Parent-reported health status of preterm survivors in a Canadian cohort.

OBJECTIVES: Health status (HS)/ health-related quality of life measures, completed by self or proxy, are important outcome indicators. Most HS literature on children born preterm includes adolescents and adults with limited data at preschool age. This study aimed to describe parent-reported HS in a large national cohort of extreme preterm children at preschool age and to identify clinical and sociodemographic variables associated with HS. METHODS: Infants born before 29 weeks' gestation between 2009 and 2011 were enrolled in a prospective longitudinal national cohort study through the Canadian Neonatal Network (CNN) and the Canadian Neonatal Follow-Up Network (CNFUN). HS, at 36 months' corrected age (CA), was measured with the Health Status Classification System for Pre-School Children tool completed by parents. Information about HS predictors was extracted from the CNN and CNFUN databases. RESULTS: Of 811 children included, there were 79, 309 and 423 participants in 23-24, 25-26 and 27-28 weeks' gestational age groups, respectively. At 36 months' CA, 78% had a parent-reported health concern, mild in >50% and severe in 7%. Most affected HS attributes were speech (52.1%) and self-care (41.4%). Independent predictors of HS included substance use during pregnancy, infant male sex, Score for Neonatal Acute Physiology-II, bronchopulmonary dysplasia, severe retinopathy of prematurity, caregiver employment and single caregiver. CONCLUSION: Most parents expressed no or mild health concerns for their children at 36 months' CA. Factors associated with health concerns included initial severity of illness, complications of prematurity and social factors.

Initial Laparotomy Versus Peritoneal Drainage in Extremely Low Birthweight Infants With Surgical Necrotizing Enterocolitis or Isolated Intestinal Perforation: A Multicenter Randomized Clinical Trial.

OBJECTIVE: The aim of this study was to determine which initial surgical treatment results in the lowest rate of death or neurodevelopmental impairment (NDI) in premature infants with necrotizing enterocolitis (NEC) or isolated intestinal perforation (IP). SUMMARY BACKGROUND DATA: The impact of initial laparotomy versus peritoneal drainage for NEC or IP on the rate of death or NDI in extremely low birth weight infants is unknown. METHODS: We conducted the largest feasible randomized trial in 20 US centers, comparing initial laparotomy versus peritoneal drainage. The primary outcome was a composite of death or NDI at 18 to 22 months corrected age, analyzed using prespecified frequentist and Bayesian approaches. RESULTS: Of 992 eligible infants, 310 were randomized and 96% had primary outcome assessed. Death or NDI occurred in 69% of infants in the laparotomy group versus 70% with drainage [adjusted relative risk (aRR) 1.0; 95% confidence interval (CI): 0.87-1.14]. A preplanned analysis identified an interaction between preoperative diagnosis and treatment group (P = 0.03). With a preoperative diagnosis of NEC, death or NDI occurred in 69% after laparotomy versus 85% with drainage (aRR 0.81; 95% CI: 0.64-1.04). The Bayesian posterior probability that laparotomy was beneficial (risk difference <0) for a preoperative diagnosis of NEC was 97%. For preoperative diagnosis of IP, death or NDI occurred in 69% after laparotomy versus 63% with drainage (aRR, 1.11; 95% CI: 0.95-1.31); Bayesian probability of benefit with laparotomy = 18%. CONCLUSIONS: There was no overall difference in death or NDI rates at 18 to 22 months corrected age between initial laparotomy versus drainage. However, the preoperative diagnosis of NEC or IP modified the impact of initial treatment.

Early caloric deprivation in preterm infants affects Bayley-III scales performance at 18-24 months of corrected age.

BACKGROUND: Adequate nutrition is essential for optimal neurodevelopment to preterm infants. Our aim was to evaluate the impact of caloric deprivation on Bayley-III scales performance at 18-24 months of corrected age, in a cohort of preterm infants. METHODS: We prospectively enrolled infants with gestational age <30 weeks and birth weight <1500 g. Apart from a whole cohort analysis, we performed a subgroup analysis between infants received inadequate calories (<85 Kcal/kg/day) during the first two weeks of age, compared to a standard nutrition group. All infants underwent a Bayley-III assessment at 18-24 months of corrected age. RESULTS: From the 63 preterm infants analysed, 25% had caloric deprivation compared to 75% with adequate nutrition. Caloric deprived infants were of lower gestational age and birth weight, and received a lower amount of enteral feeding during the first 14 days of age. There were no differences between the two groups regarding the common neonatal co-morbidities. Caloric deprived infants had significantly lower composite index scores at 18-24 months of corrected age. Caloric deprivation, late onset sepsis, necrotizing enterocolitis, and bronchopulmonary dysplasia were significant risk factors of neurodevelopmental impairment. CONCLUSIONS: Several neonatal factors affect the neurodevelopmental outcome of preterm infants, and nutrition may pose an important role.

