Jorien M. Kerstjens

Support for the global feasibility of the Ages and Stages Questionnaire as developmental screener

OBJECTIVE To investigate the psychometric properties of the Dutch version of the 48 months Ages and Stages Questionnaire (D_ASQ_48). DESIGN Prospective cohort study of a community-based sample of children born in 2002 and 2003 whose parents filled out the D_ASQ_48 and a questionnaire on school status at 60 months. The ASQ was translated into Dutch and back-translated into English by three independent translators. SETTING Well Child Centers covering 25% of the Netherlands. PARTICIPANTS Parents of 1510 preterm and 562 term children born in 2002-2003 attending routine Well Child visits at age 45-50 months. MAIN OUTCOME MEASURES Reliability, validity and mean population scores for D_ASQ_48 compared to other countries. RESULTS Mean population scores for the D_ASQ_48 were mostly similar to those in the USA, Norway and Korea. Exceptions (effect sizes of difference >0.5) were problem solving (USA) and fine motor (Korea). Reliability was good for the total score (Cronbach alpha 0.79) and acceptable for all domains (0.61-0.74). As expected, infants born at gestational age <32 weeks, children from low income families, of low educated mothers, and boys were more likely to fail on several domains (odds ratios, OR ranging from 1.5 to 4.9). The only unexpected association concerned children from one-parent families. Sensitivity to predict special education at five years of age was 89% and specificity 80%. CONCLUSIONS The good psychometric properties of the Dutch ASQ_48 and the small differences when compared to other countries support its usefulness in the early detection of developmental problems amongst children worldwide.

Neonatal Morbidities and Developmental Delay in Moderately Preterm-Born Children

BACKGROUND AND OBJECTIVE: Children born moderately preterm (32–356/7 weeks’ gestation) are at increased risk of both neonatal morbidities and developmental delays in early childhood. It is unknown whether neonatal morbidities contribute to the increased risk of developmental delay. The objective of this study was to determine the effect of neonatal morbidities after moderately preterm birth on development at preschool age. METHODS: In a community-based, stratified cohort, parents of 832 moderately preterm children born in 2002 or 2003 completed the Ages and Stage Questionnaire when their child was 43 to 49 months old. Data on Apgar scores, asphyxia, tertiary NICU admission, hospital transfer, circulatory insufficiency, hypoglycemia, septicemia, mechanical ventilation, continuous positive airway pressure, apneas, caffeine treatment, and hyperbilirubinemia were obtained from medical records. We assessed associations of neonatal characteristics with developmental delay, adjusted for gender, small-for-gestational-age status, gestational age, and maternal education. RESULTS: Hypoglycemia and asphyxia were associated with developmental delay; odds ratios (ORs) were 2.42 (95% confidence interval [CI]: 1.23–4.77) and 3.18 (95% CI: 1.01–10.0), respectively. Tertiary NICU admission and hyperbilirubinemia had positive but statistically borderline nonsignificant associations with developmental delay: ORs were 1.74 (95% CI: 0.96–3.15) and 1.52 (95% CI: 0.94–2.46), respectively. No other neonatal morbidities were associated with developmental delay. In multivariate analyses, only hypoglycemia was associated with developmental delay (OR: 2.19; 95% CI: 1.08–4.46). CONCLUSIONS: In moderately preterm-born children, only hypoglycemia increased the risk of developmental delay at preschool age. A concerted effort to prevent hypoglycemia might enhance developmental outcome in this group.

Developmental Delay in Moderately Preterm-Born Children with Low Socioeconomic Status: Risks Multiply

OBJECTIVE To assess separate and joint effects of low socioeconomic status (SES) and moderate prematurity on preschool developmental delay. STUDY DESIGN Prospective cohort study with a community-based sample of preterm- and term-born children (Longitudinal Preterm Outcome Project). We assessed SES on the basis of education, occupation, and family income. The Ages and Stages Questionnaire was used to assess developmental delay at age 4 years. We determined scores for overall development, and domains fine motor, gross motor, communication, problem-solving, and personal-social of 926 moderately preterm-born (MP) (32-36 weeks gestation) and 544 term-born children. In multivariable logistic regression analyses, we used standardized values for SES and gestational age (GA). RESULTS Prevalence rates for overall developmental delay were 12.5%, 7.8%, and 5.6% in MP children with low, intermediate, and high SES, respectively, and 7.2%, 4.0%, and 2.8% in term-born children, respectively. The risk for overall developmental delay increased more with decreasing SES than with decreasing GA, but the difference was not statistically significant: OR (95% CI) for a 1 standard deviation decrease were: 1.62 (1.30-2.03) and 1.34 (1.05-1.69), respectively, after adjustment for sex, number of siblings, and maternal age. No interaction was found except for communication, showing that effects of SES and GA are mostly multiplicative. CONCLUSIONS Low SES and moderate prematurity are separate risk factors with multiplicative effects on developmental delay. The double jeopardy of MP children with low SES needs special attention in pediatric care.

