Neurodevelopmental outcomes of extremely low birth weight infants <32 weeks’ gestation between 1993 and 1998. Pediatrics

Women & Infants Hospital, Providence, Rhode Island, United States
PEDIATRICS (Impact Factor: 5.3). 10/2005; 116(3):635-43. DOI: 10.1542/peds.2004-2247
Source: PubMed

ABSTRACT This study evaluated the impact of changes in perinatal management on neurodevelopmental impairment (NDI) at 18 to 22 months' corrected age of low gestation (22-26 weeks) and higher gestation (27-32 weeks) extremely low birth weight infants (401-1000 g birth weight) who were cared for in the National Institute of Child Health and Human Development Neonatal Research Network during 3 epochs (1993-1994, 1995-1996, and 1997-1998). It was hypothesized that outcomes would improve over the 3 epochs.
A multicenter cohort study was conducted of the outcomes of 3785 infants with assessments at 18 to 22 months' corrected age. Regression analyses were completed to evaluate for epoch effects, gestational age effects, and time plus gestational age interaction. Regression analyses were also performed to identify the independent associations of epoch and 4 study perinatal interventions: antenatal steroids (yes, no), high-frequency ventilation (yes, no), number of days to regain birth weight as a marker of nutritional intake, and postnatal steroids for treatment of bronchopulmonary dysplasia (yes, no) with outcomes.
Survival improved for both the low (55%-61%) and higher (82%-86%) gestational age groups during the 3 epochs. Regression analyses indicated that the decreased risk for adverse outcome was significantly lower in epoch 2 compared with epoch 1 with decreased rates of low Bayley Mental Development Index (MDI) and neurodevelopmental impairment (NDI). Antenatal steroids were associated with decreased risk for moderate to severe cerebral palsy (CP) and low Bayley Psychomotor Development Index. High-frequency ventilation was associated with a low Bayley MDI and NDI, and postnatal steroids were associated with moderate to severe CP, any CP, low Bayley MDI, low Bayley Psychomotor Development Index, and increased NDI.
Survival of extremely low birth weight infants improved between 1993 and 1998. Although some outcomes remained unchanged, the rates of low Bayley MDI scores and NDI improved. Antenatal steroid administration was the only study intervention associated with improved outcomes.