Congenital Esophageal Atresia-Surgical Treatment Results in the Context of Quality of Life.

INTRODUCTION: Esophageal atresia (EA) is one of the most frequent congenital malformations of the gastrointestinal tract. The aim of the study was to assess surgical treatment results in the context of the quality of life (QoL) of children after correction of EA. MATERIALS AND METHODS: The data were collected among 73 patients after surgery of EA. The work diagnostic survey method was applied using authors' own questionnaire and standardized questionnaire, the PedsQL 4.0 generic core scales. Analysis of children growth was done based on World Health Organization percentile charts for body height and weight. Medical background for each patient, including demographic data, type of EA, type of delivery, the age of gestation, associated anomalies, mode of repair-primary and subsequent, if applicable, was collected from clinical records. Additional anomalies were divided into cardiac, skeletal, respiratory, renal, central nervous system, and other malformations (VACTERL association, CHARGE syndrome, trisomy chromosomes 18 and 21, and others). RESULTS: In this study, 23% of children in the study group weighted below third percentile, 36% were born between 33rd and 37th week of gestation; 56% had at least one associated congenital anomalies. The QoL of children born before 37th week of gestational age was lower (p < 0.034) in social functioning than children born in term. The presence of concomitant anomalies does affect the overall generic QoL. No statistical correlation was found between the type of anomaly (with/without TEF) and patients' QoL. CONCLUSION: It seems to be needed to extend psychological care of premature infants with EA.

Neurodevelopmental and Behavioral Outcomes in Extremely Premature Neonates With Ventriculomegaly in the Absence of Periventricular-Intraventricular Hemorrhage.

Importance: Studies of cranial ultrasonography and early childhood outcomes among cohorts of extremely preterm neonates have linked periventricular-intraventricular hemorrhage and cystic periventricular leukomalacia with adverse neurodevelopmental outcomes. However, the association between nonhemorrhagic ventriculomegaly and neurodevelopmental and behavioral outcomes is not fully understood. Objective: To characterize the outcomes of extremely preterm neonates younger than 27 weeks' gestational age who experienced nonhemorrhagic ventriculomegaly that was detected prior to 36 weeks' postmenstrual age. Design, Setting, and Participants: This longitudinal observational study was conducted at 16 centers of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Infants born prior to 27 weeks' gestational age in any network facility between July 1, 2006, and June 30, 2011, were included if they had a cranial ultrasonogram performed prior to 36 weeks' postmenstrual age. Comparisons were made between those with ventriculomegaly and those with normal cranial sonograms. Data analysis was completed from August 2013 to August 2017. Main Outcomes and Measures: The main outcome was neurodevelopmental impairment, defined as a Bayley Scales of Infant and Toddler Development III cognitive score less than 70, moderate/severe cerebral palsy, a Gross Motor Function Classification System score of level 2 or more, vision impairment, or hearing impairment. Secondary outcomes included Bayley Scales of Infant and Toddler Development III subscores, components of neurodevelopmental impairment, behavioral outcomes, and death/neurodevelopmental impairment. Logistic regression was used to evaluate the association of ventriculomegaly with adverse outcomes while controlling for potentially confounding variables and center differences as a random effect. Linear regression was used similarly for continuous outcomes. Results: Of 4193 neonates with ultrasonography data, 300 had nonhemorrhagic ventriculomegaly (7%); 3045 had normal cranial ultrasonograms (73%), 775 had periventricular-intraventricular hemorrhage (18.5%), and 73 had cystic periventricular leukomalacia (1.7%). Outcomes were available for 3008 of 3345 neonates with ventriculomegaly or normal scans (90%). Compared with normal cranial ultrasonograms, ventriculomegaly was associated with lower gestational age, male sex, and bronchopulmonary dysplasia, late-onset sepsis, meningitis, necrotizing enterocolitis, and stage 3 retinopathy of prematurity. After adjustment, neonates with ventriculomegaly had higher odds of neurodevelopmental impairment (odds ratio [OR], 3.07; 95% CI, 2.13-4.43), cognitive impairment (OR, 3.23; 95% CI, 2.09-4.99), moderate/severe cerebral palsy (OR, 3.68; 95% CI, 2.08-6.51), death/neurodevelopmental impairment (OR, 2.17; 95% CI, 1.62-2.91), but not death alone (OR, 1.09; 95% CI, 0.76-1.57). Behavioral outcomes did not differ. Conclusions and Relevance: Nonhemorrhagic ventriculomegaly is associated with increased odds of neurodevelopmental impairment among extremely preterm neonates.

