Decrease in frequency of cerebral palsy in preterm infants.
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Cerebral Palsy↗
Biomedical subjects
Maureen Hack
Publications and source records attributed to Maureen Hack.
Improved neurodevelopmental outcomes for extremely low birth weight infants in 2000-2002.
BACKGROUND: Neurodevelopmental impairment of extremely low birth weight infants increased in the 1990s. Modern therapeutic changes may have influenced more recent neonatal outcomes. OBJECTIVE: We sought to compare neonatal therapies and outcomes among all extremely low birth weight infants born in 2000-2002 (period III) to 2 previous periods: 1982-1989 (period I) and 1990-1999 (period II). METHODS: The population included 496 extremely low birth weight infants born at our perinatal center during period I, 749 during period II, and 233 during period III. Therapies, rates of death, and survival with and without impairment at 20 months' corrected age were compared. RESULTS: Between periods I and II, survival increased from 49% to 68% as did neonatal morbidity. This resulted in increased survival without impairment but also increased survival with impairment. Changes in therapy during period III included an increase in antenatal steroid use and a decrease in postnatal steroid use, although the rate of chronic lung disease did not change. Sepsis decreased, as did severe intraventricular hemorrhage. On follow-up, the rate of cerebral palsy decreased from 13% to 5%, resulting in a decrease in neurodevelopmental impairment from 35% to 23%. As a result, during period III versus II, survival without impairment increased, whereas survival with impairment decreased. CONCLUSION: Since 2000, neurodevelopmental impairment has decreased among extremely low birth weight infants. A variety of perinatal and neonatal factors were associated with the improved outcomes including increased antenatal steroid use and cesarean section delivery, as well as decreased sepsis, severe cranial ultrasound abnormalities, and postnatal steroid use despite no change in the rate of chronic lung disease.
Cerebral Palsy↗
Young adult attainments of preterm infants.
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Adult↗
Grades I-II intraventricular hemorrhage in extremely low birth weight infants: effects on neurodevelopment.
OBJECTIVE: To quantify the effect of grades I-II intraventricular hemorrhage (IVH) on the neurosensory and cognitive outcomes of extremely low birth weight infants. STUDY DESIGN: Of 706 extremely low birth weight infants without major malformations admitted to our center from 1992 to 2000, 537 survived to 20 months' corrected age (CA) and had cranial ultrasound studies performed, of whom 490 (91%) had complete neurodevelopmental assessments. Infants with severe cranial ultrasound abnormalities or meningitis were excluded, leaving a population of 362 infants, 258 of whom had a normal cranial ultrasound and 104 had an isolated grade I-II IVH. The groups had similar birth weight (808 vs 801 grams) and gestational age (26.5 vs 26.3 weeks). Outcomes of infants with normal cranial ultrasound were compared with those with grades I-II IVH at 20 months' CA. Outcomes included the Bayley Scales of Infant Development Mental Developmental Index (MDI) and major neurosensory abnormality. Logistic regression was used to assess the effect of grades I-II IVH on outcomes while adjusting for other risk factors. RESULTS: Extremely low birth weight infants with grades I-II IVH had a significantly lower mean MDI score than infants with normal cranial ultrasound (74 +/- 16 vs 79 +/- 14, P = .006). They had higher rates of MDI <<70 (45% vs 25%; OR, 2.00; 95% CI, 1.20 to 3.30; P = .008), major neurologic abnormality (13% vs 5%; OR, 2.60; 95% CI, 1.06 to 6.36; P = .036), and neurodevelopmental impairment (47% vs 28%; OR, 1.83; 95% CI, 1.11 to 3.03; P = .018) at 20 months' CA, even when adjusting for confounding factors. CONCLUSIONS: Extremely low birth weight infants with grades I-II IVH have poorer neurodevelopmental outcomes at 20 months' CA than infants with normal cranial ultrasound. Advanced radiologic imaging may indicate additional brain injury associated with grade I-II IVH, which could explain these outcomes.
Brain↗
Consequences and risks of <1000-g birth weight for neuropsychological skills, achievement, and adaptive functioning.