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    • "It is unclear, however, whether multiple births are at increased risk for neurologic impairment compared with birth weight–matched singletons. Some reports indicated a higher rate of neurodevelopmental impairments for preterm multiple births [56], but others did not [92]. "
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    ABSTRACT: Prediction of outcome after preterm birth is critical, but remains difficult, particularly in the early postnatal period. The ability to predict outcome improves parental counseling and selection of infants for early therapeutic strategies aiming at preventing or ameliorating cerebral injury. This review gives an overview of the spectrum and severity of neurodevelopmental, behavioral, and psychosocial outcomes, with discussion of predictors of outcome and, in particular, the clinical, electrophysiological, and imaging predictors. A detailed neurologic examination of infants is a valuable predictive tool in terms of later moderate to severe neurodevelopmental impairments; however, it may be limited in the immediate newborn period. Electrophysiological, neuroimaging, and clinical risk factors for adverse neurodevelopmental outcome have been identified. Good prediction is usually achieved for major functional disabilities in early childhood, but is poorer for moderate or mild long-term outcome. Future research should focus on the long-term quality of life, academic achievement, and the influence of the sociocultural environment. More emphasis should be placed on genetic diversity as a modifying factor for the large variability in outcome.
    Pediatric Neurology 07/2009; 40(6):413-9. DOI:10.1016/j.pediatrneurol.2009.01.008 · 1.50 Impact Factor
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    ABSTRACT: The project consisted of two long-term follow-up studies of preterm children addressing the question whether intrauterine growth restriction affects the outcome. Assessment at 5 years of age of 203 children with a birth weight less than 1000 g born in Finland in 1996-1997 showed that 9% of the children had cognitive impairment, 14% cerebral palsy, and 4% needed a hearing aid. The intelligence quotient was lower (p<0.05) than the reference value. Thus, 20% exhibited major, 19% minor disabilities, and 61% had no functional abnormalities. Being small for gestational age (SGA) was associated with sub-optimal growth later. In children born before 27 gestational weeks, the SGA had more neuropsychological disabilities than those appropriate for gestational age (AGA). In another cohort with birth weight less than 1500 g assessed at 5 years of age, echocardiography showed a thickened interventricular septum and a decreased left ventricular end-diastolic diameter in both SGA and AGA born children. They also had a higher systolic blood pressure than the reference. Laser-Doppler flowmetry showed different endothelium-dependent and -independent vasodilation responses in the AGA children compared to those of the controls. SGA was not associated with cardio-vascular abnormalities. Auditory event-related potentials (AERPs) were recorded using an oddball paradigm with frequency deviants (standard tone 500 Hz and deviant 750-Hz with 10% probability). At term, the P350 was smaller in SGA and AGA infants than in controls. At 12 months, the automatic change detection peak (mismatch negativity, MMN) was observed in the controls. However, the pre-term infants had a difference positivity that correlated with their neurodevelopment scores. At 5 years of age, the P1-deflection, which reflects primary auditory processing, was smaller, and the MMN larger in the preterm than in the control children. Even with a challenging paradigm or a distraction paradigm, P1 was smaller in the preterm than in the control children. The SGA and AGA children showed similar AERP responses. Prematurity is a major risk factor for abnormal brain development. Preterm children showed signs of cardiovascular abnormality suggesting that prematurity per se may carry a risk for later morbidity. The small positive amplitudes in AERPs suggest persisting altered auditory processing in the preterm in-fants. Hyvin ennenaikainen syntymä ja sikiön kasvuhäiriö ovat riskitekijöitä lapsen kehitykselle. Tutkimuksessa selvitettiin viisivuotiaitten pienipainoisten keskosten neurologista suoriutumista, sydän-ja verenkiertoelimistön toimintaa sekä kuuloaivokuoren erottelukyvyn kehitystä. Suomessa 1996 1997 syntyneistä, alle 1000g painaneista keskosista 9 %:lla todettiin kehitysvammaisuus, 14 %:lla aivohalvaus, 4 %:lla oli kuulokoje. Vaikka keskosten älykkyys- ja neuropsykologisten testien tulosten keskiarvot asettuivat normaalialueelle, ne olivat merkittävästi viitearvoja pienempiä. Merkittävä toiminnallinen haitta todettiin 20 %:lla, lievä haitta 19 %:lla, ja 61 % lapsista oli toiminnallisesti normaaleja. Sikiökautinen kasvuhäiriö jatkui myöhemmin hitaana kasvuna. Toisessa, alle 1500 g painaneiden keskosten seurantatutkimuksessa sydämen ultraäänitutkimus 5 vuoden iässä osoitti kammioväliseinän paksuuntuneen, vasemman kammion diastolisen läpimitan pienentyneen ja systolisen verenpaineen nousseen verrattuna viitearvoihin. Ihon pintaverenkierron laser-Doppler tutkimuksessa raskauden kestoon nähden normaalipainoisina syntyneillä keskosilla todettiin erilainen vaste lääkeaineilla provosoituun endoteeliriippuvaiseen tai sileälihasriippuvaiseen verisuonten laajenemiseen kuin täysiaikaisina syntyneillä verrokeilla. Vastasyntyneisyyskaudella näillä keskosilla todettiin kuuloaivokuoren erottelukokeessa positiivinen jännitevaste 350 ms ärsykkeen alusta. Vuoden iässä äänisarjan poikkeama aiheutti keskosilla positiivisen erotusjännitevasteen, kun taas täysiaikaisina syntyneillä kontrollilapsilla vaste oli muuttunut odotetusti negatiiviseksi. Viiden vuoden iässä varhaiset positiiviset jännitevasteet, jotka kuvastavat primaarikuuloaivokuoren toimintaa, olivat vaimeammat kuin verrokeilla. Nämä varhaiset vasteet sekä äänisarjan poikkeaman erottaminen korreloivat kielelliseen suoriutumiseen. Kuuloerottelun aktiivista tarkkaavaisuutta vaativassa kokeessa tarkkaavuuden perusmekanismit olivat keskosilla samanlaisia kuin kontrolleilla, mutta kontrolleja vaimeammat jännitepotentiaalit voivat viitata kuuloärsykkeen poikkeavaan prosessointiin. Ennenaikaisuus on merkittävä riski keskushermoston kehitykselle. Ennenaikaisuus voi lisätä sydän- ja verenkiertoelimistön poikkeavaa toimintaa. Keskosten kuuloaivokuoren erottelukokeen poikkeavuudet voivat assosioitua poikkeavaan kielelliseen kehitykseen.
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