Association between Off-Peak Hour Birth and Neonatal Morbidity and Mortality among Very Low Birth Weight Infants.

OBJECTIVE: To assess the independent association between overnight or "off-peak" hour delivery and 3 neonatal morbidities strongly associated with childhood neurocognitive impairment. STUDY DESIGN: Retrospective population based cohort study of all infants with birth weights of 500-1499 g born without severe congenital anomalies in California or Pennsylvania between 2002 and 2009. Off-peak hour delivery was defined as birth between 12:00 a.m. and 6:59 a.m. The study outcomes were death; bronchopulmonary dysplasia, retinopathy of prematurity, and severe (grade 3 or 4) intraventricular hemorrhage among survivors; the composite of each morbidity or mortality; and the composite of death or 1 or more of the evaluated morbidities. RESULTS: Of 47 617 evaluated infants, 9317 (19.6%) were born during off-peak hours. The frequencies of all study outcomes were higher among infants born during off-peak compared with peak hours. After adjusting for maternal, infant, and hospital characteristics, off-peak hour delivery was associated with increased odds of severe intraventricular hemorrhage among survivors (OR 1.39, 95% CI 1.23-1.57) and the composite outcomes of death or severe intraventricular hemorrhage (OR 1.16, 95% CI 1.07-1.25) and death or major morbidity (OR 1.08, 95% CI 1.02-1.15). There was no evidence of subgroup effects based on delivery mode, birth hospital neonatal intensive care level or annual very low birth weight infant delivery volume, or weekday vs weekend off-peak hour delivery for any study outcome. CONCLUSIONS: Very low birth weight infants born between midnight and 7:00 a.m. are at increased risk for severe intraventricular hemorrhage and death or major neonatal morbidity.

Measuring and communicating meaningful outcomes in neonatology: A family perspective.

Medium- and long-term outcomes have been collected and described among survivors of neonatal intensive care units for decades, for a number of purposes: (1) quality control within units, (2) comparisons of outcomes between NICUs, (3) clinical trials (whether an intervention improves outcomes), (4) end-of-life decision-making, (5) to better understand the effects of neonatal conditions and/or interventions on organs and/or long-term health, and finally (6) to better prepare parents for the future. However, the outcomes evaluated have been selected by investigators, based on feasibility, availability, cost, stability, and on what investigators consider to be important. Many of the routinely measured outcomes have major limitations: they may not correlate well with long-term difficulties, they may artificially divide continuous outcomes into dichotomous ones, and may have no clear relationship with quality of life and functioning of children and their families. Several investigations, such as routine term cerebral resonance imaging for preterm infants, have also not yet been shown to improve the outcome of children nor their families. In this article, the most common variables used in neonatology as well as some variables which are rarely measured but may be of equal importance for families are presented. The manner in which these outcomes are communicated to families will be examined, as well as recommendations to optimize communication with parents.

Prenatal vitamin A supplementation associated with adverse child behavior at 3 years in a prospective birth cohort in Japan.