Moderately preterm children have more respiratory problems during their first 5 years of life than children born full term.

RATIONALE Pulmonary outcomes of moderate-preterm children (MP) are unknown. OBJECTIVES To investigate the prevalence of respiratory symptoms during infancy and at preschool age of MP compared with full-term (FT) and early preterm children (EP) and to determine factors associated with respiratory symptoms of MP at school age. METHODS Prospective cohort study. OUTCOME VARIABLES number of rehospitalizations caused by respiratory problems, prevalence of respiratory symptoms determined by ISAAC Questionnaires, and factors associated with respiratory symptoms determined by univariate and multivariate analyzes. MEASUREMENTS AND MAIN RESULTS A total of 988 MP, 551 EP, and 573 FT children were included. The number of hospitalizations caused by respiratory problems during the first year of life was doubled in MP compared with FT (6% vs. 3%; P < 0.001). At preschool age, compared with FT, MP reported more cough or wheeze during a cold (63% vs. 50%; P < 0.001); cough or wheeze without a cold (23% vs. 15%; P = 0.001); nocturnal cough (33% vs. 26%; P = 0.005); dyspnea (8% vs. 4%; P = 0.011); and use of medication (inhaled steroids, 9% vs. 6%; P = 0.042) (antibiotics, 12% vs. 7%; P = 0.002). Factors associated with respiratory symptoms at 5 years among MP were respiratory problems, eczema, rehospitalization in infancy, passive smoking in infancy, family history of asthma, and higher social class. Multivariate analyzes showed the same results except for rehospitalization in infancy. CONCLUSIONS MP have more respiratory symptoms than FT during early childhood. Factors associated with respiratory symptoms at school age are early respiratory problems, family history of asthma, higher social class, and passive smoking.

Growth of Preterm and Full-Term Children Aged 0-4 Years: Integrating Median Growth and Variability in Growth Charts

OBJECTIVES To assess the distribution of height, weight, and head circumference (HC) in preterm infants for ages 0-4 years, by gestational age (GA) and sex, and to construct growth reference charts for preterm-born children, again by GA and sex, for monitoring growth in clinical practice. STUDY DESIGN The community-based cohort study covered a quarter of The Netherlands. 1690 preterm infants (GA, 25-35(+6) weeks) and a random sample of 634 full-term control infants (GA 38-41(+6)), who were followed from birth to 4 years of age. Height, weight, and HC were regularly assessed during routine well-child visits and data were retrospectively collected. RESULTS At all ages, the median height and weight of preterm children were lower compared with full-term children. Growth depended on the childs GA. Increase in HC showed an early catch-up and was similar to full-term children by the age of 1. Height, weight, and HC were more variable in boys, particularly in the very preterm children. CONCLUSIONS At 0 to 4 years, the growth of preterm children differed from that of full-term children and depended on their GA. The greater variability of growth in boys suggests that they are more vulnerable to the complications of preterm birth that influence growth. These growth charts are the most precise tools currently available for monitoring growth in preterm children.

Risk of developmental delay increases exponentially as gestational age of preterm infants decreases: a cohort study at age 4 years

Aim  The aim of the study was to assess the influence of decreasing gestational age on the risk of developmental delay in various domains at age 4 years among children born at a wide range of gestational ages.

Growth and Predictors of Growth Restraint in Moderately Preterm Children Aged 0 to 4 Years

OBJECTIVE: To describe growth in moderately preterm-born children, determine the prevalence of growth restraint at the age of 4, and identify predictors of growth restraint. We hypothesized that growth in moderately preterm-born children differs from growth in term-born children and that growth restraint is more prevalent in those born prematurely. PATIENTS AND METHODS: This was a community-based cohort study of 1123 children born moderately prematurely (gestational age [GA]: 32–3567 weeks) between January 2002 and June 2003. RESULTS: On average, we found that moderately preterm-born children were shorter and weighed less at each assessment during the first 4 years of life than their term-born counterparts. Thirty-two boys (5.6%) and 18 girls (3.8%) were growth-restricted in height, and 21 boys (3.4%) and 27 girls (5.8%) were growth-restricted in weight. Their growth in head circumference was normal compared with term-born children. In addition, growth restraint was associated with being small for GA at birth (odds ratio [OR] for height: 7.7 [95% confidence interval (CI): 2.9–20.4]; OR for weight: 9.5 [95% CI: 3.9–23.1]) and maternal height below −1 SD (OR for height: 4.9 [95% CI: 2.6–10.2]; OR for weight: 2.6 [95% CI: 1.3–5.2]). Poor head-circumference growth was associated with a low level of maternal education (OR: 5.3 [95% CI: 1.4–20.8]). CONCLUSIONS: Growth in moderately preterm-born children significantly differs from that of term-born children. Predictors at birth are being small for GA, maternal height below −1 SD, and a low level of maternal education. The fact that growth in moderately preterm-born children may lag warrants close monitoring during routine practice. Additional research on prevention of growth restraint is needed.

