Risk of Developmental Coordination Disorder in 8- and 9-Year-Olds Following Newborn Cardiac and Non-Cardiac Surgery.

PURPOSE: To investigate the risk of developmental coordination disorder (DCD) and motor impairment for children aged 8 to 9 years following newborn surgery. METHODS: Prospective longitudinal cohort study. Motor proficiency and risk of DCD were assessed using the Movement Assessment Battery for Children (second edition) for children born 37 weeks of gestation and older who had undergone newborn cardiac surgery (CS) or non-cardiac surgery (NCS). RESULTS: Children who had undergone CS were 3.0 times more likely than controls and 1.7 times more likely than children who had undergone NCS to score below the 15th centile on MABC-2 and have increased risk of DCD. Children who had undergone CS were 1.9 times more likely than controls and 1.4 times more likely than children who had undergone NCS to score below the fifth centile on MABC-2. CONCLUSION: The surgical population should be considered at an increased risk of DCD.

Neurodevelopmental outcomes in neonatal extracorporeal membrane oxygenation survivors: An institutional perspective.

AIM: To describe the neurodevelopmental outcomes following extracorporeal membrane oxygenation (ECMO) in early infancy. METHODS: Thirty-seven patients who had survived following ECMO support from 2008 to 2018 had their neurodevelopmental outcomes assessed and analysed using the Bayley Scales of Infant and Toddler Development. Developmental outcome was defined as impairment in any of the developmental domains of motor function, cognition and language with mild impairment being 1-2 standard deviations below the test mean, moderate being 2-3 standard deviations below and severe being greater than 3 standard deviations below. RESULTS: Of these 37 patients, the median age at admission to Paediatric Intensive Care Unit was 0.4 months (interquartile range 2.8 months) with all of the study patients having an underlying diagnosis of congenital cardiac disease and 37/40 (92.5%) ECMO runs occurring in the immediate post-operative period. Of the 29 patients who had had follow-up at 12 months of age or older, 3 (10.3%) had severe impairment, 4 (13.8%) had moderate impairment, 12 (41.3%) had mild impairment and 10 (34.5%) had no impairment. Gross motor function was most significantly impacted in 18/29 (62.1%) patients, of which 7/18 (38.9%) had severe impairment. This was followed by impairment of receptive language in 8/29 (27.6%) patients and expressive language in 6/29 (20.1%) patients. CONCLUSIONS: One in four infants undergoing ECMO treatment in early infancy has moderate to severe neurodevelopmental impairment. Gross motor and language are the most affected developmental domains.

Cerebral Oxygenation and Perfusion when Positioning Preterm Infants: Clinical Implications.

OBJECTIVES: To evaluate cerebral tissue oxygenation (cTOI) and cerebral perfusion in preterm infants in supine vs prone positions. STUDY DESIGN: Sixty preterm infants, born before 32 weeks of gestation, were enrolled; 30 had bronchopulmonary dysplasia (BPD, defined as the need for respiratory support and/or supplemental oxygen at 36 weeks of postmenstrual age). Cerebral perfusion, cTOI, and polysomnography were measured in both the supine and prone position with the initial position being randomized. Infants with a major intraventricular hemorrhage or major congenital abnormality were excluded. RESULTS: Cerebral perfusion was unaffected by position or BPD status. In the BPD group, the mean cTOI was higher in the prone position compared with the supine position by a difference of 3.27% (P = .03; 95% CI 6.28-0.25) with no difference seen in the no-BPD group. For the BPD group, the burden of cerebral hypoxemia (cumulative time spent with cTOI <55%) was significantly lower in the prone position (23%) compared with the supine position (29%) (P < .001). In those without BPD, position had no effect on cTOI. CONCLUSIONS: In preterm infants with BPD, the prone position improved cerebral oxygenation and reduced cerebral hypoxemia. These findings may have implications for positioning practices. Further research will establish the impact of position on short- and long-term developmental outcomes.

Stakeholder consensus for decision making in eye-gaze control technology for children, adolescents and adults with cerebral palsy service provision: findings from a Delphi study.

