Prachi E. Shah

Long-term Outcomes of Group B Streptococcal Meningitis

OBJECTIVE: Group B Streptococcus (GBS) is the leading cause of meningitis in young infants. We evaluated long-term outcomes among GBS meningitis survivors. We hypothesized that despite reduced mortality, GBS meningitis would remain a significant cause of morbidity among GBS survivors. METHODS: Ninety term and near-term infants diagnosed with GBS meningitis from 1998 through 2006 were identified from 2 children’s hospitals. Five died acutely, and 5 died at 6 months to 3 years of age. Forty-three survivors (54%; mean age 6.8, range 3–12 years) were consented for evaluation and underwent physical and neurologic examinations, hearing and vision screening, and standardized developmental assessments. Associations among presenting features, laboratory parameters, neurologic status at hospital discharge, and later developmental outcomes were explored by using descriptive statistics and logistic regression. RESULTS: Twenty-four of 43 (56%) children evaluated demonstrated age-appropriate development, 11 (25%) had mild-to-moderate impairment, and 8 (19%) had severe impairment. Admission features associated with death after hospital discharge or severe impairment included lethargy (P = .003), respiratory distress (P = .022), coma or semicoma (P = .022), seizures (P = .015), bulging fontanel (P = .034), leukopenia (P = .026), acidosis (P = .024), cerebrospinal fluid protein >300 mg/dL (P = .006), cerebrospinal fluid glucose <20 mg/dL (P = .026), and need for ventilator (P = .002) or pressor support (P < .001). Features at discharge associated with late death or severe impairment included failed hearing screen (P = .004), abnormal neurologic examination (P < .001), and abnormal end of therapy brain imaging (P = .038). CONCLUSIONS: Survivors of GBS meningitis continue to have substantial long-term morbidity, highlighting the need for ongoing developmental follow-up and prevention strategies such as maternal immunization.

Updated clinical guidelines for diagnosing fetal alcohol spectrum disorders

The adverse effects of prenatal alcohol exposure constitute a continuum of disabilities (fetal alcohol spectrum disorders [FASD]). In 1996, the Institute of Medicine established diagnostic categories delineating the spectrum but not specifying clinical criteria by which diagnoses could be assigned. In 2005, the authors published practical guidelines operationalizing the Institute of Medicine categories, allowing for standardization of FASD diagnoses in clinical settings. The purpose of the current report is to present updated diagnostic guidelines based on a thorough review of the literature and the authors’ combined expertise based on the evaluation of >10 000 children for potential FASD in clinical settings and in epidemiologic studies in conjunction with National Institute on Alcohol Abuse and Alcoholism–funded studies, the Collaborative Initiative on Fetal Alcohol Spectrum Disorders, and the Collaboration on FASD Prevalence. The guidelines were formulated through conference calls and meetings held at National Institute on Alcohol Abuse and Alcoholism offices in Rockville, MD. Specific areas addressed include the following: precise definition of documented prenatal alcohol exposure; neurobehavioral criteria for diagnosis of fetal alcohol syndrome, partial fetal alcohol syndrome, and alcohol-related neurodevelopmental disorder; revised diagnostic criteria for alcohol-related birth defects; an updated comprehensive research dysmorphology scoring system; and a new lip/philtrum guide for the white population, incorporating a 45-degree view. The guidelines reflect consensus among a large and experienced cadre of FASD investigators in the fields of dysmorphology, epidemiology, neurology, psychology, developmental/behavioral pediatrics, and educational diagnostics. Their improved clarity and specificity will guide clinicians in accurate diagnosis of infants and children prenatally exposed to alcohol.

The paradox of prematurity: The behavioral vulnerability of late preterm infants and the cognitive susceptibility of very preterm infants at 36 months post-term

We explored associations among preterm status (very preterm infant (VPI: <30 weeks), moderate preterm (MPI: 30-33(6/7) weeks), late preterm (LPI: 34-36(6/7) weeks), parenting, and 3-year cognitive and behavioral outcomes. We hypothesized that LPIs would demonstrate better health and neurobehavioral outcomes compared with more premature infants, and that preterm status would moderate the association between parenting quality and 3-year outcomes. Sample included 123 preterm infants (gestation <37 weeks) and their mothers from a larger study of high-risk infants with measures of neonatal and socioeconomic risks at hospital discharge; maternal vocabulary at 9-months, child IQ and behavior at 36 months, and maternal depressive symptoms and parenting at all timepoints. Group differences were explored using MANOVAs while predictors of child outcomes were explored using hierarchical regression analyses. MANOVAs indicated that LPIs had more optimal neonatal health during the hospital stay, yet more externalizing (p=.043), aggressive (p=.006) and oppositional behaviors (p=.008) at 3 years compared with VPIs. There were no IQ differences between VPIs, MPIs and LPIs. However, preterm infants who experienced less negative parenting had higher IQs at 36 months (β=-3.245, p=.017), with the greatest effects seen in VPIs (β=0.406, p=.01) compared with LPIs (β=0.148, p=.381). LPIs manifested similar IQ, but more externalizing, oppositional and aggressive behavior symptoms compared to VPIs. VPIs appeared to be differentially susceptible to parenting effects, with VPIs demonstrating the highest cognitive scores in the context of more positive parenting.

