Margaret M. McGrath

Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemorrhage and late-onset sepsis: a randomized, controlled trial.

OBJECTIVE. This study compared the effects of immediate (ICC) and delayed (DCC) cord clamping on very low birth weight (VLBW) infants on 2 primary variables: bronchopulmonary dysplasia (BPD) and suspected necrotizing enterocolitis (SNEC). Other outcome variables were late-onset sepsis (LOS) and intraventricular hemorrhage (IVH). STUDY DESIGN. This was a randomized, controlled unmasked trial in which women in labor with singleton fetuses <32 weeks’ gestation were randomly assigned to ICC (cord clamped at 5–10 seconds) or DCC (30–45 seconds) groups. Women were excluded for the following reasons: their obstetrician refused to participate, major congenital anomalies, multiple gestations, intent to withhold care, severe maternal illnesses, placenta abruption or previa, or rapid delivery after admission. RESULTS. Seventy-two mother/infant pairs were randomized. Infants in the ICC and DCC groups weighed 1151 and 1175 g, and mean gestational ages were 28.2 and 28.3 weeks, respectively. Analyses revealed no difference in maternal and infant demographic, clinical, and safety variables. There were no differences in the incidence of our primary outcomes (BPD and suspected NEC). However, significant differences were found between the ICC and DCC groups in the rates of IVH and LOS. Two of the 23 male infants in the DCC group had IVH versus 8 of the 19 in the ICC group. No cases of sepsis occurred in the 23 boys in the DCC group, whereas 6 of the 19 boys in the ICC group had confirmed sepsis. There was a trend toward higher initial hematocrit in the infants in the DCC group. CONCLUSIONS. Delayed cord clamping seems to protect VLBW infants from IVH and LOS, especially for male infants.

Perinatal morbidity, mild motor delay, and later school outcomes

Four dimensions of motor competence were evaluated in 4‐year‐old term and preterm children and were related to academic achievement and use of school services at age 8 years. The objective of the study was to evaluate a graduated ‘stair‐step’ effect between perinatal morbidity, mild motor delay, and later school outcomes in 168 children (88 females, 80 males) stratified into four study groups: 134 healthy term infants ± 37 weeks’gestation, birth weight ± 2500g); 134 preterm infants ±37 weeks’gestation divided into healthy preterm (n=41), clinically ill preterms (n=59), and preterm infants with neurological illness (n=34). Significant differences were found in total, fine and gross motor performance, and visual‐motor integration at age 4 years. Scores for the preterm groups decreased with increasing morbidity. At age 4 years, mild motor delay was found in all preterm groups. Children with mild motor delay had lower academic achievement scores (Wide Range Achievement Test‐3) and higher rates of school service use at age 8 years. Perinatal morbidity and compromised motor performance are important precursors of educational underachievement.

Immediate and Delayed Cord Clamping in Infants Born Between 24 and 32 Weeks: A Pilot Randomized Controlled Trial

OBJECTIVE: This pilot studys aim was to establish feasibility of a protocol for delayed cord clamping (DCC) versus immediate cord clamping (ICC) at preterm birth and to examine its effects on initial blood pressure and other outcomes.STUDY DESIGN: A randomized controlled trial recruited 32 infants between 24 and 32 weeks. Immediately before delivery, mothers were randomized to ICC (cord clamped at 5 to 10 seconds) or DCC (30- to 45-second delay in cord clamping) groups.RESULTS: Intention-to-treat analyses revealed that the DCC group were more likely to have higher initial mean blood pressures (adjusted OR 3.4) and less likely to be discharged on oxygen (adjusted OR 8.6). DCC group infants had higher initial glucose levels (ICC=36u2009mg/dl, DCC=73.1u2009mg/dl; p=0.02).CONCLUSION: The research design is feasible. The immediate benefit of improved blood pressure was confirmed and other findings deserve consideration for further study.

Birth weight, neonatal morbidities, and school age outcomes in full-term and preterm infants.

In this prospective longitudinal study, birth weight and neonatal morbidities were evaluated relative to a broad range of school age outcomes. Fully 188 infants, 151 who were preterm, were recruited at birth, stratified by birth weight and socioeconomic status, and were followed until age 8 with a 97% retention rate. A gradient relationship was found among birth groups, with full-term children earning the highest scores. The very low birth weight and extremely low birth weight groups were equivocal in all scores except visual perception. The findings also were consistent with a pattern of nonverbal learning disability (Rourke, 1995) in which there is evidence of math underachievement and adequate performance in verbal, reading, and spelling scores. Children who had bronchopulmonary dysplasia, chronic lung disease, intraventricular hemorrhage, and sepsis differed from children without these neonatal morbidities, with an average of 10-20 points below the mean.

Early Precursors of Low Attention and Hyperactivity in a Preterm Sample at Age Four

The increased numbers of low birth weight (LBW) survivors has raised questions about the direct association between LBW and later diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) in early childhood. A longitudinal data set was used to determine the relationship among perinatal morbidity and medical and neurological status during the toddler period (18 and 30 months) with lower attention and higher activity, cardinal features of ADHD at age 4. The sample of 39 full term and 149 preterm infants were recruited at birth. Infants were assigned to 1 of 5 groups based on perinatal morbidity. Medical and neurological status were classified as normal, suspect, or abnormal at 18 and 30 months. At age 4, five measures of attention and activity were gathered from parents and independent examiners. Multivariate analysis of variance (MANOVA) showed significant effects of perinatal morbidity, birth weight, gestational age, gender, socioeconomic status at infancy, and toddler medical and neurological status with lower attention and higher activity at age 4. Prematurity, perinatal illness, and later medical status are early markers for preschool behaviors associated with clinical diagnosis of ADHD.