BACKGROUND: Many pregnant women take vitamin supplements during pregnancy. The aim of this paper was to clarify the effects of dietary supplementation prior to and/or during pregnancy on child behavior. METHODS: A prospective birth cohort study from pregnancy to 3 years of age involving 1271 pairs of Japanese pregnant women and their newborns, was carried out. The women completed a self-administered questionnaire during the third trimester of pregnancy. To evaluate deviations in child behavior as an endpoint, each mother completed the Japanese Child Behavior Checklist for ages 2-3 years after 3 years of birth. Participant characteristics were compared between supplement takers and non-takers. RESULTS: Among many kinds of supplements, intake of supplemental vitamin A/ß-carotene prior to and/or during pregnancy was associated with hazardous effects on child behavior at 3 years of age (total t-score, P = 0.003; internal t-score, P = 0.027; external t-score, P = 0.013). This association held true even after adjusting for age, number of deliveries, infertility treatment, consumption of fast food, smoking status, maternal and paternal education, maternal and paternal income, gestational age at birth, anthropometry at birth (weight, height, head circumference and body circumference), and the State-Trait Anxiety Inventory at 3 years of age by means of multiple imputation. CONCLUSIONS: Intake of supplemental vitamin A prior to and/or during pregnancy may worsen child behavior at 3 years of age.

Very preterm children are at increased risk of reduced processing speed at 5 years of age, predicted by typical complications of prematurity and prenatal smoking.

AIM: Very little is known about risk predictors for the development of reduced processing speed, which can cause intellectual problems in later life. This study identified risk predictors at 5 years of age in a population-based cohort of very preterm infants. METHODS: Between January 2003 and August 2006, all preterm infants born before 32 weeks of gestation in Tyrol were prospectively enrolled (n = 223), and 161 underwent a detailed examination at 5 years of age, including a cognitive assessment using the Wechsler Preschool and Primary Scale of Intelligence, third edition. The processing speed quotient is calculated on the basis of two subtests that assess symbol search and coding. The association between prenatal and postnatal factors and reduced processing speed was analysed by means of logistic regression analysis. RESULTS: Of 161 children tested, 55 (34.2%) showed reduced processing speed. In 55.6% (n = 30) of these children, reduced processing speed was related to full-scale intelligence quotient scores of <85. Smoking in pregnancy, steroids for chronic lung disease and intracerebral haemorrhage predicted reduced processing speed at 5 years of age. CONCLUSION: More than a third of the very preterm children we tested showed reduced processing speed at 5 years of age, and predictors were typical complications of prematurity and smoking in pregnancy.

[Visuospatial functions and prematurity]. / Funciones visuoespaciales y prematuridad.

Visuospatial functions are very important in learning process and development of abstract thought during childhood. Several studies show that preterm and low birth weight infants obtain lower scores in test that assess cognitive functions, specially in the first year of life. These differences are attenuated over time, but a developmental delay that affects working memory and visuospatial process still persists. It is unclear what factors are involved in development of these functions, and pre- or perinatal factors may interfere with the proper conduct of the same, but have been described anatomical and physiological differences between the preterm and term brain that could explain somewhere in these alterations. The different selective vulnerability to hypoxia between immature brain in which preoligodendrocytes and subplate neurons predominate, and mature brain, determine differences in the pattern of injury from hypoxia with greater involvement of the periventricular white matter in preterm children. This lesional pattern leaves to a dysfunction in attentional and visuospatial process, due to the increased vulnerability of the regions involved in the dorsal pathway of visual processing.

TITLE: Funciones visuoespaciales y prematuridad.Durante la infancia, las funciones visuoespaciales son importantes en los procesos de aprendizaje y en el desarrollo del pensamiento abstracto. Diferentes estudios muestran que los niños prematuros o con bajo peso al nacer obtienen menores puntuaciones en los tests que valoran las funciones cognitivas, siendo estas diferencias mas pronunciadas durante el primer año de vida. Con el tiempo, estas diferencias se van atenuando, pero persiste un retraso madurativo que afecta a la memoria de trabajo y a los procesos visuoespaciales. No esta claro cuales son los factores implicados en el desarrollo de estas funciones y que factores pre o perinatales pueden interferir en su buen desarrollo, pero se han descrito diferencias anatomicas y fisiologicas entre el cerebro del niño pretermino y el termino que podrian explicar, en parte, alguna de estas alteraciones. La diferente vulnerabilidad selectiva a la hipoxia entre el cerebro inmaduro, en el que predominan las neuronas de la subplaca y los preoligodendrocitos, y el cerebro maduro del niño nacido a termino determinan diferencias en el patron de lesion por hipoxia con mayor afectacion de la sustancia blanca periventricular en el niño pretermino. Este patron lesional conlleva una disfuncion en los procesos atencionales y visuoespaciales debido a la mayor vulnerabilidad de las regiones que intervienen en la ruta dorsal del procesamiento visual.

