Forrest C. Bennett

Early Intervention in Low Birth Weight Premature Infants: Results at 18 Years of Age for the Infant Health and Development Program

OBJECTIVE. To assess whether improvements in cognitive and behavioral development seen in preschool educational programs persist, we compared those in a multisite randomized trial of such a program over the first 3 years of life (INT) to those with follow-up only (FUO) at 18 months of age. METHODS. This was a prospective follow-up of the Infant Health and Development Program at 8 sites heterogeneous for sociodemographic characteristics. Originally 985 children were randomized to the INT (n = 377) or FUO (n = 608) groups within 2 birth weight strata: heavier low birth weight (HLBW; 2001–2499 g) and lighter low birth weight (LLBW; ≤2000 g). Primary outcome measures were the Peabody Picture Vocabulary Test (PPVT-III), reading and mathematics subscales of the Woodcock-Johnson Tests of Achievement, youth self-report on the Total Behavior Problem Index, and high-risk behaviors on the Youth Risk Behavior Surveillance System (YRBSS). Secondary outcomes included Weschler full-scale IQ, caregiver report on the Total Behavior Problem Index, and caregiver and youth self-reported physical health using the Medical Outcome Study measure. Assessors were masked as to study status. RESULTS. We assessed 636 youths at 18 years (64.6% of the 985, 72% of whom had not died or refused at prior assessments). After adjusting for cohort attrition, differences favoring the INT group were seen on the Woodcock-Johnson Tests of Achievement in math (5.1 points), YRBSS (−0.7 points), and the PPVT-III (3.8 points) in the HLBW youth. In the LLBW youth, the Woodcock-Johnson Tests of Achievement in reading was higher in the FUO than INT group (4.2). CONCLUSIONS. The findings in the HLBW INT group provide support for preschool education to make long-term changes in a diverse group of children who are at developmental risk. The lack of observable benefit in the LLBW group raises questions about the biological and educational factors that foster or inhibit sustained effects of early educational intervention.

Effects of Electronic Fetal-Heart-Rate Monitoring, as Compared with Periodic Auscultation, on the Neurologic Development of Premature Infants

In a multicenter, randomized clinical trial, we assessed the early neurologic development of 93 children born prematurely whose heart rates were monitored electronically during delivery and compared it with that of 96 children born prematurely whose heart rates were periodically monitored by auscultation. All the children were singletons with cephalic presentation, and all weighed less than or equal to 1750 g at birth. The mental and psychomotor indexes of the Bayley Scales of Infant Development (standardized mean score +/- SD, 100 +/- 16) and a formal neurologic examination were administered at three follow-up visits (at 4, 8, and 18 months of age, corrected for gestational age). At 18 months, the mean mental-development scores in the groups receiving electronic fetal monitoring and periodic auscultation were 100.5 +/- 2.4 and 104.9 +/- 1.8, respectively (P greater than 0.1). The mean psychomotor-development scores in the two groups at 18 months were 94.0 +/- 2.4 and 98.3 +/- 1.8, respectively (P greater than 0.1). The incidence of cerebral palsy was higher in the electronically monitored group--20 percent as compared with 8 percent in the group that was monitored by auscultation (P less than 0.03). In the electronic-fetal-monitoring group (but not in the periodic-auscultation group), the risk of cerebral palsy increased with the duration of abnormal fetal-heart-rate patterns, as assessed by retrospective review (chi 2 trend = 12.71, P less than 0.001). The median time to delivery after the diagnosis of abnormal fetal-heart-rate patterns was 104 minutes with electronic fetal monitoring, as compared with 60 minutes with periodic auscultation. We conclude that as compared with a structured program of periodic auscultation, electronic fetal monitoring does not result in improved neurologic development in children born prematurely.

Effectiveness of early intervention for children with Down syndrome

This article reviews studies evaluating the effectiveness of early intervention for children with Down syndrome. Evaluation of early intervention programs is difficult and challenging, given the wide variety of experimental designs and the limitations of research studies. Overall, however, positive changes were seen in the development of children who were exposed to early intervention programs. Children with Down syndrome and their families are likely to benefit from early intervention.

Use of physical and neurologic observations in assessment of gestational age in low birth weight infants

The relative validities of three clinical assessment methods for estimating gestational age in newborn low birth weight infants were evaluated with reference to estimates based on the date of the mothers last menstrual period. For 1246 infants in eight diverse institutions, estimates based on physical criteria correlated more strongly with dates estimates, yielded estimates more similar on average to dates estimates, and yielded higher proportions of correct classifications of prematurity and small for gestational age than did estimates based on neurologic criteria or neurologic and physical criteria combined. These results support the use of physical criteria rather than neurologic or combined criteria for the clinical assessment of gestational age in low birth weight infants. In a subsample of 511 black and white infants, there were no ethnic differences in mean error of estimate for any of the three methods.