Maternal and pregnancy-related factors associated with developmental delay in moderately preterm-born children

OBJECTIVE: To estimate the association between pre-existing maternal and pregnancy-related factors and developmental delay in early childhood in moderately preterm–born children. METHODS: We measured development with the Ages and Stages Questionnaire at age 43–49 months in 834 moderately preterm–born (between 32 0/7 and 35 6/7 weeks of gestation) children born in 2002–2003. We obtained data on preexisting maternal, maternal pregnancy-related, fetal, and delivery-related factors. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) and attributable risks for developmental delay adjusted for sociodemographic and lifestyle variables. RESULTS: Attributable risk for developmental delay for small-for-gestational-age (SGA, as a proxy for intrauterine growth restriction [IUGR]) was 14.2% (SGA 21.9%, no SGA 7.7%, P<.05, adjusted OR 2.75, CI 1.25–6.08), for preexisting maternal obesity 10.5% (obesity 18.0%, no obesity 7.5%, P<.01, adjusted OR 2.73, CI 1.35–5.52), for multiple pregnancy 4.2% (multiple 12.0%, singleton 7.8%, P<.05, adjusted OR 1.86, CI 1.02–3.42), and for male sex 9.3% (male 13.0%, female 3.8%, P<.001, adjusted OR 4.20, CI 2.09–8.46). No other preexisting or pregnancy-related maternal factors or any delivery-related factors were associated with increased risk of developmental delay. CONCLUSIONS: Of all preexisting maternal and pregnancy-related factors studied, SGA, maternal prepregnancy obesity, being one of a multiple, and male sex were associated with the risk of developmental delay in early childhood after moderately preterm birth. Reinforced focus on prevention of IUGR, preconception lifestyle interventions aiming at weight reduction in fertile women, and reinforced efforts to reduce rates of multiple pregnancies in assisted reproduction may all contribute toward more favorable developmental outcomes in moderately preterm–born children. LEVEL OF EVIDENCE: II

Patterns of functioning and predictive factors in children born moderately preterm or at term

Aim  The aim of this study was to identify subgroups of children born moderately preterm (MPT) and term with distinctive levels and patterns of functioning, and the perinatal and demographic factors that predict subgroup membership.

Symmetrical and Asymmetrical Growth Restriction in Preterm-Born Children

OBJECTIVE: To determine how symmetric (proportionate; SGR) and asymmetric (disproportionate; AGR) growth restriction influence growth and development in preterms from birth to 4 years. METHODS: This community-based cohort study of 810 children comprised 86 SGR, 61 AGR, and 663 non–growth restricted (NGR) preterms, born in 2002 and 2003. Symmetrical growth restriction was defined as a birth weight below the 16th percentile (–1 SD) compared with full-terms and a head circumference (HC) z score not exceeding the infant’s birth weight z score by >1 SD. Asymmetric growth restriction was defined as a HC z score exceeding that for by >1 SD as a proxy of brain sparing. Developmental delay was assessed by the Ages and Stages Questionnaire at 4 years. RESULTS: Longitudinal gains in weight and height were similar for SGR and AGR children and less compared with NGR children. At age 4, z scores for weight were –1.1 for SGR and –0.7 for AGR children vs –0.3 for NGR children. z scores for height were –0.8 and –0.5 vs –0.2. HC gain were 2 cm more in SGR, but at 1 year, they were –0.2 vs 0.2 (AGR) and 0.1 (NGR). Developmental delay increased with odds ratios of 2.5 (95% confidence interval 1.1–6.0) for SGR and 2.1 (95% confidence interval 0.7–5.9) for AGR. CONCLUSIONS: Weight and height gains were similar for AGR and SGR children but poorer compared with NGR children. SGR children caught up on HC. Developmental delay was more likely in growth-restricted preterms independent of HC at birth.