G Sedin

Mental Health and Social Competencies of 10- to 12-Year-Old Children Born at 23 to 25 Weeks of Gestation in the 1990s: A Swedish National Prospective Follow-up Study

OBJECTIVE. We investigated a national cohort of extremely immature children with respect to behavioral and emotional problems and social competencies, from the perspectives of parents, teachers, and children themselves. METHODS. We examined 11-year-old children who were born before 26 completed weeks of gestation in Sweden between 1990 and 1992. All had been evaluated at a corrected age of 36 months. At 11 years of age, 86 of 89 survivors were studied and compared with an equal number of control subjects, matched with respect to age and gender. Behavioral and emotional problems, social competencies, and adaptive functioning at school were evaluated with standardized, well-validated instruments, including parent and teacher report questionnaires and a child self-report, administered by mail. RESULTS. Compared with control subjects, parents of extremely immature children reported significantly more problems with internalizing behaviors (anxiety/depression, withdrawn, and somatic problems) and attention, thought, and social problems. Teachers reported a similar pattern. Reports from children showed a trend toward increased depression symptoms compared with control subjects. Multivariate analysis of covariance of parent-reported behavioral problems revealed no interactions, but significant main effects emerged for group status (extremely immature versus control), family function, social risk, and presence of a chronic medical condition, with all effect sizes being medium and accounting for 8% to 12% of the variance. Multivariate analysis of covariance of teacher-reported behavioral problems showed significant effects for group status and gender but not for the covariates mentioned above. According to the teachers’ ratings, extremely immature children were less well adjusted to the school environment than were control subjects. However, a majority of extremely immature children (85%) were functioning in mainstream schools without major adjustment problems. CONCLUSIONS. Despite favorable outcomes for many children born at the limit of viability, these children are at risk for mental health problems, with poorer school results.

Short-term outcome after active perinatal management at 23—25 weeks of gestation. A study from two Swedish tertiary care centres. Part 2: infant survival

Aim: To determine neonatal survival rates based on both foetal (stillborn) and neonatal deaths among infants delivered at 23–25 wk, and to identify maternal and neonatal factors associated with survival. Methods: The medical records of 224 infants who were delivered in two tertiary care centres in 1992–1998 were reviewed retrospectively. At these centres, policies of active perinatal and neonatal management were universally applied. Data were analysed by gestational age groups and considered in three time periods. Logistic regression models were used to identify factors associated with survival. Results: The rate of foetal death was 5%. Of infants born alive, 63% survived to discharge. Survival rates including foetal deaths in the denominator at 23, 24 and 25 wk were 37%, 61% and 74%, respectively, and survival rates excluding foetal deaths were 43%, 63% and 77%, respectively. Of infants born with 1‐min Apgar scores of 0–1, 43% survived. In the total cohort, survival rates including foetal deaths in the denominator increased from 52% in time period 1 to 61% in time period 2 and 74% in time period 3 (p > 0.02). On multivariate logistic regression analysis, higher birthweight (OR: 1.91 per 100 g increment; 95% CI: 1.45–2.52), female gender (OR: 3.33; 95% CI: 1.65–6.75), administration of antenatal steroids (OR: 2.95; 95% CI: 1.46–5.98) and intrauterine referral from a peripheral hospital (OR: 2.35; 95% CI: 1.18–4.68) were associated with survival. Apgar score ± 3 at 1 min (OR: 0.46; 95% CI: 0.22–0.95) was associated with decreased survival. The use of antenatal steroids was protective at 23–24 wk (OR: 5.2; 95% CI: 2.0–13.7), but not at 25 wk.

Speech and language skills in children who required neonatal intensive care. I. Spontaneous speech at 6.5 years of age

Spontaneous speech at age 6.5 years was studied separately in a follow‐up of speech and language skills in a regional cohort of 284 children requiring neonatal intensive care and in 40 controls. Eight aspects of spontaneous speech were evaluated in a conversation: A1, information; A2, speech motor function; A3, sound pattern; A4, word finding; A5, word selection; A6, grammar; A7, interaction; and A8, motivation. The children were grouped by gestational age. Most children had well developed spontaneous speech. The different groups showed very few differences in types of deviations in spontaneous speech. All groups differed from the controls in speech motor function and formal language (A2‐A6), but only one child, born at <32 weeks, had a pronounced deviation in one of these aspects. Obvious deviations in one or more aspects of spontaneous speech were more common among children born at 28‐31 weeks and in those born fullterm (>37 weeks) than among extremely preterm children born at 23–27 weeks.

Short-term outcome after active perinatal management at 23-25 weeks of gestation. A study from two Swedish perinatal centres. Part 3: neonatal morbidity.

Aim: To determine major neonatal morbidity in surviving infants born at 23–25 weeks, and to identify maternal and infant factors associated with major morbidity. Methods: The medical records of 224 infants who were delivered at two tertiary care centres in 1992–1998 were reviewed retrospectively. At these centres, policies of active perinatal and neonatal management were universally applied. Of the 213 liveborn infants, 140 (66%) survived to discharge. Data were analysed by gestational age and considered in three time periods. Logistic regression models were used to identify factors associated with morbidity. Results: Of the survivors, 6% had intraventricular haemorrhage grade ± 3 (severe IVH) or periventricular leukomalacia (PVL), 15% retinopathy of prematurity ± stage 3 (severe ROP) and 36% bronchopulmonary dysplasia (BPD). On logistic regression analysis, severe IVH or PVL was associated with duration of mechanical ventilation (odds ratio, OR: 1.53 per 1‐wk increment in duration; 95% confidence interval, CI: 1.01–2.33). Severe ROP was associated with the presence of a patent ductus arteriosus (PDA) (OR: 3.31; 95% CI: 1.11–9.90) and birth in time period 3 versus time periods 1 and 2 combined (OR: 6.28; 95% CI: 2.10–18.74). BPD was associated with duration of mechanical ventilation (OR: 2.71 per 1‐wk increment in duration; 95% CI: 1.76–4.18) and with the presence of any obstetric complication (OR: 2.67; 95% CI: 1.07–6.65). Gestational age and birthweight were not associated with major morbidity. Of all survivors, 81% were discharged home without severe IVH, PVL or severe ROP.