A cohort of 219 children with extremely low birth weight (<1000 g, extremely low birth weight [ELBW]) born from 1992 to 1995 was followed to mean age 8 years to evaluate outcomes and identify risk factors. We compared 204 of these children with 176 term-born normal birth weight (NBW) controls on neuropsychological skills, academic achievement, and adaptive behavior. The ELBW group had worse outcomes than the NBW on all measures. Within the ELBW group, lower scores on NEPSY tests of executive function and memory were related to <750 g birth weight, B (SE) = -0.93 (0.36), p =.010; cranial ultrasound abnormality, B = -1.03 (0.22), p =.002; postnatal steroid therapy, B = -1.00 (0.33), p =.003; and necrotizing enterocolitis, B = -2.26 (0.75), p =.008. A lower score on the Test of Motor Proficiency was related to chronic lung disease, B = -7.33 (1.98), p <.001. Neuropsychological skills mediated the effects of neonatal risk on achievement and adaptive functioning. The findings document the neuropsychological consequences of ELBW at school age in a recently born cohort and identify risks for adverse outcomes.
Achievement↗
The impact of extremely low birth weight on the families of school-aged children.
OBJECTIVE: The purpose of this study was to document the impact and burden of extremely low birth weight (<1000 g) and associated problems on the families of school-aged children in a controlled study. The study was also designed to document the salient predictors of individual differences of family impact within the extremely low birth weight group. METHODS: A prospective study was completed at 8 years of a cohort of 219 children with extremely low birth weight born 1992-1995 and 176 children with normal birth weight. Measures included the following predictor variables: socioeconomic status and parent risk, birth risk, neonatal risk, neurodevelopmental outcome, impairment in adaptive abilities, and functional impact of chronic conditions. The primary outcome measure was the Impact on Family scale. A measure of family stressors and resources (the Life Stressors and Social Resources Inventory) was also obtained. RESULTS: The primary finding was that the total family impact was greater in the extremely low birth weight group compared with controls. Moreover, the negative impact on family in specific domains was greater in the extremely low birth weight group in financial impact, caretaker burden, and familial burden. These differences were not attributable to general family stressors, socioeconomic status, child, gender, or race. Higher parent/socioeconomic risk, neurodevelopmental outcomes, and the functional impact of chronic conditions predicted greater family impact within the extremely low birth weight group, whereas birth and neonatal risk scores did not. CONCLUSIONS: Extremely low birth weight was associated with a negative impact on families. Socioeconomic parental risk, but most especially child-related factors such as neurodevelopmental and the functional impact of chronic conditions, predicted the negative family impact within the extremely low birth weight group. Findings underscore the need to develop and test interventions to provide support for families of extremely low birth weight infants to ameliorate the burden of extremely low birth weight and associated risk factors on families.
Family↗
Young adult outcomes of very-low-birth-weight children.
Information on the young adult outcomes of the initial survivors of neonatal intensive care has been reported from the United States, Canada, Australia, Great Britain and other European countries. The studies have varied with regard to whether they were regional or hospital-based, their birth-weight group and gestational age, rates of survival, socio-demographic background, and measures of assessment and types of outcome studied. Despite these differences the overall results reveal that neurodevelopment and growth sequelae persist to young adulthood. Very-low-birth-weight young adults have, with few exceptions, poorer educational achievement than normal-birth-weight controls, and fewer continue with post-high-school study. Rates of employment are, however, similar. There are no major differences in general health status, but the young adults demonstrate poorer physical abilities, higher mean blood pressure and poorer respiratory function. There is no evidence of major psychiatric disorder, although anxiety and depression are reported more often. The young adults report less risk-taking than control populations. They report fairly normal social lives and quality of life. When differences are noted they are usually due to neurosensory disabilities. Longer-term studies are needed to evaluate ultimate educational and occupational achievement. It will also be important to assess the effects of preterm birth, early growth failure and catch-up growth on later metabolic and cardiovascular health.
Adolescent↗
Subnormal head circumference in very low birth weight children: neonatal correlates and school-age consequences.
