Diane Warner

Extremely low gestational age and very low birthweight for gestational age are risk factors for autism spectrum disorder in a large cohort study of 10-year-old children born at 23-27 weeks' gestation.

Background: No prospective cohort study of high‐risk children has used rigorous exposure assessment and optimal diagnostic procedures to examine the perinatal antecedents of autism spectrum disorder separately among those with and without cognitive impairment. Objective: We sought to identify perinatal factors associated with increased risk for autism spectrum disorder with and without intellectual disability (intelligence quotient <70) in children born extremely preterm. Study Design: This prospective multicenter (14 institutions in 5 states) birth cohort study included children born at 23–27 weeks’ gestation in 2002 through 2004 who were evaluated for autism spectrum disorder and intellectual disability at age 10 years. Pregnancy information was obtained from medical records and by structured maternal interview. Cervical‐vaginal “infection” refers to maternal report of bacterial infection (n = 4), bacterial vaginosis (n = 30), yeast infection (n = 62), mixed infection (n = 4), or other/unspecified infection (n = 43; eg, chlamydia, trichomonas, or herpes). We do not know the extent to which infection per se was confirmed by microbial colonization. We use the terms “fetal growth restriction” and “small for gestational age” interchangeably in light of the ongoing challenge to discern pathologically from constitutionally small newborns. Severe fetal growth restriction was defined as a birthweight Z‐score for gestational age at delivery <–2 (ie, ≥2 SD below the median birthweight in a referent sample that excluded pregnancies delivered for preeclampsia or fetal indications). Participants were classified into 4 groups based on whether or not they met rigorous diagnostic criteria for autism spectrum disorder and intellectual disability (autism spectrum disorder+/intellectual disability–, autism spectrum disorder+/intellectual disability+, autism spectrum disorder–/intellectual disability+, and autism spectrum disorder–/intellectual disability–). Temporally ordered multinomial logistic regression models were used to examine the information conveyed by perinatal factors about increased risk for autism spectrum disorder and/or intellectual disability (autism spectrum disorder+/intellectual disability–, autism spectrum disorder+/intellectual disability+, and autism spectrum disorder–/intellectual disability+). Results: In all, 889 of 966 (92%) children recruited were assessed at age 10 years, of whom 857 (96%) were assessed for autism spectrum disorder; of these, 840 (98%) children were assessed for intellectual disability. Autism spectrum disorder+/intellectual disability– was diagnosed in 3.2% (27/840), autism spectrum disorder+/intellectual disability+ in 3.8% (32/840), and autism spectrum disorder–/intellectual disability+ in 8.5% (71/840). Maternal report of presumed cervical‐vaginal infection during pregnancy was associated with increased risk of autism spectrum disorder+/intellectual disability+ (odds ratio, 2.7; 95% confidence interval, 1.2–6.4). The lowest gestational age category (23–24 weeks) was associated with increased risk of autism spectrum disorder+/intellectual disability+ (odds ratio, 2.9; 95% confidence interval, 1.3–6.6) and autism spectrum disorder+/intellectual disability– (odds ratio, 4.4; 95% confidence interval, 1.7–11). Severe fetal growth restriction was strongly associated with increased risk for autism spectrum disorder+/intellectual disability– (odds ratio, 9.9; 95% confidence interval, 3.3–30), whereas peripartum maternal fever was uniquely associated with increased risk of autism spectrum disorder–/intellectual disability+ (odds ratio, 2.9; 95% confidence interval, 1.2–6.7). Conclusion: Our study confirms that low gestational age is associated with increased risk for autism spectrum disorder irrespective of intellectual ability, whereas severe fetal growth restriction is strongly associated with autism spectrum disorder without intellectual disability. Maternal report of cervical‐vaginal infection is associated with increased risk of autism spectrum disorder with intellectual disability, and peripartum maternal fever is associated with increased risk for intellectual disability without autism spectrum disorder.

A Quality Improvement Project to Improve the Rate of Early Breast Milk Expression in Mothers of Preterm Infants

Providing breast milk is challenging for non-nursing mothers of premature infants. Early breast milk expression results in successful and longer lactation in mothers of very low birth weight (VLBW) infants. This quality improvement initiative sought to increase the rate of early milk expression in mothers of VLBW infants and increase the proportion of infants receiving maternal breast milk (MBM) at 28 days of age and at discharge. Phase 1 (n = 45) occurred between April 1, 2012, and August 31, 2012. Phase 2 (n = 58) occurred between September 1, 2012, and February 28, 2013. Pre-phase 2 actions included increased lactation consultant workforce, early lactation consultation, tracking of MBM supply, and physician education. Inborn infants < 1500 grams were eligible. Primary outcomes were the time of first maternal milk expression (TFME) and infant feeding type at 28 days of age and at discharge. The median TFME decreased from 9 (25th, 75th percentile; 6, 16) hours to 6 (5, 11) hours after implementation (P = .06). The proportion of infants receiving exclusive MBM at 28 days and at discharge was 64% and 74%, respectively (P = .40), and the proportion of infants receiving exclusive MBM at discharge increased from 37% to 59% (P = .046). In conclusion, a multidisciplinary initiative aimed at improving the rate of early milk expression was associated with more VLBW infants receiving exclusive MBM at discharge.

