Elizabeth A. Pater

Association of intrauterine fetal growth retardation and learning deficits at age 9 to 11 years

OBJECTIVE We examined the association of fetal and newborn complications, socioeconomic status, and home environment with learning deficits as assessed between 9 and 11 years of age. STUDY DESIGN A total of 218 high-risk newborns have been assessed at 1, 4, and 9 to 11 years of age. Fetal and newborn complications included 77 newborns with growth retardation. Socioeconomic variables included parental occupation and education. Outcome measures at 9 to 11 years included the Woodcock Reading Mastery Test and the Wide Range Achievement Test. Motor and cognitive development was assessed by a neurologic examination, the Bruininks-Oseretsky Test of Motor Proficiency, and the Wechsler Intelligence Scale for Children. Behavior was assessed with the Achenbach Child Behavior Check List and Connors Teacher Rating Scale. RESULTS Learning deficits were identified in 77 of the 218 children (35%). Children with learning deficits had lower full-scale IQ scores and behavioral problems of inattention and anxiety. Both fetal growth retardation and the fathers occupation score were independently associated with these learning deficits. CONCLUSION Fetal growth retardation, socioeconomic status, and behavioral characteristics of inattention and anxiety are associated with less favourable academic achievement at 9 to 11 years of age.

Motor and cognitive deficits after intrapartum asphyxia in the mature fetus

The incidence of major and minor motor and/or cognitive deficits at 1 year of age, in 37 mature children who had experienced an intrapartum fetal asphyxial insult, was compared with the incidence of deficits at 1 year in 76 children of the control group. The incidence of both major and minor deficits was significantly greater in the group with intrapartum fetal asphyxia in relation to the control group. These findings support the concept that, beyond a critical threshold of fetal asphyxia, a continuum of casualty in the surviving newborn infants exists.

Factors associated with motor and cognitive deficits in children after intrapartum fetal hypoxia

Sixty children with biochemical evidence of intrapartum fetal hypoxia were studied to define the factors which distinguish the children with deficits from those without deficits of motor and cognitive development. Follow-up assessment included growth measures, neurological examination, Bayley Scales of Infant Development, and a modified Uzgiris and Hunt Scale. Eight children (13%) had a major deficit and 10 children (16%) had a minor deficit at 1 year. Children with deficits had an episode of hypoxia that was more severe and prolonged and, subsequent to delivery, a greater incidence of severe respiratory complications, apnea, and newborn encephalopathy. No other significant risk factors were identified. It is concluded that an episode of hypoxia less than one hour may occur without subsequent deficits. However, an episode of hypoxia in excess of 1 hour resulting in a metabolic acidosis of the order of 25 mEq/L will be followed by motor and cognitive deficits in approximately 50% of children.

Intrapartum fetal hypoxia: A study of long-term morbidity

Reported is the second phase of a prospective follow-up study of 37 children who had episodes of intrapartum fetal hypoxia at delivery identified by an acid-base assessment and of a control group of 59 children who had no evidence of intrapartum fetal hypoxia. The newborn infants were normally grown and mature at delivery. Follow-up assessments of motor, cognitive, and language development were made between 1 and 6 years of age. There was no significant difference in the pattern of physical growth and the incidences of motor and cognitive handicap or developmental delay, language developmental delay, and tests of vision and hearing in the children of the hypoxia group and the children of the control group. These findings suggest that acid-base measures of metabolic acidosis can be used as a method of assessment of the mature normally grown fetus during labor without compromising the long-term outcome of the child.

Maternal, fetal, and newborn complications associated with newborn intracranial hemorrhage

Two hundred twenty newborn infants with one or more fetal or newborn complications and 54 newborn infants without fetal or newborn complications were prospectively studied to assess the relationship between maternal, obstetric, fetal, and newborn complications and intracranial hemorrhage. Intracranial hemorrhage occurred in 47 newborn infants with fetal or newborn complications (21%) and in one infant with no fetal or newborn complications (2%). Maternal and obstetric complications, duration of labor, and mode of delivery were not associated with intracranial hemorrhage. Newborn immaturity at delivery is an important factor in the occurrence of intracranial hemorrhage. There is little evidence that fetal hypoxia is a contributing factor. Severe respiratory complications and major infections are newborn complications associated with intracranial hemorrhage.

Motor and cognitive development of infants with intraventricular hemorrhage, ventriculomegaly, or periventricular parenchymal lesions

Two hundred twenty-six moderate- or high-risk newborn infants were studied to examine the relationship between ultrasound findings in the newborn period and at 6 months and motor and cognitive deficits at 1 year. A three-part classification of abnormal ultrasound findings was used to grade intraventricular hemorrhage, ventriculomegaly, and parenchymal lesions. Abnormal ultrasound findings were observed in 48 infants, of whom 21 had intraventricular hemorrhage, 18 persistent ventriculomegaly, and nine parenchymal lesions. The incidence of deficits was as follows: normal ultrasound examination, 20%; intraventricular hemorrhage, 33%; persistent ventriculomegaly, 67%; and parenchymal lesions, 89%. The present study indicates that serial ultrasound examinations are indicated in preterm newborn infants less than 1500 gm and in selected newborn infants at risk and greater than 1500 gm at birth. The three-part classification of abnormal ultrasound findings should be used because of the predictive significance of persistent ventriculomegaly and parenchymal lesions for motor and cognitive deficits at 1 year of age.

Intrapartum asphyxia in the preterm fetus <2000 gm

The incidence of intrapartum asphyxia in the preterm fetus less than 2000 gm (6%) is greater than that in the mature fetus (2%). Severe antepartum hemorrhage is the only clinical marker predictive of asphyxia in the preterm fetus. Marked deceleration patterns and particularly late decelerations may be of predictive value for asphyxia. However, many intrapartum asphyxial episodes are not identified on the basis of clinical observations. Consistent diagnosis of intrapartum asphyxia in the preterm fetus requires routine umbilical cord blood gas and acid-base assessment at delivery.

The association of intrapartum asphyxia in the mature fetus with newborn behavior

A matched cohort study of mature newborns with biochemically determined intrapartum fetal asphyxia and mature newborns with normal blood gas and acid-base assessments at delivery were studied to demonstrate the effect of fetal asphyxia on newborn behavior as expressed by the Brazelton newborn behavioral assessment scale. The newborn behavioral assessment scale was administered 3 days after delivery and again 2 weeks after delivery. The Lester newborn behavioral assessment scale summary scores for the group with asphyxia were of the same order as those in the control group. This was also true of the group of newborns with asphyxia with the more severe metabolic acidosis and those with low Apgar scores. These findings support the contention that many newborns who have undergone an intrapartum asphyxial insult will not have evidence of central nervous system injury and that the threshold of central nervous system injury is at the severe end of the spectrum of asphyxia as expressed by a metabolic acidosis.

The predictive significance of biologic risk factors for deficits in children of a high-risk population.

Two hundred forty-two high-risk children and 47 low-risk children were prospectively studied to assess the relationship between biologic risk factors that occurred during the perinatal period and the motor and cognitive deficits that were identified during the first year of life. Multiple risk factors were present in 80% of the children of the high-risk group. Provisional deficits were classified on the degree of abnormality found in a clinical and behavioral assessment that included neurological examinations, Bayley Physical and Mental Development Scales, and the Uzgiris and Hunt Scale. Provisional deficits occurred in 10% of the children of the low-risk group. High-risk children had a significantly greater incidence of provisional deficits, particularly in respect to positive deficits. In high-risk children, the probability of a deficit was 17% in those without infection or encephalopathy, 30% in those with infection, and 40% in those with encephalopathy.