BACKGROUND: Subnormal head circumference (HC) has been associated with poor neurologic and developmental outcomes. AIM: To examine the correlates and consequences of subnormal HC in a cohort of school age, very low birth weight (VLBW, <1,500 g) children. STUDY DESIGN AND OUTCOME MEASURES: We examined developmental outcomes at a mean age of 6.8 years in a cohort of 128 VLBW children born from 1982-1986 and 58 normal birth weight controls. The VLBW cohort included a regional sample of <750 g birth weight children and matched children with 750-1,499 g birth weight. Outcomes included an IQ equivalent, neuropsychological skills, academic achievement, adaptive behavior, and attention problems. HC was defined along a continuum and as subnormal vs. normal. Linear and logistic regressions were employed to determine the effects of HC on the outcomes after controlling for confounding variables. RESULTS: Thirty one VLBW children (24%) had subnormal HC vs. none of the controls. The VLBW children with subnormal HC differed significantly from the normal HC group in birth weight (748 g vs. 977 g, p<.001), SGA status (52% vs. 27%, p<.05), high neonatal risk (57% vs. 29%, p<.05), and neurosensory impairment (23% vs. 8%, p<.05). Even after taking these risk factors into account, subnormal HC was associated with poorer IQ equivalent, perceptual motor skills, academic achievement, and adaptive behavior. Results were similar after excluding the children with neurosensory impairment. CONCLUSIONS: Subnormal HC is associated with adverse developmental outcomes in VLBW children, independent of other risk factors. Interventions to improve antenatal and postnatal growth may contribute to better school-age outcomes.
Anthropometry↗
Longitudinal changes in family outcomes of very low birth weight.
OBJECTIVES: Although children with very low birth weight (VLBW, <1500 g) are at high risk for developmental impairments, we know little about the long-term effects of VLBW on families. This study examined long-term family outcomes and their stability over time. METHODS: Participants were the families of 64 children with <750 g birth weight, 54 with 750-1499 g birth weight, and 66 term-born controls. Family burden and parental distress were assessed annually as part of longitudinal follow-up of the children from mean ages 11-14 years. RESULTS: Family burden and parental distress were higher in the <750 g group than in the term-born group, but differences varied with the child's age and family environment. CONCLUSIONS: The findings document long-term effects of VLBW on families that are moderated by the degree of low birth weight, child's age, and family environment.
Adaptation, Psychological↗
Chronic conditions, functional limitations, and special health care needs of school-aged children born with extremely low-birth-weight in the 1990s.
CONTEXT: Information on the school-age functioning and special health care needs of extremely low-birth-weight (ELBW, <1000 g) children is necessary to plan for medical and educational services. OBJECTIVE: To examine neurosensory, developmental, and medical conditions together with the associated functional limitations and special health care needs of ELBW children compared with normal-birth-weight (NBW) term-born children (controls). DESIGN, SETTING, AND PARTICIPANTS: A follow-up study at age 8 years of a cohort of 219 ELBW children born 1992 to 1995 (92% of survivors) and 176 NBW controls of similar sociodemographic status conducted in Cleveland, Ohio. MAIN OUTCOME MEASURES: Parent Questionnaire for Identifying Children with Chronic Conditions of 12 months or more and categorization of specific medical diagnoses and developmental disabilities based on examination of the children. RESULTS: In logistic regression analyses adjusting for sociodemographic status and sex, ELBW children had significantly more chronic conditions than NBW controls, including functional limitations (64% vs 20%, respectively; odds ratio [OR], 8.1; 95% confidence interval [CI], 5.0-13.1; P<.001), compensatory dependency needs (48% vs 23%, respectively; OR, 3.0; 95% CI, 1.9-4.7; P<.001), and services above those routinely required by children (65% vs 27%, respectively; OR, 5.4; 95% CI, 3.4-8.5; P<.001). These differences remained significant when the 36 ELBW children with neurosensory impairments were excluded. Specific diagnoses and disabilities for ELBW vs NBW children included cerebral palsy (14% vs 0%, respectively; P<.001), asthma (21% vs 9%; OR, 3.0; 95% CI, 1.6-5.6; P = .001), vision of less than 20/200 (10% vs 3%; OR, 3.1; 95% CI, 1.2-7.8; P = .02), low IQ of less than 85 (38% vs 14%; OR, 4.5; 95% CI, 2.7-7.7; P<.001), limited academic skills (37% vs 15%; OR, 4.2; 95% CI, 2.5-7.3; P<.001), poor motor skills (47% vs 10%; OR, 7.8; 95% CI, 4.5-13.6; P<.001), and poor adaptive functioning (69% vs 34%; OR, 6.5; 95% CI, 4.0-10.6; P<.001). CONCLUSION: The ELBW survivors in school at age 8 years who were born in the 1990s have considerable long-term health and educational needs.