Neurocognitive Outcomes at 10 Years of Age in Extremely Preterm Newborns with Late-Onset Bacteremia

OBJECTIVE To evaluate the difference in 10-year neurocognitive outcomes between extremely low gestational age newborns without bacteremia and those with suspected or confirmed late-onset bacteremia. STUDY DESIGN Neurocognitive function was evaluated at 10 years of age in 889 children born at <28 weeks of gestation and followed from birth. Definite (culture-positive) late-onset bacteremia during postnatal weeks 2-4 was identified in 223 children, and 129 children had suspected bacteremia. RESULTS Infants with the lowest gestational age and birth weight z-score had the highest prevalence of definite and suspected late-onset bacteremia. Compared with peers with no or suspected bacteremia, infants with definite bacteremia performed worse on tests of general cognitive ability, language, academic achievement, and executive function, even after adjustment for potential confounders. Adjustment for low IQ attenuated the associations between bacteremia and all dysfunctions at age 10 years. Children with suspected bacteremia did not differ appreciably from those with no evidence of bacteremia. The motor domain was unaffected. CONCLUSIONS Extremely low gestational age newborns who had definite late bacteremia during postnatal weeks 2-4 are at heightened risk of neurocognitive limitations at age 10 years.

Factors Influencing the Accuracy of Noninvasive Blood Pressure Measurements in NICU Infants.

OBJECTIVE Compare invasive blood pressure (IBP) and noninvasive blood pressure (NIBP) measurement methods in the neonatal intensive care unit (NICU) across various gestational age and postmenstrual age (PMA), and determine the effect of gestational age and PMA on accuracy of NIBP measurements. STUDY DESIGN Retrospective chart review of paired mean IBP and NIBP measurements from infants admitted to a single NICU from January 2008 through December 2010. Infants with congenital anomalies or receiving therapeutic hypothermia were excluded. Difference between paired measurements was analyzed using Bland-Altman method. We examined the association between PMA, sex, race, mechanical ventilation, medications, and axillary temperature, and the difference in measurements using a mixed effects linear regression model. RESULTS Eighty-seven infants had 243 observations. The mean (range) gestational age at birth was 31.9 (23-41) weeks and PMA at time of measurement ranged from 26 to 52 weeks. We found poor agreement between IBP and NIBP measurements, with mean difference (95% limits of agreement) of -8.8 (11, -28.7) mm Hg. The mean blood pressure percent difference ( ±  SD) was -28.3 ( ±  35.6%). A greater blood pressure percent difference between the two measurement techniques was associated with lower PMA and lower mean IBP. CONCLUSION NIBP measurements overestimate IBP measurements particularly in smaller, sicker infants at lower IBP measurements.

Antecedents of Screening Positive for Attention Deficit Hyperactivity Disorder in Ten-Year-Old Children Born Extremely Preterm

BACKGROUND The incidence of attention deficit hyperactivity disorder is higher among children born very preterm than among children who are mature at birth. METHODS We studied 583 ten-year-old children who were born before 28 weeks of gestation whose IQ was above 84 and had a parent-completed Child Symptom Inventory-4, which allowed classification of the child as having or not having symptoms of attention deficit hyperactivity disorder. For 422 children, we also had a teacher report, and for 583 children, we also had a parent report of whether or not a physician made an attention deficit hyperactivity disorder diagnosis. RESULTS The risk profile of screening positive for attention deficit hyperactivity disorder based on a parents report differed from the risk profile based on the teachers report, whereas the risk profile according to a physician and according to any two observers closely resembled the parent-reported profile. Among the statistically significant risk factors were young maternal age (parent, physician, and two observers), maternal obesity (parent, physician, and two observers), maternal smoking (parent, physician, and two observers), magnesium given at delivery for seizure prophylaxis (parent and two observers), recovery of Mycoplasma sp. from the placenta (teacher and two observers), low gestational age (parent and two observers), low birth weight (teacher and physician), singleton (parent, physician, and two observers), male (parent, teacher, physician, and two observers), mechanical ventilation on postnatal day seven (physician), receipt of a sedative (parent and two observers), retinopathy of prematurity (parent), necrotizing enterocolitis (physician), antibiotic receipt (physician and two observers), and ventriculomegaly on brain scan (parent and two observers). CONCLUSIONS The multiplicity of risk factors identified can be subsumed as components of four broad themes: low socioeconomic state, immaturity or vulnerability, inflammation, and epigenetic phenomena.

