Eye tracking based assessment of lexical processing and early lexical development in very preterm children.

BACKGROUND: Associations between lexical processing and lexical development during the second year of life have been little studied in preterm children. AIMS: To evaluate associations between lexical processing at 18 months and lexical development between 12 and 18 months in very preterm children. STUDY DESIGN: Correlational study. SUBJECTS: 25 Finnish-speaking children born <32 gestational weeks. OUTCOME MEASURES: Lexical processing (reaction time RT; correct looking time CLT) was measured with an eye tracking technology-based task at 18 months' corrected age. Lexical development was measured longitudinally at 12-, 15- and 18-months' corrected age using the following screening instruments: the short form version of the MacArthur Communicative Development Inventories and the Communication and Symbolic Behavior Scale: Infant-Toddler Checklist. RESULTS: The longer the RT of the child, the weaker expressive skills the child had at 12 and 15 months (correlations coefficient values -0.45 to -0.51). The more the child looked at the target image compared to the distractor (CLT), the stronger expressive skills the child had at 18 months (r = 0.45-0.52). A linear regression model with RT and gender as independent variables explained 33 % of the variance in lexical skills at 18 months. A model with CLT explained 40 % of expressive skills at 18 months. CONCLUSIONS: Lexical processing at 18 months was associated with expressive lexical development in very preterm children. The results suggest eye tracking technology based methods may have utility in the assessment of early lexical growth in preterm children, although further research is needed to assess psychometric properties and predictive value of the method.

Predictive value of psychological assessment at five years of age in the long-term follow-up of very preterm children.

The aims of this study were to 1) assess the predictive value of psychological assessment at five years of age on the need for educational support in very preterm children, and 2) report the neuropsychological profile of very preterm children at eleven years of age and risk factors for poorer neuropsychological functions. A cohort of 167 very preterm children was included (birth weight ≤ 1500 g and/or gestational age < 32 weeks). At five years of age, intellectual functioning was assessed with Wechsler Preschool and Primary Scale of Intelligence-Revised and neuropsychological performance with NEPSY II. At eleven years of age, neuropsychological functions were assessed using NEPSY II and data on educational support services collected using a questionnaire. Lower full-scale intelligence quotient and poorer performance in subtests inhibition, comprehension of instructions, memory for designs, visuomotor precision and design copying at five years of age were associated with a need for educational support. Neuropsychological performance at eleven years of age was overall within the average range but below the mean, with the poorest performance in tasks assessing visual memory and visuospatial functions. The results offer a novel perspective to timing and measures of follow-up of very preterm children, since they show that need for long-term educational support can be identified at five years of age. The findings also highlight the clinical value of psychological assessments including evaluation of both intellectual functioning and neuropsychological performance, covering detailed information about non-verbal functions, in the follow-up of very preterm children up to eleven years of age.

Unit-Level Variations in Healthcare Professionals' Availability for Preterm Neonates <29 Weeks' Gestation: An International Survey.

INTRODUCTION: The availability of and variability in healthcare professionals in neonatal units in different countries has not been well characterized. Our objective was to identify variations in the healthcare professionals for preterm neonates in 10 national or regional neonatal networks participating in the International Network for Evaluating Outcomes (iNeo) of neonates. METHOD: Online, pre-piloted questionnaires about the availability of healthcare professionals were sent to the directors of 390 tertiary neonatal units in 10 international networks: Australia/New Zealand, Canada, Finland, Illinois, Israel, Japan, Spain, Sweden, Switzerland, and Tuscany. RESULTS: Overall, 325 of 390 units (83%) responded. About half of the units (48%; 156/325) cared for 11-30 neonates/day and had team-based (43%; 138/325) care models. Neonatologists were present 24 h a day in 59% of the units (191/325), junior doctors in 60% (194/325), and nurse practitioners in 36% (116/325). A nurse-to-patient ratio of 1:1 for infants who are unstable and require complex care was used in 52% of the units (170/325), whereas a ratio of 1:1 or 1:2 for neonates requiring multisystem support was available in 59% (192/325) of the units. Availability of a respiratory therapist (15%, 49/325), pharmacist (40%, 130/325), dietitian (34%, 112/325), social worker (81%, 263/325), lactation consultant (45%, 146/325), parent buddy (6%, 19/325), or parents' resource personnel (11%, 34/325) were widely variable between units. CONCLUSIONS: We identified variability in the availability and organization of the healthcare professionals between and within countries for the care of extremely preterm neonates. Further research is needed to associate healthcare workers' availability and outcomes.

Executive Function Profiles at Home and at School in 11-Year-Old Very Low Birth Weight or Very Low Gestational Age Children.