BACKGROUND: Limited research exists to guide clinical decisions about trialling, selecting, implementing and evaluating eye-gaze control technology. This paper reports on the outcomes of a Delphi study that was conducted to build international stakeholder consensus to inform decision making about trialling and implementing eye-gaze control technology with people with cerebral palsy. METHODS: A three-round online Delphi survey was conducted. In Round 1, 126 stakeholders responded to questions identified through an international stakeholder Advisory Panel and systematic reviews. In Round 2, 63 respondents rated the importance of 200 statements generated by in Round 1. In Round 3, 41 respondents rated the importance of the 105 highest ranked statements retained from Round 2. RESULTS: Stakeholders achieved consensus on 94 of the original 200 statements. These statements related to person factors, support networks, the environment, and technical aspects to consider during assessment, trial, implementation and follow-up. Findings reinforced the importance of an individualised approach and that information gathered from the user, their support network and professionals are central when measuring outcomes. Information required to support an application for funding was obtained. CONCLUSION: This Delphi study has identified issues which are unique to eye-gaze control technology and will enhance its implementation with people with cerebral palsy.

Influence of patterns of neonatal transfers on breastfeeding outcomes.

AIM: To investigate/evaluate the impact of hospital transfers on breastfeeding outcomes for infants requiring neonatal intensive care and to explore approaches to supporting lactation and breastfeeding. METHODS: A national study of two cohorts of infants admitted to the nine neonatal intensive care units (NICUs) in New South Wales (NSW) Australia using data sourced from a prospectively collected NICUS data collection. RESULTS: A total of 7829 infants were admitted to the nine NICUs in NSW for two 18-month cohorts (2012/2013 and 2015/2016) and were included in the study. These infants experienced 17 238 transfers to 107 different hospitals during the study period. Multiple transfers and low gestational age were independently associated with lower breastfeeding rates at hospital discharge across both cohorts. Extremely preterm infants and those with the greatest number of hospital transfers are least likely to be breastfed at time of discharge. Breastfeeding rates remained unchanged over time. The level of lactation support varied across NICUs. CONCLUSION: This study highlights the challenges of establishing and maintaining breastfeeding for infants requiring intensive care who have had multiple hospital transfers for continuing or specialist care. There is wide variation in lactation support across facilities. The importance of a consistent approach, education programmes and the provision of appropriate lactation support is emphasised.

Skincare practices in extremely premature infants: A survey of tertiary neonatal intensive care units from Australia and New Zealand.

AIM: To investigate skincare practices in the first 2 weeks of life in extremely premature infants across tertiary neonatal intensive care units (NICUs). METHODS: A web-based secure survey invite was emailed to the medical directors of tertiary NICUs. The survey included questions on various aspects of skincare practices in the first 2 weeks of life in extremely premature infants (born before 28 weeks gestation). The person most familiar with local skincare practices was asked to complete the survey and only one response per unit was requested. We performed a descriptive analysis. RESULTS: We received responses from 30 out of 32 NICUs (response rate 93%). Twenty-five NICUs (89%) reported offering resuscitation and intensive care to infants born at ≥23 weeks gestation. All NICUs reported occurrences of skin breakdown, including medical adhesive-related skin injury (30%), abrasion/friction-associated skin injury (46%), perineal skin breakdown (55%), pressure site injury (47%) and diaper dermatitis (60%). A high level of consensus (≥75%) was observed for certain practices, such as the use of polyethylene occlusive plastic wraps at birth and aqueous chlorhexidine solution for sterile procedures, but a low level of consensus (<25%) was observed for many other practices, including the skin risk assessment tool used. CONCLUSIONS: Skin injuries in extremely premature infants are common and skincare practices vary considerably amongst NICUs. Clinical practice improvement projects and further clinical research will help improve consistency amongst NICUs. Further research is needed to assist the development of evidence-based guidelines and benchmarking for skincare practices in these vulnerable infants.

Feasibility of modifying the hospital environment to reduce the length of amnesia after traumatic brain injury: a pilot randomized controlled trial.

BACKGROUND: Reorientation programmes have been an important component of neurotrauma rehabilitation for adults who suffer from post-traumatic amnesia (PTA) after traumatic brain injury (TBI); however, research testing the efficacy of acute programmes is limited. OBJECTIVE: This study aimed to determine if it is feasible to provide a standardized environmental reorientation programme to adults suffering from PTA after TBI in an acute care hospital setting, and whether it is likely to be beneficial. METHODS: We conducted a randomized controlled trial with concealed allocation and intention-to-treat analysis. A total of 40 participants suffering from PTA after TBI were included. The control group received usual care; the experimental group received usual care plus a standardized orientation programme inclusive of environmental cues. The primary outcome measure was time to emergence from PTA measured by the Westmead PTA Scale, assessed daily from hospital admission or on regaining consciousness. RESULTS: Adherence to the orientation programme was high, and there were no study-related adverse responses to the environmental orientation programme. Although there were no statistically significant between-group differences in time to emergence, the median time to emergence was shorter for those who received the standardized reorientation programme (9.0 (6.4-11.6) versus 13.0 (4.5-21.5) days). Multivariate analysis showed that the Glasgow Coma Scale (GCS) at scene (P = 0.041) and GCS at arrival at hospital (P = 0.0001) were significant factors contributing to the longer length of PTA. CONCLUSION: Providing an orientation programme in acute care is feasible for adults suffering from PTA after TBI. A future efficacy trial would require 216 participants to detect a between-group difference of 5 days with an alpha of 0.05 and a power of 80%.

