Gehan Roberts

Rates of early intervention services in very preterm children with developmental disabilities at age 2 years.

Aim:  Preterm birth is increasing in prevalence and long‐term follow‐up studies have documented high rates of neurosensory, intellectual, academic and behavioural disabilities. The importance of early intervention (EI) is well recognised but significant barriers to receiving EI exist in the community. This study explores the association of levels of disability at age 2 years with EI services and social risk in a large cohort of very preterm children.

The stability of the diagnosis of developmental disability between ages 2 and 8 in a geographic cohort of very preterm children born in 1997

Objective Studies reporting the developmental outcomes for very preterm (VPT) children often focus on development at age 2 years. The aim of this study was to assess the stability of the rates of diagnosis of developmental disability from age 2 to 8 years in a regional cohort of VPT and extremely low–birth weight (ELBW) children and compare these with term controls. Methods VPT (22–27 completed weeks of gestation) and ELBW (birth weight 500–999 g) children and matched term controls born in Victoria, Australia, in 1997 were enrolled at birth in a regional prospective longitudinal study. Outcomes were assessed at ages 2 and 8 years. Results Of the 283 VPT/ELBW live births, 71% survived to age 8 years and 94% were assessed. Of the 199 controls, 100% survived to age 8 years and 86.9% were assessed. At age 2 years, the rates of nil, mild, moderate and severe disabilities in the VPT/ELBW children were respectively 51.9%, 20.9%, 13.4% and 13.9%; and at age 8 years, 43.9%, 36.9%, 10.7% and 8.6%. The Cohen κ statistic revealed poor agreement between disability status at ages 2 and 8 years for VPT/ELBW children (0.20, p<0.001) but a higher level of agreement (0.37, p<0.001) for the control children. This was primarily driven by differences in classification of cognitive disability between ages 2 and 8 years. Conclusions Developmental outcomes at age 2 years are only a moderate predictor of long-term outcome and are not a reliable end point for follow-up studies of VPT and ELBW children.

Neonatal white matter abnormality predicts childhood motor impairment in very preterm children

Aim  Children born very preterm are at risk for impaired motor performance ranging from cerebral palsy (CP) to milder abnormalities, such as developmental coordination disorder. White matter abnormalities (WMA) at term have been associated with CP in very preterm children; however, little is known about the impact of WMA on the range of motor impairments. The aim of this study was to assess whether WMA were predictive of all levels of motor impairments in very preterm children.

Regional Cerebral Development at Term Relates to School-Age Social-Emotional Development in Very Preterm Children

OBJECTIVE Preterm children are at risk for social-emotional difficulties, including autism and attention-deficit/hyperactivity disorder. We assessed the relationship of regional brain development in preterm children, evaluated via magnetic resonance imaging (MRI) at term-equivalent postmenstrual age (TEA), to later social-emotional difficulties. METHOD MR images obtained at TEA from 184 very preterm infants (gestation <30 weeks or birth weight <1,250 g) were analyzed for white matter abnormalities, hippocampal volume, and brain metrics. A total of 111 infants underwent diffusion tensor imaging, which provided values for fractional anisotropy and apparent diffusion coefficient. Social-emotional development was assessed with the Infant Toddler Social and Emotional Assessment (ITSEA) at age 2 and the Strengths and Difficulties Questionnaire (SDQ) at age 5 years. RESULTS Higher apparent diffusion coefficient in the right orbitofrontal cortex was associated with social-emotional problems at age 5 years (peer problems, p < .01). In females, smaller hippocampal volume was associated with increased hyperactivity (p < .01), peer problems (p < .05), and SDQ total score (p < .01). In males, a smaller frontal region was associated with poorer prosocial (p < .05) scores. Many of the hippocampal findings remained significant after adjusting for birthweight z score, intelligence, social risk, immaturity at birth, and parental mental health. These associations were present in children who had social-emotional problems in similar domains at age 2 and those who did not. CONCLUSIONS Early alterations in regional cerebral development in very preterm infants relate to specific deficits in social-emotional performance by school-age. These results vary by gender. Our results provide further evidence for a neuroanatomical basis for behavioral challenges found in very preterm children.

High rates of school readiness difficulties at 5 years of age in very preterm infants compared with term controls.