Child↗
Predictors of internalizing symptoms among very low birth weight young women.
As part of a longitudinal study of the outcomes of very low birth weight children (<1.5 kg), we sought to examine the perinatal, childhood, and young adult predictors of internalizing symptoms among very low birth weight young women and their normal birth weight controls. The cohort included 125 very low birth weight and 124 normal birth weight 20-year-old subjects. Perinatal, childhood, and young adult predictors were examined via stepwise multivariate analyses. Results revealed very low birth weight to be a significant predictor of parent-reported internalizing symptoms of their daughters but only among white subjects who had mothers with high levels of psychological distress. Additional significant predictors of 20-year internalizing symptoms included child I.Q. and internalizing symptoms at age 8 years and family expressiveness. When the results were analyzed according to the young adult self-report, additional predictors of internalizing symptoms included a history of asthma and exposure to violence. Perinatal risk factors were not found to be predictive of internalizing symptoms at age 20 years. Future studies should prospectively examine social and environmental factors associated with the neonatal intensive care experience that might explain the effect of very low birth weight on later psychopathology.
Adult↗
Blood pressure among very low birth weight (<1.5 kg) young adults.
Our objective was to compare the blood pressure of 20-y-old very low birth weight (VLBW; <1.5 kg) individuals with that of normal birth weight (NBW) control individuals. The population included 195 VLBW (92 female and 103 male) and 208 NBW (107 female and 101 male) individuals who were born between 1977 and 1979. Independent effects of birth weight status (VLBW versus NBW) and within the VLBW cohort of intrauterine growth (birth weight z score) were examined via multiple regression analyses. VLBW individuals had a higher mean systolic blood pressure (SBP) than NBW control individuals (114 +/- 11 versus 112 +/- 13 mm Hg). SBP for VLBW female infants was 110 +/- 9 versus NBW 107 +/- 12 and for VLBW male individuals was 118 +/- 11 versus NBW 117 +/- 11 mm Hg. After adjustment for gender, race, and maternal education, the difference in SBP between VLBW and NBW individuals was 1.9 mm Hg but was 3.5 mm after also adjustment for later size (20-y weight and height z scores), which reflects catch-up growth. For female individuals, the difference in SBP between VLBW and NBW individuals was significant both unadjusted and adjusted for later size, whereas for male individuals, the difference was significant only after adjustment for later size. Intrauterine growth did not have a significant effect on SBP within the VLBW group, even after adjustment for later size. VLBW individuals, specifically female individuals, have a higher SBP than NBW control individuals. This is not explained by intrauterine growth failure.
Adult↗
Improved survival rates with increased neurodevelopmental disability for extremely low birth weight infants in the 1990s.
BACKGROUND: Advances in perinatal care have resulted in increased survival rates for extremely low birth weight children. We sought to examine the relative changes in rates of survival and neurodevelopmental impairment at 20 months of corrected age among 500- to 999-g birth weight infants born at our perinatal center during 2 periods, before and after the introduction of surfactant therapy in 1990. METHODS: Four hundred ninety-six infants with birth weights of 500 to 999 g were born at our perinatal center during period I (1982-1989) (mean body weight: 762 g; mean gestational age: 25.8 weeks) and 682 during period II (1990-1998) (mean body weight: 756 g; mean gestational age: 25.5 weeks). Rates of death and survival with and without neurodevelopmental impairment at 20 months of corrected age for the 2 periods were compared with logistic regression analyses, with adjustment for gestational age. RESULTS: Survival rates increased from 49% during period I to 67% during period II. Neonatal morbidity rates also increased during period II, including rates of sepsis (from 37% to 51%), periventricular leukomalacia (from 2% to 7%), and chronic lung disease, defined as oxygen dependence at 36 weeks of corrected age (from 32% to 43%). Rates of severe cranial ultrasound abnormalities were similar (22% vs 22%). Among children monitored, the rate of neurologic abnormalities, including cerebral palsy, increased from 16% during period I to 25% during period II and the rate of deafness increased from 3% to 7%. The overall rate of neurodevelopmental impairment (major neurosensory abnormality and/or Bayley Mental Developmental Index score of <70) increased from 26% to 36%. Compared with period I, in period II there were decreased rates of death (odds ratio [OR]: 0.3; 95% confidence interval [CI]: 0.2-0.4) and increased rates of survival with impairment (OR: 2.3; 95% CI: 1.7-3.3) but also increased rates of survival without impairment (OR: 1.7; 95% CI: 1.3-2.2). Compared with period I, for every 100 infants with birth weights of 500 to 999 g born in period II, 18 additional infants survived, of whom 7 were unimpaired and 11 were impaired. CONCLUSIONS: The improved survival rates in the 1990s occurred with an increased risk of significant neurodevelopmental impairment. Prospective parents of extremely low birth weight infants should be advised of this substantial risk, to facilitate decision-making in the delivery room.