OBJECTIVE: Executive function (EF) problems of children born at very low birth weight (VLBW; ≤1500 g) or very low gestational age (VLGA; <32 gestational weeks) may present differently at school compared to the home environment. Ecological assessment of EF including parent- and teacher-rated profiles and associated risk factors of 11-year-old children born at VLBW or VLGA was evaluated. METHODS: A total of 125 VLBW or VLGA children and 132 controls were assessed using the Behavior Rating Inventory of EF, which includes 8 subscales that form the Behavioral Regulation and Metacognition Indexes. For VLBW or VLGA children, full-scale intelligence quotient (IQ) was assessed using the Wechsler Intelligence scale for Children, Fourth Edition. Neonatal data were collected systematically. RESULTS: VLBW or VLGA children with full-scale IQ ≥ 70 had clinically significant problems in the Working Memory subscale at school. Although they had clinically significant problems at home in the Behavioral Regulation Index, the difference disappeared when adjusted for paternal education. Lower gestational age, lower birth weight z-score, surgical necrotizing enterocolitis, low paternal and maternal education, and lower full-scale IQ were identified to be risk factors for higher scores in ecological assessment of EF. CONCLUSION: VLBW or VLGA children in this cohort exhibit fewer EF problems in ecological assessment of EF compared to previous literature. EF problems of this study population vary by home and school setting and are emphasized in working memory at school. Screening for EF problems in school environment is recommended to target the support.

Early neonatal death: A challenge worldwide.

Early neonatal death (ENND), defined as the death of a newborn between zero and seven days after birth, represents 73% of all postnatal deaths worldwide. Despite a 50% reduction in childhood mortality, reduction of ENND has significantly lagged behind other Millennium Developmental Goal achievements and is a growing contributor to overall mortality in children aged <5 years. The etiology of ENND is closely related to the level of a country's industrialization. Hence, prematurity and congenital anomalies are the leading causes in high-income countries. Furthermore, sudden unexpected early neonatal deaths (SUEND) and collapse have only recently been identified as relevant and often preventable causes of death. Concomitantly, perinatal-related events such as asphyxia and infections are extremely relevant in Africa, South East Asia, and Latin America and, together with prematurity, are the principal contributors to ENND. In high-income countries, according to current research evidence, survival may be improved by applying antenatal and perinatal therapies and immediate newborn resuscitation, as well as by centralizing at-risk deliveries to centers with appropriate expertise available around the clock. In addition, resources should be allocated to the close surveillance of newborn infants, especially during the first hours of life. Many of the conditions leading to ENND in low-income countries are preventable with relatively easy and cost-effective interventions such as contraception, vaccination of pregnant women, hygienic delivery at a hospital, training health care workers in resuscitation practices, simplified algorithms that allow for early detection of perinatal infections, and early initiation of breastfeeding and skin-to-skin care. The future is promising. As initiatives undertaken in previous decades have led to substantial reduction in childhood mortality, it is expected that new initiatives targeting the perinatal/neonatal periods are bound to reduce ENND and provide these babies with a better future.

Amount of Antenatal Care Days in a Context of Effective Regionalization of Very Preterm Deliveries.

OBJECTIVE: To evaluate the amount of antenatal care days in level III hospitals caused by regionalization of very preterm deliveries. STUDY DESIGN: We included all 171,997 pregnancies registered in Finland between January 1, 2004 and December 31, 2006. Data on deliveries from the Medical Birth Register were linked to the Hospital Discharge Register. Maternal zip codes were used to define whether a mother lived inside or outside a level III hospital region. Regionalization was defined as care in level III hospitals between gestational weeks 22 and 32 among mothers living outside level III hospital regions. Pregnancies were divided into 3 groups based on the gestational age at delivery: very preterm (<32 weeks), late preterm (32-36 weeks), and term (≥37 weeks). RESULTS: There were 12,354 antenatal care days in level III hospitals caused by regionalization, which amounts to a need for 12 antenatal maternal beds annually. In the very preterm pregnancies, the antenatal length of stay was comparable for mothers living inside or outside level III hospital regions (median 4 days, P = .81) but significantly longer for mothers living outside level III hospital regions in the late preterm (median 9 vs 7 days, P = .001) and term groups (median 3 vs 2 days, P < .0001). CONCLUSIONS: The costs of regionalization of very preterm deliveries were low, as measured by antenatal care days. Regionalization did not increase the antenatal length of stay in very preterm deliveries.

Health-related quality of life in very low birth weight children at nearly eight years of age.