Objective: School readiness is best understood as a framework for assessing profiles of strengths and vulnerabilities of the preschool-age child. Very preterm (VPT) children are at high risk of difficulties in school, and understanding their school readiness skills has the potential to aid successful transition into school. The aim of this study was to determine the school readiness skills of a cohort of VPT children, compared with term controls. Methods: VPT children (gestational age <30 wk or birth weights <1250 g) and term controls were enrolled from a tertiary maternity hospital, Melbourne, Australia into a prospective cohort study. At age 5 years, school readiness skills were evaluated using a combination of parent questionnaires and direct assessments. The 5 domains of school readiness assessed were health and physical development, social-emotional skills, approaches to learning, communication skills, and cognitive skills. Results: VPT children had standard scores ∼½ to 1 SD below those of the term controls in all domains of school readiness, and these differences were not greatly affected by adjustment for social risk differences. Overall, 44% of the VPT group had vulnerabilities in more than 1 domain of school readiness, compared with only 16% of the term controls. Conclusions: VPT children are more likely than term controls to have significant vulnerabilities in multiple domains of school readiness, and these differences are mostly independent of social risk.

Changing long-term outcomes for infants 500–999 g birth weight in Victoria, 1979–2005

Objective To determine the survival and neurological outcome at 2 years of age of extremely low birthweight (ELBW, birth weight 500–999 g) infants born in the state of Victoria compared with term controls, and contrasted with ELBW cohorts from previous eras. Design and setting A population-based cohort study of consecutive ELBW infants born during 2005 in the state of Victoria, and also in 1979–1980, 1985–1987, 1991–1992 and 1997. Participants All 257 live births free of lethal malformations weighing 500–999 g in 2005, 220 randomly selected term, normal birthweight (birth weight >2499 g) controls, and equivalent cohorts born in earlier eras. Main outcome measures Survival rates and quality-adjusted survival rates at 2 years of age, contrasted between cohorts. Results Of 257 ELBW live births in 2005, 66.9% survived to 2 years of age, significantly lower than the survival rate of 75.2% for 1997 (odds ratio (OR) 0.67, 95% CI 0.45 to 0.99, p=0.046), but not after adjustment for confounders of birth weight, gestational age and gender (adjusted OR 0.73, 95% CI 0.46 to 1.16, p=0.18). This was a reversal of the steady increase in survival rates up to 1997. Rates of blindness, severe developmental delay and severe disability were significantly lower in 2005 than in ELBW survivors from previous eras. Consequently the difference in the quality-adjusted survival rates between 2005 and 1997 was only −3.8% (95% CI −11.4% to 3.7%, p=0.32). Conclusions Regional survival rates for ELBW infants have plateaued since the late 1990s, but the neurosensory outcome in survivors has improved in 2005.

Neurosensory Disabilities at School Age in Geographic Cohorts of Extremely Low Birth Weight Children Born Between the 1970s and the 1990s

OBJECTIVE To contrast the rates of neurosensory disabilities at age 8 years in extremely low birth weight (ELBW; birth weight 500 to 999 g) children born in the state of Victoria, Australia in 4 four distinct eras from the late 1970s to the late 1990s. STUDY DESIGN Study subjects were assessed at age 8 years. Results were compared among 4 ELBW cohorts (87 of 89 children born in 1979-1980, 206 of 212 born in 1985-1987, 224 of 241 born in 1991-1992, and 160 of 170 born in 1997), and between each of these ELBW cohorts and normal birth weight (NBW; birth weight > 2499 g) controls. RESULTS The survival rate for ELBW children rose from 25% for the 1979-1980 cohort to 73% for the 1997 cohort. No statistically significant differences in the disability rates were seen in the 4 eras; however, in the 1997 cohort, disability rates were significantly higher in the ELBW children compared with NBW controls: mild disability, 36.7% vs 9.8%; moderate disability, 10.1% vs 2.3%; and severe disability, 8.2% vs 0.6%. CONCLUSIONS The survival rate of ELBW children continues to rise over time. Despite this, however, the rates of disability in these vulnerable children at school age have remained stable and high relative to controls.