Blindness↗
Poor predictive validity of the Bayley Scales of Infant Development for cognitive function of extremely low birth weight children at school age.
OBJECTIVE: The Bayley Scales of Infant Development, Second Edition (BSID II) are commonly used to assess outcomes of extremely low birth weight (ELBW) infants. We sought to assess the predictive validity of the BSID II Mental Developmental Index (MDI) for cognitive function at school age. DESIGN/METHODS: Of 330 ELBW infants admitted in 1992-1995, 238 (72%) survived to the age of 8 years, of whom 200 (84%) were tested at both 20 months' corrected age (CA) and 8 years. Mean birth weight was 811 g, mean gestational age was 26.4 weeks, 41% were boys, and 60% were black. Measures included the BSID II at 20 months' CA and the Kaufman Assessment Battery for Children (KABC) Mental Processing Composite (MPC) at 8 years' postnatal age. BSID II MDI and MPC scores were compared and the predictive validity calculated for all 200 ELBW children and for the 154 ELBW neurosensory-intact subgroup. Predictors of stability or change in cognitive scores were examined via logistic regression adjusting for gender and sociodemographic status. RESULTS: For all ELBW children, the mean MDI was 75.6 +/- 16 versus a mean KABC of 87.8 +/- 19. For the neurosensory-intact subgroup, the mean MDI was 79.3 +/- 16 and the mean KABC was 92.3 +/- 15. Rates of cognitive impairment, defined as an MDI or KABC of <70, dropped from 39% at 20 months' CA to 16% at 8 years for the total ELBW population and from 29% to 7% for the neurosensory-intact subgroup. The positive predictive value of having an MPC of <70 given an MDI of <70 was 0.37 (95% confidence interval [CI]: 0.27, 0.49) for all ELBW infants, 0.20 (95% CI: 0.10, 0.35) for the neurosensory-intact subgroup, and 0.61 (95% CI: 0.42, 0.77) for the neurosensory-impaired subgroup. The negative predictive values were 0.98, 0.99, and 0.85 for the 3 groups, respectively. Neurosensory impairment at 20 months' CA predicted lack of improvement of cognitive function (odds ratio: 6.9; 95% CI: 2.4, 20.2). Children whose cognitive scores improved between 20 months and 8 years had significantly better school performance than those whose scores stayed at <70, but they did less well than those whose scores were persistently >70. CONCLUSIONS: The predictive validity of a subnormal MDI for cognitive function at school age is poor but better for ELBW children who have neurosensory impairments. We are concerned that decisions to provide intensive care for ELBW infants in the delivery room might be biased by reported high rates of cognitive impairments based on the use and presumptive validity of the BSID II MDI.
Blindness↗
Adverse events associated with neonatal exchange transfusion in the 1990s.