The Relationship of Maternal Prepregnancy Body Mass Index and Pregnancy Weight Gain to Neurocognitive Function at Age 10 Years among Children Born Extremely Preterm

Objective To assess the association between maternal prepregnancy body mass index and adequacy of pregnancy weight gain in relation to neurocognitive function in school‐aged children born extremely preterm. Study design Study participants were 535 ten‐year‐old children enrolled previously in the prospective multicenter Extremely Low Gestational Age Newborns cohort study who were products of singleton pregnancies. Soon after delivery, mothers provided information about prepregnancy weight. Prepregnancy body mass index and adequacy of weight gain were characterized based on this information. Children underwent a neurocognitive evaluation at 10 years of age. Results Maternal prepregnancy obesity was associated with increased odds of a lower score for Differential Ability Scales‐II Verbal IQ, for Developmental Neuropsychological Assessment‐II measures of processing speed and visual fine motor control, and for Wechsler Individual Achievement Test‐III Spelling. Children born to mothers who gained an excessive amount of weight were at increased odds of a low score on the Oral and Written Language Scales Oral Expression assessment. Conversely, children whose mother did not gain an adequate amount of weight were at increased odds of a lower score on the Oral and Written Language Scales Oral Expression and Wechsler Individual Achievement Test‐III Word Reading assessments. Conclusion In this cohort of infants born extremely preterm, maternal obesity was associated with poorer performance on some assessments of neurocognitive function. Our findings are consistent with the observational and experimental literature and suggest that opportunities may exist to mitigate risk through education and behavioral intervention before pregnancy. (J Pediatr 2017;187:50‐7).

Further support for first-trimester disruption causing the oromandibular-limb hypogenesis spectrum of anomalies

School of Medicine, Department of Ophthalmology, UNC Center for Maternal and Infant Health, Departments of Pediatrics and Pediatrics and Genetics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA Correspondence to Arthur S. Aylsworth, MD, University of North Carolina CB# 7487 UNC Campus at Chapel Hill, Chapel Hill, NC 27599-7487, USA Tel: +1 919 966 5756; fax: +1 919 966 3025; e-mail: asayls@med.unc.edu

Among Children Born Extremely Preterm a Higher Level of Circulating Neurotrophins Is Associated with Lower Risk of Cognitive Impairment at School Age

Objectives To test the hypothesis that higher blood levels of neurotrophic proteins (proteins that support neuronal survival and function) in the first 2 weeks of life are associated with a lower risk of cognitive impairment at 10 years. Study design We evaluated 812 10‐year‐old children with neonatal blood specimens enrolled in the multicenter prospective Extremely Low Gestational Age Newborn Study, assessing 22 blood proteins collected on 3 days over the first 2 weeks of life. Using latent profile analysis, we derived a cognitive function level based on standardized cognitive and executive function tests. We defined high exposure as the top quartile neurotrophic protein blood level on ≥2 days either for ≥4 proteins or for a specific cluster of neurotrophic proteins (defined by latent class analysis). Multinomial logistic regression analyzed associations between high exposures and cognitive impairment. Results Controlling for the effects of inflammatory proteins, persistently elevated blood levels of ≥4 neurotrophic proteins were associated with reduced risk of moderate (OR, 0.35; 95% CI, 0.18‐0.67) and severe cognitive impairment (OR, 0.22; 95% CI, 0.09‐0.53). Children with a cluster of elevated proteins including angiopoietin 1, brain‐derived neurotrophic factor, and regulated upon activation, normal T‐cell expressed, and secreted had a reduced risk of adverse cognitive outcomes (OR range, 0.31‐0.6). The risk for moderate to severe cognitive impairment was least with 0‐1 inflammatory and >4 neurotrophic proteins. Conclusions Persisting elevations of circulating neurotrophic proteins during the first 2 weeks of life are associated with lowered risk of impaired cognition at 10 years of age, controlling for increases in inflammatory proteins.

Hand Preference and Cognitive, Motor, and Behavioral Functioning in 10-Year-Old Extremely Preterm Children

&NA; The association of hand preference (left, mixed, and right) with cognitive, academic, motor, and behavioral function was evaluated in 864 extremely preterm children at 10 years of age. Left‐handed and right‐handed children performed similarly but mixed‐handed children had greater odds of functional deficits across domains than right‐handed children.