Objective To examine the neurosensory and cognitive status of extremely low-birth-weight (ELBW; Design An inception cohort of ELBW infants admitted to the neonatal intensive care unit (NICU) and observed to 20 months' corrected age. Setting A tertiary level urban NICU and follow-up clinic at a university hospital. Population Of 333 ELBW infants without major congenital malformations admitted to the NICU, 241 (72%) survived to 20 months' corrected age. We studied 221 children (92%) at a mean of 20 months' corrected age. The mean birth weight was 813 g; mean gestational age, 26.4 weeks. Main Outcome Measures Assessments of cognitive and neurosensory development. Results Major neurosensory abnormality was present in 54 children (24%), including 33 (15%) with cerebral palsy, 20 (9%) with deafness, and 2 (1%) with blindness. The mean (± SD) Bayley Mental Developmental Index (MDI) score was 74.7 ± 17. Ninety-two children (42%) had a subnormal MDI score ( 171 µmol/L [>10 mg/dL]) (OR, 4.80; 95% CI, 1.46-15.73). Conclusion There is an urgent need for research into the etiology and prevention of neonatal morbidity.

https://jamanetwork.com/journals/jamapediatrics/articlepdf/350278/poa90461.pdf

Neurodevelopment and Predictors of Outcomes of Children With Birth Weights of Less Than 1000 g: 1992-1995

Extremely low birth weight (ELBW) is associated with impaired neurodevelopmental outcome in infancy. Information on the long-term cognitive and neurological consequences of ELBW is scarce. We aimed to identify the perinatal and neonatal factors of ELBW infants associated with adverse cognitive and neurological outcome at school age. A regional cohort of 135 ELBW infants born between 1993 and 1998 was prospectively evaluated at 3, 6, 12, and 18 months postmenstrual age and at yearly intervals up to age 10 years. The comprehensive follow-up programme for high-risk infants included neurological examinations and psychometric evaluations. According to the overall results of these tests, children were classified as either being normal or having minor or major impairment. At a mean age of 8.4 (SD: 1.6) years, 43% of children had survived without any impairment. Minor impairment was diagnosed in 39% and major impairment in 18% of assessed children. The proportion of disabled school children rose with decreasing gestational age. The following neonatal complications were significant risk factors for developing major or minor impairment at school age: an increase in head circumference 14 days (OR 2.3, 95% CI: 1.0–5.1). High-grade intraventricular haemorrhage (IVH) and/or PVL (OR 13.3, 95% CI: 4.0–44.9), neonatal seizures (OR 5.2, 95% CI: 1.2–22.4) and bowel perforation, and/or necrotizing enterocolitis (OR 4.4, 95% CI: 1.1–17.0) were significant risk factors for developing major impairment. In spite of the relatively large proportion of normal children, ELBW remains an important risk factor for neurodevelopmental impairment at school age. Thus, measures to prevent complications such as necrotizing enterocolitis, cerebral haemorrhage, and undernutrition remain important goals for neonatal intensive care.

Outcome of extremely low birth weight survivors at school age: the influence of perinatal parameters on neurodevelopment

Background Very low-birth-weight newborns (birth weight ≤1500 g) experience serious neonatal complications, but long-term outcomes are not completely known Most studies reflect an era of neonatal care that was fundamentally different from the present Objectives To compare the functional level of very low-birth-weight children before and after surfactant introduction and to relate functional level to clinical and socioeconomic factors Design Inception cohort followed up from birth to an average age of 5 years Setting Six regional neonatal intensive care units in a contiguous geographic area Participants Four hundred twenty-five very low-birth-weight children, born between August 1, 1988, and June 30, 1991, of 438 located among 626 whose parents provided follow-up information before neonatal intensive care unit discharge Interventions None Main Outcome Measures Diagnosis of cerebral palsy and standardized scores for self-care, mobility, and social function from the Pediatric Evaluation of Disability Inventory Results Cerebral palsy was present in 126% of the children, with no change after surfactant introduction Intraventricular hemorrhage (odds ratio, 23 per grade; 95% confidence interval, 18-28) and bronchopulmonary dysplasia (odds ratio, 23; 95% confidence interval, 12-46) were independently predictive of cerebral palsy and of functional outcome For self-care, mobility, and social function, 117%, 295%, and 107% of the children, respectively, scored at least 2 SDs below the normative means Social function was 025 to 050 normative SDs lower after general surfactant availability than before general surfactant availability Conclusions While there was no increase in major disability after surfactant introduction, there may have been a decrease in social function associated with the lower neonatal mortality Most very low-birth-weight children functioned within the normal range in everyday tasks Several predictors of outcome were identified

Functional Assessment of a Multicenter Very Low-Birth-Weight Cohort at Age 5 Years

Aim: We present a longitudinal study on the neurodevelopmental outcome in preterm infants with extremely low birth weight <1000 g (ELBW) to answer the question at which age a developmental prognosis can be given.



Methods: A group of 129 ELBW, median birth weight: 794 g (SD 123 g), gestational age: 27.0 weeks (SD 2.0 weeks), born between 1993 and1998, were followed up to the age between 6 and 10 years (mean 8.5 years [SD 1.7 years]) and evaluated by neurodevelopmental and psychometric tests. The status of children without cerebral palsy was ranked into categories of major, minor and no developmental impairments.