The effects of education levels of developmental care in Australia: Perceptions and challenges.

BACKGROUND: Developmental care consists of a range of clinical, infant-focused, and family-focused interventions designed to modify the neonatal intensive care environment and caregiving practices to reduce stressors on the developing brain. Since the inception of developmental care in the early 1980s, it has been recommended and adopted globally as a component of routine practice for neonatal care. Despite its application for almost 40 y, little is known of the attitude of neonatal nurses in Australia towards the intervention. AIMS AND OBJECTIVES: The objective of this study was to establish Australian neonatal nurse perceptions of developmental care and explore associations between developmental care education levels of the nurses and personal beliefs in the application of developmental care. DESIGN: This involves a cross-sectional survey design. METHODS: An online questionnaire was completed by 171 neonatal nurses. Participants were members of the Australian College of Neonatal Nursing (n = 783). Covariate associations between key components of developmental care and respondents' geographical location, place of employment, professional qualifications, and developmental care education level were analysed. The reporting of this study is in accordance with the Enhancing the Quality and Transparency of Health Research Checklist for Reporting Results of Internet E-Surveys. RESULTS: Differences were observed between groups for geographical location, place of employment, and professional qualification level. Rural nurses were less likely to support the provision of skin-to-skin care (odds ratio [OR]: 0.6, 95% confidence interval [CI]: 0.2-1.8) than nurses in a metropolitsan unit. Nurses working in a neonatal intensive care unit and nurses with postgraduate qualifications were more likely to support parental involvement in care ([OR: 2.3, 95% CI: 0.9-6.2] and [OR: 2.1, 95% CI: 0.6-7.4], respectively). Rural respondents were more likely to have attended off-site education (OR: 3.6, 95% CI: 1.3-9.9) than metropolitan respondents. CONCLUSION: The application of developmental care in Australia may be influenced by inadequate resources and inequitable access to educational resources, and similar challenges have been reported in other countries. Overcoming the challenges requires a focused education strategy and support within and beyond the neonatal intensive care unit.

Early Life Parechovirus Infection Neurodevelopmental Outcomes at 3 Years: A Cohort Study.

OBJECTIVE: To investigate the long-term developmental and behavioral outcomes in an established cohort of children hospitalized as infants with human parechovirus (HPeV) infection and sepsis-like illness. STUDY DESIGN: The HPeV cohort was composed of children 3 years of age after HPeV infection and hospitalization in early infancy that occurred during a well-documented HPeV genotype 3 outbreak in Australia. We assessed neurodevelopmental and behavioral outcomes using the Bayley Scales of Infant and Toddler Development-III and the Child Behavior Checklist. We compared their outcomes with a subsample of healthy control infants drawn from the independently sampled Triple B Pregnancy Cohort Study. RESULTS: Fifty children, with a mean age of 41 months, were followed for 3 years after hospital admission with HPeV infection. There were 47 children whose original illness was fever without source or sepsis-like illness and 3 who had encephalitis. All children in the HPeV cohort showed age-specific development within the population normal range on the Bayley Scales of Infant and Toddler Development-III. There was no difference in developmental attainment compared with 107 healthy control infants after adjusting for measured confounders. The HPeV cohort showed higher average scores on the Child Behavior Checklist and a higher frequency of clinical range scores compared with healthy controls. CONCLUSIONS: Although HPeV sepsis-like illness did not result in neurodevelopmental delay at 3 years of age, it was associated with increased behavioral problems compared with healthy controls. The behavioral problems reached a clinical threshold in a minority of children. Results inform clinical management and planning for children after severe HPeV infection in infancy.

Changes to hepatic tissue oxygenation, abdominal perfusion and its association with enteral feeding with liberal transfusion threshold in anaemic preterm infants: A prospective cohort study.

