: group 1, 23–31 weeks with intensive care; group 2, 32–35 weeks with intensive care; group 3, 32–35 weeks with no intensive care. The methodological approach was based on observations of the dyads performed when the infant reached a post. conceptional age of 34 weeks (4 weeks before estimated due date of delivery). The observations were conducted in the neonatal nursery during cleaning, face-to-face and feeding interactions. Significant group differences were found in infant distress, maternal sensitivity to the infant and dyadic behaviours of positive interaction. Group 1 dyads showed higher scores or more desirable performance than dyads of group 3. Group 2 dyads usually achieved intermediate scores and performed better than dyads of group 3, especially during the feeding situation. We suggest that, in addition to a possible emergence of maternal compensatory mechanisms in the higher-risk groups, the amount of dyadic experience after birth affects the quality of mother–infant interaction at this early stage.