Effectiveness of Developmental Intervention in the First Five Years of Life

Developmental intervention in the first 5 years of life is an expanding, complex enterprise. Documenting efficacy by traditional scientific methods has proven to be elusive for a number of practical reasons, e.g., target population heterogeneity, methodology variability, inadequate outcome measures, and cost of longitudinal cohort designs. Nevertheless, despite these shortcomings, there is accumulating research information as to which types of intervention approaches are likely to be most beneficial to specific groups of infants and children and their families. It is quite clear that preventive strategies for at-risk children and families are different than ameliorative strategies for children with established disabilities. It is also clear that comprehensive evaluation of effectiveness must include consideration of both functional child gains (e.g., social, communication, mobility, and adaptive skills) and enhancement of family function. It is the pediatricians responsibility to be adequately informed about contemporary developmental interventions in order to balance parental hopes and needs with potential benefits.

Long-Term Perspective on Premature Infant Outcome and Contemporary Intervention Issues

Despite improvements in survival rates for low birthweight (LBW) infants, the prevalence among survivors of major neurodevelopmental impairment seems relatively stable. Cerebral palsy, the most common major impairment, can usually be ruled out by 18 months corrected age. Minor impairments such as learning disabilities cannot be ruled out until much later. The efficacy of interventional services in this population was addressed by a national randomized trial. The intervention produced large treatment effects for heavier LBW infants and moderate effects for lighter infants. Five years later, modest residual effects were found for heavier LBW infants, but not for the lighter, suggesting that 0 to 3 services alone are not sufficient to prevent scholastic disadvantage in this population.

Uncertainty in Childhood Chronic Conditions and Family Distress in Families of Young Children

The objective of this study was to identify the relationship between the degree of uncertainty in the child’s chronic condition and family distress. Data were collected from parents (173 mothers, 150 fathers) of young children (12 to 30 months old) who had been diagnosed with a chronic physical health impairment within the past 12 months. Children were divided into separate groups, first based on the predictability of their symptoms and next based on the degree of certainty in their life expectancy. Using analysis of covariance, sex-stratified comparisons were made between the predictability groups and then between the life expectancy groups and five subscales of the Impact-on-Family Scale. Parents of young children with chronic conditions with intermittently unpredictable symptoms reported significantly more family distress than parents of children with more predictable symptoms. No significant differences were found for mothers or fathers between the degree of uncertainty in the child’s life expectancy and family distress.

Management of childhood "hyperactivity" by primary care physicians.

A questionnaire assessing current clinical approach to the problem of childhood hyperactivity was mailed to 910 primary care physicians in the state of Washington. A response of 462 (50.8%) was obtained. Pediatricians assess and manage hyperactivity in a manner significantly different from that of family physicians or general practitioners. Age of physician also accounted for significant differences, although to a lesser degree than type of training. Few differences were determined by size of community. An overall high prevalence of the problem of hyperactivity was apparent. Combined use of stimulant medications, behavioral programs, and special diets was common.

Stimulant medication for the child with attention-deficit/hyperactivity disorder.

Stimulant medications have been used to manage the associated symptoms of ADHD including inattention, developmentally inappropriate levels of activity, distractibility, and impulsivity. To date, clinical trials clearly have established the efficacy of the stimulants on the core symptoms of ADHD and associated aggression. Although the stimulants improve classroom productivity and behavior, few data have demonstrated the effectiveness of the stimulants on academic achievement. Finally, there has been a paucity of data on the long-term efficacy and safety of stimulants. Recommendations are made for future research studies that examine the integration of stimulant medication with other psychosocial therapies, particularly behavior management.

Neuromotor Development of Graduates of the Neonatal Intensive Care Unit: Patterns Encountered in the First Two Years of Life

The neurodevelopmental course of 219 Neonatal Intensive Care Unit graduates followed prospectively over 2 years was determined on retrospective chart review. Mild neuromotor abnormalities during the first year were identified in 50%, three-quarters of which proved transient with normal development at 2 years of age. Moderate abnormalities were identified in 7%, half of which proved transient. Severe neuromotor abnormalities were identified in 20%, two-thirds of whom had cerebral palsy at 2 years. Persistent noncerebral palsy neuromotor abnormalities remained in one-third of those in the severe abnormality group, one-half of those in the moderate abnormality group, and one-quarter of those in the mild abnormality group. As birthweight decreased, the incidence of always normal development and transient neuromotor abnormalities decreased while the incidence of persistent neuromotor abnormalities increased. Small for gestational age infants demonstrated a slightly higher incidence of persistent abnormalities than their appropriate for gestational age counterparts. No significant sex differences were observed.