BACKGROUND AND OBJECTIVES: In anaemic preterm infants who receive packed red blood cell (PRBC) transfusions, changes to mesenteric tissue oxygenation and perfusion have been reported using a restrictive haemoglobin (Hb)-based threshold. We aimed to investigate changes to hepatic tissue oxygenation and abdominal blood flow after PRBC transfusion and its association with enteral feeding using a liberal Hb threshold (as shown inTable1). [Table: see text] MATERIAL AND METHODS: We prospectively studied a cohort of preterm infants born at < 32 weeks' gestation who received at least one PRBC transfusion and monitored them immediately before (Time 1), immediately after (Time 2) and 24 hours after transfusion (Time 3). Data obtained included physiological parameters, the hepatic tissue oxygenation index and pulsed Doppler ultrasound measurements in the abdominal arterial circulation. Additionally, the effects of withholding enteral feeds were investigated. RESULTS: We monitored 50 PRBC transfusion episodes in 40 preterm infants, in whom the mean gestational age was 26.72 weeks (±1.6 weeks) and the mean birth weight was 855.25 g (±190.7 g). We observed significant changes to pulsed Doppler measurements in abdominal arterial circulation (coeliac artery mean peak systolic velocity Time 2 [75.08 cm/sec] versus Time 3 [71.13 cm/sec]; mean end-diastolic velocity Time 2 [15.71 cm/sec] versus Time 3 [13.76 cm/sec]; mean resistive index Time 2 0.78 versus Time 3 0.80, right renal artery mean peak systolic velocity Time 1 58.28 cm/sec versus Time 2 50.97 cm/sec, left renal artery mean peak systolic velocity Time 1 49.20 cm/sec versus Time 2 45.40 cm/sec), but not to hepatic tissue oxygenation after PRBC transfusion (Time 1 mean 53.66 [SD, 13.34]; Time 2 mean 54.93 [SD, 9.3]; Time 3 mean 55.64 [SD, 12.86]). There were no changes to hepatic tissue oxygenation or mesenteric blood flow from withholding enteral feeds during PRBC transfusion. There were no local adverse effects from hepatic tissue oxygenation monitoring. CONCLUSION: In mildly anaemic preterm infants, when allowing a liberal Hb threshold-based trigger for PRBC transfusion, changes in abdominal arterial circulation were present, but not in hepatic tissue oxygenation. Withholding enteral feeds during PRBC transfusion had no impact on hepatic tissue oxygenation or mesenteric flows.

State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy.

PURPOSE OF REVIEW: Cerebral palsy is the most common physical disability of childhood, but the rate is falling, and severity is lessening. We conducted a systematic overview of best available evidence (2012-2019), appraising evidence using GRADE and the Evidence Alert Traffic Light System and then aggregated the new findings with our previous 2013 findings. This article summarizes the best available evidence interventions for preventing and managing cerebral palsy in 2019. RECENT FINDINGS: Effective prevention strategies include antenatal corticosteroids, magnesium sulfate, caffeine, and neonatal hypothermia. Effective allied health interventions include acceptance and commitment therapy, action observations, bimanual training, casting, constraint-induced movement therapy, environmental enrichment, fitness training, goal-directed training, hippotherapy, home programs, literacy interventions, mobility training, oral sensorimotor, oral sensorimotor plus electrical stimulation, pressure care, stepping stones triple P, strength training, task-specific training, treadmill training, partial body weight support treadmill training, and weight-bearing. Effective medical and surgical interventions include anti-convulsants, bisphosphonates, botulinum toxin, botulinum toxin plus occupational therapy, botulinum toxin plus casting, diazepam, dentistry, hip surveillance, intrathecal baclofen, scoliosis correction, selective dorsal rhizotomy, and umbilical cord blood cell therapy. We have provided guidance about what works and what does not to inform decision-making, and highlighted areas for more research.

What predicts the proxy-reported health-related quality of life of adolescents with cerebral palsy in Bangladesh?