AIM: This study examined the impact of prematurity-related morbidity on the health-related quality of life (HRQoL) of premature children at eight years of age, compared to term born controls of same age. METHODS: We focused on 155 premature, very low birth weight (VLBW) infants weighing up to 1500 g who were born from 2001 to 2006 in Turku University Hospital, Finland, and compared them with 129 full-term controls. Cognitive development and length was assessed at five years of age and the children self-reported 17 dimensions of HRQoL at eight years of age. The VLBW group was subdivided into healthy children and those with prematurity-related morbidities. RESULTS: Our findings showed that 64.5% of the VLBW children did not have prematurity-related morbidities. The HRQoL of the healthy preterm VLBW children was very good and did not differ significantly from the controls. However, the VLBW children with one or more morbidities had significantly lower scores in nine of the 17 HRQoL dimensions than the children in the control group. CONCLUSION: The majority of the VLBW children survived without prematurity-related morbidities, and their HRQoL was very good and similar to the control children. The main goal of neonatal care for preterm infants should be to prevent long-term morbidities.

Trends in care practices reflecting parental involvement in neonatal care.

BACKGROUND: Everyday care practices can facilitate or hinder parents' participation and involvement in neonatal care. AIMS: To evaluate trends in family-centered care practices in the Neonatal Intensive Care unit in Turku University Hospital. STUDY DESIGN AND SUBJECTS: In this retrospective study, the patient charts of very preterm infants were reviewed in 4 cohorts: 2001 to 2002 (n=72), 2006 to 2007 (n=69), 2009 to 2010 (n=76), and 2011 to 2012 (n=78). OUTCOME MEASURES: Care practices with parental involvement were evaluated: 1) thermoregulation; 2) nutrition and feeding; 3) the beginning and number of skin-to-skin care episodes. As safety measures, the length of stay and weight gain were recorded at discharge. RESULTS: The significant trends included: a decrease in gestational age at the end of incubator care (mean 33.4 [standard deviation (SD) 1.36] to 31.6 [SD 1.1], p<0.001) and at the beginning of breast-feeding (35.3 [SD 1.34] to 33.1 [SD 1.89], p<0.001), bottle feeding (from 34.1 [SD 1.04] to 33.3 [SD 1.51], p=0.003) and skin-to-skin care (from 32.8 [SD 1.99] to 29.9 [SD 2.34], p<0.001). The changes were most remarkable in the infants below 28 weeks. In addition, weight gain increased from 110 g to 159 g per week (p<0.001). CONCLUSIONS: The hospital care practices of very preterm infants developed during the study period support parental involvement. During the same time period, the weight gain of very preterm infants improved, significantly. These practices can serve as indicators of progressive trends in family centered care.

PERFECT preterm infant study.

INTRODUCTION: This article summarizes the main findings of the preterm infant sub-study of the Performance, Effectiveness and Costs of Treatment episodes (PERFECT) study. We studied effects of birth hospital level and time of birth on mortality and morbidity and cost-effectiveness of care of very low gestational age (VLGA)/very low birth weight (VLBW) infants. MATERIAL AND METHODS: The study included all infants born below 32 weeks or 1501 g in Finland in 2000-2007. Different cohorts were used depending on the time point. RESULTS: The one-year mortality of live-born VLBW/VLGA infants was higher if born in level II versus level III hospitals, or if born during out-of-office hours in level II versus office hours in level III hospitals. Two out of three VLGA/VLBW subjects did not have any of the prematurity-related morbidities studied. The average cost of quality-adjusted life years was €19,245 by four years of age; the cost was higher in VLGA/VLBW infants with long-term morbidities. DISCUSSION: Birth in a level III hospital improved survival of VLGA/VLBW infants. Results suggest inadequate overnight competence in small hospitals. Despite high initial costs, care of VLGA/VLBW infants was already cost-effective by four years of age. Cost-effectiveness can be improved by reducing long-term morbidities.

Hospital costs and quality of life during 4 years after very preterm birth.

OBJECTIVE: To evaluate the effect of gestational age and prematurity-related morbidities on hospital costs and cost per quality-adjusted life-year (QALY) during the first 4 years of life. DESIGN: Population-based study using national register data and parental questionnaires. SETTING: Finland. PARTICIPANTS: All 2064 very preterm children (gestational age <32 weeks or birth weight <1501 g) and all 200 609 full-term control individuals (mean [SD] gestational age, 37 [0] to 41 [6] weeks) born from January 1, 2000, through December 31, 2003. MAIN EXPOSURE: Prematurity. MAIN OUTCOME MEASURES: Costs of hospital care and cost per QALY at 4 years of age according to gestational age and prematurity-related morbidities. RESULTS: By 4 years of age, the cost per QALY for full-term controls (in 2008 currency) was euro1181 (US$1736). In very preterm children, the average cost per QALY was euro19 245 ($28 290), ranging from euro11 824 to euro54 324 ($17 381 to $79 856) and increasing with decreasing gestational age. The cost per QALY was euro14 368 ($21 121) for those without any of the studied morbidities and euro36 110 ($53 082) for those with 2 or more morbidities. The costs of the initial hospital stay comprised 79.5% of the total 4-year hospital costs in very preterm children. CONCLUSIONS: We conclude that the cost per QALY in this patient group is at an acceptable level by 4 years of age. Because the initial hospital care episode accounted for most of the costs, the cost per QALY will decrease with each additional follow-up year.

