S Johnson

Neurodevelopmental outcomes following late and moderate prematurity: a population-based cohort study

Objective There is a paucity of data relating to neurodevelopmental outcomes in infants born late and moderately preterm (LMPT; 32+0–36+6 weeks). This paper present the results of a prospective, population-based study of 2-year outcomes following LMPT birth. Design 1130 LMPT and 1255 term-born children were recruited at birth. At 2 years corrected age, parents completed a questionnaire to assess neurosensory (vision, hearing, motor) impairments and the Parent Report of Childrens Abilities-Revised to identify cognitive impairment. Relative risks for adverse outcomes were adjusted for sex, socio-economic status and small for gestational age, and weighted to account for over-sampling of term-born multiples. Risk factors for cognitive impairment were explored using multivariable analyses. Results Parents of 638 (57%) LMPT infants and 765 (62%) controls completed questionnaires. Among LMPT infants, 1.6% had neurosensory impairment compared with 0.3% of controls (RR 4.89, 95% CI 1.07 to 22.25). Cognitive impairments were the most common adverse outcome: LMPT 6.3%; controls 2.4% (RR 2.09, 95% CI 1.19 to 3.64). LMPT infants were at twice the risk for neurodevelopmental disability (RR 2.19, 95% CI 1.27 to 3.75). Independent risk factors for cognitive impairment in LMPT infants were male sex, socio-economic disadvantage, non-white ethnicity, preeclampsia and not receiving breast milk at discharge. Conclusions Compared with term-born peers, LMPT infants are at double the risk for neurodevelopmental disability at 2u2005years of age, with the majority of impairments observed in the cognitive domain. Male sex, socio-economic disadvantage and preeclampsia are independent predictors of low cognitive scores following LMPT birth.

Cognitive trajectories from infancy to early adulthood following birth before 26 weeks of gestation: a prospective, population-based cohort study

Objective To determine the trajectory of cognitive test scores from infancy to adulthood in individuals born extremely preterm compared with term-born individuals. Design A prospective, population-based cohort study. Setting 276 maternity units in the UK and Ireland. Patients 315 surviving infants born less than 26 completed weeks of gestation recruited at birth in 1995 and 160 term-born classroom controls recruited at age 6. Main outcome measures Bayley Scales of Infant Development-Second Edition (age 2.5); Kaufman Assessment Battery for Children (ages 6/11); Wechsler Abbreviated Scale of Intelligence-Second Edition (age 19). Results The mean cognitive scores of extremely preterm individuals over the period were on average 25.2 points below their term-born peers (95%u2009CI −27.8 to −22.6) and remained significantly lower at every assessment. Cognitive trajectories in term-born boys and girls did not differ significantly, but the scores of extremely preterm boys were on average 8.8 points below those of extremely preterm girls (95%u2009CI −13.6 to −4.0). Higher maternal education elevated scores in both groups by 3.2 points (95%u2009CI 0.8 to 5.7). Within the extremely preterm group, moderate/severe neonatal brain injury (mean difference: −10.9, 95%u2009CI −15.5 to −6.3) and gestational age less than 25 weeks (mean difference: −4.4, 95%u2009CI −8.4 to −0.4) also had an adverse impact on cognitive function. Conclusions There is no evidence that impaired cognitive function in extremely preterm individuals materially recovers or deteriorates from infancy through to 19 years. Cognitive test scores in infancy and early childhood reflect early adult outcomes.

The bayley-III cognitive and language scales: how do scores relate to the bayley ii?

Background The widely used Mental Developmental Index (MDI) of the Bayley Scales of Infant Development-II has recently been superseded by the Bayley-III – in which cognitive and language development are assessed separately. Comparing developmental outcomes between cohorts assessed using two different editions of this test is problematic. Aims To compare MDI and Bayley-III cognitive and language scores, evaluate the agreement between classifications of disability made using the two tests, and develop an algorithm for converting Bayley-III scores into corresponding MDI scores. Methods 185 children (derived from a sub-cohort of the EPICure-2 study) aged 29–41 months were administered the MDI and Bayley-III concurrently. An average of Bayley-III cognitive and language scores (CB-III score) was calculated for comparison with MDI scores. Results Bayley-III cognitive, language and CB-III scores were 3-, 10- and 7-points higher respectively than MDI scores, but the relationship was non-linear: the CB-III progressively overestimated developmental scores at lower MDI scores. Using a conventional cut-off score <70, CB-III scores under-detected developmental impairment compared with the MDI (sensitivity 58%, specificity 100%). Predictive validity was improved using a CB-III cut-off <80 (sensitivity 89%, specificity 99%). An algorithm was derived for transforming CB-III scores into MDI-equivalent scores, with further improvement in classification of children with MDI<70 (sensitivity 95%, specificity 97%). Conclusions Caution should be exercised in classifying developmental outcomes using the Bayley-III for research purposes. To produce equivalent identification of children who would have an MDI <70, we recommend using a CB-III scores <80 or predicted-MDI scores <70.