BACKGROUND: The health-related quality of life (HRQoL) of adolescents with CP in low and middle-income countries is often poor, as is the case in Bangladesh. This exploratory study examined what factors predict the proxy-reported HRQoL of adolescents with CP in rural Bangladesh, a typical low- and middle-income country (LMIC). METHODS: Adolescents with CP (10 to 18y) were identified using the Bangladesh Cerebral Palsy Register. HRQoL was assessed using the Cerebral Palsy Quality of Life-Teens proxy-report questionnaire (CPQoL-Teens), adolescent mental health using the Strengths and Difficulty Questionnaire (SDQ) and caregiver mental health using the Depression, Anxiety and Stress Scale (DASS-21). Theoretical and statistical interests (i.e. bivariate analysis, p < 0.05) identified potential predictors which were entered into hierarchical multiple linear regression (HMLR) models in order of clinical significance; HMLR related adolescent clinical characteristics, adolescent and caregiver mental health and proxies of socioeconomic status to CPQoL-Teens dimensions. RESULTS: One hundred fifty-four adolescents with CP (mean age 15y 1mo, SD 1y 8mo, female 31.2%) participated in this study. Twenty-four factors were identified to explore for relationship to adolescent proxy-reported HRQoL. Fifteen of the factors correlated to one or more CPQoL-Teens dimension; strongest correlation was between 'feelings about functioning' and motor impairment (r = 0.545). Nine were predictive of CPQoL-Teens dimensions; adolescent sex, school attendance, severity of motor impairment, hearing and speech impairment, mother's education, primary caregiver depression and stress, and having a sanitary latrine at home resulting in score changes of between 0.79 (95% CI 0.24 to 1.35) to 35.1 (95% CI 6.03 to 64.22). CONCLUSIONS: Many of the factors predicting the proxy-reported HRQoL of adolescents with CP are amenable to intervention, and have the potential to improve adolescent wellbeing. Several determinants are priorities of the sustainable development goals (SDGs); these findings should inform resource prioritization to improve the wellbeing of adolescents with CP in Bangladesh and other LMICs.

Are there changes to regional tissue oxygenation and circulation following umbilical artery catheter placement? A prospective cohort study in newborn infants.

AIM: The use of umbilical arterial catheters (UACs) is a standard of care in monitoring critically unwell infants. Serious vascular complications are rare but when they do occur, they can be associated with significant morbidity, risking limb loss or even death. Near infra-red spectroscopy has the potential to monitor limb perfusion. Our study investigates changes in tissue oxygenation and perfusion in the abdominal and leg circulation following UAC insertion. METHODS: A prospective observational study performing ultrasound pulsed Doppler measurements in the coeliac, superior mesenteric artery, renal arteries and the femoral arteries as well as near infrared spectroscopy measurements of both thighs at three time points (immediately before = Time 1, 1 h after = Time 2 and 24 h after UAC insertion = Time 3). RESULTS: We monitored 30 infants, the mean gestational age was 30 weeks (24-41) and the mean birthweight was 1720 g (600-4070 g). We observed statistically significant changes (P < 0.05) in pulse Doppler measurements in coeliac (mean peak systolic velocity (PSV): Time 1 = 70.51, Time 2 = 61.75; resistive index (RI): Time 1 = 0.75, Time 2 = 0.67), superior mesenteric (PSV: Time 1 = 41.72, Time 2 = 36.10; RI: Time 1 = 0.92, Time 2 = 0.87), renal (same side end-diastolic velocity: Time 1 = 1.98, Time 2 = 3.80; RI: Time 1 = 0.93, Time 2 = 0.87; opposite side end-diastolic velocity: Time 1 = 2.62, Time 2 = 3.84; RI: Time 1 = 0.92, Time 2 = 0.85) and femoral arteries (same side PSV: Time 1 = 72.75, Time 2 = 62.18; opposite side PSV: Time 1 = 81.89, Time 2 = 62.74). Tissue oxygenation in lower limbs remained unaffected (same side (mean): Time 1 = 68.59, Time 2 = 68.99, Time 3 = 66.40, opposite side: Time 1 = 67.72, Time 2 = 66.92, Time 3 = 65.40). All infants on clinical examination had normal lower limb perfusion, lower limb arterial pulses and normal perfusion to the gluteal region before and after insertion of UAC. CONCLUSIONS: While sub-clinical changes in perfusion occur in abdominal and leg circulation, these changes are not consistent across vessels and regional tissue oxygenation remains unaffected.

What is the threshold dose of upper limb training for children with cerebral palsy to improve function? A systematic review.

INTRODUCTION: Neuroplasticity is harnessed through high-intensity or high-dose training. Given the costs and time burden for families of children with cerebral palsy (CP), it is important to quantify which rehabilitation training approaches and doses confer the largest clinical gain. The main objective of this systematic review was to determine any threshold dose of upper limb training needed for children with CP to achieve clinically significant functional improvements. METHODS: This systematic review included studies if they were as follows: randomised controlled trials; participants had a diagnosis of CP or brain injury; mean age of participants was 0-18 years; and intervention was an active upper limb training intervention. Two raters independently extracted data. Data were pooled and analysed using a receiver operator characteristic (ROC) curve and odds ratios to investigate the dose of practice that led to clinically significant gains. RESULTS: A total of 74 trials were included in this review. Quantitative analyses included 25 studies (707 participants; age range 18 months to 21 years) for motor function (Assisting Hand Assessment) and 20 studies (491 participants; age range 3 months to 17 years) for individual goal achievement (Canadian Occupational Performance Measure). ROC curve analyses found that approximately 40 hr of practice is needed to improve upper limb motor ability in the unilateral population. For all typographies of CP, individual goals were achieved at a lower dose (14-25 hr) of practice when goal-directed interventions were provided. CONCLUSION: To improve individual goals, children need to practice goals for more than 14-25 hr, combining face-to-face therapy with home practice. To improve general upper limb function (based on evidence in the unilateral population), children need to practice for more than 30-40 hr. Interventions that set functional goals and involve actual practice of those goals lead to goal achievement at a lower dose than general upper limb motor training.

