E. Eugenie Hartmann

Growth and Development of Premature Infants Fed Predominantly Human Milk, Predominantly Premature Infant Formula, or a Combination of Human Milk and Premature Formula

Background In a recent meta-analysis, human milk feeding of low birth-weight (LBW) infants was associated with a 5.2 point improvement in IQ tests. However, in the studies in this meta-analysis, feeding regimens were used (unfortified human milk, term formula) that no longer represent recommended practice. Objective To compare the growth, in-hospital feeding tolerance, morbidity, and development (cognitive, motor, visual, and language) of LBW infants fed different amounts of human milk until term chronologic age (CA) with those of LBW infants fed nutrient-enriched formulas from first enteral feeding. Methods The data in this study were collected in a previous randomized controlled trial assessing the benefit of supplementing nutrient-enriched formulas for LBW infants with arachidonic acid and docosahexaenoic acid. Infants (n = 463, birth weight, 750–1,800 g) were enrolled from nurseries located in Chile, the United Kingdom, and the United States. If human milk was fed before hospital discharge, it was fortified (3,050–3,300 kJ/L, 22–24 kcal/oz). As infants were weaned from human milk, they were fed nutrient-enriched formula with or without arachidonic and docosahexaenoic acids (3,300 kJ/L before term, 3,050 kJ/L thereafter) until 12 months CA. Formula fed infants were given nutrient-enriched formula with or without added arachidonic and docosahexaenoic acids (3,300 kJ/L to term, 3,050 kJ/L thereafter) until 12 months CA. For the purposes of this evaluation, infants were categorized into four mutually exclusive feeding groups: 1) predominantly human milk fed until term CA (PHM-T, n = 43); 2) ≥ 50% energy from human milk before hospital discharge (≥ 50% HM, n = 98); 3) < 50% of energy from human milk before hospital discharge (< 50% HM, n = 203); or 4) predominantly formula fed until term CA (PFF-T, n = 119). Results PFF-T infants weighed approximately 500 g more at term CA than did PHM-T infants. This absolute difference persisted until 6 months CA. PFF-T infants were also longer (1.0–1.5 cm) and had larger head circumferences (0.3–1.1 cm) than both PHM-T and ≥ 50% HM infants at term CA. There was a positive association between duration of human milk feeding and the Bayley Mental Index at 12 months CA (P = 0.032 full and P = 0.073 reduced, statistical models) after controlling for the confounding variables of home environment and maternal intelligence. Infants with chronic lung disease fed ≥ 50% HM until term CA (n = 22) had a mean Bayley Motor Index about 11 points higher at 12 months CA compared with infants PFF-T (n = 24, P = 0.033 full model). Conclusion Our data suggest that, despite a slower early growth rate, human milk fed LBW infants have development at least comparable to that of infants fed nutrient-enriched formula. Exploratory analysis suggests that some subgroups of human milk fed LBW infants may have enhanced development, although this needs to be confirmed in future studies.

Project Universal Preschool Vision Screening: A Demonstration Project

OBJECTIVES. Visual disorders among preschool-aged children are common, yet screening is infrequent. The purpose of this project was to implement the vision screening recommendations proposed by the Maternal and Child Health Bureau and National Eye Institute Vision Screening in the Preschool Child Task Force: monocular visual acuity and stereopsis testing. METHODS. Four sites fully participated in the implementation of the task force recommendations with 3- and 4-year-old children. Two of the sites worked with primary care practices (testing performed by staff); 2 worked with community-based programs (testing performed by lay volunteers). Each site tracked number of children screened by age, as well as proportion testable, referred, and with documented follow-up evaluation. RESULTS. Variations in implementation of the recommendations were observed. Successful screening among 3-year-olds ranged from 70% to 93%; referral rates were 1% to 41%, and follow-up rates were 29% to 100%. Successful screening among 4-year-olds ranged from 88% to 98%; referral rates were 2% to 40%, and follow-up rates were 41% to 100%. The proportion of 3-year-olds who were treated was significantly different between the community-based sites (n = 20) and the primary care sites (n = 2). Similarly, the proportion of 4-year-olds who were treated was significantly different between the community-based sites (n = 36) and the primary care sites (n = 11). CONCLUSIONS. The variability across pilot sites in numbers successfully screened and numbers referred suggests that all aspects of preschool vision screening need thorough review before the goal of universal preschool vision screening can be realized.