OBJECTIVE: To determine the rates of adverse events associated with neonatal exchange transfusions performed for hyperbilirubinemia. STUDY DESIGN: Retrospective chart review of 55 neonates who underwent 66 exchange transfusions at two perinatal centers in Cleveland between 1992 and 2002. Demographic data, causes of jaundice, details of exchange method, and adverse events occurring within one week of exchange were recorded. At the time of exchange, 62% of infants had other neonatal morbidities. Outcomes were stratified according to gestational ages < or =32 weeks, 33 to 36 weeks, and > or =37 weeks. RESULTS: Overall, 74% of exchanges were associated with an adverse event. The most common events were thrombocytopenia (44%), hypocalcemia (29%), and metabolic acidosis (24%), of which 69%, 74%, and 44%, respectively, required treatment. There were two serious adverse events, both in infants with other serious neonatal morbidities: seizures in one infant and the death of a critically ill preterm infant (body weight 731 g, gestational age 25 weeks). There were no cases of sepsis, necrotizing enterocolitis, or cardiac arrest. Adverse events were more frequent in exchanges done on preterm infants: < or =32 weeks (87%), 33 to 36 weeks (78%), and > or =37 weeks (67%), and in infants with other neonatal morbidity (79% vs 57%; P=.08). Controlling for neonatal morbidity, we found the odds of an adverse event were significantly higher when both umbilical venous and arterial catheters were used compared with other methods of exchange (88% vs 58%; OR, 5.17; 95% CI, 1.1, 34.2; P=.03). CONCLUSIONS: The majority of adverse events associated with exchange transfusion are laboratory abnormalities and are asymptomatic and treatable.
Exchange Transfusion, Whole Blood↗
Longitudinal outcomes of very low birth weight: neuropsychological findings.
To investigate the effects of very low birth weight (VLBW, &1500 g) on the development of neuropsychological skills, we assessed 67 children with birth weight <750 g, 64 with birth weight 750-1499 g, and 67 term-born controls. Growth modeling of raw scores from mean ages 7-14 years revealed persistent VLBW sequelae. Even when adjusting for IQ, the <750 g group scored more poorly than the term-born group on measures of language processing, verbal list learning, and perceptual-motor and organizational abilities. This group also made slower age-related progress than the control group on tests of perceptual-motor and executive functions. Environmental factors moderated group differences in change on other cognitive measures. These results revealed further evidence for slower skill development in both VLBW groups relative to controls, as well as"catch-up" growth in the 750-1499 g group on some measures. The findings suggest age-related changes in the cognitive sequelae of VLBW that depend on the skill assessed, the degree of VLBW, and environmental factors.
Adolescent↗
Long-term neuropsychological outcomes of very low birth weight: associations with early risks for periventricular brain insults.
Few follow-up studies of children with very low birth weight (VLBW, <1,500 g) have examined neuropsychological sequelae at later ages or neonatal risks as predictors of these outcomes. The present study assessed cognitive skills at mean age 16 years in 48 participants with <750 g birth weight, 47 with 750-1,499 g birth weight, and 52 term-born controls. Our major objectives were to delineate the long-term cognitive consequences of VLBW, and to determine if risks for periventricular brain insults accounted for variations in outcomes. Analysis revealed poorer outcomes for the <750 g group than for term-born controls on nearly all measures, with specific impairments in visual-motor skills, spatial memory, and executive function. Predictors of outcome for participants with VLBW included lower birth weight, lower weight for gestational age, and a longer period of oxygen requirement for chronic lung disease. The longer-term consequences of VLBW are consistent with expectations based on early brain pathology and suggest limitations to functional plasticity.
Adolescent↗
The effect of neonatal maternal milk feeding on the neurodevelopmental outcome of very low birth weight infants.
The effect of maternal milk feeding during the first 4 weeks of life on neurodevelopmental outcomes at 20 months corrected age (CA) of singleton very low birth weight (VLBW) (< 1.5 kg) infants was examined. Ninety-eight VLBW infants born from January 1997 to February 1999 were followed to 20 months CA (mean birth weight, 1012 g; gestational age, 27 weeks). Maternal milk intake was calculated as both mean milliliters per kilogram per day and graded doses. Outcomes included the Bayley Mental Development Index (MDI) and Psychomotor Development Index (PDI), and rates of cerebral palsy (CP) and of overall neurodevelopmental impairment. After adjusting for neonatal and social risk, results revealed no effect of maternal milk on outcomes. MDI was predicted by both social and neonatal risk, and PDI, CP, and neurodevelopmental impairment were predicted by neonatal risk. In this small, high-risk group of VLBW infants, the effects of social and neonatal risk appear to outweigh any possible benefits of maternal milk on neurodevelopmental outcome.
Breast Feeding↗