Aijaz Farooqi

Mental Health and Social Competencies of 10- to 12-Year-Old Children Born at 23 to 25 Weeks of Gestation in the 1990s: A Swedish National Prospective Follow-up Study

OBJECTIVE. We investigated a national cohort of extremely immature children with respect to behavioral and emotional problems and social competencies, from the perspectives of parents, teachers, and children themselves. METHODS. We examined 11-year-old children who were born before 26 completed weeks of gestation in Sweden between 1990 and 1992. All had been evaluated at a corrected age of 36 months. At 11 years of age, 86 of 89 survivors were studied and compared with an equal number of control subjects, matched with respect to age and gender. Behavioral and emotional problems, social competencies, and adaptive functioning at school were evaluated with standardized, well-validated instruments, including parent and teacher report questionnaires and a child self-report, administered by mail. RESULTS. Compared with control subjects, parents of extremely immature children reported significantly more problems with internalizing behaviors (anxiety/depression, withdrawn, and somatic problems) and attention, thought, and social problems. Teachers reported a similar pattern. Reports from children showed a trend toward increased depression symptoms compared with control subjects. Multivariate analysis of covariance of parent-reported behavioral problems revealed no interactions, but significant main effects emerged for group status (extremely immature versus control), family function, social risk, and presence of a chronic medical condition, with all effect sizes being medium and accounting for 8% to 12% of the variance. Multivariate analysis of covariance of teacher-reported behavioral problems showed significant effects for group status and gender but not for the covariates mentioned above. According to the teachers’ ratings, extremely immature children were less well adjusted to the school environment than were control subjects. However, a majority of extremely immature children (85%) were functioning in mainstream schools without major adjustment problems. CONCLUSIONS. Despite favorable outcomes for many children born at the limit of viability, these children are at risk for mental health problems, with poorer school results.

Survival and 2-year outcome with expectant management of second-trimester rupture of membranes.

Objective To evaluate the perinatal and 2-year outcomes in pregnancies complicated by preterm premature rupture of membranes (PROM) during the second trimester. Methods Fifty-three consecutive singleton pregnancies with PROM at 14 to 28 weeks of gestation were studied retrospectively. Management goals were to prolong the pregnancies to 32 weeks through expectant management and to avoid fetal compromise through closer monitoring and active intervention, when necessary, after 23 weeks. Outcome of the surviving infants was based on neurologic, audiometric, and ophthalmologic examinations at 2 years of corrected age. Results Rupture of membranes occurred at 14–19 weeks (mean 17.4 weeks) in 10 women, at 20–25 weeks (mean 24.0 weeks) in 24, and at 26–28 weeks (mean 27.6 weeks) in 19. The median latency periods to delivery were 72 days, 12 days, and 10 days when rupture of membranes occurred at 14–19 weeks, 20–25 weeks, and 26–28 weeks, respectively. The overall incidence of chorioamnionitis was 28%. There were no fetal deaths and nine neonatal deaths. When rupture of membranes occurred at 14–19 weeks, 20–25 weeks, and 26–28 weeks, the perinatal survival rates were 40%, 92%, and, 100%, respectively. Pulmonary hypoplasia accounted for seven deaths. Of the live-born infants, 81% were alive at 2 years of corrected age. Survival without major impairment was observed in 75%, 80%, and 100% of the survivors when rupture of membranes occurred at 14–19 weeks, 20–25 weeks, and 26–28 weeks, respectively. Conclusion Expectant management of second-trimester PROM offers better perinatal and long-term survival than previously thought.

Short-term outcome after active perinatal management at 23—25 weeks of gestation. A study from two Swedish tertiary care centres. Part 2: infant survival

Aim: To determine neonatal survival rates based on both foetal (stillborn) and neonatal deaths among infants delivered at 23–25 wk, and to identify maternal and neonatal factors associated with survival. Methods: The medical records of 224 infants who were delivered in two tertiary care centres in 1992–1998 were reviewed retrospectively. At these centres, policies of active perinatal and neonatal management were universally applied. Data were analysed by gestational age groups and considered in three time periods. Logistic regression models were used to identify factors associated with survival. Results: The rate of foetal death was 5%. Of infants born alive, 63% survived to discharge. Survival rates including foetal deaths in the denominator at 23, 24 and 25 wk were 37%, 61% and 74%, respectively, and survival rates excluding foetal deaths were 43%, 63% and 77%, respectively. Of infants born with 1‐min Apgar scores of 0–1, 43% survived. In the total cohort, survival rates including foetal deaths in the denominator increased from 52% in time period 1 to 61% in time period 2 and 74% in time period 3 (p > 0.02). On multivariate logistic regression analysis, higher birthweight (OR: 1.91 per 100 g increment; 95% CI: 1.45–2.52), female gender (OR: 3.33; 95% CI: 1.65–6.75), administration of antenatal steroids (OR: 2.95; 95% CI: 1.46–5.98) and intrauterine referral from a peripheral hospital (OR: 2.35; 95% CI: 1.18–4.68) were associated with survival. Apgar score ± 3 at 1 min (OR: 0.46; 95% CI: 0.22–0.95) was associated with decreased survival. The use of antenatal steroids was protective at 23–24 wk (OR: 5.2; 95% CI: 2.0–13.7), but not at 25 wk.