Infant and child vision research: present status and future directions.

At the turn of the last century William James speculated that the sensory world of an infant would be a “blooming, buzzing confusion.” In fact, relatively little was known about visual development in infants and young children until the 1950s and 1960s, just before Velma embarked on her scientific career. With the advent of new techniques to assess systematically the vision of non-verbal, seemingly uncooperative subjects, a great deal has now been learned about vision in the first months and years after birth. Although specific information was being gathered from infants and young children, neuroscientists were demonstrating that visual experience could alter the neural circuitry of the developing brain. These insights had implications for the management and treatment of amblyopia. The demonstration of a sensitive period of cortical plasticity was good news in that it held promise for success in the treatment of experience-dependent conditions, but it was also bad news in that it demonstrated that the window of opportunity for aggressive treatment is early in childhood and relatively short. Velma’s work and career exemplify the integration of two key themes in understanding the development of vision in infants and children. The first has been to ask fundamental questions about the development of visual abilities in infants and how these skills integrate with other aspects of their motor and cognitive development. The second has been to ask how clinicians might be able to detect, diagnose, treat, and potentially prevent permanent visual abnormality during the first postnatal years. These two approaches were apparent in a major review published in the early 1990s. Chapters written by a group of scientists and clinicians, including Velma, were compiled and edited by Kurt Simons into the highly cited and referenced book, “Early Visual Development, Normal and Abnormal.” This current feature issue of OVS, 16 years on, has provided an excellent opportunity to reflect on these themes in the context of additional knowledge. The contributions to this issue illustrate the number of paths that have been taken in the past two decades. The development of the optics of the eye has attracted significant attention for three clinically important reasons. First, retinal image quality defines the information being presented to the developing neural visual system and we need to ensure that this information is appropriate for normal development during infancy and early childhood. Thus, we need to understand normal refractive development and the interaction between the developing optical and neural visual systems, in the context of amblyopia in particular. Second, numerous studies have demonstrated the potential for visual experience to influence the growth of the eye. We need to understand the process of emmetropization, and determine whether it can be encouraged through appropriate refractive correction. Finally, the realization that the incidence and prevalence of myopia is increasing dramatically around the world has revealed an urgent need for understanding the pathological underpinnings of this condition. We have been able to make real progress in our understanding of refractive development with the relatively recent development of autorefractors and photorefractors, as well as more robust approaches to quantifying refractive error. However, significant elements of these core questions still remain. The clinical assessment of the status of the visual system has also attracted attention, from both vision screening and full examination perspectives. There are still significant challenges in obtaining reliable data from “wriggly” children in a screening setting, and we are still some way from reaching a consensus about how best to provide the pediatric population with vision screenings. In addition to the impact of the sensitive period, these assessments also need to occur at a young age before children enter school with its additional visual demands. The recognition that early treatment is frequently beneficial for the developing visual system still drives us to refine techniques for reliably diagnosing, assessing, and monitoring visual status in the general clinical community. Still, we have basic work to do to develop a clear understanding of the mechanisms and natural history of a number of important and relatively common clinical conditions. Large-scale population based studies using efficient techniques are still required to determine the risk factors for these conditions and their natural history. There have also been a number of interesting demonstrations in the past 20 years that visual experience impacts developing neural circuitry at higher stages of processing, and therefore that tools are required to look at the more perceptual and cognitive aspects of function. In this context, there have been a series of studies looking at typical development of these functions and the impact of lower level immaturities on them, and also of complex and difficult clinical conditions. An area in which Velma has shown particular strength is the transfer of new knowledge to clinical care. The most significant contribution has likely been her work in two large clinical trials in retinopathy of prematurity (ROP), the Cryotherapy for ROP Study, and the Early Treatment for ROP Trial. By introducing quantitative assessment of grating visual acuity in infants and young children as a major outcome measure in these two studies, an earlier determination of potential functional benefit could be made rather than waiting until the child was able to provide more “standard” measures of acuity. Such outcome measures allowed 1040-5488/09/8606-0559/0 VOL. 86, NO. 6, PP. 559–560 OPTOMETRY AND VISION SCIENCE Copyright