Are boys and girls just different? Gender differences in the Movement Assessment Battery for Children, 2nd edition (M ABC-2) suggests that they are.

INTRODUCTION: The second edition of the Movement Assessment Battery for Children (M ABC-2) is a standardised, norm referenced assessment that is frequently used by therapists to identify children with motor difficulties. The norms for the M ABC-2 were derived from a sample of children in the United Kingdom (UK) and are combined across the age groups for boys and girls. The aims of this research were to investigate gender differences in the performance of 8- and 9-year-old Australian children and if the norms in our cohort differed from UK-based M ABC-2 norms. METHODS: Children aged 8 or 9 years of age who underwent major neonatal cardiac or non-cardiac surgery and healthy controls were assessed using the M ABC-2 as part of the Development After Infant Surgery (DAISy) study. RESULTS: There were statistically significant differences in the scores for boys and girls aged 8- and 9-years old on the M ABC-2. Girls performed better than boys in manual dexterity and on total standard scores. Our control group compared to the assessment norms scored significantly poorer in manual dexterity, aiming and catching and total standard scores. CONCLUSION: Caution should be used when interpreting the results of the M ABC-2 for Australian 8- and 9-year olds. Contemporary Australian, gender-specific M ABC-2 norms should be considered. Further research is required to investigate gender differences and differences in performance of Australian children compared to the assessment norms in other age groups on the M ABC-2.

Liberal hemoglobin threshold affects cerebral arterial pulsed Doppler and cardiac output, not cerebral tissue oxygenation: a prospective cohort study in anemic preterm infants.

BACKGROUND: Red blood cell (RBC) transfusion is a standard treatment for anemia of prematurity. Cerebral tissue oxygenation and blood flow velocities improve when a restrictive transfusion threshold is followed, but little is known about the effect of practicing a liberal transfusion threshold on cerebral tissue oxygenation, cerebral blood flow velocities, and cardiac output measurements. STUDY DESIGN AND METHODS: A prospective observational study of preterm infants under 32 weeks' gestation who received RBC transfusion. Monitoring was performed immediately before, immediately after, and 24 hours after transfusion. Data obtained included physiologic parameters, cerebral tissue oxygenation index (TOI), anterior and middle cerebral artery pulsed Doppler ultrasound measurements, and cardiac output measurements. Data were analyzed using analysis of variance for repeated measures. RESULTS: Fifty RBC transfusion episodes in 40 preterm infants were monitored. The mean gestational age was 26.72 weeks (±1.6 weeks), and the mean birth weight was 855.25 g (±190.7 g). We did not observe significant changes in cerebral TOI (pretransfusion mean TOI = 70.5 [11.54], immediately after transfusion = 71.38 [12.51], [p = 0.924; 95% confidence interval (CI), -4.64 to 6.39], and 24 hours after transfusion = 75.64 [14.4]; [p = 0.07; 95% CI, -0.37 to 10.65]), cerebral fractional tissue oxygen extraction (pretransfusion = 0.25 [0.12], immediately after transfusion = 0.24 [0.13], and 24 hours after transfusion = 0.20 [0.15]), cerebral resistive index, cerebral pulsatility index, or right ventricular output. Statistically significant changes were observed immediately after transfusion in peak systolic velocity, end-diastolic velocity and time-averaged maximum velocity in the cerebral arterial circulation. Left ventricular output (pretransfusion = 374.32 mL/kg/min, immediately after transfusion = 346.67 mL/kg/min [p = 0.000; 95% CI, -39.61 to -15.68], and 24 hours after transfusion = 361.17 mL/kg/min [p = 0.027; 95% CI, -25.11 to -1.18]) and heart rate (pretransfusion = 163.37 [9.49], immediately after transfusion = 157.29 [10.2] [p = 0.000; 95% CI, -8.96 to -3.20], and 24 hours after transfusion = 160.40 [10.4] [p = 0.041; 95% CI, -5.85 to -0.09]) showed statistically significant changes throughout the monitoring period. CONCLUSION: Our findings show that practicing liberal transfusion thresholds did not improve cerebral TOI in preterm infants who have mild anemia, but it did improve the compensatory response in cerebral arterial blood flow and cardiac output.