Short-term outcome after active perinatal management at 23-25 weeks of gestation. A study from two Swedish perinatal centres. Part 3: neonatal morbidity.

Aim: To determine major neonatal morbidity in surviving infants born at 23–25 weeks, and to identify maternal and infant factors associated with major morbidity. Methods: The medical records of 224 infants who were delivered at two tertiary care centres in 1992–1998 were reviewed retrospectively. At these centres, policies of active perinatal and neonatal management were universally applied. Of the 213 liveborn infants, 140 (66%) survived to discharge. Data were analysed by gestational age and considered in three time periods. Logistic regression models were used to identify factors associated with morbidity. Results: Of the survivors, 6% had intraventricular haemorrhage grade ± 3 (severe IVH) or periventricular leukomalacia (PVL), 15% retinopathy of prematurity ± stage 3 (severe ROP) and 36% bronchopulmonary dysplasia (BPD). On logistic regression analysis, severe IVH or PVL was associated with duration of mechanical ventilation (odds ratio, OR: 1.53 per 1‐wk increment in duration; 95% confidence interval, CI: 1.01–2.33). Severe ROP was associated with the presence of a patent ductus arteriosus (PDA) (OR: 3.31; 95% CI: 1.11–9.90) and birth in time period 3 versus time periods 1 and 2 combined (OR: 6.28; 95% CI: 2.10–18.74). BPD was associated with duration of mechanical ventilation (OR: 2.71 per 1‐wk increment in duration; 95% CI: 1.76–4.18) and with the presence of any obstetric complication (OR: 2.67; 95% CI: 1.07–6.65). Gestational age and birthweight were not associated with major morbidity. Of all survivors, 81% were discharged home without severe IVH, PVL or severe ROP.

Short-term outcome after active perinatal management at 23-25 weeks of gestation. A study from two Swedish tertiary care centres. Part 1 : maternal and obstetric factors.

Aims: To provide descriptive data on women who delivered at 23–25 wk of gestation, and to relate foetal and neonatal outcomes to maternal factors, obstetric management and the principal reasons for preterm birth. Methods: Medical records of all women who had delivered in two tertiary care centres in 1992–1998 were reviewed. At the two centres, policies of active perinatal and neonatal management were universally applied. Logistic regression models were used to identify prenatal factors associated with survival. Results: Of 197 women who delivered at 23–25 wk, 65% had experienced a previous miscarriage, 15% a previous stillbirth and 12% a neonatal death. The current pregnancy was the result of artificial reproduction in 13% of the women. In 71%, the pregnancy was complicated either by preeclampsia, chorioamnionitis, placental abruption or premature rupture of membranes. Antenatal steroids were given in 63%. Delivery was by caesarean section in 47%. The reasons for preterm birth were idiopathic preterm labour in 36%, premature rupture of membranes in 41% and physician‐indicated deliveries in 23% of the mothers. Demographic details, use of antenatal steroids, caesarean section delivery and birthweight differed between mothers depending on the reason for preterm delivery. Of 224 infants, 5% were stillbirths and 63% survived to discharge. On multivariate logistic regression analysis comprising prenatally known variables, reasons for preterm birth were not associated with survival. Advanced gestational duration (OR: 2.43 per wk; 95% CI: 1.59–3.74), administration of any antenatal steroids (OR: 2.21; 95% CI: 1.14–4.28) and intrauterine referral from a peripheral hospital (OR: 2.93; 95% CI: 1.5–5.73) were associated with survival.

Behaviours related to executive functions and learning skills at 11 years of age after extremely preterm birth: a Swedish national prospective follow-up study

We investigated a national cohort of children born extremely immature (<26 weeks gestation, EI) regarding the nature, frequency and severity of the behavioural problems related to the executive functions (EF) and concerning learning skills, from the perspectives of parents and teachers.

Executive Functioning and Learning Skills of Adolescent Children Born at Fewer than 26 Weeks of Gestation