Preterm infants who are prone to distress: differential effects of parenting on 36-month behavioral and cognitive outcomes.

BACKGROUND The differential susceptibility (DS) model suggests that temperamentally prone-to-distress infants may exhibit adverse outcomes in negative environments but optimal outcomes in positive environments. This study explored temperament, parenting, and 36-month cognition and behavior in preterm infants using the DS model. We hypothesized that temperamentally prone to distress preterm infants would exhibit more optimal cognition and fewer behavior problems when early parenting was positive; and less optimal cognition and more behavior problems when early parenting was less positive. METHODS Participants included 109 preterm infants (gestation <37 weeks) and their mothers. We assessed neonatal risk and basal vagal tone in the neonatal intensive care unit; infant temperament and parenting interactions at 9 months post-term; and child behavior and cognitive skills at 36 months post-term. Hierarchical regression analyses tested study hypotheses. RESULTS Temperamentally prone-to-distress infants exhibited more externalizing problems if they experienced more critical parenting at 9 months (β = -.20, p < 0.05) but fewer externalizing problems with more positive parenting. Similarly, variations in maternal positive affect (β = .25, p < .01) and intrusive behaviors (β = .23, p < .05) at 9 months predicted 36-month cognition at high but not at low levels of infant temperamental distress. Higher basal vagal tone predicted fewer externalizing problems (β = -.19, p < .05). CONCLUSIONS Early parenting behaviors relate to later behavior and development in preterm infants who are temperamentally prone to distress, and neonatal basal vagal tone predicts subsequent externalizing behaviors. These findings suggest that both biological reactivity and quality of caregiving are important predictors for later outcomes in preterm infants and may be considered as foci for developmental surveillance and interventions.

The development of effortful control in children born preterm

This prospective longitudinal study examined emerging effortful control skills at 24- and 36-months postterm in 172 children born preterm (<36 weeks gestation). Infant (neonatal health risks), family (sociodemographic risks), and maternal risk factors (depressive symptoms, anger expressions during play interactions) were assessed at six time points across 3 years. In addition, childrens emerging effortful control skills, cognitive development, and mother-reported behavior and attention problems were assessed at 24 and 36 months. Analyses documented links between effortful control skills, cognitive skills, and concurrent attention problems in children born preterm. The study also found that preterm childrens effortful control skills improved over time. In addition, neonatal health risks, family sociodemographic risks, and angry parenting interactions were associated with less optimal effortful control skills.

Gestational Age and Kindergarten School Readiness in a National Sample of Preterm Infants.

OBJECTIVE To examine the association of gestational age with school readiness in kindergarten reading and math skills. We hypothesized that compared with infants born at 39-41 weeks, infants born at lower gestational ages would have poorer school readiness. STUDY DESIGN The study sample comprised 5250 children from the Early Childhood Longitudinal Study, Birth Cohort, assessed with specialized reading and math assessments at kindergarten. Poor school readiness was characterized by reading and math theta scores ≥1.5 SD below the sample mean. The aOR and 95% CI of poor school readiness were estimated using multivariate logistic regression, examining gestational age continuously and categorically (very preterm [VPT], moderate/late preterm [M/LPT], early term [ET], and term). Pairwise comparisons were performed to test for differences by gestational age category. RESULTS There was an association between gestational age and poor school readiness for reading and math, with the suggestion of a threshold effect in children born at ≥32 weeks gestation. In adjusted models, in VPT infants, the aORs of poor school readiness in reading and math were 2.58 (95% CI, 1.29-5.15) and 3.38 (95% CI, 1.66-6.91), respectively. For infants born M/LPT and ET, the odds of poor school readiness in reading did not differ from those of children born full-term, however. CONCLUSIONS Compared with term infants, the highest odds of poor school readiness in reading and math were seen in VPT infants, with lower odds of poor school readiness in children born at ≥32 weeks gestation. Ongoing developmental surveillance before kindergarten is indicated for VPT infants.

Developmental Outcomes of Late Preterm Infants From Infancy to Kindergarten.