Results: At the time of the last follow-up examination 17% of the children showed a major impairment including 9% cerebral palsy, 42% a minor impairment and 41% were normally developed. The longitudinal analysis of cases without cerebral palsy reveals that an assessment ‘at term’ can only give the correct developmental prognosis in 49% of the cases. At the corrected age of 12 months the prognosis is correct in 59% of the cases, whereas at the corrected age of 3 years 70% proves to be right. Diagnosis of cerebral palsy could be confirmed at the corrected age of 2 years with sufficient reliability.



Conclusion: The neurodevelopmental evaluation of former preterm infants with a birth weight <1000 g demands a follow-up period of at least 6 years in order to make reliable statements. We are doubtful that follow-up testing completed prior to this age can yield reliable results.

Neurodevelopmental outcome in extremely low birth weight infants: what is the minimum age for reliable developmental prognosis?

The Social Security Administration (SSA) of the Department of Health and Human Services requested that the Agency for Healthcare Research and Quality (AHRQ), through its Evidence-based Practice Center (EPC) program, produce an evidence report to determine whether specific factors or a combination of factors alone or in addition to birth weight predict significant developmental disability in former premature infants and whether premature infants with such factors have long-term developmental disabilities. This evidence report is prepared to assist the SSA in updating its Listing of Impairments, and revising its disability policy, as may be appropriate. This report does not provide or suggest a new listing of impairments. This report examines the evidence that Very Low Birth Weight (VLBW) in infants (birth weight <1,500 grams) with or without other conditions is associated with long-term disabling outcomes. The primary outcomes of interest included in this report are cerebral palsy (CP), mental retardation (MR), hearing/speech/ language/behavioral impairments, visual impairments, adverse pulmonary function, and disrupted growth. The category of VLBW infants was chosen because it is well recognized to represent a population of infants, primarily premature infants, at increased risk for acute and chronic impairments related to their immaturity. VLBW is often divided into subcategories of lower birth weights, such as less than 1,250, less than 1,000, and less than 750 grams, to facilitate analyses of infants within different birth weight strata. Extremely Low Birth Weight (ELBW) infants are often defined as infants with birth weight less than 1000 grams, although this definition may vary among studies by as much as 250 grams in either direction. In general, the lower the birth weight, the greater the degree of immaturity, and the greater the risk for serious complications. Birth weight, however, is not a perfect measure of immaturity since some infants may have birth weights that are disproportionately large or small for their gestational age. Many studies appropriately and preferably use gestational age as the marker of prematurity. Similar to birth weight, gestational age categories of premature infants often include groupings of premature infants less than 32 weeks gestation, less than 30 weeks gestation, less than 28 weeks gestation; or less than 26 weeks gestation. Less than 32 weeks gestational age is considered by some authorities as “very premature” and less than 28 weeks gestational age as “extremely premature.” Premature birth is an important public health problem due to the number of premature births each year, the serious acute complications of prematurity, and the long-term sequelae directly related to the vulnerability of VLBW infants. Among the four million births in the United States during the year 2000, about 58,000 (1.4%) were VLBW (<1,500 grams). Although VLBW is a relatively small proportion of total births in the USA, this category of infants accounts for the highest neonatal mortality and greatest morbidity among newborns. The long-term complications result in significantly increased tangible and intangible lifelong costs to the family and society for medical care as well as for ongoing ancillary health and educational services. Advances in neonatal/perinatal medicine have improved the survival and the quality of survival Evidence Report/Technology Assessment Number 70

Criteria for determining disability in infants and children: low birth weight.

The survival rate of extremely low birth weight (ELBW; i.e. < 1001 grams) infants has significantly improved in the past 10 years secondary to the numerous advances in neonatology. There have been many favorable reports of the neurodevelopmental outcomes of survivors, but the studies often span several years to collect sufficient number of subjects. This study assesses the outcome of 100 ELBW infants born in Maryland in 1990 and analyzes factors that may have contributed to their outcomes at one year corrected age. Of this group, 72% had no evidence of severe disability (e.g., cerebral palsy (CP) or mental retardation (MR); however, 51% of the children had abnormal or suspect neurological examinations, and 24% had CP. Eighteen percent of the children were more than one standard deviation below the mean cognitively; 30% were below normal for motor abilities, and 33% were below normal for language abilities. Prior to this study, many of these children were not recognized by their primary physician as having any developmental problems. Many of these children were not followed in neonatal intensive care unit (NICU) follow-up programs, and most were not receiving appropriate early intervention services (EIS). Previous studies have associated different neonatal events with the risk of developmental delay. Bronchopulmonary dysplasia (BPD) and periventricular leukomalacia (PVL) accounted for most of the variance of this sample's developmental outcome. Of these 100 ELBW infants, 56 received surfactant. Analysis demonstrated no significant differences in developmental outcomes between those who received surfactant and those who did not. However, those who received rescue surfactant were more likely to acquire a diagnosis of BPD. As demonstrated by this study, ELBW infants are at risk for significant developmental problems. This supports the need for targeted outreach, developmental monitoring, early intervention services, and parent support and education.

Blitz Rk

Papers

Neurodevelopmental outcome of extremely low birth weight infants in Maryland.