Francine Lefebvre

Mediators of behavioral problems in 7-year-old children born after 24 to 28 weeks of gestation

We tested the hypothesis that prematurity acts through its association with neuromotor and intellectual functioning to explain behavior problems at school age. Sixty-one extremely preterm (EP) very low birth weight (VLBW) children (< 29 wk and < 1500 g) born in 1987-1990 and 44 normal birth weight children (NBW) (> 37 wk and > 2500 g) were matched for age, sex, and socioeconomic status (SES). Mediator variables were evaluated at a hospital at 5 years and 9 months. Behaviors were evaluated at school at 7 years by peers, teachers, and parents. When compared with NBW children, EP/VLBW children had poorer IQ and neuromotor development. At school, EP/VLBW children were evaluated by peers as more sensitive/isolated, and by teachers and parents as more inattentive and hyperactive than NBW. When mediators were introduced, the previously significant relation between prematurity and behavior problems disappeared. Hyperactive and inattentive behaviors were explained by a specific working memory factor for the latter, and by a general intellectual delay for the former, whereas sensitive/isolated behaviors were best explained by neuromotor delays. Inattentive behaviors were also related to family adversity. At school age, extreme prematurity had thus an indirect effect on behaviors via specific and nonspecific intellectual and neuromotor delays.

OUTCOME AT SCHOOL AGE OF CHILDREN WITH BIRTHWEIGHTS OF 1000 GRAMS OR LESS

A follow‐up study was done of extremely low‐birthweight infants (≤ 1000g) born between 1976 and 1979, a períod when aggressive intervention was not routine practice. The survival rate was 19 per cent. 44 of the 46 survivors were followed to a mean age of 6 1/2 years. By five years of age 23 of the 44 children had been admitted to hospital, mainly for surgery and respiratory problems. Eight of 31 five‐year‐old children were growth‐retarded and five of 26 were microcephalic. Among 44 children, ophthalmological problems were found in nine cases and neurosensory impairments (cerebral palsy, deafness:) in seven. 12 children were mentally handicapped or had impaired intelligence (IQ or DQ < 85). Over‐all, 14 of the 44 children had impairments, severe in four cases and moderate in 10. Mean verbal IQ was significantly lower than mean performance IQ. Among 37 children in school or in remedial programs, nine required special education and another 12 in regular classes either failed or had very poor results, or needed extra professional help. Only 16 of the children had no significant problems in school. These findings indicate that extremely low birthweight (≤ 1000g) represents a major risk to life, health (hospital admissions), long‐term growth, neurosensory integrity, cognitive development and learning potential.

Victimization: a newly recognized outcome of prematurity

Victimization by peers affects 10 to 20% of school children under the age of 12 years. Physical, verbal, and psychological victimization (being pushed, hit, called names, teased, being the target of rumours, theft, extortion) is associated with short‐ and long‐term adjustment problems, such as peer rejection, social withdrawal, low self‐esteem, anxiety, loneliness, and depression, as well as academic problems and school drop‐out. Research on populations of school children (primary and secondary) has associated victimization with personal risk factors (the victims characteristics and behaviour) and interpersonal risk factors (social relationships between peers). Studies on the social adjustment of preterm children at school age show that, even in the absence of a major motor or cognitive disability, this population has several personal risk factors associated with victimization. The objective of this study was to compare the level of victimization experienced by a group of 96 seven‐year‐old children born extremely preterm (EP, <29 weeks of gestation; 49 females) against that experienced by a group of 63 term children (34 females) matched for age and sex, maternal level of education, and family socioeconomic status. The children born EP had a mean gestational age of 27.3 weeks (SD 1.2) and a mean birthweight of 1001.1g (SD 223) and normal birth weight children had a mean gestational age of 39.5 weeks (SD 1.5) and a mean birthweight of 3468.7g (SD 431). Physical and verbal victimization were assessed in a school setting by peers with individual sociometric interviews (Modified Peer Nomination Inventory). After controlling for physical growth (height and weight) at the age of 7 years, the data indicate two independent effects: males were more victimized than females, and children born preterm experienced more verbal victimization by their peers than their term classmates, even when participants with a visible motor, intellectual, or sensory disability were excluded. Several hypotheses are presented to account for the higher incidence of verbal victimization of preterm children.

Role of gender in morbidity and mortality of extremely premature neonates.