Screening for symptoms of postpartum traumatic stress in a sample of mothers with preterm infants.

There are no established screening criteria to help identify mothers of premature infants who are at risk for symptoms of emotional distress. The current study, using data obtained from recruitment and screening in preparation for a randomized controlled trial, aimed to identify potential risk factors associated with symptoms of depression, anxiety and posttraumatic stress in a sample of mothers with premature infants hospitalized in a neonatal intensive care unit. One hundred, thirty-five mothers of preterm infants born at 26-34 weeks of gestation completed three self-report measures: the Stanford Acute Stress Reaction Questionnaire, the Beck Depression Inventory (2nd ed.), and the Beck Anxiety Inventory to determine their eligibility for inclusion in a treatment intervention study based on clinical cut-off scores for each measure. Maternal sociodemographic measures, including race, ethnicity, age, maternal pregnancy history, and measures of infant medical severity were not helpful in differentiating mothers who screened positive on one or more of the measures from those who screened negative. Programs to screen parents of premature infants for the presence of symptoms of posttraumatic stress, anxiety, and depression will need to adopt universal screening rather than profiling of potential high risk parents based on their sociodemographic characteristics or measures of their infant's medical severity.

Breastfeeding practices in mothers of high-respiratory-risk NICU infants: impact of depressive symptoms and smoking.

AIM: Mothers of infants in the neonatal intensive care unit (NICU) have very low breastfeeding rates and these high-respiratory-risk (HRR) NICU infants may benefit from breastfeeding through decreased risk for respiratory illnesses. This population's increased risk for maternal depression and high rates (22%) of maternal smoking may negatively affect breastfeeding. OBJECTIVE: This exploratory study investigated associations of breastfeeding with depressive symptoms and maternal smoking in mothers of HRR NICU infants (i.e. presence of one household smoker and birth weight <1500 g or mechanical ventilation ≥12 h). METHODS: Breastfeeding, depression and smoking data were collected from 104 mothers in the NICU following delivery. RESULTS: Fifty-five (52.9%) mothers reported breastfeeding, 39 (37.5%) had a Center for Epidemiological Studies Depression Scale (CES-D) score (≥16) suggestive of depression, and 36 (34.6%) reported smoking. Mothers with CES-D scores ≥16 were less likely to breastfeed compared to those with scores <16 (38.5% versus 61.5%; p = 0.02). Breastfeeding and smoking were not significantly associated (p < 0.10). Mothers of HRR infants with significant depressive symptoms who smoke have significantly lower breastfeeding rates (21%) than mothers who are not depressed and do not smoke (65%). CONCLUSIONS: Interventions to improve breastfeeding initiation and continuation that target depression and smoking are necessary.

Depression among mothers of high-risk infants discharged from a neonatal intensive care unit.

PURPOSE: This study investigated potential associations between maternal depression and specific infant health conditions, smoking, and socioeconomic characteristics among mothers of high-risk infants during medical follow-up visits. STUDY DESIGN AND METHODS: Cross-sectional self-report, and interview data were collected from 114 mothers of high-risk infants previously discharged from a neonatal intensive care unit. Mothers were assessed at a postdischarge clinic visit. RESULTS: Prevalence rates for a Center for Epidemiological Studies-Depression Scale score ≥ 16) suggestive of a depressive disorder exceeded 20% at all time points for this sample of predominantly low-income, minority-race mothers. A greater number of mothers who had infants with a highly visible illness (e.g., surgical necrotizing enterocolitis) were depressed. Depression was also associated with the presence of a household smoker, younger age, and less education and income. CLINICAL IMPLICATIONS: Given the prevalence rates, routine screening for postpartum depression in mothers of high-risk infants is imperative, with particular attention to the infant's health, smoking, and socioeconomic variables.

[The evaluation neuropsychological development in preterm infants with hypoxic brain injury].

We observed 164 preterm newborns with moderate and severe hypoxic brain injury and 25 healthy newborns, who were included into control group. The clinical, laboratory and diagnostic data were analyzed and determined levels of neurospecific enolase in serum, levels of vascular endothelial factor in serum and levels of brain-derived neurotrophic factor in serum during the neonatal period followed with assessment of mental development by the method of Zhurba in the control time. Revealed that additional predictors of adverse mental outcomes in preterm newborns with severe hypoxic brain injury under one year were the intrauterine growth hypotrophic of III level type, the high level of neurospecific enolase in serum and low level of vascular endothelial growth factor in serum in 1 month after delivery.