Family functioning, burden and parenting stress 2 years after very preterm birth☆

BACKGROUND Examining rates of difficulties in family functioning following very preterm birth has been a relatively neglected area of research. AIMS To examine family functioning, burden and parenting stress in families with very preterm compared with term born children, and investigate influences of parental mental health problems and child neurodevelopmental disability on family outcomes in families with preterm children. STUDY DESIGN Participants were 184 very preterm and 71 term children and their parents. Parents completed the Family Assessment Device, Parenting Stress Index and Impact on Family questionnaires when their children were 2 years old (corrected for prematurity). Parental mental health and social risk information were also collected. Children were assessed for neurodevelopmental disability. RESULTS Families with very preterm children reported poorer family functioning (p=.03) compared with families with term born children, with less evidence for differences between families with very preterm and term born children in parenting stress and family burden. Within very preterm families, parental mental health problems were associated with higher levels of parenting stress (p=.001), and parents of children with a neurodevelopmental disability were more likely to report higher family burden (p=.04). CONCLUSIONS For families with very preterm children, parental mental health symptoms and child neurodevelopmental disability may identify families at risk of greater stress and burden who may benefit from additional support.

Changes in neurodevelopmental outcome at age eight in geographic cohorts of children born at 22―27 weeks' gestational age during the 1990s

Background The survival rate for children born with gestational ages 22–27 weeks is increasing, and this may be associated with higher rates of disability. The aims of this study were to determine the outcomes at age eight for a regional cohort of children born at 22–27 weeks during 1997, and to compare their rates of disability with a cohort of the same gestational age born in 1991–1992. Methods Consecutive children with gestational ages in the range 22–27 weeks born in the state of Victoria, Australia, in 1997 and matched term controls were assessed at 8 years. Outcomes included blindness, deafness, cerebral palsy (CP) and intellectual impairment and disabilities caused by these impairments. These outcomes were compared with a cohort of 22–27-week and term children born in 1991–1992 in the same region. Results Follow-up rates for the 1997 cohort at 8 years of age were 95% (144/151) for 22–27 weeks survivors and 89% (173/195) for controls. Rates of disability were substantially higher in the preterm cohort than the controls. The 1997 and 1991–1992 preterm cohorts had similar rates of moderate or severe disability (19%), however the rate of mild impairment was greater in 1997 (40% vs 24%). Rates of disability were almost identical in control groups. Intellectual impairment and CP were the major reasons for the higher rates of disability. Conclusions The high prevalence of adverse neurodevelopmental outcome in children born at 22–27 weeks compared with term controls at school age persists, and may even be increasing over time.

Contribution of brain size to IQ and educational underperformance in extremely preterm adolescents.

Objectives Extremely preterm (EP) survivors have smaller brains, lower IQ, and worse educational achievement than their term-born peers. The contribution of smaller brain size to the IQ and educational disadvantages of EP is unknown. This study aimed (i) to compare brain volumes from multiple brain tissues and structures between EP-born (<28weeks) and term-born (≥37weeks) control adolescents, (ii) to explore the relationships of brain tissue volumes with IQ and basic educational skills and whether this differed by group, and (iii) to explore how much total brain tissue volume explains the underperformance of EP adolescents compared with controls. Methods Longitudinal cohort study of 148 EP and 132 term controls born in Victoria, Australia in 1991-92. At age 18, magnetic resonance imaging-determined brain volumes of multiple tissues and structures were calculated. IQ and educational skills were measured using the Wechsler Abbreviated Scale of Intelligence (WASI) and the Wide Range Achievement Test(WRAT-4), respectively. Results Brain volumes were smaller in EP adolescents compared with controls (mean difference [95% confidence interval] of -5.9% [-8.0, -3.7%] for total brain tissue volume). The largest relative differences were noted in the thalamus and hippocampus. The EP group had lower IQs(-11.9 [-15.4, -8.5]), spelling(-8.0 [-11.5, -4.6]), math computation(-10.3 [-13.7, -6.9]) and word reading(-5.6 [-8.8, -2.4]) scores than controls; all p-values<0.001. Volumes of total brain tissue and other brain tissues and structures correlated positively with IQ and educational skills, a relationship that was similar for both the EP and controls. Total brain tissue volume explained between 20-40% of the IQ and educational outcome differences between EP and controls. Conclusions EP adolescents had smaller brain volumes, lower IQs and poorer educational performance than controls. Brain volumes of multiple tissues and structures are related to IQ and educational outcomes. Smaller total brain tissue volume is an important contributor to the cognitive and educational underperformance of adolescents born EP.