4.2 Infant neurodevelopmental outcomes following late and moderately preterm birth

Introduction Very preterm (<32 weeks) infants are at high risk for neurodevelopmental sequelae. Less is known about outcomes following birth at late and moderately preterm gestations (LMPT; 32–36 weeks). Methods 1130 LMPT and 1255 term-born (≥37 weeks) babies were recruited at birth to the Late and Moderately Preterm Birth Study (LAMBS). At 2-years, parents completed the Parent Report of Children’s Abilities-Revised (PARCA-R) to assess cognitive impairment and a questionnaire to assess neurosensory (vision, hearing, motor) impairment. Neurodevelopmental disability was defined where the child had a moderate/severe impairment in at least one domain. Results Parents of 651 (59%) LMPT and 771 (62%) term-born children responded at 2 years. Overall, 1.6% of LMPT infants and 0.3% of controls had a neurosensory impairment (RR 6.00; 95%CI 1.32, 27.28). Rates of cognitive impairment were higher in general (LMPT 15.6%; Term 10.0%) and LMPT infants at increased risk of cognitive delay (RR 1.56; 95% CI 1.18, 2.06). Overall, 16% of LMPT and 10% of term-born infants had neurodevelopmental disability (RR 1.57; 95% CI 1.19, 2.07). Male sex, non-white ethnicity, lower socio-economic status, pre-pregnancy hypertension, preeclampsia and recreational drug use were risk factors for neurodevelopmental disability among LMPT children. Conclusions Children born LMPT are at increased risk for neurodevelopmental disability; although the risk was largest for neurosensory impairment, the number of children affected by cognitive problems was far greater. Preeclampsia and antenatal recreational drug use are markers of poor outcome and may be potentially modifiable factors for reducing adverse outcomes following LMPT birth.

PPO.16 Understanding the impact of socioeconomic risk factors on late and moderate preterm birth: A population-based cohort study

Introduction Very preterm birth rates (<32 weeks) have been shown to rise with increasing socioeconomic deprivation but less is known about the impact of socioeconomic deprivation on birth at late and moderate preterm gestations (LMPT; 32–36 weeks). Methods A geographical population-based birth cohort study of 938 LMPT and 939 term-born (≥37 weeks) singleton babies. Socio-demographic, economic, lifestyle and stress factors were collected in a maternal interview after birth. Maternal education level was explored as a risk factor for late and moderate preterm birth, using multivariable Binomial regression analyses. Further models assessed whether demographic, lifestyle and economic factors explained any of this variation. Results The odds of delivering a LMPT infant increased with decreasing levels of education (OR 1.60 (1.23 to 2.09) for degree level education compared to no qualifications P = 0.002). This changed little after adjusting for maternal age and ethnicity. Three key economic and lifestyle risk factors explained this variation with education levels: access to a car (OR 1.30 (1.03 to 1.66); smoking during pregnancy (OR 1.28 (1.01 to 1.63) and low levels of fruit and vegetable consumption (OR 1.26 (0.99 to 1.62)) Conclusions Mothers with low levels of education were at greatest risk of delivering LMPT. Lifestyle behaviours (smoking during pregnancy and poor diet) and access to a car which may limit access to health care services appeared to explain this differential. These findings highlight that socioeconomic risk factors continue to impact on prematurity up until 36 weeks gestation.