OBJECTIVE: To compare developmental outcomes of late preterm infants (34–36 weeks’ gestation) with infants born at early term (37–38 weeks’ gestation) and term (39–41 weeks’ gestation), from infancy through kindergarten. METHODS: Sample included 1000 late preterm, 1800 early term, and 3200 term infants ascertained from the Early Childhood Longitudinal Study, Birth Cohort. Direct assessments of development were performed at 9 and 24 months by using the Bayley Short Form–Research Edition T-scores and at preschool and kindergarten using the Early Childhood Longitudinal Study, Birth Cohort reading and mathematics θ scores. Maternal and infant characteristics were obtained from birth certificate data and parent questionnaires. After controlling for covariates, we compared mean developmental outcomes between late preterm and full-term groups in serial cross-sectional analyses at each timepoint using multilinear regression, with pairwise comparisons testing for group differences by gestational age categories. RESULTS: With covariates controlled at all timepoints, at 9 months late preterm infants demonstrated less optimal developmental outcomes (T = 47.31) compared with infants born early term (T = 49.12) and term (T = 50.09) (P < .0001). This association was not seen at 24 months, (P = .66) but reemerged at preschool. Late preterm infants demonstrated less optimal scores in preschool reading (P = .0006), preschool mathematics (P = .0014), and kindergarten reading (P = .0007) compared with infants born at term gestation. CONCLUSIONS: Although late preterm infants demonstrate comparable developmental outcomes to full-term infants (early term and full-term gestation) at 24 months, they demonstrate less optimal reading outcomes at preschool and kindergarten timepoints. Ongoing developmental surveillance for late preterm infants is warranted into preschool and kindergarten.

Optimizing the Early Parent–Child Relationship: Windows of Opportunity for Parents and Pediatricians

This article explores child and parent risk factors that can affect the early parent-child relationship and highlights how a relational approach can be used in pediatric primary care to optimize early social-emotional development in the context of family-centered care. Risk factors, such as prematurity, parental mental illness, and a history of adverse care-giving experiences, can affect the parent-child relationship and influence later infant social-emotional development. The pediatrician, because of the ongoing relationship with the family, is in an optimal position to identify concerns, initiate interventions, and provide support and services to support the development of the early parent-child relationship.

Early childhood curiosity and kindergarten reading and math academic achievement

BackgroundAlthough children’s curiosity is thought to be important for early learning, the association of curiosity with early academic achievement has not been tested. We hypothesized that greater curiosity would be associated with greater kindergarten academic achievement in reading and math.MethodsSample included 6200 children in the Early Childhood Longitudinal Study, Birth Cohort. Measures at kindergarten included direct assessments of reading and math, and a parent-report behavioral questionnaire from which we derived measures of curiosity and effortful control. Multivariate linear regression examined associations of curiosity with kindergarten reading and math academic achievement, adjusting for effortful control and confounders. We also tested for moderation by effortful control, sex, and socioeconomic status (SES).ResultsIn adjusted models, greater curiosity was associated with greater kindergarten reading and math academic achievement: breading = 0.11, p < 0.001; bmath = 0.12, p < 0.001. This association was not moderated by effortful control or sex, but was moderated by SES (preading = 0.01; pmath = 0.005). The association of curiosity with academic achievement was greater for children with low SES (breading = 0.18, p < 0.001; bmath = 0.20, p < 0.001), versus high SES (breading = 0.08, p = 0.004; bmath = 0.07, p < 0.001).ConclusionsCuriosity may be an important, yet under-recognized contributor to academic achievement. Fostering curiosity may optimize academic achievement at kindergarten, especially for children with low SES.

The Influence of Early Temperament on Language Development: The Moderating Role of Maternal Input

Temperament is an individual aspect that strictly affects infants and children engagement with the environment and it is supposed to play a role in the acquiring of new competences. Several studies focused on the possible influence of temperament in the process of language acquisition in early childhood reporting not consistent findings. Since maternal input is a variable that has been widely associated with infant language development this longitudinal study aimed to explore the role of the quality of maternal input in the temperament-language association. We hypothesized that the longitudinal association between early infant temperament and language production is moderated by the quality of maternal input during the first year of life. Infant temperament at 3 months and maternal linguistic input (lexical diversity and syntactic complexity) during spontaneous mother–infant interactions at 6, 9, and 12 months were assessed. Language competences were evaluated at the end of the second year: language production at 18 months with the CDI and child syntactic complexity at 24 months during spontaneous speech. Results showed significant moderating effects of syntactic complexity and lexical variability of maternal input at 6 and 9 months on the association of duration of orienting abilities and later language production. Infants with greater attentional abilities and with mothers who spoke to them with a more complex and variable input showed the better language outcomes. The association between infant distress to limitations and child language was not moderated by maternal input. No effects were found when considering the temperamental scale smile and laugher. Attentional control temperamental characteristics could help the infant to be more focus on maternal input throughout the first year of life and could consequently facilitate language development. Our findings underlined the necessity to explore infant development considering the interaction between individual and contextual factors.