We investigated the effect of gender on survival and short-term outcomes of extremely premature infants (≤27 weeks) born in Canada. The records of infants admitted between 2000 and 2005 to a neonatal intensive care unit participating in the Canadian Neonatal Network were reviewed for infant gender, birth weight, gestational age, outborn status, Score for Neonatal Acute Physiology II, and antenatal corticosteroid exposure. The following outcomes were recorded: survival at final discharge, necrotizing enterocolitis, bronchopulmonary dysplasia (BPD), intraventricular hemorrhage grade ≥3, retinopathy grade ≥3, days on ventilation, and length of hospital stay. Among 2744 extremely premature infants, 1480 (54%) were male and 1264 (46%) were female. Mean birth weight of female neonates was significantly lower at each week of gestational age. Although no significant difference in survival at discharge was found between genders overall, the prevalence of BPD, combined adverse outcomes, and mortality for infants born between 24 and 26 weeks were significantly higher in males. This study suggests that, in the postsurfactant era, males remain at higher risk of respiratory complications and may have higher mortality when born between 24 and 26 weeks of gestation.

The Cues and Care Trial: A randomized controlled trial of an intervention to reduce maternal anxiety and improve developmental outcomes in very low birthweight infants

BackgroundVery low birthweight infants are at risk for deficits in cognitive and language development, as well as attention and behaviour problems. Maternal sensitive behaviour (i.e. awareness of infant cues and appropriate responsiveness to those cues) in interaction with her very low birthweight infant is associated with better outcomes in these domains; however, maternal anxiety interferes with the mothers ability to interact sensitively with her very low birthweight infant. There is a need for brief, cost-effective and timely interventions that address both maternal psychological distress and interactive behaviour. The Cues and Care trial is a randomized controlled trial of an intervention designed to reduce maternal anxiety and promote sensitive interaction in mothers of very low birthweight infants.Methods and designMothers of singleton infants born at weights below 1500 g are recruited in the neonatal intensive care units of 2 tertiary care hospitals, and are randomly assigned to the experimental (Cues) intervention or to an attention control (Care) condition. The Cues intervention teaches mothers to attend to their own physiological, cognitive, and emotional cues that signal anxiety and worry, and to use cognitive-behavioural strategies to reduce distress. Mothers are also taught to understand infant cues and to respond sensitively to those cues. Mothers in the Care group receive general information about infant care. Both groups have 6 contacts with a trained intervener; 5 of the 6 sessions take place during the infants hospitalization, and the sixth contact occurs after discharge, in the participant mothers home. The primary outcome is maternal symptoms of anxiety, assessed via self-report questionnaire immediately post-intervention. Secondary outcomes include maternal sensitive behaviour, maternal symptoms of posttraumatic stress, and infant development at 6 months corrected age.DiscussionThe Cues and Care trial will provide important information on the efficacy of a brief, skills-based intervention to reduce anxiety and increase sensitivity in mothers of very low birthweight infants. A brief intervention of this nature may be more readily implemented as part of standard neonatal intensive care than broad-based, multi-component interventions. By intervening early, we aim to optimize developmental outcomes in these high risk infants.Trial RegistrationCurrent Controlled Trials ISRCTN00918472The Cues and Care Trial: A randomized controlled trial of an intervention to reduce maternal anxiety and improve developmental outcomes in very low birthweight infants

Extremely Premature and Very Low Birthweight Infants: A Double Hazard Population?

This article evaluates the contributions of birth status (defined by gestational age and birthweight) and family adversity at birth and at age 7 to explaining behavior problems at age 7. The behaviors of 96 extremely preterm and very low birth-weight children and 66 full-term children were assessed in a school setting by peers, teachers and parents. The results show that a significant relationship exists between birth status and isolation and social withdrawal problems as well as between birth status and social immaturity and inattention problems. Family adversity at birth has a significant contribution to aggressive behaviors reported by the three sources whereas, at age 7, this index is associated only with aggressive behaviors and social immaturity problems reported by parents. In conclusion, the results of the present study qualify the findings of studies that suggest that at school age, the effect of prematurity decreases and that behavior problems are explained chiefly by family environment characteristics. Our results indicate that the findings must take into account the cohort studied, the environmental measures used, the type of behaviors assessed as well as the type of informants.