5.9 Behavioural, social and emotional outcomes following late and moderately preterm birth

Introduction Very preterm (<32 weeks) infants are at high risk for behaviour problems. Relatively little is known about behavioural outcomes following birth at late and moderately preterm gestations (LMPT; 32–36 weeks). Methods 1130 LMPT and 1255 term-born (≥37 weeks) babies were recruited to the Late and Moderate Preterm Birth Study (LAMBS). At 2-years, parents completed the Brief Infant and Toddler Social Emotional Assessment (BITSEA) questionnaire to screen for socio-emotional and behaviour problems, and the Modified-Checklist for Autism in Toddlers (M-CHAT) questionnaire to screen for autistic features. Parents of children with positive M-CHAT screens completed a follow-up interview to improve specificity of screening over use of the questionnaire alone. Results Parents of 651 (59%) LMPT and 771 (62%) term-born infants responded at 2-years. Overall, 38% of LMPT and 30% of term-born children had positive BITSEA screens (RR 1.23, 95%CI 1.06 to 1.42); however, LMPT children were at increased risk for delayed social-emotional competence (RR 1.42, 1.17 to 1.73) but not behaviour problems (RR 1.15, 0.93 to 1.42). LMPT children had significantly higher risk of positive M-CHAT screens (15% vs. 9%; 1.58, 1.18 to 2.11). After follow-up, LMPT children remained at significantly higher risk for autistic features (2.4% vs. 0.5%; 4.52, 1.51 to 13.56). Conclusions LMPT children are at increased risk for social-emotional but not behaviour problems at 2 years of age. This is the first study to show an increased risk for autistic features in LMPT infants. Longer term follow-up is needed to determine how these behavioural sequelae evolve throughout childhood.

PC.10 Neonatal outcomes of singleton and multiple births at 32–36 Weeks of Gestation: Results from the Late And Moderately preterm Birth Study (LAMBS)

Background There is a paucity of recent, prospectively collected data comparing outcomes between singletons and twins born at late and moderately preterm (32–36 weeks; LMPT) gestations. Methods In a prospective, geographically defined, population-based study of babies born at 32–36 weeks gestation we compared neonatal outcomes in normally formed singletons and multiples. Results We recruited 200 LMPT and 274 term-born multiples, together with 907 live-born LMPT singletons. Within the LMPT group a greater proportion of singletons than multiples had jaundice (9.3% v 6.5%; P = 0.049) and hypoglycaemia (21.9% v 15.5%; P = 0.055). Other outcomes were similar between groups. Among multiples, those born LMPT were more likely to require resuscitation at birth (20.5% v 11.3%; P = 0.007), neonatal unit admission (43.0% v 8.4%; P < 0.001) and respiratory support (28.0% v 0.7%; P < 0.001). There were higher rates of jaundice (15.5% v 1.5%; P > 0.001) and hypothermia (6.5% v 2.6%; P = 0.042) in LMPT multiples and breast-feeding at discharge was lower (53.5% v 64.6%; P = 0.018) compared with term-born multiples. Conclusions Our results suggest that many neonatal outcomes are similar between singletons and multiples and but some morbidities are reduced in multiples. LMPT multiples have poorer outcomes than their term-born counterparts. Differing maternal health, socioeconomic status, and indications for delivery in singletons and twins are likely to be key influences on neonatal outcome; postnatal management may also be important. Further analysis will explore factors contributing to birth at 32–36 weeks of gestation and neonatal outcomes. Follow-up will be crucial to determine any differences in long-term outcome related to prematurity or plurality.

PC.11 Neonatal outcomes of late and moderately preterm infants following spontaneous and no-spontaneous onset of labour.

Background Infants born late/moderately preterm (LMPT; 32–36 weeks’ gestation) have increased risk of adverse outcomes compared with term-born infants. It is unclear whether differences relate to prematurity per se, or to problems occurring during pregnancy leading to medically indicated delivery. Aim To explore outcomes in LMPT and term infants born following spontaneous onset of labour (SOL) and non-spontaneous onset of labour (NSOL). Methods In a prospective, population-based study, we compared neonatal outcomes of LMPT normally formed singleton infants according to whether birth followed SOL or NSOL. Outcomes included resuscitation at delivery, respiratory support, fluid and nutritional support. Results 907 LMPT and 972 term-born infants were studied. NSOL occurred in 42.1% of LMPT and 34.2% of term births. Of these, 50.5% of LMPT and 31.9% of term infants were delivered by caesarean section not preceded by labour. The median (range) gestation was 35+6 (32+0, 36+5) weeks for both preterm groups and for term babies was 40+1 (37+0, 43+4) and 39+5 (37+0, 42+6) for SOL and NSOL respectively. LMPT infants whose mothers had NSOL were more likely to receive resuscitation (21.7% v 14.5%; P = 0.005), respiratory support (16.2% v 8.6%; P = 0.001), intravenous fluids (34% v 21.5%; P = 0.005) and parenteral nutrition (6.0% v 1.7%; P = 0.001). In term-born infants, there were no differences in these outcomes between NSOL and SOL groups. Conclusion Delivery following obstetric intervention is commoner at LMPT than term gestation. Effects associated with medically indicated LMPT delivery compound effects caused by prematurity. Further exploration of delivery indications may identify particularly high-risk groups.