Aims To assess the cognitive and behavioral aspects of executive functioning (EF) and learning skills in extremely preterm (EPT) children compared with term control children aged 10 to 15 years. Methods A total of 132 of 134 (98% of all eligible survivors) EPT children born at the 2 Swedish regional tertiary care centers from 1992 to 1998 (mean age = 12 years, mean birth weight = 718 g, and mean gestational age = 24.4 weeks) and 103 matched term controls were assessed. General intelligence was assessed using the Wechsler Intelligence Scale for Children (WISC-III-R), and cognitive aspects of EF were analyzed using EF-sensitive subscales of the WISC-III-R and Tower test of the Delis-Kaplan Executive Function Scale (D-KEFS). Behaviors related to EF and learning skills were assessed using the Five to Fifteen questionnaire, which is a validated parent and teacher instrument. Academic performance in school was assessed by teachers’ responses on Achenbach’s Teachers Report Form. Analyses performed included multivariate analyses of covariance (ANCOVA and MANCOVA) and logistic regression analyses. Results The EPT children displayed significant deficits in cognitive aspects of EF compared with the controls, exhibiting decreases on the order of 0.9 SD to 1.2 SD for tasks of verbal conceptual reasoning, verbal and non-verbal working memory, processing speed and planning ability (P <0.001 for all). After excluding the children with major neurosensory impairment (NSI) or a Full Scale intelligence quotient (FSIQ) of < 70, significant differences were observed on all tests. Compared with controls, parents and teachers of EPT children reported significantly more EF-related behavioral problems. MANCOVA of teacher-reported learning skills in children with FSIQ >70 and without major NSI revealed no interactions, but significant main effects were observed for the behavioral composite executive function score, group status (EPT vs control) and FSIQ, for which all effect sizes were medium to large. The corresponding findings of MANCOVA of the parent-reported learning skills were very similar. According to the teachers’ ratings, the EPT children were less well adjusted to the school environment. Conclusion EPT children born in the 1990s who received active perinatal care are at an increased risk of executive dysfunction, even after excluding children with significant neurodevelopmental disabilities. Even mild to moderate executive dysfunctions has a significant impact on learning skills. These findings suggest the need for timely interventions that address specific cognitive vulnerabilities and executive dysfunctions.

Relations among upper-limb movement organization and cognitive function at school age in children born preterm.

Objective: To explore relations between aspects of upper-body spatiotemporal movement organization and intelligence in children born preterm at school age. Methods: Three-dimensional (3D) kinematic recordings of arm and head movements during a unimanual precision task were related to performance on the Wechsler Intelligence Scale for Children, 4th edition, in a sample of 32 children born preterm (gestational age, mean: 31.5 weeks [range: 22–35 weeks]; birth weight, mean: 1699 g [range: 404–2962 g]) at 6 years to 8 years with no diagnosed cognitive, sensory, or motor impairments compared with 40 age-matched control children born fullterm. Results: In the children born preterm, upper-limb movement duration and segmentation of movement trajectories were significantly associated with full-scale intelligence quotient independent of gestational age (GA) and sex. These effects pertained to the preferred side, characterized by more effective movement organization being linked with increased intelligence scores. The same relations were not seen in the controls. Within the children born preterm, a significant effect of GA was also found for some aspects of upper-limb movement organization. Full-scale intelligence quotient was within normal limits for both groups but significantly lower in the preterm (mean: 94.5 [range: 72–120]) compared with the fullterm (mean: 101.7 [range: 76–119]) born children. Conclusions: The findings demonstrate that, independent of GA, the spatiotemporal organization of upper-limb movements is partly associated with cognitive performance in children born preterm.

Two-thirds of adolescents who received active perinatal care after extremely preterm birth had mild or no disabilities.

Active perinatal care (APC) increases the survival of extremely preterm (EPT) infants, but may increase the rate of disabilities. We examined neurodevelopmental outcomes in adolescents aged 10–15 years who were born EPT and received APC in two Swedish tertiary care centres.

Chronic Conditions and Health Care Needs of Adolescents Born at 23 to 25 Weeks' Gestation

OBJECTIVE: We examined chronic conditions, functional limitations, and special health care needs in extremely preterm children (EPT; 23–25 weeks’ gestation) born between 1992 and 1998 at 2 Swedish tertiary care centers that offered regional and active perinatal care to all live-born EPT infants. METHODS: Of 134 surviving EPT children, 132 (98%) were assessed at 10 to 15 years of age alongside 103 term-born controls. Identification of children with functional limitations and special health care needs was based on a questionnaire administered to parents. Categorization of medical diagnoses and developmental disabilities was based on child examinations, medical record reviews, and parent questionnaires. RESULTS: In logistic regression analyses adjusting for social risk factors and sex, the EPT children had significantly more chronic conditions than the term-born controls, including functional limitations (64% vs 6%; odds ratio [OR], 15; 95% confidence interval [CI], 6.1–37.2; P < .001), compensatory dependency needs (60% vs 29%; OR, 3.8; 95% CI, 2.2–6.6; P < .001), and services above those routinely required by children (64% vs 25%; OR, 5.4; 95% CI, 3.0–9.6; P < .001). Specific diagnoses and disabilities for the EPT group versus controls included cerebral palsy (9.1% vs 0%; P < .001), asthma (21.2% vs 6.8%; P = 001), IQ < –2 SD (31.1% vs 4.9%; P < .001), poor motor skills without neurosensory impairment (21.9% vs 1.9%; P < .001), and psychiatric conditions (15.2% vs 1.9%; P < .001). CONCLUSIONS: Adolescents born EPT have considerable long-term health and educational needs. Few had severe impairments that curtailed major activities of daily life.