Impact of social disadvantage on cerebral palsy severity.

AIM: To investigate the impact of socio-economic disadvantage on indicators of cerebral palsy (CP) severity - motor impairment, intellectual disability, and the presence of severe comorbidities - in children with CP in Australia. METHOD: Data from the Australian Cerebral Palsy Register were analysed. Socio-economic disadvantage was assessed using maternal age, maternal country of birth, and a measure of neighbourhood socio-economic status (SES) at the time of the child's birth. Descriptive bivariate analysis, trend analysis, risk ratios, and mediation analysis were undertaken to examine the impact of disadvantage on the indicators of CP severity. RESULTS: A socio-economic gradient was demonstrated with an increasing proportion of children with non-ambulant status, at least moderate intellectual disability, and the presence of severe comorbidities (having epilepsy, functional blindness, bilateral deafness, and/or no verbal communication) with decreasing neighbourhood SES, adolescent motherhood, and maternal minority ethnicity. INTERPRETATION: In Australia, socio-economic disadvantage at birth impacts adversely on CP severity at age 5 years. By identifying that socio-economically disadvantaged children with CP are at greater risk of more severe functional outcomes, we can inform targeted interventions at the family and neighbourhood level to reduce these inequities for children with CP. WHAT THIS PAPER ADDS: Socio-economic disadvantage is associated with increased severity of cerebral palsy functional outcomes. This encompasses low neighbourhood socio-economic status, adolescent motherhood, and maternal minority ethnicity.

IMPACTO DE LA DESVENTAJA SOCIAL SOBRE LA SEVERIDAD DE LA PARÁLISIS CEREBRAL: OBJETIVO: Investigar el impacto de la desventaja socioeconómica en los indicadores de severidad de la parálisis cerebral (PC), definida como - deterioro motor, discapacidad intelectual y la presencia de severidad de las comorbilidades: en niños con PC en Australia. MÉTODO: Se analizaron los datos del Australian Cerebral Palsy Register. La desventaja socioeconómica se evaluó utilizando la edad materna, el país de nacimiento de la madre, y una medida de estado socioeconómico del vecindario (SES) en el momento del nacimiento del niño. Se realizaron análisis bivariados, análisis de tendencias, índices de riesgo y análisis de mediación para examinar el impacto de la desventaja en los indicadores de severidad PC. RESULTADOS: Se demostró un gradiente socioeconómico con una proporción creciente de niños con estado no ambulante, al menos discapacidad intelectual moderada, y la presencia de comorbilidades graves (con epilepsia, ceguera funcional, sordera bilateral y / o sin comunicación verbal) con SES vecinales, maternidad adolescente, y etnia de la minoría materna. INTERPRETACIÓN: En Australia, la desventaja socioeconómica al nacer tiene un impacto adverso en la severidad de PC a la edad de 5 años. Al identificar a los niños con desventajas socioeconómicas con PC tienen un mayor riesgo de resultados funcionales más severos. Con esta información podemos guiar intervenciones a nivel familiar y de vecindario para reducir estas inequidades en los niños con PC.

IMPACTO DA DESVANTAGEM SOCIAL NA SEVERIDADE DA PARALISIA CEREBRAL: OBJETIVO: Investigar o impacto da desvantagem sócio-econômica nos indicadores de severidade da paralisia (PC) - comprometimento motor, deficiência intelectual, e a presença de comorbidades graves - em crianças com PC na Austrália. MÉTODO: Dados do Registro Austrliano de Paralisia Cerebral foram analisados. Desvantagens sócio-econômicas foram avaliadas usando-se a idade materna, o país de Nascimento da mãe, e uma medida do estado sócio-econômico (ESE) da vizinhança no momento do nascimento da criança. Análise bivariada descritiva, análise de tendências, taxas de risco, e análise de mediação foram realizados para examinar o impacto da desvantagem nos indicadores da severidade da PC. RESULTADOS: Um gradiente sócio-econômico foi demonstrado com um aumento da proporção de crianças com situação não ambilante, deficiência intelectual pelo menos moderada, e presença de comorbidades severas (epilepsia, cegueira funcional, surdez bilateral, e/ou nenhuma comunicação verbal) quanto menor o ESE da vizinhança, a minoria étnica materna e maternidade na adolescência. INTERPRETAÇÃO: Na Austrália, a desvantagem sócio-econômica ao nascimento impacta adversamente a severidade da PC na idade de 5 anos. Ao identificar que crianças com PC em desvantagem sócio-econômica têm maior risco de resultados funcionais mais severos, podemos informar intervenções específicas voltadas para a família e para a vizinhança para reduzir o nível destas inequidades para crianças com PC.