Impact of very preterm birth on health care costs at five years of age.

OBJECTIVE: We assessed the effects of very preterm birth (gestational age <32 weeks or birth weight <1501 g) and prematurity-related morbidities on health care costs during the fifth year of life. METHODS: The study population consisted of 588 very preterm children and 176 term control subjects born in 2001-2002. Costs of hospitalizations, visits to health care professionals and therapists, and the use of other social welfare services were assessed during the fifth year of life. Hospital visits were derived from register data and other health care contacts, and the use of social welfare services were derived from parental reports. The effects of 6 prematurity-related morbidities (cerebral palsy [CP], seizure disorder, obstructive airway disease, hearing loss, visual disturbances or blindness, and other ophthalmologic problems) on the costs of health care were studied. RESULTS: The average health care costs during the fifth year of life were 749 euro in the term control subjects, 1023 euro in the very preterm children without morbidities, and 3265 euro in those with morbidities. The costs of social welfare services and therapies exceeded the hospitalization costs in all groups. Among children who were born preterm, CP was associated with 5125 euro higher costs, whereas later obstructive airway diseases increased the costs by 819 euro compared with individuals without these morbidities. CONCLUSIONS: The health care costs during the fifth year of life in very preterm children with morbidities were 4.4-fold and in those without morbidities 1.4-fold compared with those of term control subjects. This emphasizes the importance of prevention of morbidities, especially CP, to reduce the long-term costs of prematurity.

Relations between brain volumes, neuropsychological assessment and parental questionnaire in prematurely born children.

The objective of this study is to assess the relationship between brain volumes at term equivalent age and neuropsychological functions at 5 years of age in very low birth weight (VLBW) children, and to compare the results from a neuropsychological assessment and a parental questionnaire at 5 years of age. The study group included a regional cohort of 97 VLBW children and a control group of 161 children born at term. At term equivalent age, brain magnetic resonance imaging (MRI) was performed on the VLBW children, and analysed for total and regional brain volumes. At 5 years of age, a psychologist assessed the neuropsychological performance with NEPSY II, and parents completed the Five to fifteen (FTF) questionnaire on development and behaviour. The results of the control group were used to give the age-specific reference values. No significant associations were found between the brain volumes and the NEPSY II domains. As for the FTF, significant associations were found between a smaller total brain tissue volume and poorer executive functions, between a smaller cerebellar volume and both poorer executive functions and motor skills, and, surprisingly, between a larger volume of brainstem and poorer language functions. Even after adjustment for total brain tissue volume, the two associations between the cerebellar volume and the FTF domains remained borderline significant (P = 0.05). The NEPSY II domains Executive Functioning, Language and Motor Skills were significantly associated with the corresponding FTF domains. In conclusion, altered brain volumes at term equivalent age appear to affect development still at 5 years of age. The FTF seems to be a good instrument when used in combination with other neuropsychological assessment.

Morbidities and hospital resource use during the first 3 years of life among very preterm infants.

OBJECTIVE: The objective of this study was to determine how the use of hospital resources during the first 3 years of life was associated with prematurity-related morbidity in very preterm infants (gestational age of <32 weeks or birth weight of <1501 g). METHODS: The study was a retrospective, national register study including all very preterm infants born alive in Finland between 2000 and 2003 (N = 2148). Infants who died before the age of 3 years (n = 264) or who had missing register data (n = 88) were excluded from the study. The relationship between 6 morbidity groups and the need for hospital care during the first 3 years of life was studied by using a negative binomial model. RESULTS: A total of 66.2% of the infants did not have any of the morbidities studied. Infants who were subsequently diagnosed as having cerebral palsy (6.1% of the study group), later obstructive airway disease (20.0%), hearing loss (2.5%), visual disturbances or blindness (3.8%), or other ophthalmologic problems (13.4%) had initial hospital stays that were a mean of 7, 8, 12, 17, and 3 days longer, respectively, than those for infants without these conditions. All morbidity groups were associated with increased numbers of hospital visits during either the second or third year of life, compared with infants without these morbidities. The need for hospitalizations and outpatient hospital care decreased with postnatal age for infants with later morbidities and for infants without later morbidities. CONCLUSIONS: Most very preterm infants born in Finland survived without severe morbidities and required relatively little hospital care after the initial discharge. However, those with later morbidities had a long initial length of stay and more readmissions and outpatient visits during the 3-year follow-up period.