[To what degree does the NICU environment influence neurodevelopment of preterm infants?]. / Intensivmedizinisches Reizumfeld und Stressoren--welchen Einfluss haben sie auf die Gehirnentwicklung frühgeborener Kinder?

What effect do the various stressing stimuli in a neonatal intensive care unit have on the very sensitive process of synaptogenesis and apoptosis, dendritic growth and neuronal differentiation? To what degree can even minimal changes in the neuronal network of the developing cortex lead to behavioural disorders? And is there any possibility to improve the long term outcome of preterm infants by offering special support within the framework of individualized developmental care? This article combines the results of several studies and discovers interactions to illustrate the complexity and vulnerability of the developing human brain and to discuss the potential benefit of individualized developmental care interventions.

Development and behaviour of 5-year-old very low birthweight infants.

The place and time of birth influence the mortality of premature infants. We studied the effect of prematurity, time of birth, birth hospital level and district on the development and behaviour in a national cohort of 5-year-old Finnish very low birthweight infants (VLBWI). All surviving VLBWI (gestational age <32 weeks or birthweight

Five-year follow-up of prematurely born children with postnatally developing caudothalamic cysts.

AIM: To assess the long-term developmental outcome of very low birth weight children with postnatally developing caudothalamic cysts. METHODS: Five very low birth weight children with postnatal caudothalamic cysts were examined using cranial ultrasound and brain Magnetic Resonance Imaging as neonates, the Bayley Scales of Infant Development, 2nd edition, and the Hammersmith Infant Neurological Examination at 2 years of corrected age, and with the Wechsler Preschool and Primary Scale of Intelligence-Revised and the standardization version of NEPSY II at 5 years of age. The Magnetic Resonance Imaging of the brain was repeated at 5 years of age. The developmental outcome at 5 years of age was compared with that of 23 very low birth weight children with normal brain structure. RESULTS: A cognitive level below normal and/or neuropsychological impairments was seen in all the children with caudothalamic cysts as well as in those with normal brain structure. CONCLUSION: Very low birth weight children with postnatally developing caudothalamic cysts had cognitive and neuropsychological impairments similar to very low birth weight children without such cysts.

Early emergence of behavior and social-emotional problems in very preterm infants.

OBJECTIVE: Children born very preterm are reported to have an increased frequency of social, emotional, and behavioral problems at school age compared with their peers born at term. The primary aim of this study was to compare social-emotional difficulties and competencies of very preterm and full-term children at 2 years' corrected age. In addition, the relation between perinatal variables and early behavior problems was also examined to help identify those very preterm children most at risk. METHOD: At 2 years' corrected age, the parents of 188 very preterm (gestational age <30 weeks or birth weight <1,250 g) and 70 full-term (gestational age >or=37 weeks) children completed the Infant Toddler Social and Emotional Assessment to determine externalizing, internalizing, and dysregulation problems and social-emotional competencies. For the very preterm sample, extensive perinatal data were collected including sex, birth weight, gestational age, chronic lung disease, and postnatal steroids, as well as neonatal cerebral white matter abnormalities detected by magnetic resonance imaging. RESULTS: The very preterm children at 2 years demonstrated significantly higher internalizing and dysregulation scores and lower competence scores than peers born at term. There was no significant difference in externalizing scores between groups. Female sex, lower birth weight z score, white matter abnormalities, and postnatal corticosteroids were significantly associated with lower competence scores in the very preterm group. CONCLUSIONS: Very preterm children exhibit higher rates of behavior problems early in development, in particular internalizing and dysregulation problems and poorer competence.

The quality of preterm infants' spontaneous movements: an early indicator of intelligence and behaviour at school age.

BACKGROUND: The quality of very preterm infants' spontaneous movements at 11 to 16 weeks post-term age is a powerful predictor of their later neurological status. This study investigated whether early spontaneous movements also have predictive value for the intellectual and behavioural problems that children born very preterm often experience. METHODS: Spontaneous movement quality was assessed, using Prechtl's method, at 11 to 16 weeks post-term in 65 infants born at