The epicure studies: better survival, better outcomes?

Background Despite increases in survival after extremely preterm (EP) birth, it is unclear whether the prevalence of neurodevelopmental morbidity has changed. Aim To compare the prevalence of disability between national cohorts of EP children born in 1995 and 2006, respectively. Methods Independent assessors evaluated children born at 25 weeks of gestation or less in England in 1995 (EPICure) and 2006 (EPICure-2). Bayley-III scores were adjusted to produce MDI-equivalent scores for comparison purposes. Results Of the 260 eligible children in the EPICure cohort, 235 (90%) underwent formal neurodevelopmental assessment at 29–36 months corrected age. In the EPICure-2 cohort, 325/586 (55%) children were assessed at 27–48 months. Use of antenatal steroids, surfactant and effective hypothermia prevention were higher and postnatal steroid use lower in the 2006 cohort compared to 1995 births. Multiple imputation to correct for selective dropout revealed no differences in severe disability (18.9% vs 19.9% respectively) or cerebral palsy (20.1% vs 19.9%). Conclusions Despite improved survival and reduced early morbidity in EP children between 1995 and 2006, we were unable to detect significant improvements in neurodevelopmental morbidity during early childhood. Abstract 12.3 Table 1 EPICure (1995) n=235 EPICure-2 (2006) n=325 p Gestational age (weeks) 22/23 10% 12% 0.74 24 32% 30% 25 58% 58% Moderate/Severe Disability (%) Cognitive 26% 20% 0.08 Motor 24% 20% 0.23 Vision 13% 9% 0.14 Hearing 3% 6% 0.09 Overall 40% 34% 0.10 Cerebral palsy 19% 18% 0.63 Severe disability 18% 18% 0.96

Growth attainment in extremely preterm children-has it changed over time? the epicure 2 study

Background Children born extremely preterm have poor growth attainment; it is not known whether recent advances in neonatal care have led to an improvement. Aim To compare SD scores of growth parameters at 35 months corrected age for children born ≤25 weeks in England in 1995 (EPICure) and 2006 (EPICure-2). Methods Measures of height (ht), weight (wt), head circumference (HC) and mid upper arm circumference (MUAC) were taken as part of a neurodevelopmental assessment. Body mass index (BMI) and SD scores were calculated using British Growth Foundation normative data. Results In 2006 325/586 (55%) of survivors ≤25 week were seen, of whom 98% had growth measures. Weight, height, MUAC and BMI were all significantly improved at 35 months corrected age compared to the 1995 EPICure cohort (table 1). There was no significant difference in HC. Improvement in weight gain was due to greater post-discharge growth. Abstract PB.01 Table 1 Comparison of growth SD scores at 2.5-3 years n EPICure (1995) n EPICure2 (2006) p Wt 223 −1.19 (−1.37, −1.02) 317 −0.67 (−0.82, −0.52) <0.001 HC 229 −1.64 (−1.83, −1.45) 319 −1.78 (−1.94, −1.61) 0.29 Ht 214 −0.65 (−0.83, −0.49) 303 −0.40 (−0.57, −0.23) <0.05 BMI 209 −1.06 (−1.25, −0.87) 301 −0.59 (−0.78, −0.40) <0.001 MUAC 229 −0.74 (−0.87, −0.62) 314 −0.43 (−0.52, −0.33) <0.001 Conclusion There has been a significant improvement since 1995 in all growth parameters except HC at 35 months corrected age. Improved weight gain at 35 months was attributable to post-discharge catch-up growth.