Maternal interaction patterns and preschool competence in high-risk children.

BACKGROUNDnThe influence of specific maternal interaction patterns as compensatory mechanisms in promoting development of medically high-risk children has been understudied.nnnOBJECTIVESnTo investigate the association of three maternal interaction patterns, maternal responsivity, involvement, and control style, with preschool competency in a medically heterogeneous sample.nnnMETHODnChildren (N= 184) and their mothers participating in a prospective longitudinal study were assessed in a laboratory protocol and home visit. The methods of measurement were maternal self-report, global rating scales, interview, and nationally standardized instruments.nnnRESULTSnEvidence of a maternal compensatory mechanism was exhibited in mothers higher involvement with their children who were born at high medical risk (F(1,183) = 6.26, p = .01). Mothers of the most competent children demonstrated higher maternal responsivity, involvement, and more appropriate control than mothers of children who were not as competent. In hierarchical regression models, the three maternal interaction patterns were significant predictors after perinatal risk and maternal education were controlled explaining 29-37% of the variance in child competence scores.nnnCONCLUSIONnThese findings imply that differential child outcomes are associated with specific maternal interaction patterns. It suggests that a combination of diverse information revealed in specific maternal interaction pattern is needed to predict cognitive, linguistic, and problem-solving competencies. Future research should consider individual differences in mother-child interaction patterns in order to isolate their significance for optimal child development.

Determinants of maternal self-esteem in the neonatal period

The purpose of this study was to determine whether maternal perceptions of infant health and behavior made a unique contribution in understanding maternal self-esteem beyond what could be achieved from objective measures. The Perception of Infant Health (POIH) questionnaire and the Bates ICQ captured the perception of infant health and temperament. Standard medical variables including the Hobel Medical Risk Summary measured the objective aspect of infant health. The Brazelton Neonatal Behavioral Assessment (NBAS) measured objective infant behavior. The Maternal Self-Report Inventory measured self-esteem. Eighty mother-infant dyads, which included healthy, middle socioeconomic class mothers of both full-term, neurologically normal and preterm infants with a range of medical problems were studied. Negative maternal perceptions of infant health and behavior as well as poorer objective health status were associated with decreased maternal self-esteem. Perceptual variables of temperament and health made a unique contribution to maternal self-esteem scores. Regression analysis indicated fussy/difficult, POIH, and NBAS autonomic scores explained a significant amount of variance in maternal self-esteem.

Growth trajectories of preterm infants: birth to 12 years.

INTRODUCTIONnBirth weight often is used to predict how preterm infants will grow, but scant attention has been paid to the effect of neonatal morbidities on growth trajectories. We investigated birth weight and neonatal morbidity in preterm infants growth to age 12 years.nnnMETHODnA five-group, prospective, longitudinal study was conducted with 194 infants: 46 full term; 29 healthy preterm without morbidity; 56 preterm with medical illness (MPT); 34 preterm with neurologic illness; and 29 preterm small for gestational age (SGA). Height, weight, and body mass index were measured at six ages.nnnRESULTSnThe full-term group had greater height than the preterm groups to age 8 years, when healthy preterm and MPT groups caught up. Only the SGA group had smaller height at age 12 years. The MPT, preterm with neurologic illness, and SGA groups had lower weight through age 12 years. Body mass index was appropriate for preterm groups by age 4 years. Across time, neonatal morbidity had a significant effect on height and weight trajectories. Birth weight was significant for weight trajectories only.nnnDISCUSSIONnWith variation in growth trajectories, details of neonatal morbidity in health history interviews will inform child health assessments.

Medical and ecological factors in estimating motor outcomes of preschool children.

The twofold purpose of this study was to compare motor function in preschool children born with varying degrees of medical risk and to determine the independent contribution to motor function of three domains of ecological influence. One hundred and eighty-four 4-year-old children and their mothers participated. Three predictor sets, proximal, distal, and child, and four motor outcomes were measured by multiple methods. Children born prematurely scored lower on all dimensions of motor function. Prematurity complications had a different effect on motor function. Hierarchical regression models explained 16-40% of motor score variance. Results are discussed in relation to heterogeneity of prematurity and ecological influences on motor outcomes.

Testing proximal and distal protective processes in preterm high-risk children.

The purpose was to examine a model that incorporates cumulative medical risk at age 4 and distal and protective processes at age 8 to assess school-age competency outcomes of cognition, school achievement, and socioemotional well-being in a sample of preterm children born at various degrees of medical risk. Cumulative medical risk and distal protective and proximal maternal protective processes were constructed into indexes. Hierarchical multiple regression analysis were performed entering the cumulative medical risk index first, followed by distal and proximal protective processes in the next two steps to test the effect on cognitive, academic, and socioemotional competence. For participants, 151 preterm and 39 full-term infants were recruited at birth into a prospective longitudinal study and followed until age 8 with a 97% retention rate. Children were stratified by birth weight and socioeconomic status. The hypotheses were supported. Significant main effects for cumulative medical risk and distal and proximal protective processes in all competency outcome models are key findings. The addition of protective processes was small to moderate in effect (6%-18%) yet clinically significant. These findings illustrate the advantage of applying cumulative medical risk and protection approach to better understand school-age outcomes. Multiple risk and protective models emphasize the joint occurrence of individual contextual processes in the understanding of competence outcomes in high-risk children.