Cerebral palsy trends in Australia (1995-2009): a population-based observational study.

AIM: To investigate trends in birth prevalence of cerebral palsy (CP) overall and by gestational age, and examine the distribution of motor type, spastic topography, and severity using Australian CP Register data from 1995 to 2009. METHOD: Prenatal and perinatal CP data were collated from state/territory CP registers. Birth prevalence estimates per 1000 live births and per 1000 neonatal survivors (NNS) were calculated in five epochs. Data from three state registers with population-level ascertainment were used to investigate birth prevalence trends by gestational age using Poisson regression. Distribution of motor type, spastic topography, and moderate to severe disability (IQ≤50 and/or Gross Motor Function Classification System levels III-V) were evaluated within birthweight categories. RESULTS: Birth prevalence of CP varied across population-level states but within each state declined significantly over time (p<0.05). Birth prevalence per 1000 neonatal survivors declined amongst children born before 28 weeks (South Australia, Victoria p<0.001) and those born at or after 37 weeks (Victoria p<0.001, Western Australia p<0.002). Across Australia the percentage of children with bilateral spastic CP declined amongst those born less than 1000g. The percentage of children with moderate to severe disability decreased (48%-34%, p<0.001). INTERPRETATION: Birth prevalence of CP declined. Encouragingly, the percentage of children with CP whose disability was moderate to severe also decreased. WHAT THIS PAPER ADDS: Birth prevalence of cerebral palsy (CP) differed but declined across Australian states (1995-2009). Australian CP birth prevalence declined significantly amongst children born before 28 weeks and those born at or after 37 weeks. The percentage of children with moderate to severe disability decreased.

Developmental outcome at 3 years of age of infants following surgery for infantile hypertrophic pyloric stenosis.

PURPOSE: The study compared neurodevelopmental outcome at 3 years of age of infants with infantile hypertrophic pyloric stenosis (IHPS) who underwent pyloromyotomy with healthy control infants in New South Wales, Australia. METHODS: Infants with IHPS as well as controls were recruited between August 2006 and July 2008. Developmental assessments were performed using the Bayley scales of infant and toddler development (version III) (BSITD-III) at 1 and 3 years of age. RESULTS: Of the 43 infants originally assessed at 1 year, 39 returned for assessment at 3 years (90%). The majority were term infants (77%). Assessments were also performed on 156 control infants. Infants with IHPS scored significantly lower on four of the five Bayley subsets (cognitive, receptive and expressive language and fine motor) compared to control infants. Analysis of co-variance showed statistically significant results in favour of the control group for these four subsets. CONCLUSION: Compared with the outcomes at 1 year, infants with IHPS at 3 years of age continue to score below controls in four of the BSITD-III subscales. This suggests they should have developmental follow-up with targeted clinical intervention. There is a need for further studies into functional impact and longer term outcomes.

Immediate effect of a functional wrist orthosis for children with cerebral palsy or brain injury: A randomized controlled trial.

STUDY DESIGN: Two-group randomized controlled trial. INTRODUCTION: Upper limb orthoses worn during functional tasks are commonly used in pediatric neurologic rehabilitation, despite a paucity of high-level evidence. PURPOSE OF THE STUDY: The purpose of this study was to investigate if a customized functional wrist orthosis, when placed on the limb, leads to an immediate improvement in hand function for children with cerebral palsy or brain injury. METHODS: A 2-group randomized controlled trial involving 30 children was conducted. Participants were randomized to either receive a customized functional wrist orthosis (experimental, n = 15) or not receive an orthosis (control, n = 15). The box and blocks test was administered at baseline and repeated 1 hour after experimental intervention, with the orthosis on if randomized to the orthotic group. RESULTS: After intervention, there were no significant differences on the box and blocks test between the orthotic group (mean, 10.13; standard deviation, 11.476) and the no orthotic group (mean, 14.07; standard deviation, 11.106; t[28], -0.954; P = .348; and 95% confidence interval, -12.380 to 4.513). DISCUSSION: In contrast to the findings of previous studies, our results suggest that a functional wrist orthosis, when supporting the joint in a 'typical' position, may not lead to an immediate improvement in hand function. CONCLUSIONS: Wearing a functional wrist orthosis did not lead to an immediate improvement in the ability of children with cerebral palsy or brain injury to grasp and release. Further research is needed combining upper limb orthoses with task-specific training and measuring outcomes over the medium to long term.