Pregnancy complications among women born preterm

Background: Adults who were born with low birth weights are at increased risk of cardiovascular and metabolic conditions, including pregnancy complications. Low birth weight can result from intrauterine growth restriction, preterm birth or both. We examined the relation between preterm birth and pregnancy complications later in life. Methods: We conducted a population-based cohort study in the province of Quebec involving 7405 women born preterm (554 < 32 weeks, 6851 at 32–36 weeks) and a matched cohort of 16 714 born at term between 1976 and 1995 who had a live birth or stillbirth between 1987 and 2008. The primary outcome measures were pregnancy complications (gestational diabetes, gestational hypertension, and preeclampsia or eclampsia). Results: Overall, 19.9% of women born at less than 32 weeks, 13.2% born at 32–36 weeks and 11.7% born at term had at least 1 pregnancy complication at least once during the study period (p < 0.001). Women born small for gestational age (both term and preterm) had increased odds of having at least 1 pregnancy complication compared with women born at term and at appropriate weight for gestational age. After adjustment for various factors, including birth weight for gestational age, the odds of pregnancy complications associated with preterm birth was elevated by 1.95-fold (95% confidence interval [CI] 1.54–2.47) among women born before 32 weeks’ gestation and 1.14-fold (95% CI 1.03–1.25) among those born at 32–36 weeks’ gestation relative to women born at term. Interpretation: Being born preterm, in addition to, and independent of, being small for gestational age, was associated with a significantly increased risk of later having pregnancy complications.

Nursery Neurobiologic Risk Score and outcome at 18 months

The aim of this study was to confirm the predictive value of the nursery Neurobiologic Risk Score. Prospectively, 121 infants (mean birthweight 961 ± 179 g, gestation 27.0 ± 1.2 weeks) were followed at 18 months. The nursery Neurobiologic Risk Score was correlated to the developmental quotient (r=– 0.54). From low (scores 0‐4), to moderate (scores 5–7) to high (scores ≥8) risk groups, respectively, significant differences were found in mean developmental quotient (101 ± 9 vs 92 ± 19 vs 76 ± 24) and in prevalence of developmental quotients < 90 (12 vs 24 vs 71%), of cerebral palsy (4 vs 19 vs 41%), of severe disabilities (0 vs 24 vs 50%) and of any disability (16 vs 30 vs 71%). Sensitivity, specificity, positive and negative predictive values for any disability were 81, 54,49 and 84% for a score ≥ 5 and 56, 87, 71 and 78% for a score ≥ 8. The nursery Neurobiologic Risk Score was useful in predicting 18 months outcome of very premature infants.

Developmental pathways leading to externalizing behaviors in 5 year olds born before 29 weeks of gestation

&NA; Longitudinal data for 62 infants born before 29 weeks of gestation were used to assess the influence of four factors (i.e., neonatal health, family environment, language skill, and nonverbal ability) on the parental report of hyperactive and oppositional behaviors of children at 5 years 9 months. The proposed path analysis model tested the following: (1) whether neonatal health and family environment have a direct influence on language skill and nonverbal ability both measured at 18 months corrected age, (2) the predictive value of language skill and nonverbal ability on oppositional and hyperactive behaviors, and (3) whether the effects of neonatal health and/or family environment on oppositional and hyperactive behaviors can be conceived as mediated by language skill and/or nonverbal ability. The results revealed three main pathways. First, family environment predicted language skill, which, in turn, was negatively associated with childrens hyperactivity. Second, neonatal health predicted nonverbal ability, which was positively linked to oppositional behaviors. Third, a direct negative relation between neonatal health and hyperactive outcome was observed. The implications of these substantially different pathways for hyperactive and oppositional behaviors are discussed.

The cues and care randomized controlled trial of a neonatal intensive care unit intervention: effects on maternal psychological distress and mother-infant interaction.

Objective: This study tested the efficacy of a brief intervention (Cues program) with mothers of very low birth weight (VLBW <1500 g) infants. The primary hypothesis was that mothers in the Cues program would report lower levels of anxiety compared with mothers in the control group. Secondary hypotheses examined whether Cues mothers would report less stress, depression, and role restriction, and exhibit more sensitive interactive behavior, than control group mothers. Methods: A total of 121 mothers of VLBW infants were randomly assigned to either the experimental (Cues) intervention or an attention control (Care) condition. The Cues program combined training to reduce anxiety and enhance sensitivity. The control group received general information about infant care. Both programs were initiated during the neonatal intensive care unit stay. Maternal anxiety, stress, depression, and demographic variables were evaluated at baseline, prior to randomization. Postintervention outcomes were assessed during a home visit when the infant was ∼6 to 8 weeks of corrected age. Results: Although mothers in the Cues group demonstrated greater knowledge of the content of the experimental intervention than mothers in the Care group, the groups did not differ in levels of anxiety, depression, and symptoms of posttraumatic stress. They were similar in their reports of parental role restrictions and stress related to the infants appearance and behavior. Cues and Care group mothers were equally sensitive in interaction with their infants. Conclusion: Nonspecific attention was as effective as an early skill-based intervention in reducing maternal anxiety and enhancing sensitive behavior in mothers of VLBW infants.