Gender differences in outcome after neonatal intensive care: speech and language skills are less influenced in boys than in girls at 6.5 years.

Aim: To study language development at age 6.5 y in 230 children who had required neonatal intensive care (NIC) and 71 full‐term neonatally healthy control children, all born in 1986–1989, with a focus on comparison between genders. Methods: Eight aspects of spontaneous speech, 3 fine motor functions, 10 linguistic areas, Peabody Picture Vocabulary Test, and digit recall (ITPA) were assessed. Results: Achievements for gender and gestational age groups were analysed (group I, 23–31 wk; subgroup IA, 23–27 wk; IB, 28–31 wk; group II, 32–36 wk; group III, >36 wk), with children with congenital malformations as a separate group. As a group, at 6.5 y NIC girls had more developed spontaneous speech than NIC boys, and performed better than NIC boys in some linguistic areas. NIC girls of group I had lower results than control girls in spontaneous speech aspects such as speech motor function, interaction and motivation, and in many areas of linguistic skills. In contrast, NIC boys of group I had higher results than control boys in auditory memory, and only regarding information and speech motor function in spontaneous speech were their results lower. Analysis of results of matched pairs of group I NIC girls versus control girls and group I NIC boys versus control boys revealed even more marked differences between NIC girls and their matched controls than between NIC boys and their matched controls.

Short-term outcome after active perinatal management at 23-25 weeks of gestation. A study from two Swedish tertiary care centres. Part 1 : maternal and obstetric factors.

Aims: To provide descriptive data on women who delivered at 23–25 wk of gestation, and to relate foetal and neonatal outcomes to maternal factors, obstetric management and the principal reasons for preterm birth. Methods: Medical records of all women who had delivered in two tertiary care centres in 1992–1998 were reviewed. At the two centres, policies of active perinatal and neonatal management were universally applied. Logistic regression models were used to identify prenatal factors associated with survival. Results: Of 197 women who delivered at 23–25 wk, 65% had experienced a previous miscarriage, 15% a previous stillbirth and 12% a neonatal death. The current pregnancy was the result of artificial reproduction in 13% of the women. In 71%, the pregnancy was complicated either by preeclampsia, chorioamnionitis, placental abruption or premature rupture of membranes. Antenatal steroids were given in 63%. Delivery was by caesarean section in 47%. The reasons for preterm birth were idiopathic preterm labour in 36%, premature rupture of membranes in 41% and physician‐indicated deliveries in 23% of the mothers. Demographic details, use of antenatal steroids, caesarean section delivery and birthweight differed between mothers depending on the reason for preterm delivery. Of 224 infants, 5% were stillbirths and 63% survived to discharge. On multivariate logistic regression analysis comprising prenatally known variables, reasons for preterm birth were not associated with survival. Advanced gestational duration (OR: 2.43 per wk; 95% CI: 1.59–3.74), administration of any antenatal steroids (OR: 2.21; 95% CI: 1.14–4.28) and intrauterine referral from a peripheral hospital (OR: 2.93; 95% CI: 1.5–5.73) were associated with survival.

Evaporation rate and skin blood flow in full term infants nursed in a warm environment before and after feeding cold water

Earlier results have shown that some infants born by elective Caesarean section start to sweat in a warm environment while others do not, and that sweating can be inhibited by feeding cold glucose. To determine whether these earlier observations, indicating a difference in postnatal temperature adaptation, could be reproduced in vaginally born infants, we measured the rate of evaporation from the skin surface, body and skin temperatures from several sites, skin blood flow and respiratory rate in newborn infants nursed in a warm environment, before and after feeding cold water. In all infants the body and skin temperatures increased in the warm environment (p < 0. 01), with a decreasing difference between oesophageal and leg skin temperature (p < 0. 01). Visible sweating occurred in 9/14 infants at a rectal temperature of 37.5°C. In the infants who started to sweat, evaporation rate increased from 5.6 ± 2. 8 (SD) g/m2/h 15min before sweating to 15.7 ± 10.6 g/m2/h (p < 0.05) when sweat became visible and the infants were fed cold water. After feeding of cold water the evaporation rate decreased and within 10min returned to a value not significantly different from the pre‐sweating value. Interscapular skin blood flow had increased by 42% (p < 0. 01) at the time of sweating and decreased by 22% (p < 0. 01) after feeding cold water. In the infants who did not start to sweat, no increase in evaporation rate was noted and the changes in skin blood flow were not statistically significant. The infants who started to sweat did not differ from those who did not regarding maternal medication during delivery. We conclude that some, but not all, newborn infants start to sweat at a body temperature of 37.5°C. In the infants who start to sweat, sweating and an increase in skin blood flow can be inhibited by feeding cold water. There seem to be individual differences in the regulation of body temperature in newborn infants, possibly due to a delayed change in the central temperature set‐point in some infants.